General BCN Notes

Session 1 :
Care of the patient with fluid and

electrolyte imbalance
LEARNING OBJECTIVES
 Define the following terms fluid and

electrolyte
 Identify functions of fluid and electrolyte
 Explain about fluid compartments
 Identify factors affecting fluid and
electrolyte balance
 Teach client measures to maintain fluid and
electrolyte balance
Definition of terms
 Electrolytes: is a substance which when

dissolves in water splits into separate
electrically charged particles known as ions
 Electrolytes are a major component of body
fluids that play important roles in
maintaining chemical balance.
Definition of terms cont…
 There are six major electrolytes; sodium,
potassium, calcium, chloride, phosphorus,
and magnesium.
 Electrolyte imbalance occurs when the
levels of electrolytes in the body are either
too high or too low.
Body fluids
• Water= most important nutrient for life.
• Water= primary body fluid.
Adult weight is 55-60% water.
• Loss of 10% body fluid = 8% weight loss
SERIOUS
• Loss of 20% body fluid = 15% weight loss FATAL
• Fluid gained each day should = fluid lost each day
(2 -3L/day average)
Functions of Body Fluid
• Medium for transport
• Needed for cellular metabolism
• Solvent for electrolytes and other
constituents
• Helps maintain body temperature
• Helps digestion and elimination
• Acts as a lubricant
Mechanisms of
Fluid Gain and Loss
Gain
• Fluid intake 1500ml
• Food intake 1000ml
• Oxidation of nutrients 300ml
(10ml of H20 per 100 Kcal)
Loss
• “Sensible”
Can be seen.
Urine 1500ml
Sweat 100ml
• “Insensible”
Not visible.
Skin (evaporation) 500ml
Lungs 400ml
Feces 200ml
Regulation of Fluids
Hypothalmus –thirst receptors

(osmoreceptors) continuosly monitor serum
osmolarity (concentration). If it rises, thirst
mechanism is triggered.
Pituitary regulation- posterior pituitary
releases ADH (antidiuretic hormone) in
response to increasing serum osmolarity.
Causes renal tubules to retain H20.
Regulation of body fluids cont…
• Renal regulation- Nephron receptors sense
decreased pressure (low osmolarity) and
kidney secretes RENIN.
Renin – Angiotensin I – Angiotensin II
• Angiotensin II causes Na and H20
retention by kidneys AND…..
• Stimulates Adrenal Cortex to secrete
Aldosterone which causes kidneys to
excrete K and retain Na and H20.
Fluid Compartments
Intracellular fluid (ICF)
 Fluid inside the cell
 Most( 2/3) of the body’s water is in the ICF
Extracellular fluid(ECF)
 fluid outside the cell
 1/3 of the body’s water
 Prone to loss
 fl (2/3) of the body’s H20 is in the ICF.
Fluid compartment cont…
 Three types of extracellular fluids
Interstitial fluid
• Fluid around or between the cell
Intravascular (plasma)
• Fluid in the blood vessels
Transcellular fluid
• Fluid found in the CSF , synovial fluid etc
Electrolytes
• Work with fluids to keep the body healthy
and in balance
• They are solutes that are found in various
concentrations and measured in terms of
milliequivalent (mEq) units
• Can be negatively charged (anions) or
positively charged (cations)
• For homeostasis body needs:
Total body ANIONS = Total body
CATIONS
Cations
Positively charged
 Sodium Na+
 Potassium K+
 Calcium Ca++
 Magnesium Mg++
Anions
Negatively charged
• Chloride Cl-
• Phosphate PO4-
• Bicarbonate HCO3-
Functions of electrolyte
 Regulate water distribution

 Muscle contraction
 Nerve impulse transmission
 Blood clotting
 Regulate enzyme reactions (ATP)
 Regulate acid-base balance
Factors affecting fluid and
electrolyte balance
• Age
• Gender
• Body size
• Environmental temperature
• Lifestyle
Risk Factors for Fluid and
Electrolyte Imbalances
 Chronic diseases
 Acute conditions
 Medications
 Treatments
 Extremes of age
 Inability to access food and fluids
Collecting Assessment Data
• Nursing history
• Physical assessment
• Clinical measurement
• Review of laboratory test results
• Evaluation of edema
Assessment for dehydration
 Observations vital signs, such as pulse,

blood pressure and respiratory rate, will
change when a patient becomes dehydrated
 Skin elasticity the elasticity of skin, or
turgor, is an indicator of fluid status in most
patients. However, this assessment can be
an unreliable indicator of dehydration in
older people as skin elasticity reduces with
age
Assessment of dehydration cont…
Nursing assessment for edema
Nursing assessment of edema
cont…
Laboratory test
• Serum electrolyte, complete blood count
CBC, osmolality, urine pH, urine specific
gravity etc

Care to patient with fluid and
electrolyte imbalance
Intake and output
• Record intake and output for 24 hours
• Intake should include oral, intravenous and
tube feeding and retains irrigants
• Output include urine excess persipirations,
wound or tube drainage, vomitus and
diarrhea
• Estimate fluid loss from wounds and
perspirations
• Measure urine specific gravity according to the
agency policy, reading greater than 1.02
indicates concentrated urine, those less than
1.010 indicates diluted urine
Cardiovascular changes
• Monitor patient from cardiovascular changes
to prevent or detect complications from fluid
and electrolyte imbalances.
• Signs and symptoms of ECF volume excess
and deficit are reflected in changes of blood
pressure, pulse force, and jugular venous
distension.
• In fluid excess the pulse is full, bounding and
not easily obliterated
• Increased volume causes distended neck
veins(jugular venous distention
• In mild fluid to moderated fluid volume deficit
the blood pressure is normal
• Severe volume deficit can cause flattened neck
veins and weak, thread pulse rate
• Severe fluid deficit will result in shock
Respiratory changes
• Both fluid deficit and excess affect respiratory
status
• Excess can result in pulmonary congestion and
pulmonary oedema
• Deficit the patient will demonstrate increased
respiratory rate
Neurological
• Changes of neurologic function may occur
with fluid volume excess or deficit
• Assessment will include evaluating level of
consciousness, which include response to
verbal and painful stimuli and determination of
patients orientation to time place, and person.
Pupillary response to light and equality of
pupil size and voluntary movement of the
extremities, degree of muscle, and reflexes.
Daily weights
• Check weight daily to evaluate volume status
Skin assessment and care
• Inspect the skin daily to exclude clues of ECF
volume deficit and excess
• Examine skin for turgor and mobility
• Provide frequent skin care and changes in
position to prevent skin breakdown
• Dehydrated skin needs frequent care without
the use of soap
• Apply moistening creams or oils to increase
moisture retention and stimulus circulation
• Protect oedematous tissue from extremities of
heat and cold, prolonged pressure and trauma
• Elevate edematous extremities to promote
venous return and fluid reabsorption.
Other nursing measures
• Carefully monitor rates of IV infusion
• Encourage older people to maintain adequate
oral intake
• Promoting wellness
• Prevent associated risks
Promoting Fluid and Electrolyte
Balance
• Consume 6-8 glasses water daily
• Avoid foods with excess salt, sugar,
caffeine
• Eat well-balanced diet
• Limit alcohol intake
• Increase fluid intake before, during, after
strenuous exercise
• Replace lost electrolytes
Promoting Fluid and Electrolyte
Balance cont…
• Maintain normal body weight
• Learn about, monitor, manage side effects
of medications
• Recognize risk factors
• Seek professional health care for notable
signs of fluid imbalances
Teaching the patient on measures
to maintain fluid and electrolyte
balance
 Monitoring fluid intake and output
 Maintaining food and fluid intake
 Safety
 Medications
 Measures specific to client’s problem
 Referrals
Key point
• Electrolytes are a major component of body
fluids that play important roles in
maintaining chemical balance, there are six
major electrolytes; sodium, potassium,
calcium, chloride, phosphorus, and
magnesium
Evaluation
• What is electrolytes imbalance?

• How will you assess a client for
dehydration?

Session 2:
Care to patient with hygienic
needs
Learning Objectives
At the end of this session a learner is expected to be able:

• Define terms hygienic needs and assisting patient in personal
hygiene
• Explain basic nursing procedures for personal hygienic needs
• Mention Basic nursing procedures for personal hygienic needs
• Explain bed making
• Explain purposes for making beds
• Identify types of bed prepared in hospital settlement( empty,
occupied , post-operative cardiac bed amputation bed)
• Explain Principles of Making Hospital Beds
• Identify equipment for bed making
Definition of terms
• Personal hygiene refers to maintaining
cleanliness of one's body and clothing to
preserve overall health and well-being.
• Assisting the patient with personal
hygienic need is the process of aiding the
patient to keep his body well groomed all
the time
Basic nursing procedures for personal
hygienic needs
The following are the hygienic needs which is required
in daily nursing practice:
 Bed making
 Skin care
 Care of mouth
 Care of hair
 Care of nails and feet
 Care of eye
 Care of ear and prostheses
Introduction to bed making
• Bed making: Is a process of preparing patient’s bed
in relation to his/her condition
• The bed is where the client will spend most of his
time while in hospital.
• A properly made bed provides comfort to the person
occupying it and contributes to general ward tidiness.
• The nurse uses judgment to decide on the necessary
bed modifications to suite the condition of the
particular client
Common terms used in bed making
– A bed is a couch or support for the body
during sleep
– Bed accessory are additional requirement
used during bed making to promote
comfort of the patient e.g. sand bags,
back rest, bed cradle bed blocks.
Purposes for making beds
• Facilitate specialized care
• Facilitate easy breathing of clients e.g. beds
for cardiac or asthmatic patients
• Provide a hygienic and comfortable
sleeping area for clients
• Prevent odour from sweat and soiled linen
Purpose cont….
• Provide neatness of the ward
• Provide easy visualization of the operated
part
• Provide proper alignment of bones e.g.
fracture bed
• Prevent bed sores by ensuring there are no
wrinkles to cause pressure points
Types of bed prepared in hospital settlement
• Unoccupied bed
– Is an empty bed
• Occupied bed
– Is the bed having a patient
• Post operative bed
– Is the bed made for receiving a patient from the
operating theatre after undergoing a surgical
procedure
Types of bed cont….
• Cardiac bed
– Is the bed used for nursing patient with certain
cardiac disease and some respiratory infections
• Amputation / Divided bed
– Is the bed made for patients with amputation of
the lower limb
Principles of Making Hospital Beds
• Prepare yourself for the procedure by making a
systematic plan for time and effort.
• Collect all requirements before starting the procedure
by arranging them in order for use.
• Inform the patient about the procedure and assess his
condition as whether he can get out of the bed or not.
• Two nurses are advisable in bed making so as to
make the procedure easier and successful provides
safety for the patient.
Principles cont….
• Remove all soiled linen from top of bed to bottom and
avoid linen touching the floor, your face and uniform.
Don’t shake or fan linen to prevent spread of micro-
organisms and dust.
• Maintain privacy for the patient, avoid exposing him
unnecessarily, and use screens where necessary.
• Communicate with the patient while making his bed,
encourage him to express his feelings, needs and
problems.
Principles cont…
• Utilize principles of body mechanics and
use each movement during bed making.
• Have your centre of gravity close to your
base of support, avoid twisting your body,
stand facing the direction which your work.
• Adhere to Infection, Prevention and control
measures.
Assessments and equipment for
making various beds used in Hospitals
• Assessments
o Determine patient’s condition and needs
o Obtain information on the type of bed needed
o Determine the materials needed including the
bed accessories
o Check for special precautions or considerations
to be taken while changing the client’s bed.
o Determine how much can the client assist in the
procedure
Equipment
• Hospital bed
• Mattress
• Large bed sheets two or more (depending on the
type of bed)
• One draw mackintosh
• One draw sheet
• One or more pillows and pillow cases
• One or two blankets (depends on client’s condition
and weather)
• One counterpane
Equipment cont….
• One laundry bag
• One chair
• Bed accessories as required e.g. backrest, bed
cradle, sand bags, fracture boards bed
• elevators pulleys
• Gloves (depending on the condition of the
bed/patient)
• Trolley( stainless with two shelves top and bottom)
Evaluation
• What are the Purposes for Making Beds?
• What are the principles of making a bed in
hospitals?
• What are the equipment for making various
beds used in hospital?
Key Points
• Bed making: Is a process of preparing
patient’s bed in relation to his/her condition
• Common types of beds used in hospital
facilities for care of patient include
unoccupied , occupied post operative ,
Cardiac and Amputation / Divided bed:
Session 3 :
MAKING AN OCCUPIED AND
UNOCCUPIED BEDS
Learning Tasks
At the end of this session a learners is expected to

be able
• Explain the Indication for making an occupied bed
and un occupied bed
• Describe the procedures in making un occupied
beds in hospitals
• Describe procedure for making an occupied beds in
hospitals
• Demonstrate steps for making beds in hospitals
Indication for making an occupied bed
and un occupied bed
 To provide clean and comfortable bed for
the patient
 To reduce the risk of infection by
maintaining a clean environment
 To prevent bed sores by ensuring there are
no wrinkles to cause pressure points.
Procedures in making un occupied in
hospitals
An unoccupied bed is prepared to receive a new
patient
Steps:
• Wash hands and dry to prevent spread of infection
• Assemble all required supplies and place them on
the trolley to facilitates easy performance
• Take trolley to the bed side
• Place bottom sheet in the middle of the bed, rough
side edge facing down towards the mattress
Steps for making unoccupied bed
cont….
• Tuck the sheet well under the top of the mattress
using ‘envelop corners’.
• Then tuck the bottom side, pulling tight to prevent
wrinkles.
• Place the draw mackintosh and draw sheet on the
bed so that it will be under the patient’s buttocks
• Place the top sheet on the bed so as the top edge
become even with the top edge of the mattress, the
rough edge side facing up
Steps for making unoccupied bed
cont….
• Place the blanket and counterpane over the top sheet
(right side up).Bring them even with the top of the
mattress.
• Tuck the bottom end under the mattress, leave the sides
hanging
• Fold the top linen back at the top so that bottom sheet is
revealed
• Make a pleat of top linen at the bottom to prevent
pressure on the feet of the client
• Put pillow cases and place at the end of the bed.
Unoccupied bed
Procedures making an occupied bed
Indication:
• Bedridden patients (i.e. unconscious,
helpless, and patient with fractures)
Method: Side to side
Steps
Inform the client about the procedure to foster cooperation
Meet the patient’s needs before starting the procedure e.g.
urination, defecation
Two nurses should work together if convenient
Screen the bed to provide privacy
Place the chair at the foot of the bed
Place the trolley with clean linen and laundry bag within
easy reach
Steps for making occupied bed cont…
 Wash hands and put on gloves if necessary
 Loosen top linen, remove counterpane starting from top
to bottom, fold it into three and place it on the back of
the chair
 Repeat with the blanket(s), but leave the top sheet on the
patient to avoid exposure
 Remove pillows but leave one under the patient’s head to
ensure comfort Ask the patient to move or roll to the far
end of the bed and assist him as necessary, facing away
from you
 Loosen bottom sheet, mackintosh, and draw
sheet
 Roll sheets separately towards the patient,
tuck each roll as close to the patient as
possible
 Place the clean sheet on the bed, tuck near
edge under the mattress.
 Roll far end and tuck under the patient
Unroll the mackintosh, stretch it over the bottom
sheet and tuck edge under the mattress
Place the clean draw sheet on the bed, tuck near
edge under the mattress.
Roll far end and tuck under the patient
 Place clean sheet on the patient.
Remove the soiled top sheet by sliding it from
underneath the clean one to avoid exposure of the
patient
Ask patient to move or roll over the ridge of tucked
linen to the clean side of the bed.
Assist as necessary.
Loosen soiled bottom linen, remove from bed and
discard into the laundry bag.
 Pull bottom sheet to proper position, tuck under the
mattress
 Straighten the sheet, tuck the bottom side under the
mattress
Place the blanket and counterpane over the top
sheet; tuck the bottom end under the mattress.
 Fold the top sheet back over the blanket and
counterpane.
Tuck the sides under the mattress
 Put pillows in clean pillow cases and place
under the patient’s head
Make sure the patient is comfortable in bed
Changing Bottom Sheet: Method: top to bottom
• Take a clean sheet; roll it from one end leaving
30 cm unrolled. Put it on trolley
• Roll the draw mackintosh and draw sheet in the
same manner, put them on trolley
• Inform the client about the procedure
• Lower or remove the backrest if any
• Wash hands and dry, put on gloves
• Ask patient (while in sitting position) to move far
down the end of bed as convenient, assisting him in
doing so. If he is unable to move, two nurses will
support and lift him down the bed
• Remove the pillows, draw sheet and draw mackintosh
• Roll the bottom sheet down to the patient’s buttocks
• Spread the clean bottom sheet, with the rolled side
against the roll of the soiled linen.
• Tuck it at the top under the mattress
• Replace the draw mackintosh and draw sheet
in position
• Replace backrest and pillows
• Assist the patient to move over the rolled up
sheet to the top side of the bed with his back
resting on the pillows
• Remove the soiled bottom sheet, discard to
the laundry bag
• Unroll the clean bottom sheet, tuck at the
bottom as for unoccupied bed
• Change the top sheet and complete making
the bed as for the occupied bed
• Ensure comfort of the patient
Evaluation
• What are the indications for making an
unoccupied be?
• What are the Identify the indication for
making occupied bed?
Key Points
• An occupied bed is made for bedridden
patients.
• Consider the patient’s condition when
changing the bottom sheet while making
occupied
Session 4:
Making post-operative bed
Learning Objectives
At the end of this session a learner is

expected to be able:
• State indication for post-operative bed
• Describe the procedure for making post-
operative bed
Indication for making post-operative bed
• To receive the post-operative client from
surgery and transfer him/her from stretcher
to a bed
• To arrange client’s convenience and safety
Procedure for making post-operative
bed
Equipment
• As for unoccupied bed
Additional requirement:
• Resuscitation tray (at bedside)
• Drip stand
• Bed blocks
• Post operative tray
• Hot water bottle
• Small mackintosh and towel to protect beddings, put under
patient’s head
Additional requirements cont…
• Vomiting bowl
• Stethoscope,
• Sphygmomanometer,
• Kidney dish
• Galipot,
• Padded tongue depressor,
• Sponge holder,
• Airway tube.
Steps:
 Make the bed as for an unoccupied bed with the

following differences
 Leave the top bed clothes loose
 Fold back the top end of the bed clothes about 50 cm
and do the same for the bottom end
 Fold each side of bed clothes to meet at the centre
 Fold one side on top of the other
 Fold in half from top to bottom to make a small park
(square)
Steps cont…
 Place the pillows on a chair
 If hot water bottle is used to warm the bed, make
sure it is removed before the patient is put in bed
 After the patient is put in the bed, bring the pack
of clothes place it over the patient and loosen
them
 Cover the patient and tuck the ends as for an
occupied bed
Evaluation
• What are the reasons for making post-
operative bed?
• What are the steps to be followed in making
post-operative bed?
Key Points
• Post operative bed is made for the post
operative patient
Session 5:
Making cardiac and divided beds
Learning Objectives
By the end of this session, a learner is

expected to be able to:
• State purposes for making cardiac and divided
bed
• Describe the procedure for making cardiac
bed and divided bed
• Demonstrate steps for making cardiac and
divided bed
Purpose for making cardiac
• This procedure is used for patients who
have to be nursed in upright Position e.g.
Patients with asthmatic and cardiac
conditions
purpose for making divided/amputation
bed
• To avoid weight of bed clothes on the stump
for clients who had amputation of the lower
limbs
• For easy viewing of the amputated limb
such as observation of any discharge or
bleeding
Making a Cardiac Bed
Requirement: As for an unoccupied bed
Additional requirement:
• Extra pillows
• Backrest
• Cardiac table (if available)
• Air rings when necessary
Steps:
 Prepare unoccupied bed

 Place the backrest at the head of the bed
 Put extra pillows so that the patient is comfortable in
sitting up position
 Position the heart table across the bed with required
pillows on it so that the patient may
 lean forward to rest his head and arms as need arises
 Make sure bedclothes are enough to provide comfort
 Place an air ring under the patient’s buttocks if necessary
Divided (amputation) bed
• Assessment:
o Is there any bleeding from the stump?
o Does the patient’s condition allow for bed
making?
o Is there enough linen?
Divided bed cont….
Equipment: As for unoccupied bed
Additional equipment:
• A pair of large sheets
• A pair blankets
• Bed cradle
• Bed cover
• Soft pillow
• Sand bags
Divided bed cont….
Steps for the procedure:
o Prepare the unoccupied bed as far as the draw sheet
o Position the bed cradle
o Make top half of the bed, fold the bed clothes to reach the
middle of the bed
o Make the bottom half in the usual way, and let it overlap
the top half
o Tuck in the bottom and the sides
o The sand bags are to be placed on either side of the
amputated stump
Evaluation
• What are the purposes of making cardiac
bed?
• What are the steps to be followed in making
cardiac bed?
• What is the importance of keeping the
affected area to be viewed easily?
• What is the purpose of divided bed?
Key Points
• Cardiac bed is made for patients who have to be
nursed in upright positione.g. Patients with asthmatic
and cardiac conditions
• Observe the client for any abnormalities as you make
the bed
• Never expose the client at any time of the procedure
• Keep on communicating with the client as you
proceed with the procedure
• Make sure the sand bags are correctly secured
SESSION 6:
BED BATHING OF AN ADULT

PATIENT
Learning Objectives
At the end of this session a learner is expected

to be able:
• Define bed bath
• Explain purposes of bed bath
• Outline principles of bed bath
• Describe steps guiding bed bath of the
patient
Definition of bed bath
• Bed bathing: A bath given to client who is

in the bed (unable to bath him/her self)
Purpose for Bathing a Patient
 To provide body hygiene and comfort
 To relieve skin irritation and promote
relaxation
 To encourage blood circulation
 To reduce body temperature in case of fever
 To promote self-esteem through improved
physical appearance.
Purpose of bed bath cont…
 To improve general muscular tone and joint
 To prevent bacteria spreading on skin
 To make client comfort and help to induce
sleep
 To observe skin condition and objective
symptoms.
Steps guiding bathing an adult client
Assessment:
• Does the general condition of the client allow
for the bath?
• Is the environment conducive for the
procedure?
• Is the client ready for the procedure?
• How much can he do by himself in this
procedure?
Equipment:
o Top shelf:
o Two basins dish two flannels
o two towels
o comb
o soap in a soap
o Vaseline or body lotion
o Pair of gloves
Equipment cont…
Bottom Shelf:
o Bed linen- sheets, blankets, pillow cases
and draw sheets
o Draw Mackintosh
o Bucket for used water
o Linen bag for dirty linen
o Chair or stool at the foot of the bed
Steps for bed bathing an adult client
• Inform the client about the procedure

• One nurse may wash the client but if he is helpless
two nurses are required
• If the client is able to wash himself, put all
required equipment within reach and
• screen the bed
• Leave him to wash himself and when he is
through assist him with areas where he couldn’t .
For a helpless client:
• Bring the trolley to the client’s bedside

• Close the curtain or the door and screen the bed
• Loose the linen, remove the sheets and leave
the client with one blanket
• Put clean linen on the chair and dirty ones in
the linen bag
• Reduce pillows and leave the client with only
one pillow under his head for comfort
Steps for bathing a helpless client cont…
• Put water in the basins and test temperature using

your elbow (should be at body temperature)
• Place the draw Mackintosh and towel under the
client’s head to protect the pillow and bottom
sheet
• Ask the client if he likes soap on his face
• Wash his face, paying attention to the eyes and
ears. Rinse well and dry
• Put towel under the client’s arm farther from

you
• Wash with soapy flannel, rinse and dry
• Wash the nearest arm in the same manner
• Wash chest and abdomen, paying attention to
the umbilicus and under the breasts (in
females)
• Rinse and dry
• Cover the client and change water

• Expose the leg farthest from you, put towel
under it, wash with soapy flannel, rinse and dry
• Proceed with the leg nearest to you in the same
manner
• Turn the client to his side his back towards
you, place towel on the bed surface to protect
bottom sheet
• Wash the back from neck to buttocks, rinse and

dry. Observe for any signs of pressure sores.
• Turn client on his back, put towel under his
buttocks, wash the genital region, rinse and dry
• Remake the bed, changing the bed linen as
necessary.
• Replace the pillows
• Apply body lotion

• Put on his bed wear
• Comb his hair and make him comfortable
• Thank the patient
• Clear equipment, remove screens and open
windows
• Record and report any abnormalities observed
Key Points
• Bed bathing is bath given to client who is in

the bed (unable to bath him/her self)
• Assessment needed for patient before bed
bath include does the general condition of
the client allow for the bath? ,is the
environment conducive for the procedure?
is the client ready for the procedure?, how
much can he do by himself in this
procedure?
Evaluation
• What are the purposes of bed bathing?
• What are the steps of bathing an adult
patient?
Session 7 :
Mouth Wash
Learning Objectives
At the end of this session a learner is expected to
be able:
• Define mouthwash
• Explain purposes of mouthwash
• Outline principles of mouthwash
• Identify equipment and supplies for mouth wash
• Describe steps guiding mouthwash of the patient
Definition of mouth wash
• Mouth wash is defined as the scientific care
of the teeth and mouth.
Purposes for mouth wash
 To provide cleanliness of mouth and teeth
 To prevent dental decay and infections
 To stimulate circulation to oral tissue
 To keep oral mucosa moist and intact
 To promote client’s comfort and prevent
halitosis
Purposes cont…
 To freshen mouth
 To keep the lips clean, soft, moist and intact
 To remove food debris as well as dental
plaque without damaging the gum
 To alleviate pain, discomfort and enhance
oral intake with appetite
Assisting the patient with oral care
• The mouth requires care even during
illness.
• If the patient can assist with mouth care
provide the necessary materials.
Equipment /requirements
• Toothbrush
• Toothpaste.
• Kidney dish(emesis basin)
• A cup with water.
• Towel
• Water repellet towel
• Mouth wipe tissues.
Recommended technique
• Bring articles/materials to the bedside and
place them within the reach of the patient.
• Raise head of bed to place patient in sitting
up position.
• Protect patient's gown and bed with water
repellant towel.
• Remove articles when patient has finished.
Technique cont…
• Clear and clean them, rinse the toothbrush
under running water and return to the bed
side table ,do not place the brush in closed
case or box in order to dry
• Wash hands.
Perform Mouth Wash for an Unconscious
Patient
Assessment:
• What is the general condition of the patient?
• Is the environment conducive?
Equipment:
• Mouth wash solution e.g. sodium bicarbonate

teaspoonful to 1 pint of water in galipot
• Hydrogen peroxide 1% if mouth is very dirty
• Potassium permanganate solution
• Toothpaste
• Toothbrush or padded tongue depressor –
padded with gauze swab and secured with
plaster
Equipments cont…
• Gloves
• Glycerin with borax or Vaseline for lip care
• Gauze swabs in a container
• Receiver for used swabs
• Mackintosh and towel
• Mouth gauge for opening the mouth
Steps:
• Inform the patient about the procedure

• Wash hands and put on gloves
• Screen the bed for privacy
• Position back of head on a pillow so that
face tips downwards. This will allow fluid
to flow out of the mouth. Client lays head
turned to the side
Steps cont…
• Place towel and Mackintosh under the client’s
head and chin to protect bed linen
• Apply some toothpaste on toothbrush or moisten
padded tongue depressor in mouth solution
• Wash surface of teeth, between cheeks and gums,
roof of mouth, the tongue and lips
• Rinse mouth with sodium bicarbonate, changing
the gauze swabs as necessary
Steps cont…
• Hydrogen peroxide is used instead of sodium
bicarbonate in a very dirty mouth
• Apply Glycerin or Vaseline to lips if they are
dry or cracking
• Clear and clean equipment and return to
proper place
• Remove screen and leave client comfortable
lying on the side
Key Points
• Mouth wash is defined as the scientific care
of the teeth and mouth.
• Some of the purposes to perform mouth
wash are To provide cleanliness of mouth
and teeth ,To prevent dental decay and
infections ,To stimulate circulation to oral
tissue and To keep oral mucosa moist and
intact
Evaluation
• How will you position an unconscious

patient for mouth wash?
• What are the complications associated with
poor oral hygiene?
• What are the equipment needed for mouth
wash for an unconscious patient?
Session 8:
Washing a patient’s hair in bed
Learning Tasks
to be able:
• Define hair care
• Identify purpose of hair care
• Outline principles of hair care
• Identify equipment and supplies for hair care
• Describe steps guiding hair care
Definition of washing hair
• Hair washing is defined as one of general
care provided to a client who cannot clean
the hair by himself/ herself.
Purpose for washing patients hair in bed
o To maintain personal hygiene

o To stimulate circulation to scalp
o To promote self- esteem by enhancing
physical appearance
o To eradicate pediculosis infestations
Equipment and supplies for washing
patients hair in bed
o A jug of warm water
o 2 bath towels – 2
o 2 mackintosh – 1 floor Mackintosh – 1 draw Mackintosh
o Soap of Shampoo in a soap dish
o Basin
o Comb
o Personal belongings for hair styling
o Bucket for used water
o Pint measure
Steps guiding washing Patient’s Hair in
Bed
Assessment:
• What is the general condition of the client?
• Is it appropriate to carry out the procedure?
• Is the environment conducive?
• Is there any extra equipment needed for the
procedure?
Steps:
 Inform client about the procedure and screen

the bed for privacy
 Remove pillows and top bed linen, leave the
top sheet
 Pull the mattress towards the bottom end of the
bed leaving the wire springs expose at the top
 Put Mackintosh and towel at the top of the bed
to protect bed linen
Steps cont…
 Place floor Mackintosh on the floor beneath
the bucket
 Assist client to move towards top end of bed
so that his head is close to the edge of bed
 Pour warm water into the basin
 Using the pint measure, take water from the
basin, pour on client’s head to wet hair
 Apply soap or shampoo, measure well
Steps cont…
 Pour water from pint measure to rinse hair,
taking care that water runs into the bucket.
 Repeat soap or shampoo application if hair
is exceptionally dirty
 Dry hair thoroughly using the bath towel
 Remove protective Mackintosh from the
bed and replace mattress in proper position.
Steps cont…
 Assist client to comb hair in the desired
style
 Change any soiled linen, remake the bed
and make client comfortable
 Clear equipment, clean and return to
appropriate place
Key Points
• Purposes for caring patient’s hair include to maintain
personal hygiene ,to stimulate circulation to scalp ,to
promote self- esteem by enhancing physical
appearance and to eradicate pediculosis infestations
• To assess the patient’s condition you will ask
questions such as what is the general condition of the
client? , is it appropriate to carry out the procedure?
Is the environment conducive? is there any extra
equipment needed for the procedure
Evaluation
• What is the definition hair care?

• What are the steps guiding on the care of
patient in the bed
Session 9:
Care of patient with retention of

urine
Learning Tasks
At the end of this session a learner is expected to

be able to:
• Define retention of urine
• Explain causes of retention of urine
• Outline signs and symptoms of retention of urine
• Describe the nursing measures of patient with
retention of urine
• Outline the complication of retention of urine
Definition of retention of urine
• Retention of urine refer to the inability to
pass urine from the bladder despite the
desire to do so.
• Urine is normally produced by the kidneys
but cannot be excreted from the bladder
Causes of retention of urine
 Strong emotions, especially excitement, fear or
embarrassment.
 Obstruction, such as enlargement of the
prostate gland, tumour in the bladder or urethra,
calculi, urethral stricture and swelling at the
urethral meatus following childbirth.
 Following abdominal, pelvic or anal operations.
Causes cont…
 Injury to sensory or motor nerves involved
in the act of micturition, such as in spinal
cord injury.
 Neurogenic bladder dysfunction
 Certain drugs, such as atropine and some
antidepressants
Signs and symptoms of retention of urine
o Absence of voiding within 8 to 10 – hours period

during which the patient has had normal fluid intake.
o Distended bladder above the symphysis pubis which
can be palpated.
o The patient may have constant desire to urinate but
efforts to pass the urine are unsuccessful.
o The patient will be uncomfortable, restless and may
sweat profusely. He may experience severe pain in
the pelvic area.
Nursing measures of patient with retention
of urine
• Providing privacy for the patient and helping him to relax
• Assisting the patient to assume a position as close to a
normal voiding position as possible. For example,
helping him to sit upright in bed or stand at bedside while
using urinal.
• A female patient may be helped to sit on a commode if
permitted.
• Giving the female patient a wormed bedpan. The bedpan
can be warmed by rinsing it in hot water.
Nursing measures cont…
• Providing local warmth to suprapubic region,
such as hot – water bottle or a warm pad.
• Offering the patient hot drinks, such as tea,
coffee or milk.
• If the patient is fit allow him to have a warm
bathe.
• Placing the patient’s hot drinks, hands in
warm water.
Nursing measures cont…
• Providing for the sound of running tap water near
the patient
• Offering psychological reassurance and support.
• Administering prescribed analgesics post-operative
patients as the retention may be due to pain in the
operation site.
• If the above nursing measures fail to effect
micturition, you need to catheterize the bladder
under strict surgical asepsis.
Complication of patient with retention of
urine
 Inflammation of the bladder (cystitis). The
stagnation of the bladder provides a good
medium for bacteria to grow and multiply.
 Back pressure is created on the ureters and
reflux of urine may impair the proper
functioning of the kidneys.
Complications cont…
 Loss of tone of the muscles of the bladder
wall.
 Kidney damage
 Bladder damage
 Urinary tract infection
Key Points
• Retention of urine refer to the inability to
pass urine from the bladder despite the
desire to do so. Urine is normally produced
by the kidneys but cannot be excreted from
the bladder.
Evaluation
• What is retention of urine
• What are the causes of retention of urine
• What are the complications of retention of
urine
Module name: Basic Clinical Nursing
Module code: NMT 04208
Session 10:
Collection of Stool and Urine Specimens
Learning Tasks

• Define specimen
• Outline purposes of specimen collection
• Principles of specimen collection
• List the equipment needed in stool and
urine collection
Definition of Specimen
• Specimen is a sample of a substance or
material for examination or diagnostic
purposes
Purposes of Specimen Collection
• To diagnose illness
• To monitor the disease process
• To evaluate the efficacy of treatment
Principles of Specimen Collection
• Label specimen tubes or bottles with the client’s
name, age, sex, date, time, inpatient no. and other
data if needed before collecting the specimen.
• Always perform hand hygiene before and after
collecting any specimen.
• Always observe body substance precautions when
collecting specimens
• Collect the sample according your hospital/agent
policy and procedure.
Principles of Specimen Collection
cont…
• Clean the area involved for sample
collection
• Maintain the sterile technique if needed for
sample or culture.
• Transport the specimen to laboratory
immediately
• Be sure specimen is accompanied by
laboratory request form
Equipment Needed in Specimen
Collection
• Laboratory request form
• Clean container with lid or cover
• Bedpan or urinal
• Disposable gloves
• Toilet paper as required
• Clean bedpan with cover
Recommended Technique
• Collect specimens at the time requested.
• Use proper containers and avoid over filling (50 ml of
urine is enough).
• If the specimen is intended for bacteriological
examination use a sterile container.
• For routine laboratory examination use clean urine jar or
any clean glass container or bottle. Close the container
tightly.
• Give a simple explanation to the patient to obtain his
cooperation.
Recommended Technique cont…
• Label the specimen container clearly with:
oFull name of the patient
oThe ward and bed number
oDate and time of collection
oType of specimen
• An appropriately filled and signed laboratory
request form must accompany every specimen
sent to the laboratory.
Recommended Technique cont…
• Send the specimens to the laboratory
according to the routine of the hospital.
Emergency specimens and specimens for
bacteriological examinations must be sent
immediately.
• Indicate in the patient’s chart that a
specimen of urine has been sent to the
laboratory.
Procedure for Collection of Stool and
Urine Specimen
The following is a procedure for the collection
of urine specimen
• Explain the procedure to the patient
• Assemble equipment and check the specimen
form with client’s name, date and content of
urinalysis
• Label the bottle or container with the date,
client’s name, department identification
Procedure for Collection cont…
• Perform hand hygiene and put on gloves
• Instruct the client to void in a clean
receptacle.
• Remove the specimen immediately after the
client has voided
• Pour about 10-20 mL of urine into the labeled
specimen bottle or container and cover the
bottle or container
• Dispose of used equipment or clean them.
Remove gloves and perform hand hygiene.
• Send the specimen bottle or container to the
laboratory immediately with the specimen
form.
• Document the procedure in the designated
place and mark it off on the Kardex.
• Collection of stool specimen
• Assemble equipment.
• Label the specimen with;
o Patient’s full name
o Room or ward number
o Hospital registration number
o Examination to be done.
o Date and time of collection.
• Explain the procedure to the client
• Ask the client to tell you when he/she feels the
urge to have a bowel movement
• Perform hand hygiene and put on gloves if
available.
• Close door and put curtains/ a screen
• Give the bedpan when the client is ready.
• Allow the client to pass feces
• Instruct not to contaminate specimen with urine
• Collecting a stool specimen
• Remove the bedpan and assist the client to clean
if needed
• Use the tongue depressor to transfer a portion of
the feces to the container without any touching
• Take a portion of feces from three different
areas of the stool specimen
• Cover the container
• Remove and discard gloves.
• Perform hand Hygiene
• Send the container immediately to the
laboratory
• Document the procedure
Key Points
• Since nursed have the responsibility of collecting
patients’ specimens of urine and stool, they are
obliged to be conversant with the proper
collection methods in order to obtain reliable
laboratory findings.
• Each hospital has its own policy on collection of
specimens.
• The nurse is expected to follow the instructions
with accuracy
Session Evaluation
• What is specimen?
• What are the equipment needed in
collection of specimen?
• What are the principles of specimen
collection?
Module Name: Basic Clinical Nursing
Session11:
Giving and Removing Urinals and Bed Pans
Learning Tasks
At the end of this session a learner is expected to be able

to:
• Outline the characteristics of normal urine
• Explain the abnormality of urine
• Explain normal characteristics of stool
• Explain the abnormalities of faeces
• Outline the equipment needed in giving and removing bed
pans and urinals
• Demonstrate the procedure for giving and removing bed
pans and urinals
Characteristics of Normal Urine
• Amount
o 1000 ml to 1500 ml in 24 hours.
o The amount varies greatly with the fluid
intake and the amount of fluid excreted
through the skin, lings and intestinal tract.
• Odour
o Normal urine is aromatic.
• Specific gravity.
o Specific gravity is the heaviness of urine compared to
water.
o The specific gravity of water is 1000.
o The normal range of the specific gravity of urine is
form 1010 to 1,025.
o The specific gravity varies according to fluid intake.
o Concentrated urine has a higher than normal specific
gravity, and diluted urine has a lower specific gravity
than normal.
Characteristics cont…
• Reaction (pH)
o Urine is slightly acid.
o Its normal pH ranges from 4.5 to 7.5.
o Urine becomes alkaline on standing because
urea is decomposed by an organism in the air
to form ammonia.
• Clarity
o Fresh urine of healthy person is clear and amber.
o Urine becomes cloudy if allowed to stand for
sometime
o This is caused by precipitation of salts.
• Constituents
o Normal urine is composed of water in which
soluble waste products of metabolism are
dissolved.
• They include inorganic mineral salts and
organic compounds in the following
proportions:
Water 96 per cent
Urea 2 per cent
Uric acid and salts 2 per cent

Abnormality of Urine
Knowledge of common problems related to urinary
eliminations is vital for the nurse to identify and
report promptly for appropriate intervention.
• Amount
o Polyuria is the term used to describe excessive
production and elimination of urine.
o Polyuria may be an indication certain disorders such
as, diabetes insipidus and uncontrolled diabetes
mellitus.
Abnormality of Urine cont…
• Certain drugs may cause temporary polyuria.
examples of such drugs include, frusemide (lasix)
potassium citrate and digitalis.
• Oliguria is decreased output of urine in 24 hours.
• The urine is more concentrated. Oliguria is found
in acute nephritis, congestive heart failure, febrile
conditions, and dehydration
• Anuria or urinary suppression means that no urine is
being produced by the kidneys.
• It is a serious disorder, it may be an
indication of disorders such as, acute
nephritis, crushing injuries, and in
incompatible blood transfusion.
• The difference between anuria and retention
of urine is that in anuria no urine is
produced where as in retention, urine is
produced and retained in the bladder
• Colour
o Haematuria refers to urine that contains blood, if there is
much blood in the urine, the urine will appear red, if less
blood is present it will appear reddish brown or smoky.
o Blood in the urine may be an indication of kidney
damage, schistosomiasis haematobium, bladder or
urethral injuries or infections.
o Bile pigments when present the urine will appear dark
orange to olive green.
o Certain drugs may also alter the colour of urine, for
example a patient on rifampicin may pass urine which is
red – orange in colour
• Odour
o Ammonia - when urine stands for some time it
will begin smelling like ammonia due to bacterial
action.
o Fishy offensive smell indicates the presence of pus
in the urine, pus in the urine in called pyuria
o Sweet smell indicates the presence of acetone or
ketone bodies in the urine.
o Acetone may be present in the urine of a patient
suffering from diabetes mellitus or starvation.
• Specific gravity.
o Concentrated urine has a higher specific gravity
than normal. GLYCOSURIA is presence of sugar
in the urine and such urine will have a higher
specific gravity than normal.
o Conversely diluted urine has a lower specific
gravity than normal. The urine of patients
suffering from diabetes insipidus will have lower
specific gravity than normal.
• Clarity
o Cloudiness in fresh urine may be a sign of
bacteriuria resulting from inflammation within
the urinary tract.
o Increased frequency of micturition may be due
to anxiety associated with unfamiliar
environment of the ward or fear of some
diagnostic or therapeutic procedures.
o Inflammation of the bladder (cystitis) is
often accompanied by increased frequency
of micturition.
o Excessive voiding during the night is
termed nocturia
o Decreased frequency may be associated
with some kidney diseases and dehydration.
• Urinary retention
o This is the inability to pass urine from the bladder.
o The causes are numerous and may be obstructive
or nervous in origin
• Urinary incontinence
o This is the inability to control the passing of urine.
o The bladder fails to retain urine.
Normal characteristics of stool
• Quantity
o The quantity depend on the amount and type
of food a person eats. For instance, a person
who has eaten “ugali”, beans and cabbages
will produce more faeces than a person who
has taken soup and milk only.
Normal characteristics of stool cont…
• Colour:
o Normal faeces is brown in colour. The
brown colour is due to the presence of bile
pigments.
o The stools of a newborn infant (meconium)
are characteristically dark greenish- black in
colour for the first two to three days of life.
o The stools of a breast – fed baby have
orange – yellow colour.
• Consistency:
o Normal faeces is soft, semi – solid and well
formed.
o Often it is cylindrical in shape.
• Constituents:
o Normal faeces consist of: Indigestible food
residue, water, dead and live micro-
organisms, epithelial cells from the lining
membrane of the intestine, bile pigments,
inorganic material such as calcium and
phosphates, fatty acids and mucus which
help to lubricate the faeces
Abnormalities of faeces
After the nurse has observed stool, she must

record and report the abnormalities
detected. Some of the common
abnormalities include:
• Constipation
o This is the infrequent emptying of the
bowel.
o The faeces are dry and hard.
Abnormalities of faeces cont…
• Diarrhoea
o This involves passing stools more frequently
than usual.
o The stools are liquid or semi-liquid.
o Diarrhoea may be due to dietary problems or
certain diseases.
• Bright red blood in the stool
o Bright red blood in the stool
o This is a sign of recent bleeding or bleeding
which comes from the colon.
o The colour indicates that the blood has not
undergone digestion in the upper alimentary
tract.
o Bright red blood in the stool may be due to:
 Cancer of the colon.
 Haemorrhoids
 Colitis
 Bacillary dysentery.
• Melaena
o This term refers to stools which are dark
and tarry in appearance due to presence of
partly digested blood.
o The bleeding is from the upper alimentary
tract such as the stomach or duodenum
• Black stools
o When a patient is taking iron or bismuth
preparation his stools will appear black and
may resemble melaena.
o It is therefore important to check what
drugs the patient is getting before
undertaking extensive investigations of
melaena.
• Green stools
o These may be a sign of digestive disorders
and in children it is often seen when they
are suffering from gastro – enteritis.
o Green stools may also be due to the
chlorophyll from green vegetables.
• Pea – soup stools
o These are seen in patients suffering from typhoid
fever.
o The stools are liquid or semi – liquid and greenish in
appearance.
• Rice – water stools
o These are seen in patients suffering from cholera.
o The stools are watery and contains small white flecks
of mucus
• Putty – colored stools
o When there is obstruction to the flow of bile into the
duodenum the stools will not contain bile pigments which
normally give the characteristic brown colour of faeces.
o Consequently, the faeces will be pale and offensive
smell.
• Pus in the stools
o Pus in the stools may be due to abscess in the rectum or
due to ulcerative colitis.
• Excessive mucus in the stools
o Normal faeces have mucus but when the
mucus is excessive it may be due to:
 Colitis
 Bacillary or amoebic dysentery
 Bowel irritation due to intolerable diet.
 The use of strong laxatives and purgatives.
• Foreign bodies
o Children are prone to swallow foreign bodies, such
as, coins, stones, or buttons.
o These objects may appear in the stool when careful
inspection is done.
• Intestinal worms
o The most common intestinal worms which can be
found in the stool include: round – worm, thread
worm and segments of tape – worm.
Equipment Needed in Giving and
Removing Bed Pans and Urinals
Equipment needed for giving and removing bed
pan and urinal
• Bedpan and cover
• Covered urinal (for the male patient)
• Toilet paper or tissues
• Basin of warm water for washing perineal area
• Basin of warm water for washing patient’s hands
Equipment Needed cont…
• Soap
• Wash – cloth
• Towel
• Disposal bag
• Clean bed linen, if necessary
Procedure for Giving and Removing
Bed Pans and Urinals
• Wash your hands and prepare equipment. In cold
weather warm the bedpan by running hot water into it
and emptying it. Dry the outside of the bedpan.
• Explain the procedure to the patient and gain his
cooperation. Help him to relax.
• Take the trolley to the bedside and ensure privacy by
screening the bed. If it is a side room shut the door and
pull the curtains.
• Fold back the top bedclothes and raise the patient’s
gown.
Procedure cont…
• Ask the patient to flex his knees and rest his
weight on the heels if he is able.
• Slide your hand under his lower back and ask
the patient to lift his hips as you assist him.
• With your other hand slide the bedpan into
place and adjust it for the patient’s comfort.
• The patient’s buttocks should rest on rounded
shelf of bedpan.
• The narrow end should face the foot of the bed
Procedure cont…
• If the patient is too weak to raise buttocks, two
nurses will be needed to lift the patient.
• Roll the patient to one side and place the bedpan
tightly pressed against the patient’s buttocks and
holding it there roll the patient back and support him.
• Replace top bedclothes and raise the head for the bed
to a comfortable height (if not contraindicated.)
Place toilet paper and signal cord within easy reach
of the patient
Procedure cont…
• Leave the patient alone but stay within call in
case he needs help. If the patient is too weak
stay with him and support him as necessary.
• Ask the patient to signal when he is ready. Let
the patient flex his knees and raise his hips.
With one hand assist the patient to lift his
buttocks and with the other hand remove the
bedpan. Cover the bedpan and place on the
trolley.
Procedure cont…
• Assist the patient if he is unable to clean himself.
Turn him to one side and wipe his anal area with
toilet paper. Wash and dry as needed.
• Position the patient comfortably and replace the
bedclothes. Change draw – sheet if necessary. Let
the patient wash and dry his hands.
• Unscreen the bed and open nearby windows. Use
a deodorant (air freshener) if available and if
necessary.
Procedure cont…
• Remove trolley. Take bedpan to sluice room.
Check the bowel contents for any abnormalities.
Obtain a stool specimen if it has been ordered.
• Empty the bedpan. Rinse with cold water and
clean with warm soapy water and disinfect
according to hospital policy.
• Chart the time of the bowel movement and report
any unusual observations to the supervising nurse.
Procedure cont…
• Recommended technique for giving and
removing urinals
o When a patient requests for a urinal, respond to
his request promptly.
o Provide privacy
o Bring the urinal covered, to the patient’s bed
and hand it to him.
Procedure cont…
o If the patient needs your assistance, fold back the
top bedclothes and expose the genitals.
o Position the patient’s legs slightly apart and with
your right hand place the urinal between the legs
and with your left hand insert the penis into the
opening of the urinal.
o When the patient is ready, carefully remove the
urinal with the opening directed upwards to
prevent spilling urine on the bed.
Procedure cont…
o Cover the urinal and send it to the sluice room. Before
discarding check if it is required to measure for
recording in the fluid balance chart
o Note any abnormalities before discarding it.
• Empty the urinal. Rinse with cold water and clean
with warm soapy water and disinfect according to
hospital policy. Rinse and hang upside- down to drain.
• Wash and dry your hands and give the patient soap and
water to wash his hands.
• Report to the supervising nurse any abnormalities
detected.
Key Points
• Some patient may be bed-ridden or may be too
weak to go to the toilet by themselves to urinate.
• The male patient may be offered a urinal for the
voiding of urine.
• Female patients use bedpans for passing urine
and /or faeces.
• If a male patient wishes to defaecate as well as to
urinate he should be given a bedpan and a urinal.
Key Points cont…
• New patients who are confined to bed may not
know what to ask for or how to ask when they
have the urge to void urine.
• The nurse should teach such patients on
admission how to ask for a urinal.
• The nurse is therefore required to be very tactful
in order to help the patient get bowel and urinary
elimination with as little problems as possible.
Session Evaluation
• What are the normal characteristics of the
urine?
• What are the equipment needed in giving
and removing bed pan and urinals?
• What are the abnormalities of faeces?
Module Name: Basic Clinical Nursing
Session 12:
Care of Patient with Urinary Catheterization
Learning Tasks

to be able to:
• Define catheterization
• Explain purposes catheterization
• Outline principles of catheterization
• Identify equipment and supplies for
catheterization
• Describe steps for catheterization of the patient
Definition of catheterization
• Catheterization is the procedure of
introducing rubber or plastic tube through
the urethra into the urinary bladder
Purposes catheterization
• To relieve acute or chronic urinary retention
• For helpless patients
• To empty bladder before, during and after
surgery.
• To instill medications into the bladder
• To irrigate the bladder
• To obtain urine specimen for diagnostic
purposes.

Principles of catheterization
• Maintain aseptic technique during the
procedure
• Position below level of bladder/off floor
• Cleaning of urethral meatus
Indications
Indications for catheterization includes the
following;
• Acute urinary retention (e.g., benign prostatic
hypertrophy, blood clots)
• Chronic obstruction that causes hydronephrosis.
• Initiation of continuous bladder irrigation.
• Intermittent decompression for neurogenic bladder.
• Hygienic care of bedridden patients.
Contraindications for catheterization
• Urethral trauma
• Pelvic fractures
• Scrotal hematoma
• High riding prostate
Equipment and supplies for
catheterization
Equipment:
• Sterile gloves
• Sterile drapes
• Cleansing solution e.g. Savlon
• Cotton swabs
• Forceps
• Sterile water (usually 10 cc)
Equipment and supplies cont…
• Foley catheter (usually 16-18 French)
• Syringe (usually 10 cc)
• Lubricant (water based jelly or xylocaine
jelly)
• Collection bag and tubing
Steps for catheterization
• Explain procedure to the patient
• Gather equipment.
• Screen the bed for privacy
• Assist patient into supine position with legs spread and feet
together
• Open catheterization kit and catheter
• Prepare sterile field, put on sterile gloves
• Check balloon for patency.
• Generously coat the distal portion (2-5 cm) of the catheter
with lubricant
Steps cont…
• Apply sterile drape
• Using dominant hand to handle forceps, cleanse peri-
urethral mucosa with cleansing solution. Cleanse
anterior to posterior, inner to outer, one swipe per
swab, discard swab away from sterile field.
• If female, separate labia using non-dominant hand. If
male, hold the penis with the nondominant hand.
Maintain hand position until preparing to inflate
balloon.
Steps cont…
• Pick up catheter with gloved (and still sterile)
dominant hand. Hold end of catheter loosely
coiled in palm of dominant hand.
• In the male, lift the penis to a position
perpendicular to patient's body and apply light
upward traction (with non-dominant hand)
• Identify the urinary meatus and gently insert
until 1 to 2 inches beyond where urine is noted
Figure 12:1 Catheterization for female
Source: Department of Emergence Medicine-
University of Ottawa
Figure 12:2 Catheterization for male patients
Source: Department of Emergence Medicine-
University of Ottawa
Steps cont…
• Inflate balloon, using correct amount of sterile
liquid (usually 10 cc but check actual balloon size)
• Gently pull catheter until inflation balloon is snug
against bladder neck
• Connect catheter to drainage system
• Secure catheter to abdomen or thigh, without
tension on tubing
• Place drainage bag below level of bladder
Steps cont…
• Evaluate catheter function and amount,
color, odor, and quality of urine
• Remove gloves, dispose of equipment
appropriately, wash hands
• Document size of catheter inserted, amount
of water in balloon, patient's response to
procedure, and assessment of urine
Key Points
• Urinary catheterization is commonly done when a
person is unable to urinate using a toilet, bedpan,
urinal, bedside commode, or when accurate urinary
output is required
• Catheterization procedure is contraindicated in the
presence of urethral trauma. Urethral injuries may
occur in patients with multisystem injuries and pelvic
factures, as well as straddle impacts. So before
insertion of catheter it is important to assess for
urethral problems
Evaluation
• What is the purpose of catheterization?

• What are steps of catheterization?
Session 13:
Care of Patients with Nutritional Needs
Learning Objectives

• Explain concept of nutritional needs
• Identify equipment/supplies for assisting
oral feeding and naso-gastric feeding
• Assist helpless client in oral feeding
The Concept of Nutrition Needs
• There is no single food that provides all the
nutrients. Food is what is eaten or taken in
the body for the purpose of nourishing the
body.
• The chemical substances found in food are
nutrients and all processes involved in food
• Intake, assimilation and utilization by the
body is what we considered to be nutrition
The Concept cont…
• Nutrients can be sorted into two major groups;
• Those required in large amounts -
macronutrients
• Those required in small quantities -
micronutrients
• There are 5 types of food groups, they include;
• Cereals, green bananas, roots and tubers,
• Pulses, nuts and foods of animal origin,
The Concept cont…
• Vegetables,
• Fruits
• Sugar, honey, fats and oils
• Other important food substances include
dietary fibres and water.
Equipment/Supplies for Assisting Oral
Feeding
The patient will need;
• A plate for main food
• A bowl for vegetables, beans, meat
• Bottle of drinking water
• A glass or mug
• A bowl of fruits
• A table spoon
Equipment/Supplies cont…
In grade one ward would include;

• A plate
• Spoons, knives and forks
• Glass for water
• A clean napkin
• Tray cover
Assisting Helpless Client in Oral
Feedingfor nurse to feed a
• Sometimes it is necessary
patient when he cannot, for some reasons, feed
himself.
• Depending on the condition of the patient the
doctor may put the patient on special or
therapeutic diet, full diet, or light diet.
• Preparation of the patient for oral feeding
o Environment should be conducive for taking
meals.
Assisting Helpless Client cont…
o The ward should be clean and orderly
o Remove or cover all objectives which are unsightly at
meal times such as drainage containers, dustbins, urinals
and bedpans.
o Remove soiled linen and replace with clean linen as
necessary
o Painful or unpleasant treatments, such as dressings,
injections or enemata should not be given immediately
before or soon after meal as they tend to reduce the
appetite.
o Inform the patient that soon the food will be
served.
o Ask the patient if would like to have bedpan
or urinal
o Offer bedpans or urinals as required.
o Provide water and soap for washing hands.
o Assist those who are unable to wash hands
• Prepare patient for meal
o Where desirable, adjust the head of the bed and arrange
pillows to keep the patient in a position which is
comfortable for eating.
o A locker maybe used for putting the food tray. For some
patients a bed table is more convenient. It should be
positioned properly before serving the food.
o Give oral hygiene as necessary before serving meals
o Adjust the bed and arrange the pillows so that the patient
sits or lies in comfortable position
o Place napkin under the patient’s chin.
o Remove unnecessary articles from locker.
o Move the locker to a convenient position
for the food tray
o Bring the food tray and place it over the
locker
o Wash and dry your hands
o Sit by the besides facing head of bed or if
not convenient stand beside the bed facing
the head of the bed.
o Feed the patient from the tip of the spoon
(rice, soup, beans)
o Use tip of fork if it is meat eggs or pawpaw
o Fill the spoon only half full to avoid spilling
o Feed the patient slowly. Take time
o Do not rush with the procedure
o Allow enough time between mouthfuls.
o Alternate the foods as the patient desires
e.g. 2 mouthfuls of rice followed by piece
of meat
• Allow him to rest at intervals.
• During the intervals talk to patient about nice
things.
• Give drinking water or juice slowly through a
straw or a feeding cup.
• Dry the patient’s lips with napkin when
necessary.
• Try to encourage the patient to do for
himself all those activities which he is
capable
• Remove the tray when finished.
• Give oral hygiene after the meal and leave
the patient comfortable
Inserting a Naso-gastric Tube
• Method of Introducing a tube through nose into
stomach
Equipment required includes but not limited to:
• Nasogastric tube in appropriate size (1)
• Syringe 10ml (1)
• Lubricant
• Cotton balls
• Kidney tray (1)
• Adhesive tape
Inserting a Naso-gastric Tube cont…
• Stethoscope (1)
• Clamp (1)
• Marker pen (1)
• Steel Tray (1)
• Disposable gloves if available (1 pair)
Procedure for insertion of NGT
• Check the Doctor’s order for insertion of Nasal-

gastric tube.
• Explain the procedure to the client.
• Gather the equipments.
• Assess client’s abdomen
• Perform hand hygiene. Wear disposable gloves if
available.
• Assist the client to high Fowler’s position, or 45
degrees, if unable to maintain upright position.
Procedure cont…
• Checking the nostril:
o Check the nares for patency by asking the client
to occlude one nostril and breathe
normallythrough the other.
o Clean the nares by using cotton balls
o Select the nostril through which air passes more
easily.
Procedure cont…
• Measure the distance to insert the tube by
placing:
o Place the tip of tube at client’s nostril extending
to tip of earlobe
o Extend it to the tip of xiphoid process
o Mark tube with a marker pen or a piece of tape
• Lubricate the tip of the tube (at least 1-2
inches) with a water soluble lubricant
Procedure cont…
• Inserting the tube:
o Insert the tube into the nostril while directing the tube
downward and backward.
o The client may gag when the tube reaches the pharynx.
o Instruct the client to touch his chin to his chest.
o Encourage him/her to swallow even if no fluids are
permitted.
o Advance the tube in a downward and backward
direction when the client swallow.
Procedure cont…
Stop when the client breathes

o If gagging and coughing persist, check
placement of tube with a tongue depressor
and flashlight if necessary.
o Keep advancing the tube until the marking
or the tape marking is reached.
Procedure cont…
• While keeping one hand on the tube, verify the tube’s
placement in the stomach.
o Aspiration of a small amount of stomach contents:
Attach the syringe to the end of the tube and aspirate
small amount of stomach contents. Visualize aspirated
contents, checking for colour and consistency.
o Auscultation: Inject a small amount of air (10- 15 ml)
into the nasogastric tube while you listen with a
stethoscope approximately 3 inches ( about 8 cm) below
the sternum.
Procedure cont…
o Obtain radiograph of placement of tube (as
ordered by doctor.)
• Secure the tube with tape to the client’s
nose.
• Clamp the end of nasal-gastric tube while
you bend the tube by fingers not to open
• Putt off and dispose the gloves, Perform
hand hygiene
• Replace and properly dispose of equipment.
Procedure cont…
• Record the date and time, the size of the
nasal-gastric tube, the amount and colour of
drainage aspirated and relevant client
reactions.
• Sign the chart.
• Report to the senior staff.
Read
Handout 13:1 Feeding the client using

nasal gastric tube
Key Points
• Nutrients can be sorted into two major

groups;
• Those required in large amounts -
macronutrients
• Those required in small quantities –
micronutrients
• Assisting helpless client in oral feeding, by
using nasal gastric tube
Session Evaluation
• How can you assist helpless client in oral

feeding?
• What is the equipment needed when
inserting nasal gastric tube?
Session 14:
Care of a Patients with Wound
Learning Objectives

• Define common term wound
• Outline types of wound
• Explain purposes of wound dressing
• Explain process of wound healing
• Identify factors influencing wound healing
Definitions of terms
• Wound: Disruption in the normal integrity and function
of the skin and underlying tissues. Or is a break in the
continuity of soft part of the body structures caused by
violence or trauma to tissues
• Asepsis: Sterile, a condition free from gems, infection,
and any form of life.
• Aseptic: Free from septic matter
• Aseptic techniques: method used to prevent
contamination in procedures where a sterile field is
required 
Definitions of terms cont…
• Sterilization: Is a process of completely removing or
destroying all microorganism on a substance by
exposure to chemical or physical agents, exposure to
ionizing radiation, or by filtering gas or liquids through
porous material that remove micro-organisms.
• Decontamination: is the process of killing
microorganisms except spores.
• Dressing: Covering, protective or supportive, for
diseased or injured part
Types of wound
• According to this respect wounds are classified
as follows:
o Clean wounds
o Contaminated wounds
o Infected wounds
• According to the presence or absence of a break
in the surface tissue the wounds are classified as:
o Closed wounds
o Open wounds
Types of wound cont…
• According to the manner in which the
wounds are made the wounds are classified
as:
o Contused wounds
o Abrased wounds
o Incised wounds
o Lacerated wounds
Refer to
• Handout 14:1 Types of wound

Purpose of Wound dressing
• To protect wound from micro organisms
• To absorb exudates
• To immobilize and support an injured part
• To reduce tension on the edges of the wound
• To apply pressure on the wound and prevent bleeding
• To promote psychological and physical comfort to toe
client by minimizing moisture and bad smell
• To enhance healing
• To provide opportunity for wound inspection
Process of wound healing
• The way wound healing occurs varies with the
individual person, locating and type of the
wound. basically there are 3 types of healing.
o Healing by first Intention
 Healing by first intention occurs when the wound
edges are well approximated and infection is absent.
 There is little granulation and scar formation is
minimal.
 These are very little tissue reaction and healing is
usually fast.
Process of wound healing cont…
 Most surgical incisions heal by first intention
because the instruments used for cutting are
sterile and the wound edges are sutured
o Healing by second Intention
 Healing by second intention occurs when the
wound is infected and the wound edges are not
approximated.
 A large amount of granulation tissue is required
to fill the opening before healing takes place.
Process of wound healing cont…
 The healing process takes a longer time and the
resultant scar is large.
 In some patients the scar formation can be excessive
and is known as “keloid”.
o Healing by Third Intention
 Healing by third intention is a combination of first
and second intention healing.
 Either the wound is initially left open for repeated
debridement or drainage and sutured.
 The healing is slow and the
 Resultant scar large.
Factors influencing wound healing
• Extent of the wound.
• Nutritional status.
• Location of the wounds.
• Age of the person.
• Foreign bodies.
• Hemorrhage and hematoma.
• Presence of other diseases.
• Certain drugs.
Refer to
• Handout 14:2 Factors influencing wound

healing
Equipment and supplies for wound
dressing
• In cleaning a Wound and Applying a Sterile
Dressing the following equipment are required:
• Sterile gloves (1)
• Gauze dressing set containing scissors and
forceps (1)
• Cleaning disposable gloves if available (1)
• Cleaning basin(optional) (1) as required
• Plastic bag for soiled dressings or bucket (1)
Equipment and supplies cont…
• Waterproof pad or mackintosh (1)
• Tape (1)
• Surgical pads as required
• Additional dressing supplies as ordered, e.g.
antiseptic ointments, extra dressings
• Acetone or adhesive remover (optional)
• Sterile normal saline (Optional)
Wound Dressing Procedure
• Explain the procedure to the client
• Assemble equipments
• Perform hand hygiene to prevent the spread of infection
• Check Dr’s order for dressing change. Note whether
drain is present.
• Close door and put screen or pull curtains.
• Position waterproof pad or mackintosh under the client
if desired to prevent bed sheets from wetting body
substances and disinfectant
Procedure cont…
• Assist client to comfortable position that
provides easy access to wound area for Proper
positioning provides for comfort.
• Place opened, cuffed plastic bag near working
area. Soiled dressings may be placed in
disposal bag without contamination outside
surfaces of bag.
• Loosen tape on dressing. Use adhesive remover
if necessary. If tape is soiled, put on gloves.
Procedure cont…
• Put on disposable gloves
o Remove soiled dressings carefully in a clean to less
clean direction.
o Do not reach over wound.
o If dressing is adhering to skin surface, it may be
moistened by pouring a small amount of sterile
saline or NS onto it.
o Keep soiled side of dressing away from client’s
view.
Procedure cont…
• Assess amount, type, and odor of drainage.
Wound healing process or presence of
infection should be documented.
• Cleaning wound:
o When you clean wearing sterile gloves:
 Open sterile dressings and supplies on work
using aseptic technique.
 Open sterile cleaning solution
Procedure cont…
 Pour over gauze sponges in place container or
over sponges placed in sterile basin.
 Put on gloves.
 Clean wound or surgical incision
 Clean from top to bottom or from center
outward
 Use one gauze square for each wipe, discarding
each square by dropping into plastic bag.
Procedure cont…
 Clean around drain if present, moving from
center outward in a circularmotion.
 Use one gauze square for each circular motion.
o When you clean using sterile forceps:
 Open sterile dressings and supplies onwork
area using aseptic technique.
 Open sterile cleaning solution
Procedure cont…
 Pour over gauze sponges or cottons in place
container or over sponges or cottons placed in sterile
basin.
 Clean wound or surgical incision:
Follow the former procedure using sterile gloves.
• Apply antiseptic ointment by forceps if ordered.
Growth of microorganisms may be retarded and
healing process improved.
•
Procedure cont…
• Apply a layer of dry, sterile dressing over wound
using sterile forceps.
• If drainage is present: Use sterile scissors to cut sterile
4 X 4 gauze square to place under and around drain.
• Apply second gauze layer to wound site.
• Place surgical pad over wound as outer most layer if
available.
• Remove gloves from inside out and discard the min
plastic bag if you worn.
Procedure cont…
• Apply tape or existing tape to secure
dressings. Tape is easier to apply after
gloves have been removed.
• Perform hand hygiene. Remove all
equipment and disinfect them as needed.
Make him./her comfortable.
Procedure cont…
• Document the following:
o Record the dressing change
o Note appearance of wound or surgical incision
including drainage, odor, redness, and presence of
pus and any complication.
o Sign the chart
• Check dressing and wound site every shift.
Close observation can find any complication as
soon as possible.
Key Points
• The way wound healing occurs varies with the

individual person, locating and type of the wound.
• When Cleaning wound Assess amount, type, and
odor of drainage. Wound healing process or presence
of infection should be documented
• Document the following: Record the dressing change
• Note appearance of wound or surgical incision
including drainage, odor, redness, and presence of
pus and any complication. Sign the chart
Evaluation
• What are the factors wound influencing
healing?
• What are the common antiseptics used in
cleaning a wound?
• Explain the process of cleaning the
instrument after procedure
Session 15:
Provide Care of Patients with Pain
Learning Objectives
At the end of this session participants are expected to

be able:
• Define pain
• Identify causes of pain
• Outline types of pain
• Explain the impact of chronic pain
• Assess patients for pain
• Provide pharmacological and non –pharmacological
intervention’s for pain management
Definition of Pain
• Pain is a sensation of discomfort caused by
the action of stimuli of a hurting nature.
o It is one of the most common symptoms of
illness
Causes of pain
• When special nerves that detect tissue, damage send

signals to transmit information about the damage along the
spinal cord to the brain.
• These nerves are known as nociceptors. The pain message
will continue to the brain. Once there, it will cause an
unpleasant sensation to be felt.
• Also the following are causes of pain
• Headache
• Cramps
• Muscle strain or overuse
Causes of pain cont…
• Cuts
• Arthritis
• Bone fractures
• Stomach ache
Types of pain
• Pain can be classified according to:
o Duration and severity
o Location or source of pain
• Duration and severity of the pain:
o Acute pain.
 The pain comes suddenly and usually subsides in a
short time if treated properly.
 Acute pain causes the sufferer to seek treatment
promptly.
Types of pain cont…
 Examples of acute pain include the pains the pain of
acute appendicitis and the pains associated with
traumatic injury
o Chronic pain
 The pain may begin gradually and persists over a
long time or recurs for an indefinite length of time.
 It is difficult to treat.
 Examples of chronic pain include the pains
associated with cancer and rheumatoid-arthritis.
• Location or source of pain:
o Superficial or cutaneous pain
 Refer to the pain which occurs when the skin or
surface structure are affected by a painful
stimulus.
 The patient can accurately point where the pain is
 Usually the pain has a pricking or burning
characteristic.
o Deep pain
 Refers to pain affecting deeper structures, such
as the muscles, tendons, joints and visceral
tissues.
 Deep pain may localize at the affected part or it
may be poorly localized.
 The patient describes the pain as dull, aching,
cramping or gnawing.
o Referred pain
 Is the pain which is experienced at a site other than
the area of stimulus
 The pain is projected from various internal organs of
the body to the body surface for example, a client
suffering from angina pectoris has ischemia of his
heart muscle, he will complain of pain in the
substermal region, the base of the neck, and the inner
aspect of the left arm instead of pain in the heart.
o Central pain
 Refers to that pain which is produced by sensory
nerve injury of an area in the brain which is
concerned with the perception of pain.
o Phantom pain
 Is the pain that a patient feels in his limb after the
limb has been amputated.
 It is thought to be due to persistence of the “pain
memory” which may take time to get off.
o Psychogenic pain
 Refers to the pain experienced by some people
in the absence of physiological disorder.
 This may occur in people suffering from
hysteria.
 Such pains are not easily relieved by analgesics
but sedatives and placebos can be of help.
Impact of chronic pain
• Mood and Mental Health
o Patients with chronic pain are more likely to
develop psychological disorders than those
without chronic pain
o Chronic pain has been associated with
 Increased rates of major depressive disorder
 Suicidal ideation
 Suicide attempts
Impact of chronic pain cont…
• Sleep
o Disturbed sleep is common in patients with
chronic pain
o early treatment of chronic pain is important for
minimizing sleep disturbance
• Sexual Function
o A combination of issues associated with
chronic pain contributes to sexual
dysfunction, including
 Difficulty with arousal, confidence,
performance, positions, fear of worsening pain,
and relationships
• Quality of Life and Functionality
o In patients with chronic pain, overall quality of
life is diminished as it affected by the
aforementioned sequelae, including mental health
and sleep, also affected by social interactions and
daily activities such as The frequency of
interference with social life, work, and daily
activities is increased in chronic pain patients
personal relationships and employment status
• Cardiovascular Health
o Chronic pain is a predictor of hypertension,
independent of demographic predictors
such as age, sex, race, and family history.
o This increased risk may be due in part to
altered processes in pain pathways and
cardiovascular function that normally
overlap.
Assessing patients for pain
• Accurate assessment of the patient`s pain is

essential in order to plan effective
management of the patient.
• The nurse should use all the observation
skills when assessing the pain.
• Because pain is a subjective symptom, the
patient should be encouraged to describe in
detail about his pain
Assessing patients cont…
The following factors should be assessed:

o Location of pain
 Where is the pain?
 If more than one part; does the pain occur
simultaneously?
 Does the pain spread diffusely over a large area or
can it be pinpointed?
 Does the pain start on one area and radiate to distant
areas?
o History of the pain
 When did the pain start?
 How did it start?
 Is it first occurrence?
 Does the pain interfere with sleep or other
essential activities?
o Duration and frequency of the pain
 How long does the pain last?
 Is it persistent or intermittent?
 If intermittent, what is the interval?
o Intensity of pain
 Is the pain mild, moderate or very severe?
 Design an “intensity scale” “o” to “10” . “o”
should represent no pain and “10” should
represent pain at its worst degree.
 Teach the patient to rate himself. this will help
to identify the need for stronger analgesics and
other measures.
o Character of the pain
 Let the patient describe the pain in terms
familiar to himself, such as sharp, knife-like
cutting, aching, squeezing, gnawing, dull,
pressing, prickling, piercing and burning,
 Record and report using the terms which the
patient himself described.
 Has the pain any relationship with meals or
certain times of the day or season?
 Are there any associated symptoms, such as fever,
swelling, photophobia, flushed face o vomiting?
 What is the facial expression in relation to the
intensity of the pain? (e.g. Clenched teeth, tightly
shut lips, grimacing, or exhausted).
 Try to determine what the pain signifies to the
patient.
Non –pharmacological and pharmacological
intervention’s for pain management
• Non pharmacological intervention

o Nursing measures
 Developing and maintaining a therapeutic
relationship with the patient
 Care for the entire person and not just the pain
symptom.
 Accept the behavior or the patient.
Non –pharmacological and
pharmacological cont…
o Providing comfort measures for the patient
 Handle the patient carefully and gently.
 Change position and ensure that the bed is clean
and comfortable.
 Provide soft support to affected parts e.g. limbs.
 Have them in good body alignment and handle
them gently.
 Elevate the affected part.
o Physical therapies
 Heat or cold applications, massage and analgesic
external preparations.
 Heat relieves pain through increasing circulation in
the part of the body to which it is applied.
o Acupuncture
 This is a technique which originated in China.
 It involves the insertion of special needles in
particular parts of the body in order to relieve pain.
o Distraction and Diversion
 Help the patient to focus his attention away from
his painful sensations.
 There are many types of distraction, such as
involving the patient in interesting conversation,
listening to soft nice music, reading interesting
books or magazines, taking slow rhythmic
breaths, singing a song, playing cards and for a
child giving a favorites toy to play with
o Pharmacological interventions
 Using analgesics for the relief of pain
 Analgesics are drugs that relieve pain.
 Using Placebos
 A place is an inactive substance intended to
have no pharmacologic effect. “Placebo” is a
Latin word which means”I shall please”.
Refer to
• Handout 15:1 Non –pharmacological and

pharmacological and intervention’s for
pain management
Key points
• Pain is a sensation of discomfort caused by the action of

stimuli of a hurting nature.
o It is one of the most common symptoms of illness
• Impact of chronic pain are as follows Mood and Mental
Health, Sleep, Sexual Function, Quality of Life and
Functionality , Cardiovascular Health
• Accurate assessment of the patient`s pain is essential in
order to plan effective management of the patient. The
nurse should use all the observation skills when assessing
the pain
Session Evaluation
• What is pain?
• What are the causes of pain?
• What are types of pain?
Session 16:
Care of Patient with Limited Mobility using
Nursing Process
Learning Objectives
At the end of this session participants are expected to

be able:
• Define immobility, body alignment, body mechanics
• Describe normal body alignments for standing, sitting
and lying.
• Explain purposes of maintaining body mechanics
• Explain principles used in body mechanics
• Assist patients with limited mobility
• Maintaining body mechanics
:
Definition of Common Terms used in Application of Body Mechanics
• Immobility is the state of not moving; motionlessness

or inability to move or be moved
• Body mechanics is the term used describe the manner
in which you move your body during everyday activities
• Alignment: is defined as the relationship of the
individual body segments to each other
• Body alignment is ideal balanced posture in which
positioning is centered and relaxed for all the joint of
the body
Normal body alignments for standing,
sitting and lying
• Posture is the position in which you hold
your body upright against gravity while
standing, sitting, or lying down
Figure 15:1 Proper Sitting Posture
Source:
https://www.medicalnewstoday.com/articles/321863.php
Proper Sitting posture
• Shoulders over hips, feet flat on the floor,
low back support provided, and chin
aligned over the chest
Figure 15:2 Proper Sleeping Posture
Source:
https://www.medicalnewstoday.com/articles/321863.php
Proper Sleeping Posture:
• When lying on your back a pillow support
should be utilized under the knees.
Remember a pillow should support the neck
not the head
Purpose of Maintaining Body Mechanics
• To assist client move from one place to

another for different reasons
• To promote comfort
• To promote good body alignment to prevent
complications in cases of prolonged bed
rest
• To prevent further damage e.g. in fractures
Principles used in Body Mechanics
Good body mechanics can be maintained by adhering to
the following basic principles.
• Keep feet apart (at least 12 inches) when lifting objects
• Get as close to the object as possible, bend at the hips
and knees and lift with your leg muscles, while
maintaining a straight back
• Wear appropriate shoes i.e. flat shoes
• If the health care provider sits for a long period of time,
place a roll behind the back to maintain straight back.
Principles used cont…
• Moving in a rhythmic way and avoiding jerky and
uncoordinated movements.
• Assess the weight of the load before lifting and
determine if assistance is required
• Avoid stretching, reaching, and twisting, which
may place the line of gravity outside the base of
support
• Tighten abdominal, gluteal, and leg muscles in
anticipation of the move
• Stand up straight to protect the back and provide balance.
• Stand close to the object being moved to place the weight
of the object being moved close to your centre of gravity
for balance.
• Stand close to the object being moved to maintain as long
as the line of gravity passes through its base of support
• Face the direction of movement to prevents abnormal
twisting of the spine
• Keep all work at waist level to avoid stooping.
• Raise the height of the bed or object if possible.
• Do not bend at the waist.
• Reduce friction between surfaces so that less
force is required to move the patient
• Bend the knees to maintain your center of
gravity and lets the strong muscles of your legs
do the lifting.
• .
• Push the object rather than pull it, and
maintain continuous movement
• Use assistive devices (gait belt, slider
boards, and mechanical lifts) as required to
position patients and transfer them from one
surface to another
Assist patients with limited mobility
(Lifting to/from Bed, Stretcher/wheel chair

• Perform the following assessment:
o Is it appropriate time for the procedure
o What support will you need for the
procedure
o What is the client’s general condition
Assist patients cont…
• Prepare the following equipment:
o Clean sheet and blanket
o Stretcher
o Pillow and pillow cases
o Clean readymade bed
o Gloves (If necessary)
• Moving a patient from stretcher to bed
o Assess patient’s status in order to plan correctly
o Ask for three nurses to help in lifting the patient
o Inform the patient , wash hands, dry and put on
glove if necessary
o Organize the three nurses to stand on the side of
the stretcher facing the bed, as close to the
stretcher as possible facing the client
o The three nurses put their arms as far as possible
under the patient. One nurse support client’s head
and shoulders, one support the back and buttocks,
and the third nurse support the thighs and ankles.
o With legs slightly apart, they lift the patient onto
bed. Make sure the patient is well covered with
the top sheet. Position patient comfortably by
arranging pillows, and tidying the rest of the bed
• Moving client from bed to chair
o Two nurses will be needed for the procedure
o Inform the patient about the procedure and obtain his
cooperation
o Wash hands, dry them and put on gloves if necessary
o Place chair/wheelchair close to the side of the bed
o Help patient to sit at the edge of the bed for a few
seconds to prevent orthostatic hypotension
o Two nurses join hands under patient’s thighs, and other
hands support the back. Patient put his hands around
nurses’ shoulders
o Both nurses stoop and lift the patient simultaneously,
they rotate slowly so that the chair is behind the patient
o Put the patient gently on the chair, position him to be
comfortable in the chair.
o Put slippers on his feet and cover him well with sheet
to prevent chilling
• Turning patient in bed
o Inform patient of the planned action and
obtain his co operation
o Screen the bed for privacy
o Remove patient’s top linen leaving him
covered with a top sheet
o Adjust bed accessories that need protection
during movement
o Place your foot in front of the other, one
arm under the patient’s shoulder and the
other arm under his hips.
o Rock to your rear leg to move patient
towards you.
o If the patient is to turn to the left side, move
him on the right side of the bed
Maintaining Body Mechanics
• If the patient is to turn to the right side, cross his right leg
over the left
• If only one nurse working alone, go around the bed and
stand on the side of bed towards which the patient will be
turned.
• Place one hand under the shoulder and the other under his
hips, roll him towards you
• Replace bed linen and make patient comfortable
• Remove screen and clear up the equipment used
• Wash hands after procedure
Maintaining Body cont…
• Turning patient by using Log Rolling for client
who must not flex his back
• Two nurses are necessary for this procedure
• Inform patient about the planned action
• Screen the bed to provide privacy
• Wash hands, dry and put on gloves if necessary
• Re adjust necessary equipment e.g. drip stand,
urinary catheter and so on
• Loose draw sheet under patient and roll it
on both sides to about 10 inches from the
patient
• Use the draw sheet to move the patient to
the side of the bed.
• If the client is to turn to the left side,
position left arm next to body and the right
arm across the chest, and vice versa if
turning to the right side
• In unison both nurses use the draw sheet to
turn patient to the side lying position
• Straighten bottom sheet to remove bed
wrinkles
• Remake the bed and leave the patient
comfortable
• Clear up equipment after procedure and wash
hands after procedure
Key Points
• Patients who have been lying in bed for a long time get
low blood pressure when brought to a sitting up
(orthostatic hypotension).
• Allow the patient to sit on the bed for few seconds before
lifting him to the chair
• Never attempt to log-roll a patient with spinal cord injury
or surgery by yourself to avoid flexion on his back
• While turning a patient with spinal cord injury the nurses
should turn in unison to keep patient’s back straight.
Session Evaluation
• What can nurses do in order to avoid

straining their backs while lifting and
turning patients in bed?
• How unconscious patient should be moved
from stretcher to bed?
Session 17:
Common Positions Used in Caring Patients
Learning Objectives

to be able:
• Describe common positions used in caring
patients
• Outline reasons for positioning patients
• Position patient in bed
• Describe the technique used in positioning
patients
Common Positions Used in Hospitals
• Appropriate positioning of patients in bed is important

and is part of care given depending on the condition
of the patient; It is also used to facilitate various
investigation procedures and examinations of patients.
o Supine Dorsal/ Recumbent position
o Lateral/Side –lying position
o Prone position
o IV Sim’s Position
o Knee-chest position
Common Positions Used cont…
o Orthopedic position
o Trendelenburg position
o Lithotomy position
o Fowler’s position (semi recumbent)

Reasons for positioning patients
• For specific examinations
• For various nursing procedure
• For care and treatment e.g. First Aid measures
for a patient in shock, asthmatic attack,
• cardiac attack, fracture
• For comfort and pain relief
• For prevention of pressure sores
• For operation procedures
Techniques Used in Positioning of
Patients
• Preparation of patient
o Inform patient about the procedure
o Assess patient condition and determine the
position, equipment and number of staff required
• Preparation of the environment
o Assess the environment and provide adequate
space
o Ensure privacy of the patient
Techniques Used cont…
• Equipment
o Towels
o Pillows
o Sandbags
o Footboards
o Backrest
o Fracture boards
o Air rings
o Stirrups
o Over bed table
• Positioning of patients in Supine Dorsal/ Recumbent
position
o Procedure
 Position patient on his/her back with the spine in
straight alignment
 Place a pillow under the head to prevent neck extension
 Arms may be at the patient’s side with the hands
prorated (inner side of the palm facing down)
 If patient is paralyzed, hand rolls should be in
place to maintain the hand
 If both legs are paralyzed, place a roll on either
side at the hip or the ankle.
 The foot should be supported so that the toes
point upwards in an anatomical position
 Use footboards, sandbags or a strong cardboard/
carton to maintain the feet at right angles to the
legs
Figure 17: 1 Supine recumbent position
Source: Brookside press.org
• Lateral/Side –lying position
o Procedure
 Place the patient on his/her side (left or right) with
head supported on a low pillow
 Under tuck a pillow along the patients back to
support the back and maintain position
 Bring the underlying arm forward and flex it out
on the pillow in front of the body, put hand rolls in
place if needed
 The top leg should be flexed and brought
slightly forward to provide balance
 A pillow placed lengthwise under the top leg
keeps the legs separated and supports the top
leg
 Take care to support the feet to prevent planter
flexion and foot drop
 Change position two hourly to prevent pressure
sores.
Figure 17: 2 Lateral
position:
Source:
• Prone position
o Procedure
 Place patient on the abdomen and turn the head to one side
 Make sure the spine is straight
 Use small pillow or a folded bath towel for comfort under
his head
 Place the arms flat at patient‘s side or flexed at the elbow
with the hands near the patient’s head
 Place hand rolls if needed.
 For tall patients, the feet should extend beyond
the end of the mattress so that they point down
in the space between the mattress and foot
board.
 With short patients, place a roll under the
ankles to keep the feet in proper alignment

Figure 17:3 Prone position

• Sim’s Position
o Procedure
 Place the patient as per lateral position Using
only one pillow under the head
 Flex the knee of bottom leg sharply and the
right knee sharply on the abdomen
Figure 17.4: Sims position
Source: Stanford School of Medicine
• Knee-chest position
o Procedure
 Kneels the patient on the bed or table
 Tell the patient to lean forward with hips in the air
and chest arms on the bed or table
 A pillow can be placed under the patient‘s head
 Drape patient to allow visibility of rectal area and
cover the rest of the body
 NB: Knees should be flexed
• Trendelenburg position
o Procedure
 Place a patient on his/her back as (dorsal
position)
 Low the patient head at 45 degree angle below
the horizontal level
Figure 17:5: Trendelenburg position
Source: lpnkorea.com
Figure 17:5: Trendelenburg position

Source: lpnkorea.com
• Orthopedic position
o Procedure
 Place patient in sitting up position in the bed or at
the edge of the bed with chest or over bed table
 Place small flat pillow over the table
 Elevate the table to a comfortable height
 Ask/Assist the patient to lean forward and rest
head and arms on the table for support
• Lithotomy position
o Procedure
 Place patient in a supine/dorsal position
 Flex both knees simultaneous Separate the legs
widely maintaining the flex position
 If the patient is on the examination table, the
feet can be placed on the stirrups
 Drape the patient to provide visibility of the
perineal area
 If necessary adjust the foot of the bed to
provide access to the perineal area
 Cover the legs and the body
Figure 17:6: Lithotomy position
Source: Hopkinsarthritis.org
• Fowler’s position (semi recumbent)
o Procedure
 Place patient in a supine position with the head of bed
elevated to an angle more than 45degrees (high
fowlers position)
 Center the patient on his back so that when the head is
elevated, the break /center the bed will be in the hips
 Raise the head of the bed to the desired height
 Allow the patient’s head to rest against the mattress or
support it with a small pillow
 Support the patient’s hands on a pillow so that they
are in line with the forearms and slightly elevated in
relation to elbows
 Support forearms so that they are elevated
sufficiently to prevent pull on patients shoulders
 Use air ring on the buttocks to relieve pressure
 Slightly elevate knees for brief periods only
 Support the feet at right angles at ankle joint to the
lower legs using pillows, a toot board or a foot block
Figure17: 7 Fowlers position:
Figure 17: 8 Semi Fowlers’ position.
Key Points
• Appropriate positioning of patients in bed is important

and is part of care given depending the condition of the
patient; also is used to facilitate various investigation
procedures and examinations of patients.
• Reasons for position patient in bed include specific
examinations, various nursing procedure, care and
treatment e.g. First Aid measures for a patient in shock,
asthmatic attack, cardiac attack, fracture, comfort and
pain relief, for prevention of pressure sores and for
operation procedures
Evaluation
• How will you prepare the patient for

positioning?
• What equipment will you prepare for
position the patient?
Session 18:
Care of Patient with Pressure Ulcer
and Foot Drop
Learning Tasks

• Define pressure ulcer and foot drop
• Identify risk factors for a pressure ulcer and
foot drop
• Explain care of patient with pressure ulcer
• Describe measures to prevent pressure sores
Definition of Pressure Ulcer and Foot
Drop
• A pressure ulcer or sore is an area of
cellular necrosis caused by lack of
circulation of the involved area
• Foot drop describes the inability to raise
the front part of the foot due to weakness or
paralysis of the muscles that lift the foot
Risk Factors for a Pressure Ulcer and
Foot Drop
• Compression force
o This is the force exerted when the tissue are
compressed between two hard surfaces. This is the
major cause of pressure sores.
• Shearing force
o Patients who are dragged or pulled when moved
from bed to chair or form bed to stretcher are
exposed to shearing force as skin and underlying
tissues are pulled over each other.
Risk Factors cont…
• Moisture
o Prolonged moisture form sweat, urine, faeces or
other secretion on the skin encourages the
development of pressure sores which start as
maceration of devitalizes epithelium.
o It is therefore important to keep the patient‘s skin as
clean and dry as possible.
o Incontinent patients need extra attention in this
respect.
• Friction
o The patient who lies on wrinkled sheets is likely to
suffer from tissue damage due to friction which can
result in the loss of epidermal cells (abrasion).
o Sometimes the first evidence of a friction sore is a
blister.
o The common sites are the heels, ankles and knees
especially in restless patients or when poor
techniques of moving and lifting patients are used
• Lack of spontaneous body movement (immobility)
o Normal people when sitting or sleeping make
spontaneous movements in response to sensory
stimuli received by the brain.
o This is a protective mechanism to avoid excessive
pressure on a particular are of the body.
o When a person is immobile due to illness such as
paralysis and unconsciousness, protective mechanism
is lost. Hence the development of pressure sores
• Malnutrition
o Poor nutrition results in loss of
subcutaneous tissues and muscle bulk, both
of which normally act as mechanical
padding.
o Poorly nourished tissue cells are easily
damaged, for example, Vitamin C
deficiency causes capillaries to be fragile,
and poor circulation to the area results when
Care of Patient with Pressure Ulcer
• Protect area from friction, shear, and maceration using

a transparent film dressing or thin hydrocolloids
• Provide pressure relieving devices to reduce friction
and shearing forces
• Clean the ulcer with normal saline
• Protect the wound by covering it with a transparent
dressing or hydrocolloid
• For moderate number of exudates, use an absorbent
foam dressing
Care of Patient cont…
• Use liquid or solid barriers to protect periwound skin from
maceration damage
• Clean the ulcer with normal saline
• Protect the wound by covering it with a transparent dressing
or hydrocolloid
• For moderate number of exudates, use an absorbent foam
dressing
• Use liquid or solid barriers to protect periwound skin from
maceration damage
• Protect periwound skin using a protective barrier
• Cover with transparent dressing
Refer to
• Handout 18:1 Care of patients with

pressure Ulcers
Measures to prevent pressure sores
• Skin Inspections: a patient’s skin should be
examined regularly for signs of pressure
damage the signs of skin damage include heat,
pain and swelling.
• Skin care: keeping a patient’s skin clean, dry,
and hydrated can help prevent damage. Skin
should be dried carefully and any rubbing or
friction should be avoided.
Measures to prevent cont…
• Moisture: excessive perspiration, oedema and
incontinence can cause skin damage from excess
moisture. Incontinence can be particularly harmful to a
patient’s skin and appropriate measures should be taken
to prevent any associated damage.
• Incontinence: incontinence and pressure ulcers often
co-exist. The use of incontinence pads with the
appropriate application of a barrier cream can be
helpful, while the use of indwelling urethral catheters
should only be considered as a last resort due to the risk
of infection.
Measures to prevent cont…
• Nutrition: good nutrition is essential for pressure
ulcer prevention and healing. A Patient’s diet
should be assessed regularly and any nutritional
needs should be addressed. Keeping patients
hydrated is also a vital part of preventing pressure
ulcers.
• Position: the position of a patient’s body should
be considered when trying to prevent pressure
ulcers.
Key points
• A pressure ulcer or sore is an area of

cellular necrosis caused by lack of
circulation of the involved area
• Foot drop describes the inability to raise the
front part of the foot due to weakness or
paralysis of the muscles that lift the foot
Session Evaluation
• What are the risk factors for a pressure

ulcer and foot drop?
• How will you prevent pressure sores to a
confined patient?

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Session 1 :

Care of the patient with fluid and

 Define the following terms fluid and

 Electrolytes: is a substance which when

Hypothalmus –thirst receptors

 Regulate water distribution

 Observations vital signs, such as pulse,

• What is electrolytes imbalance?

At the end of this session a learner is expected to be able:

At the end of this session a learners is expected to

At the end of this session a learner is

 Make the bed as for an unoccupied bed with the

By the end of this session, a learner is

 Prepare unoccupied bed

BED BATHING OF AN ADULT

At the end of this session a learner is expected

• Bed bathing: A bath given to client who is

• Inform the client about the procedure

• Bring the trolley to the client’s bedside

• Put water in the basins and test temperature using

• Put towel under the client’s arm farther from

• Cover the client and change water

• Wash the back from neck to buttocks, rinse and

• Apply body lotion

• Bed bathing is bath given to client who is in

• Mouth wash solution e.g. sodium bicarbonate

• Inform the patient about the procedure

• How will you position an unconscious

o To maintain personal hygiene

 Inform client about the procedure and screen

• What is the definition hair care?

Care of patient with retention of

At the end of this session a learner is expected to

o Absence of voiding within 8 to 10 – hours period

At the end of this session a learner is

At the end of this session a learner is expected to be able

Urea 2 per cent

Uric acid and salts 2 per cent

After the nurse has observed stool, she must

At the end of this session a learner is expected

• What is the purpose of catheterization?

At the end of this session a learner is

In grade one ward would include;

• Check the Doctor’s order for insertion of Nasal-

Stop when the client breathes

Handout 13:1 Feeding the client using

• Nutrients can be sorted into two major

• How can you assist helpless client in oral

At the end of this session a learner is

• Handout 14:1 Types of wound

• Handout 14:2 Factors influencing wound

• The way wound healing occurs varies with the

At the end of this session participants are expected to

• When special nerves that detect tissue, damage send

• Accurate assessment of the patient`s pain is

The following factors should be assessed:

• Non pharmacological intervention

• Handout 15:1 Non –pharmacological and

• Pain is a sensation of discomfort caused by the action of

At the end of this session participants are expected to

Definition of Common Terms used in Application of Body Mechanics

• Immobility is the state of not moving; motionlessness

• To assist client move from one place to