The Glasgow Coma Scale (GCS) is a neurological assessment tool used to evaluate a patient’s level of consciousness (LOC) in cases of head injury, coma, stroke, or critical illness.
GCS measures three parameters of consciousness:
| Component | Maximum Score | Minimum Score |
|---|---|---|
| Eye Opening (E) | 4 | 1 |
| Verbal Response (V) | 5 | 1 |
| Motor Response (M) | 6 | 1 |
| Total GCS Score | 15 (Best) | 3 (Worst/Coma) |
✅ Minimum Score = 3 (Deep Coma or Death).
✅ Maximum Score = 15 (Fully Conscious).
| Score | Response |
|---|---|
| 4 | Spontaneous (opens eyes without stimulation) |
| 3 | Opens eyes to speech (not necessarily obeying commands) |
| 2 | Opens eyes to pain (response to painful stimulus) |
| 1 | No eye opening |
| Score | Response |
|---|---|
| 5 | Oriented (knows name, place, time) |
| 4 | Confused (disoriented but able to speak) |
| 3 | Inappropriate words (random or unrelated words) |
| 2 | Incomprehensible sounds (moaning, groaning) |
| 1 | No verbal response |
| Score | Response |
|---|---|
| 6 | Obeys commands (moves as instructed) |
| 5 | Localizes pain (tries to remove painful stimulus) |
| 4 | Withdrawal from pain (pulls away from pain) |
| 3 | Flexion (Decorticate posture – abnormal limb flexion) |
| 2 | Extension (Decerebrate posture – abnormal limb extension) |
| 1 | No motor response |
✅ Posturing in GCS:
📌 Decorticate (Flexion Posturing) (GCS M3): Arms flexed, legs extended – indicates severe brain damage.
📌 Decerebrate (Extension Posturing) (GCS M2): Arms and legs extended – worse prognosis than decorticate.
✅ Mild Head Injury (GCS 13-15):
✅ Moderate Head Injury (GCS 9-12):
✅ Severe Head Injury (GCS ≤ 8):
✅ GCS Score of 3 (Lowest Possible Score):
✅ Intubated Patients:
✅ Pediatric GCS (Modified for Infants and Children):
✅ Brain Death:
📌 GCS 9-15 (Mild to Moderate Injury):
📌 GCS ≤ 8 (Severe Injury/Coma):
✔ Best GCS Score? – 15 (Fully Conscious).
✔ Worst GCS Score? – 3 (Deep Coma or Death).
✔ GCS Score ≤ 8 means? – Severe brain injury, needs intubation.
✔ Which parameter has the highest score in GCS? – Motor Response (M = 6).
✔ What does GCS M3 indicate? – Decorticate (Flexion) posturing.
✔ What does GCS M2 indicate? – Decerebrate (Extension) posturing, worse prognosis.
✔ GCS used for which conditions? – Head injury, stroke, coma assessment.
✅ Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection (as per Sepsis-3 definition, 2016).
✅ Septic shock is severe sepsis with circulatory, cellular, and metabolic dysfunction leading to hypotension that requires vasopressor support.
1️⃣ Infection triggers an immune response.
2️⃣ Excessive cytokine release (“Cytokine Storm”) leads to widespread inflammation.
3️⃣ Increased vascular permeability → Hypotension & Organ Dysfunction.
4️⃣ Tissue Hypoxia & Multi-Organ Failure.
✅ Bacterial Infections (Most Common):
📌 Elderly (>65 years) & Neonates
📌 Immunocompromised (HIV, Cancer, Diabetes, Organ Transplant)
📌 Post-Surgical Patients (Nosocomial Sepsis)
📌 Patients with Chronic Diseases (COPD, CKD, Cirrhosis)
✅ Early Signs (Warm Sepsis)
📌 Fever (>38°C) or Hypothermia (<36°C)
📌 Tachycardia (>90 bpm)
📌 Tachypnea (>22 breaths/min)
📌 Altered Mental Status (Confusion, Restlessness)
📌 Warm, flushed skin (early stage)
✅ Late Signs (Cold Sepsis / Septic Shock)
📌 Hypotension (SBP <90 mmHg, MAP <65 mmHg)
📌 Cold, clammy skin (due to poor perfusion)
📌 Oliguria (low urine output <0.5 mL/kg/hr → Acute Kidney Injury)
📌 Metabolic Acidosis & Multi-Organ Dysfunction (MODS)
✅ Quick SOFA (qSOFA) Score (Identifies high-risk patients for poor outcomes)
✅ Sequential Organ Failure Assessment (SOFA) Score
✅ Laboratory Investigations in Sepsis
📌 Complete Blood Count (CBC): Leukocytosis (>12,000) or Leukopenia (<4,000).
📌 Serum Lactate >2 mmol/L (Indicates tissue hypoxia).
📌 Procalcitonin (PCT) – High in bacterial sepsis.
📌 Blood Culture (Confirms infection).
📌 ABG (Metabolic Acidosis, Hypoxemia).
“6 Crucial Steps within the First Hour” (1-Hour Bundle):
✅ 1. Measure Lactate Levels (Lactate >2 mmol/L = Poor Perfusion).
✅ 2. Obtain Blood Cultures Before Starting Antibiotics.
✅ 3. Administer Broad-Spectrum Antibiotics (Meropenem, Piperacillin-Tazobactam, Vancomycin).
✅ 4. Start IV Fluids (30 mL/kg Crystalloids for Hypotension/Lactate >4).
✅ 5. Give Vasopressors (Norepinephrine) if MAP <65 mmHg.
✅ 6. Reassess Fluid Status (Urine Output, BP, CVP, Lactate).
✅ Antibiotics
✅ IV Fluids (Fluid Resuscitation)
✅ Vasopressors (If Hypotension Persists After IV Fluids)
✅ Corticosteroids (Hydrocortisone) – Used if Fluids & Vasopressors Fail.
✅ Supportive Therapy:
📌 Monitor vital signs (BP, HR, RR, SpO₂, Temperature).
📌 Check urine output (for signs of kidney failure).
📌 Monitor GCS (for neurological deterioration).
📌 Assess for skin changes (cyanosis, poor perfusion).
📌 Administer IV Fluids & Antibiotics Immediately.
📌 Maintain Strict Aseptic Technique (Prevent Hospital-Acquired Infections).
📌 Monitor Blood Culture Results (De-escalate Antibiotics If Needed).
📌 Educate Patient & Family on Sepsis Prevention.
📌 Septic Shock → Persistent hypotension despite fluids & vasopressors.
📌 Acute Respiratory Distress Syndrome (ARDS) → Severe lung damage.
📌 Disseminated Intravascular Coagulation (DIC) → Widespread clotting & bleeding.
📌 Multiple Organ Dysfunction Syndrome (MODS) → Failure of two or more organs.
✔ Most common cause of sepsis? → Bacterial infections (Pneumonia, UTI, Wound infections).
✔ Best predictor of sepsis severity? → Lactate level (>2 mmol/L suggests poor perfusion).
✔ First-line vasopressor for septic shock? → Norepinephrine.
✔ Key components of the 1-hour sepsis bundle? → Blood cultures, Lactate check, IV fluids, Antibiotics, Vasopressors.
✔ Common complications of sepsis? → Septic shock, MODS, ARDS, DIC.
✔ Gold standard test for sepsis diagnosis? → Blood Culture.
✅ Blood transfusion is the administration of whole blood or blood components (RBCs, plasma, platelets) intravenously to replace lost blood or correct deficiencies.
✅ Types of Blood Transfusion:
📌 Whole Blood Transfusion → Rarely used, given only in massive hemorrhage.
📌 Component Therapy (Most Common) → Includes Packed RBCs (PRBCs), Platelets, Fresh Frozen Plasma (FFP), Cryoprecipitate.
✅ Packed RBCs (PRBCs) → Used for anemia, blood loss, hemoglobin <7 g/dL.
✅ Platelets → Used for thrombocytopenia (platelet count <10,000), bleeding disorders.
✅ Fresh Frozen Plasma (FFP) → Used for coagulation disorders, liver disease, DIC.
✅ Cryoprecipitate → Used for hemophilia, fibrinogen deficiency.
✅ ABO Blood Group System:
📌 Universal Donor: O Negative (O−) (Can donate to all blood groups).
📌 Universal Recipient: AB Positive (AB+) (Can receive all blood groups).
✅ Rh System:
📌 Rh-Positive → Can receive Rh+ or Rh− blood.
📌 Rh-Negative → Can receive only Rh− blood (to prevent Rh sensitization).
✅ Blood Transfusion Compatibility Table:
| Recipient | Can Receive From |
|---|---|
| O− | O− |
| O+ | O+, O− |
| A− | A−, O− |
| A+ | A+, A−, O+, O− |
| B− | B−, O− |
| B+ | B+, B−, O+, O− |
| AB− | AB−, A−, B−, O− |
| AB+ | All (Universal Recipient) |
✅ Pre-Transfusion Nursing Actions:
📌 Check Physician’s Order (Type of blood, volume, rate).
📌 Obtain Informed Consent (Explain risks & benefits).
📌 Perform Blood Grouping & Crossmatching (To prevent incompatibility reactions).
📌 Assess Baseline Vitals (BP, HR, Temperature, SpO₂).
📌 Use Correct IV Cannula (18-20G for PRBCs, 22-24G for platelets/FFP).
📌 Use Normal Saline (0.9% NaCl) Only – No Dextrose or LR (Prevents Hemolysis).
✅ During Transfusion (Monitoring Phase):
📌 Start Infusion Slowly (First 15 minutes at 1-2 mL/min).
📌 Monitor for Transfusion Reactions (Every 15-30 min for the first hour).
📌 Check for Signs of Allergic or Hemolytic Reaction (Fever, chills, rash, dyspnea, hypotension).
📌 Complete Transfusion Within 4 Hours (Prevents Bacterial Contamination).
✅ Post-Transfusion Nursing Care:
📌 Monitor Vitals & Observe for Delayed Reactions (Up to 24 hours).
📌 Document the Procedure (Time, Volume, Reactions).
📌 Dispose of Used Blood Bags Safely (Biomedical Waste Management).
Blood transfusion reactions are serious complications requiring immediate intervention.
| Type of Reaction | Cause | Symptoms | Management |
|---|---|---|---|
| Acute Hemolytic Reaction | ABO incompatibility | Fever, chills, flank pain, dark urine, hypotension | Stop transfusion, IV fluids, Oxygen, Notify Physician |
| Febrile Non-Hemolytic Reaction | Cytokines from donor WBCs | Fever, chills, headache | Stop transfusion, Antipyretics (Paracetamol), Restart Slowly |
| Allergic Reaction | Plasma proteins in donor blood | Itching, hives, rash, wheezing | Stop transfusion, Administer Antihistamines (Diphenhydramine) |
| Anaphylactic Reaction | IgA deficiency (Severe allergy) | Hypotension, Dyspnea, Shock | Stop transfusion, Administer Epinephrine, Oxygen |
| Circulatory Overload (TACO) | Rapid infusion in CHF patients | Pulmonary edema, Hypertension, Dyspnea | Slow transfusion rate, Give Diuretics (Furosemide) |
| Sepsis (Bacterial Contamination) | Contaminated blood products | High fever, chills, hypotension | Stop transfusion, IV antibiotics, Culture Blood Bag |
✅ Management of Any Transfusion Reaction:
📌 Stop Transfusion Immediately.
📌 Maintain IV Line with Normal Saline (Do Not Flush Same Line).
📌 Monitor Vital Signs & Airway.
📌 Notify Physician & Send Blood Bag for Testing.
✅ Massive Blood Transfusion (≥10 units in 24 hours)
✅ Rh-Incompatibility & Hemolytic Disease of Newborn (HDN)
✅ Autologous Blood Transfusion
✅ Pediatric Transfusion:
✅ Geriatric Transfusion:
✅ Immunocompromised Patients (Cancer, HIV, Transplant Patients):
✔ What is the Universal Donor Blood Group? → O Negative (O−).
✔ What is the Universal Recipient Blood Group? → AB Positive (AB+).
✔ What IV Fluid Can Be Used With Blood Transfusion? → Normal Saline (0.9% NaCl).
✔ What is the First Action for a Transfusion Reaction? → Stop the Transfusion Immediately.
✔ What is the Most Common Transfusion Reaction? → Febrile Non-Hemolytic Reaction.
✔ Which Blood Component is Used for Hemophilia? → Cryoprecipitate (Rich in Factor VIII).
✔ What Medication is Given to Prevent Allergic Reactions Before Transfusion? → Antihistamines (Diphenhydramine).
✔ What Drug is Given for Fluid Overload During Transfusion? → Diuretics (Furosemide).
✅ Heat-related illnesses occur when the body fails to regulate temperature due to excessive heat exposure and inadequate cooling mechanisms (e.g., sweating).
✅ Severe forms (Heatstroke) can be life-threatening!
✅ Normal Body Temperature: 36.5–37.5°C (97.7–99.5°F)
✅ Hyperthermia (Heat-Related Illness) Begins at: ≥38.3°C (101°F)
| Disorder | Cause | Key Symptoms | Treatment |
|---|---|---|---|
| Heat Cramps (Mild) | Loss of electrolytes (Na+, K+, Cl-) due to sweating | Muscle cramps, sweating, thirst, weakness | Oral fluids, electrolytes (ORS), rest, stretching |
| Heat Exhaustion (Moderate) | Dehydration + Salt depletion | Profuse sweating, dizziness, headache, nausea, cool clammy skin, tachycardia | Oral/IV Fluids, cooling, electrolyte replacement |
| Heat Stroke (Severe, Life-Threatening) | Failure of thermoregulation → Body temp >40°C (104°F) | Hot, dry skin (NO SWEATING), confusion, seizures, coma, hypotension | Medical emergency: Rapid cooling (ice packs, cold IV fluids, cooling blankets), oxygen, ICU care |
1️⃣ Excessive heat exposure → Sweating → Fluid & Electrolyte loss
2️⃣ Dehydration + Reduced Blood Volume → Hypotension & Shock
3️⃣ Failure of Heat Dissipation (In Heatstroke) → Organ Dysfunction & Multi-Organ Failure
✅ Severe hyperthermia (>41°C or 106°F) → Can lead to brain damage & death!
📌 Prolonged exposure to high temperatures (hot climate, sun exposure).
📌 Strenuous physical activity (sports, military training, outdoor work).
📌 Inadequate fluid intake → Dehydration.
📌 Wearing heavy or non-breathable clothing.
📌 Use of alcohol, caffeine, or diuretics (causes excessive water loss).
📌 Elderly & Infants (Poor Thermoregulation).
📌 Athletes, Soldiers, Outdoor Workers.
📌 Obese individuals (More heat retention).
📌 People with Chronic Illnesses (Heart disease, diabetes, kidney disease).
📌 Medications: Diuretics, Anticholinergics, Beta-blockers, Antipsychotics.
| Feature | Heat Exhaustion (Moderate) | Heat Stroke (Severe, Life-Threatening) |
|---|---|---|
| Body Temperature | 37.8–40°C (100–104°F) | >40°C (104°F) |
| Sweating | Profuse sweating (present) | Absent (Hot, Dry Skin) |
| Mental Status | Dizziness, Weakness, Headache | Confusion, Seizures, Coma |
| Skin | Pale, Cool, Moist | Hot, Flushed, Dry |
| Heart Rate | Tachycardia (Fast HR) | Very High HR, Hypotension |
| Complications | Dehydration, Electrolyte Imbalance | Multi-Organ Failure, Shock, Death |
| Treatment | Cooling, IV Fluids, Rest | Medical Emergency – ICU, Rapid Cooling, Oxygen |
✅ Heat Stroke = Medical Emergency → Requires ICU Management!
📌 Brain Damage (Cerebral Edema, Coma).
📌 Multi-Organ Failure (Kidneys, Liver, Heart, Lungs).
📌 Rhabdomyolysis (Muscle Breakdown → Kidney Failure).
📌 Disseminated Intravascular Coagulation (DIC) – Widespread Clotting & Bleeding.
✅ Primary Goal: Lower Body Temperature & Restore Fluid Balance.
✅ Ensure Airway, Breathing, Circulation (ABC).
✅ For Heat Cramps:
✅ For Heat Exhaustion:
✅ For Heat Stroke (Medical Emergency – ICU Care Required!):
📌 Rapid Cooling Measures:
✅ Stay Hydrated (Drink plenty of fluids, avoid alcohol & caffeine).
✅ Wear Light, Loose-Fitting Clothing.
✅ Avoid Direct Sunlight During Peak Hours (10 AM – 4 PM).
✅ Use Fans, Air Conditioning, and Cool Showers in Hot Weather.
✅ Take Breaks in the Shade During Outdoor Work.
✅ Educate High-Risk Groups (Elderly, Athletes, Workers).
| Nursing Diagnosis | Nursing Interventions | Expected Outcomes |
|---|---|---|
| Hyperthermia related to excessive heat exposure | Monitor temperature, HR, BP, RR every 15 min. Initiate rapid cooling measures. Apply ice packs & use cooling blankets. Administer IV fluids. | Patient’s body temperature returns to normal. Vital signs stabilize. |
| Fluid Volume Deficit related to dehydration | Monitor urine output, check electrolytes. Give IV Normal Saline with electrolyte replacement. Encourage oral fluids if conscious. | Adequate hydration maintained. Urine output normal (>30 mL/hr). |
✔ Most severe heat-related illness? → Heat Stroke.
✔ Key sign of Heat Stroke? → Hot, Dry Skin + Altered Mental Status.
✔ What is the most effective cooling method for Heat Stroke? → Ice water immersion (if available).
✔ What is the first intervention for Heat Exhaustion? → Move to a cool place, hydrate with fluids.
✔ Why is Aspirin not used in Heat Stroke? → It does not lower core body temperature.
✔ Best way to prevent Heat Stroke? → Hydration, Avoid sun exposure, Light clothing.
✔ Which electrolyte is commonly lost in Heat Cramps? → Sodium (Na+).
✅ Heat and Cold Applications are non-pharmacological nursing interventions used to provide pain relief, reduce inflammation, improve circulation, and promote healing.
✅ Heat Therapy (Thermotherapy) → Increases blood flow, relaxes muscles, and reduces stiffness.
✅ Cold Therapy (Cryotherapy) → Reduces swelling, numbs pain, and slows down inflammation.
| Therapy | Types of Application |
|---|---|
| Heat Application | 🔹 Dry Heat (Heating pads, Hot packs, Infrared therapy) 🔹 Moist Heat (Warm compress, Sitz bath, Hydrotherapy) |
| Cold Application | 🔹 Dry Cold (Ice bags, Cold packs, Cooling blankets) 🔹 Moist Cold (Cold compress, Ice bath, Cold water soaks) |
✅ Mechanism of Action:
📌 Vasodilation → Increases blood flow.
📌 Reduces muscle spasms and stiffness.
📌 Increases tissue metabolism and oxygen supply.
📌 Promotes wound healing.
✅ Indications for Heat Therapy:
📌 Muscle pain, joint stiffness (Arthritis, Chronic Pain).
📌 Soft tissue injuries (Strains, Sprains, Back pain).
📌 Abscess drainage (Moist Heat Compress).
📌 Menstrual cramps, Sinus congestion.
✅ Contraindications for Heat Therapy:
📌 Acute Inflammation or Swelling (e.g., Fresh Injuries, Sprains).
📌 Bleeding Disorders (Heat Increases Bleeding).
📌 Peripheral Neuropathy (Diabetic Patients May Not Feel Burns).
📌 Open Wounds or Burns.
✅ Types of Heat Therapy:
🔹 Moist Heat: Hot compress, Sitz bath, Hydrotherapy (better penetration).
🔹 Dry Heat: Electric heating pad, Hot water bag, Infrared therapy (less effective but more convenient).
✅ Precautions in Heat Application:
📌 Temperature Should Not Exceed 40°C (104°F) to Prevent Burns.
📌 Apply for 15-20 minutes Only (Prolonged Use May Cause Burns).
📌 Monitor for Skin Redness, Blisters, or Excessive Warmth.
✅ Mechanism of Action:
📌 Vasoconstriction → Reduces blood flow and swelling.
📌 Slows nerve conduction → Provides pain relief.
📌 Decreases metabolic demand → Prevents tissue damage in trauma.
✅ Indications for Cold Therapy:
📌 Acute Injury, Sprains, Strains.
📌 Post-Surgical Swelling, Fractures.
📌 Headache (Cold Compress on Forehead).
📌 Fever Reduction (Cooling Blanket, Ice Packs).
📌 Minor Burns, Insect Bites (Reduces Inflammation).
✅ Contraindications for Cold Therapy:
📌 Peripheral Vascular Disease (PVD) – Reduces Circulation Further.
📌 Raynaud’s Disease (Cold Can Trigger Vasospasm).
📌 Diabetic Neuropathy (Decreased Sensation → Frostbite Risk).
📌 Open Wounds (Cold Delays Healing).
✅ Types of Cold Therapy:
🔹 Moist Cold: Cold compress, Ice packs, Ice bath (Better penetration).
🔹 Dry Cold: Cooling blankets, Ice bags, Cold spray.
✅ Precautions in Cold Application:
📌 Temperature Should Not Drop Below 15°C (59°F) to Prevent Frostbite.
📌 Apply for 15-20 minutes Only (Prolonged Use May Cause Tissue Damage).
📌 Monitor for Skin Pallor, Numbness, or Pain (Indicates Overcooling).
✅ Assessment Before Application:
📌 Check Skin Condition (Redness, Swelling, Sensation).
📌 Assess Circulatory Status (Pulse, Capillary Refill).
📌 Monitor Patient’s Pain Level and Response.
✅ During Application:
📌 Use Barrier (Towel) Between Skin and Heat/Cold Source.
📌 Reassess Skin Every 5-10 Minutes to Prevent Injury.
📌 Document Temperature, Duration, and Patient’s Response.
✅ After Application:
📌 Check for Adverse Reactions (Burns, Frostbite, Excessive Pain).
📌 Reassess Pain Relief and Comfort Level.
📌 Educate Patient on Proper Use at Home.
| Feature | Heat Therapy | Cold Therapy |
|---|---|---|
| Effect | Increases blood flow (Vasodilation) | Decreases blood flow (Vasoconstriction) |
| Pain Relief Mechanism | Relaxes muscles, increases oxygenation | Numbs pain, reduces nerve activity |
| Best for | Chronic pain, arthritis, muscle stiffness | Acute injuries, swelling, inflammation |
| Application Time | 15-20 minutes | 15-20 minutes |
| Precautions | Risk of burns, avoid in bleeding disorders | Risk of frostbite, avoid in circulation issues |
✔ Best therapy for acute ankle sprain? → Cold therapy (Ice pack).
✔ Best therapy for chronic arthritis pain? → Heat therapy (Hot compress, Heating pad).
✔ Best therapy for postoperative swelling? → Cold therapy (Ice packs).
✔ How long should heat or cold therapy be applied? → 15-20 minutes.
✔ Why should heat not be applied to acute injuries? → It increases inflammation and bleeding.
✔ Why should cold not be applied to open wounds? → It reduces circulation and delays healing.
✔ What is the main risk of cold therapy? → Frostbite, tissue damage.
✔ What is the main risk of heat therapy? → Burns, increased swelling.
✅ A patient unit refers to the area in a hospital or healthcare setting assigned to a patient for their care, comfort, and treatment.
✅ It includes the bed, furniture, equipment, and surroundings necessary for patient care.
A standard patient unit consists of the following:
| Furniture | Purpose |
|---|---|
| Hospital Bed | Adjustable height, side rails for safety |
| Bedside Table | Holds patient’s personal items, water, medicines |
| Overbed Table | Used for meals, reading, and procedures |
| Chair | For patient use, visitors, and sometimes caregivers |
| Locker/Cabinet | Stores patient belongings, medical records |
| Equipment | Purpose |
|---|---|
| Call Bell / Nurse Call System | Allows patient to alert nursing staff |
| Oxygen Cylinder / Oxygen Flowmeter | For oxygen therapy |
| Suction Apparatus | Removes secretions in respiratory conditions |
| Bedpan / Urinal / Commode Chair | Used for patients with mobility issues |
| IV Stand | Holds intravenous fluids and medications |
| Cardiac Monitor / BP Apparatus | For continuous monitoring of vital signs |
| Thermometer / Pulse Oximeter | Measures temperature and oxygen saturation |
✅ General Ward Unit → Multiple beds in a common room, separated by curtains.
✅ Private / Semi-Private Unit → One or two patients per room for privacy.
✅ Intensive Care Unit (ICU) Unit → Special unit for critically ill patients with advanced monitoring.
✅ Pediatric Unit → Designed for children with special furniture and toys.
✅ Maternity Unit → Specialized for obstetric and gynecological patients.
📌 Ventilation: Well-ventilated to allow fresh air circulation.
📌 Lighting: Sufficient natural and artificial light.
📌 Temperature: Maintained at 21-24°C (70-75°F) for patient comfort.
📌 Noise Control: Minimized noise levels for rest and recovery.
📌 Hygiene: Regular cleaning to prevent infections.
📌 Safety: Call bells, side rails, and proper furniture arrangement.
✅ Before Admission:
📌 Prepare a clean and well-equipped patient unit.
📌 Ensure the bed is made properly and all equipment is functional.
📌 Arrange necessary documents, admission charts, and wristbands.
✅ During Patient Stay:
📌 Maintain cleanliness (bed making, disinfection of furniture).
📌 Ensure patient safety (side rails up for fall-risk patients).
📌 Monitor comfort and accessibility (positioning, lighting, call bell access).
📌 Check oxygen supply, IV fluids, and suction setup if needed.
✅ After Discharge / Transfer:
📌 Remove used linen and disinfect the bed.
📌 Dispose of medical waste properly.
📌 Restock supplies (gloves, syringes, bedpan, IV sets, etc.).
✅ Types of Beds in Nursing:
📌 Occupied Bed → Patient is inside the bed while making it.
📌 Unoccupied Bed → Patient is not in bed during preparation.
📌 Post-Operative Bed → Prepared for post-surgical patients with special positioning.
📌 Cardiac Bed → Bed adjusted at high Fowler’s position for cardiac patients.
📌 Fracture Bed → Hard mattress with traction setup for fractures.
✅ Principles of Bed Making:
📌 Ensure clean and wrinkle-free sheets (prevents bedsores).
📌 Use draw sheets for easy patient movement.
📌 Keep call bell within patient’s reach.
📌 Ensure bed height is adjusted properly for patient comfort.
✅ Standard Precautions in Patient Unit:
📌 Hand Hygiene – Wash hands before and after patient contact.
📌 Disinfection of Surfaces – Regularly clean beds, tables, and equipment.
📌 Waste Disposal – Follow biomedical waste management guidelines.
📌 Personal Protective Equipment (PPE) – Use gloves, masks, gowns as needed.
✅ Isolation Precautions:
📌 Contact Precautions – For MRSA, C. difficile (Gloves, gowns, disinfect surfaces).
📌 Droplet Precautions – For flu, COVID-19 (Wear masks, limit patient movement).
📌 Airborne Precautions – For TB, Measles (N95 mask, negative pressure room).
✔ What is a Patient Unit? → A designated hospital space with necessary equipment for patient care.
✔ What is the standard room temperature in a hospital unit? → 21-24°C (70-75°F).
✔ What is the purpose of a call bell? → To allow patients to communicate with nursing staff.
✔ Which bed position is used for cardiac patients? → High Fowler’s Position.
✔ Why should bed sheets be wrinkle-free? → To prevent bedsores (pressure ulcers).
✔ How often should patient units be cleaned? → Daily, and after patient discharge.
✔ What is the purpose of an IV stand? → To hold intravenous fluids for continuous infusion.
✅ Oxygen therapy is the administration of supplemental oxygen to patients with hypoxia (low oxygen levels in blood) to maintain adequate tissue oxygenation.
✅ Oxygen is delivered through various devices depending on the patient’s oxygen needs and condition.
📌 Hypoxia (SpO₂ < 90%)
📌 Respiratory Distress (Dyspnea, Cyanosis, Tachypnea)
📌 COPD, Pneumonia, Asthma, COVID-19
📌 Shock, Anemia, Carbon Monoxide Poisoning
📌 During Surgery & Postoperative Recovery
Oxygen can be administered via low-flow and high-flow delivery systems.
✅ 1. Nasal Cannula
📌 Flow Rate: 1-6 L/min
📌 FiO₂ Delivered: 24-44%
📌 Best for: Mild hypoxia, post-surgical patients, home therapy.
📌 Advantages: Comfortable, allows eating and talking.
📌 Disadvantages: Limited oxygen delivery, nasal dryness.
✅ 2. Simple Face Mask
📌 Flow Rate: 5-10 L/min
📌 FiO₂ Delivered: 40-60%
📌 Best for: Short-term oxygen therapy, mild to moderate hypoxia.
📌 Advantages: Provides more oxygen than nasal cannula.
📌 Disadvantages: Must be removed for eating, causes discomfort.
✅ 3. Partial Rebreather Mask
📌 Flow Rate: 6-10 L/min
📌 FiO₂ Delivered: 40-70%
📌 Best for: Moderate hypoxia, patients needing higher oxygen levels.
📌 Advantages: Reservoir bag conserves exhaled oxygen.
📌 Disadvantages: Not suitable for long-term use.
✅ 4. Non-Rebreather Mask (NRM) – High-Concentration Mask
📌 Flow Rate: 10-15 L/min
📌 FiO₂ Delivered: 80-95%
📌 Best for: Severe hypoxia, emergencies (ARDS, Shock, Trauma).
📌 Advantages: Delivers the highest oxygen concentration without intubation.
📌 Disadvantages: Must fit tightly; suffocation risk if the bag collapses.
✅ 5. Venturi Mask (Air-Entrainment Mask)
📌 Flow Rate: 4-12 L/min
📌 FiO₂ Delivered: 24-50%
📌 Best for: COPD patients (Precise Oxygen Control Needed).
📌 Advantages: Delivers precise FiO₂ using color-coded adaptors.
📌 Disadvantages: Expensive, cumbersome.
✅ 6. High-Flow Nasal Cannula (HFNC)
📌 Flow Rate: Up to 60 L/min
📌 FiO₂ Delivered: Up to 100%
📌 Best for: Severe respiratory distress, COVID-19, ARDS, Pre-intubation.
📌 Advantages: Heated humidified oxygen prevents nasal dryness.
📌 Disadvantages: Requires specialized equipment.
✅ 7. Mechanical Ventilation (Intubation & Ventilator Support)
📌 FiO₂ Delivered: Up to 100%
📌 Best for: ARDS, Coma, Severe Respiratory Failure, Surgery.
📌 Advantages: Controls breathing completely.
📌 Disadvantages: Requires ICU care, risk of ventilator-associated pneumonia (VAP).
✅ 8. Oxygen Hood / Tent (For Neonates & Pediatrics)
📌 Flow Rate: 10-15 L/min
📌 FiO₂ Delivered: Up to 90%
📌 Best for: Newborns & Infants with respiratory distress.
📌 Advantages: Less invasive, covers entire head.
📌 Disadvantages: Risk of CO₂ buildup if not ventilated properly.
📌 Oxygen Toxicity: Long-term exposure to high oxygen levels can cause lung damage.
📌 CO₂ Retention (Hypercapnia): High oxygen levels in COPD patients can suppress breathing.
📌 Dry Mucous Membranes: Oxygen therapy can cause nasal and throat dryness.
📌 Retinopathy of Prematurity (ROP): In preterm infants, high oxygen levels can cause blindness.
📌 Fire Hazard: Oxygen is highly flammable; must avoid open flames.
✅ Before Oxygen Administration:
📌 Assess SpO₂ (Pulse Oximetry), Respiratory Rate, and Lung Sounds.
📌 Check for COPD patients (Oxygen should be given cautiously to avoid hypercapnia).
📌 Ensure proper equipment is set up (Flowmeter, Humidifier, Mask, Tubing).
✅ During Oxygen Administration:
📌 Monitor oxygen saturation (SpO₂), respiratory effort, and level of consciousness.
📌 Adjust oxygen flow rate based on ABG results and physician’s orders.
📌 Ensure correct device placement (Mask should fit snugly, no leakage).
📌 Prevent Oxygen Dryness → Use humidification for flow rates >4 L/min.
✅ After Oxygen Therapy:
📌 Gradually reduce oxygen flow as per protocol.
📌 Monitor for withdrawal effects (Hypoxia, Increased Work of Breathing).
📌 Educate the patient on home oxygen use (for COPD, Chronic Respiratory Diseases).
| Feature | Low-Flow Oxygen Devices | High-Flow Oxygen Devices |
|---|---|---|
| FiO₂ Range | 24-95% | 24-100% |
| Flow Rate | 1-15 L/min | Up to 60 L/min |
| Best for | Mild to moderate hypoxia | Severe hypoxia, ARDS, COVID-19 |
| Examples | Nasal Cannula, Simple Mask, Non-Rebreather Mask | Venturi Mask, HFNC, Mechanical Ventilation |
✔ Which oxygen device delivers the highest concentration of oxygen? → Non-Rebreather Mask (NRM) (80-95% FiO₂).
✔ Which device delivers the most precise oxygen concentration? → Venturi Mask (Used in COPD).
✔ What is the maximum flow rate for a nasal cannula? → 6 L/min.
✔ Why is humidification needed for high-flow oxygen therapy? → Prevents nasal and throat dryness.
✔ Which oxygen device is used for neonates? → Oxygen Hood or Incubator.
✔ What is the first sign of oxygen toxicity? → Cough, chest pain, difficulty breathing.
✔ Why should oxygen be given cautiously in COPD patients? → High oxygen levels can cause CO₂ retention (Hypercapnia).