Fundamental of Nursing Procedure Manualwww.drjayeshpatidar.blogspot.comFUNDAMENTAL OF NURSINGPROCEDURE MANUALMR. JAYESH PATIDARM.Sc. NURSING
Fundamental of Nursing Procedure Manualwww.drjayeshpatidar.blogspot.com11.Administering Nasal-Gastric tube feeding 10212. Cleaning a wound andApplying a sterile dressing 10613. Supplying oxygen inhalation 109a. Nasal Cannula Method 111b. Mask Method: Simple face mask 113Table of ContentsI. Basic Nursing Care/ Skill1. Bed makinga. Making an Un-occupied bedb. Changing an Occupied bedc. Making a Post-operative bed2. Performing oral carea.Assisting the client with oral careb. Providing oral care for dependent client3. Performing bed bath4. Performing back care5. Performing hair washing6. Care for fingernails/ toenails7. Performing perineal care8. Taking vital signsa. Taking axillary temperature by glass thermometerb. Measuring radial pulsec. Counting respirationd. Measuring blood pressure9. Performing physical examination10. Care for Nasal-gastric Tubea. Inserting a Nasal-Gastric Tubeb. Removal a Nasal-Gastric Tube79131619212326303235373941434546499898101II. Administration of Medications 1151. Administering oral medications 1172. Administering oral medications through a Nasal-Gastric Tube 1203. Removing medications from an ampoule 1234. Removing medications from a vial 1265. Prevention of the needle-stick injuries 1296. Giving an Intra-muscular injection 1307. Starting an Intra-venous infusion 1358. Maintenance of I.V. system 1409. Administering medications by Heparin Lock 14410. Performing Nebulizer Therapy 147a. Inhaler 148b. Ultrasonic nebulizer 149
Fundamental of Nursing Procedure Manualwww.drjayeshpatidar.blogspot.comIII. Specimen collection 1511.Collecting blood specimen 153a. Performing venipuncture 153b. Assisting in obtaining blood for culture 1572.Collecting urine specimen 159a. Collecting a single voided specimen 160b. Collecting a 24-hour urine specimen 161c. Collecting a urine specimen from a retention catheter 163d. Collecting a urine culture 1643. Collecting a stool specimen 1664. Collecting a sputum specimen 168a. Routine test 168b. Collecting a sputum culture 169AppendixReferences171181
9Bed makinga. Making an Un-occupied BedDefinition:Abed prepared to receive a new patient is an un-occupied bed.Fig.1. Un-occupied bedPurpose1. To provide clean and comfortable bed for the patient2. To reduce the risk of infection by maintaining a clean environment3. To prevent bed sores by ensuring there are no wrinkles to cause pressure pointsEquipment required:1. Mattress (1)2. Bed sheets(2): Bottom sheet (1)Top sheet (1)3. Pillow (1)4. Pillow cover (1)5. Mackintosh (1)6. Draw sheet (1)7. Blanket (1)8. Savlon water or Dettol water in basin9. Sponge cloth (4): to wipe with solution (1)to dry (1)✽ When bed make is done by two nurses,sponge cloth is needed two each.10. Kidney tray or paper bag (1)11. Laundry bag or Bucket (1)12. Trolley(1)Fig. 2. Equipment required on a trolley
1010www.drjayeshpatidar.blogspot.comProcedure: by one nurseCareAction Rationale1. Explain the purpose and procedure to the client. Providing information fosters cooperation.2. Perform hand hygiene. To prevent the spread of infection.3. Prepare all required equipments and bring thearticles to the bedside.Organization facilitates accurate skillperformance4. Move the chair and bed side locker It makes space for bed making and helps effectiveaction.5. Clean Bed-side locker:Wipe with wet and dry.To maintain the cleanliness6. Clean the mattress:1) Stand in right side.2) Start wet wiping from top to center and fromcenter to bottom in right side of mattress.3) Gather the dust and debris to the bottom.4) Collect them into kidney tray.5) Give dry wiping as same as procedure 2).6) Move to left side.7) Wipe with wet and dry the left side.To prevent the spread of infection7. Move to right side.Bottom sheet:1) Place and slide the bottom sheet upward overthe top of the bed leaving the bottom edge of thesheet.2) Open it lengthwise with the center fold along thebed center.3) Fold back the upper layer of the sheet toward theopposite side of the bed.4) Tuck the bottom sheet securely under the head ofthe mattress(approximately 20-30cm). (Fig.3)Make a mitered corner.➀Pick up the selvage edge with your handnearest the hand of the bed.➁Lay a triangle over the side of the bed (Fig.4 )➂Tuck the hanging part of the sheet under themattress.( Fig. 5)➃Drop the triangle over the side of the bed.( Fig. 6ⓐ→ 6ⓑ)⑤Tuck the sheet under the entire side of bed.(Fig.7)5) Repeat the same procedure at the end of thecorner of the bed6) Tuck the remainder in along the sideUnfolding the sheet in this manner allows you tomake the bed on one side.A mitered corner has a neat appearance and keepsthe sheet securely under the mattress.Tucking the bottom sheet will be done by turn,the corner of top firstly and the corner of thebottom later.To secure the bottom sheet on one side of the bed.
1111www.drjayeshpatidar.blogspot.com8. Mackintosh and draw sheet:1) Place a mackintosh at the middle of the bed ( ifused), folded half, with the fold in the center ofthe bed. used), folded half, with the fold in thecenter of the bed.2) Lift the right half and spread it forward the nearSide.Mackintosh and draw sheet are additionalprotection for the bed and serves as a lifting orturning sheet for an immobile client.
1212www.drjayeshpatidar.blogspot.comFig.3 Tuck the bottom sheetunder the mattressFig.4 Picking the selvage and laying a triangle onthe bedFig.6a Putting and holding the sheet bedside themattress at the level of topFig.6b Dropping the triangle over the side of the bedFig.5 Tucking the hanging part of the sheet underthe mattressFig.7 Tucking the sheet under the entire side of thebed
1313www.drjayeshpatidar.blogspot.comCareAction Rationale3) Tuck the mackintosh under the mattress.4) Place the draw sheet on the mackintosh. Spreadand tuck as same as procedure 1)-3).9.Move to the left side of the bed.Bottom sheet , mackintosh and draw sheet:1) Fold and tuck the bottom sheet as in the aboveprocedure 7.2) Fold and tuck both the mackintosh and the drawsheet under the mattress as in the aboveprocedure 8.Secure the bottom sheet, mackintosh and drawsheet on one side of the bed10. Return to the right side.Top sheet and blanket:1) Place the top sheet evenly on the bed, centeringit in the below 20-30cm from the top of themattress.2) Spread it downward.3) Cover the top sheet with blanket in the below 1feet from the top of the mattress and spreaddownward.4) Fold the cuff (approximately 1 feet) in the neckpart5) Tuck all these together under the bottom ofmattress. Miter the corner.6) Tuck the remainder in along the sideAblanket provides warmth.Making the cuff at the neck part preventsirritation from blanket edge.Tucking all these pieces together saves time andprovides a neat appearance.11. Repeat the same as in the above procedure 10 inleft side.To save time in this manner12. Return to the right side.Pillow and pillow cover:1) Put a clean pillow cover on the pillow.2) Place a pillow at the top of the bed in the centerwith the open end away from the door.Apillow is a comfortable measure.Pillow cover keeps cleanliness of the pillow andneat.The open end may collect dust or organisms.The open end away from the door also makesneat.13. Return the bed, the chair and bed-side table totheir proper place.Bedside necessities will be within easy reach forthe client .14. Replace all equipments in proper place.Discard lines appropriately.It makes well-setting for the next.Proper line disposal prevents the spread ofinfection.15. Perform hand hygiene To prevent the spread of infection.NursingAlert Do not let your uniform touch the bed and the floor not to contaminate yourself.Never throw soiled lines on the floor not to contaminate the floor.Staying one side of the bed until one step completely made saves steps and time to do effectively andsave the time.
1414www.drjayeshpatidar.blogspot.comBed makingb. Changing an Occupied BedDefinitionThe procedure that used lines are changed to a hospitalized patient is an occupied bed.Fig. 8 Occupied bedPurpose:1. To provide clean and comfortable bed for the patient2. T reduce the risk of infection by maintaining a clean environment3. To prevent bed sores by ensuring there are no wrinkles to cause pressure pointsEquipment required:1. Bed sheets(2) : Bottom sheet( or bed cover) (1)Top sheet (1)2. Draw sheet (1)3. Mackintosh (1) (if contaminated or needed to change)4. Blanket (1) ( if contaminated or needed to change)5. Pillow cover (1)6. Savlon water or Dettol water in bucket7. Sponge cloth (2): to wipe with solution (1)to dry (1)✽When the procedure is done by two nurses, sponge cloth is needed two each.8. Kidney tray or paper bag (1)9. Laundry bag or bucket (1)10. Trolley (1)
1515www.drjayeshpatidar.blogspot.comProcedure: by one nurseCareAction Rationale1. Check the client‟s identification and condition. To assess necessity and sufficient condition2. Explain the purpose and procedure to the client Providing information fosters cooperation3. Perform hand hygiene To prevent the spread of infection.4. Prepare all required equipments and bring thearticles to the bedside.Organization facilitates accurate skill performance5. Close the curtain or door to the room. Put screen. To maintain the client‟s privacy.6. Remove the client‟s personal belongings frombed-side and put then into the bed-side locker orsafe place.To prevent personal belongings from damage andloss.7. Lift the client‟s head and move pillow from centerto the left side.The pillow is comfortable measure for the client.8. Assist the client to turn toward left side of thebed. Adjust the pillow. Leaves top sheet in place.Moving the client as close to the other side of thebed as possible gives you more room to make thebed.Top sheet keeps the client warm and protect his orher privacy.9.Stand in right side:Loose bottom bed linens. Fanfold (or roll) soiledlinens from the side of the bed and wedge themclose to the client.Placing folded (or rolled) soiled linen close to theclient allows more space to place the clean bottomsheets.10. Wipe the surface of mattress by sponge clothwith wet and dry.To prevent the spread of infection.11. Bottom sheet, mackintosh and draw sheet:1) Place the clean bottom sheet evenly on the bedfolded lengthwise with the center fold as close tothe client‟s back as possible.2) Adjust and tuck the sheet tightly under the headof the mattress, making mitered the uppercorner.3) Tighten the sheet under the end of the mattressand make mitered the lower corner.4) Tuck in along side.5) Place the mackintosh and the draw sheet on thebottom sheet and tuck in them together.Soiled linens can easily be removed and cleanlinens are positioned to make the other side of thebed.12. Assist the client to roll over the folded (rolled)linen to right side of the bed. Readjust the pillowand top sheet.Moving the client to the bed‟s other side allows youto make the bed on that side.13. Move to left side:Discard the soiled linens appropriately. Holdthem away from your uniform. Place them in thelaundry bag (or bucket).Soiled linens can contaminate your uniform,which may come into contact with other clients.14. Wipe the surface of the mattress by sponge clothwith wet and dry.To prevent the spread of infection.15. Bottom sheet, mackintosh and draw sheet:1) Grasp clean linens and gently pull them out fromunder the client.2) Spread them over the bed‟s unmade side. Pull thelinens tautWrinkled linens can cause skin irritation.
Fundamental of Nursing Procedure ManualCareAction Rationale3) Tuck the bottom sheet tightly under the head ofthe mattress and miter the corner.4) Tighten the sheet under the end of the mattressand make mitered the lower corner.5) Tuck in along side.6) Tuck the mackintosh and the draw sheet underthe mattress.16. Assist the client back to the center of the bed.Adjust the pillow.The pillow is comfort measure for the client.17. Return to right side:Clean top sheet, blanket:1) Place the clean top sheet at the top side of thesoiled top sheet.2)Ask the client to hold the upper edge of the cleantop sheet.3) Hold both the top of the soiled sheet and the endof the clean sheet with right hand and withdrawto downward. Remove the soiled top sheet andput it into a laundry bag (or a bucket).4) Place the blanket over the top sheet. Fold topsheet back over the blanket over the client.5) Tuck the lower ends securely under the mattress.Miter corners.6)After finishing the right side, repeat the left side.Tucking these pieces together saves time andprovides neat, tight corners.18. Remove the pillow and replace the pillow coverwith clean one and reposition the pillow to thebed under the client‟s head.The pillow is a comfortable measures for a client19. Replace personal belongings back. Return thebed-side locker and the bed as usual.To prevent personal belongings from loss andprovide safe surroundings20. Return all equipments to proper place. To prepare for the next procedure21. Discard linens appropriately. Perform handhygiene.To prevent the spread of infection.15
1616Bed makingc. Making a Post-operative BedDefinition:It is a special bed prepared to receive and take care of a patient returning from surgery.Fig.9 Post-operative bedPurpose:1. To receive the post-operative client from surgery and transfer him/her from a stretcher to a bed2. To arrange client‟s convenience and safetyEquipment required:1. Bed sheets: Bottom sheet (1)Top sheet (1)2. Draw sheet (1-2)3. Mackintosh or rubber sheet (1-2)✽According to the type of operation, thenumber required of mackintosh and drawsheet is different.4. Blanket (1)5. Hot water bag with hot water (104- 140 ℉)if needed (1)6. Tray1(1)7. Thermometer, stethoscope,sphygmomanometer: 1 each8. Spirit swab9. Artery forceps (1)10. Gauze pieces11. Adhesive tape (1)12. Kidney tray (1)13. Trolley (1)14. IV stand15. Client‟s chart16. Client‟s kardex17. According to doctor‟s orders:- Oxygen cylinder with flow meter- O2cannula or simple mask- Suction machine with suction tube-Airway- Tongue depressor- SpO2monitor- ECG- Infusion pump, syringe pump
1717Procedure: by one nurseCareAction Rationale1. Perform hand hygiene To prevent the spread of infection2.Assemble equipments and bring bed-side Organization facilitates accurate skillperformance3. Strip bed.Make foundation bed as usual with a largemackintosh, and cotton draw sheet.Mackintosh prevents bottom sheet from wettingor soiled by sweat, drain or excrement.Place mackintosh according to operativetechnique.Cotton draw sheet makes the client felt dry orcomfortable without touching the mackintoshdirectly.4. Place top bedding as for closed bed but do nottuck at footTuck at foot may hamper the client to enter thebed from a stretcher5. Fold back top bedding at the foot of bed. (Fig.10 ) To make the client „s transfer smooth6. Tuck the top bedding on one side only. (Fig. 11 ) Tucking the top bedding on one side stops the bedlinens from slipping out of place and7. On the other side, do not tuck the top sheet.1) Bring head and foot corners of it at the center ofbed and form right angles. (Fig.12 )2) Fold back suspending portion in 1/3 (Fig. 13 )andrepeat folding top bedding twice to opposite sideof bed(Fig.14, 15)The open side of bed is more convenient forreceiving client than the other closed side.8. Remove the pillow. To maintain the airway9 Place a kidney-tray on bed-side. To receive secretion10. Place IV stand near the bed. To prepare it to hang I/Vsoon11. Check locked wheel of the bed. To prevent moving the bed accidentally when theclient is shifted from a stretcher to the bed.12.Place hot water bags(or hot bottles) in themiddle of the bed and cover with fanfolded top ifneededHot water bags (or hot bottles) prevent the clientfrom taking hypothermia13.When the patient comes, remove hot water bagsif put beforeTo prepare enough space for receiving the client14. Transfer the client:1) Help lifting the client into the bed2) Cover the client by the top sheet and blanketimmediately3) Tuck top bedding and miter a corner in the end ofthe bed.To prevent the client from chilling and /or havinghypothermia
1818Fig. 10 Folding back top beddingat the foot Fig. 13 Folding 1/3 side of top bedding at right sideFig. 11 Tucking the top bedding on left side Fig.14 Rolling top bedding againFig. 12 Bringing both head and foot corners to thecenter and forming right anglesFig. 15 Folding it again and complete top bedding
1919Performing Oral CareDefinition:Mouth care is defined as the scientific care of the teeth and mouth.Purpose:1. To keep the mucosa clean, soft, moist and intact2. To keep the lips clean, soft, moist and intact3. To prevent oral infections4. To remove food debris as well as dental plaque without damaging the gum5. To alleviate pain, discomfort and enhance oral intake with appetite6. To prevent halitosis or relieve it and freshen the mouthEquipment required:1. Tray (1)2. Gauze-padded tongue depressor (1): to suppress tongue3. Torch(1)4. Appropriate equipments for cleaning:- Tooth brush- Foam swabs- Gauze-padded tongue depressor- Cotton ball with artery forceps (1) and dissecting forceps (1)5. Oral care agents:Tooth paste/ antiseptic solution❖NURSING ALERT❖You should consider nursing assessment, hospital policy and doctor‟s prescription if there is,when you select oral care agent. Refer to Table 1. on the next page6. If you need to prepare antiseptic solution as oral care agent:Gallipot (2): to make antiseptic solution(1)to set up cotton ball after squeezed (1)7. Cotton ball8. Kidney tray (1)9. Mackintosh (1): small size10. Middle towel (1)11. Jug with tap water (1)12. Paper bag(2): for cotton balls (1)for dirt(1)13. Gauze pieces as required: to apply a lubricant14. Lubricants: Vaseline/ Glycerin/ soft white paraffin gel/ lip cream (1)15. Suction catheter with suction apparatus (1): if available16. Disposable gloves( 1 pair): if available
2020NOTE:Table 1. Various oral care agents for oral hygieneThe choice of an oral care agent is dependent on the aim of care. The various agents are available and shouldbe determined by the individual needs of the client.Agents Potential benefits Potential harmsTap water To refreshbe availableShort lastingnot contain a bactericideTooth paste Not specifiedTo remove debrisTo refreshIt can dry the oral cavity if notadequately rinsed *1Nystatin To treat fungal infections Tastes unpleasantChlorhexidine gluconate:a compound withbroad-spectrumanti-microbial activity *2To suppress the growing of bacteria indoses of 0.01-0.2 % solution *2not be significant to preventchemotherapy- induced mucositis *2Tastes unpleasantbe stainable teeth with prolonged useSodium bicarbonate: To dissolve viscous mucous*3 Tastes unpleasantmay bring burn if not dilutedadequatelycan alter oral pH allowing bacteria tomultiply *1Fluconazole:an orally absorbedantifungal azole, soluble inwaterfor the treatment of candidosis of theoropharynx, oesophagus and variety ofdeep tissue sites *3not reportedSucralfate:a mouth-coating agentInitially for the clients under radiotherapyand chemotherapyTo reduce pain of mucositisnot reportedFluoride To prevent and arrest tooth decayespecially radiation caries,demineralization and decalcificationTo show toxicity in high densityGlycerine an thymol To refresh Refreshing lasts only 20-30 seconds*1Can over-stimulate the salivaryglands leading to reflex action andexhaustion *1Another solutions for oral care such as Potasium permanganate(1:5000), Sodium chloride(I teaspoon to a pint ofwater), Potasium chroride( 4 to 6 %), Hydrogen perpxide(1: 8 solution) are used commonly*4.References:1. PenelopeAnn Hilton(2004) fundamental nursing skills , I.K. International Pvt. Ltd., p.632. http://www.herhis.nhs.uk/RMCNP/content/mars32.htm The Royal Marsden Hospital Manual ofClinical Nursing procedure, 6th edition, Personal hygiene: mouth care3. http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=7153&nbr=4285Nursing management of oral hygiene, National Guideline Clearinghouse4. I Clement(2007) Basic Concepts on Nursing Procedures, Jaypee, p. 68
2121Procedure:a. Assisting the client with Oral careCareAction Rationale1.Explain the procedures Providing information fosters cooperation,understanding and participation in care2. Collect all instruments required Organization facilitates accurate skillperformance3. Close door and /or put screen To maintain privacy4. Perform hand hygiene and wear disposablegloves if possibleTo prevent the spread of infection5. If you use solutions such as sodium bicarbonate,prepare solutions required.Solutions must be prepared each time before useto maximize their efficacy6.Assist the client a comfortable upright position orsitting positionTo promote his/her comfort and safety andeffectiveness of the care including oral inspectionand assessment7. Inspect oral cavity1) Inspect whole the oral cavity ,such as teeth,gums, mucosa and tongue, with the aid ofgauze-padded tongue depressor and torch2) Take notes if you find any abnormalities, e.g.,bleeding, swollen, ulcers, sores, etc.Comprehensive assessment is essential todetermine individual needsSome clients with anemia, immunosuppression,diabetes, renal impairment epilepsy and takingsteroids should be paid attention to oral condition.They may have complication in oral cavity.8. Place face towel over the client chest or on thethigh with mackintosh (Fig. 16)To prevent the clothing form wetting and not togive uncomfortable condition9. Put kidney tray in hand or assist the clientholding a kidney trayTo receive disposal surelyFig16 Setting the kidney tray up with face towel covered mackintosh
Fundamental of Nursing Procedure ManualCareAction Rationale10. Instruct the client to brush teethPoints of instruction1) Client places a soft toothbrush at a 45 °angle tothe teeth.2) Client brushes in direction of the tips of thebristles under the gum line with tooth paste.Rotate the bristles using vibrating or jigglingmotion until all outer and inner surfaces of theteeth and gums are clean.3) Client brushes biting surfaces of the teeth4) Client clean tongue from inner to outer and avoidposterior direction.Effective in dislodging debris and dental plaquefrom teeth and gingival marginCleansing posterior direction of the tongue maycause the gag reflex11. If the client cannot tolerate toothbrush (orcannot be available toothbrush), form swabs orcotton balls can be usedWhen the client is prone to bleeding and/or pain,tooth brush is not advisable12. Rinse oral cavity1) Ask the client to rinse with fresh water and voidcontents into the kidney tray.2) Advise him/her not to swallow water. If needed,suction equipment is used to remove any excess.To make comfort and not to remain any fluid anddebrisTo reduce potential for infection and13. Ask the client to wipe mouth and around it. To make comfort and provide the well-appearance14. Confirm the condition of client‟s teeth, gums andtongue.Apply lubricant to lips.To moisturize lips and reduce risk for cracking15. Rinse and dry tooth brush thoroughly. Returnthe proper place for personal belongings afterdrying up.To prevent the growth of microorganisms16. Replace all instruments To prepare equipments for the next procedure17. Discard dirt properly and safety To maintain standard precautions18. Remove gloves and wash your hands To prevent the spread of infection19. Document the care and sign on the records. Documentation provides ongoing data collectionand coordination of careGiving signature maintains professionalaccountability20. Report any findings to senior staffs To provide continuity of care22
2323b. Providing oral care for dependent clientFig. 17 Equipments required for oral care in depending clientProcedure: The procedure with cotton balls soaked sodium bicarbonate is showed here.CareAction Rationale1. Check client‟s identification and condition Providing nursing care for the correct client withappropriate way.2. Explain the purpose and procedure to the client Providing information fosters cooperation andunderstanding3.Perform hand hygiene and wear disposable gloves To prevent the spread of infection.4. Prepare equipments:1) Collect all required equipments and bring thearticles to the bedside.2) Prepare sodium bicarbonate solutions in gallipot.❖NursingAlert❖If the client is unconscious, use plain tap water.3) Soak the cotton ball in sodium bicarbonatessolution(3 pinches / 2/3 water in gallipot) withartery forceps.4) Squeeze all cotton balls excess solution by arteryforceps and dissecting forceps and put intoanother gallipotOrganization facilitates accurate skillperformanceSolutions must be prepared each time before useto maximize their efficacyTo reduce potential infectionCleaning solutions aids in removing residue onthe client‟s teeth and softening encrusted areas.To avoid inspiration of the solution5. Close the curtain or door to the room. Put screen. It maintains the client‟s privacy6. Keep the client in a side lying or in comfortableposition.Proper positioning prevents back strainTilting the head downward encourages fluid todrain out of the client‟s mort and it preventsaspiration.
2424CareAction Rationale7. Place the mackintosh and towel on the neck tochest.The towel and mackintosh protect the client andbed from soakage.8. Put the kidney tray over the towel andmackintosh under the chin.(Fig. 18)It facilitates drainage from the client‟s mouth.9. Inspect oral cavity:1) Inspect whole the oral cavity, such as teeth,gums, mucosa and tongue, with the aid ofgauze-padded tongue depressor and torch.2) Take notes if you find any abnormalities, e.g.,bleeding, swollen, ulcers, etc.Comprehensive assessment is essential todetermine individual needs.Some clients with anemia, immunosuppression,diabetes, renal impairment, epilepsy and takingsteroids should be paid attention to oral condition.They may have complication in oral cavity.10. Clean oral surfaces: (Fig.19)1) Ask the client to open the mouth and insert thepadded tong depressor gently from the angle ofmouth toward the back molar area. You never useyour fingers to open the client‟s mouth.The tong depressor assists in keeping the client‟smouth open. As a reflex mechanism, the clientmay bite your fingers.2) Clean the client‟s teeth from incisors to molarsusing up and down movements from gums tocrown.Friction cleanses the teeth.3) Clean oral cavity from proximal to distal, outerto inner parts, using cotton ball for each stroke.Friction cleanses the teeth.11. Discard used cotton ball into small kidney tray. To prevent the spread of infection.12. Clean tongue from inner to outer aspect. Microorganisms collect and grow on tonguesurface and contribute to bad breath.Fig.18 Placing a kidney tray on the mackintoshcovered a face towelFig. 19 Cleansing teeth with supporting paddedtongue depressor
2525CareAction Rationale13. Rinse oral cavity:1) Provide tap water to gargle mouth and positionkidney tray.2) If the client cannot gargle by him/herself,a) rinse the areas using moistened cotton ballsorb) insert of rubber tip of irrigating syringe intothe client‟s mouth and rinse gently with a smallamount of water.3) Assist to void the contents into kidney tray. If theclient cannot spit up, especially in the case ofunconscious client, suction any solution.To remove debris and make refreshRinsing or suctioning removes cleaning solutionand debris.Solution that is forcefully irrigated may causeaspirationTo avoid aspiration of the solution14. Confirm the condition of client‟s teeth, gums,mucosa and tongue.To assess the efficacy of oral care and determineany abnormalities15. Wipe mouth and around it. Apply lubricant tolips by using foam swab or gauze piece withartery forcepsLubricant prevents lips from drying and cracking.16. Reposition the client in comfortable position. To provides for the client‟s comfort and safety.17. Replace all equipments in proper place. To prepare equipments for the next care18. Discard dirt properly and safety To maintain standard precautions19. Remove gloves and perform hand hygiene To prevent the spread of infection20. Document the care and sign on the records. Documentation provides ongoing data collectionand coordination of care.Giving signature maintains professionalaccountability21. Report any findings to the senior staff. To provide continuity of care❖NursingAlert❖Oral care for the unconscious clients1. Special precautions while the procedure The client should be positioned in the lateral position with the head turned toward the side.( Rationale: It can not only provide for drainage but also prevent accidental aspiration.) Suction apparatus is required. ( Rationale: It prevents aspiration.) To use plain water for cleaning of oral cavity of unconscious clients may beadvisable.( Rationale: Potential infection may be reduced by using plain water whenthe solution flows into the respiratory tract by accident.)2. Frequency of careOral care should be performed at least every four hours. ( Rationale: Four hourly care will reduce thepotential for infection from microorganisms. byhttp://www.heris.nhs.uk/RMCNP/contant/mars32.htm The Royal Marsden Hospital Manual ofClinical Nursing Procedures 6th edition.)
2626Performing Bed BathDefinition:Abath given to client who is in the bed (unable to bath itself)Purpose:1. To prevent bacteria spreading on skin2. To clean the client‟s body3. To stimulate the circulation4. To improve general muscular tone and joint5. To make client comfort and help to induce sleep6. To observe skin condition and objective symptomsEquipments required:1. Basin (2): for without soap (1)for with soap (1)2. Bucket (2): for clean hot water (1)for waste (1)3. Jug (1)4. Soap with soap dish (1)5. Sponge cloth (2): for wash with soap (1)for rinse (1)6. Face towel (1)7. Bath towel (2) : Ⓐ for covering over mackintosh (1)Ⓑ for covering over client‟s body (1)8. Gauze piece (2-3)9. Mackintosh (1)10. Trolley (1)11. Thermometer (1)12. Old newspaper13. Paper bag(2): for clean gauze (1)for waste (1)
2727Procedure: complete bed bathCareAction Rationale1. Confirm Dr.‟s order.Check client identification and condition.The bath order may have changed.In some instances a bed bath may be harmful for aclient, who is in pain, hemorrhaging, or weak. Nsneed to defer the bath.2. Explain the purpose and procedure to the client.If he or she is alert or oriented, question the clientabout personal hygiene preferences and ability toassist with the bath.Providing information fosters cooperation.Encourage the client to assist with care and topromote independence.3. Gather all required equipments. Organization facilitates accurate skill performance4. Wash your hands and put on gloves. To prevent the spread of organisms. Gloves areoptional but you must wear them if you are givingperineal and anal care.5.Bring all equipments to bed-side. Organization facilitates accurate skillperformance6. Close the curtain or the door. To ensure that the room is warm.To maintain the client‟s privacy.7.Put the screen or curtain. To protect the client‟s privacy.8.Prepare hot water (60℃). Water will cool during the procedure.9. Remove the client‟s cloth. Cover the client‟s bodywith a top sheet or blanket.If an IV is present on the client‟s upperextremity, thread the IV tubing and bag throughthe sleeve of the soiled cloth. Rehang the IVsolution. Check the IV flow rate.Removing the cloth permits easier access whenwashing the client‟s upper body.Be sure that IV delivery is uninterrupted andthat you maintain the sterility of the setup.10.Fill two basins about two-thirds full with warmwater(43-46℃or 110-115F).Water at proper temperature relaxes him/her andprovides warmth. Water will cool during theprocedure.11.Assist the client to move toward the side of thebed where you will be working. Usually you willdo most work with your dominant hand.Keep the client near you to limit reaching acrossthe bed.12. Face, neck, ears:1) Put mackintosh and big towel Ⓐunder theclient‟s body from the head to shoulders. Placeface towel under the chin which is also coveredthe top sheet.2) Make a mitt with the sponge towel and moistenwith plain water.3) Wash the client‟s eyes. Cleanse from inner toouter corner. Use a different section of the mitt towash each eye.4) Wash the client‟s face, neck, and ears.Use soap on these areas only if the client prefers.Rinse and dry carefully.To prevent the bottom sheet from making wet.Soap irritates the eyes.Washing from inner to outer corner preventssweeping debris into the client‟s eyes. Using aseparate portion of the mitt for each eye preventsthe spread of infection.Soap is particularly drying to the face.
Fundamental of Nursing Procedure ManualCareAction Rationale13. Upper extremities:1) Move the mackintosh and big towel ○A to underthe client‟s far arm.2) Uncover the far arm.3) Fold the sponge cloth and moisten.4) Wash the far arm with soap and rinse. Use longstrokes: wrist to elbow→ elbow to shoulder→axilla→ hand5) Dry by face towel6) Move the mackintosh and big towel ○A to underthe near arm and uncover it7) Wash, rise, and dry the near arm as same asprocedure 4).To prevent sheet from making wetWashing the far side first prevents dripping bathwater onto a clean area.Long strokes improve circulation be facilitatingvenous return14. Chest and abdomen:1) Move the mackintosh and bath towel ○A tounder the upper trunk2) Put another bath towel ○B to over the chest3) Fold the sponge towel and moisten4) Wash breasts with soap and rinse. Dry by the bigtowel covering.5) Move the bath towel ○B covering the chest toabdomen.6)Fold the sponge cloth and moisten.7) Wash abdomen with soap, rinse and dry8) Cover the trunk with top sheet and remove thebath towel ○B from the abdomen.Mackintosh and bath towel ○A prevent sheetfrom wettingBath towel ○B provides warmth and privacy15. Exchange the warm water. Cool bath water is uncomfortable. The water isprobably unclean. You may change water earlier ifnecessary to maintain the proper temperature.16. Lower extremities:1) Move the mackintosh and bath towel ○A tounder the far leg. Put pillow or cushion under thebending knee. Cover the near legg with bathtowel ○B .2) Fold the sponge cloth and moisten.3) Wash with soap, rinse and dry.Direction to wash: from foot joint to knee→ fromknee to hip joint4) Repeat the same procedure as 16.1)- 3) on thenear side.5) Cover the lower extremities with top sheetRemove the cushion, mackintosh and big towel○A .Pillow or cushion can support the lower leg andmakes the client comfort.17. Turn the client on left lateral position with backtowards you.To provide clear visualization and easier contactto back and buttocks care28
Fundamental of Nursing Procedure ManualCareAction Action18.Back and buttocks:1) Move the mackintosh and big towel ○A underthe trunk.2) Cover the back with big towel ○B .3) Fold the towel and moisten. Uncover the back.4) Wash with soap and rinse. Dry with big towel ○B .5) Back rub if needed✽ See our nursing manual “Back Care”6) Remove the mackintosh and big towel ○ASkin breakdown usually occurs over bonyprominences. Carefully observe the sacral areaand back for any indications.19. Return the client to the supine position. To make sustainable position for perineal care20. Perineal care:✽See our nursing manual “Perineal care”Clean the perineal area to prevent skin irritationand breakdown and to decrease the potentialodor.21.Assist the client to wear clean cloth. To provide for warmth and comfort22.After bed bath:1) Make the bed tidy and keep the client incomfortable position.2) Check the IV flow and maintain it with the speedprescribed if the client is given IV.These measures provide for comfort and safetyTo confirm IV system is going properly and safely23. Document on the chart with your signature andreport any findings to senior staff.Documentation provides coordination of careGiving signature maintains professionalaccountability29
3030Performing Back CareDefinition:Back care means cleaning and massaging back, paying special attention to pressure points. Especiallyback massage provides comfort and relaxes the client, thereby it facilitates the physical stimulation to theskin and the emotional relaxation.Purpose:1. To improve circulation to the back2. To refresh the mode and feeling3. To relieve from fatigue, pain and stress4. To induce sleepEquipments required:1. Basin with warm water (2)2. Bucket for waste water (1)3. Gauze pieces (2)4. Soap with soap dish (1)5. Face towel (1)6. Sponge cloth (2): 1 for with soap1 for rinse7. Big Towel (2): 1 for covering a mackintosh1 for covering the body8. Mackintosh (1)9. Oil/ Lotion/ Powder (1): according to skin condition and favor10. Tray (1)11. Trolley (1)12. Screen (1)
3131Procedure:CareAction Rationale1. Perform hand hygiene To prevent spread of infection2.Assemble all equipments required. Organization facilitates accurate skillperformance3. Check the clients identification and condition. To assess sufficient condition on the client4.Explain to the client about the purpose and theprocedure.Providing information fosters cooperation5.Put all required equipments to the bed-side andset up.Appropriate setting can make the time of theprocedure minimum and effective.6.Close all windows and doors, and put the screenor / and utilize the curtain if there is.To ensure that the room is warm.To maintain the privacy.7. Placing the appropriate position:1) Move the client near towards you.2) Turn the client to her/ his side and put themackintosh covered by big towel under theclients body.To make him/her more comfortable and providethe care easily.Mackintosh can avoid the sheet from wetting.8.Expose the clients back fully and observe itwhether if there are any abnormalities.To find any abnormalities soon is important tothat you prevent more complication and/ orprovide proper medication and/or as soon aspossible.If you find out some redness, heat or sores, youcannot give any massage to that place.If the client has already some red sore or broken-down area, you need to report to the senior staffand /or doctor.9. Lather soap by sponge towel. Wipe with soap andrinse with plain warm water.To make clean the back before we give massagewith oil/ lotion/ powder.10. Put some lotion or oil into your palm. Apply theoil or the lotion and massage at least 3-5minutes by placing the palms:1) from sacral region to neck2)from upper shoulder to the lowest parts ofbuttocksDon‟t apply oil or lotion directly to the back skin.Too much apply may bring irritation anddiscomfort11. Help for the client to put on the clothes andreturn the client to comfortable position.To provide for warmth and comfort12. Replace all equipments in proper place. To prepare for the next procedure13. Perform hand hygiene. To prevent the spread of infection14. Document on the chart with your signature,including date, time and the skin condition.Report any findings to senior staff.Documentation provides coordination of careGiving signature maintains professionalaccountability
3232Performing Hair WashingDefinition:Hair washing defines that is one of general care provided to a client who cannot clean the hair by himself/herself.Purpose:1. To maintain personal hygiene of the client2. To increase circulation to the scalp and hair and promote growing of hair3. To make him/her feel refreshedEquipments required:1. Mackintosh(2): to prevent wet (1)to make Kelly pad (1)2. Big towel(2): to cover mackintosh (1)to round the neck (1)3. Middle towel (1)4. Shampoo or soap (1)5. Hair oil (1): if necessary6. Brush, comb: (1)7. Paper bag (2): for clean (1)for dirty (1)8. Cotton boll with oil or non-refined cotton9. Bucket (2): for hot water (1)for wasted water (1)10. Plastic jug (1)11. Clothpin or clips (2)12. Steel Tray (1)13. Kidney tray (1)14. Cushion or pillow (1)15. Clean cloth if necessary16. Old newspaper17. Trolley (1)
3333Procedure:CareAction Rationale1. Perform hand hygiene To prevents the spread of infection2.Gather all equipments Organization facilitates accurate skill performance3.Check the condition of client. Explain thepurpose and the procedure to the client.Proper explanation may allay his/her anxiety andfoster cooperation4. Bring and set up all equipments to the bed-side To save the time and promote effective care5. Help the client move his/her head towards edgeof the bed and remove the pillow from the head.To arrange appropriate position with consideringyour body mechanics6.Put another pillow or a cushion under thebending knee. Make him/her comfortableposition.Putting a pillow or a cushion could prevents fromhaving some pain while the hair washing process7. Setting mackintosh and towel to the client:1) Place a mackintosh covered a big towel underthe upwards from the client head to theshoulders of client2) Have a big towel around his/her neck3) Roll another mackintosh to make the shape of afunnel, by using the way to hold from both sidesin a slanting way. The narrow end should befolded and put under the client‟s neck and the freeend should be put into the bucket to drain forthe waste water.4) Put the folding mackintosh under the client‟sneck.To prevent the sheet from soilingTo prevent the cloth and the body from solingTo induce water drainage8. Washing:1) Brush the hair.2) Insert the cotton balls into the ears3) Wet the hair by warm water and wash itroughly4) Apply soap or shampoo and massage the scalpwell while washing the hair using fingernails5) Rinse the hair and reapply shampoo for asecond washing, if indicated6) Rinse the hair thoroughly7) Apply conditioner if requested or if the scalpappears dryTo remove dandruff and fallen hairs, and make thehair easier washingTo prevent water from entering into the ears9. Wrapping the hair:1)Remove the cotton balls from the ears into thepaper bag and mackintosh with the towel fromthe clients neck.2) Wrap the hairs in the big towel which are usedto cover the clients neck part.
Fundamental of Nursing Procedure ManualCareAction Rationale10. Drying the hair:1) Wipe the face and neck if needed2) Dry the hair as quick as possible3) Massage the scalp with oil as required4) Comb the hair and arrange the hair according tothe client‟s preference5) Make the client tidy and provide comfortablepositionTo prevent him/her from becoming chilledTo increase circulation of the scalp and promotesense of well-beingTo raise self-esteem10. Clean the equipments and replace them toproper place. Discard dirty.To prepare for the next procedure11. Perform hand hygiene To prevent the spread of infection12. Document the condition of the scalp, hair andany abnormalities on the chart with yoursignature. Report any abnormalities to seniorstaff.Documentation provides coordination of careGiving signature maintains professionalaccountability34
3535Caring for fingernails and toenailsDefinition:Nail cutting that one of nursing care and general care for personal hygiene is to cut nails on hands andfoots.Purpose:1. To keep nails clean2. To make neatness3. To prevent the client‟s skin from scratching4. To avoid infection caused by dirty nailEquipments required:1. Nail Cutter (1)2. Gallipot with water (1): for cotton3. Kidney tray (1)4. Sponge cloth (1)5. Middle towel (1)6. Mackintosh (1)7. Plastic bowl in small size (1)8. Soap with soap dish (1)Fig.20 Equipments required for nail cutting
3636Procedure: Caring for FingernailsCareAction Rationale1. Perform hand hygiene To prevent the spread of infection2. Gather all the required equipments. Organization facilitates accurate skillperformance3. Check the client‟s identification. To assess needs4. Explain to the client about the purpose and theprocedure.Providing explanation fosters cooperation5. Put all the required equipments to the bed-sideand set up it.To save the time an promote effective care6.Assist the client to a comfortable upright position. To provide for comfort7.In sitting position:1) Soaking①Put a mackintosh with covering towel on thebed.②Put the basin with warm water over themackintosh.③Soak the client‟s fingers in a basin of warmwater and mild soap.④Scrub and wash them up.⑤Dry the client‟s hands thoroughly by using themiddle towel covering the mackintosh.2) Cutting①Trim the client‟s nails with nail clippers.②Wipe all fingernails from thumb to 5th nail sideby side by wet cotton ball. One cotton ball isused for one nail finger.③Shape the fingernails with a file, rounding thecorners and wipe both hands by a sponge towel.Mackintosh can prevent the sheet from wettingTo make nails soft, thereby you can cut nailseasily and safetySpecial orders are required before cutting the nailsor cuticles of a client with diabetes to avoidaccidental injury to soft tissues.8. Replace equipments and discard dirty. To prepare equipments for the next procedure9. Perform hand hygiene. To prevent the spread of infectionProcedure: Caring for ToenailsFollow the same procedure as for the fingernails with some exceptions:CareAction Rationale7.2) Cutting①Cut toenails straight across and do not roundoff the corners②Do not shape cornersCutting into the corners may cause ingrownnails. If the nails tend to grow inward at thecorners, place a wisp of cotton under the nail toprevent toe pressure.A notch cut in the center will pull in edges andcorners. Sometimes, very thick, hard toenailsrequire surgical removal. NURSINGALERTNever cut the toenails of the clients with diabetes or hemophilia. These clients are particularly susceptibleto injury.
3737Performing Perineal CareDefinition:Perineal care is bathing the genitalia and surrounding area. Proper assessment and care of the perinealarea will need professional clinical judgment.Purpose:1. To keep cleanliness and prevent from infection in perineal area2. To make him/her comfortableEquipments required:1. Gloves( non- sterile) (1 pair)2. Sponge cloth (1)3. Basin with warm water (1)4. Waterproof pad or gauze5. Towels (1)6. Mackintosh (1)7. Soap with soap dish (1)8. Toilet paper9. Bed pan (1): as requiredProcedure: For general case (without urinary catheter)CareAction Rationale1. Gather all required equipments. Organization facilitates accurate skillperformance2. Explain the procedure to the client. Providing information fosters cooperation.3. Perform hand hygiene and wear on gloves ifavailable.To prevent the spread of infection4. Close the door to the room and place the screen. To protect the clients privacy.5.Raise the bed to a comfortable height if possible. Proper positioning prevents back strain.6. Preparation the position:1) Uncover the clients perineal area.2) Place a mackintosh and towel ( or waterproofpad) under the clients hips.A towel or pad protects the bed. You can use thetowel to dry the clients perineal and rectal area.7. Cleanse the thighs and groin:1) Make a mitt with the sponge cloth.2) Cleanse the clients upper thighs and groin areawith soap and water.3) Rinse and dry.4) Wash the genital area next.
3838CareAction RationaleFemale client: (Fig.21)①Use a separate portion of the sponge towel foreach stroke②Change sponge towel as necessary.③Separate the labia and cleanse downward fromthe pubic to anal area.④Wash between the labia including the urethralmeatus and vaginal area.⑤Rinse well and pat dry.Male Client: (Fig.22)①Gently grasp the client‟s penis.②Cleanse in a circular motion moving from thetip of the penis backwards toward the pubic area③In an uncircumcised male, carefully retract theforeskin prior to washing the penis.④Return the foreskin to its former position.⑤Wash, rinse, and dry the scrotum carefully.Cleanse from the pubis toward the anus to washfrom a clean to a dirty area. Preventcontaminating the vaginal area and urinarymeatus with organisms from the anus.Cleanse from the tip of the clients penisbackward to prevent transferring organisms fromthe anus to the urethra.Secretions that collect under the foreskin cancause irritation and odor. Return the foreskin toits normal position to prevent injury to the tissue.8. Assist the client to turn on the side. Separate theclients buttocks and use toilet paper, if necessary,to remove fecal materials.Removing fecal material provides for easiercleaning.9.Cleanse the anal area, rinse thoroughly, and drywith a towel. Change sponge towel as necessary.Keep the anal area clean to minimize the risk ofskin irritation and breakdown.10.Apply skin care products to the area accordingto need or doctors order.Lotions may be prescribed to treat skin irritation.11. Return the client to a comfortable position. To provide for comfort and safety.12. Remove gloves and perform hand hygiene. To prevent the spread of infection13. Document the procedure, describing the clientsskin condition. Sign the chart.To provide continuity of careGiving signature maintains professionalaccountability(from Caroline Bunker Rosdabl: Textbook of Basic Nursing, 1999, p.591)Fig.21 Female client Fig. 22 Male client
3939Taking Vital Signs：Temperature, Pulse, Respiration, Blood pressureDefinition:Taking vital signs are defined as the procedure that takes the sign of basic physiology that includestemperature , pulse, respiration and blood pressure. If any abnormality occurs in the body, vital signschange immediately.Purpose:1. To assess the client‟s condition2. To determine the baseline values for future comparisons3. To detect changes and abnormalities in the condition of the clientEquipments required:1. Oral/ axilla / rectal thermometer (1)2. Stethoscope (1)3. Sphygmomanometer with appropriate cuff size (1)4. Watch with a second hand (1)5. Spirit swab or cotton (1)6. Sponge towel (1)7. Paper bag (2): for clean (1)for discard (1)8. Record form9. Ball- point pen: blue (1)black (1)red (1)10. Steel tray (1): to set all materialsFig.23 Equipments required of taking a vital signs
4040Fig.24 StethoscopeAstethoscope consists of : ear pieces, tubing, two heads such as the bell and the diaphragm.Fig.25 The bell of head of stethoscopeThe bell has cup-shaped and is used to correctlow-frequency sounds, such as abnormalheart sounds.Fig. 26 The diaphragm of head of stethoscopeThe diaphragm is flat side of the head and is used totest high-frequency sounds: breath, normal breath, andbowel sounds.Fig. 27 Aneroid manometerAneroid manometer is a kind of sphygmomanometer. Sphygmomanometer consists of:an inflatable bladder, attached to a bulb and a diameter, enclosed in a cuff, with adeflating mechanism
4141a. Taking axillary temperature by glass thermometerDefinition:Measuring/ monitoring patient‟s body temperature using clinical thermometerPurpose:1. To determine body temperature2. To assist in diagnosis3. To evaluate patient‟s recovery from illness4. To determine if immediate measures should be implemented to reduce dangerously elevated bodytemperature or converse body heat when body temperature is dangerous low5. To evaluate patient‟s response once heat conserving or heal reducing measures have beenimplementedProcedure:CareAction Rationale1. Wash your hands. Handwashing prevents the spread of infection2. Prepare all required equipments Organization facilitates accurate skillperformance.3. Check the client‟s identification. To confirm the necessity4. Explain the purpose and the procedure to theclient.Providing information fasters cooperation andunderstanding5. Close doors and/or use a screen. Maintains client‟s privacy and minimizeembarrassment.6. Take the thermometer and wipe it with cottonswab from bulb towards the tube.Wipe from the area where few organisms arepresent to the area where more organisms arepresent to limit spread of infection7.Shake the thermometer with strong wristmovements until the mercury line falls to at least95 ℉ (35 ℃).Lower the mercury level within the stem sothat it is less than the client‟s potential bodytemperature8.Assist the client to a supine or sitting position. To provide easy access to axilla.9. Move clothing away from shoulder and arm To expose axilla for correct thermometer bulbplacement10. Be sure the client‟s axilla is dry. If it is moist, patit dry gently before inserting the thermometer.Moisture will alter the reading. Under thecondition moistening, temperature is generallymeasured lower than the real.11. Place the bulb of thermometer in hollow of axillaat anteriorinferior with 45 degree or horizontally.(Fig.28)To maintain proper position of bulb against bloodvessels in axilla.12. Keep the arm flexed across the chest, close tothe side of the body ( Fig. 29)Close contact of the bulb of the thermometer withthe superficial blood vessels in the axilla ensuresa more accurate temperature registration.13.Hold the glass thermometer in place for 3minutes.To ensure an accurate reading
4242CareAction Rationale14.Remove and read the level of mercury ofthermometer at eye level.To ensure an accurate reading15. Shake mercury down carefully and wipe thethermometer from the stem to bulb with spiritswab.To prevent the spread of infection16. Explain the result and instruct him/her if he/shehas fever or hypothermia.To share his/her data and provide care neededimmediately17. Dispose of the equipment properly. Wash yourhands.To prevent the spread of infection18. Replace all equipments in proper place. To prepare for the next procedure19. Record in the client‟s chart and give signatureon the chart.Axillary temperature readings usually are lowerthan oral readings.Giving signature maintains professionalaccountability20. Report an abnormal reading to the senior staff. Documentation provides ongoing data collectionFig.28 Placing the glass thermometer into the axilla Fig. 29 Keeping the forearm across the chest
4343b. Measuring a Radial PulseDefinition: Checking presence, rate, rhythm and volume of throbbing of artery.Purpose:1. To determine number of heart beats occurring per minute( rate)2. To gather information about heart rhythm and pattern of beats3. To evaluate strength of pulse4. To assess hearts ability to deliver blood to distant areas of the blood viz. fingers and lower extremities5. To assess response of heart to cardiac medications, activity, blood volume and gas exchange6. To assess vascular status of limbsProcedure:CareAction Rationale1. Wash hands. Handwashing prevents the spread of infection2. Prepare all equipments required on tray. Organization facilitates accurate skill problems3. Check the client‟s identification To confirm the necessity4. Explain the procedure and purpose to the client. Providing information fosters cooperation andunderstanding5. Assist the client in assuming a supine or sittingposition.1) If supine, place client‟s forearm straight alongsidebody with extended straight (Fig.30ⓐ) or upperabdomen with extended straight( Fig.30ⓑ)2) If sitting, bend client‟s elbow 90 degrees andsupport lower arm on chair (Fig.31ⓐ) or onnurse‟s arm slightly flex the wrist (Fig. 31ⓑ)6. Count and examine the pulse1) Place the tips of your first, index, and third fingerover the clients radial artery on the inside of thewrist on the thumb side.To provide easy access to pulse sitesRelaxed position of forearm and slight flexion ofwrist promotes exposure of artery to palpationwithout restriction.The fingertips are sensitive and better able to feelthe pulse. Do not use your thumb because it has astrong pulse of its own.2)Apply only enough pressure to radial pulse Moderate pressure facilitates palpation of thepulsations. Too much pressure obliterates thepulse, whereas the pulse is imperceptible with toolittle pressure3) Using watch, count the pulse beats for a fullminute.4) Examine the rhythm and the strength of thepulse.7.Record the rate on the client‟s chart.Sign on the chart.Counting a full minute permits a more accuratereading and allows assessment of pulse strengthand rhythm.Strength reflects volume of blood ejected againstarterial wall with each heart contraction.Documentation provides ongoing data collectionTo maintain professional accountability8. Wash your hands. Handwashing prevents the spread of infection9. Report to the senior staff if you find anyabnormalities.To provide nursing care and medication properlyand continuously
4444Fig. 30 ⓐ CareAction 5. 1) → 6.Placing the clients forearm straight alongside body andputting the fingertips over the radial pulseFig. 30 ⓑ 5.1) →6.Placing the client‟s forearm straight of across upperabdomen and putting the fingertips over the radialpulseFig. 31 ⓐ CareAction 5. 2) → 6.Placing the client‟s forearm on the armrest of chair andputting your the fingertips over the radial pulseFig. 31 ⓑ 5.2) →6.Supporting the client‟s forearm by nurse‟s palmwith extended straight and your putting threefingertips
4545c. Counting RespirationDefinition: Monitoring the involuntary process of inspiration and expiration in a patientPurposes:1. To determine number of respiration occurring per minute2. To gather information about rhythm and depth3. To assess response of patient to any related therapy/ medicationProcedure:CareAction Rationale1. Close the door and/or use screen. To maintain privacy2. Make the clients position comfortable, preferablysitting or lying with the head of the elevated 45 to60 degrees.To ensure clear view of chest wall and abdominalmovements. If necessary, move the bed linen.3. Prepare count respirations by keeping yourfingertips on the client‟s pulse.Aclient who knows are counting respirations maynot breathe naturally.4. Counting respiration:1) Observe the rise and fall of the client‟s (oneinspiration and one expiration).2) Count respirations for one full minute.3) Examine the depth, rhythm, facial expression,cyanosis, cough and movement accessory.One full cycle consists of an inspiration and anexpiration.Allow sufficient time to assess respirations,especially when the rate is with an irregularChildren normally have an irregular, more rapidrate. Adults with an irregular rate require morecareful assessment including depth and rhythmof respirations.5. Replace bed linens if necessary. Record the rateon the client‟s chart. Sign the chartDocumentation provides ongoing data collection.Giving signature maintains professionalaccountability6. Perform hand hygiene To prevent the spread of infection7. Report any irregular findings to the senior staff. To provide continuity of care
4646d. Measuring Blood PressureDefinition: Monitoring blood pressure using palpation and/or sphygmomanometerPurpose:1. To obtain baseline data for diagnosis and treatment2. To compare with subsequent changes that may occur during care of patient3. To assist in evaluating status of patient‟s blood volume, cardiac output and vascular system4. To evaluate patient‟s response to changes in physical condition as a result of treatment with fluids ormedicationsProcedure: by palpation and aneroid manometerCareAction Rationale1. Wash your hands. Handwashing prevents the spread of infection2. Gather all equipments. Cleanse the stethoscope sear pieces and diaphragm with a spirit swabwipe.Organization facilitates performance of the skill.Cleansing the stethoscope prevents spread ofinfection.3. Check the client‟s identification. Explain thepurpose and procedure to the client.Providing information fosters the client‟scooperation and understanding.4. Have the client rest at least 5 minutes beforemeasurement.Allow the client to relax and helps to avoid falselyelevate readings.5. Determine the previous baseline blood pressure ,if available, from the client‟s record.To avoid misreading of the client‟s blood pressureand find any changes his/her blood pressure fromthe usual6. Identify factors likely to interfere which accuracyof blood pressure measurement : exercise, coffeeand smokingExercise and smoking can cause false elevationsin blood pressure.7. Setting the position:1)Assist the client to a comfortable position. Be sureroom is warm, quiet and relaxing.2) Support the selected arm. Turn the palmupward. (Fig. 32 )3) Remove any constrictive clothing.The clients perceptions that the physical orinterpersonal environment is stressful affect theblood pressure measurement.Ideally, the arm is at heart level for accuratemeasurement. Rotate the arm so the brachialpulse is easily accessible.Not constricted by clothing is allowed to accessthe brachial pulse easily and measure accurately.Do not use an arm where circulation iscompromised in any way.Fig. 32 CareAction 7. 2)Placing the selected arm on the bed and turn the palmupward
4747CareAction Rationale8. Checking brachial artery and wrapping the cuff:1) Palpate brachial artery.2) Center the cuff‟s bladder approximately 2.5 cm(1 inch) above the site where you palpated thebrachial pulse3) Wrap the cuff snugly around the client‟s arm andsecure the end approximately(Fig. 33)4) Check the manometer whether if it is at levelwith the client‟s heart (Fig. 34 ).Center the bladder to ensure even cuff inflationover the brachial arteryLoose-fitting cuff causes false high readings.Appropriate way to wrap is that you can put only2 fingers between the arm and cuff. (Fig. 33)Improper height can alter perception of reading.Fig. 33 CareAction 8. 3)Wrapping the cuff with appropriate wayFig. 34 CareAction 8. 4)Placing manometer at the level of heartCareAction Rationale9.Meausre blood pressure by two step method:(A) Palpatory method1) Palpate brachial pulse distal to the cuff withfingertips of nondominant hand.2) Close the screw clamp on the bulb.3) Inflate the cuff while still checking the pulse withother hand. (Fig. 35 )4) Observe the point where pulse is not longerpalpable.5) Inflate cuff to pressure 20-30 mmHg above pointat which pulse disappears.6) Open the screw clamp, deflate the cuff fully andwait 30 seconds.(B)Auscultation1) Position the stethoscope‟s earpieces comfortablyin your ears( turn tips slightly forward). Be suresounds are clear, not muffled.2) Place the diaphragm over the client‟s brachialartery. Do not allow chestpiece to touch cuff orclothing. (Fig. 36 )Palpation identifies the approximate systolicreading. Estimating prevents false low readings,which may result in the presence of an auscultorygap.Maximal inflation point for accurate reading canbe determined by palpation.Short interval eases any venous congestion thatmay have occurred.Each earpiece should follow angle of ear canal tofacilitate hearing.Proper stethoscope placement ensures optimalsound reception.Stethoscope improperly positioned sounds thatoften result in false low systolic and high diastolicreadings.
4848CareAction Rationale9. (B)3) Close the screw clamp on the bulb and inflate thecuff to a pressure30 mmHg above the pointwhere the pulse had disappeared4) Open the clamp and allow the aneroid dial to fallat rate of 2 to 3 mmHg per second.5) Note the point on the dial when first clear soundis heard. The sound will slowly increase inintensity.6) Continue deflating the cuff and note the pointwhere the sound disappears. Listen for 10 to 20mmHg after the last sound.7) Release any remaining air quickly in the cuff andremove it.8) If you must recheck the reading for any reason,allow a 1 minute interval before taking bloodpressure again.Ensure that the systolic reading is notunderestimated.If deflation occurs too rapidly, reading may beinaccurate.This first sound heard represents the systolicpressure or the point where the heart is able toforce blood into the brachial artery.This is the adult diastolic pressure. It representsthe pressure that the artery walls exert on theblood at rest.Continuous cuff inflation causes arterialocclusion, resulting in numbness and tingling ofclient‟s arm.The interval eases any venous congestion andprovides for an accurate reading when you repeatthe measurement.10. Assist the client to a comfortable position.Advise the client of the reading.Indicate your interest in the clients well-beingand allow him/her to participate in care.11. Wash your hands. Handwashing prevents the spread of infection.12. Record blood pressure on the client‟s chart. Signon the chart. Report any findings to senior staffs.Documentation provides ongoing data collection.Giving signature maintains professionalacountability13. Replace the instruments to proper place anddiscard.To prepare for the next procedure.Fig. 35 CareAction 9. (A) 3) : Palpatory methodInflating the cuff while checking brachial arteryFig. 36 CareAction 9. (B) 2) :AuscultationPlacing the diaphragm without touching the cuff
4949Performing Physical ExaminationDefinition：Physical examination is an important tool in assessing the client‟s health status. Approximate 15 % of theinformation used in the assessment comes from the physical examination. It is performed to collectobjective data and to correlate it with subjective data.Purpose:1. To collect objective data from the client2. To detect the abnormalities with systematic technique early3. To diagnose diseases4. To determine the status of present health in health check-up and refer the client for consultation ifneededPrinciples of Physical Examination:A systematic approach should be used while doing physical examination. This helps avoiding anyduplication or omission. Generally a cephalocaudal approach (head to toe) is used, but in the case of infant,examination of heart and lung function should be done before the examination of other body parts, becausewhen the infant starts crying , his/her breath and heart rate may change.Methods of Physical Examination:InspectionPalpationPercussionAuscultation1. InspectionInspection means looking at the client carefully to discover any signs of illness. Inspection gives moreinformation than other method and is therefore the most useful method of physical examination.2. PalpationPalpation means using hands to touch and feel. Different parts of hands are used for different sensationssuch as temperature, texture of skin, vibration, tenderness, and etc. For examples, finger tips are used forfine tactile surfaces, the back of fingers for feeling temperature and the flat of the palm and fingers forfeeling vibrations.3. PercussionPercussion determines the density of various parts of the body from the sound produced by them, whenthey are tapped with fingers. Percussion helps to find out abnormal solid masses, fluid and gas in the bodyand to map out the size and borders of the certain organ like the heart. Methods of percussion are:① Put the middle fingers of his/her hand of the left hand against the body part to be percussed② Tap the end joint of this finger with the middle finger of the right hand③ Give two or three taps at each area to be percussed④ Compare the sound produced at different areas
50504.AuscultationAuscultation means listening the sounds transmitted by a stethoscope which is used to listen to the heart ,lungs and bowel sounds.Equipments required:1. Tray (1)2. Watch with a seconds hand (1)3. Height scale (1)4. Weight scale (1)5. Thermometer (1)6.. Stethoscope (1)7. Sphygmomanometer (1)8. Measuring tape (1)9. Scale (1)10.Tourch light or penlight (1)11. Spatula (1)12 Reflex hammer (1)13. Otoscope if available (1 set)14. Disposable gloves (1 pair)15. Cotton swabs and cotton gauze pad16. Examination table17. Record form18. Ballpoint pen, pencilsProcedure:Action (✽Rationale) Normal findings Abnormal findings/Changes from normal1. Explain the purpose and procedure( ✽ Providing information fostershis/her cooperation and allaysanxiety)2. Close doors and put screen.(✽ Toprovide privacy)3. Encourage the client to emptybladder( ✽ A full bladder makeshim/her uncomfortable)４．Perform physical examinationA. General examinationAssess overall body appearance andmental statusInspectionObserve the client‟s ability to respondto verbal commands.( ✽ Responsesindicate the client‟s speech andcognitive function.)The client respondsappropriately to commandsThe client confused,disoriented, or inappropriateresponses
5151Action (✽Rationale) Normal findings Abnormal findings/Changes from normalObserve the client‟s level ofconsciousness( ; LOC) andorientation. Ask the client to statehis/her own name, current location,and approximate day, month, oryear.(✽Responses indicate the client‟sbrain function. LOC is the degree ofawareness of environmental stimuli.It varies from full wakefulness andalertness to coma. Orientation is ameasure of cognitive function or theability to think and reason. )Observe the client‟s ability to think,remember, process information, andcommunicate.( ✽ These processesindicate cognitive functioning.)Inspect articulation on speech, styleand contents of speackingThe client is fully awake andalert: eyes are open and followpeople or objects. The client isattentive to questions andresponds promptly andaccurately to commands.If he/she is sleeping, he/sheresponds readily to verbal orphysical stimuli anddemonstrates wakefulnessand alertness.The client is aware of whohe/she is( orientation toperson), where he/she is( orientation to place), andwhen it is( orientation totime).The client is able to followcommands and repeat andremember information.smooth/ appropriate nativelanguageClient has lowered LOC andshows irritability, shortattention span, or dulledperceptions.He/she is uncooperative orunable to follow simplecommands or answer simplequestions.At a lowered LOC, he/shemay respond to physicalstimuli only. The lowestextreme is coma, when theeyes are closed and the clientfails to respond to verbal orphysical stimuli, when novoluntary movement.If LOC is between fullawareness and coma,objectively note the client‟seye movement: voluntary,withdrawal to stimuli orwithdrawal to noxiousstimuli( pain) only.DysphasiaDysarthriaMemory lossDisorientationHallucinationsnot clear/ not smooth/inappropriate contentsObserve the client‟s ability to see,hear, smell and distinguish tactilesensations.Observe signs of distress(✽ Alert theexaminer to immediate concerns. Ifyou note distress, the client mayrequire healthcare interventionsbefore you continue the exam. )The client can hear eventhough the speaker turnsaway.He/she can identify objects orreads a clock in the room anddistinguish between sharpand soft objects.The client cannnot hear lowtones and must look directlyat the speaker.He/she cannot read a clock ordistinguish sharp from soft.The client shows laboredbreathing, wheezing, coughing,wincing, sweating, guarding ofbody part (suggests pain),anxious facial expression, offidgety movements.
5252Fundamental of Nursing Procedure ManualAction (✽Rationale) Normal findings Abnormal findings/Changes from normalObserve facial expression and mood( ✽ These could be effected bydisease or ill condition)Eyes are alert and in contactwith you.The client is relaxed, smiles orfrowns appropriately and hasa calm demeanor.Eyes are closed or averted.The client is frowning orgrimacing.He/she is unable to answerquestionsObserve general appearance: posture,gait, and movement( ✽To identifyobvious changes)Posture is uprightGait is smooth and equal forthe client‟s age anddevelopment. Limbmovements are bilateral.Posture is stopped or twisted.Limbs movements areuneven or unilateral.Observe grooming, personal hygiene,and dress(✽ Personal appearancecan indicate self-comfort. Groomingsuggests his/her ability to performself-care.)Clothing reflects gender, age,climate.Hair, skin , and clothing areclean, well-groomed, andappropriate for the occasion.He/she wears unusualclothing for gender, age, orclimate.Hair is poor groomed, lack ofcleanlinessExcessive oil is on the skin.Body odor is present.MeasurementHeight1) Ask the client to remove shoes andstand with his/her back and heelstouching the wall.2) Place a pencil flat on his/her headso that it makes a mark on thewall.3) This shows his/her heightmeasured with cm tape from thefloor to the mark on the wall(or ifavailable, measure the height withmeasuring scale)>140(or 145)cm in female <140(or 145) cm in female
5353Fundamental of Nursing Procedure ManualAction (✽Rationale) Normal findings Abnormal findings/Changes from normalWeightWeigh him/her without shoes and muchclothing.Body Mass index (;BMI) is used to assess the status of nutritionusing weight and height in the world.Formula for BMI = weight(kg)/ height (m)2Table 2 BMIInAdults Women Menanorexia < 17.5underweightin normal rangemarginally overweightoverweightobese< 19.119.1-25.825.8-27.327.3-32.3> 32.3< 20.720.7-26.426.4-27.827.8-31.1> 31.1severely obese 35-40morbidity obese 40-50super obese 50-60Take vital signs(✽ Vital signs providebaseline data)Temperature 36-37 ℃ hypothermia < 35 ℃pyrexia 38-40 ℃hyperpyrexia > 40.1 ℃Pulse(rate/minute)Tale the pulse rate and check the beats rate/minute in adult60-80 / min.regular and steadyRespirationCount the breaths without giving notice Breaths /minute 16-20/ min.clear sound of breathsregular and steadyrate/ minute in adultbradycardiatachycardiapulse deficit, arrhythmiaBreaths /minutebradypnea <10/ min.tachypnea >20/min.Biot‟sCheyne-StokesKussmaul‟s (Fig.37 -41)wheeze, stridorFig.37 Bradypnea Fig. 38 Tachypnea Fig. 39 Biot‟sFig. 40 Cheyne-Stokes Fig. 41 Kussmaul‟s(from Caroline Bunker Rosdabl, p.509)
5454Fundamental of Nursing Procedure ManualAction (✽Rationale) Normal findings Abnormal findings/Changes from normalClassification SBP(mmHg) DBP(mmHg)NormalPre-hypertensionGrade 1Grade 2Grade 3<120120-139140-159160-179>/= 180<8080-8990-99100-109>/= 110Blood pressureTake blood pressure under quiet andwarm room.Hypotension: In normal adults < 95/60HypertensionTable 3 WHO/ ISH classification of Hypertension(1999)B. SkinAssessmentAssess integumentary structures(skin,hair, nails) and functionSkinSBP: Systolic Blood Pressure, DBP: Diastolic Blood pressureInspection and palpation1) Inspect the back and palms of theclient‟s hands for skin color. Comparethe right and left sides. Make a similarinspection of the feet and toes,comparing the right and left sides. (✽Extremities indicate peripheralcardiovascular function)1) Palpate the skin on the back andpalms of the client‟s hands formoisture, texture.a. moistureb. textureThe color varying fromblack brown or fairdepending upon thegenetic factorsColor variations on darkpigmented skin may bebest seen in the mucousmembranes, nail beds,sclera, or lips.slight moist, no excessivemoisture or drynessfirm, smooth, soft, elasticskinerythemaloss of pigmentationcyanosispallorjaundiceExcessive dryness indicateshypothyreidisionOiliness in acne.Roughness inhypothyroidismVelvety texture inhyperthyroidismflakingperspiration (diaphoresis)3)Palpate the skin‟s temperaturewith the back of your hand.warmth Generalized warmth in feverlocal warmthCoolness in hypothyroidism4) Pinch and release the skin on the backof the client‟s hand. (✽ This palpationindicates the skin‟s degree of hydrationand turgor.)Pinched skin that promptlyor gently returns to itsprevious stste whenreleased signifies normalturgor.Pinched skin is very slow toreturn to normal position.
5555Fundamental of Nursing Procedure ManualAction (✽Rationale) Normal findings Abnormal findings/Changes from normal5) Press suspected edematous areaswith the edge of your fingers for 10seconds, and observe for thedepressionDepression recovers quickly Depression recovers slowly orremains. Edema indicatesfluid retention, a sign ofcirculatory disorders.Fig. 42 Pitting edema (from Carolyn Jarvis, p.547)6) Inspect the skin for lesions. Notethe appearance, size, location,presence and appearance ofdrainage.(✽ Locate abnormal cell,growths, or trauma that suggestabnormal physiologic processes.)Nail1) Inspect and palpate the fingernailsand toenails. Note color, shape andany lesions.2) Check capillary refill by pressingthe nail edge to blanch and thenrelease pressure quickly, noting thereturn of color.Hair and scalp1) Inspect the hair for color, texture,growth, distributionSkin is intact, without reddenedareas but with variations inpigmentation and texture,depending on the area‟s locationand exposure to light andpressure. Freckles, moles, wartsare normal.Pink colorLogitadional bands of pigmentmay be seen in the nails ofnormal people.Normally color return isinstant(<3 seconds)Nails should have nodiscoloration, ridges, pitting,thickening, or separation fromthe edge.Color may vary from paleblonde to total black.Texture varies fine to coarseand looks straight to curly.ErythemaEccymosisLesions includes rashes,macules, papules, vesicles,wheals, nodules, pustules,tumors, or ulcers.Wounds include incisions,abrasions, lacerations,pressure ulcers.Cyanosis and marked pallorClub being nailsKoilonychia(spoon nail)Onycholysis( fungalinfection)Cyanosis nail beds orsluggish color returnconsider cardiovascular orrespiratory dysfunction.Hair is excessively dry or oilyExcessive hair loss( alopecia)or coarse hair inhypothyroidismfine silky hair inhyperthyroidismpediculosisdandruff
5656Fundamental of Nursing Procedure ManualAction (✽Rationale) Normal findings Abnormal findings/Changes from normal2) Inspect the scaly, lumps, nevi, orother lesions.C. Head and NeckAssessmentAssess central neurologic function,vision, hearing, and mouthstructures.Skull1) Observe for the size, shape, andsymmetry.2) Palpate and note any deformities,depressions, lumps, or tenderness.FaceInspect the client‟s facial expression,asymmetry, involuntary movements,edema, and massesEyes1) Position and alimentation:Stand in front of the client andinspect the both eyes for positiona n d a l i g n m e n t .2) Eyebrows:Inspect the eyebrows , noting theirquantity and distribution and anyscaliness3) Eyelids:Inspect the position, presence ofedema, lesions, condition anddirection of the eyelashes, andadequacy with eyelids doze.All area should be clean andfree of any lesions, scaly,lumps, and nevi.Head is symmetrical, round,and erect in the midline.relaxed facial expressionHe/she doesn‟t haveinvoluntary movementNo deviation and abnormalprofusionredness and scaling inseborrheic dermatitispsoriasisEnlarged skull inhydrocephalus, Paget‟sdiseases of bone.Redness after traumaMoon face with red cheeks inCushing‟s syndromeEdematous face around theeyes (in the morning ) andpale in nephritic syndromeDecreased facial mobilityand blunt expression inParkinson‟s diseaseInward and outwarddeviationAbnormal profusion indisease or ocular tumorsScaliness in seborrheicdermatitisLateral sparseness inhypothyroidismPtosisEntropianEctropionLid riractionChalazionStyDacryocystitisRed inflamed lid marginInwards directionFailure of the eyelids to closeexposes the corneas toserious damage
Fundamental of Nursing Procedure ManualAction (✽Rationale) Normal findings Abnormal findings/Changes from normal4) Lacrimal apparatusInspect the region of the lacrimalgland and lacrimal sac for swelling.Look for excessive tearing ordryness of the eye5) Conjunctiva and sclera① Expose the sclera andconjunctiva② Inspect the color of palpebralconjunction, vascular patternagainst the white scleralbackground and any nodules orswelling.Fig.43 Inspection conjunctiva andsclera(from Carolyn Jarvis, p.311)6) Cornea and LensWith oblique lighting, inspect thecornea of each eye for opacities andnote any opacities in the lens.7) Pupils( ✽ Pupillary size, shape, andaccomonation indicate the statusod intracranial pressure)Inspect the size, shapes andcompare symmetry. If the pupilsare larger(>5 mm), small(<3 mm) orunequal, measure them.No lumps and swellingaround the eyesTransparent white color ofscleraDark pink color of conjunctivaNo palenessNo nodules or swelling andrednessTransparent, no abrasionsand white spotsPupils are equal, round, andsymmetry.Lumps and swellingExcessive tearing may bedue to increased production,drainage of tear andinfection ( such asconjunctiva inflammationand corneal irritation)A yellow sclera indicatesjaundicePaleness in palpebralconjunctiva indicates theanaemia.Local redness due toinfectionFig. 44 Conjunctiviis(from Carolyn Jarvis, p.335)Opacities in the lens due tocataractA superficial grayish veiledopacity in the cornea due toold injury or to inflammationPupils are unequal.Miosis refers to constrictionof the pupilsMydriasis to dilation57
Fundamental of Nursing Procedure ManualAction (✽Rationale) Normal findings Abnormal findings/Changes from normal8) Pupillary response to light①Ask the client to look into thedistance and light a torch fromthe side of the eye②Remove it on the other side toand observe how pupil reacts③ Repeat other side with sameprocedureFig.45 Papillary response(from Carolyne Jarvis, p.703)9)Coordination of eye movements(✽Coordination of eye movementsindicates brain function andmuscular attachments to eyes.)①Hold as object at a distance fromthe client②Ask him/her to keep his/her headstill and follow the object with theeyes only③Move the object towards his/herright and left eye ,then towardsthe ceiling and floor.④Repeat it on the other side to10) Convergence test①Ask the client to follow yourfinger or a pencil as you move itin toward the bridge of the nose.② The converging eyes normallyfollows the object to within 5 cmto 8 cm of the eyes11) Snellen eye chart test(✽ To check visual acuity)①Use the Snellen eye chart,which includes objects, letters, ornumbers of different sizes inrows, under well-light② Position the client 20 feetfrom the chart and ask the clientto identify the items.③ Compares visual acuity of theclient with normal visionAs the torch approaches theeye, the pupil constricts. Andas the torch removed, thepupil dilates.Both eyes move togetherwhile following the objects:coordinationGood convergence20/20 vision as normalUnresponsive to lightPupil remains dilated evenafter torch removed due tooculomotior nerve paralysis.Small irregular pupils seenas central nervous systemsyphilis.Eyes do not move togetherwhen the object moves inparalysis of the cranialnerve.Strabismus(cross-eyed orwall-eyed)Client reportsdiplopia(double-vision)Poor convergence inhypothyroismMyopia(near-sightedness)Hyperopia(far-sightedness)is impaired in middle andelder people.Legal blindness58
Fundamental of Nursing Procedure ManualAction (✽Rationale) Normal findings Abnormal findings/Changes from normalEarsInspect and palpate the external ears.1) Inspect location of ears2) Inspect the shape and measure thesize.The top of the pinnae meet orcrosses the eye-occiput line(imaginary line drawn fromthe outer canthus of the ear tothe occipital protuberance)Equal size bilaterallyNo swelling or thickeningUnusual size and shape maybe familial trail withoutclinical significanceThe top of the pinnae don‟tmeet or cross the eye –occiput line.Microtia(:ears smaller than 4cm vertically)Macrotia(: ears larger than10 cm vertically)EdemaAsymmetry shape due totraumaPain with movement occurswith otitis externa andPain at the mastoid processmay indicate mastoiditis orlymphadenitis of theposterior auricular node.Atresia(:absence or closure ofthe ear canal)Clear blood of the brainhaemorrhageA sticky yellow dischargeaccompanies otitis externa orotitis media.Impacted cerumen is acommon cause of conductivehearing lossFig. 46Auricle(from Carolyne Jarvis, p.342)3) Tenderness①Move the pinna and push on the No pain while moving thetragus pinna, pushing the tragus,② Palpate the mastoid process and palpating mastoid process4) External auditory meatusInspect the external auditory canal(by touch or otoscope) (✽ To inspectswelling, redness, discharge, foreignbody or cerumen.)59
Fundamental of Nursing Procedure ManualAction (✽Rationale) Normal findings Abnormal findings/Changes from normal5) Voice test(✽ Whispered is a high frequencysound and is used to detect hightone loss)①Test one ear at a time.②Stay 30-60 cm from client‟s ear.③Exhale and whisper slowly sometwo syllable words (such asTuesday, Baseball and fourteen.)Nose1) Inspect the anterior and inferiorsurface of the nose.① Give gentle pressure in the tipof the nose with your thumb towiden the nostrils②with the aid of penlight, you canget a partial view of each nasalvestibule.③ Observe symmetry, deformity,size, and flaring.④ If indicated by pressing oneach ala nasi in turn and ask theclient to breath in.(✽To test for nasal obstruction)2) Inspect the inside of the noseInspect the inside with otoscope orpenlight cafefully.( ✽ To detect any deformities orabnormalities in nasal mucosa,nasal septum.)Normally the client repeatseach word correctly after yousaid it.No painSymmetry in sizeNostril uniform in sizeNo flareno obstruction in bothvestibuleAsymmetry of two sidesshape is normal.No deviationNo polypNasal mucosa redder than theoral mucosaNo bleeding, swelling orexudates in nasal mucosano bleeding, perforation ordeviation of the septumNo polyps, ulcers or foreignbodiesThe client is unable to hearHigh tone lossTenderness of nasal tip or alasuggests local infectionAsymmetry in sizeAsymmetrical in sizeFlaring nostrilsObstruction in rightvestibule by polyp.Deviation of the lowerseptum is common and maybe easily visible abovedeviation, seldom obstructsair flow.In viral rhinitis, the mucosais reddened and swollenIn allergic rhinitis, it may bepale bluish or red.Fresh blood or crusting maybe seen causes of septalperforation includes trauma,surgery, and the intranasaluse of cocaine.60
Fundamental of Nursing Procedure ManualAction (✽Rationale) Normal findings Abnormal findings/Changes from normal3) Palpate for sinus tenderness① Press up on the frontal sinusesfrom under the bony brows,avoiding pressure on the eyes.② Press upon the maxillarysinusesFig. 47 Pressing over the frontal sinuses→Fig.48 Pressing over the maxillarysinuses (from Carolyne Jarvis, p.382)→MouthIf the client wears dentures, offer apiece of paper towel and ask toremove it so that you can see themucosa underneath.1) Lips① Observe the color, moisture② Note any lumps, ulcers,cracking or scaliness.2) Oral mucosa/ gums/teeth① Inspect the color, presence ofulcers, swelling, white patches andnodules in mucosa and gumsPink, moist and intact skinNo bluish, discoloration,cracks and ulcers.Pink color in both oral mucosaand gumsPatches brownness may bepresent, especially in blackpeople.Polyps are pale translucentmasses that usually comefrom the middle meatusUlcers may result from nasaluse of cocaineLocal tenderness, togetherwith symptoms such as pain,fever and nasal discharge,suggest acute sinusitisinvolving the frontal ormaxillary sinuses.Lips bluish(: cyanosis) andpallorCracks, ulcerAphthous ulcerYelloish spotsKoplik‟s spotsSmall red spots(: petechiae)Thickened white patch( :Leuloplakia)Redness of gingivitisBlack line of lead poisoningSwollen interdental papillaein gingivitisUlcerative gingivitisGums enlargements61
Fundamental of Nursing Procedure ManualAction (✽Rationale) Normal findings Abnormal findings/Changes from normal② Inspect the teeth for missing,discolored, misshapen orabnormally positioned. Palpatethem for check looseness withgloved thumb and index finger.③ Inspect the color of roof of themouth and architecture of theharelip.3) Tongue and floor of the mouthInspect the tongue for color, textureof dorsum, papillae symmetry4) Inspect the sides and undersurfaceof the tongue and the floor of themouth.Pharynx1)Ask the client to open the mouthand say “ah”. This actions help tosee the pharynx well. If not pressthe tongue, press spatula firmlydown upon the midpoint of thearched tongue.2) Inspect soft palate anterior andposterior pillars, uvula, tonsils, andpharynx( ✽ To detect color,symmetry, presence of exudates,swelling, ulceration or tonsillarenlargement, and tenderness.)No lesions, white plaque andextra bony growthPink, moist and papillaeMidline fissure presents andbe symmetrical.No whit or reddened areasNo nodules or ulcerationsPink throatPink and small tonsilsNo swelling, exudates, andulcerationNo difficulty in swallowingMissing or looseness of teethDental cariesAttrition of teethErosion of teethAbrasion of teeth withnotchingThrush on the palpate(:thick, white plaques)Kaposi‟s sarcoma(: deeppurple color of lesions) inAIDsTorus palatinus (: midlinebony growth in the hardpalate)Hairy tongueFissured tongueSmooth tongueWhitening coating tongueRed or pale, dry papillaefissure absentAsymmetric protrusionsuggests a lesion of cranialnerve XIIAny persistent nodule orulcerRed or white area must besuspected the cancerExudative tonsillitis(: redand enlarged tonsils)Throat with white exudatesRedness and varcularity ofthe pillars and uvula inpharyngitis62
Fundamental of Nursing Procedure ManualAction (✽Rationale) Normal findings Abnormal findings/Changes from normalNeck1) Inspect the neck(✽To detect its symmetry and anymasses or scars, enlargment of theparotid or submandibular glands,and condition of any visible lymphnodes)2) Range of Motion(; ROM)①Ask the client to touch the chin tothe chest turn the head to the rightand left②Try to touch each ear to theshoulder without elevatingshoulders③ Extend the head backward(Head lift occurs with musclespasm.) Head positionscentered in the midline andthe head should be held erectLymph nodes are neithervisible or rednessThroat is dull red and grayexudates is present in uvula,pharynx and tongue, whichcause airway obstructionDifficulty in swallowingIn CN X paralysis, the softpalate fails to rise and theuvula deviates to theopposite site.Rigid head and neck occurswith arthritisScar at thyroid siteEnlargement of lymph nodesRedness of lymph nodesPain at any particularmovement, limitedmovement due to cervicalarthritis or inflammation onof the neck musclesRigid neck with arthritis② Posterior auricular③ Occipital⑥ Jugulodigstric⑦ Superficial cervical⑨ Posterior cervical⑩ SupraclavicularFig. 49 Lymph nodes (from Carolyne Jarvis, p. 281)① Preauricular⑤ Submandibular④ Submental⑧ Deep cervical chain63
Fundamental of Nursing Procedure ManualAction (✽Rationale) Normal findings Abnormal findings/Changes from normalLymph nodes1)Palpate the lymph nodes by usingthe pads of your index and middlefingers2)Move the underlying tissues in eacharea3)Examine both sides at once4)Feel in sequence for the followingnodes: (Fig. 49)① preauicular② posturiaduricular③ occipital④ tonsillar⑤ submandibular⑥ submental⑦ superficial cervical⑧ posterior cervical⑨ deep cervical chain⑩ supracravicular(✽To detect any palpable nodes withlocation, size, shape, delimitation,mobility, consistency, andtenderness.)Cervical nodes often arepalpate in healthy person,although this palpabilitydecrease with ageNormal nodes feel movable,discrete, soft, non-tenderParotid is swollen withmumpsTender nodes suggestinflammationHard or fixed nodes suggestmalignancyLymphadenopathy isenlargement of the lymphnodes( > 1 cm) due toinfection, allergy orneoplasmEnlargement of asupraclavicular node,especially on the left,suggests possible metastasisfrom a thorax or anabdominal malignancyDiffuse lymphadenopathyraises the suspicious ofHIV/AIDsTrachea1) Inspect the trachea (✽To detectany deviation from its usualmidline position)2) Palpate for any trachea shift. Placeyour index finger on the trachea inthe sternal notch and slip it off toeach side( ✽ To detect anyabnormalities)Normally trachea is inmidline.The space should besymmetry on both sidesNo deviation from the midlineMasses in the neck maypush the trachea to one side.Tracheal deviation may alsosignify important problemsin thorax, such as amediastinal mass, atelectasisor large pneumothoraxThyroid gland1) Inspect thyroid gland:① Ask the client to sip some water,to extend the neck, and swallow.② Observe for upward movementof the thyroid gland, noting itscontour and symmetry.③You must confirm that thyroidgland rise with swallowing andthen fall to their resting position.Normally trachea is inmidlineThe space should besymmetry in both sidesNo deviation from the midlineGoiter as a general tern foran enlarged thyroid gland64
Fundamental of Nursing Procedure ManualAction (✽Rationale) Normal findings Abnormal findings/Changes from normal2) Palpate the thyroid gland:① move behind the client② Ask the client to flex the neckslightly forward to relax thesternomastoid muscles.③ Place the fingers of both handson the clients neck so that yourindex fingers are just below thecranial cartilage.④ Ask the client to sip as swallowwater as before. Feel for the thyroidisthmus rising up tender yourfingers pads.⑤ Displace the trachea to the rightwith the fingers of the left hand,with the right hand fingers, palpatelaterally for the right lobe of thethyroid in the space between thedisplaced trachea and the relaxedsternomastoid. Find the lateralmargin. Examine the left lobe insame way.Normally you cannot palpatethe thyroid glandNo enlargement, presence ofnodules, and tendernessDiffuse enlargement inendemic goiterSoft in Graves diseaseFirm in malignancyTenderness in thyroiditisMultinodular goiter isadditional risk factors formalignancyFig. 50 Posterior approach to Thyroid gland Fig. 51 Anterior approach to thyroid gland(from Carolyne Jarvis, p.284) (from Carolyne Jarvis, p.284)65