HANDWASHING

1. Removes Jewelry.

2. Assesses hand for hangnails, cuts or breaks in skin and areas that are heavily soiled.

3. Turns on water.

4. Adjusts flow and temperature.

5. Wets hand and lower forearms thoroughly by holding under running water.

6. Keeps hands and foreamrsin down position with elbows straight.

7. Avoids splashing water and touching sides of the sink.

8. Applies about 5 mL (1 tsp) of liquid soap.

9. Lathers thorougly by:

9.1. Rubbing palm to palm

9.2 Right over left dorsum with interlaced fingers and vice versa palm to palm with fingers interlaced
back of fingers to opposing palms with fingers interlaced.

9.3. Rotational rubbing of left thumb clasped in right palm and vice versa.

9.4. Rotational rubbing backwards and forwards with clasped fingers of right in left palm and vice versa.

10. Rubs hands vigorously together for 15 seconds.

11. Rinses hamds with elbows straight, in direction of forearm to wrist and fingers.

12. Dries hands thoroughly.

13. Dries in direction of fingers to wrist and forearms.

14. Turns off the water.

15. Discards paper towels in proper receptacle.

PPE

1. Washes hands.

2. Dons cap or surgical hat or hood first. Hair should be tucked and covered/

3. Dons a clean gown.

4. Picks up a clean gown, allow it to unfold in front without touching any area.

5. Dons a facemask.
6. Holds the mask by the top two strings or loops

7. Places the upper edge of the mask over the bridge of the nose, tie at the back of the head or secure
the loops around the ear.

8. Secures the lower edge of the mask under the chin, and tie the lower ties at the nape of the neck

9. Wears the mask only once.

10. Ensures that used facemask is not left hanging around the neck.

11. Dons protective eyewear if it is not combinesd with thefacemask.

12. Dons clean, disposable gloves.

13. Removes the gloves first. IF wearing a gown, undo the ties beforeremoving gloves.

14. Grasps the glove on its palm surface just below the cuff

15. Pulls the first glove completely off by inverting or rollig the glove inside out.

16. Performs hand hygiene.

17. Removes protective eyewear and dispose properly in the appropriate receptacle.

18. Removes the gown.

19. Grasps the gown alon the inside of the neck and pull down over the shoulders then removes the cap.

20. Removes the mask from the face.

21. Discards the disposable mask in the waste container.

22. Performs proper hand hyfiene again.

TEMPERATURE

1. Reviews medical record for factors that influence vital signs.

2. Introduces procedure, self, explains the procedure.

3. Gathers equipment.

4. Performs hand hygiene.

5. Provides for privacy.

6. Places the client in the appropriate position.

AXILLARY TEMPERATURE

1. Removes client's arm and shoulder from sleeve of grown. Avoid exposing chest.
2. Makes sure axillary skin is dry.

3. Prepares thermometer.

4. Places thermometer or probe into center of axilla.

5. Folds client's arm across the chest.

6. Leaves thermometer until it beeps. Leaves an electronic thermometer in place until signal is heard.

7. Removes and reads thermometer, informs client’s of the temperature reading.

8. Cleans thermometer down, rinses and returns to storage.

9. Records reading and indicates site.

PR

1. Introduces self, informs client of the site/s at which to measure pulse.

2. Flexes client's elbow and places lower part of arm across chest.

3. Supports client's elbow and places lower part of arm across chest.

4. Places index and middle finger over the radial artery and palpate pulse.

5. Assesses the pulse rhythm and volume.

6. Determines pulse volume.

7. Counts pulse rate by using second hand of a watch.

8. Counts pulsations in one full minute.

9. Records the pulse in beats per minute on your worksheet.

10. Documents the pulse rate, rhythm, and volume, and actions in the client record.

RR

1. Washes hands.

2. Provides client privacy.

3. Ensures thec hest movement is visible.

4. Observes or palpates and counts therespiratory rate.

5. Counts the respiratory rate in one full minute.

6. Observes one complete respiratory cycle.

7. Observes the depth, rhythm, and character of respirations.

8. Observes the respirations for depth by watching the movement of the chest.

9. Observes the respirations for regular or irregular rhythm.

10. Observes the character of respirations, the sound theyproduce and the effort they require.

11. Washes hands.

12. Documents the respiratory rate, depth, rhythm, and character on the appropriate record.

BP

1. Introduces self, and verify the client's identity.

2. Explains why the BP is taken and what it means.

3. Performs hand hygiene.

4. Provides client privacy.

5. Places the client in sitting position unless otherwise specified.

6. Moves client's clothing away from upper aspect of arm.

7. Positions client's arm at heart level, extending elbow with palm turned upward.

8. Wraps the deflated cuff evenly around the upper arm.

9. Applies the center of the bladder directly over the artery.

10. Places the lower border of the cuff approximately 2.5 cm (1 inch) above the antecubital space.

11. Locates the brachial artery in the antecubital space with the fingertips.

12. Palpates the brachial artery with the fingertips.

13. Closes the valve on the bulb.

14. Pumps up the cuff until you no longer feel the brachial pulse.

15. Notes the pressure on the sphygmomanometer at which the pulse is no longer felt.

16. Releases the pressure completely in the cuff, and waits 1-2 minutes before taking further
measurements.

17. Positions the stethoscope appropriately.

18. Places the bell side of the amplifier of the stethoscope over the brachial pulse.

19. Places the stethoscope directly on skin, not on clothing over the brachial pulse.

20. Holds the diaphragm wih the thumb and index finger.

21. Auscultates the client's blood pressure.

22. Pumps up the cuff until the sphygmomanometer is 30 mmHg above the point where the brachial
pulse disappears.

23. Releases the valve so that the pressure decreases at the rate of 2-3 mg Hg per second.

24. Identifies the manometer reading at korotkoff phases I, IV and V as the pressure fails.

25. Deflates the cuff rapidly and completely.

26. Repeats the above steps once or twice as necessary to confirm the accuracy of reading.

27. Repeats the procedure on the client's other arm.

28. Removes the cuff.

29. Documents and report pertinent assessment data.

APICAL

1. Introduces self.

2. Performs hand hygiene.

3. Provides client privacy

4. Positions the client appropriately in a comfortable position or assists to a sitting position.

5. Exposes the area of the chest over the apexof the heart

6. Locates the apical pulse.

7. Palpates the angle of Louis, just below the suprasternal notch, which is felt as a prominence

8. Slides index finger just to the left of the client’s sternum, and palpates the second intercostals space.

9. Places middle or next finger in the third intercostal space, and continues palpating downward until
the fifth intercostal space is located.

10. Moves index finger laterally along the fifth intercostals space towards the MCL.

11. Auscultates and counts heartbeats

"12. Places the diaphragm of the stethoscope over the apical pulse, and listens for the normal S1 and S2
heart sounds."

13. Counts the heartbeats for complete 60 seconds

14. Assesses the strength (volume) of the heartbeat.

15. Records and report findings.

ORAL CARE

1. Introduces self and explain the procedure to the watcher.

2. Assembles equipment.

3. Provides privacy.

4. Puts on gloves.

5. Positions the unconscious client in a side-lying position with the head of the bed lowered.

6. Places the towel under the client's chin.

7. Places the curved basin against the client's chin and lower cheek to receive the fluid from the mouth.

8. Brushes the teeth carefully and avoid injuring the gums.

9. Rinses the client's mouth drawing about 10 ml of water or alcohol-free mouthwash into the syringe
and injecting it gently into each side of the mouth.

10. Makes sure that all the rinsing solution has run out from the mouth into the basin.

11. Repeats rinsing until mouth is free of dentrifice used.

12. Cleans mouth tissues with foam swabs or gauze and cleaning solution on one cheek if they appear
dry and unclean.

13. Does the same on the other area.

14. Discards the swab / tongue blades in the waste container.

15. Rinses the client's mouth.

16. Removes the basin, and dry around the client's mouth with the towel.

17. Replaces artificial dentures, if indicated.

18. Lubricates the client's lips with lip moisturizer.

19. Removes and discard gloves.

BEAD BATH

1. Introduce self.

2. Explains procedure to the patient.

3. Assembles equipment.

4. Performs hand hygiene.

5. Provides client privacy.

6. Offers a client bedpan or urinal.

7. Lowers the side rail on the side close to you.

8. Keeps the other side rail up.

9. Assists the client to move near you.

10. Places a bath blanket over the top sheet.

11. Removes the top sheet.

12. Loosens and removes gown.

13. Makes bath mitt with wascloth.

•triangular

•rectangular

14. Washes the face then dry

15. Washes the neck then dry.

16. Washes the arms and hands then dry.

17. Washes the chest and abdomen then dry.

18. Washes the legs and feet then dry.

19. Wsahes the back then the perineum (can do back massage).

20. Assists the client with grooming aids.

21. Assists the client to put on a clean gown/pajamas.

22. Performs after care.

23. Documents the procedure.