Nursing skills procedure manualll

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released in November 6, 2012@ UoD College of Nursing (Male)
1NURS 241 Nursing Skills Procedure: Manual
(cover page)
NURS 241 Nursing Skills Procedure: Manual

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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

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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

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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
thermometer
15
-Rectal Temperature Measurement w/ e-thermometer 17
-Axillary Temperature Measurement w/ glass
thermometer
18
-Axillary Temperature Measurement w/ e-
thermometer
19
-Tympanic Membrane Measurement w/ e-
thermometer
20
Advantages & Disadvantages of Selecting Temperature
Measurement
21
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

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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

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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.

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Equipment and Supplies
o Source of running water
(warm if available)
o Soap
o Soap dish
o Orangewood stick
o Towel or tissue paper
o Lotion
Procedure:
STEPS RATIONALE
1 Stand in from of the sink. Do not
allow your uniform to touch the sink
during the washing procedure.
The sink is considered
contaminated. Uniforms may carry
organisms from place to place.
2 Remove jewelries. Remove watch 3-
5 inch above wrist
Removal of jewelries facilitates
proper cleansing. Microorganisms
may accumulate in settings of
jewelries.
3 Turn on water and adjust the force.
Regulate the temperature until the
water is warm. Do not allow water to
splash.
Water splashed from the
contaminated sink will contaminate
your uniform. Warm water is more
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
hands lower than the elbows to
allow water to flow toward the
fingertips.
Water should flow from the cleaner
area toward the more
contaminated area. Hands are
more contaminated than the
forearm.
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.
Rinsing the soap removes the
lather, which may contain
microorganisms.

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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.
Friction caused by firm rubbing and
circular motions helps to loosen the
dirt and organisms which can lodge
between the fingers, in skin crevices
of knuckles, on palms and backs of
the hands, as well as the wrist and
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
to 30 seconds.
Length of hand washing is
determined by the degree of
contamination.
8 Use fingernails of the other hand or
use orangewood stick to clean
under fingernails.
Organisms can lodge and remain
under the nails where they can grow
and be spread to others.
9 Rinse thoroughly. Running water rinses organisms and
dirt into sink.
10 Dry hands and wrists with paper
towel. Use paper towel to turn off
the faucet.
Drying the skin well prevents
chapping. Dry hands first because
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.

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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)

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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
during menstruation.
 Environment
  Obesity
 Diurnal variations.   Food intake;  fasting
 Exercise  Drugs  or 
 Hormones  Disturbance in hypothalamus

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

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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.

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Procedure:
STEPS RATIONALE
1 Assess for signs and symptoms of
temperature alterations and for
factors that influence body
temperature.
Physical signs and symptoms may
indicate abnormal temperature.
Nurse can accurately assess nature
of variations.
2 Determine any previous activity that
would interfere with accuracy of
temperature measurement. When
taking temperature, wait 20 to 30
minutes before measuring
temperature if client has smoked or
ingested hot or cold liquids or foods.
Smoking and hot or cold substances
can cause false temperature
readings in oral cavity.
3 Determine appropriate site and
measurement device to be used.
Chosen on basis of preferred site for
temperature measurement.
4 Explain why temperature will be
taken and maintaining the proper
position until reading is complete.
Clients are often curious about such
measurements and should be
cautioned against prematurely
removing thermometer to read
results.
5 Wash hands. Reduces transmission of
microorganisms.
6 Assist client in assuming
comfortable position that provides
easy access to mouth.
Ensures comfort and accuracy of
temperature reading.
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
fingertips.
Reduces contamination of
thermometer bulb.
3 Read mercury level while gently
rotating thermometer at eye level,
grasp tip of thermometer securely,
stand away from solid objects, and
sharply flick wrist downward.
Continue shaking until reading is
below 35 C (96 F).
Mercury should be below 35 C.
Thermometer reading must be
below client’s actual temperature
before use. Brisk shaking lowers
mercury level of glass tube.
4 Insert thermometer into plastic
sleeve or cover.
Protects from contact with saliva.

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

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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 unit. Attach oral probe to
thermometer unit. Grasp top of
stem, being careful not to apply
pressure to ejection button.
Charging provides battery power.
Ejection button releases plastic
cover from probe.
3 Slide disposable plastic cover over
thermometer probe until it locks in
place.
Soft plastic cover will not break in
client’s mouth and prevents
transmission of microorganisms
between clients.
4 Ask client to open mouth, then place
thermometer probe under the
tongue in posterior sublingual
pocket lateral to center of lower jaw.
Heat from superficial blood vessels
in sublingual pocket produces
temperature reading. With electronic
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
probe with lips closed.
thermometer during recording.
6 Leave thermometer probe in place
until audible signal occurs and
client’s temperature appears on
digital display; remove thermometer
probe under client’s tongue.
Probe must stay in place until signal
occurs to ensure accurate
recording.
7 Push ejection button on
thermometer stem to discard plastic
cover into appropriate receptacle.
microorganisms.
8 Return thermometer stem to storage
well of recording unit.
Protects probe from damage.
Automatically causes digital reading
to disappear.
9 If gloves are worn, remove and
dispose in appropriate receptacle.
Wash hands.
microorganisms.
10 Return thermometer to charger. Maintains battery charge.
C. Rectal temperature measurement with glass thermometer.
1 Draw curtain around bed and / or
close room door. Assist client to
Sim’s position with upper leg flexed
Move aside bed linen to expose only
anal area. Keep covered with sheet
or blanket.
Maintain client’s privacy, minimizes
embarrassment, and promotes
comfort. Exposes anal area for
correct thermometer placement.

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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
fingertips.
Reduced contamination of
thermometer bulb.
4 Read mercury level while gently
rotating thermometer at eye level. If
mercury is above desired level,
grasp tip of thermometer securely,
and stand away from solid objects,
and sharply flick wrist downward.
Continue shaking until reading is
below 35 C.
Mercury should be below 35 C.
Thermometer reading must be
below client’s actual temperature
before client’s actual temperature
before use. Brisk shaking lowers
mercury level in glass tube.
5 Insert thermometer into plastic
sleeve cover.
Protects from contact with feces.
6 Squeeze liberal portion of lubricant
on tissue. Dip thermometer’s blunt
end into lubricant, covering 2.5 cm
(1 to 1 ½ inch) for adult.
Lubrication minimizes trauma to
rectal mucosa during insertion.
Tissue avoids contamination of
remaining of remaining lubricant in
container.
7 With non-dominant hand, separate
client’s buttocks to expose anus.
Ask client to breathe slowly and
relax.
Fully exposes anus for thermometer
insertion. Relaxes anal sphincter for
easier thermometer insertion.
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,
withdraw thermometer immediately.
Never force thermometer.
Prevents trauma to mucosa. Glass
thermometers can break.
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
policy.
Prevents injury to client. Studies
vary as to proper length of time for
recording. Holtzclaw (1992)
recommends 2 minutes.

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11 Carefully remove thermometer,
remove and discard plastic cover in
appropriate receptacle and wipe off
remaining secretions with clean
tissue. Wipe in rotating fashion from
fingers toward the bulb. Dispose of
tissue in appropriate receptacle.
Prevents cross contamination. Wipe
from area of least contamination to
area of most contamination.
12 Read thermometer at eye level.
Gently rotate until scale appears.
Ensures accurate reading.
13 Wipe client’s anal area with soft
tissue to remove lubricant or feces
and discard tissue. Assist client in
assuming a comfortable position.
Provides for comfort and hygiene.
14 Store thermometer in appropriate
storage container.
Glass thermometers should not be
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
hands.
microorganisms.
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
audible signal occurs and client’s
temperature appears on digital
display; remove thermometer probe
from anus.
occurs to ensure accurate reading.
probe cover into appropriate
receptacle.
microorganisms.
5 Return thermometer stem to storage
well of recording unit.
to disappear.
6 Wipe client’s anal area with soft
tissue to remove lubricant or feces
and discard tissue. Assist client in
assuming a comfortable position.
Provides comfort and hygiene.
appropriate receptacle.
microorganisms.
8 Return thermometer to charger. Maintains battery charge.

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E. Axillary temperature measurement with glass thermometer.
microorganisms.
2 Draw curtain around bed and/or
close door.
Provides privacy and minimizes
embarrassment.
3 Assist client to supine or sitting
position.
Provides easy access to axilla.
4 Move clothing or gown away from
shoulder and arm.
Exposes axilla.
5 Prepares glass thermometer
following steps A –2, 3.
Mercury must be below client’s
temperature level before insertion.
6 Insert thermometer into the center of
axilla, lower arm over thermometer,
and place arm across chest.
thermometer against blood vessels
in axilla.
7 Hold thermometer in place for 3
policy.
Studies as to proper length of time
for recording vary. They concluded
that changes after 3 minutes had
little or no significance.
8 Remove thermometer, remove
plastic sleeve, and wipe off
remaining secretions with tissue.
Wipe in rotating fashion from fingers
toward bulb. Dispose of sleeve and
tissue in appropriate receptacle.
Avoids nurse’s contact with
microorganisms. Wipe from are of
least contamination to area of most
contamination.
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
protective covering container.
Glass thermometers should not be
shared between clients unless
terminal disinfection is performed
between each measurement.
Storage container prevents
breakage and reduces risk of
mercury spill.

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12 Assist client in replacing clothing pr
gown.
Restore sense of well-being.
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
shoulder and arm.
Provides optimal access to axilla.
3 Remove the thermometer pack from
charging unit. Be sure oral 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.
Ejection button releases plastic
cover from probe.
4 Slide disposable plastic cover over
thermometer probe until it locks in
place.
Soft plastic cover will not break in
client’s mouth and prevents
between clients.
5 Raise client’s arm away from torso,
inspect for skin lesion and excessive
perspiration. Insert probe into the
center of axilla, lower arm over
thermometer, and place arm across
chest.
Maintains proper position of probe
against blood vessels in axilla.
6 Leave probe in place until audible
signal occurs and client’s
temperature appears on digital
display.
7 Remove probe from axilla.
probe cover into appropriate
receptacle.
microorganisms.
9 Return probe to storage well of
recording unit.
to disappear.
10 Assist client in assuming a
comfortable position.
Restores comfort and promotes
privacy.
microorganisms.

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G. Tympanic membrane temperature measurement with
electronic thermometer.
1 Assist client in assuming
comfortable position with head
turned toward side, away from the
nurse.
Ensures comfort and exposes
auditory canal for accurate
temperature measurement.
2 Remove thermometer handheld unit
from charging base, being careful
not to apply pressure to ejection
button.
Base provides battery power.
Removal of handheld unit from base
prepares it to measure temperature.
3 Slide disposable speculum cover
over otoscope like tip until it locks
into place.
Soft plastic probe cover prevents
between clients.
4 Insert speculum into ear canal
following manufacturer’s instructions
for tympanic probe positioning.
Correct positioning of the probe with
respect to ear canal ensures
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
adult.
Some manufacturers recommend
movement of the speculum tip in a
figure – 8 pattern that allows the
sensor to detect maximum tympanic
membrane heat radiation. Gentle
pressure seals ear canal from
ambient air temperature.
b. Move thermometer in a figure–
eight pattern.
c. Fit probe snug into canal and
do not move.
d. Point toward nose.
5 Depress scan button on handheld
unit. Leave thermometer probe in
place until audible signal occurs and
client’s temperature appear on
digital display.
Depression of scan button causes
infrared energy to be detected.
6 Carefully remove speculum from
auditory meatus.

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7 Push ejection button on handheld
unit to discard plastic probe cover
into appropriate receptacle.
microorganisms. Automatically
causes digital readings to
disappear.
8 Return handheld unit into charging
base.
9 Assist client in assuming a
comfortable position.
Restores comfort and sense of well
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
for children.
May be less accurate by axillary route.
2 Quick readings.
Tympanic Membrane Sensor:
1 Easily accessible site Hearing aids must be removed before
measurements.
2 Minimal client repositioning
required.
Should not be used for clients who have
had surgery of the ear or tympanic
membrane.
3 Provides accurate care reading. Requires disposable probe cover.
4 Very rapid measurements (2 to 5
sec.).
Expensive.
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
changes.
Affected by ingestion of fluids or foods,
smoke, and oxygen delivery (Neff and
others, 1992).

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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
children, or confused, unconscious, or
uncooperative client.
4 Indicates rapid change in core
temperature.
Risk of body fluid exposure.
Axilla:
1 Safe and non-invasive. Long measurement time.
2 Can be used with newborns and
uncooperative clients.
Requires continuous positioning by
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

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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
apical pulse:
a. Note risk factors for
alterations in apical pulse
b. 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.
Certain conditions place clients at
risk for pulse alterations. Heart
rhythm can be affected by heart
disease, cardiac dysrhythmias,
onset of sudden chest pain or acute
pain from any site, invasive
cardiovascular diagnostic tests,
surgery, sudden infusion of large
volume of IV fluids, internal or
external hemorrhage, and
administration of medications that
alter heart function.
indicate alterations in cardiac
functions.

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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
Allows nurse to accurately assess
presence and significance of pulse
alterations.
Normal PR change with age.
Physical activity requires an
increase in CO that is met by an
increase HR and SV. HR increases
temporarily when changing from
lying to sitting or standing position
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
caffeine can increase the HR.
Fever or exposure to warm
environments increases HR; HR
declines with hypothermia.
Results in stimulation of the
sympathetic nervous system, which
increases the HR.
3 Determines previous baseline
balance apical site.
Allows nurse to assess change in
condition. Provides comparison with
future apical pulse measurements.
4 Explain that PR or HR is to be
assessed.
Activity and anxiety can elevate HR.
Client’s voice interferes with nurse’s
ability to hear sound when apical
pulse is measured.
microorganisms.
6 If necessary, draw curtain around
bed and/or close door.
Maintains privacy.
7 Obtain pulse measurement.

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A. Radial Pulse
STEPS RATIONALE
1 Assist client to assume supine
position.
Provides easy access to pulse sites.
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.
Relaxed position of lower arm and
extension of wrists permits full
exposure of artery to palpation.
3 Place tips of first two fingers of hand
over groove along radial or thumb
side of client’s inner wrist.
Fingertips are most sensitive parts
of hand to palpate arterial
pulsations. Nurse’s thumb has
pulsation that may interfere with
accuracy.
4 Lightly compress against radius,
obliterate pulse initially, and then
relax pressure so pulse becomes
easily palpable.
Pulse is more accurately assessed
with moderate pressure. Too much
pressure occludes pulse and
impairs blood flow.
5 Determine strength of pulse. Note
whether thrust of vessel against
fingertips is bounding, strong, weak
or thready.
Strength reflects volume of blood
ejected against arterial wall with
each heart contraction.
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.
Rate is determined accurately only
after nurse is assured pulse can be
palpated. Timing begins with zero.
Count of one is first beat palpated
after timing begins.
7 If pulse is regular, count rate for 30
seconds and multiply by 2,
A 30 second count is accurate for
rapid, slow, or regular pulse rates.
8 If pulse is regular, count rate for 60
seconds. Assess frequency and
pattern if irregularity.
Inefficient contraction of heart fails
to transmit pulse wave, interfering
with CO2, resulting in irregular
pulse. Longer time ensures accurate
count.

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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.
Expose portion of chest wall for
selection of auscultation.
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
Use of anatomical landmarks allows
correct placement of stethoscope
over apex of heart, enhancing ability
to hear heart sounds clearly. If
unable to palpate the PMI,
reposition client on left side. In the
presence of serious heart disease,
the PMI may be located to the left of
the MCL, or at the sixth ICS.
3 Place diaphragm of stethoscope in
palm of hand for 5 to 10 seconds.
Warming of metal or plastic
diaphragm prevents client from
being startled and promotes
comfort.

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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”).
Allow stethoscope tubing to extend
straight without kinks that would
distort sound transmission. Normal
S1 and S2 are high pitched and best
heard with the diaphragm.
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.
Apical rate is determined accurately
only after nurse is able to auscultate
sounds clearly. Timing begins with
zero. Count of one is first sound
auscultated after timing begins.
6 If apical rate is regular, count for 30
seconds and multiply by 2.
Regular apical rate can be assessed
within 30 seconds.
7 If HR is irregular or client is
receiving cardiovascular
medications, count for
1 minute (60 seconds).
Irregular is more accurately
assessed when measured over long
intervals.
Regular occurrence of dysrhythmias
within 1 minute may indicate
inefficient contraction of heart and
alteration on cardiac output.
8 Discuss findings with client as
needed.
Promotes participation in care and
9 Clean earpieces and diaphragm of
stethoscope with alcohol swab as
needed.
Control transmission of
microorganisms when nurses share
stethoscope.
microorganisms.
11 Compare readings with previous
baseline and/or acceptable range of
heart rate for client’s age.
Evaluates for change in condition
and alterations.
12 Compare peripheral pulse rate with
apical pulse rate and note
discrepancy.
Differences between measurements
indicate pulse deficit and may warn
of cardiovascular compromise.
Abnormalities may require therapy.
13 Compare radial pulse equality and
note discrepancy.
Differences between radial arteries
indicate compromised peripheral
vascular system.

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14 Correlate PR with data obtained
from BP and related signs and
symptoms (palpitations, dizziness).
PR and BP are interrelated.
 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
listening for apical pulse. Using both
senses, determine if the apical and
radial pulses are synchronous. If the
apical and radial pulses are not
synchronous, get a second nurse
and
Identifies differences between
pulsations and heart sounds.
2 Explain to the client that one nurse
is counting his or her heart beats
while the second counts his or her
radial pulse.
Informs the client’s answers his or
her questions because the unusual
procedure may arouse his or her
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
location of the second hand and
signal the second nurse to begin
counting at “one, two …”
Synchronizes the count, essential to
determine if deficit is present.
6 Count the remaining 60 seconds
silently as the second nurse counts
the radial pulse silently.
Ensures accuracy.

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7 Say “Stop” when exactly 60 seconds
have passed.
Ensures accuracy.
8 Reposition the client comfortable.
9 Record the apical and radial rates
immediately. Note any deficits.
Ensures prompt and accurate
documentation.
Applying moderate pressure
to accurately assess the pulse
Assessing the radial pulse
Mapping the apical pulse Assessing apical pulse

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Comparing radial pulse equality and
discrepancy.
Assessing pedal pulse

1st

1st
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
2. Conduction of air
3. Diffusion and
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.

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

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Abnormal Breathing Patterns
Procedure:
STEPS RATIONALE
1 Determine need to assess client’s
respirations:
a Note risk factors for respiratory
alterations.
Certain conditions place client at
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
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.
indicate alterations in respiratory
status related to ventilation.
2 Assess pertinent laboratory values:
a. Arterial blood gases (ABGs): normal
ABGs (values may vary slightly within
institutions.
Arterial blood gases measure
arterial blood pH, partial pressure of
O2, and CO2, and arterial O2
saturation, which reflects client’s
oxygenation.
b. Pulse oxymetry (SpO2): normal SpO2 =
90% - 100%; 85% – 89% may be
acceptable for certain chronic disease
conditions less than 85% is abnormal.
SpO2 less than 85% is often
accompanied by changes in
respiratory rate, depth, and rhythm.

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c. Complete blood count (CBC): normal
CBC for adults (values may vary within
institutions)
Complete blood count measures red
blood cell count, volume of red
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
rate (if available) from client’s record.
Allows nurse to assess for
change in condition. Provides
comparison with future
respiratory measurements.
4 Be sure client is in comfortable position,
preferably sitting or lying with the head of
the bed elevated 45 to 60 degrees.
Sitting erect promotes full
ventilatory movement.
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
door. Wash hands.
Maintains privacy. Prevents
transmission of microorganisms.
6 Be sure client’s chest is visible. If
necessary, move bed linen or gown.
Ensures clear view of chest wall and
abdominal movements.
7 Place client’s arm in relaxed position
across the abdomen or lower chest, or
place nurse’s hands directly over client’s
upper abdomen.
A similar position used during pulse
assessment allows respiratory rate
assessment to be inconspicuous.
Client’s or nurse’s hand rises and
falls during respiratory cycle.
8 Observe complete respiratory cycle (one
inspiration and one expiration).
Rate is accurately determined only
after nurse has viewed respiratory
cycle.
9 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.
Timing begins with count of one.
Respirations occur more slowly than
pulse; thus timing does not begin
with zero.
10 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.
Respiratory rate is equivalent to
number of respirations per minute.
Suspected irregularities require
assessment for at least 1 minute.

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11 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.
Character of ventilatory movement
may reveal specific disease state
restricting volume of air from moving
into and out of the lungs.
12 Note rhythm of ventilatory cycle. Normal
breathing is regular and uninterrupted.
Sighing should not be confused with
abnormal rhythm.
Character of ventilations can reveal
specific types of alterations.
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
16 If respirations are assessed for the first
time, establish rate, rhythm, and depth
as baseline if within normal range.
Used to compare future respiratory
assessment.
17 Compare respirations with client’s
previous baseline and normal rate,
rhythm, and depth.
Allows nurse to assess for changes
in client’s condition and for
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.

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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

1st
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

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

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

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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:
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
 Overlapping securely covers the
uniform at the back, waist ties keep
the gown from falling away from the
body, which can cause inadvertent
soiling of the uniform.

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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.
 To be effective the mask must cover
both the nose and the mouth,
because the air moves in and out of
both.
 A sure fit prevents both the escape
and the inhalation of microorganisms
around the edges of the mask.
 Mask should used only once because
it becomes ineffective when wet.
5. Apply clean gloves.
If wearing gowns pull the
gloves up to cover the cuffs of
the gown.
To remove soiled PPE:

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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 .

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9. Remove the mask
a) Remove the mask at
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
c) 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.
d) Discard a disposable
mask in the waste
container
e) Perform proper hand
hygiene again.
 This prevents the top part of the
mask from falling onto the chest.
 The front of the mask through which
the nurse has been breathing is
contaminated.
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:

1st
Step Rationale
1. Perform hand hygiene
2. Open the package of sterile gloves
a. Place the package on a clean, dry
surface.
b. Remove the inner package from
the outer package.
c. Open the inner package as
instructed, if no tabs are provided,
pluck the flap so that the fingers
do not touch the inner surface.
d. Grasp the glove for the dominant
hand by its folded cuff edge on
the palmer side with the thumb
and first finger of the
nondominant hand. Touch only
the inside of the cuff.
e. Insert the dominant hand into the
glove and pull the glove on. Keep
the thumb of the inserted hand
against the palm of the hand
during the insertion.
f. Leave the cuff in place once the
unsterile hand releases the glove.
 Any moist on the surface could
contaminate the gloves.
 To keep the inner surface sterile
 Put the first glove on the dominant hand
 The hands are not sterile. By touching
only the inside of the gloves, the nurse
avoids contaminating the outside.
 If the thumb is kept against the palm, it is
less likely to contaminate the outside of
the glove.
 Attempting to further unfold the cuff is
likely to contaminate the glove.

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3. Put the second glove on the
nondominante hand
a. Pick up the other glove with the
sterile gloved hand. Inserting the
gloved fingers under the cuff and
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.
c. Adjust each glove so that it is fits
smoothly, and carefully pull the
cuffs up by sliding the fingers
under the cuffs.
 This helps prevent accidental
contamination by the bare hand.
 In this position, the thumb is less likely to
touch the arm and become
contaminated.
4. Remove and dispose the gloves.
 Same technique as removing
non-sterile gloves.
 Document that sterile technique
was used in the procedure.

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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
1
Assess
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
in the room to avoid stockpiling of the
unnecessary extra linens
This avoids stockpiling of
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.

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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:
(1) Removing top linens under a bath
blanket.
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. ( 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
toward. If there is no side rail, have another
nurse support the client at the edge of the bed.
This protects clients from falling
and allows them to support
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.
(2) Moving soiled linen as close to the
client as possible.
Doing this leaves the near half of
the bed free to be changed.
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.
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.

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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.
(5)Client hold top edge of sheet while nurse
removes bath blanket.
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)
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.

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b Attach the call light bed linen within the client’s
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,
and so forth.
This prevents errors in
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
1
Assess
Client’s health status to determine that the person
can safely get out of bed.
In some hospital it is necessary
to have a written order to get out
of bed if the client has been in
bed continuously.
2 Client’s BP, pulse and respirations if indicated.
Client may experience postural
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.

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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.
2 Perform hand hygiene and observe other
appropriate infection control procedures.
3 Provide for client privacy.
4 Place the fresh linen on the client’s chair or over
bed table; do not use another client’s bed.
This prevents cross-
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
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.
. Moving around the bed
systematically prevents
stretching and reaching and
possible muscle strain.
c Remove the pillowcases, if soiled, and place
the pillows on the bed-side near the foot of the
bed.

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d Fold reusable lines, such as the bedspread
and top sheet on the bed, into fourths, First,
fold the linen in half by bringing he top edge
even with the bottom edge, and then grasp it at
the center of the middle fold and bottom edges
(1).
Folding linens saves time and
energy when reapplying the
linens on the bed and keeps
them clean.
(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,
hold it away from your uniform, and place it
directly in the linen hamper (2).
These actions are essential to
prevent the transmission of
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
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 (3).
The top of the sheet needs to be well tucked
under to remain securely in place, especially
when the head of the bed is elevated.
(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.

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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
the bed, place the top linens on the hemside
up, unfold them, tuck them in, and miter the
bottom corners.
Completing one entire side of the
bed at a time saves time and
energy.
1
0
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.
Wrinkles can cause discomfort
for the client and breakdown of
skin. Tuck the sheet in at the
side.
c Tuck in the drawsheets, if appropriate.
1
1
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 (7).
The cuff of a sheet makes it
easier for the client to pull the
covers up.
(7) Making a cuff of the top linens.

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f Move to the other side of the bed and secure
the bedding in the same manner.
1
2
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.(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
the corners of the case and the seams are
straight.
A smoothly fitting pillowcase is
more comfortable than a wrinkled
one.
e Place the pillows appropriately at the head of
the bed.
1
3
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.
This makes it easier for the client
to get into 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
4
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.

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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

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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

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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".

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

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c. Bring object to waist level by using the
leg and thigh muscles for greater
thrust while beginning to straighten
the back.
This brings load as close as possible
to center of gravity.
Method 2
a. Position feet 18 inches apart with left
foot forward.
Position maintains wide base of
support while allowing use of the left
knee as a fulcrum.
b. Tuck chin in and squat down with
back straight.
This protects intervertebral disks.
c. Grasp object with both hands, tipping
it if necessary to attain balance.
This allows firm control of object.
d. Rest left elbow on left thigh, just
above knee and apply pressure as
needed to stand up. Straighten legs.
Position allows use of leverage.
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

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COMMON POSITIONS
Positions Description Areas
Examined/Indications
Cautions
1
Standing
Arms are held
relaxed at sides
of the body; feet
6 to 8 inches
apart, face
should look
straight ahead.
Body contour, posture
balance, muscles and
extremities.
Elderly and
weak; patients
may need
support.
2
Sitting
Buttocks firmly on
the edge of the bed,
thighs well
supported, knees
bent, feet positioned
flat against the floor.
1. Assessing vital
signs.
2. Examination of
the head and
neck, posterior
and anterior
thorax.
3. Inspection and
palpation of
thyroid, breasts
and axilla.
4. Auscultation of
the lungs.
Elderly and weak;
may require
support.
3
Dangling
position
The client sits on
the side of the bed,
with the feet
dangling over its
edge. The client
dangles after
remaining
horizontal in bed for
more than a day or
two.
Same as the
sitting position.
Same as above.
Lightheadedness or
vertigo may result
when client sits up for
the first time.

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4
Dorsal recumbent
Back lying
position with
knees flexed
and hips
externally
rotated; small
pillow under
the head.
Flexed knees
reduce tension
on lower back
and abdominal
muscles and
increase client
comfort.
Abdomen and
external
genitalia.
May be difficult
for clients who
have cardio-
pulmonary
problems. The
client should
not raise arms
over the head
or clasp the
hands behind
the head
because this
increases
contraction of
the abdominal
muscles.
5
Horizontal recumbent
Back lying
position with
legs
extended;
small pillow
under the
head.
1.Head, neck,
axillae,
anterior
thorax,
lungs, breasts,
heart,
extremities.
2. Peripheral
pulses.
Not used for
abdominal
assessment
because of the
increased
tension of
abdominal
muscles.
6
Dorsal (Supine)
Back lying
without a
pillow.
As for
horizontal
recumbent.
Tolerated poorly
by clients with
cardiovascular
and respiratory
problems. An
alternate position
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.

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7
High Fowler’s
Head of bed 60º angle. Thoracic surgery,
severe respiratory
conditions.
Need
to
suppor
t the
poplite
al
vessel
s.
8
Fowler’s Head of
bed 45º
angle, hips
may or
may not be
flexed.
Post operative,
gastrointestinal
conditions,
promotes lung
expansion; As
client rests, eats,
or drink; has
visitors, or wishes
to read or watch
TV.
9
Semi-
Fowler’s
Head of bed
30º angle.
Relieving
cardiac,
respiratory
distress, and
neurological
conditions.
10
Low
Fowler’s
Head of bed
15º angle.
Necessary
degree
elevation for
ease of
breathing,
promotes skin
integrity,
client comfort.

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11
Lithotomy
Back lying
position
with feet
supported
in
stirrups;
the hips
should be
in line
with the
edge of
the table.
Female
genitalia,
rectum, and
female
reproductive
tract.
May be difficult
and tiring to
elderly people
and those with
arthritis or joint
deformities.
This position is
assumed
immediately
before it is
needed
because it is
embarrassing
and
uncomfortable.
The client is
kept draped.
12
Genu-pectoral
(knee-chest)
Kneeling
position
with torso at
90º angle to
hips.
Rectal or
vaginal
examinations.
Uncomfortable
position,
tolerated poorly
by clients who
have
cardiovascular or
respiratory
problems.
13
Standing,
bent-over
the
examining
table or
Jack-knife
position
This is more comfortable
position then knee-chest.
Palpation
of the
prostate
gland.
This position is
assumed
immediately
before it is
needed because
it is
embarrassing.
Client with back
problems may
need assistance.
14
Lateral
(side
lying)
The client is
supported on
the right or left
side with the
opposite arm,
thigh, and
knee flexed
and resting on
the bed. A
Clients who are
obese or older
may not be able
to tolerate this
position for any
length of time.
Left: Rectum,
vagina.

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pillow is
placed under
the head to
keep the head,
neck, and
spine in
alignment. The
upper arm is
flexed at the
hips and knee
positioned on
a small pillow.
Right: Rectal
examination,
administering
enema or
inserting a rectal
tube.
15
Sim’s The client is in
semi-prone
position on the
right or left side
with the
opposite arm,
thigh, and knee
flexed and
resting on the
bed. The
client’s weight
is placed on the
anterior ileum,
humerus, and
clavicle.
Improper
positioning can
cause
unnecessary
harm to clients,
especially if they
have pre-existing
conditions such
as peripheral
vascular disease
or diabetes.
Positions that
compromise
peripheral blood
flow may
damage nerves
as well.
1
6 Knee
-
Gatc
h
Lower
sectio
n of
bed
(under
knees)
slightl
y bent.
For client’s comfort;
contraindicated for
vascular disorders.

1st
17
Prone
Position
The client
lying on
abdomen,
with the
head turned
to the side.
This
facilitates
respiration
and
drainage of
oral
secretions.
A pillow is
placed
under the
head for
comfort and
relief from
pressure.
Contraindicated
in possible
complications
such as
increasing
intracranial
pressure or
cardiopulmonary
disease.
18
Trendelenburg’s Head of
bed
lowered
and foot
part raised.
Percussion,
vibration, and
drainage,
(PVD)
procedure.
19
Reverse
Trendelenburg’s
Bed frame
is tilted up
with foot of
bed down.
Gastric
condition
prevents
esophageal
reflux.

1st
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 ,
introduce self .Explain the procedure
to the client, why it is necessary, and
how he or she can participate.
Will help to reduce the anxiety of
the client, and help build a trusting
relationship with the client.
3 Gather the equipment. Provides organized approach to
task
4 Perform hand hygiene .Apply gloves
if performing rectal temperature.
To prevent risk of infection.
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
bed and as close to the bed as
possible.
For easy movement.
d. Put the wheelchair on the side of the
bed that allows the client to move
toward his stronger side.
For easy transfer from bed to chair.

1st
e. Lock the wheels of the wheelchair
and raise the footplate.
So that the chair remains stationary
while the client is being transferred.
5. Prepare and asses the client.
a. Assist the client to a sitting position
at the side of the bed.
To transfer the patient to the wheel
chair.
b. Asses the client for orthostatic
hypotension before moving from
bed.
If not assessed condition may
worsen while transferring .
c. Assist the client in putting on a bath
robe/appropriate clothing and
nonskid slippers or shoes.
To prevent the client from fall and
injury.
d. Place a gait/transfer belt snugly
around the client's waist. Check that
the belt is securely fastened.
The belt helps in easy transfer of
the client without discomfort.
6. Give explicit instructions to the client.
Ask the client to:
a. Move forward and sit on the edge of
the bed with feet placed flat on the
floor.
This brings the client's center of
gravity closer to the nurses.
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
beneath the edge of the bed and put
the other foot forward.
In this way the client can use the
stronger leg muscles to stand and
power the movement.
d. Place the client's hand on the bed's
surface so that the client can push
while standing.
This provides additional force for
the movement and reduces the
potential for strain on the nurses'
back.
7. Position yourself correctly.
a. Stand directly in front of the client
and to the side requiring the most
support. Hold the gait/transfer belt
with the nearest hand ;the other
hand supporting the back of the
clients shoulder.
Helps prevents loss of balance
during transfer.
b. Lean your trunk forward from hips.
Flex Your hips ,knees and ankles.
Helps prevents loss of balance
during transfer.
c. Assume a broad stance, placing one
foot forward and one back. Brace the
client's feet with your feet .
To prevent the client from sliding
forward or laterally.
8. Assist the client to stand and then
move together towards the
wheelchair.
Coordination allows easy transfer.

1st
a. On the count of three or verbal
instructions ask the client to push
down against the mattress /side of
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.
If there is in coordination in lifting it
will be discomfortable for both the
patient and the nurse.
b. Support the client in an upright
position for a few moments.
This allows the nurse and client to
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
from the chair or take a few steps
towards the chair.
Pivoting the farthest foot will assist
in balancing body and maintaining
the centre of gravity.
9. Assist the client to sit.
a. Have the client back upto the
wheelchair and place the client's
legs against the seat
Minimizes the risk of client falling
while sitting down.
b. Make sure the wheelchair brakes are
on.
To securely allow the client to sit on
the chair and prevent fall.
c. Have the client reach back and
feel/hold the arms of the wheelchair.
To prevent falling.
d. Stand directly in front of the client
.place one foot front and one back.
To equally distribute the centre of
gravity.
e. Tighten your grasp on the transfer
belt, and tighten your gluteal,
abdominal, leg and arm muscles.
To securely hold the client while
sitting and prevent fall.
f. Have the client sit down while you
bend your knees/hips and lower the
client onto the wheelchair seat.
Bending knees and hips prevents
strain on the back of the nurse.
10. Ensure client safety.
a. Ask the client to push back into the
wheelchair seat.
Provides a broader base of support
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
clients feet on them.
To give support to the feet.
Variation: For clients having
difficulty in walking place the
wheelchair at 45°angle to the bed.
This allows the client to pivot into
the chair easily without much
movement.

Nursing skills procedure manualll

Nursing skills procedure manualll

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