Hospital Corpsman 3 &
2: June 1989
Chapter 5: Patient Care
Naval Education and Training Command
Twentieth century advances in the medical and
technological sciences have made a significant impact on the
methods of marketing health care services. The numbers and kinds
of health care providers have expanded greatly. The consumers have
become more informed regarding both their health care needs and
expectations. Additionally, the consumers has become more vocal,
seeking answers for both the whats and whys of the entire spectrum
of health care services.
The goal of this chapter is to provide the hospital
corpsman with a limited amount of theory concerning the
multidisciplinary aspects of patient care. It is an introduction
to some of the more critical basic concepts applicable to
providing care to individuals whose physical or psychological
needs have motivated them to seek some kind of health care
Personnel seeking information concerning the how and
what to do regarding a specific procedure will find step-by-step
instructions in the Nursing Procedures Manual, NAVMED P-5066-A,
January 1985 edition. Use of both the Nursing Procedures Manual
and the Hospital Corpsman 3 & 2 Rate Training Manual will not
only assist the hospital corpsman in advancing in rate but more
importantly will prepare him or her to provide safe and effective
health care services. An additional and very important reference
is the Navy Customer Service Manual, NAVEDTRA 10119-B. It presents
the importance of proper attitude and its effect on everyday
performances and stresses the need for developing positive
attitudes in interpersonal relationships. The concepts in the Navy
Customer Service Manual integrate closely with the patient contact
Health and Illness
To intelligently and skillfully discharge your duties
as a member of the Navy Medical Department health care team, it
is critical that you first understand the concepts of health
The concept of health includes the physical, mental,
and emotional condition of a human being that provides for the
normal and proper performance of one's vital functions. Not
only is health the absence of disease or disability, but health
is also a state of soundness of the body, mind, and spirit.
On the other hand, the concept of illness includes
those conditions often accompanied by pain or discomfort that
inhibit a human being's ability to physically, mentally, or
emotionally perform in a normal and proper manner.
In most cultures when people need assistance in
maintaining their health, dealing with illness, or coping with
problems related to health and illness, they seek assistance
from personnel specialized in the fields of health care.
In chapter 1, the concepts of the health care team
were briefly introduced. Although physicians, nurses, and
hospital corpsmen are frequently referred to as the core team,
all health and allied health personnel comprise the total
health care team. Obviously, each member of the team uses his
or her skills differently, depending upon their personal,
professional, and technical preparation and experience.
Nevertheless, despite the differences in clinical expertise,
they all share one common objective; that is, to respond to the
consumer's health needs. The overall goal of this response is
to assist the consumer to maintain, sustain, restore, or
rehabilitate a physical or psychological function.
No discussion about health care or the health care team
would be complete without including the patient, often referred to
as the consumer. A patient may be defined as a human being under
the care of one or more of the health care providers. The patient
may or may not be hospitalized. However, regardless of their
health care needs or environmental disposition, they are the most
important part of the health care team. Without the patient, the
health care team has little, if any, reason for existence.
As a hospital corpsman, you are tasked to provide every
patient committed to your charge with the best care possible. This
care must reflect your belief in the value and dignity of every
person as an individual human being. Additionally, you must be
knowledgeable about both the patient's rights and responsibilities
as they apply to the providing and receiving of health care
The Joint Commission on Accreditation of Hospitals
(JCAH) has developed standards that address both the rights and
responsibilities of patients. Because the goal of JCAH is the
continual promotion of excellence in providing health care
services, these goals are compatible with those of the Navy
Medical Department. The following breakout is a brief summary of
some of the major rights and responsibilities of patients when
they enter into a relationship with a health care service
facility. Students seeking additional information are referred to
the Accreditation Manual for Hospitals that is published by the
Access to care
Respect and dignity
Privacy and confidentiality
Hospital (facility) rules and regulations
Provision of information
Compliance with instructions
Hospital (facility) rules and regulations
Respect and consideration
The above listing is in no way intended to be all
inclusive. It is, however, an introduction that emphasizes the
need for the observance of rights and responsibilities of patients
when they are engaged in a provider-consumer relationship.
The above listing is in no way intended to be all
inclusive. It is, however, an introduction that emphasizes the
need for the observance of rights and responsibilities of patients
when they are engaged in a provider-consumer relationship.
The word ethics is derived from the Greek "ethos" that
means custom or practice, a characteristic manner of acting, or a
more or less constant style of behavior in the deliberate actions
of people. When we speak of ethics, we refer to a set of rules or
a body of principles. Each social, religious, and professional
group has a body of principles or standards of conduct that
provide ethical guidance to its members.
During your indoctrination into the military, you were
introduced to the Code of the U.S. Fighting Forces. This code of
conduct is an ethical guide that charges you with certain high
standards of general behavior as a member of the Armed Forces.
All professional interactions must be directly related
to certain codes of behavior that support the universal principles
of justice, equality of human beings as persons, and respect for
the dignity of human beings. In chapter 1 of this manual,
professional ethics in relation to your responsibilities as a
hospital corpsman was briefly discussed. Upon completion of basic
Hospital Corps School, you took the following pledge.
"I solemnly pledge myself before God and these
witnesses to practice faithfully all of my duties as a
member of the Hospital Corps. I hold the care of the
sick and injured to be a privilege and a sacred trust
and will assist the Medical Officer with loyalty and
honesty. I will not knowingly permit harm to come to
any patient. I will not partake nor administer any
unauthorized medication. I will hold all personal
matters pertaining to the private lives of patients in
strict confidence. I dedicate my heart, mind, and
strength to the work before me. I shall do all within
my power to show in myself an example of all that is
honorable and good throughout my naval career."
The Hospital Corpsman Pledge morally binds you to
certain responsibilities and rules that are included in the
science of health care ethics. Health care ethics is not unique in
the development of methods, assumptions, and principles. Ethics,
whether they be classified general or special (e.g., legal or
medical), teach us how to judge accurately the moral rightness or
wrongness of our actions. The one element that makes health care
ethics different from general ethics is the inclusion of the moral
rule "Do your duty." This is a moral rule because it involves
expectations (e.g., confidentiality). It involves what others have
every reason to believe will be forthcoming. To fail in fulfilling
these expectations of others is to harm them. Through the Hospital
Corpsman Pledge, you committed yourself to fulfilling certain
duties, not only to those entrusted to your care but also to all
members of the health care team. It is this commitment to service
and to human beings that has traditionally distinguished the
United States Navy Hospital Corps wherever its members have
As a health care provider, you must be able to identify,
understand, master, and use various kinds of information and
scientific skills. In addition to information data and scientific
skills, it is also very important that you develop a special kind
of skill called interpersonal relations. In providing total
patient care, it is important that you see the individual not only
as a biological being but as a thinking, feeling person. Your
commitment to this concept is the key to the development of good
Simply stated, your interpersonal relationships are the
result of how you regard and respond to people. Many elements
influence the development of that regard and those responses. In
the following discussion, some of these elements will be discussed
as they apply to your involvement in the military service and your
relationships with other health care providers and the
Because of the cross-cultural nature and military
mission of the Navy Medical Department, you will frequently
encounter members of various cultures. Culture may be defined
as a group of socially learned, shared standards (norms) and
behavior patterns. Things such as perceptions, values, beliefs,
and goals are examples of shared norms; whereas health
practices, eating habits, and personal hygiene reflect common
behavior patterns of specific groups of people. An
understanding of common norms and behavior patters enhances the
quality and often quantity of service a provider is able to
make available. An individual's cultural background has an
effect on every area of health care services, ranging from a
simple technical procedure to the content and effectiveness of
health education activities. Becoming familiar with the beliefs
and practices of different cultural and subcultural groups (the
military community for example) is not only enriching to the
health care provider but promotes an understanding and
acceptance of the various peoples in the world community.
The term race is a classification assigned to a group
of people who share inherited physical characteristics. This
term becomes a socially significant reality since people tend
to attach great importance to assuming or designating a racial
identity. Information identifying racial affiliation can be an
asset to the health care provider in assessing the patient's
needs, carrying out direct care activities, and planning and
implementing patient education programs. Racial identification
has the potential to create a negative environment in the
health care setting when factors such as skin color differences
motivate prejudicial and segregational behaviors. When this is
permitted to occur, an environment that feeds a multitude of
social illnesses and destructive behaviors develops. In the
Navy Medical Department, no expressions or actions based on
prejudicial attitudes will be tolerated.
It is both a moral and legal responsibility of the
health care provider to render services with respect for the
life and human dignity of the individual without regard to
race, creed, sex, political views, or social status.
A large majority of people have some form of belief
system that guides many of their life decisions and to which
they turn to in times of distress. A person's religious beliefs
frequently help give meaning to suffering and illness; they
also may be helpful in the acceptance of future incapacities or
Close contact with illness and death can increase our
awareness of our own mortality and that of our patients. For
some there will be heightened religious involvement and for
others a sense of frustration or loneliness. It is important
for health care personnel to be aware of this to meet the needs
of patients, co-workers, and even ourselves. We must accept in
a nonjudgmental way the religious or nonreligious beliefs of
others as valid for them, even if we personally disagree with
such beliefs. Although we may offer religious support when
asked and should always provide chaplain referrals when
requested or indicated, it is not ethical for us to abuse our
patients by forcing our beliefs (or nonbeliefs) upon them. We
must respect their freedom of choice, offering our support for
whatever their needs or desires may be.
An individual is born either male or female and
learns roles and responses associated with their gender through
parental models, family relationships, and his or her specific
society. As one enters into the world of providing health care
services, it is necessary to learn and adopt new roles and
responses regarding gender identification. As the number of
females entering the military service increases, health care
providers are increasingly being challenged to expand their
functions in relation to caring for patients of the opposite
sex. The health care provider who has developed sound moral
principles and consciously strives to provide a service based
on a firm ethical foundation has little to fear when providing
care for an individual of either sex. However, the development
of such a foundation requires diligent study, a commitment to
growth, and an availability of professionally guided
experiences. Throughout your career as a member of the Hospital
Corps, you will be given opportunities and guidance to achieve
a sound ethical background. Your only responsibility toward
this growth is a desire and commitment to make yourself
available and respond as a real professional.
Because of the increasing frequency with which
hospital corpsmen are required to attend to persons of either
sex, the following guidelines are presented to assist you in
developing some decision-making judgments.
To ensure the protection of health care personnel
from unjustified accusations, a witness should be present when
a member of the opposite sex is being examined or treated.
Whether this witness is a member of the same sex as the patient
may be dictated by the availability of personnel. When you are
caring for a patient, sensitivity to both verbal and nonverbal
communication is paramount. A grin, a frown, or an expression
of surprise may all be misinterpreted by the patient.
Explanations and reassurances will go far in preventing
misunderstandings of actions or intentions. Knowledge, empathy,
and mature judgment should guide the care provided to any
patient; this is especially crucial when the care involves
touching. As a member of the health care team, you are
responsible for providing complete, quality care to all who
need and seek your service. This care must be provided in a
manner compatible with your individual legal and technical
Communication is a highly complicated interpersonal
process of people relating to each other through conversation,
writing, gestures, appearance, behavior, and at times, even
silence. Such interpersonal relating not only occurs among health
care providers and patients but also between health care providers
and support personnel. Some of these support personnel include
housekeeping, maintenance, security, supply, and food service
staff. Another critical communication interaction occurs among
health care providers and visitors. Because of the critical nature
of communication in health care delivery, it is important that the
hospital corpsman understand the communication process and the
techniques used to promote open, honest, and effective
interactions. It is only through effective communication that the
health care provider is able to identify the goals of the
individual and the Navy health care system.
The human communication process consists of four basic
parts: the sender of the message, the message, the receiver of the
message, and the feedback. The sender of the message starts the
The receiver is that individual intended to receive the
message. The message is that body of information the sender wishes
to transmit to the receiver. Feedback is the response given by the
receiver to the message. It can be a way of validating that
effective communication has taken place.
There are two basic modes of communication; verbal and
nonverbal. Verbal communication is that which is spoken or
written. A characteristic that distinguishes the verbal from the
nonverbal is that verbal communication involves the use of words.
Nonverbal communication, on the other hand, does not involve the
use of words. Dress, gestures, touching, body language, face and
eye behavior, and even silence are forms of nonverbal
communication. It should be remembered that even though there are
two forms of communication, both the verbal and nonverbal are
inseparable in the total communication process. Conscious
awareness of this aspect is extremely important for the health
care provider whose professional effectiveness is highly dependent
upon successful communication.
Ineffective communication occurs when obstacles or
barriers are present. These barriers can be classified as
physiological, physical, or psychosocial. Physiological barriers
are those that result from some kind of sensory dysfunction on the
part of either the sender or the receiver. Such things as hearing
impairments, speech defects, and even vision problems influence
the effectiveness of communication. Physical barriers consist of
elements in the environment (such as noise) that frequently
contribute to the development of physiological barriers (such as
inability to hear). The final kind of obstacle, called
psychosocial barriers, are usually the result of one's inaccurate
perception of self or others, the presence of some defense
mechanism an individual employs to cope with some form of
threatening anxiety, or factors such as age, education, culture,
language, nationality, and a multitude of other socioeconomic
factors. This last category of barriers is the most difficult to
identify and the most common cause of communication failure or
Listening is a critical element of the communication
process and becomes a primary activity for the health care
provider who must use communication as a tool for collecting or
giving information. When one is engaged in listening, it is
important to direct attention to both the verbal and nonverbal
cues provided by the other person. Like many other skills
necessary for providing a health care service, the skill of
listening requires conscious effort and constant practice.
Listening skill can be improved and enhanced by developing the
following attitudes and skills:
Want to listen.
Develop your interests and knowledge.
Look at the content of the message.
Hear the speaker out.
Focus on ideas.
Remove or adjust distractions.
Concentrate on the immediate interaction.
As a health care provider, you will be using the
communication process to service a consumer's needs. Briefly,
these needs can be classified as either short-term or long-term.
To simplify this discussion, short-term needs of communication
will be discussed under the heading of "contact point. " Long-term
needs will be discussed under the heading of "therapeutic
To provide you with a frame of reference for the
following discussion, the following definitions will clarify
and standardize some critical terms:
Initial contact point-a physical location where the
consumer experiences his or her first communication
encounter with a person representing, in some role, the
health care facility.
Contact point-the place or event where the contact point
person and the consumer meet. The contact point meeting can
occur anywhere in a facility and also includes telephone
Contact point person-the health care provider in any
health care experience who is tasked by role and
responsibility to provide a service to the consumer.
The contact point person has certain criteria to meet
in establishing a good relationship with the patient. Helping
the patient through trying experiences is partially the
responsibility of all contact point personnel. Such health care
providers must not only have skills related to their
professional assignment, but they must also have the ability to
interact in a positive, meaningful way to communicate concern
and the desire to provide a service.
Consumers of health care services expect to be
treated promptly, courteously, and correctly. They expect their
care to be personalized and communicated to them in terms they
understand. The Navy health care system is a service system,
and it is the responsibility of every health care provider to
improve the professional nature of the system.
The significance of the contact point and the
responsibility of the personnel staffing these areas are
important to emphasize. The following message from a former
Surgeon General of the Navy reflects the philosophy of the Navy
Medical Department regarding contact point interactions.
"Some of the most frequent complaints received
by the Bureau of Medicine and Surgery [now
known as Commander, Naval Education and Training Command] are
those pertaining to the lack of courtesy, tact, and
sympathetic regard for patients and their families
exhibited by Medical Department personnel at
initial points of contact within Navy Medical
facilities. These points of initial patient
contact, which include central appointment desks,
telephones, patient affairs offices, emergency
rooms, pharmacies, laboratories, records offices,
information desks, walk-in and specialty clinics,
and gate guards, are critical in conveying to the
entering patient the sense that Navy Medicine is
there to help them. The personnel, both military
and civilian, who man these critical areas are
responsible for ensuring that the assistance that
they provide is truly reflective of the spirit of
"caring" for which the Navy Medical Department must
No matter how excellent and expert the care in
the facility may be, an early impression of
nonchalance, disregard, rudeness, or neglect of the
needs of patients reflects poorly on its efforts
and achievements. Our personnel must be constantly
on their guard to refrain from off-hand remarks or
jokes in the presence of patients or their
families. We must insist that our personnel in all
patient areas are professional in their attitudes.
What may be commonplace to us may be to a patient
frightening or subject to misinterpretation.
By example and precept, we must insist that, in
dealing with our beneficiaries, no complaint is
ever too trivial not to deserve the best response
of which we are capable. . . . "
As mentioned earlier in this chapter, a
distinguishing aspect of therapeutic communication is its
application to long-term communication interactions.
Therapeutic communication may be defined as the face-to-face
process of interacting that focuses on advancing the physical
and emotional well-being of a patient. This kind of
communication has three general purposes: collecting
information to determine illness, assessing and modifying
behavior, and providing health education. In the process of
using therapeutic communication, we attempt to learn as much as
we can about the patient in relation to the illness. To
accomplish this, both the sender and the receiver must be
consciously aware of the confidentiality of the information
disclosed and received during this process. The health care
provider must always have a therapeutic reason for invading the
When used to collect information, therapeutic
communication requires a great deal of sensitivity and
expertise in using interviewing skills. To ensure the
identification and clarification of thoughts and feelings, the
interview must include observing behavior, listening, giving
and receiving verbal and nonverbal responses, and interpreting
and recording data.
Observation of behavior is simply the recognition of
any sign the body makes when responding to a need. The
quivering, excited tone of voice you hear when a mother rushes
into the emergency room after her child has swallowed bleach is
communicating fear and anxiety.
Listening is probably one of the most difficult
skills to master. It requires the health care provider to
maintain an open mind, eliminate both internal and external
noise and distractions, and channel attention to all verbal and
nonverbal messages. Listening involves the ability to recognize
pitch and tone of voice, evaluate vocabulary and choice of
words, and recognize hesitancy or intensity of speech as part
of the total communication attempt. The patient crying aloud
for help after a fall is communicating a need for assistance,
which is different from the way you might sound in
communicating a need for assistance in requesting help to
transcribe a physician's order.
The ability to recognize and interpret nonverbal
responses depends upon consistent development of observation
skills. As you continue to mature in your role and
responsibilities as a member of the health care team, both your
clinical knowledge and understanding of human behavior will
also grow. Your growth in both knowledge and understanding will
contribute to your ability to recognize and interpret many
kinds of nonverbal communication. Your sensitivity in listening
with your eyes will become as refined as, if not better than,
listening with your ears.
The effectiveness of an interview is influenced by
both the amount of information and degree of motivation
possessed by the consumer (interviewee). Factors that enhance
the quality of an interview consist of the participant's
knowledge of the subject under consideration, their patience,
temperament, listening skills, and attention to both verbal and
nonverbal cues. Courtesy, understanding, and nonjudgmental
attitudes must be mutual goals of both the interviewee and the
interviewer. Finally, the health care provider must be an
informed and skilled practitioner to function effectively in
the therapeutic communication process. This kind of provider
development requires an individual's commitment to consistently
seek out and participate in a variety of continuing education
learning experiences related to the entire spectrum of health
Assessing and Reporting
Although the physician determines the overall medical
management of the person requiring health care services, he or she
depends upon the assistance of other members of the health care
team in implementing and evaluating the patient's ongoing
treatment. Nurses and hospital corpsmen spend more time with the
hospitalized patient than all other providers. This places them in
a key position as data collecting and reporting resource
The systematic gathering of information is called data
collection and is an essential aspect in assessing an individual's
health status, identifying existing problems, and developing a
combined plan of action to assist the patient in his or her health
needs. The initial assessment is usually accomplished by
establishing a health history. Included in this history are
elements such as previous and current health problems; patterns of
daily living activities, medication, and dietary requirements; and
other relevant occupational, social, and psychological data.
Additionally, both subjective and objective observations are
included in both the initial assessment gathering interview and
throughout the course of hospitalization.
Subjective observations, which include symptoms, consist
of the verbal information given to the provider by the patient or
a significant other person. These include such things as a
description of pain or discomfort, the presence of nausea or
dizziness, and a multitude of other descriptions of dysfunction,
discomfort,' or illness.
Objective observations, which may also include symptoms,
are those that can be actually seen, heard, touched, felt, or
smelled by the health care, provider. Included in objective
observations are measurements such as temperature, pulse,
respiration, skin color, swelling, and even the results of
Intelligent assessments are the result of accurate
observations that require a combination of theoretical insight and
perfected skills, both of which require a constant effort towards
professional development in the provider. Accurate and intelligent
assessments are the basis of good patient care and are essential
elements for providing a total health care service. As such,
hospital corpsmen must know what to watch for and what to expect.
It is important to be able to recognize even the slightest change
in a patient's condition, since this may indicate a definite
improvement or deterioration. Health care providers must be able
to recognize the desired effects of medications and treatments, as
well as undesirable reactions to them. Both of these factors may
influence the physician's decision to continue, modify, or
discontinue parts or all of the treatment plan.
Equally as important as assessments is the reporting of
these data to appropriate team members. Reporting consists of both
vocal and written communications and to be effective must be done
accurately, completely, and in a timely manner. Written reporting,
commonly called recording, is documented in the patient's record.
Maintaining an accurate, descriptive clinical record serves a dual
purpose. It provides a written report of the information gathered
about the patient and serves as a means of communication to all
those involved in the patient's care. The record also serves as a
valuable source of information for the development of a variety of
care-planning activities. Additionally, the clinical record is a
legal document and is admissible as evidence in a court of law in
claims of negligence and malpractice. Finally, these record serve
as an important source of material that can be used for educating
and training health care personnel and for compiling research and
It is imperative that the health care provider follows
some basic guidelines when making written entries in the record.
All entries must be recorded accurately and truthfully. The
omission of an entry is as inaccurate as an incorrect recording.
Each entry should be concise and brief; therefore, extra words and
vague notations are to be avoided. Recordings must be legible; if
an error is made, it must be deleted following the standard Navy
policy for correcting erroneous written notations. Lastly, all
health care providers making entries in the clinical record must
indicate the time and date and sign their name and rate or
The following self-questioning technique is a good guide
to assist you in developing proficiency in assessing and reporting
Is the patient
of average build, short, tall, thin, or obese?
apparently in pain?
walking with a limp, wearing a cast, walking on
crutches, or wearing a prosthetic extremity?
Does the patient
appear worried, nervous, excited, depressed, angry,
oriented, confused, or unconscious?
refuse to talk?
connect thoughts appropriately?
lisp, stutter, or have slurred speech?
appear sullen, bored, aggressive, friendly, or
sleep well or arouse early?
sleep poorly, moan, talk, or cry out when
join in ward activities?
react well toward other patients, staff, and
Does the patient
remain in one position in bed?
have difficulty breathing while in any position?
use just one pillow or require more to sleep
move about in bed without difficulty?
Is the patient's skin
flushed, pale, cyanotic, hot, moist, clammy, cool, or
bruised, scarred, lacerated, scratched, or showing a
rash, lumps, or ulcerations?
showing signs of pressure, redness, mottling, edema,
or pitting edema?
appearing shiny or stretched?
infested with lice?
Are the eyelids swollen, bruised, discolored, or
Is the sclera clear, dull, yellow, or bloodshot?
Are the pupils constricted or dilated; are they equal in
size; do they react equally to light?
Does the patient complain about pain; burning; itching;
sensitivity to light; or blurred, double, or lack of
Are the eyes tearing or showing signs of inflammation or
Does the patient
hear well bilaterally?
hold or pull on his or her ears?
complain of a buzzing or ringing sound?
have a discharge or wax accumulation?
complain of pain?
Is the nose bruised, bleeding, or difficult to breathe
Is it excessively dry or dripping?
Are both nares equal in size?
Does the patient sniff excessively?
Is the mouth excessively dry?
Does the breath smell sweet, sour, or alcoholic?
Does the tongue appear dry, moist, clean, coated,
cracked, red, or swollen?
Are the gums inflamed, ulcerated, swollen, or
Are the teeth white, discolored, broken, or absent?
Does the patient:
wear dentures, braces, or partial plates?
complain of mouth pain or ulcerations?
complain of an unpleasant taste?
Does the patient have shortness of breath, wheezing,
gasping, or noisy respirations?
Does he or she cough?
If coughing, is it dry, moist, hacking, productive,
deep, or persistent?
Is the sputum white, yellow, rusty, or bloody?
Does the patient complain of chest pain?
Where is the pain?
Is the pain a dull ache, sharp, crushing, or
Is the pain relieved by resting?
Is the patient using medication to control the pain
Does the abdomen look or feel distended, boardlike, or
If distended, is the distention above or below the
umbilicus or over the entire abdomen?
Does the patient belch excessively?
Is the patient nauseated or vomiting?
If so, how often and when?
What is the volume, consistency, and odor of the
Is it coffee ground, bilious, or bloody in
Is it projectile?
Bladder and Bowel:
Is the patient incontinent of urine or stool?
What is the volume and frequency of urination?
Does the urine have an odor?
Is it dark amber or bloody?
Is it cloudy; does it have sediment in it?
Is there pain, burning, or difficulty when
Does the patient have diarrhea, soft stools, or
What is the color of the stool?
Does it contain blood, pus, fat, or worms?
Does the patient have hemorrhoids, fistulas, or
Vagina or Penis:
Food and Fluid Intake:
Is the patient's appetite good, fair, or poor?
Does the patient get thirsty often?
Does the patient have any kind of food intolerance?
As mentioned earlier in this chapter, patient
education (health education) is an essential part of the health
care delivery system. In the Navy Medical Department, patient
education is defined as "the process that informs, motivates,
and helps people to adapt and maintain healthful practices and
life styles." Specifically, the goals of this process are:
To assist individuals to acquire knowledge and skills
that will promote their ability to care for themselves more
To influence individual attitudinal changes from a
disease to a health orientation
To support behavioral changes to the extent that
individuals are willing and able to maintain their
All health care providers, whether they recognize it
or not, are teaching almost constantly. Teaching is a unique
skill that is developed through the application of principles
of learning. Patient teaching begins with an assessment of the
patient's knowledge. Through this assessment, learning needs
are identified. For example, a diabetic patient may have a need
to learn how to self-administer an injection. After the
learner's needs have been established, goals and objectives are
developed. Objectives inform the learner of what kind of
(learned) behavior is expected. Objectives also assist the
health care provider in determining how effective the teaching
has been. These basic principles of teaching/learning are
applicable to all patient-education activities, from the simple
procedure of teaching a patient how to measure and record his
or her fluid intake/output to the more complex programs of
behavior modification in situations of substance abuse (i.e.,
drug or alcohol) or weight control.
As a member of the health care team, you share a
responsibility with all other members of the team to be alert
to patient education needs, to undertake patient teaching
within the limitation of your own knowledge and skills, and to
communicate to other team members the need for patient
education in areas you are not personally qualified to
Each member of the health care team has certain
responsibilities and limitations that define their area of
practice. To fulfill your role as a member of the Hospital Corps
within the context of the total mission of the Navy Medical
Department, it is imperative that your practice be based on a
sound body of knowledge and the development of well-defined
technical skills. The rate training manuals are one mechanism that
contribute to the development of your body of knowledge. The
occupational standards define minimal technical skills required of
hospital corpsmen at various levels in their career. Other members
of the health care team through the mechanism of on-the-job
training, inservice classes, and continuing education programs
con- tribute significantly to your continued growth in both health
care knowledge and skills.
In conjunction with their professional responsibilities,
all health care providers must realize that they are subject to
certain limitations in providing health care services. These
limitations are based on amount and kind of education, training,
experience, and local regulations and guidelines. It is the
mature, responsible individual who recognizes, accepts, and
demands that these limitations be respected. In clinical settings,
hospital corpsmen are tasked with administering medication,
performing treatments, and providing individual patient care in
compliance with a physician's orders. In the hospital and some
clinical environments, a Nurse Corps officer divides and delegates
portions of the patient's care to other members of the team based
on the skills and experience of each. In situations where a Nurse
Corps officer is not a member of the team, such delegation of
duties will generally be made by a senior and experienced petty
officer of the Hospital Corps.
Regardless of rank, rate, or corps membership, all
members of the health care team are held accountable for their
performance. Accountable means to be held answerable. As a health
care provider, you must continue to acquire new knowledge and
skills and strive for professional proficiency. Equally important
is your ability to apply new knowledge and acquired skills as a
helping professional in providing total health care.
Accountability becomes a critical issue when determining
incidents of malpractice. Malpractice occurs when an individual
delivers improper care due to negligence or practicing outside of
his or her area of expertise. Because the areas of expertise and
responsibility in medicine are frequently overlapping, legal
limits of practice are defined by each state. The assignments and
responsibilities of hospital corpsmen frequently include areas of
practice usually provided by physicians and nurses in the civilian
sector. These responsibilities are only legal when hospital
corpsmen are performing such duties while under the authority of
the United States Government. Because of this, it is vital that
you thoroughly understand your legal rights and limitations when
providing patient care services both in government and civilian
Another area that has potential medicolegal implications
regarding your role as health care provider consists of giving
advice or opinions. As a result of your frequent and close contact
with patients, you will often be asked your opinion of the care or
the proposed care a patient is undergoing. For the most part,
these questions are extremely difficult to respond to, regardless
of who the health care provider is. No one is ever totally
prepared or has so much wisdom that they can respond spontaneously
in such situation. In such cases, it is best to refer the question
to the nurse or physician responsible for the patient's care.
You must always be conscious that you are seen as a
representative of Navy medicine by the recipients of your care. As
such, you will be accorded the respect that goes with having a
specialized body of knowledge and an inventory of unique skills. A
caduceus on the sleeve of the hospital corpsman marks that person
as a member of a prestigious corps worthy of respect. How one
responds to this respect will quickly determine whether the
individual will continue to earn it.
Remember, you have been charged to provide care to a
total, feeling, human person. The person seeking health care
service has the same needs for security, safety, love, respect,
and self-fulfillment as everyone else. When something threatens
the soundness of the body, mind, or spirit, an individual
frequently behaves inappropriately. Occasionally there are temper
outbursts, episodes of pouting, sarcastic remarks, unreasonable
demands, or other inappropriate responses, often to the point of
disruptive behavior. The health care provider is challenged to
look beyond the behavior being displayed to identify the
underlying stress and to attempt to relieve the immediate and
obvious source of anxiety. This is as simple as communicating,
through your care and understanding of the patient as an
individual, that Navy medicine is pleased to provide a caring
In the introductory section of this chapter, we
established the primary goal of the health care provider as
maintaining, sustaining, restoring, and rehabilitating a physical
or psychological function of the consumer. To achieve this goal,
health care facilities and providers are charged with developing
policies and implementing mechanisms that ensure safe, efficient,
and therapeutically effective care. The theme of this discussion
is safety and will address the major aspects of both environmental
and personal safety.
For purposes of this discussion, the environment is
defined as the physical surroundings of the patient and
includes such things as lighting, equipment, supplies,
chemicals, architectural structure, and the ever present
accident potential activities of both patient and staff
personnel. Maintaining safety becomes even more difficult when
working with people who are ill or anxious and cannot exercise
their usual control over the environment. Loss of strength,
decreased sensory input, and disability often accompany
illness. Because of this, the health care provider must be
constantly alert and responsive to maintaining a safe
Both JCAH and the National Safety Council of the
American Hospital Association (AHA) have identified four major
types of accidents that continually occur to patients. These
hazards consist of falls, electrical shocks, physical and
chemical burns, fires, and explosions. The most basic of
hospital equipment, the patient's bed, is a common cause of
falls. Falls occur among oriented patients getting in and out
of bed at night in situations where there is inadequate
lighting. Falls occur among disoriented or confused bed
patients when bedrails are not used or used improperly.
Slippery or cluttered floors contribute to patient, staff, and
even visitor falls. Patients with physical limitations or those
being treated with sensory altering medications fall when
attempting to ambulate without proper assistance. Falls result
from running in passageways, carelessness when going around
blind corners, and personnel and equipment collisions.
Unattended and improperly secured patients fall from gurneys
Health care personnel can do much to prevent the
incident of falls by following some simple procedures, such as
properly using side rails on beds, gurneys, and cribs; and
locking the wheels of gurneys and wheelchairs when transferring
a patient or leaving one unattended. Safety straps must also be
used to secure patients on gurneys as well as those in
wheelchairs. Maintaining dry and uncluttered floors markedly
reduces the number of accidental falls. Patients with physical
or sensory deficiencies should always be assisted during
ambulation. Those using crutches, canes, or walkers must
receive adequate instructions in ambulating with the aids
before being permitted to ambulate independently. The total
care environment must be equipped with adequate night lights to
assist orientation and to prevent falls resulting from an
inability to see potential hazards.
The expanded variety, quantity, and complexity of
electrical and electronic equipment used for diagnostic and
therapeutic care has markedly increased the hazards of burns,
shock, explosions, and fire. It is imperative that health care
providers at all levels be alert to such hazards and exert a
continued effort to maintain an electrically safe environment.
Knowledge and adherence to the following guidelines will
contribute markedly to providing an electrically safe
environment for all personnel whether they be patients, staff,
Do not use electrical equipment with damaged plugs or
Do not attempt to repair defective equipment.
Do not use electrical equipment unless it is properly
grounded with a three-wire cord and three-prong plug.
Do not use extension cords or plug adapters unless
approved by medical repair or the safety officer.
Do not create a trip hazard by passing electrical cords
across doorways or walkways.
Do not remove a plug from the receptacle by gripping the
Do not allow the use of personal electrical appliances
without approval of the safety officer.
Do not put water on an electrical fire.
Do not work with electrical equipment with wet hands or
Have newly purchased electronic medical equipment tested
for electrical safety by medical repair before putting it
Operate all electrical and electronic equipment
according to manufacturer's instructions.
Remove from service electrical equipment that sparks,
smokes, or give a slight shock. Tag defective equipment and
Be aware that patients with intravenous therapy and
electronic monitoring equipment are at high risk from minor
Call medical repair when equipment is not functioning
properly or public works if there is difficulty with the
power distribution system.
Since accidents resulting in physical and chemical
burns have initiated numerous consumer claims of health care
provider and facility malpractice, all health care personnel
must be thoroughly indoctrinated in the proper use of potential
hazardous equipment, supplies, and chemicals.
The following discussion will address common causes
and precautions to be taken to eliminate the occurrence of
injurious burns. Additional information regarding the equipment
and specific procedure for its use will be found in the Nursing
Hot water bottles-a common cause of burns particularly
in the elderly, diabetics, and patients with circulatory
impairments. When you are filling the bottle, the water
temperature must never exceed 125 degrees F (51 degrees C).
Test the bottle for leaks and cover it so that there is a
protective layer of cloth between the patient and the bottle
Heating pads-these appliances create a dual hazard of
potential burns and electrical shock. The precautions taken
when using heating pads are the same ones used for hot water
bottles in relation to the kind of patient, temperature
control, and protective cloth padding. Precautions to avoid
shock consist of proper maintenance of the equipment, preuse
inspections and testing of the equipment for wiring and plug
defects, and periodic safety inspections that are conducted
by medical repair personnel.
Ice bags-like hot water bottles, ice bags can cause skin
contact burns. This kind of burn is commonly referred to as
local frostbite. The precautions taken for applying ice bags
are the same as those for hot water bottles in regard to
attention to elderly, diabetic, and circulatory-impaired
Hypothermia blankets-like ice bags, this mode of therapy
can also cause areas of contact burns. When using
hypothermia blankets, check the patient's skin frequently
for signs of marked discoloration, indicating indirect
localized tissue damage. Ensure that the bare blanket does
not come in direct contact with the patient's unprotected
skin. This is easily accomplished by using sheets or cotton
blankets between the patient and the hypothermia blanket
itself. When using this form of therapy, follow both the
physician's orders and the manufacturer's instructions in
managing the temperature control of the equipment.
Heat cradles-when using this equipment, protect
the patient from burns resulting from overexposure or
placement of the equipment too close to the area of the
patient being treated. As with heating pads, heat cradles
create a dual hazard such as potential burns and electrical
shock. Another hazard to keep in mind is that of fire.
Ensure that the bedding and the heat source do not come in
direct contact and cause the bedding to ignite. Occasionally
heat lamps will be used to accomplish the same results as a
heat cradle. Do not use towels, pillow cases, or linen of
any kind to drape over heat lamps. In fact, no lamps of any
kind should be draped with any kind of material, regardless
of what purpose the draping is intended to accomplish.
Steam vaporizers, hot foods, and liquids-these are
common causes of patient burns. When using steam vaporizers,
ensure that the vapor of steam does not flow directly on the
patient as a result of the initial positioning of the
equipment or by accidental movement or bumping. Patients may
be more sensitive to hot foods and liquids and more likely
burned. Also, due to lack of coordination, weakness, or
medication, patients may be less able to handle hot foods
and liquids safely without spilling.
In the direct patient care units as well as in
diagnostic and treatment areas, there are unlimited potentials
for inflicting burns on patients. When modern electrical and
electronic equipment and potent chemicals used for diagnosis
and treatment are used properly they contribute to the
patient's recovery and rehabilitation. When these are used
carelessly or improperly, these same sources only cause the
patient additional pain and discomfort, serious illness, and,
in some cases, even death.
Often when we speak of safety measures, one of our
first thoughts is of a fire or an explosion involving the loss
of life or injury to a number of people. Good housekeeping,
maintenance, and discipline help to prevent such mishaps.
Remember that buildings that are constructed of fire-resistant
materials are not fireproof, and certainly not explosion proof.
Good maintenance includes checking, reporting, and ensuring
correct repair of electrical equipment, and routine checking of
fire fighting equipment by qualified personnel. The education
and training of personnel are the most effective means of
preventing fires. Used in the context of fire safety measures,
good discipline means having a plan to use as outlined in a
Fire Bill, having periodic fire drills, and enforcing
Staff members should be familiar with the fire
regulations at their duty station and know what to do in case
of fire. This includes how to report a fire, use a fire
extinguisher, and evacuate patients. When a fire occurs, there
are certain basic rules to follow: someone must take charge,
remain calm, and notify the fire department and the officer of
the day, giving the exact location of the fire. All oxygen
equipment and electrical appliances must be turned off unless
necessary to sustain life. All windows and doors should be
closed and all possible exits clear. All patients must be
removed in a calm and orderly fashion, and mustered.
Careless handling of cigarettes is one of the most
frequent causes of serious and often fatal accidents.
Cigarettes and matches must be removed from the bedside or
placed out of reach of the incompetent or irrational patient.
Regulations should specify areas and times when smoking is
permitted. Patients, visitors, and staff must be informed of
the facility's smoking regulations. To be an effective safety
measure, these regulations must be enforced by all staff
personnel. Smoking stands and ashtrays should be provided only
in areas where smoking is permitted. Metal wastebaskets must be
used throughout the hospital. They should NEVER be placed under
the bed or used for cigarette disposal. "NO SMOKING" signs
should be visibly displayed in rooms and areas where oxygen and
flammable agents are used or stored. In addition to posting NO
SMOKING signs, ALL staff must impress upon the patient and
visitors the life-threatening dangers of disobeying or ignoring
General Safety Guidelines
In addition to the specifics already presented above,
there are some basic principles that are relevant to patient
safety. The following concepts should direct the actions of the
provider in any health care service environment.
Familiarity with the environment makes it less hazardous
to the individual.
An individual's body senses inform him or her about the
nature of the environment.
Age and illness affect an individual's ability to
perceive and interpret sensory stimuli from the
All diagnostic and therapeutic measures have the
potential to cause a patient harm.
Documenting and analyzing all accidents and incidents
are necessary to identify and correct high-risk safety
Today's public is very much aware of the environment and
its effect on the health and comfort of human beings. The health
care setting is a unique environment and has a distinct character
of its own. The health care provider must be aware of that
character and ensure that the environment is one that will support
the optimum in health maintenance, care, and rehabilitation.
In the context of the environment, hygiene may best be
described as those practices that are conducive to providing a
healthy environment. Basically, this includes the following three
areas of concern: safety (which has already been addressed),
environmental comfort and stimuli, and finally infection control
(which will be discussed under "Pathogenic Organism Control"). The
health care provider has certain responsibilities to control the
facility's general environment as well as the patient's immediate
Maintaining cleanliness not only provides for patient
comfort and a positive stimulus, it also impacts on infection
control. Cleanliness is a major responsibility of all members of
the health care team, regardless of their position on the team. As
a provider, the hospital corpsman, who has the most direct and
frequent contact with the patient, becomes very familiar with
concurrent and terminal cleaning. Concurrent cleaning ensures that
the patient's individual unit is kept neat and clean during
hospitalization. Terminal cleaning is performed when the patient
is discharged from the unit or hospital. Both concurrent and
terminal cleaning are extremely important procedures that not only
aid the patient's comfort and psychological outlook but also
contribute to both efficient physical care and control of the
complications of illness and injury.
Aesthetically, an uncluttered look is far more appealing
to the eye than an untidy one. Other environmental factors such as
color and noise can also enhance or hinder the progress of a
person's physical condition. At one time almost all health care
facilities used white as a basic color for walls and even bedside
equipment. Research has shown that the use of color is quieting
and restful to the patient, and rest is a very important healing
agent in any kind of illness. Noise control is another
environmental aspect that requires the health care provider's
constant attention. The usual number of people and equipment
traffic in a facility creates a high noise level and must be
monitored. Add to that the noise of multiple radios and
televisions, and it is understandable why noise control is
necessary if a healing environment is to be created and
Another important aspect of environmental hygiene is
climate control. Many facilities use air-conditioning or similar
control systems to maintain proper ventilation, humidity, and
temperature control. In facilities without airconditioning, open
windows from the top and bottom to provide for cross ventilation.
Ensure that the patient is not located in a draft area. Windowsill
deflectors or patient screens are often used to redirect drafty
airflows. Maintain facility temperatures at recommended energy
conservation levels that are also acceptable as health promoting
temperatures. In addition to maintaining a healthy climate, good
ventilation is necessary in controlling and eliminating
disagreeable odors. In cases where airflow does not control odors,
room fresheners should be discretely used. Offensive
odor-producing articles such as soiled dressings, used bedpans,
and urinals should be removed to appropriate disposal and
disinfecting areas as rapidly as possible. Objectionable odors
such as bad breath or perspiration are best controlled by proper
personal hygiene and clean clothing.
Natural light is important in the care of the sick.
Sunlight usually brightens the area and helps to improve the
mental well-being of the patient. However, light can be a source
of irritation if it shines directly in the patient's eyes or
produces a glare from the furniture, linen, or walls. Adjust
shades or blinds for the patient's comfort. Artificial light
should be strong enough to prevent eyestrain and diffuse enough to
prevent glare. Whenever possible, provide a bedlamp for the
patient. As discussed under "Safety Aspects," a dim light is
valuable as a comfort and safety measure at night. It should be
situated so it will not shine in the patient's eyes and yet
provide sufficient light along the floor so that all obstructions
can be seen. A night light may help orient elderly patients if
they are confused as to their surroundings upon awakening.
In conclusion, it is important that the health care
provider understand the effects of the environment on the patient.
Most persons are more sensitive to excessive stimuli in the
environment when they are ill and often become irritable and
unable to cooperate in their care because of these excesses. This
is because their body is already under stress due to their illness
and does not have the energy to cope with added stimuli. This is
particularly apparent in critical care areas (e.g., in CCUs and
ICUs) and isolation, terminal, and geriatric units. It is
important that all health care providers realize and respond to
the vital importance of the environment in the total medical
management plan of each patient.
Pathogenic Organism Control
All health care, regardless of who provides it or where
it is provided, must be directed towards maintaining, promoting,
and restoring health. Because of this, all persons seeking
assistance in a health care facility must be protected from
additional injury, disease, or infection. Adherence to the
principles and practices of safety aspects protects a patient from
personal injury. Additionally, attention to personal and
environmental hygiene not only protects against further injury but
also constitutes the first step in controlling the presence,
growth, and spread of pathogenic organisms. Some of the basic
concepts of personal hygiene and communicable disease control are
addressed in the "Preventive Medicine" chapter of this manual.
Additional information concerning patient-related personal hygiene
will be found integrated throughout various sections of this
chapter. The discussion that follows addresses infection control
particularly in the context of medical and surgical aseptic
Medical asepsis is the term used to describe those
practices used to prevent the transfer of pathogenic organisms
from person to person, place to place, or person to place.
Medical aseptic practices are routinely used in direct patient
care areas as well as in other service areas in the health care
environment to interrupt a chain of events necessary for the
continuation of an infectious process. The components of this
chain of events consists of the following:
Infectious Agent - An organism capable of
producing an infection or infectious disease.
Reservoir of Infectious Agents - A carrier on
which an infectious agent depends primarily for survival. The
agent lives, multiplies, and reproduces so that it can be
transferred to a susceptible host. Reservoirs of infectious
agents are man, animal, plants, soil, or organic matter. Man
himself is the most frequent reservoir of infectious agents
pathogenic to man.
Portal of Exit - The avenue by which the
infectious agent leaves its reservoir. These avenues include
various body systems, such as respiratory, intestinal, and
genitourinary tract, and open lesions when the reservoir is a
Mode of Transmission - The mechanism by which
the infectious agent is transmitted from its reservoir to a
susceptible being (host). Air, water, food, dust, dirt,
insects, inanimate objects, and other persons are examples of
modes of transmission.
Portal of Entry - The avenue by which the
infectious agent enters the susceptible host. In the human
being, these correspond to the exit route avenues, including
the respiratory and gastrointestinal tracts, and through a
break in the skin or direct infection of the mucous
Susceptible Host - A human being or other
living organism which affords an infectious agent nourishment
or protection to survive and multiply.
Removal or control of any one component in the above
chain of events will control the infectious process.
Two basic medical asepsis practices are handwashing
and linen handling procedures. Frequent handwashing and proper
linen handling are absolutely essential practices for
preventing and controlling the spread of infection and
transmittable diseases. The following are some common instances
when provider handwashing is necessary:
Before and after each patient contact
Before handling food and medications
After coughing, sneezing, or blowing your nose
After using the toilet
Improper handling of linen results in the transfer of
pathogenic organisms through direct contact with the health
care provider's clothing and subsequent contact with the
patient, patient care items, or other materials in the care
environment. Proper linen handling is such an elementary
procedure that, in theory, it seems almost unnecessary to
mention; however, it is a procedure so frequently and
carelessly ignored that emphasis is justified. All linen,
whether clean or used, must never be held against one's
clothing or placed on the floor. The floors of a health care
facility are considered grossly contaminated, and, as such, any
article coming in contact with the floor is also contaminated.
Place all dirty linen in appropriate laundry bags. Linen from
patients having infectious or communicable diseases must be
handled in a special manner. Such procedures are discussed in
the Nursing Procedures Manual, under the section "Isolation
Isolation technique, a medical aseptic practice,
inhibits the spread and transfer of pathogenic organisms by
limiting the contacts of the patient and creating some kind of
physical barrier between the patient and others. In isolation
techniques, disinfection procedures are employed to control
contaminated items and areas. For purposes of this discussion,
disinfection is described as the killing of certain infectious
(pathogenic) agents outside the body by a physical or chemical
means. Isolation techniques employ two kinds of disinfection
practices, concurrent and terminal. Concurrent disinfection
consists of the daily measures taken to control the spread of
pathogenic organisms while the patient is still considered
infectious. Terminal disinfection consists of those measures
taken to destroy pathogenic organisms remaining after the
patient is discharged from isolation. There are a variety of
chemical and physical means used to disinfect supplies,
equipment, and environmental areas, and each facility will
determine their own protocols based on recommendations of an
Infection Control Committee.
Surgical Aseptic Technique
As used in this discussion, surgical aseptic
technique is the term used to describe the sterilization,
storage, and handling of articles to keep them free of
pathogenic organisms. The following discussion will address the
preparation and sterilization of surgical equipment and
supplies, and the preparation of the operating room for
performing a surgical procedure. It should be noted that
specific methods of preparation will vary from place to place,
but the basic principles of surgical aseptic techniques will
remain the same. This discussion will present general
guidelines, and individual providers are advised to refer to
local instruction regarding particular routines of a specific
Before an operation, it is necessary to sterilize and
keep sterile all instruments, materials, and supplies that come
in contact with the surgical site. Every item handled by the
surgeon and his or her assistants must be sterile. The
patient's skin and the hands of members of the surgical team
must be thoroughly scrubbed, prepared, and kept as aseptic as
During the operation, the surgeon, surgeon's
assistants, and scrub corpsman must wear sterile gowns and
gloves and must not touch anything that is not sterile.
Maintaining sterile technique is a cooperative responsibility
of the entire surgical team. Each member must develop a
surgical conscience, a willingness to supervise and to be
supervised by others regarding the adherence to standards.
Without this cooperative and vigilant effort, an otherwise
successful surgical procedure may result in a complete failure
if a break in sterile technique goes unnoticed or is not
To assist in maintaining the aseptic technique,
the following principles must adhere to all members of the
All personnel assigned to the operating room must
practice good personal hygiene. This includes daily
bathing and clothing change.
Those personnel having colds, sore throats, open
sores, and other infections should not be permitted in
the operating room.
Proper operating room attire, which includes scrub
suits, gowns, head coverings, and face masks, should not
be worn outside the operating room suite. If such occurs,
change all attire before re-entering the clean area. (The
operating room and adjacent supporting areas are
classified as clean areas.)
All members of the surgical team having direct
contact with the surgical site must perform the surgical
hand scrub before the operation.
All materials and instruments used in contact with
the site must be sterile.
The sterile gowns worn by surgeons and scrub corpsmen
are considered sterile from shoulder to waist, including
the gown sleeves. Only the front of the gown is
Sterile surgical gloves are considered aseptic. If
they are torn, punctured, or have touched an unsterile
surface or item, they are considered contaminated.
The safest, most practical method of sterilization
for most articles is steam under pressure.
Label all prepared, packaged, and sterilized items
with an expiration date.
Use articles packaged and sterilized in cotton muslin
wrappers within 28 calendar days.
Use articles sterilized in cotton muslin wrappers and
sealed in plastic within 180 calendar days.
Unsterile articles must not come in contact with
Make sure the patient's skin is as clean as possible
before a surgical procedure.
Take every precaution to prevent contamination of
sterile areas or supplies by airborne organisms.
Methods of Sterilization
Sterilization refers to the complete destruction
of all living organisms, including bacterial spores and
viruses. The word sterile means free from or the absence of
all living organisms. Any item to be sterilized must be
thoroughly cleaned mechanically or by hand, using soap or
detergent and water. When cleaning by hand, apply friction
to the item by using a brush. After cleaning, thoroughly
rinse the items with clean, running water before
sterilization. The appropriate sterilization method is
determined according to how the item will be used, the
material of which the item is made, and the sterilization
methods available. Physical methods of sterilization
comprise moist heat and dry heat. Chemical methods include
gas and liquid solutions.
Physical Methods - Steam under pressure
(autoclave) is the most dependable and economical method of
sterilization. It is the method of choice for metalware,
glassware, most rubber goods, and dry goods. All articles
must be correctly wrapped or packaged so that the steam will
come in contact with all surfaces of the article. Similar
items should be sterilized together, especially those
requiring the same time and temperature exposure. Articles
that will collect water must be placed so the water will
drain out of the article during the sterilization cycle. A
sterilizer should be loaded in a manner that will allow the
free flow of steam in and around all articles. Each item
sterilized must be dated with the expiration of sterility.
Sterilization indicators must be used in each load that is
put through the sterilization process. This verifies proper
steam and temperature penetration.
The operating instructions for a steam sterilizer
will vary according to the type and manufacturer. There are
a number of manufacturers, but there are only two types of
steam under pressure sterilizers. They are the downward
displacement and the prevacuum, high-temperature
In the downward (gravity) displacement autoclave,
air in the chamber is forced downward and out of the bottom
discharge outlet as pressurized steam enters from the top of
the chamber. The temperature in the sterilizer gradually
increases as the steam heats the chamber and its contents.
The actual timing does not begin until the temperature is
above 245 degrees F (118 degrees C).
The prevacuum, high-temperature autoclave is the
most modern and economical to operate and requires the least
time to sterilize a single load. By use of a vacuum pump,
air is extracted from the chamber before admitting steam.
This prevacuum process permits instant steam penetration to
all articles and through all cotton or linen dry goods. The
sterilization time is reduced to 4 minutes. The temperature
in the chamber is rapidly raised and held at 274 degrees F
(134 degrees C). Timing the cycle is done automatically.
If the temperature is increased, the sterilization
time may be decreased. The following are some practical
sterilization time periods:
3 minutes at 270°F (132°C)
8 minutes at 257°F (125°C)
18 minutes at 245°F (118°C)
All operating rooms are equipped with highspeed
(flash) sterilizers. Wrapped, uncovered, opened instruments
placed in perforated trays are "flash" sterilized for 3
minutes at 270 degrees F (132 degrees C). Sterilization
timing begins when the above temperature is reached, not
The use of dry heat as a sterilizing agent has
limitations. It should be restricted to items that are
unsuitable for exposure to moist heat. High temperatures and
extended time periods are required when using dry heat. In
most instances, this method often proves impractical. The
temperature must be 320 degrees F (160 degrees C), and the
time period must be at least 2 hours.
Chemical Sterilization - Only one liquid
chemical, if properly used, is capable of rendering an item
sterile; that chemical is glutaraldehyde. The item to be
sterilized must be totally submerged in the glutaraldehyde
solution for 10 hours. Before immersion, the item must be
thoroughly cleansed and rinsed with sterile water or sterile
normal saline. It should be noted that this chemical is
extremely caustic to skin, mucous membranes, and other
The most effective method of chemical
sterilization presently available is the use of ethylene
oxide (ETO) gas. ETO gas sterilization should be used only
for material and supplies that will not withstand
sterilization by steam under pressure. Never gas sterilize
any item that can be steam sterilized. The concentration of
the gas and the temperature and humidity inside the
sterilizer are vital factors that affect the gas
ETO gas sterilization periods range from 3 to 7
hours. All items gas sterilized must be allowed an aeration
(airing out) period. During this period, the ETO gas is
expelled from the surface of the item. It is not practical
here to present all exposure times, gas concentration, and
aeration times for various items to be gas sterilized. When
using an ETO gas sterilizer, it is important to be extremely
cautious and to follow the manufacturer's instructions
Preparation of Supplies for Autoclaving
Ensure that all articles to be sterilized are clean
and in good condition and working order.
Wrap instruments and materials to be autoclaved in
double muslin wrappers or two layers of disposable
When muslin wrappers are routinely used, launder them
after each use and carefully inspect them for holes and
tears before use.
When articles are placed in glass or metal containers
for autoclaving, place the lid of the container so the
steam will penetrate the entire inside of the
The contents of a linen pack are arranged in such a
way so the articles on top are used first.
Label every item that is packaged for sterilization
to specify the contents and expiration date.
Do not place surgical knife blades and suture
materials inside linen packs or instrument trays before
Wash each instrument after use with an antiseptic
detergent solution. When washing by hand, pay particular
attention to hinged parts and serrated surfaces. Rinse
all instruments and dry them thoroughly.
Use an instrument washer/sterilizer, if available, to
decontaminate instruments and utensils following each
Following cleaning and decontamination, leave hinged
instruments unclamped and wrapped singly or placed in
trays for resterilization.
Inspect all reusable glassware for cracks or
Wash all reusable glassware with soap or detergent
and water after use and rinse it completely.
When preparing reusable glass syringes:
Match numbers or syringe parts.
Wrap each plunger and barrel separately in
Wrap each complete syringe in a double muslin
When glassware, tubes, medicine glasses, and beakers
are part of a sterile tray, wrap each glass item in gauze
before placing it in the tray.
Suture materials are available in two major
categories: absorbable and nonabsorbable. Absorbable suture
materials can be digested by the tissues during the healing
process. Absorbable sutures are made from collagen, an
animal protein derived from healthy animals, or from
synthetic polymers. Nonabsorbable suture materials are those
that effectively resist the enzymatic digestion process in
living tissue. These sutures are made of metal or other
inorganic materials. In both types, each strand of
specifically sized suture material is uniform in diameter
and is predictable in performance.
Modern manufacturing processes make all suture
materials available in individual packages, presterilized,
with or without a surgical needle attached. Once opened, do
not resterilize either the individual package or an
individual strand of suture material. The only exception to
this rule involves the use of surgical stainless steel. This
material is often provided in unsterile packages or tubes.
Individual strands or entire packages must be sterilized
Rubber Latex Materials
Rubber tubing is to be washed in an antiseptic
Pay attention to the inside of the tubing. Rinse all
tubing well and place it flat or loosely coiled in a
wrapper or container.
When packing latex surgical drains for sterilization,
place a piece of gauze in the lumen of the drain. Never
resterilize surgical drains.
Rubber catheters bearing a disposable label must
never be resterilized.
Sterile disposable surgeon's (rubber) gloves are for
one time use only and are never resterilized.
Handling Sterile Articles
When you are changing a dressing, removing
sutures, or preparing the patient for a surgical procedure,
it will be necessary to establish a sterile field from which
to work. The field should be established on a stable, clean,
flat, dry surface. Wrappers from sterile articles may be
used as a sterile field as long as the inside of the wrapper
remains sterile. If the size of the wrapper does not provide
a sufficient working space for the sterile field, use a
sterile towel. Nothing but sterile articles and supplies are
placed on this field. Once established, the field is touched
only by those persons who have donned sterile gloves. The
following basic rules must be adhered to:
An article is either sterile or unsterile. There is
no in-between. If there is doubt about the sterility of
an item, consider it unsterile.
Any time the sterility of a field has been broached,
the contaminated field and setup must be replaced.
Do not open sterile articles until they are ready for
Do not leave sterile articles unattended once they
are opened and placed on a sterile field.
Do not return sterile articles to a container once
they are removed from the container.
Never reach over a sterile field.
When pouring sterile solutions into sterile
containers or basins, do not touch the sterile container
with the solution bottle. Once opened, bottles of liquids
must be entirely used when first poured. If any liquid is
left in the bottle, discard it.
Never use an outdated article. Unwrap it, inspect it,
and if reusable, rewrap it in a new wrapper for
Surgical Hand Scrub
The purpose of the surgical hand scrub is to
reduce resident and transient skin flora (bacteria) to a
minimum. Resident bacteria are often the result of organisms
present in the hospital environment. Because these bacteria
are firmly attached to the skin, they are difficult to
remove. However, their growth is inhibited by the antiseptic
action of the scrub detergent used. Transient bacteria are
usually acquired by direct contact and are loosely attached
to the skin. These are easily removed by the friction
created by the scrubbing procedure.
Proper hand scrubbing and the wearing of sterile
gloves and a sterile gown provide the patient with the best
possible barrier against pathogenic bacteria in the
environment and against bacteria from the surgical team. The
following is the generally accepted method for the surgical
Before beginning the hand scrub, don a surgical cap
or hood that covers all hair, both head and facial, and a
disposable mask covering your nose and mouth.
Using approximately 6 ml of antiseptic detergent and
running water, lather your hands and arms to 2 inches
above the elbow. Leave detergent on your arms and do not
Under running water, clean your fingernails and
cuticles, using a nail cleaner.
Starting with your fingertips, rinse each hand and
arm by passing them through the running water. Always
keep your hands above the level of your elbows.
From a sterile container, take a sterile brush and
dispense approximately 6 ml of antiseptic detergent onto
the brush and begin scrubbing your hands and arms.
Begin with the fingertips. Bring your thumb and
fingertips together and using the brush, scrub across
the fingertips using 30 strokes.
Now scrub all surface planes (4) of the thumb and
all surfaces of each finger, including the webbed
space between the fingers, using 20 strokes for each
Scrub the palm and back of the hand in a circular
motion, using 20 strokes each.
Visually divide your forearm into two parts, lower
and upper; scrub all surfaces of each division 20
strokes each, beginning at the wrist and progressing
to the elbow.
Scrub the elbow in a circular motion using 20
Scrub in a circular motion all surfaces to
approximately 2 inches above the elbow.
Do not rinse this arm when you have finished
scrubbing. Rinse only the brush.
Pass the rinsed brush to the scrubbed hand and
begin scrubbing your other hand and arm, using the
same procedure outlined above.
Drop the brush into the sink when you are
Rinse both hands and arms, keeping your hands
above the level of your elbows, and allow water to
drain off the elbows.
When rinsing, do not touch anything with your
scrubbed hands and arms.
The total scrub procedure must include all anatomical
surfaces from the fingertips to approximately 2 inches
above the elbows.
Dry your hands with a sterile towel. Do not allow the
towel to touch anything other than your scrubbed hands
Between operations, follow the same hand scrub
Gowning and Gloving
If you are the scrub corpsman, you will have
opened your sterile gown and glove packages in the operating
room before beginning your hand scrub. Having completed the
hand scrub, back through the door holding your hands up to
avoid touching anything with your hands and arms. Gowning
technique is shown in figure 5-1
and performed as follows:
Pick up the sterile towel that has been wrapped with
your gown. Touch only the towel.
Dry one hand and arm, starting at the hand and ending
at the elbow, with one end of the towel. Dry the other
hand and arm with the opposite end of the towel. Drop the
Pick up the gown in such a manner that hands touch
only the inside surface at the neck and shoulder
Allow the gown to unfold downward in front of
Locate the arm holes and place both hands in the
sleeves, holding your arms out and slightly up as you
slip your arms into the sleeves. Another person
(circulator) who is not scrubbed will pull your gown on
as you extend your hands through the gown cuffs.
Open the inner glove packet on the same sterile
surface on which you opened up the gown. The entire
gloving procedure is shown in figure
Pick up one glove by the cuff using your thumb and
index finger. Touching only the
cuff, pull the glove onto one hand and anchor the
cuff over your thumb.
Slip your gloved fingers under the cuff of the other
glove. Pull the glove over your fingers and hand, using a
stretching side-to-side motion.
Anchor the cuff on your thumb. With your fingers
still under the cuff, pull the cuff up and away from your
hand and over the knitted cuff of the gown.
Repeat the preceding step to finish gloving your
To gown and glove the surgeon, follow these
Pick up a gown from the sterile linen pack. Step back
from the sterile field and let the gown unfold in front
of you. Hold the gown at the shoulder seams with the gown
sleeves facing you.
Offer the gown to the surgeon. Once he or she has the
arms in the sleeves, let go of the gown. Be careful not
to touch anything but the sterile gown. The circulator
will tie the gown.
Pick up the right glove. With the thumb of the glove
facing the surgeon, place your fingers and thumbs of both
hands in the cuff of the glove and stretch it outward
making a circle of the cuff. Offer the glove to the
surgeon. Be careful that the surgeon's bare hand does not
touch your gloved hands.
Repeat the preceding step for the left glove.
Cleaning the Operating Room
Cleanliness in the operating room is an absolute
must. Cleaning routines must be clearly understood and
carefully followed. The cause of postoperative wound
infections have on occasion been traced to the operating
room. Since no two patients are alike and all patients have
their own "resident" bacteria, every surgical case must be
At the beginning of each day, all the fixtures,
equipment, and furniture in each operating room are damp
dusted with an antiseptic germicide solution. During the
operation, keep the room clean and orderly at all times.
Should sponges be dropped on the floor or if blood or other
body fluids spill, clean the area immediately using a
disinfectant germicide solution and a clean cloth. Between
each operation, clean all used items. The area of the floor
occupied by the surgical team is cleaned, using the wet
vacuum method. If a wet vacuum is not available, mops may be
used if a clean mop head is used following each operation.
Gowns and gloves are removed before leaving the room. All
linens and surgical drapes are bagged and removed from the
room. All trash and deposable items are bagged and taken
from the room. All instruments are washed by gloved hands or
placed in perforated trays and put through a
At the completion of the day's operations, each
operating room should be terminally cleaned using an
antiseptic germicide solution with the following tasks
Clean all wall- or ceiling-mounted equipment.
Clean all spotlights and lights on tracks.
Thoroughly scrub all furniture used in the room,
including the wheels.
Clean metal buckets and other waste receptacles and,
if possible, put them through the washer/sterilizer.
Clean scrub sinks.
Machine scrub the entire floor in each room. If a
machine is not available, use a large floor brush.
Suction up the disinfectant germicide solution that
is used on the floor, using a wet vacuum. If mops are
used, make sure a clean mop head is used for each room.
The use of mops in the operating room is the LEAST
DESIRABLE method of cleaning.
General Safety Precautions in the
Since safety practices are important to emphasize,
this section will cover some of the situations that are
potentially hazardous and discuss what might be done to
eliminate the hazard.
All personnel should know the location of all
emergency equipment. This includes drugs, cardiac arrest
equipment, and resuscitators. All electrical equipment and
plugs must be of the explosion-proof type and bear a label
stating such. There should be written schedules of inspections
and maintenance of all electrical equipment. Navy regulations
prohibit the use of explosive anesthetics in the operating
room. These regulations, however do not mean we can lessen our
concern for fire and explosion hazards. The surface of all
floors in the operating room must provide a path of electrical
conductivity between all persons and equipment making contact
with the floor to prevent the accumulation of dangerous
electrostatic charges. All furniture and equipment should be
constructed of metal or of other electrically conductive
material and should be equipped with conductive leg tips,
casters, or equivalent devices. Periodic inspections should be
made of leg tips, tires, casters, or other conductive devices
of furniture and equipment. This will ensure that they are
maintained free of wax, lint, or other foreign material that
may insulate them and defeat the purpose for which they are
used. Excess lubrication of casters should be avoided to
prevent accumulation of oil on conductive wheels. Dry graphite
and graphite oil are preferable lubricants.
Rubber accessories for anesthesia machines should be
of the conductive type, should be plainly labeled as such, and
should be routinely tested to ensure that conductivity is
maintained. It is essential that all replacement items be of
All personnel entering the operating room should be
in electrical contact with the conductive floor through the
wearing of conductive footwear or an alternative method of
providing a path of conductivity. Conductive footwear and other
personnel-to-floor conductive equipment should be tested on a
regularly scheduled basis.
All apparel worn in the operating room should be made
of a nonstatic producing material. Fabrics of 100 percent
cotton are the most acceptable. Fabrics made of synthetic
blends may be used only if they have been treated by the
manufacturer for use in the operating room. Wool blankets and
apparel made of untreated synthetic fabrics are not permitted
in the operating room.
Operating rooms must have adequate airconditioning
equipment to maintain relative humidity and temperature within
a constant range. The relative humidity should be kept at 55 to
60 percent. This level will reduce the possibility of
electrostatic discharge and possible explosion of combustible
gases. The temperature should be chosen on the basis of the
well-being of the patient. The recommended temperature is
between 65 degrees and 74 degrees F. The control of bacteria
carried on dust particles is facilitated when the recommended
humidity and temperature are maintained.
All oxygen cylinders in use or in storage will be
tagged with DD Form 1191, Warning Tag for Medical Oxygen
Equipment, and measures will be taken to ensure compliance with
instructions 1 through 7 printed on the form. An additional tag
is required on all cylinders to indicate "EMPTY," "IN USE," or
"FULL." Safety precautions should be conspicuously posted in
all areas in which oxygen cylinders are stored and in which
oxygen therapy is being administered. This posting should be
made so it will immediately make all personnel aware of the
precautionary measures required in the area.
All electrical service equipment, switchboards, or
panelboards should be installed in a nonhazardous location.
Devices or apparatus that tend to create an arc, sparks, or
high temperatures must not be installed in hazardous locations
unless these devices are of a type approved in accordance with
the National Electrical Code. Lamps in a fixed position will be
enclosed and will be properly protected by substantial metal
guards or other means where exposed to breakage. Cords for
portable lamps or portable electrical appliances must be
continuous and without switches from the appliance to the
attachment plug. Such cords must contain an insulated conductor
to form a grounding connection between the electrical outlet
and the appliance.
Nutrition is a scientific term applied to the process by
which food elements are taken into the body to produce energy for
body activity, rebuild body tissue, and assist in regulating all
body functions. To meet these body needs, it is essential that a
person's diet contain a proper balance of the essential food
elements that include carbohydrates, fats, proteins, vitamins,
minerals, and water. Because the well-nourished person is
generally mentally and physically alert and fairly resistant to
disease, dietary intake is an important factor in the diagnostic
and therapeutic plan of the consumer who requires a health care
Carbohydrates are the most efficient source of
energy. They provide work energy for body activities and heat
energy for the maintenance of body temperature. Additionally,
they are easily metabolized to provide quick energy. They may
also be stored in the liver as glycogen to be used by the body
when they are needed at a later time. Carbohydrates are divided
into two groups-sugars (e.g., in fruits, honey, and jellies)
and starches (e.g., bread, potatoes, and rice). When taken in
excess, carbohydrates are converted to adipose (fat) tissue and
contribute to an overweight condition. When carbohydrates are
taken too sparingly, the body metabolized its fats and then its
protein resources, and this eventually contributes to
undesirable weight loss.
Fats are nutritive substances that compose the most
concentrated source of energy of all the elements. Similar to
carbohydrates, they provide the body with work and heat-energy
resources. Fats function as carriers for the fat-soluble
vitamins (A, D, E, and K), as padding for the organs and
subcutaneous tissue, and as an energy resource when stored as
adipose tissue. Common sources of fats are butter, milk, oil,
and fatty meats. They are not as easily or quickly metabolized
as carbohydrates and in excess contribute to overweight,
digestive, and cardiovascular problems.
Proteins are the most important element required by
the body for tissue growth, development, maintenance, and
repair. They are the main structural unit of all living cells.
Proteins are expensive sources of energy, since the body does
not maintain reserve stores. Because of this, a constant source
of protein is required in the daily diet to avoid a deficiency
condition. Some of the best sources of protein are found in
meat, fish, eggs, and legumes (e.g., peas and beans).
Vitamins are natural components of most foods and are
essential for proper growth and maintenance of health. They are
needed by the body in minute amounts but play a vital role in
metabolism, helping to convert carbohydrates, fats, and
proteins into energy. It should be noted that they do not
furnish energy or act as tissue-building materials. Some
vitamins can be stored in the body; thus, in some people,
vitamin abuse can be dangerous. An example of this is the
excessive use of vitamin A. Vitamins are classified as either
water-soluble or fat-soluble. Niacin, folic acid, vitamin B
complex, and vitamin C are transported throughout the body in
water and are classified as water-soluble. These vitamins are
not stored in the body to any great extent and excesses in
intake are generally excreted by the kidneys. Vitamins A, D, E,
and K are transported throughout the body in fats and are
called fat-soluble. As stated above, many fat-soluble vitamins
are stored in the body.
Although the mineral elements constitute only a small
portion of the total body composition, they are essential in
the building and maintenance of bones, teeth, and various body
systems. Some minerals are found in large amounts in the body.
Others, detectable in small amounts, are referred to as trace
minerals. Regardless of the quantitative amounts, those mineral
essential to support and maintain optimal health are calcium,
phosphorus, magnesium, iron, iodine, potassium, sodium,
chlorine, sulfur, and fluorine.
For mineral needs to be met satisfactorily, the
consumption of each element must be sufficient to cover body
tissue requirements and to meet the changing physiological
needs due to growth or environmental changes. It was once
believed that any diet adequate in other respects would also
provide an adequate intake of the essential minerals. This is
not true. Different foods vary greatly in their mineral content
and the same type of food produced in various geographic
localities may differ considerably in the percentage
composition of the individual minerals. The differences in an
individual's eating habits may also result in considerable
variation in the mineral intake.
Water, although not a food, is essential for the
maintenance of life and health and is an integral part of most
foods. It is by far the largest single constituent of the body,
comprising almost two-thirds of the total body weight. Of the
substances essential to life, water stands second only to
oxygen. Without oxygen, humans can survive only a few minutes;
without water, they may survive for a period of hours or a few
days, depending upon many circumstances.
Water is the great solvent in the body. All basic
body constituents are held in water, and it is the medium in
which all chemical reactions take place in the body. It
functions as a vehicle for nutrients, secretions, and most body
substances; and because it is an essential element of the
protoplasm of cells, it serves as a building material for
growth and repair.
To maintain metabolic equilibrium, water intake must
equal water output. The water loss through urine, feces, skin,
and lungs must be replaced by water in food, water from the
oxidation of food, and fluid intake. Under normal conditions,
thirst is usually an adequate guide of the water requirement.
When the body is in negative water balance, the condition known
as dehydration results. Among its effects are the
Loss of weight due to reduction in tissue water as well
as to breakdown of body substances.
Disturbance in acid-base balance usually toward the acid
side, resulting in acidosis (insufficient water places a
heavy burden on the kidneys impairing their ability to
eliminate waste products through the urine).
Elevations in body temperature as a result of reduced
circulating fluid and subsequent reduced perspiration.
Exhaustion and collapse.
As previously stated, one of the important functions
of food is to provide the body with heat and energy. This is
accomplished through the process of metabolism that functions
in the following manner. In the various cells and tissues of
the body, food substances, in combination with oxygen taken
into the body through the lungs, are burned or oxidized,
producing heat and energy. The heat that is generated is used
for the control of body temperature, and the energy that is
produced provides for the muscular activity and movements of
Caloric Value of Foods
The unit of measure of heat production is the
calorie (cal). This is the amount of heat energy that is
required to raise the temperature of 1 gram (g) of water 1
degree centigrade (C). In food chemistry and metabolism, the
large calorie (kcal) is the unit of energy measurement used.
One large calorie is 1000 times the size of a standard
calorie. The amount of heat energy in terms of calories
resulting from oxidation of foodstuffs is the caloric value
of the food. By careful analysis, specific caloric values of
the basic organic foods have been determined to be the
Most foodstuffs are not pure basic elements, and
the exact caloric value of the various compound foods
containing more than one of each of the three basic elements
cannot be determined precisely. However, laboratory
determinations have provided relative caloric values of most
representative foods. The following are a few typical
1 slice of bread or small potato
1 pat of butter
1 glass of whole milk
1 small banana
1 average serving of steak or ground beef
1 candy bar
1 serving of fruit pie
It should be noted that alcoholic beverages
provide 7 calories for each g of alcohol, but these calories
have no nutritional value.
Basal Metabolic Rate
The basal metabolic rate (BMR) is an index of the
energy demand of the body for the maintenance of life and
body functions under basic conditions. Increased activity
requires more fuel and oxygen in proportion to the degree of
heat and energy requirements.
The energy requirements of a normal 150-pound man
under situation of varying activity are approximated as
Forms of Activity
8 hours of sleep (60 calories per hour)
3 hours of light exercise, going to and from
work, etc. (200 calories per hour)
8 hours of ward duty (220 calories per hour)
5 hours of recreation watching television (90
calories per hour x 5 = 450) swimming (500 calories
per hour x 5 = 2,500)
450 - 2,500
Total for the day
3,290 - 5,340
To maintain body weight without loss or gain, this
individual would have to consume food in amounts and kinds
to yield 3,290 to 5,340 calories, depending on his activity.
Since we have assumed this man to be a normal individual,
without a disease state or glandular imbalance, if he
consumed more, he would gain weight; if he consumed less, he
would lose weight. This balancing of food intake against
energy requirement is the only sound basis of weight control
with the maintenance of a balanced diet that ensures
adequate amounts of all the essential nutrients.
The Adequate Diet
The three specifications that an adequate diet must
have are the following:
Protein for growth and maintenance of body cells.
Minerals, vitamins, and water for growth, maintenance,
and regulation of body processes.
Fats and carbohydrates for energy.
No single food can be designated essential for life
or health. Most food contains one or more nutrients, but no
single one contains all the nutrients in the needed amounts.
Therefore, choosing foods wisely means selecting foods that
together supply nutrients in the needed amounts.
A food guide called the Four Food Groups has been
devised to ensure an adequately balanced, daily diet. The
following are the basic four food groups and some major
nutrients included in each group:
Grain Group-this group furnishes significant amounts of
protein, iron, and many of the B vitamins. Also included are
carbohydrates that not only provide a quick-energy source
but also supply the body with roughage. Specific foods of
this group are all breads and cereals that are
whole-grained, restored, or enriched. Many of the cereal
products furnish many vitamins and minerals. Additionally,
foods such as rice, noodles, macaroni, cornmeal, and grits
are also included in this group.
Meat Group-this group provides a major source of
protein, iron, and the B-complex vitamins. Included in the
meat group are beef, veal, lamb, pork, and the organ
nutrients such as liver and kidney. Fish, shellfish,
poultry, and eggs are also included in the meat group. Foods
such as beans, peas, and nuts are alternative sources of
protein, which are categorized in the meat group; however,
these nutrients are not as high in protein as are the other
foods in the group.
Milk Group-this group supplies the body with calcium,
some high quality protein, and vitamins, especially A and
riboflavin (B2). Foods included in this group are whole,
evaporated, skim, and dry milk. Also included are butter,
buttermilk, ice cream, and a wide variety of cheeses.
Vegetable/Fruit Group-this group provides a major source
of vitamins and minerals. Almost all the body's vitamin C
requirements and half of its vitamin D requirements are
furnished by this group. Such foods as cantaloupe,
grapefruit, oranges, strawberries, and green peppers are
good sources of vitamin C. Apricots, peaches, asparagus,
carrots, broccoli, brussel sprouts, spinach, and sweet
potatoes are excellent sources of vitamin D. Each day the
healthy adult requires 4 servings from the grain group, 2
from the meat group, 2 from the milk group, and 4 from the
vegetable/fruit group for a nutritious healthful diet.
An important part of the total health care management
of the patient is the dietary plan. Basically, a patient's diet
therapy consists of either a regular or special diet. The goals
of both categories are to provide for either a normal life
cycle, or special dietary requirements that are necessary for
treating disease or injury and for rehabilitating the patient.
Regular diets are planned in accordance with an individual's
specific life style, such as found among pediatric, adult,
maternal, or geriatric populations. Special diets, commonly
called therapeutic diets, are planned or changed in one or a
combination of the following methods:
Modification of total calories
Modification of consistency
Modification of levels of nutrients
Elimination of specific foods
An individual's nutritional care consists of the
following four essential elements: assessment, planning,
implementation, and evaluation. All of these elements are
necessary for the successful provision of effective health
care. Assessment provides the health care team with an estimate
of the patient's nutritional status upon admission and provides
a basis for planning diet therapy during hospitalization.
Dietary implementation and monitoring guide the health care
team in evaluating and adjusting both optimal calorie and
nutritional intake. These contribute to the patient's total
care by reducing tissue healing time, decreasing susceptibility
to infection, and providing for an optimal physical and
To summarize briefly, the overall objectives of
planned and implemented diet therapy are to:
Prevent nutritional deficiency
Improve and maintain the very best nutritional
Aid the maintenance and re-establishment of a positive
state of well-being in persons with a medical or physical
Identify problems associated with over-nutrition and
undernutrition and decide when these problems put a patient
at a high nutritional risk.
The Medical Patient
For purposes of this discussion, the term medical
patient will be considered as any person who is receiving
diagnostic, therapeutic, and supportive care for a condition that
is not managed by surgical, orthopaedic, psychiatric, or
maternity-related therapy. This is not to infer that patients in
these other categories are not treated for medical problems. Many
surgical, orthopaedic, psychiatric and maternity patients do have
secondary medical problems that are treated while they are
undergoing management for their primary condition. Although many
medical problems can be treated on an outpatient basis, this
discussion will address the hospitalized medical patient. It
should be noted that the basic principles of management are
essentially the same for both the inpatient and outpatient.
The medical management of the patient generally consists
of laboratory and diagnostic tests and procedures, medication,
food and fluid therapy, and patient teaching. Additionally, for
many medical patients, particularly during the initial treatment
phase, rest is a part of the prescribed treatment.
Test and Procedures
A variety of laboratory and diagnostic tests and
procedures are commonly ordered for the medical patient.
Frequently, the hospital corpsman is assigned to prepare the
patient for the procedure, collect the specimens, or assist
with both the procedure and specimen collection. Whether a
specimen is to be collected or a procedure is to be performed,
the patient needs a clear and simple explanation about what is
to be done and what the patient can do to assist with the
activity. Often the success of the test or procedure is
dependent upon the patient's informed cooperation. When
collecting specimens, the hospital corpsman must complete the
Collect the correct kind and amount of specimen at the
Place the specimen in the correct container.
Label the container completely and accurately. This
often differs somewhat for each facility and local policies
should be consulted.
Complete the laboratory request form accurately.
Record on the patient's record and other forms, as
appropriate, the date, time, kind of specimen collected, the
disposition of the specimen, and anything unusual about the
appearance of the specimen or the patient during the
When assisting with a diagnostic procedure, the
hospital corpsman must understand the sequence of steps of the
procedure and exactly how his or her assistance can best be
provided. Since many procedures terminate in the collection of
a specimen, the above principles of specimen collecting must be
followed. Following the completion of a procedure or specimen
collection, it is the responsibility of the assisting hospital
corpsman to ensure that the patient's safety and comfort have
been attended to, the physician's orders are accurately
followed, and that any supplies or equipment used are
appropriately disposed of.
A major form of therapy for the treatment of illness
is the use of drugs. It is not uncommon for the medical patient
to be treated with several drugs. As members of the health care
team, hospital corpsmen assigned to preparing and administering
medications are given a serious responsibility demanding
constant vigilance, integrity, and special knowledge and
skills. The preparation and administration of medications were
addressed in great detail in the Hospital Corps School
curriculum. Chapter 6 of the Nursing Procedures Manual is
devoted entirely to medications. These references and the
continued inservice training devoted to medication
administration at all medical facilities support the importance
of accurate preparation and administration of drugs.
An error, which also includes omissions, can
seriously affect a patient, even to the point of causing death.
Each hospital corpsman is responsible for his or her own
actions, and this responsibility cannot be transferred to
another. No one individual is expected to know all there is to
know about all patients and medications. However, in every
health care environment, the hospital corpsman has access to
other health care providers who can assist in clarifying
orders, explaining the purposes, actions, and effects of drugs,
and in general answering any questions that may arise
concerning a particular patient and his or her medications.
There should be basic drug references available to all
personnel handling medications, including the Physicians' Desk
Reference and a hospital formulary. As a hospital corpsman, it
is your responsibility to consult these members of the team and
these references for assistance in any area in which you are
not knowledgeable or whenever you have questions or doubts. You
are also responsible for knowing and following local policies
and procedures regarding the administration of medications.
Food and Fluid Therapy
An entire section of this chapter addressed the
subject of nutrition. The following will be a brief discussion
on food and fluid as it relates specifically to the medical
patient. Loss of appetite, food intolerance, digestive
disturbances, lack of exercise, and even excessive weight gain
influence a medical patient's intake requirements. Regardless
of their medical problem, patients have basic nutritional needs
that frequently differ from those of the healthy person. As a
part of the patient's therapeutic regimen, food is usually
prescribed in the form of a special diet. Regardless of the
kind of diet prescribed, the patient must understand why
certain foods are ordered or eliminated and how compliance with
the regimen will assist in his or her total care. It is the
responsibility of the corpsman to assist the patient in
understanding the importance of the prescribed diet and to
ensure that accurate recording of the patient's dietary intake
is made on the clinical record.
In many disease conditions, the patient is unable to
tolerate food or fluids or may lose these through vomiting,
diarrhea, or both. In these cases, replacement fluids as well
as nutrients is an important part of the patient's medical
management. On the other hand, there are several disease
conditions in which fluid restrictions are important aspects of
the patient's therapy. In both of these instances, accurate
measurement and recording of fluid intake and output must be
carefully performed. Very frequently this becomes a major task
of the staff hospital corpsman.
Earlier in this chapter, under "Health Education,"
the goals and principles of patient teaching were addressed.
When taken in the context of the medical patient, there are
some general areas of patient teaching needs that must be
considered, particularly as the patient approaches discharge
from an inpatient status. They include the following:
Modification in daily living activities and habits
Modification in diet, including fluid intake
Medications and treatment to be continued after
Measures to be taken to promote health and prevent
The primary reason for prescribing rest as a
therapeutic measure for the medical patient is to prevent
further damage to the body or a part of the body when the
normal demand of use exceeds the ability to respond. However,
prolonged or indiscriminate use of rest, particularly bed rest,
is potentially hazardous. Some of the common complications
occurring as a result of prolonged bed rest are:
Circulatory problems, such as development of thrombi and
emboli, and subsequent skin problems, such as decubiti.
Respiratory problems, such as atelectasis and
Gastrointestinal problems, such as anorexia,
constipation, and fecal impactions.
Urinary tract problems, such as retention, infection, or
the formation of calculi.
Musculoskeletal problems, such as weakness, atrophy, and
the development of contractures.
Psychological problems, such as apathy, depression, and
temporary personality changes.
The key concept in the therapeutic management of the
patient on prolonged bed rest is the prevention of complication
resulting from this one aspect of the total care regimen.
Awareness of the potential hazards is the first step in
prevention. Alert observations of skin condition, respirations,
food and fluid intake, urinary and bowel habits, evidence of
discomfort, range of motion, and mood are critical elements
that provide data indicating impending problems. When this data
is properly reported, the health care team has time to employ
measures that will arrest the development of preventable
The Surgical Patient
Surgical procedures are classified into two major
categories: emergency and elective. Emergency surgery is that
required immediately to save a life or maintain a necessary
function. Elective surgery is that which, in most cases, needs to
be done but can be scheduled at a time beneficial to both the
patient and the provider. Regardless of the type of surgery, every
surgical patient requires specialized care at each of four phases.
These phases are classified as preoperative, operative, recovery,
and postoperative. The following discussion will address the basic
concepts of care in each phase.
Before undergoing a surgical procedure, the patient
must be in the best possible psychological, spiritual, and
physical condition. Psychological preparation begins the moment
the patient learns he or she is going to have an operation. The
physician is responsible for explaining the surgical procedure
to the patient, including the events that can be expected
afterward. Since other staff personnel reinforce the
physician's explanation, all members of the team must know what
the physician has told the patient. In this manner, they are
better able to answer the patient's questions. All patients
approaching surgery are fearful and anxious. The staff can
assist in reducing this fear by instilling confidence in the
patient regarding the competence of those providing care. The
patient should be given the opportunity and freedom to express
any feelings or fears concerning the proposed procedure. Even
in an emergency, it is possible to give a patient and the
family psychological support. Often this is accomplished simply
by the confident and skillful manner in which the
administrative and physical preoperative preparation is
People who face operations are often afraid. This
fear can be related to fear of anesthesia, body disfigurement,
pain, and even death. Frequently, religious faith is a source
of strength and courage for these patients. If a patient
expresses a desire to see a clergyman, every attempt should be
made to arrange a visit.
Except in emergencies, the administrative preparation
usually begins the day before surgery. Since the step-by-step
procedure is clearly delineated in the Nursing Procedures
Manual, in the section titled "Preoperative Care," the entire
procedure will not be repeated here. The Request for
Administration of Anesthesia and for Performance of Operations
and Other Procedures (SF 522) will be addressed here. This
document identifies the operation or procedure to be performed,
has a statement written by the patient indicating in lay terms
a description of the procedure, and includes signatures of the
physician, patient, and a staff member who serves as a witness.
SF 522 must be completed before any preoperative medications
are administered. If the patient is not capable of signing the
document, a parent, legal guardian, or spouse may sign it. It
is customary to require the signature of a parent or legal
guardian if the patient is under 21 years of age, unless the
patient is married or a member of the Armed Forces. In these
latter two cases, the patient may sign his or her own permit,
regardless of age.
Normally, the physical preparation of the patient
begins in the late afternoon or early evening the day before
surgery. As with the administrative preparation, each step is
clearly stated in the Nursing Procedures Manual. Also, listed
under "Skin Preparation," you will find a description of both
the purpose and procedure for performing the preoperative
Preoperative teaching is an important part of the
total preparation. The exact time that preoperative teaching
should be initiated greatly depends upon the individual patient
and type of surgical procedure. Most experts recommend that
preoperative instructions be given as close as possible to the
time of surgery. Appropriate preoperative instructions given in
sufficient detail and at the proper time greatly reduce
operative and postoperative complications.
The operative, or intraoperative phase as it is
sometimes called, begins the moment the patient is taken into
the operating room. Two of the major factors to consider at
this phase are positioning and anesthesia.
The specific surgical procedure will dictate the
general position of the patient. For example, the lithotomy
position is used for a vaginal hysterectomy; whereas, the
dorsal recumbent position is used for a herniorrhaphy.
Regardless of the specific position the patient is placed
in, there are some general patient safety guidelines that
must be observed.
When positioning a patient on the
operating table, remember the following:
Whether the patient is awake or asleep, place the
patient in as comfortable position as possible.
Strap the patient to the table in a manner that
allows for adequate exposure of the operative
is secure enough to prevent the patient from
falling, but does not cut off circulation or
contribute to nerve damage.
Secure all extremities of the patient in a manner
that will prevent them from dangling over the side of the
Pad all bony prominences to prevent the development
of pressure areas or nerve damage.
Make sure the patient is adequately grounded to avoid
burns or electrical shock to either the patient or the
One of the greatest contributions to medical
science was the introduction of anesthesia. It relieves
unnecessary pain and increases the potential and scope of
many kinds of surgical procedures. Therefore, health care
providers must understand the nature of anesthetic agents
and their effect on the human body.
Anesthesia may be defined as a loss of sensation
that makes a person insensible to pain, with or without loss
of consciousness. Some specific anesthetic agents are
discussed in the "Pharmacology and Toxicology" chapter of
this manual. Health care providers must understand the
basics of anesthesiology as well as the specific drug's
Regional Anesthesia - The two major
classifications of anesthesia are regional and general.
Regional anesthetics reduce all painful sensations in a
particular area of the body without causing unconsciousness.
The following is a listing of the various methods and a
Topical anesthesia is administered topically to
desensitize a small area of the body for a very short
Local blocks consist of the subcutaneous infiltration
of a small area of the body with a desensitizing agent.
Local anesthesia generally lasts a little longer than
Nerve blocks consist of injecting the agent into the
region of a nerve trunk or other large nerve branches.
This form of anesthesia blocks all impulses to and from
the injected nerves.
Spinal anesthesia consists of injecting the agent
into the subarachnoid space of the spinal canal between
the third and fourth lumbar space or between the fifth
lumbar and first sacral space of the spinal column. This
form of anesthesia blocks all impulses to and from the
entire area below the point of insertion, provided the
patient's position is not changed following injection of
the agent. If the patient's position is changed, for
example, from dorsal recumbent to Trendelenburg's, the
anesthetic agent will move up the spinal column and the
level of the anesthesia will also move up. Because of
this, care must be exercised in positioning the patient's
head and chest above the level of insertion to prevent
paralysis (by anesthesia) of the respiratory muscles. In
general, spinal anesthesia is considered the safest for
most routine major surgery.
Epidural blocks consist of injecting the agent into
the epidural space of the spinal canal at any level of
the spinal column. The area of anesthesia obtained is
similar to that of the subarachnoid spinal method. The
epidural method is frequently used when continuous
anesthesia is desired for a prolonged period. In these
cases, a catheter is inserted into the epidural space
through a spinal needle. The needle is removed, but the
catheter is left in place. This provides for continuous
access to the epidural space.
Saddle blocks consist of injecting the agent into the
dural sac at the third and fourth lumbar space. This form
of anesthesia blocks all impulses to and from the
perineal area of the body.
Caudal blocks consist of injecting the agent into the
sacral canal. With this method, anesthesia is obtained
from the umbilicus to the toes.
General Anesthesia - General anesthetics
cause total loss of sensation and complete loss of
consciousness in the patient. They are administered by
inhalation of certain gases or vaporized liquids,
intravenous infusion, or rectal induction. The induction of
inhalation anesthesia is divided into four stages. These
stages and the body's main physiological reaction in each
phase are explained below and depicted in figure
Stage 1 is called the stage of analgesia or
induction. During this period, the patient experiences
dizziness, a sense of unreality, and a lessening
sensitivity to touch and pain. At this stage, the
patient's sense of hearing is increased and responses to
noises are intensified (fig.
Stage 2 is the stage of excitement. During this
period, there is a variety of reactions involving
muscular activity and delirium. At this stage, the vital
signs show evidence of physiological stimulation. It is
important to remember that during this stage the patient
may respond violently to very little stimulation
Stage 3 is called the surgical or operative stage.
There are four planes to this stage. It is the
responsibility of the anesthetist or anesthesiologist to
determine which plane is optimal for the procedure. The
determination is made according to specific tissue
sensitivity of the individual and the surgical site. Each
successive plane is achieved by increasing the
concentration of the anesthetic agent in the tissue
Stage 4 is called the toxic or danger stage.
Obviously, this is never a desired stage of anesthesia.
At this point, cardiopulmonary failure and death can
occur. Once surgical anesthesia has been obtained, the
health provider must exercise care to control the level
of anesthesia. Plane 4 of stage 3 is demonstrated by
cardiovascular impairment that results from diaphragmatic
paralysis. If this plane is not corrected immediately,
stage 4 quickly ensues (fig
For purposes of this discussion, the recovery phase
consists of the period that begins at the completion of the
operation and extends until the patient has recovered from
anesthesia. The recovery phase generally takes place in a
specialized area called the recovery room. This unit is usually
located near the operating room and has access to the
Surgeons and anesthesiologists or anesthetists
Nurses and Hospital Corps personnel who are specially
prepared to care for immediate postoperative patients
Special equipment, supplies, medication, and replacement
From the time of admission to the point of discharge,
routine care in the recovery room consists of the
Measuring temperature and vital signs
Maintaining airway patency
Patients having an artificial airway in place will
automatically expel it as they regain consciousness.
Have a mechanical suction apparatus available to
remove excessive excretions from the patient's
Ensuring the integrity of dressings, tubes, catheters,
Locate the presence of any of the above.
Make notations regarding all drainage including
color, type, and amount.
Immediately report the presence of copious amounts of
drainage to the nurse or physician.
Monitoring intravenous therapy (including blood and
Make notations including type of infusion, rate of
flow, and condition of the infusion site.
Observe patients receiving blood or blood components
closely for untoward reactions.
Monitoring skin color changes
Check dressings and casts frequently to ensure they
are not interfering with normal blood circulation to the
Notify the physician or nurse of general skin color
changes that may indicate airway obstruction, hemorrhage,
Assessing level of responsiveness
For general anesthetics, check for orientation to the
environment each time vital signs are taken.
For regional anesthetics, check for return of sensory
perception and voluntary movement each time vital signs
Observing for side effects of the anesthetic agent. Each
agent has the potential for causing specific side effects.
Some common major side effects that may occur following the
administration of both spinal and general anesthesia consist
of the following:
After the patient's status has stabilized in the
recovery room, a physician will order his or her transfer to
another area in the facility. Generally, this transfer is to
the unit that the patient was assigned to preoperatively. Since
both surgery and anesthesia have unavoidable temporary ill
effects on the normal physiological functions, every effort
must be made to prevent postoperative complications. From the
time the patient is admitted to the recovery room to the time
he or she has recovered from the operation, there are definite
goals of care that guide the entire postoperative course. These
goals are as follows:
Promoting respiratory function
Promoting cardiovascular function
Promoting renal function
Promoting nutrition and elimination
Promoting fluid and electrolyte balance
Promoting wound healing
Encouraging rest and comfort
Encouraging movement and ambulation
Preventing postoperative complications
The physician will write orders for postoperative
care that are directed at accomplishing the above goals.
Although each patient's orders will be based on individual
needs, there will be some common orders that apply to all
patients. These orders will center around the promotion of
certain physiological functions and areas addressed in the
Respiratory function is promoted by encouraging
frequent coughing and deep breathing. Early movement and
ambulation also help to improve respiratory function. For some
patients, oxygen therapy may also be ordered to assist
respiratory function. Cardiovascular function is assisted by
frequent position changes, by early movement and ambulation,
and, in some cases, by intravenous therapy. Renal function is
promoted by adequate fluid intake and early movement and
ambulation. Nutritional status is promoted by ensuring adequate
oral or correct intravenous intake and by maintaining accurate
intake and output records. Elimination functions are promoted
by adequate diet and fluid intake. Postoperative patients
should be advanced to a normal dietary regimen as soon as
possible, since this too promotes elimination functions. Early
movement and ambulation also helps to restore normal
elimination activities. In addition to various medications and
dressing change procedures ordered by the physician, wound
healing is promoted by good nutritional intake and by early
movement and ambulation. Rest and comfort are supported by
properly positioning the patient, providing a restful
environment, encouraging good basic hygiene measures, ensuring
optimal bladder and bowel output, and promptly administering
pain-relieving medications. Early movement and ambulation are
assisted by ensuring maximum comfort for the patient and
providing the encouragement and support for ambulating the
patient, particularly in the early postoperative period. As
indicated in the above discussion, the value of early movement
and ambulation, when permissible, cannot be overemphasized.
During the early postoperative phase, the major
complications to be guarded against are respiratory
obstruction, shock, and hemorrhage. As the patient progresses
in the postoperative period, other complications to avoid are
the development of pneumonia, phlebitis and subsequent
thrombophlebitis, gastrointestinal problems ranging from
abdominal distention to intestinal obstruction, and finally
wound infections. Accurate implementation of the physician's
orders and careful observation, reporting, and recording of the
patient's condition will contribute markedly to an optimal and
timely postoperative recovery course for the patient.
The Orthopedic Patient
Patients on the orthopedic service are those who
require treatment for fractures, deformities, and diseases or
injuries of some part of the musculoskeletal system. Some
patients will require surgery, immobilization, or both to
correct their condition. The basic principles and concepts of
care for the surgical patient will apply to orthopedic
patients. The majority of patients not requiring surgical
intervention will be managed by bed rest, immobilization, and
rehabilitation. Many of the basic concepts of care of the
medical patient are applicable for orthopedic patient care. In
the military, the usual orthopedic patient is fairly young and
in good general physical condition. For these patients, bed
rest is prescribed only because his or her admitting condition
limits other kinds of activity.
Rehabilitation is the ultimate goal when planning the
orthopedic patient's total management. Whether the patient
requires surgical or conservative treatment, immobilization is
often a part of the overall therapy. Immobilization may consist
of applying casts or traction, or using equipment, such as
orthopedic frames or Circ-O-Lectric beds. During the
immobilization phase, simple basic patient care is extremely
important. Such things as skin care, active-passive exercises,
position changes in bed (as permitted), good nutrition,
adequate fluid intake, regularity in elimination, and common
basic hygiene not only contribute to the patient's physical but
also psychological well-being.
Lengthy periods of immobilization are emotionally
stressful for patients, particularly those who are essentially
healthy except for the limitations imposed by their condition.
Prolonged inactivity contributes to boredom that is frequently
manifested by various kinds of acting out behavior. Often, the
unoccupied orthopedic patient experiences exaggerated levels of
pain. Orthopedic pain is commonly described as sore and aching.
Because this condition requires long periods of treatment and
hospitalization, the wise management of pain is an important
aspect of care. Constant pain, regardless of severity, is
energy consuming. You should make every effort to assist the
patient in conserving this energy. There are times when the
patient's pain can and should be relieved by medications. There
are, however, numerous occasions when effective pain relief can
be provided by basic patient care measures such as proper body
alignment, change of position, use of heat or cold (if
permitted by a physician's orders), back rubs and massages, and
even simple conversation with the patient. Meaningful activity
also has been found to help relieve pain. Whenever possible, a
well-planned physical/occupational therapy regimen should be an
integral part of the total rehabilitation plan.
As mentioned previously, immobilization is often a
part of the overall therapy of the orthopedic patient;
casting is the most common and well-known form of long-term
immobilization. In some instances, a corpsman may be
required to assist in applying a cast or be directed to
apply or change a cast. In this section, we will discuss the
method of applying a short- and long-arm cast, and a
In applying any cast, the basic materials are the
same: webril or cotton bunting, plaster of Paris, a bucket
or basin of tepid water, a water source (tap water),
protective linen, gloves, a working surface, a cast saw, and
seating surfaces for the patient and the corpsman. Some
specific types of casts may require additional material.
Short-Arm Cast - A short-arm cast extends
from the metacarpal-phalangeal joints of the hand to just
below the elbow joint. Depending on the location and type of
fracture, the physician may order a specific position for
the arm to be casted. Generally, the wrist is in a neutral
(straight) position with the fingers slightly flexed in the
position of function.
Beginning at the wrist, apply three layers of
webril. Then apply webril to the forearm and the hand,
making sure that each layer overlaps the other by a third as
shown in figure 5-4. Check for
lumps or wrinkles and correct any by tearing the webril and
The plaster of Paris is then dipped into the water
for approximately 5 seconds. Gently squeeze to remove excess
water, but do not wring out. Beginning at the wrist
(fig. 5-4C) wrap the plaster in
a spiral motion overlapping each layer by one-third to
one-half. Smooth out the layers with a gentle palmar motion.
When applying the plaster, make tucks by grasping the excess
material and folding it under as if making a pleat.
Successive layers cover and smooth over this fold. When the
plaster is anchored on the wrist, cover the hand and the
palmar surface before continuing up the arm (figs.
5-4D and 5-4E). Repeat this process until the cast is
thick enough to provide adequate support, generally 4 to 5
layers. The final step is to remove any rough edges and
smooth the cast surface. The ends of the cast are turned
back and covered with the final layer of plaster, and the
plaster is set for approximately 15 minutes and then trimmed
with a cast saw as needed.
Long-Arm Cast - The procedure for a
long-arm cast is basically the same as for a short-arm cast
except the elbow is maintained in a 90 degrees position, the
cast begins at the wrist and ends on the upper arm below the
axilla, and the hand is not wrapped.
Short-Leg Cast - In applying a short- leg
cast, seat the patient on a table with both legs over the
side, flexed at the knee. Instruct the patient to hold the
affected leg, with the ankle in a neutral position (90
degrees). Make sure that the foot is not rotated medially or
laterally. Beginning at the toes, apply webril (figs.
5-5A, 5-5B, and 5-5C) in the same manner as for the
short-arm cast, ensuring that there are no lumps or
wrinkles. Apply the plaster beginning at the toes (fig.
5-5E), using the same technique of tucks and folds and
smoothing as for the short-arm cast. Before applying the
last layer, expose the toes and fold back the webril. As the
final step, apply a footplate to the plantar surface of the
cast using a generous thickness of plaster splints secured
with one to two rolls of plaster (fig. 5-5F). This area
provides support to the cast and a weight-bearing surface
when used with a walking boot.
Whenever a cast is applied, you must provide the
patient with written and verbal instruction for cast care
and circulation checks, i.e., numbness, cyanosis, tingling
of extremities, and instruct him or her to return
immediately should any of these conditions occur. When a leg
cast is applied, the patient must also receive instructions
in the proper usage of crutches. The cast will take 24 to 48
hours to completely dry and must be treated gently during
this time. Since plaster is water-soluble, the cast must be
protected with a waterproof covering when bathing or during
wet weather. Nothing must be stuck down the cast, i.e., coat
hangers, as this can cause bunching of the padding and
result in pressure sores. If swelling occurs, the cast may
be split and wrapped with an ace bandage to alleviate
A cast can be removed in two ways: by soaking in
warm vinegar/water solution until it dissolves or in the
usual way by cutting. To remove by cutting, cast cutters,
spreaders, and bandage scissors are necessary. Cuts are made
laterally and medially along the long axis of the cast and
are widened with the use of spreaders. The padding is then
cut with the scissors.
The Terminally Ill Patient
The terminal patient has many needs that are basically
the same as those of other patients: spiritual, psychological,
cultural, economic, and physical. What differs in these patients
may be best expressed as the urgency to resolve the majority of
these needs within a limited time frame. Death comes to everyone
in different ways and at different times. For some patients, death
is sudden following an acute illness. For others, death follows a
lengthy illness. Death not only affects the individual patient; it
affects family and friends, staff, and even other patients.
Because of this, it is essential that all health care providers
understand the process of dying and its effect on all people.
People view death from their individual and cultural
value perspectives. An individual's personal perception of death
often affects their moral and religious attitude toward it. Many
people find the courage and strength to face death through their
religious beliefs. These patients and their families often seek
support from representatives of their religious faith. In many
cases, patients who previously could not identify with a religious
belief or the Supreme Being concept may indicate (verbally or
nonverbally) a desire to talk with a spiritual representative.
There will also be patients who throughout the whole dying
experience will neither desire nor need spiritual support and
assistance. In all these cases, it is the responsibility of the
health care provider to be attentive and perceptive to the
patient's needs and provide whatever support personnel that may be
An individual's cultural system influences behavior
patterns. When we speak of cultural systems, we refer to certain
norms, values, and action patterns of specific groups of people to
various aspects of life. Dying is an aspect of life and is often
referred to as the final crisis of living. In all of our actions,
culturally approved roles frequently encourage specific behavior
responses. For example, in the Caucasian, Anglo-European culture a
dying patient is expected to show peaceful acceptance of his/her
prognosis; the bereaved is expected to communicate grief. When
people behave differently, the health care provider frequently has
difficulty responding appropriately.
Within the last 10 years or so, a theory of death and
dying has developed that provides all persons involved with the
experience highly meaningful knowledge and skills. In this theory
of death and dying (as formulated by Dr. Elizabeth Kubler-Ross in
her book On Death and Dying), it is suggested that most people
(both patients and significant others) go through five stages:
denial, anger, bargaining, depression, and acceptance. The first
stage, denial, is one of nonacceptance. "No, it can't be me, there
must be a mistake!" It is not only important for the health care
provider to recognize the denial stage with its behavior responses
but also to realize that some people maintain denial up to the
point of impending death. The next stage is anger. This is a
period of hostility and questioning "Why me?" The third stage is
bargaining. At this point, people revert to a culturally
reinforced concept that good behavior is rewarded. Patients are
often heard stating "I'd do anything if I could just turn this
thing around." Once the patient realizes that bargaining is
futile, they quickly enter the stage of depression. In addition to
grieving because of his or her personal loss, it is at this point
that the patient becomes concerned about his or her family and
"putting affairs in order." The final stage comes when the patient
accepts death as reality and is prepared for it. It is usually at
this time that the patient's family requires more support than the
Despite the fact that each of us expects to die and
expects all others to die, there is no easy way to discuss death.
To the strong and healthy, death is a frightening thought. The
fact that sooner or later everyone dies does not make death
easier. There are no procedure books that tell health care
providers "how to do" death. The "how to" will only come from the
individual health care provider who understands that patients are
people. More than any other time in life, the dying patient needs
to be treated as an individual person, not a thing, a number, or a
An element of uncertainty and helplessness is almost
always present when death occurs. Assessment and respect for the
patient's individual and cultural value system are of key
importance in planning the care of the dying. As health care
personnel, we often approach a dying patient with some feelings of
uncertainty, helplessness and anxiety. We feel helpless in being
unable to perform tasks that will keep the patient alive;
uncertain that we are doing all we can do to either make the
patient as comfortable as possible or to postpone or prevent death
altogether. We feel anxious about how to communicate effectively
with patients, their family, and even among ourselves. This is a
normal response since any discussion about death carries a high
emotional risk for the patient as well as the health care
provider. Nevertheless, communicating can provide both strength
and comfort to all if done with sensitivity and dignity, and it is
sensitivity and dignity that is the essence of all health care
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Operational Medicine 2001
Health Care in Military Settings
Bureau of Medicine and Surgery
Department of the Navy
2300 E Street NW
Health Care in Military Settings
CAPT Michael John Hughey, MC, USNR
January 1, 2001
United States Special Operations Command
7701 Tampa Point Blvd.
MacDill AFB, Florida
This web version is provided by
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Education Division. It contains original contents from the official US
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