NMC PROCEDURE MANUAL PART ONE DAY AND TH

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Compiled by Sumani (D21)
CONTENTS
IMMEDIATE POST-OPERATIVE CARE OF PATIENT...................................................................................4
CARE OF STOMA OR OSTOMY AND CHANGING OF POUCH...................................................................5
TREATMENT OF PRESSURE AREAS..........................................................................................................6
ORIENTATION OF PATIENT TO WARD ENVINRONMENT (AMBULATORY)..............................................8
TTRANSFERE-IN (TRANS-IN)....................................................................................................................8
TRANSFERE-OUT (TRANS-OUT)...............................................................................................................9
CARE OF THE HANDS AND FEET............................................................................................................10
RECORDING OF INTAKE AND OUTPUT..................................................................................................11
EDUCATION ON CONDITION AND ITS MANAGEMENT .........................................................................12
ADMISSION OF PATIENT .......................................................................................................................13
EDUCATION OF PATIENT ON MEDICATION PRIOR TO DISCHARGE ......................................................15
EXPLANATION OF PROCEDURE TO PATIENT AND FAMILY....................................................................16
DISCHARGE PLANNING .........................................................................................................................16
DISCHARGE OF PATIENT........................................................................................................................17
CHECKING AND RECORDING OF TEMPERATURE ..................................................................................18
CHECKING AND RECORDING OF PULSE.................................................................................................20
CHECKING AND RECORDING OF RESPIRATION.....................................................................................20
CHECKING OF BLOOD PRESSURE ..........................................................................................................21
CHECKING AND RECORDING OF OXYGEN SATURATION.......................................................................22
MONITORING OF GLUCOSE LEVEL........................................................................................................23
TEPID SPONGING ..................................................................................................................................24
TREATMENT OF PRESSURE AREAS........................................................................................................25
PREOPERATIVE PREPARATION OF PATIENT..........................................................................................27
SIMPLE UNOCCUPIED BED....................................................................................................................28
SIMPLE OCCUPIED BED .........................................................................................................................29
ADMISSION BED....................................................................................................................................31
CARDIAC BED ........................................................................................................................................32
OPERATION BED....................................................................................................................................34
FRACTURED BED ...................................................................................................................................35

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DIVIDED BED .........................................................................................................................................36
BED BATHING........................................................................................................................................38
ASSISTED BED BATH..............................................................................................................................39
ASSISTED BATHROOM BATH.................................................................................................................41
SERVING OF BEDPAN ............................................................................................................................42
COMPLETE MOUTH CARE .....................................................................................................................43
ASSISTED MOUTH CARE........................................................................................................................44
BLOOD TRANSFUSION...........................................................................................................................45
ADMINISTRATION OF ORAL MEDICATIONS (TABLETS, CAPSULES ETC)................................................47
ADMINISTRATION OF ORAL MEDICATIONS (MIXTURES)......................................................................48
ADMINISTRATION OF INTRAVENOUS MEDICATIONS (INFUSIONS)......................................................49
ADMINISTRATION OF INTRAVENOUS MEDICATIONS (AMPULE/VIAL RECONSTITUTED) .....................51
ADMINISTRATION OF INTRAVENOUS MEDICATION (VIAL) ..................................................................53
ADMINISTRATION OF INTRAMUSCULAR MEDICATION........................................................................55
ADMINISTRATION OF SUBCUTANEOUS MEDICATION..........................................................................56
ADMINISTRATION OF INTRADERMAL MEDICATION.............................................................................58
ADMINISTRATION OF INTRATHECAL MEDICATION ..............................................................................59
ADMINISTRATION OF TOPICAL MEDICATION.......................................................................................60
INSTILLATION OF EYE DROPS ................................................................................................................61
ADMINISTRATION OF RECTAL MEDICATIONS.......................................................................................63
INSTILLATION OF EAR DROPS................................................................................................................64
INSTILLATION OF NASAL DROPS ...........................................................................................................65
ADMINISTRATION OF VAGINAL MEDICATIONS ....................................................................................66
COLLECTION OF BLOOD SPECIMENS.....................................................................................................67
DRESSING OF SIMPLE WOUND (WITHOUT ASSISTANT) .......................................................................69
DRESSING OF COMPLICATED WOUND WITH ASSISTANT .....................................................................70
TAKING OF WOUND SWAP ...................................................................................................................72
REMOVAL OF STITCHES.........................................................................................................................74
PROCESSING OF INSTRUMENTS AFTER USE .........................................................................................76
CATHETERIZATION OF FEMALE PATIENT ..............................................................................................77
CATHETERIZATION OF MALE PATIENT..................................................................................................79
CARE OF AN INDWELLING URINARY CATHETER ...................................................................................81
REMOVAL OF AN INDWELLING URINARY CATHETER............................................................................83
HANDING OVER A WARD......................................................................................................................84
TAKING OVER A WARD..........................................................................................................................85
WASHING OF PATIENT’S HAIR IN BED ..................................................................................................86

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SPOON FEEDING OF AN ADULT ILL PATIENT.........................................................................................88
FEEDING A PATIENT PER NASOGASTRIC TUBE......................................................................................89
COLLECTING A SINGLE VOIDED SPECIMEN...........................................................................................90
COLLECTION OF URINE SPECIMEN FROM A RETENTION CATHETER ....................................................91
COLLECTION OF 24-HOURS URINE........................................................................................................93
COLLECTION OF STOOL SPECIMEN .......................................................................................................94
PREPARATION FOR WARD ROUNDS .....................................................................................................95
DEVELOPING INTERPERSONAL RELATIONSHIP WITH THE PATIENT/CLIENT (ESTABLISHING OF
RAPPORT)..............................................................................................................................................96

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IMMEDIATE POST-OPERATIVE CARE OF PATIENT
Requirements
1. Operation bed with side rails
2. Post anaethestic tray e.g. vomit bowl, wound dressing set, padded spatula or tongue holding
forceps, receiver for soiled swab, adhesive tape, sterile gauze etc
3. Oxygen apparatus
4. Suction machine
5. Vital signs tray
6. Medication tray
7. Infusion stand
8. Mouth care tray
9. Observation chart
Steps
1. Assess patient level of consciousness by the use of stimulus e.g. pointed object or by calling
patient by name
2. Remove hot water bottles and receive patient gently into bed
3. Place patient flat on bed with the head turned to one side or in the appropriate position
according to the operation performed
4. Reassure patient if conscious
5. Provide side rails for safety if necessary
6. Read through the patient’s case notes for post-operative instructions
7. Observe operational site for bleeding and report for possible reinforcement
8. Monitor vital signs for 15minutes for first one hour, 30 minutes for the next hour, 1 hour for
the next 4 hours and 4 hourly intervals as condition stabilizes
9. Ensure cannula is in situ, check the flow rate of the intravenous fluid and regulate as ordered
10. Check and ensure that all drainage tubes e.g. naso-gastric tube and catheter are in situ and
are draining well
11. Record intake and output accurately
12. Assess for pain, administer prescribed analgesics and record
13. Check and administer all prescribed medication per the appropriate route
14. Maintain personal and oral hygiene

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15. Observe any abnormality in the patient’s condition
16. Put patient in a desirable position or as ordered by surgeon when he/she is fully conscious
17. Follow nutritional orders as prescribed by the surgeon
18. Educate patient and relatives on post-operative restrictions if any
19. Document findings and nursing interventions in appropriate notes (manual or electronic)
CARE OF STOMA OR OSTOMY AND CHANGING OF POUCH
Requirements
. A trolley containing the following:
a. New stoma pouch
b. Sterile gloves
c. Disposable gloves
d. Wipes or tissue
e. Measuring template
f. Gallipot with gauze swabs
g. Mackintosh and dressing towel
h. Towel
i. Bowl of tepid water
j. Barrier cream
k. Large receiver
l. Deodorizing tablet or liquid
m. Plastic bag
n. Scissors
o. Soap/mild detergent
Steps
1. Establish rapport with patient (Refer to steps)
2. Explain procedure to patient (Refer to steps)
3. Provide privacy
4. Prepare and send trolley to bedside
5. Position the patient and turn down top sheet to expose stoma

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6. Protect site with mackintosh and dressing towel
7. Preform hand hygiene and put on disposable gloves
8. Gently remove soiled pouch and places in large receiver/plastic bag
9. Remove disposable gloves and perform hand hygiene
10. Put on sterile gloves
11. Examine the stoma and note any abnormalities
12. Clean the stoma with the wipes/tissue
13. Wash area around the stoma with mild soap/detergent and tepid water
14. Dry area gently with sterile swabs
15. Cover the stoma with a swab while you prepare a new pouch
16. Estimate stoma using the measuring template and cut the desired opening on the pouch
17. Apply barrier cream
18. Put few drops of the deodorizing liquid or tablets in the pouch if available
19. Attach the one side of the edge of the pouch to the skin, rolling it up and over the stoma
20. Press the edges of the pouch to secure it in position
21. Remove gloves and perform hand hygiene
22. Reposition patient
23. Remove mackintosh and dressing towel
24. Dispose off, decontaminate, clean and stores used items
25. Document procedure and report findings to appropriate officer
TREATMENT OF PRESSURE AREAS
Requirements
1. A trolley with the following items:
a. Top shelf
i. A bowl
ii. Soap in a dish
iii. Barrier cream
iv. 2/3 hand towels
b. Bottom shelf

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i. Jug of warm water
ii. Bucket for used water
iii. Mackintosh and dressing towel
iv. Bed linen
Steps
1. Explain procedure to patient
2. Assess patient’s skin
3. Perform hand hygiene
4. Set trolley and send to patient bedside
5. Provide privacy
6. Remove patient’s bedclothes and cover with a sheet
7. Protect bed with long mackintosh and bath towel/blanket
8. Pour water into the basin
9. Roll patient onto the side, left/right lateral or prone, with head turned to one side
10. Examine and note any abnormality
11. Clean all pressure areas (back of the head, ears, hand, scapula, sacrum, elbows, hips,
buttocks, knees, ankles, heels and toes) with soap and water in a soft towel with gloved hands
12. Knead or rub in a circular motion all pressure areas with tip of fingers, or pad of one area
at a time
13. Rinse and dry skin with a soft dry towel
14. Ensure skin is dry without any moisture
15. Apply moisturizing cream or barrier cream
16. Groom and dress patient in a clean clothing
17. Position patient intermittently in any of the following positions at 30° angle: prone, supine,
right or left lateral, right or left sim’s
18. Remove long mackintosh and dressing towel
19. Dispose off used items, decontaminate trolley and used linen
21. Document procedure and report findings
22. Inform the appropriate officer of any abnormality

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ORIENTATION OF PATIENT TO WARD ENVINRONMENT
(AMBULATORY)
Steps
Establish rapport with patient and relatives (Refer to steps)
2. Mention the name of the ward to patient and relatives
3. Introduce patient to ward staff around
4. Show patient the nurse’s station
5. Show patient his/her bed
6. Show patient his/her bed side cabinet/locker and how it operates
7. Introduce him/her to other patients if any
8. Show patient the bathroom, toilet and how the sanitary fittings operates
9. Show patient the kitchen, day room and its uses (if available)
10. Inform patient of ward routines and activities
11. Inform patient whom to contact for any information or complaints
12. Encourage patient to ask questions for clarity
13. Thank patient and send him/her to bed
14. Report to appropriate officer
TTRANSFERE-IN (TRANS-IN)
Requirements
1. Patient’s medical records (Manual or electronic)
2. Referral notes (Manual or electronic)
Steps
. Confirm transfer of patient/client with the referring unit or hospital
2. Make appropriate bed to receive the patient/client
3. Assemble necessary equipment e.g. oxygen cylinders, suction machine, vital signs tray etc.
4. Assemble documentation and investigation forms (Manual or electronic)
5. Receive incoming patient/client, relatives and accompanying nurse warmly
6. Confirm identity of patient/client with accompanying nurse
7. Explain the importance of the transfer to the patient to obtain his/her cooperation

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8. Take over transfer notes and personal belongings from accompanying nurse
9. Ask for clarification on vital issues pertaining to patients/clients condition from the
accompanying nurse
10. Introduce yourself and other staff to patient/client and relatives
11. Admit patient into bed ensuring patient safety
12. Do quick assessment of patients/clients condition and compare with patient/clients medical
records
13. Assess for any drainage or tubings and connects appropriately e.g. oxygen, intravenous
line, urinary catheter etc.
14. Review patients notes, treatment plan and act accordingly
15. Orientate patient/client and relatives on environment and routine of the unit if necessary
16. Document all assessments, findings and treatments in nurses’ notes (manually or
electronically)
17. Plan care for the patient/client
TRANSFERE-OUT (TRANS-OUT)
Requirements
1. Confirm patient’s trans-out order with medical team
2. Assess patients/clients condition
3. Inform the receiving unit or facility about the intended transfer and the state of patient
4. Explain reason for the trans -out to patient and relatives
5. Arrange for accompanying nurse and appropriate means of transportation
6. Collect all necessary data
7. Pack patient’s personal belongings
8. Collect patient’s medication, laboratory results and transfer
9. Ensure patient settle bills where applicable
10. Assist patient onto stretcher, wheel chair or ambulance where applicable
11. Hand over patient’s notes and belongings to the accompanying nurse
12. Ensure linen are removed
13. Decontaminate beds and its accessories
14. Make new bed for next patient

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CARE OF THE HANDS AND FEET
Requirements
1. A trolley containing the following:
a. Top Shelf
i. Two bowels or basins
ii. Two bowels or basins
iii. Nail clipper and file in a receiver
iv. Soap in a dish
v. Nail brush
vi. Sponge
vii. Hand or bath towel
viii. Mackintosh and dressing towel
ix. Hand cream or lotion
x. Orange stick (toothpick)
b. Bottom Shelf
i. Two jugs containing hot and cold water
ii. Bucket to receive used water
c. Heart table
d. Chair
Steps
1. Establish rapport (Refer to steps)
4. Provide privacy and take trolley to bedside
5. Position patient in a desirable position
6. Inspect the skin of hands and feet for callous, swelling and any sores
7. Protect the bed with a mackintosh and dressing towel
8. Mix and allow patient to check the temperature of the water
9. Place bowl of warm water on the mackintosh and towel

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10. Wet fingers in a bowl of warm water
11. Immerse feet in a bowel of water
12. Cut finger nails to the shape of finger tips using a pair of scissors or nail clipper
13. Cut toe nails across to prevent in-growing toe nails
14. Put all nail clippings into a receiver
15. Put hands into the bowl of warm water and scrub nails gently with nail brush
16. Use orange stick to remove debris
17. Wash hands thoroughly using soap and sponge
18. Alternatively put feet into the bowl of warm water and scrub nails gently with a nail brush
19. Use orange stick to remove debris
20. Wash feet thoroughly using soap and sponge
21. Change warm water and rinse the hands and feet alternatively
22. Dry hands and feet thoroughly
23. Apply hand cream or lotion to the hands and feet
24. Remove mackintosh and towel
25. Assist patient into a desirable position
26. Dispose off used items and decontaminate instruments
28. Document procedure and report findings (manual or electronic)
RECORDING OF INTAKE AND OUTPUT
Requirements
a. Top shelf: Drinking cup (To measure fluid input)
b. Bottom Shelf
i. Urinal or bedpan
ii. Measuring jug (To measure output)
c. Fluid chart (manual/ electronic)
Steps

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2. Explain the importance of keeping the fluid balance chart to patient and relatives
3. Obtain fluid intake and output chart (manually or electronically) and confirm with patient’s
identity
4. Determine the types of fluid intake or output
5. Observe amount of fluids given to patient
6. Record the amount of oral and intravenous fluids prescribed at the intake column indicating
the date and time
7. Add together the values for oral and parenteral fluids
8. Assist patient to void into a bedpan or urinal if possible, empty content into the measuring
jug and note the volume OR If there is urine in a urine bag, empty content into the measuring
jug and note the volume
9. Record other forms of output such as watery stools, vomitus at the output column indicating
date, time and the amount
10. Record all measurements in milliliters
11. Add together all the values obtained for outputs
12. Total the intake and output at the end of every 24 hours
13. Find out amount of fluid retained by subtracting the values of fluid output from the intake
15. Inform the nurse in charge/doctor immediately if amount put out is greater than the amount
taken in or when there is abnormally low output
16. Record findings in the appropriate recording software and observation chart
17. Dispose off used items and decontaminate trolley (manual or electronic)
EDUCATION ON CONDITION AND ITS MANAGEMENT
Requirements
1. Patient’s folder (Manual or electronic)
2. Treatment sheet (Manual or electronic)
3. Chair
4. Care devices/gadgets (if any)
5. Pamphlets/source of readable information
Steps
1. Confirm patient’s diagnoses against the patient’s record (manually or electronic)

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2. Establish rapport with the patient (Refer to steps)
3. Explain the need for education to patient
4. Involve relatives or significant other if any
5. Ensure enabling and relaxed environment to maintain privacy and individuality of patient
7. Sit comfortably by the patient
8. Identify the suitable language for the patient
9. Find patient’s level or awareness of condition
10. Build on what the patient knows about the condition with scientific data of condition
11. Find patient’s level or awareness on possible management options
12. Explain to patient the rationale for the various investigations and treatment adopted
13. Explain the possible outcome of condition and prognoses
14. Explain and demonstrate the use of devices/gadgets (if any) included in the management
process e.g. glucometer, clutches, spirometer etc.
15. Ensure patient and significant other understands the teaching and clarify where need be
16. Allow patient and significant other to ask questions for clarity
17. Encourage patient and significant other to co-operate with health team and ask questions
whenever he/she is in doubt
18. Provide patient with clear simple pamphlets or other sources of readable information
19. Thank patient and relatives for the cooperation
20. Document procedure and report to appropriate officer
ADMISSION OF PATIENT
Requirements
1. Admission bed and its accessories (Per patient condition)
2. Manual or electronic folder
3. Vital signs tray
4. Oxygen apparatus
5. Treatment or emergency tray
6. Suction apparatus
7. Admission and Discharge documents (Manual or Electronic)

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Steps
1. Welcome patient and relatives to the nurses’ station
2. Introduce self (nurse) and any staff present
3. Collect necessary documents, admission notes and any other information from the
accompanying nurse
4. Assess the patient’s conditions and note any supportive gadgets/devices
5. Identify and confirm patient’s name, particulars and reassures him/her and relatives
6. Send patient to bedside and position him/her as per the conditions permits
7. Make relative comfortable in the waiting area
8. Take comprehensive history from the patient or relatives
9. Perform general head to toe assessment
10. Check vital signs and records
11. Secure intravenous access and extracts sample for requested laboratory investigations
12. Send patient to do other requested investigations e.g. X-rays, C.T. Scan etc. (if any)
13. Inform charge nurse of any urgent prescribed medication and ensure they are available
14. Administer prescribed medications
15. Assist patient to change into appropriate clothing
16. Ask patient to declare valuables if any according to the institution’s protocol
17. Keep patient valuables according to the institution’s protocol
18. Explain National Health/Mutual Insurance Schemes to patient and relative(s)
a. If client is a scheme holder, go ahead and process
b. If client is a cash-in client, request for deposit per the institutional protocol
19. Introduce him/her to other patients near him/her in the ward
20. Orientate patient/relative(s) to ward if condition permits
21. Inform patients/relatives about the routine ward activities
22. Enter patient’s name into admission, discharges book and daily ward state (manually or
electronically)
23. Instruct patient/relatives to read and sign consent form if necessary
24. Allow relative(s) to see patient and bid goodbye

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25. Document all assessments, findings and treatments in appropriate notes charts (manually
or electronically)
26. Plan care for the patient using the nursing process approach
EDUCATION OF PATIENT ON MEDICATION PRIOR TO
DISCHARGE
Requirements
1. Patient’s folder (Manual or electronic)
2. Treatment sheet (Manual or electronic)
3. Chair
4. Care devices/gadgets (if any)
5. Pamphlets/source of readable information
Steps
1. Confirm patient’s diagnoses against the patient’s record (manually or electronic)
3. Explain the need for education to patient
4. Involve relatives or significant other if any
5. Ensure enabling and relaxed environment to maintain privacy and individuality of patient
7. Sit comfortably by the patient
8. Identify the suitable language for the patient
9. Find patient’s level or awareness of condition
10. Build on what the patient knows about the condition with scientific data of condition
11. Find patient’s level or awareness on possible management options
12. Explain to patient the rationale for the various investigations and treatment adopted
13. Explain the possible outcome of condition and prognoses
14. Explain and demonstrate the use of devices/gadgets (if any) included in the management
process e.g. glucometer, clutches, spirometer etc.
15. Ensure patient and significant other understands the teaching and clarify where need be
16. Allow patient and significant other to ask questions for clarity

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17. Encourage patient and significant other to co-operate with health team and ask questions
whenever he/she is in doubt
18. Provide patient with clear simple pamphlets or other sources of readable information
19. Thank patient and relatives for the cooperation
20. Document procedure and report to appropriate officer
EXPLANATION OF PROCEDURE TO PATIENT AND FAMILY
Requirements
No requirements
Steps
1. Inform patient/clients about the specific procedure and its purpose
2. Find out patient/clients level of knowledge on the intended procedure
3. Explain to patient/client what he/she should expect from the nurses
4. Explain the steps of the procedure in clear and simple language
5. Explain to patient/client the level of invasion or pain (if any)
6. Outline the actions that will be taken to reduce pain (if any)
7. Explain to patient/client his/her role during and after the procedure
8. Allow patient/client to ask questions for clarity
9. Assess patient/clients level of willingness to undergo the specific procedure
DISCHARGE PLANNING
Requirements
1. Patient’s folder
2. Treatment chart (manual or electronic)
Steps
1. Review patient assessment data and admission notes
2. Estimate possible duration of hospitalization with health team members
3. Discuss with the unit staff patient treatment plan for nursing care
4. Identify with health team issues that has to be discussed with patient about his/her treatment
and after care
5. Establish rapport with patient and relatives (Refer to steps)

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6. Educate patient and relatives on the disease condition and its management
7. Discuss with patient and family the possible duration of hospitalization
8. Encourage them to express their fears and ask questions
9. Involve patient and relatives in the care process
10. Obtain signed referral forms to specific therapist if applicable
11. Arrange a visit between any of the following therapist and the patient/relatives to make
assessment and plan for continuity of care if necessary
a. Public Health Nurse
b. Nutritionist
c. Social Worker
d. Physiotherapist
12. Inform patient of any change in treatment plan as soon as it is agreed upon and indicate
progress being made towards discharge
13. Discuss plan with patient and relatives discharge
14. Conduct home visits to ascertain relative’s preparedness to receive patient and closest
referral point if any
15. Document circumstance of discharge.
16. Give emotional support all through procedure and provide patient with necessary
explanations
DISCHARGE OF PATIENT
Requirements
1. Admission and discharge documents (Manual and Electronic)
2. Patient’s medications
3. Receptacle for used linen
4. Container for disinfectant
Steps
1. Ensure that discharge papers are duly signed by discharging doctor
2. Inform patient and relatives about discharge and current state of health
3. Allay patients fear and anxiety on the impending discharge
4. Educate patient and relative(s) on need for continuing treatment and follow up care

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5. Discuss the type of follow-up care that have been prescribed e.g. physio, wound dressing
6. Ensure that patient’s hospital bill is assessed
7. Let patient and relative know the cost of treatment and payment modalities
8. Collect medication for patient from hospital’s pharmacy where applicable
9. Explain how medication should be taken and stored and disposed off at home
10. Help patient to pack his/her belongings
11. Hand over any valuables in the nurse’s custody to the patient or relative(s) and records,
witnessed and signed
12. Remove all I.V. access lines and other tubes or drainage
13. Remind patient and relative(s) of the review date, department to visit, follow-up
appointments and stresses on its importance
14. Record all payment receipt numbers in admission and discharge book and hands over
receipt to patient or relative
15. Documents in the admission and discharge book, daily ward state and nurses’ notes (manual
or electronic)
16. Thank and bids them good-bye
17. Ensure linen are removed, decontaminate beds and its accessories
18. Make new bed for next patient
CHECKING AND RECORDING OF TEMPERATURE
Requirements
1. Electronic thermometer (Oral, axilla, rectal)
2. Breast watch or appropriate timer
3. Dry cotton wool in gallipot
4. Receiver for used swabs
5. Temperature or observational chart (Manual or electronic)
6. Pen
Steps
3. Prepare and send tray to patient’s bedside

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4. Assist patient into an appropriate position
5. Provide privacy
7. Expose and clean area where temperature will be taken, if:
a. Axilla – move clothing away from the patient shoulder and arm to expose the axilla and dry
with clean cotton wool
b. Temporal – ensure that forehead is dry and wipe with dry cotton wool
c. Oral – ensure the mouth is empty
d. Rectal – move clothing away and expose the rectal area are cleaned with a clean soap
8. Press knob to show reading on the screen
9. Clean the thermometer with a dry cotton wool swab from bulb to the stem
10. Check temperature as follows:
a. Axilla – inserts thermometer into the axilla between two skin folds
b. Temporal – place the probe flush on patient’s forehead
c. Oral – slide a clean disposable plastic cover over the temperature probe and place it gently
under the tongue
d. Rectal – slide a clean disposable plastic cover over the temperature probe and place it gently
into the rectum
11. Leave thermometer for two to three minutes or as indicated by manufacturer
12. Removes thermometer after beep, read and record findings on the chart
13. Clean thermometer from stem to the bulb or remove and dispose off probe cover if used
15. Discuss findings with patient and report any abnormalities detected to appropriate officer
16. Chart readings of on observation 14 hourly chart (manual or electronic)
17. Assist patient to return to a desirable position
18. Dispose off used items and return thermometer back to its storage section

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CHECKING AND RECORDING OF PULSE
Requirements
1. Pen
Steps
3. Assist patient into an appropriate resting position
4. Place first three fingers of one hand on the anterior aspect of patient forearm just above the
base of the thumb
5. Feel the pulsations of the radial artery
6. With the aid of an appropriate timer count for a full minute
7. Concentrate on the beats of the pulse when counting rather than the timer
8. Note the rhythm, volume and tension of the pulse
9. Record the pulse on the observation chart
CHECKING AND RECORDING OF RESPIRATION
Requirements
1. Pen
Steps
3. Assist patient into an appropriate resting position
4. Observe patient respiration without his/her awareness
5. Observe the position in which patient breath better and skin colour

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6. Note the rise and fall of patient chest during inspiration and expiration, the rise and fall
counts as one cycle
7. With the aid of an appropriate timer count for a full minute
8. Note the depth rhythm and any difficulty in breathing
9. Record the findings on the observational chart (manual/electronic)
12. Discuss findings with patient and report any abnormalities detected appropriate officer
CHECKING OF BLOOD PRESSURE
Requirements
1. Pen
2. Observation or Blood Pressure chart
3. Stethoscope
4. Sphygmomanometer with appropriate cuff size
5. Ruler
6. Electronic device e.g. tablet
Steps
1. Establish rapport and identify the patient by the name
3. Prepare tray and sent to bedside
4. Assist patient into an appropriate resting position with the arm supported
5. Stretch patient’s arm and places sphygmomanometer beside arm at the same level
6. Empty cuff of air and place the center of the cuff over the brachial artery
7. Wrap the cuff around arm above the elbow making sure the artery arrow marked on the
outside of the cuff is placed correctly and secure the ends
8. Inflates cuff by:
a. Electronic – pressing the start knob and wait for reading to appear on the screen
b. Manual
i. Palpate radial artery and inflate cuff until pulse disappears and note the height of the mercury

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ii. Check, wear and place stethoscope on brachial artery
iii. Release cuff pressure slowly and listen to the sound with stethoscope against the movement
of the mercury
iv. Deflate the cuff until the mercury disappear
9. Remove cuff and reassemble apparatus
10. Thank and makes patient comfortable
11. Record the findings on the observation chart
CHECKING AND RECORDING OF OXYGEN SATURATION
Requirements
1. Pulse oximeter
2. Dry cotton wool in a gallipot
4. Pen
Steps
3. Press the start knob to check if the device is functioning
4. Prepare and send tray to patient’s bedside
5. Assist patient into an appropriate position
7. Examine the sites for capillary refill and coldness
8. Clean the site with a dry swab
9. Warm the sites if the area is cold by either rubbing or applying warm compress
10. Place the device on either the finger, toe or earlobe
11. Record findings on the oximeter on the observation chart (manual or electronic)
12. Remove the device

23
13. Discuss findings with patient and appropriate officer
MONITORING OF GLUCOSE LEVEL
Requirements
1. A tray containing the following:
a. Blood glucose monitor/glucometer
b. Test strip
c. Lancet or needle
d. Disposable gloves
e. Cotton wool swab in a gallipot
f. Receiver for used swabs
2. Sharps container
Steps
1. Check physicians order for the frequency of monitoring glucose level
2. Identify patient and establish rapport (Refer to steps)
3. Explain procedure (Refer to steps)
5. Check the functionality of the glucose meter and ensure reading is in mmol/L
6. Set the tray and send to the bedside
7. Select the site for glucose check (fingers/palmer area)
8. Assess the selected site for any cut, callous, scars or rashes (if any is found choose an
alternate site)
9. Insert glucose strip into the glucometer and check for its functionality
10. Wear disposable glove
11. Clean the area with antimicrobial solution and allow to dry
12. Stroke from the base of the finger/palmer area to fill the capillary tube and make the place
warm
13. Puncture the area using lancet or needle
14. Drop blood on the glucose strip and allow to read
15. Place dry swab on punctured area applying pressure about fifteen (15) seconds to stop
bleeding

24
16. After noting the reading on the glucometer remove the strip and dispose off
17. Remove gloves
19. Discuss findings with the patient and appropriate officer
20. Document on the appropriate recording software and observation chart (manual or
electronic)
21. Dispose off used items, decontaminate tray and place the glucometer in a safe area
TEPID SPONGING
Requirements
a. Top shelf:
i. Two bowls/basin
ii. 6-8 small towels
iii. Vital signs tray
iv. Bath thermometer (if available)
b. Bottom shelf:
i. Two jugs with hot and cold water respectively
ii. Disposable gloves
iii. Long mackintosh and bath blanket
iv. Receptacle for soiled linen
v. Receptacle for used water
vi. New linen and clothing
vii. Bath towel
Steps
2. Explain procedure to patient and relatives (Refer to steps)
3. Provide privacy
5. Prepare trolley and send to the bedside

25
6. Check and record patient’s temperature
7. Arrange top bed/counterpane clothes leaving top sheet
8. Protect bottom sheet with a long mackintosh and bath blanket
9. Undress the patient leaving him/her covered with the top sheet
10. Prepare the tepid water in the bowel/basin, test the water with the bath thermometer or
elbow
11. Place the pieces of towels into the basin with tepid water
12. Squeeze out excess water, place a wet towel in each axilla and groin
13. Change the wet towel frequently to keep them tepid
14. Sponge lower limbs, trunk, back and upper arms in strokes
15. Wash and dry the face of the patient to refresh him/her
16. Place the wet towel on the forehead of patient
17. Leave small drops of water on the skin
18. Change water as often as necessary
19. Leave patient for 15-20 minutes
20. Cover the patient with the top bedclothing
21. Recheck temperature and record
22. Repeat procedure till temperatures falls by 1℃
23. Remove long mackintosh and bath blanket
24. Assist patient to dress up and put him/her into a desirable position
26. Serve cold drink if patient can tolerate
27. Serve prescribed antipyretic
28. Document procedures, charts temperature and report findings to appropriate officer
TREATMENT OF PRESSURE AREAS
Requirements
a. Top shelf
i. A bowl

26
ii. Soap in a dish
iii. Barrier cream
iv. 2/3 hand towels
b. Bottom shelf
i. Jug of warm water
ii. Bucket for used water
iv. Bed linen
Steps
2. Assess patient’s skin
4. Set trolley and send to patient bedside
5. Provide privacy
6. Remove patient’s bedclothes and cover with a sheet
7. Protect bed with long mackintosh and bath towel/blanket
8. Pour water into the basin
9. Roll patient onto the side, left/right lateral or prone, with head turned to one side
10. Examine and note any abnormality
11. Clean all pressure areas (back of the head, ears, hand, scapula, sacrum, elbows, hips,
buttocks, knees, ankles, heels and toes) with soap and water in a soft towel with gloved hands
12. Knead or rub in a circular motion all pressure areas with tip of fingers, or pad of one area
at a time
13. Rinse and dry skin with a soft dry towel
14. Ensure skin is dry without any moisture
15. Apply moisturizing cream or barrier cream
16. Groom and dress patient in a clean clothing
17. Position patient intermittently in any of the following positions at 30° angle: prone, supine,
right or left lateral, right or left sim’s
18. Remove long mackintosh and dressing towel

27
19. Dispose off used items, decontaminate trolley and used linen
21. Document procedure and report findings
22. Inform the appropriate officer of any abnormality
PREOPERATIVE PREPARATION OF PATIENT
Requirements
a. Vital signs tray
b. Theatre gown
c. Name tag
d. Mackintosh and dressing towel
e. Sterile gauze in a gallipot
f. Antiseptic solution
g. Bowl of water
h. Soap and sponge
i. Sterile drape
j. Adhesive strip
k. Urinal/bedpan
2. Consent form
3. Pre-medication as ordered
4. Patient’s medical records (Manual or electronic)
Steps
1. Confirm the type of surgical procedure and site against physician/doctor’s order
3. Prepare and send trolley to bedside
4. Provide privacy
5. Ask patient to empty bladder/bowel
6. Place patient into a desirable position
7. Expose the site to be prepared

28
8. Protect the bed clothes with a mackintosh and dressing towel
9. Wear gloves
10. Wash the area with mild soap and water
11. Dry and clean area with antiseptic lotion
12. Cover area with sterile drape and secure it in position with adhesive strapping
13. Dress patient with a clean theatre gown
14. Label and apply the name tag as per facility’s protocol
15. Remove accessories and dentures if any
16. Check and record vital signs
17. Assist patient to sign the consent form as per facility’s protocol
18. Confirm if all laboratory results, items for surgery and medications are ready for the
procedure
19. Dispose off used items and decontaminate trolley
21. Give prescribed pre-medication when patient is ready for the theatre
22. Send patient to the theater either on a stretcher or wheelchair
23. Hand over patient, medical records and items to the theater staff
24. Document procedure in the appropriate notes (manual/electronic)
25. Prepare an operation bed to receive the patient
SIMPLE UNOCCUPIED BED
Requirements
a. Two large cotton sheet (Bed linen)
b. One water proof draw mackintosh or bed mat if necessary
c. One draw sheet
d. Pillow slips
e. One top sheet
f. Counterpane if necessary
2. Two chairs or heart table

29
3. Mattress
4. One or two pillows
Steps
2. Collect, arranges items on trolley and send to bedside
3. 3. Arrange items in order of use on chairs or heart table
4. Place bottom sheet evenly on the bed
5. Pull sheet tight so that there are no creases
6. Tuck the bottom sheet evenly under the mattress at the top and bottom using mitered or
enveloped corners
7. Pull and tuck sheet at the sides to prevent creases
8. Place bed mat or draw mackintosh at the mid portion of the bed
9. Cover mackintosh or bed mat with draw sheet and tuck in at the sides
10. Slip the pillow cases on the pillows with an assistant
11. Place pillows on bed with open ends away from the entrance
12. Place top sheet on bed with the wrong side uppermost
13. Fold over at the bottom and tuck in loosely
14. Place counterpane (if necessary) loosely over the bed
15. Tuck counterpane (if necessary) at the bottom end using mitered or envelop corners
16. Fold top sheet over the counterpane at the top end (per either Open or Closed bed)
17. Tuck in sides under the mattress to prevent creases
18. Remove trolley and chair or heart table
SIMPLE OCCUPIED BED
Types
1. Changing bottom sheet of a patient from side to side
2. Changing bottom sheet of a patient from top to bottom
Requirements

30
c. One draw sheet
d. Pillow slips
e. One top sheet
3. Mattress
5. Linen bin or receptacle
6. Disposable gloves if necessary
Steps
2. Explain procedure to patient to gain his/her cooperation and participation
3. Ensure patient privacy
5. Collect and arrange items on trolley and bring them to the bedside
6. Arrange sheets in order of use on chairs or a heart table
7. Remove any equipment attached to the bed e.g. drip stand, side rails etc.
8. Loosen sheets at the side of bed and remove extra beddings leaving only the top sheet
9. Leave patient with only one pillow and cover him/her with top sheet
10. Assist the patient to turn to the side away from the clean portion of the linen supported by
another nurse
11. Roll dirty bottom sheet under patient use glove if necessary
12. Cover the bed with a clean rolled bottom sheet halfway in the middle of the bed
13. Create a mitered or envelope corner at the ends
14. Put on bed mat or draw mackintosh and draw sheet mid portion of the bed tucking in greater
part nearest to the door
15. Assist patient gently unto the clean sheet
16. Remove dirty bottom sheet and places it in a receptacle

31
17. Pull the bottom sheet at the other end tightly and tuck in
18. Spread top sheets and counterpane if necessary over the existing sheets
19. Ask assistant to hold the top edge of the clean sheets while the old sheet is gradually pulled
down to the foot end of the bed and place in a receptacle
20. Cover patient with top sheet and counterpane if necessary and make patient comfortable
21. Clear items and removes screen
23. Document findings and report
ADMISSION BED
Requirements
1. General requirements
2. Long mackintosh or water proof sheet
3. Two bath blanket or flannelette
4. Drip stand
5. Vital signs tray
6. Oxygen apparatus
7. Suction machine
8. Medication tray
9. Hot water bottle if necessary
Steps
2. Collect, arrange items on trolley and send to bedside
3. Arrange items in order of use on a chair or heart table
6. Tuck the sheet evenly under the mattress at the top and bottom using enveloped or mitered
corners
8. Cover mackintosh with draw sheet and tuck in at the sides

32
11. Place long mackintosh over the pillow and the bottom sheet and tuck around
12. Place one bath blanket or flannelette over the mackintosh and fold under itself
13. Place second bath blanket over the bed
14. Put in hot water bottles if necessary
15. Put on top bed clothes
16. Place counterpane loosely over the top bed clothes (if necessary)
17. Tuck in the bed clothes on the other side
18. Fold the bed clothes on the other side nearest to the door, leaving it open to facilitate quick
admittance
19. Place bed accessories at the appropriate sides of the bed
21. Remove trolley and chairs
CARDIAC BED
Requirements
c. One draw sheet
d. Pillow slips
e. One top sheet
3. Mattress
5. Back rest
6. Extra pillows
7. Foot rest or sand bags

33
8. Air ring
9. Sputum mug
10. Bell
11. Heart table
12. Writing material (e.g. Pen and paper)
Steps
corners
9. Place covered air rings in between the mackintosh and draw sheet
11. Place/elevate back rest at top end of bed
12. Arrange pillows in an arm chair-like fashion
13. Place top sheet on bed with the wrong side upper most and folds sheets over at the bottom
14. Place foot rest/sand bags in position
15. Tuck in the sides of top clothing loosely
16. Place heart table with covered pillows in position
17. Place sputum mug and bell within reach of patient
18. Place writing materials within reach of patient
19. Clear items (chairs and trolley)

34
OPERATION BED
Requirements
c. One draw sheet
d. Pillow slips
e. One top sheet
3. Mattress
5. Mackintosh or any water proof material and dressing towel
6. Hot water bottles
7. Vital signs tray
8. Medication tray
9. Post anaethestic tray e.g. vomit bowl, wound dressing set, padded spatula or tongue holding
forceps, receiver for soiled swab, adhesive tape, sterile gauze etc.
10. Observation chart (manual or electronic)
11. Drip stand
12. Oxygen apparatus
13. Suction machine
Steps
corners

35
9. Place protective dressing towel at top of the bed towards the sides
10. Leave pillow on chair by the bed
11. Place hot water bottles on the bed
12. Spread blanket on bed
13. Place top sheet on with the wrong side uppermost and turns back the bottom end
14. Fold the top bed clothes at the open side in three parts over the bed for easy admission of
patient
15. Place a post anaesthetic tray by bed side
16. Arrange other bed accessories by the bedside e.g. drip stand, bed rails, vital signs tray
medication tray, suction machine, oxygen apparatus
FRACTURED BED
Requirements
c. One draw sheet
d. Pillow slips
e. One top sheet
3. Mattress
5. Fracture boards
6. Bed blocks or elevators
7. Sand bags with covers
8. Extra mackintosh and dressing towel

36
Steps
3. Arrange items in order of use on chairs or heart table
4. Place fracture boards under the mattress to provide firm support and prevent sagging
enveloped corners
11. Place small mackintosh and dressing towel at where the fracture is located on the bed
14. Place top sheet on bed with the wrong side uppermost
15. Fold over at the bottom and tuck in loosely
16. Place bed cover and counterpane (if necessary) loosely over the bed
17. Fold over top bed clothing at the bottom end
18. Place a foot board or sand bags at the foot end of the bed
19. Tuck in sheets loosely at the sides
20. Attach bed accessories if any
DIVIDED BED
Requirements

37
c. One draw sheet
d. Pillow slips
e. One top sheet
3. Mattress
5. Bed cradle
6. Sandbags if necessary
7. Extra mackintosh
8. Dressing towel or bedlinen
9. Extra top sheet
Steps
3. Arrange items in order of use on chairs or heart table
enveloped corners
10. Place extra mackintosh and dressing towel or bedlinen at the site where the injury is located
11. Place the bed cradle at the mid portion of the bed
14. Place the first top sheet at the upper half of the cradle and fold it over
15. Place the second top sheet at the lower half of the cradle and fold it over

38
16. Place counterpane (if necessary) in the same fashion as the top sheets
17. Ensure that the two sections of the top bed clothings overlap each other
18. Create an opening to aid observation of the body part
19. Tuck in sides under the mattress loosely
BED BATHING
Requirements
a. Top Shelf
i. Two basins or bowls
ii. Sponge
iii. Soap in a dish
iv. Towel
v. Pomade
vi. Bath thermometer
vii. Bottom shelf
viii. Two jugs of water (hot and cold)
ix. Bucket or bowel for used water
x. Receptacle for soiled linen
xi. Long mackintosh
xii. Bath blanket or sheet
xiii. Clean bedsheet or linen
xiv. Patient’s clothing
xv. Bed pan or urinal
Steps
2. Explain the procedure to the patient and provide privacy

39
4. Prepare and take trolley to bedside
5. Offer bedpan or urinal if required
6. Loosen and remove top bed clothes and arranges on a chair/bed table
7. Remove patient’s clothes and cover him/her with a bed linen
8. Protect bed and pillow with long mackintosh and a bath towel/blanket
9. Maintain individuality of patients by asking him/her if he/she would like soap on the face,
temperature of water or if he/she will like to clean the genitalia himself/herself
10. Wash, rinse and dry patient’s face beginning from the inner to the outer canthus of each
eye
11. Wash, rinse and dry the rest of the face, ears and neck
12. Wash, rinse and dry patient’s arm farther away from the nurse
13. Wash, rinse and dry patient’s arm near to the nurse
14. Wash, rinse and dry the chest and abdomen paying attention to the skin folds
15. Wash, rinse and dry the legs in the same way as the arms
16. Turn patient on his/her sides and wash, rinse and dry the back
17. Examine and treat pressure areas
18. Turn patient on his/her side, remove long mackintosh and change bottom linen
19. Clean patient’s genitalia (performs vulva toileting if a female)
20. Groom and dress patient in clean clothes
21. Make bed and reposition patient
22. Dispose off used items and decontaminate trolley and used linen
24. Document procedure and report findings (manual or electronic)
ASSISTED BED BATH
Requirements
a. Top Shelf
i. Two basins or bowls
ii. Sponge
iii. Soap in a dish

40
iv. Towel
v. Pomade
vi. Bath thermometer
vii. Face towel (if available)
b. Bottom shelf
i. Two jugs of water (hot and cold)
ii. Bucket or bowel for used water
iii. Receptacle for soiled linen
iv. Long mackintosh
v. Bath blanket or sheet
vi. Clean bedsheet or linen
vii. Patient’s clothing
viii. Bed pan or urinal
2. Bucket of tepid water
3. Small pale
4. Soap in a dish
5. Towel
6. Sponge
7. Chair or stool
8. Clean cloth or dress
Steps
1. Establish rapport and identify patient by name
2. Inform and explain procedure to patient
3. Assess patient ability to assist in the procedure
4. Prepare bathroom
5. Collect the necessary articles and arranges them for easy access
6. Send patient to the bathroom with the aid of an adaptive equipment e.g. wheelchair, zimna
frame etc.
7. Maintain individuality of patient by asking him/her for the correct temperature of the water

41
8. Provide privacy
9. Assist patient to undress
10. Provide chair or stool in bathroom when necessary
11. Allow the patient to do as much for him/herself as condition permits
12. Complete the areas were patient needs assistance
13. Make bed and allow patient to assume a desired position
14. Collect toiletries and tidy up the bathroom
16. Document procedure and report any findings (manual/electronic)
ASSISTED BATHROOM BATH
Requirements
1. Bucket of tepid water
2. Small pale
3. Soap in a dish
4. Towel
5. Sponge
6. Chair or stool
7. Clean cloth or dress
Steps
1. Establish rapport and identify patient by name
2. Inform and explain procedure to patient
3. Assess patient ability to assist in the procedure
4. Prepare bathroom
5. Collect the necessary articles and arranges them for easy access
6. Send patient to the bathroom with the aid of an adaptive equipment e.g. wheelchair, zimna
frame etc.
7. Maintain individuality of patient by asking him/her for the correct temperature of the water
8. Provide privacy
9. Assist patient to undress

42
10. Provide chair or stool in bathroom when necessary
11. Allow the patient to do as much for him/herself as condition permits
12. Complete the areas were patient needs assistance
13. Make bed and allow patient to assume a desired position
14. Collect toiletries and tidy up the bathroom
16. Document procedure and report any findings (manual/electronic)
SERVING OF BEDPAN
Requirements
1. Trolley containing the following:
a. Bowl
b. Jug of water
c. Soap
d. Wipes/tissue
e. Covered bedpan
f. Receiver
g. Mackintosh and dressing towel
Steps
1. Explain procedure and provide privacy
2. Prepare and send trolley to the bedside
3. Stand at the right side of the bed with assistant on the other side
4. Loosen to bed clothings
5. Place the mackintosh and dressing towel at the midsection of the bed
6. Gently lift patient with the assistant onto bedpan
7. Leave patient for some time and inform him/her to call your attention when he/she is done
8. Lift patient again with assistant to remove the bedpan after use, cover the bedpan
immediately
9. Don gloves, cleans patient with wipes/tissue and discard

43
11. Allow patient to wash hands with soap and water and dry hands
12. Arrange bed clothes and leave patient comfortable in bed
13. Take bedpan to the sluice room and inspect content before emptying
14. Measure urine if any, when necessary and record
15. Empty bedpan, decontaminate, wash, sterilize and remove screen
16. Perform hand hygiene, document procedures and report any abnormalities
COMPLETE MOUTH CARE
Requirements
2. Two gallipots (for mouth cleaning lotion and cotton wool or gauze)
3. Two receivers (for used swab and return mouth wash)
4. Mouth cleaning lotion (e.g. normal saline, sodium bicarbonate, weak strength of hydrogen
peroxide, mouthwash)
5. Padded Spatula
6. Mouth gag
7. Artery, sponge or dressing forceps
8. Dissecting forceps
9. Bowl for dentures if any
10. Lip balm e.g. glycerine or vaseline
11. Orange sticks (toothpick)
12. Towel and mackintosh
13. Jaconet cape/adult bib
14. A jug of water
Steps
2. Explain procedure to patient and provide privacy
4. Prepare tray and take to the patient’s bedside
5. Put patient in a suitable position

44
6. Protect patient’s bed linen with mackintosh and towel
7. Protect patient’s neck area with the jaconet cape/adult bib
8. Use the mouth jag to secure the mouth and position if available
9. Assess the patient’s mouth with the aid of a padded spatula for any abnormalities and
removes dentures if any
10. Pour lotion into gallipots
11. Take swab with forceps, dips into cleansing lotion and squeezes out excess
12. Clean mouth thoroughly but gently i.e. from inside the cheeks, both sides of gums, tongue
and palates changing swabs frequently
13. Control movement of the tongue with padded spatula
14. Use orange sticks to clean in between teeth
15. Clean mouth with water or any diluted mouth wash
16. Clean lips and apply lip balm e.g. vaseline or glycerin
17. Assist patient to resume desirable position
18. Dispose off used items, decontaminate, wash and sterilize instruments
20. Document procedure and findings (manual or electronic)
ASSISTED MOUTH CARE
Requirements
a. Tooth brush, chewing sponge or stick and tooth paste
b. A jug of water and a cup
c. Mouth wash (Optional)
d. Vomitus bowel
e. Bowl for dentures if any
f. Lip balm e.g. glycerine or vaseline
g. Orange sticks (toothpick)
h. Jaconet cape/adult bib

45
Steps
3. Assess patient capabilities to participate in the care
5. Arrange requirement within patient’s reach
7. Place jaconet cape/adult bib under the chin of patient (manual or electronic)
8. Give brush with paste/chewing sponge/stick to patient
9. Encourage patient to brush the teeth or assist patient to brush the teeth
10. Ensure patient cleans the mouth thoroughly and gently paying attention to the cheeks, both
sides of gums, tongue and palates
11. Give water to rinse the mouth and void content into the vomitus bowel
12. Dilute the mouth wash, encourage patient to gargle and void content into the vomitus bowel
13. Clean patient mouth and apply lip balm
14. Assist patient in a desirable in bed
15. Dispose off and clean used items
17. Record procedure and report findings (manual or electronic)
BLOOD TRANSFUSION
Requirements
1. General requirement for administration of intravenous fluids
2. Blood giving set
3. Unit of blood or blood product
4. Pre-medication as ordered
5. Patient folder (Manual or Electronic)
Steps
2. Explain procedure to the patient (Refer to steps)

46
3. Obtain formal consent from the patient
5. Prepare trolley and send to the bedside
6. Verify the following information with a colleague from the patient’s folder and label on the
unit of blood or blood product:
a. Full name of patient
b. Ward
c. Blood group
d. Rhesus factor
e. Blood unit number
f. Expiry date
7. Monitor vital signs and record
8. Ensure cannula is in situ
9. Protect the patient and bed with mackintosh and dressing towel
10. Perform hand hygiene and wear sterile gloves
11. Administer premedication if prescribed
12. Insert the giving set into the pack, fill the chamber and expel air
13. Tighten the clip on the giving set
14. Insert the giving set into the cannula
15. Regulate number of drops per minute accordingly
17. Record the amount of blood set up and the number of the unit on the fluid intake and output
chart
18. Continue to observe patient for any adverse reaction and report appropriately
19. Dispose off used items and decontaminated
20. Discuss findings with patient and relatives

47
ADMINISTRATION OF ORAL MEDICATIONS (TABLETS,
CAPSULES ETC)
Requirements
a. Medication
b. Drinking cup
c. Bottle of water
d. Spoon in a saucer or measuring cup
e. Medication Treatment Chart (Manual or Electronic)
f. Pill-crushing device if necessary
Steps
1. Check for the right patient, right medication, right time, right dose against doctor’s order and
treatment chart (manual or electronic) as well as the expiry date
3. Explain procedure to patient and ensure patient’s right to know/consent and to refuse
5. Prepare and send tray to the bedside
6. Read the label on the package and compare with patient’s treatment chart (manual or
electronic)
7. Take out the medication and compare with the patient treatment chart (manual or electronic)
for the dosage
8. Pour out water into a drinking cup if it is to be administered orally
9. Take the tablet with a spoon
10. Give the tablet to the patient and ensure patient:
a. Swallow with the aid of water if it is to be administered orally
b. Place the medication under the tongue and allow to dissolve if it is to be administered
sublingually
c. Place the medication in between the cheeks and allow to dissolve if it is to be administered
buccally
11. Stay with patient until all medications are taken

48
12. Engage patient in a brief conversation to assess if all medications are swallowed or retained
in the mouth
13. Congratulate patient and make him/her assume a desirable position
14. Observe patient for any adverse reaction
15. Encourage patient to report any adverse reaction
16. Dispose off used items
18. Document procedure in the nurses’ note and chart on treatment chart (manual or electronic)
19. Check on patient after thirty (30) minutes for therapeutic effect
ADMINISTRATION OF ORAL MEDICATIONS (MIXTURES)
Requirements
a. Medication
b. Drinking cup
c. Bottle of water
d. Spoon in a saucer or measuring cup
e. Medication Treatment Chart (Manual or Electronic)
f. Pill-crushing device if necessary
2. Straw
Steps
5. Prepare and send tray to the bedside
6. Read the label on the bottle and compare with patient’s treatment chart (manual or electronic)
7. Take out the bottle and compare with the patient treatment chart (manual or electronic) for
the dosage
8. Shake the bottle gently

49
9. Remove the cork and holds it with the little or ring finger
10. Pick the medicine glass and with the thumb nail marks the level of the measure to be taken
11. Pour out the prescribed dose at eye level in the bright light, holding the bottle with the label
upper most
12. Replace the cork and compare the quantity with the dosage on the patient’s treatment chart
(manual or electronic)
13. Carry medicine to the patient on a saucer, a teaspoon may be added for stirring if it is a
suspension
14. Encourage patient to drink the medicine and serve water if necessary
15. Congratulate patient and make him/her assume a desirable position
17. Encourage patient to report any adverse
20. Document procedure in the nurses’ note and chart on treatment chart (manual or electronic)
ADMINISTRATION OF INTRAVENOUS MEDICATIONS
(INFUSIONS)
Requirements
a. Top Shelf
i. A sterile field with two sterile gallipot with a lid
2. Bottom Shelf
a. Cannula (Different sizes)
b. Tourniquet
c. Medication (Infusion bag/bottle, ampoule or vial)
d. Syringe and needle
e. Sterile glove
f. Sterile cotton in a pack
g. Antimicrobial solution (Methylated spirit)

50
h. Sterile water
i. Receiver for used items
j. Sharps container
k. Adhesive strips/tape
l. Mackintosh and dressing towel
m. Timer
3. Giving set
4. Drip stand
Steps
5. Ensure quality of the infusion (check for cloudiness, sediments and other particles)
6. Prepare and send trolley and other equipment to the patient’s bedside
7. Read the label on the infusion and compare with patient’s treatment chart (manual or
electronic)
8. Encourage patient to use the washroom or serve a bedpan/urinal
9. Check vital signs and records
10. Select and inspect sites for administration
11. Place infusion stand at the side of the bed and prepare adhesive strips/tape
12. Insert the piercing needle of giving set into the rubber seal of the infusion bag/bottle
13. Hang the infusion bag/bottle on the drip stand
14. Remove the cap from the other end of the giving set and attach needle to it
15. Assist patient to assume a desirable position
16. Protect the bed with a mackintosh and dressing towel
17. Fill the chamber half way and expel air from the giving set
18. Perform hand hygiene using alcohol rub
19. Wears sterile gloves

51
20. Clean the site with antimicrobial solution (methylated spirit) with cotton swab
21. Ask assistant to apply tourniquet to locate the vein
22. Introduce the cannula into the vein
23. Remove the metallic stylet and put it in the sharps container
24. Release the tourniquet and connect the giving set
25. Secure cannula into position and check for infiltration or haematoma
26. Remove glove and perform hand hygiene
27. Regulate the flow rate as ordered with the aid of a timer
28. Reposition patient appropriately in bed
31. Check infusion rate accuracy after ten (10) minutes and continue to observe the site of
insertion for swelling
32. Record time of setting up, type and amount of fluid on the treatment, intake and output
chart
33. Document procedure on nurses’ notes (manually or electronically)
ADMINISTRATION OF INTRAVENOUS MEDICATIONS
(AMPULE/VIAL RECONSTITUTED)
Requirements
a. Top Shelf
2. Bottom Shelf
b. Tourniquet

52
e. Sterile glove
h. Sterile water
j. Sharps container
m. Timer
Steps
2. Check medication label and method of reconstitution as per manufacturer’s instructions
6. Prepare and sent trolley to the bed side
7. Ensure a cannula is in situ
8. Read the label on the ampoule/vial and compare with patient’s treatment chart (manual or
electronic) for the dosage
9. Reconstitute as per manufacturers instruction where necessary/prescribers order
10. Examine reconstituted medication for cloudiness and sediments
11. Draw medication with syringe, expel air from the barrel and place the syringe into a receiver
12. Protect bed linen with a mackintosh and dressing towel
13. Put patient in a desirable position
15. Wear sterile glove
16. Clean entry port of cannula with antimicrobial solution and cotton wool swab
17. Fix syringe with the medication into the entry port of cannula
18. Pull gently on the plunger to check for blood return

53
19. Push medication slowly using the push-stop-push-stop technique till administration is
completed
20. Observe patient throughout the administration for any reaction and swelling
21. Continue observing patient five (5) to ten (10) minutes later after injecting medication
25. Document procedure on nurses’ notes and chart on the treatment chart (manual or
electronic)
ADMINISTRATION OF INTRAVENOUS MEDICATION (VIAL)
Requirements
a. Top Shelf
2. Bottom Shelf
b. Tourniquet
e. Sterile glove
h. Sterile water
j. Sharps container

54
m. Timer
3. Drip stand
4. Giving set
Steps
2. Check medication label and method of reconstitution as per manufacturer’s instructions
6. Prepare and sent trolley to the bed side
7. Ensure a cannula is in situ
8. Read the label on the vial and compare with patient’s treatment chart (manual or electronic)
for the dosage
9. Reconstitute as per manufacturers instruction/prescribers order
10. Ensure quality of the medication (check for cloudiness, sediments and particles)
11. Place infusion stand at the side of the bed
12. Hang vial on the drip stand
13. Draw the medication into a syringe
14. Protect bed with a mackintosh and dressing towel
15. Remove the cap from the other end of the giving set
16. Connect giving set, fill the chamber half way and expel air
18. Wear sterile gloves
19. Clean the entry port of cannula with antimicrobial solution (methylated spirit)
20. Connect giving set to the cannula via entry port
21. Regulate the flow rate as ordered with a timer
23. Observe patient for adverse reaction

55
26. Record time of setting up medication, name of medication and amount on the intake and
output chart and Treatment Chart (Manual or Electronic)
electronic)
31. Remove giving set from cannula after administration of medication and cover the entry port
cannula
ADMINISTRATION OF INTRAMUSCULAR MEDICATION
Requirements
a. Medication
b. Two or three syringes
c. Needles
d. Cotton wool swabs in gallipot
e. Antimicrobial solution
2. Treatment chat
3. File where necessary
4. Sharps container
Steps
3. Explain procedure and reassure patient
4. Ensure patient’s right to know/consent and to refuse medication
6. Prepare and sent tray to the bed side

56
7. Check patient details and medication dosage against the treatment chart (manual or
electronic)
8. Assemble syringe and needle using sterile technique
9. File/break ampoule or remove metal cap of vial with a clean swab
10. Draw medication with a syringe and discard the needle into the sharp container
11. Replace needle with a new one and expel air
12. Assist patient into a required position and exposes site for injection
13. Clean injection site with cotton swab dipped in antimicrobial solution (i.e. upper outer
quadrant for buttocks and outer aspect for thigh)
14. Insert the needle quickly and firmly deep into the muscle at right angle
15. Withdraw plunger a little to ensure needle is not in the blood vessel (if blood appears
withdraws needle)
16. Push to release medication into the tissue
17. Withdraw the syringe and needle quickly and with a swab gently applies pressure to the
site of injection
18. Discard syringe and needle into a sharps container
19. Put patient into a desirable position
electronic)
21. Dispose off used items and decontaminate tray
ADMINISTRATION OF SUBCUTANEOUS MEDICATION
Requirements
1. A tray with the following:
a. Sterile 1-2mls syringe and needles
b. Prefilled syringe with medication (if available)
c. Ampoule containing the medication
d. Gallipot with sterile cotton wool swabs
e. Gallipot with antimicrobial solution
f. Receiver for used swabs

57
g. File if necessary
Steps
6. Choose the correct needle size
electronic)
10. File/break ampoule with a clean swab
11. Draw medication with a syringe and discard the needle into the sharps container
12. If it is a prefilled syringe with medication remove the cover of the syringe
13. Expose the chosen site
14. Clean the chosen site with a swab dipped in antimicrobial solution
15. Grasp/spread the skin firmly
16. Insert the needle into the skin at an angle of 45° and release the grasped skin
17. Avoid step 18 if it is a prefilled medicated syringe
18. Pull back the plunger, if no blood is aspirated depress the plunger and inject the medication
slowly. (If blood appears withdraw the needle, replace it and begin again. Explain to the patient
what has occurred)
19. Withdraw the needle rapidly, apply pressure to any bleeding point
20. Discard syringe and needle into a sharps container
electronic)

58
ADMINISTRATION OF INTRADERMAL MEDICATION
Requirements
a. Medication
b. Prefilled medication syringe (if available)
c. Two or three syringes (1ml)
d. Needles (26-28 gauge)
e. Cotton wool swabs in gallipot
f. Antimicrobial solution
2. Treatment chat
3. Sharps container
Steps
6. Choose the correct needle size
electronic)
10. Draw medication with a syringe and avoid creating air bubbles
11. If it is a prefilled syringe with medication remove the cover of the syringe
12. Expose the chosen site
13. Clean the chosen site with a swab dipped in antimicrobial solution
14. Pull the skin towards your hand

59
15. Insert the needle just below the skin at an angle of 10-15°
16. Inject medication slowly and steadily while observing for bleb formation
17. Remove the needle and discard into a sharps container
18. If blood is present dab the area with a dry swab (avoid rubbing the area)
19. Draw a circle with marker around the bleb
20. Observe the area for localize inflammations
22. Instruct patient not to rub or apply any pressure to the area
electronic)
26. Check on patient after five (5) and fifteen (15) minutes for reactions
ADMINISTRATION OF INTRATHECAL MEDICATION
Requirements
a. Top Shelf: A sterile field with two sterile gallipots
b. Bottom Shelf
i. Sterile and epidural pack (if available)
ii. Local anaesthetic agent
iii. Antimicrobial solution
iv. Sterile gloves
v. Sterile cotton wool swab
vi. Spinal cannula different sizes
vii. Medication
viii. Adhesive tape/strip
ix. Receiver for used items
x. Syringes and needles

60
2. Vital signs tray
3. Sharps container
Steps
3. Explain the procedure to the patient
4. Obtain verbal or formal consent from patient and relatives
5. Reassure him/her to gain co-operation
6. Provide privacy
7. Instruct patient to void before the procedure
9. Prepare sterile trolley and send to the bedside
10. Check patient’s vital signs
11. Provide adequate lightening at the puncture site
12. Assist patient into a required position i.e. lying or sitting and supports him/her
13. Open the equipment tray taking care not to contaminate
14. Continue to support, observe and reassure patient throughout the procedure
15. Wear sterile gloves and applies sterile dressing when needle is withdrawn
16. Secure punctured site firmly with a sterile dry swab and an adhesive tape
17. Allow patient to lie flat on the back and make him/her comfortable
electronic)
21. Observe patient continuously for therapeutic and adverse effects
ADMINISTRATION OF TOPICAL MEDICATION
Requirements

61
a. Medication
b. Disposable gloves
c. Gallipot containing sterile swabs
d. Receiver for used swabs
e. Mackintosh and dressing towel
2. Treatment chart (manual or electronic)
Steps
3. Explain procedure
6. Prepare tray and send to bedside
7. Provide privacy and expose the area
8. Assess the site for application of medication
9. Cover the bed with mackintosh and dressing towel
10. Perform hand hygiene and wear gloves
11. Dab skin area with a dry swab to dry and remove flicking skin
12. Apply topical agents evenly on the skin and rub if necessary
13. Remove glove and perform hand hygiene
electronic)
INSTILLATION OF EYE DROPS
Requirements

62
a. Medication with eye dropper
b. Sterile cotton wool swab in a gallipot
c. Bottle of sterile 0.9% ophthalmic saline
d. Paper towels
2. Treatment Chart (Manual or Electronic)
Steps
6. Set tray and send to the bedside
7. Check medication against the treatment chart (manual or electronic) for the right dosage
8. Assist patient to sit in an upright position or lie down with the neck slightly hyper extended
10. Clean eye gently with sterile cotton wool swab soaked in saline solution to remove any
discharge or previous ointment
11. Ask patient to look at the ceiling and retract lower eye lid with your dominant hand
12. Place a wool swab on the lower lid against the lid margin
13. Draw up eye drops
14. Supporting eye dropper on bridge of patient’s nose instill medication as ordered onto
conjunctival space of lower lid
15. Wipe off excess medication with cotton wool, moving from inner to outer canthus
16. Ask patient to keep the eye closed for one (1) to two (2) minutes
17. Encourage patient to report any irritation or blurriness of vision
18. Remove the gloves and perform hand hygiene
electronic)

63
ADMINISTRATION OF RECTAL MEDICATIONS
Requirements
a. Rectal suppository
b. Wipes/soap and water
c. Tissue
d. Disposable gloves
f. Receiver for used items
Steps
6. Send tray to bedside
7. Provide privacy
8. Assist patient to a left lateral or left Sim’s position, with the upper leg flexed
9. Protect bed with mackintosh and dressing towel at the buttocks
10. Fold back the top bedclothes to expose the buttocks
12. Clean anal area with wipes/soap, water and dry
14. Remove medication, checks label and compares with patient’s treatment chart (manual or
electronic)

64
15. Wear gloves, unwraps the suppository
16. Encourage the patient to relax by breathing through the mouth
17. Insert the suppository gently into the rectum using the gloved index finger and press the
patient’s buttocks together for few minutes
18. Ask the patient to squeeze the buttock together and remain in the left lateral or supine
position for at least ten (10) – fifteen (15) minutes
21. Document procedure on treatment chart (manual or electronic) and nurses notes
(manual/electronic)
22. Assess patient after thirty (30) minutes for therapeutic effects
INSTILLATION OF EAR DROPS
Requirements
a. Medicine with a dropper
b. Sterile cotton swabs in a gallipot
c. Gauze or paper wipes
d. Solution bowl for water bath
e. Sterile swabs stick
f. Receiver for used items
Steps

65
8. Confirm the ear for their instillation by first inspecting unaffected ear then the affected ear
9. Position patient in sitting up or lying down with the affected ear up
10. Hold auricle upward, backward and outward to straighten the auditory canal of an adult.
Hold it downward in a child
11. Clean external auditory canal with sterile swab stick if there is a discharge
12. Instruct patient to remain lying down with ear upward for about 5 minutes if necessary
13. Hold medicine dropper almost horizontally, steady patient’s head to absorb excess ear drops
electronic)
16. Remain with patient for five (5) minutes if a child
INSTILLATION OF NASAL DROPS
Requirements
1. Tray containing the following:
a. Cotton wool swabs or gauze swabs
b. Prescribed nasal drops
c. Dropper
d. Receiver
Steps

66
8. Place patient in the supine position with head extended so that his/her chin is higher than
his/her vertex
9. Clean nostrils with cotton wool swabs if necessary
10. Draw up medication and instil by drops as ordered
11. Ask patient to remain in position for a few minutes
12. Ask patient to breathe through his/her mouth and not to bow his/her nose
13. Dab any medication that may drip from his/her nostrils with a dry swab
14. Assist patient into a desirable position after five (5) to ten (10) minutes
15. Remain with patient for five (5) minutes if a child
electronic)
ADMINISTRATION OF VAGINAL MEDICATIONS
Requirements
a. Vaginal medication and applicator
b. Perineal Wipes
c. Disposable gloves
d. Mackintosh and dressing towel
2. Receiver for used items
Steps

67
6. Send tray to bedside
7. Encourage patient to void
8. Provide privacy
9. Assist patient into lithotomy position with the upper leg flexed
10. Protect bed with mackintosh and dressing towel at the buttocks
11. Fold back the top bedclothes to expose the perineal area
13. Assess and clean the perineal area with wipes
15. Wear gloves and unwrap the medication
16. Remove the medication and attach to the applicator as per manufacturer’s instructions
17. Encourage the patient to relax by breathing through the mouth
18. Expose the vaginal orifice with your non-dominant hand
19. Insert the applicator gently into the posterior wall of the vagina
20. Slowly push the plunger until the applicator is empty
21. Remove the applicator and place in a receiver
22. Dry perineal area and ask the patient to remain in the supine position for at least ten (10) –
fifteen (15) minutes
24. Dispose off used items and decontaminate applicator and tray
25. Document procedure on treatment chart (manual or electronic) and nurses notes
COLLECTION OF BLOOD SPECIMENS
Requirements
1. A tray with the following:
a. Sterile syringes and needles
b. Antimicrobial solution
c. Appropriate specimen bottle

68
d. Dry cotton wool swabs in a gallipot
e. Disposable gloves
f. Tourniquet
g. Adhesive strip
h. Receiver for used items
i. Appropriate laboratory or specimen form
j. Appropriate PPE’s e.g. apron
k. Sharps container
Steps
2. Explain procedure to the patient (Refer to steps)
4. Take tray and send to the bedside
5. Provide privacy
6. Protect the bed with a mackintosh and a dressing towel
8. Assist the doctor or laboratory technician to take the sample
9. Dispose off used items and decontaminate the tray
10. Ensure all needles are disposed off in the sharps container
11. Ensure labelled specimen with signed laboratory forms are sent to the laboratory
12. n. If the nurse is taking the blood specimen then the following steps should be followed
after step 7
13. Choose a site preferably on the forearm
14. Apply tourniquet to locate a prominent vein
15. Clean the site with antimicrobial solution
16. Insert the needle gently with syringe attached into the vein at an angle of 45
17. Withdraw the required amount of blood
18. Release the tourniquet
19. Remove the needle gently from the vein, apply a dry swab to the area immediately and hold
it in place with an adhesive strip

69
20. Disconnect needle from syringe, poor blood into specimen bottle
21. Ensure specimen container is well labelled
DRESSING OF SIMPLE WOUND (WITHOUT ASSISTANT)
Requirements
a. Top shelf (a Sterile field with the following sterile items)
i. Two (2) or three (3) gallipots for lotions
ii. Two (2) kidney dish
iii. Two (2) pairs of dressing forceps
iv. Two (2) pairs of dissecting forceps
v. Sinus forceps
vi. Probe
2. Bottom shelf with the following:
a. Dressing lotion
b. Sterile cotton and gauze swab in a drum/ pack
c. Mackintosh and dressing towel
d. Adhesive tape/strip
e. Bandage
f. Scissors
g. Apron
h. Disposable gloves
i. Sterile gloves
j. Receiver for used dressings
Steps
3. Ensure privacy
4. Put on mask perform hand hygiene

70
5. Prepare and send trolley aseptically to the patient’s bedside
7. Protect bed clothes with mackintosh and dressing towel
8. Assembly instruments and pours lotions into gallipots
10. Wear disposable gloves
11. Expose area of wound and removes plaster or bandage
12. Remove soiled dressing with dissecting forceps or disposable gloves, assess for the type of
exudate and discard
14. Dab or clean wound with sterile forceps/gloves using prescribed lotion from within
outwards
15. Where necessary gently irrigates wound with syringe and saline
16. Clean or dab wound with series of swabs until wound is clean
17. Clean the surrounding skin
18. Apply sterile dressing using prescribed dressing lotion
19. Add enough sterile dressing and secures into position or leaves exposed where necessary
20. Apply adhesive tape or bandage to the site where necessary
22. Reposition patient in bed
23. Inform patient about the state of the wound
24. Dispose off used items, decontaminate used instruments and trolley
26. Documents and reports state of the wound in the nurse notes (manually or electronically)
DRESSING OF COMPLICATED WOUND WITH ASSISTANT
Requirements

71
v. Sinus forceps
vi. Probe
b. Bottom shelf with the following:
c. Dressing lotion
d. Sterile cotton and gauze swab in a drum/pack
f. Adhesive tape/strip
g. Bandage
h. Scissors
i. Apron
j. Disposable gloves
k. Sterile gloves
l Receiver for used dressings
Steps
3. Ensure privacy
4. Put on mask and perform hand hygiene
6. Protect the bed with mackintosh and dressing towel
7. Ask assistant to:
a. Put patient into desired position
b. Protect bed clothes and exposes wound
a. Pour out lotions into gallipots
b. Wear gloves and remove plaster or bandage and discard

72
9. Remove soiled dressing with dissecting forceps or disposable gloves, assess for the type of
exudate and discard
10. Assess the state of the wound for exudates, granulation and depth
12. Dab or clean wound with sterile forceps/gloves using prescribed lotion from within
outwards
13. Where necessary gently irrigates wound with syringe and saline
18. Ask assistant to help apply the adhesive tape or bandage to the site where necessary
20. Reposition patient in bed with the help of the assistants
24. Document and report state of the wound in the nurse notes (manually or electronically)
25. Report findings to the appropriate officer
TAKING OF WOUND SWAP
Requirements
v. Sinus forceps
vi. Probe

73
a. Dressing lotion
b. Sterile cotton and gauze swab in a drum/pack
e. Bandage
f. Scissors
g. Apron
i. Sterile gloves
3. Sterile swab in a container
4. Laboratory request form
Steps
3. Provide privacy
5. Wear mask, prepare trolley and send to bedside
6. Protect bed with mackintosh and dressing towel
7. Put on disposable gloves
8. Put patient in a desirable position for wound dressing (depending on the location of the
wound)
9. Remove dressings from wound
11. Put on sterile gloves
12. Take wound swab especially from the discharging part of the wound (if any)
13. Continue with wound dressing (see procedure on wound dressing)
14. Remove gloves

74
16. Dispose off used items, decontaminate trolley and instruments
18. Label and ensure swab is sent to the laboratory with signed request form
19. Record and request observations
REMOVAL OF STITCHES
Requirements
v. Sinus forceps
vi. Probe
a. Dressing lotion
b. Sterile cotton and gauze swab in a drum/pack
e. Bandage
f. Scissors
g. Apron
i. Sterile gloves
3. Sterile stitch scissors
Steps

75
3. Ensure privacy
4. Put on mask and perform hand hygiene
6. Protect the bed with mackintosh and dressing towel
a. Put patient into desired position
b. Protect bed clothes and exposes wound
a. Pour out lotions into gallipots
b. Wear gloves and remove plaster or bandage and discard
9. Remove soiled dressing using disserting forceps or disposable gloves, assess the soiled
dressing and discard
10. Assess the state of the wound and the type of suturing
12. Dab or clean wound with sterile forceps/gloves using antimicrobial solution and swab
13. Place a sterile gauze swab near the wound to receive the sutures
14. Count the number of stitches in place if it is an alternate stitch
15. Explain to the patient that it will be a bit uncomfortable/painful and reassure
16. Hold the dissecting forceps in the left hand and stitch scissors in the right
17. Grasp the ends of the stitches with the dissecting forceps, pull it a bit to expose and area
between the knot and the skin
18. Insert one blade of the stitch scissors under the stitches, cut between the knot and the skin
19. Cut it in such a way that no piece of stitch is left in the tissue and remove the stitch without
dragging the exposed area through the tissue
20. Place all removed stitches on the swab, count and examine
25. Ask assistant to help apply the adhesive tape or bandage to the site where necessary

76
27. Reposition patient in bed with the help of the assistants
31. Document and report state of the wound in the nurse notes (manually or electronically)
32. Report findings to the appropriate officer
PROCESSING OF INSTRUMENTS AFTER USE
Requirements
1. Chlorine solution
2. Two basin
3. A bucket of tepid water
4. Empty bucket with a lid
5. Brush
6. Sponge
7. Soap/liquid detergent
8. Rubber apron
9. Utility gloves
Steps
1. Prepare a fresh 0.5% parazone solution in a bucket or bowl
2. Immerse all used instruments in the solution for at least 10 minutes
3. Put on utility gloves and remove instruments from the parazone solution after 10 minutes
4. Rinse the instruments in warm or cool water
5. Scrub instruments using a soft brush with a soap/liquid detergent, paying attention to the
crevices/serrated ends under water in a bowl
6. Rinse instruments thoroughly with clean water to remove all detergent
7. Boil for 20 minutes in a boiler covered with a well-fitting lid OR
8. Dry by air or with a clean towel if to be sterilized in CSSD
9. Document instruments and send them to CSSD

77
CATHETERIZATION OF FEMALE PATIENT
Requirements
a. Top Shelf: A sterile pack or field containing the following:
i. Two gallipots
ii. Three sterile drape, one sterile fenestrated drape
iii. Sterile cotton wool swabs
iv. Artery forceps
v. Kidney dish
b. Bottom Shelf : Various catheters of different sizes used
i. 14" and 16" for female
ii. 18" and 20" for male
iii. 8" and 10" for children
iv. Lubricant (e.g. K.Y. or xylocaine jelly)
v. Diluted antiseptic solution
vi. Receiver for used swabs
vii. Mackintosh and dressing towel
viii. Urine bag
ix. Sterile water or saline
x. Specimen bottles if necessary
xi. Hypo-allergic tape or plaster
xii. Hand lamp if necessary
xiii. Sterile gloves
xiv. 10-20mls syringe and needle
xv. Spigot if necessary
xvi. Jug of warm water and bowel/bucket
xvii. Soap and towel
xviii. Bedpan
xix. Intake and output chart

78
Steps
1. Review doctor/physician’s order for catheterization
4. Provide privacy
7. Protect bed with mackintosh, dressing towel and ensure adequate lighting
9. Turn back sheet covering the patient or ask an assistant to do this if available or necessary
10. Instruct assistant to place patient in the supine position with knees flexed and legs separated
11. Place bedpan under patient and wash perineum thoroughly with soap and water
12. Clean patient and remove bedpan
14. Open the packs of sterile dressing and catheter container and place the contents onto the
sterile field
15. Drape the patient with a sterile towel and place the fenestrated drape over the perineum
exposing the urinary meatus
16. Wear new sterile gloves
17. Use the non-dominant hand to part the labia and establishes a firm but gentle position
18. Pick a cotton wool ball soaked in antiseptic solution with forceps in the dominant hand and
swab one side of the labia majora from top to bottom, uses a new ball for opposite side
19. Repeat procedure for the labia minora, uses another cotton wool ball to clean over the
meatus
20. Lubricate catheter with K.Y. or xylocaine jelly
21. Retract the labia to fully expose the urinary meatus with your non-dominant hand
22. Insert catheter into the urethral orifice and then gently push it in an upward and backward
direction for about 5-7.5cm (2-3inches) leaving the open end in the receiver between the
patient’s thighs
23. Inflate the balloon of the catheter with the sterile water according to manufacturer’s
direction

79
24. Collect a urine specimen if necessary and allows 20 – 30mls to flow into bottle without
bottle touching the catheter
25. Connect catheter to urine bag
26. Hang urine bag to the bed and secure in position
27. Observe colour and note amount of urine
28. Remove drapes, mackintosh and dressing towel
31. Dispose off used items, decontaminate instruments and trolley
33. Document the procedure, urine output and any abnormalities in the nurses’ note, intake and
output chart (manual or electronic)
CATHETERIZATION OF MALE PATIENT
Requirements
a. Top Shelf: A sterile pack or field containing the following:
i. Two gallipots
ii. Three sterile drape, one sterile fenestrated drape
iii. Sterile cotton wool swabs
iv. Artery forceps
v. Kidney dish
b. Bottom Shelf: Various catheters of different sizes used
c. 14" and 16" for female
d. 18" and 20" for male
e. 8" and 10" for children
f. Lubricant (e.g. K.Y. or xylocaine jelly)
g. Diluted antiseptic solution
h. Receiver for used swabs
i. Mackintosh and dressing towel
j. Urine bag

80
k. Sterile water or saline
l. Specimen bottles if necessary
m. Hypo-allergic tape or plaster
n. Light source
o. Sterile gloves
p. 10-20mls syringe and needle
q. Spigot if necessary
r. Jug of warm water and bowel/bucket
s. Bedpan
t. Soap and towel
u. Intake and output chart (manual or electronic)
2. Condom catheter
3. Urinal
Steps
1. Review doctor/physician’s order for catheterization
4. Provide privacy
7. Protect bed with mackintosh and dressing towel
9. Instruct assistant to place patient in the supine position with knees flexed and legs separated
10. Cover patient’s upper body with a top sheet and fold the down over to expose the penis
11. Place bedpan under patient, wash and dry perineal area thoroughly with soap and water
12. Where necessary retract the prepuce so that the urethral meatus is exposed
13. Clean patient and remove bedpan

81
15. Open the packs of sterile dressing and catheter container and place the contents onto the
sterile field
16. Drape with a sterile towel and place the fenestrated drape over the penis exposing the
urinary meatus
17. Wear new sterile gloves
18. Clean the area with antiseptic lotion wiping with backward motion from the urethral meatus
19. To straighten the urethra, lift the penis to an angle of 90°
20. Lubricate catheter with K.Y. or xylocaine jelly
21. Insert the catheter gently for about 16cm or until urine begins to flow leaving the open end
in the receiver between the patient’s thighs
22. Inflate the balloon of the catheter with the sterile water according to manufacturer’s
direction when urine flows out
23. Collect a urine specimen if necessary and allows 20 – 30mls to flow into bottle without
bottle touching the catheter
24. Note: Slight resistance will often be met as the catheter encounters the external sphincter,
therefore paus briefly and encourage the patient to breathe in deeply resulting in sufficient
relaxation for the catheter to be passed readily for the urine to flow
25. Connect catheter to urine bag
26. Hang urine bag to the bed and secure in position
27. Observe colour and note amount of urine
28. Remove drapes, mackintosh and dressing towel
31. Dispose off used items, decontaminate and trolley
33. Document the procedure, urine output and any abnormalities in the nurses’ note, intake and
output chart (manual or electronic)
CARE OF AN INDWELLING URINARY CATHETER
Requirements
1. A trolley contaminating the following:
a. Top shelf (a sterile field with the following)
i. Two sterile gallipot

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ii. Kidney dish
iii. Sterile Cotton swab
iv. Sterile drapes
b. Bottom shelf
i. Antiseptic solution
ii. Receiver for soiled items
iv. Disposable gloves
v. Sterile gloves
vi. Urinal
vii. Measuring jug
viii. Urine bag if necessary
ix. Antibiotic ointment
Steps
3. Assemble necessary items
4. Ensure privacy
5. Perform hand hygiene, prepare trolley and send to bedside
6. Put patient in the supine position
7. Place mackintosh and dressing towel under patient
8. Cover patient up so that only genital area is exposed
9. Remove anchor device to free catheter tubing
10. Perform hand hygiene and wear sterile gloves
11. If it is a male, retract foreskin if present to expose urethral meatus, clean around catheter
first, and then wipe in a circular motion around meatus and glans
12. If it is a female, clean vulva using cotton wool swab and antiseptic solution towards anus,
clean urethral meatus, moving down the catheter
13. Inspect urethral meatus for discharge

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14. Use sterile cotton swab soaked in antiseptic lotion, wipe in a circular motion along the
length of catheter
15. Anchor catheter back
16. Apply antibiotic ointment at urethral meatus and along 2.5cm of catheter
17. Empty the urine and change the bag if necessary
18. Record urine output
19. Remove drape, mackintosh and dressing towel
22. Dispose off used items and decontaminate instruments and trolley
24. Document in nurses’ notes, intake and output chart (manual or electronic)
25. Report findings to appropriate office
REMOVAL OF AN INDWELLING URINARY CATHETER
Requirements
a. Top shelf
i. Gallipot
ii. Drape
iii. Kidney dish
iv. 10-20mls syringe
b. Bottom shelf
i. Bed pen
ii. Measuring jug
iv. Disposable gloves
v. Receiver
vi. Jug of water, bowel, soap and towel
c. Intake and output chart (Manual or Electronic)

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Steps
1. Review doctor/physician’s order for catheter removal
2. Explain the procedure to patient
3. Provide privacy
4. Prepare and take trolley to the bedside
5. Put patient into a supine position with the legs opened and flexed
6. Place mackintosh and dressing towel beneath the patient
7. Fold top bed clothings over and exposed the perineal area
9. Wear gloves and place a towel between legs of the female patient/on the thighs of the male
patient
10. Insert the syringe into the injection port of catheter and withdraw water from the balloon
11. Instruct patient to take in breath whiles you withdraw the catheter
12. Withdraw the catheter gently and place into a receiver
13. Dry the perineal area with a towel
14. Measure urine in the measuring jug
16. Remove gloves
21. Document findings and record urine output in nurses’ notes, intake and output chart
HANDING OVER A WARD
Requirements
1. The following manual or electronic documents:n. 1 24 Hourly report book
2. Patient’s folders
3. Patient observation charts
4. Ward state

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5. Nurse’s changes book
6. Other relevant documents (based on facility protocol)
Steps
1. Welcome the in-coming nurse
2. Give ward reports on patients to in-coming nurse to read
3. Enquire from in-coming nurse if she needs further explanation on occurrences on the ward
4. Hand over sensitive information about patients at the nurses’ station
5. Move to the bedside of the patient
6. Together with incoming nurse, interact with patient while handing over
7. Check and confirm information about patients’ on the charts and notes
8. Check condition of patient whether stable improving or deteriorating
9. Check with incoming nurse if gadgets on patients are functioning e.g. cardiac monitor,
oxygen flow metre etc.
10. Check on any drainage tubes if they are draining well and record the amount if necessary
e.g. intravenous line, catheter, NG tubes etc.
11. Check and hand over controlled medication and other relevant consumables available
12. Inspect the ward annexes and ensure they are clean and tidy
13. Hand over ward annexes to in-coming nurse
14. Report on any defects on equipment and request made for urgent repairs
15. Report on departmental instructions and other important information
TAKING OVER A WARD
Requirements
1. The following manual or electronic documents:
2. 24 Hourly report book
3. Patient’s folders
4. Patient observation charts
5. Ward state
6. Nurse’s changes book 6. Other relevant documents (based on facility protocol)
Steps
1. Greet the nurses on duty

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2. Ask for oral information on major happenings on the ward from the outgoing nurse
3. Read reports
4. Enquire about sensitive information on patients at the nurse’s station
5. Take over ward from bed to bed verifying the state of all patients
6. Establish rapport with patients during taking over, ask about their concerns and general
health
7. Confirm information about the patients on charts and notes provide
8. Check with outgoing nurse if gadgets on patients are functioning e.g. cardiac monitor,
oxygen flow metre etc.
9. Check on any drainage tubes if they are draining well and record the amount if necessary
e.g. intravenous line, catheter, NG tubes etc.
10. Conduct inspection of ward with the outgoing nurse and note defective equipment
11. Ensure resources needed for work are available and adequate and takes over controlled
medication
12. Counter-signs written ward report
13. Note important issues and document
14. Congratulate out-going nurse
WASHING OF PATIENT’S HAIR IN BED
Requirements
a. Top shelf
i. Bowl
ii. Two bath towel
iii. Face towel
iv. Cotton wool swabs in a gallipot
v. Shampoo and conditioner
vi. Hair comb
vii. Kidney dish
viii. Hair pins where necessary
2. vii. Hair pomade

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a. Bottom shelf
i. Two jugs containing hot and cold water
ii. Long mackintosh and a bath blanket/big towel/linen
iii. Clean linen if required
iv. Hairdryer if available
v. Bucket for used water
Steps
3. Provide privacy
4. Perform hand hygiene, prepare and send trolley to bedside
5. Assist patient into a fowler’s position or lie flat in with the head extended to the edge of the
bed (if condition permits)
6. Arrange long mackintosh and a bath blanket/big towel/linen into a trough, fashioned under
the patient’s shoulders, neck, head and extend it down into a bucket
7. Cover mackintosh with a bath towel under the patient’s neck and around the shoulders
8. Remove hair accessories, comb and remove tangles
9. Pluck the ear with cotton wool balls
10. Mix the water to the patient’s preferred temperature
11. Wet hair and apply soap/shampoo
12. Massage hair well, rinse and repeat till the hair is clean (a woman require more rinse water
than a man)
13. Wipe any moisture around eye, face and neck
14. Squeeze hair gently and tie hair up in a towel
15. Remove long mackintosh and a bath blanket/big towel/linen
16. Assist patient into a sitting up position
17. Dry thoroughly with a towel and a hand dryer
18. Apply pomade, comb and style hair to patient’s liking
19. Change linen if wet

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23. Document procedure in nurses’ notes (manual or electronic) and report findings to
appropriate officer
SPOON FEEDING OF AN ADULT ILL PATIENT
Requirements
1. A tray containing:
a. Food
b. Spoon
c. Bottle of drinking water
d. Cup
e. Napkins
f. Serviette
2. A bowl of water
3. Hand washing soap
4. Bedpan/urinal if necessary
5. Mouth wash
Steps
2. Explain the procedure to the patient and inform him/her about the kind of food about to serve
3. Ask patient if he/she want to empty the bladder/bowel before eating
4. Offer bedpan/urinal if required
5. Assist patient to perform hand hygiene
6. Perform hand hygiene and prepare meal tray
8. Give patient a mouth wash
9. Bring food in a tray to patient’s bedside and place it on the cardiac table
10. Protect patient’s clothing with the serviette
11. Ensure patient is in a comfortable position and ask if prayer is preferred

89
12. Sit beside the patient if convenient to make patient feel relaxed
13. Take food by spoon in small bits into patient’s mouth not too far back
14. Allow patient time to chew and swallow
15. Coordinate the opening of the mouth while introducing the food
16. Continue feeding until patient is satisfied
17. Give water intermittently as required by patient
18. Clean patient’s lips and give a mouth wash
19. Remove serviette and reposition patient comfortable
20. Encourage patient to comment on the food served
21. Congratulate patient and discard tray
22. Dispose off tray and wash items
23. Perform hand hygiene and document on appropriate charts (manual or electronic)
FEEDING A PATIENT PER NASOGASTRIC TUBE
Requirements
1. An inserted nasogastric tube
2. A tray containing:
a. Prescribed amount of feed
b. Feeding syringe 50/60 cc
c. Calibrated cup/container
d. Bottle of water
3. Jaconet cape/adult bib
4. Disposable gloves
5. 20cc syringe in a receiver
6. Stethoscope
Steps
2. Explain procedure to patient and relatives (Refer to steps)
3. Confirm the type and amount of feed against patient’s records

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5. Send prepared feed in a tray to the patient’s bedside
6. Assist patient into a fowler’s position or slightly elevate the head end of the bed
7. Make patient comfortable and protects his/her clothes with the jaconet cape/adult bib
8. Check for proper placement of tube in the stomach by
a. Aspirating abdominal contents for a typical gastric fluid appearance (grassy-green,
colourless with mucus shreds) in the tube OR
b. Inject 5 – 20cc of air through the tube and auscultate epigastric region with a stethoscope
and listen for the whooshing sound simultaneously
9. Pour the feed into the calibrated cup and check the temperature
10. Pinch the naso-gastric tube, remove spigot and connect the empty syringe barrel
11. NB: Ensure that throughout the procedure the tube is never allowed to empty completely
to prevent air from entering patient’s stomach
12. Hold the syringe in an upright position and pour 10-20mls of water to flush the tube before
introducing the feed
13. Pour the feed into the syringe barrel, release the pinch and allow the feed to run by gravity
14. Continue feeding and observe patient for signs of discomfort till feeding is completed
15. Flush the tube with 10-20mls of water at the end of feeding
16. Pinch tube, remove the syringe barrel and replace in spigot
17. Assist patient to remain in the sitting up position for at least 30 minutes after feeding
18. Remove protective clothing, dispose off tray and wash items
19. Perform hand hygiene and document on appropriate charts (manual or electronic)
COLLECTING A SINGLE VOIDED SPECIMEN
Requirements
1. Laboratory form
2. Specimen container
3. Bedpan or urinal
5. Tissue
6. Ballpoint pen
7. Mackintosh and dressing towel

91
Steps
1. Confirm physician/doctor’s request against the specimen form with patient’s name, date and
content of urinalysis (manual or electronic)
3. Explain the procedure (Refer to steps)
4. Assemble requirements
5. Label the bottle or container with the date, patient’s name, department identification and
physician/doctor’s name
6. Protect the bed with mackintosh and a dressing towel
7. Perform hand hygiene and put on gloves
8. Assist the patient/client to void into a clean bedpan/urinal
9. Pour about 10-20 mL of urine into the labeled specimen bottle or container and cover the
bottle or container
10. Discard the excess urine
12. Remove gloves and perform hand hygiene.
13. Send the specimen bottle or container to the laboratory immediately with the specimen
form
14. Document the procedure in the designated place
COLLECTION OF URINE SPECIMEN FROM A RETENTION
CATHETER
Requirements
1. Laboratory form
3. Bedpan or urinal
5. Tissue
6. Ballpoint pen
8. Tray containing the following:

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a. Antimicrobial solution
b. Cotton wool swabs in a gallipot
c. 10-20-mLsyringe with 21-25-gauge needle
d. Clamp or rubber band
e. Receiver for used items
Steps
5. Label the bottle or container with the date, patient’s name, department identification and
7. Assist patient into a supine position and expose the perineal area
8. Perform hand hygiene and put on gloves
9. Disconnect the urine bag if attached
10. Clamp the tubing:
a. Clamp the drainage tubing or bend the tubing
b. Allow adequate time for urine collection
11. Clean the aspiration port with an antimicrobial solution
12. Withdraw the urine by:
a. Inserting the needle into the aspiration port to withdraw sufficient amount of urine into the
syringe
b. Allowing the urine to flow from the catheter into a clean container
13. Transfer the urine to the labeled specimen container
14. Unclamp the catheter and attach urine bag if necessary

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18. Discard the excess urine, dispose of used items and decontaminate tray
20. Send the specimen bottle or container to the laboratory immediately with the specimen
form
21. Document the procedure in the designated place
COLLECTION OF 24-HOURS URINE
Requirements
1. Laboratory form
3. Bedpan or urinal
5. Tissue
6. Ballpoint pen
8. Series of specimen bottles
Steps
5. Label the containers or bottles with the following information:
a. Name of patient
b. Ward
c. Specimen
d. Examination required
e. Time, date of commencement and completion of collection of specimen
6. Choose a suitable time e.g. 9am to 9am the following day
7. Review instructions with patient in the morning of commencement of collection

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8. Put labelled container in a suitable place near patient’s bed
9. Ask patient to pass urine at the time collection begins and discard it
10. Instruct patient to pass all subsequent urine into bedpan/urinal for the next 24 hours. This
is poured into the labelled container
11. Ask patient to pass urine at time the test ends and add this to collected urine
12. Record total amount of urine collected on fluid chart and document in nurses’ notes (manual
or electronic)
14. Dispatch specimen with appropriate laboratory form to laboratory
COLLECTION OF STOOL SPECIMEN
Requirements
a. Top shelf
i. Stool specimen container and a spatula
ii. Laboratory form
iii. Disposable gloves
iv. Soap in dish
v. Bowl
vi. Clean towel
b. Bottom shelf
i. Clean bedpan with a lid
ii. Tissue paper/wipes
iii. Jug of water
iv. Receptacle
v. Mackintosh and dressing towel
Steps
1. Confirm physician/doctor’s request against the specimen form with patient’s name and date
(manual or electronic)

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4. Ask the patient to tell you when he/she feels the urge to have a bowel movement
6. Prepare and take trolley to bedside
7. Label the container with the date, patient’s name, department identification and
9. Offer bedpan to patient
10. Allow the patient to pass feces
11. Wear disposable gloves
12. Remove the bedpan
13. Assist the patient to clean and dispose tissue into a receptacle
14. Examine the faeces noting the colour, odour and consistency
15. Use the spatula to transfer a portion of the feces into the specimen container and dispose
off spatula
16. Cover the container
17. Remove and discard gloves
19. Dispose off used items, decontaminate trolley and bedpan
20. Send specimen to the laboratory immediately
21. Document the procedure in the nurses’ notes (manual or electronic)
PREPARATION FOR WARD ROUNDS
Requirements
1. A trolley containing the following: n Top shelf
a. Adequate supply of tablet for documentation or the following stationery:
i. Patient’s Medical Records
ii. Nurse’s changes book
iii. Continuation sheet
iv. Treatment sheet
v. Investigative request forms e.g. X’ray, laboratory
vi. Prescription form

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vii. Stapler with pins
2. Bottom shelf
a. Vital signs tray
b. Diagnostic set
c. Pocket torch light
d. Measuring tape
e. Disposable tongue depressors/padded spatula
f. Neurological set
g. Receiver for used articles
h. Other trays may be set depending on the specific needs of patient
Steps
1. Ensure the ward and its annexes are clean
2. Ensure all patients and visitors are in bed and out of the ward respectively
3. Conduct charge nurse’s round, note down concerns and complaints of patients
4. Classify patients according to their needs or depending on the protocol of the unit
5. Ensure all reports are dully filed and records are up to date
6. Arrange patient’s medical records in the correct sequence for the rounds
7. Facilitate rounds, present patients’ problems, concerns and progress
8. Assist when doctor is examining the patients
9. Give patients’ opportunity to ask questions
10. Provide appropriate answers to patients’ questions
11. Record all changes, directives and tasks assigned in appropriate documents
12. Ensure patient’s notes are returned to their proper place on the rack after the procedure
DEVELOPING INTERPERSONAL RELATIONSHIP WITH THE
PATIENT/CLIENT (ESTABLISHING OF RAPPORT)
Requirements
No requirements
Steps
1. Introduce yourself to the patient/client

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2. Maintain a relaxed attitude when interacting with patient/client
3. Identify patient/client’s name, title and address him/her as such
4. Speak to patient/client using simple and clear language
5. Assure patient/client of total confidentiality
6. Establish eye contact with the patient/client during the interaction
7. Enquire from the patient/client the purpose of visit (if applicable)
8. Encourage patient/client to express his/her needs and listen attentively
9. Explain to patient/client what he/she should expect from the nurses
10. Show consistency in approaching the patient/client
11. Demonstrate firmness in dealing with inappropriate requests and behaviour by the
patient/client if any
12. Express appreciation to patient/client for his/her cooperation

NMC PROCEDURE MANUAL PART ONE DAY AND TH

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