DUTIES OF SCRUB NURSE Before an operation

Undertake count of sponges and instruments with circulating nurse Informs the surgeon of count result Clears away instrument and equipment After operation: helps to apply dressing Removes and siposes of drapes De-gown Prepares the patient for recovery room Completes documentation Hand patient over to recover room

Ensures that the circulating nurse has checked the equipment Ensures that the theater has been cleaned before the trolley is set Prepares the instruments and equipment needed in the operation Uses sterile technique for scrubbing, gowning and gloving Receives sterile equipment via circulating nurse using sterile technique Performs initial sponges, instruments and needle count, checks with circulating nurse

ROLE OF SCRUB NURSE When surgeon arrives after scrubbing 1. Works directly with surgeon within the sterile field, passing instruments, sponges and other items needed during the procedure Members of the surgical team who prepares and preserves a sterile field in which the operation can take place Responsible for the sponge counts, the blades and needles and instruments check throughout the operation Has a job requiring anticipation, quick reaction and conscientious observation as well as knowledge of anatomy and of operative procedures

Perform assisted gowning and gloving to the surgeon and assistant surgeon as soon as they enter the operation suite Assemble the drapes according to use. Start with towel, towel clips, draw sheet and then lap sheet. Then, assist in draping the patient aseptically according to routine procedure Place blade on the knife handle using needle holder, assemble suction tip and suction tube Bring mayo stand and back table near the draped patient after draping is completed Secure suction tube and cautery cord with towel clips or allis Prepares sutures and needles according to use

2. 3. 4.

DUTIES OF CIRCULATING NURSE Before an operation

During an operation

Maintain sterility throughout the procedure Awareness of the patients safety Adhere to the policy regarding sponge/ instruments count/ surgical needles Arrange the instrument on the mayo table and on the back table

Checks all equipment for proper functioning such as cautery machine, suction machine, OR light and OR table Make sure theater is clean Arrange furniture according to use Place a clean sheet, arm board (arm strap) and a pillow on the OR table Provide a clean kick bucket and pail Collect necessary stock and equipment Turn on aircon unit Help scrub nurse with setting up the theater Assist with counts and records

Before the Incision Begins

Provide 2 sponges on the operative site prior to incision Passes the 1st knife for the skin to the surgeon with blade facing downward and a hemostat to the assistant surgeon Hand the retractor to the assistant surgeon Watch the field/ procedure and anticipate the surgeons needs Pass the instrument in a decisive and positive manner Watch out for hand signals to ask for instruments and keep instrument as clean as possible by wiping instrument with moist sponge Always remove charred tissue from the cautery tip Notify circulating nurse if you need additional instruments as clear as possible Keep 2 sponges on the field Save and care for tissue specimen according to the hospital policy Remove excess instrument from the sterile field Adhere and maintain sterile technique and watch for any breaks

During the Induction of Anesthesia

Turn on OR light Assist the anesthesiologist in positioning the patient Assist the patient in assuming the position for anesthesia Anticipate the anesthesiologists needs If spinal anesthesia is contemplated: Place the patient in quasi fetal position and provide pillow Perform lumbar preparation aseptically Anticipate anesthesiologists needs

After the patient is anesthetized End of Operation

Reposition the patient per anesthesiologists instruction

Attached anesthesia screen and place the patients arm on the arm boards Apply restraints on the patient Expose the area for skin preparation Catheterize the patient as indicated by the anesthesiologist Perform skin preparation

a. b. c.

Operating room personnel must wear a sterile gown, gloves and special shoe covers. Hair must be completely covered. Masks must be worn at all times in the operating room for the purpose of minimizing airborne contamination; they must be changed between operations or more often if necessary.

During Operation

Remain in theater throughout operation Focus the OR light every now and then Connect diatherapy, suction, etc. Position kick buckets on the operating side Replenishes and records sponge/ sutures Ensure the theater door remain closed and patient s dignity is upheld Watch out for any break in aseptic technique

Any personnel who harbor pathogenic organisms (e.g. those with colds or infections) must report themselves unable to be in the operating room to protect the client from outside pathogens. Scrubbed personnel wearing sterile attire should touch only sterile items. Sterile gowns and sterile drapes have defined borders of sterility. Sterile surfaces or articles may touch other sterile surfaces or articles and remain sterile; contact with unsterile objects at any point renders a sterile area contaminated. The circulator and unsterile personnel must stay at the periphery of the sterile operating area to keep the sterile area free from contamination. The utmost caution and vigilance must be used when handling sterile fluids to prevent splashing or spillage. Anything that is used for one client must be discarded or, in some cases, resterilized.

End of Operation Emergency Nursing

Assist with final sponge and instruments count Signs the theater register Ensures specimen are properly labeled and signed A. General information

1.
Hands dressing to the scrub nurse Helps remove and dispose of drapes Helps to prepare the patient for the recovery room Assist the scrub nurse, taking the instrumentations to the service (washroom) Ensures that the theater is ready for the next case 2. 3. 4.

After an Operation

Emergency nursing deals with human responses to any trauma or sudden illness that requires immediate intervention to prevent imminent severe damage or death Care is provided in any setting to persons of all ages with actual or perceived alterations in physical or emotional health. Initially, patients may not have a medical diagnosis. Care is episodic when patients return frequently, primary when it is the initial option for health or preventive care, or acute when patients need immediate and additional interventions. Emergency nursing is a specialty area of the nursing profession like no other. Emergency nurses must be ready to treat a wide variety of illnesses or injury situations, ranging from a sore throat to a heart attack.

5. 6.

ROLE OF CIRCULATING NURSE

B. Historical Development of Emergency Nursing 1. 2. 3. 4. Responsible for managing the nursing care of the patient within the OR and coordinating the needs of the surgical team with other care provider necessary for completion of surgery Observes the surgery and surgical team from broad perspective and assists the team to create and maintain a safe and comfortable environment for the patient Asses the patients condition before, during and after the operation to ensure an optimal outcome for the patient Must be able to anticipate the scrub nurses needs and be able to open sterile packs, operate machinery and keep accurate records 1. 2. 3. 4. Florence Nightingale was the first emergency nurse, providing care to the wounded in the Crimean War in 1854 The Emergency Department Nurses Association (EDNA) was organized in 1970 A competency-based examination, first administered in 1980, provides Certification in Emergency Nursing; certification is valid for 4 years EDNA developed Standards of Emergency Nursing Practice, published in 1983, to be used as a guideline for excellence and outcome criteria against which performance is measured and evaluated In 1985, the Association name was changed to Emergency Nurses Association (ENA), recognizing the practice of emergency nursing as role-specific rather than site-specific. Originally ENA aimed at teaching and networking, the organization has evolved into an authority, advocate, lobbyist, and voice for emergency nursing. It has 30,000+ members and continues to grow, with members representing over 32 countries around the world.

5.
Principles of Surgical Asepsis Operating room personnel must practice strict standard precautions (i.e. blood and body substance isolation). All items (e.g. instruments, needles, sutures, dressings, covers, solutions) used in the operating room must be sterile. All operating room personnel must perform a surgical scrub. All operating room personnel are required to wear specific, clean attire, with the goal of shedding the outside environment. Specific clothing requirements are prescribed and standardized for all operating rooms. 6.

C. Emergency Care Environment

1.

Prehospital care by emergency medical services (EMS), emergency medical technicians, and paramedics provides initial stabilizations and transport of patients; personnel

2. 3. 4.

communicate with the emergency department during patient transport The national emergency telephone number 911 is the result of an effort to improve access to EMS The concept of the emergency room has expanded to that of the emergency department, which provides various levels of care Specialized electronic technology and techniques are used to monitor patient status continuously; these may pose safety hazards to patients, such as possible exposure to electric shock

6. 7. 8.

Duty to report suspected crimes to the police Duty to gather evidence in criminal investigations; be aware of hospital policy and state laws for evidence collection Advanced directives, including durable power of attorney and living wills

H. Qualifications of an Emergency Nurse 1. 2. An emergency nurse is a registered nurse with specialized education and experience in caring for emergency patients. Emergency nurses continually update their education to stay informed of the latest trends, issues, and procedures in medicine today. Many take a special examination that proves their level of knowledge. After successful completion of this exam they are certified in emergency nursing. Some emergency nurses also acquire additional certifications in the areas of trauma nursing, pediatric nursing, nurse practitioner, and various areas of injury prevention Many emergency nurses acquire additional certifications in the areas of trauma nursing, pediatric nursing, nurse practitioner, and various areas of injury prevention

D. Triage 1. 2. 3. Triage classifies emergency patients for assessment and treatment priorities Triage decisions require gathering objective and subjective data rapidly and effectively to determine the type of priority situation present Emergent situations are potentially life-threatening; they include such conditions as respiratory distress or arrest, cardiac arrest, severe chest pain, seizures, hemorrhage, severe trauma resulting in open chest or abdominal wounds, shock, poisonings, drug overdoses, temperatures over 105F (40.5C), emergency childbirth, or delivery complications Urgent situations are serious but not life-threatening if treatment is delayed briefly; they include such conditions as chest pain without respiratory distress, major fractures, burns, decreased level of consciousness, back injuries, nausea or vomiting, severe abdominal pain, temperature between 102 and 105F (38.9 and 40.5 C), bleeding from any orifice, acute panic, or anxiety Nonemergency situations are not acute and are considered minor to moderately severe; they include such conditions as chronic backache or other symptoms, moderate headache, minor burns, fractures, sprains, upper respiratory or urinary infections, or instances in which a patient is dead on arrival

3.
4. 5.

4.

Emergency First Aid I. Definition First aid is the immediate care given to a person who has been injured or has suddenly taken ill. If includes self-help and home care if medical assistance is not available or is delayed. It includes well-selected words of encouragement, evidence of willingness to help, and promotion of confidence by demonstration of competence. II. Reasons For First Aid A. First aid knowledge and skill often mean 1. The difference between life and death 2. The difference between temporary and permanent disability 3. The difference between rapid recovery and long hospitalization B. First aid training is of value in 1. Preventing and caring for accidental injury or sudden illness 2. Caring for persons caught in a natural disaster or other catastrophe 3. Equipping individuals to deal with the whole situation, the person, and the injury 4. Distinguishing between what to do and what not to do C. First aid training is needed because 1. Statistics show that among persons from age 1 to age 38, accidents are the leading cause of death, and thereafter they remain one of the leading causes.

5.

E. Roles of the Emergency Nurse

1. 2. 3. 4.

Care provider: provides comprehensive direct care to the patient and family. Educator: provides patient and family with education based on their learning needs and the severity of the situation and allows the patient to assume more responsibility for meeting health care needs Manager: coordinates activities of others in the multidisciplinary team to achieve the specific goal of providing emergency care Advocate: ensures protection of the patients rights

F. Functions of the Emergency Nurse 1. 2. 3. 4. 5. 6. Uses triage to determine priorities based on assessment and anticipation of the patients needs Provides direct measures to resuscitate, if necessary Provides preliminary care before the patient is transferred to the primary care area Provides health education to the patient and family Supervises patient care and ancillary personnel Provides support and protection for the patient and family

G. Legal issues affecting the provision of emergency nursing 1. 2. 3. 4. 5. Negligence Malpractice Good Samaritan Laws (these statutes may protect private citizens but usually do not apply to emergency personnel on duty or in normal emergency situations) Informed consent Implied consent

a. The death rate is twice as high among males as females. b. The annual cost of medical attention, loss of earning ability due to temporary or permanent impairment, and direct property damage and insurance costs amount to many billions of dollars each year. c. Accidents take their toll in pain and suffering, disability, and personal tragedy. d. Motor vehicle accidents account for approximately half of all accidental deaths. 2. The concept of massive numbers of casualties has become a reality with the advent of the nuclear age. 3. The pattern of medical care has changed. 4. The growing population and expanding health needs have not been balanced by a proportional increase in numbers of doctors, nurses, and allied health workers. 5. The limitation of time in case of an accident or sudden illness may be so critical in terms of minutes or even seconds that only a person with first aid knowledge and skills who is on hand has any opportunity of preventing a fatal outcome. D. First aid training promotes safety awareness in the home, at work, at play, and on streets and highways. In the promotion of such awareness, it is important to closely relate three terms: cause, effect, and prevention. 1. Cause When in-depth study of an actual or hypothetical accident situation identifies all the causative factors, it becomes possible to determine what can be done to eliminate, control, or avoid the hazards. 2. Effect When analysis carefully considers both immediate and long-range, or permanent, effects of injury or sudden illness, it becomes obvious why every possible effort should be taken to eliminate, control, or avoid a situation that is hazardous to oneself or to others 3. Prevention A better understanding of the overall accident problem is developed if all the circumstances surrounding various types of accidents are carefully studied. Preventive measures should include

consideration of how accidentcausing conditions and activities can be eliminated, controlled, or avoided. III. Value of First Aid Training A. Help for others Through the study of first aid, a person is prepared to assist others wisely if they are stricken, to give them instruction in first aid, and to promote among them a reasonable safety attitude. On a humanitarian basis, there is always an obligation to assist the stricken and the helpless. There is no greater satisfaction than that of relieving suffering or saving the life of a member of your family, a coworker, an acquaintance, or a stranger. B. Self-help In being prepared to help others, the first-aider is better able to care for himself in case of injury or sudden illness. Even when his condition is so bad that he is unable to care for himself, he can direct others in the correct procedures to be taken in his behalf. C. Preparation for disaster First aid training is of particular importance in time of catastrophe, when medical and hospital services are limited or delayed. Catastrophe may taken the form of well-publicized disasters, such as hurricanes, floods, earthquakes, tornadoes, and fires. It also may take the form of a single accidental death, or life-threatening illness. Knowing what to do in an emergency helps to avoid the panic and disorganized behavior characteristic of unprepared persons at such times. Knowledge of first aid is a civic responsibility: It not only helps to save lives and prevent complications from injuries but also helps in setting up an orderly method of handling emergency problems according to their priority for treatment so that the greatest possible good may be accomplished for the greatest number of people. IV. General Directions For Giving First Aid As a first-aider, you may encounter a variety of problem situations. Your decisions and actions will vary according to the circumstances that produced the accident or sudden illness, the number of persons involved, the immediate environment, the availability of medical assistance, emergency dressings and equipment, and help from others. You will need to adapt what you have learned to the situation at hand, or to improvise. Sometimes prompt action is needed to save a life. At other times there is no need for haste, and efforts will be directed toward preventing further injury, obtaining assistance, and reassuring the victim, who may be emotionally upset and apprehensive, as well as in pain. First aid begins with action, which in itself has a calming effect. If there are multiple injuries or if several persons are hurt, priorities must be set. Enlist the help of bystanders to make telephone calls, to direct traffic, to keep others at a distance if necessary, to position safety flares in case of highway accidents, and perform similar duties. Provide life support to victims with life-threatening injuries, then care for those with less critical injuries.

Telephone, or have someone else telephone, the appropriate authorities regarding an accident. The police department or the highway patrol is a good first contact: but the circumstances surrounding the accident should be a guide as to whom to call. Always have a list of emergency numbers available; if the numbers are not readily available, ask the telephone operator for assistance. Describe the problem, indicate what is being done, and request the assistance needed, such as an ambulance, the fire department, the rescue squad, or utility company personnel. Give your name, the location of the accident, the number of persons involved, and the telephone number where you can be reached. Do not hang up the receiver until after the other party hangs up because he may wish to clarify some information. A. Urgent care In case of serious injury or sudden illness, while help is being summoned, give immediate attention to the following first aid priorities: 1. Effect a prompt rescue. (For example, remove an accident victim from water, from a fire, or from a garage or room containing carbon monoxide, smoke, or noxious fumes.) 2. Ensure that the victim has an open airway and give mouth-to-mouth or mouth-to-nose artificial respiration, if necessary. 3. Control severe bleeding. 4. Give first aid for poisoning, or ingestion of harmful chemicals. B. Additional first aid directions Once emergency measures have been taken to ensure the victims safety, the following procedures should be carried out: 1. Do not move a victim unless it is necessary for safety reasons. Keep the victim in the position best suited to his condition or injuries; do not let him get up or walk about. 2. Protect the victim from unnecessary manipulation and disturbance. 3. Avoid or overcome chilling by using blankets or covers, if available. If the victim is exposed to cold or dampness, place blankets or additional clothing over and under him. 4. Determine the injuries or cause for sudden illness. After immediate problems are under control a. Find out exactly what happened. Information may be obtained from the victim or from persons who were present and saw the accident, or saw the individual collapse in the case of sudden illness.

b. Look for an emergency medical identification, such as a card or bracelet, which may provide a clue to the victims condition. c. If the victim is unconscious and has no sign of external injury, and if the above methods fail to provide identity, try to obtain proper identification either from papers carried in a billfold or purse, or from bystanders, so that relatives may be notified. (It is advisable to have a witness when searching for identification.) 5. Examine the victim methodically but be guided by the kind of accident or sudden illness and the needs of the situation. Have a reason for what you do. a. Loosen constricting clothing but do not pull on the victims belt in case spinal injuries are present. b. Open or remove clothing if necessary to expose a body part in order to make a more accurate check for injuries. Clothing may be cut away or ripped at the seams, but utmost caution must be used or added injury may result. Do not expose the victim unduly without protective cover, and use discretion if clothing must be removed. c. Note the victims general appearance, including skin discoloration, and check all symptoms that may give a clue to the injury or sudden illness. In the case of a victim with dark skin, change in skin color may be difficult to note. It may then be necessary to depend upon change in the color of the mucous membrane, or inner surface of the lips, mouth, and eyelids. d. Check the victims pulse. If you cannot feel it at the wrist, check for a pulse of the carotid artery at the side of his neck. e. Check to see if the victim is awake, stuporous, or unconscious. Does he respond to questions? f. If the victim is unconscious, look for evidence of head injury. In a conscious person, look for paralysis of one side of the face or body. See if the victim shows evidence of a recent convulsion. (He may have bitten his tongue, producing a laceration.)

g. Check the expression of the victims eyes and the size of his pupils. h. Example the victims trunk and limbs for open and closed wounds or for signs of fractures. i. Check the front of the victims neck to determine whether he is a laryngectomy. (Most laryngectomys carry a card or other identification stating that they cannot breathe through the nose or mouth.) Do not block the stoma (air inlet) of a laryngectomy when carrying out other first aid, since blockage could cause death from asphyxiation. j. If poisoning is suspected, check for stains or burns about the victims mouth and a source of poisoning nearby, such as pills, medicine bottles, household chemicals, or pesticides. 6. Carry out the indication first aid: a. Apply emergency dressing, bandages, and splints, as indicated. b. Do not move the victim unless absolutely necessary. c. Plan action according to the situation, and the availability of human and material resources. d. Utilize proper first aid measures and specific techniques that, under the circumstances, appear to be reasonably necessary. e. Remain in charge until the victim can be turned over to qualified persons (for example, a physician, and ambulance crew, a rescue squad, or a police officer), or until the victim can take care of himself or can be placed in the care of relatives. f. Do not attempt to make a diagnosis of any sort or to discuss a victims condition with bystanders or reporters. g. Above all, as a first aid worker, you should know the limits of your capabilities and must make every effort to avoid further injury to the victim in your attempt to provide the best possible emergency first aid care. Cataract

Cataract is a clouding, or opacity of the lens that leads to blurring of vision and eventual loss of sight. The opacity of the lens is caused by chemical changes in the protein of the lens because of slow degenarative changes of age, injury, poison or intraocular infection. Cataracts occur so often in the aged. At 80 years of age, about 85% of all people have some clouding of the lens. Risk factors for cataract development includes diabetes, exposure to ultraviolet light or high dose radiation, and drugs such as corticosteroids, phenothiazines, and some chemotherapy agents. If untreated, cataracts progress to blindness.

Classification of Cataract

1. 2. 3. 4.

Senile cataracts commonly develop in elderly patient because of degenerative changes in lens proteins. Congenital cataracts occur in neonates as genetic defects or possibly from measles in the mother. Traumatic cataracts may occur after injury sufficient to force vitreous humor into the lens capsule. Secondary cataracts may occur following other eye or systemic diseases.

Assessment 1. 2. Gradual painless vision loss, blurred or distorted vision. Pupil may appear milky or white.

Diagnostic Evaluation 1. 2. Slit-lamp examination provides magnification and confirms diagnosis of an opacity. Other testing to rule out coexisting condition of the eye; tonometry (to determine if there is increased intraocular pressure [IOP], direct and indirect opthalmoscopy ( to rule out disease of retina), perimetry (to detect any loss of visual field).

Surgical Interventions 1. Surgery is the only cure and is recommended when vision causes problems in daily activities. Extracapsular extraction is usually done by cryosurgery or phacoemulsification under local anesthesia. o Eye drops are given to decrease response to pain and lessen motor activity of the eye. o Medication is given to reduce IOP. An intraocular lens implant is usually inserted at the time of surgery, designed for distance vision. Congenital cataract is corrected within first 3 months followed by cataract lens to correct vision. Nonsteroidal anti-inflammatory agents, antibiotic ointments, and possible corticosteroids may be necessary after lens implantation to reduce inflammation on other eye structures and prevent infection. If patient is not candidate for lens implant, the lens and capsule are removed (intracapsular extraction), and eye glasses and contact lenses are used to correct vision.

2. 3. 4.

5.

Nursing Interventions 1. 2. Before surgery, monitor for worsening of visual acuity, glare, and ability to perform usual activities. Monitor pain level postoperatively. Sudden onset may be caused by a ruptured vessel or suture and may lead to hemorrhage. Severe pain accompanied by nausea and vomiting may be caused by increased IOP. Assess gradual adaptation to lens implant, contact lens, or glasses.

3.

4. 5. 6.

7. 8. 9. 10. 11.

Keep the patient comfortable and advise him not to touch his eyes. If eye patch or shield is in place, advise using it for several days as prescribed, to rest and protect eye, especially at night. Caution the patient against coughing or sneezing, any rapid moment, bending from the waist to prevent increased IOP for first 24 hour. Instruct the patient to avoid heavy lifting or straining for up to 6 weeks, as directed by surgeon. Advise patient to increase activity gradually; can usually resume normal activity the day after the procedure. Teach proper installation of the eye. Encourage to follow up ophthalmologic examinations for corrective lenses and checking of IOP. Adjustment to eye glasses to correct vision may take weeks. Advise the patient not to get soap in the eyes. Advise the patient to avoid tilting the head forward when washing hair, and to avoid vigorous hand shaking, to prevent disruption of the lens until cleared by the surgeon.

1. 2.

Surgical removal is the only effective treatment (simple appendectomy or laparoscopic appendectomy). Preoperatively, maintain patient on bed rest, NPO status, I.V. hydration, possible anti-biotic prophylaxis, and analgesia, as directed.

Nursing Interventions 1. Monitor frequently for signs and symptoms of worsening condition, indicating perforation, abscess, or peritonitis (increasing severity of pain, tenderness, rigidity, distention, absent bowel sounds, fever, malaise, and tachycardia). Notify health care provider immediately if pain suddenly ceases, this indicates perforation, which is a medical emergency. Assist patient to position of comfort such as semi-fowlers with knees are flexed. Restrict activity that may aggravate pain, such as coughing and ambulation. Apply ice bag to abdomen for comfort. Avoid indiscriminate palpation of the abdomen to avoid increasing the patients discomfort. Promptly prepare patient for surgery once diagnosis is established. Explain signs and symptoms of postoperative complications to report-elevated temperature, nausea and vomiting, or abdominal distention; these may indicate infection. Instruct patient on turning, coughing, or deep breathing, use of incentive spirometer, and ambulation. Discuss purpose and continued importance of these maneuvers during recovery period. Teach incisional care and avoidance of heavy lifting or driving until advised by the surgeon. Advise avoidance of enemas or harsh laxatives; increased fluids and stool softeners may be used for postoperative constipation.

2. 3. 4.

Appendicitis

5. 6. 7. 8. 9.

Is inflammation of the vermiform appendix caused by an obstruction attributable by infection, stricture, fecal mass, foreign body or tumor. It can affect by either gender at any age, but is most common in males ages 10 to 30. It is the most common disease requiring surgery. If left untreated, appendicitis may progress to abscess, perforation, subsequent peritonitis, and death.

Assessment 1. 2. 3. 4. 5. Generalized or localized abdominal pain occurs in the epigastric or periumbilical areas in the upper right abdomen. Within 2 to 12 hours, the pain localizes in the right lower quadrant and intensity increases. Anorexia, fever, nausea, vomiting, and constipation may also occur. Bowel sounds may be diminished. Tenderness anywhere in the right lower quadrant. o Often localized at McBurneys point, just below midpoint of line between umbilicus and iliac crest on the right side. o Guarding and rebound tenderness to right lower quadrant and referred rebound when palpating the left lower quadrant. Positive Psoas Sign. o Have the patient attempt to raise the right thigh against the pressure of your hand placed over the right knee. o Increased abdominal pain indicates inflammation of the psoas muscle in acute appendicitis. Positive Obturator Sign. o Flex the patients right hip and knee and rotate the leg internally. o Hypogastric pain indicates inflammation of the obturator muscle.

10. 11.

Fetal Circulation

1. 2. 3. 4. 5. 6. 7. 8.

How to Perform LeopoldOxygenated blood enters the umbilical vein from the placenta Enters ductus venosus Passes through inferior venacava Enters the right atrium Enters the foramen ovale Goes to the left atrium Passes through left ventricle Flows to ascending aorta to supply nourishment to the brain and upper extremeties

6.

7.

Diagnostic Evaluation 1. 2. 3. 4. WBC count shows moderate leukocytosis (10,000 to 16,000/mm) with shift to the left (increased immature neutrophils) in WBC differential. Urinalysis rules out urinary disorders. Abdominal X-ray visualizes shadow consistent with fecalith in appendix. Pelvic sonogram rules out ovarian cyst or ectopic pregnancy.

9. Enters superior vena cava 10. Goes to right atrium 11. Enters the right ventricle 12. Enters pulmonary artery with some blood going to the lungs
to supply oxygen and nourishment

13. Flows to ductus arteriosus 14. Enters descending aorta ( some blood going to the lower
extremeties)

15. Enters hypogastric arteries 16. Goes back to the placenta

Special Structures in Fetal Circulation Placenta Where gas exchange takes place during fetal life

Surgical Interventions

Umbilical Arteries Carry unoxygenated blood from the fetus to placenta Umbilical Vein Brings oxygenated blood coming from the placenta to the fetus Foramen Ovale Connects the left and right atrium. It pushes blood from the right atrium to the left atrium so that blood can be supplied to brain, heart and kidney Ductus Venosus - Carry oxygenated blood from umbilical vein to inferior venacava, bypassing fetal liver Ductus Arteriosus - Carry oxygenated blood from pulmonary artery to aorta, bypassing fetal lungs. Provide excellent clues to the physiological functioning of the body. Alteration in body fxn are reflected in the body temp, pulse, respirations and blood pressure. These data provide part of the baseline info from which plan of care is developed. Any change from normal is considered to be an indication of the persons state of health. Also called Cardinal Signs. Heat producing & Heat losing Mechanisms Heat production: most body heat is produced by the oxidation of foods, the rate at which it is produced is called METABOLIC RATE. Heat Loss: Radiation Conduction Convection Evaporation Pre optic area of the HYPOTHALAMUS Temperature regulator; thermostat Receives input from temp receptors in the skin & mucous membranes (peripheral thermoreceptors) & internal structures (central thermoreceptors) * if blood temp increases, neurons of the pre optic area fire nerve if it decreases. Heat Promoting Centers VASOCONSTRICTION = Less blood flow from the internal organs to the skin = less heat transfer from the internal organs to the skin = increases internal body temp SYMPATHETIC STIMULATION = stimulation of sympathetic nerves leading to the adrenal medulla = secretes epinephrine & norepinephrine = Increases cellular metabolism = increases heat production

SKELETAL MUSCLES = stimulation of part of the brain that increases muscle tone (stretch reflex + contraction of muscles = SHIVERING) = heat production THYROXINE = increases metabolism = increase in body temp Body Temperature Abnormalities FEVER/hyperthermia/hyperpyrexia - An abnormally high temp mainly results from infection from bacteria (& their toxins) & viruses. (stimulates prostaglandin secretion) Other causes: heart attacks, tumors, tissue destruction by x ray, surgery or trauma & rxns to vaccines. HEAT CRAMPS AND HEAT EXHAUSTION - Due to fluid & electrolyte loss HEAT STROKE HYPOTHERMIA The THERMOMETER A glass clinical thermometer is most commonly used to measure body temperature. It has 2 parts: BULB contains mercury which expands when exposed to heat & rise in the stem STEM is calibrated in degrees of Celcius or Fahrenheit Sites for Obtaining Body Temperature ORAL most common site (3 or 7 to 10minutes) C.I. : unconscious, irrational, seizure prone patients and infants & young children, those who breath through their mouth or for those with diseases/sugery of their mouth or nose. RECTAL most accurate, used when obtaining an oral temp is contraindicated (2 to 3 minutes) C.I. : rectal surgery, diarrhea, other diseases of the rectum, certain heart diseases. AXILLARY used when both oral & rectal are not accessible. Commonly used site (10minutes or more)

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1.

Oral

These are indices of health, or signposts in determining clients condition. This is also known as cardinal signs and it includes body temperature, pulse, respirations, and blood pressure. These signs have to be looked at in total, to monitor the functions of the body. Different considerations in Taking Vital signs 1) The frequency of taking TPR and BP depends upon the condition of the client and the policy of the institution. The procedure should be explained to the client before taking his TPR and BP. Obtain baseline data.

This is the most accessible and convenient. However, because of the mercury in glass thermometer, this is contraindicated for children under 6 years and clients who are confused or who have convulsive disorder.

2.

Rectal

This is considered the most accurate. However, it is inconvenient and more unpleasant for client. It is contraindicated for clients who are undergoing rectal surgery or have diarrhea or diseases of the rectum.

2)

3.

Axillary

3)

1. BODY TEMPERATURE Factors that Affect Body Temperature

This is the safest and most noninvasive. It is the preferred site for measuring temperature in newborns because there was no possibility of rectal perforation.

4.

Tympanic membrane

1.

Age

The infant is greatly influenced by the temperature of the environment and must be protected from extreme changes. Childrens temperature continue to be more labile than those of adults until puberty. Elderly people are at risk of hypothermia for variety of reasons. Such as lack of central heating, inadequate diet, loss of subcutaneous fat, lack of activity, and reduced thermoregulatory efficiency.

This is readily accessible and reflects the core temperature. The tympanic has an abundant arterial blood supply, primarily from branches of the external carotid artery. The noninvasive infrared thermometers are now used for this purpose. Nursing Interventions for Clients with fever (Fund. Of Nursing, Kozier, et al.) 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. Monitor vital signs. Assess skin color and temperature. Monitor white blood cell count, hematocrit value, and other pertinent laboratory records. Remove excess blankets when the client feels warm, but provide extra warmth when the client feels chilled. Provide adequate food and fluids to meet the increased metabolic demands and prevent dehydration, if health permits. Clients who sweat profusely can become dehydrated. Measure intake and output. Maintain prescribed intravenous fluids. Reduce physical activity to limit heat producing, especially the flush stage. Administer antipyretics as ordered. Provide oral hygiene to keep the mucous membranes moist. They can become dry and cracked because of excessive fluid loss. Provide a tepid sponge bath to increase heat loss through conduction. Provide dry clothing and bed linens to increase heat loss through conduction.

2.

Diurnal variations (circadian rhythms)

This refers to the sleep wake rhythm of the body, a pattern that varies slightly from person to person. Body temperature normally changes throughout the day, varying as much as 1.0C between the early morning and the late afternoon.

3.

Exercise Hard work or strenuous exercise can increase body temperature.

4.

Hormones

Women usually experience more hormone fluctuations than men do. Progesterone secretion at the time of ovulation raises body temperature above basal temperature.

5.

2. Pulse Stress Stimulation of the SNS can increase the production of epinephrine and norepinephrine, thereby increasing metabolic activity and heat production. This is a wave of blood created by contraction of the left ventricle of the heart. The heart is a pulsating pump, and the blood enters the arteries with each heartbeat, causing pressure pulses or pulse waves. Generally, the pulse wave represents the stroke volume and the compliance of the arteries. Stroke volume is the amount of blood that enters the arteries with each contraction in a healthy adult. Compliance of the arteries is their ability to contract and expand. When a persons arteries lose their distensibility, greater pressure is required to pump the blood into the arteries.

6.

Environment Extremes in environmental temperatures can affect a persons temperature regulatory systems.

Common Sites for Measuring BT

Peripheral pulse is the pulse located in the periphery of the body, for example in the foot, hand and neck. Apical pulse is a central pulse. It is located at the apex of the heart. Factors Affecting Pulse Rate

2.

Pulse rhythm

1.

Age As age increases, the pulse rate gradually decreases.

This is the pattern of the beats and the intervals between the beats. Equal time elapses between beats of a normal pulse. A pulse with an irregular rhythm is referred to as a dysrhythmia or arrhythmia. It may consist of random, irregular beats or a predictable pattern of irregular beats.

3.

Pulse volume

2.

Sex

After puberty, the average males pulse rate is slightly lower than the females.

3.

Exercise Pulse rate normally increases with activity.

This is also called the pulse strength or amplitude. It refers to the force of blood with each beat. It can range from absent to bounding. A normal pulse can be felt with moderate pressure of the fingers and can be obliterated with greater pressure. A forceful or full blood volume that is obliterated only with difficulty is called a full or bounding pulse. A pulse that is readily obliterated with pressure from the fingers is referred to as weak, feeble, or thready. A pulse volume is usually measured on a scale 0 to 3. Pulse Sites

4.

Fever

1. 2. 3. 4. 5. 6. 7. 8.

Temporal, where the temporal artery passes over the temporal bone of the head. The site is superior and lateral to the eye. Carotid, at the side of the neck below the lobe of the ear, where the carotid artery runs between the trachea and the sternocleidomastoid muscle. Apical, at the apex of the heart. Brachial, at the inner aspect of the biceps muscle of the arm (especially in infants) or medially in the antecubital space (elbow crease). Radial, where the radial artery runs along the radial bone, on the thumb site of the inner aspect of the wrist. Femoral, where the femoral artery passes alongside the inguinal ligament. Popliteal, where the popliteal artery passes behind the knee. This point is difficult to find, but it can be palpated if the client flexes the knee slightly. Poserior tibial, on the medial surface of the ankle where the posterior tibial artery passes behind the medial malleolus. Pedal (dorsalis pedis), where the dorsalis pedis artery passes over the bones of the foot. This artery can be palpated by feeling the dorsum of the foot on the imaginary line drawn from the middle of the ankle to the space between the big and second toes.

The pulse rate increases in response to the lowered blood pressure that results from peripheral vasodilation associated with elevated body temperature, and because of the increased metabolic rate.

5.
it.

Medications Some medications decrease the pulse rate, and others increase

6.
pulse rate.

Hemorrhage Loss of blood from the vascular system normally increases

7.

Stress

9.

In response to stress, sympathetic nervous stimulation increases the overall activity of the heart. Stress increases the rate as well as the force of the heartbeat.

8.

Position changes

3. RESPIRATION Assessing Respirations Resting respirations should be assessed when the client is at rest because exercise affects respirations, and increase their rate and depth as well. Respiration may also need to be assessed after exercise to identify the clients tolerance to activity. Before assessing a clients respirations, a nurse should be aware of: The clients normal breathing pattern. The influence of the clients health problems on respirations. Any medications or therapies that might affect respirations. The relationship of the clients respirations to cardiovascular function.

When a person assumes a sitting or standing position, blood usually pools in dependent vessels of the venous system. Pooling results in a transient decrease in the venous blood return to the heart and a subsequent reduction in blood pressure reduction in blood pressure and increase in the heart rate.

Characteristics of Normal Pulse

1.

Rate

This is the number of pulse beats per minute (70 80 beats/min in the adult). An excessively fast heart rate (100 beats/min) is referred to as tachycardia. A heart rate in the adult of 60 beats/minute or less is called bradycardia.

Characteristics of Normal Respiration

1.

Respiratory rate

2)

Peripheral Vascular Resistance

This is described in breaths per minute. A healthy adult normally takes between 15 and 20 breaths per minute. Breathing that is normal in rate is eupnea. Abnormally slow respirations are referred to as bradypnea, and abnormally fast respirations are called tachypnea or polypnea.

This can increase blood pressure. The diastolic pressure is especially affected. The following are factors that create resistance in the arterial system: a. Size of the arterioles and capillaries. This determines in great part the peripheral resistance to the blood in the body pressure, whereas decreased vasoconstriction lowers the blood pressure. Compliance of the arteries. The arteries contain smooth muscles that permit them to contract, thus decreasing their compliance (distensibility). The major factor reducing arterial compliance is pathologic change affecting the arterial walls. The elastic and muscular tissues of the arteries are replaced with fibrous tissues. The condition, most common in middle-aged and elderly adults, is known as arteriosclerosis. Viscosity of the blood.

2.

Depth b.

This can be established by watching the movement of the chest. It is generally described as normal, deep, or shallow.

3.

Respiratory rhythm or pattern

This refers to the regularity of the expirations and the inspirations. Normally, respirations are evenly spaced. Respiratory rhythm can be described as regular or irregular.

4.

Respiratory quality or character 3)

c.

This refers to those aspects of breathing that are different from normal, effortless breathing. It includes:

a. b.

Blood volume. When the blood volume decreases, the blood pressure decreases because of decreased fluid in the arteries. Conversely, when the volume increase, the blood pressure increases because of the greater fluid volume within the circulatory system. Blood viscosity. This is a physical property that results from friction of molecules in a fluid. The blood pressure is higher when the blood is highly viscous, that is, when the proportion of RBCs to the blood plasma is high. This ratio is referred to as the hematocrit is more than 60 to 65%

Amount of effort a client must exert to breathe. Usually, breathing does not require noticeable effort. The sound of breathing. Normal breathing is silent, but a number of abnormal sounds such as a wheeze are obvious to the nurses ear.

4)

4. BLOOD PRESSURE This is the force exerted by the blood against a vessel wall. Arterial blood pressure is a measure of the pressure exerted by the blood as it flows through the arties. There are two blood pressure measures:

Factors Affecting Blood Pressure 1.) Age. Newborn have a mean systolic pressure of 78mmHg. The pressure rises with age. The pressure rises with age, reaching a peak at the onset of puberty, and then tends to decline somewhat. Exercise. Physical activity increase both the cardiac output and hence the blood pressure. Thus, a rest of 20 to 30 minutes is indicated before the blood pressure can be readily assessed. Stress. Stimulation of the sympathetic nervous system increase cardiac output and vasoconstriction of the arterioles, thus increasing the blood pressure. Race. African American males over 35 years have higher blood pressure than European American males of the same age. Obesity. Pressure is generally higher in some overweight and obese people than in people of normal weight. Sex. After puberty, females usually have lower blood pressures than males of the same age; this difference is thought to be due to hormonal variations. After menopause, women generally have higher blood pressures than before. Medications. Many medications may increase or decrease the blood pressure; nurses should be aware of the specific medications a client is receiving and consider their possible impact when interpreting blood pressure readings. Diurnal variations. Pressure is usually lowest early in the morning, when the metabolic rate is lowest, then rises

1. 2.

Systolic pressure. This is the pressure of the blood because of contraction of the ventricles, which is the height of the blood wave. Diastolic pressure. This is the pressure when the ventricles are at rest. It is the lower pressure present at all times within the arteries.

2.)

3.)

Pulse pressure is the difference between the diastolic and systolic pressures. 4.) Blood pressure is measured in millimeters of mercury (mm Hg) and recorded as a fraction. The systolic pressure is written over the diastolic pressure. The average blood pressure of a healthy adult is 120/80 mm Hg. A number of conditions are reflected by changes in blood pressure. The most common is hypertension, an abnormally high blood pressure. Hypotension is an abnormally low blood pressure below 100min Hg systolic. Physiology of Arterial Blood Pressure 1) Pumping action of the heart 7.) Cardiac output is the volume of blood pumped into the arteries by the heart. When the pumping action of the heart is weak, less blood is pumped into arteries, and the blood pressure decreases. When the hearts pumping action is strong and the volume of blood pumped into the circulation increases, the blood pressure increases. Cardiac output increases with fever and exercise.

5.)

6.)

8.)

throughout the day and peaks in the late afternoon or early evening. 9.) Disease process. Any conditions affecting the cardiac output, viscosity, and or compliance of the arteries have a direct effect on the blood pressure.