PROCEDURE GUIDE

INTERVENTIONS OF COMMON AND SIGNS AND SYMPTOMS

Causin, Lance Matthew, S.

BSN
Level II - A  

Submitted to: Sir John Carlo L. Divina MSN, RN, CDP, CHA, FRIN
Date Submitted: November 7, 2021
Procedure Guide for Chest PERCUSSION
PROCEDURE
1. Secure doctor’s order.
2. Explain the procedure to the patient.
3. Do medical hand washing.
4. Auscultate the lung segments.
5. Position patient in lateral, supine or
prone position based on the lung
segment to be drained.
RATIONALE
Secure doctor’s orders for safety  and
security. This is to make sure  that what
the nurse decides to do  is backed up by
the presence of a  doctor’s order.
In order to build rapport and to  inform
them how and why the  procedure is
being done.
Before doing the procedure, make  sure
to perform medical hand  washing first as
this aids in  removing microorganisms
from  the palm of the hands. This is 
required before touching the  client to
avoid cross infection of  bacteria.
This procedure examines the 
trachea-bronchial tree for airflow.  It's
critical to distinguish between  normal
and atypical respiratory  sounds, such as
crackles,  wheezes, and pleural rub, in
order  to establish an accurate diagnosis.
Percussion is performed on the  front,
back and sides of the  person’s chest and
is followed by  deep breathing and
coughing. Percussing the chest wall over
the  lung segment will drain forced
secretions into the larger  airways
6. Cover area with a towel or gown
7. Percuss or clap (with the fingers and
thumb held together and flexed slightly to
form a cup-as one would scoop up water)
each area of the lung segment for 1-2
minutes.
Alternately flex and extend the wrists
rapidly over the chest.
8. Never do percussion on bare skin or
perform over surgical incisions, breasts, lower uncomfortable for the  patient. Special
ribcage, sternum, spinal column and kidneys. attention must be  taken to never percuss
9. If the patient has tenacious
secretions, percuss area for up to 3-5
minutes several times per day.
10. Explain to the patient to utilize
coughing techniques. Provide and
emesis basin and tissue paper.
This is to provide comfortability  and
reduce patients anxiety.
Percussing or clapping each area  of the
lung segment for 1 to 2  minutes, helps
to determine  whether the lungs are filled
with  air or fluid.
The percussion technique should  not be
performed on bare skin as  this may be
over the  spine, breastbone, stomach,
lower  rib cage, and sternum to prevent 
injury and trauma.
It is crucial to not only listen for  the
sound but also feel the  intensity and
frequency of the  vibrations caused by
this  maneuver.
When sneezing or coughing, cover  your
mouth and nose with a tissue  to prevent
the spread of  microorganisms. To keep
the  place clean and to save the time  and
energy for the patient.
 11. Do auscultation. Performing Auscultation  assessment for
normal breath  sounds and abnormal
breath  sounds.

12. Document the reaction of the This will aid the health care  provider in
patient and the characteristics of the determining patient  requirements and
secretion. assessing  problems of the client.

Procedure Guide for Chest Vibration

PROCEDURE RATIONALE

1. Secure doctor’s order. It is for safety and security  as the

procedure is  executed. This is to make 
sure that every nurse’s  actions are
guided with the  doctor's order.

2. Explain the procedure to the client. Patient education is a  significant part of a

nurse's  job. Education empowers
 patients to improve their  health status.
And by doing  this step it is making them
 more involved in their  treatment,
patients who are  involved with their
treatment are more likely to  participate
in interventions  that improve their odds
of  achieving favorable results.

3. Do medical hand washing. Medical washing is an  excellent way to

avoid  infections. It is meant to  reduce
transmission of  microorganism and 
contamination from our skin  to our body
as well as the  client
 4. Do auscultation. To know if there are any  abnormal
sounds present.

5. After chest percussion, hold the hands It’s purpose is to break up  thick
flat on patient’s chest wall (one hand secretions in the lungs  so they can more
over the other with the fingers easily be  removed.
together and extended).

6. Ask the client the patient to inhale deeply
and exhale slowly through the nose/pursed
lips.
Inhaling deeply will ensure  that the
patient is using its  lung’s full capacity
and  exhaling slowly will give the  nurse a
steady and  controlled breathing 
necessary for this  procedure. This also 
relieves pain and causes  them to practice
deep  breathing.

7. During exhalation, do a vibrating A vibrating motion allows  the mucus to

motion with your hands moving them shake so it can move into the larger 
downward. Stop the vibrating when airways.
the patient inhales.

8. Vibrate during five exhalations over This is done to facilitate the  loosening of
on affected lung segment. Do this for respiratory  secretions. It can be done 
several minutes, several times each with vibration several times  a day
day.

9. Never do vibrations on patient’s This is to avoid discomfort  and to avoid

surgical incisions, breasts, sternum, any injuries  that may occur.
spinal column and kidneys.

10. Explain to the patient to utilize Coughing is important  because it helps

coughing techniques. Provide and remove  sputum from your lungs.  The
emesis basin and tissue paper. sputum being removed  would be used
for  laboratory works for  testing. Where
the emesis  basin would be utilized and
  tissue paper for the patient  to wipe and
clean the face.

Performing the auscultation  technique

11. Do auscultation. aids in diagnosing  respiratory-related  
disorders. It is a type of  assessment
technique that  requires the use of a 
stethoscope to listen for the normal
breath sounds and  abnormal breath
sounds.

12. Document the reaction of the patient In order to identify any  abnormalities
and the characteristics of the secretion. and to use  the documents for future 
purposes.

​
Procedure Guide for Home-made ORESOL Preparation

PROCEDURE RATIONALE

1. Do medical hand washing. Is essential for the prevention of 

infection and should be done on a 
regular basis.

2. Measure the correct proportion of boiled Measuring the correct proportion  of

water, salt and sugar. mixture is important because  too much
sugar can make the  situation worse and
too much salt  can be extremely harmful
2.1 1 glass mixture:
to the  child. If the solution has too
- 1 teaspoon sugar
- a pinch of salt much  salt the child may refuse to drink 
- 240 mL of boiled water it. Also, too much salt can in  extreme
cases, cause  convulsions. Too little salt
2.2 1 Liter mixture: does  no harm but is less effective in 
preventing dehydration.
- 8 teaspoon sugar
- 1 teaspoon salt
- 1000 mL/ 1 liter of boiled water

3. Prepare the solution in a clean Putting the solution in a clean  container

container. will help prevent any  contamination of
the ORESOL.

4. Stir the mixture until all the solutes
dissolve.
5. Do medical handwashing before
administering the solution. Instruct
patient to do handwashing as well.
Achieving the desired concentration in a
systemic circulation and obtaining an
effective therapeutic response.
To prevent the risk of spreading 
pathogens and obtaining  infectious
diseases. 

6. Give the client as much solution as
needed in small amounts.
7. If the client vomits, wait for 10
minutes and give ORS again.
8. If the client need an Oral Rehydration
Solution after 24 hours, make a fresh
solution. Discard leftovers.
Procedure Guide for Tepid Sponge Bath
PROCEDURE
1. Assess the condition of the patient (check
temperature if febrile).
2. Explain the procedure to the patient
and/or the significant others.
It is important to encourage the  client to
drink as much as possible.  Feeding the
client small sips after  every loose motion
will help  replace the salts and water the 
body has lost to dehydration.  Remember
to feed sips of the  liquid slowly.
Giving ORS to the patient is a great  way to
replace fluids and nutrients  lost through
vomiting and diarrhea.  And waiting for 10
minutes is needed  to not upset the tummy.
It must not be used more than 24  hours
due to the risk of  bacteriological
contamination.
RATIONALE
Assessing the condition of the  patient is
important because this  will identify and
determine the  current problem of the
patient. To  this procedure, this also helps
the  nurse check if the patient still needs
to have a tepid sponge  bath.
Discussing the information of a 
procedure with patients and to  their
significant others is always  done because
 you will always be  required to inform
patients  sufficiently and involve them in 
decisions about any procedure  they may
require.

3. Bring all prepared material and set them

on the bedside table Preparing all the necessary materials needed
for the tepid sponge bath will promote time
management and continuity of the
procedure at hand.

4. Provide screens for privacy (if patient is To provide privacy and comfort to  the
in the ward). client.

5. Wash hands thoroughly before starting Performing Hand Washing will  promote
procedure. cleanliness and prevent  contamination
onto oneself and to  the patient.

6. Adjust the patient’s bed on a certain To be efficient and provide  comfort to

height that is accessible for working. the patient.

Loosen the top sheet before  drawing the

7. Loosen top sheet. client to the side. This  will give the nurse
better access in  positioning the client
appropriately and in removing the  client’s
gown.

8. Draw patient to side nearer you. This is needed so that the  application of
the procedure does  not harm the client
upon doing the  upcoming procedures.

9. Remove patient’s gown or pajama. This provides full body exposure  while
bathing.
10. Remove pillows, leave one under
patient’s head (if he feels uncomfortable).
To keep the linens and pillows  from
being wet in order for it to be  used
again. It also keeps the head  at the right
angle when doing a  tepid sponge bath
and it keeps the  patient comfortable.
Otherwise,  leave it under the patient’s
head.

11. Place on bath towel under patient’s head It is easier to wash the client’s ear  and
and neck. neck when the pillow is  removed. Towels
are strategically  placed to keep bed
linens and  bath blankets clean.

12. Wet wash cloth. Wrap it around your
palm to make a mitten. With patting
motion, wash around the eyes, nose,
mouth, cheeks, forehead and neck. Rinse
wash cloth. Repeat three times. Dry
thoroughly.
To prevent the bottom sheet from 
getting wet. Washing from inner  to outer
corner prevents sweeping  debris into the
client’s eyes, nose,  mouth, cheeks,
forehead and  neck. Using a dry portion
of the  mitt prevents the spread of 
infection.

PROCEDURE RATIONALE

13. Expose farther arm. Place bath towel
lengthwise under it. With washcloth,
sponge from wrist to shoulder and axilla
using patting motion. Rinse wash cloth.
Repeat three times. Dry thoroughly.
Exposing the patient’s arm will  help the
nurse do the step easily.  Placing the
lengthwise towel  under the arm prevents
the  bottom sheet from getting wet as 
the nurse starts the procedure.  Using
patting motion prevents  irritation and
rashes to the  patient's skin that may
transform  to infection.

Carry out the same step on the  client’s

14. Expose other arm. Follow same other arm. Firm strokes  from distal to
procedure. proximal areas  promote circulation by
increasing  venous blood return.
15. Place towel on chest and abdomen.
Fanfold top sheet down to the pubis. Do the
same bathing technique from chest,
abdomen, sides and pubis. Rinse washcloth.
Repeat three times. Dry thoroughly. Change
water if necessary.
16. Assist patient in turning towards the
nurse. See to it that the patient will not fall.
Place the towel lengthwise under the
patients back down to the buttocks and
remove the top sheet covering these areas.
Use patting motion to wash back and
buttocks thoroughly. Rinse wash cloth.
Repeat three times. Dry thoroughly with
towel. Turn on hisback. Change water.
17. Expose farther leg. Place towel under
it. Use patting motion and dry thoroughly.
Pay attention particularly to the inguinal
area.Rinse wash cloth. Repeat three times.
Dry thoroughly .
18. Repeat procedure number 17 with the The bottom sheet will not get wet  if the
other leg. towel is placed beneath the  exposed leg.
It is important to give the patient  as
much privacy as the nurse can.  It keeps
the patient comfortable  and safer. The
order of the  bathing technique is
important  due to the principle of 
microbiology wherein cleaning  should be
from the least  contaminated area to the
most  contaminated area of the body. 
Repeating three times ensures  that the
nurse has completely and  efficiently
cleaned the patient’s  upper body. The
nurse must also  be sensitive enough to
check if the  water is still usable.
This is to avoid injury to the client  and to
avoid rash while cleaning  with the wash
cloth. Washing the  wash cloth prevents
cross  contamination.
Placing the towel under the  exposed leg
prevents the bottom  sheet from getting
wet. Washing  from inner to outer corner 
prevents sweeping debris into the  client’s
eyes, nose, mouth,  cheeks, forehead and
neck. Using  dry portion of the mitt
prevents  the spread of infection.
 Washing the client's  eyes, nose, mouth,
cheeks,  forehead, and neck from the
inside out prevents dirt from sweeping
into their eyes, nose,  mouth, cheeks,
forehead, and  neck. The use of the mitt's
dry  part inhibits the transmission of 
infection.

19. Check the patient’s temperature Checking the patient’s  temperature

(this may be done every 15 minutes after the procedure  will help the
during the procedure or 30 minutes nurse determine if  the client’s
after the procedure). condition is getting

20. Apply deodorant. Put on patient’s Deodorant will clean the patient’s 
camisa or gown. Remake the bed. axilliaries. Letting the patient down a
gown  or camisa (preferably a new one) 
improves appearance and well  being.
Remaking the bed helps reduce  the risk
of infection due to  rubbing.

21. Tidy the ward. Adjust windows and Clean the place so that the patient  will
blinds. have a comfortable place to  stay.

22. Do recording. Document the procedure Documenting provides valuable

done, along with the patient’s vital signs, information for patient needs and
response to treatment and complications, if problem assessment
any.