1. Hand Hygiene. 2. Bed Making. 3. Donning and Doffing of PPE. 4. Gloving technique. 5. Personal Hygiene care (Bed bath, eye care, ear care, nail care, indwelling catheters care). 6. Biomedical waste management. 7. Vital signs. 8. O2 delivery system. 9. Isolation precautions. 10. Comfort devices and positions. 11. Pain assessment. 12. PQRST pain assessment 13. Numeric rating scale assessment. 14. Wong-Baker FACES Scale pain assessment. 15. Glasgow coma scale(GCS). 16. Log rolling method of patients - (Video assisted teaching) 17. Cannulisation procedure. 18. Administration of Parenteral medications (IV,IM,ID,SC). 19. Oral medications. 20. Parts of Syringe and Needle. 21. Prevention of Needle stick injury. 22. Pressure sores (Prevention and management). 23. Assessment of Pressure sores - BRADEN SCALE. 24. Vaccum assisted compression ( For treatment of grade 3 pressure sores). 25. Urinary Catheterization (Male and Female). 26. Fluid drip rate calculation. 27. Nutrition administered to patients ( *Oral* , *Enteral* - NG feed, OG feed, PEG feed, J - tube feeding, *Parenteral* - Total Parenteral Nutrition -TPN ). 28. Blood transfusion (Indications, types of blood products and Checklist for Blood transfusion). 29. Emergency medications (Mechanism and dilution). 30. How to receive patients in the emergency yard based on different scenarios and nursing management of certain patients. Scenarios 1. Fever. 2. MI. 3. Stroke. 4. Head injury. 5. OP Poisoning. 6. Snake bite. 7. RTA. 8. Hypoglycemia. 31. ICU Care bundles - VAP (Ventilator associated pneumonia) - CLABSI (Central line associated blood stream infection). - CAUTI (Catheter associated Urinary tract infection) - SSI (Surgical site infection). 32. Important equipments used in ICU (Syringe pump, infusion pump, mechanical Ventilator, Defibrillator, SCD (Sequential compression device), Oxygen concentrator, suction machine, BIPAP/CPAP, ABG machine, Central monitor) 33. Initial ICU assessment of patients. - FASTHUGSBID. 34. Electrocardiograph (ECG) - procedure with lead place ment. 35. Basic life support (BLS) - Cardiopulmonary Resuscitation (CPR) with demonstration from each student.

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Here is your complete Nursing Reference Guide covering all 35 topics - step-by-step, practical, and designed for practicing nurses.

NURSING REFERENCE GUIDE

For Practicing Nurses | Moderate Clinical Detail

1. HAND HYGIENE

When to perform (WHO 5 Moments):

Before touching a patient
Before a clean/aseptic procedure
After body fluid exposure risk
After touching a patient
After touching patient surroundings

Techniques:

Alcohol-based handrub (ABHR): 60-95% ethanol; preferred for most situations. Apply 3-5 mL, rub all surfaces (6 steps) for 20-30 seconds until dry. Kills gram+/gram- bacteria, lipophilic viruses (HIV, influenza, HSV).
Soap and water: Required for Clostridioides difficile and Bacillus anthracis (spores not killed by alcohol). Wet hands, apply soap, scrub 20-40 seconds, rinse, dry with single-use towel.

Surgical hand scrub: 3-5 minute scrub with antiseptic soap OR 1.5 min with alcoholic scrub preparation.

Key points:

Compliance studies consistently show ~40% adherence to guidelines - the most preventable cause of HAI
Resident flora (deep folds) vs. transient flora (surface) - transient flora is the main source of HAIs
Remove rings and watches before hand hygiene - they harbor organisms under them
Chlorhexidine gluconate has residual antimicrobial activity (6+ hours)

2. BED MAKING

Types:

Type	When Used
Closed bed	Unoccupied, awaiting admission
Open bed	Awaiting ambulatory patient
Occupied bed	Patient confined to bed
Surgical/post-op bed (Anaesthetic bed)	Post-anaesthesia/surgical patients

Steps - Occupied Bed Making:

Explain procedure, ensure privacy
Lower side rail on your side, raise bed to working height
Loosen bottom sheet, turn patient to far side
Roll soiled linen close to patient's back, tuck clean linen in and roll the excess against soiled linen
Turn patient over the rolled linen to opposite side
Remove soiled linen, unroll and tuck clean linen
Replace top sheet, blanket, and spread
Change pillowcases - shake pillows away from patient
Return bed to lowest position, raise side rails

Principles: Never shake linen (aerosol spread). Hold linen away from uniform. Place soiled linen directly in hamper, not on floor.

3. DONNING AND DOFFING OF PPE

Sequence for DONNING (putting on):

Perform hand hygiene
Gown (tie at neck and waist)
Mask/respirator (N95 for airborne)
Eye protection/face shield
Gloves (over gown cuffs)

Sequence for DOFFING (removing) - most critical step:

Gloves first (most contaminated) - peel from wrist, invert as removed, discard
Eye protection - remove from behind, avoid front
Gown - unfasten ties, peel from neck/shoulders, roll away from body, discard
Mask/respirator - remove from behind, do NOT touch front
Hand hygiene after each step

Key rule: The FRONT of all PPE is considered contaminated. Always remove by touching only the back/straps.

N95 fit check: Positive pressure check (breathe out - no air should leak). Negative pressure check (inhale sharply - mask should collapse slightly against face).

4. GLOVING TECHNIQUE

Open Gloving (for non-sterile procedures):

Remove gloves from the inner package
First glove: grasp cuffed edge with opposite hand, pull on
Second glove: slide gloved fingers under cuff of second glove, pull on
Interlock fingers to smooth fit

Closed Gloving (sterile, surgical):

Hands remain inside gown cuffs throughout
Pick up first glove through gown sleeve
Place glove on gown-covered hand (thumb-side facing body, fingers toward elbow)
Fold cuff over sleeve end, pull through while keeping hand inside gown
Repeat for second glove

Removing gloves (non-sterile):

Grasp outside of one glove at wrist - peel off inverting it
Hold removed glove in gloved hand
Insert fingers of bare hand inside cuff of remaining glove - peel off
Discard both, perform hand hygiene immediately

5. PERSONAL HYGIENE CARE

Bed Bath

Full bed bath steps:

Gather supplies; explain procedure; provide privacy
Water temperature: 43-46°C (110-115°F); change water when cool/soiled
Order: face → neck → arms (far arm first) → chest → abdomen → legs (far leg first) → back → perineum
Use long firm strokes; rinse and pat dry each area
Apply lotion to prevent skin breakdown

Eye Care

Clean from inner to outer canthus with moistened gauze
Use a fresh swab for each wipe; separate swabs for each eye
Unconscious patients: artificial tears q2h; eye shield if corneal reflex absent

Ear Care

Clean external ear only with cloth-covered finger or washcloth
Never insert cotton swabs into ear canal - risk of impaction and injury
Note any discharge, odor, or lesions

Nail Care

Soak fingernails in warm water 10-15 min before trimming
Cut fingernails straight across, round edges with file
Toenails: cut straight across (especially diabetic patients - never cut corners)
Diabetic patients: refer to podiatrist for nail care

Indwelling Catheter Care (Foley Care)

Perform 2x daily and after each bowel movement
Cleanse urethral meatus with soap and water (or antiseptic wipe) in a front-to-back motion
Secure catheter to inner thigh (female) or upper thigh/lower abdomen (male) to prevent traction
Maintain drainage bag below bladder level at all times - never on the floor
Keep tubing free of kinks; ensure closed drainage system is unbroken
Empty bag when 2/3 full or every 8 hours; document output

6. BIOMEDICAL WASTE MANAGEMENT

Color-coded bag/container system (as per biomedical waste rules):

Color	Container Type	Waste Category
Yellow	Bag/container	Anatomical/pathological waste, soiled dressings, body fluids
Red	Bag	Contaminated recyclable waste (IV sets, catheters, gloves)
White/Translucent	Puncture-proof container	Sharps (needles, blades, glass)
Blue	Box	Glassware

Key principles:

Waste segregation at point of generation - the nurse's direct responsibility
Sharps: fill puncture-proof container to 3/4 full only; never recap needles (one-hand scoop technique if required)
No mixing of waste categories
Log and label each container: date, ward, type of waste
Do not compact or compress yellow bags

7. VITAL SIGNS

Normal adult values and technique:

Parameter	Normal Range	Key Points
Temperature	36.5-37.5°C (97.7-99.5°F)	Oral most common; rectal = 0.5°C higher; axillary = 0.5°C lower
Pulse	60-100 bpm	Count for 60 sec (arrhythmia) or 30 sec x2; assess rate, rhythm, volume
Respirations	12-20 breaths/min	Count without patient awareness (after pulse); note depth and pattern
Blood Pressure	<120/80 mmHg	Rest 5 min before; arm at heart level; correct cuff size
SpO₂	95-100%	Probe on finger; poor signal if cold extremities, nail polish, or low perfusion

Temperature sites: Oral (most common), rectal (most accurate), tympanic, axillary, temporal artery.

Postural BP: Check lying, sitting, standing. A drop >20 mmHg systolic or >10 mmHg diastolic = orthostatic hypotension.

8. O₂ DELIVERY SYSTEMS

Device	FiO₂ Range	Flow Rate	Indications
Nasal Cannula	24-44%	1-6 L/min	Mild hypoxia, chronic use
Simple Face Mask	35-55%	6-10 L/min	Moderate hypoxia
Partial Non-Rebreather	40-70%	6-10 L/min	Moderate-severe hypoxia
Non-Rebreather Mask (NRM)	60-90%	10-15 L/min	Severe hypoxia (CO poisoning, trauma)
Venturi Mask	Precise 24-60%	Variable	COPD (controlled O₂ delivery)
CPAP/BiPAP	Up to 100%	Variable	Respiratory failure, sleep apnea
Endotracheal Tube (ETT)	Up to 100%	Ventilator set	Mechanical ventilation

Nursing responsibilities:

Ensure humidification for flow >4 L/min (nasal cannula) or all face mask use
Monitor SpO₂ continuously; titrate to target (usually SpO₂ 94-98%; COPD: 88-92%)
Check for skin breakdown under mask straps and at nares
Ensure reservoir bag inflated on NRM before placing on patient

9. ISOLATION PRECAUTIONS

Standard Precautions (ALL patients, ALL times):

Hand hygiene
Gloves for contact with blood/body fluids
Gown, mask, eye protection based on anticipated splatter risk
Respiratory hygiene/cough etiquette
Safe injection practices
Sharps disposal

Transmission-Based Precautions:

Type	Diseases	PPE	Room
Contact	MRSA, VRE, C. diff, scabies, wound infections	Gown + gloves	Single room preferred
Droplet	Influenza, meningitis, pertussis, COVID-19	Surgical mask + eye protection	Single room; door can be open
Airborne	TB, measles, chickenpox, COVID-19 (aerosol procedures)	N95 respirator + eye protection	Negative pressure room; door closed

Protective (Reverse) Isolation: For severely immunocompromised patients. Visitors and staff wear mask, gown, gloves to protect the patient.

10. COMFORT DEVICES AND POSITIONS

Therapeutic Positions:

Position	Use
Fowler's (30-90°)	Post-op, respiratory distress, feeding, nasogastric tube care
Semi-Fowler's (30-45°)	VAP prevention, NG feeds, cardiac patients
Supine	Spinal injury, post-anaesthesia
Prone	ARDS (improves oxygenation), pressure ulcer prevention (turns)
Lateral (side-lying)	Unconscious patients (prevents aspiration), during log roll
Sims'	Enema, rectal examination, unconscious patients
Trendelenburg	Hypovolemic shock (elevate legs 30°; avoid full Trendelenburg)
Reverse Trendelenburg	GERD, head/neck surgery
Lithotomy	Urinary catheterization, pelvic examination

Comfort Devices:

Pillows: Support limbs, maintain alignment, pressure relief
Foam wedges: Maintain lateral tilt (30°) for pressure relief; knee flexion
Heel protectors/boots: Offload heels (highest-risk pressure area in supine patients)
Bed cradle: Keep linen off lower limbs (burns, ulcers)
Splints/footboards: Prevent foot drop in bed-bound patients
Anti-embolism (TED) stockings: DVT prevention; measure and fit correctly

11. PAIN ASSESSMENT

OLDCART mnemonic:

O - Onset: When did it start?
L - Location: Where is the pain?
D - Duration: How long does it last?
C - Character: What does it feel like?
A - Aggravating factors
R - Relieving factors
T - Treatment tried

General principles:

Pain is the "5th vital sign" - assess with every vital sign check
Self-report is the most reliable measure when patient is able to communicate
Assess pain at rest AND with movement (procedural pain)
Reassess after every intervention (within 30-60 min for analgesics)

12. PQRST PAIN ASSESSMENT

Letter	Meaning	Sample Questions
P - Provocation/Palliation	What makes it better or worse?	"What were you doing when it started? What makes it better?"
Q - Quality	What does it feel like?	"Burning, stabbing, crushing, throbbing, aching?"
R - Region/Radiation	Where is it? Does it spread?	"Show me where it hurts. Does it go anywhere else?"
S - Severity	How bad is it? (scale 0-10)	"On a scale of 0 to 10, how bad is it right now?"
T - Timing	When? Constant or intermittent?	"How long have you had it? Is it constant or does it come and go?"

Clinical application: PQRST is especially useful for cardiac chest pain - radiation to jaw/left arm (Q), crushing quality (Q), and severity (S) help distinguish STEMI from other causes.

13. NUMERIC RATING SCALE (NRS)

Simple 0-10 horizontal scale
0 = No pain | 1-3 = Mild | 4-6 = Moderate | 7-10 = Severe
Patient verbally or visually selects a number

Interpretation and action:

Score	Category	Typical Action
0	No pain	Reassess per schedule
1-3	Mild	Non-pharmacological measures (repositioning, heat/cold, distraction)
4-6	Moderate	Non-opioid analgesics (paracetamol, NSAIDs); notify physician
7-10	Severe	Strong analgesics; immediate physician notification

Limitation: Requires patient ability to understand numeric concepts. Use alternative scales for cognitive impairment.

14. WONG-BAKER FACES SCALE

6 face drawings from happy (0) to crying (10)
Used for: children aged 3+, patients with language barriers, cognitive impairment, or difficulty with numbers

Face	Score	Description
😊	0	No hurt
🙂	2	Hurts little bit
😐	4	Hurts little more
😟	6	Hurts even more
😢	8	Hurts whole lot
😭	10	Hurts worst

Instruction to patient: "Point to the face that shows how much you are hurting right now."

15. GLASGOW COMA SCALE (GCS)

Component	Response	Score
Eye Opening (E)	Spontaneous	4
	To voice/command	3
	To pain	2
	None	1
Verbal Response (V)	Oriented	5
	Confused	4
	Inappropriate words	3
	Incomprehensible sounds	2
	None	1
Motor Response (M)	Obeys commands	6
	Localizes pain	5
	Withdraws from pain	4
	Abnormal flexion (decorticate)	3
	Extension (decerebrate)	2
	None	1

Total = E + V + M (range 3-15)

GCS Score	Severity
13-15	Mild brain injury
9-12	Moderate brain injury
3-8	Severe brain injury
≤8	Airway at risk - consider intubation

Always use BEST response for scoring. Document individual scores (e.g., E3V4M5 = GCS 12) not just total.

(Clinical Procedures in Emergency Medicine)

16. LOG ROLLING METHOD

Indication: Patients with suspected or confirmed spinal injury (cervical, thoracic, or lumbar).

Requires: Minimum 3-4 staff members (1 at head, 2 at body, 1 receives board).

Steps:

Leader at head (maintains cervical spine alignment manually - two-hand hold on sides of head)
Communicate clearly - leader gives all commands
Position: one assistant at shoulders/upper chest, one at hips/thighs, one at lower legs
Command "Ready... Roll" - patient turned as a single rigid unit (no twisting of spine)
Turn to lateral position (usually for board placement or assessment)
Insert spinal board, return patient supine on command

Key principles:

Neutral spine alignment maintained throughout
No pillow during transport if cervical collar in place
If 3 staff only: leader at head, one at torso, one at legs
Maintain cervical collar (hard collar) until C-spine cleared

17. CANNULATION PROCEDURE (IV Cannula Insertion)

Equipment: IV cannula (appropriate size), tourniquet, antiseptic swab, transparent dressing, IV flush (normal saline), gloves, sharps bin.

Cannula size selection:

Size (Gauge)	Color	Use
14G	Orange	Massive transfusion, trauma
16G	Grey	Blood transfusion, surgery
18G	Green	General IV therapy
20G	Pink	Standard; IV fluids, medications
22G	Blue	Elderly, children, fragile veins
24G	Yellow	Neonates, very fragile veins

Steps:

Perform hand hygiene; apply gloves
Select vein (antecubital fossa, forearm, dorsal hand); avoid antecubital if mobility needed
Apply tourniquet 7-10 cm above site; ask patient to pump fist
Clean with 70% alcohol swab; allow to dry 30 seconds (do not fan or blow dry)
Anchor vein with non-dominant thumb; insert cannula at 15-30° angle bevel-up
Advance until flashback of blood seen in chamber
Lower angle, advance 2-3 mm further, then slide plastic cannula off needle into vein
Release tourniquet; press over vein proximal to tip while removing needle
Immediately discard needle in sharps bin (do NOT recap)
Attach cap, flush with 5 mL normal saline - observe for swelling (infiltration), pain
Apply transparent dressing; date and label (date, time, gauge)

Complications: Infiltration, phlebitis, haematoma, infection. Check site every shift.

18. PARENTERAL MEDICATIONS

Intravenous (IV)

Route	Speed	Use
IV bolus (push)	Over 1-5 min	Emergency drugs, bolus doses
IV piggyback (IVPB)	Over 15-60 min	Antibiotics, most IV drugs
IV infusion	Continuous	Fluids, vasopressors, insulin

Always check compatibility before mixing
Flush IV line before and after each drug
Monitor IV site for phlebitis, infiltration

Intramuscular (IM)

Site	Volume	Notes
Deltoid	≤1 mL	Vaccines, small volumes
Vastus lateralis	Up to 5 mL	Infants, pediatrics; preferred self-injection
Ventrogluteal	Up to 3 mL	Safest IM site (no major nerves/vessels)
Dorsogluteal	Up to 5 mL	Avoid (risk of sciatic nerve injury)

Z-track technique for irritating medications (Iron, certain vaccines): pull skin 2-3 cm laterally before injection; hold 10 sec after; release skin before withdrawing
Aspirate not required for most IM injections (per WHO/CDC 2015 guidelines)

Intradermal (ID)

Site: Volar (inner) forearm
Angle: 10-15° bevel-up
Volume: 0.1 mL
Result: Raised bleb (wheal) confirms correct placement
Uses: Mantoux (TB test), allergy testing, local anaesthesia

Subcutaneous (SC)

Site: Abdomen (2 inches from navel), outer arm, anterior thigh
Angle: 45° (thin patients) or 90° (obese patients)
Needle: 25-27G, 16 mm
Uses: Insulin, heparin, enoxaparin
Rotate injection sites; document site used each time

19. ORAL MEDICATIONS

Rights of Medication Administration (10 Rights):

Right patient (check 2 identifiers)
Right medication
Right dose
Right route
Right time
Right documentation
Right reason
Right response (assess therapeutic effect)
Right to refuse (document)
Right education (explain to patient)

Steps:

Check MAR (Medication Administration Record); check expiry dates
Perform hand hygiene; prepare medications at medication cart (not patient room)
Check patient identity with 2 identifiers (name band + verbal confirmation)
Assess swallowing ability; position upright (at least 45°)
Administer with 100-200 mL of water (unless restricted)
Remain with patient until medications are swallowed
Document immediately after administration

Never crush: Enteric-coated, extended-release, sublingual tablets. Check if capsule can be opened.

20. PARTS OF SYRINGE AND NEEDLE

Syringe components:

Tip - attaches to needle (Luer-lock or slip-tip)
Barrel - transparent cylinder with measurement markings (mL)
Plunger - piston that draws or expels fluid
Flange - projections at base of barrel (finger grip during injection)

Needle components:

Hub - attaches to syringe tip
Shaft/Cannula - hollow cylindrical body
Bevel - slanted cut at tip (creates sharp point; always bevel-up for ID/SC)
Lumen - hollow core through which fluid passes

Gauge: Higher number = smaller diameter. Examples: 18G (IV, blood draw), 21-23G (IM), 25-27G (SC/ID).

Length: Depends on route: ID (10 mm), SC (16 mm), IM (25-38 mm), IV (various).

21. PREVENTION OF NEEDLE STICK INJURY (NSI)

High-risk activities: Recapping needles, disposal, phlebotomy, IV access.

Prevention strategies:

No recapping (single most important rule) - use one-hand scoop technique ONLY if absolutely necessary
Immediately discard used sharps in puncture-proof container at point of use
Never leave sharps on bed/tray; never pass hand-to-hand
Use safety-engineered devices (retractable needles, safety IV cannulas)
Never overfill sharps containers (fill to 3/4 max)
Wear gloves during all needle-related procedures

If NSI occurs - immediate management:

Do NOT squeeze or suck the wound
Wash immediately with soap and running water for ≥5 minutes
Apply antiseptic (betadine or 70% alcohol)
Report immediately to nurse in charge / occupational health
Document: date, time, type of device, injury site, patient details
Blood tests: HBV, HCV, HIV (baseline for both exposed and source patient)
PEP (Post-Exposure Prophylaxis): HIV PEP within 72 hours; HBsIg if not immunized

22. PRESSURE SORES - PREVENTION AND MANAGEMENT

Staging (NPUAP/EPUAP):

Stage	Description
Stage 1	Non-blanchable erythema on intact skin
Stage 2	Partial thickness skin loss - open shallow ulcer, no slough
Stage 3	Full thickness skin loss - subcutaneous fat visible; no bone/tendon
Stage 4	Full thickness tissue loss - bone, tendon, or muscle exposed
Unstageable	Full thickness; base covered by slough/eschar
Deep Tissue Injury	Purple/maroon discoloration; intact skin

Prevention (SSKIN bundle):

S - Surface: Use appropriate pressure-redistributing mattress (foam, gel, air)
S - Skin inspection: Every 2-4 hours; document findings
K - Keep moving: Reposition every 2 hours (or q1h in chair)
I - Incontinence: Keep skin clean and dry; use moisture barrier creams
N - Nutrition: Adequate protein (1.0-1.5 g/kg/day), Vitamin C, Zinc, hydration

Management by stage:

Stage 1: Remove pressure, moisturize, transparent film dressing
Stage 2: Clean with NS, hydrocolloid dressing, offload pressure
Stage 3: Debridement if needed, alginate/foam dressing, consider nutrition support
Stage 4: Surgical evaluation (debridement/flap repair); VAC therapy; MDT involvement

23. BRADEN SCALE - PRESSURE SORE RISK ASSESSMENT

Subscale	1 (Highest Risk)	2	3	4 (Lowest Risk)
Sensory Perception	Completely limited	Very limited	Slightly limited	No impairment
Moisture	Constantly moist	Very moist	Occasionally moist	Rarely moist
Activity	Bedfast	Chairfast	Walks occasionally	Walks frequently
Mobility	Completely immobile	Very limited	Slightly limited	No limitation
Nutrition	Very poor	Probably inadequate	Adequate	Excellent
Friction & Shear	Problem	Potential problem	No apparent problem	-

Scoring (range 6-23):

Score	Risk Level	Action
≤9	Very high risk	Hourly repositioning, advanced mattress, MDT referral
10-12	High risk	2-hourly turns, pressure-relieving devices
13-14	Moderate risk	4-hourly repositioning
15-18	Mild risk	Prevention protocol
19-23	No risk	Routine skin care

Assess on admission, with every significant clinical change, and per institutional policy (usually daily in acute care).

24. VACUUM ASSISTED COMPRESSION (VAC/NPWT)

Indication: Grade 3-4 pressure sores, chronic non-healing wounds, post-debridement wounds.

How it works: Applies continuous or intermittent sub-atmospheric pressure (-75 to -125 mmHg) to wound bed, removing exudate, reducing edema, promoting granulation tissue formation and angiogenesis.

Components: Foam dressing (black polyurethane or white polyvinyl alcohol), transparent drape, tube, canister, therapy unit.

Procedure:

Clean wound with normal saline; debride necrotic tissue as ordered
Measure and cut foam to fit wound (do NOT pack tightly - foam should loosely fill cavity)
Place foam in wound, cover with occlusive transparent drape (extend 3-5 cm onto perilesional skin)
Make small hole in drape (or use provided pad); attach therapy tube
Connect to VAC unit; set pressure as prescribed (typically -125 mmHg continuous)
Ensure airtight seal - foam should collapse (shrink) when activated
Change dressing every 48-72 hours (more frequently if infected)

Contraindications: Untreated osteomyelitis, malignancy in wound, fistulas to organs/body cavities, exposed blood vessels/nerves.

25. URINARY CATHETERIZATION

Male Catheterization

Gather sterile equipment; explain procedure; position supine
Hand hygiene, don sterile gloves, create sterile field
Drape patient; retract foreskin (if present); clean glans with antiseptic 3x in circular motion
Apply 10 mL of 2% lignocaine gel into urethra; wait 5 minutes
Grasp penis at 90° angle to abdominal wall; insert catheter until bifurcation ("Y" junction)
Inflate balloon with 10 mL sterile water (ONLY once urine flows)
Gentle traction to confirm balloon seated at bladder neck
Replace foreskin to prevent paraphimosis
Attach drainage bag; secure catheter to thigh with tape

Female Catheterization

Position in dorsal recumbent (supine, knees bent, feet flat)
Cleanse labia majora → minora → urethral meatus (front to back, separate wipes)
Insert lubricated catheter 5-7 cm until urine flows
Inflate balloon; gentle traction; secure to inner thigh

Common catheter sizes: 12-14 Fr (female), 14-16 Fr (male). Standard balloon: 10 mL.

Indication mnemonic (ABCDE): Accurate output measurement, Bladder obstruction, Comfort in terminal illness, Decubitus ulcer healing (sacral), Extended surgery.

26. FLUID DRIP RATE CALCULATION

Formula:

Drops per minute = (Volume in mL × Drop factor) ÷ Time in minutes

Standard drop factors:

Macrodrip (standard): 15 gtts/mL or 20 gtts/mL
Microdrip (pediatric): 60 gtts/mL

Example: 1000 mL NS over 8 hours, macrodrip (15 gtts/mL)

Time = 8 × 60 = 480 minutes
Drip rate = (1000 × 15) ÷ 480 = 31.25 ≈ 31 drops/min

mL/hr calculation (for infusion pumps):

mL/hr = Total volume (mL) ÷ Total time (hours)

Example: 500 mL over 4 hours = 500 ÷ 4 = 125 mL/hr

27. NUTRITION ROUTES

Route	Method	Indication
Oral	Normal eating/drinking	Functional swallowing
NG Tube	Nasogastric - nose to stomach	Short-term (<6 weeks), unable to swallow
OG Tube	Orogastric - mouth to stomach	Neonates; facial trauma preventing nasal route
PEG Feed	Percutaneous Endoscopic Gastrostomy	Long-term enteral feeding; swallowing disorder
J-tube	Jejunostomy	Gastric motility issues, high aspiration risk
TPN	Total Parenteral Nutrition (IV)	Non-functional gut, bowel rest required

NG Tube verification (before each feed):

Aspirate stomach contents - pH ≤5.5 confirms gastric placement
Chest X-ray is gold standard (especially on initial insertion)
NEVER use the auscultation ("whoosh") method alone - unreliable

Enteral feeding care:

Check gastric residual volume (GRV) every 4-6 hours; hold feed if >200-500 mL (per protocol)
Keep HOB elevated ≥30-45° (VAP prevention)
Flush tube with 30 mL water before and after feeds, and with each medication

TPN monitoring: Blood glucose q4-6h (hyperglycemia common), electrolytes daily, liver function weekly.

28. BLOOD TRANSFUSION

Indications:

Hb <7 g/dL (stable patients); <8 g/dL (cardiac patients or symptomatic anaemia)
Acute haemorrhage with haemodynamic instability
Coagulopathy, thrombocytopenia (specific products)

Blood Products:

Product	Indication	Storage
Packed Red Blood Cells (PRBCs)	Anaemia, haemorrhage	1-6°C; use within 4 hours of spiking
Fresh Frozen Plasma (FFP)	Coagulopathy, DIC, massive transfusion	Frozen; thaw before use
Platelets	Thrombocytopenia, platelet dysfunction	Room temp (22°C), agitate continuously
Cryoprecipitate	Factor deficiency, haemophilia A, vWD, DIC	Frozen
Whole Blood	Massive haemorrhage, military settings	1-6°C

Pre-transfusion Checklist:

Informed consent
Confirm prescription
Two-nurse ID check: patient name, MRN, blood group, donation number, expiry
Check for colour changes, clots, leakage in blood bag
Baseline vitals: temperature, BP, HR, SpO₂
Administer through IV cannula (16-18G preferred); blood transfusion set (170-230 micron filter)
First 15 mL: infuse slowly (2 mL/min); remain at bedside for first 15 minutes
If reaction suspected: STOP transfusion, keep IV line open with NS, notify doctor

Transfusion reactions: Febrile non-haemolytic (most common - fever/chills), acute haemolytic (most dangerous - back pain, dark urine), allergic, TRALI, TACO.

29. EMERGENCY MEDICATIONS

Drug	Mechanism	Key Dilution/Dose	Indication
Adrenaline (Epinephrine)	α1+β1+β2 agonist - ↑HR, ↑BP, bronchodilation	1 mg IV q3-5 min (1:10,000 = 0.1 mg/mL)	Cardiac arrest, anaphylaxis
Atropine	Anticholinergic - blocks vagus → ↑HR	0.5-1 mg IV bolus (max 3 mg)	Bradycardia, organophosphate poisoning
Amiodarone	Class III antiarrhythmic - ↑refractory period	300 mg IV bolus in arrest; 150 mg over 10 min	VF/pVT, SVT
Sodium Bicarbonate	Buffers excess H⁺ ions	1 mEq/kg IV (50 mEq in 50 mL)	Metabolic acidosis, TCA overdose, hyperkalaemia
50% Dextrose (D50)	Rapid glucose replacement	25-50 mL IV bolus	Hypoglycaemia (unresponsive)
Naloxone	Opioid receptor antagonist	0.4-2 mg IV/IM/IN; repeat q2-3 min	Opioid overdose
Midazolam	GABA-A agonist - CNS depression	2.5-5 mg IV/IM	Status epilepticus, procedural sedation
Calcium Gluconate	Membrane stabilization	10 mL of 10% IV over 5-10 min	Hyperkalaemia, calcium channel blocker OD
Magnesium Sulphate	Membrane stabilizer, NMDA antagonist	2 g IV over 10 min	Torsades de Pointes, eclampsia, severe asthma

30. EMERGENCY NURSING MANAGEMENT - SELECTED SCENARIOS

1. Fever

Rapid assessment: temperature, source (UTI, LRTI, meningitis, sepsis)
Antipyretics: Paracetamol 500-1000 mg PO/IV; Ibuprofen (if no contraindication)
Tepid sponging, remove excess clothing, ensure adequate hydration
Cultures (blood, urine) BEFORE antibiotics if sepsis suspected
Sepsis screening: qSOFA (confusion, RR>22, SBP<100) → NEWS/MEWS scoring

2. Myocardial Infarction (MI)

MONA protocol (for STEMI):

Morphine 2-4 mg IV (pain, anxiety) - use cautiously; may mask symptoms
Oxygen if SpO₂ <94% (do not routinely give if normoxic)
Nitroglycerine sublingual (0.4 mg) - contraindicated if systolic BP <90 mmHg or right ventricular MI
Aspirin 300 mg stat (chewed, not swallowed) Plus: Heparin, P2Y12 inhibitor (Ticagrelor/Clopidogrel), primary PCI within 90 minutes ECG within 10 minutes; 12-lead; IV access, continuous cardiac monitor, ready defibrillator

3. Stroke

FAST acronym: Face drooping, Arm weakness, Speech difficulty, Time to call

Last known well time - critical for thrombolysis (tPA within 4.5 hours)
CT head (non-contrast) immediately - rule out haemorrhage before tPA
NIH Stroke Scale (NIHSS) assessment
Nil by mouth (swallowing assessment before oral intake)
BP management: Do NOT lower BP aggressively in ischaemic stroke unless >220/120

4. Head Injury

C-spine immobilization (assume until cleared)
ABC assessment; GCS scoring
Pupils: equality and reaction to light (herniation = fixed dilated ipsilateral pupil)
CT head - immediate in GCS ≤13
ICP monitoring in severe TBI
HOB 30°, avoid hypotension (MAP >70 mmHg), normothermia, normoglycaemia

5. Organophosphate (OP) Poisoning

SLUDGE symptoms (cholinergic excess): Salivation, Lacrimation, Urination, Defecation, GI distress, Emesis Plus: Miosis, Bradycardia, Bronchospasm, Seizures

Antidote: Atropine 2-4 mg IV every 5-10 min until secretions dry
Pralidoxime (2-PAM) 1-2 g IV (within 24-48 hours of exposure - reactivates cholinesterase)
Decontaminate (remove clothing, wash skin); wear PPE during decontamination

6. Snakebite

Immobilize limb at heart level; remove rings/watches/tight clothing
Do NOT: tourniquet, incise-and-suck, apply ice, electric shock
Identify snake if possible (photo, not capture)
Polyvalent antivenom based on signs: coagulopathy (haemotoxic), ptosis/paralysis (neurotoxic), local necrosis (cytotoxic)
Monitor: CBC, coagulation (PT, INR, APTT), renal function, urine output (watch for haemoglobinuria)

7. Road Traffic Accident (RTA)

Primary Survey - ABCDE:

A - Airway with C-spine control
B - Breathing (pneumothorax, haemothorax)
C - Circulation (haemorrhage control, 2 large bore IVs)
D - Disability (GCS, pupils)
E - Exposure (remove all clothing; log roll to check back) Haemorrhage: "Permissive hypotension" in penetrating trauma (SBP 80-90 until surgical control); aggressive resuscitation in blunt trauma/TBI

8. Hypoglycaemia

Blood glucose <3.9 mmol/L (70 mg/dL) = hypoglycaemia
Conscious patient: 15-20 g fast-acting carbohydrates (4 glucose tablets, 150 mL orange juice); reassess in 15 min
Unconscious/unable to swallow: 50 mL of 50% dextrose (D50W) IV bolus OR Glucagon 1 mg IM
Continue monitoring glucose every 15 minutes; give complex carbohydrate once conscious

31. ICU CARE BUNDLES

VAP Bundle (Ventilator-Associated Pneumonia)

HOB ≥30-45° (semi-recumbent) - reduces aspiration
Daily sedation vacation + readiness-to-extubate assessment
Peptic ulcer prophylaxis (PPI or H2 blocker)
DVT prophylaxis (LMWH or sequential compression devices)
Oral care with chlorhexidine 0.12% q4-6h (reduces oral bacterial colonization)
Subglottic secretion drainage (ETT with subglottic suction port)
Ventilator circuit: change only when soiled (not on schedule); keep water traps drained

CLABSI Bundle (Central Line-Associated Bloodstream Infection)

Hand hygiene before insertion and access
Maximum sterile barrier precautions during insertion (cap, mask, sterile gown, gloves, full drape)
Chlorhexidine 2% skin antisepsis (dry before insertion)
Optimal site selection - subclavian preferred (vs. femoral - highest risk)
Daily review - remove line as soon as no longer necessary
Use closed needleless access connectors; scrub the hub for ≥15 seconds before access

CAUTI Bundle (Catheter-Associated Urinary Tract Infection)

Insert catheter only when indicated (avoid inappropriate catheterization)
Sterile insertion technique
Maintain closed drainage system
Daily review - remove as soon as possible
Keep drainage bag below bladder level; empty when 2/3 full
Perineal care twice daily; avoid disconnecting tubing

SSI Bundle (Surgical Site Infection)

Pre-op: Hair removal with clipper (not razor); bowel prep (if applicable); patient shower with chlorhexidine night before; correct antibiotic prophylaxis within 60 min of incision Intra-op: Normothermia; normoglycaemia (blood glucose <180 mg/dL); oxygen enrichment; sterile technique Post-op: Wound inspection; early ambulation; glycaemic control

32. IMPORTANT ICU EQUIPMENT

Equipment	Purpose	Key Nursing Points
Syringe Pump	Accurate infusion of small volumes (e.g. vasopressors, sedation)	Ensure concentration labelled; prime tubing; dead volume awareness
Infusion Pump	IV fluid/medication at controlled rate	Rate in mL/hr; check for occlusion/air alarms
Mechanical Ventilator	Positive pressure ventilation	Monitor: RR, Vt (tidal volume), PEEP, FiO₂, peak airway pressure
Defibrillator	Deliver electrical cardioversion	Synchronised (VT with pulse, AF) vs. Unsynchronised (VF, pVT); check pad placement
SCD (Sequential Compression Device)	DVT prevention	Apply before ambulation; ensure correct size; assess skin integrity beneath
Oxygen Concentrator	Deliver 93-95% O₂ from room air	Ideal for home/low-resource; not for >5 L/min in critical illness
Suction Machine	Remove secretions from airway	Yankauer (oropharyngeal), catheter suction (endotracheal); pre-oxygenate before suctioning
BiPAP/CPAP	Non-invasive ventilatory support	BiPAP: IPAP and EPAP settings; CPAP: single pressure; assess mask fit for air leaks
ABG Machine	Arterial blood gas analysis	Interpret pH, PaO₂, PaCO₂, HCO₃⁻, BE; Allen's test before radial artery sampling
Central Monitor	Continuous multi-parameter monitoring	ECG rhythm, SpO₂, NIBP, ETCO₂, temperature; set appropriate alarm limits

33. INITIAL ICU ASSESSMENT - FASTHUGSBID

Letter	Assessment Element
F	Feeding - enteral or parenteral nutrition commenced?
A	Analgesia - pain adequately controlled? (NRS/CPOT)
S	Sedation - appropriate level? (RASS -2 to 0 in most patients)
T	Thrombo-prophylaxis - DVT prevention in place?
H	HOB elevation ≥30° (VAP prevention)
U	Ulcer prophylaxis (stress ulcer, PPI)
G	Glycaemic control (target 7.8-10 mmol/L or 140-180 mg/dL)
S	Spontaneous breathing trial (SBT) - daily readiness-to-wean assessment
B	Bowel care - assess for ileus, constipation; laxatives if opioids used
I	Indwelling catheters - review necessity daily; remove ASAP
D	De-escalation of therapy / Diagnostics review

34. ECG - PROCEDURE WITH LEAD PLACEMENT

Equipment: ECG machine, electrodes (10), electrode gel/pads, razor (if needed for chest hair).

Patient preparation:

Remove metal objects; ask patient to lie supine and remain still
Expose chest, wrists, and ankles; clean and dry skin; clip excessive chest hair if needed

Limb leads (4 electrodes):

Electrode	Placement	Color (IEC)
RA (Right Arm)	Right wrist or forearm	Red
LA (Left Arm)	Left wrist or forearm	Yellow
RL (Right Leg)	Right ankle	Black (earth/neutral)
LL (Left Leg)	Left ankle	Green

Chest (precordial) leads (6 electrodes) - V1 to V6:

Lead	Placement
V1	4th intercostal space, RIGHT sternal border
V2	4th intercostal space, LEFT sternal border
V3	Between V2 and V4
V4	5th intercostal space, midclavicular line
V5	Anterior axillary line (same horizontal level as V4)
V6	Midaxillary line (same horizontal level as V4 and V5)

Normal ECG values:

Heart rate: 60-100 bpm
PR interval: 0.12-0.20 seconds
QRS duration: <0.12 seconds
QT interval (corrected QTc): <0.44 sec (men), <0.46 sec (women)

35. BASIC LIFE SUPPORT (BLS) / CPR

Adult BLS Sequence (AHA/ILCOR Guidelines):

Ensure scene safety
Check responsiveness - tap shoulders, shout "Are you okay?"
Call for help - activate emergency response (111/999/911); get AED if available
Check for breathing and pulse simultaneously - maximum 10 seconds
If no pulse and no normal breathing → Begin CPR

CPR Technique:

Position: Heel of hand on lower half of sternum; second hand on top; fingers interlocked; arms straight
Depth: At least 2 inches (5 cm); no more than 2.4 inches (6 cm)
Rate: 100-120 compressions per minute
Ratio: 30 compressions : 2 breaths (30:2) - single or dual rescuer adult BLS
Recoil: Allow full chest recoil between compressions; do not lean on chest
Minimize interruptions: Pause ≤10 seconds for breaths or rhythm check

Rescue Breaths:

Head tilt-chin lift (jaw thrust if C-spine injury suspected)
Create seal; give breath over 1 second; watch for chest rise
Do NOT hyperventilate

AED:

Power on → Follow voice prompts
Attach pads: one below right clavicle (right of sternum), one on left lateral chest (apex/V6 position)
Analyse rhythm → Stand clear if shock advised
Deliver shock → Immediately resume CPR

Chain of Survival:

Early recognition → Early CPR → Early defibrillation → Advanced care → Post-resuscitation care

(Goldman-Cecil Medicine; Braunwald's Heart Disease)

QUICK REFERENCE CARD

Topic	Key Number/Value
Normal SpO₂	95-100% (COPD target: 88-92%)
Normal BP	<120/80 mmHg
Normal HR	60-100 bpm
Normal RR	12-20 breaths/min
Normal Temp	36.5-37.5°C
GCS: Severe injury	≤8 (intubate threshold)
CPR depth	≥5 cm, ≤6 cm
CPR rate	100-120/min
CPR ratio (adult)	30:2
Braden: High risk	≤12
Transfusion trigger	Hb <7 g/dL (general), <8 (cardiac)
Drip rate formula	(Vol × Drop factor) ÷ Time (min)
CAUTI: Bag position	Always below bladder level
VAP: HOB position	≥30-45°
Hypoglycaemia threshold	BG <3.9 mmol/L (70 mg/dL)

Sources: Roberts & Hedges' Clinical Procedures in Emergency Medicine; Goldman-Cecil Medicine; Braunwald's Heart Disease; Barash Clinical Anesthesia; Rosen's Emergency Medicine; Plum & Posner's Stupor and Coma; Tintinalli's Emergency Medicine.

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