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Nursing skills procedure manual.drjma

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This manual will help the student learn knowledge and demonstrate nursing skills related to the fundamental management of patient care.

Published in: Health & Medicine

Nursing skills procedure manual.drjma

  1. 1. 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)
  2. 2. NURS 241 Nursing Skills Procedure: Manual 2 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, RN1st released in November 6, 2012@ UoD College of Nursing (Male)
  3. 3. NURS 241 Nursing Skills Procedure: Manual 3Preface This manual will help the student learn knowledge anddemonstrate nursing skills related to the fundamental managementof patient care especially to patient with medical and surgicalimpediments. Special attention of the student to this manual will aid them indeveloping, enhancing their learned skills from their dedicatedclinical staff. The authors and contributors recognize the student as anactive participant who assumes a collaborative role in the learningprocess. Content is presented to challenge the student to developclinical 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 Alhurani1st released in November 6, 2012@ UoD College of Nursing (Male)
  4. 4. NURS 241 Nursing Skills Procedure: Manual 4 NURS 241 Nursing Skills Procedure: Manual TABLE OF CONTENTSSec. 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 1041st released in November 6, 2012@ UoD College of Nursing (Male)
  5. 5. NURS 241 Nursing Skills Procedure: Manual 5 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 152REFERENCES 1541st released in November 6, 2012@ UoD College of Nursing (Male)
  6. 6. NURS 241 Nursing Skills Procedure: Manual 6 HANDWASHINGIntroduction: Hand washing is important in every setting, including hospitals. It isconsidered one of the most effective infection control measures. There are two typesof microorganisms (bacteria) present on the hands: Resident bacteria, which cannotbe removed by hand washing. The second type is transient bacteria, which is easilyremoved 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 topersons who are sick or well. It becomes especially important when the client havenursing diagnoses such as:  Potential for infection.  Altered body temperature.  Impaired skin integrity.1st released in November 6, 2012@ UoD College of Nursing (Male)
  7. 7. NURS 241 Nursing Skills Procedure: Manual 7Equipment and Supplies o Source of running water o Orangewood stick (warm if available) o Towel or tissue paper o Soap o Lotion o Soap dishProcedure: 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.1st released in November 6, 2012@ UoD College of Nursing (Male)
  8. 8. NURS 241 Nursing Skills Procedure: Manual 8 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.1st released in November 6, 2012@ UoD College of Nursing (Male)
  9. 9. NURS 241 Nursing Skills Procedure: Manual 9 MEASURING BODY TEMPERATURE or VITAL SIGNSObjectives: 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)1st released in November 6, 2012@ UoD College of Nursing (Male)
  10. 10. NURS 241 Nursing Skills Procedure: Manual 10 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 hypothalamus1st released in November 6, 2012@ UoD College of Nursing (Male)
  11. 11. NURS 241 Nursing Skills Procedure: Manual 11 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.1st released in November 6, 2012@ UoD College of Nursing (Male)
  12. 12. NURS 241 Nursing Skills Procedure: Manual 12 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.1st released in November 6, 2012@ UoD College of Nursing (Male)
  13. 13. NURS 241 Nursing Skills Procedure: Manual 13Procedure: 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.1st released in November 6, 2012@ UoD College of Nursing (Male)
  14. 14. NURS 241 Nursing Skills Procedure: Manual 14 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.1st released in November 6, 2012@ UoD College of Nursing (Male)
  15. 15. NURS 241 Nursing Skills Procedure: Manual 15 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.1st released in November 6, 2012@ UoD College of Nursing (Male)
  16. 16. NURS 241 Nursing Skills Procedure: Manual 16 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.1st released in November 6, 2012@ UoD College of Nursing (Male)
  17. 17. NURS 241 Nursing Skills Procedure: Manual 17 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. 15 Remove and dispose of gloves in Reduces transmission of 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. 4 Push ejection button on Reduces transmission of thermometer stem to discard plastic microorganisms. 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. 7 Remove and dispose of gloves in Reduces transmission of appropriate receptacle. microorganisms. 8 Return thermometer to charger. Maintains battery charge.1st released in November 6, 2012@ UoD College of Nursing (Male)
  18. 18. NURS 241 Nursing Skills Procedure: Manual 18 E. Axillary temperature measurement with glass thermometer. 1 Wash hands. Reduces transmission of 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.1st released in November 6, 2012@ UoD College of Nursing (Male)
  19. 19. NURS 241 Nursing Skills Procedure: Manual 19 12 Assist client in replacing clothing pr Restore sense of well-being. gown. 13 Wash hands. Reduces transmission of 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. 8 Push ejection button on Reduces transmission of thermometer stem to discard plastic microorganisms. 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. 11 Wash hands. Reduces transmission of microorganisms.1st released in November 6, 2012@ UoD College of Nursing (Male)
  20. 20. NURS 241 Nursing Skills Procedure: Manual 20 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.1st released in November 6, 2012@ UoD College of Nursing (Male)
  21. 21. NURS 241 Nursing Skills Procedure: Manual 21 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. 10 Wash hands. Reduces transmission of 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 SELECTEDTEMPERATURE MEASUREMENT, SITES, AND METHODS. Advantages DisadvantagesElectronic 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).1st released in November 6, 2012@ UoD College of Nursing (Male)
  22. 22. NURS 241 Nursing Skills Procedure: Manual 22 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 PULSESDefinition: The pulse is a wave of blood created by contraction of the left ventricleof 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, infusion1st released in November 6, 2012@ UoD College of Nursing (Male)
  23. 23. NURS 241 Nursing Skills Procedure: Manual 23 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 gelProcedure: 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.1st released in November 6, 2012@ UoD College of Nursing (Male)
  24. 24. NURS 241 Nursing Skills Procedure: Manual 24 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. 5 Wash hands. Reduces transmission of microorganisms. 6 If necessary, draw curtain around Maintains privacy. bed and/or close door. 7 Obtain pulse measurement.1st released in November 6, 2012@ UoD College of Nursing (Male)
  25. 25. NURS 241 Nursing Skills Procedure: Manual 25 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.1st released in November 6, 2012@ UoD College of Nursing (Male)
  26. 26. NURS 241 Nursing Skills Procedure: Manual 26 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.1st released in November 6, 2012@ UoD College of Nursing (Male)
  27. 27. NURS 241 Nursing Skills Procedure: Manual 27 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. 10 Wash hands. Reduces transmission of 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.1st released in November 6, 2012@ UoD College of Nursing (Male)
  28. 28. NURS 241 Nursing Skills Procedure: Manual 28 14 Correlate PR with data obtained PR and BP are interrelated. from BP and related signs and symptoms (palpitations, dizziness).Recording and reporting:  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 PulseNormally, the apical and radial pulses are identical. Any discrepancy between twopulse rates needs to be reported promptly. An apical-radial pulse can be taken bytwo 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 allindividuals except: Newborns and children up to 2 or 3 years (apical pulse isassessed). 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.1st released in November 6, 2012@ UoD College of Nursing (Male)
  29. 29. NURS 241 Nursing Skills Procedure: Manual 29 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 pulse1st released in November 6, 2012@ UoD College of Nursing (Male)
  30. 30. NURS 241 Nursing Skills Procedure: Manual 30 Comparing radial pulse equality and Assessing pedal pulse discrepancy.1st released in November 6, 2012@ UoD College of Nursing (Male)
  31. 31. NURS 241 Nursing Skills Procedure: Manual 311st released in November 6, 2012@ UoD College of Nursing (Male)
  32. 32. NURS 241 Nursing Skills Procedure: Manual 32 ASSESSING RESPIRATIONRespiration is a complex vital function with two complementary processes, theinternal and external respirations. Respiration is the act of breathing. One act ofrespiration consists of one inhalation and on exhalation. Inhalation or inspiration isthe 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’scirculatory 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.1st released in November 6, 2012@ UoD College of Nursing (Male)
  33. 33. NURS 241 Nursing Skills Procedure: Manual 33Equipment:  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.1st released in November 6, 2012@ UoD College of Nursing (Male)
  34. 34. NURS 241 Nursing Skills Procedure: Manual 34 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.1st released in November 6, 2012@ UoD College of Nursing (Male)
  35. 35. NURS 241 Nursing Skills Procedure: Manual 35 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 heartfailure or abdominal ascites or in late stages of pregnancy should be assessed inpositions 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.1st released in November 6, 2012@ UoD College of Nursing (Male)
  36. 36. NURS 241 Nursing Skills Procedure: Manual 36 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. 14 Wash hands. Reduces transmission of 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.  Report abnormal findings to nurse in charge or physician.Home care Considerations:Assess for environmental factors in the home that may influence client’s respiratoryrate such as second-hand smoke, poor ventilation, or gas fumes.1st released in November 6, 2012@ UoD College of Nursing (Male)
  37. 37. NURS 241 Nursing Skills Procedure: Manual 37 ASSESSING BLOOD PRESSUREDefinition:Blood pressure is the force exerted produced by the volume of blood pressing onthe resisting walls of the arteries Blood pressure is commonly abbreviated BP. Itsmeasurement is expressed as a fraction.The numerator or the upper figure is the systolic pressure/ systole (the phaseduring which the heart works or contracts) and the denominator or the lower figure isthe diastolic pressure/ diastole (the heart’s resting phase).The pressure is expressed in millimeters of mercury, abbreviated mmHg. Thus arecording of120/80 means systolic blood pressure was measured at 120 mmHg and the diastolicblood pressure was measured at 80 mmHg. The difference between two readings iscalled 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, cardiac1st released in November 6, 2012@ UoD College of Nursing (Male)
  38. 38. NURS 241 Nursing Skills Procedure: Manual 38 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 formProcedure: AUSCULTATION METHOD1st released in November 6, 2012@ UoD College of Nursing (Male)
  39. 39. NURS 241 Nursing Skills Procedure: Manual 39 STEPS RATIONALE 1 Wash hands. Reduces transmission of 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.1st released in November 6, 2012@ UoD College of Nursing (Male)
  40. 40. NURS 241 Nursing Skills Procedure: Manual 40 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.Recording and reporting:  Inform client of value and need for periodic re-assessment.  Record BP. Measurement of BP after admission of specific therapies should be documented.  Report abnormal findings to nurse in charge or physician.1st released in November 6, 2012@ UoD College of Nursing (Male)
  41. 41. NURS 241 Nursing Skills Procedure: Manual 41Applying 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 glovesProcedure: 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 ties1st released in November 6, 2012@ UoD College of Nursing (Male)
  42. 42. NURS 241 Nursing Skills Procedure: Manual 42 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:1st released in November 6, 2012@ UoD College of Nursing (Male)
  43. 43. NURS 241 Nursing Skills Procedure: Manual 43 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 .1st released in November 6, 2012@ UoD College of Nursing (Male)
  44. 44. NURS 241 Nursing Skills Procedure: Manual 44 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 GlovesPurpose  To enable the nurse to handle or touch sterile objects freely without contaminating them.  To prevent transmission of potentially infective organisms from the nurses hands to clients at high risk for infection.Assessment  Review the clients 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:1st released in November 6, 2012@ UoD College of Nursing (Male)
  45. 45. NURS 241 Nursing Skills Procedure: Manual 45 Step Rationale1. Perform hand hygiene2. 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.1st released in November 6, 2012@ UoD College of Nursing (Male)
  46. 46. NURS 241 Nursing Skills Procedure: Manual 463. 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.1st released in November 6, 2012@ UoD College of Nursing (Male)
  47. 47. NURS 241 Nursing Skills Procedure: Manual 47 CHANGING AN OCCUPIED BEDPURPOSES1. To conserve the client’s energy2. To promote client comfort.3. To provide a clean, neat environment for the client4. To provide a smooth, wrinkle-free bed foundation, thus minimizing sources of skin irritation ASSESSMENT Rationale Assess1 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.PLANNINGDelegationBed-making is usually delegated to UAP (Unlicensed Assistive Personnel). Inform. Inform the UAP towhat 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 theneed 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 availableIMPLEMENTATIONPreparationDetermine what lines the client may already have This avoids stockpiling ofin the room to avoid stockpiling of the unnecessary extra linens.unnecessary extra linens Performance Rationale1 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.1st released in November 6, 2012@ UoD College of Nursing (Male)

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