Third Edition
Editors
Annamma
Jacob
MSc (N)
Professor, Bhagwan Mahaveer Jain College of Nursing
Bengaluru,
Karnataka,
India
Formerly
Professor, St Philomina’s College of Nursing
Bengaluru,
Karnataka,
India
Principal, Graduate School for Nurses, BNE, SIB, CMAI
Bengaluru,
Karnataka,
India
Nurse Supervisor, Suburban Medical Center
Paramount,
Southern California,
USA
Assistant Director of Nursing, Al-Sabah Hospital, Ministry of Public Health
Kuwait,
Sister Tutor, LT College of Nursing, SNDT Women’s University
Mumbai,
Maharashtra,
India
Junior Tutor, College of Nursing, CMC Hospital
Vellore,
Tamil Nadu,
India
Rekha
R
MSc (N)
Registered Nurse, Medical-Surgical Department Florida Medical Center
Fort Lauderdale,
Florida,
USA
Formerly
Assistant Professor, Sree Mookambika College of Nursing
Kanyakumari,
Tamil Nadu,
India
Vice-Principal, Bhagwan Mahaveer Jain College of Nursing
Bengaluru,
Karnataka,
India
Jadhav
Sonali Tarachand
MSc (N) PGDMLE
Professor, MS Ramaiah Institute of Nursing Education and Research
Bengaluru,
Karnataka,
India
Formerly
Associate Professor of Nursing, Bhagwan Mahaveer Jain College of Nursing,
Bengaluru,
Karnataka,
India
Lecturer, Medical-Surgical Nursing, St Martha’s College of Nursing,
Bengaluru,
Karnataka,
India
Assistant Lecturer, Bharati Vidyapeeth’s College of Nursing,
Pune,
Maharashtra,
India
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Clinical Nursing Procedures: The Art of Nursing Practice
First Edition: 2007
Second Edition: 2010
Third Edition: 2015
9789351525332
Printed at
5CONTRIBUTORS
-
Anita Grace Daniel BSc (N)
-
Assistant Lecturer of Nursing
-
Bhagwan Mahaveer Jain College of Nursing
-
Bengaluru, Karnataka, India
-
Annamma Jacob MSc (N)
-
Professor, Bhagwan Mahaveer Jain College of Nursing
-
Bengaluru, Karnataka, India
-
Anne Dorcas BSc (N)
-
Assistant Lecturer of Nursing
-
Bhagwan Mahaveer Jain College of Nursing
-
Bengaluru, Karnataka, India
-
Harsha Joy BSc (N)
-
Assistant Lecturer of Nursing
-
Bhagwan Mahaveerr Jain College of Nursing
-
Bengaluru, Karnataka, India
-
Jadhav Sonali Tarachand MSc (N) PGDMLE
-
Associate Professor of Nursing
-
Bhagwan Mahaveer Jain College of Nursing
-
Bengaluru, Karnataka, India
-
Jain Binny John BSc (N)
-
Assistant Lecturer of Nursing
-
Bhagwan Mahaveer Jain College of Nursing
-
Bengaluru, Karnataka, India
-
Jessy Jacob MSc (N)
-
Assistant Professor of Nursing
-
Bhagwan Mahaveer Jain College of Nursing
-
Bengaluru, Karnataka, India
-
Lakshmi BSc (N)
-
Assistant Lecturer of Nursing
-
Bhagwan Mahaveer Jain College of Nursing
-
Bengaluru, Karnataka, India
-
Mary Daniel BSc (N)
-
Assistant Lecturer of Nursing
-
Bhagwan Mahaveer Jain College of Nursing
-
Bengaluru, Karnataka, India
-
Nalini SR BSc (N)
-
Assistant Lecturer of Nursing
-
Bhagwan Mahaveer Jain College of Nursing
-
Bengaluru, Karnataka, India
-
Naveena J BSc (N)
-
Assistant Lecturer of Nursing
-
Bhagwan Mahaveer Jain College of Nursing
-
Bengaluru, Karnataka, India
-
Rekha R MSc (N)
-
Registered Nurse
-
Medical-Surgical Department, Florida Medical Center
-
Fort Lauderdale, Florida, USA
-
Sindhu Narendran BSc (N)
-
Assistant Lecturer of Nursing
-
Bhagwan Mahaveer Jain College of Nursing
-
Bengaluru, Karnataka, India
-
Subha Shankari G BSc (N)
-
Assistant Lecturer of Nursing
-
Bhagwan Mahaveer Jain College of Nursing
The third edition of Clinical Nursing Procedures: The Art of Nursing Practice is prepared with the intent to promote nursing as an expanding art and science, directed to human health and well-being. Our objective is to prepare nurses to combine the highest level of scientific knowledge and technological skills with responsible caring practice. Nurses today need skills in technology, communication and interpersonal relations to be effective members of the healthcare team, as well as, meet the demands of the changing healthcare system. They need skills in teaching, collaborating, leading, managing, advocacy and applying theory and research to practice.
This edition of the book retains all the content which have been well-received by faculty and student nurses who have used the previous editions. Revisions are made in certain procedures such as Basic Life Support (BLS) and Advanced Cardiac Life Support (ACLS) in accordance with the 2010 American Heart Association’s guidelines. Newly added information includes a chapter each on legal and ethical aspects of nursing practice. This information, the authors’ thought, is essential to understand the legalities involved with performance of procedures and techniques and enable nurses to practice safely and effectively as trained workers.
One of our primary goals in preparing the revised edition has been to help prepare nursing students to provide the quality care to patients of all age groups and families across healthcare settings and in the home, in safe and effective manner. We hope we have succeeded in that and we welcome the feedback from our readers.
Annamma Jacob
Rekha R
Jadhav Sonali Tarachand
8
9PREFACE TO THE FIRST EDITION
Today’s nursing practice has evolved through many changes influenced by advances in science and technology which has made medical care more complex. As modalities for diagnosing and treating illnesses and managing patients in different stages of health-illness continuum change, several nursing procedures are added and rewritten.
Use of specialized equipment, articles and assisting with advanced procedures have become a necessity in caring for patients. Several nursing procedures taught and practiced in yesteryears have become obsolete as a result of new knowledge of disease pathology and therapy.
The growing body of nursing research further challenges and stimulates nurses to acquire new knowledge and refine their critical thinking skills. Nursing education today aims to provide students a broad knowledge base which would help them provide expert and need-based care to clients with varying health problems. It is, therefore, essential that they master basic theories and skills and become equipped to further develop and refine their abilities to apply analytical thinking in clinical situations.
Nurse educators in India have always been faced with the need to have reference materials suited to present-day practice standards. Books which meet the above criteria are written in the context of developed countries where advanced equipment and commercially prepared articles and materials are used for performing most nursing procedures. A procedure manual, written in the Indian context, where healthcare facilities range from most advanced in the tertiary level multispecialty hospitals in large cities to primary care centers in rural India has been a felt need.
This manual will help in preparing nurses who can demonstrate critical thinking and analytical ability, capable of making adaptations in varying situations. A manual of procedures that is relevant to the present-day nursing practice in India has been a need, felt by nurse educators here. The book Clinical Nursing Procedures: The Art of Nursing Practice is an all-in-one compilation of nursing procedures.
Basic, advanced and community health nursing procedures are organized and presented in 15 chapters.
The editors and contributors have taken care to present the material in a concise, straight forward and simplified format in an easy-to-follow language and most importantly in the Indian context. Scientific rationale of every nursing action is included so as to enable nursing students and practicing nurses to use sound clinical judgment while emphasizing cognitive, interpersonal and psychomotor skills needed to carry out nursing procedures. Special considerations are included wherever additional explanations for deviations and adaptations are required.
The contents of the book include nursing procedures to be performed independently by nurses and interdependently by providing assistance to either healthcare professionals or clients themselves. Most nursing procedures prescribed for undergraduate education by apex bodies in India are included.
A special feature of this book authored and contributed by Indian nurses is the many illustrations and colored photographs which would aid to master and reinforce the skills of nursing students as well as practicing nurses.
The editors are confident that this book will prove to be a useful tool for undergraduate students as well as professional nurses working in different settings all over India.
Annamma Jacob
Rekha R
Jadhav Sonali Tarachand
10
11ACKNOWLEDGMENTS
It takes more than a great determination and sustained interest to write a book . For completion of the task, encouragement, support and cooperation of many are essential.
For the production of this book, the editors are deeply thankful to the administration of Bhagwan Mahaveer Jain College of Nursing, Bengaluru, Karnataka, India. The President of Bhagwan Mahaveer Memorial Jain (BMMJ) Trust Mr Sampathraj Gadia always encouraged us and provided the freedom and the facilities needed to the principal and senior faculty of the college to gather knowledge and teach professional nursing of high quality to their students. The members of BMMJ Trust, Mr Parasmal Bansali and Mr Phoolchand Jain did an excellent job by providing the library in the college with a large collection of books and periodicals for reference. This greatly enhanced preparation of materials for the book.
As the idea of putting together all the nursing procedures taught to nursing students in the college emerged in the minds of the first group of faculty, the Chief Executive Officer of the Hospital and College of Nursing, Dr Kishore Murthy offered great encouragement and support. The editors are thankful to Dr Kishore Murthy.
Most of the faculty members who worked in the college of nursing, since its inception in 2003, contributed by way of writing and editing the procedures for the book. The editors thank each one of them for their contribution.
The nursing staff of Bhagwan Mahaveer Jain (BMJ) Hospital whose practice standards needed updation for providing safe and effective nursing care to patients and the students of BMJ College of Nursing were our inspiration to embark on the task of preparing this manual of nursing procedures.
For the many photographs and illustrations included in the book, college and hospital staff, their family members, students and patients offered themselves and their efforts, and we record our sincere thanks to everyone of them.
It was Ms Anuradha, who in the final stages undertook the job of typing all the material in a professional manner. The preliminary work was done by Mrs Vachala, Mrs Sudheshna Mukherjee and Ms Sylvia Eileen. We thankfully acknowledge their contributions.
Finally, but importantly, we once again acknowledge the administration of BMJ College of Nursing, the BMMJ Trust in honor of which this book may be published.
- Appendix 1 Nursing Health History Format
- Appendix 2 Latin Terms Used in Medication Orders
- Appendix 3 Weights and Measurements
- Appendix 4 Drug Calculation Formulae
- Appendix 5 Abbreviations
- Appendix 6 Urine Chemistry—Normal Values
- Appendix 7 Hematology—Normal Values
- Appendix 8 Serum, Plasma and Whole Blood Chemistry
- Appendix 9 Cerebrospinal Fluid Analysis
- Appendix 10 Fecal Analysis—Normal Values
- Appendix 11 Antenatal Assessment Format
- Appendix 12 Newborn Assessment Format
- Appendix 13 Formulae for Assessing Growth Parameters in Children
- Appendix 14 Postnatal Assessment Format
- Appendix 15 Assessment of Postoperative Cesarean Section Mothers
- Appendix 16 Assessment of Patient with Gynecological Problems674
Appendix 1: Nursing Health History Format
Appendix 2: Latin Terms Used In Medication Orders
Time and frequency of medication administration
ac | = ante cibos | = Before meals |
pc | = post cibos | = After meals |
b.d or bid | = bis in die | = Twice a day |
H.S | = hora somni | = At bed time |
Noct | = nocte | = Night |
od | = Once a day | |
prn | = proarenate | = When required |
sos | = sli opus sit | = If needed |
stat | = statim | = At once |
tid/tds | = ter in die | = Three times a day |
qid | = quartuor die | = Four times a day |
q | = quoque | = Each/every |
q4h | = Every four hours | |
q6H | = Every six hours | |
qh | = Every hour | |
q am | = Every morning | |
qod | = Every other day | |
qs | = Sufficient quantity | |
adlib | = Freely as desired | |
dil | = Dilute, dissolve |
Amount to be given
| |
gr | = Grain |
Gm/g/gm | = Gram |
gtt | = Drops |
ss or s | = One-half |
Form of medication
Cap | = Capsule | |
Tab | = Tablet | |
Inj | = Injection | |
Mist | = Mixture | |
Syr | = Syrup | |
Susp | = Suspension | |
Tr/Tinct | = Tincture | |
Ung | = Ointment | |
Oc | = Occulentum | = Eye ointment |
Collyr | = Collyrium | = Eye lotion |
Comp | = Compound | |
Elix | = Elixir | |
Supp | = Suppository | |
Pulv | = Powder | |
aq | = aqueous |
Where to administer
Aur | = Qurist | = Ear |
OD | = Oculus dexter | = Right eye |
OS | = Oculus sinister | = Left eye |
PO | = Per os | = Orally |
OS | = Orifice | |
OU | = Both eyes | |
IM | = Intramuscular | |
IV | = Intravenous | |
ID | = Intradermal | |
SC | = Subcutaneous |
Appendix 3: Weights and Measurements
Weights
8 drams | 1 ounce |
12 ounces | 1 pound |
Fluid volume
60 minims | 1 fluid dram |
8 fluid drams | 1 fluid ounce |
20 fluid ounces | 1 pint |
2 pints | 1 quart (1000 ml) |
8 pints | 1 gallon. |
Weights
1000 micrograms (mcg) | 1 milligram (mg) |
1000 milligrams (mg) | 1 gram (gm) |
1000 grams (g) | 1 kilogram (kg) |
1 kilogram (kg) | 2.2 pounds (lbs) |
Approximate equivalents Weights
1 grain | 60 milligram (mg) |
1 dram | 4 gram ( g) |
1 ounce | 30 gram (g) |
1 pound | 375 gram ( g) |
1 milligram | 1/60 grains (gr). |
Volume
1 milliliter (ml) | 15 or 16 minims |
15 or 16 drops | |
1 liter | 35 fluid ounces |
1 fluid ounce | 30 ml |
1 fluid dram | 4 ml |
1 gallon | 4.5 liter |
1 minim | 0.04 ml = 1 drop |
1 pint | 500 ml. |
Household measurements:
1 teaspoon full | 4 or 5 ml |
1 fluid dram | |
60 drops | |
1 tablespoon full | 15 ml |
4 drams | |
1/2 fluid ounce |
Appendix 4: Drug Calculation Formulae
1. Fried’s formula : Infant’s dosage (<1 year):
2. Young’s rule: Child dosage (1 –12 years):
3. Clark’s rule:
4. Surface area rule:
5. Parenteral dosage:
6. Intravenous fluid flow rate:
7. Insulin dosage:
8. Ordered dose of medication in
Microgram/min:
9. Concentration:
Appendix 5: Abbreviations
S.no.
|
Description
|
Abbreviations/Symbols
|
---|---|---|
1. | Less than | < |
2. | Greater than | > |
3. | Liter | l |
4. | Milliequivalent | mEq |
5. | Milliliter | ml |
6. | Deciliter | dl |
7. | Millimeter of mercury | mm Hg |
8. | Femtoliter | fl |
9. | Millimeter | mm |
10. | Gram | g |
11. | Microgram | μg |
12. | Nanogram | ng |
13. | Picogram | pg |
14. | International unit | IU |
15. | Milliosmole | m Osm |
16. | Unit | U |
17. | Millimole | mmol |
18. | Nanomole | nmol |
19. | Picomole | pmol |
20. | Kilo Pascal | kPa |
21. | Microkatal | μkat |
Appendix 6: Urine Chemistry—Normal Values
S. no.
|
Test
|
Specimen
|
Conventional units
|
Possible etiology
| |
---|---|---|---|---|---|
Higher
|
Lower
| ||||
1. | Acetone | Random | Negative | Diabetes mellitus, high fat and low carbohydrate diets, starvation states. | |
2. | Bence Jones protein | Random | Negative | Multiple myeloma, biliary duct obstruction. | |
3. | Bilirubin | Random | Negative | Hepatitis. | |
4. | Calcium | 24 hours | 100–250 mg/day | Bone tumor, hyperparathyroidism. | Hypoparathyroidism malabsorption of Ca and vitamin D. |
5. | Chloride | 24 hours | 110–250 mEq/day | Addison's disease. | Burns, excessive perspiration, vomiting, diarrhea, mensturation. |
6. | Creatine | 24 hours | <100 mg/day | Carcinoma of liver, hyperthyroidism, diabetes, infections, burns. | Hypothyroidism. |
7. | Creatinine | 24 hours | 0.8–2.0 gm/day | Anemia, leukemia, muscular atrophy. | Renal disease. |
8. | Creatinine clearance | 24 hours | 85–132 mL/min | Renal disease. | |
9. | Glucose | Random | Negative | Diabetes mellitus, low renal threshold for glucose resorption, pituitary disorders. | |
10. | Hemoglobin (Hb) | Random | Negative | Extensive burns, hemolytic transfusion reaction, glomerulonephriitis, hemolytic anemia. | |
11. | Ketone bodies | 24 hours | 20–50 mg/day | Marked ketonuria | |
12. | Myoglobin | Random | Negative | Crushing injuries, electric injuries, extreme physical exertion. | |
13. | pH | Random | 4.0–8.0 | Choronic renal failure, compensatory phase of alkalosis, vegetarian diet. | Compensatory phase of acidosis, dehydration, emphysema. |
14. | Phenyl pyruvic acid | Random | Negative | Phenylketonuria | |
15. | Protein | 24 hours | <150 mg /day | Cardiac failure, inflammatory processes of urinary tract, nephritis, nephrosis, toxemia of pregnancy. | |
16. | Sodium | 24 hours | 40–250 mEq /day | Acute tubular necrosis. | Hyponatremia. |
17. | Specific gravity | Random | 1.003–1.030 | Albuminuria, dehydration glycosuria. | Diabetes insipidus. |
18. | Uric acid | 24 hours | 250–750 mg/day | Gout, leukemia. | Nephritis. |
19. | Urobilinogen | 24 hours | 0 .5–4.0 EU/day | Hemolytic disease, hepatic parenchymal cell damage, liver disease. | Complete obstruction of bile duct. |
Appendix 7: Hematology—Normal Values
S. no.
|
Test
|
Conventional units
|
Possible etiology
| ||
---|---|---|---|---|---|
Higher
|
Lower
| ||||
1. | Bleeding time | 3. 0–9. 5 min | Defective platelet function, thrombocytopenia. | ||
2. | Activated Partial Thromboplastin time (APTT) | 24–36 sec | Deficiency of factors I, II, V, VIII, IX and X, XI, XII, hemophilia, liver disease, heparin therapy. | ||
3. | Prothrombin time | 10–14 sec | Warfarin therapy, deficiency of factors I, II, V, VII and X, Vitamin K deficiency. Liver disease. | ||
4. | Fibrinogen | 200–400 mg/dl | Burns (after first 36 hours) inflammatory disease. | Burns (during first 36 hours) DIC, severe liver disease. | |
5. | Erythrocyte count Male Female | 4.5–6. 0 x 106/μl 4.0–5. 0 x 106/μl | |||
6. | Mean corpuscular Volume (MCV) | 82–98 fl | Macrocytic anemia. | Microcytic anemia. | |
7. | Mean corpuscular Hemoglobin (MCH) | 27–33 pg | Macrocytic anemia. | Microcytic anemia. | |
8. | Mean corpuscular hemoglobin Concentration (MCHC) | 32–36% | Spherocytosis. | Hypochromic anemia. | |
9. | Erythrocyte Sedimentation rate (ESR) Male <50 yr > 50 yr Female <50 yr > 50 yr | <15 mm/hr <20 mm/hr <20 mm/hr <30 mm/hr | Moderate increase: Acute hepatitis, myocardial infarction, rheumatoid arthritis. Marked increase: Acute and severe bacterial infections, malignancies -Pelvic inflammatory disease. -Dehydration, high altitudes, polycythemia. | Malaria, severe liver disease, sickle cell anemia. Anemia hemorrhage, overhydration. | |
10. | Hematocrit Male Female | 40–54% 38–47% | COPD, high altitudes, Polycythemia | Anemia, hemorrhage. | |
11. | Hemoglobin Male Female | 13.5–18.0 g/dl 12.0–16.0 g/dl | |||
12. | Glycosylated hemoglobin | 4. 0–6. 0 % | Poorly controlled diabetes mellitus. | Sickle cell anemia, chronic renal failure, pregnancy. | |
13. | Platelet count (thrombocytes) | 150–400 x 103/μl | Acute infections, chronic granulocytic leukemia, chronic pancreatitis, cirrhosis, collagen disorders, polycythemia, postsplenectomy. | Acute leukemia, DIC, thrombocytopenic purpura. | |
14. | White blood cell count (WBC) | 4. 0–11.0 x 103/μl | Inflammatory and infectious processes, leukemia. | Aplastic anemia, side effects of chemotherapy and irradiation. | |
15. | Lymphocytes | 20–40% | Chronic infections, lymphocytic leukemia, mononucleosis, viral infections. | Corticosteroid therapy whole body irradiation. | |
16. | Monocytes | 4–8% | Chronic inflammatory disorders, malaria, monocytic leukemia, acute infections, Hodgkin's disease. | ||
17. | Eosinophils | 0–4% | Allergic reactions, eosinophilic and chronic granulocytic leukemia, parasitic disorders, Hodgkin's disease. | Corticosteroid therapy. | |
18. | Basophils | 0–2 % | Hypothyroidism, ulcerative colitis, myeloproliferative diseases. | Hyperthyroidism stress. |
Appendix 8: Serum, Plasma and Whole Blood Chemistry
S. no.
|
Test
|
Conventional units
|
Possible etiology
| ||
---|---|---|---|---|---|
Higher
|
Lower
| ||||
1. | Acetone | 0.3–2 .0 mg/dl | Diabetic ketoacidosis, high fat diet, low carbohydrate diet, starvation. | ||
2. | Albumin | 3.5–5.00 g/dl | Dehydration. | Chronic liver disease, malabsorption, malnutrition, nephrotic syndrome, pregnancy. | |
3. | a-fetoprotein | <15 ng/ml | Cancer of testes and ovaries, carcinoma of liver. | ||
4. | Ammonia | 30–70 μg/dl | Severe liver disease. | ||
5. | Amylase | 0–130 U/L (method dependent) | Acute and chronic pancreatitis, mumps, perforated ulcers. | Acute alcoholism, cirrhosis of liver, extensive destruction of pancreas. | |
6. | Bicarbonate | 20–30 mEq/L | Compensated respiratory acidosis, metabolic alkalosis. | Compensated respiratory alkalosis, metabolic acidosis. | |
7. | Bilirubin Total Indirect (unconjugated) Direct (conjugated) | 0.2–1. 3 mg/dl 0.1–1. 0 mg/dl 0.1–0.3 mg/dl | Biliary obstruction, impaired liver function, hemolytic anemia, pernicious anemia, prolonged fasting. | ||
8. | Blood gases Arterial pH Venous pH Arterial pCO2 Venous pCO2 Arterial pO2 Venous pO2 | 7.35–7. 45 7.35–7.45 35–45 mmHg 45–52 mmHg 75–100 mmHg 30–50 mmHg | Alkalosis. Compensated metabolic alkalosis. Respiratory acidosis. Administration of high concentration of oxygen. | Acidosis Compensated metabolic acidosis Respiratory alkalosis Chronic lung disease Decreased cardiac output. | |
9. | Calcium | 9–11 mg/dl (4.5–5.5 mEq/L) | Acute osteoporosis, hyperparathyroidism, vitamin-D intoxication, multiple myeloma. | Acute pancreatitis, hypoparathyroidism, liver disease, malabsorption syndrome, renal failure, vitamin D deficiency. | |
10. | Chloride | 95–105 mEq/L | Metabolic acidosis, respiratory alkalosis, corticosteroid therapy, uremia. | Addison's disease, diarrhea, metabolic alkalosis, respiratory acidosis, vomiting. | |
11. | Cholesterol HDL (high density lipoproteins) Male Female LDL ( low density lipoproteins) | 140–200 mg/dl (Age dependent) >45 mg/dl >55 mg/dl <130 mg/dl | Biliary obstruction, Hypothyroidism, idiopathic hypercholesterolemia, renal disease, uncontrolled diabetes. | Extensive liver disease, hyperthyroidism, malnutrition, corticosteroid therapy. | |
12. | Cortisol | 8 am : 5 –25 μg/dl 8 pm : <10 μg/dl | Cushing syndrome, pancreatitis, stress. | Adrenal insufficiency, panhypopituitary states. | |
13. | Creatine | 0. 2–1.0 mg/dl | Active rheumatoid arthritis, biliary obstruction, hyperthyroidism, renal disorders, severe muscle disease. | Diabetes mellitus. | |
14. | Creatine kinase (CK) Male Female | 15–105 U/L 10–80 U/L | Musculoskeletal injury or disease, myocardial infarction, severe myocarditis, exercises, myocarditis numerous intramuscular injections, brain damage. | ||
15. | CK-MB (CK2) | 0–9 U/L | Acute myocardial infarction. | ||
16. | Creatinine | 0.5–1. 5 mg/dl | Severe renal disease. | ||
17. | Glucose Fasting | 70–120 mg/dl | Acute stress, cerebral lesions, Cushing's disease, diabetes mellitus, hyperthyroidism, pancreatic insufficiency. | Addison's disease, hepatic disease, hypothyroidism, insulin overdosage, pancreatic tumor, pituitary hypofunction. | |
18. | Lactic acid | 5–20 μg/dl | Acidosis, congestive heart failure, shock. | ||
19. | Lactic dehydrogenase (LDH) | 50–150 U/L | Congestive heart failure, hemolytic disorders, hepatitis, metastatic cancer of liver, myocardial infarction, pernicious anemia, pulmonary embolus, skeletal muscle damage. | ||
20. | Lipase | 0–160 U/L | Acute pancreatitis, hepatic disorders, perforated peptic ulcer. | ||
21. | Magnesium | 1.5–2. 5 mEq/L | Addison's disease, hypothyroidism, renal failure. | Chronic alcoholism, hyperparathyroidism, hypoparathyroidism, severe malabsorption, hyperthyroidism. | |
22. | Phosphatase acid | 0–0.6 U/L | Advanced Paget's disease, cancer of prostate, hyperparathyrodism. | ||
23. | Phosphatase alkaline | 30–120 U/L | Bone diseases marked hyperparathyroidism, obstruction of biliary system, rickets. | Excessive vitamin D ingestion, hypothyroidism, milk alkali syndrome. | |
24. | Potassium | 3.5–5. 5 mEq/L | Addison's disease, diabetic ketosis, massive tissue destruction, renal failure. | Cushing syndrome, diarrhea, (severe) diuretic therapy, gastrointestinal fistula, pyloric obstruction, starvation, vomiting. | |
25. | Sodium | 135–145 mEq/L | Dehydration, impaired renal function, primary aldosteronism, corticosteroid therapy. | Addison's disease, diabetic ketoacidosis, diuretic therapy, excessive loss from gastrointestinal tract, excessive perspiration, water intoxication. | |
26. | Proteins Total Albumin Globulin Albuminglobulin ratio | 6.0–8.0 g/dl 3.5–5.0 g/dl 2.0–3.5 g/dl 1.5:1–2.5:1 | Burns, cirrhosis, dehydration. -Multiple myeloma (globulin fraction) shock and vomiting. | Congenital agammaglobulinemia, liver disease, malabsorption. Malnutrition, nephrotic syndrome, proteinuria, renal disease, severe burns. | |
27. | T4 ( thyroxine ) total T4 ( thyroxine) free T3 uptake T3 ( triodothyronine) TSH (thyroid stimulating hormone) | 5–12 μg/dl 0.8–2 .3 ng/dl 25–35% 110–230 ng/dl 0.3–5 .4 μU/ml | Hyperthyroidism, thyroiditis Hyperthyroidism, metastatic neoplasms. Hyperthyroidism. Myxedema, primary hypothyroidism, Graves' disease. | Cretinism, hypothyroidism, myxedema. Hypothyroidism, pregnancy. Hypothyroidism. Secondary hypothyroidism. | |
28. | Serum glutamic oxaloacetic ( SGOT ) or aspartate aminotransferase (AST). Serum glutmate pyruvate SGPT or alanine aminotransferase (ALT) | 7–40 U/L 5–36 U/L | Liver disease, myocardial infarction, pulmonary infarction, acute hepatitis. Liver disease, shock. | ||
29. | Triglycerides | 40–150 mg/dl | Diabetes mellitus, hyperlipidemia, hypothyroidism, liver disease. | Malnutrition. | |
30. | Blood urea nitrogen (BUN) | 10–30 mg/dl | Increase in protein catabolism, renal disease, urinary tract infection. | Malnutrition, severe liver damage. | |
31. | Uric acid Male Female | 4. 5–6.5 mg/dl 2.5–5.5 mg/dl | Gout, gross tissue destruction, high protein weight reduction diet, leukemia, renal failure, eclampsia. | Administration of uricosuric drugs. |
Appendix 9: Cerebrospinal Fluid Analysis
S. no.
|
Test
|
Conventional units
|
Possible etiology
| |
---|---|---|---|---|
Higher
|
Lower
| |||
1. | Pressure | 60–150 mm H2O | Hemorrhage, intracranial tumor, meningitis. | Head injury, spinal tumor, subdural hematoma. |
2. | Blood | Negative | Intracranial hemorrhage. | |
3. | Cell count WBC RBC | 0–5 cells/μl 0 | Inflammations or infections of CNS. | |
4. | Chloride | 100–130 mEq /L | Uremia. | Bacterial infections of CNS. |
5. | Glucose | 40–75 mg/dl | Diabetes mellitus, viral infections of CNS. | Bacterial infections and TB of CNS. |
6. | Protein Lumbar Cisternal Ventricular | 15–45 mg/dl 15–25 mg/dl 5–15 mg/dl | Guillain-Barre syndrome, poliomyelitis, traumatic tap. Syphilis of CNS Acute meningitis, brain tumor, chronic CNS infections, multiple sclerosis. |
Appendix 10: Fecal Analysis—Normal Values
S. no.
|
Test
|
Conventional units
|
Possible etiology
| |
---|---|---|---|---|
Higher
|
Lower
| |||
1. | Urobilinogen | 30–220 mg/100 g of stool | Hemolytic anemia. | Complete biliary obstruction. |
2. | Mucus | Negative | Mucous colitis, spastic constipation. | — |
3. | Pus | Negative | Chronic bacillary dysentery, chronic ulcerative colitis, localized abscessess. | — |
4. | Blood | Negative | Anal fissures, hemorrhoids, malignant tumor, peptic ulcer, inflammatory bowel disease. | — |
5. | Color Brown Clay Tarry Red Black | — | Various color depending on diet. Biliary obstruction or presence of barium sulfate. More than 100 ml of blood in GI tract. Blood in large intestine. Blood in upper GI tract or iron medication. | — |
Appendix 11: Antenatal Assessment Format
Appendix 12: Newborn Assessment Format
Appendix 13: Formulae for Assessing Growth Parameters in Children
Parameter
|
Height/Length
|
Weight
|
---|---|---|
Infants | At birth: 50 cm 1 year: 75 cm | |
Toddler | Age in years x 6 + 77 | Age in years x 2 + 8 |
Preschoolers | Age in years x 6 + 77 | Age in years x 2 + 8 |
School age | Age in years x 6 + 77 | |
Adolescents |
Formula for Estimating Head Circumference in Ist year
Formula for calculating Body Mass Index (BMI)
Ratio of upper segment and lower segment (US/LS) of body
Age
|
US/LS
|
---|---|
At birth | 1.8/1 |
3–4 years | 1.3/1 |
9 years | 1/1 |
18 years | 0.9/1 |
Appendix 14: Postnatal Assessment Format
Appendix 15: Assessment of Postoperative Cesarean Section Mothers
Appendix 16: Assessment of Patient with Gynecological Problems
-
Demographic Data:
-
Name of the patient
-
Age
-
Education
-
Occupation
-
Income
-
Religion
-
Marital status–Duration of marriage/single/widow
-
Hospital No.
-
Date of examination
-
Address
-
Diagnosis
-
-
History:
-
Family History
-
Type of family: Joint/Nuclear
-
Family composition
-
Genetic/Hereditary disease
-
-
Socioeconomic history:
-
Income/Month
-
Type of house: Own/rented
-
Social customs/beliefs
-
-
Environmental history
-
Source of water supply
-
Disposal of waste
-
Any other health hazards
-
-
Personal health history
-
Diet
-
Sleep pattern
-
Bowel/Bladder pattern
-
Allergies
-
Hygiene
-
Addictions
-
-
Menstrual history
-
Age of menarche
-
Menstrual rhythm—Normal/Irregular
-
Duration: In days
-
Premenstrual discomfort: Yes/No
-
Dysmenorrhea: Yes/No
-
Menorrhagia–duration prolonged
-
Metrorrhagia: Yes/No
-
Scanty menstruation: Yes/No
-
Last menstrual period
-
Amenorrhea: Primary/secondary
-
-
Marital history
-
Age of marriage
-
Sexual intercourse
-
Dyspareunia: Present/absent
-
Contraceptives used
-
Sexual disorders.
-
-
Past medical history
-
Major illness — TB/DM/HT/ Hep B/Cancer
-
Hormonal therapy
-
Hospitalization
-
Surgery
-
Radiation therapy
-
Infectious disease
-
Blood transfusion
-
Endocrine disorders
-
Malaria
-
Use of contraception
-
Psychiatric problems
-
-
Obstetrical historyEach pregnancy should be recorded as follows:S. No.DateDuration of PregnancyAbnormalities in pregnancyHomeDelivery/HospitalPuerperiumInfantbreastfeedingYear and MonthWeeks of gestationAbortion/APH/PIH-------Normal/PPH/otherBaby alive/still born
-
Gravida
-
Para
-
Number of living children
-
Age of last child
-
-
Complications in last pregnancy
-
Abortion
-
APH
-
Genital infections
-
Rh incompatability
-
Polyhydramnios
-
Retained placenta
-
Multiple pregnancy
-
Breast complications
-
Infertility
-
CPD
-
Instrumental delivery
-
Vaginal discharge
-
Leukorrhea—purulent/offensive/foul smelling
-
Color—White/yellow/greenish
-
Quantity
-
Duration—hours/days
-
Character—irritating/bloodstained
-
-
-
-
a. Physical examinationHeight in cm:Weight in kg:Gait:Body built:Appearance:Pallor:Lymphadenopathy:Edema:Temperature:Pulse:Respiration:Blood pressure:
-
-
GI system:
-
Abdominal pain: Severe/intermittent/colicky.
-
Swelling /Mass/Motility/Distension/Nausea/Vomiting
-
-
Cardiovascular system
-
Heart rate:
-
Rhythm:
-
Heart sound:
-
-
Respiratory system
-
Rate:
-
Rhythm:
-
Breath sounds:
-
-
Central nervous system
-
Lethargy:
-
Irritability:
-
Dizziness:
-
Headache:
-
Nausea:
-
Vomiting:
-
-
Musculoskeletal system
-
Pain in the legs/calf muscles/weakness in leg:
-
Cramps:
-
Varicose veins:
-
Swelling:
-
Any other infection:
-
-
Genitourinary tract
-
Pain in the back:
-
Pain on micturition:
-
Burning micturition:
-
Retention of urine:
-
Incontinence of urine:
-
Frequency of micturition:
-
Urethral orifice:
-
-
Rectum:
-
Rectal bleeding/discharge:
-
Hemorrhoids:
-
Any other infection:
-
-
Gynecological examination
-
Vulva: Lesions/abrasions, redness of vaginal wall/abnormalities/edema:
-
-
Pervaginal examination
-
Perineal body: Soft/hard:
-
Cervix: Soft/abnormal:
-
Signs of infection:
-
Bleeding discharge:
-
-
Breast examination:
-
Size of breast:
-
Shape of breast:
-
Primary areola: Present/absent
-
Secondary areola: Present/absent
-
Montgomery’s tubercles: Present/absent
-
Lymph nodes: Palpable/not palpable
-
Secretion from the breast: Yellow/clear/white/ blood stained
-
Nipple: Normal/no sore/flat/inverted
-
-
Laboratory examination
-
Blood: Hb/group/type/culture
-
Urine: Culture/sugar/albumin
-
Vaginal discharge: Culture/color/consistency
-
Cervical swab: Culture
-
-
-
InvestigationsS.noInvestigationsPatient valueNormal valueRemarks
-
MedicationsS.noName of drugDosageFrequencyActionSide effectsNursing responsibilities
-
Other treatments
-
Diet recall
-
Disease condition (Book picture and patient picture)
-
List of nursing diagnoses
-
Nursing processAssessmentNursing DiagnosisGoalNursing InterventionsRationaleImplementationEvaluation
-
Daily progress
-
Health education
-
Summary and discharge plan
-
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EXTERNAL LINKS
- http:/en.wikipedia.org/w/index.php. Digital subtraction angiography.
- http:/www.houndhill.com/Blog/Entries. Internal External Electronic Monitoring.