NURSING TOOL BOX SERIES

HISTORY TAKING  IN MENTAL HEALTH   HISTORY TAKING  DEMOGRAPHIC DATA Name: Age: Sex: Address: Religion: TYPES OF ADMISSION PLANNED/VOLUNTARY ADMISSION : The patient agrees to come to the hospital and he is willing to take medication. When stable, the patient can be discharged. INVOLUNTARY ADMISSION/COMPULSORY ADMISSION: The patient is not willing to come to hospital, but he has to be admitted because he is a danger to self, family and community. Because the patient is forced to come to hospital, the family should pass through the magistrate to get the detention order so as to withdraw the patient’s rights temporarily for 2 weeks. The court order states reasons for admission and the patient should be kept in an enclosure. If the patient does not recover for 2 weeks, then the detention is revoked. If the patient recovers before 2 weeks, he should be kept on the ward until after 2 weeks. COURT ORDER ADMISSI

  *Glasgow Coma Scale* The Glasgow Coma Scale (GCS) is used to describe the general level of consciousness in patients with traumatic brain injury (TBI) and to define broad categories of head injury. [1] The GCS is divided into 3 categories, *eye opening* (E), *motor response* (M), and *verbal response* (V). The score is determined by the sum of the score in each of the 3 categories, with a maximum score of 15 and a minimum score of 3, as follows: *GCS score = E + M + V* *Eye opening scores:* 4: Spontaneously 3: To verbal command 2: To pain 1: No response *Best motor response scores:* 6: Obeys command 5: Localizes pain 4: Flexion withdrawal 3: Flexion abnormal (decorticate) 2: Extension (decerebrate) 1: No response *Best verbal response scores* 5: Oriented and converses 4: Disoriented and converses 3: Inappropriate words; cries 2: Incomprehensible sounds 1: No response *Interpretation* Patients who are intubated are unable to speak, and their verbal score cannot be assessed. They are e

  1. SEVERE PNEUMONIA OR VERY SEVERE DISEEASE Any general danger sign or chest indrawing or stridor in a calm child classifies this as severe pneumonia or very severe disease. NURSING INTERVENTIONS FOR SEVERE PNEUMONIA Manage the airway Clear a blocked nose. Use a plastic syringe (without a needle) to gently suck any secretions from the nose. Keep the infant warm Infants lose heat rapidly when wet, so keep them dry and warm.   If child is wheezing and you have a bronchodilator, give it. Treat fever If the child has an auxiliary temperature of 38.5*c or above, give Paracetamol every 6 hours. Antibiotics are very important for children with pneumonia, fever increases consumption of oxygen Manage fluids carefully Children with pneumonia or very severe disease can become overloaded with fluids. So give fluids cautiously. Children with pneumonia or very severe disease often lose water, especially if there is fever. If they can drink, give fluids by mouth. Encourage the caretaker to continue

  FEVER According to IMCI, a child with fever may have Malaria, Meningitis, Measles or another severe disease.   Causes of Malaria Ø   Plasmodium vivax Ø   Plasmodium Malariae Ø   Plasmodium Falciparum (more severe) Ø   Plasmodium Ovale.   Transmission of Malaria Malaria is transmitted by the bite of infected female Anopheles mosquito, which is found in dumpy, swampy, watery areas.   CLINICAL PICTURE Ø   Fever Ø   Headache Ø   Abdominal pains Ø   Nausea and Vomiting Ø   General body pains and body weakness.   NURSING MANAGEMENT Nurse will ask the parent or caretaker for a history of fever or if the child’s body feels hot. The child has a history of fever if child has had any fever with this illness. Measure the body temperature of all sick children or child in this case.       Find out if the child: Ø   Has history of fever. Ø   Feels hot, nurse should feel the child‘s stomach or under arm and determine if child feels hot. Ø   Has a