NURSING PROCEDURES

A. ASSESSMENT

Date of
Date of Clinical
Actions Basic To Nursing Care/ Demo/
Practice/Signature of
General Nursing Procedures Signature of
C.I.
C.I.
1. Taking A Nursing History using
Guidelines
2. Physical Health Assessment
a. General Survey
- Appearance and mental status
b. Vital signs
1. Temperature taking
-Oral
-Rectal
-Auxillary
-Tympanic
2. Pulse Taking
-Temporal
-Carotid
-Apical
-Femoral
-Brachial
-Poplitial
-Posterior tibial
-Dorsalis Pedis
c. Height
d. Weight
e. Assessment
- Assessing the skin, hair, nails
- Assessing the skull and face
- Assessing the eyes, ears, nose
- Assessing the mouth and
oropharynx
- Assessing the neck
- Assessing the thorax and lungs
 - Assessing the heart, central C. SAFETY
and peripheral vessels
- Assessing the breast and Date of
Date of Clinical
axillae Actions Basic To Nursing Care/ Demo/
Practice/Signature of
- Assessing the abdomen General Nursing Procedures Signature of
C.I.
- Assessing the musculoskeletal C.I.
System (Inclusive of upper a. Using a bed or chair exit safety
and lower extremities) b. Implementing seizure precautions
- Assessing the Neurologic
- Padding a bed
System
- Mental Status - Ready a padded tongue blade
- LOC – Level of - Ready oral airway
Consciousness - Ready oral
- Cranial Nerves
- Ready suctions machine
- Reflexes
c. Applying Restraints
- Motor Functions
d. Applying side rails on bed 1 call
- Sensory Functions
light
- Assessing the female Genital
and Inguinal Area D. DIAGNOSTIC TESTING
- Assessing the male Genital
and Inguinal Area Date of
- Assessing the Rectum and Date of Clinical
Actions Basic To Nursing Care/ Demo/
Anus Practice/Signature of
General Nursing Procedures Signature of
f. MMDST Screening C.I.
C.I.
a. Obtaining capillary blood
B. ASEPSIS specimen and measuring blob
glucose
Date of b. Collecting a urine specimen for
Date of Clinical
Actions Basic To Nursing Care/ Demo/ culture and sensitivity by clean
Practice/Signature of
General Nursing Procedures Signature of catch
C.I.
C.I. - Male
a. Hand washing
- Female
b. Donning & Removing Gloves/
(Open, Closed), Gown (Sterile, - Indwelling catheter
CD), Mask and Headgear - 24 hr urine specimen
c. Cleaning, Disinfecting, Sterilizing
c. Collecting sputum specimen
equipment
d. Establishing & Maintaining a d. Assessing with aspiration &
Sterile Field biopsy
e. Packing of gowns etc. e. Sending specimen to laboratory
E. MEDICATIONS PERIOPERATIVE NURSING

Date of Date of
Date of Clinical Date of Clinical
Actions Basic To Nursing Care/ Demo/ Actions Basic To Nursing Care/ Demo/
Practice/Signature of Practice/Signature of
General Nursing Procedures Signature of General Nursing Procedures Signature of
C.I. C.I.
C.I. C.I.
a. Administering oral medication a. Pre-operative phase: Preparing the
b. Administering sublingual client for surgery
medications 1. Pre-operative teaching
b.1. Nasogastric medications - Moving
- Leg exercise
b.2. Gastronomy medications
- Deep breathing
c. Parental Medication
- Coughing
c.1. Preparing medications from
2. Physical preparation
ampoules
c.2. Preparing medications from - Monitor clients – V/S
vials - Nutrition & fluid status
c.3. Mixing medications using - Elimination
one syringe - Hygiene
c.4. Administering intradermal - Administering Pre-op
injections medications
c.5. Administering subcutaneous - Valuables
injections - Protheses
c.6. Administering IM injections - Special orders
c.7. Adding medications IV fluid - Skin preparation
containers
- Vital signs
c.8. Administering IV
medications using IV push/ - Applying anti-emboli stockings
IV BOLUS 3. Securing Informed Consent
c.9. Administering ophthalmic b. Intra Operative Phase
Instillations 1. Position client appropriately for
c.10. Administering optic surgery
instillations 2. Perform preoperative skin
c.11. Administering vaginal preparation
instillations nasal 3. Assist in preparing / maintaining
instillations a sterile field
c.12. Administering respiratory 4. Open and dispense sterile
inhalations (nebulizer, supplies during surgery
metered dose) 5. Provide medications & solutions
d. Dosage calculation for the sterile field
 6. Monitor & maintain a safe,
aseptic environment
7. Manage catheter, drains, tubes,
specimen
8. Perform sponge, sharp and
instrument counts
9. Assist in surgical operation
(circulating nurse)
10. Assist in surgical operation
(instrument nurse)
11. Document nursing care provided
& client’s response to
interventions
12. Packing gowns/lines/
instrument - autoclaving
c. Postoperative Phase
1. Immediate post anesthetic
phase (PACU)
- Assessment airway
- Assessment CV status
- Assessment LOC
- Assessment presence of
reflexes
- Assessment ability to move
- Assessment skin color
- Assessment fluid status
- Assessment condition of
operative site
- Assessment drainage
- Assessment discomfort
- Assessment safety
2. Pain management
3. Positioning
4. Deep breathing & Coughing
exercise
5. Leg exercise
6. Moving & Ambulation
7. Hydration
8. Diet
9. Urinary Elimination
10. Managing Gastrointestinal
suction
11. Wound Care
- Wound dressing
- Care of drainage tubes
- Assist in suture removal
12. Monitoring post-up
complications
13. Home care teaching
I. Promoting Physiologic Health
Date of
Date of Clinical
Actions Basic To Nursing Care/ Demo/
Practice/Signature of
General Nursing Procedures Signature of
C.I.
C.I.
A. Activity and Exercise
1. Observe body mechanism
2. Positioning clients
a. Fowlers position
b. Orthopneic position
c. Dorsal recumbent position
d. Prone position
e. Lateral position
f. Simi’s position
3. Moving a client up in bed
4. Logrolling a client
5. Assisting the client to sit on the
side of the bed
6. Transferring clients
a. Between bed and chair
b. Between bed and stretcher
7. Providing ROM exercise
a. Active ROM
b. Passive ROM
8. Ambulating Clients
a. Assisting to ambulate
 b. Using mechanical aids for
walking
- Cane
- Walkers
- Crutches
B. Rest and Sleep
1. Supporting
2. Creating restful environment
3. Promoting comfort &
relaxation
-Provide comfortable clothing
-Assist clients with hygienic
routines
-Smoothing / Cleaning bed
linens
-Providing back massage
C. Pain Management
1. Pharmacologic
- Administration of pain
reliever (analgesic)
- Managing pain with PCA
pump
- Oral medications
- Anesthesia
- Placebo
2. Non-Pharmacologic
3. Provide comfort
a. Personal Hygiene
a.1. Cleansing bed
a.2. Partial bath
a.3. Care of the hair
a.4. Nail care
a.5. Perineal care
1. Massage
2. Application of heat
3. Application of cold
4. Acupressure
5. Contra lateral stimulation
6. Immobilization
7. Distraction
a. Visual
b. Auditory
c. Intellectual
8. Making Occupied / unoccupied
beds
a. Open bed
b. Closed bed
c. Occupied bed
D. Nutrition
1. Getting dietary history
2. Anthropometrics measurements
- Skin fold measurements
3. Care of client with special diets
- Clear liquid diet
- Full liquid diet
- Soft diet
- Diet as tolerated
- Diabetic diet
4. Stimulating client’s appetite
5. Assist client’s appetite
a. Dependent adult
b. Child
6. Internal nutrition
a. Inserting NGT checking for
correct placement of tube
b. Removing NGT
c. Feeding clients via NGT /
d. Administering tube feeding
e. Care with nasogastric tubes
f. Administering gastrostomy
or jejunostomy feeding
E. Fecal Elimination
1. Promoting regular defecation
 - Privacy
- Timing
- Nutrition & fluids
- Exercise
- Positioning
2. Care of clients with
constipation
- Cathartics & laxatives
3. Care of clients with
diarrhea/fluid/roughage
- Anti-diarrhea
4. Care of clients with fluids/I.V.
flatulent
- Anti-flatulent
5. Assist client to use bedside
commode
6. Administering Enemas
a. Cleansing
b. Carminative
c. Retention
d. Return – flow
7. Digital removal of fecal
impaction
8. Bowel training programs
9. With fecal incontinence
10. Ostomy management
a. Colostomy care and
irrigation
b. Changing a bowel diversion
ostomy appliance
F. Urinary Elimination
1. Measuring Urinary Output
2. Maintaining Urinary
Elimination
a. Promoting fluid intake
b. Maintaining normal
avoiding habits
c. Assisting with toileting
3. Maintaining urinary
elimination
a. Continue (Bladder) training
b. Habit training
c. Prompted voiding
d. Pelvic muscle exercise
(Kegel)
e. Maintaining skin integrity
f. Applying external urinary
drainage device
- Applying external
catheterization
- Foley catheter
- Condom catheter
- Straight catheter
4. Managing urinary retention
- Crede’s maneuver
- Performing urinary
catheterization
5. Care of clients with retention
catheters
a. Encourage fluid intake
b. Dietary measure-acidify
urine
c. Perineal care
d. Changing the catheter &
tubing
e. Removing retention
catheters
6. Urinary irrigations (Bladder
Irrigation)
7. Urinary Diversions
8. Suprapubic catheter care
G. Oxygenation Promoting
Oxygenation
a. Positioning
- Fowlers
 - Semi-fowlers 2. Encourage leg exercise
- High fowlers 3. Frequent position change
- Orthopedic position
4. Position-high fowlers
b. Frequent position change
5. Monitor 1 & 0
c. Encourage ambulation
d. Deep breathing & coughing 6. CPR
exercise I. Fluid, Electrolyte & Acid Base
- Diaphragmatic Balance
- Pursed – (lip) 1. Monitor 1 & 0
e. Hydration 2. Administering IV therapy –
f. Steam Inhalation Monitoring
- Fluid intake 3. Encouraging increase / restrict
fluid intake
g. Medication / nebulization
4. Calculate / regulate IV
- Bronchodilator infusion
- Expectorants 5. Replace / Discontinue IV
h. Incentive spirometry 6. Changing IV Container, tubing,
i. Percussion (chest tapping / dressing
clapping) 7. Initiating, maintaining &
j. Vibration terminating a blood
k. Postural drainage transfusion
l. Oxygen therapy 8. IV insertion (Assisting)
- Nasal cannula 9. Monitor for:
- Nasal catheter
a. Dehydration
- Face mask
b. Fluid-volume excess
- Face tent
m. Endotracheal tubes J. Promoting Tissue healing:
n. Tracheotomy tube a. Hot sit bath
o. Providing tracheotomy care b. Applying cold compress
p. Suctioning c. Applying warm compress
- Oropharyngeal d. Perilite treatment
- Nasopharyngeal
e. Tepid sponge bath
- Tracheotomy
- Endotracheal f. Vaginal douch
q. Care of clients with chest tubes g. Wound dressing
(Thoracostomy tube) h. Apply pressure dressing
H. Promoting Circulation K. Maintaining a Therapeutic
1. Elevating legs Environment
II. Promoting Physiologic Health C. Sexuality
Health education
Date of - Sex education
Date of Clinical
Actions Basic To Nursing Care/ Demo/
Practice/Signature of - STD prevention
General Nursing Procedures Signature of
C.I. - BSE
C.I.
A. Sensory Perception - Responsible sexual behavior
1. Adjusting Environment - Testicular SE
2. Stimuli D. Spirituality (Spiritual Care)
Help meet spiritual needs
- Prevent sensory overload
- Presenting
- Prevent sensory
deprivation - Supporting
(a) Care of client with - Religious practices
- Assist with prayers
- Impaired vision
E. Stress and Coping
- Impaired hearing
1. Encourage health strategies
- Impaired Olfactory sense
a. Exercise
- Impaired tactile sense b. Nutrition – balanced /
- Confused healthy
- Unconscious c. Rest and sleep
- Sensory aids (Visual- d. Time management
Hearing) 2. Minimize anxiety
- Communicating with 3. Mediating anger
Visual-Hearing deficit 4. Using relaxation technique
3. Ensuring client safety a. Breathing E
4. Communicating effectively b. Massage
5. Orienting client to time, place, c. Progressive relax
person and situation d. Imagery
B. Promoting Positive Self-Concept e. Biofeedback
1. Establish a therapeutic f. Yoga
relationship
g. Meditation
- Encourage a therapeutic
relationship h. Therapeutic touch
- Provide accurate info i. Music theory
- Explore positive qualities & j. Humor and laughter
strengths F. Loss, Grieving and Death
- Encourage to express self- 1. Meeting physiologic needs of
positively dying client
 a. Airways clearance B. Care of the mother during labor (labor Room)
b. Bathing / Hygiene
Date of
c. Physical mobility Date of Clinical
Actions Basic To Nursing Care/ Demo/
Practice/Signature of
d. Nutrition General Nursing Procedures Signature of
C.I.
C.I.
e. Constipation
1. Taking the maternal history
f. Urinary Elim a. LMP
g. Sensory / Perceptual
b. EDG
change
2. Post mortem care c. AOG
d. History of past illness
3. Supporting the family
e. Pregnancy discomforts
III. Maternal and Child Health Nursing f. Signs of pathologic conditions
2. Physical examination
A. Care of the mother during pre-natal visit
a. Vital signs taking
Date of b. Leopoid’s maneuver
Date of Clinical
Actions Basic To Nursing Care/ Demo/ c. Perineal care (flushing &
Practice/Signature of
General Nursing Procedures Signature of sharing)
C.I.
C.I. d. Assisting in internal
1. History taking examination
- Recording in HBMR e. Labor watch
2. Physical examination - Duration
3. Determination of - Intervals
- LMP - Frequency
- AOG - Intensity
- EDC f. Monitoring FHT
4. Taking of vital sign g. Providing comfort measures

- BP - Backrub
- Breathing techniques
- Weight
h. Providing comfort measures
5. Leopoid’s maneuver
1. Shaving of premium
6. Fundal height
2. Assist / conduct internal
7. Locating / evaluating FHT examination
8. Urine test (Albumin / Sugar) 3. Assist in catheterization
9. Administration of tetanus toxoid - Dilation & effacement
 - Station 2. Chest circumference
i. Identify & refer abnormal 3. Abdominal circumference
findings 4. Mid upper arm
j. Second stage (Care during circumference
delivery and Immediate new
5. Length
born Care)
4.1. During delivery 6. Weight
- Prepare instrument tray 7. Temperature
aseptically 8. PR / HR
- Mounting and positioning on 9. RR
DR table
a. taking rectal
- Perineal flushing temperature
- Coaching to bear down b. administering crede’s
- Monitoring for the progress of prophylaxis
labor c. administering vitamin K
- Signs and symptoms of d. newborn identification –
imminent delivery
wrist tag with label
- Handling of newborn e. taking / recording
- Conduct latching on footprints
4.2. Immediate care / Routine NB f. bathing
care
g. diapering
a. APGAR scoring
h. feeding
- 1 minute
- assist in BF
- 2 minutes
- assist in formula
b. Maintain patient airway
feeding
- Positioning
i. handling NB
- Suctioning
j. burping
- Wiping mouth
k. providing warmth
c. Oil bathing
d. Drying and wrapping the baby l. temperature taking
for warmth i. Third stage labor
e. Bathing newborn – lukewarm - Delivery of the placentra
water - Inspect placentra for
f. Cord dressing completeness &
g. Dressing the baby abnormality
h. Anthropometric - Assist in perineal suturing
measurements - Inspect birth canal for
1. Head circumference lacerations/ clots/ bleeding
 - Perineal care 7. Motivate and assist mothers to
practice breastfeeding
- Massaging the functions
8. Teaching postpartum exercise
- Application of cold
compress 9. Demonstrating
- Providing a clean dress and a. Bathing of the newborn
underwear
- Promote maternal – child b. Cord care
bonding
c. Breastfeeding
- Conduct latching on
d. Immunization
- Room in the baby
e. Supplementary feeding
- Assist in breastfeeding
f. Mental feeding
- Transporting to ward
10. IEC on family planning
C. Care of the mother during the postpartum period a. Motivating the couples

Date of b. Counseling
Date of Clinical
Actions Basic To Nursing Care/ Demo/
Practice/Signature of c. Method of family planning
General Nursing Procedures Signature of
C.I.
C.I. d. Dispensing of contraceptive
1. Assess for bladder distention e. Referral of patients
2. Encourage voiding
D. Care of the infant and children (under five clinic and Pediatric
3. Assess for progress of involution
ward)
a. Fundal height measurement
Date of
b. Firmness of the uterus Date of Clinical
Actions Basic To Nursing Care/ Demo/
Practice/Signature of
c. Lochial discharges General Nursing Procedures Signature of
C.I.
C.I.
4. Assess for postpartum
complications 1. Weighing of child
5. Care of episiotomy wound 2. Assessing a child
a. Perineal care a.1. Developmental skills
b. Perilite exposure 3. Administration of immunization
6. Care of the breasts a.2. BCG
 a.3. OPV B. Care of the client with cardiovascular conditions

a.4. DPT Date of

Date of Clinical
a.5. HB Actions Basic To Nursing Care/ Demo/
Practice/Signature of
General Nursing Procedures Signature of
a.6. Measles C.I.
C.I.
4. Recording in yellow card 1. Care before, during, and after
5. Care of the Hospitalized child - Cardiac catheterization
with abnormal conditions
- ECG
a. Assessing a child with ARI
case - Cardioversion
b. Assessing a child with - Defibrillation
diarrhea disease
6. Preparing oral dehydration - Trendelenburg test
therapy 2. CVP monitoring
- ORESOL 3. Conduct BCIS-CPR
- Home-made ORT 4. Application of elastic stockings
5. Burger allen exercise
IV. Medical – Surgical Nursing
C. Care of the client with Gastro-Intestinal conditions
A. Care of the clients with respiratory conditions
Date of
Date of Date of Clinical
Date of Clinical Actions Basic To Nursing Care/ Demo/
Actions Basic To Nursing Care/ Demo/ Practice/Signature of
Practice/Signature of General Nursing Procedures Signature of
General Nursing Procedures Signature of C.I.
C.I. C.I.
C.I.
1. Care before, during, and after
1. Thoracentesis
- Gastric aspiration – gastric
2. Bronchoscopy analysis
3. Bronchography - Gastrocopy
4. Pulmonary function test - Proctosecopy
- ABG analysis - Proctosigmoidoscopy
- Upper Gil series / lower GI
5. Nose
series
- Nasal irrigation - Barium enema
- Throat gargle - Liver blopsy
- Throat swab - Liver function test
 - Cholangiography F. Care of the client with nervous system conditions
- Dialysis (Peritoneal / Hemo) Date of
Date of Clinical
- G.I. decompression Actions Basic To Nursing Care/ Demo/
Practice/Signature of
General Nursing Procedures Signature of
- Cystomy tube C.I.
C.I.

D. Care of the client with genitourinary conditions 1. Assisting in lumbar puncture

2. Care before, during, and after

Date of
Date of Clinical
Actions Basic To Nursing Care/ Demo/
Practice/Signature of G. Care of oncology clients
General Nursing Procedures Signature of
C.I.
C.I.
1. Care before, during, and after Date of
Date of Clinical
Actions Basic To Nursing Care/ Demo/
a. KUB Practice/Signature of
General Nursing Procedures Signature of
C.I.
b. IVP C.I.

c. Retrograde pyelography 1. Care before, during, and after

d. Renal biopsy a. Radiotherapy

e. Renal function test b. Chemotherapy
2. Care of client with
a. Nephrostomy tube H. Care of the client w/ musculoskeletal conditions

E. Care of the client with conditions affecting the endocrine system Date of
Date of Clinical
Actions Basic To Nursing Care/ Demo/
Practice/Signature of
General Nursing Procedures Signature of
Date of C.I.
Date of Clinical C.I.
Actions Basic To Nursing Care/ Demo/
Practice/Signature of
General Nursing Procedures Signature of 1. Assisting in the application
C.I.
C.I.
a. Bandages
1. Testing the urine for sugar
a. Benedicts test b. Braces
b. Clinitest c. Plaster cast
c. Testape
2. Care of patient with traction
d. Glucose tolerance test
3. Care of patient with spinal injury
2. BMR determination
3. Care before, during, and after 4. Care of amputated clients
V. Communicable disease Nursing a. Electro-Convulsive therapy

Date of b. Chemotherapy
Date of Clinical
Actions Basic To Nursing Care/ Demo/ 2. Conduct of psychotherapy
Practice/Signature of
General Nursing Procedures Signature of a. Individual therapeutic-nurse
C.I.
C.I. patient interaction
- Promote infection control b. Group therapy
1. Practice of medical asepsis - Music and Arts
a. Hand washing
- Bibliography
b. Donning of
- Small group meeting
- Gown
3. Conduct of activity therapy
- Gloves
- Gown a. Recreational
2. Isolation Technique b. Occupational and industrial
- Respiratory isolation - Carpentry
- Blood isolation - Serving
- Enteric isolation - Gardening
- Reserve isolation - Handicraft
- Discharge isolation
- Sports
3. Disinfection methods
- Concurrent disinfection VII. Community Health Nursing
- Terminal disinfection
4. Care of client before, during, APPLICATION OF COPAR
and after
a. Tuberculin test (Mantoux, Date of
Date of Clinical
Sclavo) Actions Basic To Nursing Care/ Demo/
Practice/Signature of
b. Schick test General Nursing Procedures Signature of
C.I.
C.I.
c. Dick’s test
A. Social preparation
VI. Psychiatric Nursing a. Pre – entry activity
- Orientation
Date of
Date of Clinical - Courtesy call
Actions Basic To Nursing Care/ Demo/
Practice/Signature of
General Nursing Procedures Signature of B. Community Organizing
C.I.
C.I. 1. Data gathering
1. Care of client before, during, and
after - Ocular survey
 - Community health survey B. Community health process
- Second data review 1. Conduct of home visit
a. community profile 2. Bag technique
b. vital statistics 3. Preparation of equipment
c. target clients list
4. Case finding
d. family record
C. Conduct of health education
2. Collation of date
1. Formulate health education
3. Tabulation of data plan
4. Analysis and interpretation 2. Conduct informal health
of data teaching
5. Making of community 3. Mother’s patient class
profile
D. Conduct of environmental
6. Presentation health activities
1. Facilitate construction
PLANNING
- WST
Date of - BD
Date of Clinical
Actions Basic To Nursing Care/ Demo/
Practice/Signature of 2. Clean and green
General Nursing Procedures Signature of
C.I.
C.I. 3. Control astray animals
A. Facilitate identification
problems 4. Campaign
B. Facilitate in the formulation of - H2O resources
action plan
- Zero waste management
IMPLEMENTATION - Clean-air

Date of - Bechurero
Date of Clinical
Actions Basic To Nursing Care/ Demo/
Practice/Signature of EVALUATION
General Nursing Procedures Signature of
C.I.
C.I.
A. Conduct clinic activities Date of
Date of Clinical
Actions Basic To Nursing Care/ Demo/
- Arrange physical set-up Practice/Signature of
General Nursing Procedures Signature of
C.I.
- Facilitate work flow C.I.
- Procure supplies / resources 1. Conduct evaluation
- Record keeping 2. Evaluation team
 3. Make interpretation / analysis b. Drug abuse
4. Report c. Prevention / Control of
common ailments
5. Present
d. Prevention of herbal remedies
A. Family health care study
B. Recording and Reporting IX. Care of the Elderly
1. Community Profile
Date of
2. Accomplishments Date of Clinical
Actions Basic To Nursing Care/ Demo/
Practice/Signature of
3. Plan General Nursing Procedures Signature of
C.I.
4. TCL C.I.
1. Assessment using appropriate
5. Minutes of meetings tool
2. NCP
VIII. School Health Nursing
3. Nursing Care
Date of 4. Empowerment
Date of Clinical
Actions Basic To Nursing Care/ Demo/ a. Organize / Revive elderly
Practice/Signature of
General Nursing Procedures Signature of organization
C.I.
C.I. b. Health promotion / Disease
1. Assessment of school children prevention
2. School environmental survey c. Facilitate program plan for
elderly
3. Conduct of health clinic
a. Set-up
b. First aid
c. Nursing intervention for
health problem
- Deworming
- Delousing
- Mouth rinsing / tooth
brushing
- Feeding / Vitamin
supplement
- Treat skin problems
4. Conduct of health education
activities
a. Feminine hygiene