Nursing skills procedure manual.drjma

NURS 241 Nursing Skills Procedure: Manual 1

NURS 241 Nursing Skills Procedure: Manual
(cover page)

1st released in November 6, 2012@ UoD College of Nursing (Male)


The NURS 241 Nursing Skills Procedure Manual
Is a compilation of

The University of Dammam, College of Nursing(Male) faculty.

1st edition 2012-2013

The author and contributor have prepared this work for the
student nurses. Furthermore, no warranty, express or implied and
disclaim any obligation, loss as a consequence of the use and
application of any contents of this activity.

THE AUTHORS,

Nursing Course Coordinator:
Dr. James M. Alo, RN, MAN, MAPsycho., PhD.

Clinical Staff:
Mr. Robin Easow, RN, MAN
Mr. Abdullah Ghanem, RN, MAN
Mr. Fhaied Mobarak, RN, MAPPC
Mr. Shadi Alshadafan, RN, MAN
Mr. Darwin Agman, RN
Mr. Fathi Alhurani, RN



Preface
This manual will help the student learn knowledge and

demonstrate nursing skills related to the fundamental management

of patient care especially to patient with medical and surgical

impediments.

Special attention of the student to this manual will aid them in

developing, enhancing their learned skills from their dedicated

clinical staff.

The authors and contributors recognize the student as an

active participant who assumes a collaborative role in the learning

process. Content is presented to challenge the student to develop

clinical nursing skills.

NURS 241 TEAM

Course Coordinator:
Dr. James M. Alo
Clinical Staff:
Mr. Robin Easow
Mr. Abdullah Ghanem
Mr. Fhaied Mobarak
Mr. Shadi Alshadafan
Mr. Darwin Agman
Mr. Fathi Alhurani



NURS 241 Nursing Skills Procedure: Manual

TABLE OF CONTENTS

Sec. CONTENTS Page #
Cover Page
Acknowledgment
Preface
Handwashing 6
Measuring Body Temperature/ Vital Signs 9
-Oral Temperature Measurement 13
-Oral Temperature Measurement w/ E-Thermomemter 15
-Rectal Temperature Measurement w/ glass 15
thermometer
-Rectal Temperature Measurement w/ e-thermometer 17
-Axillary Temperature Measurement w/ glass 18
thermometer
-Axillary Temperature Measurement w/ e- 19
thermometer
-Tympanic Membrane Measurement w/ e- 20
thermometer
Advantages & Disadvantages of Selecting Temperature 21
Measurement
Assessing Radial and apical Pulse 22
-Radial Pulse 25
-Apical Pulse 26
-Apical-Radial Pulse 28
Assessing Respiration 32
-Abnormal breathing patterns 34
Assessing BP 37
Applying and Removing sterile gloves 44
Changing an occupied bed 47
Changing an unoccupied bed 50
Body mechanics 55
Lifting an object from the floor 58
Positioning clients 59
Transferring patient from bed to chair 66
Bathing adult client 69
Collecting sputum specimen 76
Collecting and testing of urine 78
Collecting a specimen from indwelling catheter 84
Collecting and testing of stool 87
Obtaining a capillary blood specimen 89
Collecting samples from nose and throat 93
Collecting samples from nasal mucosa 96
Bandage and binders 97
Bandaging 99
-Types of bandage turns 102
-Types and purpose of binders 104


Shoulder immobilization 115
APPENDIX A /Performance Checklist 118
Handwashing 118
Applying and removing of gloves 120
Axillary temperature (electronic) 122
Rectal temperature (electronic) 124
Oral temperature (electronic) 126
Heart rate 128
Respiratory rate 132
Moving the client up in bed 134
Moving the client to lateral position 138
Body mechanics 140
Logrolling a client 143
Dangling a client 145
Applying and removing gloves, gowns and mask 147
Assessing Blood Pressure 148
Changing an Unoccupied Bed 151
Changing an occupied Bed 152

REFERENCES 154


HANDWASHING

Introduction:

Hand washing is important in every setting, including hospitals. It is
considered one of the most effective infection control measures. There are two types
of microorganisms (bacteria) present on the hands: Resident bacteria, which cannot
be removed by hand washing. The second type is transient bacteria, which is easily
removed by hand washing.

It is important that hands be washed at the following time:
 Before and after eating.
 Before and after contact with any patient.
 When handling patient’s food, blood, body fluids, secretions or excretions.
 When there is contact with any object that is likely to be a reservoir of
organisms such as soiled dressings or bedpan.
 After urinary or bowel elimination.

Purposes: Handwashing is performed to:

1. Remove the natural body oil and dirt from the skin.
2. Remove transient microbes, those normally picked up by the hands in the
usual activities of daily living.
3. Reduce the number of resident microbes, those normally found in creases of
the skin.
4. Prevent the transmission of microorganisms from client to client / from nurse
to family / from client to nurse.
5. Prevent the cross-contamination among clients.

Key Points:
Handwashing is a basic aseptic practice involved in all aspects of providing care to
persons who are sick or well. It becomes especially important when the client have
nursing diagnoses such as:
 Potential for infection.
 Altered body temperature.
 Impaired skin integrity.


Equipment and Supplies
o Source of running water o Orangewood stick
(warm if available) o Towel or tissue paper
o Soap o Lotion
o Soap dish

Procedure:
STEPS RATIONALE
1 Stand in from of the sink. Do not The sink is considered
allow your uniform to touch the sink contaminated. Uniforms may carry
during the washing procedure. organisms from place to place.
2 Remove jewelries. Remove watch 3- Removal of jewelries facilitates
5 inch above wrist proper cleansing. Microorganisms
may accumulate in settings of
jewelries.
3 Turn on water and adjust the force. Water splashed from the
Regulate the temperature until the contaminated sink will contaminate
water is warm. Do not allow water to your uniform. Warm water is more
splash. comfortable and has fewer
tendencies to open pores and
remove oils from the skin.
Organisms can lodge in roughened
and broken areas of chapped skin.
4 Wet the hands and wrist area. Keep Water should flow from the cleaner
hands lower than the elbows to area toward the more
allow water to flow toward the contaminated area. Hands are
fingertips. more contaminated than the
forearm.

5 Use about one teaspoon of liquid Rinsing the soap removes the
soap from the dispenser or lather lather, which may contain
thoroughly with bar soap. Rinse bar, microorganisms.
and return it to soap dish.


6 With firm rubbing and circular Friction caused by firm rubbing and
motions, wash the palms and back circular motions helps to loosen the
of the hands, each finger, areas dirt and organisms which can lodge
between the fingers, the knuckles, between the fingers, in skin crevices
wrists, and forearms at least as high of knuckles, on palms and backs of
as contamination is likely to be the hands, as well as the wrist and
present. forearms. Cleaning least
contaminated areas (forearms and
wrists) prevents spreading
organisms from the hands to the
forearms and wrists.

7 Continue this friction motion for 10 Length of hand washing is
to 30 seconds. determined by the degree of
contamination.
8 Use fingernails of the other hand or Organisms can lodge and remain
use orangewood stick to clean under the nails where they can grow
under fingernails. and be spread to others.
9 Rinse thoroughly. Running water rinses organisms and
dirt into sink.
10 Dry hands and wrists with paper Drying the skin well prevents
towel. Use paper towel to turn off chapping. Dry hands first because
the faucet. they are the cleanest and least
contaminated area after hand
washing. Turning the faucet off with
a paper towel protects the clean
hands from contact with a soiled
surface.
11 Use lotion on hands if desired. Lotion helps to keep the skin soft
and prevents chapping.


MEASURING BODY TEMPERATURE or VITAL SIGNS

Objectives:
1. To measure the body temperature accurately and safely.
2. Recognize deviations from the normal.

Purposes:
1. To establish baseline data.
2. To identify if the body temperature is within normal range.
3. To determine changes in the body temperature in response to specific
therapies.
4. To monitor client’s at risk for alterations in temperature.

Types of Thermometers:

Clinical glass mercury
thermometers:
• Oral (long tip)
• Stubby
• Rectal

Electronic thermometer

Infra-red thermometer
(Tympanic thermometer)



Temperature sensitive strips
(Disposable thermometer strips)

(Liquid crystal thermometer)

Temperature Scales:
 Celsius (centigrade) scale – normally extends from 34.0 to 42.0 C.
 Fahrenheit scale – usually extended from 94 F to 108 F.

Factors affecting body temperature:
 Age:  children;  old age.  Stress
 Sex:  males;  c females and  Environment
during menstruation.   Obesity
 Diurnal variations.   Food intake;  fasting
 Exercise  Drugs  or 
 Hormones  Disturbance in hypothalamus



Ranges of normal temperature values and
physiological consequences of abnormal body temperature.

Sites/Routes for temperature assessment:
1. Core temperature – is the temperature of the deep tissues of the body, such
as the cranium, thorax, abdominal and pelvic cavity.
2. Surface temperature – is the temperature of the skin, the subcutaneous tissue
and fat. It rises and falls in response to the environment; varies from 20 to
40 C.

Route Normal Reading Timing
Oral 37 C (98.6 F) 3 minutes
Axillary 37.5 C (99.6 F) 5 minutes
Rectal 36.4 C (97.6 F) – 36 .7 C (98 1 minute
F)
Tympanic - 1 – 2 sec.

Alterations in body temperature:
1. Pyrexia / hyperthermia / fever (above usual range).
2. Hyperpyrexia – very high fever.
3. Afebrile – no fever.



CONTRAINDICATIONS / CAUTIONS:

A. Oral:
1. Children younger than 4 to 5 years.
2. Confused, combative or comatose individuals.
3. Irritable clients or with mental diseases.
4. With history of convulsive disorders.
5. Mouth breathers.
6. With oral infections or with injuries or conditions that prevent them from
closing their mouths fully.
7. Immediate post-op under anesthesia.
8. Surgery for nose and mouth.
9. Patient receiving oxygen therapy.
10. Wait at least 15 to 30 minutes after person smokes / drinks / eats.

B. Rectal:
1. With rectal or perineal injuries or surgeries.
2. With diarrhea, diseases of the rectum.
3. Patient with heart disease.
4. Lubricate the thermometer well and insert gently to avoid damage to the
mucosa or perforation of the rectum.
C. Axillary : NONE.
D. Tympanic: NONE.

Equipment:
 Appropriate thermometer
 Soft tissue papers
 Lubricant (for rectal measurement only)
 Pen, pencil, vital signs flow sheet or record form.
 Disposable gloves, plastic thermometer sleeves or disposable probe covers.


Procedure:
STEPS RATIONALE
1 Assess for signs and symptoms of Physical signs and symptoms may
temperature alterations and for indicate abnormal temperature.
factors that influence body Nurse can accurately assess nature
temperature. of variations.
2 Determine any previous activity that Smoking and hot or cold substances
would interfere with accuracy of can cause false temperature
temperature measurement. When readings in oral cavity.
taking temperature, wait 20 to 30
minutes before measuring
temperature if client has smoked or
ingested hot or cold liquids or foods.
3 Determine appropriate site and Chosen on basis of preferred site for
measurement device to be used. temperature measurement.
4 Explain why temperature will be Clients are often curious about such
taken and maintaining the proper measurements and should be
position until reading is complete. cautioned against prematurely
removing thermometer to read
results.
5 Wash hands. Reduces transmission of
microorganisms.
6 Assist client in assuming Ensures comfort and accuracy of
comfortable position that provides temperature reading.
easy access to mouth.
7 Obtain temperature reading.

A. Oral temperature measurement with glass thermometer:

1 Apply disposable gloves. Maintains standard precautions
when exposed to items soiled with
body fluids. (e.g., saliva)
2 Hold end of glass thermometer with Reduces contamination of
fingertips. thermometer bulb.
3 Read mercury level while gently Mercury should be below 35 C.
rotating thermometer at eye level, Thermometer reading must be
grasp tip of thermometer securely, below client’s actual temperature
stand away from solid objects, and before use. Brisk shaking lowers
sharply flick wrist downward. mercury level of glass tube.
Continue shaking until reading is
below 35 C (96 F).
4 Insert thermometer into plastic Protects from contact with saliva.
sleeve or cover.


5 Ask client to open mouth and gently Heat from superficial blood vessels
place thermometer under tongue in in sublingual pockets produces
posterior sublingual pocket lateral to temperature reading.
the center of lower jaw.

6 Ask client to hold thermometer with Maintains proper position of
lips closed. Caution against biting thermometer during recording.
down the thermometer Breakage of thermometer may
injure mucosa and cause mercury
poisoning.
7 Leave thermometer in place for 3 Studies vary as to proper length of
minutes or according to agency time for recording. Holtzclaw (1992)
policy. recommends 3 minutes.
8 Carefully remove thermometer, Prevents cross contamination.
remove and discard plastic sleeve Ensures accurate reading.
cover in appropriate receptacle, and
read at eye level. Gently rotate until
scale appears.
9 Cleanse any additional secretions Avoids contact of microorganisms
on thermometer, by wiping with with nurse’s hands. Wipe from area
clean, soft tissue. Wipe in rotating of least contamination to area of
fashion from fingers toward bulb. most contamination. Glass
Dispose of tissue in appropriate thermometers should not be shared
receptacle. Store thermometer in between clients unless terminal
appropriate storage container. disinfection is performed between
each measurement. Protective
storage container prevents
breakage and reduces risks of
mercury spills.
10 Remove and dispose of gloves in Reduces transmission of
appropriate receptacle. Wash microorganisms.
hands.



B. Oral temperature measurement with electronic thermometer.

1 Apply disposable gloves. (Optional) Use of probe covers, which can be
removed without physical contact,
minimizes needs to wear.
2 Remove the thermometer pack from Charging provides battery power.
charging unit. Attach oral probe to Ejection button releases plastic
thermometer unit. Grasp top of cover from probe.
stem, being careful not to apply
pressure to ejection button.
3 Slide disposable plastic cover over Soft plastic cover will not break in
thermometer probe until it locks in client’s mouth and prevents
place. transmission of microorganisms
between clients.
4 Ask client to open mouth, then place Heat from superficial blood vessels
thermometer probe under the in sublingual pocket produces
tongue in posterior sublingual temperature reading. With electronic
pocket lateral to center of lower jaw. thermometer temperatures, in right
and left posterior sublingual pocket
are significantly higher than in area
under front of tongue.
5 Ask client to hold thermometer Maintains proper position of
probe with lips closed. thermometer during recording.
6 Leave thermometer probe in place Probe must stay in place until signal
until audible signal occurs and occurs to ensure accurate
client’s temperature appears on recording.
digital display; remove thermometer
probe under client’s tongue.
7 Push ejection button on Reduces transmission of
thermometer stem to discard plastic microorganisms.
cover into appropriate receptacle.
8 Return thermometer stem to storage Protects probe from damage.
well of recording unit. Automatically causes digital reading
to disappear.
9 If gloves are worn, remove and Reduces transmission of
dispose in appropriate receptacle. microorganisms.
Wash hands.
10 Return thermometer to charger. Maintains battery charge.

C. Rectal temperature measurement with glass thermometer.

1 Draw curtain around bed and / or Maintain client’s privacy, minimizes
close room door. Assist client to embarrassment, and promotes
Sim’s position with upper leg flexed comfort. Exposes anal area for
Move aside bed linen to expose only correct thermometer placement.
anal area. Keep covered with sheet
or blanket.


2 Apply disposable gloves. Maintains standard precautions
when exposed to items soiled with
body fluids (e.g., feces).

3 Hold end of glass thermometer with Reduced contamination of
fingertips. thermometer bulb.
4 Read mercury level while gently Mercury should be below 35 C.
rotating thermometer at eye level. If Thermometer reading must be
mercury is above desired level, below client’s actual temperature
grasp tip of thermometer securely, before client’s actual temperature
and stand away from solid objects, before use. Brisk shaking lowers
and sharply flick wrist downward. mercury level in glass tube.
Continue shaking until reading is
below 35 C.
5 Insert thermometer into plastic Protects from contact with feces.
sleeve cover.
6 Squeeze liberal portion of lubricant Lubrication minimizes trauma to
on tissue. Dip thermometer’s blunt rectal mucosa during insertion.
end into lubricant, covering 2.5 cm Tissue avoids contamination of
(1 to 1 ½ inch) for adult. remaining of remaining lubricant in
container.
7 With non-dominant hand, separate Fully exposes anus for thermometer
client’s buttocks to expose anus. insertion. Relaxes anal sphincter for
Ask client to breathe slowly and easier thermometer insertion.
relax.

8 Gently insert thermometer into anus
3.5 cm (1 ½ inches) for adult. Do not
force themselves.
9 If resistance is felt during insertion, Prevents trauma to mucosa. Glass
withdraw thermometer immediately. thermometers can break.
Never force thermometer.

If thermometer cannot be adequately inserted into the rectum, remove the
thermometer and consider alternative method for obtaining temperature.

10 Hold thermometer in place for 2 Prevents injury to client. Studies
minutes or according to agency vary as to proper length of time for
policy. recording. Holtzclaw (1992)
recommends 2 minutes.


11 Carefully remove thermometer, Prevents cross contamination. Wipe
remove and discard plastic cover in from area of least contamination to
appropriate receptacle and wipe off area of most contamination.
remaining secretions with clean
tissue. Wipe in rotating fashion from
fingers toward the bulb. Dispose of
tissue in appropriate receptacle.
12 Read thermometer at eye level. Ensures accurate reading.
Gently rotate until scale appears.

13 Wipe client’s anal area with soft Provides for comfort and hygiene.
tissue to remove lubricant or feces
and discard tissue. Assist client in
assuming a comfortable position.
14 Store thermometer in appropriate Glass thermometers should not be
storage container. shared between clients unless
terminal disinfection is performed
between each measurement.
Protective storage container
prevents breakage and reduces risk
of mercury spill.
appropriate receptacle. Wash microorganisms.
hands.

D. Rectal temperature measurement with electronic thermometer.

1 Follow steps C-1 and C-2.
2 Follow steps C-5, 6, 7, 8, 9
3 Leave thermometer in place until Probe must stay in place until signal
audible signal occurs and client’s occurs to ensure accurate reading.
temperature appears on digital
display; remove thermometer probe
from anus.
probe cover into appropriate
receptacle.
5 Return thermometer stem to storage Protects probe from damage.
well of recording unit. Automatically causes digital reading
to disappear.
6 Wipe client’s anal area with soft Provides comfort and hygiene.
tissue to remove lubricant or feces
and discard tissue. Assist client in
assuming a comfortable position.
appropriate receptacle. microorganisms.
8 Return thermometer to charger. Maintains battery charge.



E. Axillary temperature measurement with glass thermometer.

microorganisms.
2 Draw curtain around bed and/or Provides privacy and minimizes
close door. embarrassment.
3 Assist client to supine or sitting Provides easy access to axilla.
position.
4 Move clothing or gown away from Exposes axilla.
shoulder and arm.
5 Prepares glass thermometer Mercury must be below client’s
following steps A –2, 3. temperature level before insertion.
6 Insert thermometer into the center of Maintains proper position of
axilla, lower arm over thermometer, thermometer against blood vessels
and place arm across chest. in axilla.

7 Hold thermometer in place for 3 Studies as to proper length of time
minutes or according to agency for recording vary. They concluded
policy. that changes after 3 minutes had
little or no significance.
8 Remove thermometer, remove Avoids nurse’s contact with
plastic sleeve, and wipe off microorganisms. Wipe from are of
remaining secretions with tissue. least contamination to area of most
Wipe in rotating fashion from fingers contamination.
toward bulb. Dispose of sleeve and
tissue in appropriate receptacle.
9 Read thermometer at eye level. Ensures accurate reading.
10 Inform client of reading. Promotes participation in care and
understanding of health status.
11 Store thermometer at bedside in Glass thermometers should not be
protective covering container. shared between clients unless
terminal disinfection is performed
between each measurement.
Storage container prevents
breakage and reduces risk of
mercury spill.


12 Assist client in replacing clothing pr Restore sense of well-being.
gown.
microorganisms.

F. Axillary temperature measurement with electronic thermometer.

1 Position client lying supine or sitting. Provides easy access to axilla.
2 Move clothing or gown away from Provides optimal access to axilla.
shoulder and arm.
3 Remove the thermometer pack from Ejection button releases plastic
charging unit. Be sure oral probe cover from probe.
(blue tip) is attached to thermometer
unit. Attach oral probe to
thermometer unit. Grasp top of
stem, being careful not to apply
pressure to ejection button.
4 Slide disposable plastic cover over Soft plastic cover will not break in
thermometer probe until it locks in client’s mouth and prevents
place. transmission of microorganisms
between clients.
5 Raise client’s arm away from torso, Maintains proper position of probe
inspect for skin lesion and excessive against blood vessels in axilla.
perspiration. Insert probe into the
center of axilla, lower arm over
thermometer, and place arm across
chest.
6 Leave probe in place until audible Probe must stay in place until signal
signal occurs and client’s occurs to ensure accurate reading.
temperature appears on digital
display.
7 Remove probe from axilla.
probe cover into appropriate
receptacle.
9 Return probe to storage well of Protects probe from damage.
recording unit. Automatically causes digital reading
to disappear.
10 Assist client in assuming a Restores comfort and promotes
comfortable position. privacy.
microorganisms.



G. Tympanic membrane temperature measurement with
electronic thermometer.
1 Assist client in assuming Ensures comfort and exposes
comfortable position with head auditory canal for accurate
turned toward side, away from the temperature measurement.
nurse.
2 Remove thermometer handheld unit Base provides battery power.
from charging base, being careful Removal of handheld unit from base
not to apply pressure to ejection prepares it to measure temperature.
button.
3 Slide disposable speculum cover Soft plastic probe cover prevents
over otoscope like tip until it locks transmission of microorganisms
into place. between clients.
4 Insert speculum into ear canal Correct positioning of the probe with
following manufacturer’s instructions respect to ear canal ensures
for tympanic probe positioning. accurate readings. The ear tug
straightens the external auditory
canal, allowing maximum exposure
of the tympanic membrane.
a. Pull ear pinna upward and back
for Some manufacturers recommend
adult. movement of the speculum tip in a
b. Move thermometer in a figure– figure – 8 pattern that allows the
eight pattern. sensor to detect maximum tympanic
c. Fit probe snug into canal and membrane heat radiation. Gentle
do not move. pressure seals ear canal from
d. Point toward nose. ambient air temperature.

5 Depress scan button on handheld Depression of scan button causes
unit. Leave thermometer probe in infrared energy to be detected.
place until audible signal occurs and Probe must stay in place until signal
client’s temperature appear on occurs to ensure accurate reading.
digital display.

6 Carefully remove speculum from
auditory meatus.


7 Push ejection button on handheld Reduces transmission of
unit to discard plastic probe cover microorganisms. Automatically
into appropriate receptacle. causes digital readings to
disappear.
8 Return handheld unit into charging Protects probe from damage.
base.
9 Assist client in assuming a Restores comfort and sense of well
comfortable position. being.
microorganisms.

Recording and reporting:
 Record temperature in vital signs flow sheet or record form.
 Report abnormal findings to nurse in charge or physician.

ADVANTAGES AND DISADVANTAGES OF SELECTED
TEMPERATURE MEASUREMENT, SITES, AND METHODS.

Advantages Disadvantages

Electronic Thermometer:
1 Plastic sheath unbreakable; ideal May be less accurate by axillary route.
for children.
2 Quick readings.

Tympanic Membrane Sensor:
1 Easily accessible site Hearing aids must be removed before
measurements.
2 Minimal client repositioning Should not be used for clients who have
required. had surgery of the ear or tympanic
membrane.
3 Provides accurate care reading. Requires disposable probe cover.
4 Very rapid measurements (2 to 5 Expensive.
sec.).
5 Can be obtained without disturbing
or waking client.
6 Ear drum close to hypothalamus,
sensitive to core temperature
changes.

Oral:
1 Accessible; requires no position Affected by ingestion of fluids or foods,
changes. smoke, and oxygen delivery (Neff and
others, 1992).


2 Comfortable for client. Should not be used with clients who
have had oral surgery, trauma, history of
epilepsy, or shaking chills.
3 Provides accurate surface Should not be used with infants, small
temperature reading. children, or confused, unconscious, or
uncooperative client.
4 Indicates rapid change in core Risk of body fluid exposure.
temperature.

Axilla:
1 Safe and non-invasive. Long measurement time.
2 Can be used with newborns and Requires continuous positioning by
uncooperative clients. nurse.
Measurement lags behind core
temperature during rapid temperature
changes. Requires exposure of thorax.

Skin:
1 Inexpensive Lags behind other sites during
temperature changes, especially during
hyperthermia.
2 Provides continuous reading Diaphoresis or sweat can impair
adhesion.
3 Safe and non-invasive.

ASSESSING RADIAL AND APICAL PULSES

Definition: The pulse is a wave of blood created by contraction of the left ventricle
of the heart.

Objectives:
 To establish baseline data for subsequent evaluation.
 To identify whether the pulse is within normal range.
 To determine whether the pulse rhythm is regular and pulse volume is
appropriate.
 To compare the equality of corresponding peripheral pulses on each side of
the body.
 To monitor and assess changes in the client’s health status.
 To monitor clients at risk for pulse alterations. (e.g., clients with a history of
heart disease or having cardiac arrhythmias, hemorrhage, acute pain, infusion


of large volumes of fluids, fever).

Key Points:
 Locate the pulse point properly.
 Always count pulse for one full minute if dysrhythmias or other abnormality is
present.
 Have another nurse locate and count the radial pulse while you auscultate the
apical pulse. Determine an apical-radial pulse rate by counting simultaneously
for one full minute.

Equipment:
 Watch with a second hand or indicator.
 If using Doppler/ultrasound stethoscope:
 Transducer in the probe
 Stethoscope headset
 Transmission gel

Procedure:
STEPS RATIONALE
1 Determine need to assess radial or Certain conditions place clients at
apical pulse: risk for pulse alterations. Heart
a. Note risk factors for rhythm can be affected by heart
alterations in apical pulse disease, cardiac dysrhythmias,
b. Assess for signs and onset of sudden chest pain or acute
symptoms of altered SV pain from any site, invasive
(stroke volume) and CO such cardiovascular diagnostic tests,
as dyspnea, fatigue, chest surgery, sudden infusion of large
pains, orthopnea, syncope, volume of IV fluids, internal or
palpitations, jugular venous external hemorrhage, and
distension, edema of administration of medications that
dependent body parts, alter heart function.
cyanosis or pallor of skin. Physical signs and symptoms may
indicate alterations in cardiac
functions.


2 Assess for factors that normally Allows nurse to accurately assess
influence apical pulse rate and presence and significance of pulse
rhythm: alterations.
a. Age Normal PR change with age.

b. Exercise Physical activity requires an
c. Position changes increase in CO that is met by an
increase HR and SV. HR increases
temporarily when changing from
lying to sitting or standing position
d. Medications
Anti-dysrhythmics,
sympathomimetics, and cardiotonics
affect rate and rhythms of pulse.
Large doses of narcotic analgesics
can slow HR; general anesthetics
slow HR; CNS stimulants such as
e. Temperature caffeine can increase the HR.

Fever or exposure to warm
environments increases HR; HR
f. Emotional Stress, anxiety, declines with hypothermia.
fear
Results in stimulation of the
sympathetic nervous system, which
increases the HR.
3 Determines previous baseline Allows nurse to assess change in
balance apical site. condition. Provides comparison with
future apical pulse measurements.
4 Explain that PR or HR is to be Activity and anxiety can elevate HR.
assessed. Client’s voice interferes with nurse’s
ability to hear sound when apical
pulse is measured.
microorganisms.
6 If necessary, draw curtain around Maintains privacy.
bed and/or close door.
7 Obtain pulse measurement.


A. Radial Pulse
STEPS RATIONALE
1 Assist client to assume supine Provides easy access to pulse sites.
position.
2 If supine, place client’s forearm Relaxed position of lower arm and
along side or across lower chest or extension of wrists permits full
upper abdomen with wrist extended exposure of artery to palpation.
straight. If sitting, bend client’s
elbow 90 and support lower arm on
chair on nurses’ arm. Slightly extend
wrist with palms down.

3 Place tips of first two fingers of hand Fingertips are most sensitive parts
over groove along radial or thumb of hand to palpate arterial
side of client’s inner wrist. pulsations. Nurse’s thumb has
pulsation that may interfere with
accuracy.
4 Lightly compress against radius, Pulse is more accurately assessed
obliterate pulse initially, and then with moderate pressure. Too much
relax pressure so pulse becomes pressure occludes pulse and
easily palpable. impairs blood flow.
5 Determine strength of pulse. Note Strength reflects volume of blood
whether thrust of vessel against ejected against arterial wall with
fingertips is bounding, strong, weak each heart contraction.
or thready.
6 After pulse can be felt regularly, look Rate is determined accurately only
at watch’s second and begin to after nurse is assured pulse can be
count rate; when sweep hand hits palpated. Timing begins with zero.
number on dial, start counting with Count of one is first beat palpated
zero, then one, two, and so on. after timing begins.
7 If pulse is regular, count rate for 30 A 30 second count is accurate for
seconds and multiply by 2, rapid, slow, or regular pulse rates.
8 If pulse is regular, count rate for 60 Inefficient contraction of heart fails
seconds. Assess frequency and to transmit pulse wave, interfering
pattern if irregularity. with CO2, resulting in irregular
pulse. Longer time ensures accurate
count.



B. Apical pulse
1 Assist client to supine or sitting Expose portion of chest wall for
position. Move aside bed linen and selection of auscultation.
gown to expose sternum and left
side of chest.
2 Locate anatomical landmarks to Use of anatomical landmarks allows
identify the points of maximal correct placement of stethoscope
impulse (PMI), also called the apical over apex of heart, enhancing ability
impulse. Heart is located behind and to hear heart sounds clearly. If
to left of sternum with base at top unable to palpate the PMI,
and apex at bottom. reposition client on left side. In the
Find angle of Louis just below presence of serious heart disease,
suprasternal notch between sternal the PMI may be located to the left of
body and manubrium; can be felt as the MCL, or at the sixth ICS.
a bony prominence. Slip fingers
down each side of angle to find
second intercostal space. (ICS).

Carefully move fingers down left
side to the left midclavicular line
(MCL).
A light tap felt within an area 1 to 2
cm ( ½ to 1 inch) of the PMI is
reflected from the apex of the heart
3 Place diaphragm of stethoscope in Warming of metal or plastic
palm of hand for 5 to 10 seconds. diaphragm prevents client from
being startled and promotes
comfort.


4 Place diaphragm of stethoscope Allow stethoscope tubing to extend
over PMI at the fifth ICS, at left straight without kinks that would
MCL, and auscultate for normal S1 distort sound transmission. Normal
and S2 heart sounds (heard as “lub S1 and S2 are high pitched and best
dub”). heard with the diaphragm.

5 When S1 and S2 are heard with Apical rate is determined accurately
regularity, use watch’s second hand only after nurse is able to auscultate
and begin to count rate; when sounds clearly. Timing begins with
sweep hand hits number on dial, zero. Count of one is first sound
start counting with zero, then one, auscultated after timing begins.
two, and so on.
6 If apical rate is regular, count for 30 Regular apical rate can be assessed
seconds and multiply by 2. within 30 seconds.
7 If HR is irregular or client is Irregular is more accurately
receiving cardiovascular assessed when measured over long
medications, count for intervals.
1 minute (60 seconds). Regular occurrence of dysrhythmias
within 1 minute may indicate
inefficient contraction of heart and
alteration on cardiac output.
8 Discuss findings with client as Promotes participation in care and
needed. understanding of health status.
9 Clean earpieces and diaphragm of Control transmission of
stethoscope with alcohol swab as microorganisms when nurses share
needed. stethoscope.

microorganisms.
11 Compare readings with previous Evaluates for change in condition
baseline and/or acceptable range of and alterations.
heart rate for client’s age.
12 Compare peripheral pulse rate with Differences between measurements
apical pulse rate and note indicate pulse deficit and may warn
discrepancy. of cardiovascular compromise.
Abnormalities may require therapy.
13 Compare radial pulse equality and Differences between radial arteries
note discrepancy. indicate compromised peripheral
vascular system.


14 Correlate PR with data obtained PR and BP are interrelated.
from BP and related signs and
symptoms (palpitations, dizziness).

 Record PR with assessment site in nurses’ notes or vital signs flow sheet.
Measurement of PR after administration of specific therapies should be
documented in narrative form in nurses’ notes.
 Report abnormal finding to nurse in charge or physician.

C. Assessing the Apical-Radial Pulse
Normally, the apical and radial pulses are identical. Any discrepancy between two
pulse rates needs to be reported promptly. An apical-radial pulse can be taken by
two nurses to be more accurate at the same time with a signal of start and stop.

A peripheral pulse (usually, the radial pulse) is assessed by palpation in all
individuals except: Newborns and children up to 2 or 3 years (apical pulse is
assessed).
Very obese or elderly clients apical pulse is assessed.
Individuals with a heart disease (apical pulse is assessed).

Procedure:
STEPS Rationale
1 Palpate the radial pulse while Identifies differences between
listening for apical pulse. Using both pulsations and heart sounds.
senses, determine if the apical and
radial pulses are synchronous. If the
apical and radial pulses are not
synchronous, get a second nurse
and
2 Explain to the client that one nurse Informs the client’s answers his or
is counting his or her heart beats her questions because the unusual
while the second counts his or her procedure may arouse his or her
radial pulse. anxiety; simple straight forward
explanations usually are helpful.
Listen to the client’s fears or anxiety
with empathy.
3 Prepare to monitor the apical pulse.
4 Direct the second nurse to locate
and count the radial pulse.
5 Look at the watch dial. Note the Synchronizes the count, essential to
location of the second hand and determine if deficit is present.
signal the second nurse to begin
counting at “one, two …”
6 Count the remaining 60 seconds Ensures accuracy.
silently as the second nurse counts
the radial pulse silently.


7 Say “Stop” when exactly 60 seconds Ensures accuracy.
have passed.
8 Reposition the client comfortable.
9 Record the apical and radial rates Ensures prompt and accurate
immediately. Note any deficits. documentation.

Applying moderate pressure Assessing the radial pulse
to accurately assess the pulse

Mapping the apical pulse Assessing apical pulse



Comparing radial pulse equality and Assessing pedal pulse
discrepancy.


ASSESSING RESPIRATION

Respiration is a complex vital function with two complementary processes, the
internal and external respirations. Respiration is the act of breathing. One act of
respiration consists of one inhalation and on exhalation. Inhalation or inspiration is
the act of breathing in, and exhalation, or expiration, is the act of breathing out.

External respiration is a combination of movements delivering air to the body’s
circulatory system.
1. Ventilation 3. Diffusion and
2. Conduction of air 4. Perfusion.

Objectives/Purposes:
The respiratory rate is assessed to:
 Determine the per minute rate on admission as a base for comparing future
measurements.
 Monitor the effect of injury, disease or stress on the client’s respiratory
system.
 Evaluate the client’s response to medications or treatments that affect the
respiratory system.

Key Points:
 Assess the client for factors that could indicate respiratory variations.
 Without telling the client what you are doing, watch the chest movements in
and out.
 Count in each ventilatory movement as one respiration.
 Count for 30 seconds or one full minute.


Equipment:
 Watch with second  Paper, pencil  Vital signs record.
hand.

Observe the rate, rhythm, and depth of respiration.
Normal respiration is regular in depth and rhythm.

Place hands on chest when respirations are difficult to count.


Abnormal Breathing Patterns

Procedure:

STEPS RATIONALE
1 Determine need to assess client’s
respirations:
a Note risk factors for respiratory Certain conditions place client at
alterations. risk for alterations in ventilation
detected by changes in respiratory
rate, depth, and rhythm. Fever,
pain, anxiety, diseases of chest wall
or muscles, constrictive chest or
abdominal dressings, gastric
distention, chronic pulmonary
disease (emphysema, bronchitis,
asthma), traumatic injury to chest
wall with or without collapse of
underlying lung tissue, presence of
a chest tube, respiratory infection
(pneumonia, acute bronchitis),
pulmonary edema, and emboli,
head injury with damage to brain
stem, and anemia can result in
respiratory alteration.
b Assess for signs and symptoms of Physical signs and symptoms may
respiratory alterations such as bluish or indicate alterations in respiratory
cyanotic appearance of nail beds, lips, status related to ventilation.
mucous membranes, and skin;
restlessness, irritability, confusion,
reduced level of consciousness; pain
during inspiration; labored or difficult
breathing; adventitious sounds, inability
to breathe spontaneously; thick, frothy,
blood-tinge, or copious sputum
produced on coughing.

2 Assess pertinent laboratory values:
a. Arterial blood gases (ABGs): normal Arterial blood gases measure
ABGs (values may vary slightly within arterial blood pH, partial pressure of
institutions. O2, and CO2, and arterial O2
saturation, which reflects client’s
oxygenation.
b. Pulse oxymetry (SpO2): normal SpO2 = SpO2 less than 85% is often
90% - 100%; 85% – 89% may be accompanied by changes in
acceptable for certain chronic disease respiratory rate, depth, and rhythm.
conditions less than 85% is abnormal.


c. Complete blood count (CBC): normal Complete blood count measures red
CBC for adults (values may vary within blood cell count, volume of red
institutions) blood cells, and concentration of
hemoglobin, which reflects client’s
capacity to carry O2.
1) Hemoglobin: 14 to 18 g/100 ml, males;
12 to 16 g/100 ml, females.
2) Hematocrit: 40% to 54%, males; 38% to
47%, females.
3) Red blood cell count: 4.6 to 6.2 million/μl,
males; 4.2 to 5.4 million/μl, females.

3 Determine previous baseline respiratory Allows nurse to assess for
rate (if available) from client’s record. change in condition. Provides
comparison with future
respiratory measurements.
4 Be sure client is in comfortable position, Sitting erect promotes full
preferably sitting or lying with the head of ventilatory movement.
the bed elevated 45 to 60 degrees.

Critical Decision Point:
Clients with difficulty of breathing (dyspnea) such as those with congestive heart
failure or abdominal ascites or in late stages of pregnancy should be assessed in
positions of greatest comfort. Repositioning may increase the work of breathing,
which will increase respiratory rate.

5 Draw curtain around bed and/or close Maintains privacy. Prevents
door. Wash hands. transmission of microorganisms.
6 Be sure client’s chest is visible. If Ensures clear view of chest wall and
necessary, move bed linen or gown. abdominal movements.
7 Place client’s arm in relaxed position A similar position used during pulse
across the abdomen or lower chest, or assessment allows respiratory rate
place nurse’s hands directly over client’s assessment to be inconspicuous.
upper abdomen. Client’s or nurse’s hand rises and
falls during respiratory cycle.
8 Observe complete respiratory cycle (one Rate is accurately determined only
inspiration and one expiration). after nurse has viewed respiratory
cycle.
9 After cycle is observed, look at watch’ s Timing begins with count of one.
second hand and begin to count rate: Respirations occur more slowly than
when sweep hand hits number on dial, pulse; thus timing does not begin
begin time frame, counting one with first with zero.
full respiratory cycle.
10 If rhythm is regular, count number of Respiratory rate is equivalent to
respirations in 30 seconds and multiply number of respirations per minute.
by 2. If rhythm is irregular, less than 12, Suspected irregularities require
or greater than 20, count for 1 full assessment for at least 1 minute.
minute.


11 Note depth of respirations subjectively Character of ventilatory movement
assessed by observing degree of chest may reveal specific disease state
wall movement while counting rate. restricting volume of air from moving
Nurse can also objectively assess depth into and out of the lungs.
by palpating chest wall excursion after
rate has been counted. Depth is shallow,
normal, or deep.
12 Note rhythm of ventilatory cycle. Normal Character of ventilations can reveal
breathing is regular and uninterrupted. specific types of alterations.
Sighing should not be confused with
abnormal rhythm.
13 Replace bed linen and client’s gown. Restores comfort and promotes
sense of well-being.
microorganisms.
15 Discuss findings with client as needed. Promotes participation in care and
understanding of health status.
16 If respirations are assessed for the first Used to compare future respiratory
time, establish rate, rhythm, and depth assessment.
as baseline if within normal range.
17 Compare respirations with client’s Allows nurse to assess for changes
previous baseline and normal rate, in client’s condition and for
rhythm, and depth. presence of respiratory alterations.

Recording and Reporting:
 Record respiratory rate and character in nurses’ notes or vital sign flow sheet.
Indicate type and amount of oxygen therapy if used by client during
assessment. Measurement of respiratory rate after administration of specific
therapies should be documented in narrative form in nurses’ notes.

Home care Considerations:
Assess for environmental factors in the home that may influence client’s respiratory
rate such as second-hand smoke, poor ventilation, or gas fumes.


ASSESSING BLOOD PRESSURE

Definition:

Blood pressure is the force exerted produced by the volume of blood pressing on
the resisting walls of the arteries Blood pressure is commonly abbreviated BP. Its
measurement is expressed as a fraction.

The numerator or the upper figure is the systolic pressure/ systole (the phase
during which the heart works or contracts) and the denominator or the lower figure is
the diastolic pressure/ diastole (the heart’s resting phase).

The pressure is expressed in millimeters of mercury, abbreviated mmHg. Thus a
recording of
120/80 means systolic blood pressure was measured at 120 mmHg and the diastolic
blood pressure was measured at 80 mmHg. The difference between two readings is
called pulse pressure.

Blood is circulated through a loop involving the heart and blood vessels.

Purposes: The blood pressure is assessed by:

1. Determine the systolic and diastolic pressure of the client during
admission in order to compare his current status with normal changes.
2. Acquire data that may be compared with subsequent changes that
may occur during the care of the client.
3. Assist in evaluating the status of the client’s blood volume, cardiac


output and vascular system.
4. Evaluate the client’s response to changes in his medical condition as a
result of treatment with fluids or medications.

Key Points:
1. Blood pressure is the measurements of the pressure exerted by the
blood on the walls of the arteries. The rate and force of the heartbeat
determines the reading as the ventricles contract and rest.
2. Do no take BP reading on person’s arm if:
 is injured/diseased.
 Is on the same side of body where a female has had a radical
mastectomy.
 has a shunt or fistula for renal dialysis, or is site for an
intravenous infusion.

Equipment and Supplies:

o Stethoscope o Blood pressure cuff of appropriate size
o Sphygmomanometer – an aneroid or a mercury manometer may be
available. The gauge should be inspected to validate that the needle
or mercury is within the zero mark.
o Alcohol swab o Paper, pencil, pen, V/S flow sheet or
record form

Procedure: AUSCULTATION METHOD


STEPS RATIONALE
microorganisms.
2 With client sitting or lying, position If arm is unsupported, client may
client’s forearm, supported if needed, perform isometric exercise that can
with palms turned up. increase diastolic pressure 10%.
Placement of arm above the level of
the heart causes false low reading.
3 Expose upper arm fully by removing Ensures proper cuff application.
constricting clothing.
4 Palpate brachial artery. Position cuff Inflating bladder directly over brachial
2.5 cm (1inch) above site of brachial artery ensures proper pressure is
pulsation (antecubital space). Center applied during inflation. Loose-fitting
bladder of cuff above artery. With cuff causes false high readings.
cuff fully deflated, wrap evenly and
snugly around upper arm.
5 Position manometer vertically at eye Accurate readings are obtained by
level. Observer should be no farther looking at the meniscus of the mercury
than 1 meter (approximately 1 yard) at eye level. The meniscus is the point
away. where the crescent-shaped top of the
mercury column aligns with the
manometer scale. Looking up or down
at the mercury results in distorted
readings.
6 Palpate brachial or radial artery with Identifies approximate systolic
fingertips of one hand while inflating pressure and determines maximal
cuff rapidly to pressure 30 mmHg inflation point for accurate reading.
above point at which pulse Prevents auscultatory gap. If unable to
disappears. palpate artery because of weakened
pulse, an ultrasonic stethoscope can
be used.
7 Deflate cuff fully and wait 30 Prevents venous congestion and false
seconds. high readings.
8 Place stethoscope earpieces in ears Each earpiece should follow angle of
and be sure sounds are clear, not ear canal to facilitate hearing.
muffled,
9 Relocate brachial artery and place Proper stethoscope placement
bell or diaphragm (chest piece) of the ensures optimal sound reception.
stethoscope over it. Do not allow Stethoscope improperly positioned
chest piece to touch cuff or clothing. causes muffled sounds that often
result in false low systolic and false
high readings.
10 Close valve of pressure bulb Tightening of valve prevents air leak
clockwise until tight. during inflation.
11 Inflate cuff to 30 mmHg above Ensures accurate measurement of
palpated systolic pressure. systolic pressure.
12 Slowly release valve and allow Too rapid or slow a decline in mercury
mercury to fall at rate of 2 to 3 level can cause inaccurate readings.
mmHg/sec.
13 Note point on manometer when first First Korotkoff sound indicates systolic
clear sound is heard. pressure.


14 Continue to deflate cuff, noting point Fourth Korotkoff sound involves
at which muffled or dampened sound distinct muffling of sounds and is
appears. recommended as indication of
diastolic pressure in children. (Perloff
and others, 1993).

15 Continue to deflate cuff gradually, Beginning of fifth Korotkoff sounds is
noting point at which sound recommended by American Heart
disappears in adults. Note pressure Association as indication of diastolic
to nearest 2 mmHg. pressure in adults. (Perloff and others,
1993).
16 Deflate cuff rapidly and completely. Continuous cuff inflation causes
Remove cuff from client’s arm unless arterial occlusion, resulting in
measurement must be repeated. numbness and tingling of client’s arm.
17 If this is the first assessment of Comparison of BP in both arms
client, repeat procedure on other detects circulatory problems (Normal
arm. difference of 5 to 10 mmHg exists
between arms).
18 Assist client in returning to Restores comfort and promotes sense
comfortable position and cover arm if of well-being.
previously clothed.
19 Discuss findings with client as Promotes participation in care and
needed. understanding of health status.
20 Wash hands Reduces transmission of
microorganisms.
21 Compare readings with previous Evaluates for changes in condition and
baseline and/or acceptable value of alterations.
BP for client’s age.
22 Compare BP readings in both arms. Arm with higher pressure should be
used for subsequent assessment
unless contraindicated.
23 Correlate BP with data obtained from Blood pressure and heart rate are
pulse assessment and related interrelated.
cardiovascular signs and symptoms.

 Inform client of value and need for periodic re-assessment.
 Record BP. Measurement of BP after admission of specific therapies
should be documented.


Applying and Removing Personal Protective Equipment (gloves, gown, mask)

Purpose:
 To protect health care workers and clients from transmission of potentially
infective materials.

Assessment:
 Consider which activities will be required while the nurse is in the clients room
at this time.

Equipment:
 Gown
 Mask
 Clean gloves

Procedure:

STEPS Rationale
1. Verify client identity and
introduce yourself, explain for
the client what you are to do,
why it is necessary, and how
he or she can participate.

2. Perform hand hygiene.

3. Apply a clean gown:  Overlapping securely covers the
a) Pick up a clean gown, uniform at the back, waist ties keep
and allow it to unfold in the gown from falling away from the
front of you without body, which can cause inadvertent
allowing it to touch any soiling of the uniform.
area soiled with body
substances.
b) Slide the arms and the
hands through the
sleeves.
c) Fasten the ties at the
neck to keep the gown
in place.
d) Overlap the gown at the
back as much as
possible and fasten the
waist ties


4. Applying the face mask:  To be effective the mask must cover
a) Locate the top edge of both the nose and the mouth,
the mask; the mask because the air moves in and out of
usually has a narrow both.
metal strip along the
edge.
b) Hold the mask by the
top two strings.
c) Place the upper edge of
the mask over the
bridge of the nose, and
tie the upper ties at the
back of the head or
secure the loops
around the ears.
d) Secure the lower edge
of the mask under the
chin, and tie the lower
ties at the nape of the
neck.
e) If the mask has a metal  A sure fit prevents both the escape
strip, adjust this firmly and the inhalation of microorganisms
over the bridge of the around the edges of the mask.
nose  Mask should used only once because
f) Wear the mask only it becomes ineffective when wet.
once
g) Do not let a used mask
hanging around the
neck.

5. Apply clean gloves.
If wearing gowns pull the
gloves up to cover the cuffs of
the gown.

To remove soiled PPE:


6. Remove the gloves first since
they are the most soiled. If
wearing gown that is tied in
front undo ties before
removing the gloves.

7. Perform hand hygiene  Contact with microorganisms may
occur
8. Remove the gown when
preparing to leave the room
a) Avoid touching soiled
parts on the outside of
the gown.
b) Grasp the gown along
the inside of the neck
and pull down over the
shoulders. Do not
shake the gown.
c) Roll up the gown with
the soiled part inside,
and discard it in the
appropriate container .


9. Remove the mask  This prevents the top part of the
a) Remove the mask at mask from falling onto the chest.
the doorway to the
clients room. If using
respirator mask,
remove it after leaving
the room and closing
the door.
b) If using mask with
strings, first untie the
lower strings  The front of the mask through which
c) Untie the top string and, the nurse has been breathing is
while holding the ties contaminated.
securely, remove the
mask from the face. If
side loops are presents
, lift the side loops up
and away from the ears
and face. Do not touch
the front of the mask.
d) Discard a disposable
mask in the waste
container
e) Perform proper hand
hygiene again.

Applying and Removing Sterile Gloves

Purpose
 To enable the nurse to handle or touch sterile objects freely without
contaminating them.
 To prevent transmission of potentially infective organisms from the nurse's
hands to clients at high risk for infection.

Assessment
 Review the client's record and orders to determine exactly what procedure will
be performed that require sterile gloves. Check the client record and ask
about latex allergies. Use nonlatex gloves whenever possible.

Equipment
 Package of sterile gloves.

Procedure:


Step Rationale
1. Perform hand hygiene

2. Open the package of sterile gloves
a. Place the package on a clean, dry  Any moist on the surface could
surface.
b. Remove the inner package from contaminate the gloves.
the outer package.  To keep the inner surface sterile
c. Open the inner package as
instructed, if no tabs are provided,
pluck the flap so that the fingers
 Put the first glove on the dominant hand
do not touch the inner surface.
d. Grasp the glove for the dominant  The hands are not sterile. By touching
hand by its folded cuff edge on
only the inside of the gloves, the nurse
the palmer side with the thumb
and first finger of the avoids contaminating the outside.
nondominant hand. Touch only
the inside of the cuff.  If the thumb is kept against the palm, it is
e. Insert the dominant hand into the less likely to contaminate the outside of
glove and pull the glove on. Keep
the thumb of the inserted hand the glove.
against the palm of the hand
during the insertion.
f. Leave the cuff in place once the
unsterile hand releases the glove.

 Attempting to further unfold the cuff is
likely to contaminate the glove.


3. Put the second glove on the
nondominante hand
a. Pick up the other glove with the  This helps prevent accidental
sterile gloved hand. Inserting the
gloved fingers under the cuff and contamination by the bare hand.
holding the gloved thumb close to
the gloved palm
b. Pull on the second glove
carefully. Hold the thumb of the
gloved first hand as far as
possible from the palm.  In this position, the thumb is less likely to
c. Adjust each glove so that it is fits
smoothly, and carefully pull the touch the arm and become
cuffs up by sliding the fingers contaminated.
under the cuffs.

4. Remove and dispose the gloves.
 Same technique as removing
non-sterile gloves.
 Document that sterile technique
was used in the procedure.



CHANGING AN OCCUPIED BED
PURPOSES

1. To conserve the client’s energy
2. To promote client comfort.
3. To provide a clean, neat environment for the client
4. To provide a smooth, wrinkle-free bed foundation, thus minimizing sources of
skin irritation
ASSESSMENT Rationale
Assess
1 Skin condition and need for a special mattress
(e.g., an egg-crate mattress), footboard, bed
cradle, or heel protectors)
2 Client’s ability to reposition self. This will determine if additional
assistance is needed.
3 Determine presence of incontinence or excessive
drainage from other sources indicating the need
for protective waterproof pads.
4 Note specific orders or precautions for moving and
positioning the client.
PLANNING
Delegation
Bed-making is usually delegated to UAP (Unlicensed Assistive Personnel). Inform. Inform the UAP to
what extent the client can assist or if another person will be needed to assist the UAP.
Instruct the UAP about the handling of any dressing and/or tubes of the client and also the
need for special equipment (e.g., footboard, heel protectors), if appropriate.
EQUIPMENT
1. Two flat or one fitted and one flat sheet
2. Cloth draw sheet (optional)
3. One blanket
4. One bedspread
5. Pillowcase(s) for the head pillow(s)
6. Waterproof drawsheet or waterproof pads (optional)
7. Plastic laundry bag or portable lines hamper, if available

IMPLEMENTATION
Preparation

Determine what lines the client may already have This avoids stockpiling of
in the room to avoid stockpiling of the unnecessary extra linens.
unnecessary extra linens
Performance Rationale
1 Prior to performing the procedure, introduce self
and verify the client’s identity using agency
protocol. Explain to the client what you are going
to do, why it is necessary, and how he or she can
cooperate.
2 Perform hand hygiene and observe other
appropriate infection control procedures. Apply
clean gloves if linens is soiled with body fluids.

3 Provide for client privacy.
4 Remove the top bedding.
a Remove any equipment attached to the linen,
such as signal light.
b Loosen all top linen at the foot of the bed, and
remove the spread and the blanket.
c Leave the top sheet over the client (the top
sheet can remain over the client if it is being
changed and if it will provide sufficient
warmth), or replace it with a bath blanket as
follows:
a Spread the bath blanket over the top sheet.
b Ask the client to hold the top edge of the
blanket.
c Reaching under the blanket from the side, (1) Removing top linens under a bath
blanket.
grasp the top edge of the sheet and draw it
down to the foot of the bed. Leaving the
blanket in place. ( 1 )
d Remove the sheet from the bed and place
it in the soiled linen hamper.
5 Change the bottom sheet and draw sheet.
a Raise the side rail that the client will turn This protects clients from falling
toward. If there is no side rail, have another and allows them to support
nurse support the client at the edge of the bed. themselves in the side-lying
position.
b Assist the client to turn on the side away from
the nurse and toward the raised side rail.
c Loosen the bottom linens on the side of the
bed near the nurse.
d Fanfold the dirty linen (e.g., draw sheet and
the bottom sheet toward the center of the bed.
(2) As close to and under the client as
possible.

(2) Moving soiled linen as close to the
client as possible.
Doing this leaves the near half of
the bed free to be changed.
e Place the new bottom sheet on the bed, and
vertically fanfold the half to be used on the far
side of the bed as close to the client as
possible. (3) Tuck the sheet under the near
half of the bed and miter the corner if a contour
sheet is not being used.

(3) Placing new bottom sheet on half of the
bed.


f Place the clean drawsheet on the bed with the
center fold at the center of the bed. Fanfold the
uppermost half vertically at the center of the
bed and tuck the near side edge under the
side of the mattress. (4)

(4) Placing clean drawsheet on the bed.
g Assist the client to roll over toward you, over
the fanfold bed linens at the center of the bed,
onto the clean side of the bed.
h Move the pillows to the clean side for the
client’s use. Raise the side rail before leaving
the side of the bed.
i Move to the other side of the bed and lower
the side rail.
j Remove the used linen and place it in the
portable hamper.
k Unfold the fanfold bottom sheet from the
center of the bed.
l Facing the side of the bed, use both hands to
pull the bottom sheet so that it is smooth and
tuck the excess under the side of the mattress.
m Unfold the drawsheet fanfold at the center of
the bed and full it tightly with both hands. Pull
the sheet in three divisions: (a) face the side of
the bed to pull the middle division, (b) face the
far top corner to pull the bottom division, and
(c) face the far bottom corner to pull top
division.
n Tuck the excess drawsheet under the side of
the mattress.
6 Reposition the client in the center of the bed.
a Reposition the pillows at the center of the bed.
b Assist the client to the center of the bed.
Determine what position the client requires or
prefers and assist the client to that position.
7 Apply or complete the top bedding.
a Spread the top sheet over the client and either
ask the client to hold the top edge of the sheet
or tuck it under the shoulders. The sheet
should remain over the client when the bath
blanket or used sheet is removed. (5)

(5)Client hold top edge of sheet while nurse
removes bath blanket.
b Complete the top of the bed.
8 Ensure continued safety of the client.
a Raise the de rails. Place the bed in the low
position before leaving the bedside.


Attach the call light bed linen within the client’s
b
reach
c Put items used by the client within easy reach.
9 Bed-making is not normally recorded.
EVALUATION
 Conduct appropriate follow up, such as determining
client’s comfort and safety. Patency of all dranage
tubes, and client’s access to call light to summon
help when needed.
 Reassess all tubing, oxygen apparatus, IV pumps, This prevents errors in
and so forth.
supportive devices resulting from
procedure.

CHANGING AN UNOCCUPIED BED
PURPOSES

1. To promote the client comfort
2. To provide a clean neat environment for the client
3. To provide a smooth, wrinkle-free bed foundation, thus minimizing sources of skin
irritation

STEPS Rationale
Assess
In some hospital it is necessary
1 Client’s health status to determine that the person to have a written order to get out
can safely get out of bed. of bed if the client has been in
bed continuously.
Client may experience postural
2 Client’s BP, pulse and respirations if indicated. hypotension when moved from a
lying position to standing to
sitting, particularly if it is the first
time out of bed for awhile.
3 Client’s mobility status. This may influence the need for
additional assistance with
transferring the client from the
bed to a chair.
4 Tubes and equipment connected to the client. This may influence the need for
additional linens or waterproof
pads.
PLANNING

Delegation
Bed-making is usually delegated to UAP (Unlicensed Assistive Personnel). If appropriate, inform the
UAP of the proper disposal method of linens that contain drainage. Ask the UAP to inform
you immediately if any tubes or dressings become dislodged or removed. Stress the
importance of the call light being readily available while the client is out of bed.


EQUIPMENT
8. Clean gloves, if needed
9. Two flat or one fitted and one flat sheet
10. Cloth draw sheet (optional)
11. One blanket
12. One bedspread
13. Pillowcase(s) for the head pillow(s)
14. Waterproof drawsheet or waterproof pads (optional)
15. Plastic laundry bag or portable lines hamper, if available

IMPLEMENTATION

Preparation
Determine what lines the client may already have in the room to avoid stockpiling of the
unnecessary extra linens.

STEPS RATIONALE
1 If the client is in bed, prior to performing the
procedure, introduce self and verify the client’s
identity using agency protocol. Explain to the
client what you are going to do, why it is
necessary, and how he or she can cooperate.
appropriate infection control procedures.
4 Place the fresh linen on the client’s chair or over This prevents cross-
bed table; do not use another client’s bed. contamination (the movement of
microorganisms from one client
to another) via soiled linen.
5 Assess and assist the client out of bed. This ensures client safety.
a Make sure that this is an appropriate and
convenient time for the client to be out of bed.
b Assist the client to a comfortable chair.
6 Raise the bed to a comfortable working height.
7 Apply clean gloves if linens and equipment have
been soiled with secretions and/or excretions.
8 Strip the bed.
a Check bed lines for any items belonging to the
client, and detach the call bell or any drainage
tubes from the linen.
b Loosen all bedding systematically, starting at . Moving around the bed
the head of the bed on the far side and moving systematically prevents
around the bed up to the head of the bed on stretching and reaching and
the near side. possible muscle strain.
c Remove the pillowcases, if soiled, and place
the pillows on the bed-side near the foot of the
bed.


d Fold reusable lines, such as the bedspread Folding linens saves time and
and top sheet on the bed, into fourths, First, energy when reapplying the
fold the linen in half by bringing he top edge linens on the bed and keeps
even with the bottom edge, and then grasp it at them clean.
the center of the middle fold and bottom edges
(1).

(1) Fold reusable linens into fourths when
removing them from the bed.
e Remove the waterproof pad and discard it if
soiled.
f Roll all soiled linen inside the bottom sheet, These actions are essential to
hold it away from your uniform, and place it prevent the transmission of
directly in the linen hamper (2). microorganism to the nurse and
others.

(2) Roll soiled linen inside bottom sheet and hold
away from body.
g Grasp the mattress securely. Using the lugs if
present, and move the mattress up to the head
of the bed.
h Remove and discard gloves if used. Perform
hand hygiene.
9 Apply the bottom sheet and draw sheet.
a Place the folded bottom sheet with its center The top of the sheet needs to be well tucked
under to remain securely in place, especially
fold on the center of the bed. Make sure the when the head of the bed is elevated.
sheet is hem side down for a smooth
foundation. Spread the sheet out over the
mattress, and allow a sufficient amount of
sheet at the top to tuck under the mattress.
Place the sheet along the edge of the mattress
at the foot of the bed and do not tuck it in
(unless it is a contour or fitted sheet (3). (3) Placing bottom sheet on bed.
b Miler the sheet at the top corner on the near
side (see figure 33-20) and tuck the sheet under the
mattress, working from the head of the bed to
the foot.


c If a waterproof drawsheet is used, place it over
the bottom sheet so that the centerfold is at the
centerline of the bed and the top and bottom
edges extend from the middle of the client’s
back to the area of the midthigh or knee.
Fanfold the uppermost half of the folded draw
sheet at the center or far edges of the bed and
tuck in the edge (4).
(4) Placing clean drawsheet on bed.
d OPTIONAL: before moving to the other side of Completing one entire side of the
the bed, place the top linens on the hemside bed at a time saves time and
up, unfold them, tuck them in, and miter the energy.
bottom corners.
1 Move to the other side and secure the bottom
0 linens.
a Tuck in the bottom sheet under the head of the
mattress, pull the sheet firmly, and miter the
corner of the sheet.
b Pull the remainder of the sheet firmly so that Wrinkles can cause discomfort
there are no wrinkles. Tuck the sheet in at the for the client and breakdown of
side. skin. Tuck the sheet in at the
side.
c Tuck in the drawsheets, if appropriate.
1 Apply or complete the top sheet, blanket, and
1 spread.
a Place the top sheet, hem side up; on the bed
so that its centerfold is at the center of the bed
and the top edge is even with the top edge of
the mattress.
b Unfold the sheet over the bed.

c Follow the same procedure for the blanket and
the spread, but place the top edges about 15
cm (6 in.) from the head of the bed to allow a
cuff of sheet to be folded over them.
d Tuck in the sheet, blanket, and spread at the
foot of the bed, and miter the corner, using all
three layers of linen. Leave the sides of the top
sheet, blanket, and spread hanging freely
unless toe pleats were provided.
e Fold the top of the top sheet down over the The cuff of a sheet makes it
spread, providing a cuff (7). easier for the client to pull the
covers up.

(7) Making a cuff of the top linens.


f Move to the other side of the bed and secure
the bedding in the same manner.
1 Put clean pillowcases on the pillows as required.
2
a Grasp the closed end of the pillowcase at the
center with one hand.
b Gather up the sides of the pillowcase and
place them over the hand grasping the case.
Then grasp the center of one short side of the
pillow through the pillowcase.(8)

(8) Method for putting a clean pillowcase on a
pillow.
c With the free hand, pull the pillowcase over the
pillow.
d Adjust the pillowcase so that the pillow fits into A smoothly fitting pillowcase is
the corners of the case and the seams are more comfortable than a wrinkled
straight. one.
e Place the pillows appropriately at the head of
the bed.
1 Provide for client comfort and safety.
3
a Attach the signal cord so that the client can
conveniently reach it. Some cords have clamps
that attach to the sheet or pillowcase. Others
are attached by safety pin. Most bed now have
call light bottom on the side rail.
b If the bed is currently being used by a client, This makes it easier for the client
either fold back the top covers at one side or to get into the bed.
fanfold them down to the center of the bed.
c Place the bedside table and the overbed table
so that they are available to the client.
d Leave the bed in the high position if the client
is returning by stretcher, or place in the low
position if the client is returning to bed after
being up.
1 Document and report pertinent data.
4
a Bed-making is not normally recorded.
b Recording any nursing assessments, such as
the client’s physical status and pulse and
respiratory rates before and after being out of
bed, as indicated.



BODY MECHANICS
I. Definition:

Is the term used to describe the efficient, coordinated and safe use of the body to
move objects and carry out the ADL's. correct body mechanics would facilitate the
safe and efficient use of appropriate muscle group to maintain balance, reduce the
energy required, reduce fatigue, and decrease the risk of injury for both nurses and
clients, especially during transferring, lifting and reposition.

II. Effects of gravity on body balance.
A. Definition: Gravity means mutual attraction that the earth has for an object
and the object for the earth.
B. Principles of Body Balance:
1. Center of gravity is low.
2. Base support is wide.
3. Line of gravity pass through center of gravity and base of support.
C. Principles of body mechanics:
1. Center of gravity: is "the point at which all its mass is centered". An
area located in the pelvis about the level of the second sacral vertebra.
2. Base of support: "It is the area located at the base of an object". It
provides balance of equilibrium or stability especially the line of gravity
passes through the base of support and center of gravity.
3. Line of gravity: "It is an imaginary vertical line that passes through the


center of gravity and the base of support of an object". It passes behind
the ear, downward just behind the center of jip joint and then downward
slightly in front of the knee and ankle joint (it differs according to
skeletal build and curvatures in spine).
D. Example to maintain balance:
1. A box of 4 x 3 x 12 of lengths.
a. If placed on the side, measured 4 x 12
wide base → it is balanced.

b. If placed on the side, measured 3 x 12
narrow base → it is imbalanced.

2. A number of blocks:
a. Placed on each other, the balance is maintained if column is
vertical.
b. If placed in a zigzag, the weight distributed is unequal above
the lowest block; they will fall.

Remember: Balance of the human body is much more complex than that of a
solid object, but in both instances governed by the laws of gravity.

III. Principles of Body Mechanics:
1. "Maintain body balance and alignment".
The stability of an object greater when there is:
a. Wide base of support.
b. Low center of gravity passes through base of support and center of
gravity.
Example: in helping the patient to move; praying, standing, sitting, and
stooping.
2. "Work at a comfortable height".
A comfortable working height for most people is between the waist level and
the hip joint (pelvis). Working at a comfortable height helps to do the
following:
a. Minimizes muscle strain when reaching an object at high or low level.
b. Allows the body to remain aligned and balanced.
c. Allows us easily to flex the hip and knee joints.
d. Applies leverage to our work.
Example: to place or remove object from a shelf that is higher than the
head or
near the floor – hand cranks.
3. "Keep the object close to your body".
The force required to maintain body balance is greater when the line of
gravity is farthest from the center of base of support.
Example: a person holds a weight close to his body using less effort.
4. "Use of smooth coordinated movement".
Muscles tend to act in groups rather than singly.
Example: during breathing; during stooping (not bending); praying.
5. "Large muscles fatigue less quickly than small muscles".
Example: large muscles as the muscle of the buttocks and thigh; small

muscle as sacrospinal muscle of the back.

Remember: Less strain results when a heavy object is raised by flexing the
knees rather than by bending from the waist.

6. "Set or prepare the muscles for action".
The muscle is always in slight contraction. This condition is called muscle
tone.
If the nurse prepares her muscles for action prior to activity, she will protect
her ligaments and muscles from strain and injury.
a. Not to lift more than what is safe, or get help.
b. To take a deep breath.
c. Tense or contract muscles (abdomen, pelvis, buttocks, and thigh).
d. Let your breath out slowly as you lift the object.
e. Put load down occasionally.
f. Use proper body mechanics.
g. Hold object close to the body.
7. "The use of good judgment in deciding which object you can lift or carry
alone".
If in doubt, do not attempt to lift alone, and get others to help you.
Example: in moving a patient out of bed, either helpless or dependent to
some extent on a wheelchair or trolley.
8. "The use of mechanical devices and other devices can lessen the amount of
work required in movement".
Example: in using mechanical device, the nurse uses her arm as a lever.
In using other devices as draw sheet, in moving helpless patient, the drawsheet
should extend from superior aspect of patient's arm level to the inferior
aspect of the buttocks. At least 2 nurses are needed.
9. "The amount of effort (force) required to move a body or an object depends
upon the resistance of the body or object as well as the pull of gravity".
i.e., by utilizing the pull gravity rather than working against it.
Example: It is easier for the nurse to lift a patient up in the bed when he is
lying flat than in sitting position in which the resistance of the body is much
greater.
10. " The friction between an object and the surface upon which the object is
moved affects the amount of work needed to move the object".
Friction: is a force that opposes, so that less energy is needed to move
objects on smooth surfaces.
Example: when lifting a patient up in bed, it is better to provide a smooth
foundation upon which the patient can move.

11. "Pulling or sliding an object requires less than effort than lifting it".
Because lifting necessitates moving against force of gravity.
Example: if the nurse lowers the head of the bed before she helps the
patient to move up in bed; less effort is required than when the head of the
bed is raised.
12. "Using one's own weight to counteract a heavy object's weight (as patient)
requires less energy in movement.
Example: if the nurse uses her own weight to pull or push a patient, her
weight Increases the force applied to the movement".



IV. Benefits of applying principles of body mechanics:
A. Specific benefits:
1. Avoids muscle strain.
2. Uses energy efficiently.
B. General benefits.
1. The lungs and circulatory system work better.
2. The body is less easily tired by minimal muscle strain.
3. Work is less tiring and more efficient.
4. The mind is clearer, concentration is easier.
5. The physiological state is improved.
6. It gives a good impression on others.

LIFTING AN OBJECT FROM THE FLOOR

Purposes: Enables nurses to pick up an object from floor level without self injury.
Two methods are presented.

Contraindications: Assessment of the weight of the load is especially important.
Persons with back problems should not use either of the following methods without
first consulting with a physician.

Learning/Teaching Guidelines: To teach correct body mechanics to clients or to
auxiliary personnel:
1. Serve as a role model by always using good body mechanics.
2. Carefully demonstrate the specific method to be sued.
3. Provide information about the correct use of muscles and ways to use
leverage, and
4. Supervise use of the method by those whom you have taught.

Preliminary Activities:
Assessment/Planning:
► Assess weight of the load to be lifted.
► Decide the lifting technique to be used.

Procedure:
STEPS Rationale/Discussion
1 Stand near object of the load to be This stance places object nearer your
lifted. center of gravity and provides
2 Put on internal girdle. Internal girdle helps protect intervertebral
disks.

Method 1
a. Bend toward object by flexing all the This position lowers center of gravity.
hips and partially flexing at the knees.
b. Grasp object and bring it to thigh level Muscles share the workload. Back
by pulling with arm and shoulder, muscles remain contracted to protect
muscles while thigh and leg muscles the intervertebral disks.
provide an upward thrust.


c. Bring object to waist level by using the This brings load as close as possible
leg and thigh muscles for greater to center of gravity.
thrust while beginning to straighten
the back.

Method 2
a. Position feet 18 inches apart with left Position maintains wide base of
foot forward. support while allowing use of the left
knee as a fulcrum.
b. Tuck chin in and squat down with This protects intervertebral disks.
back straight.
c. Grasp object with both hands, tipping This allows firm control of object.
it if necessary to attain balance.
d. Rest left elbow on left thigh, just Position allows use of leverage.
above knee and apply pressure as
needed to stand up. Straighten legs.

POSITIONING CLIENTS

Definition:

Positioning are achieved by placing the body of their treatment or examination.
Different position are achieved by placing the body parts in correct alignment or
using the hospital bed the client’s body in desired position

Purposes:
1. Physical Examination.
2. Nursing treatment and tests.
3. Obtain specimens.
4. Operations


COMMON POSITIONS

Positions Description Areas Cautions
Examined/Indications
1

Arms are held Body contour, posture Elderly and
relaxed at sides balance, muscles and weak; patients
of the body; feet extremities. may need
6 to 8 inches support.
apart, face
should look
straight ahead.
Standing

2

Buttocks firmly on 1. Assessing vital Elderly and weak;
the edge of the bed, signs. may require
thighs well 2. Examination of support.
supported, knees the head and
bent, feet positioned neck, posterior
flat against the floor. and anterior
thorax.
3. Inspection and
Sitting palpation of
thyroid, breasts
and axilla.
4. Auscultation of
the lungs.

3

The client sits on Same as the Same as above.
the side of the bed, sitting position. Lightheadedness or
with the feet vertigo may result
dangling over its when client sits up for
edge. The client the first time.
dangles after
remaining
Dangling horizontal in bed for
position more than a day or
two.


4
Back lying Abdomen and May be difficult
position with external for clients who
knees flexed genitalia. have cardio-
and hips pulmonary
externally problems. The
rotated; small client should
Dorsal recumbent pillow under not raise arms
the head. over the head
Flexed knees or clasp the
reduce tension hands behind
on lower back the head
and abdominal because this
muscles and increases
increase client contraction of
comfort. the abdominal
muscles.

5
Back lying 1.Head, neck, Not used for
position with axillae, abdominal
legs anterior assessment
extended; thorax, because of the
Horizontal recumbent small pillow lungs, breasts, increased
under the heart, tension of
head. extremities. abdominal
2. Peripheral muscles.
pulses.

6
Back lying As for Tolerated poorly
without a horizontal by clients with
pillow. recumbent. cardiovascular
and respiratory
problems. An
alternate position
Dorsal (Supine) is to raise the
head of the bed.
Clients with low
back pains may
unable to lie flat
without flexing
the knees. Risk
for aspiration is
greater with this
position.


7
Head of bed 60º angle. Thoracic surgery, Need
severe respiratory to
conditions. suppor
t the
poplite
al
vessel
s.
High Fowler’s

8
Fowler’s Head of Post operative,
bed 45º gastrointestinal
angle, hips conditions,
may or promotes lung
may not be expansion; As
flexed. client rests, eats,
or drink; has
visitors, or wishes
to read or watch
TV.

9
Semi- Head of bed Relieving
Fowler’s 30º angle. cardiac,
respiratory
distress, and
neurological
conditions.

10
Low Head of bed Necessary
Fowler’s 15º angle. degree
elevation for
ease of
breathing,
promotes skin
integrity,
client comfort.


11
Back lying Female May be difficult
position genitalia, and tiring to
with feet rectum, and elderly people
supported female and those with
in reproductive arthritis or joint
stirrups; tract. deformities.
the hips
Lithotomy should be This position is
in line assumed
with the immediately
edge of before it is
the table. needed
because it is
embarrassing
and
uncomfortable.
The client is
kept draped.

12
Kneeling Rectal or Uncomfortable
position vaginal position,
with torso at examinations. tolerated poorly
90º angle to by clients who
hips. have
cardiovascular or
Genu-pectoral respiratory
(knee-chest) problems.

13
Standing, This is more comfortable Palpation This position is
bent-over position then knee-chest. of the assumed
the prostate immediately
examining gland. before it is
table or needed because
Jack-knife it is
position embarrassing.
Client with back
problems may
need assistance.

14
Lateral The client is Clients who are
(side supported on obese or older
lying) the right or left may not be able
side with the to tolerate this
opposite arm, position for any
thigh, and length of time.
knee flexed
and resting on Left: Rectum,
the bed. A vagina.


pillow is
placed under Right: Rectal
the head to examination,
keep the head, administering
neck, and enema or
spine in inserting a rectal
alignment. The tube.
upper arm is
flexed at the
hips and knee
positioned on
a small pillow.

15 Improper
Sim’s The client is in positioning can
semi-prone cause
position on the unnecessary
right or left side harm to clients,
with the especially if they
opposite arm, have pre-existing
thigh, and knee conditions such
flexed and as peripheral
resting on the vascular disease
bed. The or diabetes.
client’s weight Positions that
is placed on the compromise
anterior ileum, peripheral blood
humerus, and flow may
clavicle. damage nerves
as well.

1
6 Knee Lower For client’s comfort;
- sectio contraindicated for
Gatc n of vascular disorders.
h bed
(under
knees)
slightl
y bent.


17
Prone The client Contraindicated
Position lying on in possible
abdomen, complications
with the such as
head turned increasing
to the side. intracranial
This pressure or
facilitates cardiopulmonary
respiration disease.
and
drainage of
oral
secretions.
A pillow is
placed
under the
head for
comfort and
relief from
pressure.

18
Trendelenburg’s Head of Percussion,
bed vibration, and
lowered drainage,
and foot (PVD)
part raised. procedure.

19
Reverse Bed frame Gastric
Trendelenburg’s is tilted up condition
with foot of prevents
bed down. esophageal
reflux.


TRANSFERRING A PATIENT FROM BED TO CHAIR
Purpose:
To transfer a client from bed to chair, wheelchair or commode.

Assessment:

Before transferring patient assess the client the following:
1. The clients body size.
2. Ability to follow instructions.
3. Ability to bear weight.
4. Ability to position/reposition feet on floor.
5. Ability to push down with arms and lean forward.
6. Ability to achieve independent sitting balance.
7. Muscle strength.
8. Activity tolerance.
9. Joint mobility.
10. Presence of paralysis.
11. Presence of orthostatic hypotension.
12. No. assistants required.

Equipment:
1. Appropriate clothing.
2. Slippers or shoes with non skid soles.
3. Gait/transfer belt.
4. Chair, commode, wheelchair as appropriate to client need.
5. Slide/lift if needed.

Procedure:
STEPS RATIONALE
1 Identify the patient Provides patient safety.
2 Prior to performing the procedure , Will help to reduce the anxiety of
introduce self .Explain the procedure the client, and help build a trusting
to the client, why it is necessary, and relationship with the client.
how he or she can participate.
3 Gather the equipment. Provides organized approach to
task
4 Perform hand hygiene .Apply gloves To prevent risk of infection.
if performing rectal temperature.
5 Provide for client privacy. To avoid insecurity and
embarrassment.
6 Position the equipment
appropriately.
a. Lower the bed to its lowest position. So that the clients feet will rest flat
on the floor.
b. Lock the wheels of the bed. to keep the bed stationary.
c. Place the wheelchair parallel to the For easy movement.
bed and as close to the bed as
possible.
d. Put the wheelchair on the side of the For easy transfer from bed to chair.
bed that allows the client to move
toward his stronger side.


e. Lock the wheels of the wheelchair So that the chair remains stationary
and raise the footplate. while the client is being transferred.
5. Prepare and asses the client.
a. Assist the client to a sitting position To transfer the patient to the wheel
at the side of the bed. chair.
b. Asses the client for orthostatic If not assessed condition may
hypotension before moving from worsen while transferring .
bed.
c. Assist the client in putting on a bath To prevent the client from fall and
robe/appropriate clothing and injury.
nonskid slippers or shoes.
d. Place a gait/transfer belt snugly The belt helps in easy transfer of
around the client's waist. Check that the client without discomfort.
the belt is securely fastened.
6. Give explicit instructions to the client.
Ask the client to:
a. Move forward and sit on the edge of This brings the client's center of
the bed with feet placed flat on the gravity closer to the nurses.
floor.
b. Lean forward slightly from hips . This brings the clients center of
gravity more directly over the base
of support and position the head
and trunk in the direction of
movement.
c. Place the foot of the stronger leg In this way the client can use the
beneath the edge of the bed and put stronger leg muscles to stand and
the other foot forward. power the movement.
d. Place the client's hand on the bed's This provides additional force for
surface so that the client can push the movement and reduces the
while standing. potential for strain on the nurses'
back.
7. Position yourself correctly.
a. Stand directly in front of the client Helps prevents loss of balance
and to the side requiring the most during transfer.
support. Hold the gait/transfer belt
with the nearest hand ;the other
hand supporting the back of the
clients shoulder.
b. Lean your trunk forward from hips. Helps prevents loss of balance
Flex Your hips ,knees and ankles. during transfer.

c. Assume a broad stance, placing one To prevent the client from sliding
foot forward and one back. Brace the forward or laterally.
client's feet with your feet .
8. Assist the client to stand and then Coordination allows easy transfer.
move together towards the
wheelchair.


a. On the count of three or verbal If there is in coordination in lifting it
instructions ask the client to push will be discomfortable for both the
down against the mattress /side of patient and the nurse.
the bed while you transfer your
weight from one foot to the
other(keeping your back straight)
and stand upright moving the client
forward into a standing position.
b. Support the client in an upright This allows the nurse and client to
position for a few moments. extend the joints and provides the
nurse with an opportunity to ensure
the client is stable before moving
from bed.
c. Together pivot your foot farthest Pivoting the farthest foot will assist
from the chair or take a few steps in balancing body and maintaining
towards the chair. the centre of gravity.
9. Assist the client to sit.
a. Have the client back upto the Minimizes the risk of client falling
wheelchair and place the client's while sitting down.
legs against the seat
b. Make sure the wheelchair brakes are To securely allow the client to sit on
on. the chair and prevent fall.
c. Have the client reach back and To prevent falling.
feel/hold the arms of the wheelchair.
d. Stand directly in front of the client To equally distribute the centre of
.place one foot front and one back. gravity.
e. Tighten your grasp on the transfer To securely hold the client while
belt, and tighten your gluteal, sitting and prevent fall.
abdominal, leg and arm muscles.
f. Have the client sit down while you Bending knees and hips prevents
bend your knees/hips and lower the strain on the back of the nurse.
client onto the wheelchair seat.
10. Ensure client safety.
a. Ask the client to push back into the Provides a broader base of support
wheelchair seat. and greater stability, minimizes the
risk of falling from the wheelchair.
b. Remove the gait/transfer belt. To replace the equipment after use.
c. Lower the footplates and place the To give support to the feet.
clients feet on them.
Variation: For clients having This allows the client to pivot into
difficulty in walking place the the chair easily without much
wheelchair at 45°angle to the bed. movement.


Variation : For transferring with a This can be used to move heavy
belt and two nurses., position patients easily.
yourselves on both sides of the
client, facing the same direction as
the client.
Flex your hips, knees, and ankles
.Grasp the clients' transfer belt with
the hand closest to the client, with
the other hand supporting the client's
elbows. coordinating , all three
should pivot towards the wheelchair.
Variation: For clients who cannot This method promotes client's
stand but are able to co-operate and sense of independence but also
possess sufficient upper body preserves your energy.
strength, use a sliding board to help
them move without nursing
assistance.
11. Wash hands To prevent cross infection.
12. Replace equipment. For further use.
13. Document information. For further follow up.

BATHING ADULT CLIENT
PURPOSES
1. To remove transient microorganisms, body secretions and excretion and dead skin
cells.
2. To stimulate circulation to the skin.
3. To promote sense of well-being.
4. To produce relaxation and comfort.
5. To prevent and eliminate unpleasant body odors.

ASSESSMENT

1. Physical or emotional factors (e.g. fatigue, sensitivity to cold, need for control, anxiety
or fear).
2. Condition of the skin (color, texture and turgor, presence of pigmented spots,
temperature, lesions, excoriation, abrasion, and bruises).areas of erythema (redness)
on the sacrum, bony prominences, and heels should be assessed for possible
pressure sores.
3. Presence of pain and need for adjunctive measures (e.g., an analgesic) before the
bath.
4. Range of motion of the joints.
5. Any other aspect of health that may affect the client’s bathing process (e.g., mobility,
strength, cognition).
6. Need for use of clean gloves during the bath.


Equipment
 Basin or sink with warm water (43 C˚ -46 C˚).
 Soap and soap dish.
 Linens: bath blanket, two bath towels, washcloth, clean gown or pajamas or clothes
as needed, additional bed linen and towels, if required.
 Clean gloves, if appropriate (e.g., presence of body fluids or open lesions).
 Personal hygiene articles (e.g., deodorants, powder, lotions).
 Shaving equipment.
 Laundry bag.

IMPLEMENTATION

Before start bathing your client you must be aware for the following
a. Purpose and type of bathing.
b. Self-care ability of the client.
c. Any position or movement precautions for the client.
d. Coordinate all aspects of health care and prevent unnecessary fatigue. Such as x-
ray or physical therapy…etc.
e. Client comfort level with being bathed by someone else.
f. Presence of all equipment and linens before starting bathing.

STEPS Rational
 Prepare the bed and position the
client appropriately
 Position the bed at a comfortable This avoids undue reaching and straining
working height. Lower the side rails on and promotes good body mechanics. And
the side close to you. Keep the other ensure patient safety
side rail up. Assist the client to move
near to you.
 Place bath blanket over top sheet. The bath blanket provides comfort, warmth
Remove the top sheet from under the and privacy.
bath blanket by starting at client’s
shoulder and moving linen down
toward client’s feet.[ask the client to
grasp and hold the top of bath blanket
while pulling linen to the foot of the
bed].

 NOTE: if the bed linen is to be reused,
place it over the bed side chair. If it is
to be changed, place it in the linen
hamper, not on the floor.

 Remove client’s gown while keeping
the client covered with bath blanket.
Place gown in linen hamper.
 Make a bath mitt with washcloth. A bath mitt retains water and heat better
than cloth loosely held and prevents ends
of washcloth from dragging across the skin



Making a bath mitt, triangular method. (A) Lay your hand on the washcloth; (B) fold
the top corner over
Your hand; (C) fold the side corners over your hand; (D) tuck the second corner under
the cloth on the palm side to secure the mitt.

A B C D

Making a bath mitt, rectangular method. (A) Lay your hand on the washcloth and fold
one side over your hand; (B) fold the second side over your hand; (C) fold the top of the
cloth down and tuck it under the folded side against your palm to secure the mitt.

A B D
 Wash the face. Begin the bath at the cleanest area and
work downward toward the feet.
 Place towel under patient’s head.

 Wash the patient’s eyes with water only Using separate corners prevents
and dry them well. Use a separate transmitting micro-organisms from one eye
corner of the washcloth for each eye. to the other.

 Wipe from the inner to the outer This prevents secretions from entering the
canthus. nasolacrimal ducts.

 Ask whether the patient wants soap Soap has a drying effect, and the face,
used on the face. which is exposed to the air more than
other body parts, tends to be drier.
 Wash, rinse, and dry the patient’s face,
ears and neck.
 Remove the towel from under the
patient’s head.
 Wash the arms and hands. (Omit the
arms for a partial bath.)
 Place a towel lengthwise under the arm It protects the bed from becoming wet
away from you.


 Wash, rinse and dry the arm by Firm strokes from distal to proximal areas
elevating the patient’s arm and promote circulation by increasing venous
supporting the patient’s wrist and elbow. blood return.
Use long, firm strokes from wrist to
shoulder, including the axillary area.

 Apply deodorant or powder if desired.
 (Optional) Place a towel on the bed and Many patients enjoy immersing their hands
put a washbasin on it. Place the in the basin and washing themselves.
patient’s hands in the basin. Soaking loosens dirt under the nails.
Assist the patient as needed to wash, rinse
and dry the hands, paying particular
attention to the spaces between the
fingers.
 Repeat for hand and arm nearest you. A clear transparent dressing will keep
Exercise caution if an intravenous water from an IV site; however, a gauze
infusion is present, and check its flow dressing becomes contaminated when it
after moving the arm. became wet with the water.
 Avoid submersing the IV site is not
clear, transparent dressing.

 Wash the chest and abdomen. (Omit
the chest and abdomen for a partial
bath. However, the areas under a
woman’s breast may require bathing
if this area is irritated or if the
patient has significant perspiration
under the breast.)
 Place bath towel lengthwise over Keeps the patient warm while preventing
chest. Fold bath blanket down to the unnecessary exposure of the chest.
patient’s pubic area.
 Lift the bath towel off the chest, and
bathe the chest and abdomen with
your mitted hand using long, firm
strokes (Figure 13-9). Give special
attention to the skin under the breasts
and any other skin folds particularly if
the patient is overweight. Rinse and
dry well.
 Replace the towel when the areas
have been dried.
 Wash the legs and feet. (Omit legs
and feet for a partial bath.)


 Expose the leg farthest from you by Covering the perineum promotes privacy
folding the towel toward the other leg and maintains the patient’s dignity.
being careful to keep the perineum
covered.
 Lift leg and place the bath towel Washing from the distal to proximal areas
lengthwise under the leg. Wash, rinse promotes circulation by stimulating venous
and dry the leg using long, smooth, blood flow.
firm strokes from the ankle to the knee
to the thigh.

 Reverse the coverings and repeat for
the other leg.
 Wash the feet by placing them in the
basin of water.

 Dry each foot. Pay particular attention
to the spaces between the toes. If you
prefer, wash one foot after that leg
before washing the other leg.
 Obtain fresh, warm bathwater now or Because surface skin cells are removed
when necessary. Water may become with washing, the bathwater from dark-
dirty or cold. skinned patients may be dark, however,
this does not mean the patient is dirty.
 Lower the bed and raise side rails This ensures the safety of the patient.
when refilling basin.
 Wash the back and then the
perineum.
 Assist the patient into a prone or side- This provides warmth and undue
lying position facing away from you. exposure.
Place the bath towel lengthwise
alongside the back and buttocks while
keeping the patient covered with the
towel as much as possible.


 Wash and dry the patient’s back,
moving from the shoulders to the
buttocks, and upper thighs, paying
attention to the gluteal folds

 Remove and discard gloves if used.
 Perform a back massage now or after
completion of bath.
 Assist the patient to the supine position
and determine whether the patient can
wash the perineal area independently.
If the patient cannot do so, cover the
patient as shown in picture and wash
the area.

 Assist the patient with grooming aids
such as powder, lotion, or deodorant.
 Use powder sparingly. Release as little This will avoid irritation of the respiratory
as possible into the atmosphere. tract by powder inhalation. Excessive
powder can cause caking, which leads to
skin irritation.
 Help the patient put on fresh clothing.

 Assist the patient to care for hair,
mouth, and nails. Some people prefer
or need mouth care prior to their bath.

Tub Bath/ Shower
 Prepare the client and the tub.
 Fill the tub about one-third to one-half Sufficient water is needed to cover the
full of water, put cold water in before perineal area.
hot.
( temperature 43-46C˚ )

 Cover all intravenous catheters or
wound dressings with plastic
coverings, and instruct the patient to
prevent wetting these areas if
possible.
 Put a rubber bath mat or towel on the These prevent slippage of the patient
floor of the tub if safety strips are not during the bath or shower.
on the tub floor.
 Assist the patient into the shower
or tub.


 Assist the patient taking a standing
shower with the initial adjustment of
the water temperature and water flow
pressure, as needed. Some patients
need a chair to sit on in the shower
because of weakness. Hot water can
cause elderly people to feel faint due
to vasodilation and decreased blood
pressure from positional changes.
 If the patient requires considerable
assistance with a tub bath, a
hydraulic chair may be required (see
Variation below).
 Explain how the patient can signal for
help; leave the patient for 2–5
minutes, and place an “occupied” sign
on the door. For safety reasons, do
not leave a patient with decreased
cognition or patients who may be at
risk (e.g. history of seizures,
syncope).
 Assist the patient with washing
and getting out of the tub or bath.
 Wash the patient’s back, lower legs,
and feet, if necessary.
 Assist the patient out of the bath. If Draining the water first lessens the
the patient is unsteady, place a bath likelihood of a fall. The towel prevents
towel over the patient’s shoulders and chilling.
drain the water before the patient
attempts to get out of it.

 Dry the patient, and assist with
follow-up care.
 Assist the patient with grooming aids
such as powder, lotion, or deodorant.
 Assist the patient back to his or her
room.
 Discard the used linen in the laundry
skip.
 Place the “unoccupied” sign on the
door.

Documentation:
 Type of bath given (i.e. complete, partial, or self-help).
 Skin assessment, such as excoriation, erythema, exudates, rashes, drainage or skin
breakdown.
 Nursing interventions related to skin integrity.
 Ability of the patient to assist or cooperate with bathing.
 Patient response to bathing.
 Educational needs regarding hygiene.
 Information or teaching shared with the client or their family.



COLLECTING SPUTUM SPECIMEN

I. Definition:

Sputum – is the mucous secretion from the lungs, bronchi, and
trachea. It is important to differentiate it from saliva, a watery
substance located in the mouths of organisms, secreted by the Salivary
Glands sometimes referred to as |”spit.” Healthy individuals do not
produce sputum. Clients need to cough to bring sputum up from the
lungs, bronchi, and trachea into the mouth in order to expectorate it
into a collecting container.

II. Purposes:

1. For culture and sensitivity to identify a specific microorganism and its
drug sensitivities.
2. For cytology to identify the origin, structure, function, and pathology of
cells. Specimens for cytology often require serial collection of three
early-morning specimens and are tested to identify cancer in the lung
and its specific cell type.
3. For acid-fast bacillus (AFB), this also requires serial collection, often for
3 consecutive days, to identify the presence of tuberculosis (TB).
4. To assess the effectiveness of therapy.

III. Supplies and Equipment:

Rationale
1. Sputum container with a tight cover For collecting the sputum; tight cover
ensures that the outside of the
container is free of sputum.
2. Facial tissues. Available for the client if there is
excessive tearing or coughing following
culture.
3. Identification labels. Prevents errors by correctly labeling the
culture tube.
4. Laboratory requisition form. Informs the laboratory of the client’s
identification or other required
information.
5. Emesis basin Available in case the client gags and
vomits following the throat culture.
OPTIONAL: Clean Gloves & Mask.

IV. Procedure:

STEPS Rationale
1 Wash hands then wear gloves & To prevent spread of microorganisms
personal protective equipment. and to avoid contact with the sputum.
2 Gather supplies and equipment. To save time, effort and energy.


3 Follow special precautions if If these options are not available, wear
tuberculosis is suspected, a mask capable of filtering droplet
obtaining the specimen in a room nuclei.
equipped with a special airflow
system or ultraviolet light.
4 Explain to the client what will be Informs client; encourages participation
done; instruct in whatever way is and cooperation; lessens anxiety.
necessary.
5 Draw the curtain or close the Provides privacy.
door to the room if the client
desires privacy.
6 Position the client so that he or Place the client in an optimal position to
she is upright. fully expand thee lungs and forcefully
expel air and secretions.
7 Give the specimen container Prevents contamination with
properly labeled to the client with microorganisms.
the cover removed. Warn not to
touch the inside of the container.
8 Encourage the client to take Promotes full lung expansion to loosen
several deep breaths with full and expel secretions.
expiration.
9 Instruct the client to cough Forces secretions into larger airways,
deeply, raising secretions from facilitating their expulsion.
the deep airways.
10 Instruct the client to expectorate
directly into the container.
11 Instruct the client to repeat the Provides and adequate amount of
deep breathing and coughing sputum for diagnostic testing.
sequence until approximately 5
ml of sputum in the container.
(Note: Clarify the amount with the
agency laboratory).
12 Provide comfort measures for the
client as necessary.
13 Wash hands Limits transfer of microorganisms.
14 Send the specimen container to Ensures prompt analysis and accurate
the laboratory according to the test results.
agency guidelines.



COLLECTION and TESTING of URINE

Definition:

Urinalysis – the analysis of urine samples. It is a part of the examination of every
patient at the beginning and during illness.

a. Amount of urine:
i. 1200 – 1500 ml / 24 ° = normal.
1. Less than 500 cc / 24 ° = oliguria.
2. More than 1500 cc / 24 ° = polyuria.

ii. Day volume is 2 – 3 times more than night volume.

b. Appearance / Clarity:
i. Normal urine is clear.
ii. Turbid (cloudy) urine is not always pathologic. Normal urine
may develop turbidity on refrigeration or from standing at room
temperature; bacteria ferment urine quickly at room
temperature.
iii. Abnormally cloudy urine – due to pus, blood, epithelial cells,
bacteria, fat, colloidal particles, phosphate, urates.
c. Odor:
i. Normal – faint aromatic odor.
ii. Characteristic odors produced by ingestion of asparagus,
thymol.
iii. Cloudy urine with ammonia odor – urea-splitting bacteria such
as Proteus, causing urinary tract infection.
iv. Abnormally colored urine:


a) Turbid or smoky - may be from hematuria,
urine. spermatozoa, prostatic fluid, fat
droplets, chyle.
b) Red or red brown. - may be due to blood pigments,
porphyria, transfusion reaction,
bleeding lesions on urogenital tract,
some drugs.
c) Yellow-brown or - may reveal obstructive lesions of
green-brown. bile duct.

d. Reaction:
i. Reflects the ability of kidney to maintain normal hydrogen ion
concentration in plasma and intracellular fluid; indicates acidity
or alkalinity or urine.
ii. The pH should be measured in fresh urine, since the
breakdown of urine to ammonia causes urine to become
alkaline.
iii. Normal pH is around 6 (acidic); may vary from 4.6 – 7.5.
iv. Urine acidity or alkalinity has relatively little clinical significance
unless the patient is on special diet or therapeutic program or
is being treated for renal calculous disease.
v. Alkaline urine is often cloudy because of phosphate crystals.

e. Specific gravity:
i. Reflects thee kidney’s ability to concentrate or dilute urine;
may reflect degree of hydration or dehydration.
ii. Normal specific gravity ranges from 1.005 – 1.025.
iii. Specific gravity is fixed at 1.010 in chronic renal failure.
iv. In a person eating a normal diet, inability to concentrate or
dilute urine indicates disease.

f. Osmolality:
i. Osmolality is an indication of the amount of osmotically active
particles in urine (specifically, it is the number of particles per
unit volume of water). It is similar to specific gravity, but is
considered a more precise test. It is also easy to do – only 1 –
2 ml of urine is required.
ii. The unit osmotic measure is the osmole.
Average values: Female: 300 – 1090 mosm / kg.
Male: 390 – 1090 mosm / kg.

Normal Findings in Routine Urinalysis:

Element Findings
MACROSCOPIC
Color Pale straw or amber.
More concentrated in the morning.
Odor Slightly aromatic.
Appearance Clear
Specific Gravity 1.010 – 1.025


pH 4.5 – 8.0 (average pH 6, 7- neutral, less than 7 acidic, greater than 7
alkaline).

Protein None
Glucose None
Ketones None
Sugar None
MICROSCOPIC
RBCs 0 – 3 / high-power field
WBCs 0 – 4 / high-power field
Epithelial Cells Few
Casts None, except occasional hyaline casts
Crystals Present
Yeast Cells None
Parasites None

Types of Urine Specimen:
1. Clean urine specimen or random routine urine specimen, or routine urinalysis
can be collected with a client voiding naturally through a Foley catheter or
urinary diversion collecting bag. The specimen should be clean but need not
be sterile. It is commonly used to screen urinary and systemic pathologies.
The elements of routine urinalysis are the macroscopic and microscopic.
2. Midstream specimen of clean voided or clean catch – to obtain a specimen
relatively free of microorganisms growing in the lower urethra but the sterile
procedure of catheterization is undesirable. Used for urine culture and
sensitivity.
3. 24-Hour Urine – done when a large quantity of urine is necessary to analyze
for protein and creatinine clearance.
4. Catheterized specimen – used for culture.
5. Indwelling catheter urine – urine is obtained from an indwelling catheter for
culture.
6. Double-voided specimen – used to accurate measurement of glucose and
ketones.
7. Use of Keto-Diastix, Multistix, Tes-Tape reagent strips – used to detect
glucose and ketones.

Purposes:
1. The client understands the need for the urine specimen and will be able
to provide a specimen unassisted in the future.
2. The client provides a clean or sterile urine specimen in the manner
described by the nurses within a reasonable time.

Key Points:
1. Assess the client’s ability to collect specimen independently.
2. Determine the last time the client voided.


Obtaining a clean urine specimen or random urine specimen:

STEPS Rationale

Collection by the patient:
1 Give client the urine container
properly labeled with client’s
identification (name, medical
record number, sex, age) [date
and time of urine collection will
be written after collection].
2 Instruct the patient on how to Provides the client with the information
properly collect. needed to collect specimen.
3 Send the urine to the laboratory Ensures accurate testing and
immediately or within 2 hours documentation.
with the properly filled up
laboratory requisition form.

Collection done by the nurse:
1 Wash hands. To prevent spread of microorganisms.
2 Collect needed supplies and To save time, effort and energy.
equipment:
a. Urine container properly
labeled with
Client’s identification.
b. Urinal (male) or bedpan
(female).
c. Toilet tissues.
d. Laboratory requisition form.
3 Explain the purposes(s) and To gain client’s cooperation.
procedure of the test.
4 Put on disposable gloves, place
urinal or bedpan in position.
Instruct client to void.
5 Dry client’s urethral opening Microorganisms thrive in wet areas.
with tissue and after voiding.
6 Remove urinal and bedpan, Ensures client’s comfort.
cover, and take it into the
bathroom or the utility room.
7 Put a designed amount of urine
into the urine container and
cover it tightly. Discard the
remainder.
8 Clear the urinal and bedpan, put Limits transfer of microorganisms.
back to proper place. Discard
gloves and wash hands.
9 Send to the laboratory Ensures accurate testing and
immediately or within 2 hours documentation.
with properly filled up laboratory
form.


Obtaining a midstream urine specimen:

A. Collection done by the patient:
1 Instruct the client on the purposes of
urine collection and to prepare the
needed supplies and equipment:
a. Sterile urine container properly labeled
with client’s identification.
b. Soap and water
c. Disposable washcloth.
d. Antiseptic solution
e. Sterile cotton balls
f. Laboratory requisition form
2 Instruct the client of the procedure.

Retract the foreskin if
Cleansing the female urinary needed. Using a towelette,
meatus, spread the labia minora cleanse the urinary meatus
with one hand and with the other by moving in a circular
hand, cleanse the perineal area motion from the center of the
from front to back. uretral openining around the
glans and down the distal
portion of the shaft of the
penis.
a. Wash hands To prevent transfer of microorganisms.
b. Clean the perineal area around the Removes most pathogenic organisms from the area
urinary meatus using the disposable around urethra, thus decreasing potential contamination of
the urine specimen.
washcloth.
c. Wash hands again. Limits transfer of microorganisms.
d. Soak the cotton ball after one use.
e. Using a cotton ball, clean around Removes microorganisms from peri-urethral
external meatus with a single stroke. area.
f. Discard cotton ball after on use. Avoids contamination.
g. Continue the cleansing action Removes microorganisms from the peri-urethral
discarding all used balls. area.
h. Void a small amount; hold the urinary Flushes away microorganisms from urethra.
stream.
i. Void urine into the sterile specimen Collects specimen with minimal contamination.
container, holding the container only
on the outside.
j. Stop voiding when container is about three- Prevents overflow in specimen container.
quarters full; void remaining urine in toilet,
bedpan, or urinal. Cover the container tightly
without touching the inside of the container.
k. Wash hands. Final hand wash is to remove any contamination
of hands from possible contact with urine.

B. Collection done by the Nurse:
1 Wash hands and put on clean gloves. Limits transfer of microorganisms.


2 Gather needed supplies and To save time, effort and energy.
equipment:
a. Sterile urine container.
b. Bedpan or urinal.
c. Sterile cotton balls.
d. Antiseptic soap.
e. Disposable washcloth.
f. Disposable gloves.
3 Explain purposes and procedure to the To gain client’s cooperation.
client.
4 Pull on the curtain or close the door. To provide privacy.
5 Put on disposable gloves.
6 Soak the cotton balls with antiseptic Prepares equipment; client will not have to wait
soap and set them aside. for this part of the procedure.
7 Place the female client on a bedpan.
Place urinal under the male client’s
penis.
8 Clean the area around the urinary Removes microorganisms, a decreasing
meatus using disposable washcloth. possible contamination of specimen.
9 Discard gloves, wash hands, and put Removes microorganisms that may be present
on clean gloves. after cleaning the perineal area.
10 Clean around the meatus (if client is Prevents fecal contamination of meatus.
male); clean from pubis to rectum (if
client is female) with the cotton balls
using single strokes.
11 Discard balls after single use. Repeat Prevents recontamination with used cotton balls.
cleansing.
12 Instruct the client to void a small Washes away microorganisms in and around
amount of urine into the bedpan or meatus.
urinal, then to hold the urine stream.
13 Place a sterile specimen near urethra; Collects the specimen with few if any
instruct the client to void again. microorganisms.
14 When container is nearly full, instruct Prevents overflow from specimen container.
the client to hold the urine into the
bedpan or urinal.
15 Instruct the client to void the remainder
of the urine into the bedpan of urinal.
16 Lift the client from bedpan or remove
urinal. Leave the client comfortable.
17 Close specimen container with a sterile Prevents further contamination by
top and without touching the inside of microorganisms.
the container.
18 Discard gloves and wash hands. Limits transfer of microorganisms.
19 Send to laboratory immediately with
properly filled up laboratory requisition
form.


Collecting urine specimen from Indwelling Catheter:

1 Wash hands. To prevent the spread of
microorganisms.
2 Prepare needed supplies and To save time, effort and energy.
equipment:
a. Sterile urine container properly
labeled with client’s identification.
b. Disposable 10 ml syringe with
needle.
c. Antiseptic swab or alcohol swab.
d. Clamp.
e. Disposable clean gloves.
3 Explain the purposes and procedure to To gain client’s cooperation.
the client.
4 Pull the curtain or close the door. To provide privacy.
5 Put on disposable gloves.
6 Inspect the urinary drainage tubing for Determines if sufficient amount is
amount of urine in the tubing. present to withdraw for specimen.
7 Clamp the drainage tubing at least 3 Blocks urine from draining into the
in. below the sampling port (if it collecting bag; thus rubber
contains little urine) by using a U accumulates a sufficient amount
clamp or folding the tubing and of specimen.
securing a band around the fold.
8 Leave the clamp in place for 30 Allows enough time for urine to
minutes. drain.
9 Locate the specimen port with an Identifies the area designated for
antiseptic swab. withdrawing urine from a drainage
system.
10 Clean the port with an antiseptic swab. Removes microorganisms from
the port.
11 Insert the needle of the 10 ml syringe
through the port.

Obtaining a urine specimen from a retention catheter:
A. From a specific area near the end of the
catheter.
B. From an access port in the tubing.
A B

12 Unclamp the tubing and withdraw the For example, 3 mL for a urine culture or
required amount of urine. 30 mL for a routine urinalysis.
(Depending on the system).
13 Transfer the urine to the specimen If a sterile culture tube is used, make
container. sure the needle or syringe does not touch
the outside of the container to prevent
recontamination.
14 Discard the syringe and needle in an
appropriate sharps container.

15 Cap the container.
16 Remove gloves and discard. Perform
hand hygiene.
17 Label the container, and send the
urine to the laboratory immediately for
analysis or refrigerator.
18 Record collection of the specimen and
any pertinent observations of the urine
on the appropriate records.

Collecting 24-hour urine specimen:

1 Collect the needed supplies and To save time, effort and energy.
equipment.
a. Large size urine collector properly
b. Bedpan or urinal
c. Bucket with container or
refrigerator.
d. Laboratory requisition form.
2 Explain the procedure to the client. Informs the client and gives
instructions on what he or she is to
do to help. Often the client is the key
person in the success of a 24-hour
collection because he or she
reminds all people to save the urine.
3 Place the container in a large Prevents the urine from
container filled with ice; place this on deteriorating.
the client’s bathroom or nearby
storage area.
4 Instruct the client to void and discard
the specimen.
5 Record the time and date of Ensures that all urine from this point
discarded specimen on the on is collected.
collection container. This is the
starting time of the collection.
6 Place all voided urine in the Ensures that urine is saved; this is
container during the next 24 hours. critical for the accuracy of the test.
7 Let client void (in toilet, bedpan, or
urinal). Collect urine or pour urine
from the bedpan or urinal into the
urine container.
8 Send to the laboratory immediately
requisition form.


Testing urine for contents (sugar and ketones):

A. Double-voided urine.
equipment.
a. Urine container properly labeled
with client’s identification.
b. Tissue
c. Urinal or bedpan.
d. Water to drink.
2 Explain purpose and procedure to To gain client’s cooperation.
client.
4 Ask client to void and discard urine.
5 Let client drink water, around 8 oz.
6 Wait for 30 – 45 minutes.
7 Let client to void (in toilet, bedpan, or urinal).
Collect urine or pour urine from the bedpan
or urinal.
8 Send to the laboratory immediately To ensure accuracy.
requisition form.
Using reagent strip.

After dipping the reagent strip (dipstick)
into fresh urine, wait the stated time
period and compare the results to the
color chart.
1 Wash hands. To prevent the spread of
microorganisms.
equipment
a. Sterile urine container properly
b. Reagent strip.
c. Disposable gloves (optional)
3 Explain to the client what will be Informs the client.
done.
4 Read instructions on the testing kit to Instructs on how to use the test
determine how much urine is materials. Techniques vary with
needed. many different brands.
5 Wash hands and put on gloves. Limits transfer of microorganisms.
6 Collect the urine specimen.
7 Take the specimen to a work area.
8 Dip reagent strip in the urine Strip contains chemicals that
specimen and pull it out immediately. change colors when exposed to
glucose and ketones.


9 Remove excess urine from the
reagent strip.
10 Wait for 15 to 30 seconds depending
on the manufacturer’s instructions.
11 Compare the strip’s color with that of The color scale measures the
the chart on the bottle. quality of glucose and ketones The
range of the color scales extends
from negative, trace, 1+, 2+, 3+.
12 Discard urine and reagent strip.
13 Remove gloves and wash hands.
14 Inform the client of the results and
record.

COLLECTION and TESTING of STOOL

I. Introduction:

Stool specimen yields information related to functioning of the
gastrointestinal system and its accessory organs.
a. Test for ova and parasites (O & P) – indicates the presence of
gastrointestinal parasites and / or their eggs ova.
b. Guaiac or Hemoccult or occult blood test – used to test presence of
blood in stool.

Fecal Characteristics:
Character Normal Abnormal Cause
Color Infant: Yellow White or Clay Absence of bile.
Adult: Brown – due to
metabolism of bile Black or tarry Iron ingestion or
pigments to upper GI bleeding.
stercobilin.
Red (melena) Lower GI bleeding,
hemorrhoids.

Pale with fat Malabsorption of fat.
Odor Pungent: affected by Noxious change. Blood in feces or
food type – results infection.
from the presence of
indole and skatole,
end products of
protein catabolism by
bacterial action in the
large intestines.
Consistency Soft, formed Liquid Diarrhea, reduced
absorption.

Hard Constipation.


Frequency Infant: Infant: more than 6 x Hypomotility or
Breastfed – 4 to 6 x / day or less than hypermotility.
daily once every 1 – 2
Bottle-fed – 1 – 3 x days.
daily
Adult: More than 3 x
Adult: daily or 3 x per a day or less than
week. once a week.
Amount 150 Gm/day Narrow, pencil Obstruction, rapid
shape resembles diameter shaped. peristalsis.
of rectum.
Constituents Undigested food, Blood, pus, foreign Internal bleeding,
dead bacteria, fat, bodies, mucus, infection, swallowed
bile pigment, cells worms. objects, irritation,
lining intestinal inflammation.
mucosa, water.

II. Objectives:
1. The client understands the purpose of the diagnostic test, as evidenced
by ability to explain it.
2. The client eliminates sufficient stool to provide a specimen for the
diagnostic test.

III. Key Points:
1. Assess the client’s understanding of the test and ability to collect the
specimen independently.
2. Determine the time of the client’s last bowel movement.
3. Wearing disposable gloves use a tongue depressor to transfer stool
from bedpan to specimen container.
4. Label specimen correctly.
5. Test specimen by following instructions on test packet.
6. Record results of specimen test in the health record.

IV. Supplies and Equipment:

Action Rationale
1. Bedpan, commode, ordinary Provides receptacle for stool
collecting hat.
2. Toilet tissue. Cleans perineal area after defecation.
3. Disposable gloves. Protects the nurse’s hands.
4. Tongue blades. Transfers stool from one container to
another.
5. Specimen container. Collects stool for testing.

V. Procedure:
Action Rationale

Collecting s Stool Specimen:
1 Explain the purpose of the test to Informs the client and encourages
the client. participation.


2 Describe how the specimen is to be Instructs the client who is to collect
collected. own stool.
3 Instruct the client to save his or her Collects specimen that is free of
stool in a bedpan and to discard urine, water, and toilet paper.
toilet paper elsewhere.

If the client is unable to collect specimen:
1 Wash hands. To prevent spread of
microorganisms.
2 Gather the needed equipment and To save time, effort and energy.
supplies; label the specimen
container with appropriate
identification and fill up the lab.
request form.
3 Explain the purposes(s) and Informs the client and encourages
procedure of the test. participation.
5 Remove bedpan (or commode pan)
with stool after the client evacuates.
6 Cover the bedpan and take it to the Removes stools from the client’s
bathroom or dirty work area. bed unit to minimize embarrassment
or discomfort.
7 Use tongue blades to transfer stool
from bedpan to a specimen
container. Transfer as much as is
required for the test. Place lid
securely on the container.
8 Discard tongue blades and excess
stool, wash bedpan.
9 Discard gloves and wash hands. Limits transfer of microorganisms.
10 Send specimen to the laboratory Ensures accurate testing.
immediately.
11 Record date and time of stool
collection and results.

OBTAINING A CAPILLARY BLOOD SPECIMEN TO MEASURE
BLOOD GLUCOSE

PURPOSES

1. To determine or monitor blood glucose levels of clients at risk for hyperglycemia or
hypoglycemia

2. To promote blood glucose regulation by the client

3. To evaluate the effectiveness of insulin administration


ASSESSMENT

Before obtaining a capillary blood specimen, determine:

1. The policies and procedures for the facility
2. The frequency and type of testing
3. The client’s understanding of the procedure
4. The client’s response to previous testing
5. Assess the client’s skin at the puncture site to determine if it is intact and the circulation
is not compromised. Color, warmth, and capillary refill.
6. Reviewed the client’s record for medications that may prolong bleeding such as
anticoagulants, or medical problems that may increase the bleeding response.
7. Assess the client’s self-care abilities that may affect accuracy of test results, such as
visual impairment and finger dexterity.
PLANNING

Delegation

Check the policy and procedure manual to determine who can perform this skill. It is
usually considered an invasive technique and one that requires problem solving and
application of knowledge. It is the responsibility of the nurse to know the results of the
test, and supervises unlicensed assistive personnel responsible for assisting the nurse.

EQUIPMENT

1. Blood glucose meter (glucometer)
2. Blood glucose reagent strip compatible with the
meter
3. 2 x 2 gauze
4. Antiseptic swab
5. Clean gloves
6. Sterile lancet ( a sharp device to puncture the skin)
7. Lancet injector (a string-loaded mechanism that
holds the lancet)

IMPLEMENTATION

Preparation

 Review the type of meter and the manufacturer’s instructions.
 Assemble the equipment at the bedside.

STEPS Rationale

1 Prior to performing the procedure, introduce self
and verify the client’s identity using agency
protocol.
Explain to the client what you are going to do, why
it is necessary, and how he or she can participate.
Discuss how the results will be used in planning
further care or treatments.
appropriate infection control procedures (e. g.,
gloves).


3 Provide privacy. (1) Insert the test strip into
the meter.
4 Prepare the equipment.

a Some meter turn on when a test strip is
inserted into the meter ( 1 )
b Confirm the code number.
5 Select and prepare the vascular puncture site.
a Choose a vascular puncture site (e.g., the side These actions increase the
of an adult’s finger). Avoid sites beside bone. blood flow to the area, ensure
Hold a finger in a dependent (below heart an adequate specimen, and
level) position. If the earlobe is used, rub it reduce the need for a repeat
gently with a small piece of gauze. puncture.
b Clean the site with the antiseptic swab or soap Alcohol can affect accuracy
and water and allow it to dry completely. and the site stings when
punctured when wet with
alcohol.
6 Obtain the blood specimen.
a Apply gloves.
b Place the injector, if used, against the site, and The lancet is designed to
release the needle, thus permitting it to pierce pierce the skin at a specific
the skin. Make sure the lancet is perpendicular depth when it is a
to the site. perpendicular position relative
to the skin. (2).
c Prick the site with a lancet or needle, using a
darting motion.
d Gently squeeze (but do not touch) the
puncture site until a drop of blood forms. The
size of the drop of blood can vary depending
on the meter. Some meters require as little as
0.3 mL of blood to accurately test blood sugar.

(2) Place the injector against
the site.
e Hold the reagent strip under the puncture site
until adequate blood covers the indicator
square. The pad will absorb the blood and a
chemical reaction will occur. Do not smear the
blood. This will cause an inaccurate reading.
- Some meters wick the blood by just
touching the puncture site with the strip. (3)
f Ask the client to apply pressure to the skin
puncture site with 2x2 gauze. Pressure will
assist hemostasis.
7 Expose the blood to the test strip for the period
and the manner specified by the manufacturer. As
soon as the blood is placed on the test strip:

(3) Apply the blood to the test
strip.


a Follow the manufacturer’s recommendations The blood must remain in
on the glucose meter and monitor for the contact with the test strip for a
amount of time indicated by the manufacturer. prescribe time to obtain
accurate results.
Some glucometers have the test strip placed
in the machine before the specimen is
obtained.
8 Measure the blood glucose.
a Place the strip into the meter according to the Refer to the specific
manufacturer’s instructions. manufacturer’s
recommendations for the
specific procedure.
b After the designed time, most glucose meters
will display the glucose reading automatically.
Correct timing ensures accurate results. (4).
c Turn off the meter and discard the test strip
and 2x2 gauze in a biohazard container.
Discard the lancet into a sharps container.
d Remove and discard gloves. Perform hand
hygiene.
9 Document the method of testing and results on the
client’s record. If appropriate, record the client’s
understanding and ability to demonstrate the
technique. (4) Read the results
The client’s record may also include a flow sheet
on which capillary blood glucose results and the
amount, type, route, and time of insulin
administration are recorded. Always check if a
diabetic flow sheet is being used for the client.
1 Check for orders for sliding scale insulin based on
0 capillary blood glucose results. Administer insulin
as prescribed.

EVALUATION

1. Compare glucose meter reading normal blood glucose level, status of puncture site, and
motivation of the client to perform the test independently.
2. Relate blood glucose reading to previous reading and the client’s current health status.
3. Report abnormal results to the primary care provider. Some agency may have a
standing policy to obtain a venipuncture blood glucose if the capillary blood glucose
exceeds a certain value.
4. Conduct appropriate follow-up such as asking the client to explain the meaning of the
results and/or demonstrating the procedure at the next scheduled test.
5. Prepare the client for home glucose monitoring and review frequency, record keeping,
and insulin administration if appropriate.



Collecting Samples from the Nose or Throat
I. Introduction
The oronasopharyngeal cavity is lined with mucous membrane that secretes
mucus, moistening the membrane and the air that is inhaled. Lachrymal fluid and
saliva also drain into the cavity. Viral infections are common problems in the
upper airways, but bacterial infections occur as well. Because bacterial infections
can be treated pharmacologically, samples for cultures are taken of the upper
airway secretions to distinguish between viral and bacterial infections. When
bacteria are cultured, sensitivity tests determine the proper treatment.

II. Purposes:
1. The client can accurately report the reason for the culture and explain when
and how its result will be learned.
2. The client’s nose and throat are without discomfort or bleeding from taking the
culture as evidenced by his or her report and an inspection of the area.

III. Key Points:

1. Assess the client for evidence of respiratory infection.
2. Observe the client’s ability to cough deeply.
3. Place the client in high Fowler’s position.

IV. Supplies and Equipment:
Rationale
1. Sterile cotton-tipped or polyester- Removes exudate from pharyngeal
tipped swab or applicator in a mucosa without contamination.
culture tube.
2. Tongue depressor. Depresses tongue for better visualization
of pharynx.
3. Penlight. Illuminates area to be cultured.
4. Facial tissues. Available for the client if there is
excessive tearing or coughing following
culture.
5. Identification labels. Prevents errors by correctly labeling the
culture tube.


6. Laboratory requisition form. Informs the laboratory of the client’s
identification or other required
information.
7. Emesis basin. Available in case the client gags and
vomits following the throat culture.

V. Procedure:

STEPS Rationale

Collecting Culture Samples from the Pharynx

1 Wash hands. Limits transfer of microorganisms.
2 Gather needed supplies and equipment. To save time, effort and energy.
3 Explain the exact procedure to the client. Informs the client and encourages
Tell him or her that a ticking sensation in discussions of anxiety or discomfort.
the throat may be felt and that the client Prepares for the discomfort of the
may even gag as the throat is swabbed. culture.
5 Instruct the client to sit upright or help Allows easier view visualization of the
into that position. access to the pharynx.
6 Place tissues and emesis basin within Prepares the client if need arises.
the client’s reach.
7 Ready the swab by loosening it from the Prepares the swab.
culture tube; place it within reach.
8 Depress the tongue with the tongue Permits visualization of the pharynx so
depressor while illuminating the pharynx that it can be inspected.
with the penlight.
9 Inspect the pharynx for reddened or
inflamed areas or patches of exudates.
1 Set the penlight aside and grasp the
0 swab.
1 Insert the swab through the mouth, Prevents contamination of the swab tip
1 carefully avoiding the tongue, teeth, or
cheeks.



1 Rub the swab quickly but firmly over the Ensures collection of secretions from
2 area of inflammation or patchy exudate. suspicious areas.

If no exudate is seen:
1 Rub the swab quickly but firmly over the Ensures collection of secretions in an
3 nasopharyngeal area behind the uvula. area representative of the entire
pharynx.
1 Withdraw the swab quickly without Prevents contamination of the swab.
4 touching the oral tissues.
1 Replace the swab in the culture tube.
5
1 Insert the swab tip into the medium. Inserting the collected secretions directly
6 into the medium ensures that the
bacteria will survive until cultured by the
laboratory.
1 Secure the top of the culture tube. Prevents contamination.
7
1 Discard the tongue blade.
8
1 Provide comfort measures for the client
9 as necessary; facial tissues, a drink of
water.
0
2 Secure labels to the culture tube. Prevents identification errors by the
1 laboratory.
2 Send the culture to the laboratory Ensures accurate results.
2 according to agency guidelines.

B. Collecting Culture Samples from the nasal Mucosa


2 Gather needed supplies and equipment. To save time, effort and energy.
3 Explain the exact procedure to the client. Informs the client of the procedure;
Tell him or her that she will feel itching encourages participation; prepares for
and discomfort or a desire to sneeze as the discomfort.
the swab passes through the nose.
4 Pull on the curtain or close door. To provide privacy.
5 Instruct the client to sit upright or help Allows easier visualization of the access
into that position. to the nares.
6 Place tissues within the client’s reach. Prepares the client if need arises.
7 Ready the swab by loosening it from the Prepare the swab.
culture tube; place it within reach.
8 Instruct the client to blow his or her Prepare the swab.
nose.
9 Instruct the client to tilt head back. Allows easier access to the turbinates.
1 Inspect the nostrils to determine Determines which nostril to use; select
0 patency; using the penlight for the nostril without visible obstruction.
illumination.
1 Insert the wire swab gently through the Prevents contamination of the swab tip.
1 most patent nostril; avoid touching the A wire swab is preferable for this
nasal tissue. procedure because it is less likely to
injure tissues. Bend the swab into a
curve that permits easier entry before
the package is opened.

1 Force the swab through the resistance Ensures that the swab tip rests against
2 met when it enters the turbinates. the tissues of the turbinates rather than
the anterior nares.
1 Place the tip of the swab against the Collects the secretions.
3 turbinate tissue and rotate.
1 Withdraw the swab quickly without Prevents contamination of the swab.
4 touching the sides of the nares.
1 Replace the swab in the culture tube.
5


1 Insert the swab tip into the medium. Inserting the collected secretions directly
6 into the medium ensures that the
bacteria will survive until cultured by the
laboratory.
1 Secure the top of the culture tube. Prevents contamination.
7
1 Provide comfort measures for the client
8 as necessary; facial tissues, a drink of
water.
9
2 Secure labels to the culture tube. Prevents identification errors by the
0 laboratory.
2 Send the culture to the laboratory Ensures accurate results.
1 according to agency guidelines.

Insert the wire swab gently through the most patent nostril; avoid touching the nasal tissue.

BANDAGES AND BINDERS

Introduction / Definition:
A simple gauze dressing is often not enough to immobilize or provide support to a wound.
Bandages and binders are devices that secure large dressings, wrap body parts, provide
support to body areas and facilitate immobilization of the limits.
Bandage – is a strip or roll of material that is wrapped around a body part to support or
immobilize a body part, or to secure a dressing that cannot be taped to the skin.
Bandages are available in rolls of various widths and material including gauze, elasticized
knits, elastic webbing, flannel, and muslin.
Gauze – is used for bandages because it is light and porous and conforms to body parts;
permit air circulation to underlying skin to prevent maceration, inexpensive, and can be
discarded after one use.
Elastic bandage – adhere to the skin providing support and pressure and conform to body
parts.
A binder – is a broad bandage made of a shape and size to fit and supports the underlying
muscles or incisions or dressings on a body part; is made of cotton or muslin fabric that may
or may not be elasticized. Some binders have metal or plastic ribbing (stays) to prevent


bending and add additional support. Other binders are made of netting that stretches to
accommodate shape as they encircle the entire body to secure dressings.

Bandages and binders applied over or around dressings can provide extra protection
and therapeutic benefits by:
1. Creating pressure over a body part.
2. Immobilizing a body part.
3. Supporting a wound.
4. Reducing or preventing edema.
5. Securing a splint, or
6. Securing dressings.

Principles for Applying Bandages and Binders:
• Correctly applied bandages and binders do not cause injury to underlying or nearby
body parts or create discomfort for the client.
1. Inspect the skin for abrasions, edema, discoloration, or exposed wound edges.
2. Cover exposed wounds or open abrasions with sterile dressing.
3. Assess the condition of underlying dressings and change them if they are soiled.
4. Assess the skin of underlying body parts and parts that will be distal to the bandage
for signs of circulatory impairment; (coolness, pallor, or cyanosis, diminished or
absent pulses, swelling, numbness, and tingling) to provide a means for comparing
changes in circulation after bandage application.

BANDAGING
Techniques of Applying Bandages:
1. Circular turn – is used to anchor the bandage at its beginning and end. It may also be
used to bandage small areas such as finger and wrist.
2. Spiral turn – to cover part that is uniform in shape like upper arm or leg.
3. Spiral reverse – to bandage areas of the body that are not uniform in shape such as
lower leg.
4. Recurrent turn – used to cover distal ends such as the skull, distal end of the finger,
or the stump of an amputation.
5. Figure-of-eight turn – is used to support joint areas such as knees and elbows while
slowing some movement of the body part covered.
6. Spica turn – (modification of figure-of-eight turn) – used to cover larger areas such
as upper thigh of lower hip area / upper arm with shoulder.

Supplies and Equipment:
For Bandages:


1 Bandage of approximate materials, width, Various conditions and purpose determine
and length. the type of use of different bandage.
2 Dressing change supplies. Available to change dressing if required.
3 Safety pins, clips, or tape. Secure the bandage.

Key Points for Bandage Application:
Action Rationale
1 Position body parts to be bandaged in Bandages can cause restriction in
comfortable position of normal movement. Immobilization in normal
anatomical alignment. functioning position reduces risks of
deformity or injury.
2 Prevent friction between and against Skin surfaces in contact with each other
surfaces by applying gauze or cotton (e.g., between toes or under breasts) can
padding. rub against each other to cause abrasion or
chafting. Bandages over bony prominences
may rub against each other to cause
breakdown.

3 Apply bandages securely to prevent Friction between bandages and skin can
slipping during movement. cause skin breakdown.

4 When bandaging extremities, apply Gradual application of pressure from distal
bandage first at distal end and progress toward proximal portion of extremity
toward trunk. promotes venous return and minimizes risk
of edema or circulatory impairment.

5 Apply bandages firmly, with equal Equal tension prevents unequal pressure
tension exerted over each turn on layer. distribution over bandaged body part.
Avoid excess overlapping of bandage Localized pressure causes circulatory
layers. impairment.
6 Position pins, knots, or ties away from Pins and ties used to secure bandages and
wound or sensitive skin areas. binders can exert localized pressure and
irritation.



Procedure for BANDAGING:

1 Explain the procedure and its purposes to For the client to cooperate and participate.
the client.
2 Prepare all the materials needed. Organizes the procedure saving time,
effort and energy.
4 Close door or draw the curtains. Provide privacy.
5 Inspect the skin for abrasions, edema,
discoloration, or exposed wound edges.

• Assess the condition of underlying
dressings and change them if they are
soiled.

• Cover exposed wounds or open
abrasions with a sterile dressing.
6 Assess skin of underlying body parts that Provide a means for comparing changes
will be distal to the bandage for signs of in circulation after bandage application.
circulatory impairment (coolness, pallor
or cyanosis, diminished or absent pulses,
swelling, numbness, and tingling.
7 Assist the client to assume a comfortable Prevents deformity and increase
position, maintaining a position of normal circulation to the affected area.
function for the body.

• Bandages on the lower extremities are
applied before the client sits or stands.

• An extremity may be elevated for 15 to To encourage adequate venous return.
30 minutes before wrapping.
8 Hold the bandage in the dominant hand Facilitates control when stretching and
with the roll up. unrolling the bandage.
9 Unroll 3 to 4 inches of the bandage.
10 Hold the end of the bandage in place on Maintains uniform tension.
top of the distal part using the fingers of
the non-dominant hand.
11 Leave a portion of the distal part exposed, Allows later inspection and palpation of
such as the toes or fingers. distal parts for neuro-vascular assessment.
12 Bring the bandage down and around the
body part unrolling and stretching slightly
if elastic.


13 Wrap the bandage directly over the held Anchors the bandage at the end.
end and fasten it with safety pin, clip, or
tape.

Note:
• Use circular turns to begin and end a Provides security and support to the
bandage. This is called anchoring. bandage.

• In bandaging the foot, start at the side of
the foot so that the end will not cause
pressure over the bony area on the upper
foot or create discomfort on the bottom of
the foot when the patient walks.

To wrap a Spica Bandage:
14 Anchor with two circular turns.
15 Bring the bandage up and around the body Varies the figure-8 turn used to cover
part. large areas.
16 Wrap bandage down and around the other Covers body areas such as thumb, groin,
body part forming a figure-8. breast, shoulder, and hip.
17 Continue in this pattern until the area is Provides a means of checking circulation
covered. Leave tips of finger and toes in the bandaged extremity.
exposed.
18 End with two circular turns.
19 Fasten with tape, safety pins, or clips. Prevents unwrapping.

For all bandage types:
20 Inspect bandage at frequent intervals for Ensures the bandage is in place and is of
intactness and constant tension; assess the benefit to the client.
neurovascular status of the extremity.



Types of Bandage Turns

Type Description Purpose or Use

Cecil/Feb./08



Spiral Reverse

Figure of Eight

Spica


BINDERS

Types and Purposes of binders:

1. The abdominal binder (straight) is used to
provide support and protection to the
abdomen. It is made of a rectangular fabric
(a bath blanket or draw sheet) and long
enough to encircle the body and extend from
the lower ribs to the symphysis pubis.
Commercially made binders are rectangular
and made from heavy fabric or elastic
with a Velcro closure.

2. The scultetus or many-tailed binder is also to provide support to the abdomen or to
secure dressings. This binder is made of flannel and has three to six tails on either side
of solid back. The tails are secured starting above the groin and alternated across the
abdomen to an area just below the ribs.

3. The breast binder is a vest with adjustable
straps and a front closure of safety pins.
Adjustments are made to provide a smooth
fit that does not interfere with respiration.
This binder is used to provide support the
breasts and thorax.

4. The double T-binder (A) is of the same
design as the single T-binder with the
addition of a second trip to aid in securing
rectal and perineal dressings for men. The
straps attached to the waist on either sides of
the penis and scrotum.

5. The single T-binder (B) is made of muslin.
Two narrow strips are sewn together at right
angles, one strip encircles the waist and the
other secures rectal or perineal dressings.
These are most often used for women.



6. The sling or triangular binder is made
commercially of muslin. Its purpose is to
provide support to the arm, shoulder, or
hand. Additionally, it limits movement while
not impairing circulation, and reduces edema
to the lower arm and hand.

Objectives:

1. The client’s abdominal or scultetus binder is properly applied as evidenced by the
ability to breathe normally; the presence of pulses distal to the binder, and intact skin
integrity.
2. The client’s T-binder is properly applied as evidenced by secured perineal or rectal
dressings, adequate scrotal support, and the client’s ability to remove and reapply the
binder when needed for elimination.
3. The client’s triangular binder (sling) is applied as evidenced by immobilization of the
arm, shoulder, and elbow as therapeutically prescribed without compromised
circulation.
4. The client’s binder provides adequate support to the body tissues without discomfort
to the client as evidenced by verbal and nonverbal responses.


For Binders:

 Gloves, if wound drainage is present. ▪ T and double T Binders:
 Abdominal binder: o Correct size
o Correct size cloth/elastic o Safety pins
straight binder ▪ Breast binder:
o Safety Pins (unless Velcro o Correct size
closure or metal fasteners are o Safety pins (unless Velcro closure
attached) or metal fasteners are attached)


Preparing for the application of a binder

RATIONALE
STEPS
1. Wash hands. Limits transfer of
microorganism.
2. Take supplies to the bedside.
3. Explain the procedure to the client. Promotes client cooperation and
understanding and reduces
anxiety.
4. Close door or draw bedside curtains. Provides privacy.

Procedure:

STEPS RATIONALE
1 Observe client with need for support of thorax Baseline assessment determines
or abdomen. Observe ability to breath deeply client’s ability to breathe and
and cough effectively. cough. Impaired ventilation of
lung can lead to alveolar
atelectasis and inadequate arterial
oxygenation.
2 Review medical record if medical prescription Application of supportive binders
for particular binder is required and reasons may be used on nursing judgment.
for application. In some situations, physician
input is required.
3 Inspect the skin for actual or potential Actual impairments in skin
alterations in integrity. Observe for irritations, integrity can be worsened with
abrasions, skin surfaces that rub against each application of binder. Binder can
other, or allergic response to adhesive tape cause pressure and excoriation.
used to secure dressing.
4 Inspect any surgical dressing. Dressing replacement or
reinforcement precedes
application of any binder.


Critical decision point:
Dressing should be clean, dry, and incision/wound should be entirely covered
by dressing.

5 Assess client’s comfort level, using analog Data will determine effectiveness
scale 0 to 10, and noting any objective signs of binder placement.
and symptoms.

Numerical
A 0 1 2 3 4 5 6 7 8 9 10
No pain Severe
pain

Descriptive
B No Mild Moderate Severe Unbearable
pain pain pain pain pain

Visual analog
C No pain Unbearable pain

Client designates a point on the scale corresponding to his perception of the
pain’s severity at the time of assessment.

6 Gather necessary data regarding size of client Ensures proper fit of binder.
and appropriate binder.
7 Explain procedure to patient. Promote client’s understanding
and cooperation.
8 Teach skill to client or significant other. Reduces anxiety and ensures
continuity of care after discharge.
9 Wash hands and apply gloves. (if likely to Reduces transmission of
contact wound drainage). microorganisms.
10 Close curtains or room door. Maintains client’s comfort and
dignity.
11 Apply binder.
12 Remove gloves and wash hands. Prevents cross infection.
13 Observe site for skin integrity. Circulation and Determines that binder has not
characteristics of wound. (Periodically remove resulted in complication to the
binder and surgical dressing to assess wound skin, wound or underlying organs.
characteristics).
14 Assess comfort level of client, using analog Binders should not increase
scale of 0 to 10 and noting any objective signs discomfort.
and symptoms.
15 Assess client’s ability to ventilate properly, Identifies any impaired ventilation
including deep, breathing and coughing. and potential pulmonary
complications.
16 Identify client’s need for assistance with Mobility of upper extremities may
activities such as: hair combing, dressing, and be limited depending on severity
ambulating. and location of incision.



 Report any skin irritation to nurse at between shift reports.
 Record application of binder, condition of skin, circulation, integrity of dressing,
and client’s comfort level.
 Report ineffective lung expansion to physician immediately.

Home care considerations:
 Abdominal, T, and breast binders are washable and are placed over a line to dry.
 Instruct care giver to avoid excessive pressure with binder application.
Cecil/Feb./08

Applying a Breast Binder

1 Assist client in placing arms through Eases binder placement process.
binder’s armholes.
2 Assist client to supine position in bed. Supine position facilitates normal
anatomical position of breasts;
facilitates healing and comfort.
3 Pad area under breasts if necessary. Prevents skin contact with undersurface.
4 Using Velcro closure tabs, or Horizontal placements of pins may
horizontally placed safety pins, Secure reduce risk of uneven pressure or
binder at nipple level first. Continue localized irritation.
closure process above and then below
nipple line until entire binder is closed.
5 Make appropriate adjustments, Maintains support to client’s breasts.
including individualizing fit if shoulder
straps and pinning waistline darts to
reduce binder size.
6 Instruct and observe skill development Self care is integral aspect of discharge
in self care related to reapplying breast planning. Skin integrity and comfort
binder. level goals are insured.

Applying an Abdominal Binder

1 Position client in supine position with Minimizes muscular tension on
head elevated and knees slightly abdominal muscles.
flexed. Supports the muscles and viscera,
reduces tension on an incision, if
present.
2 Fanfold binder to its midline. Reduces time client remains
uncomfortable position.
3 Instruct and assist client to roll away Aids in placement of the binder.
from nurse toward raised side rail
while firmly supporting abdominal Reduces pain and discomfort.
incision and dressing with hands.


4 Place fanfold ends of binder under Permits placements and centering of
client. binder with minimal discomfort.

Place fanfold binder under the client, Ensures proper placement that does not
with its upper border at the waist and interfere with breathing, ambulation, or
lower border at the gluteal folds. defecation.
5 Instruct client to roll over folded ends.
6 Unfold and stretch ends out smoothly Maintains skin integrity and comfort.
on far side of bed.
7 Reach over the client and straighten the Assures placement of binder and is
fanfolded binder until it is smooth and comfortable for the client. A smoothly
wrinkle free. Adjust binder so that the applied binder is less likely to impair
supine client is centered over binder skin integrity. Centers support from
using symphysis pubis and costal binder over abdominal structures, which
margins as lower and upper landmarks. reduces incidence of decreased lung
expansion.
8 Instruct client to roll toward the nurse Facilitates chest expansion and adequate
back into supine position and over the wound support when the binder is
fanfold binder. closed.

Critical decision point:
Cover any exposed areas of incision or wound with sterile dressing.

9 Pad the bony prominences. Prevents skin breakdown from
prolonged pressure.
10 Check the dressing, if present, to Limits potential for infection.
ensure that it covers wound edges.
Reinforce dressing if needed.
11 Bring the farthest portion of the binder
firmly over abdomen.
12 Place the nearest binder end over the Applies firm support against the
center of the abdomen, while holding abdominal structures.
tension on the other binder.
13 Close binder. Secure by placing safety Provide continuous support and comfort.
pins horizontally or secure the Velcro Enhances venous blood flow.
closure from the distal to proximal
edges. Rub the Velcro surfaces firmly
together to ensure full contact.
14 Place darts or tucks as needed to Provides tailored fit that is comfortable
provide a snug fit. Allow room for and provides uniform support.
breathing.
15 Assess client’s comfort level. Helps determine effectiveness of binder
application.
16 Adjust binder as necessary. Promotes comfort and chest expansion.


Applying Scultetus Binder

1 Complete steps 1 through 10 as before.
2 Bring the distal tail on the side Provides maximum upward support.
opposite you across the client’s
abdomen and hold it firmly against the
abdomen; if longer than the abdomen,
fold it back on itself.
3 Bring the opposite tail across the Provides smooth, even surfaces of
abdomen while maintaining tension on tension against the abdomen.
the first tail.
4 Fasten the tail with safety pin or Velcro Reduces pressure areas from wrinkles.
or Repeat steps 11 through 12,
smoothing Away wrinkles, until all
tails are in place.
5 Sculpture tail to accommodate body Provides adequate support while
shape. maintaining comfort.
6 Fasten visible tail ends with safety pins Secures binder in position with sufficient
or Velcro straps. pressure against the muscles to provide
support.

Applying a Single or Double T Binder

1 Prepare for the application.
2 Assist the client to a dorsal recumbent
position.
3 Have client raise hips.
4 Check or change the perineal rectal
dressing
5 Help the client to turn away from you. Positions client for proper placement of
the binder.
6 Place the horizontal band (waistband)
around the waist above the iliac crest.
7 Bring the remaining strap (perineal Secures dressing in place.
strap) down the mid-back and through
the perineal area to the lower abdomen.
8 Attach the perineal strap to the waist Secures the strap in place.
band by overlapping them and securing
with a horizontal safety pin.


If a double T-binder

1 Apply in the same manner but place
the perineal straps on either side of the
genitalia.
2 Observe the client for comfort as he Ensures adequate fit without discomfort
lies, sits, or stands. from rubbing or chafing of the binder.
3 Adjust dressings and binder as needed Prevents skin breakdown by pressure
for comfort and to reduce pressure and ischemia.
rubbing.
4 Instruct client to remove and reapply Encourages independence.
binders as necessary.

Applying Single T and Double T Binders

1 Assist client to dorsal recumbent position, Minimizes tension on perineal
with lower extremities slightly flexed and organs.
hips rotated slightly outward.
2 Have client raise hips and place horizontal Permits placement of binder. Secures
band around client’s waist (or above iliac binder around client.
crest) with vertical tails extending past
buttocks. Overlap waistband in front and
secure with safety pins.
3 Complete binder application:
a. Bring remaining vertical strip over T binders provide support to perineal
perineal dressing and continue up and muscles and organs and help
under center front of horizontal band. maintain placement of perineal or
Bring ends over waist band and secure all suprapubic dressing.
thickness with safety pin.
4 Assess client’s comfort level with client in Determines efficacy of binder to
lying, sitting, and standing positions. maintain dressings and support
Readjust front pins and tails as necessary, perineal structures.
ensuring that tails are not too tight.
Increase padding if any area rubs against
surrounding tissues.
5 Instruct client regarding removal of binder Cleanliness of binders reduces
before defecating or urinating and need to infection risk.
replace binder after performing these
bodily functions.


Applying a Triangular Bandage (Sling)

1 Prepare for application.
2 Close the door or draw bedside curtains. Provides privacy.
3 Place the client in a sitting position with Allows easier application of the sling.
fingers higher than hand, hand higher Elevation of the extremity increases
than the arm, and elbow flexed 90˚, in venous return.
correct alignment.
4 Place the open end of the bandage on the
uninjured shoulder.
5 Place the open bandage under the Positions the bandage so that it can
affected arm with the longest edge of the be secured to immobilize the arm.
hand.
6 Bring bandage’s other point up over the
arm, across the affected shoulder, and
around the neck.

7 Adjust the arm for the correct angle Assures adequate venous return and
and alignment. reduces potential for edema.
8 Tie a square knot with the points at the Avoids exerting pressure on the neck by
shoulder level. the knot.
9 Support the wrist and hand of the Lessens pressure of the bandage against
affected arm by manipulating the edge the hand and wrist, thus reducing the
of the bandage. potential for edema.


10 Fold the apex smoothly around the Provides adequate elbow support and
elbow and fasten with a safety pin. alignment.
11 Apply padding to areas where the Prevents development of pressure points
bandage presses against the soft of sores.
tissues. (This may happen around the
neck, the axilla, and between the wrist
and a cast.
12 Inspect the bandage for proper support Detects improper alignment,
of the arm, alignment of the arm, and compromised circulation, or nerve
pressure of the knot against the compression.
shoulders, assess the neurovascular
condition of the skin and arms.
13 Instruct the client or caregiver to apply
the sling using these same steps.

Applying Collar and Cuff:

1 Secure the cuff to the client's wrist.
2 Place the collar around the client's neck
making sure it is secure but not restrictive.
3 Loop a strap through the cuff and collar to
suspend the wrist. The final position of the
elbow should be at slightly less than
degrees flexion.

Applying Commercial Sling:

1 Place the injured arm in the fabric holder with the elbow in the seamed corner.
2 Loop the attached strap across the chest toward the uninjured side, and loop it
behind the neck, and then down the chest to the D-rings at the wrist end of the
holder.
3 Pass the strap upward through the rings, and secure the Velcro edges together with
the elbow flexed as slightly less than 90 degrees.



Age-specific Considerations:
1. Slings are generally not suitable for children with fractures of the humerus or elbow.
The preferred treatment is a sling and swathe, plaster casting, or surgical
interventions. Subluxation of the radial heads
2. Additional padding behind the neck may be needed for an elderly patient to avoid
excessive pressure over the spine from the weight of the arm in the sling.

Complications of the Sling:
1. Compression of soft tissues in the back.
2. Increased edema of the distal limb as a result of greater than 90 degrees elbow flexion
in the sling.

Patient Education of the Sling:
1. Keep the knot positioned at the side of the neck and not directly over the spine to
avoid excessive pressure on blood vessels, nerves, and spinous processes.


2. Keep the hand above elbow level and open and close hand and wiggle fingers
frequently to prevent or decrease swelling.

SHOULDER IMMOBILIZATION
(also known as sling and swathe and Velpeau's bandage)

Indications:
1. To immobilize the clavicle, acromioclavicular joint, shoulder, or proximal humerus. A
sling and swathe is also useful for anterior dislocations of the shoulder.
2. To immobilize unstable fractures of the proximal humerus to prevent recurrent
dislocation as a result of contraction of the pectoralis major muscles (Velpau's
bandage.
3. Too provide greater immobilization than a sling alone because the chest wall acts as a
splint.

Equipment:
1. Commercial sling and swathe or
2. 2 to 3 triangular bandages to create a sling and swathe or
3. 3 to 4 of 6-inch wide elastic bandage or 3 to 4 M length of stockinette to create a
Velpau's bandage.
4. Safety pins.
5. Axillary padding (i.e., gauze dressing, bandage, cast padding).

Patient Preparation:
1. Pad the axilla on the affected side, across the chest where the arm will lie, and over
the opposite shoulder where the bandaging material will lie.
2. Flex the elbow on the injured side and place the forearm across the chest.

Procedure:
A. Shoulder Immobilizer.
 Follow steps of "sling Application".
 Apply the elastic band around the chest, and secure with the Velcro fastener.
 Fasten the arm strap around the humerus, and then fasten the wrist strap around the
lower forearm.
B. Valpeau's Bandage.
1. Position the affected arm across the chest so that the hand rests on the opposite
shoulder.
2. Roll the bandage away from the injury beginning underneath the crossed arm in the
center of the chest, and pass the roll under the uninjured axilla.
3. Continue the roll diagonally behind the client's back and over the top of the affected


shoulder.
4. Roll downward diagonally over the folded arm and then loop the bandage behind the
elbow, across the middle of the humerus, and through the axilla.
5. Repeat the diagonal roll over the shoulder on the affected side, covering the upper
arm and supporting the elbow. Continue into the axilla.
6. Encircle the entire thorax and affected arm.
7. Continue the pattern of alternating the roll of the bandage over the shoulder and arm
with a pass around the torso.

Gilchrist Stockinette-Velpeau Sleeve:
1. Cut a piece of 4-inch wide stockinette into a 3 to 4 M (approximately 10 to 12 ft)
length. Make a horizontal alit halfway across the width of the stockinette
approximately on third from one end.
2. Insert the client's affected arm into longer end of stockinette until the axilla rests in
the slot.
3. Place the injured arm across the chest. Pass the long end of the stockinette around the
client's back, through the space between the injured arm and chest, and loosely drape
it over the client's forearm.
4. Pass the shorter end of the stockinette around the client's neck, loop it around the
wrist, and secure with a safety pin.
5. Pull the loose end of the stockinette tightly, wrap it around the affected arm, and
secure



APPENDIX A

HANDWASHING

PERFORMANCE CHECK LIST

Name: _________________________________ ID # _______________Date: ________

Objectives/Purposes: Hand washing is performed to:
1. Remove the natural body oil and dirt from the skin.
2. Remove transient microbes, those normally picked up by the hands in the usual
activities of daily living.
3. Reduce the number of resident microbes, those normally found in the skin.
4. Prevent the transmission of microorganisms from client to client / from nurse to family /
from client to nurse.
5. Prevent the cross-contamination among clients.

Equipment and Supplies
o Source of running water o Orangewood stick
(warm if available) o Towel or tissue paper
o Soap o Lotion
o Soap dish

Procedure:

STEPS Scale Comments
5 4 3 2 1
1 Stand in from of the sink. Do not allow
your uniform to touch the sink during
the washing procedure.
2 Remove jewelries.
3 Turn on water and adjust the force.
Regulate the temperature until the water
is warm.
4 Wet the hands and wrist area. Keep
hands lower than the elbows to allow
water to flow toward the fingertips.


5 Use about one teaspoon of liquid soap
from the dispenser or lather thoroughly
with bar soap. Rinse bar, and return it to
soap dish.
6 With firm rubbing and circular motions,
wash the palms and back of the hands,
each finger, areas between the fingers,
the knuckles, wrists, and forearms at
least as high as contamination is likely
to be present.

7 Continue this friction motion for 10 to
30 seconds.
8 Use fingernails of the other hand or use
orangewood stick to clean under
fingernails.
9 Rinse thoroughly.
10 Dry hands and wrists with paper towel.
Use paper towel to turn off the faucet.
11 Use lotion on hands if desired.
TOTAL

Legend:
% Scale Description Verbal Description
93-100 5 Excellent Demonstrated all the time or outstandingly
86-92 4 Very Satisfactory Demonstrated in the fullest sense,
completely or absolutely
80-85 3 Satisfactory Demonstrated at a given time or good
enough
75-79 2 Fair Demonstrated rarely or in a fair manner
72-74 1 Poor Not demonstrated at anytime

COMMENTS:

Evaluator Signature Student Signature



DONING OF GLOVES

Performance Checklist

Name: id# Date:

Equipment:
 Clean gloves

 Trash receptacle

Procedure:
STEPS SCALE COMMENTS
1 2 3 4 5
1 Wash your hands.

2 Remove the gloves from the dispenser
3 Hold glove at wrist edge and slip fingers into
openings .Pull glove up to wrist
4 Place gloved hand under wrist of second
glove and slip fingers into opening
5 Remove glove by pulling off. touch only
outside of the glove at cuff,so that gole turns
inside out
6 Place rolled-up glove in palm of second hand
7 Remove second glove by slipping one

finger under glove edge and pulling down

and off so that glove turns inside out.

8 Dispose off gloves in proper container , not
at bedside.
TOTAL:

Legend:
86-92 4 Very Satisfactory Demonstrated in the fullest sense,
enough


75-79 2 Fair Demonstrated rarely or in a fair manner

COMMENTS:



AXILLARY TEMPERATURE (ELECTRONIC )

Performance checklist

Name: id# Date:

Purpose:
 To establish subsequent data for baseline evaluation.
 To identify whether the core temperature is within normal range.
 To determine changes in the core temperature in response to specific
therapies(medication, surgeries, etc.)
 To monitor clients at risk of imbalanced body temperature.(eg. infection, extremes of
temperature exposure).
 Assessment:
 Clinical signs of fever/hyperpyrexia.
 Clinical signs of hypothermia.

Equipment:
 Electronic Thermometer.
 Thermometer sheath or cover.
 Towel if required.

Procedure:
0 1 2
1 Identify the patient
2 Prior to performing the procedure introduce
self .Explain the procedure to the client, why
it is necessary, and how he or she can
participate.
3 Gather the equipment.
4 Perform hand wash.
6 Remove the clients arm and shoulder from
the sleeve of the gown to expose the axilla.
7 Make sure axillary skin is dry, If necessary
pat dry.
8 Place disposable protective sheath over
probe.
9 Place the probe in the centre of the axilla .
Fold the client's arm across chest. place until
audible signal of recording is heard.
10 Hold the probe in place until audible signal
of recording is heard.
11 Read the temperature reading dispose off the
probe cover by pressing the probe release
button.
12 Inform the client about the temperature
reading.

13 Wash hands.
14 Record reading.
15 Replace the thermometer in its charger or
holder.
TOTAL:

Legend:
86-92 Very Satisfactory Demonstrated in the fullest sense,
enough
75-79 Fair Demonstrated rarely or in a fair manner

COMMENTS:




RECTAL TEMPERATURE (ELECTRONIC )


Name: id# Date:

Purpose:
 to identify whether the core temperature is within normal range.
 Assessment:

Equipment:
 Water soluble lubricant for rectal temperature.
 Clean gloves for rectal temperature.

Procedure:
0 1 2
participate.
4 Perform hand wash .
5 Don gloves
7 Place client in semi- lateral position or Sims
position.
8 Place disposable protective sheath over probe
and lubricate it with a water soluble
lubricant.
9 With the dominant hand, grasp the
thermometer. With the other hand separate
the buttocks so that the anal sphincter is seen
clearly.


10 Instruct the client to take a deep breath and
gently insert the thermometer into the anus.(
about 3.8 cm in adult,2.5cm in child and
1.25cm in infants.)
11 Holding the thermometer in place ,let the
buttocks fall into place, keep holding until
audible signal of recording is heard.
12 Read the temperature reading dispose off the
probe cover by pressing the probe release
button.
13 Inform the client about the temperature
reading.
14 Remove Gloves and wash hands.
15 Record reading.
holder.
TOTAL:

Legend:
enough

COMMENTS:




ORAL TEMPERATURE (ELECTRONIC )


Name: id# Date:

Purpose:
 To identify whether the core temperature is within normal range.
 Assessment:

Equipment:

Procedure:
0 1 2
1 Identify the patient.
participate.
4 Perform hand wash .
6 Place disposable protective sheath over
probe.
7 .Grasp top of the probe's stem and place the
tip of the thermometer under the clients
tongue and along the gum line.
8 Instruct the client to keep mouth closed
around the probe.
9 Hold the probe in place until audible signal
of recording is heard.
10 .Read the temperature reading dispose off
the probe cover by pressing the probe release
button.
11 . Inform the client about the temperature
reading.
12 Wash hands.
13 Record reading.

holder.
TOTAL:

Legend:
enough

COMMENTS:




Heart Rate


Name: id# Date:

Equipment:
 Watch with a second hand or indicator.
 If using Doppler/ultrasound stethoscope:
 Transducer in the probe
 Stethoscope headset
 Transmission gel

Procedure:
STEPS
0 1 2 COMMENTS
1 Determine need to assess radial or apical
pulse:
c. Note risk factors for alterations in
apical pulse
Assess for signs and symptoms of altered

SV (stroke volume) and CO such as

dyspnea, fatigue, chest pains,

orthopnea, syncope, palpitations, jugular

venous distension, edema of dependent

body parts, cyanosis or pallor of skin.

2 Assess for factors that normally influence
apical pulse rate and rhythm:
a. Age
b. Exercise
c. Position changes
d. Medications
e. Temperature
f. Emotional Stress, anxiety, fear

3 Determines previous baseline balance apical
site.
4 Explain that PR or HR is to be assessed
5 Wash hands
6 If necessary, draw curtain around bed and/or
close door.


7 Obtain pulse measurement.

A. Radial Pulse
1.Assist client to assume supine position
2. If supine, place client’s forearm along
side or across lower chest or upper abdomen
with wrist extended straight. If sitting, bend
client’s elbow 90 and support lower arm on
chair on nurses’ arm. Slightly extend wrist
with palms down.
3.Place tips of first two fingers of hand over
groove along radial or thumb side of client’s
inner wrist.
4.Lightly compress against radius, obliterate
pulse initially, and then relax pressure so
pulse becomes easily palpable.
5.Determine strength of pulse. Note whether
thrust of vessel against fingertips is
bounding, strong, weak or thready.
6.After pulse can be felt regularly, look at
watch’s second and begin to count rate; when
sweep hand hits number on dial, start
counting with zero, then one, two, and so on.
If pulse is regular, count rate for 30 seconds
and multiply by 2,
If pulse is regular, count rate for 60 seconds.
Assess frequency and pattern if irregularity.
B. Apical pulse

1 Assist client to supine or sitting position.
Move aside bed linen and gown to expose
sternum and left side of chest.
2 Locate anatomical landmarks to identify the
points of maximal impulse (PMI), also called
the apical impulse. Heart is located behind
and to left of sternum with base at top and
apex at bottom.
Find angle of Louis just below suprasternal
notch between sternal body and manubrium;
can be felt as a bony prominence. Slip fingers
down each side of angle to find second
intercostal space. (ICS).
Carefully move fingers down left side to the
left midclavicular line (MCL).
A light tap felt within an area 1 to 2 cm ( ½
to 1 inch) of the PMI is reflected from the
apex of the heart


3 Place diaphragm of stethoscope in palm of
hand for 5 to 10 seconds.
4 Place diaphragm of stethoscope over PMI at
the fifth ICS, at left MCL, and auscultate for
normal S1 and S2 heart sounds (heard as “lub
dub”).
5 When S1 and S2 are heard with regularity, use
watch’s second hand and begin to count rate;
when sweep hand hits number on dial, start
counting with zero, then one, two, and so on.
6 If apical rate is regular, count for 30 seconds
and multiply by 2.
7 If HR is irregular or client is receiving
cardiovascular medications, count for
1 minute (60 seconds).
8 Discuss findings with client as needed.
9 Clean earpieces and diaphragm of
stethoscope with alcohol swab as needed.
10 Wash hands.
11 Compare readings with previous baseline
and/or acceptable range of heart rate for
client’s age.
12 Compare peripheral pulse rate with apical
pulse rate and note discrepancy.
13 Compare radial pulse equality and note
discrepancy.
14 Correlate PR with data obtained from BP and
related signs and symptoms (palpitations,
dizziness).
TOTAL:

Legend:
enough



COMMENTS:



Respiratory Rate


Name: id# Date:

Equipment:
 Watch with second hand.  Paper, pencil  Vital signs record.
Procedure:
STEPS
0 1 2 COMMENTS
1 Determine need to assess client’s
respirations::
A .Note risk factors for respiratory

alterations.

b. Assess for signs and symptoms of

respiratory alterations such as bluish or

cyanotic appearance of nail beds, lips,

mucous membranes, and skin;

restlessness, irritability, confusion,

reduced level of consciousness; pain

during inspiration; labored or difficult

breathing; adventitious sounds, inability

to breathe spontaneously; thick, frothy,

blood-tinge, or copious sputum

produced on coughing.

2 Assess pertinent laboratory values:
ABGs, (SpO2, CBC,
3 Determine previous baseline respiratory rate
(if available) from client’s record.
4 Be sure client is in comfortable position,
preferably sitting or lying with the head of
the bed elevated 45 to 60 degrees.
5 Wash hands
6 Draw curtain around bed and/or close door.
Wash hands.
7 Be sure client’s chest is visible. If necessary,
move bed linen or gown.


8 Place client’s arm in relaxed position across
the abdomen or lower chest, or place nurse’s
hands directly over client’s upper abdomen.
9 Observe complete respiratory cycle (one
inspiration and one expiration).
10 After cycle is observed, look at watch’ s
second hand and begin to count rate: when
sweep hand hits number on dial, begin time
frame, counting one with first full respiratory
cycle.
11 If rhythm is regular, count number of
respirations in 30 seconds and multiply by 2.
If rhythm is irregular, less than 12, or greater
than 20, count for 1 full minute.
12 If rhythm is regular, count number of
respirations in 30 seconds and multiply by 2.
If rhythm is irregular, less than 12, or greater
than 20, count for 1 full minute.
13 Note depth of respirations subjectively
assessed by observing degree of chest wall
movement while counting rate. Nurse can
also objectively assess depth by palpating
chest wall excursion after rate has been
counted. Depth is shallow, normal, or deep.
14 Note rhythm of ventilatory cycle. Normal
breathing is regular and uninterrupted.
Sighing should not be confused with
abnormal rhythm.
15 Replace bed linen and client’s gown.
16 Wash hands.
17 Discuss findings with client as needed.
TOTAL:

Legend:
enough

COMMENTS:




Moving the Client up in the Bed


 Turning sheet This is a bath blanket or sheet folded in half or
quarters and positioned under the client and over the
bottom bed liners. It is used for moving the client.

 Trapeze Provides the client with a means to move in bed.
 Siderails

Procedure:
1. Introduce yourself, verify the client identity, explain to the client what you are going
to do, why, how he-she can participate.
2. Perform hand hygiene.
3. Provide privacy

STEPS 0 1 2 Comments
1 Adjust the bed of the client:
a) Head of bed flat position or low as
the client can tolerate.
b) Raise the entire bed to the height
necessary to avoid bending down
when working with client.
c) Lock the wheels of the bed and raise
the rail on the side of the bed
opposite to you.
d) Remove the pillow from under the
client’s head and place it upright
against the headboard

2. For the client who is able to reposition
without assistance:
a) Stand by and instruct him to move
his self. Assess if the client can move
without friction of the skin.
b) Ask if positioning device required
(pillow)
3. For the client who is partially able to assist:
a) For the client who weigh less than
90kg, use a friction reducing device
and two to three assistants.
b) For the client who weigh more than
90 kg use a friction reducing device
and three assistants.


c) Ask the client to flex the hips and
knees and position the feet so that
they can be used effectively for
pushing.

d) Position the client’s arms on chest,
one arm folded on the other. Ask the
client to flex the neck during the
move and to keep the head off the
bed surface.
d. Use a friction reducing device and
assistants to move the client up in the
bed. Ask the client to push on the count
of three.


4 Position yourself appropriately:
a) Stand at an angle to the side of the
bed with your feet about 2 ft. apart,
one foot on front of the other. Flex
the hip knees and ankles.
b) Tighten your gluteal, abdominal, leg
and arm muscles and rock from the
back leg to the front leg and back
again. Then shift your weight on the
front leg as the client pushes with
heels so that the client moves toward
the head of the bed.

5 For the client who is unable to assist:
( using turn sheet)
a) Place a drawsheet or a full sheet
folded in half under the shoulders to
the thighs. Each person rolls up or
fanfolds the turn sheet close to the
clients body on either side.
b) Both individuals grasp the sheet
close to the shoulders and buttocks
of the client.
c) Assist the client to flex the knees.
Place the arms across the chest.
d) Position yourself as described
previously.

6 Ensure client comfort
 Elevate the head of the bed and
provide appropriate support devices
for the clients new position.
7 Document all relevant information, record:
a) Time and change of position moved
from and position moved to.
b) Any signs of pressure ulcer.
c) Use of support device.
d) Ability of the client to assist in
moving and turning.
e) Response of the client to moving or
turning (anxiety, discomfort,
dizziness)
TOTAL

Legend:


enough

COMMENTS:



Moving the Client to Lateral or Prone Position


Procedure

STEPS 0 1 2 Comments
1 Position yourself and the client appropriately, other person
stand on the opposite side of the bed:
a) Adjust the bed of the client:

b) Head of bed flat position or low as the client can
tolerate.
c) Raise the entire bed to the height necessary to
avoid bending down when working with client.
d) Lock the wheels of the bed and raise the rail on the
side of the bed opposite to you.

e) Move the client closer to the side of the bed
opposite the side the client will face when turned.
Use a friction reducing device to pull the client to
the side of the bed.

f) While standing on the side of the bed nearest the
client; place the client near arm across the chest.
Abduct the client’s far shoulder slightly from the
side of the body and externally rotate the shoulder.

g) Place the client’s near ankle and foot across the far
ankle and foot.
h) The person on the side of the bed toward which the
client will positioned directly in the line with the
clients waistline and as close to the bed as possible

2 Roll the client to the lateral position. The second person
standing on the opposite side of the bed helps roll the
client’s from the other side:
a) Place one hand on the client’s far shoulder and the
other hand on the client’s far hip.

b) Position the client on his or her side with the arms
and leg positioned and supported properly.


3 To turn the client to the prone position follow the
preceding steps with two exception:
a) Instead of abducting the arm, keep the client's arm
alongside the body for the client to roll over

b) Roll the client completely onto the abdomen.

c) Never pull a client across the bed while the client is
in the prone position

4 Document all relevant information:

a) Time and change of position moved from and
position moved to.

b) Any signs of pressure ulcer.
c) Use of support device.
d) Ability of the client to assist in moving and turning.

e) Response of the client to moving or turning
(anxiety, discomfort, dizziness)

TOTAL

Legend:
enough

COMMENTS:



BODY MECHANICS


Score
Steps of Procedure Comments
0 1 2
1 Collect your equipment
2 Wash your hands
4 Provide privacy
5 Introduce yourself to patient
LIFTING
6
Stand near object of the load to be lifted.
7 Put on internal girdle.
Method 1
8 Bend toward object by flexing all the hips and
partially flexing at the knees.
Grasp object and bring it to thigh level by pulling
9 with arm and shoulder, muscles while thigh and
leg muscles provide an upward thrust.
Bring object to waist level by using the leg and
10 thigh muscles for greater thrust while beginning
to straighten the back.
Method 2
11 Position feet 18 inches apart with left foot
forward.
12 Tuck chin in and squat down with back straight.
Grasp object with both hands, tipping it if
13
necessary to attain balance.
Rest left elbow on left thigh, just above knee and
14 apply pressure as needed to stand up. Straighten
legs.
15
PUSHING
Stand close to the object.
Place feet in a walking position (one is in front of
16
the other)
With hands placed on the object, flex elbows and
17
lean into the object.
Place the weight from the flexor to the extensor
18
portions of the leg.
19 Apply pressure using leg muscles.
20
PULLING
Stand close to the object.
Place feet in a walking position (one is in front of
21
the other)
Hold object and flex elbows and lean away from
22
the object.
Shift weight from the extensor to the flexor
23
portions of the leg.
24 Avoid sudden, jerky movements.



25
PIVOTING
Place one foot slightly ahead of the other.
Turn both feet at the same time, pivoting on the
26
heel of one foot and the toe of the other.
Maintain a good center of gravity while holding
27
or carrying the object.
28 Squat (bending at the hips and knees).
29 Avoid stooping (bending at the waist).
Use your leg muscles to return to an upright
30 position.

TOTAL

Legend:
enough

COMMENTS:



Logrolling a Client


Student Name: University ID Number:

Procedure Date:

STEPS 0 1 2 Feedback

1. Prior to performing the procedure, introduce
self and verify the client’s identity using agency
protocol. Explain to the client what you are
going to do, why it is necessary, and how he or
she can participate.
2. Perform hand hygiene and observe other
3. Provide for client privacy.

4. Position yourselves and the client
appropriately before the move.

1) Place the client’s arms across the chest

5. Pull the client to the side of the bed.

1) Use a turn sheet or friction-reducing device to
facilitate logrolling. First, stand with another
nurse on the same side of the bed. Assume a
broad stance with one foot forward, and grasp
half of the fanfolded or rolled edge of the turn
sheet or friction-reducing device. On a signal,
pull the client toward both of you. (A)

2) One nurse counts: “One, two, three, go.” Then,
at the same time, all staff members pull the
client to the side of the bed by shifting their
weight to the back foot.


6. Move to the other side of the bed, and place
supportive devices for the client when turned.
1) Place a pillow where it will
support the client’s head after
the turn.
2) Place one or two pillows
between the client’s legs to
support the upper leg when the
client is turned.
7. Roll and position the client in proper alignment.

1) Go to the other side of the bed (farthest from
the client), and assume a stable stance.
2) Reaching over the client, grasp the far edges
of the turn sheet or friction-reducing device,
and roll the client toward you. (B)
3) One nurse counts: “One, two, three, go. “
Then, at the same time, all nurses roll the
client to a lateral position.
4) The second nurse (behind the client) helps
turn the client and provides pillow supports to
ensure good alignment in the lateral position.
5) Support the client’s head, back, and upper and
lower extremities with pillows.
6) Raise the side rails and place the call bell
within the client’s reach.

7. Document all relevant information.
Record:

1) Time and change of position moved from
and position moved to
2) Any signs of pressure areas
3) Use of support devices
4) Ability of client to assist in moving and
turning
5) Response of client to moving and turning
(e.g., anxiety, discomfort, dizziness).

Legend:
enough

COMMENTS:


Dangling A Client


Student Name: University ID Number:

Procedure Date:

STEPS 0 1 2 COMMENTS

1. Prior to performing the procedure, introduce
self and verify the client’s identity using agency
protocol. Explain to the client what you are
going to do, why it is necessary, and how he or
she can participate.
2. Perform hand hygiene and observe other
3. Provide for client privacy.

4. Position yourself and the client appropriately
before performing the move.

1) Assist the client to a lateral
position facing you.
2) Raise the head of the bed
slowly to its highest position.
3) Position the client’s feet and
lower legs at the edge of the
bed.
4) Stand beside the client’s hips
and face the far corner of the
bottom of the bed (the angle in
which movement will occur).
Assume a broad stance,
placing the foot nearest the
client and head of the bed
forward. Lean your trunk
forward from the hips. Flex your
hips, knees, and ankles.

5. Move the client to a sitting position.


1) Place the arm nearest to the
head of the bed under the
client’s shoulders and the other
arm over both of the client’s
thighs near knees.
2) Tighten your gluteal,
abdominal, leg, and arm
muscles.
3) Pivot on the balls of your feet in
the desired direction facing the
foot of the bed.
4) Keep supporting the client until
the client is well balanced and
comfortable.
5) Assess vital signs (e.g., pulse,
respirations, and blood
pressure) as indicated by the
client’s health status.
6. Document all relevant information.

Record:

1) Ability of client to assist in
moving and turning
2) Response of client to moving
and turning (e.g., anxiety,
discomfort, dizziness).

Legend:
enough

COMMENTS:




Applying and Removing Personal Protective Equipment (gloves, gown, mask)

Name: ___________________________ ID# _________ Date: ___________
STEPS 0 1 2 COMMENTS

1 Verify client identity and introduce yourself, explain for
the client what you are to do, why it is necessary, and
how he or she can participate.

2 Perform hand hygiene.

3 Apply a clean gown:
a. Pick up a clean gown, and allow it to unfold in
front of you without allowing it to touch any
area soiled with body substances.

b. Slide the arms and the hands through the sleeves.

c. Fasten the ties at the neck to keep the gown in
place.
d. Overlap the gown at the back as much as possible
and fasten the waist ties
4 Applying the face mask:
a. Locate the top edge of the mask; the mask usually
has a narrow metal strip along the edge.
b. Hold the mask by the top two strings.

c. Place the upper edge of the mask over the bridge of
the nose, and tie the upper ties at the back of the
head or secure the loops around the ears.
d. Secure the lower edge of the mask under the chin,
and tie the lower ties at the nape of the neck.
e. If the mask has a metal strip, adjust this firmly over
the bridge of the nose
f. Wear the mask only once

g. Do not let a used mask hanging around the neck.

5 Apply clean gloves.
If wearing gowns pull the gloves up to cover the cuffs
of the gown

6 Remove the gloves first since they are the most soiled.
If wearing gown that is tied in front undo ties before
removing the gloves.

7 Perform hand hygiene


8 Remove the gown when preparing to leave the room

a. Avoid touching soiled parts on the outside of the
gown.
b. Grasp the gown along the inside of the neck and
pull down over the shoulders. Do not shake the
gown.
c. Roll up the gown with the soiled part inside, and
discard it in the appropriate container.
9 Remove the mask
a) Remove the mask at the doorway to the client’s
room. If using respirator mask, remove it after leaving
the room and closing the door.

a. If using mask with strings, first untie the lower
strings
b. Untie the top string and, while holding the ties
securely, remove the mask from the face. If side
loops are presents , lift the side loops up and away
from the ears and face. Do not touch the front of
the mask.
c. Discard a disposable mask in the waste container.

d. Perform proper hand hygiene again

Verbal description Description

- Able to perform 2

- Able to perform with assistance or 1
incomplete

- Cannot PERFORM at any time 0

Legend:
enough

COMMENTS:



ASSESSING BLOOD PRESSURE


Name: _________________________________________ ID# __________ Date: ______

PURPOSES:

1. To obtain a baseline measure of arterial blood pressure for subsequent evaluation
2. To determine the client’s hemodynamic status (e.g., stroke volume of the heart and blood
vessel resistance)
3. To identify and monitor changes in blood pressure resulting from a disease process and
medical therapy (e.g., presence or history of cardiovascular disease, circulatory shock, or
acute pain; rapid infusion of fluids or blood products).

ASSESSMENT

1. Signs and symptoms of hypertension (headache, ringing in the ears, flushing of face,
nosebleeds, fatigue)
2. Signs and symptoms of hypotension ( e.g., tachycardia, dizziness, mental confusion,
restlessness, and clammy skin, pale or cyanotic skin)
3. Factors affecting blood pressure (e.g., activity, emotional stress, pain, and time the client last
smoked or ingested caffeine)

PLANNING

- Blood pressure measurement may be delegated to UAP (Unlicensed assistive personnel).
The interpretation of abnormal blood pressure readings and determination of appropriate
responses are done by the nurse.

EQUIPMENT:

1. Stethoscope
2. Blood pressure cuff of the appropriate size
3. Sphygmomanometer

IMPLEMENTATION
Preparation
1. Ensure that the equipment is intact and functioning properly. Check for leaks in the
rubber tubing of the sphygmomanometer.
2. Make sure that the client has not smoked or ingested caffeine within 30 minutes prior
to measurement.



STEPS SCALE COMMENTS 0 1 2 COMMENTS
1 Explain to the client what you are going to do?
e. Why it is necessary, and how he or she can
cooperate.
f. Discuss how the results will be used in planning
further care or treatments.
2 Observe appropriate infection control procedures.
4 Position the client appropriately.
5 Wrap the deflated cuff evenly around the upper arm..
a. Locate the brachial artery.
b. Apply the center of the bladder directly over the
artery.
6 If this is the client’s initial examination, perform a
preliminary palpatory determination of systolic
pressure.
a. Palpate the brachial artery with the fingers.
b. Close the knob clockwise.
c. Pump up the cuff until you no longer feel the
brachial pulse.
d. Release the pressure completely in the cuff, and wait
1 to 2 minutes before making further measurements.
7 Position the stethoscope appropriately.
d. Cleanse the earpieces with alcohol or recommended
disinfectant.
e. Insert the ear attachments of the stethoscope in your
ears so that they tilt slightly forward.
f. Ensure that the stethoscope hangs freely from the
ears to the diaphragm.
g. Place the bell side of the amplifier of the
stethoscope over the brachial pulse.
h. Hold the diaphragm with the thumb and index
finger.
8 Auscultate the client’s blood pressure.
e. Pump up the cuff until the sphygmomanometer
reads 30 mm Hg above the point where the brachial
pulse disappeared.
f. Release the valve on the cuff carefully so that the
pressure decreases at the rate of 2 to 3 mm Hg per
second.
g. As the pressure falls, identify the manometer
reading at each of the five phases.
h. Deflate the cuff rapidly and completely.
i. Wait 1 to 2 minutes before making further
determinations.
9 If this is the client’s initial examination, repeat the
procedure on the client’s other arm.
10 Remove the cuff.
11 Wipe the cuff with an approved disinfectant.


12 Document and report pertinent assessment data
according to agency policy.

Verbal description Description
- Able to perform 2
- Able to perform with assistance or 1
incomplete
- Cannot PERFORM at any time 0
Legend:
enough

COMMENTS:



CHANGING AN UNOCCUPIED BED
Name:_________________________________________ID#____________Date:________

STEPS 0 1
1 If the client is in bed, prior to performing the procedure, introduce self and verify the client’s
identity using agency protocol. Explain to the client what you are going to do, why it is
necessary, and how he or she can cooperate.
2 Perform hand hygiene and observe other appropriate infection control procedures.
4 Place the fresh linen on the client’s chair or over bed table; do not use another client’s bed.
5 Assess and assist the client out of bed.
a Make sure that this is an appropriate and convenient time for the client to be out of bed.
b Assist the client to a comfortable chair.
6 Raise the bed to a comfortable working height.
7 Apply clean gloves if linens and equipment have been soiled with secretions and/or
excretions.
8 Strip the bed.
a Check bed linens for any items belonging to the client, and detach the call bell or any
drainage tubes from the linen.
b Loosen all bedding systematically, starting at the head of the bed on the far side and
moving around the bed up to the head of the bed on the near side.
c Remove the pillowcases, if soiled, and place the pillows on the bed-side near the foot of
the bed.
d Fold reusable lines, such as the bedspread and top sheet on the bed, into fourths, First,
fold the linen in half by bringing the top edge even with the bottom edge, and then grasp
it at the center of the middle fold and bottom edges.
e Remove the waterproof pad and discard it if soiled.
f Roll all soiled linen inside the bottom sheet, hold it away from your uniform, and place it
directly in the linen hamper.
g Grasp the mattress securely. Using the lugs if present, and move the mattress up to the
head of the bed.
h Remove and discard gloves if used. Perform hand hygiene.
9 Apply the bottom sheet and draw sheet.
a Place the folded bottom sheet with its center fold on the center of the bed. Make sure the
sheet is hem side down for a smooth foundation. Spread the sheet out over the mattress,
and allow a sufficient amount of sheet at the top to tuck under the mattress. Place the
sheet along the edge of the mattress at the foot of the bed and do not tuck it in (unless it
is a contour or fitted sheet.
b Miler the sheet at the top corner on the near side and tuck the sheet under the mattress,
working from the head of the bed to the foot.
c If a waterproof drawsheet is used, place it over the bottom sheet so that the centerfold is
at the centerline of the bed and the top and bottom edges extend from the middle of the
client’s back to the area of the midthigh or knee. Fanfold the uppermost half of the folded
draw sheet at the center or far edges of the bed and tuck in the edge.
d OPTIONAL: before moving to the other side of the bed, place the top linens on the
hemside up, unfold them, tuck them in, and miter the bottom corners.
10 Move to the other side and secure the bottom linens.
a Tuck in the bottom sheet under the head of the mattress, pull the sheet firmly, and miter
the corner of the sheet.
b Pull the remainder of the sheet firmly so that there are no wrinkles. Tuck the sheet in at
the side.

c Tuck in the drawsheets, if appropriate.
11 Apply or complete the top sheet, blanket, and spread.
a Place the top sheet, hem side up; on the bed so that its centerfold is at the center of the
bed and the top edge is even with the top edge of the mattress.
b Unfold the sheet over the bed.
c Follow the same procedure for the blanket and the spread, but place the top edges about
15 cm (6 in.) from the head of the bed to allow a cuff of sheet to be folded over them.
d Tuck in the sheet, blanket, and spread at the foot of the bed, and miter the corner, using
all three layers of linen. Leave the sides of the top sheet, blanket, and spread hanging
freely unless toe pleats were provided.
e Fold the top of the top sheet down over the spread, providing a cuff.
f Move to the other side of the bed and secure the bedding in the same manner.
12 Put clean pillowcases on the pillows as required.
a Grasp the closed end of the pillowcase at the center with one hand.
b Gather up the sides of the pillowcase and place them over the hand grasping the case.
Then grasp the center of one short side of the pillow through the pillowcase.
c With the free hand, pull the pillowcase over the pillow.
d Adjust the pillowcase so that the pillow fits into the corners of the case and the seams are
straight.
e Place the pillows appropriately at the head of the bed.
13 Provide for client comfort and safety.
a Attach the signal cord so that the client can conveniently reach it. Some cords have
clamps that attach to the sheet or pillowcase. Others are attached by safety pin. Most bed
now have call light bottom on the side rail.
b If the bed is currently being used by a client, either fold back the top covers at one side or
fanfold them down to the center of the bed.
c Place the bedside table and the overbed table so that they are available to the client.
d Leave the bed in the high position if the client is returning by stretcher, or place in the
low position if the client is returning to bed after being up.
14 Document and report pertinent data.
a Bed-making is not normally recorded.
b Recording any nursing assessments, such as the client’s physical status and pulse and
respiratory rates before and after being out of bed, as indicated.
Legend:
enough

COMMENTS:



CHANGING AN OCCUPIED BED

Name:_______________________________________ID#_______________________Date:_______________
_
STEPS 0 1
1 Prior to performing the procedure, introduce self and verify the client’s identity using agency protocol. Explain to the
client what you are going to do, why it is necessary, and how he or she can cooperate.
2 Perform hand hygiene and observe other appropriate infection control procedures. Apply clean gloves if linens are
soiled with body fluids.
4 Remove the top bedding.
a Remove any equipment attached to the linen, such as signal light.
b Loosen all top linen at the foot of the bed, and remove the spread and the blanket.
c Leave the top sheet over the client (the top sheet can remain over the client if it is being changed and if it will
provide sufficient warmth), or replace it with a bath blanket as follows:
a Spread the bath blanket over the top sheet.
b Ask the client to hold the top edge of the blanket.
c Reaching under the blanket from the side, grasp the top edge of the sheet and draw it down to the foot of
the bed. Leaving the blanket in place.
d Remove the sheet from the bed and place it in the soiled linen hamper.
5 Change the bottom sheet and draw sheet.
a Raise the side rail that the client will turn toward. If there is no side rail, have another nurse support the client at
the edge of the bed.
b Assist the client to turn on the side away from the nurse and toward the raised side rail.
c Loosen the bottom linens on the side of the bed near the nurse.
d Fanfold the dirty linen (e.g., draw sheet and the bottom sheet toward the center of the bed. As close to and
under the client as possible.
e Place the new bottom sheet on the bed, and vertically fanfold the half to be used on the far side of the bed as
close to the client as possible. Tuck the sheet under the near half of the bed and miter the corner if a contour
sheet is not being used.
f Place the clean drawsheet on the bed with the center fold at the center of the bed. Fanfold the uppermost half
vertically at the center of the bed and tuck the near side edge under the side of the mattress.
g Assist the client to roll over toward you, over the fanfold bed linens at the center of the bed, onto the clean side
of the bed.
h Move the pillows to the clean side for the client’s use. Raise the side rail before leaving the side of the bed.
i Move to the other side of the bed and lower the side rail.
j Remove the used linen and place it in the portable hamper.
k Unfold the fanfold bottom sheet from the center of the bed.
l Facing the side of the bed, use both hands to pull the bottom sheet so that it is smooth and tuck the excess
under the side of the mattress.
m Unfold the drawsheet fanfold at the center of the bed and full it tightly with both hands. Pull the sheet in three
divisions: (a) face the side of the bed to pull the middle division, (b) face the far top corner to pull the bottom
division, and (c) face the far bottom corner to pull top division.

n Tuck the excess drawsheet under the side of the mattress.
6 Reposition the client in the center of the bed.
a Reposition the pillows at the center of the bed.
b Assist the client to the center of the bed. Determine what position the client requires or prefers and assist the
client to that position.
7 Apply or complete the top bedding.
a Spread the top sheet over the client and either ask the client to hold the top edge of the sheet or tuck it under
the shoulders. The sheet should remain over the client when the bath blanket or used sheet is removed.
b Complete the top of the bed.
8 Ensure continued safety of the client.
a Raise the side rails. Place the bed in the low position before leaving the bedside.
b Attach the call light bed linen within the client’s reach
c Put items used by the client within easy reach.
9 EVALUATION

COMMENTS: ………………………………………………………………………………………………………………………………

Evaluator Signature: ____________________ Students' signature: _________________________



REFERENCES:
1. Kozier & Erbs, (2011). Fundamentals of Nursing. 9th Edition.
2. Potter & Perry, (2009). Fundamentals of Nursing, 7th Edition, by
Elsevier Faculty Development and Training.
3. Delaune S.C., & Ladner P.K. (2002). Fundamentals of Nursing/
Standards & Practice. 2nd Edition. Published by Delmar & Thomson
Learning.
4. Gaylene Bouska Altman.(2005). Delmars Fundamental & Advanced
Nursing Skills. 2nd Ed. Thomson and Delmar Learning.
5. Carol R. Taylor, (2009). Fundamentals of Nursing: The Art and Science
of Nursing Care (Fundamentals of Nursing: The Art & Science of
Nursing Care)
6. Kozier & Erb's, (2011). Fundamentals of Nursing with My Nursing Lab
and Pearson e-Text (Access Card) (9th Edition)
7. Potter &Perry, (2009). Clinical Nursing Skills and Techniques, 7th
Edition
By Anne Griffin Perry, Patricia A. Potter.
8. Springhouse, (2006). Fundamentals of Nursing Made Incredibly Easy!
(Incredibly Easy! Series).
9. Burton & Ludwig, (2010). Fundamentals of Nursing Care: Concepts,
Connections & Skills.
10. Mosby's Medical Dictionary, 9th Edition., ISBN: 978-0-323-08541-0.
11. Lippincott & Williams, (2006). Lippincott Manual of Nursing Practice:
Handbook, 3rd edition.
12. Kaplan Nursing, (2002). Th Basics; Essential Conten for International
Nurses. 2nd Edition.


Nursing skills procedure manual.drjma

More Related Content

What's hot

Viewers also liked

Similar to Nursing skills procedure manual.drjma

More from James Malce Alo, PhD, MAN, MAPsych, RN, OSHA

Recently uploaded

Nursing skills procedure manual.drjma