Professional Documents
Culture Documents
Performance Manual On Nursing Procedures
Performance Manual On Nursing Procedures
Performance Manual On Nursing Procedures
MANULA ON
NURSING
PROCEDURES
CHAPTER 1
ASEPSIS
HANDWASHING
DONNING A CAP AND A MASK
SURGICAL SCRUB
GLOVING
CLOSE GOWNING AND GLOVING
HANDWASHING
PERFORMANCE POINTS
1. Assess hands for cuts and breaks contaminated in the skin and areas that are heavily.
2. Remove jewelries and wristwatch,
3. Do not touch any part of the skin.
4. Open the faucet and adjust the flow of water.
5. Wet hands and lower forearm under running water. Keep hands downward in position.
6. Get the soap and lather thoroughly.
7. While holding the soap with one hand, use your other hand in rubbing all areas of your
hand. Do the same with other hand.
8. Rinse the soap and return it on the soap dish without touching any part of the skin.
9. With hands in downward position, rinse starting from the water to fingers.
10. Get paper towel/towel and dry your hands starting from the fingers to forearms.
11. Close the faucet using the paper towel.
12. Discard the paper towel.
DONNING A CAP AND A MASK
PERFORMANCE POINTS
PERFORMACE POINTS
PERFORAMANCE POINTS
PERFORMANCE POINTS
PERFORMANCE POINTS
1. Prepare equipment’s such as oral glasses thermometer, cotton balls (with and without
alcohol), and wristwatch with secondhand.
2. Wash hands before starting the procedures.
3. Identify the patient and explain the procedure.
4. Provide privacy.
5. Place client in appropriate position.
6. Obtain oral thermometer form the container.
7. Wipe the thermometer with cotton ball with alcohol from the bulb to the stem. Dry it with
dry cotton ball in the same manner.
8. Check level of mercury and shake down 35.5 C (96 F).
9. Using snapping wrist action, instruct patient to open his mouth and raise the tongue.
10. Place in thermometer client’s mouth under the tongue and along the gum line with the tip
end exposed. Instruct client to hold lips closed.
11. Leave the thermometer in place for 5-10 minutes. (While waiting the nurse may count
the client’s radial pulse and respiration).
ASSESSING RADIAL PULSE
12. While taking the client’s temperature. Begin to assess his radial rate.
13. Position client’s arm comfortably by resting on either his lap, table, in bed.
14. Support client’s wrist by grasping outer aspect with thumb. Place index and middle finger
over the client’s artery and palpate pulse.
15. Count pulse to one full minute using wristwatch with second hand.
16. Assess rhythm, volume of pulse.
ASSESSING RESPIRATION
17. After taking the pulse rate, do not remove fingers from the wrist. Observe the chest
movement while supposedly taking the radial pulse.
18. Count the respiratory rate for one full minute. An inhalation and exhalation in count as
one respiration. This is observed with the rise and fall of the chest wall.
19. Observe the depth, rhythm, and character of respirations.
20. Remove thermometer from the client’s mouth. Wipe it dry cotton ball from the stem to
bulb.
21. Read at eye level rotating slowly until mercury level in visualized.
22. Shale thermometer down to 35.5 C (95 F).
23. Wash thermometer with soap and water. Return thermometer to proper container.
24. Wash hands.
25. Document reading of body temperature, pulse and respiration. Record pertinent data.
ADMINISTERING PULSE OXIMETRY
PERFORMAMCE POINTS
1. Assess baseline data: vital signs, nail bed, and skin color and tissue perfusion.
2. Check oximeter equipment if functioning properly.
3. Identify the client and explain the procedure.
4. Choose sensor appropriate for client’s weight, size desired location.
5. Wash hands.
6. Select an appropriate site for the sensor.
7. Clean the site with an alcohol wipe or soap and water.
8. Apply the sensor.
9. Connect the sensor to the oximeter with sensor cable. Turn on the machine.
10. Set and turn on the machine.
11. Inspect and/or move or change the location of an adhesive toe or finger sensor every 4
hours and a spring tension sensor every 2 hours to provide client’s safety.
12. Immobilize the client’s monitoring site to ensure accuracy of measurement.
13. Document and notify physician of abnormal.
TAKING BLOOD PRESSURE
PERFORMANCE POINTS
PERFORMANCE POINTS
PERFORMANCE POINTS
PERFORMANCE POINTS
1. Wash hands
2. Greet an identify client. Explain the procedure.
3. Provide privacy.
4. Position client appropriately
5. Palpate
a. Skull. Inspect for size, shape and symmetry.
b. Scalp. Inspect for dandruff, lesions, and masses.
c. Hair. Inspect color, distribution and nits or pediculosis.
d. Face. Note symmetry of facial movements. Assess function of the facial nerve. Ask
the client to smile, frown, elevate, and lower eyebrows, close eyes tightly, puff the
cheeks and show the teeth.
6. Palpation.
a. Skull. Palpate for nodule or masses and depression.
b. Hair. Notice the texture.
c. Face. Palpate the temporomandibular joint for pain and tenderness.
7. Position client comfortably after the assessment.
8. Inform client of finding as necessary.
9. Wash hands.
10. Document findings and report significant deviation from normal to the physician.
PHYSICAL ASSESSMENT 4: ASSESING THE EYES, NOSE, MOUTH AND THROAT
PERFORMANCE POINTS
1. Preparer equipments:
a. Eyes. Penlight, opthalmoscope, Snellen chart.
b. Ears, otoscope, tuning fork.
c. Nose. Nasal speculum.
d. Mouth. Tongue depressor.
e. Others,
2. Greet and identify the patient. Explain the procedure.
3. Wash hands and wear gloves.
4. Provide privacy and position client appropriately and comfortably.
EYES
5. Inquire client’s history of eye disease, injury or surgery; family history of diabetes;
current symptoms of eye problems; and use of eyeglasses, contact lenses or
medication.
6. Inspection.
a. Palpebral fissures. Assess symmetry and width.
b. Lid margins. Observe for scaling, secretions, erythema and position of
eyelashes.
c. Conjunctivae. Inspect for congestion and color.
d. Sclerae and irises. Observe color.
e. Pupils, observe the size, shape symmetry, and reaction to light and
accommodation.
f. Muscles and nerves. Assess the six ocular movements.
g. Inner eye. Perform fundoscopic examination with the use of an opthalmoscope
and locate the red reflex. Check the transparency of the anterior and posterior
chambers, cornea and lens. Examine the retina optic disc, macula and blood
vessels.
7. Palpation.
a. Upper lids. Evaluate strength by attempting to open the client’s closed lid against
her resistance.
b. Eyeballs. Assess tenderness and tension.
8. Vision testing.
a. Test visual acuity with Snellen chart. Test a client wearing corrective lenses with
and without lenses.
b. Test visual peripheral fields using the cover and uncover test and note
nystagmus or convergence.
c. Perform functional vision test using light perception hand movement (HM) and
counting finger (CF)
EARS
9. Inquire client’s family history of hearing problems of loss; presence of any ear
problems; medication history and signs and symptoms of ear problems.
10. Inspection.
a. Auricles. Inspect, color, symmetry of size and position.
b. External ear canal. Inspect for discharges, impact cerumen and inflammation
using an otoscope.
c. Tympanic membrane. Inspect for color and gloss.
11. Palpation. Examine the pinna for tenderness, consistency of cartilage, swelling and
pain.
12. Assess gross hearing acuity test.
a. Assess client’s response to normal voice tones.
b. Perform the watch tick test.
c. Perform weber’s test to assess bone conduction.
d. Conduct the rinne test to compare air conduction to bone conduction.
NOSE AND SINUSES
13. Inquire client’s history of allergies and difficulty breathing through the nose, sinus
infections, injuries to nose or face, nose bleeds; any medication taken; any changes
in sense of smell.
14. Palpation.
a. External nose. Inspect for any deviations in shape, size or color and flaring or
discharges from the nares.
b. Nasal passageway. Assess interior structure using nasal speculum. Note nasal
septum for position. Bleeding or perforation; mucous membranes for hydration
and color and nasal turbinates for color and swelling.
15. Palpation.
a. External nose. Determine any areas of tenderness, masses and displacement of
bone and cartilage.
b. Sinuses. Palpate the maxillary and frontal sinuses and tenderness.
MOUTH AND OROPARYNX
16. Inquire of client’s history of mouth, gums and dental problems.
17. Inspection.
a. Lips. Observe color, moisture and pigmentation, masses, ulceration and fissures.
b. Teeth. Note the number, arrangement and general condition.
c. Gingivae. Asses for color, vesicles, ulcerations and masses.
d. Buccal mucosa. Assess for color, ulcerations, masses and vesicles.
e. Pharynx. Note inflammation, exudates and masses.
f. Tongue.
Assess postion, color and
Assess function of the glossopharyngeal nerve.
Assess function of the hypoglossal nerve.
g. Salivary glands, inspect the hard and soft palate for color, shape, texture and the
presence of bony prominences,
h. Palates. Inspect the hard and soft palate for color, shape, texture and the
presence of bony prominences.
i. Uvula. Inspect for position and mobility while examining the palate. Ask the client
say “ah” so that the soft palate rises.
j. Oropharynx. Inspect for color and texture using a tongue depressor. Use a
penlight for illumination.
k. Tonsils. Inspect for color, discharge and size.
18. Palpation.
a. Cervical nodes and salivary glands. Palpate for enlargement ad tenderness.
b. Trachea. Note deviation for midline.
c. Thyroid. Palpate for nodules, masses or irregularities.
d. Carotid arteries. Note amplitude and asymmetry of pulsations.
19. Auscultations. Listen for bruits over carotid arteries.
NECK
20. Inquire client’s history of any problems with neck lumps, neck pain or stiffness, any
previous diagnosis of thyroid problems and any other treatment provided.
21. Inspection.
a. Neck muscles (sternocleidomastoid and trapezius). Inspect for abnormal
swellings or masses. Assess muscle symmetry. Assess range of motion and
strength.
b. Thyroid glands. Inspect for symmetry and visible masses. Ask client hyperextend
the head and swallow. Observe movement of the thyroid and cricoid cartilage as
client swallow and note if swallowing causes as bulging of the gland.
c. Jugular veins. Note distention.
22. Palpation.
a. Lymph nodes. Palpate for tenderness and swelling
b. Trachea palpate for lateral deviation.
c. Thyroid gland. Palpate for smoothness, enlargement, masses or nodules.
23. Position client comfortably in bed.
24. Inform client of finding as necessary.
25. Wash hands.
26. Document findings and report significant deviations from normal to the physician.
PHYSICAL ASSESSMENT 5: ASSESSING THR ABDOMEN
PERFORMANCE POINTS
1. Prepare equipment, examine light, tape measure, water-soluble skin-marking pencil and
stethoscope.
2. Wash hands.
3. Greet and identify patient. Explain the procedure.
4. Provide for client procedure.
5. Inquire client’s history of bowel habits, change in appetite, specific abdominal signs and
symptoms, hematemesis, previous and current problems and treatment.
6. Position client in supine position with the arms placed comfortably at the sides. Place
small pillows beneath the knees and the head to reduce tension in the abdomen from
chest line to the public area.
7. Inspection.
a. Observe for contour and symmetry, if distention is present, measure the abdominal
girth with a tape measure.
b. Observe abdominal movements associated with respiration, peristalsis or aortic
pulsation.
c. Observe for scars, striae, rashes and lesions
8. Auscultation. Auscultate the abdomen before percussing and palpating to avoid
stimulating intestinal activity and altering bowel sounds.
a. In all quadrants, listen for active bowel sounds irregular gurgling noises occurring
about every 5-20 seconds. Note frequency, pitch and duration of sounds.
b. Auscultate for bruits over the abdominal aorta and the renal, iliac, and femoral
arteries.
9. Percussion.
a. Percuss all quadrants. Notes of areas tympany or dullness. Use a symmetric pattern.
Begin in the lower left quadrants, proceed to the lower right quadrant, the upper right
quadrant and upper left quadrant.
b. Percuss liver size starting in the right midclavicular line below the level of the
umbilicus and moving upward and downward to locate the liver border.
c. Strike at the costovertebral angles, noting tenderness or pain.
10. Palpation.
a. Abdomen. Palpate in all quadrant and follow with deep palpation. Assess organ
location and abdominal muscle tone. Note unusual masses, pulsations, tenderness
or pain.
b. Kidney. Palpate kidney bimanually slightly below umbilicus. Note size, shape and
tenderness.
c. Abdominal aorta. Palpate contour and pulsations.
d. Lymph nodes. Palpate inguinal and femoral areas bilaterally. Note enlargement.
11. Position client comfortably in bed after assessment.
12. Inform client findings as necessary.
13. Wash hands.
14. Document findings and report significant deviations from normal to the physicians.
PHYSICAL ASSESSMENT 6: ASSESSING THE MUSCULOSKELETAL MUSCLE
PERFORMANCE POINTS
1. Wash hands.
2. Greet and identify client. Explain procedures.
3. Provide for client privacy.
4. Position client appropriately.
5. Inquire client’s history of presence of muscle pain and associated signs and symptoms,
limitations to movement, loss of funetion, or previous and current problems involving
musculoskeletal system.
6. Inspection.
a. Observe the client’s able to perform functional task of daily living. (e.g. performing
personal hygiene, rising from sitting and standing, walking up and down stairs,
walking on a level surface). Note an pain the client experiences while performing
functions are being examined.
b. Extremities. Examine arms and legs. Note the size symmetry, muscle mass and
deformities.
c. Spine. Assess for range of motion (i.e. flexion, extension, lateral flexion and rotation)
and lateral or anteroposterior curvature.
d. Joints. Assess all major points, noting any limitations to active range motion, sweliing
or redness.
Neck. Assess flexion, lateral extension and lateral rotation.
Shoulders. Assess flexion, extension and rotation.
Elbows. Assess flexion, extension, supination, and pronation.
Wrists. Assess flexion, extension ulnar and radial deviation.
Fingers. Assess flexion, extension abduction and adduction.
Hips. Assess flexion, extension and rotation.
Knees. Assess flexion, extension.
Ankles. Assess dorsiflexion, plantar flexion, inversion and eversion.
Toes. Assess flexion, extension, abduction and adduction.
7. Palpation,
a. Joints of the neck and upper and lower extremities. Palpating while noting
tenderness, swelling, temperature, limitations to passive range of motion and
crepitation.
b. Muscle. Palpate to assess size, tone and any tenderness.
c. Spine. Palpate noting any deformities and crepitation.
8. Percussion.
Directly percuss the spine from the cervical to lumber region, using the ulnar surface of
the list. Note any pain or tenderness.
9. Position client comfortably after the assessment.
10. Inform client findings as necessary.
11. Wash hands.
12. Document findings and report significant deviation from normal to the physician.
PHYSICAL ASSESSMENT 7: ASSESS THE NEUROLOGICAL SYSTEM
PERFORMANCE POINTS
1. Prepare equipment: percussion hammer, tongue depressor, wisps of cotton, test tubes
of hot and cold water.
2. Wash hands.
3. Greet and identify client. Explain procedure.
4. Provide for client privacy.
5. Position client appropriately.
6. Note the components of the neurological examination.
a. Mental status.
b. Cranial nerve function
c. Cerebellar function
d. Motor function
e. Sensory function
f. Reflexes
7. Assess mental status. During history taking, determine the following:
a. State consciousness. Note whether the client is alert, somnolent, stuporous or
comatose.
b. Orientation to person, place and time.
c. Memory, including immediate, recent and remote.
d. Cognition, including calculations, current events and response to proverbs.
e. Judgement and problem solving ability.
f. Emotion, including mood, affect and congruence response.
8. Assess cranial nerve (CN) functions.
a. Olfactory nerve (CNI). With the client’s eye close, present various odors, occluding
one nostril at a time. Note client’s ability to identify odor.
b. Optic nerve (CNII). Test visual acuity and visual fields. Examine the optic disc with
an opthalmoscope.
c. Oculomotor (CNIII), trochlear (CNIV) and abducens (CNVI) nerves. Assess
extraoculomotor motion.
Evaluate the six cardinal positions of gaze. Look for parallelism and note
nystagmus (involuntary movement).
Perform the cover/uncover test note movement of eye when uncovered or
opposed eye when contralateral eye covered.
Assess corneal light reflex. Note symmetry of reflection to light of the pupil.
Check size and shape of pupils and papillary reaction to light and
accommodation.
d. Trigeminal eye (CNV)
Motor. Assess the client’s ability to chew and strength to bite.
Sensory. Assess the client’s ability to distinguish light touch and pain. Lightly
stroke client’s face with a cotton wisp, and gently prick the skin with a sterile
pin or toothpick on forehead (to assess ophthalmic branch), check (to assess
the maxillary branch), and chin (to assess the mandibular branch).
e. Facial nerve (CNVII)
Motor. Assess symmetry of facial movement as the client smiles, frown,
grimaces, clenches his teeth and so forth.
Sensory. Ask the client to identify various distinct flavors placed on the
anterior two thirds of the tongue.
f. Acoustic nerve (CN VII)
Vestibular branch. Perform the Romberg test to evaluate equilibrium. Have
the client to stand with feet together and eyes closed for 20-30seconds
without support. Note excessive swaying.
Cochlear branch. Assess client’s ability to hear spoken words and vibration of
tuning fork.
g. Glossopharyngeal nerve (CNIX)
Motor. Ask the client to move tongue from side to side and up and down. Test
for the gag reflex by gently touching the posterior pharyngeal wall with a
tongue blade.
Sensory. Apply taste on posterior tongue for identification.
h. Vagus nerve (CNX). Ask client to swallow and note swallowing and vocal cord
movement. Ask client’s speech for hoarseness.
i. Accessory nerve (CNXI). Assess strength of sternocleidomastoid and upper
trapezius muscles by asking the client to move the head against resistance of your
hand. Observe and palpate the contraction of the sternocleidomastoid muscle on the
opposite resistance of your hands.
j. Hypoglossal nerve (CNXII). Test strength and articulation of the tongue by having the
client push the tongue to the side of the mouth against resistance applied to the
check. Ask the client to stick out of the tongue and the returns it to the mouth while
you observe for deviation, asymmetry, tremors and fascicultations.
9. Cerebellar function.
a. Assess posture, gait and balance. Have the client walk forward and backward in
straight line.
b. Assess coordination in the upper extremities by having the client perform the finger
to nose test.
c. Assess coordination in the lower extremities by having the client tap the toes and
slide the heel down the contralateral skin.
10. Motor function.
a. Muscle mass. Assess symmetry and distribution distally and proximally, and
circumference of extremities.
b. Tone. Evaluate resistance of muscle in response to passive motion during flexion
and extension of extremities.
c. Strength. Assess hands and squeeze muscle strength in each extremity against
resistance during flexion and extension (abduction and adduction) comparing
bilaterally. Rate on a 5-point scale. (0-absence, 1-trace,2-poor, 3-fair/good, 5-
normal).
d. Observe for involuntary movements (tremors, tics, twitching, fasciculations), and
abnormal postures (fetal, decorticate or decerebrate).
11. Sensory function.
a. Light touch. With client’s eyes closed, have the client indicate response to cotton
wisp lightly stroked on the skin (back of hands, forearms and upper arms, torso,
thigh, tibia, and dorsal portion of foot). Compare bilaterally and distal proximal.
b. Pain. Repeat the pattern of light touch assessment, using a sterile safety pin to elicit
sharp sensation. Alternate with the pin’s rounded end for contrast.
c. Stereognosis. Ask the client to identify small objects placed in his hands, one at a
time.
d. Graphesthesia. Ask the client to identify a number that is trace in his palm with your
finger tip.
12. Deep tendon reflexes. Striking with the reflex hammer, compare reflex amplitude
bilaterally, grading on a 4-point (4+=hyperactive, 2+ or 3+= average, 1+= diminished,
0=no response).
a. Brachioradialis (C5, C6). Strike the radius tendon about 1-2 inches above the wrist.
Observe the flexion and supination of the forearm.
b. Biceps (C5, C6). Place your thumb or forefinger at the base of the base of the tendon
and strike it. Observe for flexion of the arm at the elbow.
c. Triceps (C7, C8). Strike the triceps tendon just above the elbow. Observe for slight
elbow extension.
d. Patellar quadriceps (L2, L3, L4). Sharply strike the patellar tendon. Observe the
extension of knee.
e. Achilles ankle jerk (S1, S2). Support the client’s foot in the dorsiflexed position, tap
the Achilles tendon and observe for plantar flexion.
13. Superfacial cutaneous reflexes.
a. Abdominal. Stroke the abdomen above (T8, T9, T10) and below (T10, T11, T12) the
umbilicus bilaterally. Observe for contraction of abdominal muscles and deviation of
the umbilicus toward the stimulus.
b. Cremasteric (L1, L2). In a male patient, stroke the inner surface of the thigh. Observe
for prompt elevations of the testes on the ipsilateral side.
c. Plantar/Babinski (L4, L5, S1, S2). Extend the client’s leg with the feet relaxed. Stroke
the lateral aspect of the soloed rom the heel to the ball of the foot, curving medially
across the ball. Observe for flexion of toes.
14. Pathological reflexes.
a. Brudzinski’s sign. Flex patient’s neck forward while in recumbent position. Observe
involuntary flexion of the knee and pain.
b. Kernig’s sign. Flex patient’s leg at hip and knee. Observe neck flexion and pain.
c. Ankle clonus. Support client’s knee in partly flexed position while other hands sharply
dorsiflexes the foot and maintains it in dorsiflexion.
15. Position client comfortably.
16. Inform client findings as necessary.
17. Wash hands.
18. Document findings and report significant deviation from normal to the physician.
PHYSICAL ASSESSMENT8: ASSESSING FEMALE AND MALE GENITALS AND INGUINAL
AREA
PERFORMANCE POINTS
1. Prepare equipment:
Female: gloves, drape, supplement lighting.
2. Wash hands.
3. Greet and identify client. Explain procedures.
4. Provide client privacy.
5. Position and drape client appropriately.
6. Don gloves.
FEMALE GENITALIA.
7. Inquire client’s history of menstruation, last menstrual period (LMP), regularity of cycle,
sexually transmitted disease, previous and current problems on reproduction and urinary
system.
8. Inspection and palpation. These examinations are performed almost simultaneously.
Place the client in lithotomy position and drape her properly.
a. External genitalia. Assess pubic hair distribution. Note any nits and lice. Inspect the
labia majora, mons pubis, and perineum. Note skin color integrity.
b. Internal genitalia. Separate the labia majora, and inspect clitoris, urethral meatus,
and vaginal opening. Note abnormal color, ulcerations, edema, nodules or discharge.
c. Inguinal lymph nodes. Use the pads of the finger in rotary motion, noting any
enlargement or tenderness.
MALE GENITALIA
9. Inquire client history of voiding patterns and any changes, bladder control, urinary
incontinence, frequency urgency, abdominal pain, any symptoms of sexually transmitted
disease, any swelling that could indicate presence of hernia, family history of nephritis,
malignancy of the prostate or kidney.
10. Inspection.
a. Pubic hair. Assess distribution, and not any lice or nits.
b. Penis. Retract the foreskin, if present. Note any ulcerations, masses, or scaring on
the glans of penis. Inspect the urethral meatus for locations and discharge.
c. Scrotum. Inspect posterior and anterior aspects, assessing size, contour, and
symmetry. Note ulcerations, masses, redness or swelling.
d. Inguinal area. Look for bulges with or without the client bearing down or when raising
his head of the bed.
11. Palpation.
a. Penis. Palpate the shaft for lesions, nodules or masses, if present, note tenderness,
contour, size and degree of induration.
b. Scrotum. Palpate each testes and epididymis, assessing shape, and consistency.
Note any masses or unusual tenderness. Look for any nodules or tenderness of
spermatic, cord and vas deferens.
c. Inguinal and femoral areas. Assess for hernias.
RECTUM
12. Inspection. Examine the anus and perineal and sacral regions with the client lying in the
left Sims positon and properly draped, if necessary, use an alternative position for the
examination. Male clients may stand and bend over the table: female clients may
assume the lithotomy position.
a. Spread the buttocks, and note any inflammation, nodule or scars, lesions,
ulcerations, rashes, bleeding, fissures or hemorrhoids.
b. Check for bulges when the client bears down.
13. Palpation.
a. Sphincter. Ask the client to bear down. Slowly insert your lubricant index finger of the
gloved hand through the anal sphincter. Assess sphincter tone.
b. Rectum and rectal walls. Gently rotate your index finger to palpate the rectum and
rectal walls anteriorly and posteriorly. Note any nodules, masses or tenderness.
Palpate for fecal impaction.
c. Prostate. In the male client, anteriorly palpate the two lateral lobes of the prostate
gland for irregularities, nodule, edema or tenderness.
d. Fecal material. Withdraw your finger gently. Test any fecal material on the glove for
occult blood.
14. Remove gloves.
15. Position client comfortably after the assessment.
16. Inform client findings as necessary.
17. Wash hands.
18. Document findings and report significant deviation from normal to the physician.
PHYSICAL ASSESSMENT 9: ASSESSING PERIPHERAL VSCULAR SYSTEM
PERFORMANCE POINTS
1. Wash hands.
2. Greet and identify client. Explain procedures.
3. Provide for client privacy.
4. Position client appropriately and comfortably.
5. Inquire client history of heart disorders, varicosities, arterial diseases and
hypertension; lifestyle habits such as exercise pattern, activity patterns and
tolerance, smoking and use of alcohol.
6. Inspection.
a. Peripheral views. Inspect peripheral views in the arm and the legs for the
presence of superficial veins when limbs are dependent and when limbs are
elevated.
b. Peripheral perfusion. Inspect the skin of the hands and feet for color, edema,
texture and skin changes.
7. Palpation.
a. Peripheral pulses. Palpate peripheral pulses on both sides of the client’s body
individual, simultaneously and systematically to determine the symmetry of pulse
volume and pulsations.
b. Peripheral veins. Assess peripheral leg veins for sign for phlebitis. Note
tenderness on palpation and pain on calf muscles with forceful dorsiflexion of
both foot. ( (+) homan’s sign) and warmth to touch.
c. Peripheral perfusion. Assess for adequacy of arterial blood flow.
Buerger’s test (arterial adequacy test). Ask the client to raise one leg or
one arm at about 30cm. (1feet) above heart level move the foot or hand
briskly up and down for about 1 minute and then sit up and dangle the leg
or arm. Original color returns in 10 seconds; veins in feet and hands fill in
about 115 seconds.
Capillary feet refill test. Squeeze client’s fingernail and toenail between
your fingers sufficiently to cause blanching. Note immediate return of
color.
8. Positon client comfortably after the assessment.
9. Inform client findings as necessary.
10. Wash hands.
11. Document findings and report significant deviation from normal to the physician.
PHYSICAL ASSESSMENT 10: ASSESSING THORAX, HEART, BREAST AND AXILLAE
PERFORMANCE POINTS
PERFORMANCE POINTS
PERFORMANCE POINTS
1. Determine the contents of the vial for the correct medication and dosage.
2. Assess for the integrity of the vial and its content.
3. Perform handwashing technique.
4. Verify doctor’s orders and check against the vial prepared.
5. Check for medication route and select the needle and syringe size appropriate for
the technique.
6. Withdraw the plunger to the desire volume of medication.
7. Clear the rubber top of the vial with an alcohol pad or cotton ball.
8. Remove needle cap. Maintain sterility of the needle.
9. Lay the needle cap on a clear surface or on the hypotray.
10. Place the needle in the center of the vial and inject the air slowly.
11. Invert vial and withdraw the desired volume of medication.
12. One again check for the appropriate dose of the drug to be administered.
13. Slowly draw the needle form the vial.
14. Recap needle and replace it with a new needle for injection.
15. Label the syringe with the drug, dose, date, and time.
16. Store medication properly until it is ready to be administered to the client.
WITHDRAWING MEDICATIONS FROM VIAL
PERFORMANCE POINTS
1. Determine the contents of the vial for the correct medication and dosage.
2. Assess for the integrity of the vial and its content.
3. Perform handwashing technique.
4. Verify doctor’s orders and check against the vial prepared.
5. Check for medication route and select the needle and syringe size appropriate for
the technique.
6. Withdraw the plunger to the desire volume of medication.
7. Clear the rubber top of the vial with an alcohol pad or cotton ball.
8. Remove needle cap. Maintain sterility of the needle.
9. Lay the needle cap on a clear surface or on the hypotray.
10. Place the needle in the center of the vial and inject the air slowly.
11. Invert vial and withdraw the desired volume of medication.
12. One again check for the appropriate dose of the drug to be administered.
13. Slowly draw the needle form the vial.
14. Recap needle and replace it with a new needle for injection.
15. Label the syringe with the drug, dose, date, and time.
16. Store medication properly until it is ready to be administered to the client.
ADMISITERING AN INTRADERMAL INJECTION
PERFORMANCE POINTS
1. Verify doctor’s order for the medication and prepare materials and solution for injection
and applies and sterile technique during in the entire procedure.
2. Identifies the patient and explain the procedure, read the medicine card.
3. Allay any tears/anxiety client may have.
4. Place the patient in comfortable and right position.
5. Identifies the anatomical landmarks by palpation and inspection and identifies injections
site correctly.
6. Cleans the injection site with cotton ball with alcohol using circular motion working from
the site of injection outward.
7. Uses free hand of stretch skin.
8. Insert needle, level up 10-15 degree angle just under the skin.
9. Releases the skin, anchors the barrel and injects the medication slowly until wheal is
formed.
10. At the same angle, withdraws the needle.
11. Wipes with dry cotton ball excess medication from skin without pressing the wheal.
12. Encircles the site of the wheal with blue or black ball pen and mark the due date and
time.
13. Does not recap the needle and make the patient comfortable.
14. Explains the patient the possible outcomes.
15. Dispose the needle and syringe properly.
16. Performs proper and correct documentation of the procedure (verbalize the written
documentation.
ADMINISTERING A SUBCUTANEOUS INJECTION
PERFORMACE POINTS
PERFORMANCE POINTS
1. Verify doctor’s order for the medication and prepare materials and solution for injection
and applies and sterile technique during in the entire procedure.
2. Identifies the patient and explain the procedure, read the medicine card.
3. Place pt in a comfortable position.
4. Identifies the anatomical landmarks by palpation and inspection and identifies injection
site correctly.
5. Cleans the injection site with alcohol using circular motion working from the site of
injection outward.
6. Place the cotton ball with alcohol in between fingers, removes cap of needle and
maintains sterility of the needle.
7. While maintaining sterility of the needle, taut skin if injection site and thrust the needle
into the muscle at 90 angles.
8. Checks for presence of blood by pulling the plunger backward and verbalizes what to do
in case of blood is aspirated.
9. If blood is not present, inject the solution.
10. Removes the needle smoothly and quickly 90 angles.
11. Applies the gentle pressure against injection site using a swab.
12. Does not recap the needle and position the pt comfortably. Dispose the needle and
syringe properly.
13. Position the pt properly.
14. Performs proper correct documentation of the procedure done.
ADMINISTERING AN INTRAMASCULAR INJECTION (DORSO-GLUTEAL)
PERFORMANCE POINTS
1. Verify doctor’s order for the medication and prepare materials and solution for injection
and applies and sterile technique during in the entire procedure.
2. Identifies the patient and explain the procedure, read the medicine card.
3. Place pt in a comfortable position.
4. Identifies the anatomical landmarks by palpation and inspection and identifies injection
site correctly.
5. Cleans the injection site with alcohol using circular motion working from the site of
injection outward.
6. Place the cotton ball with alcohol in between fingers, removes cap of needle and
maintains sterility of the needle.
7. While maintaining sterility of the needle, taut skin if injection site and thrust the needle
into the muscle at 90 angles.
8. Checks for presence of blood by pulling the plunger backward and verbalizes what to do
in case of blood is aspirated.
9. If blood is not present, inject the solution.
10. Removes the needle smoothly and quickly 90 angles.
11. Applies the gentle pressure against injection site using a swab.
12. Does not recap the needle and position the pt comfortably. Dispose the needle and
syringe properly.
13. Position the pt properly.
14. Performs proper correct documentation of the procedure done.
ADMINISTERING MEDICATIONS VIA PIGGYBACK
PERFOMACE POINTS
PERFORMANCE POINTS
PERFORMANCE POINTS
PERFORMANCE POINTS
PERFORMANCE POINTS
PERFORMANCE POINTS
APPLYING RETRAINTS
BATHING A CLIENT IN BED
SHAMPOING A CLEINT IN BED
MAKING UNOCCUPIED BED
MAKING AN OCCUPIED BED
PROVIDING PERINEAL AND GENITAL CARE
BACK RUB
APPLYING RESTRAINTS
PERFORMNACE POINTS
PERFORMANCE POINTS
PERFORMANCE POINTS
PERFORMANCE POINTS
PERFORMANCE POINTS
PERFORMANCE POINTS
PERFORMANCE POINTS
PERFORMANCE POINTS
PERFORMANCE POINTS
PERFORMANCE POINTS
PERFORMANCE POINTS
1. Verify the order indicating the type of solution, the amount to be given, rate of flow of the
infusion and any client allergies (e.g. to tape).
2. Prepare equipment (infusion set, IVF, IV pole, adhesive tape, etc.)
3. Identify client and explain procedure.
4. Wash hands.
5. Open and prepare the infusion set.
6. Remove the tubing from the container, and straighten it out.
7. Slide the tubing clamp along the tubing untie it is just below the drip chamber to facilitate
its access.
8. Close the clamp.
9. Leave the ends of tubing covered with plastic caps until the infusion started.
10. Spike the solution container.
11. Remove the protective cover from the entry site of the bag.
12. Remove the cap from the spike, and insert the spike into the insertion site of the bag or
bottle.
13. Hang the solution container on the pole.
14. Adjust the pole so that the container is suspended about 1m (3ft) above client’s head.
15. Partially fill the drip chamber with solution.
16. Squeeze the chamber gently until it is half full of solution.
17. Prime the tubing.
18. Remove the protective cap, and hold the tubing over a container. Maintain the sterility of
the end of the tubing and cap.
19. Release the protective cap, and hold the tubing over a container. Maintain the sterility of
the end of the tubing and cap.
20. Release the clamp, and let the fluid run through the tubing until all bubbles are removed.
Tap the tubing if necessary with your fingers to help the bubbles move.
21. Wash hands.
22. Document procedure.
MONITORING AN INTRAVENOUS INFUSION
PERFORMANCE POINTS
PERFORMANCE POINTS
1. Check the order for the medication, dosage, time and route of administration.
2. Review information regarding the drug.
3. Determine the additives in the solution of an existing IV line.
4. Assess the patency of the IV.
5. Assess the skin of the IV site.
6. Assess the client’s drug allergy history.
7. Assess the client’s understanding of the purpose of the medication.
8. Check order for the IV solution additives ordered.
9. Determine the whether the ordered additives are compatible with the IV solution and with
each other.
10. Wash hands; apply gloves, if needed.
11. Using appropriate technique, draw up ordered additives.
ADDING MEDICATION TO A NEW SOLUTION.
12. Remove protective cover form new bag or bottle.
13. Inspect the bag or bottle. Inspect the fluid. Check expiration date.
14. Add medication to IV solution.
For plastic IV bag, locate port with rubber topper.
For IV bottle, locate the x, circle, or triangle over ht IV injection site.
Wipe off port or site antiseptic swab.
Insert needle into center of port or site.
Inject medication into bag.
Remove needle from bag.
15. Mix medication into IV solution.
16. Label the bag.
Write the name and dose of medication, date, time, and your initials.
Apply to bag outside down.
ADDING MEDICATION TO AN EXISTING SOLUTION
17. Identify client by using armband and calling name.
18. Explain the purpose and route of the medication.
19. Clamp the IV tubing and remove bag from IV pole.
20. Add medication to IV solution.
For plastic IV bag, locate port with rubber stopper.
For IV bottle, locate the x, circle or triangle over the IV injection site.
Wipe off port or site with antiseptic swab.
Insert the needle into center of port or site.
Inject medication into bag.
Remove needle from bag.
21. Mix medication into IV solution.
22. Apply new label.
Write the name and dose of medication, date, time, and your initials.
Apply to bag upside down.
23. Unclamp the tubing and regulate the flow.
24. Remove gloves and dispose of all used materials.
25. Wash hands.
26. Document the preparation of the IV solution.
ADMINISTERING BLOOD TRANSFUSION
PERFORMANCE POINTS
NUTRITION
PERFORMANCE POINTS
PERFORMANCE POINTS
PERFORMANCE POINTS
PERFORMANCE POINTS
PERFORMANCE POINTS
PERFORMANCE POINTS
PERFORMANCE POINTS
PERFORMANCE POINTS
1. Gather supplies.
2. Provide privacy.
3. Greet and identify patient.
4. Explain procedure to client.
5. Wash hands.
6. Apply clean exam gloves.
7. Remove dressing and place in appropriate receptacle.
8. Observe the undressed wound.
9. Cleanse around the incision with warm, wet washcloth.
●Cleanse the suture line with prescribe solution.
●Used application should not be reintroduce into the sterile solution.
10. Remove used exam gloves.
11. Wash hands.
12. Set up supplies.
13. Apply a new pair of clean exam gloves.
14. Grasping just the edge, apply a new gauze dressing. Tape lightly.
15. Remove gloves and wash hands.
16. Conduct client/family education about the dressing.
17. Document the procedure.
APPLYING A WET TO DAMP DRESSING (WET TO DRY TO MOIST DRESSING)
PERFORMANCE POINTS
PERFORMANCE POINTS
PERFOMANCE POINTS
PERFORMANCE POINTS
PERFROMANCE POINTS
a. Assess the patient’s need for catheterization and refer patient to the doctor.
b. Verify doctor’s order for catheterization.
c. Prepare the necessary materials.
d. Perform hand washing.
1. Identifies patient and explains the procedure.
2. Positions the patient properly and ensures patient’s privacy.
3. Applies aseptic technique in the entire procedure.
4. Open catheterization kit.
5. Adds and prepares materials that will be used.
6. Dons first glove and fills the syringe with distilled water.
7. Dons the second glove and applies sterile drapes to the patient.
8. With non-dominant hand, separates the labia minor what the thumb and index finger.
Never removes the finger until catheter is inserted.
9. With the dominant hand, uses sterile forcep to pick swabs. Clean first from the meatus
downward and then on either side using a new swab for each stroke.
10. Picks up the catheter in the urine receptacle using the uncontaminated hand.
11. Lubricates the insertion end or tip of the catheter.
12. Gently insert the catheter in the direction of the urethra until urine flows.
13. Connects to the catheter to the urine bag and ensures that the emptying base of the bag
is closed.
14. Inflates the balloon by inject 5-10cc of distilled water and checks the anchor.
15. Tapes the catheter with non-allergic tape at the thigh of the patient.
16. Remove drapes and makes the patient comfortable.
17. Disposes soiled materials properly.
18. Accurately records the procedure done.
MALE CATHETERIZATION
PERFORMANCE POINTS
a. Assess the patient’s need for catheterization and refer patient to the doctor.
b. Verify doctor’s order for catheterization.
c. Prepare the necessary materials.
d. Perform hand washing.
1. Identifies patient and explains the procedure.
2. Positions the patient properly and ensures patient’s privacy.
3. Applies aseptic technique in the entire procedure.
4. Open catheterization kit.
5. Adds and prepares materials that will be used.
6. Dons first glove and fills the syringe with distilled water.
7. Dons the second glove and applies sterile drapes to the patient.
8. Grabs the penis firmly behind the glans with the non-dominant hand and retracts the
foreskin of the uncircumcised male
9. With the dominant hand, uses sterile forcep to pick swabs. Clean first from the meatus
downward and then on either side using a new swab for each stroke.
10. Picks up the catheter in the urine receptacle using the uncontaminated hand.
11. Lubricates the insertion end or tip of the catheter.
12. Lifts the penis to a position at 90 degree angle and inserts the catheter until urine flows.
13. Inflates the balloon by inject 5-10cc of distilled water and checks the anchor.
14. Connects to the catheter to the urine bag and ensures that the emptying base of the
bag is closed.
15. Tapes the catheter with non-allergic tape at the thigh of the patient.
16. Remove drapes and makes the patient comfortable.
17. Disposes soiled materials properly.
18. Accurately records the procedure done.
CLOSED BLADDER IRRIGATION
PERFORMANCE POINTS
PERFORMANCE POINTS
PERFORMANCE POINTS
MOBILITY
PERFORMANCE POINTS
PERFORMANCE POINTS
PERFORMANCE POINTS
PERFORMANCE POINTS
1. Wash hands.
2. Identifies the patient and explains the procedure.
3. Lowers bed to level of wheelchair seat.
4. Position wheelchair next to bed.
5. Make sure wheelchair and be wheels are locked.
6. Raise footrest pedals and leg supports.
7. Assist patient to sitting positon in bed.
8. Assists patient with robe and slippers.
9. Assist patient into chair.
10. Places patient’s feet and legs on support.
11. Uses good body mechanics throughout.
12. Washes hands.
13. Document procedure.
HIMPLEGIC TRANSFER TO WHEELCHAIR
PERFORMANCE POINTS
1. Wash hands.
2. Identifies the patient and explains the procedure.
3. Lowers bed to level of wheelchair and makes sure that bed wheels are locked.
4. Positions and prepares wheelchair. Place chair on the patient’s unaffected side, with
wheels locked, and food and leg supports raised.
5. Assists patient to side of bed.
6. Assist patient to sitting positon.
7. Helps patient with robe and slippers.
8. Block’s patient affected leg with own knee.
9. Raise patient to feet.
10. Pivots patient on affected side.
11. Lowers patient into chair.
12. Uses good body mechanics throughout.
13. Aligns patient and makes him comfortable.
14. Washes hands.
15. Documents the procedure.
LIFT SHEET TRANSFER TO WHEELCHAIR
PEROFRMANCE POINTS
1. Wash hands.
2. Identifies the patient and explains the procedure.
3. Folds lift sheet and positons it properly.
4. Positions bed and stretcher correctly, with all wheels locked.
5. Coordinates own and assistant’s movements to move patient to edge of bed..
6. Coordinates own and assistant’s movements to move patient onto stretcher.
7. Uses good body mechanics throughout.
8. Covers patient.
9. Raise and rinse or fastens safety belt.
10. Washes hands.
11. Documents the procedure.
ADMIINISTERING PASSIVE RANGE OF MOTION (ROM) EXERCISES
PERFORMANCE POINTS
14. ARM
Flexion and extension. Extend a straight arm upward toward the head, the downward
along the side.
Adduction and abduction. Extend a straight arm toward the midline away from the
midline.
SHOULDER
15. Internal and external rotation. Ben the elbow at a 90 angle with upper arm parallel to the
shoulder. Move the lower arm upward and downward.
16. ELBOW
Flexion and extension. Supporting the arm, flex and extend the elbow.
Pronationand supination. Flex elbow, move the hand in a palm up and palm
down position.
17. WRIST
Flexion and extension: supporting the wrist, flex and extend the wrist.
Adduction and abduction: supporting the lower arm, turn wrist right to left, left to
right, then rotate the wrist in a circulation motion.
18. HAND
Flexion and extension. Support the wrist, flex and extend the fingers.
Adduction and abduction. Support wrist, spread fingers apart and then bring
them close together.
Opposition: supporting the wrist, touch each finger with the tip of the thumb.
Thumb rotation: support the wrist, rotate the thumb in a circular motion.
HIP AND LEG
19. With client in supine position, if possible.
Flexion and extension: support the lower leg. Flex leg toward the chest and
extend the leg.
Internal and external rotation. Support the lower leg, angle the foot inward and
outward.
Adduction and abduction. Slide the leg away from the client’s midline and then
back to the midline.
20. KNEE
Flexion and extension: support the lower leg, flex and extend the knee.
21. ANKLE
Flexion and extension: support the lower leg, flex and extend the ankle.
22. FOOT
Adduction and abduction: support the ankle, spread the toes apart then bring
them close together.
Flexion and extension. Support the ankle, extend the toes upward and then flex
the toes downward.
23. Observe client for signs of exertion, pain or fatigue.
24. Replace covers and position client in proper body alignment.
25. Place side rails in original position.
26. Wash hands.
27. Document the procedure.
LOG ROLLING A CLIENT
PERFORMANCE POINTS
PERFORAMNCE POINTS
PERFORMANCE POINTS
PERFORMANCE POINTS
1. Preparatory phase
a. Define traction
b. Enumerate
1. Indication for traction
2. Principle for traction
3. [arts of the orthopedic bed
c. Check for doctor’s order.
2. Psychological preparation
a. Speaks clearly on a pleasant tone of voice
b. Facial expression indicates interests and understanding.
Guide conversation so that the patient is allowed to express his wishes and inner
feelings.
Explain and discusses procedures with patients or relatives.
3. Actual application
a. Attach pearson attachment in Thomas splint observing the proper alignment (screw
of Pearson attachment should be in line with the knee of the patient)
b. Tie one end of the thigh rope at the medical junction of the Thomas splint; the mount
rest splint to Thomas splint and Pearson attachment.
c. Applying slings observing the principles:
1. Apply from medical to lateral upright of Thomas splint and Pearson attachment.
2. Smooth surface should get contact with the skin of the patient.
3. Apply snugly, not too tight nor too loose.
4. Provide space 1-1 ½ inch between slings.
5. Popliteal area and ankle should be free form slings.
6. If the slings is too long, fanfold it.
d. Transfer affected leg to prepare Thomas splint ad Pearson attachment.
1. Inform patient to hold on the overhead trapeze. Flex the unaffected leg and at the
count of three lift the buttocks.
2. Nurse A should apply manual traction
3. Nurse B should support the affected led and do alignment of the deformity by:
Placing the 1st pulley, in line with groin of the patient.
Placing the 2nd pulley, in line with the knee of the patient.
Placing the 3rd pulley, in line with 2nd and 3rd pulley.
4. Nurse B will lift the affected leg.
5. Nurse C should apply the prepared Thomas splint and Pearson attachment.
6. Nurse D should remove the Braun boiler splint.
e. Apply traction weight by trying one end of the traction rope to the Steinman holder
pass one end of the traction rope to third puller and pass to the traction bag making
a square knot.
f. Tie the other end of the thigh rope to attach the suspension rope at the middle of the
thigh rope and pass the other end to the first pulley; then pass the suspension bag
(hang suspension bag temporarily in the clamp); tie at the Thomas splint and
Pearson attachment making clove-hitch knot.
g. Places the foot board making a ribbon knot.
h. Hang the suspension bag; check the alignment of the traction, then remove the rest,
splint and check the efficiency of traction with the patient coordination.
i. Give at least 5 nursing care related with skeletal balance traction.
4. Removal of the set up (balance skeletal muscle) from orthopedic bed.
a. Re-application of rest splint; hang the suspension bag.
b. Removal of suspension rope.
c. Application of manual traction.
d. Removal of traction tape from the 3rd pulley and finish with a clove hitch knot in
the rest splint; Thomas splint and end in the Pearson attachment.
5. Able to finish at reasonable time.
6. Skills, systematic and well-coordinated movements in moving the whole procedure.
MONITORING SKELETAL MUSCLE
PERORMANCE POINTS
PERFORMANCE POINTS
1. Washes hands.
2. Greet and identifies patient.
3. Explain the procedure.
4. Examines the material (tape, foam rubber, or plastic) that attaches the weights the
extremity.
a. Material should be held in place, not slipping
b. Material should be fit comfortably, neither too loose or too tight.
5. Examine all body prominences for pressure areas or abrasions.
a. Traction should be removed ever y4 hrs.
b. Washes, dries thoroughly and powders skin before applying traction.
6. Examine the extremity distal to the traction.
a. Note any presence of edema.
b. Takes and records peripheral pulses.
c. Checks temperature and color to see if both are normal.
7. Observe for possible for neurological impediment form traction sling encouraging on
popliteal space or axilla.
8. Asks the patient to move the extremity that is distal to traction.
a. Note if full range of motion is present.
b. Ask patient if he has any decreased or unusual sensations.
9. Examine the ropes and weights to see that the pull directly through the long axis of the
fracture bone.
10. Checks the traction mechanism.
a. Weigh should be hang freely, off the floor and bed.
b. Knots should be away from the pulleys.
c. Ropes should be move freely through pulleys.
d. Pulleys should not be constrained by knots.
11. Make sure that the patient is positioned correctly in bed.
12. Places sheepskin or alternative material under the affected area.
13. Provides footboard to prevent foot drop.
14. Documents the procedure.
WPLACING A JEWETT-TAYLOR BACK BRACE
PERFORMANCE POINTS
1. Washes hands.
2. Explains procedure to patient.
3. Provide privacy.
4. Puts T-shirt on patient.
5. Place the bed in flat position. Keeps side rails in UP position on side of the bed from you.
6. Log rolls or ask patient to turn side to farthest away from you.
7. Position brace on the back so that struts fit on either side of the spinal cord and fits
natural lumbar curve of the back.
8. Log rolls to the patient to a supine position.
9. Places the front section of the brace positioning the iliac wings (made of plastic material)
over the iliac crest. Adjust the triangular sternum piece; the metal struts will fell into
place.
10. Secures the brave with Velcro straps.
11. Observe under the brace for pressure areas.
12. If pressure areas are present, pas the area under the brace with ABD pads until brace
can be adjusted.
13. Document the procedure.
ASSISTING WITH AMBUALTION
PERFORMANCE POINTS
PERFORMANCE POINTS
PEROFRMANCE POINTS
PERFORMANCE POINTS
PERFORMANCE POINTS
PROMOTING OXYGENATION
PERFORMANCE POINTS
PERFOMANCE POINTS
PERFORMANCE POINTS
1. Assess the client the need for oxygen therapy and verify the doctor’s order for the
therapy.
2. Prepare equipment such as oxygen tank with flow mete, humidifier with sterile or distilled
water, nasal cannula of appropriate size and padding or the elastic band.
3. Wash hands before staring the procedure.
4. Identify pt and explain procedure alleviate any fear as anxiety pt may be feeling.
5. Place pt on ssemi fowler’s positon.
6. Set-up the oxygen equipment and the humidifier.
7. Attach nasal cannula and tubing to the humidifier.
8. Open the value of the oxygen tank and check the content of the tank.
9. Turn on the regulator at the prescribed rate and ensure proper functioning.
10. Check that the oxygen is flowing freely through the tubing.
11. Put the cannula over the client’s face with the outlet prong setting into the nares and
elastic band to left and right ears and adjust strap under the chin.
12. Assess the client regularly, assess vital signs, color, breathing pattern and chest
movements.
13. Inspect the equipment on a regular basis.
14. Make sure that safety precautions are being followed.
15. Record procedure done and all nursing assessment.
ADMINISTERING OXYGEN THERAPY BY FACE MASK.
PERFORMANCE POINTS
1. Determine the need for O2 therapy and verify the order for therapy
2. Prepare equipment such as O2 tank with flow meter, humidifier with sterile or distilled
water, face mask, of appropriate size and padding for the elastic band.
3. Wash hands before staring the procedure.
4. Identify pt and explain procedure. Entertain any questions the client may have.
5. Place pt on semi-fowlers position.
6. Set-up the oxygen equipment and the humidifier.
7. Turn on the O2 at prescribed rate and ensure proper functioning.
8. Check if O2 is properly flowing through the tube mask.
9. Guide the mask toward the client’s face and apply form the nose down to the chin.
10. Fit the mask to the contours of the client’s face.
11. Secure the elastic band around the client’s head so that the mask is comfortable but
snug.
12. Pad the band behind the ears and over the bony prominences.
13. Assess client regularly assess vital signs, color, breathing pattern and chest movements.
14. Inspect the facial skin frequency for dampness dry as necessary.
15. Inspect the equipment on a regular basis.
16. Make sure that safety precautions are being followed.
17. Record procedure done and all nursing assessment.
PERFORMING HEIMLICH MANEUVER
PERFORMANCE POINTS
PERFORMANCE POINTS
LEOPOLD’S MANEUVER
FUNDIC HEIGHT MEASUREMENT
AUSCULTATING FETAL HEART TONE
IMMEDIATE CARE OF THE NEWBORN
BATHING A NEWBORN
ADMINISTRATION OF VITAMIN K
ADMINISTRATION OF CREDE’S PROPHYLAXIS
NEWBORN CARE
LEOPOLD’S MANUEVER
PERDORMANCE POINTS
PERFORMANCE POINTS
PERFORMANCE POINTS
1. Do hand washing.
2. Gather the equipment to be use.
3. Identify the client and explain the procedure.
4. Instruct the patient to void first before the procedure.
5. Provide privacy in the entire procedure
6. Place the client in supine position.
7. Locate for the fetal back
8. Locate for the fetal presentation.
9. Lubricate the Doppler of Fetoscope.
10. Place the fetoscope at the fetal back.
11. Listen for the fetal heart tone.
12. Count the feta heart rate.
13. Remove excess lubricant and place the patient in a comfortable postion.
14. Do hand handwashing
15. Record the data gathered.
IMMEDIATE CARE OF THE NEWBORN.
PERFOMANCE POINTS
1. Do hand washing.
2. Checks identification (name of mother, baby’s sex and room number) upon receiving for
the DR nurse.
3. Hold a warm sterile blanket, grasp the infant through the blanket by placing one hand
under the back and the other around the leg.
4. Rub infant dry so that so that no body heat is lost by evaporation
5. Swaddle the infant loosely with blanket so that respiratory efforts are compromised.
6. Lay the infant in the bassinet.
7. Place a drop light to maintain body temperature.
8. Place the infant in a trendelenberg position. Head down and to the side, allowing
mucuos and fluid drain from the mouth.
9. Sucti0on the infant first and then the nose to clear airway (5-10 seconds)
10. Assess for the consistency, color and for presence of blood.
11. Record the first cry of infant.
12. Assess for the APGAR score.
a. Auscultate for the heart rate.
b. Asses for the respiratory effort.
c. Assess for the muscle tone. Infant should resist any effort to extend their extremities.
d. Tet for reflex irritability.
e. Assess for the color.
13. Obtain body temperature using rectal thermometer.
14. Clean the thermometer form the bulb to the stem.
15. Do hand washing.
16. Document procedure done.
BATHING NEWBORN
PERFORMANCE POINTS
PERFORMANCE POINTS
1. Do handwashing
2. Prepare all materials needed.
3. Get the vitamin k.
4. Check for the expiration date if it is clearly labeled.
5. Tap liquid in top chamber of the ampule into the bottom part.
6. Alcohol wipe the neck of the ampule.
7. Snap top off away from your body.
8. Using tuberculin syringe, withdrew medication by inverting the ampule or by holding it an
insert the needle. Then pull the plunger.
9. Withdraw 0.1 cc of vitamin k.
10. Remove the syringe form the ampule and remove bubbles from syringe.
11. Check the dosage of medication in the syringe
12. Place the infant in supine position.
13. Locate for the vastus lateralis.
14. Clean the injection site using cotton ball with alcohol. Do it in a circular motion, form
inner to outer.
15. Hold the thigh of the infant firmly.
16. Inject the needle in a 90 degree angle then aspirate.
17. If no blood, introduce the medication slowly.
18. Remove the needle and apply pressure on site.
19. Discard the syringe after use.
20. Do hand washing.
21. Document procedure done
ADMINISTRATION OF CRED’S PROPHYLAXIS
PERFORMANCE POINTS
PERFORMANCE POINTS
BAG TECHNIQUE
PERFORMING BENEDICT’S TEST
APPLICATION OF ICE BAG
APPLICATION OF HOT WATER BAG
BAG TECHNIQUE
PERFORMANCE POINTS
PERFORMANCE POINTS
PERFORMANCE POINTS
PERFORMANCE POINT