NMT05105 Basic Care of Patient With Surgical Condition New 1 1 1

THE UNITED REPUBLIC OF TANZANIA
MINISTRY OF HEALTH, COMMUNITY DEVELOPMENT, GENDER, ELDERLY AND

CHILDREN
DIRECTORATE OF HUMAN RESOURCE DEVELOPMENT
FACILITATORS GUIDE FOR TECHNICIAN CERTIFICATES

IN NURSING AND MIDWIFERY
NTA LEVEL 5
NMT 05105: Basic Care of Patient with Surgical Conditions

© Ministry of Health, Community Development, Gender, Elderly and Children, Department of Human Resources
Development Nursing Training Section 2018, Dodoma, Tanzania
NMT05105: Basic Care of Patient with Surgical Conditions ii

Table of Contents
Acronyms................................................................................................................................................. iv
Preamble.................................................................................................................................................. v
Acknowledgement....................................................................................................................................vi
1.0. Background................................................................................................................................. vii
2.0. Rationale..................................................................................................................................... vii
3.0. Goals and Objectives of the Training Manual.............................................................................viii
3.1. Overall Goal for Training Manual............................................................................................viii
3.2. Objectives for Training Manual...............................................................................................viii
4.0. Introduction.................................................................................................................................viii
4.1. Module Overview....................................................................................................................viii
4.2. Who is the Module For?...........................................................................................................ix
4.3. How is the Module Organized?................................................................................................ix
4.4. How Should the Module be Used?...........................................................................................ix
Sessions one:........................................................................................................................................... 1
NMT05105: Basic Care of Patient with Surgical Conditions iii

Acronyms
AGYW Adolescents Girl and Young Women
AIDS Acquired Immune Deficiency Syndrome
AIHA American International Health Alliance
ARV Antiretroviral
VMMC Voluntary Medical Male Circumcision
WHO World Health Organization
NMT05105: Basic Care of Patient with Surgical Conditions iv

Preamble
The Ministry of Health Community Development Gender Elderly and Children among other roles
ensures that Tanzanians receive quality health care and service. This can be achieved through
production of competent nurses and midwives amongst other health cadres. The training of competent
nurses and midwives can be achieved through various teaching and learning materials; one of them being
facilitators guides and students manual.
The challenges of today in nursing profession include among others, the preparation of the competent
nurses and midwives to meet the current and future complex clients needs. Therefore, the provision of
quality training to learners in nursing and midwifery is crucial in achieving the intended exit outcomes.
Therefore monitoring of the learners acquisition of practical competences is the cornerstone for judging
effectiveness of the programme. A logbook serves as a key instrument for monitoring the ability of the
learner towards deliberation of the expected quality of care to all clients in all areas of health care
services. The current logbook has taken into consideration the competencies stipulated in the revised
curriculum in order to meet the current societal, institutional and professional needs.
This Practical Experience Logbook is deemed to be an important tool to verify learners acquisition of
the necessary competences needed for the provision of quality health care services. Furthermore, it is
anticipated to also be used by other stakeholders of health care delivery industry in verifying the ability
of the graduate to deliver respected health care.
Dr. Otilia F. Gowelle

Director for Human Resource Development
Ministry of Health, Community Development, Gender, Elderly and Children
NMT05105: Basic Care of Patient with Surgical Conditions v

Acknowledgement
Ministry of Health, Community Development, Gender, Elderly and Children through the Directorate of
Human Resource Development, Nursing training section has reviewed Facilitators guide for Nursing
and Midwifery training program. The review was informed by revised curriculum of the same. The
successfully completion of this facilitators guide has been made possible by the commitment of the
technical team through a series of writers workshops. Understanding the crucial role of the team, the
Ministry would like to express sincere appreciation to all those who involved in the completion of this task.
Special gratitude goes to coordinators of Nursing and Midwifery training, technical expert from NACTE
and other facilitators who tirelessly supported the development of this guide whose names are listed
with appreciation:-
SN FULL NAME INSTITUON/ ORGANIZATION
1. Nassania Shango CDNT -MOHCDGEC-Dodoma
2. Professor Eliezer Tumbwene Lecturer -Aga Khan University
3. Ramadhani Samainda NACTE-Dodoma
4. Dr. Patrick Mwidunda Program Manager-Amref Health Africa
5. Lupyana Kahemela Program Officer-Amref Health Africa
6. Joseph Pilot Program Officer- Amref Hhealth Africa
7. Mary Kipaya Principal- Kahama School of Nursing
8. Paul Magessa Ag. Principal Newala School of Nursing
9. Dominic Daudi Tutor Newala School of Nursing
10. Dr. Beatrice Mwilike Lecturer-MUHAS
11. Lilian Wilfred Tutor KCMC School of Nursing
12. Upendo Mamchomy Tutor KCMC School of Nursing
13. Tito William Nurse Officer Muhimbili National Hospital
14. Sixtus Ruyumbu Nurse Officer- Mbeya Refferal
15. Dr Lenatus Kalolo Medical Specialist-Mbeya Refferal
16. Emmanuel Mwakapasa Principal Mbeya -OTM
17. Salma Karim Tutor- Mirembe School of Nursing
18. Athanas Paul Principal- Mirembe School of Nursing
19. Dr. Jiyenze Mwangu Kini Tutor -CEDHA
20. Joseph Mayunga Tutor- Kisare
21. Elizabeth Kijugu Principal-Kairuki School of Nursing
22. Charles Magwaza Principal Njombe School of Nursing
23. Meshaki Makojijo Tutor Bugando School of Nursing
24. Stellah Kiwale Tutor- PHN Morogoro
25. Evance Anderson Tutor Geita School of Nursing
26. Juliana Malingumu Tutor Mchukwi School of Nursing
27. Rehema Mtonga Tutor -
28. Masunga Isassero Assistant Lecturer -MUHAS
29. Mbaruku Luga Driver-Mirembe School of Nursing
Lastly would like to thank the collaboration and financial support from Amref Health Africa who made
this task successfully completed.
Ndementria Arthur Vermand

Assistant Director Nursing Training Section, Ministry of Health, Community Development,
Gender, Elderly and Children
1.0. Background
In 2015 the Ministry of Health, Community Development, Gender, Elderly and Children through the
Directorate of Human Resource Development, Nursing training section started the process of reviewing

vi
vi
the nursing curricula NTA level 4-6. The process completed in the year 2017 and its implementation
started in the same year. The rationale for review was to comply with the National Council for Technical
award (NACTE) Qualification framework which offers a climbing ladder for higher skills opportunity.
Amongst other rationale was to meet the demand of the current health care service delivery. The
demand is also aligned with human resource for health strategic plan and human resource for health
production plan which aims at increasing number of qualified human resource for health.
The process of producing qualified human resource for health especially nurses and midwives requires
the plentiful investment of resources in teaching at the classroom and practical setting and the
achievement of clinical competence is acquired in step wise starting from classroom teaching to skills
laboratory teaching. In addition, WHO advocates for skilled and motivated health workers in producing
good health services and increase performance of health systems (WHO World Health Report, 2006).
Moreover, Primary Health Care Development Program (PHCDP) (2007-15) needs the nation to
strengthen and expand health services at all levels. This can only be achieved when the Nation has
adequate, appropriately trained and competent work force who can be deployed in the health facilities
to facilitate the provisions of quality health care services.
In line with the revised curricula, the MOHCDGEC in collaboration with developing partners and team of
technical staff developed quality standardized training materials to support the implementation of
curricula. These training materials address the foreseen discrepancies in the implementation of the
curricula by training institutions.
This facilitators guide has been developed through a series of writers workshop (WW) approach. The
goals of Writers Workshop were to develop high-quality, standardized teaching materials and to build
the capacity of tutors to develop these materials. The new training package for NTA Level 4-6 includes
a Facilitator Guide and Student Manual. There are 33 modules with approximately
520 content sessions
2.0. Rationale
The vision and mission of the National Health Policy in Tanzania focuses on establishing a health
system that is responsive to the needs of the people, and leads to improved health status for all.
Skilled and motivated health workers are crucially important for producing good health through
increasing the performance of health systems (WHO, 2006). With limited resources (human and non-
human resources), the MOHSW supported tutors by developing standardized training materials to
accompany the implementation of the developed CBET curricula. These training manuals address the
foreseen discrepancies in the implementation of the new curricula.
Therefore, this training manual for Certificate and Diploma program in Nursing (NTA Levels 4-6) aims at
providing a room for Nurses to continue achieving skills which will enable them to perform competently.
These manuals will establish conducive and sustainable training environment that will allow students
and graduates to perform efficiently at their relevant levels. Moreover, this will enable them to aspire for
attainment of higher knowledge, skills and attitudes in promoting excellence in nursing practice.
3.0. Goals and Objectives of the Training Manual

3.1. Overall Goal for Training Manual
The overall goal of these training manuals is to provide high quality, standardized and Competence-
based training materials for Diploma in nursing (NTA level 4 to 6) program.
3.2. Objectives for Training Manual

To provide high quality, standardized and competence-based training materials.
To provide a guide for tutors to deliver high quality training materials.

vii
vii
To enable students to learn more effectively.
4.0. Introduction
4.1. Module Overview
This module content has been prepared as a guide for tutors of NTA Level 5 for training students. The
session contents are based on the sub-enabling outcomes of the curriculum of NTA Level 5 Technician
Certificate in Nursing and Midwifery.
The module sub-enabling outcome as follows:

3.3.3 Provide nursing care to patients with tonsillitis using nursing process
3.4.1 Provide nursing care to patients with fracture and dislocation using nursing process
3.4.2 Provide nursing care to patients with wound using nursing process
3.4.3 Provide nursing care to patients with burn according to guideline
3.7.3 provide nursing care to male patients with disorders of reproductive system (phimos,
paraphimosis, epispadiasis, hypospadias, balanitis, urethral stricture Orchitis, Undescended
testicles, and prostatitis) using nursing process
3.7.6 Provide nursing care to patient with Ovarian cyst using nursing process
3.8.1 Describe concepts of operating theatre in relation to theatre management
3.8.2 Prepare Operating theatre room for surgery according to standards
3.8.3 Provide Pre-operative nursing care to patients for surgery using guidelines
3.8.4 Provide intra-operative nursing care to patients undergoing surgery using nursing process
3.8.5 Provide post-operative nursing care to patients following surgery using nursing process
4.2. Who is the Module For?

This module is intended for use primarily by tutors of NTA Level 4 certificate and diploma in nursing
schools.
The module sessions give guidance on the time and activities of the session and provide information
on how to teach the session to students. The sessions include different activities which focus on
increasing students knowledge, skills and attitudes.
4.3. How is the Module Organized?

The module is divided into14 sessions; each session is divided into sections. The following are the
sections of each session:
 Session Title: The name of the session.
 Learning Tasks Statements which indicate what the student is expected to learn at the end of the
session.
 Session Content All the session contents are divided into steps. Each step has a heading and an
estimated time to teach that step. Also, this section includes instructions for the tutor and activities
with their instructions to be done during teaching of the contents.
 Key Points Each session has a step which concludes the session contents near the end of a
session. This step summarizes the main points and ideas from the session.
 Evaluation The last section of the session consists of short questions based on the learning
objectives to check the understanding of students.
 Handouts are additional information which can be used in the classroom while teaching or later for
students further learning. Handouts are used to provide extra information related to the session
topic that cannot fit into the session time. Handouts can be used by the participants to study
material on their own and to reference after the session. Sometimes, a handout will have questions
or an exercise for the participants. The answers to the questions are in the Facilitator Guide
Handout, and not in the Student Manual Handout.

viii
viii
4.4. How Should the Module be Used?
Students are expected to use the module in the classroom and clinical settings and during self-study.
The contents of the modules are the basis for learning Basic Care of Patient with Surgical Conditions,
Students are therefore advised to learn each session and the relevant handouts and worksheets during
class hours, clinical hours and self-study time. Tutors are there to provide guidance and to respond to
all difficulty encountered by students.

ix
ix
SESSION 01: CARE OF A PATIENT WITH TONSILLITIS
Total Session Time: 120 Minutes

Prerequisite: NMT04103 Human Anatomy and Physiology
Learning Objectives
At the end of this session a learner is expected to be able:
Define tonsillitis
Identify causes of tonsillitis
Explain pathophysiology of tonsillitis
Identify clinical features of a patient with tonsillitis
Identify diagnostic measures of tonsillitis
Mention complications of tonsillitis
Give nursing Care to patients with tonsillitis
Resources Needed:
 Flip charts, marker pens, and masking tape
 Black/white board and chalk/whiteboard markers
 LCD Projector and computer
 Note Book and Pen
Session Overview Box

Step Time (min) Activity/ Content
Method
1 05 Presentation Introduction, Learning Tasks
2 05 Presentation, Brainstorming Definition of Tonsillitis
3 10 Lecture Discussion Causes of Tonsillitis
4 10 Lecture Discussion Pathophysiology of Tonsillitis
5 20 Presentation; Buzzing Clinical Features of Tonsillitis

6 15 Lecture Discussion Diagnostic Measures of Tonsillitis
7 10 Complications of Tonsillitis
Lecture Discussion
8 35 Nursing Care to Patients with
Tonsillitis
Presentation/Lecture Discussion
9 05 Key Points
Presentation
10 05 Presentation Session Evaluation
SESSION CONTENTS
NMT 05105:Basic Care of a Patient with Surgical Conditions

10
10
STEP 1: Presentation of Session Title and Learning Objectives (05 Minutes )
READ or ASK participants to read the learning objectives
ASK participants if they have any questions before continuing
STEP 2: Definition of Tonsillitis (05 Minutes)

Activity: Brainstorming (02 Minutes)
ASK students to pair up and brainstorm on the definitions of tonsillitis
ALLOW few pairs to respond and let other pairs to add on points not mentioned
WRITE their response on the flip chart/board
CLARIFY and SUMMARIZE by using the content below
 Tonsillitis is an inflammation of the tonsils caused by infection and swelling of the tonsils.
o Tonsils are oval-shaped masses of lymph gland tissue located on both sides of the
back of the throat.
o Most cases of tonsillitis are caused by viruses, which cannot be treated with antibiotics
STEP 3: Causes of Tonsillitis (15 Minutes)

 Tonsillitis is caused by:
o Viruses (the leading cause)
o Bacteria (mostly streptococcal).
o Malnutrition (especially vitamin deficiency) is a predisposing factor.
STEP 4: Pathophysiology of Tonsillitis (10 Minutes)

 The tonsils are masses of lymphoid tissue that lie on each side of the oropharynx. They filter
microorganisms to protect the lungs from infection.
 Tonsillitis occurs when the filtering function becomes overwhelmed with a virus or bacteria and
 Infection results. The adenoids, a mass of lymphoid tissue located at the back of the
nasopharynx, can also become involved.
 Tonsillitis is more common in children, but it is more serious when it occurs in adults.
 The most common organisms causing tonsillitis are Streptococcus species, Staphylococcus
aureus, Haemophilus influenzae, and Pneumococcus species.
STEP 5: Clinical Features of Tonsillits (20 Minutes)

The signs and symptoms of tonsillitis are as follows:
 Difficulty and pain with swallowing
 Throat pain and can be mild to severe
 Headache (occasionally)
 Ear pain (occasionally)

11
11
 Cough (occasionally)
 Vomiting and abdominal pain especially in children
 Fever and chills over 38 degrees Celsius or more
 Red and swollen tonsils, often with exudate
 Swollen and tender lymph glands on either side of the jaw
 Negative response to eat in young children (loss of appetite)
 Change in sound of the patients voice, i.e., muffled
 Accurate diagnosis of the cause of tonsillitis requires a throat culture, however, clinical
signs may be helpful.
 Viral tonsillitis is commonly associated with runny nose, cough and conjunctivitis
 Bacterial infections are commonly associated with fever, swollen nodes, headache and
 abdominal pain without runny nose, cough or conjunctivitis
 NOTE: It is important to distinguish viral from bacterial infection so that antibiotics will not be
prescribed unless necessary.
Figure 1.1: Normal and Inflamed Tonsils

Source: Mayo Foundation for Medical Education and research .
STEP 6: Diagnostic Measures of Tonsillitis (15 Minutes)

 Thorough physical examination is performed and a careful history is obtained to rule out related
or systemic conditions
 A throat culture is done to discover the causative organism and determine effective treatment.
 A white blood cell count helps identify whether the infection is viral or bacterial.
 A chest x-ray examination may be done if respiratory symptoms are present.

12
12
STEP 7: Complications of Tonsillitis (10 Minutes)
Tonsillitis if not treated properly may complicate to other medical conditions such as:
 Rheumatic fever
 Kidney inflammation (glomerulonephritis)
 Abscesses (para-tonsillar or retropharyngeal)
 Pneumonia
 Infection to adjacent organs e.g. ears, mastoid
 Obstructive sleep apnea especially in children
 Respiratory obstruction
STEP 8: Nursing Care of a Patient with Tonsillitis (35 Minutes)
Activity: Small Group Discussion (20 Minutes)

DIVIDE students into small manageable groups
ASK students to discuss nursing care and management of a patient with tonsillitis
ALLOW students to discuss for 20 minutes
ALLOW few groups to present and the rest to add points not mentioned
CLARIFY and SUMMARIZE by using the contents below
Specific management includes:

 Keep the patient comfortable while the illness runs its course by:
o Mouth gargles with warm salt water or Potassium Permanent
o Analgesics like Paracetamol.
o Provide comforting foods and beverage.
o Warm liquids like broth, caffeine-free tea
o Warm water with honey
o Cold drinks like ice pops can soothe a sore throat.
o Maintaining warmth to patient
o Administering oral antibiotic if prescribed and educate patient that it must be taken for the
full course of treatment even if the symptoms are no longer present.
o Reassuring the patients and family members about his condition.
o Educating family on ways to prevent transmission to other family members
o Educating the patients and family members about the importance of balanced diet.
o Encouraging rest. Encourage your child to get plenty of sleep.
o Providing adequate fluids. Give your child plenty of water to keep his or her throat moist
and prevent dehydration.
 Except for certain diseases, children and teenagers should not take aspirin because when
used to treat symptoms of cold or flu-like illnesses, it has been linked to Reye's syndrome, a
rare but potentially life-threatening condition.
 If the child has several episodes of severe tonsillitis, the doctor may recommend
tonsillectomy, which is the surgical removal of the tonsils.
o Tonsillectomy is usually performed for recurrent tonsillitis when medical treatment is
unsuccessful and there is severe hypertrophy, asymmetry, or peritonsillar abscess

13
13
that occludes the pharynx, making swallowing difficult and endangering the airway
(particularly during sleep)
o Educate the patient and family member about causes of Tonsillitis.
Post-Operative Care Following tonsillectomy

 Continue performing nursing observation in postoperative and recovery period because of
the significant risk of hemorrhage.
 Place the patient in prone position with the head turned to the side to allow drainage from
the mouth and pharynx. The nurse must not remove the oral airway until the patients gag
and swallowing reflexes have returned.
 Notify the surgeon if there is hemorrhage i.e if the patient vomits large amounts of dark
blood or bright-red blood at frequent intervals, or if the pulse rate and temperature rise and
the patient is restless,
 If there is no bleeding, give water and ice chips may to the patient as soon as desired.
 Instruct the patient to refrain from too much talking and coughing because these activities
can produce throat pain.
Teaching patients self-care
 Tonsillectomy and adenoidectomy usually do not require hospitalization and are performed
as outpatient surgery with a short length of stay. Because the patient will be sent home
soon after surgery, the patient and family must understand the signs and symptoms of
hemorrhage. Hemorrhage usually occurs in the first 12 to 24 hours. The patient is
instructed to report frank red bleeding to the physician.
 Alkaline mouthwashes and warm saline solutions are useful in coping with the thick mucus
and halitosis that may be present after surgery. It is important to explain to the patient that
a sore throat, stiff neck, and vomiting may occur in the first 24 hours.
 A liquid or semi-liquid diet is given for several days. Sherbet and gelatin are acceptable
foods. The patient should avoid spicy, hot, acidic, or rough foods. Milk and milk products
(ice cream and yogurt) may be restricted because they may make removal of mucus more
difficult.
STEP 9: Key Points (05 Minutes)

 Most cases of tonsillitis are caused by viruses, which cannot be treated with antibiotics
 Other cause of tonsillitis is bacteria, Malnutrition (especially vitamin deficiency) is a
predisposing factor
 Tonsils filter microorganisms to protect the lungs from infection. Tonsillitis occurs when the
filtering function becomes overwhelmed with a virus or bacteria and infection results
 Tonsillitis is more common in children, but it is more serious when it occurs in adults. The most
common
organisms causing tonsillitis are Streptococcus species, Staphylococcus aureus, Haemophilus
influenzae, and Pneumococcus species.
STEP 10: Session Evaluation (05 Minutes)

 What is the tonsillitis?
 What are the complications of tonsillitis?
 What are the causative organisms of tonsillitis?

14
14
References
Black, J. M., & Hawks, J.H. (2009). Medical surgical Nursing. (8th ed.). Philadelphia, W.B:
Saunders Company
Brunner & Suddath., (2010). Medical Surgical Nursing. (12th ed.). New York: Lippincott
Digiulio, M. K., Edward, J. (2014). Medical Surgical Nursing. McGraw-Hill Education Medical
Kluwer, W., Williams., & Wilkins. (2011). Review for Medical-Surgical Nursing Certification. (5th ed.).
Philadepia: Lippincott Williams
Lewis, S.L., Bucher, L., Dirkson, S.R., Heitkemper, M.M., & Harding, M.H. (2014). Medical Surgical
Nursing: Assessment and Management of Clinical Problems (9th ed.). Canada: Elsevier Mosby
Monahan F.D and Sands J.K (2007). Medical surgical nursing health and illness perspective (8thed.).
Canada:Mosby Elsvier
Phipps, L.W., (2007) Medical Surgical Nursing. Concepts and clinical Practice (7th ed) Mosby Canada

15
15
Suzane, C.S. et al, (2010). Brunner & Suddarths Text Book of Medical Surgical-Nursing (12thed).
Lippincott Philadelphi
Workman, I. (2016). Medical Surgical Nursing: Patient Centered Collaborative (8thed.). St Louis,
Missouri: Elsever, Inc

16
16
SESSION 02: CARE OF A PATIENT WITH FRACTURE
Learning Tasks
Define fracture
Identify classifications of fracture
Identify causes of fracture
Explain clinical features of a patient with fracture
Explain stages of fracture healing
Outline general managements of fracture
Explain the nursing management of fracture
Outline the prevention of fracture

ResourcesExplain
Needed:the complications of fracture
 Flip charts, marker
Prepare pens, and
a patient masking tape
for traction

Method
1 05 Presentation Presentation of session title and
learning tasks
2 05 Brainstorming, Lecture/ Definition of fracture
discussion
3 15 Buzzing, Lecture/discussion Cclassification of fracture
4 05 Lecture/discussion Causes of fracture

17
17
5 10 Lecture/ discussion Clinical features of a patient with
fracture
6 10 Lecture /discussion Stages of fracture healing
7 15 Buzzing, Lecture/ discussion General managements of fracture
8 10 Lecture/ discussion Nursing management of fracture
9 10 Lecture/ discussion Prevention of fracture
10 15 Lecture/ discussion Complications of fracture
11 10 Lecture/ discussion Preparation of a patient for traction
12 05
Presentation Key Points
13 05
Presentation Session Evaluation
SESSION CONTENTS
STEP 1: Presentation of Session Title and Learning Tasks (05 Minutes)
STEP 2: Definition of Fracture (05 Minutes)

ASK students to brainstorm on the definition of fracture
ALLOW time for them to respond
WRITE their answers on a flip chart/board.
CLARIFY and SUMMARISE by using the content below
Fracture is defined as a disruption or break in the continuity of the structure of bone that often affects
mobility and sensory perception.
STEP 3: Classifications of Fractures (15 Minutes)

18
18
Activity: Buzzing (05 Minutes)
ASK students to pair up and buzzing on classification of fractures
ALLOW students to provide responses and let others provide additional responses
WRITE their responses in the chalk/white board or flip chart
CLARIFY and summarize their responses using the content below
 A fracture is classified by the extent of the break:

o Complete fracture: the break is across the entire width of the bone in such
away that the bone is divided into two distinct sections
o Incomplete fracture: the fracture does not divide the bone into two portions
because the break is through only part of the bone
 An incomplete fracture is often the result of bending or crushing
forces applied to a bone
 A fracture is described by the extent of associated soft tissue damage:
o Open or compound: the skin is broken, exposing bone and causing soft tissue
injury (external wound)
o Open fractures are graded according to the following criteria:
 Grade I is a clean wound less than 1 cm long.
 Grade II is a larger wound without extensive soft tissue damage.
 Grade III is highly contaminated, has extensive soft tissue damage,
and is the most severe.
o Closed or simple: the skin has not been ruptured and remains intact, therefore
has no visible wound
 Fractures are also classified according to the direction of the fracture line.
o Types include:
 Linear - a fracture that extends parallel to the long axis of a bone but
does not displace the bone tissue.
 Oblique: is a fracture that is diagonal to a bone's long axis
 Transverse is a straight break right across a bone.
 longitudinal is fracture where the break is along the length of the
bone.
 Spiral fractures is a fracture where at least one part of the bone has
been twisted.
 Comminuted fracture - is when the bone is shattered into many
pieces.
 Greenstick fracture -it occurs when the bone partly fractures on one
side, but does not break completely because the rest of the bone can
bend. This is more common among children, whose bones are softer
and more elastic.

19
19
Fig 1.1: Types of Fracture
Source: https:// www.webmed.com/first-aid/ss/slideshow
 Fractures can also be classified as displaced or non displaced.

o In a displaced fracture the two ends of the broken bone are separated from
one another and out of their normal positions.
o Displaced fractures are usually comminuted (more than two fragments) or
oblique
 In a non- displaced fracture the periosteum is intact across the
fracture and the bone is still in alignment.
 Non- displaced fractures are usually transverse, spiral, or greenstick
STEP 4: Causes of Fracture (05 Minutes)

 The causes of fracture are:
o Traumatic injuries that account for the majority of fractures
o Secondary to a disease process (pathologic fractures from cancer or osteoporosis).
STEP 5: Clinical Features of a Patient with Fractures (10 Minutes)

 The clinical manifestations of a fracture are
o Pain
o Loss of function
o Deformity
o Shortening of the extremity
o Crepitus
o Local swelling and discoloration.

20
20
o Oedema and Swelling: Localized swelling occurs after a fracture as a result of trauma
and bleeding into the tissues. These signs may not develop for several hours after the
injury
o Disruption and penetration of bone through skin or soft tissues, or bleeding into
surrounding tissues
o Pain and Tenderness Muscle: The pain is continuous and increases in severity until
the bone fragments are immobilized. The muscle spasm that accompanies fracture is a
type of natural splinting designed to minimize further movement of the fracture
o Muscle Spasm: Irritation of tissues and protective response to injury and fracture
o Deformity: Abnormal position of extremity or partas result of original forces of injury
and action of muscles pulling fragment into abnormal position. Seen as a loss of
normal bony contours. Displacement, angulations, or rotation of the fragments in a
fracture of the arm or leg causes a deformity (either visible or palpable) that is
detectable when the limb is compared with the uninjured extremity
o Ecchymosis, Contusion: Discoloration of skin as a result of extravasations of blood
subcutaneous tissues.
o Loss of Function: After a fracture, the extremity cannot function properly, because
normal function of the muscles depends on the integrity of the bones to which they are
attached. Pain contributes to the loss of function. In addition, abnormal movement
(false motion) may be present.
o Crepitation: When the extremity is examined with the hands, a grating sensation, called
crepitus, can be felt. It is caused by the rubbing of the bone fragments against each
other.
o Shortening: In fractures of long bones, there is actual shortening of the extremity
because of the contraction of the muscles that are attached above and below the site
of the fracture. The fragments often overlap by as much as 2.5 to 5 cm (1 to 2 inches).
 NOTE: Not all of these clinical manifestations are present in every fracture.
STEP 6: Stages of Fracture Healing (10 Minutes)

 The principles of fracture healing is to provide appropriate therapeutic interventions.
 Bone goes through a complex multistage healing process (termed union) that occurs in the
following stages:
o Fracture hematoma:
 When a fracture occurs, bleeding creates a hematoma, which surrounds the
ends of the fragments.
 The hematoma is extravasated blood that changes from a liquid to a semisolid
clot. This occurs in the initial 72 hours after injury.
o Granulation tissue:
 During this stage, active phagocytosis absorbs the products of local necrosis.
 The hematoma converts to granulation tissue. Granulation tissue (consisting of
new blood vessels, fibroblasts, and osteoblasts) produces the basis for new
bone substance called osteoid during days 3 to 14 postinjury.
o Callus formation:
 As minerals (calcium, phosphorus, and magnesium) and new bone matrix are
deposited in the osteoid, an unorganized network of bone is formed that is
woven about the fracture parts.

21
21
 Callus is primarily composed of cartilage, osteoblasts, calcium, and
phosphorus. It usually appears by the end of the second week after injury.
 Evidence of callus formation can be verified by x-ray.
o Ossification:
 Ossification of the callus occurs from 3 weeks to 6 months after the fracture
and continues until the fracture has healed.
 Callus ossification is sufficient to prevent movement at the fracture site when
the bones are gently stressed. However, the fracture is still evident on x-ray.
 During this stage of clinical union, the patient may be allowed limited mobility
or the cast may be removed.
o Consolidation:
 As callus continues to develop, the distance between bone fragments
diminishes and eventually closes.
 During this stage ossification continues. It can be equated with radiologic
union, which occurs when there is x-ray evidence of complete bony union.
 This phase can occur up to 1 year after injury.
o Remodeling:
 Excess bone tissue is resorbed in the final stage of bone healing, and union is
complete.
 Gradual return of the injured bone to its pre injury structural strength and
shape occurs.
 Bone remodels in response to physical loading stress or Wolfs law. Initially,
stress is provided through exercise.
 Weight bearing is gradually introduced. New bone is deposited in sites
subjected to stress and resorbed at areas where there is little stress
STEP 7: General Managements of Fracture (15 Minutes)

ASK students to pair up and buzz on general managements of fractures

ALLOW 2 to 3 students to provide responses and let others provide additional responses
CLARIFY and SUMMARIZE their responses using the content below
 The overall goals of fracture treatment are:

o Anatomic realignment of bone fragments (reduction)
o Immobilization to maintain realignment
o Restoration of normal or near normal function of the injured part
o Reduction
 Reduction of a fracture (setting the bone) refers to restoration of the fracture
fragments to anatomic alignment and rotation.
 Either closed reduction or open reduction may be used to reduce a fracture.
 The specific method selected depends on the nature of the fracture; however,
the underlying principles are the same.

22
22
Usually, the physician reduces a fracture as soon as possible to prevent loss
of elasticity from the tissues through infiltration by oedema or haemorrhage.
 In most cases, fracture reduction becomes more difficult as the injury begins
healing.
 Closed Reduction. In most instances, closed reduction is
accomplished by bringing the bone fragments into apposition (ie,
placing the ends in contact) through manipulation and manual traction.
 The extremity is held in the desired position while the physician
applies a cast, splint, or other device.
 Traction (skin or skeletal) may be used to effect fracture reduction and
immobilization.
 Traction may be used until the patient is physiologically stable and
able to withstand surgical fixation.
 Open Reduction. Some fractures require open reduction.
 Through a surgical approach, the fracture fragments are reduced.
 Internal fixation devices (metallic pins, wires, screws, plates, nails, or
rods) may be used to hold the bone fragments in position until solid
bone healing occurs.
 These devices may be attached to the sides of bone, or they may be
inserted through the bony fragments or directly into
o Immobilization
 After the fracture has been reduced, the bone fragments must be immobilized,
or held in correct position and alignment, until union occurs
 Immobilization may be accomplished by external or internal fixation.
 Methods of external fixation include bandages, casts, splints, continuous
traction, and external fixators.
 Metal implants used for internal fixation serve as internal splints to immobilize
the fracture
o Maintaining and Restoring Function

 Reduction and immobilization are maintained as prescribed to promote bone
and soft tissue healing.
 Swelling is controlled by elevating the injured extremity and applying ice as
prescribed.
 Neurovascular status (circulation, movement, sensation) is monitored, and the
orthopedic surgeon is notified immediately if signs of neurovascular
compromise are identified
 Restlessness, anxiety, and discomfort are controlled with a variety of
approaches, such as
 Reassurance
 Position changes
 Pain relief strategies, including use of analgesics.
 Participation in activities of daily living (ADLs) is encouraged to
promote independent functioning and self-esteem
 With internal fixation, the surgeon determines the amount of
movement and weight-bearing stress the extremity can withstand and
prescribes the level of activity
STEP 8: Nursing Care of Patient with Fracture (10 Minutes)

 The goal of nursing care of a patient with a fracture, whether casted or in traction, is to promote
healing and prevent complications.

23
23
 Performing an accurate nursing assessment on a regular basis is essential.
 Assessment of vital signs and nutritional intake is important.
 When assessing a patient with a fracture, check the "5 P's"--pain, pulse, pallor, paresthesia,
and paralysis.
o Pain: Determine where the pain is located and if it is worse or better? Worsening pain
may indicate increased oedema, lack of adequate blood supply, or tissue damage.
o Pulse: Check the peripheral pulses, especially those distal to the fracture site.
Compare all pulses with those on the unaffected side. Pulses should be strong and
equal.
o Pallor: Observe the colour and temperature of the skin, especially around the fracture
site. Perform the capillary refill (blanching) test.
o Paresthesia: Examine the injured area for increase or decrease in sensation.
o Paralysis: Check the patient's mobility. Can the patient wiggle toes and fingers? Can
the patient move his extremities?
 Administer medication ( analgesics, antibiotics)
 Administer analgesics for pain relief to patient with fracture
 Observe potential complication with fracture and dislocation
 Monitor input and output
 Perform wound Dressing
STEP 9: Prevention of Fractures (10 Minutes)
The prevention of fracture includes the following:
 Prevention of falls by doing the following practices:
o Stairways should be gated if possible.
o Any liquid spilled should be swabbed and the area must be wiped dry to prevent
slipping
o Use handrails on staircases
o Use non-skid mats near bathrooms and other places.
o Keep floors free of clutter
o Provide grab bars in bathroom near shower and tub
o Elderly may benefit from use of canes or walkers
o Wear supportive, low heel shoes and avoid walking is socks and floppy backless
slippers
o Keep home well lighted and use a flashlight in dark areas
o Use a safe stool to reach high places
 Use protective equipment while driving such as helmets, elbow pads, knee pads, and shin
pads.
 Teach children regarding safety and supervise them carefully
STEP 10: Complications of Fractures (15 Minutes)

 Complications of fractures are classified according to whether they are local or systemic, and
when they occur - early or late.
 Early complications occur at the time of the fracture (immediate) or soon after tend to affect
mainly the soft tissues.
Local
o Vascular injury causing haemorrhage internal or external
o Visceral injury causing damage to structures such as the brain, lung or bladder
o Damage to surrounding tissue, nerves or skin

24
24
o Haemarthrosis
o Compartment syndrome (or Volkmann's ischemia)
o Wound Infection - more common for open fractures
 Systemic
o Fat embolism
o Shock
o Thromboembolism (pulmonary or venous)
o Exacerbation of underlying diseases such as diabetes or coronary artery disease (CAD)
 Late complications of fractures

o Local
 Delayed union
 Non- union
 Malunion
 Joint stiffness
 Contractures
 Myositis ossificans (inflammation of the muscle due to transformation of
muscle tissue to bone)
 Avascular necrosis
 Algodystrophy (or Sudeck's atrophy)
 acute atrophy of the bone at the site of injury probably due to local vasospasm
 Osteomyelitis
 Growth disturbance or deformity
o Systemic
 Gangrene
 Tetanus
 Septicaemia
 Fear of mobilizing
 Osteoarthritis
STEP 11: Preparation of a Patient for Traction ( 10 Minutes)

 Traction is the application of a pulling force to an injured or diseased part of the body or an
extremity. Counter traction pulls in the opposite direction.
 Traction devices apply a pulling force on a fractured extremity to attain realignment while
counter traction pulls in the opposite direction.
 Traction is used to :
o Prevent or reduce pain and muscle spasm associated with low back pain or cervical
sprain (e.g., whiplash)
o Immobilize a joint or part of the body
o Reduce a fracture or dislocation, and
o Treat a pathologic joint condition (e.g., tumor, infection)
 Traction is also indicated to:
o Provide immobilization to prevent soft tissue damage
o Promote active and passive exercise

25
25
o Expand a joint space during arthroscopic procedures
o Expand a joint space before major joint reconstruction.
 The two most common types of traction are:
o Skin traction
 Skin traction is generally used for short-term treatment (48 to 72 hours) until
skeletal traction or surgery is possible.
 Tape, boots, or splints are applied directly to the skin to maintain alignment,
assist in reduction, and help diminish muscle spasms in the injured extremity.
 The traction weights are usually limited to 5 to 10 lb (2.3 to 4.5 kg).
 A Bucks traction boot is a type of skin traction used to immobilize a fracture,
prevent hip flexion contractures, and reduce muscle spasms
 Pelvic or cervical skin traction may require heavier weights applied
intermittently.
 In skin traction, assessment of the skin is a priority, since pressure points and
skin breakdown may develop quickly.
 Assess key pressure points every 2 to 4 hours.
o Skeletal traction.
 Skeletal traction, generally in place for longer periods than skin traction,
 Is used to align injured bones and joints or to treat joint contractures and
congenital hip dysplasia.
 It provides a long-term pull that keeps the injured bones and joints aligned.
 To apply skeletal traction, the physician inserts a pin or wire into the bone,
either partially or completely, to align and immobilize the injured body part.
 Weight for skeletal traction ranges from 5 to 45 lb (2.3 to 20.4 kg).
 The use of too much weight can result in delayed union or non - union.
 The major complications of skeletal traction are infection in the area of the
bone where the skeletal pin is inserted and the consequences of prolonged
immobility.
 Preparation of a patient for traction
o Inform the patient about the procedure
o Prepare a patient physically and emotionally including family members
o Perform laboratory investigations as required
o Prepare equipments for the procedure
o Assist in signing a consent form when necessary
o Administer pre medication as prescribed
o Assist in procedure accordingly
STEP 12: Keys Points (05 Minutes)

 The managements of fracture involve the Anatomic realignment of bone fragments (reduction),
immobilization to maintain realignment and restoration of normal or near normal function of the
injured part

26
26
 What is a fracture?
 What are the classifications of fractures?
References
Saunders Company
Canada: Mosby Elsvier

27
27
SESSION 03: CARE OF A PATIENT WITH DISLOCATION
Learning Tasks
Define dislocation
Identify classifications of dislocation
Identify causes and risk factors of dislocation
Outline symptoms of dislocation
Give care to patient with dislocation
ResourcesOutline
Needed:complications of dislocation
 Flip charts, marker
Outline the pens, and masking
prevention tape
of dislocation

28
28
Method
1 05 Lecture/discussion Presentation of session title and
learning tasks
2 05 Brainstorming Definition of dislocation
3 10 Buzzing, Classifications of dislocation
Lecture/discussion
4 10 Lecture/discussion Causes and risk factors of dislocation
5 05 Lecture/ discussion Symptoms of dislocation
6 05 Lecture /discussion Care to patient with dislocation
7 05 Lecture /discussion Complications of dislocation
8. 05 Lecture /discussion Prevention of dislocation
9 05 Presentation Key Points

SESSION CONTENTS
STEP 2: Definition of Dislocation (05 Minutes)

ASK students to brainstorm on the definition of dislocation
 Dislocation is defined as an injury to a joint, a place where two or more bones come together in
which the ends of your bones are forced from their normal position
o This painful injury temporarily deforms and immobilize your joint
o This is most common in shoulders and fingers, also elbow, knees and hips
STEP 3: Classifications of Dislocation (10 Minutes)

ASK students to pair up and buzz on classification of dislocation
ALLOW 2 to 3 students to provide responses and let others provide additional responses 29
WRITE their responses in the chalk/white board or flip chart 29
CLARIFY and SUMMARIZE their responses using the content below
 Classification of dislocation are as follows:
o Dislocations can be classified as being partial or complete
 A partial dislocation is one in which the surfaces of the joint are not completely
separated.
 A complete dislocation is one in which the surfaces of the joint are fully
separated.
STEP 4: Causes and Risk Factors of Dislocation (10 Minutes)

 Causes
 A dislocation may occur in any bone joint.
o It may be traumatic, caused by an injury or violence
o Abnormal twisting or stretching
o May accompany a fracture
 Risk factors
o Susceptibility to falls:
 Falling increases your chances of dislocated joint if you use your arms to land
forcefully on a body part such as your hip or shoulder
o Heredity
 Some people are born with ligaments that are looser and more prone to injury
o Sports participations
 Many occur during high impacts or contact sports such as gymnastics,
wresting, basketball and football
o Motor vehicle accidents
 Most cause of hip dislocations especially for people not wearing seat belt
STEP 5: Signs and Symptoms of Dislocation (05) Minutes

 Signs and symptoms of dislocation include:
o Local joint pain
o Local bruising
o Deformity at the joint
o Difficult in moving the joint
o Swelling and discoloration around the joint
o Shock in severe cases
STEP 6: General Managements of Dislocation (05 Minutes)

 Treatment and Nursing management of dislocation involves:

30
30
o Initial reduction and immobilization of the affected joint.
o Administer analgesics for pain relief and other ordered medications.
o Apply immobilization device in order to prevent further injury after reduction
o Observe for complications, if the dislocation has involved a major joint, the patient will
require the same care and assistance given to any other immobilized patient
STEP 7: Prevention of Dislocation (05 Minutes)

 Falls are a major cause of dislocation especially in the children, the elderly and the disabled
o Stairways should be gated if possible.
o Any liquid spilled should be swabbed and the area must be wiped dry to prevent
slipping
o Use handrails on staircases
o Use non-skid mats near bathrooms and other places.
o Keep floors free of clutter
o Provide grab bars in bathroom near shower and tub
o Use canes or walkers for eelderly
o Wear supportive, low heel shoes and avoid walking is socks and floppy backless
slippers
o Keep home well lighted and use a flashlight in dark areas
o Use a safe stool to reach high places
 Use protective equipment while driving such as helmets, elbow pads, knee pads, and shin
pads.
 Teach children regarding safety and supervise them carefully
 Avoid recurrence, once you have dislocated a joint, you might be more susceptible to future
dislocation
STEP 8: Complications of Dislocation (05 Minutes)

 Tearing of muscles, ligaments and tendons that reinforce the injured joint
 Nerve or blood vessels damage in or around your joint
 Development of arthritis in the affected joint as you age

 Treatment for dislocations involves Initial reduction and immobilization of the affected joint,
administration of analgesics and other medications as well as observation for complications
STEP 10: Session Evaluation (05 minutes

 What is a dislocation?
 What are the classifications of dislocation?
 What are the risk factors for dislocation?

31
31
References
Saunders Company

32
32
SESSION 04: CARE OF A PATIENT WITH WOUND
Pre-requisite: NMT 04103 Human Anatomy and Physiology
Learning Tasks
Define wound
Identify causes and types of wound
Explain wound healing process
Identify factors delaying wound healing
Explain complications of wound
Control bleeding
Prepare requirement for wound dressing
Dress wound
Resources Needed:
 Handout 4.1: Regenerative ability of Tissue

Method
1 05 Presentation Session Title and Learning
Objectives
2 05 Presentation Definition of wound
3 10 Brainstorming , Lecture Causes and types of wound

discussion

33
33
4 15 Buzzing , Lecture discussion Wound healing process
5 15 Brainstorming , Lecture Factors delaying wound healing

discussion
6 15 Lecture discussion Complications of wound healing
7 15 Lecture discussion Controlling bleeding
8 10 Lecture discussion Prepare requirement for dressing
9 20 Lecture discussion Dress wound
10 05 Lecture discussion
Key Points
11 05 Lecture discussion
Session Evaluation
SESSION CONTENTS
READ or ASK learner to read the learning objectives
STEP 2: Definition of Wound (05 Minutes)

Activity: Brainstorming (03 minutes)
ASK students to brainstorm the definition of wound
ALLOW 3 to 4 students to respond and let others provide additional responses
WRITTE their responses on the flip chart/ board
 A term wound is implies as any disruption to the anatomic or physiologic function of tissue
OR
 Wound is a type of injury which happens relatively quickly in which skin is torn, cut, or
punctured (an open wound), or where blunt force trauma causes a contusion (a closed wound)
STEP 3: Causes and Types of Wound (10 Minutes)
Causes of wound

34
34
 Causes of wound depends on the type of the wound as follows:
o Surgical wound
 Caused by sterile incision, which is then closed with glue, staples, sutures, or
steri-strips which heals by first intention
o Ischemic Ulcer
 Insufficient arterial perfusion to an extremity. Risk increases with history of
peripheral vascular disease, diabetes mellitus, or advanced age
o Diabetic ulcers
 Peripheral neuropathy. Risk increases with history of diabetes mellitus or
arterial insufficiency
o Venous ulcer
 Disturbance in return blood flow from legs. Risk increases with history of valve
incompetence, perforating veins, deep vein thrombophlebitis or thrombosis,
previous ulcers, obesity, or advanced age
o Pressure Ulcers
 Excessive pressure (either high pressure over a short time or low pressure
over a longer time) that causes localized tissue damage
 Types of Wound
o Wounds are classified as follows:
 According to the cause which may be surgical or nonsurgical
 Acute: For example a wound caused by surgical incisions and trauma wounds
 Chronic: When underlying pathophysiology causes the wound or interferes
with the course of healing
 Depth of tissue affected: superficial, partial thickness, or full thickness
 A superficial wound involves only the epidermis.
 Partial-thickness wounds extend into the dermis.
 Full-thickness wounds have the deepest layer of tissue destruction
because they involve the subcutaneous tissue and sometimes even
extend into the fascia and underlying structures such as the muscle,
tendon, or bone
o Another system used to classify open wounds is based on the colour of the wound e,g
red, yellow, black
 The red-yellow-black classification can be applied to any wound allowed to
heal by secondary intention, including surgically induced wounds left to heal
without skin closure because of a risk for infection.
 A wound may have two or three colors at the same time. In this situation the
wound is classified according to the least-desirable color present.
STEP 4: Wound Healing Process (15 Minutes)

Wound healing process includes two major components are regeneration and repair
 Regeneration:
o Is the replacement of lost cells and tissues with cells of the same type
o The ability of cells to regenerate depends on the cell type

35
35
Refer Students to Handout 4.2: Regenerative ability of Different Types of Tissues
 Repair is healing as a result of lost cells being replaced by connective tissue.

o Repair is the more common type of healing and usually results in scar formation.
o Repair is a more complex process than regeneration.
o Most injuries heal by connective tissue repair.
o Repair healing occurs by:
 Primary intention
 Secondary intention
 Tertiary intention
 Primary Intention.
o Primary intention healing takes place when wound margins are neatly approximated,
as in a surgical incision or a paper cut.
o A continuum of processes is associated with primary healing
o These processes include three phases.
 Initial Phase:
o In the initial (inflammatory) phase, the edges of the incision are first
aligned and sutured (or stapled) in place.
o The incision area fills with blood from the cut blood vessels, blood
clots form, and platelets release growth factors to begin the healing
process.
o This forms a matrix for WBC migration. An acute inflammatory
reaction occurs.
o The area of injury is composed of fibrin clots, erythrocytes, neutrophils
(both dead and dying), and other debris.
o Macrophages ingest and digest cellular debris, fibrin fragments, and
red blood cells (RBCs).
o Extracellular enzymes derived from macrophages and neutrophils
help digest fibrin.
o As the wound debris is removed, the fibrin clot serves as a meshwork
for future capillary growth and migration of epithelial cells.
 Granulation Phase.
o The granulation phase is the second step.
o The components of granulation tissue include proliferating fibroblasts;
proliferating capillary sprouts (angioblasts); various types of WBCs;
exudates; and loose, semifluid, ground substance.
o Fibroblasts are immature connective tissue cells that migrate into the
healing site and secrete collagen.
o In time the collagen is organized and restructured to strengthen the
healing site.

36
36
o At this stage it is termed fibrous or scar tissue.
o During the granulation phase, the wound is pink and vascular.
Numerous red granules (young budding capillaries) are present
o At this point the wound is friable, at risk for dehiscence, and resistant
to infection.
o Surface epithelium at the wound edges begins to regenerate.
o In a few days a thin layer of epithelium migrates across the wound
surface in a one-cell-thick layer until it contacts cells spreading from
the opposite direction.
o The epithelium thickens and begins to mature, and the wound now
closely resembles the adjacent skin.
o In a superficial wound, re-epithelialization may take 3 to 5 days.
 Maturation Phase and Scar Contraction.

o The maturation phase, during which scar contraction occurs, overlaps
with the granulation phase.
o It may begin 7 days after the injury and continue for several months or
years.
o This is the reason abdominal surgery discharge instructions limit lifting
for up to 6 weeks.
o Collagen fibers are further organized, and the remodeling process
occurs.
o Fibroblasts disappear as the wound becomes stronger.
o The active movement of the myofibroblasts causes contraction of the
healing area, helping to close the defect and bring the skin edges
closer together.
o A mature scar is then formed. In contrast to granulation tissue, a
mature scar is virtually a vascular and pale.
o The scar may be more painful at this phase than in the granulation
phase.
 Secondary Intention
o Wounds that occur from trauma, ulceration, and infection have large
amounts of exudates and wide, irregular wound margins with
extensive tissue loss.
o These wounds may have edges that cannot be approximated (brought
together).
o The inflammatory reaction may be greater than in primary healing.
o This results in more debris, cells, and exudates. The debris may have
to be cleaned away (debrided) before healing can take place.
o The process of healing by secondary intention is essentially the same
as healing by primary intention.
o The major differences are the greater defect and the gaping wound
edges.

37
37
o Healing and granulation take place from the edges inward and from
the bottom of the wound upward until the defect is filled.
o There is more granulation tissue, and the result is a much larger scar.
 Tertiary Intention
o Tertiary intention (delayed primary intention) healing occurs with
delayed suturing of a wound in which two layers of granulation tissue
are sutured together.
o This occurs when a contaminated wound is left open and sutured
closed after the infection is controlled.
o It also occurs when a primary wound becomes infected, is opened, is
allowed to granulate, and is then sutured.
o Tertiary intention usually results in a larger and deeper scar than
primary or secondary intention
Refer Students to Handout 4.3: Wound Healing Process
STEP 5: Factors for Delaying Wound Healing (15 Minutes)

 Local factors
o Moisture for example from incontinence leads to skin maceration and oedema, making
the epidermis more susceptible to abrasion. The chemicals and bacteria in urine and
stool also cause tissue breakdown
o Necrotic debris and other foreign material in a wound interfere with optimal healing and
must be removed; by increasing the bacterial count, dead tissue increases the risk of
infection
o Infection at a level of more than 1 million organisms per gram of tissue inhibits
granulation and epithelialization
o Mechanical friction on wound: Destroys granulation tissue and prevents opposition of
wound edges
 Systemic factors
o Aging has a profound impact on all body systems; it affects wound healing by
 Decreasing the inflammatory response
 Delaying angiogenesis
 Decreasing collagen synthesis and degradation
 Slowing epithelialization (resulting in a thinner epidermal layer)
 Decreasing cohesion between the epidermal and dermal layers
 Decreasing the function of sebaceous glands (resulting in dryness)
 Altering the function of melanocytes (resulting in skin discoloration)
 Impairs circulation
 Requires longer time for epithelialization of skin
 Alters phagocyte and immune responses
 Obesity: Decreases blood supply in fatty tissue
o Malnutrition delays or prevents healing by

38
38
 Depriving the body of the nutrients it needs to combat the physiologic stress of
infection and to meet the increased metabolic demands of tissue repair;
patients with chronic or difficult-to-heal wounds have special dietary needs
o Nutritional deficiencies
 Vitamin C: delays formation of collagen fibres and capillary development
 Protein: Decrease supply of amino acids for tissue repair
 Zinc: impairs epithelialization
 Anaemia: Supplies less oxygen at tissue level
o Dehydration can hasten debilitation and death; a patient with a large wound can lose
far more than 1 L of water per day, the water loss of a healthy adult
o Vascular insufficiency can lead to poor healing and the development of leg ulcers
 Arterial insufficiency results in an inadequate blood supply, which can lead to
tissue hypoxia, infection, and death
 Cardiovascular insufficiency leads to systemic hypoxemia, which impedes
wound healing
 Venous insufficiency impaired flow toward the heart and elevated pressure in
the venous system leads to the leakage of fibrinogen around capillaries into
the dermis; this results in formation of a fibrin layer that blocks tissue
oxygenation, nutrient exchange, and waste removal
 Metabolic factors
o A patient with diabetes mellitus requires strict maintenance of normal blood glucose
levels for proper wound healing, particularly for the acute phase of tissue repair, during
periods of stress, after surgery, and for combating sepsis; poorly controlled diabetes
results in notoriously slow and complicated wound healing for several reasons
o Impaired circulation caused by thickening of the capillary basement membrane results
in reduced local blood flow
o Reduced sensation from diabetic neuropathy significantly reduces sensation in the
lower extremities, making patients less aware of injuries and serious infections
o Hyperglycaemia impairs the inflammatory response and collagen synthesis and
produces leukocyte dysfunction, which increases the risk of infection
o Renal failure or insufficiency increases the risk of infection and wound dehiscence and
delays granulation
o Diabetes mellitus also retards early capillary growth, impairs phagocytosis due to
hyperglycaemia and reduce supply of oxygen and nutrients secondary to vascular
disease
o A newly recognized disorder, reperfusion injury is thought to result from the
uncontrolled release of free radicals (superoxide anion, hydroxyl radicals, and
hydrogen peroxide) when ischemic tissue is re perfused or re oxygenated; oxygen-free
radicals can cause damage to cell membranes, lipids, proteins, blood vessels, and
deoxyribonucleic acid and can trigger the inflammatory process
 Neurologic factors
o The absence of pain sensation can lead to significant tissue damage from pressure or
trauma; a patient who doesn’t feel pain can’t respond to alleviate the pain

39
39
o Immobility and impaired sensory perception contribute to pressure ulcer development
and delayed healing
 Psychological factors
o Stress, depression, and sleep disorders can alter the immune response
o A stressed, depressed, or sleep-deprived patient is less likely to participate in self-
care, including wound care
o The sleep deprivation that can result from many psychological disorders interferes with
the restorative properties of rest and sleep
o Some patients with severe psychiatric disorders may deliberately injure themselves or
interfere with wound care measures
 Immunologic deficiencies
o Immunologic deficiencies impair many aspects of the inflammatory phase of healing
o Such deficiencies also predispose patients to infection Clotting disorders
o Clotting disorders interfere with the coagulation cascade critical in wound healing
o Platelet aggregation normally initiates haemostasis and the release of chemotactic
and growth promoting substances, but clotting factor deficiencies (for instance, from
haemophilia, malnutrition, or hepatic disease), thrombocytopenia, and anticoagulation
therapy can prolong bleeding into a wound and delay healing
 Other factors
o Glucocorticoid therapy (for instance, with prednisone or hydrocortisone) can interfere
with healing by
 Suppressing the inflammatory response
 Preventing macrophages from migrating into the wound
 Reducing fibroblast and endothelial cell activity
 Delaying contraction and epithelialization
o Medications, including anti-inflammatory drugs, cancer-fighting agents, anticoagulants,
and anti -prostaglandins,
 Interfere with the normal healing process
 Impair phagocytosis by WBCs
 Inhibit fibroblast proliferation and function
 Depress formation of granulation tissue
 Inhibit wound contraction
 Inadequate blood supply
o Decreases supply of nutrients to injured area
o Decrease removal of exudative debris
o Inhibit inflammatory response
 Smoking
o Nicotine is a potent vasoconstrictor that impedes blood flow to healing areas
STEP 6: Complications of Wound (15 Minutes)

The complications of wound include:
 Adhesions
o Bands of scar tissue that form between or around organs
o Adhesions may occur in the abdominal cavity or between the lungs and the pleural

40
40
o Adhesions in abdomen may cause an intestinal obstruction
 Contractions
o Wound contraction is a normal part of healing
o Complications occur when excessive contraction results in deformity
o Shortening of muscle or scar tissue, especially over joints, results from excessive
fibrous tissue formation
 Dehiscence
o Separation and disruption of previously joined wound edges
o Usually occurs when a primary healing site bursts open.
o It may be preceded by an increase in seros anguineous drainage
o May be caused by the following:
 Infection causing an inflammatory process
 Granulation tissue not strong enough to withstand forces imposed on wound
 Obesity placing individuals at high risk for dehiscence because adipose tissue
has less blood supply and may slow healing
 Pocket of fluid (seroma, hematoma) developing between tissue layers and
preventing the edges of the wound from coming together
 Evisceration
o Evisceration is the viscera spilling out of the abdomen
o Occurs when wound edges separate to the extent that intestines protrude through
wound
o When evisceration occurs, the patient may have pain and vomiting and may report that
something let loose or gave way.
o Often occur with abdominal incisions in patients who are malnourished, obese, elderly,
or who have poor wound healing
o Supporting the wound during coughing and other activities that pull on the incision or
applying an abdominal binder on patients who are at risk help prevent evisceration
 Excess Granulation Tissue (Proud Flesh)

o Excess granulation tissue may protrude above surface of healing wound
o If the granulation tissue is cauterized or cut off, healing continues in normal manner.
 Fistula Formation
o An abnormal passage between organs or a hollow organ and skin (abdominal or
perianal fistula).
 Infection
o Risk of infection when wound contains necrotic tissue or blood supply is decreased
patients immune function is decreased (e.g. from immunosuppressive drugs such as
corticosteroids), under nutrition, multiple stressors, and hyperglycemia in diabetes.
 Hemorrhage
o Bleeding is normal immediately after tissue injury and ceases with clot formation.
o Hemorrhage occurs as abnormal ,internal, or external blood loss caused by suture
failure, clotting abnormalities, dislodged clot, infection, or erosionof a blood vessel by
a foreign object (tubing, drains) or infection process

41
41
 Hypertrophic Scars
o Inappropriately large, raised red and hard scars
o Occur when an overabundance of collagen is produced during healing.
 Keloid Formation
o Wound edges and may form tumor-like masses of scar tissue
o Permanent without any tendency to subside
o Patients often complain of tenderness, pain, and hyperparesthesia, especially in
early stages
o Thought to be a hereditary condition occurring most often in dark-skinned people,
particularly African Americans.
 A hematoma occurs from bleeding in the wound and into the tissue around the wound.
o A clot forms from the bleeding. If the clot is large with swelling, the clot may need to be
removed by the physician.
o Infected wounds may be warm, reddened, and tender and have purulent (pus)
drainage.
o The drainage may have a foul odor.
o A fever and elevated white blood cell (WBC) count may be present
o Antibiotics are used to treat the infection.
STEP 7: Controlling Bleeding (15 Minutes)

Assessment reveals the seriousness of the condition
o If multiple injuries has occurred, the most serious problem, such as haemorrhage,
pneumothorax, or shock are treated first
o The victims are assessed for the other problems, such as fractures and internal
bleeding, which may not readily apparent but also require immediate attention
o After the victims condition has been stabilized and other potentially life threatening
problems treated attention may be given to the wounds
 If the wound is minor it is important to determine when and how the wound is
occurred
 In some cases part of the treatment may depend on the cause of the wound.
For the example wound caused by an instruments contaminated with soil may
require administration of tetanus prophylaxis, whereas a wound cause by
kitchen knife may not.
 Control blood loss by the following:
o Apply pressure over the wound
o Rise the injure part
o Take step to minimize shock which can result from severe blood loss
o Cover any open wound with a dressing to protect from infection and promote natural
healing
o Pay special attention to hygiene, so that there is no spread of infection between the
casualty and yourself.
o Remove debridement (dead tissue or foreign particles or objects) if suturing is
necessary under local anesthetic agent

42
42
o Clean the wound before suturing the wound edges under local anesthetic agent
o Apply sterile dress If suturing is not necessary
o Immobilize the arm or leg if involved
o Administer antibiotics depending on the extent and the cause of the injury (topical or
systemic)
o Remove clothing covering the wound carefully , if stuck to the wound, apply the saline
solution or hydrogen peroxide to aid in removing
o Shave the area around the wound and clean it with antiseptic agent
o Educate the client regarding care of the wound on discharge
o Give appointment for suture removal
STEP 8: Prepare Requirement for Dressing (10 Minutes)

The requirements for dressing include:
 Assessment:
o Assess the clients general comfort
o Check the condition of the wound and the size of the dressing
o Determine special or additional equipment will be needed e.g. presence of drain in a
wound Equipment:
 Top shelf:
o Sterile equipment
o Dressing towels
o 2 non toothed dissecting forceps
o 2 dressing forceps
o 2 galipot
o Gauze swabs
o Pair of scissors
o Sterile Gloves
 Bottom shelf:
o Plastic paper bag or receiver
o Bottle of antiseptic solution
o Receiver for used instruments
o Clean dressing mackintosh and towel
o Drum or pack with extra gauze swabs
o Adhesive plasters and bandages
o Cheatle forceps in a rub jar
o Hand rub
STEP 9: Dress wound (20 Minutes)

 Steps:
o Inform the patient about the procedure
o Screen the bed for privacy

43
43
o Close the nearby windows
o Bring trolley to the patients bedside
o Position patient comfortably and remove the bedclothes to expose old dressings
o Place dressing mackintosh and towel under the area to protect bottom sheet
o Wash hands and dry/use hand rub
o Open the dressing pack, and create a sterile working field by spreading the sterile
towel under the dressing site
o Arrange equipment on the trolley in order, using a dissecting forceps.
o Put enough gauze swabs
o Pour appropriate antiseptic into the galipot, Do not touch the sterile area with unsterile
material
o Remove old dressing by loosening the adhesive tapes gently, if dressings are sticky,
wet them with normal saline for easy removal
o Discard forceps into the receiver at the bottom of the shelf
o Observe condition of the wound
o If drains are present, remove the inner dressing layer by layer to avoid pulling the drain
o Wash hands again and put on sterile gloves if necessary
o If drains need shortening, cut the stitch between the drain and the skin before pulling (if
first shortening)
o Use a sterile forceps to pull the drain and a sterile pair of scissors to cut it. Replace a
sterile safety pin to hold the drain in position
o Dip a gauze swab into the cleaning solution, using a dressing forceps.
o Clean the wound from centre outward to wash away exudates from the wound.
o Use one gauze swab at one stroke only once.
o One forceps to be used for picking sterile swabs and the one for cleaning the wound.
o When the wound is clean apply sterile gauze swabs as required.
o If drains are present place gauze swab under each one so that the rubber drains do
not rest directly on the skin surface and cause excoriation
o Secure dressings by pieces of adhesive plaster. Make sure the dressings are
appropriately secured so that entrance of micro organisms into the wound is minimized
o Replace patients bed clothes and make him comfortable
o Thank the patient, remove screen
o Clear, decontaminate and clean equipment as appropriate
o Wash hands, dry and record the procedure with observed findings in the patients chart

 In management of wound it is important to understand the healing process of wound as well as
factors affecting the wound healing

 What is a wound?

44
44
 What are the wound complications?

45
45
References
Saunders Company
Handouts 4.1: Regenerative ability of Different Types of Tissues

46
46
47
47
Handouts 4.2: Wound Healing Process
Source: Lewis, S.L. et al, (2014). Medical Surgical Nursing (9th e.d )
(A) Primary intention. Wound healing occurs in a clean wound, such as a surgical wound, whose edges are
approximated typically with staples or sutures. Healing occurs quickly with slight scarring (B) Secondary intention.
Large irregular or infected wounds are left open to allow healing to occur from the inside out. Pressure ulcers or
chronic wounds are often treated this way. Large scarring occurs with lengthy healing time. (C)Tertiary intention.
Infected or contaminated wound is left open for a brief time period until wound is clean. Granulation tissue fills in
for some wound healing and then edges are approximated and closed surgically. Wider scarring occurs.

48
48
SESSION 05: CARE OF A PATIENT WITH BURN

Pre-requisite: NMT 04103 Human Anatomy and Physiology
NMT 04101 Infection Prevention and Control
Learning Tasks
Define burn
Identify causes and types of burn
Explain pathophysiology of burn
Explain extent and degree of burn injury use rule of nine
Explain complications of burn
Assess airway, breathing and circulation
Administer fluid and electrolyte
Monitor intake and output
Monitor vital signs
Administer antibiotics, analgesics,
Dress the wound
Counsel on balanced diet
Resources Needed:
 Handouts 5.1 :Photos showing appearance of degrees of burn
 Handouts 5.2 : Classification of burn
 Handouts 5.3: Description of burn
 Handouts 5.4: Phases of burn
 Handouts 5.5: Nursing Care Plan

Method

49
49
1 05 Presentation Session Title and Learning Objectives
2 05 Presentation Definition of burn
3 10 Brainstorming , Lecture discussion Causes and Types of burn
4 10 Buzzing , Presentation Extent and degree of burn
5 10 Brainstorming , Presentation Complications of burn
6 15 Lecture discussion Assessment of airway, breathing and

circulation
7 10 Lecture discussion Administration of fluid and electrolyte
8 10 Buzzing , Presentation Monitoring of intake and output
9 5 Brainstorming , Lecture discussion Monitoring of vital signs
10 10 Lecture discussion Administering antibiotics, analgesics
11 10 Lecture discussion Wound dressing
12 10 Buzzing, Lecture discussion Counselling on balanced diet
13 5
14 5
SESSION CONTENTS
STEP 1: Presentation of Session Title and Learning Tasks (05 minutes)
READ or ASK learners to read the learning objectives
STEP 2: Definition of Burn (05 Minutes)

50
50
ASK students to pair up and brainstorm on burn2 minutes for 3 minutes
 Burn is defined as the skin tissue destruction/injury resulting from excessive exposure to thermal, chemical,
electrical, or radioactive agents
o It usually resulting into loss of tissue integrity that cause patient to develop many physiologic,
metabolic, and psychological changes.
o The burn patient needs comprehensive care for a period of time (weeks or months) to survive the
injuries, reduce complications, and return to his or her best functional status.
STEP 3: Causes and Types of Burn (10 Minutes)
ASK the student to pair up and buzz on causes and types of burn
ALLOW 3 to 4 students to respond and let other provide additional responses
Causes of burn
 The following are causes of burn:
o Flame
o Scalding with steam or hot fluids
o Direct contact with hot surfaces
o Chemicals
o Electrical current
o Radiation
o Low-intensity flash
Types of burn
 Burn is categorized into two types based on nature of the source.
 The following are the types of burn:

51
51
o Dry Burns - Result from being contact with flames, hot objects or friction
o Scalds - This is the result of contact with hot fluids such as steam, hot water or hot cooking oil or hot fat
o Electrical burn this ca result from low and high voltage currents, lighting strike
o Chemical burn this can result from domestic chemicals, eg bleach and industrial chemicals including
fumes/corrosive gases
o Radiation burn usually sunburn or over-exposure to sunlamp ultraviolet rays
o Cold injury Frostbite, contact with freezing product
STEP 4: Extent and Degree of Burn (15 Minutes)

 Estimating the extent of the burn injury is the first step in estimating the burn injury severity.
 The severity of the burn is determined by how much of the body surface area is involved and the depth of
the burn.
 The following factors are considered in determining the depth of the burn:
o How the injury occurred
o Causative agent, such as flame or scalding liquid
o Temperature of the burning agent
o Duration of contact with the agent
o Thickness of the skin eg., eyelids, ears, nose, genitalia, tops of the hands and feet, fingers and toes
 The most commonly method for assessing the burn area is the use of Wallace rule of nine.
 The rule of nine is quick and easy way of estimating burns in adults >14 years.
o The body is divided into area divisible by 9
o The rule of nine is inaccurate in children less than 14 years.
o The system assigns percentages in multiples of nine to major body surfaces as shown in the figure3.1
below:
Estimated percentage of total body surface

area (TBSA) in the adult is arrived at by
sectioning the body surface into areas with a
numerical value related to nine.
Note:
 The anterior and posterior head total

9% of TBSA.
 The anterior leg 9% posterior 9%
 The anterior of the arm 4.5%
posterior 4.5%
In burn victims, the total estimated
percentage of TBSA injured is used to
calculate the patients fluid replacement
needs
Fig 3.1: The rule of nines: (Source: Brunner & Suddart. Text book of Medical Surgical Nursing, 3rd ed.2006)

52
52
.
 The Lund and Bowder chart provides a formula that can be used in children
o Lund and Browder method recognizes that the percentage of TBSA of various anatomic parts,
especially the head and legs, and changes with growth.
o By dividing the body into very small areas and providing an estimate of the proportion of TBSA
accounted for by such body parts, one can obtain a reliable estimate of the TBSA burned.
o It is more precise method of estimating the extent of a burn
NOTE: Simple erythema (reddening of the skin) should not be included when estimating burn area. Assessment of
both the TBSA burned and the depth of the burn is completed after soot and debris have been gently cleansed
from the burn wound
Classification of burns
 Burn wounds are classified as follows:
o First degree burn (Superficial Thickness Wounds)

 A superficial burn in which damage is limited to the outer layer of the epidermis and is marked by
redness, tenderness and mild pain
 Blisters do not form and the burn heals without scar formation
o Second degree (Partial Thickness Wounds)
 The burn involves tissue integrity loss of the entire epidermis and varying depths of the dermis
 Depending on the amount of dermal tissue damaged, Partial-Thickness Wounds are subdivided
into:
o Superficial Partial Thickness characterized by blisters forming immediately (pink/red wound
under blister), painful, sensitive to changes in temperature, moist, brisk capillary refill
o Deep Partial Thickness- Pale, white, large easily liftable blisters may be present, initially less
moist, and slightly painful with areas that are insensate but not a pin prick
 A burn that damages epidermal and some dermal tissue but does not damage the lower-lying hair
follicles, sweat or sebaceous glands
 The burn is painful and red; blisters form, and wound may heal with a scar
o Third degree (Full Thickness Wounds)
 A burn that extends through the full thickness of the skin layer and often into underlying tissues
epidermis and dermis, subcutaneous tissues,
 The skin has a Waxy white, deep red, pale, brown, gray, or blackened appearance; no response
to pressure or temperature minimal or no pain, the burn is painless because it destroys nerves in
the skin
 Deeper structures may be affected if chemical or electrical burn
 Scar formation is likely
Refer students to handout number 5.1. Photos showing appearance of degrees of burn
Refer students to handout number 5.2. Classification of burn
Description of burn
 Burn injuries are also described according to the depth of the injury and the extent of body surface area
injured and location of the burnt area as follows:

53
53
o Minor burn
o Moderate burn
o Major burn
Refer students to handout number 5.3. Description of burn
STEP 5: Complications of Burn (10 Minutes)

 Based on the assessment data, potential complications that may develop in the acute phase of burn care may
include:
o Heart failure and pulmonary edema
o Sepsis
o Acute respiratory failure
o Acute respiratory distress syndrome
o Visceral damage (electrical burns)
o Paralytic ileus (absence of intestinal peristalsis)
o Curlings ulcer Acute gastroduodenal ulcer that occurs with stress of severe injury
 Based on the assessment data, potential complications that may develop in the rehabilitation phase include:
o Contractures
o Inadequate psychological adaptation to burn injury
 The following are physiologic changes which may require attention of the nurse to prevent complications of
burn:
Cardiovascular changes involves:
o Disruption of blood circulation
o Tissue necrosis due to blood vessel thrombosis
o Fluid and electrolyte imbalance leading to loss of plasma fluid and proteins. Imbalances include:
 Hypovolemia - is the immediate consequence of fluid loss resulting in decreased perfusion and
oxygen delivery
 Metabolic acidosis
 Hyperkalemia
 Hypernatremia
o Edema
o Tachycardia
o Decreased cardiac output as fluid loss continues and vascular volume decreases, cardiac output
continues to fall and blood pressure drops. Cardiac output decreases before any significant change in
blood volume is evident.
o Burn shock
Pulmonary changes
 Inhalation injury is the leading cause of death in fire victims. Pulmonary changes includes:
o Bronchoconstriction caused by release of histamine, serotonin, and thromboxane, a powerful
vasoconstrictor,
o Chest constriction secondary to circumferential full-thickness chest burns
o Hypoxia (oxygen starvation)
o Decreased lung compliance, decreased arterial oxygen levels, and respiratory acidosis may occur
gradually over the first 5 days after a burn
o Pulmonary complications secondary to inhalation injuries include

54
54
 Acute respiratory failure
 Acute respiratory distress syndrome
 Diagnosis of inhalation injury is an important priority for many burn victims.

o Indicators of possible pulmonary damage include the following:
 History indicating that the burn occurred in an enclosed area
 Burns of the face or neck
 Singed nasal hair
 Hoarseness, voice change, dry cough, stridor, sooty sputum
 Bloody sputum
 Labored breathing or tachypnea (rapid breathing) and other signs of reduced oxygen levels
(hypoxemia)
 Erythema and blistering of the oral or pharyngeal mucosa
Gastrointestinal changes
o Hyper metabolism the patients oxygen use and calorie need increases
o Potential gastrointestinal complications may occur, these include:
 Paralytic ileus
 Curlings ulcer
Immunological changes
o Burn injury disrupts or destroys the protective skin tissue integrity increasing the risk for infection.
o The injury activates the inflammatory response and often suppresses all types of immune functions
 Management of patient with burn involves the following:

o Assessment of airway, breathing and circulation
o Administration of fluid and electrolyte
o Monitoring of intake and output
o Monitoring vital signs
o Administering antibiotics, analgesics,
o Dressing the wound
o Counselling on balanced diet
Refer students to handout number 5.4. Phases of burn
STEP 6: Assessment of Airway, Breathing and Circulation (10 Minutes)

ASK students to brainstorm on assessment of Airway, Breathing and Circulation
ALLOW 2 to 3 groups to respond and let other provide additional responses

55
55
 Although the local effects of a burn are the most evident, the systemic effects pose a greater threat to life.
Therefore, it is important to remember the ABCs of all trauma care during the early post burn period:
o Airway
o Breathing
o Circulation;
 Cervical spine immobilization for patients with high-voltage electrical injuries and if indicated for other
injuries; cardiac monitoring for patients with all electrical injuries for at least 24 hours after cessation of
dysrhythmia
 Some practitioners include “DEF” in the trauma assessment:
o Disability
o Exposure, and
o Fluid resuscitation
 The circulatory system must also be assessed quickly.
o Tachycardia (abnormally rapid heart rate) and slight hypotension are expected soon after the burn
 After adequate respiratory status and circulatory status have been established, the patient is assessed for
cervical spinal injuries or head injury if the patient was involved in an explosion, a fall, a jump, or an
electrical injury
 Apical pulse and blood pressure are monitored frequently
 Often the burn patient is awake and alert initially, and vital information can be obtained at that time.
 A secondary head-to-toe survey of the patient is carried out to identify other potentially life-threatening
injuries
 Preventing shock in a burn patient is imperative
 Once the patients condition is stable, attention is directed to the burn wound itself
 In emergency, cool the wound, establish an airway, supply oxygen, and insert at least one large-bore
intravenous line.
 Handling respiratory difficulties, the most urgent need is preventing irreversible shock by replacing lost
fluids and electrolytes
NURSING ALERT: No food or fluid is given by mouth, and the patient is placed in a position that will prevent
aspiration of vomitus because nausea and vomiting typically occur due to paralytic ileus resulting from the stress
of injury.
Refer students to handout number 5.5. Nursing Care Plan
STEP 7: Administration of Fluid and Electrolyte (10 Minutes)

 In administration of fluid and electrolyte involves the following:
o A large-bore (16- or 18-gauge) intravenous catheter should be inserted in a non-burned area (if not
inserted earlier).
o Most patients have a central venous catheter inserted so that large amounts of intravenous fluids can be
given quickly and central venous pressures can be monitored.
o If the burn exceeds 25% TBSA or if the patient is nauseated, a nasogastric tube should be inserted and
connected to suction to prevent vomiting due to paralytic ileus (absence of peristalsis)
 Give half of the fluid volume calculated for the first 24 hours after burn injury in the first 8 hours post burn
 The following Evans formula cab be used to calculate the required fluid and electrolyte

56
56
o Colloids: 1 mL × kg body weight × % TBSA burned
o Electrolytes (saline): 1 mL × body weight × % TBSA burned
o Glucose (5% in water): 2,000 mL for insensible loss
o Day 1: Half to be given in first 8 hours; remaining half over next 16 hours
o Day 2: Half of previous days colloids and electrolytes; all of insensible fluid replacement
o Maximum of 10,000 mL over 24 hours. Second- and third-degree (partial- and full-thickness) burns
exceeding 50% TBSA are calculated on the basis of 50% TBSA.
STEP 8: Monitoring of Intake and Output (15 Minutes)

 Survival of burn victims depends on adequate fluid resuscitation.
o Large-bore intravenous catheters and an indwelling urinary catheter are inserted to permit more accurate
monitoring of fluid intake, urine output and renal function for patients with moderate to severe burns.
 Urine output, an indicator of renal perfusion, is monitored carefully and measured hourly
 Intravenous lines and an indwelling catheter must be in place before implementing fluid resuscitation
 Record the amount of urine first obtained when the urinary catheter was inserted .This may assist in
determining the extent of preburn renal function and fluid status
 The nurse needs to know the maximum volume of fluid the patient should receive
o Baseline height, weight, laboratory test results such as arterial blood gases, hematocrit, electrolyte values,
blood alcohol level, drug panel, urinalysis, and chest x-rays are obtained.
 These parameters must be monitored closely in the immediate post-burn (resuscitation) period
o If the patient is elderly or has an electrical burn, a baseline electrocardiogram is obtained.
o Administer the low-dose dopamine to increase renal perfusion and diuretics if prescribed to promote
increased urine output monitor the patient’s response
o Assess IV access site, infusion rate, and infused volume at least hourly
 Assess urine output at least hourly for the following key indicators:
o Volume
o Color
o Specific gravity
o Character
o Presence of protein
 Measure additional body fluid output hourly
 Assess for fluid overload for the following key indicators:
o Formation of dependent edema
o Engorged neck veins
o Rapid, thread pulse
o Presence of lung crackles or wheezes on auscultation
STEP 9: Monitoring of Vital Signs (5 Minutes)

 Monitor the following vital signs at least hourly:

57
57
o Blood pressure
o Pulse rate
o Respiratory rate
o Breath sounds
o Voice quality (if not intubated)
o Oxygen saturation
o End-tidal carbon dioxide levels
STEP 10: Administering Antibiotics, Analgesics (10 Minutes)

 Administer antibiotics as prescribed.
 Because burns are contaminated wounds, tetanus prophylaxis is administered if the patient’s immunization
status is not current or is unknown.
 Pain is inevitable during recovery from any burn injury.
 Management of the often-severe pain is one of the most difficult challenges facing the burn team.
 Morphine sulfate remains the analgesic of choice for treatment of acute burn pain. It is titrated to obtain pain
relief based on the patients self-report of pain using a standardized pain rating scale.
 The use of non-pharmacologic measures has also proven effective in the management of burn pain. These
measures include:
o Relaxation techniques
o Deep breathing exercises
o Distraction
o Guided imagery
o Hypnosis
o Therapeutic touch
o Humor
o Information giving, and
o Music therapy - Music therapy has gained interest recently in the treatment of pain. Researchers have
found that music affects both the physiologic and psychological aspects of the pain experience.
 Anxiety and pain go hand in hand for burn patients. The entire burn experience can produce severe anxiety,
which can, in turn, exacerbate pain.
o Therefore, the ideal pain management regimen must incorporate the treatment of pain and anxiety and
must be individualized for each patient.
o The following are the nursing management of pain for burn patient:
 Assess pain level using pain intensity scale. Observe for nonverbal indicators of pain: grimacing,
tachycardia, clenched fists.
 Educate the patient about the usual pain trajectory in burn recovery and options for pain control. Allow
patient as much control as possible regarding pain management.
 Offer analgesics approximately 20 minutes before painful procedures.
 Provide analgesia before pain becomes severe.
 Instruct and assist patient in relaxation, imagery, distraction techniques.
 Assess and document the patients response to interventions.
 Administer antianxiety and antipruritic agents as indicated.
 Lubricate healing burn wounds with water- or silica-based lotion.

58
58
STEP 11: Wound Dressing (10 Minutes)
 When the wound is clean, the burned areas are patted dry and the prescribed topical agent is applied; the
wound is then covered with several layers of dressings.
 A light dressing is used over joint areas to allow for motion (unless the particular area has a graft and
motion is contraindicated).
 A light dressing is also applied over areas for which a splint has been designed to conform to the body
contour for proper positioning.
 Circumferential dressings should be applied distally to proximally.
 If the hand or foot is burned, the fingers and toes should be wrapped individually to promote adequate
healing.
 Burns to the face may be left open to air once they have been cleaned and the topical agent has been
applied. Careful attention must be given to burns left exposed to ensure that they do not dry out and
convert to a deeper burn.
 Close communication and cooperation among the patient, surgeon, nurse, and other health care team
members are essential for optimal burn wound care.
 Different wound areas on a given patient may require a variety of wound care techniques.
 Diagrams posted at the bedside are useful to inform staff of the current prescription for wound care,
splints to be applied over dressings, and the exercise regimen to be followed before dressings are
reapplied
Dressing changes
 Dressings are changed in the patient’s unit, hydrotherapy room, or treatment area approximately 20 minutes
after an analgesic agent is administered.
 They may also be changed in the operating room after the patient is anesthetized.
 A mask, goggles, hair cover, disposable plastic apron or cover gown, and gloves are worn by health care
personnel when removing the dressings.
 The outer dressings are slit with blunt scissors, and the soiled dressings are removed and disposed of in
accordance with established procedures for contaminated materials.
 Dressings that adhere to the wound can be removed more comfortably if they are moistened with tap water or
if the patient is allowed to soak for a few moments in the tub.
 The remaining dressings are carefully and gently removed. The patient may participate in removing the
dressings, providing some degree of control over this painful procedure.
 The wounds are then cleaned and debrided to remove debris, any remaining topical agent, exudate, and dead
skin.
 Sterile scissors and forceps may be used to trim loose eschar and encourage separation of devitalized skin.
During this procedure, the wound and surrounding skin are carefully inspected.
 The color, odor, size, exudate, signs of re-epithelialization, and other characteristics of the wound and the
eschar and any changes from the previous dressing change are noted
Refer students to handout number 5.6. Overview of topical Antimicrobial agents used for Burn
wound

59
59
STEP 12: Counselling on balanced diet (10 Minutes)
Activity: Buzzing (3 minutes)
ASK the student to pair up and buzz on counselling a burn patient/families on balanced diet
ALLOW 3 to 4 students to respond and let other provide additional responses
CLARIFY and summarize by using the content below
 Effective nutrition management depends on how well the energy expenditure due to the burn injury can be
estimated and matched with appropriate amounts of micronutrients, carbohydrates, lipids, and protein.
 Encouraged family members to bring nutritious and favorite foods to the hospital. Milkshakes and sandwiches
made with meat, peanut butter, and cheese may be offered as snacks between meals and late in the evening
 Provide high-calorie, high-protein diet; include patient preferences and homemade food.
 Provide nutritional supplements as prescribed, the patient needs sufficient nutrients for wound healing and
increased metabolic requirements
 Monitor patients daily weight and calorie count. These measures assist in determining whether dietary needs
are being met
 Administer supplemental vitamins and minerals as prescribed. These help meet additional nutritional needs;
adequate vitamins and minerals are necessary for wound healing and cellular function.
 Administer enteral or parenteral nutrition per protocol if dietary needs are not met through oral intake.
Nutritional techniques ensure that nutritional needs are met.
 Report abdominal distention, large gastric residual volumes, or diarrhea to physician. These signs may
indicate intolerance of route or type of feeding
 The nurse collaborates with the dietitian or nutrition support team to plan a protein- and calorie-rich diet that is
acceptable to the patient.
 Nutritional supplements such as Vitamin and mineral supplements may be prescribed.
 Caloric intake must be documented.
 If caloric goals cannot be met by oral feeding, a feeding tube is inserted and used for continuous or bolus
feedings of specific formulas.
 The volume of residual gastric secretions should be checked to ensure absorption.
 Parenteral nutrition may also be required but should be used only if gastrointestinal function is compromised
Indications for parenteral nutrition
 Indications for parenteral nutrition include:

o Weight loss greater than 10% of normal body weight
o Inadequate intake of enteral nutrition due to clinical status
o Prolonged wound exposure

60
60
o Malnutrition or debilitated condition before injury.
 The risk of infection at the site of the central venous catheter required for parenteral nutrition must be
considered.
STEP 13: Key Points (05 Minutes

 Assess the burn patients airway and adequacy of breathing before assessing any other body system
 Use strict aseptic technique when caring for patients who have open wound to prevent infection
 Monitor patients vital signs at least every 8 hours for indication of wound infections or sepsis
 Give the prescribed analgesics and opioid analgesics by the IV route during the resuscitation phase of
burn recovery
 Reassure patient that pain will be managed effectively
 Support the patient and family in coping with permanent changes in appearance and function
 Evaluate the patients wound healing during the acute phase of burn injury
 Encourage patient to actively participate in pain control and self-care
 Position patients to prevent contractures and promote joint function

 What is burn injury?
 What are the complications of burn?
 What are the non-pharmacological interventions proved to release pain?
References

61
61
Australia Ski Patrol Association. (2011). Adavnced emergency care manual (10th ed.). Retrieved from
http://www.skipatrol.org.au
Saunders Company
Jevon, P. (2007). Emergency Care and First Aid for Nurses: A practical Guide. Elsevier
Monahan F.D and Sands J.K (2007). Medical surgical nursing health and illness perspective (8thed.). Canada:
Mosby Elsvier
Primary Trauma Care Foundation. (2010). Primary care trauma manual: A manual for trauma management in
district and remote locations. Retrieved from http://www.primarytraumacare.org
St. Andrews Ambulance Association. (2001). First aid manual: Emergency procedure for everyone at home, at
work, at leisure (7th ed.). London: Dorling Kindersley
Suzane, C.S. et al, (2010). Brunner & Suddarths Text Book of Medical Surgical-Nursing (12thed). Lippincott
Philadelphia
WedMd. (n.d.) Brain hemorrhage: Causes, symptoms, treatments. Retrieved from http://www.webmd.com

62
62
HANDOUT 5.1: Photos showing appearance of degree of burn
Fig 5.1: The typical appearance of a superficial partial thickness burn injury.
Fig 5.2: The typical appearance of a deep partial-thickness burn injury.

63
63
Fig 3.3: The typical appearance of a full-thickness burn injury
Fig 5.5: The typical appearance of a deep full-thickness burn injury

(Source fig 3.1 -3.5: Ignatavicius, D.D & Workman, L.M. (2016). Medical Surgical Nursing. Patient-Centered
Collaborative Care. (8th Ed). Elsevier)

64
64
HANDOUT 5.2: Classification of Burn
(Source: Brunner & Suddart. Text book of Medical Surgical Nursing, 3rd ed.2006)
HANDOUT 5.3. Description of Burn.

Minor Burn Injury
 Second-degree burn of less than 15% total body surface area (TBSA) in adults or less than 10% TBSA in
children
 Third-degree burn of less than 2% TBSA not involving special care areas (eyes, ears, face, hands, feet,
perineum, joints)
 Excludes electrical injury, inhalation injury, concurrent trauma, all poor-risk patients (eg, extremes of age more
than 60, concurrent disease)
Moderate, Uncomplicated Burn Injury

 Second-degree burns of 15%–25% TBSA in adults or 10%–20% in children
 Third-degree burns of less than 10% TBSA not involving special care areas
 Excludes electrical injury, inhalation injury, concurrent trauma, all poor-risk patients (eg, extremes of age,
concurrent disease)
Major Burn Injury

 Second-degree burns exceeding 25% TBSA in adults or 20% in children

65
65
 All third-degree burns exceeding 10% TBSA
 All burns involving eyes, ears, face, hands, feet, perineum, joints
 All inhalation injury, electrical injury, concurrent trauma, all poor-risk patients
HANDOUT 5.4: Phases of Burn Care

66
66
HANDOUT 5.5: Nursing Care Plan

67
67
68
68
69
69
70
70

71
71
HANDOUT 5.6: Overview of Topical Antibacterial Agents Used for
Burn Wounds

72
72
SESSION 06:NURSING CARE TO PATIENTS WITH PHIMOSIS
PARAPHIMOSIS AND BALANITIS
Prerequisite: NMT 04103 Human Anatomy and Physiology
Learning Tasks
Provide a Descriptive definition of phimosis
List complications of phimosis
Demonstrate the nursing management of a patient with phimosis
Provide a Descriptive definition of paraphimosis
Demonstrate the nursing management of a patient with paraphimosis
List complications of paraphimosis
Provide a Descriptive definition of balanitis
Demonstrate the nursing management of the patient with balanitis
List complication of balanitis
Resources Needed:

Method
1 05 minutes Presentation Overview of the Learning Tasks
2 Small group discussion,
15 Minutes Presentation Descriptive Definition of Phimosis
3 Brainstorm, Presentation
05Minutes Complication of Phimosis
4 15 Minutes Buzzing, Presentation Nursing Care and Management of a
Patient with Phimosis
5 15 Minutes Presentation Descriptive Definition of Paraphimosis
6 05 Minutes Presentation Complication of Paraphimosis

73
73
7 15 Minutes Small Group Discussion, Nursing Care and Management of a
Presentation Patient with Paraphimosis
8 15 Minutes Lecture Discussion Descriptive Definition of Balanitis
9 05 Minutes Lecture Discussion Complications of Balanitis
10 15 Minutes Small Group Discussion, Nursing Care and Management of a
Presentation Patient with Balanitis
11 05 minutes
12 05 minutes
STEP 1: Overview of the Learning Task (05 Minutes)

Read or Ask students to read the Learning Task and Clarify
Ask students if they have understood the Learning Tasks
STEP 2: Descriptive Definition of Phimosis (15 Minutes)

Descriptive definition of Phimosis
o Phimosis is a condition where the penile foreskin (prepuce) is constricted at the opening, so that it
cannot be retracted over the glans.
o Stenosis or narrowness of the prepuce orifice, so that the foreskin cannot be pulled back over the
glans penis.
Causes of Phimosis
 Can occur congenitally
o Inflammation (swelling, redness) of the foreskin from infection or local trauma causes the foreskin
to stay too tight
o In adults who do not clean the prepurial area, normal secretions accumulate, causing subsequent
inflammation (balanitis), which can lead to adhesions and fibrosis.
 Bacterial infection
o Phimosis can occur in males with diabetes if they use catheters
o Phimosis can develop in babies and teenagers and adults because of infections (including diaper
rash) or irritation
o Prolonged phimosis, caused by chronic inflammation and irritation, predisposes the patient to
penile cancer
 Predisposing factors
o Diaper rash
o Being uncircumcised
o Young age
o Penile Infection
 Signs and Symptoms of Patient with Phimosis

o Oedema.
o Erythema

74
74
o Tenderness
o Pain in the glans penis
o Purulent discharge from the penis and/or foreskin
Figure 6.1: Picture showing Phimosis
Source:Med Help. (2012). Phimosis. Retrieved from http://www.medhelp.org

 Preventive measures of Phimosis
o Phimosis is generally prevented by teaching uncircumcised males to pull the foreskin back
carefully,
o Wash with mild soap and water daily, and replace the foreskin to its normal position.
STEP 3: Complications of Phimosis (05 Minutes)

ASK students to pair up and brainstorm on complications of Phimosis

75
75
The list of complications that have been mentioned in various sources for Phimosis includes:
 Difficulty urinating
 Balanitis
 Painful erections
 Paraphimosis
STEP 4: Nursing Care and Management of a Patient with Phimosis (15 Minutes)
Activity: Small Group Discussion (10 minutes)
ASK students to discuss nursing care and management of a patient with Phimosis
 Nursing care and managements include the followings:
o Applly topical steroid cream, such as betamethasone, applied four times per day, for two to four
weeks to the narrowed part of the foreskin is relatively simple, less expensive than surgical
treatments and highly effective.
o Teach the patient to keep the foreskin clean to prevent future infections that may cause phimosis
o Apply warm compresses or hot soaks to help reduce inflammation.
o Administer antibiotics as prescribed to treat infection
o Surgical methods consist Circumcision, the removal of the foreskin or a minor operation to let out
the foreskin
 The procedure should be done with the client under general anesthesia.
 Potential risks include excessive bleeding, infection, and penile trauma
 Teach the patient and family how to apply petroleum dressing and observe for signs of
infection and/or bleeding
 If severe bleeding occurs apply a firm dressing and return to the Doctors office or
hospital
 Explain the use of oestrogen that may be prescribed to prevent painful erections during
the healing time.
 Contraindications of circumcision
 Balanitis (infection under the prepuce)
 Ammonical dermatitis of the prepuce
 Blood clotting/bleeding disorder
o Observe for complications following circumcision which includes
 Haemorrhage.
 Infection.
 Urethritis, particulary damage to the external urinary meatus
 Ulcer on the glans penis or at the meatus

76
76
Step 5: Descriptive Definition of Paraphimosis (15 Minutes)
Activity: Brainstorm (3 Minutes)
ASK students to brainstorm the definition of Paraphimosis for 2 minutes
ALLOW few students to provide their responses
WRITE their responses on the flip chart/board
CLARIFY and SUMMARIZE using the content below
 Paraphimosis is the condition in which the foreskin is retracted behind the glans, because of narrowness
and subsequent oedema cannot be returned to its usual position (covering the glans).
 Paraphimosis is the strangulation of the glans penis due to retraction of a narrowed or inflamed foreskin
 The cause paraphimosis is when the foreskin is not returned to its normal position, circulation is thus
impeded and the glans swells rapidly.
 This may happen during or after:
o Rigorous cleaning
o Masturbation or sexual intercourse
o Catheter insertion
o Cystoscopy
 Signs and Symptoms of Paraphimosis

o Pain of the glans penis
o Severe oedema of the glans penis, and urinary retention may be seen if the condition is allowed
to continue.
Fig 6.2: Picture of Phimosis

77
77
Source:Fast Bleep. (n.d.). Phimosis. Retrieved from http://www.fastbleep.com
STEP 6: Complications of Paraphimosis (05 Minutes)

 Complications for Paraphimosis includes:
 Penis circulation loss
 Penis amputation
STEP 7: Nursing Care and Management of the Patient with Paraphimosis (20 Minutes)
 Management
o Apply cool compresses to reduce swelling
o By firmly compressing the glans to reduce its size and pushing the glans back while
simultaneously moving the prepuce forward (manual reduction)
o Patient is instructed to clean the area under the foreskin daily and see a doctor immediately if
unable to return the foreskin to the normal position covering the glans penis
o Circumcision: Refer to phimosis for nursing care after circumcision
o Circumcision (removal of the foreskin) is done to prevent recurrence of Paraphimosis.
STEP 8: Descriptive Definition of Balanitis(15 Minutes)

 Balanitis is the inflammation of the glans penis and the mucous membrane beneath it.
 Cause of balanitis
o Balanitis can be a symptom of the following skin conditions
o Lichen planus - a skin disease with small, itchy, pink or purple spots on the arms or le.g.s.
o Eczema - A chronic (long-term) skin condition, in which the skin becomes itchy, reddened, cracked
and dry.
o Dermatitis - inflammation of the skin that is caused either by direct contact with an irritant, or an
allergic reaction
o Psoriasis - a dry, scaly skin disorder; believed to be genetic. It is caused by the immune system being
mistakenly "triggered", resulting in skin cells being produced too quickly.
o Irritation to the penis - irritation of the skin of the glans may be caused by
 Chemicals that exist in condoms, lubricants and spermicides
 Detergents (washing powders) if not completely rinsed
 Fabric conditioners if not completely rinsed
 Perfumed soaps and shower gels
o Infection
 Candida - this is a type fungus. The one that causes thrush.
 Bacteria - which may multiply rapidly in the moist and warm conditions under the the foreskin
o Diabetes - males with diabetes are more susceptible to infections, especially if the blood sugar is
poorly controlled. If glucose is present in urine, some of it may remain on the foreskin. Glucose helps
bacteria to multiply more quickly.

78
78
o Phimosis Old sweat, urine and other substances may accumulate under the foreskin, causing
irritation and allowing germs to multiply. Phimosis is very rare among teenage and adult males
o Unprotected sex - if the woman has vaginal thrush, the male may become infected, increasing the
risk of developing balanitis. Genital herpes, Chlamydia and syphilis may also cause balanitis
o Signs and symptoms of balanitis
 The area around the glans (head of the penis) is red
 Inflammation of the glans
 Soreness of the glans
 Irritation of the glans
 Under the foreskin there may be a lumpy, thick discharge
 Itchiness around the glans area
 An unpleasant smell
 Phimosis - the foreskin is tight and does not retract (can't pull it back)
 Painful urination
 The soreness, irritation and discharge under the foreskin typically occurs two to three days after
sexual intercourse
Figure 6.3.Picture showing patient with Balanitis

79
79
Med Help. (2012). Balanitis. Retrieved from http://www.medhelp.org
 Diagnostic evaluation of balanitis
o History taking from the patient.
o Physical examination.
o Laboratory studies: urinalysis and blood for glucose to check for diabetes
o Swab the glans penis to check for infection
o Biopsy to rule out the malignancies, though rare
STEP 9: Complications of Balanitis (05 Minutes)

 Complications that may develop with balanitis and balanoposthitis include:
o Cellulitis, a bacterial infection of the deeper layers of the skin
o Buried penis syndrome, a condition where the penis is buried beneath folds of skin (usually
associated with obesity)
o Meatal stenosis, an abnormal narrowing of the opening at the tip of the penis
o Balanitis xerotica obliterans, a chronic dermatitis of the glans penis and foreskin
o Scarring
o Reduced blood flow to the glans penis
o Increased risk of penile cancer
STEP 10: Nursing care and Treatment of the Patient with Balanitis (15 Minutes)
 Treatment for balanitis depends on the cause. In most cases the doctor will advise on what
substances to avoid.

80
80
o Allergic reaction - if the inflammation is thought to be caused by an allergic reaction or some irritant
the doctor may prescribe a mild steroid cream, such as 1% hydrocortisone, for the swelling. An
antifungal or antibiotic medication may also be prescribed. If there is an infection the patient should
not use a steroid cream on its own. All soaps and other potential irritants should be avoided during
treatment, and until signs and symptoms have completely gone.
o Candida (yeast infection) - the doctor will prescribe an antifungal cream, such as clotrimazole or
miconazole. The patient's sex partner should also be treated. While treatment is underway he should
either abstain from sex or use a condom.
o Bacterial infection - the patient will be prescribed an antibiotic, such as erythromycin or penicillin.
o If the GP determines that there is no infection and no irritant has been identified, the patient may be
referred to a dermatologist (a doctor specialized in skin conditions), or a genitor-urinary clinic.
 Phimosis and Recurrence

 If the patient has a tight foreskin and the balanitis keeps coming back, the doctor might suggest
circumcision.
o Teach the patient and family the patient information on good hygiene
o The foreskin should be retracted (pulled back) so that the glans is exposed.
o The area should be washed thoroughly and gently with warm water. As soap may irritate
it should not be used.
o An aqueous cream or some other neutral nonsoap cleanser may be used - but it should
be completely rinsed off.
o Before replacing the foreskin the glans should be completely dry.
o Men who tend to develop balanitis after sex should wash their penis after sex.
o Avoid irritants
o It is important to assess for diabetes, which predisposes the client to secondary infection.

 Phimosis is a condition whereby the penile foreskin (prepuce) is constricted at the opening, so that it
cannot be retracted over the glans.
 Paraphimosis is the condition in which the foreskin is retracted behind the glans.
 Paraphimosis requires immediate care to prevent complications.
 Balanitis is the inflammation of the glans penis and the mucous membrane beneath it
STEP 6: Evaluation (05 Minutes)

 What are the management of the patient with Paraphimosis?
 What are the sign and symptoms of the patient with balanitis?
 What are preventive strategies for phimosis and balanitis?
References

81
81
Saunders Company
Monahan F.D and Sands J.K (2007). Medical surgical nursing health and illness perspective (8thed.). Canada:
Mosby Elsvier
Primary Trauma Care Foundation. (2010). Primary care trauma manual: A manual for trauma management in
district and remote locations. Retrieved from http://www.primarytraumacare.org
St. Andrews Ambulance Association. (2001). First aid manual: Emergency procedure for everyone at home, at
work, at leisure (7th ed.). London: Dorling Kindersley
Suzane, C.S. et al, (2010). Brunner & Suddarths Text Book of Medical Surgical-Nursing (12thed). Lippincott
Philadelphia
WedMd. (n.d.) Brain hemorrhage: Causes, symptoms, treatments. Retrieved from http://www.webmd.com

82
82
SESSION 07: CARE OF A PATIENT WITH EPISPADIASIS, HYPOSPADIASIS
AND URETHRA STRICTURE

Learning Objectives
Define epispadiasis and hypospadiasis
Enumerate causes of epispadiais and hypospadiasis
Differentiate signs and symptoms between hypospadiasis and epispadiasis
Describe nursing management of epispadiasis and hypospadiasis
List complications of epispadiasis and hypospadiasis
Define the term Urethra stricture
List the causes of urethra stricture
List signs and symptoms of urethra stricture
Describe the nursing management of urethra stricture
List complications of urethra stricture
Resources Needed:

Ste Time Teaching Activities Content
p
1 05 minutes Presentation Overview of session title and learning tasks
Presentation/
2 05 minutes Brainstorm Definition of Epispadiasis and Hypospadiasis
3 05 minutes Presentation Causes of Epispadiais and Hypospadiasis
Differentiate Signs and Symptoms between

4 5 minutes Presentation Hypospadiasis and Epispadiasis
Presentation/ Nursing Management of Epispadiasis and
5 5 minutes Brainstorm Hypospadiasis
Presentation/ Complications of Epispadiasis and
6 5 minutes Buzz Hypospadiasis

83
83
Presentation/ Definition and Causes of Urethra Stricture
7 10 minutes Brainstorm
8 5 minutes Presentation Signs and Symptoms of Urethra Stricture
9 10 minutes Presentation Nursing Management of Urethra Stricture
10 05 minutes Presentation Key Points
11 05 minutes Presentation Session Evaluation
SESSION CONTENTS
STEP 1: Overview of Session Title and the Learning Task (05 Minutes)
READ or ASK students to read the Learning Task and Clarify
ASK students if they have understood the Learning Tasks
STEP 2: Definition of Epispadiais and Hypospadiasis (05 Minutes)

ASK the students to brainstorm on the definition of epispadiais and hypospadiasis
ALLOW few students to respond
CLARIFY and SUMMARIZE utilizing information below
Definition
 Epispadiais: Is a rare type of malformation of the penis in which the urethra ends in an opening
on the upper aspect (the dorsum) of the penis. It can also develop in females when the urethra
develops too far anteriorly.
 Hypospadiasis: Is a congenital abnormality where the urethral opening is a groove on the
underside of the penis.
Figure 7.1 :Diagram showing Epispadiasis and Hypodiasis

84
84
Epispadiasis Hypospadiasis
Source:Med Help. (2012). Hypospadiasis. Retrieved from http://www.medhelp.org
STEP 3: Causes of Epispadiasis and Hypospadiasis (05 Minutes)

 The cause is unknown but it may occur with a failure of abdominal and pelvic fusion in the
first trimester of embryogenesis.
STEP 4: Signs and Symptoms of Hypospadiasis and Epispadiasis (05 Minutes)

 Signs and symptoms of epispadiasis
o Abnormal opening from the bladder neck to the area above the normal urethra opening
o Backward flow of urine into the kidney (reflux nephropathy)
o Urinary incontinence
o Urinary tract infections
o Widened pubic bone
Signs and symptoms of hypospadiasis

o Inability to pass urine with the penis in the normal elevated position
o Urine comes out underside(bottom) the penis
o In severe forms it interferes with the ability to procreate
STEP 5: Nursing Management of Epispadiasis and Hypospadiasis (05 Minutes)

Nursing management
o Both epispadius and hypospadius need reconstructive surgery to correct the anomaly
o The goals of surgical procedures are
 Correction of the curvature
 Reconstruction of the missing portion of urethra
 Restoration of the normal aspect of the external genitalia
o Reconstruction of the anterior wall of the bladder when necessary.
o Surgery differs according to the complexity of the malformation.

85
85
Nursing Care Postoperatively
 Urinary catheter and /or other tubes will be in place to keep reconstructed urethra open and patent,
It is important to minimize movement or pulling on tubes in order to protect the surgical site.
 The dressings remain in place for 4 days if no problems occur.
 The diverting urinary catheter is usually removed after 8-10 days.
 Patient may be discharged after removal of the urinary diversion and when spontaneous voiding
occurs without difficulty.
 Talk to the patient to allay anxiety.
 Cover the wound with gauze impregnated with petroleum
 Monitor for bleeding
 Provide cradle to keep bed linen off penis
 Use aseptic technique when changing dressings
 Give prescribed analgesics for pain and antibiotic to prevent infection
 Effective genital hygiene is essential to prevent acquired infections
STEP 6: Complications of Epispadiasis and Hypospadiasis (05 Minutes)
 Urinary tract infections occur more frequently.

 Ureter and kidney damage and infertility may occur
 Postoperative bleeding and infection are possible.
 Some people with this condition may continue to have urinary incontinence, even after surgery.
 Fistula may develop postoperatively
 Scar tissue formation may cause stricture
STEP 7: Definition and Causes of Urethral Stricture (10 minutes)
Activity: Brainstorm (5 minutes)
ASK students to give the definition of urethral stricture
ALLOW few students to respond and let others provide unmentioned response
CLARIFY and SUMMARIZE using the information below
Definition
 A urethral stricture is a narrowing of the lumen of the urethra as a result of scar tissue and
contraction
Causes of urethral stricture

The following are common causes of scarring or narrowing of the urethra:
 Trauma from injury or accidents with damage to the urethra or bladder (for
example, falling on a frame of a bicycle between the legs, or a car accident)
 Pelvic injury or trauma
 Previous procedures involving the urethra (urinary catheters, surgeries, cystoscopy)
 Previous prostate surgery (TURP or transurethral resection of the prostate)
 Prostate enlargement
 Cancer of the urethra (rare)

86
86
 Infections of the urethra (sexually transmitted diseases or STDs, urethritis,
gonorrhea, Chlamydia)
 Prostate infection or inflammation (prostatitis)
 Previous hypospadias surgery (a congenital birth defect in which the opening of
the urethra is on the underside of the penis instead of the tip)
 Congenital malformations of the urethra, which rarely can cause urethral stricture
in children
STEP 8: Sign and Symptoms of Urethral Stricture (05 Minutes)

 Symptoms of urethral stricture can range from no symptoms at all (asymptomatic), to mild
discomfort, to complete urinary retention (inability to urinate).
 Some of the possible symptoms of urethral stricture include the following:
o Difficulty starting urine flow
o Painful urination (dysuria)
o Urinary retention
o Incomplete emptying of bladder
o Decreased urine stream
o Dribbling of urine
o Spraying or double streaming urine
o Blood in the urine (hematuria)
o Blood in the semen
o Urinary incontinence
o Pelvic pain
o Discharge from the urethra
o Reduced ejaculation force
STEP 9: Management, Complication and Prevention of Urethra Stricture (10 Minutes)

 Surgical treatment of urethral stricture may include:
o Urethral dilation
o Urethroplasty
o Permanent stent placement
 Nursing Management
o Monitoring of urine output and characteristics..
o Maintain constant bladder irrigation for 24 hours.
o Maintain the catheter with irrigation.
o Pursue fluid intake (2500-3000).
o Once the catheter is removed, continue to monitor the symptoms of impaired bladder
elimination patterns
o Monitoring of patients at regular intervals for 24 hours, to recognize early symptoms of bladder
spasmus.
o Providing ordered drugs (analgesic, antispasmodic).
o Tell the patient that the intensity and frequency will be reduced within 24 hours to 28 hours.
o Monitoring of vital signs, reported symptoms of shock and fever.
o Monitoring of fresh red blood urine color, not dark red just a few hours after surgery.

87
87
o Prevent the use of a rectal thermometer, rectal examination at least 1 week.Rational: It can
cause bleeding.
o Maintain aseptic technique of urine drainage systems, irrigation, if necessary alone.
 Complications
o Urine retention
o Urethral diverticulum
o Periurethral abcess
o Urethral fistula
o Urinary tract infections
o Bilateral enlargement of kidneys and damage to kidneys
o Urinary calculus
o Hernia, hemorrhoids or rectal straining from straining
 Prevention
o Treat urethral infection promptly
o Avoid prolonged urethral catheter
o Take utmost care when introducing any instrument including a catheter into the
o urethra

 Epispadiais is a malformation of the penis in which the urethra ends in an opening on the upper
aspect (the dorsum) of the penis.
 Hypospadiasis is a congenital abnormality where the urethral opening is a groove on the
underside of the penis.
 A urethral stricture is a narrowing of the lumen of the urethra as a result of scar tissue and contraction

 What is the different between epispadiais and hypospadiasis
 What are the possible complications of urethra stricture

88
88
References
Saunders Company
Primary Trauma Care Foundation. (2010). Primary care trauma manual: A manual for trauma
management in district and remote locations. Retrieved from http://www.primarytraumacare.org
St. Andrews Ambulance Association. (2001). First aid manual: Emergency procedure for everyone at
home, at work, at leisure (7th ed.). London: Dorling Kindersley
Lippincott Philadelphia
WedMd. (n.d.) Brain hemorrhage: Causes, symptoms, treatments. Retrieved from

http://www.webmd.com

89
89
SESSION 08 : CARE OF A PATIENT WITH ORCHITIS, AND
PROSTATITIS

Learning Objectives
Define orchitis
Enumerate causes of orchitis
Outline signs and symptoms orchitis
Outline preventive measures of orchitis
Provide nursing care and management of orchitis
Define prostatitis
Enumerate causes of prostatitis
Outline signs and symptoms prostatitis
Outline preventive measures of prostatitis
Provide nursing care and management of prostatitis
Resources Needed:

Method
1 5 Presentation Overview of Session Title and Learning
Tasks
2 05 Presentation/ Brainstorm Definition of Orchitits
3
10 Presentation Causes of Orchitits
4 10 Presentation Signs and Symptoms of orchitits
5 10 Presentation, Brainstorming Preventive Measures of Orchitis

90
90
6 15 Presentation, Nursing Care Management of Orchitis
7 05 Brainstorm, Presentation, Definition of Prostatitis
8
10 Presentation Causes of Prostatitis
9 10 Presentation Signs and Symptoms of Prostatitis
10
10 Presentation Preventive Measures of Prostatitis
11 20 Presentation Nursing Care and Management of
causes of Prostatitis
12 05
13 05
SESSION CONTENTS
STEP 1: Overview of Session Title and Learning Task (05 Minutes)
Read or Ask students to read the Learning Task and Clarify
Ask students if they have understood the Learning Tasks
STEP 2: Definition of Orchitis (05 minutes)

. Activity: Brainstorming (03 Minutes)
ASK students to brainstorm the definition of wound

 Orchitis is a rare inflammation or infection of the testes.
STEP 3: Causes of Orchitis (10 Minutes)

 Orchitis may be caused by:
o Trauma or surgical procedures
o Chemical substance
o Infection from epididymitis, UTI, or systemic diseases such as influenza, infectious
mononucleosis, tuberculosis, gout, pneumonia, or mumps (after puberty).
 Risk factors for nonsexual transmitted orchitis include:

91
91
o Not being immunized against mumps
o Having recurring urinary tract infections
o Having surgery that involves the genitals or urinary tract
o Being born with an abnormality in the urinary tract
 Sexual behaviours that can lead to STIs put an individual at risk of sexually transmitted orchitis.
Those behaviours include having:
o Multiple sexual partners
o Sex with a partner who has an STI
o Sex without a condom
o A personal history of an STI
STEP 4: Signs and Symptoms of Orchitis ( 10 Minutes)

 Orchitis signs and symptoms usually develop suddenly and can include:
o Swelling in one or both testicles
o Pain ranging from mild to severe
o Fever
o Nausea and vomiting
o General feeling of un wellness (malaise)
o The terms "testicle pain" and "groin pain" are sometimes used interchangeably. But
groin pain occurs in the fold of skin between the thigh and abdomen not in the
testicle. The causes of groin pain are different from the causes of testicle pain.
STEP 5: Preventive Measures of Orchitis (10 Minutes)

 To prevent orchitis:
o Get immunized against mumps, the most common cause of viral orchitis
o Practice safe sex, to help protect against STIs that can cause bacterial orchitis
STEP 6: Nursing Care and Management of Orchitis (15 minutes)

 If the cause of orchitis is bacterial, viral, or fungal, therapy is directed at the specific infecting
organism.
 Provide adequate rest
 Elevate the scrotum, ice packs to reduce scrotal oedema,
 Administer prescribed antibiotics, analgesic agents, and anti-inflammatory medications are
 Educate the patient about the causes and prevention measures of orchits
 Explore coping skills previously used by the patient to relieve anxiety, reinforce these skills and
explore other outlets for stress.
 Coping mechanisms that have been helpful in the past may aid patient in dealing with current
stressors that result in anxiety.
 Encourage the patient to discuss possible complications and questions about sexual practices
with his health-care provider.
 In some cases, sexual intercourse is encouraged as a means of relieving prostatic congestion;
in other situations, it may be contraindicated
STEP 7: Definition and Causes of Prostatitis (05 Minutes)

 Prostatitis is an inflammation of the prostate gland
STEP 8: Causes of Prostatitis ( 10 Minutes)

92
92
 Prostatitis is caused by infectious agents (bacteria, fungi, mycoplasma) or other conditions (eg,
urethral stricture, prostatic hyperplasia).
o E. coli is the most commonly isolated organism. Microorganisms are usually carried to
the prostate from the urethra.
o Prostatitis may be classified as bacterial or abacterial, depending on the presence or
absence of microorganisms in the prostatic fluid
STEP 9: Signs and Symptoms of Prostatitis (10Minutes)

 Symptoms of prostatitis may include:
o Perineal discomfort
o Burning, urgency, frequency, and pain with or after ejaculation.
o Prostatodynia (pain in the prostate) which is manifested by pain on voiding or perineal
pain without evidence of inflammation or bacterial growth in the prostate fluid.
o Acute bacterial prostatitis may produce sudden fever and chills and perineal, rectal, or
low back pain.
o Urinary symptoms, such as dysuria, frequency, urgency, and nocturia (urination
during the night), may occur.
o Chronic bacterial prostatitis is a major cause of relapsing urinary tract infection in men.
 Symptoms are usually mild, consisting of frequency, dysuria, and occasionally
urethral discharge. High temperature and chills are uncommon.
o Impotence or decreased libido
 Complications of prostatitis may include swelling of the prostate gland and urinary retention.
Other complications include epididymitis, bacteremia, and pyelonephritis.
STEP 10: Preventive Measures of Prostatitis (10 Minutes)

 It is unknown whether prostatitis can be prevented, but the following tips may help to reduce
your risk:
o Prompt seeking medical attention for symptoms or prostatitis or a urinary tract
infection.
o Wearing appropriate protective gear when playing sports to prevent trauma to the
pelvic area.
o For cyclists, invest in a well-engineered seat that minimizes pressure on the prostate.
o Drinking plenty of water and stay hydrated. Limit your intake of caffeine and alcohol
and spicy or acidic substances that can irritate the bladder.
o If antibiotics for prostatitis have been prescribed, take them as directed. Avoid skipping
doses or stopping early, even if you feel better.
o Regular and complete emptying of the bladder to prevent urinary tract infection (UTI),
o Avoiding excess alcohol (more than 2 to 3 oz per dayalcohol is a bladder irritant),
o Avoiding certain high-risk sexual practices.
o Avoiding contamination of the urinary tract and factors that produce congestion of the
prostate gland are the best preventive measures
STEP 11: Nursing Care and Management, Complication and Prevention Prostatitis
(20 Minutes)
 Determine urinary residual volume by catheterizing if suspicion of urinary retention is present,
patient or obtaining a bladder ultrasound immediately after voiding. Incomplete emptying of the
bladder may lead to increased discomfort or ascending infection.

93
93
 Encourage patient to complete a bladder log including patterns of elimination and urine loss,
as well as volume/type of fluid consumed for 3 to 7 days. This will provide for an objective
verification of intake and output volumes and aid in determination of urinary retention.
 Educate patient about avoidance of risk factors for urinary retention (e.g., alpha-adrenergic
agonist ,overfilling of the bladder). These are modifiable variables that may limit retention of
urine.
 Determine patients current knowledge and understanding about cause and treatment of
prostatitis. This will allow for additional and/or correct information to be provided about the
disorder for appropriate understanding.
 Provide patient with additional and/or correct information about the cause and treatment of
prostatitis. This will allow the patient to have a full understanding of the aetiology and care
related to the disorder and increase likelihood of patient compliance.
 Include patients partner in care. Some treatment options may also include treatment of the
partner
(e.g., sexually transmitted diseases such as gonorrhea, chlamydiosis, or trichomoniasis; .
 Encourage use of antibiotics as directed, and advise to take medication until finished in order to
best treat infection and prevent development of antibiotic-resistant bacteria.
 Encourage appropriate use of anti-inflammatory medication as ordered. This will decrease
inflammation and promote comfort.
 Encourage use of comfort measures such as warm sitz baths or prostatic massage, as needed,
to decrease swelling and promote comfort.
 Consult physician about need for stool softeners. Firm stool will further irritate the prostate
during defecation and increase discomfort. Identify source of concern related to sexual activity
and meaning assigned to disorder as described by the patient. This will help in guiding
interventions that are appropriate for the patient related to aetiology of concern.
 Explore coping skills previously used by the patient to relieve anxiety, reinforce these skills, and
explore other outlets for stress. Coping mechanisms that have been helpful in the past may aid
patient in dealing with current stressors that result in anxiety.
 Encourage the patient to discuss possible complications and questions about sexual practices
with his health-care provider. In some cases, sexual intercourse is encouraged as a means of
relieving prostatic congestion; in other situations, it may be contraindicated

 Orchitis may be caused by trauma or surgical procedures, chemical substance, infection from
epididymitis, UTI, or systemic diseases such as influenza, infectious mononucleosis,
tuberculosis, gout, pneumonia, or mumps (after puberty).
 Not being immunized is a risk factor for nonsexual orchitis
 Sexual behaviours can lead to STIs and put an individual at risk of sexually transmitted orchitis
 Orchitis signs and symptoms usually develop suddenly
 Prostatitis is an inflammation of the prostate gland
 Chronic bacterial prostatitis is a major cause of relapsing urinary tract infection in men.
 Avoiding contamination of the urinary tract and factors that produce congestion of the prostate
gland are the best preventive measures of prostatitis

 What is orchitis?
 What are the preventive measures of orchitis?
 What is the Nursing care of a patient with prostatitis?

94
94
References
Saunders Company

95
95


96
96
SESSION 09: CARE OF A PATIENT WITH UNDESCENDED
TESTICLES
Learning Tasks
At the end of this session a learner is expected to be able to:
Define undescended testicles
Enumerate causes of undescended testicles
Outline signs and symptoms undescended testicles
Outline preventive measures of undescended testicles
Provide nursing care and management of undescended testicles
Resources Needed

Step Time Activity/ Content
(min) Method
1 05
Presentation Session Title and Learning Tasks
2 05 Brainstorm, Presentation Definition of Undescended
Testicles
10 Presentation Causes of Undescended Testicles
3 10 Signs and Symptoms

Buzzing ,Presentation Undescended Testicles
4 15 Presentation Preventive Measures of
Undescended Testicles
5 40 Small Group Discussion, Presentation Complications of Undescended
Testicles
6 25 Small group Discussion, Presentation Nursing Care and Management of
Undescended

97
97
7 5
8 5
SESSION CONTENTS
READ or ASK participants to read the learning tasks
STEP 2: Definition of Undescended Testicles (05Minutes)

ASK students to brainstorm the definition of undescended testicles
 An undescended testicle (cryptorchidism) is a testicle that hasn't moved into its proper position
in the bag of skin hanging below the penis (scrotum) before birth.
o Usually just one testicle is affected, but about 10 percent of the time both testicles are
undescended.
o An undescended testicle is uncommon in general, but common among baby boys born
prematurely.
o The vast majority of the time, the undescended testicle moves into the proper position
on its own, within the first few months of life
STEP 3: Causes of Undescended (10 Minutes)

 The exact cause of an undescended testicle isn't known. A combination of genetics, maternal
health and other environmental factors might disrupt the hormones, physical changes and
nerve activity that influence the development of the testicles.

98
98
 Factors that might increase the risk of an undescended testicle in a newborn include:
o Low birth weight
o Premature birth
o Family history of undescended testicles or other problems of genital development
o Conditions of the foetus that can restrict growth, such as Down syndrome or an abdominal
wall defect
o Alcohol use by the mother during pregnancy
o Cigarette smoking by the mother or exposure to second hand smoke
o Parents' exposure to some pesticides
STEP 4: Signs and Symptoms Undescended Testicles (10 Minutes)

ASK students to pair up and buzz on signs and symptoms of undescended testicles

 Undescended testicle is suspected when the testis is not easily identified in the scrotum.
 The testes are easiest to find when the boy is relaxed and warm with the knees flopped
apartas in a warm bath.
 Sometimes the scrotum is smaller and less developed on the side of the undescended testicle,
with fewer folds and wrinkles.
 The initial diagnosis of undescended testicle is made on physical exam.
 If the testis is not located, an imaging study, such as an ultrasound, or surgery is needed to
locate the testicle
STEP 5: Preventive Measures of Undescended Testicles (15 Minutes)

 Prevention is often not possible.
 Preventing preterm delivery is the best way to prevent undescended testicles. This would
include obtaining good prenatal care and avoiding exposures (such as tobacco smoke,
infections, or drugs) that might trigger early labour.
STEP 6: Complications of Undescended Testicles (40 Minutes)

ASK students to discuss complications of Undescended Testicles

99
99

 In order for testicles to develop and function normally, they need to be slightly cooler than
normal body temperature. The scrotum provides this cooler environment. Complications of a
testicle not being located where it is supposed to be include:
o Testicular cancer. Testicular cancer usually begins in the cells in the testicle that
produce immature sperm. What causes these cells to develop into cancer is unknown.
Men who've had an undescended testicle have an increased risk of testicular cancer.
o The risk is greater for undescended testicles located in the abdomen than in the groin,
and when both testicles are affected. Surgically correcting an undescended testicle
might decrease, but not eliminate, the risk of future testicular cancer.
o Fertility problems. Low sperm counts, poor sperm quality and decreased fertility are
more likely to occur among men who've had an undescended testicle. This can be due
to abnormal development of the testicle, and might get worse if the condition goes
untreated for an extended period of time.
o Testicular torsion. Testicular torsion is the twisting of the spermatic cord, which
contains blood vessels, nerves and the tube that carries semen from the testicle to the
penis. This painful condition cuts off blood to the testicle. If not treated promptly, this
might result in the loss of the testicle. Testicular torsion occurs 10 times more often in
undescended testicles than in normal testicles.
o Trauma. If a testicle is located in the groin, it might be damaged from pressure against
the pubic bone.
o Inguinal hernia. If the opening between the abdomen and the inguinal canal is too
loose, a portion of the intestines can push into the groin.
STEP 7: Nursing Care and Management (25 Minutes)

 Perform a surgical procedure known as orchiopexy if the testis does not descend as the
boy matures to position it properly. An incision is made over the inguinal canal, and the
testis is brought down and anchored in the scrotum. It is performed at the earliest
appropriate age.
 Treat the patient by hormonal treatment to attempt triggering the testicles journey to
continue into the scrotum.
 Prevent trauma to the surgical area two to three weeks after the surgery, the child should
avoid rough-housing, contact sports, bicycle riding or physical education.
 Ensure the position of the patients testicles is in the base of the scrotum
 Educate the care taker that it is normal for the incision to be pinkish or red; however, if it
becomes very red or dark red and/or has pus he/she should seek medical interventions
 Administer prescribed ant pain

100
100
 Encourage the patient to consume clear liquids immediately after surgery and then
progress to a regular diet as tolerated. The anesthesia can cause some stomach
discomfort and nausea.

 An undescended testicle the condition is also known as cryptorchidism
 Cryptorchidism means a testicle that hasn't moved into its proper position in the bag of skin
hanging below the penis (scrotum) before birth. A surgical procedure known as orchiopexy is
performed to position it properly
 In order for testicles to develop and function normally, they need to be slightly cooler than
normal body temperature. The scrotum provides this cooler environment.

 What are the risk factors of undescended testicle?
 What are the complications of undescended testicle?
 How can you prevent undescended testicle?
References
Saunders Company

101
101

SESSION 10: NURSING CARE TO PATIENTS WITH OVARIAN CYST
Learning Tasks
Define Ovarian cyst
Enumerate the causes of Ovarian cyst
Identify types of ovarian cyst
Identify diagnostic measures of Ovarian cyst
Outline clinical features of a patient with Ovarian cyst
Identify treatment of a patient with Ovarian cyst

Resources Needed:
Give care to a patient with ovarian cyst
Prepare the patient for possible surgery

Provide post-operative nursing care 102
Counsel the patient for coping with the condition

102

(min) Method
1 05 Lecture/discussion Presentation of session title and learning tasks
2 05 Brainstorming Definition of Ovarian cyst
3 10 Lecture/discussion Causes of Ovarian cyst
4 10 Buzzing, Lecture/discussion Types of ovarian cysts
5 05 Lecture/ discussion Diagnostic measures of Ovarian cyst
6 05 Lecture /discussion Clinical features of a patient with Ovarian cyst
7 05 Lecture /discussion Treatment of a patient with Ovarian cyst
8. 05 Lecture /discussion Nursing managements of ovarian cysts

9 05 Presentation Key Points
SESSION CONTENTS
STEP 2: Definition of Ovarian Cyst (05 Minutes)

ASK students to brainstorm on the definition of ovarian cyst

103
103
 Ovarian cyst is fluid filled sacs or pockets in an ovary or on its surface
 The ovary is a common site for cysts, which may be simple enlargements of normal ovarian
constituents, the graafian follicle, or the corpus luteum, or they may arise from abnormal growth
of the ovarian epithelium
STEP 3: Causes of Ovarian Cyst (03 Minutes)

 Most occurs as a result of menstrual cycle (functional cysts).
STEP 4: Types of Ovarian Cyst (15 Minutes)

ASK students to pair up and buzz on types of ovarian cyst for 2 minutes
 Dermoid
CLARIFY cysts
and SUMMARIZE their responses using the content below
o Tumours that are thought to arise from parts of the ovum that normally disappear with
ripening (maturation).
o Their origin is undefined, and they consist of undifferentiated embryonal cells.
o They grow slowly and are found during surgery to contain a thick, yellow, sebaceous
material arising from the skin lining.
o Hair, teeth, bone, and many other tissues are found in a rudimentary state within these
cysts.
o Dermoid cysts are only one type of lesion that may develop.
o Many other types can occur, and treatment usually depends on the type.
Signs and Symptoms include

o The patient may or may not report acute or chronic abdominal pain.
o Symptoms of a ruptured cyst mimic various acute abdominal emergencies,
o Such as appendicitis or ectopic pregnancy.
o Larger cysts may produce abdominal swelling and exert pressure on adjacent
abdominal organs.
 Polycystic ovary syndrome

 Complex endocrine condition involving a disorder in the hypothalamic-pituitary and ovarian
network or axis resulting in an ovulation, occurs in women of childbearing age.
 Signs and Symptoms

o Irregular periods resulting from lack of regular ovulation
o Obesity
o Hirsutism may be presenting complaints.
o Women with polycystic ovary syndrome may develop insulin resistance and may be at
higher risk for cardiac disorders in later life
 Cytadenomas

104
104
o These develop on the surface of an ovary and might be filled a watery or a mucous
material
 Endometriomas
o These develop as a result of a condition in which uterine endometrial cells grow
outside uterus (endometriosis) some of the tissue can attach to your ovary and form a
growth
STEP 5: Diagnostic Measure of Ovarian Cyst (05 Minutes)

 Pregnancy test: A positive test might suggest that its corpus luteum cyst
 Pelvic ultrasound: it shows the presence of ovarian cyst
 Laparascopy: it is a surgical removal of cyst
 Blood test: blood levels of a protein called cancer antigen 125 often are elevated in women with
ovarian cancer.
STEP 6: Symptoms of Ovarian Cyst (05 Minutes)

 Pelvic pain:
o A dull or sharp ache in the lower abdomen on the side of the cyst
 Fullness or heaviness in your abdomen
 Bloating
 Pain with fever or vomiting
Complications Symptoms
 Ovarian torsion: cysts that enlarge can cause the ovary to move increasing the chance of
painful twisting of your ovary
o Symptoms include an abrupt onset of severe pelvic pain, nausea and vomiting and
decrease blood flow to ovaries
 Rupture: A cyst that ruptures can cause severe pain and internal bleeding.
The larger the cyst , the greater the risk of rupture
STEP 7: Treatment of Patient with Ovarian Cyst (05 Minutes)

 Surgery
o The treatment of large ovarian cysts is usually surgical removal.
 Medication:
o For cysts that are small and appear to be fluid-filled or physiologic in a young, healthy
patient, however, oral contraceptives may be used to suppress ovarian activity and
resolve the cyst.
o Oral contraceptives are also usually prescribed to treat polycystic ovary syndrome.
o About 98% of cysts that occur in women aged 29 years and younger are benign.
o In women older than 50 years of age, only half of these cysts are benign
STEP 8: Nursing Managements of Ovarian Cyst (07 Minutes)

 Administer prescribed medications
 Prepare the patient for possible surgery
 Counsel the patient for coping with the condition
 Provide post-operative nursing care

105
105
o The postoperative nursing care after surgery to remove an ovarian cyst is similar to
that after abdominal surgery, with one exception.
o The marked decrease in intra-abdominal pressure resulting from removal of a large
cyst usually leads to considerable abdominal distention.
 This complication may be prevented to some extent by applying a snug-fitting
abdominal binder.
 Some surgeons discuss the option of a hysterectomy when a woman is
undergoing a bilateral ovary removal because of a suspicious mass because it
may increase life expectancy, avoid a later second surgery, and save on
health care costs.
 It is preventive in that future cancer is avoided, as is benign disease that might
require hysterectomy.
 Patient preference is a priority in determining its appropriateness

 The managements of cysts include mainly surgery and hormonal oral contraceptives

 What is ovarian cysts?
 What are the types of ovarian cysts?

106
106
References
Saunders Company


107
107
108
108
SESSION 11: THE CONCEPTS OF OPERATING THEATRE
Prerequisite: None
Learning Tasks
Define operating theatre
Explain operating theatre layout
Explain function of different theatre zones
Identify operating theatre routines

Resources Needed:

(min) Method
1. 05 Lecture/discussion Presentation of session title and learning
tasks
2. 05 Brainstorming Define operating theatre
3. 25 Lecture/discussion Operating theatre team
4. 15 Lecture/discussion Operating theatre layout
5. 20 Buzzing, Functions of different theatre zones

Lecture/discussion
6. 20 Lecture/ discussion Operating theatre routines
7. 20 Lecture/discussion Principles of aseptic technique
8. 05 Presentation Key Points

9. 05 Presentation Session Evaluation
SESSION CONTENTS

109
109
STEP 2: Definition of Operating Theatre (05 Minutes)

ASK students to brainstorm on the definition of operating theatre
Theatre techniques:
 Are the skills utilized in the operating room
Operating theatre:
 Is the room in which surgical operation and some diagnostic procedures are carried out.
Theatre team:
 Is the team of the members working together in unison and harmony responsible for the
wellbeing of the patient throughout the surgical procedures
STEP 3: Operating Theatre Team (25 Minutes)

 The surgical team consists of the following:
 Circulating nurse (the circulator, scout nurse/ runner)
o Must be a registered nurse
o Is the nurse who is responsible for monitoring and coordinating all activities within the
room.
o Provides assistance to any member of the operating room team with strict observation
to avoid a break in sterility
o Play the vital role in the smooth the flow of events before, during and after the
operation.
o Should be available throughout procedure
o Responsibility
 The duties of a circulating nurse in relation to the operating room include:
 Checking the room for general cleanliness and orderliness prior to
each operation
 Checking operating room to ensure that lights, proper temperature,
humidity, suction and other equipment is properly functioning
 Manages the operating room and protects the patients safety and
health
 Monitoring the activities of the surgical team
 Ensuring the safe functioning of equipment; and the availability of
supplies and materials.


110
110
In relation to the patient:
 Receiving and identifying the patient from the receiving area
 Receiving pre-operative checklist and be certain it is complete
 Assisting in transferring the patient to the operating table
 Position the patient on the table and confirming the position with the
surgeon
 Continually assessing the patient for signs of injury and implementing
appropriate interventions.
 Verifying consent form
 Monitors the patient and documents specific activities throughout the
operation to ensure the patients safety and well-being.
 At the end of operation assists in the transfer of the patient to recovery
room and prepares operating room for next procedure.
 In relation to the operating room personnel
 Helping to gown all members of the scrub team
 Keeping a constant vigilance on proper dress, movements and
techniques of all personnel to ensure no break of aseptic technique
 Coordinating the team
 Labeling and recording all specimens received from the surgeon
 Ensuring that the scrub nurse has everything she/he needs to begin
the operation
 Supervising and assisting in swabs, needle and instrument counts
 Monitors aseptic practices to avoid breaks in technique while
coordinating the movement of related personnel
 Keeping the room clean and orderly during the operation
 The Scrub Nurse:
o The member of staff who prepares the sterilized instruments and equipment ready for
the preparation
o This may be registered nurse or an operating department assistant.
o The scrub Nurse may also be called; sterile nurse, Instrument nurse, suture nurse.
o Responsibility
 Prepares operating room for surgery
 Activities of the scrub role include performing a surgical hand scrub
 Setting up the sterile tables
 Preparing sutures, ligatures, and special equipment
 Assisting the surgeon and the surgical assistants during the procedure by
anticipating the instruments that will be required, such as sponges, drains, and
other equipment
 Assists the surgeon and his assistant in draping the patient
 Hands instruments swabs, sutures and so forth to surgeon and his assistants
as needed
 Count all needles, sponges, and instruments to be sure they are accounted for
and not retained as a foreign body in the patient.
 Labelling and sent to laboratory tissue specimens obtained during surgery
 Observes the team for breaks in aseptic technique.
 The surgeon

111
111
o Is the licensed physician trained and qualified in performing surgeries
o He or she is a licensed physician (MD), osteopath (DO), oral surgeon (DDS or DMD),
or podiatrist (DPM) who is specially trained and qualified.
o The surgeon performs the surgical procedure and heads the surgical team.
 Anesthesiologist:
o Is a physician who is specialty trained to administer anesthetic agents to the surgical
patient
o An anesthetist is a qualified health care professional who administers anesthetics.
o Most anesthetists are nurses who have graduated from an accredited nurse
anesthesia program
o Responsibilies
 The anesthesiologist or anesthetist interviews and assesses the patient prior
to surgery
 Selects the anesthesia
 Administers it
 Intubates the patient if necessary
 Manages any technical problems related to the administration of the anesthetic
agent
 Supervises the patients condition throughout the surgical procedure
 Assessment of patient before enters the operating room, often at preadmission
testing, the anesthesiologist or anesthetist visits the patient to provide
information and answer questions.
 The type of anesthetic to be administered
 Previous reactions to anesthetics
 Known anatomic abnormalities that would make airway management
difficult
 When the patient arrives in the operating room,
 The anesthesiologist or anesthetist reassesses the patient’s physical
condition immediately prior to initiating anesthesia.
 The anesthetic is administered
 The patient’s airway is maintained either through a laryngeal mask
airway (LMA) or an endotracheal tube.
 During surgery, the anesthesiologist or anesthetist
 Monitors the patients blood pressure
 Pulse
 Respirations
 Electrocardiogram (ECG)
 Blood oxygen saturation level
 Tidal volume
 Blood gas levels
 Blood pH
 Alveolar gas concentrations
 Body temperature
STEP 4: Operating Theatre Layout ( 20 Minutes)

 The surgical suite is located out of the mainstream of the hospital and near Post Anesthesia
Care Unit PACU and support service (blood bank, pathology and laboratory departments

112
112
 Traffic is patterned to reduce contamination from outside the suite
 Within the suite clean and contaminated areas are separate
 The surgical area contained three zones namely, unrestricted, semi restricted and restricted
zone to ensure proper movement of patients and personnel
 Most suite contain staff area, area related to patient care, surgery and surgical support
 Staff area
o Locker room
o Staff lounge
 Patient Care
o Admission
o Operating room
o Recovery room
 Support areas
o Operating room
o Cabinet for sterile supplies
o Separate utility rooms for clean and soiled equipment
o Clean linen room
 The number of tables and equipment in the operating room is based on the need of each
patient see figure 9.1 and 9.2 for more elaborations.
 New operating theatre design use computers with surgical equipment, light, OR bed and
communications
 The OR has special air filtration devices to screen out contaminating particles, dust, and
pollutants.
 The temperature, humidity, and airflow patterns are controlled
 Electrical hazards, emergency exit clearances, and storage of equipment and anesthetic
gases are monitored periodically by official entities.
Operating Theatre Layouts

113
113
Fig 11.1: The operating Theatre Room Layouts

114
114
Fig 11.2: The Operating Room Layouts
Source: (Workman, medical surgical nursing, 2016)
STEP 5: Functions of different Theatre Zone (20 Minutes)

ASK students to pair up and buzz on functions of different theatre zone for 3 minutes
 WRITEThe
theirsurgical
responses in the chalk/white
environment board
is known for or flipappearance
its stark chart and cool temperature.
 CLARIFY
Theand
surgical suite is behind
SUMMARIZE double doors,
their responses usingandtheaccess is below
content limited to authorized personnel.

115
115
 External precautions include
o Adhering to principles of surgical asepsis
o Strict control of the operating room (OR) environment
 Policies governing this environment address such issues as the
o Health of the staff
o Cleanliness of the rooms
o Sterility of equipment and surfaces
o Processes for scrubbing
o Gowning
o Gloving
o Operating theatre attire.
 The Theatre layout is arranged in four zones namely:
o Unrestricted zone
 Areas outside the theatre complex including control point to monitor the entrance
of patients, personnel, visitors.
 Street clothes are permitted in the area
 Traffic is not limited
o Semi-restricted zone
 Attire consists of scrub clothes and caps
 This area includes peripheral support area and access corridors to the operating
rooms.
 The patient may be transferred to a clean inside stretcher or wheel chair upon
entry to this area
o Restricted zone
 Includes operating rooms and scrub areas
 Personnel must wear full surgical attire, hair coverings, masks where open sterile
supplies and scrubbed persons are present
 Masks are worn to reduce the dispersal of microbial droplets from the mouth and
naso-pharynx of personnel high filtered
 Masks must cover the mouth and nose entirely, and be tied securely to prevent
venting.
o Disposal area Unrestricted zone
 For the waste products and soiled or used equipment and supplies
 Essential Rooms and Areas of the operating department
o The reception and transfer area
 This is the special area or room outside the operating room where the final checks
of patient are made before entering the operating room.
o The anaesthetic room
 This is the room where the patient receives induction of anaesthetic.
 The room should be large enough to accommodate the patients bed or trolley and
the anaesthetic equipment and also allow sufficient space for staff to move freely.
o Recovery room
 This room is used to accommodate patients after operation for monitoring until are
able to return to the ward.
 It is equipped with sufficient suction apparatus, oxygen supply and monitors for
the observation and Nursing.

116
116
o Sterilizing and supplies area
 Is the room where operating instruments are prepared and sterilized
o Operating suite:
 Consist of the following; Anesthetic room for induction of anesthesia
o Operating room equipped with operating table and equipments
o Scrub room for hand scrubbing, gowning and gloving of the surgical team
o Utility room for the disposal and cleaning used instruments
o Layout area for preparation of sterile trolleys
o Staff changing room
 Is the room where operating team change from outdoor clothing and uniform into
clean theatre garment before entering the clean zone
o Operating Room Attire include:

 Close-fitting cotton dresses
 Pantsuits
 Jumpsuits
 Gowns.
 Knitted cuffs on sleeves and pant legs prevent organisms shed from the perineum,
legs, and arms from being released into the immediate surroundings.
 Shirts and waist drawstrings should be tucked inside the pants to prevent
accidental contact with sterile areas and to contain skin shedding.
 Wet or soiled garments should be changed.
 Masks are worn at all times in the restricted zone of the OR.
 High-filtration masks decrease the risk for postoperative wound infection by
containing and filtering microorganisms from the oropharynx and nasopharynx.
 Masks should fit tightly, should cover the nose and mouth completely, and should
not interfere with breathing, speech, or vision.
 Masks must be adjusted to prevent venting from the sides.
 Disposable masks have a filtration efficiency exceeding 95%.
 Masks are changed between patients and should not be worn outside the surgical
department.
 The mask must be either on or off; it must not be allowed to hang around the neck.
 Headgear should completely cover the hair (head and neckline, including beard)
so that single strands of hair, bobby pins, clips, and particles of dandruff or dust do
not fall on the sterile field.
 Shoes should be comfortable and supportive.
 Shoes worn in from the outside must be covered with disposable shoe covers for
protection from soiling.
 Shoe covers are worn one time only and are removed upon leaving the restricted
area.
 NOTE: Barriers such as scrub attire and masks do not entirely protect the patient
from microorganisms.
 Upper respiratory tract infections, sore throats, and skin infections in staff and
patients are sources of pathogens and must be reported
STEP 6: Operating Theatre Routine ( 20 Minutes)

117
117
 There are a variety of important jobs that must be done to keep a theatre well stocked and
maintained.
 Many of these are rather obvious, but without maintenance equipment will break down, and
without planning spare parts and consumable materials will run out and take a long time to be
replaced.
 The general routine will include:
o Building maintenance
 A good sound building is an obvious requirement for safe surgery.
 However, the room should be as insect-proof as possible and well ventilated.
 It does not have to be blacked-out, although the windows should be shaded.
 Paint work should be in good condition and a secure water supply present.
 The room should have doors that can be closed during surgery.
 Regular inspections of the insect-proofing are important.
o Cleaning
 General cleaning should be carried out regularly in addition to preparations on
the day of surgery
 Floors and sometimes walls and ceilings must be washed in all rooms used
as part of the operating theatre suite.
 Any furniture including instrument tables, operating tables and cabinets must
be wiped clean to avoid the build up of dust
 Spilt blood or other debris should be wiped up as soon as possible, because
once dried it may be difficult to remove.
 A weak solution of bleach is adequate for cleaning purposes and will kill most
micro-organisms including the HIV virus
 Anyone who washes drapes and surgical instruments MUST wear gloves to
protect themselves from the risk of infection
o Maintenance of equipment and instruments:

 Equipment can only function if it is regularly maintained
 A schedule needs to be drawn up for items such as sterilisers, operating lights
and air conditioners
 The importance of having spares to enable quick repairs to be carried out
locally cannot be stressed too much
 Surgical instruments need to be carefully looked after and checked that they
are working properly.
o Manufacture of dressings and drapes
o Swabs.
 Swabs used externally can be made easily from cotton wool and gauze and
then autoclaved.
 Surgical drapes. These can also be made locally out of close woven cotton
preferably in a dark colour which reduces glare.
 The drape should be large enough to extend from the chest of the patient over
the head and to the top of the operating table.

118
118
 Ideally all the theatre staff and the patient should have special clothes to wear
in theatre. Sterilisation and disinfection procedures
o The sterilising of instruments, swabs, linen
o The most important step in safe surgery.
 Sterilisation means that all living micro-organisms, bacteria, viruses, fungi,
including spores have been killed.
 Disinfection means that bacteria which are likely to cause infection have been
killed, but spores and some very resistant micro-organisms may survive
disinfection.
 Obviously, sterilisation is better than disinfection.
 There are four common ways of sterilising or disinfecting.
 Methods of Sterilisation and Disinfection
 Autoclave
 Dry heat oven
 Boiling
 Immersion in chemical solutions
 Autoclaving
 Dry heat oven will sterilise, and boiling
 Chemical solutions will only disinfect.
 The methods of sterilisation may only disinfect if the treatment is not
applied for long enough, and a chemical which disinfects may sterilise
after a long period of immersion.
 Instruments must first be cleaned before sterilising.
 The best time for cleaning instruments is immediately after they have
been used, otherwise blood and secretions may become dried and
encrusted
 Dried blood and secretions are much more difficult to remove, and
they prevent spores and bacteria from being killed by the sterilisation
process.
 Instruments should be washed with soap and water using a soft brush
or cloth, paying particular attention to the joints of scissors, artery
forceps and needle holders.
 Theatre linen and drapes can be washed at the end of the list and left
to dry in the sun.
o Stock-keeping, storage and security
 Good stock keeping to maintain essential supplies is often overlooked.
 A system of monitoring stores and the rate at which consumables such as
medicines, dressings, sutures etc. are used will allow for ordering and
budgeting.
 The only way to be aware of annual usage and any seasonal variations in
consumption is to have a strict system of stock keeping.
 This important part of theatre management should be the responsibility of the
person in charge of the theatre.

119
119
 It is obvious that equipment and supplies should be stored in a place where
they will not deteriorate, and where they are safe.
o Managing with Limited Resources
 In many circumstances the volume of surgical work or financial limitations
mean that correct theatre procedures cannot be followed strictly.
 In correct theatre procedures everybody who enters the operating theatre and
all the staff and patients should wear a complete change of clothes.
 All those operating scrub up completely between cases with fresh gloves and
a fresh gown.
 Often it may not be possible to maintain these standards. The patients may
have to come to the operating theatre wearing their own clothes.
 The surgical staff should always scrub up completely at the beginning of a list,
but may be obliged just to change their gloves in between cases or even to
wipe their gloves in alcohol between cases.
 In order to maintain surgical through put it may be necessary to have more
than one operating table in the same operating room.
 To ensure safe surgery there are four areas in which cutting corners and
compromises are strictly forbidden.
 Correct preparation of the patient for surgery, with a thorough cleaning
 Sterilisation of all instruments, drapes and dressings.
 Sterilisation and purity of all solutions used
 The correct handling of instruments and dressings and the use of a
no touch technique.
o Security
 Post-operative infections do sometimes occur, even with the most careful and
well trained surgical team.
 Good units have an infection rate of about one case in a thousand or less. It is
reasonable to assume that any infection developing within the first post-
operative week has been contracted at the time of the operation.
 Even an isolated case of post-operative infection should make the surgeon
and the surgical team review all their techniques, equipment and procedures.
 If several infections occur close to each other an even more radical overhaul of
theatre procedures is required.
 Any irrigating fluids should be discarded and a new batch obtained.
 All made up disinfectant solutions should be discarded and new ones made,
and the steriliser changed or a new method of sterilisation tried of infection
during surgery
STEP 7: Principles of Aseptic Techniques in Operating Room ( 20 Minutes)

 Aseptic technique is most strictly applied in the operating room because of the direct and often
extensive disruption of skin and underlying tissue.
 Aseptic technique encompasses practices performed immediately before and during a surgical
procedure to reduce postoperative infection such as:
o Hand washing

120
120
o Surgical attire
o Surgical scrub
o Sterile gowning and gloving
o Patients surgical skin prep
o Using surgical barriers, including sterile surgical drapes and personal protective
equipment
o Maintaining a sterile field
o Using safe operative technique
o Maintaining a safe environment in the operating room
 All practitioners involved in the intraoperative phase have a responsibility to provide and
maintain a safe environment. Adherence to aseptic practice is part of this responsibility.
o The eight basic principles of aseptic technique follow:
 All materials in contact with the surgical wound and used within the sterile field
must be sterile.
 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.
 Sterile drapes are used to create a sterile field. Only the top surface of a
draped table is considered sterile.
 During draping of a table or patient, the sterile drape is held well above the
surface to be covered and is positioned from front to back.
 Items should be dispensed to a sterile field by methods that preserve the
sterility of the items and the integrity of the sterile field.
 After a sterile package is opened, the edges are considered unsterile.
 Sterile supplies, including solutions, are delivered to a sterile field or handed to
a scrubbed person in such a way that the sterility of the object or fluid remains
intact.
 The movements of the surgical team are from sterile to sterile areas and from
unsterile to unsterile areas.
 Scrubbed persons and sterile items contact only sterile areas; circulating
nurses and unsterile items contact only unsterile areas.
 Movement around a sterile field must not cause contamination of the field.
 Sterile areas must be kept in view during movement around the area. At least
a 1-foot distance from the sterile field must be maintained to prevent
inadvertent contamination.
 Whenever a sterile barrier is breached, the area must be considered
contaminated. A tear or puncture of the drape permitting access to an unsterile
surface underneath renders the area unsterile. Such a drape must be
replaced.
 Every sterile field should be constantly monitored and maintained. Items of
doubtful sterility are considered unsterile. Sterile fields should be prepared as
close as possible to the time of use.
 The parts of a surgical gown considered sterile are the sleeves (except for the
axillary area) and the front from waist level to a few inches below the neck
opening. A "sterile" person should keep his hands in sight and at waist level or
above

121
121
 Items should be considered unsterile if there is doubt about their sterility; if a
sterile appearing package is found in an area not designated for sterile storage
it is considered unsterile and must be reprocessed and resterilized or
discarded.
 Only the top surface of a draped table is considered sterile. Linen or sutures
falling over the edge of the table should be discarded. The scrub nurse should
not touch the part hanging below the table level.
 Sterile team members should be within the sterile area. Sterile team members
should stand back at a safe distance from the operating table while draping the
patient and should pass each other back-to-back.
 Sterile areas should be protected from moisture because a moist item may
become contaminated.Therefore sterile packages should be laid on dry sterile
areas, if any portion of a sterile package becomes damp or wet, the entire
package should be either resterilized or discarded.
 Theatre Attire
 Purposes of theatre attire
o To provide effective barriers that prevent the dissemination of microorganisms to
patient
o To protect personnel from contamination from blood and body fluids of patients
o Proper attire is a part of aseptic environmental control
o Protects personnel against exposure to communicable diseases and hazardous
material
Theatre attire consists of the following
 Clean theatre attire
o One piece half sleeve clean cotton gown for the female staff.
o Two pieces of clean cotton pajamas and half sleeve, collarless, button-less shirt for the
male staff.
o A clean cotton head cover or cap
o A pair of clean operating theatre sandals or shoes
 Sterile theatre attire
o Sterile face masks
o Sterile gowns
o Sterile surgical gloves
 Steps of theatre attire:
o Personnel entering the theatre has to change clothing from street clothes to clean
theatre attire in the changing room
o The head cover or the cap is to be put on first, so as to prevent contamination of the
sterile gown or other clean theatre attire by hair or dandruff.
o After changing the street clothes to operating theatre clean attire one can move in the
semi restricted or restricted area in operating theatre
o Before the sterile theatre team put on sterile attire, they should perform surgical hand
scrub in order to remove as many microorganisms as possible from the hands and
arms by mechanical washing and chemical antisepsis.
 Steps of surgical hand scrubbing

122
122
o The scrub personnel have to wear sterile facemask which should cover the nose and
mouth, sterile gown and sterile surgical gloves
o Operating room attire should not be worn outdoors; this protects the operating room
environment from microorganisms inherent in the outdoor environment and vice-versa.
o After changing the street clothes to operating theatre clean attire one can move in the
semi restricted or restricted area in operating theatre
o Before the sterile theatre team put on sterile attire, they should perform surgical hand
scrub in order to remove as many microorganisms as possible from the hands and
arms by mechanical washing and chemical antisepsis.
o The scrub personnel have to wear sterile facemask which should cover the nose and
mouth, sterile gown and sterile surgical gloves
o Operating room attire should not be worn outdoors; this protects the operating room
environment from microorganisms inherent in the outdoor environment and vice-versa.
o Before leaving the operating theatre, everyone should take off the theatre gowns
Fig 12.1:Surgical hand Rubbing

123
123
124
124
Figure 11.3: Steps of surgical hand scrubbing
Source: WHO 2018

 The operating room teams goal is the efficient and effective delivery of care to the individual
patient for the relief of suffering, the restoration of bodily structure and function, and a
favourable post operative outcome contributing to the patients optimal health and return to
society or death with dignity.
 Proper aseptic techniques is one of the most fundamental and essential principles of infection
control and is most strictly applied in the operating room.
 All practitioners working in the operating theatre must be skilled and knowledgeable on
principles of theatre technique

 What is theatre team?
 What is the layout of theatre?
 What are the principles of aseptic technique in the operating theatre?
References

125
125
Saunders Company


126
126
SESSION 12: PREPARATION OF OPERATING THEATRE FOR SURGERY
Prerequisite: None
Learning Tasks
Identify requirements needed for procedure
Perform sterilization and disinfection of instrument
Assemble equipment for procedure
Arrange equipment to their respective places

Resources Needed:
 Explain
Black/white operating
board theatre layout markers
and chalk/whiteboard
 Explain
Note Book and function
Pen of different theatre zones
Identify operating theatre routines

(min) Method
1. 05 Lecture/discussion Presentation of session title and learning
tasks
2. 15 Buzzing, Lecture Requirements needed for procedure to be
Discussion done
3. 45 Demonstration, Sterilization and disinfection of instrument

Lecture/discussion
4. 25 Lecture/discussion Assembling of equipment for procedure
5. 15 Buzzing, Arrangement of equipment to their

Lecture/discussion respective places
6. 05 Presentation Key Points

7. 05 Presentation Session Evaluation
8. 05 Presentation Take home assignment

127
127
SESSION CONTENTS
STEP 2: Requirements needed for Procedure to be done (15 Minutes)

ASK students to brainstorm on the definition of operating theatre
 Preparation of environment
o Prepare the room to ensure privacy, prevention of infection and safety
o Address the unique need of each patient for safe surgical experience
 Preparation of equipment and Supplies
o Sodium bicarbonate solution for keeping dentures
o Theatre gowns for patient wear
o Operation list for reference and accurate information
o Identity bands/ tags plastic materials for patient identification
o Stretcher for transporting patient
o Patient case note for reference
o Consent form for legal agreement
o Weight machine for weight patient
o Diagnostic results such as x-rays and laboratory tests for confirmation of
o Vital signs tray for checking vital signs
o Socks for warming feet
o Pre- medication to allay anxiety
o Pre- operative checklist for accurate information
 Preparation of the patient
o Provide adequate information for relatives and patients
o Ensure the patient has signed the consent form accurately
o Provide adequate pre-operative instructions, exercises and offered with psychological
support
o Ensure clients understand the intended surgery and physiological and psychological
responses to surgery
o Ensure the patient wears clean gowns provided by the facility
o Remove all devices such as dentures, rings and eye glasses from the patient and kit
them

128
128
o Ensure the patient is accompanied with all necessary documents which include
consent form, case note, diagnostic results
 Preparation of the Nurse
o Review all necessary preparations before surgery using the pre operative checklist
o Review medications to be administered
o Review institutional policy guidelines pertaining to pre operative preparations
o Review plan for preoperative pre operative preparations
o Collaborate with the surgeon and anaesthiologist pertaining to the kind of the operation
to be performed
o Review operation list as per schedule
o Identify time for transporting patent to operating theatre
o Review patients history against patients case note
o Review other instructions required before surgery
 Intervention
o Identify and confirm pre- anaesthetic review note
o Ensure medication are given
o Ensure all patient documents are accompanied which include consent form, case note,
diagnostic results
o Confirm the right patient for the right operation
o Send the patient to theatre after receiving the message from the theatre
superintendent
o Handle over patient to operating theatre staff and make preparation to receive the
patient
o Make postoperative bed
STEP 3: Sterilization and Disinfection of Instrument ( 45 Minutes)

Activity: Demonstration (20 minutes)
DIVIDE students in small manageable groups.
PREPARE equipment and materials needed for sterilization and decontamination
POSITION students so that everyone can see and hear
REVIEW steps of that skill with students using a checklist
REFER Fig 12.3: key steps in Instrument Processing
DEMONSTRATE the procedure of conducting delivery using the child birth model with running
comments
ALLOW one student from each group to do a return demonstration and let others comment on it
INFORM the students that every student will practice in the skills laboratory under supervision until is
competent
 Decontamination is a process of making equipment, instruments and linens safer to be handled

by health care provider
 Hospital instruments for sterilization has been divided into three categories based on the risk of
infection
o Critical items
 Implants

129
129
 Prosthetic devices
 Needles
 Cardiac catheter
 Urinary catheter
 Biopsy
 forceps of endoscopes
o Semi critical item: Contact mucous membranes but do not penetrate soft tissue or
body surfaces. Meticulous physical cleaning followed by appropriate high-level
disinfection
 Flexible fiberoptic endoscopes
 Respiratory therapy equipment
 Anaesthesia equipment
 Endotracheal tubes
 Bronchoscopes
 Vaginal specula
 Cystoscope
 Hand-piece
o Semi critical Instruments
o Fig 12.1: Ambu bag and mask
o Non- critical items:

 Direct contact with the patients intact skin (unbroken skin)
 Little risk of pathogen transmission directly to patient
 Clean and disinfect using a low to intermediate level disinfectant
o Non- critical instrument

Fig 12.2: Sphegenomamometer

130
130
Items which are in contact with intact skin
 Bedpans
 Blood pressure cuffs
 Crutches
 Stethoscopes
 Face mask
 X-ray machine
Table12.1: Categories of item and Treatment
Category Description Example Treatment

Critical Instrument penetrate Surgical instruments Heat sterilization
mucosa or bone
Semi- Instruments come in Hand pieces Heat sterilization
critical contact with oral mucosa
Heat sterilization Heat sterilization
Heat-sensitive instruments Immersion in high-level

disinfectant/sterilizant
Non-critical Instruments come in Extra-oral instruments Immersion in high-level
contact with intact skin disinfectant/sterilant
Process in intermediate-
level disinfectant
 Disinfection:
o Is a process that eliminates many or all pathogenic microorganism from an
instrument by the use of chemical agent.
o Disinfection means to reduce the number of pathogens on an inanimate surface or
object using heat, chemicals, or both.
o Disinfectants are substances that are applied to non-living objects (e.g.,
instruments) to destroy microorganisms that are living on the objects.
o Most disinfection procedures have little activity against bacterial spores; any
reduction in the spore load is mainly achieved by mechanical action during
cleaning and flushing with water
Sterilisation
o Is the process used to render an item free from viable microorganisms, including
o spores.
o Heat is the most reliable sterility; most surgical instruments are heat-resistant.
o Heat-sensitive items require low-temperature sterilisation; ethylene oxide (EO)
gas, hydrogen peroxide gas-plasma, and steam-formaldehyde are often used for
this purpose

131
131
Decontamination
o Is the process of removing pathogenic microorganisms from objects so they are
safe to handle, use, or discard. It can be done using physical or chemical means.
High Level Disinfectant
 Is a process that kills all microorganisms but not necessarily all bacterial
spores.
 HLD is achieved by soaking items in liquid chemicals classified as high-
level disinfectants or by boiling or steaming for the appropriate time (20
minutes).
 Active against vegetative bacteria, viruses (including the non-enveloped
ones), fungi, and mycobacteria
 May have some activity against bacterial spores
 With extended contact times
HLDs are used to disinfect heat-sensitive and semi-critical devices Such
as flexible fibreoptic endoscopes
Level of disinfection include High-level, Intermediate-level and Low-level
 Processing, Contaminated instruments and other items
o The recommended steps to reduce disease transmission from soiled instruments and
other reusable items are decontamination, cleaning and other sterilization or high level
disinfection
o Method to be used will depend on:
 Devices intended use
 Risk of infection
 Degree of soilage
 Reduction in numbers of pathogens on inanimate surfaces/objects
 For items that will contact intact skin or mucous membrane
 Use physical or chemical agents or both
o Seven steps of Instrument processing
 Transport :Placing contaminated instruments to the processing area, using
PPE in a leakproof container
 Cleaning: Clean instruments using hands-free, mechanical process, such
as an ultrasonic cleaner or instrument washer. If instruments can't be
cleaned, use holding solution
 Packaging: In the clean area, wrap and/or package instruments in
appropriate types of materials. Place chemical indicator in package, if not,
use a package that contains a chemical indicator
 Sterilization: Load sterilizer, label packages, and make sure to allow
circulation. Allow packages to cool before removing them from
sterilizer ,allow packages to cool before handling.
 Storage: Store instruments in a clean, dry environment. Rotate packages
so that those with the oldest sterilization dates will be used first
 Delivery: Deliver packages to the point of use in a manner that maintains
sterility of the instruments until they're used. Inspect package before use.
 Quality assurance: Training, record keeping, maintenance and use of
biologic indicators.
Fig 12.3: Key Steps in Instrument Processing

POINT OF USE CLEANING
(Occurs immediately after use)

132
132
CLEANING
Thoroughly wash, rinse, and dry
Acceptable Methods
Preferred
STERILIZATION HIGH LEVEL DISINFECTION
Chemical Autoclave Dry Heat Pasteurization Chemical

Soak time (Steam sterilization), Temperature
depends on time, temperature, and depends on Lid on 20 minutes Soak time
Manufacturers pressure depend on manufacturers depends on
instructions manufacturers instructions Manufacturers
Instructions
instructions
COOL
Store appropriately or use
immediately
Source: Reference Manual for Health Care Facilities with Limited Resources
 Decontamination is the first step in handling used (soiled) instruments and gloves to make
them safer to handle by the cleaning staff
 This require a 10 minutes soak in a 0.5%chlorine solution
 This important step kills hepatitis B, C and HIV
 Instruments with secretions or blood from client must be decontaminated before being cleaned
and high level disinfected or sterilized
 Supplies needed for decontamination include
o Soap: for hand washing
o Utility gloves: for personal protection while cleaning
o Tap water: for washing and cleaning purposes
o Apron for personnel protection
o 3 Buckets : one for decontamination solution, one for soapy water and one for clean
water
o Decontamination solution: for decontaminating equipment
o Brush: for cleaning instrument
o Pint measure: for measuring solution
o Eye goggles: for eye protection

133
133
o Hamper: for dirty linen
STEP 4: Assembling of Equipment for Procedure ( 25 Minutes)

DIVIDE students into 6-8 groups
ASK students to discuss on basic surgical tools in operating theatre
AFTER small groups discussion, ask students to provide their responses
CLARIFY and SUMMARIZE using the information below

Surgical Instruments
 Surgical instruments are-precisely designed and manufactured tools.
 For single (disposable) or multiple use (non-disposable)
 Must be resisted physical and chemical effects, body fluids, secretions, cleaning agents and
sterilization
 For this reason, most of them are made of high-quality stainless steel; chromium and vanadium
alloys ensure the durability of edges, springiness and resistance to corrosion
 Classification
o Cutting and dissecting instruments
 The function of these instruments is to divide tissues, sutures, bandages for
example
 Scalpes, handle and detached blade,
 Scissors,
 Dissecting homeostatic forceps three main functions are dissecting
tool, grasping tool ad haemostatic tool
 Electrocoagulating system include monopolar and Bipolar
 Dissector
 Amputating knives
 Saws
 Raspatories
o Grasping, clamping, occluding instruments
 These are used to grasp, pick up, hold and manipulate tissues, tools and
materials
 Forceps
o It should be held like pencill
o It MUST never be held in the palm
 Towel holding clamps
o Bachaus towel clamp
o Schaedel towel clips
 Haemostatic forceps
o Traumatic like kocher and lumnitzer

134
134
o Atraumatic haemostatic forceps like bulldog, blalock and
satinsky
 Needle holders like Mathieu needle holder, hegar needle holder
 Organ clamps like allis (lungs), ringed gall bladder clamp, babcock
(gall bladder), klammer (intestinal clamp)
 Sponge holding clamp
o Haemostatic instruments
 These instruments are establishing haemostasis during the operation
 Important instrument in this group are pean, mosquito, abdominal pean,
kocher, lumnitzer, satinsky bulldog and electrocoagulatins system
 Deschamp needle and payr probe
 Argon beam coagulator
o Retracting and exposing instruments
 These instruments are used to hold tissues and organs in order to improve the
exposure and hence the visibility and accessibility of the surgical field
 Hook
 Rake retractor
 Roux retractor
 French retractor
 Visceral retractor
 Abdominal wall retractor
 Weilaner self retratorgosset self retractor
o Wound-closing instruments and materials6.Special instruments
 These instrument and surgical materials are used during tissue closure
procedures
 Staplers
o Linear and circular
 Clips : michel clips,self adhesive strips,surgical adhesive
 Surgical materials
o Special instruments
 These instruments are not used routinely during all surgical interventions
 Volkmanns curette
 Instruments of bone surgery
 Probe
 Sucker system
Surgical materials
 Surgical needles
 The criteria for ideal surgical needle
o Made in best quality and minimal tissue reaction causing
o stainless steel
o Slim and narrow, but strong
o Stabil fixation and control in the needle holder
o Lead the thread by safely and minimal traumatisation
o Sharp to get through the tissues
o Rigid, but flexible

135
135
o Easy sterilisation
 Conventional needles
 This needle are:
o Double thread (traumatisation)
o Lace time
o Re-sterilisation
o Care of needle-tip
o Corrosion
o The examples are:
 French eye and closed eye
 A traumatic needles
o Simple thread (a traumatic)
o Manufactured connection of needle and threads
o - No Lace time
o - No re-sterilisation
o - No Care of needle-tip
o - No Corrosion
 Shape of needle
o ¼ circle
o 3/8 circle
o ½ circle
o 5/8 circle
o Progressive curved
o Straight
o Multiple curved
o J shape
 Criteria of ideal surgical materials
o Nonelectrolytic, noncapillary, nonallergenic, noncarcinogenic.
o Nonferromagnetic, as is the case with stainless steel sutures.
o Easy to handle.
o Minimally reactive in tissue and not predisposed to bacterial growth.
o Capable of holding tissue layers throughout the wound healing
o Resistant to shrinking in tissues.
o Absorbed completely with minimal tissue reaction after serving its purpose.
o Sterile.
o Classification of surgical materials
 Raw material there are Natural and Synthetic
 Structure there are Monofil and Multifil
 Absorbability there are Absorbable and Non-absorbable
o Absorbable
 Polyglycolic acid (Safil®, Safil Quick®, Dexon®)
 Polyglactin (Vicril®, Vicryl Rapide®)
 Glycomer (Biosyn®)
 Polyglytone (Caprosyn®)
 Glyconate (Monosyn®)

136
136
 Polyglyconate (Maxon®)
 Polydioxanone (PDS II®, MonoPlus®)
 Lactomer (Polysorb®)
 Gut (Cromic Gut®, Plain Gut®)
o Non absorbable
 Polyamide (Dafilon® , Ethilon®, Supramid®, Nurolon®, Surgilon®)
 Polyester (Ethibond®, Ti-Cron®, Synthofil®, Dagrofil®, Mersilene®)
 Polybutester (Novafil®, Vascufil®)
 Polypropylene (Premilene®, Prolene®, Surgipro®)
 Silk (Silkam®, Virgin silk®, Mersilk®, Softsilk®)
 Steel (Steelex®, Steel wire®, Steel®)
Figures 12.1: Basic Surgical equipment and materials

Scapel Handle and detachable blade
Scissors

137
137
Dissecting hoemostatic forceps Mosquito and abdominal pean

138
138
Dissector
Saws
Raspatories

139
139
Forceps

140
140
Towel holding clamps (Bachaus towel clamp)
Scahedel towel clamps

141
141
Refer Students to Handout 12.1: Basic Surgical Tools
STEP 5: Arrangement of equipment to their respective places ( 15 Minutes)
 What is 'equipment layout'?

o Equipment layout is where pieces of equipment, such as displays and controls, are laid
out in relation to everything else around them, including the person using them.
 Good equipment layout helps to ensure that:
o Equipment can be clearly identified;
o Equipment is easy and efficient to use;
o Errors are avoided, especially under emergency conditions.
 The equipment itself maybe well designed, but if it is not positioned well, then you may be
confused and make mistakes in reading an instrument or controlling the equipment. Some
examples of bad control placement are:
 Good equipment layout means working out what should go where, considering the size of the
work place and the size and position of the user, including their optimum viewing angles and
reach. Even if the equipment is itself well designed, its position may be confusing unless
certain principles are applied in its arrangement.
 These principles can be applied after examining the tasks that the equipment is used for. This
can be done by:

142
142
o Observing the user's body movements, including their eye movements, during all
tasks;
o Analysing links between the user and their equipment, the user and other people, and
the user and any other tool or job aid that they might use during the task;
o Carrying out interviews with the user to get information about the sequence of their
activities, the characteristics of the tasks, and the overall nature of their job. This will
also help to find out about the frequency and importance of critical or infrequent
activities which might not be found out during observations of 'normal' activities
Optimum location
o Ideally, all equipment would be placed in the optimum location for its purpose.
o This would depend on the user's characteristics, such as their size, and their
movement, vision and hearing capabilities.
o Equipment should be located in the optimum (best) space, according to some criterion
of use, such as convenience, accuracy, speed or strength to be applied.
o Workplace layout can be considered in terms of the optimum, and the overall
dimensions or space. Optimum dimensions define the most desirable space for the
location of equipment - highest priority equipment should be placed here.
o Overall dimensions define the acceptable, but not necessarily the most desirable,
dimensions or space - less important equipment, for example that used periodically
during normal operations should be placed within this region.
o Several other principles can help you to do this, and these are usually applied in the
following descending order:
 Importance principle
o Important equipment should be placed in convenient locations. 'Importance' is
determined by how critical a piece of equipment is in terms of achieving the task or
goals of the system
o Emergency equipment should be placed in readily accessible positions (somewhere
within the overall workspace), but not necessarily in the optimum workspace.
 Frequency of use principle
o Frequently used equipment should be placed in convenient locations, close to or
preferably, in front of you.

 Sequence of use principle
o Equipment should be arranged to take advantage of any sequences or patterns of use
that occur during a task. If a number of controls are normally operated in a particular
sequence, then they and their corresponding displays should be arranged on the panel
in that order, from left to right, or from top to bottom. Thinking time is reduced as you
don't have to remember a particular order of actions, and movement is reduced as
related equipment will be located close to each other.
 Grouping principle
o Equipment should be grouped according to its function. For example, equipment that is
related to a particular task, such as temperature displays and temperature controls
should be grouped together. This grouping can be highlighted by the use of colour,
labelling, demarcation lines or simply by placing groups of items in rows. Look on your
keyboard - text keys, numeric keys, and cursor control keys are all positioned together
in groups.
 Note: In practice, these principles cannot always be applied. In these cases, you should assess
any risks to ensure that tasks can be performed with minimal risk to the user, equipment or
others people.

143
143
 Cleaning, disinfection, and sterilisation are the backbone of infection prevention and control
 Proper cleaning essential before any disinfection or sterilisation process
 Failure to sterilise or disinfect reusable medical devices properly may spread infections

 What is theatre team?
 What is the layout of theatre?
 What are the principles of aseptic technique in the operating theatre?
STEP 8: Take Home Assignment (05 Minutes)
Activity: Take home Assignment (50 Minutes)

DIVIDE students in groups
ASK the students to work on the following assignment
 To visit operating theatre and perform the following:

o Decontamination of used instruments
o Packing of equipment according to type of operation
o Packing of gowns
o Perform the sterilization of equipment
ALLOCATE time for students to do the assignment and submit report
REFER students to recommended references

144
144
References
Australia Ski Patrol Association. (2011). Advanced emergency care manual (10th ed.). Retrieved from
Saunders Company


145
145
Handout 12.1: Basic Instruments in Operating Theatre

146
146
147
147
148
148
149
149
150
150
SESSION 13: PREOPERATIVE NURSING CARE OF A PATIENT FOR
SURGERY
Total Session Time: 120 minutes
Prerequisite:None
Learning Tasks
Define preoperative nursing care
Describe a comprehensive preoperative assessment
Identify legal and ethical consideration related to informed consent
Identify right patient for the right operation
Perform the immediate preoperative preparation
Provide preoperative nursing measures
Resources Needed
 Handouts 13.1: Surgical Risk Factors and Potential Complications
 Handouts 13.2: Preoperative Teaching to Prevent Postoperative Complications
 Handouts 13.3: Drug Therapy: Preoperative Medications
Session Overview
Method
1 05 minutes Presentation Session Title and Students Learning Tasks
2 05 minutes Brainstorming, Presentation Definition of Preoperative Phase,

Preoperative Nursing Care
3 20 minutes Lecture Discussion Comprehensive Preoperative Assessment
4 20 minutes Lecture Discussion Legal and Ethical Consideration Related to

Informed Consent
5 20 minutes Group Discussion, Right Patient for the Right Operation
Presentation
6 15 minutes Presentation Immediate Preoperative Preparation

151
151
7 25 minutes Presentation Preoperative Nursing Measures
8 05 minutes
9 05 minutes
SESSION CONTENTS
STEP 2: Preoperative Nursing Care (05 Minutes)

ASK the students to brainstorm on the definition of Preoperative Phase and Preoperative
Nursing Care
CLARIFY and SUMMARIZE utilizing information below
 The preoperative phase is the period that begins when the decision to proceed with surgical
intervention is made and ends with the transfer of the patient onto the operating room area
 Preoperative nursing care is defined as care given to a patient/client before surgery according
to the individual needs of the patient/client
STEP 3: Comprehensive Preoperative Assessment (20 Minutes)

 When surgery is not an emergency, the nurse performs a Comprehensive Assessment to
assesses the clients understanding of the surgical procedure, postoperative expectations, and
ability to participate in recovery
 Comprehensive nursing assessment usually addresses the following parameters:
 Psychosocial Assessment
o Any surgical procedure is preceded by an emotional reaction, whether obvious or not
obvious. Patient and family may experience fear and anxiety which are related to surgical
outcome, change of body image, effects from anesthesia, fear of pain, fear of long
separation and death
o Family members also experience fear and anxiety
o Therefore, give adequate, simple explanations, allow patient and family to ask questions
and express feelings and ideas
o Give divisional activities to keep the patient occupied
o Any surgical procedure is preceded by an emotional reaction, whether obvious or not
obvious

152
152
o Patient and family may experience fear and anxiety which are related to surgical outcome,
change of body image, effects from anaesthesia, fear of pain, fear of long separation and
death
Physical Assessment
 General physical assessment
o Take history of the patient and physical examination and vital signs
o Assist on carrying out Diagnostic studies e.g. HB level, blood groping and Xmatching,
radiological studies, urinary analysis
o physical nutritional status
 Respiratory Status
o Assess for nasal flaring, audible wheezing, tachypnea, stridor and dyspnea, accessory muscle
breathing and any respiratory infection.
 Cardiovascular states
o Assess for palpitations, neck vein distension, fatigue, clubbing of fingers, edema and murmurs
 Endocrine function
o Assess for weight loss, polyphagia, polydipsia, increase urinary output, weakness and fatigue
 Hepatic and renal function
o Hepatic: Assess for jaundice, ascities, anorexia, splenome.g.aly and dark urine
o Renal: Assess for dysuria, frequency, nocturia, anuria and hematuria.
 Immunological functions
o Immunological deficiency is a risk factor for delayed wound healing
o Assess for history of allergies and allergic reactions (type, frequency, perceived causes)
Laboratory Results of blood tests, x-ray studies, and other diagnostic tests
Nutritional and fluid status
Previous Medication Use
o A medication history is obtained from each patient because interactions with such
medications with anaesthetics agents can cause serious problems, such as arterial
hypotension and circulatory collapse
Assessment of Surgical Risk Factors and Potential Complications
Refer Students to Handout 13.1: Surgical Risk Factors and Potential Complications
STEP 4: Legal and Ethical Consideration Related to Informed Consent (20

Minutes)
 A consent form is a signed permission by the patient or relative (in case of Children) so as to have
the operation done (performed)
 Informed consent is the patients autonomous decision about whether to undergo a surgical
procedure; based on the nature of the condition, the treatment options, and the risks and benefits
involved
o The consent form must be witnessed by an authorized person

153
153
o After the patient assessment, before surgery is done, the nurse and the doctor must make
sure the patient signs consent form
o This is a medical le.g.al requirement before surgery and administration of anesthesia
 The purposes of informed consent:
o Ensure that the patient understands the nature of treatment including potential complications
o Indicate that the patients decision was made without pressure
o Protect the patient against an authorized procedure
o Protect the surgeon and hospital against legal action by patient who claim that an
authorized procedure was carried out
 Before signing the consent form the patient should:
o Be told in clear and simple terms by the surgeon what is to be done
o Be aware of the risks possible, complications, disfigurements, and removal of parts
o Have an idea of the time involved in surgery to recovery
o To have an idea of what to expect in the early and late post-operative period
o Have an opportunity to ask questions
o Sign a separate form for each operation
The following are the Legal and Ethical Consideration for valid informed consent;
 Voluntary Consent
o Valid consent must be freely given, without coercion
 Incompetent Client
o Legal definition: Individual who is not autonomous and cannot give or withhold consent
o If an adult client is confused, unconscious, or not mentally competent, a family member or
guardian must sign the consent form
o the client is younger than 18 years of age, a parent or legal guardian must sign the consent
form Persons younger than age 18 years of age, living away from home and supporting
themselves, are regarded as emancipated minors and sign their own consent forms
o In an emergency, the surgeon may have to operate without consent
 Informed Subject
o Informed consent should be in writing and contain the following:
 Patients full name
 Explanation of procedure and its risks
 Descriptions of benefits and alternatives
 Site of procedure
 Side of procedure
 An offer to answer questions about procedure
 Instructions that the client may withdraw consent
 A statement informing the client if the protocol differs from customary procedure
 Client able to understand
o Information must be written and delivered in language understandable to the client.
Questions must be answered to facilitate comprehension if material is confusing
The following circumstances required Informed consent;
 Invasive procedures, such as a surgical incision, a biopsy, cystoscopy, or paracentesis
 Procedures requiring sedation and/or anesthesia
 A nonsurgical procedure, such as an arteriography, that carries more than slight risk to the
patient
 Procedures involving radiation
STEP 5: Right Patient for the Right Operation (20 Minutes)

154
154
DIVIDE students into 3-8 groups
ASK students to discuss on right patient for the right operation
CLARIFY and summarize using the information below
 While wrong-operation (wrong-site) or wrong-patient surgery is rare, even a single incident can
result in considerable harm to the patient
 The following are the are three universal protocol to Preventing Wrong Site, Wrong Procedure,
Wrong Surgery as follow;
Step 1: Verification
 Verifying the correct patient, site and procedure at every stage from the time a decision is made to
operate to the time the patient undergoes the operation
 This should be done:
o When the procedure is scheduled
o At the time of admission or entry to the operating theatre
o Any time the responsibility for care of the patient is transferred to another person
o Before the patient leaves the preoperative area or enters the procedure or surgical room
o The step is undertaken insofar as possible with the patient involved, awake and aware
o This is an active process that must include all members of the team involved in the
patients care
o Patients or their caregivers should participate actively in verification.
Step 2: Marking
 The Universal Protocol states that the site or sites to be operated on must be marked
 The protocol stipulates that marking must be at or next to the operative site
 Non-operative sites should not be marked
 Unambiguous, clearly visible and made with a permanent marker so that the mark is not removed
during site preparation
 Made by the surgeon performing the procedure or delegated, as long as the person doing the
marking is also present during surgery, particularly at the time of incision
 Completed, to the extent possible, while the patient is alert and awake, as the patients involvement
is important.
Step 3: Time out

 Time out or surgical pause is a brief pause before the incision to confirm the patient, the procedure
and the site of operation
 It is also an opportunity to ensure that the patient is correctly positioned and that any necessary
implants or special equipment are available
 All team members are actively involved
 Any concerns or inconsistencies are clarified at this stage
 The checks during the time out must be documented, potentially in the form of a checklist
STEP 6: Immediate Preoperative Preparation (15 Minutes)

155
155
The following are the immediate preoperative preparation of the patient;
 Physical and psychological attention
 Provide pre-medications in time as indicated by the surgeon
 Check that proper identification band is on client (identify)
 Check that pre-operative consent forms are signed and medical record is in order
 Complete pre-operative checklist and record of clients pre-operative preparation
 Make sure the patient is physically well prepared, check the site of operation
 Provide patient with clean gowns to be worn to the operating theatre
 Remove artificial material e.g. dentures, jewellers, contact lenses and keep them properly
 Let the patient pass urine and record, check the vital signs so as to have the base line for later
comparison
 Continue to support the patient emotionally and correct any misconception
 Transporting the patient to the pre surgical area using a wheel chair or stretcher if needed
STEP 7: Preoperative Nursing Measures (25 Minutes)
Activity: Small Group discussion (15 Minutes)

ASK students to discuss in groups preoperative nursing measures
 Review nursing data base history and physical examinations

 Check the diagnostic testing if has been completed and results are available
 Promote optimal hydration and nutritional status of the client
 Identify learning needs of client and conduct pre-operation teaching regarding the following;
o Preoperative medicationswhen they are given and their effects

o Postoperative pain control
o Explanation and description of the post anesthesia recovery room or postsurgical area
o Discussion of the frequency of assessing vital signs and use of monitoring equipment
o Coughing and deep breathing exercise
o Leg exercise and ambulation
o use of incentive spirometry
o how to splint the incision for breathing exercises and moving
o position changes
Day before Surgery
 Provide emotional support to the client, answer questions realistically, correct any
misconceptions he/she may have, provide spiritual assistance
 Follow pre-operatively dietary restrictions, have the patient fasted for 4 6 hrs before operation
 Prepare for elimination needs during and after surgery
 Attend to clients special hygiene needs (use of antiseptic cleaning agents)

156
156
Refer Students to Handout 13.1: Preoperative Teaching to Prevent Postoperative
Complications
Refer Students to Handout 13.3: Drug Therapy: Preoperative Medications

 The patients experience of surgery is divided into three main phases that are pre-operative phase,
intra-operative phase and post-operative phase
 After the patient pre-operative assessment before, the nurse and the doctor must make sure the
patients or guardians consent is obtained and signed
 Safe Surgery Saves Lives

 How can you define the following terms- preoperative phase, informed consent?
 What are the immediate preoperative preparations that a nurse would offer to a client?
References
Saunders Company

157
157
Web Md. (n.d.) Brain hemorrhage: Causes, symptoms, treatments. Retrieved from
Workman, I. (2016). Medical Surgical Nursing: Patient Centered Collaborative (8thed.). St
Louis, Missouri: Elsever, Inc
Handout 13.1: Preoperative Teaching to Prevent Postoperative Complications

158
158
159
159
Refer Students to Handout 13.2: Drug Therapy: Preoperative Medications
SESSION 14: INTRAOPERATIVE NURSING CARE OF A PATIENT

UNDERGOING SURGERY

Prerequisite: None
Learning Tasks
NMTDefine
05105:Basic Care of aand
intraoperative Patient
carewith Surgical Conditions
intraoperative nursing care 160
Describe the interdisciplinary approach to care of the patient during surgery
Describe the principles of surgical asepsis 160
Describe nursing roles in the intra operative phase of care
Resources Needed
Session Overview
Method
1 05 minutes Presentation
Session Title and Students Learning Tasks
2 10 minutes Brainstorming, Presentation Definition of Intraoperative care,
Intraoperative Nursing Care
3 30 minutes Presentation Interdisciplinary Approach to Care of the
Patient During Surgery
4 20 minutes Buzzing, Lecture Discussion Describe the Principles of Surgical Asepsis
5 45 minutes Group Discussion, Nursing Roles in the Intraoperative Phase

Presentation
6 05
7 05
Session Contents
STEP 2: Definition of Intraoperative Nursing Care (10 Minutes)
Activity: Brainstorm (03 minutes)
ASK the students to brainstorm on the definition of intraoperative care and intraoperative

161
161
nursing care
CLARIFY and summarize utilizing information below
 The intraoperative nursing care is a care begins when the patient is transferred onto the operating
room table and ends when he or she is admitted to the postanesthesia care unit (PACU)
STEP 3: Interdisciplinary Approach to Care of the Patient During Surgery (35

Minutes)
 Interdisciplinary approach is a strategy whereby members of diverse health care disciplines jointly
plan, implement, and evaluate care
 It is a complex process in which different types of surgical team work together to share expertise,
knowledge, and skills
 During surgery, surgical team from the departments of anesthesia, nursing, and surgery work
collaboratively to implement professional standards of care, to control iatrogenic (adverse effects)
and individual risks, and to promote high-quality patient outcomes
 The surgical team consists of:
o The Circulating Nurse (also known as the circulator);
 Manages the operating room by ensuring cleanliness, proper temperature, humidity,
and lighting, the safe functioning of equipment; and the availability of supplies and
materials
 Protects the patients safety and health by monitoring the activities of the surgical
team
 Assessing the patient continually for signs of injury and implementing appropriate
interventions
 Verifying consent
 Coordinating the team
 Monitors aseptic practices to avoid breaks in technique
 Implementing fire safety precautions
 Monitors the patient and documents specific activities throughout the operation to
ensure the patients safety and well-being
o The Scrub Nurse;
 Performing a surgical hand scrub
 Setting up the sterile tables
 Preparing sutures, ligatures, and special equipment (such as a laparoscope); and
assisting the surgeon and the surgical assistants during the procedure by
anticipating the instruments that will be required, such as sponges, drains, and other
equipment
 Count all needles, sponges, and instruments as the surgical incision is closed to be
sure they are accounted for and not retained as a foreign body in the patient
 Label tissue specimens obtained during surgery and sent to the laboratory by the
circulator nurse
o The Anesthesiologist and Anesthetist;
 An anesthesiologist is a physician specifically trained in the art and science of
anesthesiology

162
162
An anesthetist is a qualified health care professional who administers anesthetics.
Most anesthetists are nurses
o The anesthesiologist or anesthetist roles include;
 Interview and assesses the patient prior to surgery to provide information and
answer questions. Assessment will be on type of anesthetic to be administered,
previous reactions to anesthetics, and known anatomic abnormalities that would
make airway management difficult
 Selects anesthesia
 Administers anesthesia
 Intubates the patient if necessary
 Manages any technical problems related to the administration of the anesthetic
agent
 Supervises the patients condition throughout the surgical procedure
 Reassesses the patients physical condition immediately prior to initiating
anesthesia when the patient arrives in the operating room
 Monitors the patients blood pressure, pulse, and respirations, electrocardiogram
(ECG), blood oxygen saturation level, tidal volume, blood gas levels, blood pH,
alveolar gas concentrations, and body temperature
STEP 4: Describe the Principles of Surgical Asepsis (20 Minutes)
TELL the students to buzz on Principles of Surgical Asepsis
ALLOW few students to respond and the rest to provide unmentioned responses
CLARIFY and summarize utilizing information below
Surgical asepsis prevents the contamination of surgical wounds and all surgical team have the
responsibility to provide and maintain a safe environment
The following are the principles of surgical asepsis;
 All surgical supplies, instruments, needles, sutures, dressings, gloves, covers, and solutions
that may come in contact with the surgical wound and exposed tissues, must be sterilized
before use
 The surgeon, surgical assistants, and nurses prepared themselves by scrubbing their hands
and arms with antiseptic soap and water
 Surgical team members wear long-sleeved sterile gowns and gloves, head and hair are
covered with a cap, and a mask is worn over the nose and mouth to minimize the possibility
that bacteria from the upper respiratory tract will enter the wound
 During surgery, the personnel who have scrubbed, gloved, and gowned touch only sterilized
Objects
 Non-scrubbed personnel refrain from touching or contaminating anything sterile
 An area of the patients skin considerably larger than that requiring exposure during the surgery
is meticulously cleansed, and an antimicrobial agent is applied. If hair needs to be removed,
it is done immediately prior to the procedure to minimize the risk of wound infection. The
remainder of the patients body is covered with sterile drapes

163
163
STEP 5: Nursing Roles in the Intraoperative Phase (40 Minutes)
Activity: Small Group discussion (25 Minutes)
ASK students to discuss in groups nursing roles in the intraoperative phase
The following are the nursing roles in the intraoperative phase;

 Adhere to the principles of maintaining the comfort and safety of the patient
 Proper handing over the patient to operating staff (e.g. important information such as name,
diagnosis, risk factors, type of surgery)
 Have all the charts and needed documents ready and handed to the person receiving the
patient
 Make sure there is proper coordination and team effort that the patient arrives in theatre in time
 Have the family well informed and involved
 Prepare the instruments needed, ensure the sterility, and setup the sterile field
 Scrub when the anesthesiologist is administering the anesthesia
 Arrange all materials and instruments according to use
 Assist in the draping the patient
 Count the instruments and supplies (such as gauze, sponges, clips) before skin incision and
ensures that are correct
 Perform second counting of the instruments and supplies before suturing
 Perform the final count of instruments and supplies during closure of the adipose tissue and
inform surgeon
 Chart that all instruments and supplies are accounted for and verify with the circulating nurse
 Wash the instruments
 Maintains aseptic, controlled environment
 Effectively manages human resources, equipment, and supplies for individualized patient care
 Transfers patient to operating room bed or table
 Positions the patient to protect from injury
o Functional alignment
o Exposure of surgical site
 Completes intraoperative documentation
 Calculates effects on patient of excessive fluid loss or gain
 Distinguishes normal from abnormal cardiopulmonary data
 Reports changes in patients vital signs
 Institutes measures to promote normothermia
 The intraoperative nursing care is a care begins when the patient is transferred onto the
operating room table and ends when he or she is admitted to the postanesthesia care unit

164
164
 During surgery, surgical team from the departments of anesthesia, nursing, and surgery work
collaboratively to implement professional standards of care, to control iatrogenic (adverse
effects) and individual risks, and to promote high-quality patient outcomes

 What are the principles of surgical asepsis to prevent contamination of surgical wounds?
References
Saunders Company

165
165

166
166
SESSION 14: POST OPERATIVE NURSING CARE
Prerequisite: None
Learning Tasks
Define post-operative nursing care
Identify common post-operative complications and prevention
Describe the responsibilities of a nurse in the immediate prevention of postoperative
complications
Describe variable that affect wound healing
Assess a patient in a recovery area
Provide post-operative nursing care to prevent post-operative complication
Resources Needed
Session Overview
(min) Method
1 05
Presentation Session Title and Learning Tasks
2 05 Brainstorm, Presentation Definition of Post-operative Nursing Care
10 Presentation Common Post-Operative Complications and

Prevention
3 10 Responsibilities of A nurse in the Immediate
Buzzing ,Presentation Prevention of Postoperative Complications
4 15 Presentation Variable that Affect Wound Healing
5 40 Presentation, Small Group Assessing A patient in Recovery Area

Discussion
6 25 Small, group Discussion, Post- Operative Nursing Care to Prevent
Presentation Post- Operative Complications

167
167
7 5
8 5
SESSION CONTENTS
STEP 2: Definition of Post-operative Nursing Care (05 Minutes)
ACTIVITY: Brainstorm (05 Minutes)
ASK students to brainstorm on the definition of postoperative care
ALLOW a few students to respond.
WRITE their responses to the board.
CLARIFY and SUMMARIZE their responses by using the contents below
 The postoperative Nursing care is the care given to the client who begins with the admission of
the patient to the post aesthesia care unit (PACU) and ends with a follow-up evaluation in the
clinical setting or at home.
STEP 3: Common Post-Operative Complications and Prevention (10 Minutes)

The following are the post 0perative complications:
 Hemorrhage.
o Hemorrhage can be internal or external. If the client loses a lot of blood, he or she will
exhibit signs and symptoms of shock.
o The nurse inspects dressings frequently for signs of bleeding and checks the bedding
under the client, because blood may pool under the body and be evident on the
bedding.
o If bleeding is internal, the client may need to return to surgery for ligation of the
bleeding vessels. Blood transfusions may be necessary to replace lost blood.
o When bleeding occurs, the nurse notes the amount and colour on the chart. Bright red
blood signifies fresh bleeding; dark, brownish blood indicates older blood. The nurse
may need to reinforce soiled or saturated dressings.
o A written order is needed to change dressings. The nurse also must be aware of any
wound drains and the type and amount of drainage expected.

168
168
o If such drainage is expected, the nurse explains to the client that the drainage is
normal and does not indicate a complication. He or she places incontinence pads
under the client if drainage occurs.
 Shock:
o Fluid and electrolyte loss, trauma (both physical and psychological), anesthetics, and
preoperative medications all may contribute to shock.
o Signs and symptoms include pallor, fall in BP, weak and rapid pulse rate, restlessness,
and cool, moist skin.
o Shock must be detected early and treated promptly because it can irreversibly damage
vital organs such as the brain, kidneys, and heart.
o Narcotics are not administered to a client in shock until a physician evaluates the
client, who should remain supine.
o Some physicians advocate elevating the legs to enhance the flow of venous blood to
the heart.
o Treatment of shock varies and depends on the cause, if known. Blood, plasma
expanders, parenteral fluids, oxygen, and medications such as adrenergic agonists
may be used.
 Hypoxia.
o Factors such as residual drug effects or overdose, pain, poor positioning, pooling of
secretions in the lungs, or obstructed airway predispose the client to hypoxia (decreased
oxygen).
o Oxygen and suction equipment must be available for immediate use. The nurse observes
the client closely for signs of cyanosis and dyspnea.
o Breathing may be obstructed if the tongue falls back and blocks the nasopharynx. If this
occurs, the nurse pulls the lower jaw and inserts an oropharyngeal airway.
o Positioning the client on his or her side also may relieve nasopharyngeal obstruction.
Restlessness, crowing or grunting respirations, diaphoresis, bounding pulse, and rising BP
may indicate respiratory obstruction. If a client cannot breathe effectively, mechanical
ventilation is used.
 Aspiration.
o Danger of aspiration from saliva, mucus, vomitus, or blood exists until the client is fully
awake and can swallow without difficulty. Suction equipment must be kept at the clients
bedside until the danger of aspiration no longer exists.
o The nurse closely observes the client for difficulty swallowing or handling of oral
secretions. Unless contraindicated, the nurse places the client in a side-lying position until
the client can swallow oral secretions.
STEP 3: Responsibilities of a nurse in the Immediate Prevention of Postoperative

Complications (10 Minutes)
ASK students to pair up and responsibilities of a nurse in immediate prevention of post operative
complications

169
169
The following are responsibilities of a nurse in the immediate prevention of post -operative
care includes:
 Encouraging early mobilization:
o Deep breathing and coughing
o Active daily exercise
o Joint range of motion
o Muscular strengthening
o Make walking aids such as canes, crutches and walkers available and provide
instructions for their use
 Ensuring adequate nutrition
 Preventing skin breakdown and pressure sores:
o Turn the patient frequently
o Keep urine and faeces off skin
 Providing adequate pain control
STEP 4: Variable that Affect Wound Healing (15 Minutes)

 Whether due to injury or surgery, wound healing normally progresses steadily through an
orderly set of stages.
 Wounds that don't heal within 30 days are considered chronic.
 Wounds that become chronic generally stall in one or more of the phases of wound healing.
 The following are 10 of the most common factors affecting wound healing in chronic wounds:
 Age of Patient
o There are many overall changes in healing capacity that are related to age. Studies
have shown that people over the age of 60 may have delayed wound healing due
factors associated with physical changes that occur with advanced age.
o In addition to multiple existing comorbidities, there is decrease in the body's
inflammatory response, a delay in angiogenesis and the process of epithelialization is
slower.
o Some visible changes to the skin are related to the alteration in melanocytes, such as
age spots, as well as drier skin due to a decreased function of the sebaceous glands.
o Decreased collagen synthesis is attributed to slower scar formation in the wound
healing process, as well.
 Type of Wound
o The characteristics of a wound can affect the speed of wound healing. Obviously,
larger wounds take longer to heal, but the shape of the wound can also play a part in
the time of healing.

170
170
o Linear wounds typically heal faster than rectangular wounds, and circular wounds are
the slowest to heal. In addition, wound healing is slower when wounds have necrotic
tissue, desiccation, and foreign bodies.
 Infection
o All skin breaks can allow bacteria, virus, or fungus to enter the wound site. Normally,
these pathogens are overtaken and eliminated by white blood cells and other
components of the immune system.
o When infection is present, up through the surface and create sore or lesion which
requires treatment through excellent wound care and perhaps administration of
antibiotics.
 Chronic Diseases
o Patients who have diabetes or have diseases affecting their circulatory system may
have inhibited wound healing.
o Efficient wound healing requires good blood flow and chronic conditions which have
compromised blood flow to the wound site may require therapeutic intervention.
Individuals with chronic wounds are advised to consult a medical professional for a
comprehensive assessment to identify appropriate treatment interventions.
 Poor Nutrition
o In a chronically ill or geriatric patient, poor nutrition can cause the body to have insufficient
resources to heal the wound. Inadequate nutrition can occur because infections increase the
protein and caloric needs of an individual.
o Moreover, wounds can exude large quantities of protein daily, especially in the case of large
pressure ulcers (injuries) or leg ulcers.
o When calories are inefficient, the body may break down protein for energy, further depleting the
body's ability to heal.
 Lack of Hydration
o A lack of moisture at the surface of a wound can halt cellular migration, decrease blood
oxygenation, and seriously delay wound healing.
o Dehydration caused by either a depletion of sodium or water can delay all aspects of the
healing process.
o While most people need 64 ounces of fluid daily, a person trying to recover from a wound will
need to drink more to help the process of white blood cells travelling to the injury site to supply
needed oxygen and nutrients.
o A properly hydrated patient will have urine that is clear and generally odourless.
 Poor Blood Circulation

o Since blood delivers the necessary components to tissue for the wound healing process to take
place, people with low blood pressure or vascular disease can have problems with delayed
healing.

171
171
o Blocked or narrowed blood vessels or diseases of the heart, kidneys and lungs can also cause
issues in the body delivering vital wound healing components, including white blood cells and
adequate oxygen, to wounded tissues.
 Edema
o While most traumatic injuries cause some tissue swelling, excessive edema can increase the
pressure on blood vessels, resulting in poorer blood circulation in the wound area.
o Tissue swelling can be caused by heart conditions or blood vessel problems. Compression
therapy is often effective at transporting fluids back into the circulatory system to reduce edema
so proper healing can occur.
 Repeated Trauma
o Wounds that continue to be reinjured due to shear force or pressure against a surface can
have their healing process delayed or even stopped.
o Repetitive trauma often occurs with bed-bound patients and can be treated by careful
repositioning on a regular schedule or use of offloading or protective devices under the
supervision of a health care professional.
 Patient Behaviours
o Unfortunately, some patients contribute to delayed wound healing through lifestyle choices like
smoking or excessive drinking.
o Other patient behaviours that can affect wound healing are a lack of adequate sleep, failure to
elevate the affected area, not properly cleaning the wound, using inadequate wound dressing
procedures, not keeping the wound moist and not moving enough.
o Listening to patients and providing careful education can help create better compliance with
good wound healing practices.
STEP 5: Assessing A patient in Recovery Area (40 Minutes)

ASK students to discuss on assessment of a patient in recovery room
 Assessment during this period includes respiratory function; general condition; vital signs;
cardiovascular function and fluid status; pain level; bowel and urinary elimination; and
dressings, tubes, drains, and IV lines.
 Respiration.
o The nurse focuses on promoting gas exchange and preventing atelectasis.
Hypoventilation related to anesthesia, postoperative positioning, and pain is a common

172
172
problem. Preoperative and postoperative instructions include teaching the client to
deep breathe and cough, and how to splint the incision to minimize pain. Clients who
have abdominal or thoracic surgery have greater difficulty taking deep breaths and
coughing.
o Some clients require supplemental oxygen. Nursing management to prevent
postoperative respiratory problems includes early mobility, frequent position changes,
deep breathing and coughing exercises, and use of incentive spirometer.
o Hiccups (singultus) also may interfere with breathing.They result from intermittent
spasms of the diaphragm and may occur after surgery, especially abdominal surgery.
They may be mild and last for only a few minutes. Prolonged hiccups not only are
unpleasant but also may cause pain or discomfort. They may result in wound
dehiscence or evisceration, inability to eat, nausea and vomiting, exhaustion, and fluid,
electrolyte, and acid-base imbalances. If hiccups persist, the nurse needs to notify the
physician.
Circulation.
o The nurse must assess the clients BP and circulatory status frequently. Although
problems with postoperative bleeding decrease as the recovery time advances, the
client is still at risk for bleeding. Some clients experience syncope when moving to an
upright position. To prevent this (and the danger of falling), the nurse helps the client to
move slowly to an upright or standing position.
o The client also is at risk for impaired venous circulation related to immobility. When
clients lie still for long periods without moving their legs, blood may flow sluggishly
through the veins (venous stasis). Venous stasis predisposes the client to venous
inflammation and clot formation in the veins (thrombophlebitis), or clot formation with
minimal or absent inflammation (phlebothrombosis).
o These two conditions are most common in the lower extremities. If the clot travels in
the bloodstream (an embolus), it may obstruct circulation to a vital organ, such as the
lungs, and cause severe symptoms and possibly death.
o To prevent venous stasis and other circulatory complications, the nurse encourages
the client to move his or her legs frequently and do leg exercises. The nurse also does
not place pillows under the clients knees or calves unless ordered. He or she avoids
placing pressure on the clients lower extremities, applies elastic bandages or
antiembolism stockings as ordered, ambulates the client as ordered, and administers
low-dose subcutaneous heparin every 12 hours as ordered.
 Pain Management.
o Most clients experience pain after an operation, and a range of postoperative
analgesics usually are ordered. Postoperative pain reaches its peak between 12 and
36 hours after surgery and diminishes significantly after 48 hours.
o Pain creates varying degrees of anxiety and emotions. If accompanied by great fear,
the degree of pain can increase. Clients must receive pain and discomfort relief.
o When patient-controlled analgesia (PCA) is used, clients administer their own
analgesic.The nurse assesses for adverse effects of analgesics, timing of the
medication in relation to other activities, effects of other comfort measures,
contraindications, and source of thepain.
o The need for pain medications depends on the type and extent of the surgery, and the
client. Pain unrelieved by medication may signal a developing complication, which
underscores the need for a thorough assessment of the cause and type of pain.

173
173
 Fluids and Nutrition.
o IV fluids usually are administered after surgery. Length of administration depends on
the type of surgery and the clients ability to take oral fluids.
o The nurse monitors the IV fluid flow rate and adjusts it as needed. He or she also
assesses for signs of fluid excess or deficit and notifies the physician of any such
signs.
o Many clients complain of thirst in the early postoperative recovery period. Because
anesthesia slows peristalsis, ingesting liquids before bowel activity resumes can lead
tonausea and vomiting.
o Pain medications also may cause nausea and vomiting. Nursing Guidelines 14-1
includes factors to consider before resuming oral fluids.
o Once peristalsis has returned and the client is tolerating clear liquids, the nurse helps
the client to increase dietary intake.
o Dietary progression (from clear liquids to a full, solid diet) often depends on the type of
surgery, the clients progress, and physician preference. IV fluids usually are
discontinued when the client can take oral fluids and food, and nutritional needs are
met Skin
 Integrity/Wound Healing.
o A surgical incision is a wound or injury to skin integrity. Initially the client may have a
wound or incisional drain, which is a tube that exits from the peri-incisional area into
either a dressing or portable wound suction device.
o When assessing the wound, the nurse inspects for approximation of the wound edges,
intactness of staples or sutures, redness, warmth, swelling, tenderness, discoloration,
or drainage. He or she also notes any reactions to the tape or dressings.
 Bowel Elimination.
o Constipation may develop after the client begins to take solid food. Causes of this
constipation include inactivity, diet, and narcotic analgesics. Some clients may
experience diarrhoea as a result of diet, medications such as antibiotics, or the surgical
procedure.
o The nurse maintains a record of bowel movements and notifies the physician of either
problem. Abdominal distention results from the accumulation of gas (flatus) in the
intestines because of failure of the intestines to propel gas through the intestinal tract
by peristalsis. Contributing factors include manipulation of the intestines assessment
includes inspecting the abdomen for distention, palpating for rigidity, and auscultating
for bowel sounds.
o Ifbowel sounds are absent or abnormal or the abdomen is distended or rigid, the nurse
notifies the physician immediately.
o A nasogastric tube usually is inserted and food and fluids withheld until bowel sounds
return.
 Urinary Elimination.
o Some clients experience difficulty voiding after surgery, particularly lower abdominal
and pelvic surgery.
o Operative trauma in the region near the bladder may temporarily decrease the voiding
sensation. Fear of pain also causes tenseness and difficulty voiding.
o If the client has an indwelling catheter, the nurse monitors urine output frequently. If the
client does not have a catheter, the nurse assesses the clients ability to void and
measures urine output.

174
174
o If the client cannot void within 8 hours after surgery, the nurse notifies the physician
unless catheterization orders are in place. Signs and symptoms of bladder distention
include restlessness, lower abdominal pain, discomfort or distention, and fluid intake
without urinary output.
 Psychosocial Status.
o Many clients experience anxiety and fear after surgery, as well as an inability to cope
with changes in body image, lifestyle, and other factors.
o The nurse assesses what the client is experiencing and how the client is dealing with
those issues. Many clients need referrals for counseling, support groups, and social
services. The nurse acts as an effective listener, identifies areas of concern, and works
with other healthcare professionals to assist the client and family to work through the
problems.
STEP 6: Post- Operative Nursing Care to Prevent Post- Operative Complications

(25 Minutes)
Immediate Postoperative Period

 When clients are transferred from the OR to the PACU, the anesthesiologist or anesthetist is
responsible for the clients safety. Critical considerations include maintaining an intact surgical
site (incision), observing for potential vascular changes, and keeping the client warm. Position
of the client is also important so that the incision is not compromised, drains do not obstruct,
and the client does not experience orthostatic hypotension. The nurse receiving the client from
the OR needs the following information (Smeltzer et al., 2008):
Initial Postoperative Assessment

 Initial postoperative assessments include airway patency;effectiveness of respirations;
presence of artificial airways,mechanical ventilation, or supplemental oxygen; circulatory status;
vital signs; wound condition, including dressings and drains; fluid balance, including IV fluids,
output from catheters and drains, and ability to void; level of consciousness; and pain. The
nurses major responsibilities during the clients PACU stay are to ensure a patent airway; help
maintain adequate circulation; prevent or assist with the treatment of shock; maintain proper
position and function of drains, tubes, and IV infusions; and monitor for potential complications.
 An important assessment is determining how the clientis recovering from anesthesia. A useful
assessment tool is the Aldrete scale, which rates the clients mobility, respiratory status,
circulation, consciousness, and pulse oximetry rising BP may indicate respiratory obstruction. If
a client cannot breathe effectively, mechanical ventilation is used.
 Aspiration. Danger of aspiration from saliva, mucus, vomitus, or blood exists until the client is
fully awake and can swallow without difficulty. Suction equipment must be kept at the clients
bedside until the danger of aspiration no longer exists. The nurse closely observes the client for
difficulty swallowing or handling of oral secretions. Unless contraindicated, the nurse places the
client in a side-lying position until the client can swallow oral secretions.
Later Postoperative Period
 The later postoperative period begins when the client arrives in the hospital room or
postsurgical care unit. Because the nurse can anticipate, prevent, or minimize many
postoperative problems, he or she must approach the care of the client systematically.

175
175
 The recovery process is different for every individual and depends on the type of procedure,
but you can give your patients these four general guidelines to help ensure a successful
recovery:
Rest
 Many patients think they just need to rest the affected area after surgery. For example, they
assume that keeping a shoulder immobilized after rotator cuff repair is sufficient. However,
the body needs more energy than usual during surgery recovery, which is why it is important to
not only rest the injury but to rest the entire body.
 This includes getting enough quality sleep, which is not always easy when patients are in pain
or cannot get in a comfortable position. The body heals more quickly during sleep, so getting
more sleep after surgery may help patients speed up the recovery process. Helping patients
effectively manage pain and recommending suitable positions will help them get more rest
while they heal.
Hydration
 Another important factor in the healing process is hydration. Staying hydrated allows the body
to flush cellular waste, which accumulates more quickly as cells repair themselves. Drinking
enough water also allows blood to bring more oxygen and nutrients to the surgical site. Both
are important elements of the healing process.
 Encourage patients to drink more water than usual and recommend a low-sugar electrolyte
beverage to help maintain hydration.
Stress Reduction
 In addition to getting enough high-quality sleep, its important for patients to keep stress levels
low during the day. Studies have shown that stress can have a negative impact on the healing
process and increase the risk of infection.
 When possible, recommend that patients take time off work and get help from friends and
family to manage daily tasks. You might also recommend stress-relieving techniques like
breathing exercises or meditation to help patients stay calm during the recovery process. If the
procedure is planned in advance, talk to your patients about ways they can prepare their
homes for an easier recovery by moving furniture, setting up single-floor living, and preparing
meals they can reheat. The more prepared that patients are before having surgery, the less
stressful the recovery process may be.
Comprehensive Assessment
 It includes taking and documenting vital signs
 Perfuming quick head to toe assessment to ascertain deviation from normal
 Take special note to the incision site

 The postoperative Nursing care is the care given to the client which begins with the admission
of the patient to the post aesthesia care unit (PACU) and ends with a follow-up evaluation in
the clinical setting or at home.
 The responsibilities of a nurse in the immediate prevention of postoperative care includes;
encouraging early mobilization, ensuring adequate nutrition, preventing skin breakdown and
pressure sores and providing adequate pain control

176
176
 Assessment in recovery area includes respiratory function; general condition; vital signs;
cardiovascular function and fluid status; pain level; bowel and urinary elimination; and
dressings, tubes, drains, and IV lines

 What are the variables of wound healing?
 What are the general principles of post-operative care in the prevention of post-operative
complications?
References
Saunders Company

177
177

178
178
179
179
180
180
181
181
182
182
183
183
184
184
185
185
186
186
187
187
188
188
189
189
190
190
191
191
192
192
193
193
194
194
195
195
196
196
197
197
198
198
199
199
200
200
201
201
202
202
203
203
204
204
205
205
206
206
207
207
208
208
209
209
210
210
211
211
212
212
213
213
214
214
215
215
216
216
217
217
218
218
219
219
220
220
221
221
222
222
223
223
224
224
225
225
226
226
227
227
228
228
229
229

NMT05105 Basic Care of Patient With Surgical Condition New 1 1 1

Uploaded by

Copyright:

Available Formats

NMT05105 Basic Care of Patient With Surgical Condition New 1 1 1

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

NMT05105 Basic Care of Patient With Surgical Condition New 1 1 1

Uploaded by

Copyright:

Available Formats

THE UNITED REPUBLIC OF TANZANIA

MINISTRY OF HEALTH, COMMUNITY DEVELOPMENT, GENDER, ELDERLY AND

DIRECTORATE OF HUMAN RESOURCE DEVELOPMENT

FACILITATORS GUIDE FOR TECHNICIAN CERTIFICATES

NMT 05105: Basic Care of Patient with Surgical Conditions

NMT05105: Basic Care of Patient with Surgical Conditions ii

NMT05105: Basic Care of Patient with Surgical Conditions iii

NMT05105: Basic Care of Patient with Surgical Conditions iv

Dr. Otilia F. Gowelle

NMT05105: Basic Care of Patient with Surgical Conditions v

Ndementria Arthur Vermand

NMT 05105: Basic Care of Patient with Surgical Conditions

3.0. Goals and Objectives of the Training Manual

3.2. Objectives for Training Manual

NMT 05105: Basic Care of Patient with Surgical Conditions

The module sub-enabling outcome as follows:

4.2. Who is the Module For?

4.3. How is the Module Organized?

NMT 05105: Basic Care of Patient with Surgical Conditions

NMT 05105: Basic Care of Patient with Surgical Conditions

Total Session Time: 120 Minutes

Session Overview Box

5 20 Presentation; Buzzing Clinical Features of Tonsillitis

NMT 05105:Basic Care of a Patient with Surgical Conditions

STEP 2: Definition of Tonsillitis (05 Minutes)

WRITE their response on the flip chart/board

CLARIFY and SUMMARIZE by using the content below

STEP 3: Causes of Tonsillitis (15 Minutes)

STEP 4: Pathophysiology of Tonsillitis (10 Minutes)

STEP 5: Clinical Features of Tonsillits (20 Minutes)

NMT 05105:Basic Care of a Patient with Surgical Conditions

Figure 1.1: Normal and Inflamed Tonsils

STEP 6: Diagnostic Measures of Tonsillitis (15 Minutes)

NMT 05105:Basic Care of a Patient with Surgical Conditions

STEP 8: Nursing Care of a Patient with Tonsillitis (35 Minutes)

Activity: Small Group Discussion (20 Minutes)

ALLOW students to discuss for 20 minutes

CLARIFY and SUMMARIZE by using the contents below

Specific management includes:

NMT 05105:Basic Care of a Patient with Surgical Conditions

Post-Operative Care Following tonsillectomy

STEP 9: Key Points (05 Minutes)

STEP 10: Session Evaluation (05 Minutes)

NMT 05105:Basic Care of a Patient with Surgical Conditions

NMT 05105:Basic Care of a Patient with Surgical Conditions

NMT 05105:Basic Care of a Patient with Surgical Conditions

Total Session Time: 120 Minutes

Prerequisite: NMT04103 Human Anatomy and Physiology

Identify classifications of fracture

Identify causes of fracture

Explain clinical features of a patient with fracture

Explain stages of fracture healing

Outline general managements of fracture

Explain the nursing management of fracture

Outline the prevention of fracture

Session Overview Box

4 05 Lecture/discussion Causes of fracture

NMT 05105:Basic Care of a Patient with Surgical Conditions

6 10 Lecture /discussion Stages of fracture healing

7 15 Buzzing, Lecture/ discussion General managements of fracture

FACILITATORS GUIDE FOR TECHNICIAN CERTIFICATES