Republic of the Philippines

UNIVERSITY OF EASTERN PHILIPPINES

University Town, Northern Samar
Web: http://uep.edu.ph Email: uepnsofficial@gmail.com

COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES

BS NURSING

NCM 103:
FUNDAMENTALS OF NURSING PRACTICE
RELATED LEARNING EXPERIENCE

NURSING SKILLS NO. 3 & 4

HANDWASHING – MEDICAL TECHNIQUE

Prepared by:

NEMIA G. FLORANO, RN, MMEM

Professor

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RLE Nursing Skills # 3: Mobility & Exercise
PRINCIPLES OF BODY MECHANICS
a. The wider the base of support, the greater the stability of the nurse
b. The lower the center of gravity, the greater the stability of the nurse
c. The equilibrium of an object is maintained as long as the line of gravity passes through the
base of support
d. Facing the direction of movement prevents abnormal twisting of the spine
e. Dividing balance activity between arms and legs reduces the risk of back injury
f. Leverage, rolling, turning, or pivoting requires less work than lifting
g. When friction is reduced in between arms and legs reduces the risk of back injury
h. When friction is reduced between the object to be moved and the surface on which it is
moved, less force is required to move it
i. Reducing the force of work reduces the risk of injury
j. Maintaining good body mechanics reduces fatigue of the muscle groups
k. Alternating periods of rest and activity helps to reduce fatigue

Devices Used for Proper Positioning

Devices Uses & Description

Trochanter Rolls Prevent external rotation of legs when clients are in supine position.
The roll is place under the buttocks and then rolled away from the
client until the high is in neutral position or an inward position with
the patella facing upward.
Maintain the thumb slightly adducted and in opposition to the fingers;
Hand Rolls
they maintain fingers in a lightly flexed position
Individually molded for the client to maintain proper alignment of the
Hand-wrist splint thumb in slight adduction and the wrist in slight dorsiflexion. These
splints should be used only for the client for whom they were made
Descends from a securely fastened overhead bar attached to the bed
Trapeze bar frame. Allows the client to use upper extremities to raise the trunk off
the bed, to assist in transfer from bed to wheelchair, or to perform
upper arm strengthening exercises.
Side rails Are bars positioned along the sides of the length of the bed

Are plywood boards placed under the entire surface of the mattress.
They are useful for increasing back support and alignment, especially
with a soft mattress

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 Or abductor pillow is a triangular-shaped pillow made of heavy foam.
It is used to maintain legs in abduction following total hip
replacement surgery

Positioning Techniques
 In general, clients should be repositioned as needed and at least
– every 2 hours if they are in bed
– Every 30 minutes if they are sitting in a chair
Kinds of Positioning Techniques
 Fowler’s (45-60% head elevation)
 Supine (rests on the back)
 Prone (face-down position)
 Lateral (side-lying)
 Sim’s (semi-prone)
Principles & Considerations to Remember
 Improper positioning can cause unnecessary harm to clients, such as
– skin breakdown and joint contractures, especially if they have certain pre-existing
conditions such as
 peripheral vascular disease or diabetes
 Positions that compromise peripheral blood flow
– may damage nerves as well
 Every time your client is repositioned, make certain to check
-total body alignment,
-placement of extremities
-Skin breakdown
-Joint contractures

RLE Nursing Skills # 4: EMERGENCY PREPAREDNESS

NURSING IN DISASTER CONDITIONS
 DISASTER
 Is a catastrophe which may be natural in origin or manmade, whether produced
accidentally or by design

 TYPES:
1. Typhoon, floods
2. Fire, vehicular accident
3.earthquakes, landslides
4. Plane crash, nuclear warfare
Emergency Operations Plan (EOP)
 Health care facilities are required by the Joint Commission on Accreditation of Healthcare
Organizations to create a plan for emergency preparedness and to practice this plan twice a year

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  Essential components of the plan:
 An activation response
 An internal/external communication plan

 A plan for coordinated patient care

 Security plans

 Identification of external resources

 A plan for people management and traffic flow

 Essential components of the plan:

 A data management strategy

 Deactivation response

 Post-incident response

 A plan for practice drills

 Anticipated resources

 Mass casualty incident planning

 An education for all of the above

Managing Short- and Long-Term Psychological Effects After a Disaster

 Provide active listening and emotional support
 Provide information as appropriate
 Refer to therapist or other resources
 Discourage repeated exposure to media regarding the event
 Encourage return to normal activities and social roles
 Critical incident stress management (CISM)
 Programs that include education, field support, defusing, debriefing, demobilization, and
follow-up components
 Persons with ongoing stress reactions should be referred to mental health specialists

Personal Protective Equipment (PPE)

 Purpose: to shield the health care provider from chemical, physical, biological, and
radiologic hazards that may exist when caring for contaminated patients

Categories of protective equipment:

 Level A: self-contained breathing apparatus (SCBA) and vapor-tight chemical-resistant suit,
gloves, and boots
 Level B: high level of respiratory protection (SCBA) but lesser skin and eye protection;
chemical-resistant suit

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  Level C: air-purified respirator, coverall with splash hood, and chemical-resistant gloves and
boots
 Level D: typical work uniform

MANAGEMENT
 TRIAGE - sorting of casualties

 Prevent panic or hysteria

 Priority should be given to the severely injured who have a good chance to live
 Treat as many in the shortest possible time
 Deal with radiations

STAGES OF DISASTER

 1. THREAT STAGE
- when situations occurs that have potential or creating crises but do not show actual
conditions of peril
 2. WARNING
- is most specific than the first stage of threat & almost assures the reality of disaster
 3. IMPACT
- when the disaster is manifested full-blown
 4. RECOVERY
- when the assessment of the disaster effects is made, the injured are rescued, &
rehabilitation of people & their lives is begun

CARE OF CLIENT PRESENTING TO AN EMERGENCY DEPARTMENT

 TRIAGE
- the classification of all clients presenting to the emergency department for the purpose
of prioritizing treatment.
- it is utilized to promptly identify those clients requiring immediate, life-saving
treatment & those who would receive more efficient & effective care in another area

  Advance skill
 Ensures that patients most in need of care do not wait to receive it
 Nurse must also collect crucial initial data: vital signs and history, neurologic assessment
findings, diagnostic data

ROUTINE HOSPITAL TRIAGE

 Directs all available resources in the patient who are most critically ill, regardless of the
potential outcome

 FIELD TRIAGE
 Scarce resources must be used to benefit the most people possible
 

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  FAST TRACK
 Requires simple first aid or basic primary care
 May be treated in the ED or safety referred to a clinic or physician’s office

3 CATEGORIES OF TRIAGE RATING SYSTEM

 1. EMERGENT -- HIGHEST PRIORITY
- those conditions that require immediate care & intervention because of increased risk of
mortality or threat to life, limb or vision; pre-hospital care providers usually transport these
clients
- ex. Major burns, cardiac arrest, chest pain, respiratory distress, major blunt or penetrating
trauma or hemorrhage
 2. URGENT - SERIOUS HEALTH PROBLEM
 - those conditions that require care as soon as possible generally within 1 hour because the
condition has the potential for causing the deterioration of health status if not treated
 - fever, abdominal pain, stable fractures, headache, lacerations with controlled bleeding or
dehydration
 3. NON-URGENT
- those conditions that require routine care that can be delayed for greater than 2 hours
without the possibility of deterioration
- frequently utilized the emergency department because they don’t have primary care
physician
- ex. Colds, sore throat, toothache, rashes or abrasions.

DISASTER MANAGEMENT PLAN

-A community-wide, hospital-wide, or emergency department plan to handle mass casualty incidents
that may occur at any time.

A. ASSESSMENT
 PRIMARY ASSESSMENT
 - rapid initial assessment of the client’s presenting symptoms to determine the presence of
life- threatening conditions while simultaneously intervening

A = AIRWAY C-spine (cervical spine) immobilization

 *possible interventions to maintain a patent airway include chin lift/jaw thrust,
suctioning, oropharyngeal or nasotracheal intubation, or tracheostomy
 *all interventions, cervical spine must remain in anatomically neutral position & may
be immobilized with cervical collar or manually stabilized to prevent morbidity due to
potential spinal cord injury

B – BREATHING
 * possible interventions for INEFFECTIVE BREATHING PATTERN include
application of supplemental oxygen by mask or bag-valve mask device, assisting with
chest tube insertion or intubation, covering of open chest wound with 3-sided occlusive
dressing & use of pressure dressing on a flail segment of ribs

C - CIRCULATION/CONTROLLED HEMORRHAGE
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  *Finding of adequate perfusion include:

-full, regular, & normal pulse rate; pink, warm, & dry skin with capillary refill
*Indications of decreased circulation include:
 - bradycardia, tachycardia, hypotension, cool, pale & diaphoretic skin, external
bleeding, decreased level of consciousness
 *Interventions: direct pressure to control external bleeding, insertion of IV access
device, fluid volume replacement with normal saline, blood or blood products, CPR

D – DISABILITY
 * Complete a brief neurological assessment to determine baseline functioning,
potential life-threatening complications, & level of consciousness.
 *Glasgow Coma Scale assess the arousal component of responsiveness; it measures
eye opening, best verbal response, & best motor response minimum score of 3 & max
score is 15

E - EXPOSE
 * Remove all clothing from the client to facilitate a through complete secondary
assessment examination

 B. SECONDARY ASSESSMENT
 - A brief systematic head-to-toe assessment that identifies injuries; cervical immobilization is
maintained at all times during the secondary assessment as well as the continual assessment
of hemodynamic & oxygenation status

 F – FAHRENHEIT
 * is important to provide measures to prevent body heat loss at this time through the use of
warmed IV fluids, warmed blankets, or heating lamps

 G - GET VITAL SIGNS

 * obtain a full set of vital signs

 H - HISTORY & HEAD-TO-TOE ASSESSMENT

 *to obtain a thorough history of mechanism of injury, pre-hospital vital signs & treatment
& past medical history, allergies, & medications

CLASSIFICATION FOR PRIORITY OF TREATMENT

* based on how likely it is that the casualties will respond to the medical personnel & supplies that are
immediately available.

1. MINIMAL TREATMENT

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  Minor treatment can be delayed hours to days
 - patients who can be returned to active duty immediately
 This group should be moved away from the main triage area.
 Can be returned to active duty immediately
 Priority -3
 Color –GREEN

 MINIMAL CONDITIONS
 Upper extremity fractures
 Minor burns
 Sprains
 Small laceration without significant bleeding
 Behavioral disorders
 Psychological disturbance

2. IMMEDIATE TREATMENT
 LIFE THREATENING
 patients whom the available expedient procedures will save life or limb
 Survivable with minimal interventions
 Can progress rapidly to expectant if treatment is delayed
 Priority -1
 Color – RED Sucking chest wound

 Airway obstruction
 Shock
 Hemothorax
 Tension pneumothorax
 Asphyxia
 Unstable chest
 Abdominal wounds
 Incomplete amputations

 IMMEDIATE CONDITIONS
 Open fractures of long bones
 2nd and 3rd degree burns of 15-40% TBSA

3. DELAYED TREATMENT
 Injuries are significant and require medical care
 patients who, after emergency treatment will incur little increased risk by having surgery
withheld temporarily.
 Can wait hours without threat to life or limb
 Treated only after immediate causalities
 Priority -2
 Color – YELLOW

 DELAYED CONDITIONS
 Stable abdominal wounds without hemorrhage

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  Soft tissue injuries
 Maxillofacial wounds without airway compromise
 Vascular injuries with adequate collateral circulation
 Genitourinary tract disruption
 Fractures for ORIF
 Debridement external fixation
 Eye injury
 CNS injury

4. EXPECTANT TREATMENT
-Injuries are extensive and chances of survival are unlikely even with definitive care
-critically injured patients who will be given treatment if time & facilities are available
-This group should be separated from other causalities but not abandoned
-Comfort measures should be provided when possible
-Priority -4
-Color- BLACK

EXPECTANT CONDITIONS
 Unresponsive patients with penetrating head wounds
 High spinal cord injuries
 Wounds involving multiple anatomical sites and organs
 2nd and 3rd degree burns in excess of 60% of body surface area
 Seizures and vomiting within 24 hours after radiation exposure
 Profound shock with multiple injuries
 Agonal respirations
 No pulse, BP, pupils fixed and dilated.
 
***the following is a priority schedule which serves as a guide to establish the flow of
casualties from the disaster are through the FIRST AID STATION to FORWARD
TREATEMENT CENTER AND HOSPITAL

PRIORITIES OF TREATMENT
 1. FIRST PRIORITY
-individual needing immediate attention to save life
a. any wound interfering with airway or causing airway obstruction
=includes sucking chest wounds, tension pneumothorax & maxillofacial wounds 9n
which asphyxia is present
b. any wound requiring immediate pressure for bleeding
c. shock due to major hemorrhage, to wounds of any organ systems, fractures

 2. SECONDARY PRIORITY
- individual needing early surgery
a. visceral injuries, including perforations of the gastro intestinal tract; wounds of the
biliary & pancreatic system
b. vascular injuries requiring repair
c. closed cerebral injuries with increasing loss of consciousness

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  3. THIRD PRIORITY
- patients who requires surgery but can tolerate a delayed
a. spinal injuries in which decompression is required
b. soft tissue wounds in which debridement is necessary
c. lesser fractures & dislocations
d. injuries of the eyes
e. maxillofacial injuries without asphyxia

Isolation Precautions for Biological Terrorism Agents

 1.Biological agents may be delivered or spread in a number of ways

 2.Due to modern travel, spread of infection may occur in areas thousands of miles apart
 3. Health care providers need to be aware of potential signs of biological weapon
dissemination; signs and symptoms are similar to those of common disease process
 4. Isolation practices depend upon the infecting agent
 5. Always use Standard Precautions
 6. Some agents require Transmission-Based Precautions
 7. Terminal disinfection and disposal of wastes depends on the infecting agent

Chemical Weapons
 Chemical substances that quickly cause injury and/or death and cause panic and social
disruption

Agents:
 Nerve agents
 Blood agents
 Vesicants
 Pulmonary agents
 Agents vary in volatility, persistence, toxicity, and period of latency
 Limitation of exposure is essential with evacuation and decontamination as soon possible
and as close to the scene of the incident as possible
 Sarin and soman organophosphates
 Inhibit cholinesterase-causing cholinergic symptoms progressing to loss of consciousness,
seizures, copious secretions, apnea, and death
 Treatment: supportive care, atropine, benzodiazepine, and pralidoxime
 Decontaminate with copious amounts of soap and water or saline for at least 20 minutes
 Blot; do not wipe off
 Plastic equipment will absorb sarin gas

Vesicants
 Lewisite, sulfur mustard, nitrogen mustard, and phosgene
 Cause blistering and burning
 Respiratory effects can be serious and cause death
 Decontaminate with soap and water; do not scrub or use hypochlorite solutions
 Eye exposure requires copious irrigation
 Treatment for lewisite exposure: dimercaprol IV or topically

Radiation Exposure

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 Radiation exposure may occur due to nuclear weapons, nuclear reactor incidents, or
exposure to radioactive samples
 Exposure to radiation is affected by time, distance, and shielding

 Types of radiation exposure:

 External radiation: all or part of the body is exposed to radiation; as decontamination is not
necessary, it is not a medical emergency

Contamination:
-exposure to radioactive gases liquids or solids; requires immediate medical management
to prevent incorporation
 Incorporation: uptake of the radioactive material into the body

Radiation Decontamination
 Triage outside the hospital
 Cover floor and use strict isolation precautions to prevent the tracking of contaminants
 Seal air ducts and vent
 Waste is double bagged and put in a container labeled radiation waste
 Staff protection
 Water-resistant gowns, 2 pairs of gloves, caps, goggles, masks, and booties
 Dosimetry devices
 Patients are surveyed for radiation and directed to the decontamination area
 Each patient is decontaminated with a shower outside the ED
 Water, tarps, towels, soap, gowns, all the patient’s belongings, etc., must be collected and
contained
 Patients are surveyed and showered again as necessary
 Showering should be performed so as not to contaminate clean areas with runoff from the
showering
 Biologic samples: nasal and throat swabs; blood
 Internal contamination requires additional treatment: catharsis and gastric lavage with
chelating agents

Radiation Injuries
 Acute radiation syndrome (ARS): dose of radiation determines if ARS will develop
 All body systems are affected by ARS
 Presenting signs and symptoms determine predicted survival
 Probable survivors have no initial symptoms or only minimal symptoms
 Possible survivors present with nausea and vomiting that persists for 24 to 48 hours
 Improbable survivors are acutely ill with nausea, vomiting, diarrhea, and shock; neurologic
symptoms suggest lethal dose; and survival time is variable

THANK YOU!
Prepared by:

NEMIA G. FLORANO, RN, MMEM

Clinical Instructor

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