c


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c 

PURPOSE:
Skin is a major potential source of microbial contamination in the surgical environment.
Although scrubbed members of the surgical team wear sterile gloves, the skin of their hands and
forearms should be cleaned preoperatively to reduce the number of microorganisms in the event
of glove tears. The purpose of the surgical hand scrub is to remove debris and transient
microorganisms from the nails, hands, and forearms; reduce the resident microbial count to a
minimum; and inhibit rapid rebound growth of microorganisms.

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

RECOMMENDATIONS:

A. Preparation for Surgical Hand Scrub:

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

Rationale: During hand washing, rings, watches, and bracelets may harbor or protect
microorganisms from removal. Allergic skin reactions may occur as a result of a scrub agent or a
glove powder accumulating under the jewelry.

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

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

3. Artificial nails should not be worn.

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

4. Skin on hands and arms should be intact.

Rationale: Breaks in skin integrity and open lesions increase the risk of patient and surgical team
member infection. Cuts, abrasions, exudative lesions, and hangnails tend to ooze serum, which
may contain pathogens. Broken skin permits microorganisms to enter the various layers of skin,
providing deeper microbial breeding grounds.

5. If timed scrub technique is used, a clock should be visible for the timed scrub.
Rationale: Standard timing is necessary for effective preparation of the surgical team¶s hands and
arms.

6. An effective antimicrobial surgical hand scrub agent approved by the health care facility
should be used for all surgical hand scrubs. The agent should be used according to the
manufacturer¶s instructions.

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

7. The selected antimicrobial hand scrub agent should:

‡ Significantly reduce selected microorganisms on intact skin
‡ Contain a nonirritating antimicrobial preparation
‡ Be broad spectrum
‡ Be fast acting
‡ Have a residual effect

Rationale: Organisms reproduce in the moist environment of gloves, and gloves frequently
become damaged during procedures; therefore, persistent chemical activity is desirable to
suppress microbial growth. No agent is ideal in every situation. Agents should be selected based
on these factors and their acceptability to the surgical team for their consistent use according to
the manufacturer¶s direction.

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

used.

Rationale: The primary action of cleansing with soap is the mechanical removal of transient
organisms. Vigorous rubbing with enough alcohol-based hand cleanser to cover the hands and
forearms completely has been shown to be an effective method of antisepsis.

9. Surgical hand scrub agents should be stored in clean, closed containers. Reusable containers
should be washed and dried thoroughly before refilling. Adding surgical hand scrub agents to
partially filled reusable containers should be avoided. Disposable containers should be discarded
when empty.

Rationale: Refilling before cleaning dispensers and adding surgical hand scrub agents to partially
filled containers may cause contamination and contribute to the spread of potentially harmful
microorganisms.

10. If brushes are used the selection of reusable or disposable brushes or sponges for scrubbing
should be based on realistic considerations of effectiveness and economy.

Rationale: Studies show no significant difference in scrub effectiveness between reusable

brushes and disposable brushes or sponges. Individually prepackaged disposable brushes and
sponges provide a cost-effective, laborsaving alternative to reusable brushes. If a reusable brush
is desired, it should be easy to clean and maintain and should be durable enough to withstand
repeated sterilization without bristles becoming soft or brittle.

B. Surgical Hand Scrub:

1. The surgical hand scrub procedure should be standardized for all personnel according to the
health care facility¶s policy and procedure.

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

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

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

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

Rationale: Setting the temperature and flow of the water before beginning the surgical hand
scrub prevents cross-contamination.

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

Rationale: Hands and forearms are held higher than the elbows and out from the surgical attire to
prevent contamination and to allow water to run from the cleanest area down the arm. Water
droplets dispersed by shaking can contaminate surrounding attire or supplies.

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

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

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

Rationale: The principle action of hand washing is mechanical-vigorous rubbing that produces
friction, which removes dirt, transient microorganisms, and some resident microorganisms.

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

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

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

Rationale: The majority of flora on the hands is found under and around the fingernails. Brushing
other areas of the hands and arms has been shown to abrade the skin surface detrimentally.

9. If using the timed technique, the total time of the surgical hand scrub should be at least two
minutes. It is useful to break the process into three stages: First, wash hands and arms as far as
elbows; second, wash hands and arms but not as far as the elbow; third, wash hands and only
two-thirds of forearm.

Rationale: Optimal length of scrub time is not known, but recent studies suggest scrubbing for at
least two minutes is as effective at reducing bacterial colony counts as the traditional ten minute
scrub. Longer scrubs lead to a greater number of skin problems among staff and discourage
compliance.

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

‡ Each plane requires 10 strokes with the scrub sponge.

‡ The digits have 4 planes and each digit will have a total of 40 strokes.
‡ The dorsal and palm of the hand will have a total of 30 strokes.
‡ The forearm has 4 planes and it will have a total of 40 strokes.
‡ The elbow has 4 planes and it will have a total of 40 strokes.
‡ The arm 5 cm above the elbow has 4 planes and it will have a total of 40 strokes.
‡ The counted stroke technique will be completed on the right and left side.

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

Rationale: Rubbing skin to dry it will further disturb skin cells. The fingertip to elbow process
completed on one hand and using another portion of the sterile towel (or another sterile towel) to
dry the other hand preserves the hands as the cleanest area.

12. Brushes or sponges used should be discarded appropriately.

Rationale: Appropriate disposal of used items prevents cross-contamination of the surgical hand
scrub area. Reusable brushes should be decontaminated and sterilized before reuse.

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

Rationale: If the traditional role of water is replaced by another mechanism, that mechanism
must be efficacious.
 



 

!"#  $
To don the gown, the scrub person:
?a. Lifts the folded gown directly upward from the sterile package.
b. Steps back from the table into an unobstnrcted area;
c. Carefully locates the neckband and holds the inside front of the gown just
below the neckband with both hands;
d. Lets the gown unfold while keeping the inside of the gown toward the
body with, out touching the sterile exterior of the gown with bare hands
(NOTE :If the gown does not unfold completely, then the circulating
nurse may assist by pulling down the unfolded bottom inside the gown);
e. Holds the hands at shoulder level and slips both arms into the armhole
simultaneously

h" $
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 -
In the closed-glove technique, the scrub person's hands remains inside the sleeves and should not
touch the cuffs. In the open-glove technique the scrub person's hands slide all the way through
the sleeves out beyond the cuffs.
r? †eeps both hands within the cuff so that the hands do not touch the cuff edges;
r? Šrasps the folded cuff of the left glove with the right hand;
r? Holds the top edge of the cuff in the left hand above the palm;
r? Places the palm of the glove against the palm of the left hand-the glove fingers point up
the forearm;
r? Šrasp the back of the cuff in the right hand and turn it over the open end of the left sleeve
and hand while holding the top of the left glove and underlying gown sleeve with the
covered right hand;
r? Pulls the glove over the extended left finger onto the wrist by pushing the hand through
the glove until it completely covers the cuff of the glove;
r? Šloves the right hand in the same manner by reversing the above steps
r? Inspects the gloves for integrity after donning; and
r? Hands the tie end to the circulator and secures the wraparound glove (when used.)
v"  % &
The closed glove technique should not be used when changing one or both gloves because once
the hand has been passed through the cuffs, they are contaminated. When a glove must be
changed without assistance during a surgical procedure, the open-glove technique is used.

"   one glove during the procedure using the open-glove technique, the scrub Person:
l) Steps away from the sterile field;
 2) extends the contaminated glove away from the sterile field so that the circulator, using exam
gloves to protect his/her hands, can remove it;
3) lifts the new sterile glove under the cuff with the uncontaminated gloved hand;
4) Inserts the hand into the glove and pulls it on, leaving the cuff turned well down over the hand
and avoiding inward rolling of the cuff. The bare hand does not touch the outside of the glove;
5) and Rotates the arm and pulls the cuff of the glove up and over the sleeve cuff, letting the
gloved fingers touch only the outside of the other glove.

"   both gloves during a procedure using an open-glove technique, the scrub Person:
1) Follows instructions 1 and 2 above;
2) Picks up the left glove cuff, touching only the edge of the cuff with his or her right thumb and
index finger;
3) Pulls the glove onto the left hand and leaves the glove cuff turned down;
4) Picks up the right glove with the gloved left hand, keeping the
gloved fingers under the folded cuff;
5) Slides the right hand fingers inside the right glove cuff and pulls
the glove onto the right hand while avoiding inward rolling of the
cuff;
6) Pulls the right glove cuff over the sleeve cuffby rotating the arm;
7') Places the gloved right-hand fingers under the folded left glove
cuff, rotates the arm, and pulls the left glove cuff over the sleeve
cuff.
"'''
#  
 
1. Assisting gowning- The scrub person may assist another member in drying, gowning, and
gloving by:
a. Opening the towel that the other member will use to dry his/her hands
b. laying the towel on the team member's hand without touching his/her hands;
c. Holding the gown at the neckband and carefully unfolding
d. †eeping the hands on the outside of the gown, forming a protective cuff of the neck and
shoulder area as the person being gowned holds both arms outstretched;
e. Offering the inside of the gown to the other member so he or she can slip his or her hands into
the sleeves; and
f. Releasing the gown when the team members' hands are in the sleeves.

h"'''
 - To glove another team member, the scrub person always gloves the
other person's right hand first. The scrub person:
a. Picks up the glove with his or her fingers under the cuff
b. Holds the palm of the glove toward the person being gloved
c. Stretches the cuff to open the glove and holds his or her thumbs out to keep them from
touching the other team member's bare hands
d. As the other person inserts his or her hands into the glove, exerts upward firm pressure making
sure the hand does not go below the waist
e. Unfolds the inverted glove cuff over the cuff of the sleeve
f. Šloves the left hand with the assistance of a team member by repeating the steps
g. Hold the tie as the other team member turns to secure wraparound sterile gown when it is used.
K"'''

& -
When a team member other than the scrub nurse contaminates a glove during the surgical
procedure, the circulator, using examination gloves so that her hands are protected ,will grasp the
out side of the gloves and pull it off inside out. The scrub nurse then regloves the team members
as described in assisted gloving.

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

 '
& %  cannot be used to reglove. In closed gloving, the hand passes
through the cuff of the gown, contaminating the end of the cuff . this would cause the out side
of new glove to be contaminated.

"() # 
'
At the end of the procedure, the gown is always removed before the gloves to prevent cross
contamination of the wearer's scrub attire. The circulator can assist by unfastening the neck and
back closures of the gown. The scrub person:
l. grasps the shoulders of the gown, pulls it downward from the shoulder and off the arms, and
turns the sleeves inside out;
2. folds the contaminates surface of the gown on the inside and rolls it away from the body; and

3. Discards the rolled gown in the appropriate receptacle.

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

would usually occur from handling the soiled gown.

 


 (pronounced /triÖY ù/) is a process of determining the priority of patients' treatments
based on the severity of their condition. This rations patient treatment efficiently when resources
are insufficient for all to be treated immediately. The term comes from the French verb à  ,
meaning to separate, sort, sift or select.
1.Two types of triage exist: simple and advanced.
2.Triage may result in determining the order and priority of emergency treatment, the order and
priority of emergency transport, or the transport destination for the patient.
3.Triage may also be used for patients arriving at the emergency department, or to telephone
medical advice systems among others. This article deals with the concept of triage as it occurs in
medical emergencies, including the prehospital setting, disasters, and during emergency room
treatment.
*'+

c)

Simple triage is usually used in a scene of a "mass-casualty incident" (MCI), in order to sort
patients into those who need critical attention and immediate transport to the hospital and those
with less serious injuries. This step can be started before transportation becomes available. The
categorization of patients based on the severity of their injuries can be aided with the use of
printed triage tags or colored flagging.
c"""("")

ï  à  à 
  à  àà
S.T.A.R.T. (Simple Triage and Rapid Treatment) is a simple triage system that can be performed
by lightly-trained lay and emergency personnel in emergencies. It is not intended to supersede or
instruct medical personnel or techniques. It has been (2003) taught to California emergency
workers for use in earthquakes. It was developed at Hoag Hospital in Newport Beach, California
for use by emergency services. It has been field-proven in mass casualty incidents such as train
wrecks and bus accidents, though it was developed for use by community emergency response
teams (CERTs) and firefighters after earthquakes. In 2009, the Newport Beach Fire Department
gave approval for a bilingual version of the S.T.A.R.T. system to be included in a series of books
called EMSpañol , produced by Emergency Language Systems.
Triage separates the injured into four groups:
r? The    who are beyond help
r? The injured who can be helped by  à transportation
r? The injured whose transport can be  
r? Those with 
injuries, who need help less urgently

 


In advanced triage, doctors may decide that some seriously injured people should not receive
advanced care because they are unlikely to survive. Advanced care will be used on patients with
less severe injuries. Because treatment is intentionally withheld from patients with certain
injuries, advanced triage has ethical implications. It is used to divert scarce resources away from
patients with little chance of survival in order to increase the chances of survival of others who
are more likely to survive.
In Western Europe, the criterion used for this category of patient is a trauma score of consistently
at or below 3. This can be determined by using the Triage Revised Trauma Score (TRTS), a
medically-validated scoring system incorporated in some triage cards.
Another example of a trauma scoring system is the Injury Severity Score (ISS). This assigns a
score from 0 to 75 based on severity of injury to the human body divided into three categories: A
(face/neck/head), B(thorax/abdomen), C(extremities/external/skin). Each category is scored from
0 to 5 using the Abbreviated Injury Scale, from uninjured to critically injured, which is then
squared and summed to create the ISS. A score of 6, for "unsurvivable", can also be used for any
of the three categories, and automatically sets the score to 75 regardless of other scores.
Depending on the triage situation, this may indicate either that the patient is a first priority for
care, or that he or she will not receive care due to the need to conserve care for more likely
survivors.
The use of advanced triage may become necessary when medical professionals decide that the
medical resources available are not sufficient to treat all the people who need help. The treatment
being prioritized can include the time spent on medical care, or drugs or other limited resources.
This has happened in disasters such as volcanic eruptions, thunderstorms, and rail accidents. In
these cases some percentage of patients will die regardless of medical care because of the
severity of their injuries. Others would live if given immediate medical care, but would die
without it.
In these extreme situations, any medical care given to people who will die anyway can be
considered to be care withdrawn from others who might have survived (or perhaps suffered less
severe disability from their injuries) had they been treated instead. It becomes the task of the
disaster medical authorities to set aside some victims as hopeless, to avoid trying to save one life
at the expense of several others.
If immediate treatment is successful, the patient may improve (although this may be temporary)
and this improvement may allow the patient to be categorized to a lower priority in the short
term. Triage should be a continuous process and categories should be checked regularly to
ensure that the priority remains correct. A trauma score is invariably taken when the victim first
comes into hospital and subsequent trauma scores taken to see any changes in the victim's
physiological parameters. If a record is maintained, the receiving hospital doctor can see a
trauma score time series from the start of the incident, which may allow definitive treatment
earlier.
   ' 



Continuous Integrated Triage is an approach to triage in mass casualty situations which is both
efficient and sensitive to psychosocial and disaster behavioral health issues that affect the
number of patients seeking care (surge), the manner in which a hospital or healthcare facility
deals with that surge (surge capacity and the overarching medical needs of the event.
Continuous Integrated Triage combines three forms of triage with progressive specificity to most
rapidly identify those patients in greatest need of care while balancing the needs of the individual
patients against the available resources and the needs of other patients. Continuous Integrated
Triage employs:
r? Šroup (Šlobal) Triage (i.e., M.A.S.S. triage)
r? Physiologic (Individual) Triage (i.e., S.T.A.R.T.)
r? Hospital Triage (i.e., E.S.I. or Emergency Severity Index)
However any Šroup, Individual and/or Hospital Triage system can be used at the appropriate
level of evaluation.




During the early stages of an incident, first responders may be overwhelmed by the scope of
patients and injuries. One valuable technique, is the Patient Assist Method (PAM); the
responders quickly establish a casualty collection point (CCP) and advise ; either by yelling, or
over a loudspeaker, that "anyone requiring assistance should move to the selected area (CCP)".
This does several things at once, it identifies patients that are not so severely injured, that they
need immediate help, it physically clears the scene, and provides possible assistants to the
responders. As those who can move, do so, the responders then ask, "anyone who still needs
assistance, yell out or raise your hands"; this further identifies patients who are responsive, yet
maybe unable to move. Now the responders can rapidly asses the remaining patients who are
either expectant, or are in need of immediate aid. From that point the first responder is quickly
able to identify those in need of immediate attention, while not being distracted or overwhelmed
by the magnitude of the situation.
(
'

In addition to the standard practices of triage as mentioned above, there are conditions where
sometimes the less wounded are treated in preference to the more severely wounded. This may
arise in a situation such as war where the military setting may require soldiers be returned to
combat as quickly as possible, or disaster situations where medical resources are limited in order
to conserve resources for those likely to survive but requiring advanced medical care. Other
possible scenarios where this could arise include situations where significant numbers of medical
personnel are among the affected patients where it may be advantageous to ensure that they
survive to continue providing care in the coming days especially if medical resources are already
stretched. In cold water drowning incidents, it is common to use reverse triage because drowning
victims in cold water can survive longer than in warm water if given immediate basic life support
and often those who are rescued and able to breathe on their own will improve with minimal or
no help.

 +
'


Triage is an old French term that was first used to refer to the sorting and treatment of those
injured in battle. Today, the term is used in situations where there are more casualties than there
are rescuers. It is a method that involves assessing quickly, then assisting those casualties that
truly need help, but at the same time not wasting resources on casualties who have very, if any,
chance of being saved.
c)

(

) ,c(-
This involves quickly assessing and prioritizing casualties into three categories: immediate,
delayed, and dead/non-salvageable.
First, all casualties that can walk need to be moved away from the immediate area so rescuers
can deal with the critically injured. The casualties that walk away should still be looked at by
rescuers that arrive later.
))


 This designation is for casualties that need immediate care to have their airway cleared to enable
breathing to continue.
*


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

. &c
These are the casualties that are found not breathing and who fail to breath after attempts are
made to open and clear the airway. It also includes obviously mortal injuries such as
decapitation. Never begin CPR on such a casualty because once you begin you can't stop. As a
result you can not continue to triage and other casualties may die that otherwise may have been
saved.
As casualties are assessed they are generally marked with ribbons e.g. around the wrists to
indicate their classification to others. The colors used are:
Ô? Immediate: Red
Ô? Delayed: Yellow or Šreen
Ô? Dead: Black or Šray




















 




 '/*)
*
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Pulse oximetry is a simple non invasivemethod of monitoring the percentage of haemoglobin
(Hb) which is saturated with oxygen. The pulse oximeter consists of a probe attached to the
patient's finger or ear lobe which is linked to a computerised unit. The unit displays the
percentage of Hb saturated with oxygen together with an audible signal for each pulse beat, a
calculated heart rate and in some models, a graphical display of the blood flow past the probe.
1.? Provides an estimate of arterial oxyhemoglobin saturation by using selected wavelengths
of light to noninvasively determine the saturation of oxyhemoglobin. Oximeters function
by passing a light beam through a vascular bed, such as the finger or earlobe, to determine
the amount of light absorbed by oxygenated (red) and deoxygenated (blue) blood.
2.? Calculates the amount of arterial blood that is saturated with oxygen (Sao2) and displays
this as a digital value.
#
' /)
#
01
A source of light originates from the probe at two wavelengths (650nm and 805nm). The light is
partly absorbed by haemoglobin, by amounts which differ depending on whether it is saturated
or desaturated with oxygen. By calculating the absorption at the two wavelengths the processor
can compute the proportion of haemoglobin which is oxygenated. The oximeter is dependent on
a pulsatile flow and produces a graph of the quality of flow. Where flow is sluggish (eg
hypovolaemia or vasoconstriction) the pulse oximeter may be unable to function. The computer
within the oximeter is capable of distinguishing pulsatile flow from other more static signals
(such as tissue or venous signals) to display only the arterial flow

 ' 
$
a. Monitor adequacy of oxygen saturation; quantify response to therapy.
b. Monitor unstable patient who may experience sudden changes in blood oxygen level.
c. Evaluation of need for home oxygen therapy.
d. Determine supplemental oxygen needs at rest, with exercise, and during sleep.
e. Need to follow the trend and need to decrease number of ABŠ sample drawn.
4. The oxyhemoglobin dissociation curve allows for correlation between Sao2 and PaO2
5. Increased bilirubin, increased carboxyhemoglobin, low perfusion or Sao2 < 80% may alter
light absorption and interfere with results

' 
 
 '

 '
1.? Assess patient¶s hemoglobin. Sao2 may not correlate well with PaO2 if hemoglobin is not
within normal limits.
 2. Remove patient¶s nail polish because it can affect the ability of the sensor to correctly
determine oxygen saturation, particularly polish with blue or dark colors.
3. Correlate oximetry with ABŠ values and then use for single reading or trending of
oxygenation (does not monitor Paco2).
4. Display heart rate should correlate with patient¶s heart rate.
5.. To improve quality of signal, hold finger dependent and motionless (motion may alter
results) and cover finger sensor to occlude ambient light.
6. Assess site of oximetry monitoring for perfusion on a regular basis, because pressure
ulcer may occur from prolonged application of probe.
7. Device limitations include motion artifact, abnormal hemoglobins (carboxyhemoglobin
and methemoglobin), I.V. dye, exposure of probe to ambient light, low perfusion states,
skin pigmentation, nail polish or nail coverings, and nail deformities such as severe
clubbing.
8. Document inspired oxygen or supplemental oxygen and type of oxygen delivery
device.
9. Accuracy can be affected by ambient light, I.V. dyes, nail polish, deeply pigmented
skin, patients in sickle cell crisis, jaundice, severe anemia, and use of antibiotics such as
sulfas.
In the following situations the pulse oximeter readings may not be accurate:
1.? A reduction in peripheral pulsatile blood flow produced by peripheral vasoconstriction
(hypovolaemia, severe hypotension, cold, cardiac failure, some cardiac arrhythmias) or
peripheral vascular disease. These result in an inadequate signal for analysis.
2.? Venous congestion, particularly when caused by tricuspid regurgitation, may produce
venous pulsations which may produce low readings with ear probes. Venous congestion
of the limb may affect readings as can a badly positioned probe. When readings are lower
than expected it is worth repositioning the probe. In general, however, if the waveform on
the flow trace is good, then the reading will be accurate.
3.? Bright overhead lights in theatre may cause the oximeter to be inaccurate, and the signal
may be interrupted by surgical diathermy. Shivering may cause difficulties in picking up
an adequate signal.
4.? Pulse oximetry cannot distinguish between different forms of haemoglobin. Carbo-
xyhaemoglobin (haemoglobin combined with carbon monoxide) is registered as 90%
oxygenated haemoglobin and 10% desaturated haemoglobin - therefore the oximeter will
overestimate the saturation. The presence of methaemoglobin will prevent the oximeter
working accurately and the readings will tend towards 85%, regardless of the true
saturation.
5.? When methylene blue is used in surgery to the parathyroids or to treat
methaemoglobinaemia a shortlived reduction in saturation estimations is registered.
6.? Nail varnish may cause falsely low readings. However the units are not affected by
jaundice, dark skin or anaemia.
''$
 ë? Pulse oximeters may be used in a variety of situations but are of particular value for
monitoring oxygenation and pulse rates throughout anaesthesia.
ë? They are also widely used during the recovery phase. The oxygen saturation should
always be above 95%.
ë? In patients with long standing respiratory disease or those with cyanotic congenital heart
disease readings may be lower and reflect the severity of the underlying disease.
ë? In intensive care oximeters are used extensively during mechanical ventilation and
frequently detect problems with oxygenation before they are noticed clinically.
ë? They are used as a guide for weaning from ventilation and also to help assess whether a
patient's oxygen therapy is adequate.
ë? In some hospitals oximeters are used on the wards and in casualty departments. When
patients are sedated for procedures such as endoscopy, oximetry has been shown to
increase safety by alerting the staff to unexpected hypoxia.
) '$
ë? Oximeters give no information about the level of CO2 and therefore have limitations in
the assessment of patients developing respiratory failure due to CO2 retention. 
ë? On rare occasions oximeters may develop faults and like all monitoring the reading
should always be interpreted in association with the patient's clinical condition. Never
ignore a reading which suggests the patient is becoming hypoxic. 
ë? Since pulse oximeters cost at least £1200 their purchase will depend mainly on economic
considerations

'  '''') 
The history and the physical exam provide much of the information known about the patient's
health status. As a practical nurse, we may be called upon to assist the physician or other health
care providers during a physical examination. we should know the basics of the examination in
order to have the appropriate equipment and supplies on hand, and so that you may place the
patient in the proper position and drape him correctly. Assessment is the first step in the nursing
process. A nurse uses every tool available to gather the information required to write a patient's
diagnoses and care plan.
Nursing Health Assessment Tools
 
'
1.? A patient's chart provides information about his health status. It includes details about the
current medical condition, treatment plan, related past medical history and other important
data required to create a care plan.
c '
2.? Regular monitoring of a patient's heart rate, blood pressure, temperature and respiratory rate
allows the nurse to help prevent life-threatening complications and evaluate a patient's
overall condition. Abnormalities can indicate a variety of problems ranging from anxiety to
heart failure.
  
#
3.? One of the most important assessment tools in nursing is the patient herself. A nurse
performs an initial detailed interview to get a full picture of the patient's physical and mental
status. A nurse also does shorter interviews throughout the day by asking the patient how she
is feeling and other questions about her well-being.
'
 
4.? Nurses use every interaction with patients as a way to gather information by observing
patients' responses to stimuli. This helps a nurse recognize pain, emotional disturbances and
reaction to treatment. It is an especially important tool for patients who are unable to
communicate.
 
 

+'' '
5.? Communicating with other health care professionals involved in a patient's care is vital to
assessment, especially when a patient is transferred from another location. In a hospital
setting, a patient may be seen by a doctor, nurse, respiratory therapist, physical therapist or
other specialists. Šathering information from all these sources helps the nurse create a well-
rounded care plan.
 (cc2((2(34c53
ë? The physical examination can be performed by the following health care providers: a
physician, nurse practitioner, or physician assistant. The health care provider makes specific
and general observations as he examines the patient from head to toe. The exam should
include the eyes, ears, nose, mouth, throat, neck, chest, breasts, abdomen, and extremities. A
 vaginal or rectal examination is performed if indicated. The purposes for performing a
physical examination are:
ë? a. To determine the patient's level of health or physiological function.
ë? b. To arrive at a tentative diagnosis when there is a health problem or disease.
ë? c. To confirm a diagnosis of disease or dysfunction.
ë? d. To evaluate the effectiveness of prescribed medical treatment and therapy.
ë? 2 c2( (c (53
( (
ë? a. Ensure that the patient feels comfortable and is not embarrassed. Prior to the examination,
tell the patient what will take place and explain the reason for the procedure. The patient who
knows what to expect will be more relaxed and cooperative.
ë? b. Ask the patient to void into a urine specimen cup in order to empty the bladder and save
the urine specimen for urinalysis. Have the patient put on a hospital gown so that his body is
more accessible for examination.
ë? c. Arrange equipment and supplies. Be sure that you have everything needed. Test all
equipment to make certain that it works correctly.
Supplies and Equipment

Hospital gown Otoscope (for examining ears)

Sheet or disposable paper drapes Tuning fork
Bath blanket (to prevent chill) Blood pressure apparatus and
Tray with flashlight, gloves, stethoscope
lubricant normal saline, cotton- Percussion hammer (to check
tipped applicators, and tissues reflexes)
Basin for soiled instruments Red and blue pencils (to mark skin)
Waste container for paper goods Small speculum (for nose
Scale with height measuring rod examination)
Šooseneck lamp or hospital light Head mirror (to reflect light into
Šloves body orifice, such as the throat
Thermometer (oral or rectal) You may also need slides, blood
Tape measure tubes, a vaginal speculum, or
Tongue depressors other equipment; medications;
Ophthalmoscope (for examining and a surgical permit if a
eyes) biopsy or other tests are to be
done.
ë? d.Accompany the patient to the examination room and assist him onto the table. Your
presence lends support and reassurance to the patient. If a male is examining a female
patient, or vice versa, stay in the room to protect the patient, the health care provider, and the
hospital or clinic.
ë? e. Wash your hands and measure the patient's vital signs (temperature, pulse, respiration,
blood pressure), height, and weight. Wear gloves if the patient has a draining wound, is
bleeding, is vomiting, or has an infection.
ë? . Have the patient's chart available. The physician needs to know the information that has
already been obtained via the nursing observations and lab reports. Call the physician's
attention to any abnormal lab values. Do this away from the patient.
ë? g. Have all lab slips and x-ray slips ready with the patient's name, rank, social security
number, date, and other required information.
ë? h. Assist the patient to assume the proper position for each part of the examination (see
figures 1-1 to 1-7). To provide continuing privacy, be sure to adjust the drapes each time the
patient assumes a different position. If the patient is asked to stand erect, place paper towels
on the floor or have the patient put on slippers.
Ô? Hand instruments and supplies to the physician. Properly label and care for all
specimens collected.
ë? j. See that the patient is returned safely to his room and is comfortable.
ë? k. Place all instruments in the proper area for disinfection or sterilization and dispose of all
wastes. Wash your hands again. See that the examination room is cleaned. Decontaminate the
room if necessary. Change the cover on the tables. Replace all equipment.
c2(53((3
ë? Patients are put in special positions for examination, for treatment or test, and to obtain
specimens. You should know the positions used, how to assist the patient, and how to
adjust the drapes.
ë? a. Horizontal Recumbent Position. Used for most physical examinations. Patient is on his
back with legs extended. Arms may be above the head, alongside the body or folded on
the chest.
ë? b. Dorsal Recumbent Position. Patient is on his back with knees flexed and soles of feet
flat on the bed. Fold sheet once across the chest. Fold a second sheet crosswise over the
thighs and legs so that genital area is easily exposed.
ë? c. Fowler's Position. Used to promote drainage or ease breathing. Head rest is adjusted to
desired height and bed is raised slightly under patient's knees
ë? d. Dorsal Lithotomy Position. Used for examination of pelvic organs. Similar to dorsal
recumbent position, except that the patient's legs are well separated and thighs are acutely
flexed. Feet are usually placed in stirrups. Fold sheet or bath blanket crosswise over
thighs and legs so that genital area is easily exposed. †eep patient covered as much as
possible.
ë? e. Prone Position. Used to examine spine and back. Patient lies on abdomen with head
turned to one side for comfort. Arms may be above head or alongside body. Cover with
sheet or bath blanket.
ë? NOTE: An unconscious patient, or one with an abdominal incision or breathing difficulty
usually cannot lie in this position.
ë? f. Sim's Position. Used for rectal examination. Patient is on left side with right knee
flexed against abdomen and left knee slightly flexed. Left arm is behind body; right arm
is placed comfortably.
ë? NOTE: Patient with leg injuries or arthritis usually cannot assume this position.
ë? g. †nee-Chest Position. Used for rectal and vaginal examinations and as treatment to
bring uterus into normal position. Patient is on knees with chest resting on bed and
elbows resting on bed or arms above head. Head is turned to one side. Thighs are straight
and lower legs are flat on bed.
ë? NOTE: Do not leave patient alone; he/she may become dizzy, faint, and fall.
2
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Name : Sabasiva
Age : 50 Years
Sex : Male
Address : Charwada road
vapi
Religion : Hindu
Marital status : Married
Education : 8th Std
Occupation : Cooley
Income : Rs.2000 / month
Ward : '
#

+
)''   $ !;.!!.!<
Date of Surgery : 20/11/10
I.P No :1011-172161
O. P No : 1011-21013

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3.c( c2(($
Patient had chest pain, dyspnea on exertion since 3 months.

"(ccc.(cc c$
a)? Symptoms or complaints
Patient had chest pain dyspnea on exertion and history of palpitation since 3 days.
b)? Onset - Acute
 c)? Location - Chest region
d)? Quality - Stabbing in nature
e)? Quantity - Continues pain
f)? Associated phenomenon - lack of myocardial demand
g)? Alleviating factors - PTCA

"cc(4$
a)? He has a history of Hypertension and irregular treatment therapy
b)? No allergy to any medication and food
c)? No history of, tuberculosis and Diabetes mellitus
d)? Immunization ± has mark of small pox vaccination and BCŠ scar

"234c(4$
 He belongs to middle class family, got married 25 years back and has two Son.

c" )+   c/    

  (   
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 ' '
th
!" Mr.sambasiva 50 Male Cooley 8 std Self IHD-
yrs PTCA
th
h" Mrs.kavitha 42yrs Female Housewife 10 Wife Healthy
standard
K" Mr. pavan 24 Male Labour 12th Son Healthy
yrs standard
8" Mr. †rishna 22 Male Tailor 10th Std Son Healthy
yrs

He has family history of hypertension and heart diseases


"c4cc(4$
Economic history: He belongs to Middle class family and Minister supports him
economically for operation
Mother tongue - †annada
Language known - †annada and Tamil.
Cultural Šroup - Friends
Mood - Social
" (c(4$
 He is taking all types of food either vegetarian and Non vegetarian. He used to take
alcohol once in a week and 10 cigarettes per day.

5"3@v($
Bowel ± he has regular bowel movement once a day in the morning and no history of
constipation.

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

5"(3c(4$
He lives with his family in concrete house, which has three room and a kitchen. They use
toilet for defecation and getting water from the boring well. he has electricity supply and closed
drainage system in his house.

4c53

!-(vc($
? a) Constitution : Moderate body built
b) Stature : Normal
c) State of Nutrition : Šood
d) Personal appearance : anxious
e) Posture : Šood
f) Emotional stage : Anxious
g) Skin : Pallor
h) Cooperativeness : Cooperative
h-cc$
Temperature : 99oF
Pulse : 72 bpm
Respiration : 22 Bpm
Blood pressure : 130 / 80 mmhg
Pulse pressure : 50 mmhg
K- HEIŠHT : 165 CMS
4) WEIŠHT : 59 †ŠS
5) S†IN AND MUCUS MEMBRANE:
a) Colour of skin : Pallor
b) Edema : Absent
 c) Moist Temperature : Normal
d) Turgor : Normal
e) Texture : Moist
=-   $
 a) Skull : No abnormality noted
b) Hair : Black hair, hair distribution normal
c) Movements of the head : Full range of movement
d) Fore head : No scars or lesion
e) Face : Anxious looking
?- 4c   $
 a) Expression : Anxious & fear
b) Eye brows : Equal
c) Eye lids : No lesion
d) Lacrimation : Clear fluid
e) Conjunctiva : Pale
f) Sclera : pallor
g) Cornea : Clear and moist
h) Iris : Normal
i) Pupils : PERRLA
;- (c  $
a) Appearance : No mass
b) Discharge : No
c) Hearing : Normal
d) Lesion : Absent
A- c  $
a) Appearance : No Septal deviation
b) Discharge : No
c) Patency : Both nostrils are patent
d) Sense of smell : Šood
!<- 3 ($
a) Lips : Dry
b) Tongue : Normal, un coated
c) Teeth : Intact in upper and lower jaw
 d) Šums : Pink and moist
e) Buccal mucosa : No lesion
f) Tonsil : Normal
d) Taste : Normal
!!-:$
a) Šeneral appearance : Normal
b) Trachea : Normal in position
c) Lymph node : No enlargement
d) Thyroid gland : Feel smooth and firm
e) Cyst and tumor : Absence
!h-c(c((4c4c3$
a) Inspection : Size and shape normal, chest
expansion equal in both side and
respiration are normal
b) Palpation : No local swelling, no lymph node
enlarge
c) Percussion : Normal resonance in both lungs
d) Auscultation : Breath sounds are normal, high pitched
in both side. Respiratory rate 24 bpm,
S1 and S2 heart normal, heart rate ± 74
bpm.
!K-(c (c4c3
 a) Inspection : Size and shape of the chest is with in
normal limit;
b) Palpation : Carotid pulse and peripheral pulses
which is regular; normal sinus rhythm; rate- 74
bpm
c) Percussion : Cardiac borders well with in normal
Limits.
d) Auscultation : S1 and S2 heard well. No abnormalities
noted. HR _ 74/mt and regular.
!K-v3$
 a) Inspection : No abnormality
b) Palpation : No organomegaly
c) Percussion : No fluid filled spaces could be found
d) Auscultation : Peristalsis present
!8-v:$
a) Spine and curvature : No abnormalities is noted
b) Movements : All range of movements are normal
c) Tenderness : No tenderness noted
!9-$
r? Normal - no discharges
!=- (5(3c$
r? Normal movement
r? No deformities
r? No lymph node enlargement
!?-(5(3c$
r? Normal movement
r? No deformities
r? Surgical dressing present in left femoral region
!;-( cc4c3$
a)? Higher function ± consciousness
b)? Memory ± immediate, recent, remote is good
c)? Speech ± fluent and comprehensive
d)? Cranial nerves ± no abnormalities
e)? Sensory function ± good
f)? Coordination finger to nose ± not impaired