Professional Documents
Culture Documents
Manual Rle
Manual Rle
Manual Rle
LEVEL 2:
NURSING SKILLS
A.Y. -
NAME OF STUDENT:
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NAME OF STUDENT:
YEAR/SECTION:
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TABLE OF CONTENT PAGE
NUMBER
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UNIVERSITY OF MAKATI
VISION
We envision the University of Makati as the primary instrument where
University education and Industry training programs interface to mold Makati
youth into productive citizens and IT-enabled professionals who are exposed to
the cutting edge of technology in their areas of specialization. The University
shall be the final stage of Makati City's integrated primary level to university
educational system that allows its less privileged citizens to compete for high
paying job opportunities in its business and industries.
A.Y. 2021-2022
MISSION
1st SEMESTER,
VISION
The College of Allied Health Studies is dedicated to becoming the top of the
mind innovative provider of relevant and needs based-health care education.
MISSION
Development of health care industry workforce that is resilient to its dynamics;
and who are competent, creative and socially responsible.
CORE VALUES
• Resiliency
• Competence
• Creativity
• Social Responsibility
CENTER OF NURSING
VISION-MISSION
The Center supports the College’s vision in becoming the top of mind
innovative provider of relevant and needs-based education by producing
graduate nurses who are fully competent in delivering standard and quality
nursing care, as well as expanded nursing career roles, integrating theory,
practice, and values.
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A.Y. 2021-2022
NP 4 - Community
1st SEMESTER,
Health Nursing 1
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NAME OF STUDENT:
Correctly Needs
Not Done
SKILL: BAG TECHNIQUE RATIONALE Done Improvement
(0)
(2) (1)
ASSESSMENT
1. Assess the family health record.
2. Assess the health needs of the client and
family.
3. Assess the articles, supplies which may be
used to answer emergency needs.
4. Assess for the arrangements of the contents
of the bag.
A.Y. 2021-2022
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touching the table). Tuck the strap beneath
the bag
42. Ask for a basin of water, if faucet is not
available. Place it outside the working area
43. Open the bag, take the plastic linen and
spread over the work field area (folded part
out of the paper lining)
44. Take out the hand towel, soap & apron,
leaving the plastic wrappers of the towel and
soap dish inside the bag. Place the towel,
soap dish and apron at the corner with the
confines of the linen.
45. Perform hand washing, pat dry with towel.
46. Put on the apron right side out and wrong
side with crease touching the body.
47. Put out the things most needed for the
specific case.
48. Place the waste bag outside the work area.
49. Close the bag
50. Proceed to the specific nursing care or
treatment
51. After completing nursing care, clean with
A.Y. 2021-2022
Clinical Instructor: %
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NAME OF STUDENT:
Correctly Needs
SKILL: CLEANING A WOUND AND Not Done
RATIONALE Done Improvement
(0)
APPLYING STERILE DRESSING (2) (1)
ASSESSMENT
1. Verify the physician’s order
2. Assess the situation to determine the need
for wound cleaning and a dressing change.
3. Assess the patient’s level of comfort and the
need for analgesics before wound care.
4. Assess if the patient experienced any pain
related to prior dressing changes and the
effectiveness of interventions employed to
minimize the patient’s pain.
A.Y. 2021-2022
is intact.
6. Assess for excess drainage, bleeding, or
saturation of the dressing.
7. Inspect the wound and the surrounding
tissue.
8. Assess the appearance of the wound for the
approximation of wound edges, the color of
the wound and surrounding area, and signs
of dehiscence.
9. Assess for the presence of sutures, staples,
or adhesive closure strips.
10. Note the stage of the healing process and
characteristics of any drainage.
11. Assess the surrounding skin for color,
temperature, and edema, ecchymosis, or
maceration.
PLANNING / EXPECTED OUTCOMES:
12. The expected outcome to achieve when
cleaning a wound and applying a dry, sterile
dressing is that the wound is cleaned and
protected with a dressing without
contaminating the wound area, without
causing trauma to the wound, and without
causing the patient to experience pain or
discomfort.
13. Other outcomes that are appropriate include:
the wound continues to show signs of
progression of healing, and the patient
demonstrates understanding of the need for
wound care and dressing change.
MATERIALS:
14. Sterile gloves
15. Clean disposable gloves
16. Additional PPE, as indicated
17. Sterile gauze dressing
18. Surgical or abdominal pads
19. Sterile dressing set or suture set (for the
sterile scissors and forceps)
20. Sterile cleaning solution (0.9% normal saline
solution)
21. Sterile basin (optional)
22. Sterile drape (optional)
23. Plastic bag or other appropriate waste
container for soiled dressings
24. Waterproof pad and bath blanket
25. Adhesive tape or Ties
26. Other linen for draping patient
27. Additional dressings and supplies, as
needed or physician’s order
IMPLEMENTATION:
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28. Review the medical orders for wound care or Reviewing the order and plan of
the nursing plan of care related to wound care validates the correct patient
care. and correct procedure.
29. Gather the necessary supplies and bring to Preparation promotes efficient time
the bedside stand or overbed table. management and organized
approach to the task. Bringing
everything to the bedside
conserves time and energy.
30. Perform hand hygiene and put on PPE, if Hand hygiene and PPE prevent
indicated. the spread of microorganisms.
PPE is required based on
transmission precautions.
31. Identify the patient. Identifying the patient ensures the
right patient receives the
intervention and helps prevent
errors.
32. Close curtains around bed and close door to This ensures the patient’s privacy.
room if possible. Explain what you are going Explanation relieves anxiety and
to do and why you are going to do it to the facilitates cooperation.
patient.
33. Assess the patient for possible need for Pain is a subjective experience
nonpharmacologic pain reducing influenced by past experience.
interventions or analgesic medication before Wound care and dressing changes
A.Y. 2021-2022
wound care dressing change. Administer may cause pain for some patients.
1st SEMESTER,
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over gauze sponges over a container for
small cleaning jobs, or into a basin for more
complex or larger cleaning.
43. Put on sterile gloves Use of sterile gloves maintains
surgical asepsis and sterile
technique and reduces the risk for
spreading microorganisms.
44. Clean the wound. Clean the wound from top Cleaning from top to bottom and
to bottom and from the center to the outside. center to outside ensures that
Following this pattern, use new gauze for cleaning occurs from the least to
each wipe, placing the used gauze in the most contaminated area and a
waste receptacle. Alternately, spray the previously cleaned area is not
wound from top to bottom with a contaminated again. Using a single
commercially prepared wound cleanser. gauze for each wipe ensures that
the previously cleaned area is not
contaminated again.
45. Once the wound is cleaned, dry the area Moisture provides a medium for
using a gauze sponge in the same manner. growth of microorganisms. The
Apply ointment or perform other treatments, growth of microorganisms may be
as ordered. inhibited and the healing process
improved with the use of ordered
ointments or other applications.
46. If a drain is in use at the wound location, Cleaning the insertion site helps
A.Y. 2021-2022
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60. The expected outcome is met when the
patient exhibits a clean, intact wound with a
clean dressing in place.
61. The wound is free of contamination and
trauma.
62. Patient reports little to no pain or discomfort
during care.
63. Patient demonstrates signs and symptoms of
progressive wound healing.
TOTAL
/ 126
Clinical Instructor: %
REMARKS:
A.Y. 2021-2022
1st SEMESTER,
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NAME OF STUDENT:
Correctly Needs
Not Done
SKILL: FIRST AID RATIONALE Done Improvement
(0)
(2) (1)
ASSESSMENT
1. Assess if the scene is safe
2. Assess the client's condition to be sure the The condition of the client may
order of the health care provider is have changed.
appropriate.
3. Assess the client's age. As pediatric/geriatric clients may
have special needs.
4. Assess the client’s understanding of the
purpose of the intervention
PLANNING / EXPECTED OUTCOMES:
5. To prevent further complications
A.Y. 2021-2022
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33. Elevate the extremity or the splinted part, if
possible
34. Remove PPE and dispose to the proper
receptacle
35. Advise patient to seek medical evaluation or
call EMS, if necessary
BURN
36. Remove watches, rings and bracelet on the To prevent any further injury cause
affected limb. And put to a properly labelled by possible swelling.
container.
37. Flush the burned area with cool running
water for several minutes. Do not use ice.
38. Apply a light gauze bandage. Do not break Do not apply ointments, butter, or
any blisters that may have formed. oily remedies to the burn.
39. Classify the degree and depth of a burn. Use The extent of burn, clinically
rule of nines to determine the measurement referred to as the total surface area
or extent of burn. (Lund and Browder Chart burned, is defined as the
is used for children younger than 10 years). proportion of the body burned.
40. Call EMS for serious burns The severity of burn is based on
depth and size.
NOSEBLEED
41. Ask the patient to lean forward Do not ask the patient to lean back
A.Y. 2021-2022
42. Pinch the nose just below the bridge Do not pinch the nostril closed by
pinching lower.
1st SEMESTER,
43. Check after five minutes to see if bleeding If not, continue pinching and check
has stopped. after another 10 minutes.
44. Apply cold pack to the bridge of the nose
while pinching.
45. Call EMS or bring to nearest medical center
to be assessed
EVALUATION:
46. Client was able to discuss the purpose of the
procedure
47. Bleeding was controlled, with minimal blood
loss
48. No untoward incident; fracture was
immobilized
49. For burns. Client was removed from the
source and given the appropriate treatment
50. Appropriate intervention was provided to the
client
TOTAL
/ 100
Clinical Instructor: %
REMARKS:
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NAME OF STUDENT:
Correctly Needs
SKILL: INTRADERMAL Not Done
RATIONALE Done Improvement
(0)
INJECTION (2) (1)
ASSESSMENT
1. Assess the 10 Rights of Medication
Administration
2. Verify the physician’s order
3. Assess the client’s allergies to medication
4. Check the specific drug action, side effects,
interactions and adverse effects.
5. Check the appearance of injection site.
(redness, hair distribution, skin condition)
6. Assess client’s knowledge about the
A.Y. 2021-2022
procedure.
1st SEMESTER,
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SYRINGE PREPARATION
28. Remove the needle cap while waiting for the
antiseptic to dry.
29. Expel any air bubbles from the syringe.
*Small bubbles that adhere to the plunger
are of no consequences.
30. Grasp the syringe in your dominant hand,
close to the hub, holding it between the
thumb and forefinger.
31. Hold the needle almost parallel to the skin
surface, with the bevel of the needle up.
INJECTION PREPARATION
32. Assist the client to a comfortable position
33. Discard the uncapped needle and syringe in
a sharps container
34. With the nondominant hand, pull the skin at Taut skin allows for easier entry of
the site until it is taut. the needle hence less discomfort
for the client.
35. Insert the tip of the needle far enough to
place the bevel through the epidermis into the
dermis. The outline of the needle should be
visible under the skin.
A.Y. 2021-2022
37. Withdraw the needle, gently wipe the Massage can disperse the
injection site with clean dry cotton. Do not medication into the tissue or out
massage the site. through the needle insertion site.
38. Dispose the syringe and needle into the Prevent needle stick injury.
sharp’s container.
DO NOT RECAP THE NEEDLE.
39. Remove and discard gloves.
40. Perform hand hygiene.
41. Encircle the wheal, note the time of injection,
name of medication and initials of the nurse.
DOCUMENTATION:
42. Document the relevant information:
medication, time, site, route and nursing
assessment.
EVALUATION:
43. Evaluate the client’s response to the
procedure. The client verbalized
understanding of the procedure.
44. Evaluate the site after 30 mins depending on
the test. Measure the area of redness and
induration.
45. The client experienced minimal discomfort
during the procedure.
TOTAL
/ 90
Clinical Instructor: %
REMARKS:
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NAME OF STUDENT:
ASSESSMENT
1. Assess the 10 rights of giving medication
2. Review the physician’s orders
3. Review information regarding the drug
ordered such as action, purpose, time, of
onset and peak action, normal dosage,
common side effects, and nursing
implications
4. Assess the client for factors that may
influence any injection, such as circulatory
shock, reduced local tissue perfusion, or
muscle atrophy
A.Y. 2021-2022
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31. Don clean gloves.
32. Cleanse the skin at the site using a firm
circular motion starting at the center and
widening the circle outward (about 5cm).
Allow the area to dry thoroughly.
SYRINGE PREPARATION
33. Remove the needle cap while waiting for the
antiseptic to dry.
34. *IF USING A PRE-FILLED UNIT-DOSE Medication left on the needle can
MEDICATION: cause pain when it is tracked
Take caution to avoid dripping medication on through the subcutaneous tissue.
the needle prior to injection. If this occurs,
wipe the medication off the needle with a
sterile gauze or replace the needle.
INJECTION PROCEDURE
35. While holding the swab/ cotton ball between Pulling the skin and subcutaneous
the fingers of the nondominant hand, use the tissue or pinching the muscle make
ulnar side to pull the skin approximately it firmer and facilitates needle
2.5cm into the side, or pinch the muscle for insertion.
emaciated infant or child.
36. Hold the syringe between thumb and
forefinger using the dominant hand like a
pen/ dart.
A.Y. 2021-2022
37. Inject the needle quickly and smoothly at a using a quick motion lessens the
1st SEMESTER,
Clinical Instructor:
%
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NAME OF STUDENT:
Correctly Needs
SKILL: SUBCUTANEOUS Not Done
RATIONALE Done Improvement
(0)
INJECTION (2) (1)
ASSESSMENT
1. Assess the 10 Rights of Medication
Administration
2. Verify the physician’s order
3. Assess the client’s allergies to medication
4. Check the specific drug action, side effects,
interactions and adverse effects.
5. Check the appearance of injection site and
tissue integrity. (redness, hair distribution,
skin condition)
6. Assess client’s knowledge about the
A.Y. 2021-2022
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31. *IF USING A PRE-FILLED UNIT-DOSE Medication left on the needle can
MEDICATION: cause pain when it is tracked
Take caution to avoid dripping medication on through the subcutaneous tissue.
the needle prior to injection. If this occurs,
wipe the medication off the needle with a
sterile gauze or replace the needle.
INJECTION PROCEDURE
32. Grasp the syringe in your dominant hand by
holding it between your thumb and fingers.
33. With the nondominant hand, pinch or spread
the skin at the site.
34. With palm facing to the side or upward for a
45-degree angle insertion, prepare to inject.
35. Insert the needle using the dominant hand
and a firm steady push.
36. Hold the barrel of the syringe steady with
your nondominant hand.
37. The dominant hand will aspirate by pulling
back on the plunger.
38. Inject the medication steadily and slowly Injecting medication slowly
(approx. 10 seconds per mL) while holding promotes comfort and allows time
the syringe steadily. for tissue to expand and begin
A.Y. 2021-2022
Clinical Instructor: %
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NAME OF STUDENT:
Correctly Needs
Not Done
SKILL: BREAST EXAMINATION RATIONALE Done Improvement
(0)
(2) (1)
ASSESSMENT
1. Ask the client’s age, menstrual period,
number of pregnancies and lactation
2. Assess the client’s breast for obvious lumps,
nodules, or lesions
3. Assess the client’s previous breast surgeries
4. Assess the amount and color of breast
discharges
5. Assess for anxiety, restlessness and fear of
the procedure
A.Y. 2021-2022
the procedure
PLANNING / EXPECTED OUTCOMES:
7. Procedure will be performed without trauma
to the client
8. Client’s anxiety will be minimal during
procedure
9. Client’s breast will be free of redness and
excoriation
MATERIALS:
10. Antimicrobial soap
11. water
12. Clean gloves
13. Drape sheet or blanket
14. screen
IMPLEMENTATION:
15. Identify the client, introduce yourself and
explain the procedure
16. Ask the client’s menstrual period
17. Provide privacy. Expose only the area to be
examined
18. For male examiner, ask someone to be with
while performing the procedure
19. Wash and warm hands. Don clean gloves if
necessary
20. Ask the patient to sit and raise arm over her
head (one arm at a time)
21. With the patient’s arm raised, inspect the
axilla for any rash, infection or unusual
pigmentation
22. Palpate the tail of the breast tissue and any
lymph or nodules on the axilla
23. Ask the patient to press her hands against
her hips and assess for asymmetry.
24. Lower the head of the bed and position
patient in supine
25. Place a small pillow under the patient’s
shoulder on the side you are examining
26. Ask her to raise her arms above her head
27. Begin with the lateral portion of the breast
28. Palpate one breast at a time, starting from
the tail using parallel line technique
29. Palpate in circular motion, soft to medium.
30. Use a systematic pattern to palpate the
entire breast
31. Try to identify any nodule or mass that is
larger or different from the rest of the breast
tissue
32. To examine the median portion of the
breast, position patient in supine
33. Palpate in straight line with one hand above
the shoulder between nipple and bra line
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then up to the clavicle using the same
systematic pattern
34. Palpate the nipple, note for the elasticity and
check for discharges
35. Drape the breast and proceed to the other
using the same technique
MALE:
36. Inspect for symmetry and size
37. Inspect each nipple and areola for nodules
38. Check for axillary’s lymph nodes in the
same technique you used for female clients
39. Make sure male patients arm remains on
the side
40. If the breast appears to be large at the
areola, try to distinguish some fats from the
firm disc of tissue
41. Wash hands
42. Document necessary findings such as color,
contour, symmetry description of nodules
EVALUATION:
43. Presence of lymph, nodules, lesions, color,
and discharges was noted
A.Y. 2021-2022
Clinical Instructor: %
REMARKS:
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NAME OF STUDENT:
Correctly Needs
Not Done
SKILL: LEOPOLD’S MANUEVER RATIONALE Done Improvement
(0)
(2) (1)
ASSESSMENT
51. Assessment of the maternal pelvis’ shape
52. Assess the need for cesarean section
53. Assess the presenting part into the maternal
pelvis, extent of flexion of the fetal head,
estimated fetal weight and size,
54. Determine if complication will occur during
delivery
55. Determine the fetal position in the maternal Accuracy is greatest after 36
abdomen. weeks of gestation
56. Identify the upper and lower fetal poles
A.Y. 2021-2022
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75. Steady the uterus with one hand and palpate The fetal arms and legs feel like
the fetus with the other, looking for the back irregular bumps. The fetus may
on one side and extremities on the other. kick if awake and active.
THIRD MANEUVER (LOWER FETAL POLE AND DESCENT INTO
PELVIS)
76. Face the woman’s feet.
77. Place the flat palmar surfaces of the Again, the fetal head feels very
fingertips on the fetal pole just above the firm and globular; the buttocks feel
pubic symphysis. firm but irregular, and less globular
78. Palpate the presenting fetal part for texture than the head.
and firmness to distinguish the head from the
buttock. In a vertex or cephalic
79. Judge the descent, or engagement, of the presentation, the fetal head is the
presenting part into the maternal pelvis. presenting part.
80. Alternatively, use the Pawlik grip by grasping
the lower fetal pole with the thumb and If the most distal part of the lower
fingers of one hand to assess the presenting fetal pole cannot be palpated, it is
part and descent into pelvis; however, this usually engaged in the pelvis.
technique tends to be uncomfortable to the
gravid patient. If you can depress the tissues over
the maternal bladder without
touching the fetus, the presenting
part is proximal to your fingers.
A.Y. 2021-2022
81. This maneuver assesses the flexion or If the cephalic prominence juts out
extension of the fetal head, presuming that along the line of the fetal back, the
the fetal head is the presenting part in the head is extended.
pelvis.
82. Still facing the woman’s feet, with your hands If the cephalic prominence juts out
positioned on either side of the gravid uterus, along the line of the fetal anterior
identify the fetal front and back sides. side, the head is flexed.
83. Using one hand at a time, slide your fingers
down each side of the fetal body until you
reach the “cephalic prominence,” that is,
where the fetal brow or occiput juts out.
EVALUATION:
84. Patient verbalizes knowledge regarding the
procedure
85. No untoward incident for both patient
86. Patient remains free from injury
87. Patient tolerate the procedure
TOTAL
/ 74
Clinical Instructor: %
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NAME OF STUDENT:
Bag Technique
First Aid
1st SEMESTER,
Intradermal Injection
Intramuscular Injection
Subcutaneous
Injections
Breast Examination
Leopold’s Maneuver
TOTAL
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