MINDANAO STATE UNIVERSITY- MARAWI CITY

College of Health Sciences

COMPILED BY:
THERESA SUAN, RN
ALFRANCIS VERDIDA, RN
DEXTER DAVE M. TARIMAN, RN, MAN
CYNTHIA M. FILIPINAS, RN, MAN, PhD

2016

NCM 104.4 SKILLS

PROCEDURE CHECKLIST
 NURSE’S PRAYER

Bless me oh Lord, for I am about to begin the day’s work

Teach me to receive the sick in Thy name
Give me to my efforts success, Heavenly Father
For the glory of Thy Holy name

It is Thy work without Thee I cannot succeed

Grant the sick Thou hast place in my care
May be abundantly blessed and not one of them be lost
Because of anything that is lacking in me

Help Thou me to overcome every temporal weakness

And strengthen in me, whenever may enable me
To bring the sunshine and joy to the lives
That are gathered around me day by day

Make me beautiful within for the sake of the sick ones

And those lives which will be influenced by them.
AMEN/AMEEN.

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 TABLE OF CONTENTS

TITLE PAGE
Nurse’s Prayer …………………………………………………………………. 1

PROCEDURE
I. Ambulation with the Use of Assistive Devices……………………….. 3
II. Crutch Walking ……………………………………………………….……. 5
III. Cast Application ………………………………………………………….. 13
IV. Cast Care …………………………..……………………………………….. 15
V. Logrolling a Client ……………...…………………………………………. 17
VI. Glascow Coma Scale ………….…………………..……………………….. 19
VII. Neuro Assessment ……………………………….………………………… 21
VIII. Providing ROM Exercises …………………………………………..…… 29
IX. Skeletal Traction and External Fixation Care …..…………………… 32
X. Removing Sutures ……………………………………………………….… 34
XI. Removing Staples ………………………………………………………..... 37
XII. Assisting a Lumbar Puncture …………………..………………………. 39
Lectures
Infection Precaution…………………..………………………………………….. 42
Providing Pin Care …………………..…………………………………………… 46
Wound Drains and Suction …………………..……………………………….. 47

NANDA – Approved Nursing Diagnoses ……………………………………. 48

Bibliography ……………………………………………………………………… 49

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NAME: __________________________________________ DATE: ______________

AMBULATION WITH THE USE OF ASSISTIVE DEVICES

DEFINITION
_____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________

PURPOSE
_____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________

EQUIPMENT
_____________________________________________________________________________________
____________________________________________________________________________________
_____________________________________________________________________________________

THINGS TO CONSIDER
_____________________________________________________________________________________
____________________________________________________________________________________
_____________________________________________________________________________________

PROCEDURE RATIONALE 5 4 3 2 1
1. Explain the procedure to the patient.
2. Assess the patient’s strength, mobility,
range of motion, visual acuity, perceptual
difficulties, and balance.
(The nurse and physical therapist often
collaborate on this assessment.)
A. AMBULATION WITH CANE
3. Grasp the cane in the hand opposite the
affected leg.
4. Slide hips forward in the chair.
5. Grasp the arm of the chair with the free
hand then push to a standing position.
6. When the patient is standing, encourage
to pause in place.
7. Move the cane forward about 4-6 inches.
8. The weak leg is moved ahead opposite
the cane. Place weight on the weak leg
and the cane.
9. Move the strong leg forward. The steps
of both legs should be equal.

3
10. Repeat pattern.
B. AMBULATION WITH WALKER
11. Place the walker in front of the seated
patient.
12. Let the patient place both hands on the
arms of the chair.
PROCEDURE RATIONALE 5 4 3 2 1
13. Transfer the hands to the handgrips of
the walker.
14. The walker and the weak leg are
simultaneously moved ahead 4-6 inches.
15. Place weight on the arm for support.
16. Move the strong leg forward.
17. Repeat pattern.

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NAME: __________________________________________ DATE: ______________

CRUTCH WALKING
DEFINITION
_____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________

PURPOSE
_____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________

EQUIPMENT
_____________________________________________________________________________________
____________________________________________________________________________________
_____________________________________________________________________________________

THINGS TO CONSIDER
_____________________________________________________________________________________
____________________________________________________________________________________
_____________________________________________________________________________________

PROCEDURE RATIONALE 5 4 3 2 1
1. Identify and explain the procedure to the
patient.
2. Assess the patient’s strength, mobility,
range of motion, visual acuity, perceptual
difficulties, and balance.
(The Nurse and therapist often
collaborate on this assessment.)
3. Adjust crutches to fit the patient. Place
the patient in a supine position, measure
from the heel to the axilla.
4. Let the patient stand, position the crutch
4-5 inches laterally and 4-6 inches in
front of the patient.
5. The crutch pad should fit the 1.5-2
inches below the axilla. The hand grip
should be adjusted to have elbows bent
at 300 flexion.

6. Instruct patient to position crutches

lateral to and forward of the feet.
Demonstrate correct positioning.

5
7. Assist the patient to a standing position
with crutches (tripod position).

Four-Point Alternate Gait

1. Move the right crutch ahead a suitable
distance, such as 10 to 15 cm (4 to 6
in.).
2. Move the left front foot forward,
preferably to the level of the left crutch.
3. Move the left crutch forward.
4. Move the right foot forward

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Three-Point Gait
1. Move both crutches and the weaker leg
forward.
2. Move the stronger leg forward.

Two-Point Alternating Gait

1. Move the left crutch and the right foot
forward together.
2. Move the right crutch and the left foot
ahead together.

Swing-To Gait
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1. Move both crutches ahead together.
2. Lift body weight by the arms and swing
to the crutches.

Swing-Through Gait
1. Move both crutches forward together.
2. Lift body weight by the arms and swing
through and beyond the crutch.

Getting into a Chair

1. Stand with the back of the unaffected
leg centered against the chair.
2. Transfer the crutches to the hand on the
affected side and hold the crutches by
the hand bars. The client grasps the
arm of the chair with the hand on the
unaffected side
3. Lean forward, flex the knees and hips,
and lower into the chair
Getting Out of a Chair
1. Move forward to the edge of the chair
and place the unaffected leg slightly
under or at the edge of the chair.
2. Grasp the crutches by the hand bars in
the hand on the affected side, and grasp
the arm of the chair by the hand on the
unaffected side. The body weight is
placed on the crutches and the hand on
the armrest.
3. Push down on the crutches and the chair
armrest while elevating the body out of
the chair.
4. Assume the tripod position before
moving
Going Upstairs
1. Assume the tripod position at the bottom
of the stairs.
8
2. Transfer the body weight to the crutches
and move the unaffected leg onto the
step
3. Transfer the body weight to the
unaffected leg on the step and move the
crutches and affected leg up to the step.
The affected leg is always supported by
the crutches.
4. Repeat steps 2 and 3 until the client
reaches the top of the stairs
Going Downstairs
1. Assume the tripod position at the top of
the stairs
2. Shift the body weight to the unaffected
leg, and move the crutches and affected
leg down onto the next step
3. Transfer the body weight to the crutches,
and move the unaffected leg to that step.
The affected leg is always supported by
the crutches.
4. Repeat steps 2 and 3 until the client
reaches the bottom of the stairs.

Ability to answer questions

TOTAL SCORE

9
FIGURE 1. CRUTCH WALKING GAIT PATTERNS

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FIGURE 2. CRUTCH WALKING GAITS

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NAME: __________________________________________ DATE: ______________

CAST APPLICATION
DEFINITION
_____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________

PURPOSE
_____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________

EQUIPMENT
_____________________________________________________________________________________
____________________________________________________________________________________
_____________________________________________________________________________________

THINGS TO CONSIDER
_____________________________________________________________________________________
____________________________________________________________________________________
_____________________________________________________________________________________

PROCEDURE RATIONALE 5 4 3 2 1
1. Identify the patient and explain the
procedure. Verify the area to be casted.
2. Do pain assessment and assess for
muscle spasm. Give pain medications as
ordered.
3. Gather the necessary equipment and
bring to the bedside.
4. Provide privacy. Place bed at an
appropriate and comfortable working
height.
5. Do handwashing, and don on gloves.
6. Position the patient depending on the
type of cast being applied, and the
location of the injury.
7. Drape the patient with waterproof pads.
Cleanse and dry the affected body part.
8. Support the extremity or body part to be
casted. Position and maintain the
affected body part in the position
indicated by the physician as the
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 stockinette, wadding sheet, and padding
is applied.
9. The stockinette should extend beyond
the ends of the cast. As the wadding
sheet is applied check for wrinkles.
10. Continue maintaining the position of the
affected body part as the casting material
is applied.
PROCEDURE RATIONALE 5 4 3 2 1
11. Assist with finishing by folding the
stockinette or other padding down over
the outer edge of the cast.
12. Support the cast during hardening.
Handle the cast with the palms of your
hands. Avoid placing pressure on the
cast.
13. For injured upper limb, elevate injured
limb above heart level with pillow or
blanket.
14. Remove gloves, dispose properly.
15. Obtain x-ray of affected area as ordered.
16. Instruct patient to report pain, odor,
drainage, changes in sensation,
abnormal sensation, or inability to move
fingers or toes of affected extremity.
17. Leave cast uncovered and exposed to
the air. A fan may be used to dry the
cast.
18. Reposition patient every 2 hours
19. Do aftercare.
20. Document time, date, and type of cast
applied.

Ability to answer questions

TOTAL SCORE

13
NAME: __________________________________________ DATE: ______________

CAST CARE
DEFINITION
_____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________

PURPOSE
_____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________

EQUIPMENT
_____________________________________________________________________________________
____________________________________________________________________________________
_____________________________________________________________________________________

THINGS TO CONSIDER
_____________________________________________________________________________________
____________________________________________________________________________________
_____________________________________________________________________________________

PROCEDURE RATIONALE 5 4 3 2 1
1. Identify the patient and explain the
procedure.
2. Do handwashing and don on gloves if
necessary.
3. Assess the condition of the cast. Check
for cracks, dents or presence of
drainage.
4. Perform skin and neurovascular
assessment as often as 1-2 hours.
5. Check for pain, edema, inability to move
body parts distal to the cast, pallor,
pulses, and abnormal sensations.
6. If cast is on an extremity, compare it to
the uncasted extremity.
7. If breakthrough bleeding or drainage is
noted on the cast; mark the area,
indicate date and time next to the area.
8. Assess for any signs of infection.
9. Turn patient to sides every 2 hours, do
back massage and skin care.

14
10. Encourage ROM, deep breathing
exercises, and coughing exercises.
11. Instruct patient to report pain, odor,
drainage, changes in sensation, or
inability to move fingers or toes of
affected extremity.
12. Place patient comfortably on bed.
PROCEDURE RATIONALE 5 4 3 2 1
13. Remove gloves and do handwashing
14. Document assessment and care
provided, patient’s response, and health
teachings.

Ability to answer questions

TOTAL SCORE

15
NAME: __________________________________________ DATE: ______________

LOGROLLING A CLIENT
DEFINITION
_____________________________________________________________________________________________
_____________________________________________________________________________________________
____________________________________________________________________

PURPOSE
_____________________________________________________________________________________________
_____________________________________________________________________________________________
____________________________________________________________________

EQUIPMENT
_____________________________________________________________________________________
____________________________________________________________________________________
_____________________________________________________________________________________

THINGS TO CONSIDER
_____________________________________________________________________________________
____________________________________________________________________________________
_____________________________________________________________________________________

PROCEDURE RATIONALE 5 4 3 2 1
1. Prior to performing the procedure,
introduce self and verify the client’s
identity using agency protocol.
Explain to the client what you are
going to do, why it is necessary, and
how he or she can participate.

2. Perform hand hygiene and observe

other appropriate infection prevention
procedures.

3. Provide for client privacy.

4. Position yourselves and the client

appropriately before the move. Place
the client’s arms across the chest.

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

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

16
6. One nurse counts: “One, two, three,
go.” Then, at the same time, all staff
members pull the client to the side of
the bed by shifting their weight to the
back foot.

7. One person moves to the other side

of the bed, and placessupportive
devices for the client when turned.
 Place a pillow where it will support
the client’s head after the turn.
 Place one or two pillows between the
client’s legs to support the upper leg
when the client is turned.

8. Roll and position the client in proper

alignment.
 Go to the other side of the bed
(farthest from the client), and assume
a stable stance.
 Reaching over the client, grasp the
friction-reducing device, and roll the
client toward you
 One nurse counts: “One, two, three,
go.” Then, at the same time, all
nurses roll the client to a lateral
position.
 The second nurse (behind the client)
helps turn the client and provides
pillow supports to ensure good
alignment in the lateral position.
 Support the client’s head, back, and
upper and lower extremities with
pillows.
 Raise the side rails and place the call
bell within the client’s reach.
9. Document all relevant information.
Record:
 Time and change of position moved
from and position moved to
 Any signs of pressure areas
 Use of support devices
 Ability of client to assist in moving
and turning
 Response of client to moving and
turning (e.g., anxiety, discomfort,
dizziness).

Ability to answer questions

17
 TOTAL SCORE
NAME: __________________________________________ DATE: ______________

GLASCOW COMA SCALE

DEFINITION
_____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________

PURPOSE
_____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________

EQUIPMENT
_____________________________________________________________________________________
____________________________________________________________________________________
_____________________________________________________________________________________

THINGS TO CONSIDER
_____________________________________________________________________________________
____________________________________________________________________________________
_____________________________________________________________________________________

PROCEDURE RATIONALE 5 4 3 2 1
1. Identify and explain the procedure to the
patient.
2. Do handwashing.
A. EYE OPENING
3. Call the patient’s name.
4. If there is no response pinch the patient’s
finger or toe
5. If no response, apply firm and gentle
pressure on sternum.
6. Record patient score:
Spontaneously - 4
On Command - 3
To Pain - 2
No Response -1
B. VERBAL RESPONSE
7. Ask patient the time and place
8. Record patient score:
Alert and oriented - 5

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 Confused - 4
Inappropriate - 3
Incomprehensible - 2
No Response - 1
C. MOTOR RESPONSE
9. Ask patient to wiggle toes or move/raise
arms.
PROCEDURE RATIONALE 5 4 3 2 1
10. If no response, apply firm and gentle
pressure on sternum
11. Record patient score:
Follows Direction - 6
Localizes Pain - 5
Withdraws from Pain - 4
Decorticate Posturing - 3
Decerebrate Posturing - 2
No Response - 1
12. Add up the score. Refer the score to the
doctor.
13. Place the patient in a comfortable
position.
14. Document time GCS was done and GCS
score.

Ability to answer questions

TOTAL SCORE

19
NAME: __________________________________________ DATE: ______________

NEURO ASSESSMENT
DEFINITION
_____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________

PURPOSE
_____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________

EQUIPMENT
_____________________________________________________________________________________
____________________________________________________________________________________
_____________________________________________________________________________________

THINGS TO CONSIDER
_____________________________________________________________________________________
____________________________________________________________________________________
_____________________________________________________________________________________

PROCEDURE RATIONALE 5 4 3 2 1
1. Identify the patient and explain each
assessment technique before
performing.
2. Instruct the patient to void first before
starting the neurologic exam.
3. Gather the necessary equipment.
4. Do handwashing and don on gloves if
necessary.
5. Obtain the patient’s height, weight and
vital signs
6. Provide privacy and ask the patient to sit
comfortably at the edge of the
examination table.
7. Carefully observe the patient throughout
the interview.
A. MENTAL STATUS EXAM
8. Pay close attention to the patient’s
general appearance, posture, and
grooming.
9. Assess the patient’s level of
consciousness, facial expression,
20
 mood and affect.
10. Observe the patient’s speech and
language during the interview.
11. Pay attention to the patient’s speech
volume, speech rate, articulation and
fluency.
PROCEDURE RATIONALE 5 4 3 2 1
12. Assess patient’s thought process and
content, his perception, insight and
judgment.
13. Ask patient what he is feeling or his
feelings to his surroundings or the
world.
14. Observe if the patient’s thoughts are
logical, relevant, organized and
coherent.
15. Ask if the patient has any abnormal
perceptions, such as illusions or
hallucinations.
16. Check if the patient is oriented to
person, place and time.
17. Test the patient’s attention span. Like
backwards spelling and new learning
ability. Test his remote memory; ask
events relevant to his past. Test his
recent memory like asking what he had
for breakfast.
18. Assess patient’s knowledge of
information, vocabulary, and
complexity of thoughts. Like
calculating ability, abstract thinking and
constructional ability.
B. CRANIAL NERVES ASSESSMENT
19. OLFACTORY (CN I)
Test sense of smell on each nostril
separately. Have the patient occlude the
opposite nostril and use various scents.
20. OPTIC (CN II)
Check the patient’s visual acuity using
the Snellen Chart. If the patient uses eye
glasses or contact lens let him wear it.
Test visual fields. Let the patient follow
your finger coming into the visual field
from all directions.
Inspect the optic discs with an
ophthalmoscope.

21
21. OPTIC& OCCULOMOTOR (CN II & III)
Check papillary reaction to light in both
eyes.
22. OCCULOMOTOR, TROCHLEAR, and
ABDUCENT (CN III, IV, and VI)
Ask the patient to follow your finger as
you trace an “H” in mid air.
PROCEDURE RATIONALE 5 4 3 2 1
23. TRIGEMINAL (CN V)
Ask patient to clench his jaw, feel for
strength and bulk of the temporalis and
masseter muscles.
24. TRIGEMINAL & FACIAL (CN V & VII)
Check the corneal reflex by lightly
touching the cornea with a wisp of
cotton.
25. FACIAL (CN VII)
Ask the patient to raise his eyebrows, to
close eyes tightly, puff of cheeks, smile,
frown, and show teeth.
26. VESTIBULOCOCHLEAR (CN VIII)
Test hearing by rubbing hairs together
or whispering a word into each ear.
Do the Rinne and Weber test as well.
Weber’s Test
A. Using a 512 Hz tuning fork (Please do
NOT use 128Hz or 256Hz tuning forks
as these are used to assess vibration
sensation in neurological examinations.)
is well w/in range normal hearing & used
for testing – Get turning fork vibrate by
striking ends against heel of hand or
Squeeze tips between thumb & 1st finger
B. Place vibrating fork mid line skull •
Sound should be heard equally R and L
for bone conducts to both sides.
C. If conductive hearing loss (e.g.
obstructing wax in canal on L) since it is
louder on L as less competing noise.
D. If sensorineural on L then it is louder on
R (Finger in ear mimics conductive loss)

Rinne’s Test
A. Place vibrating 512 hz tuning fork on
mastoid bone (behind ear)
B. Patient states when can’t hear sound.
C. Place tines of fork next to ear so that the
pt should hear it again – as air conducts
22
 better then bone.
D. If BC better then AC, suggests
conductive hearing loss.
E. If sensorineural loss, then AC still > BC
(pattern is similar to what is found in
people with normal hearing wherein
AC>BC, but patients with sensorineural
hearing loss will indicate that the sound
has stopped much earlier)

27. GLOSSOPHARYNGEAL and VAGUS

(CN IX and X)
Assess and listen to the patient’s voice.
Have the patient drink a glass of water
and check if the uvula is midline when he
swallows.
Have the patient say “ahh”, observe if the
soft palate rises evenly.
Check the gag reflex on each side.
28. ACCESSORY (CN XI)
Have the patient turn his head and shrug
his shoulders against a resistance.
29. HYPOGLOSSAL (CN XII)
Observe the patient’s tongue for any
atrophy or fasciculation.
Have the patient stick out his tongue and
check if it protrudes midline.
Have the patient press his tongue on the
insides of his cheeks.
C. MOTOR EXAM
30. Observe the patient’s posture and
stance. Look for any involuntary
movements or tremors.
31. Assess muscle bulk, by inspecting the
major muscle groups, and the intrinsic
muscles of the hands.
32. Assess muscle tone and range of motion
by passively moving the limbs of a relax
patient.
PROCEDURE RATIONALE 5 4 3 2 1
33. Check muscle strength of the following
major muscle groups:
Shoulder abduction; elbow flexion and
extension;, wrist flexion and extension;
thumb opposition; grip; trunk flexion,
extension and lateral movement; hip
flexion and extension; leg flexion and
extension; foot dorsiflexion and plantar
23
 flexion.
34. Describe muscle strength on a scale
from 1-5 as follows:
5/5 – full strength and movement against
full resistance.
4/5 – movement against gravity and
minimal resistance.
3/5 – movement against gravity only
2/5 – minimal movement present but
unable to overcome gravity.
1/5 – tiny traces of detectable movement
0/5 – no detectable movement
35. Assess for pronator drift. Ask the patient
to close his eyes and hold their arms out
straight in front with palms up. Keep the
position for 30 seconds.
D. DEEP TENDON REFLEXES
36. Have the patient relax. Provide support
for the extremity to be tested.
37. Compare reflex amplitude of the same
tendons on either side of the body.
38. BICEPS
Place your right thumb on the patient’s
right biceps tendon (located in the
antecubital fossa) with the patient’s arm
slightly flexed.
Strike your thumb with the pointed end of
the hammer head. Strike with the least
amount of pressure.
39. TRICEPS TENDON
Have the patient hang his arm freely;
support the arm with your non-dominant
hand.
With the elbow flexed, strike the elbow
directly with the pointed end of the
hammer.
40. BRACHIORADIALIS TENDON
Strike the forearm with the hammer
about 1” above the wrist over the radius.
41. QUADRICEPS REFLEX
Have the patient sit with his legs hanging
over the edge of the table.
Strike the tendon just below the patella.
PROCEDURE RATIONALE 5 4 3 2 1
42. ACHILLES REFLEX

24
 Support the foot in dorsiflexed position.
Tap the Achilles tendon with the
hammer.
43. PLANTAR REFLEX
Stroke the sole of the patient’s foot with a
flat object.
E. SENSORY EXAM
44. Patient’s eyes should be closed
whenever possible and test should
always be bilateral. Always ask: “Does
this feel normal and equal on both
sides?”
45. LIGHT-TOUCH SENSATION
Ask the patient to close his eyes.
Let him respond “yes” or “now” when he
feels the cotton wisp touching his skin.
With a cotton wisp, lightly touch one
specific spot and then the same spot on
the other side of the body.
Ask the patient to point the spot where
the touch was felt.
46. PAIN SENSATION
Ask the patient to close his eyes.
Let him respond “sharp”, “dull”, or “don’t
know” when he feels the sharp or dull
end of a safety pin or needle is felt.
Alternately use the sharp and dull end of
the sterile pin or needle to lightly prick
the hand, forearm, abdomen, lower leg
and foot.
Do NOT test the face.
Allow at least 2 seconds between each
test.
47. TEMPERATURE SENSATION
Touch skin areas with test tubes filled
with either hot or cold water.
Let the patient respond “hot”, “cold”, or
“don’t know”
48. KINESTHETIC SENSATION
Ask the patient to close his eyes.
Grasp the patient’s middle finger or big
toe by the sides and move it up and
down.
Have the patient tell you the orientation
of the middle finger or big toe.
49. TACTILE DISCRIMINATION (ONE and
25
 TWO POINT DISCIMINATION)
Alternately stimulate the skin with two
pins simultaneously and then with one
pin. Ask whether the patient felt one or
two pinpricks.
PROCEDURE RATIONALE 5 4 3 2 1
50. TACTILE DISCRIMINATION
(STEREOGNOSIS)
Place a distinct familiar object like a key
in the patient’s palm, and then ask him to
identify it.
51. TACTILE DISCRIMINATION
(EXTINCTION PHENOMENON)
Simultaneously stimulate two symmetric
areas of the body, and ask the patient
where they were touched.
F. MOTOR FUNCTION TESTS
52. WALKING GAIT
Ask the patient to walk across the room
and back. Assess the patient’s gait.
53. ROMBERG TEST
Ask the patient to stand with feet
together and arms at the sides.
First with eyes open, then eyes closed.
Let your patient do this for 30 seconds.
Stand close to the patient during this
test.
54. STANDING ON ONE FOOT WITH EYES
CLOSED
Ask the patient to close his eyes and to
stand on one foot, and then with the
other foot.
Stand close to the patient during this
test.
55. HEEL TOE WALKING
Ask the patient to walk a straight line,
placing the heel of one foot directly in
front of the toes of the other foot.
56. FINGER TO NOSE TEST
Have the patient touch your index finger,
and then their nose with their index finger
back and forth.
57. ALTERNATING SUPINATION AND
PRONATION OF HANDS AND KNEES
Ask the patient to pat both knees with the
palms and back of both hands
26
 alternately at an ever increasing rate.
58. FINGERS TO THUMB
Ask the patient to touch each finger of
one hand to the thumb of the same hand
as rapidly as possible.
59. HEEL TO SHIN
Have the patient take the heel of one foot
and slide it up and down the shin of the
other leg. Repeat with the other foot.
PROCEDURE RATIONALE 5 4 3 2 1
60. After the neurological assessment. Place
the patient comfortably on bed.
61. Do aftercare.
62. Document all pertinent information, and if
there were any abnormalities noted refer
it to the physician.

Ability to answer questions

TOTAL SCORE

27
NAME: __________________________________________ DATE: ______________

PROVIDING ROM EXERCISES

DEFINITION
_____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________

PURPOSE
_____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________

EQUIPMENT
_____________________________________________________________________________________
____________________________________________________________________________________
_____________________________________________________________________________________

THINGS TO CONSIDER
_____________________________________________________________________________________
____________________________________________________________________________________
_____________________________________________________________________________________

PROCEDURE RATIONALE 5 4 3 2 1
1. Check the doctor’s orders. Identify any
movement limitations.
2. Identify the patient and explain the
procedure.
3. Do handwashing. Don on gloves if
necessary.
4. Provide privacy. Place the bed at an
appropriate and comfortable working
height.
5. Adjust the head of bed to a flat position
or as low as the patient can tolerate.
6. Stand on the side of the bed where the
joints are to be exercised. Uncover only
the limb to be used during the exercise.
7. Do the exercises slowly and gently.
Provide support by holding the areas
proximal and distal to the joint.
8. Repeat each exercise 2-5 times. Move
each joint in a smooth and rhythmic
manner.
9. Do not force a joint. Stop movement if
28
 the patient feels pain, and when you
meet resistance.
10. Start from the head and move down one
side of the body at a time.
11. Move chin down to rest on the chest.
Return head to normal upright position.
Tilt head as far as possible toward each
shoulder.
PROCEDURE RATIONALE 5 4 3 2 1
12. Move the head from side to side. Bring
the chin toward each shoulder.
13. Lift the arm forward towards the head.
Return the arm to the sides.
14. Raise the arm to the side until the upper
arm is in line with the shoulder. Bend the
elbow at a 90° angle. Move the forearm
up and down, and then return to the side.
15. Bend the elbow and move the lower arm
and hand upward toward the shoulder.
Return the arm to the side.
16. Rotate the lower arm and hand.
17. Move the hand downward toward the
inner aspect of the forearm. Return it to
neutral position. Move the dorsal portion
of the hand backward as far as possible.
18. Bend the fingers to make a fist, and then
straighten it out. Spread the fingers apart
and return it back together.
19. Extend the leg laterally away from the
patient’s body. Return the leg back
toward the other leg; try to extend it
beyond the midline.
20. Bend the leg and bring the heel towards
the back of the leg. Return the leg to a
straight position.
21. Rotate foot internally, then externally.
22. Move the foot up and back until the toes
are upright. Move the foot with the toes
pointing downward.
23. Curl the toes downward, and then
straighten it out. Spread the toes apart
then bring it together.
24. After providing ROM exercises. Place
patient comfortably on bed. Return bed
height.

29
25. Remove gloves and do handwashing.
26. Document exercises performed, any
observations, and the patient’s reaction.

Ability to answer questions

TOTAL SCORE

30
NAME: __________________________________________ DATE: ______________

SKELETAL TRACTION AND EXTERNAL FIXATION CARE

DEFINITION
_____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________

PURPOSE
_____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________

EQUIPMENT
_____________________________________________________________________________________
____________________________________________________________________________________
_____________________________________________________________________________________

THINGS TO CONSIDER
_____________________________________________________________________________________
____________________________________________________________________________________
_____________________________________________________________________________________

PROCEDURE RATIONALE 5 4 3 2 1
1. Identify the patient and explain the
procedure.
2. Gather the necessary equipment and
bring to the bedside.
3. Do handwashing.
4. Inspect the devices:
For traction, all ropes and pulleys should be
in proper alignment. Correct weights should
be attached, and ropes should be hanging
freely.
For external fixation, all components should
be free of pressure and the extremity
supported.
5. Inspect operative sites including pin or
tong insertions for excessive bleeding or
drainage.
6. Give pain medications as ordered before
exercising or mobilizing the affected
body part.
7. Check circulation, motion, and sensation
of the affected extremity as a baseline.
31
8. Do pin site care.
Don on sterile gloves.
Use a cotton swab with alcohol and clean the
pin site starting at the insertion area and
working outward away from the pin site.
Use a cotton swab once. Use a new cotton
swab for each pin site.
PROCEDURE RATIONALE 5 4 3 2 1
9. Apply antibacterial ointment if ordered.
Apply dressing.
10. Do aftercare. Remove gloves and do
handwashing.
11. Document procedure done, include skin
and pin site assessment. Chart patient’s
response and neurovascular status of
the affected area.

Ability to answer questions

TOTAL SCORE

32
NAME: __________________________________________ DATE: ______________

REMOVING SUTURES
DEFINITION
_____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________

PURPOSE
_____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________

EQUIPMENT
_____________________________________________________________________________________
____________________________________________________________________________________
_____________________________________________________________________________________

THINGS TO CONSIDER
_____________________________________________________________________________________
____________________________________________________________________________________
_____________________________________________________________________________________

PROCEDURE RATIONALE 5 4 3 2 1
1. Before removing skin sutures, verify (a)
the orders for suture removal (in many
instances, only alternate sutures are
removed one day, and the remaining
sutures are removed a day or two later)
and (b) whether a dressing is to be
applied following the suture removal.

2. Inform the client that suture removal may

produce slight discomfort, such as a
pulling or stinging sensation, but should
not be painful.

3. Remove dressings and clean the incision

in accordance with agency protocol.

4. Apply sterile gloves.

5. Remove sutures as follows:

a. Grasp the suture at the knot with a pair of

forceps.
b. Place the curved tip of the suture scissors
under the suture as close to the skin as
possible, either on the side opposite the knot
33
or directly under the knot. Cut the suture.
Sutures are cut as close to the skin as
possible on one side of the visible part
because the suture material that is visible to
the eye is in contact with resident bacteria of
the skin and must not be pulled beneath the
skin during removal. Suture material that is
beneath the skin is considered free from
bacteria.

c. With the forceps or hemostat, pull the

suture out in one piece. Inspect the suture
carefully to make sure that all suture
material is removed. Suture material left
beneath the skin acts as a foreign body and
causes inflammation.

6. Discard the suture onto a piece of sterile

gauze or into the moisture-proof bag,
being careful not to contaminate the
forceps tips

7. Continue to remove alternate sutures,

that is, the third, fifth, seventh, and so
forth. Alternate sutures are removed first
so that remaining sutures keep the skin
edges in close approximation and
prevent any dehiscence from becoming
large.

8. If no dehiscence occurs, remove the

remaining sutures. If dehiscence does
occur, do not remove the remaining
sutures, and report the dehiscence to the
nurse in charge.

9. If Steri-Strips are ordered by the primary

care provider, apply them to the wound
after removing the sutures or clips. Some
primary care providers order Steri-Strip
application to provide additional support
to the healing wound.
34
10. Reapply a dressing, if indicated.

11. Document the suture removal; number of

sutures removed; appearance of the
incision; application of a dressing, Steri-
Strips, or butterfly tapes (if appropriate);
client teaching; and client tolerance of
the procedure.

Ability to answer questions

TOTAL SCORE

35
NAME: __________________________________________ DATE: ______________

REMOVING STAPLES
DEFINITION
_____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________

PURPOSE
_____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________

EQUIPMENT
_____________________________________________________________________________________
____________________________________________________________________________________
_____________________________________________________________________________________

THINGS TO CONSIDER
_____________________________________________________________________________________
____________________________________________________________________________________
_____________________________________________________________________________________

PROCEDURE RATIONALE 5 4 3 2 1
1. Verify orders to remove staples.

2. Remove dressings and clean the incision

in accordance with agency protocol.

3. Apply sterile gloves.

4. Remove staples as follows:

a. Remove dressings and clean the incision

in accordance with agency protocol.

36
b. Place the lower tips of a sterile staple
remover under the staple.
c. Squeeze the handles together until they
are completely closed. Pressing the handles
together causes the staple to bend in the
middle and pulls the edges of the staple out
of the skin. Do not lift the staple remover
when squeezing the handles.
d. When both ends of the staple are visible,
gently move the staple
away from the incision site.
e. Hold the staple remover over a disposable
container and release the staple remover
handles, which releases the staple.

5. Document the staple removal including

number of sutures removed and
appearance of the incision.

Ability to answer questions

TOTAL SCORE

37
NAME: __________________________________________ DATE: ______________

ASSISTING A LUMBAR PUNCTURE

DEFINITION
_____________________________________________________________________________________________
_____________________________________________________________________________________________
____________________________________________________________________

PURPOSE
_____________________________________________________________________________________________
_____________________________________________________________________________________________
____________________________________________________________________

EQUIPMENT
_____________________________________________________________________________________
____________________________________________________________________________________
_____________________________________________________________________________________

THINGS TO CONSIDER
_____________________________________________________________________________________
____________________________________________________________________________________
_____________________________________________________________________________________

PROCEDURE RATIONALE 5 4 3 2 1
Preprocedure

1. Determine whether written consent

for the procedure has been obtained.

2. . Explain the procedure to the patient

and describe sensations that are
likely during the procedure (ie, a
sensation of cold as the site is
cleansed with solution, a needle prick
when local anesthetic is injected).

3. . Determine whether the patient has

any questions or misconceptions
about the procedure; reassure the
patient that the needle will not enter
the spinal cord or cause paralysis.

4. . Instruct the patient to void before

the procedure.

. Procedure

5. The patient is positioned on one side

at the edge of the bed or examining
table with back toward the physician;
38
 the thighs and legs are flexed as
much as possible to increase the
space between the spinous
processes of the vertebrae, for easier
entry into the subarachnoid space.

6. A small pillow may be placed under

the patient's head to maintain the
spine in a horizontal position; a pillow
39
 may be placed between the legs.

7. .The nurse assists the patient to

maintain the position.

8. . The patient is encouraged to relax

and is instructed to breathe normally.

9. . The nurse describes the procedure

step by step to the patient as it
proceeds.

10. . The physician cleanses the

puncture site with an antiseptic
solution and drapes the site.

11. . The physician injects local

anesthetic to numb the puncture site,
and then inserts a spinal needle into
the subarachnoid space through the
third and fourth or fourth and fifth
lumbar interspace.

12. . A specimen of CSF is removed and

usually collected in three test tubes,
labeled in order of collection. A
pressure reading may be obtained.
The needle is withdrawn.

13. . The physician applies a small

dressing to the puncture site.

14. . The tubes of CSF are sent to the

laboratory immediately.

. Postprocedure

15. Instruct the patient to lie prone for 2

to 3 hours to separate the alignment
of the dural and arachnoid needle
punctures in the meninges.

16. Monitor the patient for complications

of lumbar puncture; notify physician if
complications occur.

17. Encourage increased fluid intake.

Ability to answer questions

TOTAL SCORE
40
Lectures

Infection Precaution

Isolation Precaution

Isolation precautions are guidelines created to prevent transmission of microorganisms in hospitals.

The Hospital Infection Control Practices Advisory Committee (HICPAC) of the CDC recommends two tiers
of isolation precautions. The first tier, called Standard Precautions, is designed for the care of all patients in
the hospital and is the primary strategy for preventing HAIs. The second tier, called Transmission-Based
Precautions, is designed for care of patients with known or suspected infectious diseases spread by
airborne, droplet, or contact routes.

Category-specific isolation precautions use seven categories: strict isolation, contact isolation,
respiratory isolation, tuberculosis isolation, enteric precautions, drainage/secretions precautions, and
blood/ body fluid precautions.

Disease-specific isolation precautions provide precautions for specific diseases. These precautions
delineate use of private rooms with special ventilation, having the client share a room with other clients
infected with the same organism, and gowning to prevent gross soilage of clothes for specific infectious
diseases.

Standard Precaution

The tenets of Standard Precautions are that all patients are colonized or infected with
microorganisms, whether or not there are signs or symptoms, and that a uniform level of caution should be
used in the care of all patients. The elements of Standard Precautions include hand hygiene, use of gloves
and other barriers (eg, mask, eye protection, face shield, gown), proper handling of patient care equipment
and linen, environmental control, prevention of injury from sharps devices, and patient placement (ie, room
assignments) within health care facilities.

Hand Hygiene

The most frequent cause of infection outbreaks in health care institutions is transmission by the
hands of health care workers. Hands should be washed or decontaminated frequently during patient care.

When hands are visibly dirty or contaminated with biologic material from patient care, hands should
be washed with soap and water. In intensive care units and other locations in which virulent or resistant
organisms are likely to be present, antimicrobial agents (eg, chlorhexidine gluconate, iodophors,
chloroxylenol, and triclosan) may be used. Effective hand washing requires at least 15 seconds of vigorous
scrubbing, with special attention to the area around nail beds and between fingers, where there is a high
bacterial load. Hands should be thoroughly rinsed after washing.

If hands are not visibly soiled, health care providers are strongly encouraged to use alcohol-based,
waterless antiseptic agents for routine hand decontamination. These solutions are superior to soap or
antimicrobial handwashing agents in their speed of action and effectiveness against microorganisms.
Because they are formulated with emollients, they are usually better tolerated than other agents, and
because they can be used without sinks and towels, health care workers have been found to be more
compliant with their use. Nurses working in home health care or other settings where they are relatively
mobile should carry pocket-sized containers of alcohol-based solutions (Rhinehart & McGoldrick, 2005).

41
 Normal skin flora usually consist of coagulase-negative staphylococci or diphtheroids. In the health
care setting, workers may temporarily carry other bacteria (ie, transient flora) such as S. aureus,
Pseudomonas aeruginosa, or other organisms with increased pathogenic potential. Generally, transient
flora are superficially attached and are shed with hand hygiene and skin regeneration.

Hand washing or disinfection reduces the bacterial load and decreases the risk of transfer to other
patients. All health care settings should have mechanisms to evaluate compliance with hand disinfection by
all who care for patients.

Nurses should not wear artificial fingernails or nail extenders when providing patient care. These
items have been epidemiologically linked to several significant outbreaks of infections. Natural nails should
be kept less than 0.25 inches (0.6 cm) long, and nail polish should be removed when chipped, because it
can support increased bacterial growth (CDC, 2002a).

Hand Decontamination With Alcohol-Based Product

o After contact with body fluids, excretions, mucous membranes, nonintact skin, or wound dressings
as long as hands are not visibly soiled

o After contact with a patient’s intact skin (as after taking pulse or blood pressure or lifting a patient)

o In patient care, when moving from a contaminated body site to a clean body site

o After contact with inanimate objects in the patient’s immediate vicinity

o Before caring for patients with severe neutropenia or other forms of severe immune suppression

o Before donning sterile gloves when inserting central catheters

o Before inserting urinary catheters or other devices that do not require a surgical procedure

o After removing gloves

Handwashing
o When hands are visibly dirty or contaminated with biologic material from patient care

o When health care workers do not tolerate waterless alcohol product

Glove Use

Gloves provide an effective barrier for hands from the microflora associated with patient care.
Gloves should be worn when a health care worker has contact with any patient's secretions or excretions
and must be discarded after each patient care contact. Because microbial organisms colonizing health care
workers' hands can proliferate in the warm, moist environment provided by gloves, hands must be
thoroughly washed with soap or an antimicrobial agent after gloves are removed. As patient advocates,
nurses have an important role in promoting hand washing and glove use by other hospital workers, such as
laboratory personnel, technicians, and others who have contact with patients.

Latex gloves are often preferred over vinyl gloves because of greater comfort and fit and because
some studies indicate that they afford greater protection from exposure. However, their increased use in
recent years has been accompanied by increased reports of allergic reactions to latex among health care
workers. Reactions range from local skin irritation to more severe reactions, including generalized
dermatitis, conjunctivitis, asthma, angioedema, and anaphylaxis.

42
 The nurse who experiences irritation or an allergic reaction associated with exposure to latex
should report symptoms to an occupational health specialist or physician. Suggested methods for reducing
the incidence of such reactions include the use of vinyl gloves, powder-free gloves, or “low-protein” latex
gloves.

Needlestick Prevention

The most important aspect of reducing the risk of bloodborne infection is avoidance of
percutaneous injury. Extreme care is essential in all situations in which needles, scalpels, and other sharp
objects are handled. Used needles should not be recapped. Instead, they are placed directly into puncture-
resistant containers near the place where they are used. If a situation dictates that a needle must be
recapped, the nurse must use a mechanical device to hold the cap or use a one-handed approach to
decrease the likelihood of skin puncture. Since 2001, the Occupational Safety and Health Administration
(OSHA) has required nurses to use needleless devices and other instruments designed to prevent injury
from sharps when appropriate (OSHA, 2001).

Avoidance of Splash and Spray

When the health care provider is involved in an activity in which body fluids may be sprayed or
splashed, appropriate barriers must be used. If a splash to the face may occur, goggles and a face mask
are warranted. If the health care worker is handling material that may soil clothing or is involved in a
procedure in which clothing may be splashed with biologic material, a cover gown should be worn.

Transmission-Based Precautions

Some microbes are so contagious or epidemiologically significant that precautions in addition to the
Standard Precautions should be used when such organisms are recognized. The CDC recommends a
second tier of precautions, called Transmission-Based Precautions. The additional isolation categories are
Airborne, Droplet, and Contact Precautions (CDC, 2004g).

Airborne Precautions are required for patients with presumed or proven pulmonary TB, chickenpox,
or other airborne pathogen. Airborne precautions are also advised if a patient is infected with smallpox (eg,
as a result of a bioterrorist attack). When hospitalized, patients should be in rooms with negative air
pressure; the door should remain closed, and health care providers should wear an N-95 respirator (ie,
protective mask) at all times while in the patient's room.

Droplet Precautions are used for organisms that can be transmitted by close, face-to-face contact,
such as influenza or meningococcal meningitis. While taking care of a patient requiring Droplet
Precautions, the nurse should wear a face mask, but because the risk of transmission is limited to close
contact, the door may remain open.

Contact Precautions are used for organisms that are spread by skin-to-skin contact, such as
antibiotic-resistant organisms or Clostridium difficile. Contact Precautions are designed to emphasize
cautious technique and the use of barriers for organisms that have serious epidemiologic consequences or
those easily transmitted by contact between health care worker and patient. When possible, the patient
requiring contact isolation is placed in a private room to facilitate hand hygiene and decreased
environmental contamination. Masks are not needed, and doors do not need to be closed.

Transporting Clients with Infections

Avoid transporting clients with infections outside their own rooms unless absolutely necessary. If a
client must be moved, the nurse implements appropriate precautions and measures to prevent
contamination of the environment. For example, the nurse ensures that any draining wound is securely
43
covered or places a surgical mask on the client who has an airborne infection. In addition, the nurse
notifies personnel at the receiving area of any infection risk so that they can maintain necessary
precautions. Follow agency protocol.

44
 Providing Pin Care

The wound at the pin insertion site requires attention. The goal is to avoid infection and
development of osteomyelitis. For the first 48 hours after insertion, the site is covered with a sterile
absorbent nonstick dressing and a rolled gauze or Ace-type bandage. After this time, a loose cover
dressing or no dressing is recommended. (A bandage is necessary if the patient is exposed to airborne
dust.) Pin site care is individually prescribed and performed initially one or two times a day. The frequency
of pin care needs to be increased if mechanical looseness of pins or early signs of infection are present
(eg, edema, purulent drainage, erythema, tenderness). Chlorhexidine solution is recommended as the
most effective cleansing solution; however, water and saline are alternate choices. Hydrogen peroxide and
Betadine solutions have been used, but they are believed to be cytotoxic to osteoblasts and may actually
damage healthy tissue (Rabenberg, Ingersoll, Sandrey, et al., 2002).
The nurse must inspect the pin sites daily for reaction (ie, normal changes that occur at the pin site
after insertion) and infection. Signs of reaction may include redness, warmth, and serous or slightly
sanguinous drainage at the site. These signs subside after 72 hours. Signs of infection may mirror those of
reaction but also include the presence of purulent drainage, pin loosening, and odor. Minor infections may
be readily treated with antibiotics, whereas infections that result in systemic manifestations may additionally
warrant pin removal until the infection resolves (Holmes & Brown, 2005). When pins are mechanically
stable (after 48 to 72 hours), weekly pin site care is recommended.

Crusting may occur at the pin site and should remain undisturbed unless there are concomitant
signs of infection. Crusts provide a normal protective barrier, and their removal may disturb healing tissue
and make it more vulnerable to infection (Holmes & Brown, 2005).

The patient should be taught to perform pin site care prior to discharge from the hospital and should
be provided with written follow-up instructions that include the signs and symptoms of infection. The patient
is permitted to take showers within 5 to 10 days of pin insertion and is encouraged to leave the pins open
to water flow. The sites are dried with a clean towel and left open to air.

45
 Wound Drains and Suction

Surgical drains are inserted to permit the drainage of excessive serosanguineous fluid and purulent
material and to promote healing of underlying tissues. These drains may be inserted and sutured through
the incision line, but they are most commonly inserted through stab wounds a few centimeters away from
the incision line so that the incision itself may be kept dry. Without a drain, some wounds would heal on the
surface and trap the discharge inside, and an abscess might form. These drains (e.g., the Penrose drain)
have an open end that drains onto a dressing.

A closed-wound drainage system consists of a drain connected to either an electric suction or a

portable drainage suction, such as a Hemovac or Jackson-Pratt. The closed system reduces the potential
entry of microorganisms into the wound through the drain. The drainage tubes are sutured in place and
connected to a reservoir. For example, the Jackson-Pratt drainage
tube is connected to a reservoir that maintains constant low suction. These portable wound suctions also
provide for accurate measurement of the drainage.

The surgeon inserts the wound drainage tube during surgery. Generally the suction is discontinued
from 3 to 5 days postoperatively or when the drainage is minimal. Nurses are responsible for maintaining
the wound suction, which hastens the healing process by draining excess exudate that might otherwise
interfere with the formation of granulation tissue.

Closed-wound drainage systems have directions for use printed on the drainage container. When
emptying the container, the nurse should wear gloves and avoid touching the drainage port. To reestablish
suction, the nurse places the container on a solid, flat surface with the port open. The palm of one hand
presses the top and bottom together while the other hand cleanses the opening and plug with an alcohol
swab. Replace the drainage plug before releasing hand pressure to reestablish the vacuum necessary for
the closed drainage system to work.

Jackson-Pratt Hemovac

46
 NANDA* – APPROVED NURSING DIAGNOSES
Risk for Activity intolerance Excess Fluid volume Ineffective Peripheral tissue perfusion
Ineffective Activity planning Risk for deficient Fluid volume Risk for Poisoning
Ineffective Airway clearance Risk for imbalanced Fluid volume Post-Trauma syndrome
Latex Allergy response Impaired Gas exchange Risk for Post-Trauma syndrome
Risk for latex Allergy response Dysfunctional Gastrointestinal motility Readiness for enhanced Power
Anxiety Risk for dysfunctional Gastrointestinal motility Powerlessness
Death Anxiety Risk for ineffective Gastrointestinal tissue Risk for Powerlessness
Risk for Aspiration perfusion Ineffective Protection
Risk for impaired parent/infant/child Risk for unstable Glucose level Rape-trauma syndrome
Attachment Grieving Readiness for enhanced Relationship
Autonomic dysreflexia Complicated Grieving Impaired Religiosity
Risk for Autonomic dysreflexia Risk for complicated Grieving Readiness for enhanced Religiosity
Risk prone health Behavior Delayed Growth and development Risk for impaired Religiosity
Risk for Bleeding Effective Health management Relocation stress syndrome
Disturbed Body image Risk for disproportionate Growth Risk for Relocation stress syndrome
Risk for imbalanced Body temperature Ineffective Health maintenance Risk for ineffective Renal perfusion
Bowel incontinence Effective self Health management Risk for compromised Resilience
Effective Breastfeeding Ineffective self Health management Readiness for enhanced Resilience
Ineffective Breastfeeding Readiness for enhanced self Health Impaired individual Resilience
Interrupted Breastfeeding management Ineffective Role performance
Ineffective Breathing pattern Health-seeking behaviors Readiness for enhanced Self-Care
Decreased Cardiac output Impaired Home maintenance Bathing/hygiene Self-care deficit
Risk for decreased Cardiac perfusion Readiness for enhanced Hope Dressing/grooming Self-Care deficit
Risk for ineffective Cardiac tissue perfusion Hopelessness Feeding Self-Care deficit
Caregiver role strain Hyperthermia Toileting Self-Care deficit
Risk for Caregiver role strain Hypothermia Readiness for enhanced Self-Concept
Risk for ineffective Cerebral tissue perfusion Disturbed personal Identity Chronic low Self-esteem
Readiness for enhanced Childbearing Readiness for enhanced Immunization status Situational low Self-esteem
process Functional urinary Incontinence Risk for situational low Self-esteem
Readiness for enhanced Comfort Overflow urinary Incontinence Self-mutilation
Impaired Comfort Reflex urinary Incontinence Risk for Self-mutilation
Impaired verbal Communication Stress urinary Incontinence Disturbed Sensory perception
Readiness for enhanced Communication Urge urinary Incontinence Sexual dysfunction
Decisional Conflict Risk for urge urinary Incontinence Ineffective Sexuality patterns
Parental role Conflict Disorganized Infant behavior Risk for Shock
Acute Confusion Risk for disorganized Infant behavior Impaired Skin integrity
Chronic Confusion Readiness for enhanced organized Infant Risk for impaired Skin integrity
Risk for Acute Confusion behavior Sleep deprivation
Constipation Ineffective Infant feeding pattern Readiness for enhanced Sleep
Perceived Constipation Risk for Infection Disturbed Sleep pattern
Risk for Constipation Risk for Injury Social isolation
Contamination Risk for perioperative positioning Injury Chronic Sorrow
Risk for Contamination Neonatal Jaundice Spiritual distress
Compromised family Coping Insomnia Risk for Spiritual distress
Defensive Coping Decreased Intracranial adaptive capacity Readiness for enhanced Spiritual well-being
Disabled family Coping Deficient Knowledge Stress overload
Ineffective Coping Readiness for enhanced Knowledge Risk for Suffocation
Ineffective community Coping Sedentary Lifestyle Risk for Suicide
Readiness for enhanced Coping Risk for impaired Liver function Delayed Surgical recovery
Readiness for enhanced community Coping Risk for Loneliness Impaired Swallowing
Risk for sudden infant Death syndrome Risk for disturbed Maternal/Fetal dyad Ineffective family Therapeutic regimen
Readiness for enhanced Decision making Impaired Memory management
Ineffective Denial Impaired bed Mobility Ineffective Thermoregulation
Impaired Dentition Impaired physical Mobility Impaired Tissue integrity
Risk for delayed Development Impaired wheelchair Mobility Ineffective Tissue perfusion
Diarrhea Nausea Impaired Transfer ability
Risk for compromised human Dignity Self Neglect Risk for Trauma
Moral Distress Unilateral Neglect Impaired Urinary elimination
Risk for Disuse syndrome Noncompliance Readiness for enhanced Urinary elimination
Deficient Diversional activity Imbalanced Nutrition: less than body Urinary retention
Risk for Electrolyte imbalance requirements Risk for Vascular trauma
Disturbed Energy field Imbalanced Nutrition: more than body Impaired spontaneous Ventilation
Impaired Environmental interpretation requirements Dysfunctional Ventilatory weaning response
syndrome Readiness for enhanced Nutrition Risk for other-directed Violence
Adult Failure to thrive Risk for imbalanced Nutrition: more than body Risk for self-directed Violence
Risk for Falls requirements Impaired Walking
Dysfunctional Family processes: alcoholism Impaired Oral mucous membrane Wandering
Interrupted Family processes Acute Pain
Readiness for enhanced Family processes Chronic Pain * North American Nursing
Fatigue Readiness for enhanced Parenting Diagnosis Association
Fear Impaired Parenting
Readiness for enhanced Fluid balance Risk for impaired Parenting (2009-2011)
Deficient Fluid volume Risk for Peripheral neurovascular dysfunction

47
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Evans-Smith, Pamela. Taylor’s Clinical Nursing Skills: A Nursing Process Approach.

Lippincott Williams & Wilkins. USA. 2005.

Kozier, Barbara and et.al. Fundamentals of Nursing: Concepts, Process, and Practice 8 th ed.
Pearson Education Asia Pte. Ltd. Singapore.

Kozier, Barbara and et.al. Fundamentals of Nursing: Concepts, Process, and Practice 10 th
ed. Pearson Education Asia Pte. Ltd. Singapore. 2012.

Suzanne C. Smeltzer EdD, RN. FAAN, Brenda G. Bare RN, MSN, Janice L. Hinkle PhD, RN,
CNRN, Kerry H. Cheever PhD, RN. Brunner & Suddarth’s Textbook of Medical-Surgical Nursing
11th edition. 2008
Lippincott Manual of Nursing Practice 8th ed. Lippincott Williams & Wilkins. Philippines. 2006.

Myers, Ehren. RNotes: Nurse’s Clinical Pocket Guide. F.A. Davis Co. Thailand.

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Timby, Barbara. Fundamental Nursing Skills and Concepts 8th ed. Lippincott Williams &
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