Introduction

Blood pressure measurements are obtained for a wide variety of reasons, including screening for hypertension, assessing a person’s suitability for a sport or certain occupations, estimating cardiovascular risk and determining risk for various medical procedures

Indications

• Screening for hypertension
• Assessing a person’s suitability for a sport or certain occupations
• Estimation of cardiovascular risk
• Determining for the risk of various medical procedures

Equipment

• Stethoscope
• Blood pressure cuff with a sphygmomanometer
• (OR) An automated ascillometric cuff

Procedure

• Initially before taking the blood pressure, the patient should remain seated and at a rest for 5 minutes
• Consumption of caffeinated products such as coffee, cola, or tea should be avoided for at least 30 minutes prior to measuring the blood pressure. Additionally, activities such as smoking and exercise 30 minutes prior to measuring the blood pressure should also be avoided.
• Choose a standardized mercury or aneroid sphygmomanometer with an adequate cuff size based on patients arm size
• Place the chosen cuff on either the right or left arm of the participant
• While obtaining the blood pressure, neither the patient nor the person obtaining the blood pressure should talk.
• The stethoscope should be placed tightly over the brachial artery. If the stethoscope is pressed too firmly against the artery, it may cause turbulence and the disappearance of sound, thus artificially reducing the diastolic pressure.
• Inflate the cuff to a pressure of 30mmhg above the level at which the radial pulse is no longer palpable
• While slowly deflating the cuff (approximately 2-3 mmhg per heartbeat), listen for korotkoff phase 1 while watching the blood pressure gauze.

Korotkoff phase 1 can be identified by when the first pulse is auscultated. This sound is clear, repetitive, and tapping in nature and often coincides with the reappearance of a palpable pulse.

Record the measurement from the sphygmomanometer at which the sound first appear, this represents the patient’s systolic blood pressure.

• While watching the sphygmomanometer, continue to slowly deflate the cuff. Initially, an abrupt soft, indistinct, muffling sound may be heard (korotkoff phase IV). After this sound, continue listening until the sounds disappear completely (korotkoff V). Record the measurement from the sphygmomanometer when the korotkoff V starts; this represents the patient’s diastolic pressure. If there is a 10mmhg or greater difference between korotkoff phase IV and phase V then the pressure reading at phase IV should be recorded as diastolic blood pressure. This may occur in cases of high cardiac output or peripheral vasodilation, children under 13 years old, or pregnant women.

After the last korotkoff sound is heard, continue deflating the cuff for another 10mmhg to ensure that no further sounds are heard. Then deflate the cuff and allow the patient to rest.

• Wait at least 30 seconds and repeat the previous 3 steps to obtain a second blood pressure measurement. If the measurements have greater than a 5 mmhg difference, then readings should continue until 2 consecutive stable measurements are obtained. An average of the 2 stable measurements should be recorded as the patient’s blood pressure.
• Wait another 1-2 minutes and repeat the steps 4-10 to measure the blood pressure in the patient’s opposite arm. If a measurement discrepancy exists between the 2 arms, then the arm with the highest measurement should be used.
• When recording the blood pressure measurement, note not only the pressure but also which arm was used, the arm position, and the cuff size used.
• Alternatively, the blood pressure may be obtained using the thigh or the wrist. A thigh blood pressure is typically obtained when an arm to leg gradient is suspected such as with aortic coarctation or if there is a contraindication to upper extremity measurements.

The wrist blood pressure is typically obtained in obese patients, where it may be difficult to find an appropriately sized cuff for the arm or thigh. The same measurement techniques are used for the leg and wrist as discussed above for the arm. Of note, values obtained from thigh or wrist measurements may be higher than arm pressures due to increased hydrostatic pressure related to the lower position of the thigh and wrist to the heart.

• The accuracy of the wrist measurements can be improved by keeping the wrist at the level of the heart.

Contraindications

• Avoid obtaining blood pressure in the same arm in which arteriovenous fistula (such as used in hemodialysis) is present or where lymphedema exists
• Exercising before measuring the blood pressure can lower the reading
• Caffeine or other exogenous adrenergic stimulants taken before the measurement can acutely raise the blood pressure reading.
• One should delay obtaining a blood pressure if the patient has smoked, exercised, or had caffeinated products or other stimulants prior to the measurement. Smoking 30 minutes before the procedure can transiently elevate the blood pressure.

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Introduction

Blood transfusion is generally the process of receiving blood products into one’s circulation intravenously.
Transfusions are used for various medical conditions to replace lost components of the blood.

Early transfusions used whole blood, but modern medical practice commonly uses only components of blood such as red blood cells, plasma, clotting factors, and platelets

One unit of packed RBCs should increase levels of hemoglobin by 1g per dl (10g per litre) and hematocrit by 3 percent.

Indications

Red Blood Cells

• Patient’s hemoglobin level falls below 10g/dl or hematocrit falls below 30% (the 10/30 rule)
• Acute or massive hemorrhage
• Symptomatic anemia
• Acute sickle cell crisis

Fresh frozen plasma infusion

• Reversal of anticoagulant effects
• International Normalized Ratio (INR) greater than 16
• Before an invasive procedure or surgery if a patient has been ant coagulated
• Emergent reversal of warfarin (Coumadin)
• Acute disseminated intravascular coagulopathy
• Micro vascular bleeding during massive transfusion

Platelet transfusion

• Major surgery or invasive procedure, no active bleeding
• Ocular surgery or neurosurgery, no active bleeding
• Surgery with active bleeding
• Thrombocytopenia
• Platelet function defects

Cryoprecipitate

• Hemorrhage after cardiac surgery
• Massive hemorrhage or transfusion
• Surgical bleeding
• Anticoagulant factor VIII deficiency
• Anticoagulant factor XIII deficiency
• Congenital dysfibrinogenemiavon
• Willebrant disease
• Congenital fibrinogen deficiency

Equipment

• Transfusion record chart
• Non sterile gloves
• Thermometer
• Tourniquet
• An IV cannular
• 2x2xgauze
• A syringe
• Normal saline
• Transparent dressing
• Sphygmomanometer
• Blood transfusion set
• Observation recording sheet (The record of transfusion form)
• Blood/blood component pack
• Disposable apron

Procedure

1. Gather the equipment stated above
2. Check the blood /blood component has been correctly prescribed (on the fluid chart)
3. Record baseline observations of temperature, pulse and blood pressure and respiratory rate on the record of transfusion form
4. Check the blood/blood component has not passed its expiry date and will not expire during the transfusion episode
5. Put on apron, wash hands and put on gloves
6. Attach the administration set to the venous access device (IV Cannula)
7. Set the rate and volume to be infused as stated on the fluid chart
8. For each unit transfused check the patients record temperature, pulse, blood pressure and respiratory rate every 15 minutes for the hour and hourly thereafter.

Complications

• Acute hemolytic reactions
• Delayed hemolytic reactions
• Febrile non hemolytic reactions
• Post transfusion purpura
• Allergic reactions
• Transfusion- associated acute lung injury (TRIALI)
• Infection
• Volume overload
• Hypothermia
• Metabolic alkalosis
• Hypocalcemia

Contraindications

• Severe injuries and concussion
• Hemorrhage and thrombosis of the brain
• Peripheral vascular thrombosis and acute thrombophlebitis
• Severe coronary sclerosis
• Circulatory failure

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Checking Vital Signs – Temperature, Pulse, Respiration, Blood Pressure (Using Mercural Thermometer And Mecurial Sphygmomanomerter)

1. Explain the procedure to the patient and provides privacy
2. Prepare and send tray to patient’s bedside
3. Make patient comfortable by lying or sitting up in bed
4. Rinse thermometer in cold water
5. Dry thermometer with cotton wool from bulb towards the stem
6. Shake thermometer until mercury falls below 35 degrees Celsius
7. Dry axilla with clean cotton wool and discard
8. Insert thermometer in the axilla between two folds of skin and leaves in position for 2-3 minutes
9. Whiles thermometer in the axilla, checks and records pulse and respiration
10. Remove thermometer and wipe from stem towards bulb
11. Read at eye level and record temperature, replace thermometer in a container
12. Stretch patient’s arm and places sphygmomanometer beside arm at the same level
13. Wound cuff around arm above elbow
14. Inflates cuff and palpates radial artery and notes level of mercury at which pulse disappears
15. Wear and place stethoscope on brachial artery
16. Release pressure slowly and listen to sound with stethoscope
17. Remove cuff and reassemble apparatus
18. Thank and make patient comfortable in bed
19. Wash and dry hands
20. Record blood pressure reading on vital signs chart and nurses note.

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For more information please visit the respective departments for further guidance on specific services.

FEEDBACK CHANNELS INCASE OF A COMPLAINT/COMPLIMENT

• Inform the Hospital Administrator or fill a customer feedback forms at the reception.
• Contact the hospital through the following channels: email: or Mobile:
• Drop written compliment/complaint in the suggestion boxes provided.

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Introduction

Indications

• To diagnose rectal tumors
• To obtain feces for a fecal occult blood test

• To prepare you for a colonoscopy
• To assess the function of the anal sphincter in cases of fecal incontinence
• To assess the extent of hemorrhoids
• Inflammatory bowel disease, including ulcerative colitisandcrohn disease
• To check pelvic organs, especially in women
• Anal fissures

Equipments

• Surgical gloves
• Lubricants e.g. lidocain gel
• Light source

Procedure

• Explain procedure to patient and tell patient to relax during examination
• Ask patient to lye on left side with his/her right knee flexed and touches chest
• Put on gloves and lubricate your index finger
• Ask patient to take deep breath and try to relax
• Insert your index finger into rectum
• Check for any mass, fissure, blood and also tone of the rectal mucosa
• Try to rotate finger clock or anticlock wise around rectum so to examine all sides of rectum
• Note if there is any abnormality

Contraindications

1. Explain the procedure to patient and provide privacy
2. Puts on mask, prepare and take trolley to bedside
3. Ask assistant to;

• Put patient into desired position
• Protect bed clothes and expose area
• Pour out lotion into gallipots
• And remove plaster or bandage

4. Wash and dry hands and wear sterile gloves or use sterile forceps
5. Remove soiled dressing using dissecting forceps or disposable gloves and discard
6. Clean wounds with swab soaked in normal saline using sterile forceps or sterile gloves starting from the wound outward using one swab at a time
7. Clean wound with series of swabs until clean
8. Apply sufficient sterile dressing and secure into position
9. Inform patient about the state of the wound, thank him and make him comfortable in bed
10. Discard trolley, decontaminate used items and removes gloves
11. Wash and dry hands and remove screen
12. Document and report the state of the wound

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1. Don’t eat or drink 30 minutes before the test
2. Empty your bladder (go for a short call)
3. Sit in a comfortable chair with the back supported for at least 5 minutes before the test
4. Put both feet flat on the ground uncrossed
5. Rest your arm with the cuff on a table at chest height.
6. Place the cuff on bare skin firm but not tight. (Ensure the first 2 fingers fit under it)
7. Do not talk while your blood pressure is being measured

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PURPOSE OF INDUCTION:

• Stimulating the uterus to bring on the onset of labor pain.
• As far as possible, start induction early in the morning

COMMONLY USED DRUGS FOR INDUCTION

• Oxytocin
• Misoprostol

Instruction for using Oxytocin on: Multi gravid (G4 or >):

• Use 2.5 IU of oxytocin in 500 ml in NS.
• Start with 10 drops /min.
• Increase by 10 drops/min ½ hourly until it reaches 60drops/min.
• If the target of uterine contraction is not achieved, use second bottle with same regimen.
• Check heart, contractions ½ hourly and pulse and BP and temperature 2 hourly.
• Ask patient to pass urine 2 hourly.

Primi Gravida:

 Primigravidas with favorable cervix (Bishop score > 6) should be induced

 with Oxytocin

• Use 5 IU of oxytocin with 500 ml of NS
• Start with 10 drops /min.
• Increase by 10 drops/min. ½ hourly until it reaches 60 drops/min.
• If the target of uterine contraction is not achieved use second bottle with

same regimen.

• Check heart and contraction ½ hourly and BP, pulse and temperature 2

hourly.

• Ask patient to pass urine 2 hourly.
• If the result is not achieved, repeat induction for 3 consecutive days.

Note: If the uterine contraction is lasting >60 sec. or there are >4 contraction in 10

minutes, stop oxytocin infusion immediately. Turn patient to left lateral position,

give oxygen 4-5 l/min and inform doctor on call

Instruction for using Misoprostol

 Misoprostol is a Prostaglandin E analogue and used mainly for priming of

 unfavourable cervix (Bishop score less than 6)

• Admit patient and explain procedures to patient and party.
• Caesarean section facilities are available.
• Medications to deal with hyperstimulation are available like nifidepine &

salbutamol.

• AFI status must be checked.
• CTG must be done for 20 minutes before insertion of Misoprostol.
• Repeat CTG after 2 hours of Misoprostol insertion (this is to rule out hyperstimulation of uterus).
• Inform doctor on call if there is abnormal CTG

Doses

Primigravida

• Insert 50 mcg in the posterior fornix of the vagina.
• Make patient lie down for 2 hours.
• Do CTG after 2 hours for 20 minutes.
• Repeat if no progress for three consecutive doses.
• The total dose per patient should not be more than 200 mcg.

Multigravida

• Insert 25 mcg in the posterior fornix of the vagina.
• Make her lie down for 2 hours and do CTG for 20 minutes.
• Repeat if no progress for three consecutive doses at an interval not < 6 hours.
• The total dose per patient should not be more than 200 mcg.

Note: Do not use oxytocin either for induction or augmentation within 6 hours of misoprostol insertion!

 Contraindications of Misoprostol

• Sensitivity to Misoprostol
• Scarred uterus including past caesarean section, myomectomy and hysterotomyGravida more than 3
• History of bleeding (APH)
• Membrane rupture (SROM)
• Favorable cervix (Bishop score > 6 )
• Multiple pregnancy
• Mal-presentation of foetus

Note: Do not use misoprostol for augmentation of labor

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Introduction

An intradermal (ID) injection is the injection of a small amount of fluid into the dermal layer of the skin. It is frequently done as a diagnostic measure, such as for tuberculin testing (screening test for tuberculosis referred to as a tine test) and allergy testing (placing very small amounts of the suspected antigen or allergen in a solution under the skin). The intradermal injection is made in skin areas of the body that are soft and yielding

Indications

Administration of medications

Equipment’s

• One alcohol wipe
• One sterile 2×2 gauze pad
• A new needle and syringe that ate the correct size
• Disposable gloves

Procedure

• Select injection site and prepare patient
• Selecting site usually palmer (inner) forearm or subscapular region of the back is selected. The site selected should be an easily obtainable area and relatively free from being rubbed by clothing
• Position patient place arm in a relaxed position, elbow flexed
• Place palm up, exposing palmer or inner arm area
• Use only acetone or alcohol to clean injection site and allow the area to dry before injection is administered
• Remove needle guard; Pull the guard straight off
• Stabilize injection site using your non dominant thumb, apply downward pressure, directly below and outside the prepared injection site.(Do not draw the skin back or move the skin to the side because the skin will return to its normal position when pressure is released and will cause the needle bevel to either go deeper into the skin or to leave the skin, depending upon which direction the skin moves)
• Hold the skin taut until the needle bevel has been inserted between the skin layers
• Insert needle using your dominant hand, hold syringe, bevel up, with fingers and thumb resting on the sides of the barrel. If you insert the needle at a 20 degree angle, lower it at once to 15 degrees Do not place thumb or fingers under syringe because this will cause the angel of insertion to exceed 15 degrees causing the needle to insert beyond the dermis
• Insert needle, bevel up, just under the skin at an angle of 15 to 20 degrees until the bevel is covered. Continue stabilizing thumb pressure. You should feel some resistance. If the needle tip moves freely, you have inserted the too deeply. At this point, withdraw needle slightly and check again for resistance

Inject medication; It is not necessary to aspirate the syringe since no large vessels are commonly found in the superficial layer of the skin. Inject the medication as follows;

• Continue holding the syringe with same hand
• Release the skin tension with other hand
• With free hand, push plunger slowly forward until the medication is injected and a wheal appears at the site of the injection. The appearance of a wheal indicates that the medication has entered the area between the intradermal tissues
• If a wheal does not appear, withdraw the needle, and repeat the procedure in another site.
• Withdraw needle; to withdraw the needle, quickly withdraw it at the same angle that it was inserted
• Cover injection site; Without applying pressure, quickly cover injection site with a dry sterile small gauze

• Perform post injection patient care
• Evaluate reaction of medication usually you, as the medical specialist, will not evaluate the reaction of a suspected allergic reaction or a tuberculin test, but will record the reaction. For a tuberculin test, the patient will wait for 48-72 hours and then return to have an evaluation to determine if the patient has been exposed to tuberculosis If the intradermal injection is done to determine if the patient is allergic to dust, pollen, or similar substances, a reaction will take place in a few minutes after the substance has been placed under the skin
• Instruct the patient to wait or return to have the test read according to local SOP
• Caution patient not to rub, scratch, or wash injection site. Rubbing, scratching, or washing may spread or dilute the medication, causing a false reading at a later time
• Dispose of Equipment. Dispose of equipment according to local SOP
• Record administration of intradermal injection. Record the injection information on the patient’s chart or record

Complications

• Infection
• Bleeding
• Numbness
• Pain
• Thrombophlebitis
• Injury to blood vessels and peripheral nerves
• Abscess
• Hematoma

Allergic reaction

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Introduction

An intramuscular (IM) injection is the preferred route of administering medication when fairly rapid acting and long acting and long-lasting dosage of medication is required. Some medications that are irritating to the subcutaneous tissue may be given into the deep muscle tissue.

Injection of medication into muscle tissue forms a deposit of medication that is absorbed gradually into the blood stream. An Intramuscular injection is the safest, easiest, and best tolerated of the injection routes.

Indications

• One alcohol wipe
• One sterile 2×2 gauze pad
• Anew needle and syringe that are the correct size
• Disposable gloves

Procedure

• Open the alcohol wipe; Wipe the area where you plan to give the injection. Let the area dry. Do not touch this area until you give the injection
• Prepare the needle hold the syringe with your writing hand and pull the cover off with your other hand. Place the syringe between your thumb and first finger. Let the barrel of the syringe rest on your second finger
• Hold the skin around where you will give the injection. With your free hand , gently press on and pull the skin so that it is slightly tight.
• Insert the needle into the muscle; Hold the syringe barrel tightly and use your wrist to inject the needle through the skin and into the muscle at a 90 degrees angle
• Check the needle; Let go of the skin with your other hand. Hold the syringe so that it stays pointed straight in. Pull back on the plunger a little to make sure you did not hit a blood vessel. If blood comes back, remove the needle immediately.

Do not inject the medicine. Dispose of both the syringe and the medicine. Get more medicine in a new syringe. When you give the second injection, give it on the other side.

• Inject the medicine; Push down on the plunger to inject the medicine by pushing hard. Some medicines hurt.

You can inject the medicine slowly to reduce the pain

• Remove the needle; Once the medicine is injected, remove the needle t the same angle as it went in. Place gauze over the area where you gave the injection

Complications

• Infection
• Bleeding
• Numbness
• Pain
• Thrombophlebitis
• Injury to blood vessels and peripheral nerves
• Abscess
• Hematoma
• Allergic reaction

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Introductions

Indications

Diagnostic

• Meningitis (bacterial, fungal, tuberculosis, viral, carcinomatosis, lymphomatosis or aseptic)
• Early subarachnoid hemorrhage
• Pseudotumor cerebri
• Multiple sclerosis
• Guillain –Barre syndrome
• Possible lupus cerebritis, cns Vasculitis,

Therapeutic

• Spinal anesthesia
• Treatment of pseudotumor cerebri
• Intrathecal administration of chemotherapy
• Intrathecal administration of antibiotics
• Injection of contrast media for myelography or cisternography

Equipments

• Sterile gloves & gown
• 1% lidocaine solution
• 22G or 25G needle
• 5ml disposable syringe
• Povidine- iodine prep
• Sterile drape
• Spinal needle with stylet

• Manometer with 3 way stopcock
• 4 labeled sterile specimen containers
• Sterile bandage

Procedure

1. First the patient is usually placed in a left (or right) lateral position with their back bent in full flexion up to their chest or sitting up position
2. Draw an imaginary line between the top of the iliac crests. This intersects the spine at approximately the L3-4 intersect (Mark this if necessary)
3. Wash hands and aseptically put on sterile gloves
4. Prepare the skin with povidone- iodine or chlorhexidine and set up sterile drapes
5. Allow adequate time for the skin preparation to dry
6. Take the tops off the tubes, ensuring that they remain sterile
7. Infiltrate the skin with 1% lignocaine using a 22G needle
8. Withdraw stylet and check for fluid return
9. Attach end of stopcock with manometer to read the opening pressure (opening pressure can only be checked in lateral decubitus position)
10. Collect 1-2 ml of CSF in each of the four labeled sterile tubes
11. Replace the stylet and withdraw the spinal needle.
12. Clean off povidone – iodine prop solution
13. Apply a sterile band air over the puncture site

Complications

• Post LP headache
• Infection
• Bleeding
• Cerebral herniation
• Minor neurologic symptoms such as radicular pain or numbness
• Late onset of epidermoid tumors of the sac
• Back pain

Contraindications

• Possible raised intracranial pressure
• Thrombocytopenia or other bleeding diathesis(including ongoing anticoagulant therapy)
• Suspected spinal epidural abscess
• Brain abscess

STEPS

Step One:Prepare the Aspirator

• Position the plunger all the way inside the cylinder.
• Have collar stop in place with tabs in the cylinder holes.
• Push valve buttons down and forward until they lock
• Pull plunger back until arms snap outward and catch on cylinder base

Step Two: Prepare the Patient

• Administer pain medication to have maximum effect when procedure begins.
• Give prophylactic antibiotics to all women, and therapeutic antibiotics if indicated.
• Ask the woman to empty her bladder.
• Conduct a bimanual exam to confirm uterine size and position.
• Insert speculum and observe for signs of infection, bleeding or incomplete abortion

Step Three: Perform Cervical Antiseptic Prep

• Use antiseptic-soaked sponge to clean cervical os.

 Start at os and spiral outward without retracing areas.

Continue until os has been completely covered by antiseptic.

Step Four: Perform Paracervical Block

• Paracervical block is recommended when mechanical dilatation is required with MVA.
• Administer paracervical block and place tenaculum.
• Use lowest anesthetic dose possible to avoid toxicity – for example, if using lidocaine, the recommended dose is less than 200 mg.

Step Five: Dilate Cervix

• Observe no-touch technique when dilating the cervix and during aspiration.

Instruments that enter the uterine cavity should not touch your gloved hands, the patient’s skin, the woman’s vaginal walls, or unsterile parts of the instrument tray before entering the cervix.

• Use mechanical dilators or progressively larger cannulae to gently dilate the cervix to the right size

Step Six: Insert Cannula

• While applying traction to tenaculum, insert cannula through the cervix, just past the os and into the uterine cavity until it touches the fundus, and then withdraw it slightly.
• Do not insert the cannula forcefully

Step Seven: Suction Uterine Contents

• Attach the prepared aspirator to the cannula if the cannula and aspirator were not previously attached.
• Release the vacuum by pressing the buttons.
• Evacuate the contents of the uterus by gently and slowly rotating the cannula 180° in each direction, using an in-and-out motion.
• When the procedure is finished, depress the buttons and disconnect the cannula from the aspirator. Alternatively, withdraw the cannula and aspirator without depressing the buttons.

Signs that indicate the uterus is empty:

• Red or pink foam without tissue is seen passing through the cannula.
• A gritty sensation is felt as the cannula passes over the surface of the evacuated uterus.
• The uterus contracts around or grips the cannula.
• The patient complains of cramping or pain, indicating that the uterus is contracting

Step Eight: Inspect Tissue

• Empty the contents of the aspirator into a container.
• Strain material, float in water or vinegar and view with a light from beneath.
• Inspect tissue for products of conception, complete evacuation and molar pregnancy.
• If inspection is inconclusive, reaspiration or other evaluation may be necessary

Step Nine: Perform Any Concurrent Procedures

• When procedure is complete, proceed with contraception or other procedures, such as IUD insertion or cervical tear repair.

Step Ten: Process Instruments

• Immediately process or discard all instruments, according to local protocols

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Introduction

Nebulization is the process of medication administration via inhalation. It utilizes a nebulizer which transports medications to the lungs by means of mist inhalation.

Indications

• Tightness in chest
• Excessive and thick mucus secretions
• Pneumonia (congestion)
• Atelectasis
• Bronchospasms
• Respiratory congestions
• Asthma

Equipments

• Nebulizer
• Compressor oxygen tank (to driver nebulizer)
• Oxygen tubing
• Respiratory medication
• Normal saline(cc vials)
• Mouth piece/mask

Procedure

• Remove cup portion of the nebulizer
• Draw up prescribed amount of the mediation into the eye dropper
• Place medication in the medicine cup with 3cc normal saline
• Return cup to the nebulizer
• Place oxygen tubing on the nipple on the nebulizer and attach other end to the compressor or oxygen tank.
• Turn on the compressor or tank until mist is seen coming out of the mouthpiece
• Check pulse
• Place the mouthpiece in your mouth and take slow, deep breaths. If on ventilator, the nebulizer can be placed in line in the ventilator circuit. To do this, remove the mouthpiece and connect the nebulizer between the dead space tubing and the exhalation valve assembly.
• During the treatment, monitor the pulse. If the pulse increases more than 20 beats a minute, discontinue the treatment. Otherwise continue until the medication is used up.
• Following the treatment, use postural drainage, percussion, assisted coughing and / or suctioning, as appropriate

Complications

• Palpitation
• Tremors
• Tachycardia
• Headache
• Nausea
• Bronchospasms (too much ventilation may result or exacerbate bronchospasms)

Contraindications

• • Patients with unstable and increased blood pressure
  • Individuals with cardiac irritability (may result into dysrhythmias)
  • Persons with increased pulses
  • Unconscious patients (inhalation may be done via mask but the therapeutic effect may be significantly low)

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Newborn resuscitation is a set of emergency interventions and procedures performed to support and restore breathing and circulation in a newborn who is not breathing or is experiencing difficulty breathing after birth. Effective newborn resuscitation is crucial for preventing long-term complications and ensuring the baby’s survival.

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An obstetric history involves asking questions relevant to a patient’s current and previous pregnancies. Some of the questions are highly personal; therefore good communication skills and a respectful manner are absolutely essential.

AN OBSTETRIC HISTORY SHOULD INCLUDE:

1. Current Pregnancy History
2. Past obstetric history
3. Past gynecological history
4. Past medical and surgical history
5. Drug history and allergies
6. Family history-especially multiple pregnancy, diabetes, hypertension, chromosome or congenital malformations
7. Social history
8. History of systemic review
9. Case summery

Current Obstetric history

• Gravidity
• Parity
• History of LAPs, draining, bleeding and perception of fetal movement
• LMP
• EDD
• The booking status e.g bp
• Number of ANC visits
• ANC Profile
• If received preventative drugs e.g IPT,IFAS, T.T,LLTN

Past obstetric History

• Details of all previous pregnancies (including miscarriages and terminations)
• Length of gestation
• Date and place of delivery
• Onset of labour (including details of induction of labour)
• Mode of delivery
• Sex and birth weight
• Fetal and neonatal life
• Clear details of any complications or adverse outcomes(such as shoulder dystocia, Postpartum haemorrhage or still birth)
• History often repeats itself, so previous antenatal, intrapartum, or postpartum complications should influence the management of this pregnancy

Gynecological History

• Started menarche at which age?
• Regularity of menses, duration?
• Method of FP before pregnancy?
• History of cervical cancer screening?
• Coital problems

Chief complain?

• What brought the client to the facility

Past Medical History

• History of previous admission
• Current medications?
• Any allergies and their severities e.g rash or anaphylaxis?

Surgical History

• History of surgical operation
• History of blood transfusion

Family History

• History of hereditary illness or congenital defects
• Previous affected pregnancies
• Multiple gestations

History of Systemic review

• CNC
• CVS
• Respiratory
• GIT
• GENITALIA
• URINARY SYSTEM
• LOCOMORTY

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Things to consider in before Oxygen  administration

• The amount of oxygen required (liters/minute).
• A sliding scale of parameters indicating when to seek advice and who to contact.   The mode of delivery and system required. 
• Equipment to be used.

The following equipment are required for oxygen therapy

• Oxygen concentrator.
• Prescription
• Back-up oxygen cylinder(s).
• Flow meter.
• Face or tracheostomy mask.
• Nasal cannula.
• Disposable oxygen tubing.
• Humidification equipment.
• Sterile water.
• Saturation monitor and probes or apnea monitor if recommended.
• Duoderm/mefix or alternative dressing for fixation of nasal cannula.

 Safety Guidance: staff and carers should adhere to the following:

• Wash hands before use.
• Close the cylinder valve after use.
• Do not use oxygen near a naked flame or fire. 
• DO NOT SMOKE near oxygen.
• Ensure rooms in which oxygen is used, are well ventilated.
• Do not use aerosols near oxygen.
• Use electrical equipment with care near oxygen.
• Do not allow children to play with equipment.
• Do not allow untrained staff or carers to use equipment.
• Keep cylinders free of dust and dirt.
• Do not hang clothing or other items on oxygen equipment.
• Do not use oil or grease on valves or connectors.
• Do not use Liquid paraffin based products on patient due to fire risk.
• Store cylinders preferably inside, upright and away from heat or cold and flammable liquids. Cylinders expire three years from filling date.
• Where practical, store oxygen cylinders near an exit, to facilitate rapid removal in emergency situations. If possible indicate where oxygen is stored.

Always consider whether a cylinder needs to be transported at all. Oxygen administration outside the home, via a portable cylinder may be required to promote mobility and social inclusion. 

• No more than two cylinders should be carried at a time.
• Cylinders must be checked for leaks before the journey commences. 
• Cylinders should be secured. Free movement may result in damage to the cylinder or present a hazard to the occupants of the vehicle. 
• Cylinders should be stored out of direct sunlight.
• DO NOT SMOKE in a car carrying oxygen cylinders.
• Vehicle windows should be partially open to provide ventilation

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A pain assessment tool is an indispensable instrument for physicians to evaluate and quantify a patient’s pain level effectively. It typically involves a structured questionnaire or scale, such as the Numeric Rating Scale (NRS) or Visual Analog Scale (VAS), which allows physicians to assess the intensity, location, and quality of pain reported by the patient. This tool assists in tailoring appropriate pain management strategies, tracking treatment efficacy, and ensuring patient comfort. By using a pain assessment tool, physicians can provide more precise care, enhance patient communication, and contribute to overall improved healthcare outcomes.

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PPH stands for Postpartum Hemorrhage, which is a significant and potentially life-threatening complication that can occur after childbirth. PPH protocol refers to a set of guidelines and procedures followed by healthcare professionals to prevent, identify, and manage postpartum hemorrhage effectively. The protocol aims to ensure a prompt and coordinated response to minimize the risk of complications and protect the health of the mother.

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1. Establish rapport and explain procedure to the patient
2. Wear mask, prepare and take trolley to bed side and provide privacy
3. Ask assistant to;

• Put patient into a comfortable position, protect bed cloth and expose area to be dressed only
• Pour out lotions into gallipot and remove plaster or bandages

4. Wash and dry hands
5. Remove soiled dressing with dissecting forceps and discard
6. Clean wound with series of swabs soaked in antiseptic lotion, place sterile swab near the wound
7. Takes dissecting forceps and stitch removes scissors, grasp end of the stitch with the dissecting forceps and pull gently to expose an area between the knot and the skin
8. Cut stitch between the knot and the knot and the skin, pulls out suture gently and slowly
9. Inspect carefully to make sure suture are removed and discarded on a piece of gauze, noting number of sutures removed
10. Clean wound, apply dressing and secure into position
11. Thank and make patient comfortable in bed
12. Discard trolley and decontaminate instruments
13. Remove gloves, wash and dry hands and remove screen
14. Document and report state of wound

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Shoulder dystocia is a childbirth complication that occurs when the baby’s head passes through the birth canal, but one or both of the baby’s shoulders become stuck behind the mother’s pelvic bone. This can lead to a delay in the delivery of the baby’s shoulders after the head has already emerged. Shoulder dystocia is considered an obstetric emergency because it poses risks to both the baby and the mother.

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1. Prepare and check equipment
2. Dry and stimulate the baby, change the towel
3. Assess the ABC, “shout for help”. Show the mother the sex, after clamping and cutting the cord, explain what you are going to do to the baby
4. Airway – Position the baby in ‘sniffing’ position

• Suction visible secretions

1. Breathing  -Look –chest movements

• Listen to breath sounds
• Feel for warm air current coming from the nose
• If no breathing, give a rescue breath, ventilate 40-60 breaths/minute, stop and assess
• Use a three word syllable in counting the breaths
• Verbalize the counts
• If no breathing after the rescue breath, move to circulation.
• If Heart rate is <60b/minute, give chest compression and ventilation breaths at 3:1
• If >60b/minute continue with bagging(Ventilation alone until baby achieves spontaneous breathing)
• If difficulty in breathing administer oxygen

1. Give Health Messages to the mother on;

              – Breast feeding

              – Keeping the baby warm

              – Signs of baby not breathing well and any other danger sign

               – Hygiene practices

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Introduction

A subcutaneous injection is an injection administered into the fatty area just under the skin. Because they gave a slower, more gradual release than intravenous injections, subcutaneous injections are frequently used as a way to administer both vaccines and medications (for instance. Type I diabetics often use this type of injection to administer insulin)

Indications

Administration of medications

Equipments

• One alcohol wipe
• One sterile 2×2 gauze pad
• A new needle and syringe that are the correct size
• Disposable gloves

Procedure

• Subcutaneous injections can be given straight in at a 90 degree angle or at a 45 degree angle, give the injection at a 90 degree angle if you can grasp 2 inches of skin between your thumb and first finger. If you can grasp only 1 inch of skin, give the injection at 45 degree angle.
• Open the alcohol wipe; Wipe the area where you plan to give the injection. Let the area dry. Do not touch this area until you give the injection
• Prepare the needle. Hold the syringe with your writing hand and pull the cover off with your other hand. Place the syringe between your thumb and first finger. Let the barrel of the syringe rest on your second finger.
• Grasp the skin; With your other hand, grasp the skin
• Insert the needle into the skin; Hold the syringe barrel tightly and use your wrist to inject the needle into the skin. Once the needle is all the way in, push the plunger down to inject the medicine
• Pull out the needle; Remove the needle at the same angle you put in. Gently wipe the area with the pad.

Complications

• • Infections
  • Bleeding
  • Numbness
  • Pain
  • Thrombophlebitis
  • Injury to the blood vessels and peripheral nerves
  • Abscess
  • Hematoma
  • Allergic reactions

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All the patients should be triaged according to the triage protocol which will decide the level of care by the nurse. Triage category IV and V will be directed to the ACO chamber and rest should be directed to the treatment room for the further assessment by the doctor on duty.

Resuscitation room care:

• Patients should be managed accordingly as per the resuscitation protocol.
• Isolation Room Care: Patients with the suspected communicable illness should be observed in this room until further disposition.

Observation Room Care:

• The nurse should perform the initial assessment. This should be further assessed by the doctor.
• Doctor and nurses should follow ethical code of conduct and universal precautions.
• Assessment, evaluation and monitoring of the patient should be done as per the ED protocol.
• All the investigations (Laboratory, Radiology, etc.) should be done as soon as possible and reports to be collected at the earliest.
• Concerned specialist should be informed as soon as possible. Meanwhile detail information should be obtained from the family/party.
• Effective treatments should be started as soon as possible.
• Drugs and equipments should be checked and monitored on every shift of duty.
• Hygiene and sanitation should be maintained at all time. Infection control and waste management protocol should be strictly followed.
• All important information regarding patients should be written on the information board and updated on time.
• Documentation and record should be maintained properly and strictly.

 MONITORING

• Monitoring of the patients should be done strictly as per protocol.

DISPOSITION

• Disposition of the ED patients should be done within 24 hours as far as possible.
• After consultation with the specialist, if the patient is sent to OT, the concerned specialist and the ward should be informed.
• All patients discharged from the ED should be given appropriate information regarding medicines, diet, care and follow up.
• Death certificate will be given to only those patients who die in ED or those who die under medical escort.
• Patient brought dead to ED should be reported to police and forensic specialist.

CASE MANAGEMENT FOR SPECIFIC DISORDERS

• Case management for specific disorders should follow the protocol provided by respective departments.

MASS CASUALTY

In the event of mass casualty following guidelines should be followed:

• Hospital administration should be alerted.

• All the HODs and In-charges should be informed for the activation of their staff.
• Necessary infrastructure, human resource and logistics should be provided.
• Further management should be carried out as per protocol.
• Registration and Triaging should be carried out at the same time.

CODE BLUE (CARDIAC ARREST):

• The emergency team should attend to code blue any time.
• Code blue announcement and response should be carried out as and when situation arises.

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1. Explain the procedure to the patient stressing the need to maintain his nutritional status
2. Provide privacy and send prepared feeding tray to patient’s bedside
3. Put patient in the most comfortable position, together with the assistant
4. Assign the assistant to study the patient’s head
5. Wash, dry hands and check if the NG tube is in stomach
6. Remove spigot and fix the barrel of 20cc syringe to the NG tube
7. Run about 10-15 mils of normal saline or water through the tube
8. Check temperature of feed and pour it into syringe and allow to run by gravity
9. Pour the feed gradually until the required amount is administered
10. Observe the patient throughout the procedure
11. Run water(10-15mils) through the NG tube after feeding
12. Remove the syringe, clean the tip of the tube and fix the spigot and secure the NG on the patient’s neck
13. Make patient comfortable and thank him
14. Discard tray and wash hands
15. Document procedure on the intake and output chart and nurse’s note indicating patient’s reaction and any other observations

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Definition

Is a process whereby a latex, polyurethane, or silicon tube known as a urinary catheter is inserted into a patient’s bladder via the urethra.

Indication

Diagnostic indications include the following

• Collection of uncontaminated urine specimen
• Monitoring of urine output
• Imaging of the urinary tract

Therapeutic indications include the following

• Acute urinary retention (e.g. benign prostatic hypertrophy, blood clots)
• Chronic obstruction that causes hydronephrosis
• Initiation of continuous bladder irrigation
• Intermittent decompression for neurogenic bladder
• Hygienic care of bedridden patients

Equipment

• Urine bag holder
• Catheterization pack and drapes
• Sterile gloves
• Appropriate size catheter
• Xylocaine jelly
• Sterile water for balloon
• 5-10 ML syringes
• Specimen jar or urinary bag
• Tape to secure catheter to leg
• Drainage bag

Procedure

• Place patient in supine position
• If soiling evident, clean genital area with soap and water first
• Perform hand hygiene
• Open catheter pack
• Add equipment needed using aseptic technique
• Pour antiseptic onto tray
• Perform aseptic hand wash and don sterile gloves
• Apply the drapes
• Lift the penis and retract the foreskin if non circumcised. Do not force the foreskin back, especially in infants
• For older boys insert the Xylocaine gel into the urethra. Hold the distal urethra closed and wait 2-3 minutes to give the gel time to work

For infants apply sterile lubricant to catheter before insertion. Post urology surgery consider using two syringes

• Hold the penis with slight upward tension and perpendicular to the patient’s body. Insert the catheter
• Advance the catheter and gently insert it into the urethra until urine flows
• Inflate the balloon slowly(do not use balloon catheter in neonates) using sterile water to the volume recommended on the catheter. Check that the patient feels no pain. If there’s pain, it could indicate that the catheter is not in the bladder

Deflate the balloon and insert further into the bladder ALWAYS ensure urine is flowing before inflating the balloon

• Withdraw the catheter slightly till resistance is felt and attach to drainage system
• Attach catheter to the urine bag
• Secure the catheter to the thigh with tape
• Reposition the foreskin if applicable
• Remove gloves and dispose of used articles into yellow bioharzard bag
• Perform hand hygiene

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OBJECTIVES

1. Perform a complete vaginal examination during labour.
2. Assess the state of the cervix.
3. Assess the presenting part.
4. Assess the size of the pelvis.

Preparation for a vaginal examination in labor

1. Equipment that should be available for a sterile vaginal examination

A vaginal examination in labor is a sterile procedure if the membranes have ruptured or are going to be ruptured during the examination. Therefore, a sterile tray is needed. The basic necessities are:

1. Swabs.
2. Tap water for swabbing.
3. Sterile gloves.
4. A suitable instrument for rupturing the membranes.
5. An antiseptic vaginal cream or sterile lubricant.

An ordinary surgical glove can be used, and the patient does not need to be swabbed if the membranes have not ruptured yet and are not going to be ruptured during the examination.

1. Preparation of the patient for a sterile vaginal examination

1. Explain to the patient what examination is to be done, and why it is going to be done.
2. The woman needs to know that it will be an uncomfortable examination, and sometimes even a little painful.
3. The patient should lie on her back, with her legs flexed and knees apart. Do not expose the patient until you are ready to examine her. It is sometimes necessary to examine the patient in the lithotomy position.
4. The patient’s vulva and perineum are swabbed with tap water. This is done by first swabbing the labia majora and groin on both sides and then swabbing the introitus while keeping the labia majora apart with your thumb and forefinger

1. Preparation needed by the examiner
2. The person to do the vaginal examination must have thoroughly washed his/her hands and wrists.
3. Sterile gloves must be worn.
4. The examiner must think about the findings, and their significance for the patient and the management of her labour.

Procedure of examination

A vaginal examination in labour is a systematic examination, and the following should be assessed:

1. Vulva and vagina.
2. Liquor.
3. Cervix.
4. Membranes.
5. Presenting part.
6. Pelvis.

Always examine the abdomen before performing a vaginal examination in labour.

The vulva and vagina

1. Important aspects of the examination of the vulva and vagina

This examination is particularly important when the patient is first admitted:

1. When you examine the vulva you should look for ulceration, condylomata, varices and any perineal scarring or rigidity.
2. When you examine the vagina, the presence or absence of the following features should be noted:
   • A vaginal discharge.
   • A full rectum.
   • A vaginal stricture or septum.
   • Presentation or prolapse of the umbilical cord.
3. A speculum examination, not a digital examination, must be done if it is thought that the patient has preterm or prelabour rupture of the membranes.

The cervix

When you examine the cervix you should observe:

1. Length
2. Dilation

1. Measuring cervical length

The cervix becomes progressively shorter in early labour. The length of the cervix is measured by assessing the length of the endocervical canal. This is the distance between the internal os and the external os on digital examination. The endocervical canal of an uneffaced cervix is approximately 3 cm long, but when the cervix is fully effaced there will be no endocervical canal, only a ring of thin cervix. The length of the cervix is measured in centimetres and millimetres. In the past the term ‘cervical effacement’ was used and this was measured as a percentage.

1. Dilatation

Dilatation must be assessed in centimetres, and is best measured by comparing the degree of separation of the fingers on vaginal examination, with the set of circles in the labour ward. In assessing the dilatation of the cervix, it is easy to make two mistakes:

1. If the cervix is very thin, it may be difficult to feel, and the patient may be said to be fully dilated, when in fact she is not.
2. When feeling the rim of the cervix, it is easy to stretch it, or pass the fingers through the cervix and feel the rim with the side of the fingers. Both of these methods cause the recording of dilatation to be more than it really is. The correct method is to place the tips of the fingers on the edges of the cervix.

The membranes and liquor

1. Assessment of the membranes

Rupture of the membranes may be obvious if there is liquor draining. However, one should always feel for the presence of membranes overlying the presenting part. If the presenting part is high, it is usually quite easy to feel intact membranes. It may be difficult to feel the membranes if the presenting part is well applied to the cervix. In this case, one should wait for a contraction, when some liquor often comes in front of the presenting part, allowing the membranes to be felt. Sometimes the umbilical cord can be felt in front of the presenting part (a cord presentation).

If the membranes are intact, the following two questions should be asked:

1. Should the membranes be ruptured?
   • In most instances, if the patient is in the active phase of labour, the membranes should be ruptured.
   • When the presenting part is high, there is always the danger that the umbilical cord may prolapse. However, it is better for the cord to prolapse while the hand of the examiner is in the vagina, when it can be detected immediately, than to have the cord prolapse with spontaneous rupture of the membranes while the patient is unattended.
   • Women living with HIV, unless their viral load is lower than detectable, and women in preterm labour should not have their membranes ruptured unless there is poor progress of labour.
2. What is the condition of the liquor when the membranes rupture?

The presence of meconium may change the management of the patient as it indicates that fetal distress has been and may still be present.

The presenting part

An abdominal examination must have been done before the vaginal examination to determine the lie of the fetus and the presenting part. If the presenting part is the fetal head, the number of fifths palpable above the pelvic brim must first be determined.

When palpating the presenting part on vaginal examination, there are four important questions that you must ask yourself:

1. What is the presenting part, e.g. head, breech or shoulder?
2. If the head is presenting, what is the presentation, e.g. occiput, brow or face presentation?
3. What is the position of the presenting part in relation to the mother’s pelvis?
4. If the presentation is occiput, vault or brow, is moulding present?

1. Assessing the presenting part

The presenting part is usually the head but may be the breech, the arm, or the shoulder.

1. Features of an occiput presentation. The posterior fontanelle is normally felt. It is a small triangular space. In contrast, the anterior fontanelle is diamond shaped. If the head is well flexed, the anterior fontanelle will not be felt. If the anterior fontanelle can be easily felt, the head is deflexed and the presenting part the vault.
2. Features of a face presentation. On abdominal examination the presenting part is the head that has not yet engaged. However, on vaginal examination:
   • Instead of a firm skull, the presenting part is soft.
   • The gum margins distinguish the mouth from the anus.
   • The cheek bones and the mouth form a triangle.
   • The orbital ridges above the eyes can be felt.
   • The ears may be felt.
3. Features of a brow presentation. The presenting part is high. The anterior fontanelle is felt on one side of the pelvis, the root of the nose on the other side, and the orbital ridges may be felt laterally.
4. Features of a breech presentation. On abdominal examination the presenting part is the breech (soft and triangular) and the fetal head is ballotable in the fundus. On vaginal examination:
   • Instead of a firm skull, the presenting part is soft.
   • The anus does not have gum margins.
   • The anus and the ischial tuberosities form a straight line.
5. Features of a shoulder presentation. On abdominal examination the lie will be transverse or oblique. Features of a shoulder presentation on vaginal examination will be quite easy if the arm has prolapsed. The shoulder is not always that easy to identify, unless the arm can be felt. The presenting part is usually high

1. Determining the position of the presenting part

Position means the relationship of a fixed point on the presenting part (i.e. the point of reference or the denominator) to the symphysis pubis of the mother’s pelvis. The position is determined on vaginal examination.

1. In a vertex presentation the point of reference is the posterior fontanelle (i.e. the occiput).
2. In a face presentation the point of reference is the chin (i.e. the mentum).
3. In a breech presentation the point of reference is the sacrum of the fetus.

1. Determining the descent and engagement of the head

The descent and engagement of the head is assessed on abdominal and not on vaginal examination.

Moulding

Moulding is the overlapping of the fetal skull bones at the saggital suture which may occur during labour due to the head being compressed as it passes through the pelvis of the mother.

1. The diagnosis of moulding

In a cephalic (head) presentation, moulding is diagnosed by feeling the overlap at the saggital suture of the skull on vaginal examination, and assessing whether or not the overlap can be reduced (corrected) by pressing gently with the examining finger.

The presence of caput succedaneum can also be felt as a soft, boggy swelling, which may make it difficult to identify the presenting part of the fetal head clearly. With severe caput the sutures may be impossible to feel.

1. Grading the degree of moulding

The sagittal suture is palpated and the relationship or closeness of the two adjacent bones assessed.

The degree of moulding is assessed according to the following scale:

0 = Normal separation of the bones with open sutures.

1+ = Bones touching each other.

2+ = Bones overlapping, but can be separated with gentle digital pressure.

3+ = Bones overlapping, but cannot be separated with gentle digital pressure. (3+ is regarded as severe moulding.)

1. Assessing the pelvis

When assessing the pelvis, the size and shape of the pelvic inlet, the mid-pelvis, and the pelvic outlet must be determined.

1. To assess the size of the pelvic inlet, the sacral promontory and the retropubic area are palpated.
2. To assess the size of the mid-pelvis, the curve of the sacrum, the sacrospinous ligaments and the ischial spines are palpated.
3. To assess the size of the pelvic outlet, the subpubic angle, intertuberous diameter and mobility of the coccyx are determined.
4. It is important to use a step-by-step method to assess the pelvis.

1. Step 1. The sacrum

Start with the sacral promontory and follow the curve of the sacrum down the midline.

1. 1. An adequate pelvis: The promontory cannot be easily palpated, the sacrum is well curved and the coccyx cannot be felt.
   2. A small pelvis: The promontory is easily palpated and prominent, the sacrum is straight, and the coccyx is prominent and/or fixed.
2. Step 2. The ischial spines and sacrospinous ligaments

Lateral to the midsacrum, the sacrospinous ligaments can be felt. If these ligaments are followed laterally, the ischial spines can be palpated.

1. 1. An adequate pelvis: 2 fingers can be placed on the sacrospinous ligaments (i.e. they are 3 cm or longer) and the spines are small and round.
   2. A small pelvis: The ligaments allow less than 2 fingers and the spines are prominent and sharp.
2. Step 3. Retropubic area

Put 2 examining fingers, with the palm of the hand facing upwards, behind the symphysis pubis and then move them laterally to both sides:

1. 1. An adequate pelvis: The retropubic area is flat.
   2. A small pelvis: The retropubic area is angulated.
2. Step 4. The subpubic angle and intertuberous diameter

To measure the subpubic angle, the examining fingers are removed from the vagina and turned so that the palm of the hand faces upward, a third finger is held at the entrance of the vagina (introitus) and the angle under the pubis felt. The intertuberous diameter is measured with the knuckles of a closed fist placed between the ischial tuberosities.

1. 1. An adequate pelvis: The subpubic angle allows 3 fingers (i.e. an angle of about 90°) and the intertuberous diameter allows four knuckles.
   2. A small pelvis: The subpubic angle allows only 2 fingers (i.e. an angle of about 60°) and the intertuberous diameter allows only three knuckles.

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Introduction

Venipuncture, venipuncture or venipuncture is the process of obtaining intravenous access for the purpose of intravenous therapy or for blood sampling of venous blood

Indications

• To obtain blood for diagnostic purposes
• To monitor level of blood components
• To administer therapeutic treatments including medications, nutrition, or chemotherapy
• To remove blood due to excess levels of iron or erythrocytes (red blood cells)
• To collect blood for later uses, mainly transfusion either in the donor or in another person

Equipment’s

• Safety needles, G22 or less
• Butterfly needles g21 or less
• Syringes
• Blood collection tubes. The vacuum tubes are designed to draw a predetermined volumes of blood
• Tourniquets
• Antiseptic individual packaged 70% isopropyl alcohol wipes
• 2×2 Gauze or cotton balls
• Sharps Disposal container
• Bandages or tape
• Surgical gloves

Procedure

• Identify the patient
• Reassure the patient that the minimum amount of blood required for testing will be drawn
• Assemble the necessary equipment appropriate to the patient’s physical characteristics
• Wash hands and put on gloves
• Position the patient with the arm extended to form a straight – line from shoulder to wrist
• Select the appropriate vein for venipuncture (The larger median cubital, basilica and cephalic veins are most frequently used, but other may be necessary)
• Apply the tourniquet 3-4 inches above the collection site (Never leave the tourniquet on for over 1 minute)
• Clean the puncture site by making a smooth circular pass over the site with the 70% alcohol pad
• Perform the venipuncture

Attach the appropriate needle to the hub by removing the plastic cap over the small end of the

Remove plastic cap over needle and hold bevel up

Pull the skin tight with your thumb or index finger just below the puncture site

Holding the needle in line with the vein, use a quick, small thrust to penetrate the skin and enter the vein in one smooth motion

Holding the hub securely, insert the first vacu-tainer tube following proper order of draw into the large end of the hub penetrating the stopper.

Blood should flow into the evacuated tube

After blood starts to flow, release the tourniquet and ask the patient to open his or her hand

When blood flow stops, remove the tube (light blue top) should be gently inverted 4 times after being removed from the hub.

Red and gold tops should be inverted 5 times. All other tubes containing an additive should be gently inverted 8-10 times

Venipuncture procedure using a syringe

• Place a sheathed needle or butterfly on the syringe
• Remove the cap and turn the bevel up
• Pull the skin tight with your thumb or index finger just below the puncture site
• Holding the needle in line with the vein, use a quick, small thrust to penetrate the skin and vein in one motion
• Draw the desired amount of blood by pulling back slowly on the syringe stopper
• Release the tourniquet
• Place a gauze pad over the punctured site and quickly remove the needle. Immediately apply pressure. Ask the patient to apply pressure to the gauze for at least 2 minutes. When bleeding stops, apply a fresh bandage, gauze or tape
• Transfer blood drawn into the appropriate tubes as soon as possible using a needleless BD vacutainer blood transfer Device, as a delay could cause improper coagulation
• Gently invert tubes containing an additive 5-8 times
• Dispose of the syringe and needles as a unit into an appropriate sharps container.

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