Fundamental of nursing procedure mannual
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    Fundamental of nursing procedure mannual Fundamental of nursing procedure mannual Document Transcript

    • 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
    • Fundamental of Nursing Procedure Manual6
    • Fundamental of Nursing Procedure ManualI. Basic Nursing Care/ Skill7
    • Fundamental of Nursing Procedure Manual8
    • 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. NURSINGALERTNever 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:InspectionPalpationPercussionAuscultation1. 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
    • Fundamental of Nursing Procedure ManualAction (✽Rationale) Normal findings Abnormal findings/Changes from normalD. Chest and LungsInitial survey of respiration and thethorax1)Remove or open the client‟sclothing.2)Have the client sit on the side ofexamining table or bed. Whenexamine in supine position, theclient should lie comfortably witharms somewhat abducted. A clientwho is having difficulty breathingshould be examined is the sittingposition or with head of the bedelevated to a comfort level.Examination of the posterior chestInspection:Observe the shape and movement ofthe posterior chest. Compare one sidewith other.(✽To identifyasymmetrical shape or movement;assess respiratory movement.) Note:① deformities or asymmetry② abnormal retraction of the lowerinterspaces③ impairment in respiratorymovementPalpationPalpate the posterior wall overareas.(✽ To distinguish betweennormal and abnormal structures:tender, masses, swelling or painfularea )InspectionStand behind the client and observethe posterior chest for shape andmovement. (✽To identify shape ormovement; assess respiratorymovement)Shoulders are level; breast,lower rib margin aresymmetrical.Chest wall rises and fallsslightly with inspiration andexpiration.equal respiratory movementno retraction or bulging of theinterspaces should occur oninspirationThorax in normal adult iswider that it is deep, itslateral diameter is larger thanin anterioposterior(;AP)AP diameter may increasewith age.No tenderness, superficiallumps or masses, normal skinmobility and turgorShoulders are even; scapulaeare at the same level; spine ismidline and straight.Posterior chest slightly risesand falls on respiration.Movement of the chest wallis asymmetrical onrespiration; shoulders areuneven; rib cage, or breastsare asymmetrical:funnel chest(:depression inthe lower portioningsternum)barrel chest(: increased APdiameter)Client has supraclavicularretractions or contractions ofaccessory muscles duringinspiration:AP diameter may increase inchronic obstructivepulmonary diseaseTender pectoral muscles orcostal cartilagePainMassesStructural deformities orasymmetry are present:Scoliosis(:lateral curvature)Lordosis(: pronouncedlumbar curvature)Kyphosis(: abnormal spinalcurvature and vertebralrotation deform the chest)66
    • Fundamental of Nursing Procedure ManualNormal adult thorax Barrel thoraxFunnel breast Pigeon breastScoliosis KyphosisFig. 52 Abnoramal thorax(from Carolyne Jarvis, p.470-471)67
    • Fundamental of Nursing Procedure ManualAction (✽Rationale) Normal findings Abnormal findings/Changes from normalInspection and palpation:1) Assess chest expansion on theposterior chest: Symmetricexpansion (Fig.53 )① Place your hands in theposterolateral chest wall withthumbs at the level of T9 or T10② Slide your hands medially topinch up a small fold of skinbetween your thumbs③Ask the client to take a deepbreath.④Watch your thumbs‟ move apartsymmetrically and not smoothchest expansion with your finger2) Assess tactile(vocal) fremitus ( Fig.54)①Begin palpating by using the ballor ulnar surface of your hand fromthe lung apices② Touch the client‟s chest whilehe/sherepeats the words“ninety-nine” or “ blue moon”③ Compare vibration from oneside to the otherChest expansion is symmetric.Vibrations should feel thesame in the correspondingarea on each sideAn abnormally wide costalangle with little inspiratoryvariation occurs withemphysema.A lag in expansion occurswith atelectasis andpneumoniaPain accompanied deepbreathing when the pleuraeare inflamedA palpable grating sensationwith breathing indicatespleural friction fremitusDecreased fremitus occurswhen anything obstructstransmission of vibration,e.g., obstructed bronchus,pleural effusion,pneumothorax, oremphysema.Increased fremitus occurswith compression orconsolidation of lung tissue,e.g., lobar pneumonia.Rhonchal fremitus ispalpable with thick bronchialsecretionsPleural friction fremitus ispalpable with inflammationof the pleura.68
    • Fundamental of Nursing Procedure ManualAction (✽Rationale) Normal findings Abnormal findings/Changes from normalFig.53 Palpation symmetric expansion Fig. 54 Palpation tactile fremitusin the posterior chest in the posterior chest(from Carolyne Jarvis, p.450) (from Carolyne Jarvis, p.450PercussionLung FieldsPercuss the posterior chestcomparing both sides.( ✽ Toidentify and locate any areawith an abnormalpercussion).( ✽ To enhancepercussion) (Fig. 55 )1) Percuss the posterior chestfrom the apices and then tointerspaces with a -5 cmintervals.2) Note any abnormal findingsDiaphragm excursion(✽To map out the lower lungborder, both in expiration andinspiration ) (Fig. 56)1) Ask the client to exhale andhold it briefly while you percussdown the scapular lineResonance is normal lungsound: except heart areabecause heart normallyproduces dullness bound, liverproduces dullness stomachproduces tympany, muscles andbone produces flatThe diaphragm excursionshould be equal bilaterally andmeasure about 3 to 5 cm inadultsDullness replaces resonancewhen fluid or solid tissuereplaces air containing lung oraccupies the pleural space, i.g.,pneumonia, pleural effusion,atelectasis, or tumor.Hyperresonance is found inCOPD and asthmaHyperresonant or tympanitic inpneumothoraxAn abnormal high level ofdullness or absence of excursionoccurs with pleural effusion oratelectasis of the lower lobes69
    • Fundamental of Nursing Procedure ManualAction (✽Rationale) Normal findings Abnormal findings/Changes from normal2) Continue percussion until thesounds changes from resonantto dull on each side3) Mark the spotFig. 55 Sequence for percussion(from Carolyne Jarvis, p.452)Fig. 56A. Determine diaphragm excursion B. Measuring the differences (from Carolyne Jarvis, p. 452-453)70
    • Fundamental of Nursing Procedure ManualAction (✽Rationale) Normal findings Abnormal findings/Changes from normalAuscultation1)Listen to the breathposteriorilly with mouth openand more deeply than thenormal (✽ To note intensity,identify any variation and anyadventitious sounds)2) Repeat auscultation in theposterior chest.Breath sounds are usuallylouder in upper anterior lungfieldsBronchial, bronchovesicular,vesicular sounds are normalbreath soundsNone adventitious soundsDecreased or abscent breathsounds occur i.g., atelectasis,pleural effusion,pneumothorax, chironicobstructd pulmonary disease(;COPD)Increased breath sounds occurwhen consolidation orcompression yields a denselung area, i.g., pneumonia,fluid in the intrapleural spaceFig. 57Auscultation the posterior chest using the sequence(from Carolyne Jarvis, p.455)Examination of the anteriorchestPalpate the anterior chest1)Assess symmetric expansion① Place your hands on theanterolateral wall with yourthumbs along the costalmargins and pointing towardthe xiphoid process② Ask the client to take a deepbreath③ Watch your hand move apartSymmetricallySymmetrical expansionSmooth chest expansionAn abnormal wide costal anglewith little inspiratory variationoccurs with emphysemaA lag expansion occurs withatelectasis or pneumoniaA palpable grating sensationwith breathing indicatespleural fremitus71
    • Fundamental of Nursing Procedure ManualAction (✽Rationale) Normal findings Abnormal findings/Changes from normal2)Assess tactile fremitus① Begin palpating over thelung apices in thesupraclavicular areas② Compare vibrations from oneside to other side whilerepeating “ninety-nine”③Avoid palpating over femalebreast tissue because breasttissue normally clamps thesound.3) Palpate the anterior chest wall(✽To note any tenderness, anddetect any superficial lumps ormasses) Note skin mobility,turgor, skin temperature andmoisturePercuss the anterior chest1) Begin percussing the apices inthe supraclavicular areas2) Percuss the interspaces andcompare one side to the other3) Move down the anterior chestAuscultation1) Auscultate the lungs fields overthe anterior chest from theapices in the supraclavicularareas down to the 6th rib2) Progress from side to side andlisten to one full respiration ineach location3) Evaluate normal breathsounds and note abnormalbreath sounds(Refer to the posterior chest) (Refer to the posterior chest)Lungs with chronicemphysema result inhyperresonnance72
    • Fundamental of Nursing Procedure ManualFig.58 Palpate anterior expansion Fig. 59Assess tactile fremitus Fig. 60 Sequence of percussion andauscultation(from Carolyne Jarvis, p.40-461)Table 4 Abnormal/ adventitious lung sounds(from Carolyne Jarvis, p.474)73
    • Fundamental of Nursing Procedure ManualAction (✽Rationale) Normal findings Abnormal findings/Changes from normalE. Heart/ PrecordiumFor most of the cardiacexamination, the client should besupine with the head elevated30°. Two other position are alsoneeded, a. turning to the left side,b. leaning forward. the examinershould stand at the client‟sright.InspectionInspect the anterior chest forpulsation, you may or may notsee the apical impulse.Palpate theApical impulse(✽ To detect some abnormalconditions)1) Localize the apical impulse byusing one finger pad2) Asking the client to “exhaleand then hold it “aids theexaminer in locating thepulsation.3) Ask the client to roll midway tothe left to find4) Note location, size, amplitude,and duration.It is easier to see in childrenand in those with thinner chestThe apical impulse is palpablein about half of adultNot palpable in obese clientswith thick chest wallsLocation: the apical impulseshould occupy only oneinterspace, the fourth or fifth,and be at or medial to themidclavicular lineSize: Normally 1cm×2cmAmplitude: normally a short,gentle tapDuration: Short, normallyoccupies only firsthalf of systoleA heave or lift is a sustainedforceful thrusting of theventricle during systole. itoccurs with ventricularhypertrophy; A rightventricular heave is seen at thesternal border. A left ventricularheave is seen at the apexCardiac enlargement:Left ventricular dilatationdisplaces impulse down and toleft , and increases size morethan one spaceIncreased fore and durationoccurs with left ventricularhypertrophyNot palpable with pulmonaryemphysema due to overridinglungs→Fig. 61 Localizing the apical impulse Displacing the apical impulse (from Carolyne Jarvis, p.504)74
    • Fundamental of Nursing Procedure ManualAction (✽Rationale) Normal findings Abnormal findings/Changes from normalPalpate across the precordium1)Using the palmer aspects ofyour four fingers, gently palpatethe apex, the left sternal border,and the base2)Searching for any otherpulsations3) If any present, note the timingPercussion(✽To outline the heart‟s bordersand detect heart enlargement)1) Place your stationary finger inthe client‟s fifth intercostalsspace over on the left side of thechest near the anterior axillaryline2) Slide your stationary fingertoward yourself, percussing asyou go3) Note the change of sound fromresonance over the lung todull( over the heart)AuscultationIdentify the auscultatory areaswhere you listen. These includethe four traditional valve areas.They are:Second right interspace – aorticvalve areaSecond left interspace-pulmonic valve areaLeftlower sternal border-tricuspid valve areaFifth interspace at around leftmidclavicular line- mitral valveareaNone occurThe left border of cardiacdullness is at the midclavicularline in the fifth interspace, andby the second interspace theborder of dullness concides withthe left sternal border.The right border of dullnessmatches the sternal borderPercussion sounds doesn‟tenlargeA thrill is a palpable vibration.The thrill signifies turbulentblood flow and accompaniesloud murmursCardiac enlargement is due toincreased ventrivular volumeorwall thickness: it occurs withhypertension, heart failure andcardiomyopathyFig. 62 Auscultatory areas (from Carolyne Jarvis, p.506)75
    • Fundamental of Nursing Procedure ManualAction (✽Rationale) Normal findings Abnormal findings/Changes from normal(continued from the former)1) Place the stethoscope2) Try closing eyes briefly to tuneout any distractions.Concentrate, and listenselectively to one sound at atime3) Note the rate and rhythm:① When you notice anyirregularity, check for a pulsedeficit by auscultating theapical beat whilesimultaneously palpating theradial pulse② Count a serialmeasurement(one after theother) of apical beat and radialpulse4) Identify S1 and S2①First heart sound is S1(lub)caused by closure of the AVvalves. S1 signals the beginningof systole② Second heart sound isS2(dup) is associated withclosure of the aortic andpulmonic valves.5) Listen S1 and S2① Focus on systole, thendiastole②Listen for any extra heartsounds to note its timing andcharacteristics6) Listen for murmursIf you hear a murmur, describeit by indicating thesecharacteristics: timing,loudness(Grade i- vi), pitch,pattern, quality, location.radiation, and postureRate ranges normally from 60-100 beats/ minuteThe rhythm should be regular,although sinus arrhythmiaoccurs normally is young adultand childrenS1 is loudest at the apexS2 is loudest at the baseLub-dup is the normal heartsoundS3 occurs immediately after S2and S4 occurs just before S1Some clients may haveinnocent murmursPremature beat; an isolatedbeat is earlyIrregularly irregular; nopattern to the soundsPulse deficit signals a wearcontraction of the ventricules; itoccurs with atrial fibrillationand heart failureBoth heart sounds arediminished in emphysema,obesity and pericardial fluid.A pathologic S3 (ventriculargallop) occurs until heart failureA pathologic S4 (atrial gallop)occurs with CADA systolic murmur may occurwith a normal heart or withheart diseaseA diastolic murmur alwaysindicates heart diseases76
    • Fundamental of Nursing Procedure ManualAction (✽Rationale) Normal findings Abnormal findings/Changes from normalF. Breasts andAxillaeGeneral appearanceNote symmetry of size and shapeSkinInspect color, textile, bulging,dimpling, any skin lesions oredema.Lymphatic drainage areasObserve the axillary andsupraclavcular regions. Note anybulging, discoloration, or edemaNippleInspect symmetry, shape, any dryscaling, any fissure or ulceration,and bleeding or other discharge.Symmetry or a slightasymmetry in sizeOften the left breast is slightlylarger than the rightThe skin normally is smoothand of even colorA fine blue vascular network isvisible normally duringpregnancyPale linear striae, or stretchmarks, often follow pregnancyNo edemaThe nipples should besymmetrically placed on thesame plane on the two breastsNipples usually protrudeA normal variation in about 1 %o men and women is asupernumerary nippleA sudden increase in the size ofone breast signifiesinflammation or new growthHyperpigmentationRedness and heat withinflammationUnilateral dilated superficialveins in a nonpregnant womanEdemaDeviation in pointingRecent nipple retractionsignifies acquired diseaseExplore any discharge,especially in the presence of abreasts massRarely, glandular tissue, asupermumerary breast, orpolymastia is presentFig. 63 Paget‟s disease Fig.64 Mastitis Fig.65 Breast abscess(from Carolyne Jarvis, p.433)77
    • Fundamental of Nursing Procedure ManualAction (✽Rationale) Normal findings Abnormal findings/Changes from normalManeuvers to screen(✽To inspect skin retraction signsdue to fibrosis in the breaststissue)1) Direct the woman to changeposition while you check thebreasts for skin retraction sings2) First ask her to lift the armsslowly over the head3) Next ask her to push herhands onto her hips and topush her two palms together4) Ask the woman with largependulous breasts to leanforward while you support herforearmsInspect and palpate the axillae1) Ask the woman to have sittingposition2) Inspect the skin, noting anyrash or infection3) Lift the woman‟s arm andsupport it yourself① use your right hand topalpate the left axilla② Reach your fingers high intoaxilla③ Move them firmly down infour directions: down the chestwall in a line from the middle ofthe axxila, along the anteriorborder of the axilla, along teposterior border, and along theinner aspect of the upper arm④ Move the woman‟s armthrough ROM to increase thesurface area you can reachPalpate the breasts1) Help her to a supine position2) Tuck a small pad or towelunder the side to be palpatedand raise her arm over herheadBoth breasts should move upsymmetricallyA slight lifting of both breastwill occurBoth breast show thesymmetric free-forwardmovementUsually nodes are not palpableAny enlarged and tender lymphnodesA lag in movement of onebreastA dimpling or a pucker(, whichindicates skin retraction)Fixation to chest wall or skinretractionNodes enlarge with any localinfection of the breast, arm, orhand, and with breast cancermetastasesAny significant lumps78
    • Fundamental of Nursing Procedure ManualAction (✽Rationale) Normal findings Abnormal findings/Changes from normal3) Use the pads of your threefingers and make a gentlerotary motion on the breast① Start at the nipple andpalpate out to the periphery asif “Spokes-on- a- wheel patternof palpation”, or② Start at the nipple andpalpate in “Concentric-circlespattern of palpation”,increasing out to the periphery③ Move in a clockwisedirection, taking care toexamine every square inch ofthe breast④ If you feel a lump or mass,note these characteristics:Location, shape, consistency,movable, distinctness, nipple(;is it displaced or retracted?),skin over the lump, tenderness,lymphadenopahy4) Palpate the nipple, noting anyinduration or subareolar mass① Use your thumbs andforefinger to apply gentlepressure or stripping action tothe nipple② Start at the outside of theareola, “milk” your fingerstoward the nipple, repeat froma few different directions③ if any discharge appears,note its color and consistencyThe male breast1) Inspect the chest wall, notingthe skin surface and any lumpsor swelling2) Palpate the nipple area for anylump or tissue enlargementIn nulliparous women, normalbreast tissue feels firm, smooth,and elasticAfter pregnancy, the tissue feelssofter and looserPremenstrual enlargement isnormalInflammary ridge(; a firmtransverse ridge of compressestissue in the lower quadrants)The normal male breast hasflat disk of undeveloped breasttissueGynecomastia; an enlargementof breast tissue occurs normallyduring puberty on only one sideand is temporaryHeat, redness, and swelling innonlactating andnonpostpartum breasts indicateinflammationExcept in pregnancy andlactation, discharge is abnormalGynecomastia also occurs withuse of anabolic steroids, somemedications, and some diseasestates.79
    • Fundamental of Nursing Procedure ManualAction (✽Rationale) Normal findings Abnormal findings/Changes from normalFig. 66 Gynemastia(from Carolyne Jarvis, p.434)G. AbdomenPreparationExpose the abdomen to be visiblefullyThe client should be emptied thebladder(✽ To prevent discomfort)Keep the room warm. Thestethoscope endpiece , your handsmust be warm(✽ To avoid chillingand tensing of muscles)Position the client supine, with thehead on a pillow, the knees bent oron pillow, and arms at the sides oracross the chest( ✽ To enhanceabdominal wall relaxation)Inquire about any painful areasand examine such an area last(✽Toavoid any muscle guarding)Inspect the abdomenContour1) Stand on the client‟s right side andlook down on the abdomen2) Stoop or sit to gaze across theabdomen. Your head should beslightly higher than the abdomen3) Determine the profile from the ribmargin to the pubic boneSymmetry1) Shine a light across the abdomentoward you or shine it lengthwiseacross the clientNormally ranges from flatto roundedThe abdomen should besymmentric bilaterallyScaphoid abdomenProtuberant abdomenAbdominal distensionBulges, massesHernia; protrusion ofabdominal viscera throughabnormal opening in musclewall80
    • Fundamental of Nursing Procedure ManualAction (✽Rationale) Normal findings Abnormal findings/Changes from normal2) Note any localized bulging,visible mass, or asymmetricshape while the client takes adeep breathSkin1) Inspect the skin(✽To detectabnormalities, i.g.,pigmentation)2)Note striae, scars, lesions,rashes, dilated veins, andturgorUmbilicusObserve its contour, location,inflammation or bulgesPulsation or movement1)Observe the pulsations fromthe aorta beneath the skin inthe epigastric area2) Observe for peristlsis wavesThe abdomen should be smoothand symmetricThe surface is smooth and even,with homogenous colorOld silver striae or stretchmarks is normal afterpregnancy or gained excessiveweightRecent striae are pink or blueGood turgorNormally it is midline andinverted, with no sign ofdiscoloration, inflammation, orherniaIt becomes everted and pushedupward with pregnancyNormally, aortic pulsations isvisible in epigastriumWaves of peristalsis sometimesare visible in very thin personsLocalized bulges in theabdominal wall due to herniaBulging flanks of ascites,suprapubic bulge of a distendedbladder or pregnant uterusLower abdominal mass of anovarium or uterine tumorAsymmetry from an enlargedorgan or massRedness with localizedinflammationJaundiceSkin glistening, taut, and striaein ascitesPink-purple striae withCushing‟s syndromeProminent, dilated veins ofhepatic cirrhosis or of inferiorvena caval obstructionLesions, rashesPoor turgor occurs withdehydrationEverted with ascites, orunderlying massEnlarged and everted withumbilical herniaBluish periumbilical coloroccurs with intraabdominalbleeindMarked pulsation of the aortaoccurs with widened pulsepressure; i.g., hypertension,aortic insufficiency,thyrotoxicosisIncreased peristalsis waveswith a distended abdomenindicates intestinal obstruction81
    • Fundamental of Nursing Procedure ManualAction (✽Rationale) Normal findings Abnormal findings/Changes from normalAuscultate Bowel sounds andVascular soundsBowel sounds1) Listen to the abdomen beforeperforming percussion orpalpation( ✽Not to alter thefrequency of the bowel sounds)2) Place the diaphragm of yourstethoscope gently in theabdomen3) Listen for the sounds, andnoting the character andfrequency of bowel sounds4) If suspected the absence ofbowel sounds, you must listenfor 5 minutes by your watchbefore deciding bowel soundsare completely absentVascular sounds1) Listen to the abdomen , notingthe presence of any vascularsounds or bruits2) Using firmer pressure, checkover the aorta, renal arteries,iliac, and femoral arteries,especially in person withhypertension3) Note location, pitch, andtiming of a vascular sound4)Listen over the liver and spleenfor friction rubsNormal sounds consist of clicksand gurgles, occurring atestimated frequency of 5 to 30(-34 ) times per minuteUsually no such sounds ispresentTwo distinct patterns of abnormalbowel sounds occur:Hyperactive sounds: loud,highpitched, rushing, tinklingsounds that signal increasedmotilityHypoactive or absent sounds:abdominal surgery or withinflammation of theperitoneum, paralytic ileusA systolic bruit(; a pulsatileblowing sound) occurs withstenosis or occlusion of anarteryFriction rubs in liver tumor orabscess, gonococcal infectionaround liver , splenic infectionFig. 67 Vascular sounds (from Carolyne Jarvis, p.574)82
    • 8383Action (✽Rationale) Normal findings Abnormal findings/Changes from normalPercussion general tympany, liverspan, and splenic dullness(✽To assess the amount anddistribution gas in the abdomenand to identify possible massesthat are solid or liquid filled,also to estimate the size of theliver and spleen)1) Percuss the abdomen lightly inall four quadrants(✽ To assessthe distribution of tympany anddullness)2) Note any large dull areas thatmight indicate an underlyingmass or enlarged organ3) On each of side of a protuberantabdomen, not where abdominaltympany changes to thedullness of solid posteriorstructureTympany shouldpredominate because of gas ingastrointestinal tractScattered area of dullnessfrom fluid and fecesNormal dullness in the liverand spleenA protuberant abdomen that istympanitic throughout suggestsintestinal obstructionLarge dullness in pregnantuterus, ovarian tumor,distendedBladder, large liver or spleenDullness in both flanksindicates further assessmentfor ascitesAbsence of tympanyFig. 68 Percussing for general tympanyFig. 69 Shifting dullness A: in supine position B: in right lateral position(from Carolyne Jarvis, p. 574 and p.578)
    • 8484Action (✽Rationale) Normal findings Abnormal findings/Changes from normalPalpate surface and deep areasPerform palpation( ✽To judgethe size, location, and consistencyof certain organs, mobility of anypalpable organs and to screen forany abnormal enlargement,masses or tenderness)Light palpation(✽To from an overall impressionof the skin surface and superficialmusculature)1) Place the client is the supineposition, keeping your handand forearm on a horizontalplane with the first four fingersclose together and flat on theabdominal surface2)Ask him/her to relax his/herabdomen3) Depress the abdominal surfaceabout 1 cm2) Make a light and gentle rotarymotion, sliding the fingers andskin together3) Lift the fingers and moveclockwise to the next locationaround the abdomen4) Palpate in all quadrantsDeep palpationPerform deep palpation(Fig. 70A. –B.)No abdominal massNo tendernessMuscle guardingMassTendernessInvoluntary rigidity indicatesacute peritoneal inflammationFig.70 Deep palpation ( from Carolyne Jarvis, p.578)A. with Single hand B. Bimanual technique
    • 8585Action (✽Rationale) Normal findings Abnormal findings/Changes from normal1) Perform deep palpation usingthe same technique describedearlier, but push down 5 to 8cm (2 to 3 inches)2) Moving clockwise, explore theentire abdomen3) To over come the resistance ofa very large or obese abdomen,use a bimanual technique① The top hand does thepushing② The bottom hand is relaxedand can concentrate on thesense of palpationLiver1) Stand on the client‟s right side2) Place your left hand under theclient‟s back parallel to the11th and 12th ribs3) Lift up to support theabdominal contents4) Place your right hand on theRUQ, with fingers parallel tothe midline(Fig. 71 )5) Push deeply down and underthe right costal margin6) Ask the client to take a deepbreath7) Feel for liver sliding over thefingers as the client inspires8) Note any enlargement ortenderness.Normally palpable structure:xiphoid process, normal liveredge, right kidney, pulsatileaorta, rectus muscles, sacralpromontory, cecum ascendingcolon, sigmoid colon, uterus, fullbladderMild tenderness is normallypresent when palpating thesigmoid colonLiver is not usually palpablePeople may be palpable theedge of the liver bumpimmediately below the costalmargin as the diaphragmpushes it down duringinhalation: a smooth structurewith a regular contour, firmand sharp edgeTenderness occurs with localinflammation, withinflammation of theperitoneum or underlyingorgan, and with an enlargedorgan whose capsule isstretchedLiver palpable as soft hedge orirregular contourExcept with a depresseddiaphragm, a liver palpatedmore than 1 to 2 cm below theright costal margin is enlargedIf enlarged, estimate theamount of enlargement beyondthe right costal margin.Express it in centimeters withits consistency and tendernessFig. 71 Palpation the liver in the RUQ(from Carolyne Jarvis, p.582)
    • 8686Action (✽Rationale) Normal findings Abnormal findings/Changes from normalSpleenIn supine position:1) Reach your left hand over theabdomen and behind the leftside at the 11th and 12th ribs (Fig.72A. )2) Lift up for support3) Place your right hand obliquelyon the LUQ with the fingerspointing toward the left axillaand just inferior to the ribmargin4) Push your hand deeply downand under the left costalmargin5) Ask the client to take a deepbreathIn right lateral position:1) Roll the client onto his/herright side to displace the spleenmore forward anddownward(Fig. 72 B.)2) Palpate as described earlierNormally spleen is not palpableNo enlargement andtendernessThe spleen must be enlargedthree times its normal size to befeltThe enlarged spleen is palpableabout 2 cm below the left costalmargin on deep inspirationFig. 72 A. Palpation the spleen in supine position B. Palpation the spleen in right lateral position(from Carolyne Jarvis, p.583)
    • 8787Action (✽Rationale) Normal findings Abnormal findings/Changes from normalKidneysPalpation in the right kidney:1) Place the client in the supineposition2) Place your left hand on theclient between lowest rib andthe pelvic bone3) Place your right hand on theclient‟s side below the lowestrib or in the RUQ. Your handsare placed together in a“duck-bill” position at theclient‟s right flank (Fig.73 A.)4) Ask the client to take a deepbreath.5) At the peak of inspiration,press your right hand anddeeply into the RUQ, justbelow the coastal margin6) Try to capture the kidneybetween two hands7) Note the enlargement ortenderness.Palpation in the left kidney:1) Search for the left kidney byreaching your left hand acrossthe abdomen and behind theleft flank for support(Fig. 73 B.)2) push your right hand deep intothe abdomen3) Ask the client to take a deepbreath4) Feel the change while inspiringBoth kidneys are not usuallypalpableA normal right kidney may bepalpable in well-relaxed womenNo change while breathingdeeply on both sidesNormally no changeEnlarged kidneyTendernessKidney massCauses of kidney enlargementinclude hydronephrosis, cyst ortumorsBilateral enlargement suggestspolycystic kidney diseaseFig. 73 Palpation the kidney A. Right kidney B. Left kidney(from Carolyne Jarvis, p.584)
    • 8888Action (✽Rationale) Normal findings Abnormal findings/Changes from normalPercussion in the kidney:(✽To assess the tenderness in thekidney)1) Place the ball of one hand inthe costovertebral angle2) Strike it with the ulnar surfaceof your fist, using enough forceto cause a perceptibleRebound tenderness( Bulumberg‟s sign)(✽To test rebound tendernesswhen the client feels abdominalpain or when you elicittenderness during palpation )1) Choose a site away from thepainful area2) Hold your hand 90 degrees, orperpendicular, to the abdomen3) Push down slowly and deeplyand then lift up suddenly(Fig. 74A.,B.)Painless jar in fist percussionAs a normal or negative, nopain on release of pressurePain with fist percussionsuggests pyelonephritis, butmay also have amusculoskeletal causePain in release of pressureconfirms rebound tenderness,which is a reliable sign ofperitoneal inflammation.Peritoneal inflammationaccompanies appendicitisFig. 74 Rebound tendernessn(from Carolyne Jarvis, p.585)A. Pushing down the abdomen slowly B. Lift your hand up quicklyAction (✽Rationale) Normal findings Abnormal findings/Changes from normalInguinal area1) Lift the drape or cloth toexpose the inguinal area andlegs2) Inspect and palpate each groinfor the femoral pulse and theinguinal nodesNormally no palpable nodules Palpable nodesSwollen, tenderness
    • 8989Action (✽Rationale) Normal findings Abnormal findings/Changes from normalBladder1) The bladder normally cannotbe examined unless it isdistended above the symphysispubis on palpation.2) Check for tenderness3) Use percussion to check fordullness and to determine howhigh the bladder rises abovethe symphysis pubisNormally not palpable andtendernessThe dome of distended bladderfeels smooth and roundBladder distension from outletobstructionSuprapubic tenderness inbladder infectionNOTE:Table 5 Common sites of referred abdominal pain(from Carolyne Jarvis, p.593)
    • Fundamental of Nursing Procedure ManualAction (✽Rationale) Normal findings Abnormal findings/Changes from normalH. Musculoskeletal systemInspection the muscle and joints1)Ask the client to stand2) Inspect his/her neck , shoulder,arms, hands, hips, knees, legs,ankle and feet.3) Compare one side with otherside4) Note the size and contour ofthe joint, skin and tissues overthe joints for color, swelling,and any masses or deformitiesRange of motion(; ROM)(✽To inspect the client‟s ability tomove musculoskeletal system)1) Ask the client to move his/herneck, shoulders, elbows, wrists,fingers, hip, knees, ankles andtoes one by one in all possibledirections2) Note the range of motion andwatch for the signs of painSupine1)Ask the client to stand2) Place yourself far enough back3) Inspect and note the line andthe equal horizontal positionsfor the shoulders, scapulae,iliac crests, gluteal folds, andequal spaces between arm andlateral thorax on the two sides.4) From the side, note the normalconvex thorax curve andconcave lumbar curve.No bone or joint deformitiesNo redness or swelling of jointsNo muscle wastingAble to move joins freelyNo sign of pain while movingjointsThe kneel and feet should bealigned with the trunk andshould be pointing forwardAn enhanced thorax curve, orkyplosis , is common in agingpeopleA pronounced lumbar curve, orlordosis, is common in obesepeoplePresence of bone deformities orjoint deformitiesRedness or swelling issignificant and signals jointirritationMuscle wastingSwelling may be due to excessjoint fluid, thickening of thesynovial lining, inflammation ofsurrounding soft tissue or bonyenlargementDeformities include dislocation,subluxation, contracture, orankylosisLimited movement of the jointsSign of pain when moving thejointsA difference of shoulderelevation and in level ofscapulae and iliac crest occurwith scoliosisLateral tilting and forwardbending occur with a herniatednucleus pulposus90
    • Fundamental of Nursing Procedure ManualAction (✽Rationale) Normal findings Abnormal findings/Changes from normalPalpation1) Palpate each joint, includingits skin for tenderness, itsmuscles, bony articulations,and area of joint capsule2) Note any heat, tenderness,swelling or masses.3) If any tenderness occur, try tolocalize it to specific anatomicstructure(skin, muscle,ligaments, tendons, fat pads orjoint capsule)4) Holding the each joint one byone, ask the client to movethese areas. note the range ofmotion and for any roughsensation at the jointPeripheral vascular examinationInspection and palpation1) Inspect the arms for color, size,any lesion and skin changes2) Palpate pulses: radial andbrachial pulse3) Inspect legs for color, size, anylesions, trophic skin changes orswelling4) Palpate temperature of feetand legs5) Palpate inguinal nodes6) Palpate pulses: femoral,popliteal, posterior tibial,dorsalis pedisNo swelling, tenderness orredness in jointNormal temperatureThe synovial membranenormally is not palpableA small amount of fluids ispresent in the normal joint, butnot palpableFull range of joint movementSmooth joint movementSymmetrical in size and shapeNo edemaNo lesionNo changes in skin colorsNormal pulse rateSymmetrical in size and shapeNo edemaNo lesionNo changes in skin colorsWarm and equal bilaterallyNot palpable nodes and nontendernessNormal pulseRedness, swelling or tendernessLimited joint movementHard muscle with musclespasmInoreased, temperature overthe jointPalpable fluidLimited joint movementRough sensation(crepitation) inmoving a jointEdema of upper extremitisIncreased or decreased pulsePallor with vasoconstrictionCyanosisVaricose veinA unilateral cool foot or legoccursWith arterial deficitEnlarged nodes, tender or fixedA bruit occurs with turbulentblood flow indicating partialocclusion91
    • Fundamental of Nursing Procedure ManualAction (✽Rationale) Normal findings Abnormal findings/Changes from normalPalpation1) Press the skin gently andfirmly at the arms, hands overthe skin of the tibia, ankles andfeet for 5 seconds, and thenrelease .2) Note whether the finger leavesan impression on the skinindication edema3) Ask the client to stand so thatyou assess the venous system4) Note any visible dilated andtortuous veinsMuscles strengthen1) Push against the client‟shands, and then feet2)Ask him/her to resist the pushNo impression left on the skinwhen pressedPit edema commonly is seen ifthe person has been standingall day or during pregnancyEqual strengthen is both handsand feetNo muscular weaknessBilateral pitting edema occurswith heart failure, diabeticneuropathy, or hepatic cirrhosisUnilateral edema occurs withocclusion of a deep veinUni- or bilateral edema occurswith lymphatic obstructionVaricosities occur in thesaphenous veinsMuscular weakness on one orboth hands and feetI. Nervous systemFor sensation1)Ask the client to close the eyes2) Select areas on face , arms,hands, legs and feet3) Give a superficial pain, lighttouch and vibration to each siteby turn4) Note the client‟s ability ofsensation on each siteTest for Cranial nervesCranial nerve I: Olfactory nerve(✽To test the sense of smell )1)Ask the client to close his/hereyes2) Ask him/her the source of smellusing familiar, convenientlyobtainable, and non-noxioussmell such as coffee or toothpasteFeels pain, light touch andvibrationEqually in both side of his/herbodyDecreased pain sensation ortouch sensationUnable to feel vibrationOne can not test smell whenupper respiratory infection orwith sinusitis decreases or lossof smell with tobacco smokingor cocaine use92
    • Fundamental of Nursing Procedure ManualAction (✽Rationale) Normal findings Abnormal findings/Changes from normalTest stereognosis1) Ask the client to close his/ hereyes2) Place a familiar object(i.g., clip,key or coin) in the client‟s hand3)Ask the client to identify itTest for the cerebellar function ofthe upper extremitiesUse finger-to- nose test orrapid-altering –movement testTest for the cerebellar function ofthe lower extremities1) Ask the client to reach heel downthe opposite shin or2) Ask the client to stand and walkacross the room in his/herregular walk back ward, andthen turn toward youDeep tendon reflex(✽To elicit the intactness of the arcat specific spinal level)Biceps reflex(C5 to C6)1) Support the client‟s forearm onyours2) Place your thumb on the bicepstendon and strike a blow on yourthumb3) Observe the responseTriceps reflex(C7 to C8)1) Tell the client to let the arm “justgo dead” as you suspend it byholding the upper arm2) Strike the triceps tendon directlyjust above the elbow3) Observe the responseBrachioradialis reflex(C5 to C6)1) Hold the client‟s thumb tosuspend the forearms inrelaxationNormal client can identify thefamiliar objectCoordinated, smoothmovementStraight and balanced walkNormal response iscontraction of the bicepsmuscle and flexion of theforearmNormal response is extensionof the forearmNormal response is flexionand supination of the forearmInability to identify objectcorrectly, especially in brainstrokeUncoordinated movementLimping, unbalanced walk,uncoordinated or unsteady gaitHyperreflexiaHyporeflexia93
    • Fundamental of Nursing Procedure ManualAction (✽Rationale) Normal findings Abnormal findings/Changes from normal2) Strike the forearm directly,about 2 to 3 cm above theradial styloid process3) Observe the responseQuadriceps reflex(“Knee jerk”)(L2 to L4)1) Let the lower legs dangle freelyto flex the knee stretch thetendons2) Strike the tendon directly justbelow the patella3) Observe the response andpalpate contraction of thequadricepsAchilles reflex(“Ankle jerk”) (L5to S2)1) Position the client with theknee flexed and hip externallyrotated2) Hold the foot in dorsiflexion3) Strike the Achilles tendondirectly4) Feel the responseSuperficial reflexPlanter reflex (L4 to S2)1) Position the thigh in slightexternal rotation2) With the reflex hammer,draw a light stroke up thelateral side of the sole of thefoot and inward across the ballof the foot3) Observe the responseNormal response is extension ofthe lower legNormal response is the footplanter flexes against yourhandNormal response is planterflexion of all the toes andinversion and flexion of theforefootBabinski sign: this occurs withupper motor neuron disease94
    • Fundamental of Nursing Procedure ManualFig. 75 Biceps reflex Fig. 76 Triceps reflexFig. 77 Brachioradilis reflex Fig. 78 Quadriceps reflexFig. 79Achilles reflex (from Carolyne Jarvis, p.687, 688, 689)95
    • Fundamental of Nursing Procedure ManualAction (✽Rationale) Normal findings Abnormal findings/Changes from normalJ. AnusInspect the perineal area for anyirritation, cracks, fissure orenlarged vesselsNo irritation, fissure, cracksNo enlarged blood vessels inanusPresence of anal irritation, analfissure, enlarged and bloodvesselsK. Male GenitaliaInspect and palpate the penis1) Inspect the skin, glans, andurethral meatus2) If you note urethral discharge,collect a smear for microscopicexamination and a culture3) Palpate the shaft of penisbetween your thumb and firsttwo fingersInspect and palpate the scrotum1) Inspect the scrotum2) Palpate gently each scrotal halfbetween your thumb and firsttwo fingersThe skin normally lookswrinkled, hairless, and withoutlesions. The dorsal vein may beapparentThe glans looks smooth withoutlesionsForeskin easily retractableThe urethral meatus ispositioned just about centrallyNormally the penis feelssmooth, semifirm, andnon-tenderAsymmetry is normal, with theleft scrotal half usually lowerthan the rightNo scrotal lesionsThe skin of scrotum is thin andlooseNo lump, no tendernessTestes are equal in sizeInflammationLesionsPresence of sore or lumpPhimosis: unable to retract theforeskinEdges that are red, everted,edematous, along with purulentdischarge, suggested urethritisNodule or induration,tenderness on the penisScrotal swelling occurs withheart failure, renal failure, orlocal inflammationLesionsThick or swollen scrotal skinAbnormalities in the scrotum:hernia, tumor, orchitis,epididymitis, hydrocele,spermatocele, varicoceleL. Female genitalsFor inspection of femalegenitals place the client in thesupine position with the kneeflexed and feet resting on theexamination table.External genitaliaInspection1)Note skin color, hairdistribution, labia majora, anylesions, clitoris, labia minora,urethral opening, vaginalopening, perineum, and anus.Labia are of the same color andsizeno redness or swelling in labiaUrethral opening appearsstellate and in midlineExcoriation, nodules, rash, orlesionsInflammationPolyp in urethral openingFoul-smelling, white, yellow,green discharge from vagina96
    • Fundamental of Nursing Procedure ManualAction (✽Rationale) Normal findings Abnormal findings/Changes from normal2) Look for any discharge orbleeding, prolapse, from thevaginaVaginal opening may appear asa vertical slitPerineum is smoothAnus has coarse skin increasedpigmentationNo usual discharge from thevaginaNo prolapseNo bleeding from the vaginaexcept during mensturationBleeding97
    • 9898Care for Nasal-Gastric Tubea. Inserting a Nassal-Gastric TubeDefinition:Method of introducing a tube through nose into stomachPurpose:1. To feed client with fluids when oral intake is not possible2. To dilute and remove consumed poison3. To instill ice cold solution to control gastric bleeding4. To prevent stress on operated site by decompressing stomach of secretions and gas5. To relieve vomiting and distentionEquipments required:1. Nasogastric tube in appropriate size (1)2. Syringe 10 ml (1)3. Lubricant4. Cotton balls5. Kidney tray (1)6. Adhesive tape7. Stethoscope (1)8. Clamp (1)9. Marker pen (1)10.Steel Tray (1)11.Disposable gloves if available (1 pair)
    • 9999Procedure:CareAction Rationale1. Check the Doctor‟s order for insertion ofNasal-gastric tube.This clarifies procedure and type of equipmentrequired.2.Explain the procedure to the client. Explanation facilitates client cooperation.3. Gather the equipments. Organization provides accurate skill performance.4.Assess client‟s abdomen Assessment determines presence of bowel soundsand amount of abdominal distention.5. Perform hand hygiene. Wear disposable gloves ifavailable.Hand hygiene deters the spread ofmicroorganisms. But sterile technique is notneeded because the digestive tract is not sterile.Gloves protect from exposure to blood or bodyfluids.6.Assist the client to high Fowler‟s position, or 45degrees, if unable to maintain upright position.Upright position is more natural for swallowingand protects against aspiration, if the clientshould vomit.7. Checking the nostril:1) Check the nares for patency by asking the clientto occlude one nostril and breathe normallythrough the other.2) Clean the nares by using cotton balls3) Select the nostril through which air passes moreeasily.Tube passes more easily through the nostril withthe largest opening.8. Measure the distance to insert the tube byplacing:1) Place the tip of tube at client‟s nostril extendingto tip of earlobe2) Extend it to the tip of xiphoid process3) Mark tube with a marker pen or a piece of tapeMeasurement ensures that the tube will be longenough to enter the client‟s stomach.9. Lubricant the tip of the tube ( at least 1-2 inches)with a water soluble lubricantLubricant reduces friction and facilitates passageof the tube into the stomach.Xylocaine jelly may not be recommended to useas a lubricant due to the risk of xylocaine shock.Water–soluble lubricant will not causepneumonia if tube accidentally enters the lungs.10. Inserting the tube:1) Insert the tube into the nostril while directingthe tube downward and backward.2) The client may gag when the tube reaches thepharynx.3) Instruct the client to touch his chin to his chest.4) Encourage him/her to swallow even if no fluidsare permitted.Following the normal contour of the nasalpassage while inserting the tube reducesirritation and the likelihood of mucosal injuryThe gag reflex stimulated by the tubeSwallowing helps advance the tube, causes theepiglottis to cover the opening of the trachea, andhelps to eliminate gagging and coughing
    • Fundamental of Nursing Procedure ManualCareAction Rationale5) Advance the tube in a downward and backwarddirection when the client swallow.6) Stop when the client breathes7) If gagging and coughing persist, checkplacement of tube with a tongue depressor andflashlight if necessary.8) Keep advancing the tube until the marking orthe tape marking is reached.❖NursingAlert❖ Do not use force. Rotate the tube if it meetsresistance. Discontinue the procedure and remove thetube if the tube are signs of distress, such asgasping, coughing, cyanosis, and theinability to speak or hum.Excessive coughing and gagging may occur if thetube has curled in the back of throat.Forcing the tube may injure mucous membranes.The tube is not in the esophagus if the clientshows signs of distress and is unable to speak orhum.11. While keeping one hand on the tube, verify thetube‟s placement in the stomach.a. Aspiration of a small amount of stomachcontents:Attach the syringe to the end of the tube andaspirate small amount of stomach contents.Visualize aspirated contents, checking for colorand consistency.b. Auscultation:Inject a small amount of air( 10- 15 ml)intothe nasogastric tube while you listen with astethoscope approximately 3 inches ( about 8cm) below the sternum.c. Obtain radiograph of placement of tube( asordered by doctor.)The tube is in the stomach if its contents can beaspirated.If the tube is in the stomach, you will be able tohear the air enter (a whooshing sound) If the tubeis in the esophagus, injecting the air will bedifficult or impossible. In addition, injection of airoften causes the client to belch immediately. If thetube is in the larynx, the client usually is unableto speak.12. Secure the tube with tape to the client‟s nose.❖NursingAlert❖Be careful not to pull the tube too tightlyagainst the nose.Constant pressure of the tube against the skinand mucous membranes causes tissue injury.13. Clamp the end of nasal-gastric tube while youbend the tube by fingers not to openBending tube prevents the inducing of secretion14. Putt off and dispose the gloves, Perform handhygieneTo prevent the spread of infection16. Replace and properly dispose of equipment. To prepare for the next procedure17. Record the date and time, the size of thenasal-gastric tube, the amount and color ofdrainage aspirated and relevant client reactions.Sign the chart.Documentation provides coordination of care18. Report to the senior staff. To provide continuity of care100
    • 101101101Procedure:b. Removal a Nasal-Gastric TubeCare action Rationale1.Assemble the appropriate equipment, such askidney tray, tissues or gauze and disposablegloves, at the client‟s bedside.Organization facilitates accurate skillperformance2. Explain the client what your are going to do. Providing explanation fosters cooperation3. Put on the gloves To prevent spread of infection4. Remove the tube1) Take out the adhesive tape which holding thenasal-gastric tube to the client‟s nose2) Remove the tube by deflating any balloons3) Simply pulling it out, slowly at first and thenrapidly when the client begins to cough.4) Conceal the tube .5) Be sure to remove any tapes from the client‟sface.Acetone may be necessary.Do not remove the tube if you encounter anyresistance not to harm any membranes or organs.Do another attempts in an hour.Continuous slow pulling it out can lead coughingor discomfortAcetone helps any adhesive substances from theface. You should also wipe acetone out afterremoved tapes because acetone remained on theskin may irritate.6. Provide mouth care if needed. To provide comfort7. Put off gloves and perform hand hygiene. To prevent the spread of infection8. Record the date, time and the client‟s condition onthe chart. And be alert for complains of discomfort,distension, or nausea after removal. Sign thesignature.Documentation provides coordination of careGiving signature maintains professionalaccountability9. Dispose the equipments and replace them. To prepare for the next procedure10.Report to the senior staff. To provide continuity of care
    • 102102102Administering a Nasal- gastric Tube FeedingDefinition:A nasal-gastric tube feeding is a means of providing liquid nourishment through a tube into the intestinaltract, when client is unable to take food or any nutrients orallyPurpose:1. To provide adequate nutrition2. To give large amounts of fluids for therapeutic purpose3. To provide alternative manner to some specific clients who has potential or acquired swallowingdifficultiesEquipments required:1. Disposable gloves (1)2. Feeding solution as prescribed3. Feeding bag with tubing (1)4. Water in jug5. Large catheter tip syringe (30 mLor larger than it) (1)6. Measuring cup (1)7. Clamp if available (1)8. Paper towel as required9. Dr.‟s prescription10. Stethoscope (1)
    • 103103103Procedure:CareAction Rationale1. Assemble all equipments and supplies afterchecking the Dr.‟s prescription for tube feedingOrganization facilitates accurate skillperformanceChecking the prescription confirms the type offeeding solution, route, and prescribed deliverytime.2. Prepare formula:a. in the type of can:Shake the can thoroughly. Check expirationdateb. in the type of powder:Mix according to the instructions on thepackage, prepare enough for 24 hours only andrefrigerate unused formula. Label and date thecontainer. Allow formula to reach roomtemperature before using.c. in the type of liquid which prepare by hospitalor family at a time:Make formula at a time and allow formula toreach room temperature before using.Feeding solution may settle and requires mixingbefore administration.Outdated formula may be contaminated or havelessened nutritional value.Formula loses its nutritional value and canharbor microorganisms if kept over 24 hours.Cold formula cause abdominal discomfort orsometimes diarrhea.3. Explain the procedure to the client Providing explanation fosters client‟s cooperationand understanding4. Perform hand hygiene and put on disposablegloves if availableTo prevent the spread of infection5. Position the client with the head of the bedelevated at least 30 degree angle to 45 degreeangleThis position helps avoiding aspiration of feedingsolution into lungs
    • 1041041046. Determine placement of feeding tube by:a. Aspiration of stomach secretions① Attach the syringe to the end of feeding tube② Gently pull back on plunger③ Measure amount of residual fluid④ Return residual fluid to stomach via tubeand proceed to feeding.❖NursingAlert❖If amount of the residual exceed hospitalprotocol or Dr.‟s order, refer to these order.b. Injecting 10- 20 mL of air into tube:① Attach syringe filled with air to tube② Inject air while listening with stethoscopeover left upper quadrantAspiration of gastric fluid indicates that the tubeis correctly placed in the stomachThe amount of residual reflects gastric emptyingtime and indicates whether the feeding shouldcontinue.Residual contents are returned to the stomachbecause they contain valuable electrolytes anddigestive enzymes.In the case of non present of residual, youshould check placement carefully.Residual over 120 mL may be caused by feedingtoo fast or taking time more to digest. Holdfeeding for 2 hours, and recheck residual.Inject 3-5 mL of air for childrenA whooshing or gurgling sound usually indicatesthat the tube is in the stomach
    • 105105105CareAction Rationalec. Taking an x-ray or ultrasound It may be needed to determine the tube‟splacementFig. 79a.Aspiration of stomach secretion b. Injecting 10-20 mL air into Tube(from Caroline : Textbook of Basic Nursing, 1999, p.355)CareAction Rationale
    • 106106106Intermittent or Bolus feedingUsing a feeding bag:7. Feeding the following1) Hang the feeding bag set-up 12 to 18 inchesabove the stomach. Clamp the tubing.2) Fill the bag with prescribed formula and preparethe tubing by opening the clamp. Allow thefeeding to flow through the tubing . Reclamp thetube.3) Attach the end of the set-up to the gastric tube.Open the clamp and adjust flow according to theDr.‟s order.4) Add 30-60 mL of water to the feeding bag asfeeding is completed.Allow the flow into basin.5) Clamp the tube and disconnect the feedingset-up.Using the syringe:7. Feeding the following1) Clamp the tube. Insert the tip of the large syringewith plunger, or bulb removed into the gastrictube.2) Pour feeding into the syringeRapid feeding may cause nausea and abdominalcramping.Water clears the tube, keeping it patent.Clamping when feeding is completed prevents airfrom entering the stomach
    • Fundamental of Nursing Procedure ManualCareAction Rationale3) Raise the syringe 12 to 18 inches above thestomach. Open the clamp.4) Allow feeding to flow slowly into the stomach.Raise and lower the syringe to control the rate offlow.5)Add additional formula to the syringe as itempties until feeding is completeGravity promotes movement of feeding into thestomachControlling administration and flow rate offeeding prevents air from entering the stomachand nausea and abdominal cramping fromdeveloping8. Termination feeding:1) Terminate feeding when completed.2) Instill prescribed amount of water3) Keep the client‟s head elevated for 20-30 minutes.To maintain patency of the tubeElevated position discourages aspiration offeeding solution into the lung9. Mouth care:1) Provide mouth care by brushing teeth2) Offer mouthwash3) Keep the lips moistMouth care promotes oral hygiene and providecomfort10. Clean and replace equipments to proper place To prevent contamination of equipment andprepare for the next procedure11. Remove gloves and perform hand hygiene To prevent the spread of infection12. Document date, time, amount of residual,amount of feeding, and client‟s reaction tofeeding. Sign the chartDocumentation provides continuity of careGiving signature maintains professionalaccountability105
    • 106106106Performing Surgical Dressing:Cleaning a Wound and Applying a Sterile DressingDefinition:Sterile protective covering applied to a wound/incision, using aseptic technique with or without medicationPurpose:1. To promote wound granulation and healing2. To prevent micro-organisms from entering wound3. To decrease purulent wound drainage4. To absorb fluid and provide dry environment5. To immobilize and support wound6. To assist in removal of necrotic tissue7. To apply medication to wound8. To provide comfortEquipments required:1. Sterile gloves (1)2. Gauze dressing set containing scissors and forceps (1)3. Cleaning disposable gloves if available (1)4 Cleaning basin(optional) (1) as required5. Plastic bag for soiled dressings or bucket (1)6. Waterproof pad or mackintosh (1)7. Tape (1)8. Surgical pads as required9.Additional dressing supplies as ordered, e.g. antiseptic ointments, extra dressings10.Acetone or adhesive remover (optional)11. Sterile normal saline (Optional)
    • 107107107Procedure:CareAction Rationale1. Explain the procedure to the client Providing information fosters his/her cooperationand allays anxiety.2.Assemble equipments Organization facilitates accurate skillperformance3. Perform hand hygiene To prevent the spread of infection4.Check Dr‟s order for dressing change. Notewhether drain is present.The order clarifies type of dressing5. Close door and put screen or pull curtains. To provide privacy6. Position waterproof pad or mackintosh under theclient if desiredTo prevent bed sheets from wetting bodysubstances and disinfectant7.Assist client to comfortable position that provideseasy access to wound area.Proper positioning provides for comfort.8.Place opened, cuffed plastic bag near workingarea.Soiled dressings may be placed in disposal bagwithout contamination outside surfaces of bag.9. Loosen tape on dressing . Use adhesive removerif necessary. If tape is soiled, put on gloves.It is easier to loosen tape before putting in gloves.10.1) Put on disposable gloves2) Removed soiled dressings carefully in a clean toless clean direction.3) Do not reach over wound.4) If dressing is adhering to skin surface, it may bemoistened by pouring a small amount of sterilesaline or NS onto it.5) Keep soiled side of dressing away from client‟sview.Using clean gloves protect the nurse whenhandling contaminated dressings.Cautious removal of dressing(s) is morecomfortable for client and ensures that drain isnot removed if it is present.Sterile saline provides for easier removal ofdressing.11.Assess amount, type, and odor of drainage. Wound healing process or presence of infectionshould be documented.12.1) Discard dressings in plastic disposable bag.2) Pull off gloves inside out and drop it in the bagwhen your gloves were contaminated extremelyby drainage.Proper disposal dressings prevent the spread ofmicroorganisms by contaminated dressings.13.Cleaning wound:a. When you clean wearing sterile gloves:1) Open sterile dressings and supplies on work areausing aseptic technique.2) Open sterile cleaning solution3) Pour over gauze sponges in place container orover sponges placed in sterile basin.4) Put on gloves.5) Clean wound or surgical incision①Clean from top to bottom or from centeroutwardSupplies are within easy reach, and sterility ismaintained.Sterility of dressings and solution is maintained.Cleaning is done from least to most contaminatedarea.
    • Fundamental of Nursing Procedure ManualCareAction Rationale5) ② Use one gauze square for each wipe,discarding each square by dropping into plasticbag. Do not touch bag with gloves.③Clean around drain if present, moving fromcenter outward in a circular motion.④Use one gauze square for each circularmotion.b. When you clean using sterile forceps:1) Open sterile dressings and supplies on work areausing aseptic technique.2) Open sterile cleaning solution3) Pour over gauze sponges or cottons in placecontainer or over sponges or cottons placed insterile basin.4) Clean wound or surgical incision:Follow the former procedure using sterile gloves.Previously cleaned area is re-contaminated.Do not touch bag with sterile forceps to preventcontamination14. Dry wound or surgical incision using gauzesponge and same motion.Moisture provides medium for growth ofmicroorganisms.15.Apply antiseptic ointment by forceps if ordered. Growth of microorganisms may be retarded andhealing process improved.16. Apply a layer of dry, sterile dressing over woundusing sterile forceps.Primary dressing serves as a wick for drainage.17. If drainage is present:Use sterile scissors to cut sterile 4 X 4 gauzesquare to place under and around drain.Drainage is absorbed, and surrounding skin areais protected.18.Apply second gauze layer to wound site. Additional layers provide for increased absorptionof drainage.19. Place surgical pad over wound as outer mostlayer if available.Wound is protected from microorganisms inenvironment.20. Remove gloves from inside out and discardthem in plastic bag if you worn.To prevent cross-infection21.Apply tape or existing tape to secure dressings Tape is easier to apply after gloves have beenremoved.22.1) Perform hand hygiene.2) Remove all equipments and disinfect them asneeded. Make him./her comfortable.To prevent the spread of infection23. Document the following:1) Record the dressing change2) Note appearance of wound or surgical incisionincluding drainage, odor, redness, and presence ofpus and any complication.3) Sign the chartDocumentation provides coordination of care.Giving signature maintains professionalaccountability24. Check dressing and wound site every shift. Close observation can find any complication assoon as possible.108
    • 109109109Supplying Oxygen InhalationDefinition:Method by which oxygen is supplemented at higher percentages than what is available in atmospheric air.Purpose:1. To relieve dyspnoea2. To reduce or prevent hypoxemia and hypoxia3. To alleviate associated with struggle to breatheSources of Oxygen:Therapeutic oxygen is available from two sources1. Wall Outlets(; Central supply)2. Oxygen cylinders❖NursingAlert❖Explain to the client the dangers of lighting matches or smoking cigarettes, cigars, pipes. Be surethe client has no matches, cigarettes, or smoking materials in the bedside table.Make sure that warning signs (OXYGEN- NO SMOKING) are posted on the client‟s door andabove the client‟s bed.Do not use oil on oxygen equipment.( Rationale: Oil can ignite if exposed to oxygen.)With all oxygen delivery systems, the oxygen is turned on before the mask is applied to the client.Make sure the tubing is patent at all times and that the equipment is working properly.Maintain a constant oxygen concentration for the client to breathe; monitor equipment at regularintervals.Give pain medications as needed, prevent chilling and try to ensure that the client gets needed rest.Be alert to cues about hunger and elimination.( Rationale: The client‟s physical comfort isimportant.)Watch for respiratory depression or distress.Encourage or assist the client to move about in bed. ( Rationale: To prevent hypostatic pneumoniaor circulatory difficulties.) Many clients are reluctant to move because they are afraid of the oxygenapparatus.Provide frequent mouth care. Make sure the oxygen contains proper humidification.( Rationale:Oxygen can be drying to mucous membrane.)Discontinue oxygen only after a physician has evaluated the client. Generally, you should notabruptly discontinue oxygen given in medium-to-high concentrations( above 30%). Graduallydecrease it in stages, and monitor the client‟s arterial blood gases or oxygen saturation level.( Rationale: These steps determine whether the client needs continued support.)Always be careful when you give high levels of oxygen to a client with COPD. The elevated levels ofoxygen in the patient‟s body can depress their stimulus to breathe.Never use oxygen in the hyperventilation patient.Wear gloves any time you might come into contact with the client‟s respiratorysecretions.( Rationale: To prevent the spread of infection).
    • 110110110Equipments required:1. Client‟s chart and Kardex2. Oxygen connecting tube (1)3. Flow meter (1)4. Humidifier filled with sterile water (1)5. Oxygen source: Wall Outlets or Oxygen cylinder6. Tray with nasal cannula of appropriate size or oxygen mask (1)7. Kidney tray (1)8. Adhassive tape9. Scissors (1)10. Oxygen stand (1)11. Gauze pieces, Cotton swabs if needed12. “No smoking” sign board13. Globes if available (1)NOTE:Table 6 Characteristics of low flow system of oxygen administrationMethod Flowrate(L/min.)OxygenconcentrationdeliveredAdvantages DisadvantagesNasal cannulaSimple face mask1 22-24 %2 26-28 %3 28-30 %4 32-36 %5 36-40 %6 40-44 %5-6 40 %6-7 50 %7-8(-10) 60 %ConvenientComfortable more than facemaskbring less anxietyAllows client to talk and eatMouth breathing does notaffect the concentration ofdelivered oxygenCan deliver highconcentration of oxygenmore than nasal cannulaAssumes an adequatebreathing patternUnable to deliverconcentrations above44 %May cause anxietyable to lead hotness andclaustrophobicmay cause dirty easier, socleansing is neededfrequentlyshould be removed whileeating and talkingTight seal or long wearingcan cause skin irritationon faceThere are another high flow devices such as venture mask, oxygen hood and tracheostomy mask. Youshould choose appropriate method of oxygen administration with Dr‟s prescription and nursingassessment.
    • 111111111CareAction Rationale1. Check doctor‟s prescription including date, time,flow liter/minute and methodsTo avoid medical error2. Perform hand hygiene and wear gloves ifavailableTo prevent the spread of infection3.Explain the purpose and procedures to thepatientProviding information fosters the client‟scooperation and allays his/her anxiety4.Assemble equipments Organization facilitates accurate skillperformance5.Prepare the oxygen equipment:1)Attach the flow meter into the wall outlet oroxygen cylinder2)Fill humidifier about 1/3 with sterile water orboiled water3)Blow out dusts from the oxygen cylinder4)Attach the cannula with the connecting tubing tothe adapter on the humidifierHumidification prevents drying of the nasalmucosaTo prevent entering dust from exist of cylinder tothe nostril6. Test flow by setting flow meter at 2-3L/ minuteand check the flow on the hand.Testing flow before use is needed to provideprescribed oxygen to the client7.Adjust the flow meter‟s setting to the ordered flowrate.The flow rate via the cannula should not exceed6L/m. Higher rates may cause excess drying ofnasal mucosa.8. Insert the nasal cannula into client‟s nostrils,adjust the tubing behinds the client‟s ears andslide the plastic adapter under the client‟s chinuntil he or she is comfortable.Proper position allows unobstructed oxygen flowand eases the client‟s respirations9. Maintain sufficient slack in oxygen tubing To prevent the tubing from getting out of placeaccidentally10.Encourage the client to breathe through the noserather than the mouth and expire from themouthBreathing through the nose inhales more oxygeninto the trachea, which is less likely to be exhaledthrough the mouth11. Initiate oxygen flow To maintain doctor‟s prescription and avoidoxygen toxicity12. Assess the patient‟s response to oxygen andcomfort level.Anxiety increases the demand for oxygen13. Dispose of gloves if you wore and perform handhygieneTo prevent the spread of infection14.Place “No Smoking” signboard at entry into theroomThe sign warns the client and visitors thatsmoking is prohibited because oxygen iscombustible15.Document the following:Date, time, method, flow rate, respiratorycondition and response to oxygenDocumentation provides coordination of careSometimes oxygen inhalation can bring oxygenintoxication.16. Sign the chart To maintain professional accountabilityProcedure: a. Nasal Cannula Method1
    • 112112112CareAction Rationale17. Report to the senior staff To provide continuity of care and confirm theclient‟s condition18. Check the oxygen setup including the waterlevel in the humidifier. Clean the cannula andassess the client‟s nares at least every 8 hours.Sterile water needs to be added when the levelfalls below the line on the humidificationcontainer.Nares may become dry and irritated and requiredthe use of a water-soluble lubricant.In long use cases, evaluate for pressure sores overears, cheeks and nares.❖NursingAlert❖After used the nasal cannula, you should cleanse it as follows:1. Soak the cannula in salvon water for an hour2. Dry it properly3. Cleanse the tip of cannula by spirit swab before applying to client
    • 113113113Procedure: b. Oxygen Mask Method; Simple face maskCare action Rationale1.Perform hands hygiene and put on gloves ifavailableTo prevent the spread of infection2.Explain the procedure and the need for oxygen tothe client.The client has a right to know what is happeningand why.Providing explanations alley his/her anxiety3.Prepare the oxygen equipment:1)Attach the humidifier to the threaded outlet ofthe flowmeter or regulator.2)Connect the tubing from the simple mask to thenipple outlet on the humidifier3)Set the oxygen at the prescribed flow rate.To maintain the proper settingThe oxygen must be flowing before you apply themask to the client4.To apply the mask, guide the elastic strap over thetop of the clients head. Bring the strap down tojust below the client‟s ears.This position will hold the mask most firmly5.Gently, but firmly, pull the strap extensions tocenter the mask on the client‟s face with a tightseal.The seal prevents leaks as mush as possible6.Make sure that the client is comfortable. Comfort helps relieve apprehension, and lowersoxygen need7.Remove and properly dispose of gloves. Wash yourhandsRespiratory secretions are consideredcontaminated8.Document the procedure and record the client‟sreactions.Documentation provides for coordination of care9.Sign the chart and report the senior staffs To maintain professional accountability10.Check periodically for depresses respirations orincreased pulse.To assess the respiratory condition and find outany abnormalities as soon as possible11.Check for reddened pressure areas under thestrapsThe straps, when snug, place pressure on theunderlying skin areas❖NursingAlert❖The Simple mask is a low-flow device that providers an oxygen concentration in the 40-60% range, with aliter flow 6 to 10 L/m. BUT! The simple mask requires a minimum oxygen flow rate of 6 L/m to preventcarbon dioxide buildup
    • Fundamental of Nursing Procedure Manual114
    • 115115115II. Administration of Medications
    • 116116116Our responsibilities for administration of medicationStep the principle procedure for safety and the best-efficacy based on 5 Rights: Right drug, Right dose,Right route, Right time, Right client( ,Right form) Perform hand hygiene. (Rationale: to prevent the spread of infection) Collect prescription and ensure that the client is available and understandable to take themedication.(Rationale: to secure informed-consent) Check the medicine as the points: name, components, dose, expiry date(Rationale: to provide safeand efficient medication) Prior to administration ensure you are knowledgeable about the drug(s) to be administered. Thisshould include: therapeutic use, normal dosage, routes/forms, potential side effects,contra-indications.(Rationale: to ensure safety and well-being of client and enable you to identifyany errors in prescribing) Confirm identity of client verbally and with chart, prescription, checking full name, age, date ofbirth: Right client.(Rationale: to ensure that the correct drug is being administered to the correctclient) Ensure that the medication has not been given till that time(Rationale: to ensure right dose)
    • 117117117Administering Oral MedicationsDefinition:Oral medication is defined as the administration of medication by mouth.Purposes:1. To prevent the disease and take supplement in order to maintain health2. To cure the disease3. To promote the health4. To give palliative treatment5. To give as a symptomatic treatmentEquipments required:1. Steel tray (1)2. Drinking water in jug (1)3. Dr‟s prescription4. Medicine prescribed5. Medicine cup (1)6. Pill crusher/ tablet cutter if needed7. Kidney tray/ paper bag (to discard the waste) (1)
    • 118118118Procedure:CareAction Rationale1. Perform hand hygiene To prevent the spread of infection2.Assemble all equipments Organization facilitates accurate skillperformances3. Verify the medication order using the client‟skardex. Check any inconsistencies with Dr. beforeadministrationTo reduce the chance of medication errors4. Prepare one client‟s medication at a time Lessen the chances for medication errors5. Proceed from top to bottom of the kardex whenpreparing medicationsThis ensures that you do not miss any medicationorders6. Select the correct medication from the shelf ordrawer and compare the label to the medicationorder on the kardexa. From the multidose bottle:Pour a pill from the multidose bottle into thecontainer lid and transfer the correct amount toa medicine cup.b. In the case of unit packing:Leave unit dose medication in wrappers andplace them in a medication cupc. Liquid medications:Measure liquid medications by holding themedicine cup at eye level and reading the levelat the bottom of the meniscus. Pour from thebottle with the label uppermost and wipe theneck if necessaryComparing medication to the written order is acheck that helps to prevent errorsPouring medication into the lid eliminateshandling it.Unit dose wrappers keep medications clean andsafe.Holding a cup at eye level to pour a liquid givesthe most accurate measurement.Pouring away from the label and wiping the liphelps keep the label readable7. Recheck each medication with the Kardex To ensure preparation of the correct dose8. When you have prepared all medications on atray, compare each one again to the medicationorder.To check all medications three times to preventerrors9. Crush pills if the client is unable to swallowthem:1) Place the pill in a pill crusher and crush the pilluntil it is in powder form❖NursingAlert❖Do not crush time-release capsules orenteric-coated tablets2) Dissolve substance in water or juice, or mix withapplesauce to mask the taste3) If no need to crush, cut tablets at score mark onlyCrushed medications are often easier to swallowEnteric-coated tablets that are crushed mayirritate the stomach‟s mucosal lining. Openingand crushing the contents of a time-releasecapsule may interfere with its absorption10.Bring medication to the client you haveprepared.Hospital/ Agency policy considers 30 minutesbefore or after the ordered time as an acceptablevariation
    • 119119119CareAction Rationale11. Identify the client before giving the medication:a.Ask the client his/her nameb.Ask a staff member to identify the clientc. Check the name on the identification braceletif available12. Complete necessary assessments before givingmedications13. Assist the client to a comfortable position to takemedications14.Administer the medication:1) Offer water or fluids with the medication2) Open unit dose medication package and givethe medication to the medicine cup3) Review the medication‟s name and purpose4) Discard any medication that falls on the floor5) Mix powder medications with fluids at thebedside if needed6) Record fluid intake on the balance sheet15. Remain with the client until he/she has takenall medication. Confirm the client‟s mouth ifneeded.To abide by Five rights to prevent medicationerrorsChecking the identification bracelet is the mostreliableAdditional checking includes taking vital signsand allergies to medications, depending on themedication‟s actionSitting as upright as possible makes swallowingmedication easier and less likely to causeaspirationYou should be aware of any fluid restrictions thatexistPowdered forms of drugs may thicken whenmixed with fluid. You should give themimmediatelyRecording fluid taken with medicationsmaintains accurate documentationBe sure that the client takes the medication.Leaving medication at the bedside is unsafe.16.Perform hand hygiene To prevent the spread of infection17. Record medication administration on theappropriate form:1) Sign after you have given the medication Documentation provides coordination of care andgiving signature maintains professionalaccountability2) If a client refused the medication, recordaccording to your hospital/agency policy on therecord.3) Document vital sign‟s or particular assessmentsaccording to your hospital‟s form4) Sign in the narcotic record for controlledsubstances when you remove them from thelocked area( e.g, drawer or shelf).18. Check the client within 30 minutes after givingmedication.To verifies the reason medications were omittedas well as the specific nursing assessmentsneeded to safely administer medicationTo confirm medication‟s actionFederal law regulates special documentation forcontrolled narcotic substancesTo verify the client‟s response to the medicationParticularly, you should check the response afteradministered pain killer whether if themedication relieves pain or not.
    • 120120120Administering oral medications through a Nasal-Gastric tubeDefinition:Administering through a nasal-gastric tube is a process that administer oral medication through anasal-gastric tube instead of mouth.Purpose:as “Administering oral medication”Equipments required:1. Client‟s kardex and chart2. Medication prescribed3. Medicine cup (1)4. Water or another fluids as needed5. Mortar and pestle or pill crusher if an order to crush medications has been obtained ()6. Disposable gloves (1): if available7. Large syringe (20-30 mL) (1)8. Small syringe (3-5 mL) (1)9. Stethoscope (1)
    • 121121121Procedure:CareAction Rationale1. Confirmation the medication:1) Check the name, dosage, type, time of medicationwith the client‟s kardex.2) If you are going to give more than onemedication, make sure they are compatibleBe sure to administer the correct medication anddosage to the correct client2. Check the kardex and the client‟s record forallergies to medicationsYou cannot administer a medication to which theclient previously experienced an allergicreaction3. Perform hand hygiene To prevent the spread of infection4.Assemble all equipments Organization helps to eliminate the possibility ofmedication errors5. Set up medication following the Five right ofadministrationStrictly adhere to safety precautions to decreasethe possibility of errors6. Explain the procedure To allay his/her anxiety7. Put on gloves if available To maintain standard precautions which indicateto avoid possibility to be infected by any bodyfluids or secretions8. Check the placement of the nasal-gastric tube1) Connect a small syringe to the end of tube2) Gently aspirate the gastric juice or endogastricsubstances by a syringe❖NursingAlert❖Do not aspirate if the client has a button –typegastric-tubeEnsure that medication will be delivered into thestomachIf you cannot confirm the tubing‟s placement,consult senior staffs and be sure the correctplacement.Aspiration can damage the antireflux valve9. After checking for the gastric-tube‟s placement,pinch or clamp the tubing and remove the syringePinch or clamp the tubing prevents endogastricsubstances form escaping through the tubingEnsure that no air enters the stomach, causingdiscomfort for the client10.Administering medications:1) Remove the plunger from the large syringe andreconnect the syringe to the tube2) Release the clamp and pour the medication intothe syringe3) If the medication does not flow freely down thetube, insert the plunger and gently apply a slightpressure to start the flow.4) If medication flow does not start, determine if thegastric-tube of plugged.5) After you have administered the medication,flush the tube with 15 to 30 ml of water.6) Clamp the tubing and remove the syringe7) Replace the tubing plug. If feeding is continued,reconnect the tubing to the feeding tubingTo clear the tube and decrease the chance of thetubing becoming cloggedTo prevent the medication and water fromescaping
    • Fundamental of Nursing Procedure ManualCareAction Rationale11.Assist the client to a comfortable position To provide comfort12. Document administration of gastric-tubefeeding of medication and signDocumentation provides continuity of care andgiving signature maintain professionalaccountability122
    • 123123123www.drjayeshpatidar.blogspot.comRemoving Medications from an AmpouleDefinition:To remove medication form an ampoule defines that you prepare medication from an ampoule for IV, IM oranother administration of medication.Purpose:1. To prepare medication for administration of medication by sterilized methodEquipments required:1. Medication chart2. Sterile syringe (1)3. Sterile needle (1)4. Second needle (optional)5. Spirit swab6.Ampoule of medication prescribed7.Ampoule cutter if available (1)8. Kidney tray (1)9. Steel Tray (1)10.Container for discards if possible (1)NOTE:Fig. 80 Syringe and Needle
    • 124124124www.drjayeshpatidar.blogspot.comProcedure:CareAction Rationale1.Gather equipments. Check the medication orderagainst the original Dr.s order according tohospital/ agency policy.This comparison helps to identify that may haveoccurred when orders were transcribed.2.Perform hand hygiene To prevent the spread of infection3.Tap the stem of ampoule or twist your wristquickly while holding the ampoule vertically.(Fig. 83A, B )This facilitates movement of medication in thestem to the body of the ampoule.4. Wipe the neck around of the ampoule by spiritswabTo prevent entering of dust and microorganisms5.After drying spirit, put and round a ampoulecutter to the neck of the ampoule roundly.To cut smoothly and avoid making any shatteredglass fragments6. Put spirit swab to the neck of the ampoule. Use asnapping motion to break off the top of theampoule along the pre-scored line at its neck.Always break away from your body.This protects the nurses face and finger from anyshattered glass fragments.7.1) Remove the cap from the needle by pulling itstraight off.2) Hold the ampoule by your non-dominant hand(usually left hand) and insert the needle into theampoule, being careful not to touch the rim.The rim of the ampoule is consideredcontaminated .use of a needle prevents theaccidental withdrawing of small glass particleswith the medication.Fig. 81 Cut-point on the ampoule Fig. 82cut the ampoule with holding cut-point upFig. 83 How to drop medication from the stemA: Tapping the stem of an ample B: Twisting your wrist holding it vertically
    • 125125125www.drjayeshpatidar.blogspot.comFig. 84 Inserting the tip of needle Fig. 85 Withdrawing medication from an ampouleCareAction Rationale8. Withdraw medication in the amount ordered plusa small amount more (- 30 %). Do not inject airinto solutions.1) Insert the tip of the needle into the ampoule.(Fig. 84 )2) Withdraw fluid into the syringe Touch theplunger at the knob only. (Fig. 85 )By withdrawing a small amount more ofmedication, any air bubbles in the syringe can bedisplaced once the syringe is removed.Handling the plunger at the knob only will keepthe shaft of the plunger sterile.9.1) Do not expel any air bubbles that may form inthe solution.2) Wait until the needle has been withdrawn to tapthe syringe and expel the air carefully.3) Check the amount of medication in the syringeand discard any surplus.Ejecting air into the solution increases pressure inthe ampoule and can force the medication to spillout over the ampoule. Ampoules may haveoverfill.Careful measurement ensures that the correctdose is withdrawn.10.Discard the ampoule in a kidney tray or asuitable container after comparing with themedication chart.If not all of the medication has been removed fromthe ampoule, it must be discarded because thereis no way to maintain the sterility of the contentsin an unopened ampoule.11.Recap to the syringe by sterilized method andkeep the syringe in safe and clean tray. If themedication is to be given IM or if agency policyrequires the use of a needle to administermedication, attach the selected needle to thesyringe.Used needle might be touched with the inside ofthe ampoule so the lumen might become dull. Ifyou give IM, needle should be changed to new oneto insert smoothly into muscle.12. Perform hand hygiene. To prevent the spread of infection
    • 126126126www.drjayeshpatidar.blogspot.comRemoving medications from a vialDefinition:To remove medication form a vial defines that you prepare medication from an ampoule for IV, IM oranother administration of medication.Purpose:1. To prepare medication for administration of medication by sterilized methodEquipments required:1. Medication chart2. Sterile syringe (1)3. Sterile needle (1)✽Size depends on medication being administration and client4. Vial of medication prescribed5. Spirit swabs6. Second needle (optional)✽Size depends on medication being administration and client7. Kidney Tray (1)8. Steel Tray (1)
    • 127127127www.drjayeshpatidar.blogspot.comProcedure:CareAction Rationale1.Gather equipments. Check medication orderagainst the original Dr.‟s order according toagency policy.This comparison helps to identify errors that mayhave occurred when orders were transcribed.2. Perform hand hygiene. To prevent the spread of infection3. Remove the metal or plastic cap on the vial thatprotects the rubber stopper.The metal or plastic cap prevents contaminationof the rubber top.4. Swab the rubber top with the spirit swab. Sprit removes surface bacteria contamination.This should be done the first the rubber stopper isentered, and with any subsequent re-entries intothe vial.5. Remove the cap from the needle by pulling itstraight off.. Draw back an amount of air into thesyringe that is equal to the specific dose ofmedication to be withdrawn.Before fluid is removed, injection of an equalamount of air is required to prevent the formationof a partial vacuum because a vial is a sealedcontainer. If not enough air is injected, thenegative pressure makes it difficult to withdrawthe medication .6. Pierce the rubber stopper in the center with theneedle tip and inject the measured air into thespace above the solution. The vial may bepositioned upright on a flat surface or inverted.Air bubbled through the solution could result inwithdrawal of an inaccurate amount ofmedication.7. Invert the vial and withdraw the needle tipslightly so that it is below the fluid level. (Fig. 86 )This prevents air from being aspirated into thesyringe.8. Draw up the prescribed amount of medicationwhile holding the syringe at eye level andvertically.❖NursingAlert❖Be careful to touch the plunger at the knob only.Holding the syringe at eye level facilitatesaccurate reading ,and vertical position makesremoval of air bubbles from the syringe easy.Handling the plunger at the knob only will keepthe shaft of the plunger sterile.Fig. 86 A: Holding a vial with the syringe Fig. B: Withdrawing medication from a vialwithout touching needle and connected in inverting positionsite
    • Fundamental of Nursing Procedure Manualwww.drjayeshpatidar.blogspot.comCareAction Rationale9. Removal of air:1) If any bubbles accumulate in the syringe , tap thebarrel of the syringe sharply and move the needlepast the fluid into the air space to re-inject the airbubble into the vial.2) Return the needle tip to the solution andcontinue withdrawing the medication.Removal of air bubbles is necessary to ensure thatthe dose of medication is accurate.10. After the correct dose is withdrawn, remove theneedle from the vial and carefully replace the capover the needle.❖NursingAlert❖Some agencies recommended changing needles, ifneeded to administer the medication, beforeadministering the medication.This prevents contamination of he needle andprotects the nurse against accidental needlesticks.This method can decrease possibility ofcontamination by the first needle and maintainsharp of the tip on needle11. If a multidose vial is being used, label the vialwith the date and time opened, and store the vialcontaining the remaining medication according toagency policy.Because the vial is sealed, the medication insideremains sterile and can be used for futureinjections.12. Perform hand hygiene. To prevent the spread of infection128
    • 129129129Prevention of the Needle-Stick Injuries:One-handed Needle Recapping TechniqueDefinition:One-handed needle recapping is a method that place the cap to needle on clean and safe place such asinside a big trayPurpose: To prevent own finger or another person by needle from sticking accidentallyProcedure:Action Rationale1. Until giving injection:1) Before giving the injection, place the needle coveron a solid, immovable object such as the rim of abedside table or big tray.2) The open end of the cap should face the nurseand be within reach of the nurse‟s dominant, orinjection hand.3) Give the injection.Plan safe handling and disposal if needles beforebeginning the procedure.2. Recapping: (Fig. 87)1) Place the tip of the needle at the entrance of thecap.2) Gently slide the needle into the needle cover.This method can allow time3. Once the needle is inside the cover, use theobject‟s resistance to completely cover theneedle.Confirm that the needle is covered by the cap.4. Dispose of the needle at the first opportunity. This can reduce the risk of needle-sticking5. Perform hand hygiene. To prevent the spread of infectionNURSINGALERTThis procedure should be used only when a sharpes disposal box is unavailable and the nurse cannot leavethe client‟s room.Fig.87 A. Preparing to slideneedle into the capB. Lifting cap onto needle C. Covering needle with cap
    • 130130130www.drjayeshpatidar.blogspot.comDefinition:Giving an Intra-Muscular InjectionIntra-muscular injection is the injection of medicine into muscle tissue. To produce quick action an patientas the medicine given by injection is rapidly absorbed. Intramuscular injections are often given in thedeltoid, vastus laterials, ventrogluteal and dorsogluteal muscles.Purpose:1.To relieve symptoms of illness2. To promote and prevent from disease3. To treat the disease accordinglyContraindication:IM injections may be contraindicated in clients with;Impaired coagulation mechanismsOcclusive peripheral vascular diseaseEdemaShockAfter thrombolytic therapyduring myocardial infarction(Rationale: These conditions impair peripheral absorption)Equipments required:1. Client‟s chart and kardex2. Prescribed medication3. Sterile syringe (3-5 mL) (1)4. Sterile needle in appropriate size: commonly used 21 to 23 G with 1.5”(3.8cm) needle (1)5. Spirit swabs6. Kidney tray (1)7. Disposable container (1)8.Ampoule cutter if available (1)9. Steel Tray (1)10. Disposable gloves if available (1)11. Pen❖NursingAlert❖The needle may be packaged separately or already attached to the sterile syringe. Prepackaged loadedsyringes usually have a needle that is 1” long. BUT! check the package with care before open it.The needles used for IM injections are longer thansubcutaneous needles (Rationale: Needles must reachdeep into the muscle.)Needle length also depends on the injection site, client‟s size, and amount of subcutaneous fat coveringthe muscle.The needle gauge for IM injections should be larger to accommodate viscous solutions and suspensions.
    • 131131131www.drjayeshpatidar.blogspot.com❖NursingAlert❖Selection of appropriate site for IM injection(from Caroline Bunker Rosdabl,p.769)Fig. 88 Dorsogluteal site Fig. 89 Deltoid siteInject above and outside a line drawn from the posterior Find the lower edge of the acromial process and thesuperior iliac spine to the greater trochanter of the point on the lateral arm in line with the axilla. Insertfemur. Or, divide the buttock into quadrants and the needle 1” to 2” (2.5 cm to 5cm) below theinject in the upper outer quadrant, about 2” to 3”( 5 to acromial process, usually two or three7.6 cm) below the iliac crest. Insert the needle fingerbreadths, at a 90-degree angle or angledat a 90- degree angle. slightly toward the process.
    • 132132132Fundamental of Nursing Procedure ManualProcedure:CareAction Rationale1.Assemble equipments and check the Dr.‟s order This ensures that the client receives the rightmedication at the right time by the proper route.2. Explain the procedure to the client Explanation fosters his/her cooperation and allaysanxiety3. Perform hand hygiene and put on gloves ifavailableTo prevent the spread of infectionGloves act as a barrier and protect the nurse‟shands from accidental exposure to blood duringthe injection procedure4. Withdraw medications from an ampoule or a vialas described in the procedure “Removingmedication from an ampoule” or ” Removingmedication from a vial”❖NursingAlert❖Do not add any air to the syringeTo prepare correct medication safely before usingSome references recommend adding air to thesyringe with mediation. But the addition of airbubble to the syringe is unnecessary andpotentially dangerous because it could result inan overdose of medication5. Identify the client carefully using the followingway:a. Check the name in the identification braceletb.Ask the client his/her namec. Verify the client‟s identification with a staffmember who knows the clientYou should not rely on the name on the door, onthe board or over the bed. It is sometimesinaccurate.This is the most reliable method if availableThis requires an answer from the client. In theelderly and/or illness the method may causesconfusion.This is double-checked identify6. Close the door and put a screen. To provide for privacy7.1)Assist the client to a comfortable position.2)Select the appropriate injection site usinganatomic landmarks3) Locate the site of choice❖NursingAlert❖Ensure that the area is not tender and is free oflumps or nodulesCollect site identification decreases the risk ofinjuryGod visualization is necessary to establish thecorrect location of the site and avoid damage totissuesNodules or lumps may indicate a previousinjection site where absorption was inadequate8. Cleanse the skin with a spirit swab:1) Start from the injection site and move outward ina circular motion to a circumference of about 2” (5cm) from the injection site2)Allow the area to dryCleansing the injection site prepares it for theinjectionThis method remove pathogen away from theinjection siteAlcohol or spirit gives full play to disinfect afterdried
    • Fundamental of Nursing Procedure ManualCareAction Rationale3) Place a small, dry gauze or spirit swab on a clean,nearby surface or hold it between the fingers ofyour non-dominant hand.To prepare a dry gauze or spirit swab to give lightpressure immediately after I.M.9. Remove the needle cap by pulling it straight off This technique lessens the risk of accidentalneedle-stick and also prevents inadvertentlyunscrewing the needle from the barrel of thesyringe10. Spread the skin at the injection site using yournon-dominant handThis makes the tissue taut and facilitates needleentry.You may minimize his/her discomfort11. Hold the syringe in your dominant hand like apencil or dart.This position keeps your fingers off the plunger,preventing accidental medication loss whileinserting the needle12. Insert the needle quickly into the tissue at a 90degree angleAquick insertion is less painfulThis angle ensures you will enter muscle tissue.13. Release the skin and move your non-dominanthand to steady the syringe‟s lower endTo prevent movement of the syringe14.Aspiration blood:1) Aspirate gently for blood return by pulling backon the plunger with your dominant hand2) If blood enters the syringe on aspiration,withdraw the needle and prepare a newinjection with a new sterile set-up.Ablood return indicates IV needle placementPossibly a serious reaction may occur if a drugintended for intramuscular use is injected into aveinBlood contaminates the medication, which mustbe redrawn15. If no blood appears, inject the medication at aslow and steady rate(; 10 seconds/ mL ofmedication)Rapid injection may be painful for the client.Injecting slowly reduces discomfort be allowingtime for the solution to disperse in the tissues16. Remove the needle quickly at the same angleyou inserted itSlow needle withdrawal may be uncomfortablefor the client17. Massage the site gently with a small, dry gauzeor spirit swab, unless contraindicated for specificMedication. If there are contraindications tomassage, apply gentle pressure at the site with asmall, dry gauze or a spirit swab.Massaging the site promotes medicationabsorption and increases the client‟s comfort.Do not massage a heparin site because of themedication‟s anticoagulant actionLight pressure causes less trauma and irritationthe tissues. Massage can force medication into thesubcutaneous tissues in some medications18. Discard the needle:1) Do not recap the needle2) Discard uncapped needle and syringe inappropriate container if availableMost accidental needle-sticks occur whilerecapping needlesProper disposal prevents injury19. Assist the client to a position of comfort To facilitate comfort and make him/her relax20. Remove your gloves and perform hand hygiene To prevent the spread of infection133
    • 134134134CareAction Rationale21.Recording:Record the medication administered, dose, date,time, route of administration, and IM site on theappropriate form.Documentation provides coordination of careSite rotation prevents injury to muscle tissue22. Evaluation the client‟s response:1) Check the clients response to the medicationwithin an appropriate time2) Assess the site within 2 to 4 hours afteradministrationDrugs administered parenterally have a rapidonsetAssessment of the site deters any untowardeffects❖NursingAlert❖No more than 5 mL should be injected into a single site for an adult with well-developed musclesIf you must inject more than 5 mLof solution, divide the solution and inject it at two separate sites.The less developed muscles of children and elderly people limit the intramuscular injection to 1 to 2 mLSpecial considerations for pediatric:The gluteal muscles can be used as the injection site only after a toddler has been walking for about 1yearSpecial considerations for elder:IM injection medications can be absorbed more quickly than expected because elder clients havedecreased muscle mass.
    • 135135135Starting an Intra-Venous InfusionDefinition:Starting intra-venous infusion is a process that gives insertion of Intra-venous catheter for IV therapyPurpose:1. To give nutrient instead of oral route2. To provide medication by vein continuouslyEquipments required:1. I.V. solution prescribed2. I.V. infusion set/ IV. tubing (1)3. IV. catheter or butterfly needle in appropriate size (1)4. Spirit swabs6. Adhesive tape7. Disposable gloves if available (1)8. IV. stand (1)9. Arm board, if needed, especially for infant10. Steel Tray (1)11. Kidney tray (1)NOTE:Fig.90 IV infusion set
    • 136136136Procedure:CareAction Rationale1.Assemble all equipments and bring to bedside. Having equipment available saves time andfacilitates accurate skill performance2. Check I.V. solution and medication additives withDr.‟s order.Ensures that the client receives the correct I.V.solution and medication as ordered by Dr.3. Explain procedure to the client Explanation allays his/her anxiety and fostershis/her cooperation4. Perform hand hygiene To prevent the spread of infection5. Prepare I.V. solution and tubing:1) Maintain aseptic technique when opening sterilepackages and I.V. solution2) Clamp tubing, uncap spike, and insert into entrysite on bag as manufacturer directs3) Squeeze drip chamber and allow it to fill at leastone-third to half way.4) Remove cap at end of tubing, release clamp,allow fluid to move through tubing. Allow fluid toflow until all air bubbles have disappeared.5) Close clamp and recap end of tubing,maintaining sterility of set up.6) If an electric device is to be used, followmanufacturer‟s instructions for inserting tubingand setting infusion rate.This prevents spread of microorganismsThis punctures the seal in the I.V. bag.Suction effects cause to move into drip chamber.Also prevents air from moving down the tubingThis removes air from tubing that can, in largeramounts, act as an air embolusTo maintain sterilityThis ensures correct flow rate and proper use ofequipment7)Apply label if medication was added to container This provides for administration of correctsolution with prescribed medication or additive.Pharmacy may have added medication andapplied label8) Place time-tape (or adhesive tape) on containeras necessary and hang on I.V. stand6. Preparation the position:1) Have the client in supine position or comfortableposition in bed.2) Place protective pad under the client‟s arm.7. Selection the site for venipuncture:1) Select an appropriate site and palpate accessibleveins2) Apply a tourniquet 5-6 inches above thevenipuncture site to obstruct venous blood flowand distend the vein.3) Direct the ends of the tourniquet away from thesite of injection.This permits immediate evaluation of I.V.according to scheduleMostly the supine position permits either arm tobe used and allows for good body alignmentThe selection of an appropriate site decreasesdiscomfort for the client and possible damage tobody tissuesInterrupting the blood flow to the heart causesthe vein to distend.Distended veins are easy to seeThe end of the tourniquet could contaminate thearea of injection if directed toward the site ofinjection.
    • Fundamental of Nursing Procedure ManualCareAction Rationale4) Check to be sure that the radial pulse is stillpresentToo much tight the arm makes the clientdiscomfort.Interruption of the arterial flow impedes venousfilling.8.Palpation the vein1)Ask the client to open and close his/her fist.2) Observe and palpate for a suitable vein3) If a vein cannot be felt and seen, do the following:a. Release the tourniquet and have the client lowerhis/her arm below the level of the heart to fill theveins. Reapply tourniquet and gently over theintended vein to help distend itb. Tap the vein gentlyc. Remove tourniquet and place warmed-moistcompress over the intended vein for 10-15minutes.Contraction of the muscle of the forearm forcesblood into the veins, thereby distending themfurther.To reduce several puncturingLowering the arm below the level of the heart,tapping the vein, and applying warmth helpdistend veins by filling them with blood.9. Put on clean gloves if available. Care must be used when handling any blood orbody fluids to prevent transmission of HIV andother blood-born infectious disease10. Cleanse the entry site with an antisepticsolution( such as spirit) according to hospitalpolicy.a. Use a circular motion to move from the centerto outward for several inchesb. Use several motions with same direction asfrom the upward to the downward aroundinjection site approximate 5-6 inchesCleansing that begins at the site of entry andmoves outward in a circular motion carriesorganisms away from the site of entryOrganisms on the skin can be introduced into thetissues or blood stream with the needle.11. Holding the arm with un-dominant handa. Place an un-dominant hand about 1 or 2 inchesbelow entry site to hold the skin taut againstthe vein.b. Place an un-dominant hand to support theforearm from the back side❖NursingAlert❖Avoid touching the prepared site.Pressure on the vein and surrounding tissueshelps prevent movement of the vein as the needleor catheter is being inserted.The needle entry site and catheter must remainfree of contamination from un-sterile hands.12.Puncturing the vein and withdrawing blood:1) Enter the skin gently with the catheter held bythe hub in the dominant hand, bevel side up, at a15-30 degree angle.2) The catheter may be inserted from directly overthe vein or the side of the vein.This technique allows needle or catheter to enterthe vein with minimum trauma and deterspassage of the needle through the vein137
    • 138138138CareAction Rationale3) While following the course of the vein, advancethe needle or catheter into the vein.4) A sensation can be felt when the needle entersthe vein.5) When the blood returns through the lumen of theneedle or the flashback chamber of the catheter,advance either device 1/8 to 1/4 inch farther intothe vein.6) A catheter needs to be advanced until hub is atthe venipuncture site13. Connecting to the tube and stabilizing thecatheter on the skin:1) Release the tourniquet.2) Quickly remove protective cap from the I.V.tubing3)Attach the tubing to the catheter or needleThe tourniquet causes increased venous pressureresulting in automatic backflow.Having the catheter placed well into the veinhelps to prevent dislodgementThe catheter which immediately is connected tothe tube causes minimum bleeding and patencyof the vein is maintained4) Stabilize the catheter or needle with non-dominant hand14.Starting flow1) Release the clamp on the tubing2) Start flow of solution promptly Blood clots readily if I.V. flow is not maintained.3) Examine the drip of solution and the issuearound the entry site for sign of infiltrationIf catheter accidentally slips out of vein, solutionwill accumulate and infiltrate into surroundingtissue15. Fasten the catheter and applying the dressing:1) Secure the catheter with narrow non-allergenictape2) Place strictly sided-up under the hub and crossedover the top of the hubNon-allergenic tape is less likely to tear fragileskinThe weight of tubing is enough to pull it out of thevein if it is not well anchored.There are various way to anchor the hub. Youshould follow agency /hospital policy.3) Loop the tubing near the site of entry To prevent the catheter from removingaccidentally16. Bring back all equipments and dispose in propermanner.To prepare for the next procedure.17. Remove gloves and perform hand hygiene To prevent the spread of infection18. If necessary, anchor arm to an arm board forsupport19.Adjust the rate of I.V. solution flow according toDr.‟s orderAn arm board helps to prevent change in theposition of the catheter in the vein. Site protectorsalso will be used to protect the I.V. site.Dr. prescribed the rate of flow or the amount ofsolution in day as required to the client‟s conditionSome medications are given very less amount.You may use infusion pump to maintain the flowrate
    • 139139139CareAction Rationale20. Document the procedure including the time,site , catheter size, and the client‟s responseThis ensures continuity of care21. Return to check the flow rate and observe forinfiltrationTo find any abnormalities immediately❖Nursing Alert❖You should have special consideration for the elderly and infant.To Older adultsAvoid vigorous friction at the insertion site and using too much alcohol.(Rationale: Both can traumatizefragile skin and veins in the elderly)To Infant and ChildrenHand insertion sites should not be the first choice for children. (Rationale: Nerve endings are more veryclose to the surface of the skin and it is more painful)
    • 140140140Maintenance of I.V. SystemDefinition:Maintenance of I.V. system is defined as routine care to keep well condition of I.V. therapyPurpose:1. To protect injection site from infection2. To provide safe IV therapy3. To make the client comfort with IV therapy4. To distinguish any complications as soon as possibleEquipments required:1. Steel Tray (1)2. Spirit swab3. Dry gauze or cotton4.Adhesive tape5. IV infusion set if required6. Kardex, client‟s record7. Kidney tray (1)
    • 141141141Maintenance of I.V. system: General caring for the client with an I.V.Care Action Rationale1.Make at least hourly checks of the rate, tubingconnections, and amount and type of solutionpresent. If using an electronic infusiondevice( pump or controller), check that all settingsare correct.Regular checking give proper amount2. Watch for adverse reactions. One such problemis infiltration, in which the I.V. solution infusesinto tissues instead of the vein. Check the insertionsite for redness, swelling, or tenderness hourly.Document that you have checked the site.Keen observation prevent any complicationswith I.V.3. Report any difficulty at once. The doctor mayorder the I.V. line to be discontinued or to beirrigated.4. Safeguard the site and be aware of tubing andpump during transfers, ambulation, or otheractivities.If a controllers is being used, remember thissystem works on the principle of gravity.If the bag of solution is too low, blood will flow upthe tubing and may cause complications.5. Change the I.V. dressing every 72 hours and if itbecomes wet or contaminated with drainage.Change of the dressing with wet orcontamination of drainage prevents infection inthe I.V. insertion site.6. Wear gloves when changing dressings or tubing. Wear gloves prevents from infection.The few times that nurses handle dressings, thelower the clients risk of infection.7. Be sure to double-check all clamps whenchanging tubing, adding medications, or removingI.V. tubing ( from a pump or controller).Double -check system prevents from medicalerror.8. If the rate of flow is not regulated properly, itcould result in the client receiving a bolus ofmediation.The rate of flow regulated prevent the clientfrom overdose.9. Always check to make sure medications,solutions, or additives are compatible beforeadding them to existing solutions.Checking before adding avoid havingincompatibility.10. Protect the I.V. site from getting wet or soiled. Protection of the I.V. site reduces the possibilityof infection.11. If the client will be away from the nursing unitfor tests or procedures, be sure there is adequatesolution to be infused while he/she is gone.It will avoid having shortage of IV. or makingcoagulation while having tests or procedures.
    • 142142142Maintenance of I.V. system: Changing of I.V. systemCareAction Rationale1. Check I.V. solution. Ensure that correct solution will be used.2.Determine the compatibility of all I.V. fluids andadditives by consulting appropriate literature.Incompatibilities may lead to precipitateformation and can cause physical, chemical,and therapeutic client changes.3.Determine clients understanding of need forcontinued I.V. therapy.Reveals need for client instruction.4.Assess patency of current I.V. access site. If patency is occluded, a new I.V. access site maybe needed. Notify a doctor.5. Have next solution prepared and accessible( atleast 1 hour) before needed. Check that solution iscorrect and properly labeled. Check solutionexpiration date and for presence of precipitateand discoloration.Adequate planning reduces risk of clotformation in vein caused by empty I.V. bag.Checking prevents medication error.6. Prepare to change solution when less than 50 mlof fluid remains in bottle or bag or when a newtype of solution is ordered.Preparation ahead of time prevents air fromentering tubing and vein from clotting from lackof flow.7.Prepare client and family be explaining theprocedure, its purpose, and what is expected ofclient.Appropriate explanation decreases his/heranxiety and promote cooperation.8. Be sure drip chamber is at least half full. Half full in Chamber provides fluids to veinwhile bags is changed.9 Perform hand hygiene. Hand hygiene reduces transmission ofmicroorganisms.10.Prepare new solution for changing. If usingplastic bag, remove protective cover from I.V.tubing port . If using glass bottle, remove metalcap.It permits quick, smooth and organized changefrom old to new solution.11. Move roller clam to stop flow rate. It Prevents solution removing in drip chamberfrom emptying while changing solutions.12. Remove old I.V. fluid container from I.V. stand. Brings work to nurses eye level.13. Quickly remove spike from old solution bag orbottle and, without touching tip, insert spike intonew bag or bottle.Reduces risk of solution in drip chamberrunning dry and maintains sterility.14. Hang new bag or bottle of solution on I.V. stand. Gravity assists delivery of fluid into dripchamber.15. Check for air in tubing. If bubbles form, they canbe removed by closing the roller clamp, stretchingthe tubing downward, and tapping the tubing withthe finger.Reduces risk of air embolus.
    • 14314314316. Make sure drip chamber is one-third to one-halffull. If the drip chamber is too full, pinch off tubingbelow the drip chamber, invert the container,squeeze the drip chamber, hang , hang up thebottle, replace the tubing.Reduces risk of air entering tubing.
    • Fundamental of Nursing Procedure ManualCareAction Rationale17. Regulate flow to prescribed rate. Deliver I.V. fluid as ordered.18.Place on bag.( Mark time on label tape or onglass bottle).Ink from markers may leach through polyvinylchloride containers.19. Observe client for signs of overhydration ordehydration to determine response to I.V. fluidtherapy.Provides ongoing evaluation of clients fluid andelectrolyte status.20. Observe I.V. system for patency anddevelopment of complications.Provides ongoing evaluation of I.V. system.143
    • 144144144Administering Medications by Heparin LockDefinition:A heparin lock is an IV catheter that is inserted into a vein and left in place either for intermittentadministration of medication or as open line in the case of an emergency.Administering medications by heparin lock is defined as one of IV therapy which can allow to be freedomclients while he/she has not received IV therapy.Purpose:1. To provide intermittent administration of medication2. To administer medication under the urgent conditionEquipments required:1. Client‟s chart and Kardex2. Prescribed medication3. Spirit swabs4. Disposable gloves if available (1)5. Kidney tray (1)6. Steel Tray (1)For flush7. Saline vial or saline in the syringe (1)8. Heparin flush solution (1)9. Syringe (3-5 mL) with 21-25 gauge needle (1)For Intermittent infusion10. IV bag or bottle with 50-100 mLsolution (1)11. IV tubing set (1)12. IV stand (1)13. 21-23 gauge needle (1)14.Adhesive tape❖NursingAlert❖Aheparin lock has an adapter which is attached to the hub(end)of the catheter.An anticoagulant, approximately 2 mL heparin, is injected into the heparin lock.To reduce the possibility of clotting , flush the heparin lock with 2-3 mL of saline 8 hourly (or once a everyduty); Saline lock.Choose heparin lock or saline lock to decrease the possibility of making coagulation according to yourfacility‟s policy or Dr.‟s order.
    • 145145145Procedure:CareAction Rationale1. Perform hand hygiene To prevent the spread of infection2.Assemble all equipments Organization facilities accurate skill performance3. Verify the medication order To reduce the chances of medication errors4. Check the medication „s expiration date Outdated medication may be ineffectiveFor Bolus Injection5. Prepare the medication. If necessary, withdrawfrom an ampoule or a vialPreparing the medication before entering theclient‟s room facilitates administration6. Explain the procedure to the client Providing information fosters his/her cooperation7. Identify the client before giving the medication Abiding by the “Five rights” prevents medicationerrors8. Put on gloves Gloves act as a barrier9. Cleanse the heparin lock port with a spirit swab Spirit swab removes surface contaminants anddecreases the potential for introducing pathogensinto the system10.1) Steady the heparin lock with your dominanthand2) Insert the needle of the syringe containing 1mL of saline into the center of the port3) Aspirate for blood return4) Inject the saline5) Remove the needle and discard the syringe inthe sharps container without recapping itBlood return on aspiration generally indicatesthat the catheter is positioned in the vein.Saline clears the tubing of any heparin flush orprevious medicationMost accidental needle-sticks occur duringrecapping. Proper disposal prevents injury11.1) Cleanse the port again with a spirit swab2) Insert the needle of the syringe containing themedication3) Inject the medication slowly4) Withdraw the syringe and dispose of it properlyRapid injection of medication can lead to speedshock12.1) Cleanse the port with a spirit swab2) Flush the lock with 1 mL heparin flush solutionaccording your hospital/agency policy.For Intermittent Infusion5.1) Use premixed solution in the bag2)Connect the tubing and add the needle orneedless component3) Prepare the tubing with solution6. Follow the former action 6.-10.To remove contaminants and prevents infectionvia the portFlush clears the lock of medication and keeps itopenSome agencies recommend only a saline flush toclear the lockPreparing the medication before you enter theclient‟s room facilitates administration
    • Fundamental of Nursing Procedure ManualCareAction Rationale11.1) Cleanse the port again with a spirit swab2) Insert the needle or needleless componentattached to the IV setup into the port3) Attach it to the IV infusion pump or calculate theflow rate4) Regulate drip according to the prescribeddelivery time5) Clamp the tubing and withdraw the needle whenall solution has been infused6) Discard the equipments used safely according tohospital/ agency‟s policy12.1) Cleanse the port with a spirit swab2) Flush the lock with 1 mL heparin flush solutionaccording your hospital/agency policy.To remove contaminants and prevents infectionvia the portFlush clears the lock of medication and keeps itopenSome agencies recommend only a saline flush toclear the lock13. Remove gloves and perform hand hygiene To prevent the spread of infection14. Record:1) Record the IV medication administration on theappropriate form2)Record the fluid volume on the client‟s balancesheetDocumentation provides coordination of care15. Check the client‟s response to the medicationwithin the appropriate timeDrugs administered parenterally have rapidonsets of action146
    • 147147147Performing Nebulizer TherapyDefinition:Nebulizer Therapy is to liquefy and remove retained secretions from the respiratory tract. Anebulizer is adevice that a stable aerosol of fluid and /or drug particles.Most aerosol medication have bronchodilating effects and are administered by respiratory therapypersonnel.Purpose:1. To relieve respiratory insufficiency due to bronchospasm2. To correct the underlying respiratory disorders responsible for bronchospasm3. To liquefy and remove retained thick secretion form the lower respiratory tract4. To reduce inflammatory and allergic responses the upper respiratory tract5. To correct humidify deficit resulting from inspired air by passing the airway during the use ofmechanical ventilation in critically and post surgical patientsTypes of nebulizer:1. Inhaler or meterd-dose nebulizer2. Jet nebulizer3. Ultrasonic nebulizer❖NursingAlert❖Teach the client how to use personnel device. (Rationale: To ensure appropriate self-care after discharge)Avoid treatment immediately before and after meals.(Rationale: To decrease the chance of vomiting orappetite suppression, especially with medication that cause the client to cough or expectorate or thosethat are done in conjunction with percussion/ bronchial drainage )
    • 148148148Equipments required:1. Dr.‟s order card, client‟s chart and kardex2. Inhaler (1)3. Tissue paper4. Water, lip cream as requiredProcedure:a. InhalerCareAction Rationale1. Perform hand hygiene To prevent the spread of infection2. Prepare the medication following the Five rightsof medication administration:①Right drug②Right dose③Right route④Right time⑤Right clientStrictly observe safety precautions to decrease thepossibility of a medication error3. Explain to the client what you are going to do. Providing explanation fosters his/her cooperationand allays anxiety4. Assist the client to make comfortable position insitting or semi-Fowler position.Upright position can help expanding the chest5. Shake the inhaler well immediately prior to use Shaking aerosolizes the fine particles6. Spray once into the air. To fill the mouthpiece7. Instruction to the client:1) Instruct the client to take a deep breath andexhale completely through the nose2) The client should grip the mouthpiece with thelips, push down on the bottle, and inhale asslowly and deeply as possible through the mouth.3) Instruct the client to hold his/her breath for adult10 seconds and then to slowly exhale with pursedlips4) Repeat the above steps for each ordered “ puffs”,waiting 5-10 seconds or as prescribed betweenpuffs.5) Instruct the client to gargle and wipe the face ifneeded.The procedure is designed to allow the medicationto come into contact with the lungs for themaximum amount of timeThis method achieve maximum benefitsGargling cleanse the mouth. When steroidremains inside the mouth, infection of fungusmay occur.8. Replace equipments used properly and discarddirt.To prepare for the next procedure prevent thespread of infection and9. Perform hand hygiene. To prevent the spread of infection10.Document the date, time, amount of puffs, andresponse. Sign on the documentationDocumentation provides continuity of careGiving signature maintains professionalaccountability11. Report any findings to a senior staff. To provide continuity of care
    • 149149149Equipments required:b. Ultrasonic Nebulizer1. Dr.‟s order card, client‟s chart and kardex2. Ultrasonic nebulizer (1)3. Circulating set-up (1)4. Sterile water5. Mouthpiece or oxygen mask (1)6. Prescribed medication7. Sputum mug if available (1)8. Tissue paper9. Water, lip cream as requiredProcedure:CareAction Rationale1. Check the medication order against the originalDr‟s orderTo ensure that you give the correct medication tothe correct client.2. Perform hand hygiene To prevent the spread of infection3. Prepare the medication following the Five rightsof medication administration:①Right drug②Right dose③Right route④Right time⑤Right clientStrictly observe safety precautions to decrease thepossibility of a medication error4. Explain to the client what you are going to do Providing explanation fosters his/her cooperationand allays anxiety.5. Assist to the client to a make comfortable positionin sitting or semi-Fowler position.Upright position can help expanding the chest6. Setting the nebulizer:1) Plug the cord into an electrical outlet2) Fill the nebulizer cup with the ordered amount ofmedication3) Turn on the nebulizer at the prescribed timeTo ensure that you give the correct amount ofmedication7. Instructing the client during nebulization:1) Instruct the client to close the lips around themouthpiece and to breathe through the mouth2) Instructing the client to continue the treatmentuntil he/she can no longer see a mist onexhalation from the opposite end of themouthpiece or vent holes in the mask❖NursingAlert❖Discontinue when the client feel ill and you findside effects. You should take vital signs, checkrespiration sound and report to the Dr.If the client is using a mask, he/she may breathenormallyTo ensure that the client inhales the entire doseSide effect includes nausea, vomiting, palpitation,difficult breathing, cyanosis and cold sweat.
    • 150150150CareAction Rationale3) Encourage the client to partially cough andexpectorate any secretions loosed during thetreatment8.After nebulization finished,1) Turn off the nebulizer and take off the cord fromthe electrical outlet.2) Instruct the client to gargle and wipe the face ifneeded.Apply lip cream if needed.3) Soak the nebulizer cup and mouthpiece oroxygen mask in warm salvon water for an hour.Disinfect the nebulizer by spirit swab.Gargling cleanse the mouth. When steroidremains inside the mouth, infection of fungusmay occur.Applying lip cream provide moisten on lips.To avoid contamination4) Rinse and dry it after each use To prepare for the next procedure5) Replace equipments used properly and discarddirt.To prepare for the next procedure and prevent thespread of infection9. Perform hand hygiene. To prevent the spread of infection10.Document the date, time, type and dose ofmedication, and response. Sign on thedocumentationDocumentation provides continuity of careGiving signature maintains professionalaccountability11. Report any findings to a senior staff. To provide continuity of care
    • 151151151III. Specimen Collection
    • 152152152❖NursingAlert❖Collecting SpecimenYou always should follow the principle steps as the following:Label specimen tubes or bottles with the client‟s name, age, sex, date, time, inpatient no. and other dataif needed before collecting the specimen.Always perform hand hygiene before and after collecting any specimen.Always observe body substance precautions when collecting specimensCollect the sample according your hospital/agent policy and procedure.Clean the area involved for sample collectionMaintain the sterile technique if needed for sample or culture.Transport the specimen to laboratory immediatelyBe sure specimen is accompanied by specimen form or appropriate order formRecord the collection and forwarding of the sample to laboratory on the client‟s record
    • 153153153Collecting Blood Specimena. Performing VenipunctureDefinition:Venipuncture is using a needle to withdraw blood from a vein, often from the inside surface of the forearmnear the elbow.Purpose:1. To examine the condition of client and assess the present treatment2. To diagnose diseaseEquipments required:1. Laboratory form2. Sterilized syringe3. Sterilized needles4. Tourniquet (1)5. Blood collection tubes or specimen vials as ordered6. Spirit swabs7. Dry gauze8. Disposable Gloves if available (1)9.Adhesive tape or bandages10. Sharps Disposal Container (1)11. Steel Tray (1)12. Ball point pen (1)
    • 154154154Procedure:CareAction Rationale1. Identify the patient.Outpatient are called into the phlebotomy areaand asked their name and date of birth.Inpatient are identified by asking their nameand date of birth.This information must match the requisition.2. Reassure the client that the minimum amount ofblood required for testing will be drawn.To perform once properly without anyunnecessary venipuncture3.Assemble the necessary equipment appropriateto the clients physical characteristics.Organization facilitates accurate skillperformance4.Explain to the client about the purpose and theprocedure.Providing explanation fosters his/hercooperation and allays anxiety5.Perform hand hygiene and put on gloves ifavailable.To prevent the infection of spreading.6. Positioning1) Make the client to be seated comfortably or supineposition2) Assist the client with the arm extended to forma straight-line from shoulder to wrist.3) Place a protective sheet under the arm.To make the position safe and comfortable ishelpful to success venipuncture at one try.To prevent the spread of blood7. Check the client‟s requisition form, blood collectiontubes or vials and make the syringe-needle ready.To assure the Dr‟s order with the correct clientand to make the procedure smoothed8. Select the appropriate vein for venipuncture. The larger median cubital, basilica and cephalicveins are most frequently used, but other may benecessary and will become more prominent if theclient closes his/her fist tightly.9.Applying the tourniquet:1)Apply the tourniquet 3-4 inches( 8 - 10 cm)abovethe collection site. Never leave the tourniquet onfor over 1 minute.2) If a tourniquet is used for preliminary veinselection, release it and reapply after two minutes.To prevent the venipunctue site from touchingthe tourniquet and keep clear visionTightening of more than 1 minute may bringerroneous results due to the change of someblood composition.10. Selection of the vein:1) Feel the vein using the tip of the finger and detectthe direction, depth and size of vein.2) Massage the arm from wrist to elbow. If the vein isnot prominent, try the other arm.To assure venipuncture at one try.11. Disinfect the selected site:1) Clean the puncture site by making a smoothcircular pass over the site with the spirit swab,moving in an outward spiral from the zone ofpenetration.2)Allow the skin to dry before proceeding.3) Do not touch the puncture site after cleaning.To prevent the infection from venipuncture siteDisinfectant has the effect on dryingTo prevent the site from contaminating
    • 155155155CareAction Rationale4)After blood is drawn the desired amount,release the tourniquet and ask the client to openhis/her fist.5) Place a dry gauze over the puncture site andremove the needle.6) Immediately apply slight pressure.Ask the clientto apply pressure for at least 2 minutes.7) When bleeding stops, apply a fresh bandage orgauze with tape.To avoid making ecchymomaThe normal coagulation time is 2-5 minutes.12.1) Transfer blood drawn into appropriate bloodspecimen bottles or tubes as soon as possibleusing a needless syringe .2)The container or tube containing an additiveshould be gently inverted 5-8 times or shakingthe specimen container by making figure of 8.Adelay could cause improper coagulationDo not shake or mix vigorously.13.Dispose of the syringe and needle as a unit intoan appropriate sharps container.To prevent the spread of infection14. Label all tubes or specimen bottles with clientname, age, sex, inpatient no., date and time.To prevent the blood tubes or bottles frommisdealing.15.Send the blood specimen to the laboratoryimmediately along with the laboratory orderform.To avoid misdealing and taking erroneous results16. Replace equipments and disinfects materials ifneeded.To prepare for the next procedure and prevent thespread of infection and17. Put off gloves and perform hand hygiene. To prevent the spread of infection❖NURSING ALERT❖❍Factors to consider in site selection:Extensive scarring or healed burn areas should be avoided.Specimens should not be obtained from the arm on the same side as a mastectomy.Avoid areas of hematoma.If an I.V. is in place, samples may be obtained below but NEVER above the I.V. site.Do not obtain specimens from an arm having a cannula, fistula, or vascular graft.Allow 10-15 minutes after a transfusion is completed before obtaining a blood sample. SafetyObserve universal (standard ) precaution safety precautions. Observe all applicable isolationprocedures.Needle are never recapped, removed, broken or bent after phlebotomy procedure.Gloves are to be discarded in the appropriate container immediately after the procedure.Contaminated surfaces must be cleaned with freshly prepared 10 % bleach solution. All surfaces arecleaned daily with bleach.In the case of an accidental needle-stick, immediately wash the area with an antibacterial soap,express blood from the wound, and contact your supervisor.
    • 156156156 I f a blood sample is not available,Reposition the needle.Loosen the tourniquetProbing is not recommended.Apatient should never be stuck more than twice unsuccessfully by a same staff. The supervisor or asenior staff should be called to assess the client.
    • 157157157b. Assisting in Obtaining Blood for CultureDefinition:Collecting of blood specimen for culture is a sterile procedure to obtain blood specimen. Sterile techniquesis used in whole of the procedure.Purpose:1.To identify s disease-causing organisms2. To detect the right antibiotics to kill the particular microorganismsEquipments required:1. Laboratory form2. Sterilized syringes (10 mL): (2-3)3. Sterilized needles : (2-3)4. Tourniquet (1)5. Blood culture bottles or sterile tubes containing a sterile anticoagulant solution as required6. Disinfectant : Povidon-iodine or spirit swabs7. Dry gauze8. Disposable gloves if available (1)9.Adhesive tape or bandages10. Sharps Disposal Container (1)11. Steel Tray (1)12. Ball point pen (1)
    • 158158158Procedure:❖NursingAlert❖Your role is that of assistant. You are responsible to notify the proper client when the culture is to be done.Use the following actions in assisting with blood cultures:CareAction Rationale1. Identify the patient. This information must match the requisition.2. Reassure the client that the minimum amount ofblood required for testing will be drawn.To perform once properly without anyunnecessary collecting of blood3.Assemble the necessary equipment appropriateto the clients physical characteristics.Organization facilitates accurate skillperformance4.Explain to the client about the purpose and theprocedure.Providing explanation fosters his/hercooperation and allays anxiety5. Label all tubes or specimen bottles with clientname, age, sex, inpatient no., date and time.To prevent the blood tubes or bottles frommisdealing.6.Perform hand hygiene and put on gloves ifavailable.To prevent the infection of spreading.7. Protect the bed with a pad under the client‟s arm. To prevent the bed of escaping or wetting thedisinfectant and blood.8. Place the arm with proper position and disinfectaround the injection site approximate 2-3 inchesTo prevent unnecessary injury and protect ofentering organisms from the skin surfaces9. While puncturing:1)Assist the person who is drawing blood2) Confirm the amount3) After obtaining sufficient blood specimen, receiveand place the specimen into the specimencontainer with strict sterile technique.4) Close the container promptly and tightlySometimes the blood may be placed into twe ormore tubes or bottles.To secure the sterilized condition of container10.After puncturing:1) Place a sterile gauze pad and folded into acompress tightly over the site2) Secure firmly with tape3) Check the stop of bleeding a few minutes later To make sure all bleeding has stopped11.Dispose of the syringe and needle as a unit intoan appropriate sharps container.To prevent the spread of infection12.Send the specimen to the laboratoryimmediately along with the laboratory orderform.To avoid misdealing and taking erroneous results13. Replace equipments and disinfects materials ifneeded.To prepare for the next procedure and prevent thespread of infection and14. Put off gloves and perform hand hygiene. To prevent the spread of infection15. Document the procedure in the designated placeand mark it off on the Kardex.To avoid duplicationDocumentation provides coordination of care
    • 159159159Collecting Urine SpecimenDefinition:Urinalysis, in which the components of urine are identified, is part of every client assessment at thebeginning and during an illness.Purpose:1. To diagnose illness2. To monitor the disease process3. To evaluate the efficacy of treatment❖NursingAlert❖Label specimen containers or bottles before the client voids.(Rationale: Reduce handling after thecontainer or bottle is contaminated.)Note on the specimen label if the female client is menstruating at that time.(Rationale: One of the testsroutinely performed is a test for blood in the urine. If the female client is menstruating at the time aurine specimen is taken, a false-positive reading for blood will be obtained. )To avoid contamination and necessity of collecting another specimen, soap and water cleansing of thegenitals immediately preceding the collection of the specimen is supported.(Rationale: Bacteria arenormally present on the labia or penis and the perineum and in the anal area.)Maintain body substances precautions when collecting all types of urine specimen.(Rationale: Tomaintain safety.)Wake a client in the morning to obtain a routine specimen.(Rationale: If all specimen are collected at thesame time, the laboratory can establish a baseline. And also this voided specimen usually representsthat was collecting in the bladder all night. )Be sure to document the procedure in the designated place and mark it off on the Kardex.(Rationale: Toavoid duplication.)
    • 160160160a. Collecting a single voided specimenEquipments required:1. Laboratory form2. Clean container with lid or cover (1): wide-mouthed container is recommended3. Bedpan or urinal (1): as required4. Disposable gloves (1): if available5. Toilet paper as requiredProcedure:CareAction Rationale1. Explain the procedure Providing information fosters his/her cooperation2. Assemble equipments and check the specimenform with client‟s name, date and content ofurinalysisOrganization facilitates accurate skillperformanceEnsure that the specimen collecting is correct3. Label the bottle or container with the date,client‟s name, department identification, and Dr‟sname.Ensure correct identification and avoid mistakes4. Perform hand hygiene and put on gloves To prevent the spread of infection5.Instruct the client to void in a clean receptacle. To prevent cross-contamination6. Remove the specimen immediately after theclient has voidedSubstances in urine decompose when exposed toair. Decomposition may alter the test results7. Pour about 10-20 mL of urine into the labeledspecimen bottle or container and cover the bottleor containerEnsure the client voids enough amount of theurine for the required testsCovering the bottle retards decomposition and itprevents added contamination.8.Dispose of used equipment or clean them. Removegloves and perform hand hygiene.To prevent the spread of infection9. Send the specimen bottle or container to thelaboratory immediately with the specimen form.Organisms grow quickly at room temperature10.Document the procedure in the designated placeand mark it off on the Kardex.To avoid duplicationDocumentation provides coordination of care
    • 161161161b. Collecting a 24-hour Urine SpecimenDefinition:Collection of a 24-hour urine specimen is defined as the collection of all the urine voided in 24 hours,without any spillage of wastage.Purpose:1. To detect kidney and cardiac diseases or conditions2. To measure total urine componentEquipments required:1. Laboratory form2. Bedpan or urinal (1)3. 24 hours collection bottle with lid or cover (1)4. Clean measuring jar (1)5. Disposable gloves if available (1)6. Paper issues if available7. Ballpoint pen (1)Procedure:CareAction Rationale1. Explain the procedure Providing information fosters his/her cooperation2. Assemble equipments and check the specimenform with client‟s name, date and content ofurinalysisOrganization facilitates accurate skillperformanceEnsure that the specimen collecting is correct3. Label the bottle or container with the date,client‟s name, department identification, and Dr‟sname.Ensure correct identification and avoid mistakes4. Instruct the client:1) Before beginning a 24 hour urine collection, askthe client to void completely.2) Document the starting time of a-24 hour urinecollection on the specimen form and nursingrecord.3) Instruct the client to collect all the urine intoa large container for the next 24 hours.4) In the exact 24 hours later, ask the client to voidAnd pour into the large container.5) Measure total amount of urine and record it onthe specimen form and nursing record.6) Document the time when finished the collectionTo measure urinal component and assess thefunction of kidney and cardiac function accuracyThe entire collected urine should be stored in acovered container in a cool place.
    • 1621621625. Sending the specimen:1) Perform hand hygiene and put on gloves ifavailable.2) Mix the urine thoroughlyTo prevent the contamination
    • Fundamental of Nursing Procedure ManualCareAction Rationale3) Collect some urine as required or all the urine ina clean bottle with lid.4) Transfer it to the laboratory with the specimenform immediately.Ensure the client voids enough amount of theurine for the required testsCovering the bottle retards decomposition and itprevents added contamination.Substances in urine decompose when exposed toair. Decomposition may alter the test results6.Dispose of used equipment or clean them. Removegloves and perform hand hygiene.To prevent the spread of infection7.Document the procedure in the designated placeand mark it off on the Kardex.To avoid duplicationDocumentation provides coordination of care162
    • 163163163c. Collecting a urine specimen from a retention catheterEquipments required:1. Laboratory form2. Disposable gloves if available (1)3. Container with label as required4. Spirit swabs or disinfectant swabs5. 10-20-mLsyringe with 21-25-gauge needle6. Clamp or rubber band (1)7. Ballpoint pen (1)Purpose:CareAction Rationale1.Assemble equipments. Label the container. Organization facilitates accurate skillperformance2. Explain the procedure to the client Providing information fosters his/her cooperation3. Perform hand hygiene and put on gloves ifavailable.To prevent the spread of infection4. Clamp the tubing:1) Clamp the drainage tubing or bend the tubing2)Allow adequate time for urine collection❖NursingAlert❖You should not clamp longer than 15minutesCollecting urine from the tubing guarantees afresh urine.Long-time clamp can lead back flow of urine andis able to cause urinary tract infection5. Cleanse the aspiration port with a spirit swab oranother disinfectant swab (e.g., Betadine swab)Disinfecting the port prevents organisms fromentering the catheter.6. Withdrawing the urine:1) Insert the needle into the aspiration port2) Withdraw sufficient amount of urine gently intothe syringeThis technique for uncontaminated urinespecimen, preventing contamination of the client‟sbladder7.Transfer the urine to the labeled specimencontainer❖NursingAlert❖The container should be clean for a routineurinalysis and be sterile for a cultureCareful labeling and transfer preventscontamination or confusion of the urine specimenAppropriate container brings accurate results ofurinalysis.8.Unclamp the catheter The catheter must be unclamped to allow freeurinary flow and to prevent urinary stasis.9.Prepare and pour urine to the container fortransportProper packaging ensures that the specimen isnot an infection risk10. Dispose of used equipments and disinfect ifneeded. Remove gloves and perform handhygieneTo prevent the spread of infection11.Send the container to the laboratoryImmediatelyOrganisms grow quickly at room temperature12.Document the procedure in the designated placeand mark it off on the Kardex.To avoid duplicationDocumentation provides coordination of care
    • 164164164d. Collecting a urine cultureDefinition:Collecting a urine culture is a process that it obtain specimen urine with sterile techniquePurpose:1. To collect uncontaminated urine specimen for culture and sensitivity test2. To detect the microorganisms causes urinary tract infection (; UTI)3. To diagnose and treat with specific antibioticEquipments required:1. Laboratory form2. Sterile gloves (1)3. Sterile culture bottle with label as required4. Sterile kidney tray or sterile container with wide mouthed if needed5. Bed pan if needed (1)6. Paper tissues if needed7. Ballpoint pen (1)Procedure:CareAction Rationale1. Assemble equipments and check the specimenform with client‟s name, date and content ofurinalysisOrganization facilitates accurate skillperformanceEnsure that the specimen collecting is correct2. Label the bottle or container with the date,client‟s name, department identification, and Dr‟sname.Ensure correct identification and avoid mistakes3. Explain the procedure to the client Providing information fosters his/her cooperation4. Instruct the client:1) Instruct the client to clean perineum with soapand water2) Open sterilized container and leave the coverfacing inside up3) Instruct the client to void into sterile kidney trayor sterilized container with wide mouth4) If the client is needed bed-rest and needs to passurine more, put bed pan after you collectedsufficient amount of sterile specimenTo prevent the contamination of specimen fromperineum areaThe cover should be kept the state sterilizedTo secure the specimen kept in sterilizedcontainer surely5. Remove the specimen immediately after theclient has voided. Obtain 30-50 mL at midstreampoint of voidingSubstances in urine decompose when exposed toair. Decomposition may alter the test resultsEnsure the client voids enough amount of theurine for the required testsEmphasize first and last portions of voiding to bediscarded
    • 1651651657. Close the container securely without touchinginside of cover or cap.Covering the bottle retards decomposition and itprevents added contamination.
    • Fundamental of Nursing Procedure ManualCareAction Rationale8. Dispose of used equipment or clean them.Remove gloves and perform hand hygiene.To prevent the spread of infection9. Send the specimen bottle or container to thelaboratory immediately with the specimen form.Organisms grow quickly at room temperature10.Document the procedure in the designated placeand mark it off on the Kardex.To avoid duplicationDocumentation provides coordination of care165
    • 166166166Collecting a stool specimenDefinition:Collection of stool specimen deters a process which is aimed at doing chemical bacteriological orparasitological analysis of fecal specimenPurpose:1. To identify specific pathogens2. To determine presence of ova and parasites3. To determine presence of blood and fat4. To examine for stool characteristics such as color, consistency and odorEquipments required:1. Laboratory form2. Disposable gloves if available (1)3. Clean bedpan with cover (1)4. Closed specimen container as ordered5. Label as required6. Wooden tongue depressor (1-2)7. Kidney tray or plastic bag for dirt (1)Procedure:CareAction Rationale1.Assemble equipments. Label the container. Organization facilitates accurate skillperformanceCareful labeling ensures accuracy of the reportand alerts the laboratory personnel to thepresence of a contaminated specimen2. Explanation:1) Explain the procedure to the client2) Ask the client to tell you when he/she feels theurge to have a bowel movementProviding information fosters his/her cooperationMost of clients cannot pass on command3. Perform hand hygiene and put on gloves ifavailable.To prevent the spread of infection4. Placing bedpan:1) Close door and put curtains/ a screen.2) Give the bedpan when the client is ready.3)Allow the client to pass feces4) Instruct not to contaminate specimen with urineTo provide privacyYou are most likely to obtain a usable specimen atthis time.To gain accurate results
    • 167167167CareAction Rationale5. Collecting a stool specimen:1) Remove the bedpan and assist the client to cleanif needed2) Use the tongue depressor to transfer a portion ofthe feces to the container without any touching3) Take a portion of feces from three different areasof the stool specimen4) Cover the containerIt is grossly contaminatedTo gain accurate resultsIt prevents the spread of odor6. Remove and discard gloves. Perform handhygieneTo prevent the spread of infection7. Send the container immediately to the laboratory Stools should be examined when fresh.Examinations for parasites, ova, and organismsmust be made when the stool is warm.8.Document the procedure in the designated placeand mark it off on the Kardex.To avoid duplicationDocumentation provides coordination of care❖NursingAlert❖The procedure is exact same in routine test of stool and culture. BUT!! when you collect stool specimen youshould caution on the next point;Collect stool specimen with clean wooden tongue depressor or spatula for routine stool testCollect stool specimen with sterile wooden tongue depressor or spatula for culture
    • 168168168Collecting a sputum specimena. Routine testDefinition:Collecting a sputum specimen is defined as a one of diagnostic examination using sputumPurpose:1. To diagnose respiratory infection2. To assess the efficacy of treatment to diseases such as TBEquipments required:1. Laboratory form2. Disposable gloves if available (1)3. Sterile covered sputum container (1)4. Label as required5. Sputum mug or cup (1)6. Kidney tray or plastic bag for dirt (1)7. Paper tissues as required8. Ballpoint pen (1)Procedure:CareAction Rationale1.Assemble equipments. Label the container. Organization facilitates accurate skillperformanceCareful labeling ensures accuracy of the reportand alerts the laboratory personnel to thepresence of a contaminated specimen2. Explain the procedure to the client Providing information fosters his/her cooperation3. Perform hand hygiene and put on gloves ifavailable.To prevent the spread of infection. The sputumspecimen is considered highly contaminated, soyou should treat it with caution.4. Collecting the specimen:1) Instruct the client to cough up secretions fromdeep in the respiratory passage.2) Have the client expectorate directly into thesterile container.3) Instruct the client to wipe around mouth ifneeded. Discard it properly4) Close the specimen immediatelyA sputum specimen should be from the lungs andbronchi. It should be sputum rather thanmucousAvoid any chance of outside contamination to thespecimen or any contamination of other objectsPaper tissues used by any client are consideredcontaminatedTo prevent contamination5. Remove and discard gloves. Perform handhygieneTo prevent contamination of other objects,including the label6. Send specimen to the laboratory immediately. To prevent the increase of organisms
    • 1691691697.Document the procedure in the designated placeand mark it off on the Kardex.To avoid duplicationDocumentation provides coordination of care
    • 170170170b. Collecting a sputum cultureDefinition:Collection of coughed out sputum for culture is a process to identify respiratory pathogens.Purpose:1. To detect abnormalities2. To diagnose disease condition3. To detect the microorganisms causes respiratory tract infections4. To treat with specific antibioticsEquipments required:1. Laboratory form2. Disposable gloves if available (1)3. Sterile covered sputum container (1)4. Label as required5. Kidney tray or plastic bag for dirt (1)6. Paper tissues as required7. Ballpoint pen (1)❖NursingAlert❖You should give proper and understandable explanation to the client1. Give specimen container on the previous evening with instruction how to treat2. Instruct to raise sputum from lungs by coughing, not to collect only saliva.3. Instruct the client to collect the sputum in the morning4. Instruct the client not to use any antiseptic mouth washes to rinse hid/her mouth before collectingspecimen.
    • 170170170Procedure:CareAction Rationale1.Assemble equipments. Label the container. Organization facilitates accurate skillperformanceCareful labeling ensures accuracy of the reportand alerts the laboratory personnel to thepresence of a contaminated specimen2.Explain the procedure to the client Providing information fosters his/her cooperation3. Perform hand hygiene and put on gloves ifavailable.To prevent the spread of infection. The sputumspecimen is considered highly contaminated, soyou should treat it with caution.4. Instruct the client:1) Instruct the client to collect specimen earlymorning before brushing teeth2) Instruct the client to remove and place lid facingupward.3) Instruct the client to cough deeply andexpectorate directly into specimen container4) Instruct the client to expectorate until you collectat least 10 mL of sputum5) Close the container immediately when sputumwas collected6) Instruct the client to wipe around mouth ifneeded. Discard it properlyTo obtain overnight accumulated secretionsTo maintain the inside of lid as well as inside ofcontainerA sputum specimen should be from the lungs andbronchi. It should be sputum rather thanmucousTo obtain accurate resultsTo prevent contaminationPaper tissues used by any client are consideredcontaminated5. Remove and discard gloves. Perform handhygieneTo prevent contamination of other objects,including the label6. Send specimen to the laboratory immediately. To prevent the increase of organisms7. Document the procedure in the designated placeand mark it off on the Kardex.To avoid duplicationDocumentation provides coordination of care
    • 171171171Appendix 1Checklist for Taking Vital SignsStudent: ( )Instructor: ( )Evaluated on : ( )Step Satisfied Unsatisfied:( Put comments )NotPerformedGeneral steps for taking vital signs:1. Confirmed the client identification andassess the client condition, send him/hertoilets if needed2. Explained the purpose and all procedures3. Performed hand washing4. Collected all equipments required5. Made him/her comfortable position6. Maintained his/her privacy by closing dooror using screenMeasuring temperature of axilla1. Explained the procedure2. Loosen the cloth if needed3. Confirmed the client whether if the axillais dry or not, if not, make dry by patting4. Cleaned a thermometer and confirm thelevel of thermometer placing under 35degree5. Put the thermometer with 45 degree fromanterioinferior to the client7s arm pit andhold the arm tightly across the chest for 3minutes6. Took away and read at eye level ,and noteit7. Cleaned the thermometer by spirit swab8.Assessed the dataNormalityAbnormality: hyerthermiahypothermiaCounting radial pulse1.Explained the procedure2. Supported the client with supine or sittingposition3. Assisted the client‟s forearm across thelower chest in supine position. In sittingposition, assist the client‟s forearm to bendwith 90 degree on armrest of chair or onthe nurse‟s arm.
    • 172172172Step Satisfied Unsatisfied:(Put comments)NotPerformed4. Palpated radial pulse by three fingertips5. Counted the rate for 1 minute6. Checked the rhythm, regularity,volume( or strength)7.Took notes8. Assessed the data and advised the clientas needed.9.Reported any abnormalitiesCounting respirations1. Explained the procedures2. Provided privacy3.Positioned the client to ensure view ofchest movement4.Placed the client arm relaxed across thelower chest or abdomen5.Counted the rate completely for 1 minute6. Checked the cycle with rhythm anddepth.7. Took notes8. Replaced the client‟s clothes if needed.9.Assesses the data and advised as needed10. Reported any abnormalitiesMeasuring blood pressure: by two stepsbefore measured:1. Explained the procedures2.Assisted the supine or sitting position3. Removed constricting clothing from theupper arm selected4. Positioned the client‟s forearm at heartlevel with the palm turned up5. Palpated brachial artery by nondominanthand.6. Positioned the center of bladder ofdeflated cuff above brachial artery7.Wrapped cuff evenly around upper armwith two fingers loose8.Set up manometer properlyMeasured blood pressure in two steps:1) Palpatory method1)Identified approximate systolic pressureby palpating brachial pulse
    • 173173173Step Satisfied Unsatisfied NotPerformed9.2) Inflated 20-30 mmHg more than thepoint identified as systolic pressure toensure3) Deflated cuff evenly by open screw of bulbto fall mercury at rate of 2-3 mm Hg persecond4) Identified the scale of manometer whereyou palpated brachial pulse again5) Deflated cuff completely6) Removed cuff from the upper arm7) Took 3 minutes interval beforeauscultation2) Auscultation1) Checked stethoscope amplification ofsound2) Rechecked brachial pulse and placed thecenter part of bladder above it3) Wrapped cuff evenly and snugly aroundthe upper arm. Closed the screw clamp ofbulb.4) Applied diaphragm of stethoscope overbrachial artery5) Inflated cuff to 20-30 mmHg above that ofpalpated systolic pressure.6) Allowed mercury to fall evenly at the rateof 2-3 mmHg per second7) Noted the point on manometer when firstsound clearly was listened8) Deflated cuff continuously and noted thepoint at which sound disappeared9) Continued deflation 10 -20 mmHg afterthe last sound listened10) Released the pressure from cuffcompletely and rapidly.11) Removed cuff from the upper arm12) Took notes11. Assisted client to return comfortableposition and arrange the clothing12. Informed the reading to the client andadvised as needed13. Cleaned earpieces and diaphragm ofstethoscope with spirit swab.14.Performed hand hygiene15. Reported any abnormal findings
    • 174174174General Comments:Well performance ( ) Just performed ( ) Poor performance ( ) Students given poor performance need to receive the back evaluation.Feedback from instructor
    • 175175175Appendix 2Checklist for Bedmaking: un-occupied bedStudent: ( )Instructor: ( )Evaluated on : ( )Step(by one nurse)1. Performed hand hygiene2. Assembled all equipments required andbrought them to bedside3. Make enough space for bedmaking4. Cleaned bedside locker by wet and drysponge cloth5. Clean the both side of mattress by wetand dry sponge cloth6. Started bedmaking from right side of bed:1) Apply a bottom sheet and smoothed out it2) Made a mitered corner in top corner ofbottom sheet and secondly in end corner ofbottom sheet3) Tucked bottom sheet under mattress4) Applied mackintosh and draw sheet tobed correctly and tucked the edge undermattress tightly7.Move to left side of bed:1) Spread bottom sheet smoothly over thebed2) Mitered corner in top corner and in endcorner of bottom sheet3) Tucked bottom sheet under mattress4) Pulled mackintosh and draw sheet fromthe center of bed and tucked tightly undermattress8.Returned to right side again:1) Applied top sheet to the end of bed in rightside of bed2) Place blanket at the level of 1 feet belowfrom the top edge of bed. Spread theblanket to the end of bed in right side ofbed3) Made cuff out of top edge of sheet overblanket11.Mitered corner in end of bed and tuckedin remained portion of top sheet withblanket tightly under mattress.Satisfied Unsatisfied:( Put comments )NotPerformed
    • 176176176Step(by one nurse)9. Moved to left side:1) Pull the top sheet and smoothed it over tobed2) Smoothed blanket over to bed3) Made cuff out of top edge of sheet overblanket4) Mitered corner in end of bed and tuckedthe remained tightly under mattress10. Applied a clean pillowcace over pillowand placed it at the center of bed neatly11. Rearranged the place of bed and bedsidelocker if needed12. Return all equipments and disposal13. Perform hand hygieneSatisfied Unsatisfied:( Put comments )NotPerformedGeneral Comments:Well performance ( ) Just performed ( ) Poor performance ( ) Students given poor performance need to receive the back evaluation.Feedback from instructor
    • 177177177Appendix 3Checklist for Changing occupied bedStudent: ( )Instructor: ( )Evaluated on : ( )Step(by one nurse)1. Confirmed client‟s identification andexplain the procedures2.Performed hand hygiene3. Assembled all equipments required andbrought them to bedside4. Closed door and/or put screen5.Removed personal belongings frombed-side and put them into bedside lockeror safe place. Arranged enough space forbedmaking6.Cleaned bedside locker by wet and drysponge cloth7. Loosened top lines from mattress8. Remove blanket by folding and coveredthe client‟s body by only top sheet9. Assisted the client to turn toward left sideof the bed.Adjust ed the pillow.10. Started bedmeaking from right side:1) Fanfolded (or rolled) soiled lines from theside of bed and wedged them close to theclient2) Clean the surface of mattress by wet anddry sponge cloth3) Placed bottom sheet evenly on the bedfolded lengthwise with the center fold4) Adjusted bottom sheet and Mitered acorner in top corner of bottom sheet5) Tighten bottom sheet and mitered acorner in end corner of bottom sheet.6) Tucked in along side.7) Place the mackintosh and draw sheetcorrectly on the bottom sheet and tuckedthem under mattress11. Assisted client to roll over the foldedlinen to right side.12.Moved to left side:1) Removed the soiled lines.2) Discarded the soiled linen correctly.Satisfied Unsatisfied:( Put comments )NotPerformed
    • 17817817812.Step(by one nurse)Satisfied Unsatisfied:( Put comments )NotPerformed3) Clean the surface of mattress by wet anddry sponge cloth4) Grasped clean linens and pull them outgently on the mattress5) Tuck the bottom sheet tightly in topcorner of bed and mitered a corner.6) Tucked the bottom sheet tightly in endcorner of bed and mitered a corner.7) Tucked in along side8) Spread mackintosh and draw sheet overbottom sheet and tucked them tightlyunder mattress.13. Assisted the client back too the center ofbed.Adjust the pillow.14. Returned to right side:1) Placed clean top sheet at the top side ofthe soiled top sheet2) Asked the client to hold the upper edge ofclean top sheet3) Held both the top of the soiled sheet andthe end of the clean sheet with right hand.Withdrew to downward.4) Removed the soiled top sheet anddiscarded into laundry bag or bucket.5) Placed blanket over top sheet correctly.Made cuff out of top edge of sheet6) Tucked the lower ends securely undermattress. Mitered corners.15. Repeated procedure 14. in left side.16. Removed the pillow and replace thepillow cover with clean one. Repositionedthe pillow under client‟s head.17. Replaced persona belongings back.Returned the bed-side locker and bed asusual18. Return all equipments to proper places20. Discarded soiled linens appropriately.20. Perform hand hygiene.
    • 179179179General Comments:Well performance ( ) Just performed ( ) Poor performance ( ) Students given poor performance need to receive the back evaluation.Feedback from instructor
    • Fundamental of Nursing Procedure Manual180180180Appendix 4Checklist for making post-operative bedStudent‟s name: ( )Instructor: ( )Evaluated on : ( )Step Satisfied NotSatisfiedNotdoneRemarks1. Performed hand hygiene2. Assembled all equipments and broughtbed-side.3. Made foundation bed with a largemackintosh and draw sheet4. Placed top bedding as for closed bed withouttucked at foot5. Folded back top bedding at the foot of bed6. Tucked the top bedding on one side only.7. On the other side, did not tuck the topbedding:1) Brought head and foot corners of them atthe center of bed and formed right angles2) Folded back suspending portion and rolledto opposite 1/3 side of bed.8. Removed pillow and placed in oppositeside from entering client (or in foot side)9. Placed a kidney tray on bed-side10. Placed IV stand near the bed11. Checked locked wheel of the bed12. Placed hot water bag if needed. If putbefore, removed it when client came back13. Transferred client:1) Helped lifting client into the bed2) Covered client by top bedding immediately3) Tucked top bedding and mitered corners inend of bedGeneral Comments:Well performance ( ) Just performed ( ) Poor performance ( ) Students given poor performance need to receive the back evaluation.Feedback from instructor
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