anp procedures

8/8/2019 Anp Procedures

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Surgical Hand Scrubbing in the Perioperative Setting

PURPOSE:

Skin is a major potential source of microbial contamination in the surgical environment.Although scrubbed members of the surgical team wear sterile gloves, the skin of their hands and

forearms should be cleaned preoperatively to reduce the number of microorganisms in the eventof glove tears. The purpose of the surgical hand scrub is to remove debris and transient

microorganisms from the nails, hands, and forearms; reduce the resident microbial count to aminimum; and inhibit rapid rebound growth of microorganisms.

Each facility should have a policy and procedure for surgical hand scrubbing that considers theresources available in that facility. The following recommendations should be considered when

drafting the policy and procedure for surgical hand scrubbing.

RECOMMENDATIONS:

A. Preparation for Surgical Hand Scrub:

1. Rings, watches, and bracelets should be removed before beginning the surgical hand scrub.

Rationale: During hand washing, rings, watches, and bracelets may harbor or protectmicroorganisms from removal. Allergic skin reactions may occur as a result of a scrub agent or a

glove powder accumulating under the jewelry.

2. Fingernails must be kept short, clean, and healthy.

Rationale: The subungual region harbors the majority of microorganisms found on the hand. Therisk of tearing gloves increases if fingernails extend past the fingertips.

3. Artificial nails should not be worn.

Rationale: Artificial nails may harbor organisms and prevent effective hand washing.

4. Skin on hands and arms should be intact.

Rationale: Breaks in skin integrity and open lesions increase the risk of patient and surgical teammember infection. Cuts, abrasions, exudative lesions, and hangnails tend to ooze serum, which

may contain pathogens. Broken skin permits microorganisms to enter the various layers of skin,providing deeper microbial breeding grounds.

5. If timed scrub technique is used, a clock should be visible for the timed scrub.


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Rationale: Standard timing is necessary for effective preparation of the surgical teams hands and

arms.

6. An effective antimicrobial surgical hand scrub agent approved by the health care facility

should be used for all surgical hand scrubs. The agent should be used according to themanufacturers instructions.

Rationale: An antimicrobial agent kills microorganisms and reduces the level further by itsresidual effect, but can be inactivated by organic material. Efficacy of all agents depends on its

proper use.

7. The selected antimicrobial hand scrub agent should: Significantly reduce selected microorganisms on intact skin

Contain a nonirritating antimicrobial preparation Be broad spectrum

Be fast acting Have a residual effect

Rationale: Organisms reproduce in the moist environment of gloves, and gloves frequently

become damaged during procedures; therefore, persistent chemical activity is desirable tosuppress microbial growth. No agent is ideal in every situation. Agents should be selected based

on these factors and their acceptability to the surgical team for their consistent use according tothe manufacturers direction.

8. A nonmedicated soap scrub followed by application of an alcohol-based hand cleanser may be

used.

Rationale: The primary action of cleansing with soap is the mechanical removal of transientorganisms. Vigorous rubbing with enough alcohol-based hand cleanser to cover the hands and

forearms completely has been shown to be an effective method of antisepsis.

9. Surgical hand scrub agents should be stored in clean, closed containers. Reusable containersshould be washed and dried thoroughly before refilling. Adding surgical hand scrub agents to

partially filled reusable containers should be avoided. Disposable containers should be discardedwhen empty.

Rationale: Refilling before cleaning dispensers and adding surgical hand scrub agents to partially

filled containers may cause contamination and contribute to the spread of potentially harmfulmicroorganisms.

10. If brushes are used the selection of reusable or disposable brushes or sponges for scrubbing

should be based on realistic considerations of effectiveness and economy.

Rationale: Studies show no significant difference in scrub effectiveness between reusablebrushes and disposable brushes or sponges. Individually prepackaged disposable brushes and


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sponges provide a cost-effective, laborsaving alternative to reusable brushes. If a reusable brushis desired, it should be easy to clean and maintain and should be durable enough to withstand

repeated sterilization without bristles becoming soft or brittle.

B. Surgical Hand Scrub:

1. The surgical hand scrub procedure should be standardized for all personnel according to the

health care facilitys policy and procedure.

Rationale: A standardized surgical hand scrub procedure establishes a single standard of care.Although the skin can never be rendered sterile, it can be made surgically clean by reducing the

number of microorganisms.

2. The hands and forearms are thoroughly moistened and washed using an approved surgicalscrub agent and rinsed before beginning the surgical scrub procedure.

Rationale: A short, pre-scrub wash loosens surface debris and transient microorganisms.

3. The water is of a comfortable temperature and steady flow.

Rationale: Setting the temperature and flow of the water before beginning the surgical hand

scrub prevents cross-contamination.

4. The hands should be held higher than the elbows and away from surgical attire. Rinsing isperformed from fingertips to elbows, using water flow and not hands. Vigorous shaking to dispel

water from hands and arms is not sound practice.

Rationale: Hands and forearms are held higher than the elbows and out from the surgical attire toprevent contamination and to allow water to run from the cleanest area down the arm. Water

droplets dispersed by shaking can contaminate surrounding attire or supplies.

5. Care should be taken to avoid splashing water onto surgical attire.

Rationale: A sterile gown cannot be put on over damp surgical attire without risk of resultantcontamination of the gown by strike-through moisture.

6. An antimicrobial agent should be applied with friction to the wet hands and forearms.

Rationale: The principle action of hand washing is mechanical-vigorous rubbing that produces

friction, which removes dirt, transient microorganisms, and some resident microorganisms.

7. Fingers, hands, and arms should be visualized as having four sides; each side must bescrubbed effectively.

Rationale: The surgical scrub is effective only if all surfaces are exposed to mechanical cleaning


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and chemical antisepsis.

8. Nails and subungual areas, and only nail and subungual areas, should be brushed

Rationale: The majority of flora on the hands is found under and around the fingernails. Brushing

other areas of the hands and arms has been shown to abrade the skin surface detrimentally.

9. If using the timed technique, the total time of the surgical hand scrub should be at least two

minutes. It is useful to break the process into three stages: First, wash hands and arms as far aselbows; second, wash hands and arms but not as far as the elbow; third, wash hands and only

two-thirds of forearm.

Rationale: Optimal length of scrub time is not known, but recent studies suggest scrubbing for atleast two minutes is as effective at reducing bacterial colony counts as the traditional ten minute

scrub. Longer scrubs lead to a greater number of skin problems among staff and discouragecompliance.

10. If using the counted stroke technique, the digits, hands, forearms, and arms are divided into

four planes.

Each plane requires 10 strokes with the scrub sponge. The digits have 4 planes and each digit will have a total of 40 strokes.

The dorsal and palm of the hand will have a total of 30 strokes. The forearm has 4 planes and it will have a total of 40 strokes.

The elbow has 4 planes and it will have a total of 40 strokes. The arm 5 cm above the elbow has 4 planes and it will have a total of 40 strokes.

The counted stroke technique will be completed on the right and left side.

11. Hands and forearms should be blotted dry starting with the fingertips and proceeding toelbows with a sterile cloth or disposable towel before donning sterile gown or gloves.

Rationale: Rubbing skin to dry it will further disturb skin cells. The fingertip to elbow process

completed on one hand and using another portion of the sterile towel (or another sterile towel) todry the other hand preserves the hands as the cleanest area.

12. Brushes or sponges used should be discarded appropriately.

Rationale: Appropriate disposal of used items prevents cross-contamination of the surgical hand

scrub area. Reusable brushes should be decontaminated and sterilized before reuse.

13. If a waterless microbial agent is selected, the agent must be used in strict accordance with themanufacturers directions.

Rationale: If the traditional role of water is replaced by another mechanism, that mechanism

must be efficacious.


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GOWNING AND GLOVING TECHNIQUE

1.Gowning:To don the gown, the scrub person:

a. Lifts the folded gown directly upward from the sterile package.b. Steps back from the table into an unobstnrcted area;

c. Carefully locates the neckband and holds the inside front of the gown justbelow the neckband with both hands;

d. Lets the gown unfold while keeping the inside of the gown toward thebody with, out touching the sterile exterior of the gown with bare hands

(NOTE :If the gown does not unfold completely, then the circulatingnurse may assist by pulling down the unfolded bottom inside the gown);

e. Holds the hands at shoulder level and slips both arms into the armholesimultaneously

2. Gloving:Closed Glove Technique-In the closed-glove technique, the scrub person's hands remains inside the sleeves and should not

touch the cuffs. In the open-glove technique the scrub person's hands slide all the way throughthe sleeves out beyond the cuffs.

y Keeps both hands within the cuff so that the hands do not touch the cuff edges;y Grasps the folded cuff of the left glove with the right hand;y Holds the top edge of the cuff in the left hand above the palm;y Places the palm of the glove against the palm of the left hand-the glove fingers point up

the forearm;

y Grasp the back of the cuff in the right hand and turn it over the open end of the left sleeveand hand while holding the top of the left glove and underlying gown sleeve with thecovered right hand;

y Pulls the glove over the extended left finger onto the wrist by pushing the hand throughthe glove until it completely covers the cuff of the glove;

y Gloves the right hand in the same manner by reversing the above stepsy Inspects the gloves for integrity after donning; andy Hands the tie end to the circulator and secures the wraparound glove (when used.)

B. Open Glove Technique-The closed glove technique should not be used when changing one or both gloves because once

the hand has been passed through the cuffs, they are contaminated. When a glove must bechanged without assistance during a surgical procedure, the open-glove technique is used.

a. To change one glove during the procedure using the open-glove technique, the scrub Person:

l) Steps away from the sterile field;


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2) extends the contaminated glove away from the sterile field so that the circulator, using examgloves to protect his/her hands, can remove it;

3) lifts the new sterile glove under the cuff with the uncontaminated gloved hand;4) Inserts the hand into the glove and pulls it on, leaving the cuff turned well down over the hand

and avoiding inward rolling of the cuff. The bare hand does not touch the outside of the glove;

5) and Rotates the arm and pulls the cuff of the glove up and over the sleeve cuff, letting thegloved fingers touch only the outside of the other glove.

b. To change both gloves during a procedure using an open-glove technique, the scrub Person:1) Follows instructions 1 and 2 above;

2) Picks up the left glove cuff, touching only the edge of the cuff with his or her right thumb andindex finger;

3) Pulls the glove onto the left hand and leaves the glove cuff turned down;4) Picks up the right glove with the gloved left hand, keeping the

gloved fingers under the folded cuff;5) Slides the right hand fingers inside the right glove cuff and pulls

the glove onto the right hand while avoiding inward rolling of thecuff;

6) Pulls the right glove cuff over the sleeve cuffby rotating the arm;7') Places the gloved right-hand fingers under the folded left glove

cuff, rotates the arm, and pulls the left glove cuff over the sleevecuff.

II. Assisted Gowning and Gloving1. Assisting gowning- The scrub person may assist another member in drying, gowning, and

gloving by:a. Opening the towel that the other member will use to dry his/her hands

b. laying the towel on the team member's hand without touching his/her hands;c. Holding the gown at the neckband and carefully unfolding

d. Keeping the hands on the outside of the gown, forming a protective cuff of the neck andshoulder area as the person being gowned holds both arms outstretched;

e. Offering the inside of the gown to the other member so he or she can slip his or her hands intothe sleeves; and

f. Releasing the gown when the team members' hands are in the sleeves.

2. Assisted gloving- To glove another team member, the scrub person always gloves theother person's right hand first. The scrub person:

a. Picks up the glove with his or her fingers under the cuffb. Holds the palm of the glove toward the person being gloved

c. Stretches the cuff to open the glove and holds his or her thumbs out to keep them fromtouching the other team member's bare hands

d. As the other person inserts his or her hands into the glove, exerts upward firm pressure makingsure the hand does not go below the waist

e. Unfolds the inverted glove cuff over the cuff of the sleevef. Gloves the left hand with the assistance of a team member by repeating the steps

g. Hold the tie as the other team member turns to secure wraparound sterile gown when it is used.


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3. Assisted re-gloving-When a team member other than the scrub nurse contaminates a glove during the surgical

procedure, the circulator, using examination gloves so that her hands are protected ,will grasp theout side of the gloves and pull it off inside out. The scrub nurse then regloves the team members

as described in assisted gloving.

The options for the scrub nurse who needs to change gloves are to: remove both gown andgloves, have another team member assist in regloving, or use the open-glove technique.

The closed-glove technique cannot be used to reglove. In closed gloving, the hand passes

through the cuff of the gown, contaminating the end of the cuff . this would cause the out sideof new glove to be contaminated.

III. Removing Gown and Gloves

At the end of the procedure, the gown is always removed before the gloves to prevent crosscontamination of the wearer's scrub attire. The circulator can assist by unfastening the neck and

back closures of the gown. The scrub person:l. grasps the shoulders of the gown, pulls it downward from the shoulder and off the arms, and

turns the sleeves inside out;2. folds the contaminates surface of the gown on the inside and rolls it away from the body; and

3. Discards the rolled gown in the appropriate receptacle.

Removing the gloves after removing the gown prevents the bare hands from contamination that

would usually occur from handling the soiled gown.


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Triage

Triage (pronounced /tri-a-/) is a process of determining the priority of patients' treatments

based on the severity of their condition. This rations patient treatment efficiently when resources

are insufficient for all to be treated immediately. The term comes from the French verb trier,meaning to separate, sort, sift or select.

1.Two types of triage exist: simple and advanced.2.Triage may result in determining the order and priority of emergency treatment, the order and

priority of emergency transport, or the transport destination for the patient.3.Triage may also be used for patients arriving at the emergency department, or to telephone

medical advice systems among others. This article deals with the concept of triage as it occurs in

medical emergencies, including the prehospital setting, disasters, and during emergency roomtreatment.

Types of triage

Simple triageSimple triage is usually used in a scene of a "mass-casualty incident" (MCI), in order to sort

patients into those who need critical attention and immediate transport to the hospital and thosewith less serious injuries. This step can be started before transportation becomes available. The

categorization of patients based on the severity of their injuries can be aided with the use ofprinted triage tags or colored flagging.

S.T.A.R.T. modelMain article: Simple triage andrapidtreatment

S.T.A.R.T. (Simple Triage and Rapid Treatment) is a simple triage system that can be performedby lightly-trained lay and emergency personnel in emergencies. It is not intended to supersede or

instruct medical personnel or techniques. It has been (2003) taught to California emergencyworkers for use in earthquakes. It was developed at Hoag Hospital inNewport Beach, California

for use by emergency services. It has been field-proven in mass casualty incidents such as trainwrecks and bus accidents, though it was developed for use by community emergency response

teams (CERTs) and firefighters after earthquakes. In 2009, the Newport Beach Fire Departmentgave approval for a bilingual version of the S.T.A.R.T. system to be included in a series of books

called EMSpaol , produced by Emergency Language Systems.Triage separates the injured into four groups:

y The deceasedwho are beyond helpy The injured who can be helped by immediate transportationy The injured whose transport can be delayedy Those with minor injuries, who need help less urgently

Advanced triageIn advanced triage, doctors may decide that some seriously injured people should not receive

advanced care because they are unlikely to survive. Advanced care will be used on patients withless severe injuries. Because treatment is intentionally withheld from patients with certain

injuries, advanced triage has ethical implications. It is used to divert scarce resources away from


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patients with little chance of survival in order to increase the chances of survival of others whoare more likely to survive.

In Western Europe, the criterion used for this category of patient is a trauma score of consistentlyat or below 3. This can be determined by using the Triage Revised Trauma Score (TRTS), a

medically-validated scoring system incorporated in some triage cards.

Another example of a trauma scoring system is the Injury Severity Score (ISS). This assigns ascore from 0 to 75 based on severity of injury to the human body divided into three categories: A(face/neck/head), B(thorax/abdomen), C(extremities/external/skin). Each category is scored from

0 to 5 using the Abbreviated Injury Scale, from uninjured to critically injured, which is thensquared and summed to create the ISS. A score of 6, for "unsurvivable", can also be used for any

of the three categories, and automatically sets the score to 75 regardless of other scores.Depending on the triage situation, this may indicate either that the patient is a first priority for

care, or that he or she will not receive care due to the need to conserve care for more likelysurvivors.

The use of advanced triage may become necessary when medical professionals decide that themedical resources available are not sufficient to treat all the people who need help. The treatment

being prioritized can include the time spent on medical care, or drugs or other limited resources.This has happened in disasters such as volcanic eruptions, thunderstorms, and rail accidents. In

these cases some percentage of patients will die regardless of medical care because of theseverity of their injuries. Others would live if given immediate medical care, but would die

without it.In these extreme situations, any medical care given to people who will die anyway can be

considered to be care withdrawn from others who might have survived (or perhaps suffered lesssevere disability from their injuries) had they been treated instead. It becomes the task of the

disaster medical authorities to set aside some victims as hopeless, to avoid trying to save one lifeat the expense of several others.

If immediate treatment is successful, the patient may improve (although this may be temporary)and this improvement may allow the patient to be categorized to a lower priority in the short

term. Triage should be a continuous process and categories should be checked regularly toensure that the priority remains correct. A trauma score is invariably taken when the victim first

comes into hospital and subsequent trauma scores taken to see any changes in the victim'sphysiological parameters. If a record is maintained, the receiving hospital doctor can see a

trauma score time series from the start of the incident, which may allow definitive treatmentearlier.

Continuous integrated triageContinuous Integrated Triage is an approach to triage in mass casualty situations which is both

efficient and sensitive topsychosocial and disasterbehavioral health issues that affect thenumber of patients seeking care (surge), the manner in which a hospital or healthcare facility

deals with that surge (surge capacity and the overarching medical needs of the event.Continuous Integrated Triage combines three forms of triage with progressive specificity to most

rapidly identify those patients in greatest need of care while balancing the needs of the individualpatients against the available resources and the needs of other patients. Continuous Integrated

Triage employs:y Group (Global) Triage (i.e., M.A.S.S. triage)y Physiologic (Individual) Triage (i.e., S.T.A.R.T.)y Hospital Triage (i.e., E.S.I. orEmergency Severity Index)


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However any Group, Individual and/or Hospital Triage system can be used at the appropriatelevel of evaluation.

Practical applied triageDuring the early stages of an incident, first responders may be overwhelmed by the scope of

patients and injuries. One valuable technique, is the Patient Assist Method (PAM); the

responders quickly establish a casualty collection point (CCP) and advise ; either by yelling, orover a loudspeaker, that "anyone requiring assistance should move to the selected area (CCP)".This does several things at once, it identifies patients that are not so severely injured, that they

need immediate help, it physically clears the scene, and provides possible assistants to theresponders. As those who can move, do so, the responders then ask, "anyone who still needs

assistance, yell out or raise your hands"; this further identifies patients who are responsive, yetmaybe unable to move. Now the responders can rapidly asses the remaining patients who are

either expectant, or are in need of immediate aid. From that point the first responder is quicklyable to identify those in need of immediate attention, while not being distracted or overwhelmed

by the magnitude of the situation.

Reverse triage

In addition to the standard practices of triage as mentioned above, there are conditions wheresometimes the less wounded are treated in preference to the more severely wounded. This may

arise in a situation such as war where the military setting may require soldiers be returned tocombat as quickly as possible, or disaster situations where medical resources are limited in order

to conserve resources for those likely to survive but requiring advanced medical care. Otherpossible scenarios where this could arise include situations where significant numbers of medical

personnel are among the affected patients where it may be advantageous to ensure that theysurvive to continue providing care in the coming days especially if medical resources are already

stretched. In cold water drowning incidents, it is common to use reverse triage because drowningvictims in cold water can survive longer than in warm water if given immediatebasic life support

and often those who are rescued and able to breathe on their own will improve with minimal orno help.

Triage in first aid

Triage is an old French term that was first used to refer to the sorting and treatment of those

injured in battle. Today, the term is used in situations where there are more casualties than there

are rescuers. It is a method that involves assessing quickly, then assisting those casualties that

truly need help, but at the same time not wasting resources on casualties who have very, if any,

chance of being saved.

Simple Triage and Rapid Treatment (START)

This involves quickly assessing and prioritizing casualties into three categories: immediate,delayed, and dead/non-salvageable.

First, all casualties that can walk need to be moved away from the immediate area so rescuers

can deal with the critically injured. The casualties that walk away should still be looked at by

rescuers that arrive later.

Immediate Care


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This designation is for casualties that need immediate care to have their airway cleared to enable

breathing to continue.

Delayed Care

This group includes casualties that are breathing, have a pulse, but can't move on their own e.g.

because of a broken leg.Dead/Non-Salvageable

These are the casualties that are found not breathing and who fail to breath after attempts are

made to open and clear the airway. It also includes obviously mortal injuries such as

decapitation. Never begin CPR on such a casualty because once you begin you can't stop. As a

result you can not continue to triage and other casualties may die that otherwise may have been

saved.

As casualties are assessed they are generally marked with ribbons e.g. around the wrists to

indicate their classification to others. The colors used are:

oImmediate: Red

o Delayed: Yellow orGreeno Dead: Black orGray


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Pulse oxymetryDESCRIPTION:Pulse oximetry is a simple non invasivemethod of monitoring the percentage of haemoglobin

(Hb) which is saturated with oxygen. The pulse oximeter consists of a probe attached to thepatient's finger or ear lobe which is linked to a computerised unit. The unit displays the

percentage of Hb saturated with oxygen together with an audible signal for each pulse beat, acalculated heart rate and in some models, a graphical display of the blood flow past the probe.

1. Provides an estimate of arterial oxyhemoglobin saturation by using selected wavelengthsof light to noninvasively determine the saturation of oxyhemoglobin. Oximeters function

by passing a light beam through a vascular bed, such as the finger or earlobe, to determine

the amount of light absorbed by oxygenated (red) and deoxygenated (blue) blood.

2. Calculates the amount of arterial blood that is saturated with oxygen (Sao2) and displaysthis as a digital value.

How does an oximeter work?

A source of light originates from the probe at two wavelengths (650nm and 805nm). The light is

partly absorbed by haemoglobin, by amounts which differ depending on whether it is saturated

or desaturated with oxygen. By calculating the absorption at the two wavelengths the processor

can compute the proportion of haemoglobin which is oxygenated. The oximeter is dependent on

a pulsatile flow and produces a graph of the quality of flow. Where flow is sluggish (eghypovolaemia or vasoconstriction) the pulse oximeter may be unable to function. The computer

within the oximeter is capable of distinguishing pulsatile flow from other more static signals

(such as tissue or venous signals) to display only the arterial flow

Indications include:

a. Monitor adequacy of oxygen saturation; quantify response to therapy.

b. Monitor unstable patient who may experience sudden changes in blood oxygen level.

c. Evaluation of need for home oxygen therapy.

d. Determine supplemental oxygen needs at rest, with exercise, and during sleep.

e. Need to follow the trend and need to decrease number of ABG sample drawn.4. The oxyhemoglobin dissociation curve allows for correlation between Sao2 and PaO2

5. Increased bilirubin, increased carboxyhemoglobin, low perfusion or Sao2 < 80% may alter

light absorption and interfere with results

Nursing and Patient Care Considerations

1. Assess patients hemoglobin. Sao2 may not correlate well with PaO2 if hemoglobin is notwithin normal limits.


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2. Remove patients nail polish because it can affect the ability of the sensor to correctly

determine oxygen saturation, particularly polish with blue or dark colors.

3. Correlate oximetry with ABG values and then use for single reading or trending of

oxygenation (does not monitor Paco2).

4. Display heart rate should correlate with patients heart rate.5.. To improve quality of signal, hold finger dependent and motionless (motion may alter

results) and cover finger sensor to occlude ambient light.

6. Assess site of oximetry monitoring for perfusion on a regular basis, because pressure

ulcer may occur from prolonged application of probe.

7. Device limitations include motion artifact, abnormal hemoglobins (carboxyhemoglobin

and methemoglobin), I.V. dye, exposure of probe to ambient light, low perfusion states,

skin pigmentation, nail polish or nail coverings, and nail deformities such as severe

clubbing.

8. Document inspired oxygen or supplemental oxygen and type of oxygen deliverydevice.

9. Accuracy can be affected by ambient light, I.V. dyes, nail polish, deeply pigmented

skin, patients in sickle cell crisis, jaundice, severe anemia, and use of antibiotics such as

sulfas.

In the following situations the pulse oximeter readings may not be accurate:

1. A reduction in peripheral pulsatile blood flow produced by peripheral vasoconstriction(hypovolaemia, severe hypotension, cold, cardiac failure, some cardiac arrhythmias) or

peripheral vascular disease. These result in an inadequate signal for analysis.2. Venous congestion, particularly when caused by tricuspid regurgitation, may produce

venous pulsations which may produce low readings with ear probes. Venous congestionof the limb may affect readings as can a badly positioned probe. When readings are lower

than expected it is worth repositioning the probe. In general, however, if the waveform onthe flow trace is good, then the reading will be accurate.

3. Bright overhead lights in theatre may cause the oximeter to be inaccurate, and the signalmay be interrupted by surgical diathermy. Shivering may cause difficulties in picking up

an adequate signal.4. Pulse oximetry cannot distinguish between different forms of haemoglobin. Carbo-

xyhaemoglobin (haemoglobin combined with carbon monoxide) is registered as 90%oxygenated haemoglobin and 10% desaturated haemoglobin - therefore the oximeter will

overestimate the saturation. The presence of methaemoglobin will prevent the oximeterworking accurately and the readings will tend towards 85%, regardless of the true

saturation.5. When methylene blue is used in surgery to the parathyroids or to treat

methaemoglobinaemia a shortlived reduction in saturation estimations is registered.6. Nail varnish may cause falsely low readings. However the units are not affected by

jaundice, dark skin or anaemia.

Uses:


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Pulse oximeters may be used in a variety of situations but are of particular value formonitoring oxygenation and pulse rates throughout anaesthesia.

They are also widely used during the recovery phase. The oxygen saturation shouldalways be above 95%.

In patients with long standing respiratory disease or those with cyanotic congenital heartdisease readings may be lower and reflect the severity of the underlying disease.

In intensive care oximeters are used extensively during mechanical ventilation andfrequently detect problems with oxygenation before they are noticed clinically.

They are used as a guide for weaning from ventilation and also to help assess whether apatient's oxygen therapy is adequate.

In some hospitals oximeters are used on the wards and in casualty departments. Whenpatients are sedated for procedures such as endoscopy, oximetry has been shown to

increase safety by alerting the staff to unexpected hypoxia.

Limitations:

Oximeters give no information about the level of CO2 and therefore have limitations inthe assessment of patients developing respiratory failure due to CO2 retention.

On rare occasions oximeters may develop faults and like all monitoring the readingshould always be interpreted in association with the patient's clinical condition. Never

ignore a reading which suggests the patient is becoming hypoxic.

Since pulse oximeters cost at least 1200 their purchase will depend mainly on economicconsiderations


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Nursing Health AssessmentThe history and the physical exam provide much of the information known about the patient'shealth status. As a practical nurse, we may be called upon to assist the physician or other health

care providers during a physical examination. we should know the basics of the examination inorder to have the appropriate equipment and supplies on hand, and so that you may place the

patient in the proper position and drape him correctly. Assessment is the first step in the nursingprocess. A nurse uses every tool available to gather the information required to write a patient's

diagnoses and care plan.Nursing Health Assessment Tools

Charts

1. A patient's chart provides information about his health status. It includes details about thecurrent medical condition, treatment plan, related past medical history and other important

data required to create a care plan.

Vital Signs

2. Regular monitoring of a patient's heart rate, blood pressure, temperature and respiratory rateallows the nurse to help prevent life-threatening complications and evaluate a patient's

overall condition. Abnormalities can indicate a variety of problems ranging from anxiety toheart failure.

Patient Interview3. One of the most important assessment tools in nursing is the patient herself. A nurse

performs an initial detailed interview to get a full picture of the patient's physical and mental

status. A nurse also does shorter interviews throughout the day by asking the patient how sheis feeling and other questions about her well-being.

Observation

4. Nurses use every interaction with patients as a way to gather information by observingpatients' responses to stimuli. This helps a nurse recognize pain, emotional disturbances and

reaction to treatment. It is an especially important tool for patients who are unable tocommunicate.

Other Health Care Professionals5. Communicating with other health care professionals involved in a patient's care is vital to

assessment, especially when a patient is transferred from another location. In a hospitalsetting, a patient may be seen by a doctor, nurse, respiratory therapist, physical therapist or

other specialists. Gathering information from all these sources helps the nurse create a well-rounded care plan.

PURPOSES FOR PERFORMING A PHYSICAL EXAMINATION The physical examination can be performed by the following health care providers: a

physician, nurse practitioner, or physician assistant. The health care provider makes specificand general observations as he examines the patient from head to toe. The exam should

include the eyes, ears, nose, mouth, throat, neck, chest, breasts, abdomen, and extremities. A


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vaginal or rectal examination is performed if indicated. The purposes for performing aphysical examination are:

a. To determine the patient's level of health or physiological function.b. To arrive at a tentative diagnosis when there is a health problem or disease. c. To confirm a diagnosis of disease or dysfunction.

d. To evaluate the effectiveness of prescribed medical treatment and therapy. FUNCTIONS OF THE PRACTICAL NURSE DURING THE EXAMINATION

PROCEDURE

a. Ensure that the patient feels comfortable and is not embarrassed. Prior to the examination,tell the patient what will take place and explain the reason for the procedure. The patient who

knows what to expect will be more relaxed and cooperative.b. Ask the patient to void into a urine specimen cup in order to empty the bladder and save

the urine specimen for urinalysis. Have the patient put on a hospital gown so that his body ismore accessible for examination.

c. Arrange equipment and supplies. Be sure that you have everything needed. Test allequipment to make certain that it works correctly.

Supplies and Equipment

Hospital gown

Sheet or disposable paper drapes

Bath blanket (to prevent chill)

Tray with flashlight, gloves,

lubricant normal saline, cotton-

tipped applicators, and tissues

Basin for soiled instruments

Waste container for paper goods

Scale with height measuring rod

Gooseneck lamp or hospital light

Gloves

Thermometer (oral or rectal)

Tape measure

Tongue depressors

Ophthalmoscope (for examining

eyes)

Otoscope (for examining ears)

Tuning fork

Blood pressure apparatus and

stethoscope

Percussion hammer (to check

reflexes)

Red and blue pencils (to mark skin)

Small speculum (for nose

examination)

Head mirror (to reflect light into

body orifice, such as the throat

You may also need slides, blood

tubes, a vaginal speculum, or

other equipment; medications;

and a surgical permit if a

biopsy or other tests are to be

done.

d.Accompany the patient to the examination room and assist him onto the table. Yourpresence lends support and reassurance to the patient. If a male is examining a femalepatient, or vice versa, stay in the room to protect the patient, the health care provider, and the

hospital or clinic. e. Wash your hands and measure the patient's vital signs (temperature, pulse, respiration,

blood pressure), height, and weight. Wear gloves if the patient has a draining wound, isbleeding, is vomiting, or has an infection.


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. Have the patient's chart available. The physician needs to know the information that hasalready been obtained via the nursing observations and lab reports. Call the physician's

attention to any abnormal lab values. Do this away from the patient. g. Have all lab slips and x-ray slips ready with the patient's name, rank, social security

number, date, and other required information.

h. Assist the patient to assume the proper position for each part of the examination (seefigures 1-1 to 1-7). To provide continuing privacy, be sure to adjust the drapes each time thepatient assumes a different position. If the patient is asked to stand erect, place paper towels

on the floor or have the patient put on slippers.o Hand instruments and supplies to the physician. Properly label and care for all

specimens collected.j. See that the patient is returned safely to his room and is comfortable. k. Place all instruments in the proper area for disinfection or sterilization and dispose of all

wastes. Wash your hands again. See that the examination room is cleaned. Decontaminate the

room if necessary. Change the cover on the tables. Replace all equipment.

POSITIONING A PATIENT FOR EXAMINATION OR TREATMENT

Patients are put in special positions for examination, for treatment or test, and to obtainspecimens. You should know the positions used, how to assist the patient, and how to

adjust the drapes. a. Horizontal Recumbent Position. Used for most physical examinations. Patient is on his

back with legs extended. Arms may be above the head, alongside the body or folded onthe chest.

b. Dorsal Recumbent Position. Patient is on his back with knees flexed and soles of feetflat on the bed. Fold sheet once across the chest. Fold a second sheet crosswise over the

thighs and legs so that genital area is easily exposed. c. Fowler's Position. Used to promote drainage or ease breathing. Head rest is adjusted to

desired height and bed is raised slightly under patient's knees d. Dorsal Lithotomy Position. Used for examination of pelvic organs. Similar to dorsal

recumbent position, except that the patient's legs are well separated and thighs are acutelyflexed. Feet are usually placed in stirrups. Fold sheet or bath blanket crosswise over

thighs and legs so that genital area is easily exposed. Keep patient covered as much aspossible.

e. Prone Position. Used to examine spine and back. Patient lies on abdomen with headturned to one side for comfort. Arms may be above head or alongside body. Cover with

sheet or bath blanket.NOTE: An unconscious patient, or one with an abdominal incision or breathing difficulty

usually cannot lie in this position. f. Sim's Position. Used for rectal examination. Patient is on left side with right knee

flexed against abdomen and left knee slightly flexed. Left arm is behind body; right armis placed comfortably.

NOTE: Patient with leg injuries or arthritis usually cannot assume this position. g. Knee-Chest Position. Used for rectal and vaginal examinations and as treatment to

bring uterus into normal position. Patient is on knees with chest resting on bed andelbows resting on bed or arms above head. Head is turned to one side. Thighs are straight

and lower legs are flat on bed.NOTE: Do not leave patient alone; he/she may become dizzy, faint, and fall.


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Figure 1-1. Horizontal recumbent

position.

Figure 1-2. Dorsal recumbent

position.

Figure 1-3. Fowler's position.

Figure 1-4. Dorsal lithotomy

position.

Figure 1-5. Prone position.


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HISTORY TAKING

I. DEMOGRAPHICAL INFORMATION

Name : Sabasiva

Age : 50 YearsSex : Male

Address : Charwada road

vapi

Religion : Hindu

Marital status : Married

Education : 8th

Std

Occupation : Cooley

Income : Rs.2000 / month

Ward : Post operative ward

Date of Admission : 18/11/10

Date of Surgery : 20/11/10

I.P No :1011-172161O. P No : 1011-21013

II.

CHI

EF

CO

MPLAINT / CLIENTS REQUEST FOR CARE:

Patient had chest pain, dyspnea on exertion since 3 months.

III. PRESENT ILLNESS / PRESENT HEALTH STATUS:

a) Symptoms or complaintsPatient had chest pain dyspnea on exertion and history of palpitation since 3 days.

b) Onset - Acute

Figure 1-6. Sims position.

Figure 1-7. Knee-chest position.

DIAGNOSIS : I H D, Double vessels diseases


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c) Location - Chest regiond) Quality - Stabbing in naturee) Quantity - Continues painf) Associated phenomenon - lack of myocardial demandg) Alleviating factors - P T C A

IV. PAST HISTORY:

a) He has a history of Hypertension and irregular treatment therapyb) No allergy to any medication and foodc) No history of, tuberculosis and Diabetes mellitusd) Immunization has mark of small pox vaccination and BCG scar

V. FAMILY HISTORY:

He belongs to middle class family, got married 25 years back and has two Son.

Sl.

No.

Name of the

family member

Age Sex Occupation Education Relation Health

status

1. Mr.sambasiva 50

yrs

Male Cooley 8th

std Self IHD-

PTCA

2. Mrs.kavitha 42yrs Female Housewife 10th

standard

Wife Healthy

3. Mr. pavan 24yrs

Male Labour 12t

standard

Son Healthy

4. Mr. Krishna 22

yrs

Male Tailor 10th

Std Son Healthy

He has family history of hypertension and heart diseases

VI. PSYCHO SOCIAL HISTORY:

Economic history: He belongs to Middle class family and Minister supports him

economically for operationMother tongue - Kannada

Language known - Kannada and Tamil.

Cultural Group - Friends

Mood - Social

VIII. NUTRITIONAL HISTORY:


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He is taking all types of food either vegetarian and Non vegetarian. He used to takealcohol once in a week and 10 cigarettes per day.

IX. ELIMINATION & BOWEL PATTERN:

Bowel he has regular bowel movement once a day in the morning and no history of

constipation.

Bladder bladder patterns are regular, voids approximately 5 times a day. No history ofdysuria, hematuria.

X. ENVIRONMENTAL HISTORY:

He lives with his family in concrete house, which has three room and a kitchen. They usetoilet for defecation and getting water from the boring well. he has electricity supply and closed

drainage system in his house.

PHYSICAL EXAMINATION

1) GENERAL OBSERVATION:a) Constitution : Moderate body built

b) Stature : Normal

c) State of Nutrition : Good

d) Personal appearance : anxious

e) Posture : Good

f) Emotional stage : Anxious

g) Skin : Pallorh) Cooperativeness : Cooperative

2) VITAL SIGNS:

Temperature : 99oF

Pulse : 72 bpm

Respiration : 22 Bpm

Blood pressure : 130 / 80 mmhg

Pulse pressure : 50 mmhg

3) HEIGHT : 165 CMS

4) WEIGHT : 59 KGS

5) SKIN AND MUCUS MEMBRANE:

a) Colour of skin : Pallor

b) Edema : Absent


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c) Moist Temperature : Normal

d) Turgor : Normal

e) Texture : Moist

6) HEAD :

a) Skull : No abnormality noted

b) Hair : Black hair, hair distribution normal

c) Movements of the head : Full range of movement

d) Fore head : No scars or lesion

e) Face : Anxious looking

7) EYES :

a) Expression : Anxious & fear

b) Eye brows : Equal

c) Eye lids : No lesion

d) Lacrimation : Clear fluid

e) Conjunctiva : Pale

f) Sclera : pallor

g) Cornea : Clear and moist

h) Iris : Normal

i) Pupils : PERRLA

8) EARS :

a) Appearance : No mass

b) Discharge : No

c) Hearing : Normal

d) Lesion : Absent

9) NOSE :

a) Appearance : No Septal deviation

b) Discharge : No

c) Patency : Both nostrils are patentd) Sense of smell : Good

10) MOUTH AND THROAT:

a) Lips : Dry

b) Tongue : Normal, un coated

c) Teeth : Intact in upper and lower jaw


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d) Gums : Pink and moist

e) Buccal mucosa : No lesion

f) Tonsil : Normal

d) Taste : Normal

11) NECK:

a) General appearance : Normal

b) Trachea : Normal in position

c) Lymph node : No enlargement

d) Thyroid gland : Feel smooth and firm

e) Cyst and tumor : Absence

12) CHEST AND RESPIRATORY SYSTEM:

a) Inspection : Size and shape normal, chest

expansion equal in both side and

respiration are normal

b) Palpation : No local swelling, no lymph node

enlarge

c) Percussion : Normal resonance in both lungs

d) Auscultation : Breath sounds are normal, high pitched

in both side. Respiratory rate 24 bpm,

S1 and S2 heart normal, heart rate 74

bpm.

13) CARDIO VASCULAR SYSTEM

a) Inspection : Size and shape of the chest is with in

normal limit;

b) Palpation : Carotid pulse and peripheral pulses

which is regular; normal sinus rhythm; rate- 74

bpmc) Percussion : Cardiac borders well with in normal

Limits.

d) Auscultation : S1 and S2 heard well. No abnormalities

noted. HR _ 74/mt and regular.

13) ABDOMEN:


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a) Inspection : No abnormality

b) Palpation : No organomegaly

c) Percussion : No fluid filled spaces could be found

d) Auscultation : Peristalsis present

14) BACK:

a) Spine and curvature : No abnormalities is noted

b) Movements : All range of movements are normal

c) Tenderness : No tenderness noted

15) GENITALIA:

y Normal - no discharges16) UPPER EXTREMITIES:

y Normal movementy No deformitiesy No lymph node enlargement

17) LOWER EXTREMITIES:

y Normal movementy No deformitiesy Surgical dressing present in left femoral region

18) NERVOUS SYSTEM:

a) Higher function consciousnessb) Memory immediate, recent, remote is goodc) Speech fluent and comprehensived) Cranial nerves no abnormalitiese) Sensory function goodf) Coordination finger to nose not impaired

anp procedures

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