Clinical Nursing Procedures: The Art of Nursing Practice Annamma Jacob, Rekha R, Jadhav Sonali Tarachand
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1Clinical Nursing Procedures: The Art of Nursing Practice2
3Clinical Nursing Procedures: The Art of Nursing Practice
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
4
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Medical knowledge and practice change constantly. This book is designed to provide accurate, authoritative information about the subject matter in question. However, readers are advised to check the most current information available on procedures included and check information from the manufacturer of each product to be administered, to verify the recommended dose, formula, method and duration of administration, adverse effects and contraindications. It is the responsibility of the practitioner to take all appropriate safety precautions. Neither the publisher nor the author(s)/editor(s) assume any liability for any injury and/or damage to persons or property arising from or related to use of material in this book.
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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 7PREFACE TO THE THIRD EDITION
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.
12

Appendices673Appendices

  • 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
675
676
677
678
 
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
679
 
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
680
 
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:
681
 
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
682
 
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.
683
 
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.
684
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.
685
 
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.
686
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.
687
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.
688
 
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.
689
 
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.
690
 
Appendix 11: Antenatal Assessment Format
691
692
693
 
Appendix 12: Newborn Assessment Format
694
695
696
 
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
Head circumference in cm =
Formula for calculating Body Mass Index (BMI)
1. Rao’s index
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
697
 
Appendix 14: Postnatal Assessment Format
698
699
700
 
Appendix 15: Assessment of Postoperative Cesarean Section Mothers
701
702
703
 
Appendix 16: Assessment of Patient with Gynecological Problems
  1. 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
  2. History:
    1. Family History
      • Type of family: Joint/Nuclear
      • Family composition
      • Genetic/Hereditary disease
    2. Socioeconomic history:
      • Income/Month
      • Type of house: Own/rented
      • Social customs/beliefs
    3. Environmental history
      • Source of water supply
      • Disposal of waste
      • Any other health hazards
    4. Personal health history
      • Diet
      • Sleep pattern
      • Bowel/Bladder pattern
      • Allergies
      • Hygiene
      • Addictions
    5. 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
    6. Marital history
      • Age of marriage
      • Sexual intercourse
      • Dyspareunia: Present/absent
      • Contraceptives used
      • Sexual disorders.
    7. 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
    8. Obstetrical history
      Each pregnancy should be recorded as follows:
      S. No.
      Date
      Duration of Pregnancy
      Abnormalities in pregnancy
      HomeDelivery/Hospital
      Puerperium
      Infantbreastfeeding
      Year and Month
      Weeks of gestation
      Abortion/APH/PIH
      -------
      Normal/PPH/other
      Baby alive/still born
      • Gravida
      • Para
      • Number of living children
      • Age of last child
    9. 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
  3. a. Physical examination
    Height in cm:
    Weight in kg:
    Gait:
    Body built:
    Appearance:
    Pallor:
    Lymphadenopathy:
    Edema:
    Temperature:
    Pulse:
    Respiration:
    Blood pressure:
  1. 704 Systemic examination:
    • 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
  1. Investigations
    S.no
    Investigations
    Patient value
    Normal value
    Remarks
  2. Medications
    S.no
    Name of drug
    Dosage
    Frequency
    Action
    Side effects
    Nursing responsibilities
  3. Other treatments
  4. Diet recall
  5. Disease condition (Book picture and patient picture)
  6. List of nursing diagnoses
  7. Nursing process
    Assessment
    Nursing Diagnosis
    Goal
    Nursing Interventions
    Rationale
    Implementation
    Evaluation
  8. Daily progress
  9. Health education
  10. Summary and discharge plan
  11. Bibliography
705BOOKS
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  1. Augustine A, Augustine J, Chacko A. Clinical Nursing and Procedure Manual, BI Publications, 2004.
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  1. Black JM, Hawks JH, Keene AM. Medical-Surgical Nursing, Clinical Management for Positive Outcomes, volume 1, 6th edition, Harcourt Private Limited, 2001.
  1. Black JM, Hawks JH, Keene AM. Medical-Surgical Nursing, Clinical Management for Positive Outcomes, volume 2, 6th edition, Harcourt Private Limited, 2001.
  1. Bennett VR, Brown LK. Myles Textbook for Midwives. 13th edition, Harcourt Publishers,2000.
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  1. Bourne M. Shaw’s Textbook of Gynaecology. 13th edition. Elsevier Publications,2004.
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  1. Potter PA, Perry AG. Fundamentals of Nursing, 6th edition, Elsevier Publications, 2005.
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  1. Phipps WJ, Long BC Woods NF. Shafer’s Medical-Surgical Nursing, 7th edition, BI Publications Pvt Ltd.,1985.
  1. Prema TP, Graicy KF. Essentials of Neurological and Neurosurgical Nursing, 1st edition, Jaypee Brothers Medical Publishers (P) Ltd.,2002.
  1. Park K. Textbook of Preventive and Social Medicine, 7th edition, Banarsidas Bhanot Publishers, 2002.
  1. Russell R, Williams N, Bulstrode C, Bailey and Love’s. Short Practice of Surgery, 23rd edition, Arnold, 2000.
  1. Rao KS. An Introduction to Community Health Nursing, 4th edition, BI Publications Pvt Ltd, 2004.
  1. Sr Nancy MSJ. Stephenie’s. Priniciples and Practice of Nursing, volume 1, 5th edition, NR Publishing House, 1996.
  1. Sr NancyMSJ. Stephenies. Principles and Practice of Nursing, volume 2, 3rd edition, NR Publishing House, 1995.
  1. Sr Nancy MSJ. A reference Manual for Nurses on Coronary Care Nursing, 2nd edition Kumar Publishing House, 1996.
  1. Taylor C, Lillis E, Lemone P. Fundamentals of Nursing, 5th edition, Lippincott Williams and Wilkins Publications, 2005.
  1. The Lippincott. Manual of Nursing Practice, 7th edition, Lippincott William and Wilkins Publications, 2001.
  1. Thygerson AL. First Aid Handbook, Jones and Bartlett Publishers, 1995.
  1. Yalayyaswamy NN. First Aid and Emergency Nursing, 1st edition, Gajanana Book Publishers,706 1997.
  1. Lararia T, Stuart GW. Principles and Practice of Psychiatric Nursing, 7th edition, Mosby Publication, 2001.
  1. Ahaja N. A Short Textbook of Psychiatry, 5th edition, Jaypee Brothers Medical Publishers (P) Ltd., 2002.
  1. Kapoor B. Textbook f Psychiatric Nursing No1 and vol I, Kumar Publication, 2001.
  1. Omayal Achi College of Nursing. Manual on Nursing Principles and Practice, 1997.
PERIODICALS
  1. Ayello EA, Baranoski S, Salati SD. Wound care – Survey report. Nursing.2005. pp. 36-44.
  1. Barton M, Davies D, Graham J, Teonlett J. A new approach to training in intravenous drug therapy. Nursing times. 2003. pp.26-7.
  1. Braden BJ, Marklebust J. Preventing pressure ulcers with Braden scale. Am J Nurs. 2005. pp. 70–2.
  1. Boyd S. Treatment of physiological and pathological neonatal jaundice. Nursing Times. 2003. pp. 40–1.
  1. Bower LM. Is your patient’s metered dose inhaler technique up to snuff? Nursing. 2005; 35: 50–1.
  1. Cooley C, Gabriel J. Reducing the risks of sharps injuries in health care professionals. Nursing Times. 2004. pp. 28–9.
  1. Crowley A, Bains RM, Pellico LH. A model preschool vision and hearing screening program. Am J Nurs. 2005;105:6,52-5.
  1. Davies C. The use of phosphate enemas in the treatment of constipation. Nursing Times. 2004. pp. 32–3.
  1. Duimel IP. Preventing pressure ulcers with massage? Am J Nurs. 2005; 105: 30–1.
  1. English J. Importance of breast awareness in identification of breast cancer, Nursing Times. 2003. pp. 18–9.
  1. Grosser L. Meeting the needs of younger women with breast cancer. Nursing Times. 2004. pp. 43.
  1. Grace PJ, McLanghlin M. When consent is not informed enough. Am J Nurs. 2005;105:79.
  1. Hoban V. Online learning tool for preoperative assessment. Nursing Times. 2004. pp. 43.
  1. Hainsworth T. Guidelines for preventing errors in administering blood transfusion. Nursing Times. 2004. pp. 30–1.
  1. Hubbard J. Management of atrial fibrillation, Nursing Times. 2004.
  1. Hoban V. How to improve your record keeping, Nursing Times. 2003; 78–9.
  1. Lindgren VA, Ames NJ. Caring for patients on mechanical ventilation. Am J Nurs. 2005. pp. 50–9.
  1. Mendez-Eastman S. Using negative pressure wound therapy for positive results. Nursing.2005;35:48–9.
  1. Marders J. Sounding the alarm for IV infiltration. Nursing. 2005. pp. 18.
  1. Nandi G, Biswas D. Effect of cold compress and manual application of pressure on cardiac catheterization related hematoma, Asian J Cardiovasc Nurs. 2005;13(2):26-8.
  1. Nirmala R. Urinary investigations. Health Screen. 2005. pp. 10–1.
  1. Privet S. Clean hands are a vital part of care. Nursing Times. 2004. pp. 47.
  1. Pittet D, Boyce JM. Organising an awareness week to target hand hygiene practice. Nursing Times;2004.
  1. Pruitt B. Clear the air with closed suctioning, Nursing. 2005; 35: 44–9.
  1. Reising DL, Ronald S. Enteral tube flushing. Am J Nurs.2005;105:58–63.
  1. Stevenson T. Improving policy and practice in the prevention of pressure ulcers. Nursing Times;2004.
  1. Sangar K. Engorgement of breast, potential problem in lactation, Nightingale. Nursing Times.2004;1:12–6.
  1. Webb C. The benefits and the pitfalls of preoperative fasting, Nursing Times. 2003; 32–3.
EXTERNAL LINKS
  1. http:/en.wikipedia.org/w/index.php. Digital subtraction angiography.
  1. http:/www.houndhill.com/Blog/Entries. Internal External Electronic Monitoring.