advance nursing is about nursing advance care.

1. ADVANCED NURSING
JOYCE KUMAH
(DIP, BSC, MPHIL NURSING)

2. COURSE DESCRIPTION
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The course will equip the student with skills to manage patients at the medical, surgical, theatre,
recovery public health, adolescent health and the infectious disease unit.
The students will have demonstrations and return demonstrations in the skills laboratory.
Students will have the opportunity to utilize the nursing process to manage patients with several
problems.
Students will be expected to spend 6 hours in the skills lab per week as part of this course.
The course will also help the students develop skills that will enable them administer medications,
infusions and oxygen safely, dress wounds and remove stitches and drainage tubes, insert urethral and
nasogastric tube appropriately and also apply the principles of infection prevention in their care.

3. COURSE OBJECTIVES
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By the end of the course, the students will:
• Develop skills for safe administration of drugs
• Administer prescribed oxygen safely
• Demonstrate skills in administering intravenous (I.V) infusions and
blood transfusion.
• Give health education to patients and relatives
• Medical and surgical asepsis
• Pre-operative preparation of patient for surgical procedure
• Manage surgical wounds and remove stitches and clips aseptically
• Pass Naso-Gastric Tube

4. COURSE CONTENT
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Administration of drugs: Calculation of dosages, dilution of lotions, correct handling and
assembling of equipment for preparation and administration of drugs. Routes of
administration: oral, skin, rectal, ear, nose, eye, injections. Inhalation - moist, dry, oxygen
therapy; local applications: hot, cold; Abbreviations used in prescription, Interpretation of
prescription; Dangerous Drugs Act.
Removal of drainage tubes, clips and stitches from wounds, care of colostomy wounds.
• Preparation and administration of I.V. therapy; Trolley for intravenous therapy e.g.
blood transfusion, infusion and drugs.
• Setting trays and trolleys for cardiac catheterization, positioning of patients with
cardiac problems etc.
• Positioning of patient with respiratory problems, use of suctioning machines, setting
trays and trolleys for special procedures e.g. thoracentesis, strapping

5. COURSE CONTENT
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Pre-operative preparation of patient for surgical procedure (psychological, skin
preparation, physiological)
• Education of patients and family on their condition and medications
• Setting of sterile strays and trolleys, and performing the following procedures
• Urethral catheterization (the procedure and care of indwelling catheter of males
and females)
• Passage of Naso-Gastric Tube
• Administration of oxygen (via the various oxygen delivery devise)
• Assessment of client for family planning services; Counselling clients for
informed choice of family planning methods; visiting client at home for follow ups.

6. WOUND
• Wound is the break in the
continuity of the skin

7. TYPE OF WOUNDS
WE HAVE INTENTIONAL AND UNINTENTIONAL WOUND.
INTENTIONAL WOUNDS
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Intentional wounds are as result of planned
therapy causes or examples. Surgical
incisions lumbar puncture, thoracentesis
and paracentesis.
Characteristics of intentional wounds
These wounds have clean edges,
bleeding is controlled
risk of infection is decreased
done under sterile conditions
UNINTENTIONAL WOUNDS
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Unintentional wounds are caused by
accidents, forceful injuries, burns and
scars.
Characteristics
wound edges are not clean
occur under unsterile conditions
bleeding is uncontrolled
could be multiple trauma

8. CARE OF SURGICAL WOUNDS
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Preparation of a trolley for wound dressing
Put on mask
Set a trolley
Wash hand thoroughly and put on disposable gloves
Clean shelves and the rails with soap and water. Rinse and dry.
Clean again with spirits to keep the trolley dry or use bleach of 1:10 to
clean and dry with spirit.
All sterile equipment are set on the top shelves and then non sterile
equipment on the bottom shelves.

9. TOP SHELF
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3 galipots for lotions
2 pairs of dressing forceps
2 pairs of dissecting forceps
1 sinus forceps
A probe
A stitch scissors
A kidney dish for cotton and gauze swabs
A clip removal forceps
A sterile dressing towel

10. BOTTOM SHELF
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Bottles of lotions e.g. normal saline, methylated spirit, povidone iodine,
hydrogen peroxide.
an adhesive or plaster
a pair of scissors
bandages
a covered receiver or a bowl with 1:10 bleach solution
A receptacle for soiled dressings
A mackintosh
Sterile gloves
Disposable gloves
Sterile packs in a drum or box
Face mask

11. PROCEDURE/STEPS FOR WOUND DRESSING
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Review the physician’s order and agency policy.
Inform and explain procedure to the patient
Put on face mask
Wash and dry hands
Ensure privacy
Move trolley to bedside
Wash your hands again and dry
Go to patient, ask the assistant to adjust the bed and position the patient comfortably
Avoid exposing the patient

12. PROCEDURE/STEPS FOR WOUND DRESSING
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Pour out lotions into the galipots
Assistant should remove the plaster and bandages and proceed to wash hands
Remove tape by pulling toward wound small sections at a time while holding down the skin in front of the tape. Prevents skin
breakdown and injury to newly formed tissue.
Remove soil dressings with dissecting forceps and discard
Assess wound.
Wash hands.
Open supplies and set up sterile field. Using aseptic technique, place fine mesh gauze into sterile container. Pour enough
solution into container.
Put on sterile gloves or pick up the instruments.
Clean and/or irrigate wound as ordered by physician, from center of wound outward using a new swab for each stroke.
Clean the wound with series of swabs or clean until the wound is clean

13. PROCEDURE/STEPS FOR WOUND DRESSING
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Apply enough dressing to ensure the wound is always dry
Apply your adhesive tapes or plaster and stroke your plaster with bandages
Assist patient to position of comfort and assess level of comfort and thank him/her for
cooperation
Remove your screen
Discard the trolley
Decontaminate, clean and disinfect your instruments
Wash your hands and dry
Record and report on the state of the wound

14. NOTE:
Dressing should be done after bed making, dusting, checking and recording of vital signs
No visitors allowed during wound dressing
Clean or incisional wounds should be done before working on the dirty wounds
Bandage from the distal to the proximal and from the proximal to the distal.

15. FREQUENCY OF WOUND DRESSING
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In the absence of slough, debris, feaces, devitalized tissue or infection in the
wound bed frequent wound dressing is not recommended because it may
damage newly formed capillaries and disrupt fragile new tissue growth.
The body perceive this as a new injury and re-initiate the inflammatory process.

16. FACTORS THAT PROMOTE WOUND HEALING
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Frequent dressing of infected wound
Aseptic techniques
Proper use of anti-biotic
Adequate rest and sleep
Adequate nutrition
Sufficient blood supply to the wound area

17. FACTORS THAT IMPAIRS WOUND HEALING
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Disease conditions like Coronary Artery Disease, Congestive Heart Failure, Peripheral Vascular Disease, Peripheral
Arterial Disease
Old age
Prolong use of some drugs e.g. corticosteroids
cancer
Poor aseptic technique
Smoking i.e. (hardens the blood vessels leading to arteriosclerosis)
Obesity
Inadequate nutrition
Foreign bodies
Necrotic tissues

18. ADVANTAGES OF WOUND DRESSING
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absorb drainage to promote wound healing
protect from mechanical injury
promote homeostasis
aid in wound edge approximation
prevent further trauma
prevent contamination from external environment
Provide physical, psychological and external comfort.

19. SUTURE
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A suture is a stitch or series of stitches made to secure apposition of the edges of a
surgical or accidental wound.
Types of suturing materials
These sutures are grouped into absorbable and non – absorbable
Examples of absorbable are facia, cutgut, kangaroo, ribbon gut and synthetic types
like polyglycolic acid, polydioxanone and caprolactone.
Examples of non – absorbable are silk, nylon, linen, wire silver, clips (thyroidectomy),
polyprophylene suture, polyamide suture. Clips are metal fastening used on the skin.
It can also be grouped into retention and skin sutures. The skin sutures are black
synthetic materials, clips wires etc.
Retention is used for obese people and dehiscence/gaping wounds. There are also
tension stitches.

20. SUTURES

21. TYPES OF SUTURES
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continuous suture
blanket sutures
subcuticular continuous suture
(done on skin)
simple interrupted suture
simple running suture
running locked suture
buried absorbable sutures
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interrupted vertical mattress
plain mattress
vertical mattress suture
figure of eight sutures
interrupted horizontal mattress
pulley suture
far- near near –far mattress suture
staples

22. LIGATURE (TIE)
• a free peace of sutured material of
considerable length about 10 – 15
inches, for the purpose of tying blood
vessels that have previously been
clamped by a forceps

23. SUTURING OF WOUNDS (LACERATIONS)
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Requirements
A sterile tray containing
Sterile gloves
Sterile towels
Suturing needles (curve, straight and cutting)
Needle holder
Tooth dissecting forceps
Dressings (gauze swabs clean lotion)
Strapping’s (celotape, plaster etc)
Local anaesthetic agent e.g. xylocaine
Syringe (5cc)

24. STEPS
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Explain procedure to the patient
Scrub hands and dry with a sterile towel
Wear sterile gloves
Clean area around the wound with antiseptic lotion
Protect area with sterile towel
Check for bleeding after cleaning and arrest haemorrhage with gauze swab
Tread needle with desire suture material, grab wound edge with dissecting forceps, pass the
treaded needle through the two sides of the wound making a reef knot and cut leaving 0.65 or ¼
inch from the knot. Then space stitches evenly, continue with stitches
Clean suture line with antiseptic
Apply dressing and strapping
Remove gloves, discard tray
Wash hands and document procedure.

25. ASSESSMENTS OF SURGICAL WOUNDS
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Inspection
Appearance – redness, wound edges, drainage tubes, signs of
dehiscence
Skin sutures – metal staple, status of sutures, drains and tubes
Pain – most important in terms of detecting complication and planning
for future wound care.
If the wound is extensive and discomfort seems to be related to dressing
removal of application, the nurse plans to administer analgesics before
dressing changes.
If discomfort is related to plaster removal, institute measures to relieve the
pain such as careful removal of the plaster

26. WOUND ASSESSMENT
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Related assessment – vital signs, WBC
Palpitation – the nurse gently applies finger tips along the wound edges. If
pressure causes wound to be expressed, the nurse notes the character of the
drainage. It may be necessary to collect the drainage for culture. Extreme
tenderness may indicate infection.
Signs of infection such as fever, chills or elevated white blood cells (WBC)

27. WOUND ASSESSMENT
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Assess patient for history for factors that impairs wound healing process
Tissue types – Assess characteristics, amount (document in percentage) & location
a. Necrotic Tissue – dead; non-viable
Slough – yellow, green, grey, nonviable (necrotic) tissue, usually lighter in color, thin, wet stringy
Eschar – black, brown, dry, nonviable (necrotic) tissue, usually darker in color, thicker, hard
b. Epithelial tissue – deep pink to pearly pink, light purple from edges in full thickness
wounds or may form islands in superficial wounds
c. Granulation tissue – beefy red, puffy or mounded bubbly appearance
d. Hypergranulation tissue – granulation tissue forms above the surface of the
surrounding epithelium. Delays epithelialization.

28. GRANULATION/EPITHELIAL TISSUE

29. ESCHAR/SLOUGH

30. COLOR
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Red – healthy, good blood flow
Pale pink – poor blood flow; ischemia, anemia
Purple – engorged; edema; excessive bioburden; trauma
Black or brown – nonviable, necrotic tissue
Yellow – nonviable, necrotic tissue
Gray – nonviable, necrotic tissue
Green – infection; nonviable tissue
White – ischemia; maceration, may be confused with bone or
fascia

31. EXUDATE
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a. Type
1) Serous – thin clear watery plasma (seen in partial thickness wounds/venous
ulcerations). Moderate to heavy amount may indicate heavy bio-burden or chronicity
due to sub-clinical infection. Normal in the acute inflammatory stage
2) Sanguinous – bloody (fresh bleeding) seen in deep partial thickness & full
thickness wounds during angiogenesis. Small amount normal in the acute
inflammatory stage.
3) Serosanguineous- thin, watery, pale red to pink, plasma with RBC‘s
4) Purulent – thick, opaque, tan, yellow, green or brown color, never in wound

32. AMOUNT
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b. normal
None – wound tissues dry
Scant – wound tissues moist, no measurable drainage
Small/minimal – wound tissues very moist/wet, drainage <25% of bandage
Moderate – wound tissues wet, drainage involves 25 – 75% bandage
Large/copious – wound tissues filled with fluid – involves >75% of bandage

33. ODOR
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a. Clean wound prior to assessment
b. Descriptors – strong, foul, pungent, fecal, musty, sweet
Presence of Foreign Bodies
Sutures, staples, drain tubes, hardware
Environmental debris (wood, metal, dirt, asphalt, etc.)

34. WOUND MEASUREMENT- LINEAR
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Always measure & document in centimeters and measure wound edge to edge in a
straight line. Always measure Length first then measure width and Document - Length x
Width x Depth
a. Length: Consider wound as face of clock. 12:00 points to patients head, 6:00 points
toward patient’s feet
b. Width = 3:00 – 9:00 side to side
c. Depth – distance from visible surface to the deepest area
Cotton tip applicator into deepest portion of wound
Grasp applicator with the thumb & forefinger at the point corresponding to the wounds
margin
Withdraw applicator while maintaining the position of the thumb and forefinger
Measure from tip of applicator to position against centimeter ruler

35. WOUND RULER AND PROBE

36. DOCUMENTATION OF SURGICAL WOUND
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sight of the incision e.g. abdominal incision
wound edges (well approximated)
edges of incision (oedematous)
dressing on wound – whether it is saturated with pus
solutions used
sterile technique used/applied
Example of wound documentation
Four inch midline abdominal incision cleaned with 0.9% sterile normal saline, wound
edges well approximated, skin sutures intact. Crust along suture line, edges of
incision slightly oedematous and dark pink. Penrose drain present in lower ¼ of
incision. Old dressing moderately saturated with serosanguinous drainage. New
dressing applied with sterile technique, using telfa for 4 x 4s and two ABPs applied
with non allergic tap.

37. COMPLICATIONS OF WOUND HEALING
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bleeding – detected by swelling or distention in the area. (haematoma)
Nursing management – greatest during the first 24hours after surgery haemorrhage
is an emergency:
Apply pressure dressing to the area
Monitor the clients vital signs (temperature, pulse, respirations and blood pressure)
Call the doctor if bleeding persist
Infection – change in wound colour, pain or drainage confirmed by performing
culture of the wound. Severe infection causes fever and elevated WBC.

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Dehiscence – the total or partial rupturing of a sutured wound usually
abdominal wound.
Evisceration – protrusion of internal viscera (organs) through an incision
caused by factors like obesity, poor nutrition, multiple and dehydration.
Nursing management – The wound should be supported by large sterile
dressings soaked in sterile normal saline.
Place the client in bed with knees bent to decrease pull on the incision
Notify the surgeon immediately for surgical repair

39. NURSING DIAGNOSIS
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Impaired skin integrity related to surgical incision (laparotomy)
High risk for infection related to
Assignment:
Pressure ulcer assessment (written)
Using a foam demonstrate suturing
Use Bates Jenson wound assessment tool to assess a wound with picture evidence
Total marks 15