This is the nursing management of a patient after a surgical procedure. The nurse/midwife has a role to ensure that the patient recovers fully from the effect of anaesthesia.
This is the care given to patients before a surgical procedure. The nurse/midwife has a role to ensure that the patient is physically, psychologically and physiologically fit for the intended procedure.
It is the removal of the pouch and cleaning of an artificial opening created on the lower abdominal surface of a patient. The opening may be temporary or permanent.
It is the specific care rendered to the skin and bony prominences of a bedridden patient. It is performed to prevent pressure sores or decubitus ulcers. Untreated pressure areas may lead to tissue ischeamia and death.
Tepid sponging is the application of lukewarm water on the skin surface when the body temperature is above 39℃. The temperature of the water used should be between 27-37℃. The procedure is based on the principle of conduction and evaporation of heat.
Ward rounds is an organized review of in-patients by the health care team members. It is to discuss, make decisions and assign responsibilities to various practitioners in relation to the management of patients’ condition. The nurse/midwife has the responsibility to ensure that the needed gadgets or devices are readily available for the activity. The nurse/midwife ensures that accurate documentation is done.
This is the process of building a therapeutic relationship with patient/client and family who visits the hospital. It makes the patient/client and family feel at ease to discuss his/her needs with the nurse. This action is performed by the nurse immediately he/she comes into contact with a patient/client and family.
It is the act of describing a procedure, an action or task that will be carried out for a patient/client and or the family during the delivery of care.
Is the practice of introducing the in-patient to the staff and ward setting. This activity enables the patient and relatives to adapt to his/her new setting and know the routines of the ward.
This is when a patient is received from another unit or place of first admission to a new unit or department. The patient can be received from a wheelchair, bed or trolley within the same facility. The ambulance can be used when the patient is being transferred from one unit/department to the other within the same hospital.
This is when a patient is moved out from one unit of admission within the same hospital for update treatment. It is done at the discretion of the medical team or at the request of the patient. A good knowledge of patients/clients condition is very important.
This is the act of maintaining cleanliness of the hands and feet of a patient while on admission. It is recommended that this procedure is performed after the bath of a patient/client. Nail care can also be given after soaking the hands or feet in a basin of warm water for 10-15 minutes to soften the nails.
It is the process of measuring and noting the amount and type of fluids introduced into the body and excreted from the body over a 24-hour period. This procedure assists the nurse to maintain an accurate record of a patient’s fluid balance. Fluid intake includes: 1. Oral fluids 2. Intravenous fluids 3. Nasopharyngeal fluids 4. Intragastric fluids Fluid output includes: Urine Vomitus Aspirates Diarrhoeal stool Sweat
This is an ongoing interaction between the patient and the nurse, through which the patient’s condition and its management are discussed into details using clear and simple language. This procedure is very essential in the health care process as it provides the patient the opportunity to know about the possible diagnoses, treatment and prognoses.
Admission is an act of allowing the patient/client to stay in the health facility for a period. This brings about a change in the patient(s) environment which could be: a. Sudden and drastic due to an emergency or b. Planned The first impression created is very important therefore the nurse should be understanding, courteous, confident and efficient.
This is an ongoing interaction between the patient and the nurse, through which the patient’s condition and its management are discussed into details using clear and simple language. This procedure is very essential in the health care process as it provides the patient the opportunity to know about the possible diagnoses, treatment and prognoses.
This is when a patient is authorized to leave the ward after the completion of the treatment. his is granted when the doctor/physician deems patient fit to return home or to his/her community. Occasionally, the discharge is carried out upon patient’s own request. It is important that patient and relatives have pre-knowledge of the discharge.
This is the process of measuring the amount of heat in the body which represents the balance between heat production and heat loss. Body temperature is usually measured by the use of digital clinical thermometer. The unit of measurement is degree centigrade (℃) and the normal range is 36.5℃ to 37.2℃. Sites for measuring the body temperature can be any part of the body using the digital thermometer.
Checking of pulse is the act of measuring the number of times the heart beats, rhythm and strength of the beat within a minute. During the procedure an artery is located under the skin directly on a bone by firmly pressing on the selected artery to feel the beat. The unit of measurement is beats per minutes (bpm). The normal ranges for adults and children are stated below: a. Adults : 60 – 100, average 80bpm b. Children: i. 1 – 12 months : 80 – 140, average of 120bpm ii. 2 – 6 years : 75 – 130, average of 100bpm iii. 7 – 12 years : 75 – 110, average of 95bpm
This is the act of measuring the number of breaths of a patient/client in cycles per minute. Each cycle involves one sequence of inspiration, expiration and a pause. It is measured by counting the number of times a patient’s/client’s chest rises and falls in a minute. The unit of measurement is cycles or breaths per minute(bpm). The normal ranges for adults and children are stated below: a. Children: i. Infants (Birth – 1 year) : 30 – 60bpm ii. Toddler (1 – 3years) : 24 – 40bpm iii. 3 – 6 years : 22 – 34bpm iv. 6 – 12 years : 18 – 30bpm v. Adolescent (12 – 18 years) : 12 – 16bpm b. Adults: 16 – 20bpm
This is one of the components of vital signs. This is the process of checking and recording of oxygen saturation levels in a patient’s blood. It is done with the aid of a clip-like device known as pulse oximeter. A pulse oximeter helps to identify the oxygen changes in patients with the aid of light-emitting diode (LED). During the procedure the device is attached to either the patient’s earlobe, finger or toe. The measuring unit is SpO2 and the normal value is 95% above. The receiving sensors permeate through the LED and help to absorb the oxygenated and deoxygenated haemoglobin levels in the arterial blood. The receiving sensors permeated through the LED helps to absorb the oxygenated and deoxygenated haemoglobin levels in the arterial blood. The normal measuring levels of the SpO2 is 95% and above.
This is an empty bed covered with top linen so that all linen beneath are fully protected from dust and dirt while waiting for the admission of patient.
This is a type of bed made for an in-patient. It may also be made for a patient who has difficulty in moving out of bed. During the procedure, the patient stays in bed while the bed is made.
This is a type of open bed made in readiness for easy admittance of a client/patient.
Is a specialized kind of bed that is made in an upright position to afford a patient the greatest amount of comfort and relieve during breathing.
It is a special bed prepared to receive a patient returning from the theatre after a surgical procedure has been performed.
This is a special bed with a firm base or support for nursing patients with fracture(s). The bed has an overhead frame for traction apparatus and trapeze to aid lifting, exercise and movement.
Divided bed is a special bed in which the top linen is separated into two parts with the aid of a bed cradle to create a visual window. It helps the nurse to visualize a particular part of the body that needs regular observation without disturbing the patient. This type of bed is ideal for the management of patient with burns and amputation; thus it takes the weight of the bedclothes off the site of injury.
This is the act of cleaning a patient who is bedridden and solely dependent on the nurse to maintain his/her self-care needs.
This is the act of cleaning a patient who is confined to bed but has the ability to perform some aspects of self-care with assistance from a nurse.
This is the process of promptly assisting a bedridden patient with a bedpan to maintain his/her bowel elimination pattern without getting out of bed. Most patients feel embarrassed when requesting for this assistance, the nurse must therefore be courteous and understanding when assisting the patient.
This is the act of cleaning the buccal cavity of seriously ill, unconscious patients’ or those who have difficulty utilizing their upper extremities. This procedure is carried out solely by the nurse.
This is the act of the nurse assisting the patient in the cleaning of the buccal cavity.
Enteral medications are administered through the oral, sublingual and buccal routes. These medications come in the form of either tablets, capsule, caplets or mixtures. In oral administration the medication is mostly swallowed whilst with sublingual, the medication is placed under the tongue and allowed to dissolve whereas with buccal, the medication is placed in between the cheek and allowed to dissolve.
Enteral medications are administered through the oral, sublingual and buccal routes. These medications come in the form of either tablets, capsule, caplets or mixtures. In oral administration the medication is mostly swallowed whilst with sublingual, the medication is placed under the tongue and allowed to dissolve whereas with buccal, the medication is placed in between the cheek and allowed to dissolve.
Parenteral route of medication administration entails the introduction of medications directly through the skin for gradual distribution into systemic circulation and body tissues. The various routes of parenteral medicine administration are: a. Intravenous – through the vein b. Intramuscular – through the muscle c. Subcutaneous – under the skin d. Intradermal – through the dermis e. Intrathecal – through the spinal canal These medications are delivered in the form of sterile ampoule, vial or volumes of fluid(s). During the procedure, the nurse is required to generally observe the patient and also observe strict aseptic technique to minimize the introduction of micro-organisms into the body.
Parenteral route of medication administration entails the introduction of medications directly through the skin for gradual distribution into systemic circulation and body tissues. The various routes of parenteral medicine administration are: a. Intravenous – through the vein b. Intramuscular – through the muscle c. Subcutaneous – under the skin d. Intradermal – through the dermis e. Intrathecal – through the spinal canal These medications are delivered in the form of sterile ampoule, vial or volumes of fluid(s). During the procedure, the nurse is required to generally observe the patient and also observe strict aseptic technique to minimize the introduction of micro-organisms into the body.
Parenteral route of medication administration entails the introduction of medications directly through the skin for gradual distribution into systemic circulation and body tissues. The various routes of parenteral medicine administration are: a. Intravenous – through the vein b. Intramuscular – through the muscle c. Subcutaneous – under the skin d. Intradermal – through the dermis e. Intrathecal – through the spinal canal These medications are delivered in the form of sterile ampoule, vial or volumes of fluid(s). During the procedure, the nurse is required to generally observe the patient and also observe strict aseptic technique to minimize the introduction of micro-organisms into the body.
This is the administration of chemical substances that alter the physiological function of the patient/client with the potential of improving his/her health status. As part of the care process the nurse is expected to administer all medications prescribed for the patient/client during hospitalization. The nurse has the responsibility of familiarizing him/herself with the approved institutional protocols and safety measures on medications. Amongst the rights of medication administration, the nurse must adhere to the basic seven (7) rights which include: a. Right patient b. Right medication c. Right dosage d. Right route e. Right time f. Right of patient to refuse the medication g. Right to documentation
This is the introduction of the low doses of medication into the highly vascular layer beneath the epidermis.
It is the administration of medication into the dermal layer of the skin which is directly underneath the epidermis.
This is the administration of medication into the spinal canal or the subarachnoid space which gradually reaches the cerebro-spinal fluid. This route of medication administration is mostly performed by a physician or an anaesthetist. The nurse therefore has the responsibility to prepare trolley, assist and observe the patient throughout the procedure.
This is the application of medication directly on the skin and the mucous membrane. These medications are available in the form of creams, lotions, ointment and patches.
It is the administration of medication in the form of liquid drop by drop into a body space of cavity.
This is the administration of medication through the rectum in the form of suppository.
It is the administration of medication in the form of liquid drop by drop into a body space of cavity.
It is the aseptic administration of medication into the vagina. These medications come in the form of creams, jellies, foams and pessaries.
Blood specimens are required for numerous investigations e.g. full blood count, white blood cells and erythrocyte sedimentation rate. Among others are grouping and cross matching, culture and sensitivity, blood urea, electrolytes and creatinine. The amount required range from a few drops to 10mls from the capillaries or veins depending on the test requested. Two types of bottles or tubes are used – plain/universal or bottles containing some chemical substance or culture medium.
This is the act of checking the amount/concentration of glucose in the blood with the use of a glucometer or blood glucose meter. During the procedure a drop of capillary blood is obtained from any of the fingers or the palmer surface area and dropped on the blood glucose test strip which is attached to the glucose monitor for reading. The normal values for random blood sugar are as follows: a. Adult - 3 – 6mmol/L per litre
It is the process of collecting urine from a patient/client to aid in the diagnosis of a condition.
It is the process of collecting urine from a patient/client to aid in the diagnosis of a condition.
It is the collection of samples of all urine voided by the patient in 24-hours. The nurse should explain the collection technique carefully to the patient. Other nursing staff should be aware that such a request is needed to avoid them from discarding patient/clients urine.
Collection of stool specimen is the process of obtaining a sample of a patient’s faecal matter for diagnostic purposes. A specimen of freshly passed faecal matter is collected into a small container with a small spoon or spatula without contamination.
It is the process of aseptically caring for an injury to body tissues or break in the continuity of the skin or mucous membrane.
It is the process of aseptically caring for an injury to body tissues or break in the continuity of the skin or mucous membrane.
This involves obtaining a sample of exudate from a wound for analysis. The specimen is usually taken with the aid of a sterile swab before the wound is dressed.
It is the process of aseptically caring for an injury to body tissues or break in the continuity of the skin or mucous membrane.
It is the systematic approach to rendering used instruments free from all microorganisms/endospores. This is done through decontamination, cleaning, drying and sterilization.
Urinary catheterization is the process of inserting a fine latex or silicon catheter into the urinary bladder to aid urine flow or keep the urethra open. This procedure is mostly done for patient/client who have urinary condition that affects their micturition. It is also passed for patients who are to undergo major surgical procedures. It is an invasive procedure which requires strict aseptic technique. There are two main types of catheters namely: indwelling (Two-way and three-way) and external (Condom).
Urinary catheterization is the process of inserting a fine latex or silicon catheter into the urinary bladder to aid urine flow or keep the urethra open. This procedure is mostly done for patient/client who have urinary condition that affects their micturition. It is also passed for patients who are to undergo major surgical procedures. It is an invasive procedure which requires strict aseptic technique. There are two main types of catheters namely: indwelling (Two-way and three-way) and external (Condom).
It is the act of cleaning the catheter insertion point and its periphery with an antiseptic lotion and changing of the urine bag to prevent the introduction of microorganisms into the urinary tract. This is done as often as it is necessary or as stated in the ward’s protocol.
Removal of an indwelling catheter is the act of deflating the balloon and slipping the catheter out after its use.
It is the practice of exchanging important and relevant information physically and electronically about a patient (using Electronic Medical Records Review (EMR), staff, equipment and nursing activities that occurred during a shift from outgoing team of nurses/midwives to incoming team of nurses/midwives i.e. morning, afternoon and night.
It is the practice of exchanging important and relevant information physically and electronically about a patient (using Electronic Medical Records Review (EMR), staff, equipment and nursing activities that occurred during a shift from outgoing team of nurses/midwives to incoming team of nurses/midwives i.e. morning, afternoon and night.
This is the process of maintaining the cleanliness of a patient’s hair by washing the hair with water and shampoo. This activity is mostly performed for patient who are bedridden and need assistance in the maintenance of their personal hygiene care.
It is the provision of nutritional meals through the gastrointestinal tract. This can be done directly through the mouth, stoma or with the aid of nasogastric (NG) tube.
Feeding of a patient is one of the essential task nurses/midwives perform for patients during admission. This is the process of assisting an incapacitated patient to eat in order to meet the daily nutritional requirements. It is the provision of nutritional meals through the gastrointestinal tract. This can be done directly through the mouth, stoma or with the aid of nasogastric (NG) tube
This is the act of measuring the blood pressure exerted laterally on the walls of blood vessels when the heart contracts and relaxes. The digital or manual sphygmomanometer can be used to record the pressure levels. These values are recorded in millimetres of mercury (mmHg). During the procedure two (2) values are recorded namely systolic and diastolic pressure. The upper value is the systolic while the lower value is the diastolic. The normal ranges are stated below: Age and Blood Pressure (mm Hg) (Reference: Potter, Perry, Stockert & Hall 8th Edition, 2014) a. 1 month – 12 months : 85/54 b. 1 – 5 years : 95/65 c. 6 – 9 years : 105/65 d. 10 – 13 years : 110/65 e. 14 – 17 years : 119/75 f. 18 years and older : <120/<80
This is a type of bathing which is performed in the bathroom for a patient who is not confined to bed but weak or convalescing/recovering requiring some level of assistance from a nurse to maintain his/her self-care needs.
It is the administration of medication in the form of liquid drop by drop into a body space of cavity.
These are activities organized during the hospitalization phase of the care of patient towards his/her return to the home or community to maintain his/her health status and prevent further ill-health. Discharge planning is initiated on the day of admission and co-ordinated by the entire health team.
Blood transfusion is the infusion of whole blood or its fraction i.e. plasma, red blood cells (packed cells) into a patient’s vein. Whole blood is usually given when a patient’s total blood volume, cells or plasma drops below the normal values.
This is the aseptic management of drainage tube inserted in a wound to help draw out exudates from the wound bed. There are two main types of drainage tubes used; namely: the close system and open system. The removal of the tube is based on rate of healing, hospital’s protocol and the surgeon’s discretions.
This is a process by which a nurse removes a drainage tube from a wound once the exudates has stopped or becomes less than about 25 ml/day. Drains can be 'shortened' by withdrawing them gradually every day until it is removed completely. Removal of a drain is usually ordered by a doctor or done according to hospital protocol.
This is the administration of nutritional support such as proteins, carbohydrates, fats, vitamins, and minerals intravenously.
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