LEOPOLD’S MANEUVER

DESCRIPTION

Leopold’s maneuver is a systematic method of observation and palpation which provide

information about the number of fetuses, the identity of presenting part , the fetal line and
attitude, the degree of descent into the pelvis and the location of the point of maximum impulse
of fetal heart rate (FHR) in relation to woman’s abdomen.

PURPOSES

1. Systematically observing and palpating the abdomen to:

1.1 Determine what is in the fundus
1.2 Evaluate the fetal back and extremities
1.3 Palpate the presenting part above the symphysis.
1.4 Determine the direction and degree of flexion of the head

2. To plan care during the antepartum and intrapartum periods.

ASSESSMENT

1. Assess the health status of the mother and the fetus

2. Inspect the patient’s abdomen for the longest diameter and where the fetal
movement is apparent.
3. Assess for bladder distention

PLANNING

1. Prepare the needed materials

2. Explain the procedure to the patient and provide opportunity for the patient to verbalize
understanding of the procedure

IMPLEMENTATION

DIRECTIONS: Please rate the students’ level of competency on each expected skill using the
scale provided.

0 – NOT DONE
1 – DONE WITH ASSISTANCE
2 – DONE INDEPENDENTLY
 PROCEDURE
PREPARE THE CLIENT
1. Provide for client privacy.
2. Ask the patient to empty her
bladder or offer bed pan/
female urinal if the client has
distended bladder
3. Wash hands (preferably with
warm water)
4. Assist the client in a position
with knees slightly flexed and
the head is resting on one
pillow
5. Place small rolled cloth/ towel
under the mother’s right or
left hip
First Maneuver:
6. Stand on the right side of the
mother facing her for right-
handed examiner and on the
left side for left-handed
examiner
7. Place both hands on the
mother’s abdomen
8. Palpate the superior part of
the fundus, observing for
tenderness, shape,
irregularities and mobility
Second Maneuver:
9. Place both hands on each side
of the abdomen. Using the
palmar surface of one hand,
palpate the abdomen while the
other hand is in a stationary
supporting the opposite side
RATIONALE 0 1 2
To prevent undue exposure of
other body parts.
Promotes comfort and allows
more productive palpation
because a distended bladder
will not obscure fetal contour (
Pilliterri)
Handwashing prevents the
spread of possible infection.
Using warm water aids in
client’s comfort and prevents
tightening ( Pilliteri)
This position provides good
access to the woman’s
abdomen. Flexing the knees
helps relax the abdominal
muscles. (Ladewig et.al)
This procedure determines
whether fetal hand or breech is
in the fundus
(Pilliteri)
Proper positioning of hands
ensures accurate findings.
The fetal head is firm, hard,
and round and moves
independently of the trunk. The
breech (fetal buttocks) feels
softer and symmetric and has
small bony prominences; it
moves with the trunk.
This maneuver locates the fetal
back.
The fetal back, on one side of
the abdomen, feels firm and
smooth and should connect
what was found in the fundus
 of the.
10. Repeat the procedure using
the other hand while the other
is stationary supporting.
11. Note for the smooth convex
contour of the fetal back and
irregularities of the small parts
Third Maneuver:
12. With the dominant hand,
grasp the lower pole of the
uterus between the thumb and its mobility.
fingers, pressing in slightly.
13. Determine any movement
whether the presenting part is
soft or firm
Fourth Maneuver:
14. Turn to face the woman’s feet. fetal attitude and degree of
15. Using both hands, outline the The fingers of one hand will
presenting part with the
palmar surface of the
fingertips by placing them
approximately 2 inches above neck. The other hand will not
the inguinal ligament. Press
downward and inward while
allowing the fingertips
moving downward. Press
downward and inward while
allowing the fingertips
moving downward.
with a mass in the outlet. The
fetal extremities, which feel
small and knobby, should be
found on the other side.
This maneuver determines the
part of the fetus at the inlet and
This maneuver yields the
opposite information from that
gained with the first maneuver
and validates the presenting
part. If the head is presenting
and is not engaged, it may be
gently pushed back and forth.
This maneuver determines the
fetal extension into the pelvis.
slide along the uterine contour
and meet no obstruction,
indicating the back of the fetal
meet an obstruction by an inch
or so above the ligament- this
is the fetal brow. The position
of the fetal brow should
correspond to the side of the
uterus that contains the elbows
and knees of the fetus. If the
fetus is in poor attitude, the
examining fingers will meet an
obstruction on the same side of
the fetal back. That is why the
fingers will touch hyper
extended head. If the brow is
 easily palpated (as if it lies
under the skin), the fetus is
probably in a posterior position
(the occiput is pointing toward
a woman’s back.
16. Assist the client in a
comfortable position
17. Wash hands and dispose used
materials
18. Document findings accurately
TOTAL RAW SCORE
TOTAL 0 18 36

EVALUATION
Evaluate client’s response to the procedure.

NURSING CONSIDERATIONS
1. As a rule, you can accurately assess fetal position after the 28th week because the
uterine and abdominal muscles are stretched and thinned.
2. You may have trouble assessing fetal position if the patient has hydramnios, very
obese, carrying more than one fetus, the fetus is unusually small, a tumor or other
unusual growth is present in the uterus or the placentas placement obstructs palpation.

Sequence of Leopold’s Of Maneuver

 Palpating the fetal back

COMPUTATION OF GRADES:
STEP 1 : Get the sum of all the points for the entire procedure
STEP 2 : Use the formula below to get the final grade for the particular competency
checklist.

FORMULA: RAW SCORE / PERFECT SCORE X 75 + 25 = FINAL GRADE

Evaluated by: Conforme:

Signature Over Printed Name Signature Over Printed Name

(Clinical Instructor) (Student)

Date: _______________________ Date: ________________________

 FETAL HEART RATE MONITORING

DESCRIPTION:
Fetal heart rate is a major clue to fetal well- being during gestation and labor It may be
assessed by auscultating with a fetoscope or a Doppler ultrasound stethoscope place in the
maternal abdomen .
PURPOSES:
1. To monitor fetal heart rate , which provide information regarding the status of the fetus .
2. The external electronic monitor also provides information about uterine contractions ,
which allows visualization of many characteristics of fetal heart rate

ASSESSMENT:
1. History of previous stillborn
2. Presence of complications of pregnancy
3. Induction of labor
4. Preterm labor
5. Decreased fetal movement
6. Fetal stress or distress.
7. Meconium staining of amniotic fluid

PLANNING:

1. Prepare the needed equipment:

 Clients gown
 Sheet
2. For Electronic monitoring:
 Monitor
 Monitor belts
 Tocodynamometer (TOCO )
 Ultrasonic transducer
 Ultrasonic gel
3. For Auscultation:
 Doppler
 Ultrasound Gel

IMPLEMENTATION
DIRECTIONS: Please rate the students’ level of competency on each expected skill using the
scale provided.
0 – NOT DONE
1 – DONE WITH ASSISTANCE
2 – DONE INDEPENDENTLY
PROCEDURE
1. Identify the client
2. Gather the equipment
needed
3. Wash hands/ hand hygiene
4. Introduce self and explain
the procedure to client,
why is it indicated, and the
information that will be
obtained.
5. Ask the mother to empty
her bladder prior to the
procedure.
6. Wash hands and don non-
sterile gloves
7. Assist the patient to a
supine position, and drape
her in a way that minimizes
exposure.
8. If you’re using a Doppler
stethoscope, apply the
water soluble lubricant to
the patient’s abdomen.
9. Calculating FHR during
gestation:
A. To assess FHR in a
fetus age 20 weeks or
older, place the
earpieces in your ears
RATIONALE 0 1 2
Verifying the patient’s
identity helps ensure that
you are performing the right
skill for the right patient.
Prevents the spread of
microorganism.
Prevents the spread of
microorganism.
Reduces anxiety and
increases client cooperation.
A full bladder may increase
the frequency and strength
of the contractions.
Practices clean
technique and Reduces
transmission of pathogens
from gastric content
Put the client at ease
This gel or paste creates an
airtight seal between the
skin and the instrument and
promotes optimal ultrasound
wave conduction and
reception.
The presentation and the
position of the fetus may
change.
 and position the bell of
the fetoscope or
Doppler stethoscope on
the abdominal midline
above the pubic
hairline.
 Use Leopold’s
maneuvers after 20
weeks when you
can palpate fetal
position to locate
the back of the fetal
thorax
 Using a Doppler
stethoscope, place
the earpieces, and
press the bell gently
on the patient’s
abdomen. Start
listening at the
midline, midway
between the
umbilicus and the
symphysis pubis. Or
using a fetoscope,
place the earpieces
in your ears with
the fetoscope
positioned centrally
on your forehead.
Gently press the
bell about ½ (1.3
cm) into the
patient’s abdomen.
10. Remove your hands from To avoid extraneous noise.
the fetoscope.
11. Move the bell of either To locate the hardest heart
instrument slightly from tones.
side to side, as necessary to
locate heart tones then
palpate the maternal pulse.
12. While monitoring the
maternal pulse, count the
fetal heartbeats for at least
15 seconds and record.
( If the maternal radial pulse
and FHR are the same, try to
locate the fetal thorax by using
Leopold’s maneuvers; then
reassess FHR.)
13. Counting FHR during
labor.
A. Allow the mother and
her support person to
listen to the fetal heart
if they wish.
B. Place the fetoscope or
Doppler on the
abdomen – midway
between the umbilicus
and symphysis pubis
for cephalic
presentation, or at the
umbilicus or above for
breech presentation.
Locate the loudest
heartbeats, and
simultaneously palpate
the maternal pulse.
14. Monitor maternal pulse rate To determine baseline FHR.
and count fetal heart beats (Ambrose and Quinless)
for 60 seconds during the
relaxation period between
contractions.
Note:
a. Auscultate low risk
women:
 Every 1 hour in the
latent phase
 Every 30 minutes in
the active phase
 Every 15 minutes in
the second stage

b. Auscultate high risk

women:
 Every 30 minutes in
the latent phase
 Every 15 minutes in
the active phase
 Every 5 minutes in
the second stage
15. Auscultate FHR during a To identify the response to
contraction and for 30 the contraction.
seconds afterward.
16. Notify the doctor or nurse- Periodic changes
midwife immediately if fluctuations in FHR occur in
you observe marked response to contractions and
changes in FHR from fetal movement.
baseline values. (If fetal
distress develops, begin
indirect or direct electronic
fetal monitoring). Repeat
the procedure as ordered.
17. Remove gloves after the
procedure and perform
hand hygiene.
18. Documentation
 The fetal heart rate and
rhythm
 Characteristics of
uterine activity
 Any actions taken as a
result of the fetal heart
rate
TOTAL RAW SCORES
TOTAL GRADES 0 18 16

EVALUATION:
 Evaluate the status of the fetus and the woman’s contraction pattern.

NURSING CONSIDERATION:
1. If you’re auscultating FHR with a Doppler stethoscope, be aware that obesity and
hydramnios can interfere with sound wave transmission, making accurate results more
difficult to obtain.
2. If the doctor orders continuous FHR monitoring, apply the ultrasound transducer to the
patient’s abdomen.
3. The monitor will provide a printed record of FHR. The toco transducer may also be
applied to monitor the contractile pattern at this time.
COMPUTATION OF GRADES:
STEP 1 : Get the sum of all the points for the entire procedure
STEP 2 : Use the formula below to get the final grade for the particular competency
checklist.

FORMULA: RAW SCORE / PERFECT SCORE X 75 + 25 = FINAL GRADE

Evaluated by: Conforme:

Signature Over Printed Name Signature Over Printed Name

(Clinical Instructor) (Student)

Date: _______________________ Date: ________________________

BAG TECHNIQUE
Definition
 BAG TECHNIQUE – a tool making use of public health bag through which the nurse,
during his/her home visit, can perform nursing procedures with ease and deftness, saving
time and effort with the end in view of rendering effective nursing care.

 PUBLIC HEALTH BAG - is an essential and indispensable equipment of the public
health nurse which he/she must carry along when he/she goes out home visiting. It
contains basic medications and articles which are necessary for giving care.

Rationale
 To render effective nursing care to clients and /or members of the family during home
visit.

Principles
1. The use of the bag technique should minimize if not totally prevent the spread of
infection from individuals to families, hence, to the community.
2. Bag technique should save time and effort on the part of the nurse in the performance of
nursing procedures.
3. Bag technique should not overshadow concern for the patient rather should show the
effectiveness of total care given to an individual or family.
4. Bag technique can be performed in a variety of ways depending upon agency policies,
actual home situation, etc., as long as principles of avoiding transfer of infection is
carried out.

Special Considerations in the Use of the Bag

1. The bag should contain all necessary articles, supplies and equipment which may be used
to answer emergency needs.
2. The bag and its contents should be cleaned as often as possible, supplies replaced and
ready for use at any time.
3. The bag and its contents should be well protected from contact with any article in the
home of the patients. Consider the bag and its contents clean and /or sterile while any
article belonging to the patient as dirty and contaminated.
4. The arrangement of the contents of the bag should be the one most convenient to the user
to facilitate the efficiency and avoid confusion.
5. Hand washing is done as frequently as the situation calls for, helps in minimizing or
avoiding contamination of the bag and its contents.
6. The bag when used for a communicable case should be thoroughly cleaned and
disinfected before keeping and re-using.

Contents of the Bag

 1. Paper lining
2. Extra paper for making bag for waste materials (paper bag)
3. Plastic linen/lining
4. Apron
5. Hand towel in plastic bag
6. Soap in soap dish
7. Thermometers in case [one oral and rectal]
8. 2 pairs of scissors [1 surgical and 1 bandage]
9. 2 pairs of forceps [ curved and straight]
10. Syringes [5 ml and 2 ml]
11. Hypodermic needles g. 19, 22, 23, 25
12. Sterile dressings [OS, C.B]
13. Sterile Cord Tie
14. Adhesive Plaster
15. Dressing [OS, cotton ball]
16. Alcohol lamp
17. Tape Measure
18. Baby’s scale
19. 1 pair of rubber gloves
20. 2 test tubes
21. Test tube holder
22. Medicines
 betadine
 70% alcohol
 Ophthalmic ointment (antibiotic)
 Zephiran solution
 Hydrogen peroxide
 Spirit of ammonia
 Acetic acid
 Benedict’s solution
Note: Blood Pressure Apparatus and Stethoscope are carried separately.
DIRECTIONS: Please rate the students’ level of competency on each expected skill using the
scale provided.

0 – NOT DONE
1 – DONE WITH ASSISTANCE
2 – DONE INDEPENDENTLY

PROCEDURE RATIONALE 0 1 2
1. Upon arriving at the client’s To protect the bag from
home, place the bag on the table contamination.
or any flat surface lined with
paper lining, clean side out
(folded part touching the table).
Put the bag’s handles or strap
beneath the bag.
2. Ask for a basin of water and a To be used for
glass of water if faucet is not handwashing.
available. Place these outside the To protect the work field
work area. from being wet.
3. Open the bag, take the To make a non-
linen/plastic lining and spread contaminated work field or
over work field or area. The paper area.
lining, clean side out (folded part
out)
4. Take out hand towel, soap dish To prepare for
and apron and the place them at handwashing.
one corner of the work area
(within the confines of the
linen/plastic lining).
5. Do handwashing. Wipe, dry Handwashing prevents
with towel. Leave the plastic possible infection from
wrappers of the towel in a soap one care provider to the
dish in the bag. client.
6. Put on apron right side out and To protect the nurses’
wrong side with crease touching uniform. Keeping the
the body, sliding the head into the crease creates aesthetic
neck strap. Neatly tie the straps at appearance.
the back.
7. Put out things most needed for To make them readily
the specific case (e.g.) accessible.
thermometer, kidney basin, cotton
ball, waste paper bag) and place
at one corner of the work area.
8. Place waste paper bag outside To prevent contamination
of work area. of clean area.
9. Close the bag. To give comfort and
 security, maintain personal
hygiene and hasten
recovery.
10. Proceed to the specific To prevent contamination
nursing care or treatment. of bag and contents.
11. After completing nursing care To protect caregiver and
or treatment, clean and alcoholize prevent spread of infection
the things used. to others.
12. Do handwashing again.
13. Open the bag and put back all
articles in their proper places.
14. Remove apron folding away
from the body, with soiled
sidefolded inwards, and the clean
side out. Place it in the bag.
15. Fold the linen/plastic lining,
clean; place it in the bag and
close the bag.
16. Make post-visit conference on To be used as reference for
matters relevant to health care, future visit.
taking anecdotal notes
preparatory to final reporting.
17. Make appointment for the For follow-up care.
next visit
(either home or clinic), taking
note of the date, time and
purpose.
TOTAL RAW SCORES
TOTAL GRADES

AFTER CARE
1. Before keeping all articles in the bag, clean and alcoholize them.
2. Get the bag from the table, fold the paper lining (and insert), and place in between the flaps
and cover the bag.

EVALUATION AND DOCUMENTATION

1. Record all relevant findings about the client and members of the family.
2. Take note of environmental factors which affect the clients/family health.
3. Include quality of nurse-patient relationship.
4. Assess effectiveness of nursing care provided.
COMPUTATION OF GRADES:
STEP 1 : Get the sum of all the points for the entire procedure
Step 2 : Use the formula below to get the final grade for the particular competency
checklist.

FORMULA: RAW SCORE / PERFECT SCORE X 75 + 25 = FINAL GRADE

EVALUATED BY: CONFORME:

Signature over printed name Signature over printed name

(Clinical Instructor) (Student)

Date: Date:
_____________________________
 ADMINISTRATION OF MEDICATION

BASIC PRINCIPLES :
1. Talk with the individual and explain what you are doing before you give medications.
Answer any questions that the individual has.
2. Help the individual to be as involved as possible in the process.
3. Provide privacy for the individual.
4. Give medication administration your complete attention. o Give medications in a quiet
area, free from distractions. o Never leave medications unattended, even for a moment!
5. Wash your hands! You must wash your hands before giving medications and then again
after you have given medication to each individual.

10 RIGHTS OF MEDICATION ADMINISTRATION

1. Right Client 6. Right Assessment
2. Right Drug 7. Right Documentation
3. Right Dose 8. Client’s Right to Education
4. Right Time 9. Right Evaluation
5. Right Route 10. Client’s Right to Refuse

ADMINISTERING AN INTRAMUSCULAR INJECTION

DESCRIPTION
Intramuscular injection delivers medication through the skin and subcutaneous tissues
into certain muscles. Muscles have larger and greater number of blood vessels than
subcutaneous tissue, allowing faster onset of action than with subcutaneous injections.
PURPOSE

 To provide a medication that is required to client.

ASSESSMENT
1. Client’s allergies to medication
2. Specific drug action, side effects and adverse reactions.
3. Client’s knowledge of and learning needs about the medication.
4. Tissue integrity of the selected site.
5. Client’s age and weight to determine site and needle size.
6. Client’s ability or willingness to cooperate.
PLANNING
1. Check for physician’s order for the procedure
2. Assemble equipment.
3. Introduce self and verify client’s identity
4. Explain the procedure to the patient and provide opportunity for the patient to verbalize
understanding of the procedure.
5. Provide for client privacy.

IMPLEMENTATION

DIRECTIONS: Please rate the students’ level of competency on each expected skill using the
scale provided.

0 – NOT DONE
1 – DONE WITH ASSISTANCE
2 – DONE INDEPENDENTLY

PROCEDURE
1. Perform hand hygiene. Don
disposable gloves
2. Select appropriate site for
injection or as indicated.
Select site free of skin
lesions, tenderness,
swelling, scarring, itching
and localized inflammation
and one that has not been
frequently used.
3. Cleanse the area with an
antimicrobial swab by
wiping with a firm circular
motion and moving outward
from the injection site.
Allow skin to dry.
4. Remove needle cap with
non-dominant hand, pulling
it straight off.
5. Holding the skin between
your thumb and your
RATIONALE 0 1 2
Hand hygiene deters the spread of
microorganisms. Gloves acts as
barrier and protect the nurses
hands from accidental exposure to
blood during the injection
procedure.
Injection in a tense extremity
causes discomfort (Smith).
A relax muscle at the site
minimizes comfort (Kozier et. al).
These conditions could hinder the
absorption of the medication and
also increase the likelihood of
injury and discomfort at the
injection site.
The mechanical action of
swabbing removes the skin
secretions which contain
microorganisms.
The cap protects the needle from
contact with microorganisms.
This technique lessens risk of an
accidental needle stick.
Pulling the skin and subcutaneous
tissue or pinching the muscle
 forefinger, pierce the skin makes it firmer and facilitates
quickly and smoothly at a needle insertion. Using a quick
90degree angle and insert motion lessens client’s
the needle into the muscle. discomfort.
6. Hold the barrel of the If the needle is in small blood
syringe steady with your non vessel, it takes time for the blood
dominant hand and aspirate to appear.
by pulling back on the
plunger with your dominant
hand. Aspirate for 5-10
seconds.
For Newborn:
 Change to the 23 g 25
mm needle or 25 g 16
mm needle.
 Be aware that a second
staff member to help
position the infant on
his/her back on an
appropriate surface may
be required.
 Undo the infant’s nappy Using the vastus lateralis muscle
to locate the junction of avoids the risk of sciatic nerve
the upper and middle damage from gluteal injection.
thirds of the vastus Also, the vastus lateralis muscle
lateralis thigh muscle. has a larger muscle mass than the
 Place your forearm gluteal region and therefore has
across the infant’s pelvis reduced risk of severe local
and secure the thigh reactions. 
between your thumb and
forefinger if you are the Make sure that infants do not
clinician performing the move during the IM injection.
injection. This is very important. However,
 Position the limb to relax excessive restraint can increase
the muscle. the infant’s fear and can result in
 Pierce the skin at an increased muscle tension.
angle of 90 degrees to
the skin. Provided an
injection angle of > 70
per cent is used, the
needle should reach the
muscle layer. The
following figures of the
thigh show the
recommended injection
site.
7. If blood appears in the
syringe, withdraw the
needle, discard the syringe
and prepare a new injection.
8. If blood does not appear,
inject the medication
steadily and slowly
( approximately 10 sec per
milliliter) while holding the
syringe steady.
9. After injection, wait for 10
second.
10. Withdraw the needle
smoothly at the same angle
of insertion. Release the
skin.
11. Apply gentle pressure at the
site with a dry sponge /
cotton balls.
12. Do not recap used needle.
Discard needle and syringe
in the appropriate receptacle.
13. Assist patient into a position
of comfort.
14. Remove gloves and dispose
them properly. Perform
hand hygiene.
15. Document accurately the
administration of medication necessary to prevent medication
and site of administration.
TOTAL RAW SCORES
TOTAL SCORES
This step determines whether the
needle has been inserted into a
blood vessel.
Injecting medications slowly
promotes comfort and allows time
for tissue to expand and begin
absorption of the medication.
Holding the syringe steady
minimizes discomfort.
To permit the medication to
disperse into the muscle tissue,
thus decreasing the client’s
discomfort.
This minimizes tissue injury.
Light pressure causes less trauma
and irritation to tissue.
Proper disposal of the needle
protects the nurse from accidental
injection. Most of the accidental
puncture wound occurs when
recapping the needle.
It maintains safety, comfort and
communication.
Accurate documentation is
error.
0 15 30

EVALUATION
 Conduct appropriate follow up such as:
 Desired effect
 Any adverse reactions or side effects
 Local skin or tissue reactions at injection site
COMPUTATION OF GRADES:
STEP 1 : Get the sum of all the points for the entire procedure
Step 2 : Use the formula below to get the final grade for the particular competency
checklist.

FORMULA: RAW SCORE / PERFECT SCORE X 75 + 25 = FINAL GRADE

EVALUATED BY: CONFORME:

Signature over printed name Signature over printed name

(Clinical Instructor) (Student)

Date: Date:
_____________________________
 ADMINISTERING A SUBCUTANEOUS INJECTION

DESCRIPTION
Subcutaneous injections are administered into the adipose tissue layer just below the epidermis
and dermis. The tissue has few blood vessels, so drugs administered here have a slow, sustained
rate of absorption into the capillaries. (Lynn)
PURPOSES
 To provide a medication that is required to client
 To allow slower absorption of a medication compared with either the intramuscular or
intravenous route.

ASSESSMENT
1. Client’s allergies to medication
2. Specific drug action, side effects and adverse reactions.
3. Client’s knowledge of and learning needs about the medication
4. Status and appearance of subcutaneous site for lesions, erythema, swelling, ecchymosis,
inflammation and tissue damage from previous injections.
5. Ability of client to cooperate during the injection.
6. Previous injection site.

PLANNING
1. Check for physician’s order for the procedure
2. Assemble equipment.
3. Introduce self and verify client’s identity

IMPLEMENTATION

DIRECTIONS: Please rate the students’ level of competency on each expected skill using the
scale provided.

0 – NOT DONE
1 – DONE WITH ASSISTANCE
2 – DONE INDEPENDENTLY
 PROCEDURE
1. Provide for client privacy.
2. Perform hand hygiene. Don
disposable gloves
3. Select appropriate site for
injection or as indicated.
Select site free of skin
lesions, tenderness,
swelling, scarring, itching
and localized inflammation
and one that has not been
frequently used.
4. Cleanse the area with an
antimicrobial swab by
wiping with a firm circular
motion and moving outward
from the injection site.
Allow skin to dry.
5. Remove needle cap with
non-dominant hand, pulling
it straight off.
6. Hold the syringe in your
dominant hand between
thumb and fingers.
7. Using the non-dominant
hand, pinch or spread the
skin at the site.
8. Inject the needle quickly at
an angle of 45* to 90*,
depending on the amount
and turgor of tissue and
length of needle.
RATIONALE 0 1 2
To promote comfort
Hand hygiene deters the spread of
microorganisms. Gloves acts as
barrier and protect the nurses
hands from accidental exposure to
blood during the injection
procedure.
Injection in a tense extremity
causes discomfort (Smith).
A relax muscle at the site
minimizes comfort (Kozier et. al).
These conditions could hinder the
absorption of the medication and
also increase the likelihood of
injury and discomfort at the
injection site.
The mechanical action of
swabbing removes the skin
secretions which contain
microorganisms.
The cap protects the needle from
contact with microorganisms.
This technique lessens risk of an
accidental needle stick
It facilitates injection into the
subcutaneous tissue.
This provides for easy, less
painful entry into the
subcutaneous tissue. The decision
to pinch or spread tissue at the
injection site depends on the size
of the patient. If the patient is
thin, skin needs bunching to
create skin fold.
Inserting the needle quickly
causes less pain to the patient.
Subcutaneous tissue us abundant
in a well-nourished and
dehydrated and emaciated in a

9. After the needle is in place,
release tissue. If you have a
large skin fold pinched up,
ensure that the needle stays
in place as the skin is
released.
10. Grasp the lower end of the
syringe with non-dominant
hand and position dominant
hand to the end of the
plunger.
11. Remove needle slowly and
smooth, pulling along the
line of insertion, pulling
along the line of insertion
while depressing the skin
with your non dominant
hand. If bleeding occurs,
apply pressure to the site
with dry sterile gauze until it
stops.
12. Do not recap used needle.
Discard needle and syringe
in the appropriate receptacle.
13. Assist patient into a position
of comfort.
14. Remove gloves and dispose
them properly. Perform
hand hygiene.
15. Document accurately the
administration of medication necessary to prevent medication
and site of administration.
TOTAL RAW SCORES
TOTAL SCORES
very thin person. For thin person,
it is best to insert the needle in a
45* angle
Injecting the solution into
compressed tissue in pressure
against nerve fibers and creates
discomfort. If there is a large skin
fold, the skin may retract away
from the needle. The dominant
hand secures the syringe and
allows smooth aspiration.
Injection requires smooth
manipulation of syringe parts.
Movement of syringe may cause
discomfort.
Slow withdrawal of the needle
pulls the tissue and causes
discomfort. Applying counter
traction around the injection site
helps prevent pulling on the
tissues when the needle is
withdrawn. Removing the needle
at an angle which it was inserted,
this minimizes tissue damage and
discomfort for the patient.
Proper disposal of the needle
protects the nurse from accidental
injection. Most of the accidental
puncture wound occurs when
recapping the needle.
It maintains safety, comfort and
communication.
To prevent transfer of infection to
other healthcare workers.
Accurate documentation is
error.
0 15 30

EVALUATION
 Conduct appropriate follow up such as:
 Desired effect
 Any adverse reactions or side effects
  Clinical signs of side effects.
 Relate to previous findings if available.

COMPUTATION OF GRADES:
STEP 1 : Get the sum of all the points for the entire procedure
Step 2 : Use the formula below to get the final grade for the particular competency
checklist.

FORMULA: RAW SCORE / PERFECT SCORE X 75 + 25 = FINAL GRADE

EVALUATED BY: CONFORME:

Signature over printed name Signature over printed name

(Clinical Instructor) (Student)

Date: Date:
 ADMINISTERING AN INTRADERMAL INJECTION

DESCRIPTION
Intradermal injections are administered into the dermis, just below the epidermis. The
intradermal route has the longest absorption time of all parenteral routes.

PURPOSES
 To administer medication into the dermal layer of the skin just beneath the epidermis.
 This method of administration is frequently indicated for allergy test, tuberculin tests and
for vaccination.

ASSESSMENT
1. Client’s allergies to medication
2. Specific drug action, side effects and adverse reactions.
3. Client’s knowledge of and learning needs about the medication
4. Status and appearance of subcutaneous site for lesions, erythema, swelling, ecchymosis,
inflammation and tissue damage from previous injections.
5. Previous injection site.

PLANNING
1. Check for physician’s order for the procedure
2. Assemble equipment.
3. Introduce self and verify client’s identity
4. Explain the procedure to the patient and provide an opportunity for the patient to
verbalize understanding of the procedure.

IMPLEMENTATION
Directions: Please rate the students’ level of competency on each expected skill using the
scale provided.

0 – NOT DONE
1 – DONE WITH ASSISTANCE
2 – DONE INDEPENDENTLY
 PROCEDURE
1. Provide for client privacy.
2. Perform hand hygiene.
Don disposable gloves
3. Select area on inner aspect
of forearm that is not
heavily pigmented or
covered with hair.
4. If necessary, withdraw
medication from ampule or
vial.
5. Cleanse the area with an
antimicrobial swab by
wiping with a firm circular
motion and moving
outward from the injection
site. Allow skin to dry.
6. Using the non-dominant
hand, to spread skin taut
over injection site.
7. Remove needle cap with
non-dominant hand,
pulling it straight off.
8. Hold the syringe in your
dominant hand between
thumb and fingers.
RATIONALE 0 1 2
To promote comfort
Hand hygiene deters the spread of
microorganisms. Gloves acts as
barrier and protect the nurses
hands from accidental exposure to
blood during the injection
procedure.
The foreman is a convenient easy
location for introducing an agent
intradermally. Hair or lesions at
the injection site may interfere
with assessment of skin changes
at the site. (Smith)
Forearm is a standard beginning
point for intradermal injection and
the area at which subcutaneous fat
is least likely to interfere with the
administration and absorption.
Pathogens on the skin can be
forced into the tissues by the
needle. Introducing alcohol into
the tissues irritates the tissues and
is uncomfortable to the patient.
Taut skin provides an easy
entrance into the intradermal
tissue. Taut skin allows for easier
entry of the needle and less
discomfort for the client.
The cap protects the needle from
contact with microorganisms.
This technique lessens risk of an
accidental needle stick
It facilitates injection into the
subcutaneous tissue.
9. Using the non-dominant This provides for easy, less
hand, pinch or spread the painful entry into the
skin at the site. subcutaneous tissue. The decision
to pinch or spread tissue at the
injection site depends on the size
of the patient. If the patient is
thin, skin needs bunching to
create skin fold.
10. Place needle almost flat Intradermal tissue is entered when
against patient’s skin, contact with microorganisms.
bevel side up. Insert needle This technique lessens risk of an
into skin so that point of accidental needle stick.
the needle can be seen
through skin. Insert needle
only about 1/8 inch with
the entire bevel under the
skin.
11. Stabilize the needle and This verifies that the medication
inject medication carefully entered the dermis.
and slowly so that it
produces a small wheal on
the skin.
12. Once the agent has been Withdrawing the needle quickly
injected, withdraw needle and at the angle at which is
quickly at the same angle it entered, the skin minimizes tissue
was inserted. damage and discomfort for the
patient.
13. Do not massage area after Massage can disperse the
removing needle. Instruct medication into the tissue or out
patient not to rub or scratch through the needle insertion site.
the site.
14. Do not recap used needle. Proper disposal of the needle
Discard needle and syringe protects the nurse from accidental
in the appropriate injection. Most of the accidental
receptacle. puncture wound occurs when
recapping the needle.
15. Assist patient into a It maintains safety, comfort and
position of comfort. communication.
16. Remove gloves and
dispose them properly.
Perform hand hygiene.
17. Encircle the injection site Circling the injection site allows
with an ink enough to mark for easy identification of the
the wheal size. Chart the injection site and permits careful
administration of observation of the exact area.
medication and the site of
 administration
18. Observe the area for any With many intradermal injections,
signs of reaction the nurse will need to look for a
localized reaction(after a period of
time) in area of injection.

EVALUATION
 Evaluate the client’s response to the testing substance. Some medications used in testing
may cause allergic reactions.
 Evaluate the condition of the site in 24 or 48 hours, depending on the test. Measure the
area of redness and indurations in millimeters at the largest diameter and document
finding.

NURSING CONSIDERATIONS
1. A small child or infant will need to be gently restrained during the procedure to prevent
injury from sudden movement.
2. Make sure the child understands that the procedure is not a punishment.
3. Ask the child not to rub or scratch the injection site. Place a stockinet or gauze dressing
over the site if needed.

COMPUTATION OF GRADES:
STEP 1 : Get the sum of all the points for the entire procedure
Step 2 : Use the formula below to get the final grade for the particular competency
checklist.

FORMULA: RAW SCORE / PERFECT SCORE X 75 + 25 = FINAL GRADE

EVALUATED BY: CONFORME:

Signature over printed name Signature over printed name
(Clinical Instructor) (Student)

Date: Date: