Learn — First aid & basic life support

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Oral care (unconscious patient)

Oral care for an unconscious patient is the mechanical cleaning of the teeth, gums, tongue, palate and lips of someone who has no swallow, no cough to protect himself and often a tube through his mouth. It matters because within 48 hours of admission the mouth of a dependent patient is colonised by hospital organisms, and those organisms, carried down on micro-aspirated secretions, are the direct source of ventilator-associated and aspiration pneumonia.

Position first: turn the patient onto his side, or turn the head to one side, so that fluid runs out of the mouth by gravity instead of into the pharynx; if he is ventilated keep the head of the bed at 30 to 45 degrees unless it is contraindicated.
Set up before you touch the mouth: suction switched on and tested with a Yankauer within reach, gloves, a towel and a kidney tray, a padded tongue depressor or bite block to hold the mouth open, and a torch to inspect first.
Frequency is every 2 to 4 hours for an unconscious or mouth-breathing patient, with a thorough brushing at least twice a day; a dry mouth needs moistening more often than a clean one needs cleaning.
Brush with a small soft toothbrush, not just a swab, because only brushing breaks up dental plaque; clean the teeth, the gum margins, the palate and the tongue, and use swabs between the brushings.
Use only small amounts of fluid on the brush or swab and suction continuously as you work; never pour or syringe fluid into the mouth of a patient who cannot swallow.
Chlorhexidine gluconate 0.12% to 0.2% twice daily is the classical ventilator-care-bundle item, but its routine use in non-cardiac-surgical patients has been questioned, so many units now use plain brushing with water or saline; follow your unit's current protocol rather than assuming.
Avoid lemon and glycerine swabs, which dry the mucosa and decalcify enamel, and avoid undiluted hydrogen peroxide, which burns and delays healing; keep the lips moist with a water-based product, which is also the safer choice when oxygen is running.
Move the endotracheal tube and its tie to the other corner of the mouth at each full mouth care and inspect the lip and the corner of the mouth underneath, because a device-related pressure injury forms there within hours.
Oral care sits inside the wider bundle: head of the bed elevated, cuff pressure 20 to 30 cmH2O, subglottic secretion drainage where the tube allows, a daily sedation break with an assessment of readiness to extubate, and no unnecessary changing of the ventilator circuit.

Cardiopulmonary resuscitation (CPR)

Cardiopulmonary resuscitation is the combination of chest compressions and rescue breaths that keeps oxygenated blood moving to the brain and heart muscle until a shock or a treatable cause restores a rhythm of the patient's own. Its quality decides survival: compressions that are too shallow, too slow, interrupted or given without full chest recoil generate almost no coronary perfusion, so the technical numbers are not academic detail but the treatment itself.

Recognition takes no more than 10 seconds: the patient is unresponsive, is not breathing or is only gasping, and has no definite pulse; agonal gasping is not breathing, and if you are unsure, start compressions.
Adult compressions are given on the lower half of the sternum with the heel of the hand, at a rate of 100 to 120 a minute, to a depth of at least 5 cm and not more than 6 cm, allowing complete chest recoil between each one and keeping any interruption under 10 seconds.
The compression-to-ventilation ratio is 30:2 for an adult with one or two rescuers, and for a child or infant it is 30:2 with a single rescuer and 15:2 with two rescuers; once an advanced airway is in place, compressions run continuously with 1 breath every 6 seconds in an adult and 1 every 2 to 3 seconds in a child or infant.
Paediatric depth is about one-third of the anteroposterior diameter of the chest, roughly 5 cm in a child and 4 cm in an infant; an infant is compressed with two fingers by a single rescuer and with the two-thumb encircling-hands technique when two rescuers are present.
Rescuers swap the compressor role every 2 minutes, at the same moment as the rhythm check, because compression quality falls measurably after about two minutes even when the rescuer does not feel tired.
Ventricular fibrillation and pulseless ventricular tachycardia are shockable: defibrillate once and resume compressions immediately for 2 minutes before rechecking; asystole and pulseless electrical activity are not shockable and are treated with compressions, adrenaline and a search for the cause.
Adrenaline is given as 1 mg intravenously or intraosseously every 3 to 5 minutes, as early as possible in a non-shockable rhythm and after the initial shocks in a shockable one; amiodarone 300 mg followed by 150 mg, or lidocaine, is used for ventricular fibrillation that persists after shocks.
The reversible causes are memorised as the Hs and Ts: hypoxia, hypovolaemia, hydrogen ion (acidosis), hypo- or hyperkalaemia and hypothermia, and tension pneumothorax, tamponade, toxins and thrombosis of the coronary or pulmonary circulation.
Waveform capnography during CPR tells you the truth about quality: a persistently low end-tidal carbon dioxide of under about 10 mmHg means the compressions are ineffective, and an abrupt rise towards normal usually means the circulation has returned.
After return of spontaneous circulation, do not over-oxygenate or over-ventilate: aim for a saturation of 92% to 98%, get a 12-lead ECG, support the blood pressure, treat the cause and use targeted temperature management for the patient who does not obey commands.

Bandaging

A bandage is a strip of material applied to a part of the body to hold a dressing in place, to support or immobilise a joint, to apply compression or to limit swelling. It matters at the bedside because a bandage is the one piece of nursing equipment that can strangle the part it is meant to protect, so every application ends with a check of the circulation, movement and sensation beyond it.

The turns are named and each has its own use: circular turns anchor the start and finish, spiral turns cover a cylindrical part such as an upper arm or a finger, reverse spiral turns cover a conical part such as the forearm or calf, figure-of-eight turns cover a joint such as the ankle, knee or elbow, spica turns are a figure-of-eight over the hip, shoulder or thumb, and recurrent turns cover a stump or the head.
Bandage from distal to proximal so that the venous and lymphatic return is squeezed towards the heart, hold the roll uppermost and roll it onto the body rather than pulling lengths off it, and overlap each turn by one-half to two-thirds of the width of the bandage with even tension and no wrinkles.
Leave the fingertips or toes exposed so that colour, warmth, movement, sensation and a capillary refill of under 2 seconds can be checked; assess them immediately after application, again after 15 to 30 minutes, and then at least once a shift, and record each check.
Pad bony prominences and place gauze between skin surfaces such as the toes, fingers or under a breast, because two damp skin surfaces held together macerate and break down within a day.
Put the part into the functional position before you start and hold it there while you bandage, since a joint bandaged in a flexed or rotated position will stiffen in that position.
Match the width to the part, roughly 2.5 cm for a finger, 5 cm for the hand and arm, 7.5 to 10 cm for the leg and 10 to 15 cm for the trunk, and never start or finish a bandage over a wound, a bony prominence or the inner aspect of a limb where the knot will press on skin.
For elastic compression, apply with the limb elevated and the pressure graduated, firmest at the ankle and easing as you go up, and remove and reapply it at least once a day with a skin inspection.
Loosen and reapply, rather than adding another layer, whenever the bandage slips, becomes wet or soiled, or the limb swells; a wet bandage shrinks as it dries and tightens on the limb.

Needle stick injury — PEP

A needle stick injury is a percutaneous exposure of a health worker to a patient's blood or body fluid through a needle or other sharp, and post-exposure prophylaxis is the short course of antiretroviral drugs, immunoglobulin or vaccine given afterwards to prevent infection taking hold. It matters because the whole outcome depends on the first hour: what the nurse does at the sink, and how quickly she reports, decides whether prophylaxis can still work.

First aid immediately: let the wound bleed freely and wash it with soap and running water; do not scrub it, do not squeeze or suck it, and do not put bleach, alcohol, iodine or any caustic antiseptic into the wound.
For a splash, irrigate the eye with running water or normal saline for 10 to 15 minutes with the contact lens left in place during irrigation and removed and cleaned afterwards, and rinse the mouth with water several times without swallowing.
Report at once to the nurse in charge and to the designated officer or infection control nurse, and record the date and time, the device, whether the needle was hollow-bore and visibly blood-stained, the depth of the injury, the fluid involved and the identity of the source patient.
The approximate risk of transmission after a single percutaneous exposure is up to about 30% for hepatitis B from a highly infectious source in an unvaccinated worker, about 2% to 3% for hepatitis C, and about 0.3% for HIV, falling to about 0.09% for a mucous membrane splash.
Test the source patient and the exposed worker for HIV, hepatitis B surface antigen and hepatitis C antibody after counselling and consent; a rapid HIV test on the source is what decides whether prophylaxis continues.
HIV prophylaxis is started as soon as possible, ideally within hours, and is not offered beyond 72 hours after the exposure; the currently recommended regimen is a tenofovir-based backbone with lamivudine or emtricitabine plus dolutegravir, taken once daily for 28 days.
Follow-up HIV testing is done at baseline and again at about 6 weeks, 3 months and 6 months; during that period the worker uses condoms, does not donate blood and discusses breastfeeding with the counsellor.
For hepatitis B, a worker with a documented anti-HBs of 10 mIU/mL or more needs nothing; an unvaccinated worker or a known non-responder is given hepatitis B immunoglobulin as soon as possible, ideally within 24 hours, together with the vaccine course started at a different injection site.
Hepatitis C has neither a vaccine nor a prophylactic drug: the worker is tested at baseline and again in follow-up, and an infection detected early is treated with direct-acting antivirals, which is why the follow-up appointments matter.
Tetanus prophylaxis is considered when the injury is dirty or the immunisation history is incomplete, and counselling and psychological support are part of the protocol, not an extra.
Prevention is the real answer: no recapping, a needle cutter at the point of use, puncture-proof containers filled to three-quarters at the bedside, safety-engineered devices, never passing sharps hand to hand, and hepatitis B vaccination of every health worker in three doses at 0, 1 and 6 months with an antibody check after the course.

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