FATHER SATURNINO URIOS UNIVERSITY

San Francisco St. Butuan City 8600, Region XIII Caraga, Philippines
Tel. Number 085-3421830 local 4853
Nursing Program

NCM 220 RLE

Care of Mother and Child
At Risk or with Problems (Acute or Chronic)
Compilation of Procedures

Name: ___________________________ Section: ______

NURSING PROCEDURES LECTURE RETURN DEMONSTRATION GRADE
DEMONSTRATION
DATE CI’s SIGNATURE DATE CI’s SIGNATURE

Breast Self-Examination
Changing, Monitoring and
Discontinuing IVF;
Assisting with Blood
Transfusion

Infant Nasogastric Tube

(Infant NGT)

Infant Resuscitation

Communicable Disease
Technique
(CD Technique)
Name: _________________________________________________ Section____________________________
Clinical Instructor (Lecture Demo): __________________________ Date of Lecture Demo________________

Breast Self-Examination

Basic Concept:
Breast self-examination is a modality used for early detection of breast cancer. BSE can be taught in group
or one-on-one or during patient’s routine physical examination. BSE is best performed 5 to 7 days after menses
or right after menstrual cycle ends; and once monthly for postmenopausal women.
Objectives:
1. To assess breast for any changes in contour, lumps, nodules, or discharge.
2. To notice early signs of breast cancer.
Materials/ Equipment:
Pillow
Mirror
Preparation:
1. Perform hand hygiene.
2. Room should be bright and provides privacy.

PROCEDURE RATIONALE

Step 1
1. Stand before a mirror.
2. Check both breasts for anything unusual.
3. Look for discharge from the nipple and puckering,
dimpling, or scaling of the skin.

The next two steps check for any changes in contour of

breasts. As you do them, you should be able to feel your
muscles tighten.

Step 2
1. Watch closely in the mirror as you clasp your hands
behind your head and press your hands forward.
2. Note any change in the contour of your breasts.

Step 3
1. Next, press your hands firmly on your hips and bow
slightly toward the mirror as you pull your shoulders and
elbows forward.
2. Note any change in the contour of your breasts.

Some women perform the next part in the shower.

Step 4
1. Raise your left arm.
2. Use 3 or 4 fingers of your right hand to feel your left
breast firmly, carefully and thoroughly. When palpating,
 use three levels of palpation, light, medium, firm
pressures.
3. Beginning at the outer edge, press the flat part of your
fingers in small circles, moving circles slowly around
your breast.
4. Gradually work toward the nipple.
5. Be sure to cover the whole breast.
6. Pay special attention to the area between the breast and
the underarm, including the under arm itself. Examine
axilla for any lymph nodes.
7. Feel for any unusual lumps or masses under the skin.
8. Squeeze nipple gently with your thumb and index
finger, and note any discharge. If you have any
spontaneous discharge during the month –whether or not
it is during your BSE-see your doctor.
9. Repeat examination on your right breast.

Step 5
1. Lie flat on your back with your left arm over your head
and a pillow or folded towel under your left shoulder.
2. Repeat actions of Step 4 in this position for each breast.
American Cancer Society

US Health Department and Human Services

Name: _________________________________________________ Section____________________________
Clinical Instructor (Return Demo): __________________________ Date of Return Demo________________

PERFORMANCE CHECKLIST
Breast Self-Examination
Criteria for evaluation or rating the student’s performance:
1 - Performs the step or procedure independently, correctly and appropriately. Shows excellent attitude and gives
the correct rationale of the step/ procedure to be performed. Answers the question/s correctly and analyzes the
situation on or before performing the procedure.
2 – Performs more independently with increasing dependability but occasionally needing assistance. Shows very
satisfactory attitude and gives the correct rationale of the step/ procedure to be performed but occasionally needing
follow-up instructions and explanations.
3 – Performs expected step/ procedure but needs supervision, follow-up instructions and explanations. Has
knowledge about the topic, step or procedure but needs reinforcement.
4 – Performs with close supervision. The student needs repeated, specific, detailed guidance and direction to be
able to perform the step/ procedure correctly and appropriately. There is a need to improve performance.
5 – Performs with very close supervision. The student shows poor or no interest in the step/ procedure to be
performed; cannot answer the question raised by the supervising clinical instructor based on the step or
procedure to be performed; unable to grasp understanding of the topic or procedure; unable to perform the
required step and state the rationale after being instructed, guided or directed. Student’s behavior is
inappropriate and potentially harmful to the client.

Steps of the Procedure 1 2 3 4 5

Preparation:
1. Perform hand hygiene.
2. Room should be bright and provides privacy.

Step 1
1. Stand before a mirror.
2. Check both breasts for anything unusual.
3. Look for discharge from the nipple and puckering, dimpling, or
scaling of the skin.

The next two steps check for any changes in contour of breasts.
As you do them, you should be able to feel your muscles tighten.

Step 2
1. Watch closely in the mirror as you clasp your hands behind
your head and press your hands forward.
2. Note any change in the contour of your breasts.

Step 3
1. Next, press your hands firmly on your hips and bow slightly
toward the mirror as you pull your shoulders and elbows forward.
2. Note any change in the contour of your breasts.

Some women perform the next part in the shower.

 Step 4
1. Raise your left arm.
2. Use 3 or 4 fingers of your right hand to feel your left breast
firmly, carefully and thoroughly. When palpating, use three levels
of palpation, light, medium, firm pressures.
3. Beginning at the outer edge, press the flat part of your fingers
in small circles, moving circles slowly around your breast.
4. Gradually work toward the nipple.
5. Be sure to cover the whole breast.
6. Pay special attention to the area between the breast and the
underarm, including the under arm itself. Examine axilla for any
lymph nodes.
7. Feel for any unusual lumps or masses under the skin.
8. Squeeze nipple gently with your thumb and index finger, and
note any discharge. If you have any spontaneous discharge during
the month –whether or not it is during your BSE-see your doctor.
9. Repeat examination on your right breast.

Step 5
1. Lie flat on your back with your left arm over your head and a
pillow or folded towel under your left shoulder.
2. Repeat actions of Step 4 in this position for each breast.

EVALUATION
1. Applies previously learned concepts and principles
2. Performs the procedure with ease and deftness
3. Displays a positive attitude of an Urian student nurse
(punctual, prepared, caring and confident, etc)
4. Keeps the patient safe throughout the performance of
procedure
5. Has kept the patient free from injury or complication

Comments:

Rating: ______

________________________________________
Signature Over Printed Name of CI
Name: _________________________________________________ Section____________________________
Clinical Instructor (Lecture Demo): __________________________ Date of Lecture Demo________________

INTRAVENOUS SET UP, CHANGE AND DISCONTINUATION

CONCEPT
A short catheter inserted through the skin into the vein where substances can be given directly. This is usually in
the form of cannula-over-needle device in which a flexible plastic cannula advanced inside the vein to the
appropriate position and secured.

OBJECTIVES:
1. To restore and maintain fluid and electrolyte balance
2. To administer continuous or intermittent solutions or medications for treatment and Pain management.
3. To transfuse blood and blood products
4. To establish intravenous access.

Materials:
IV tray with IV solution
IV Administration set
IV cannula/catheter
Forceps soaked in antiseptic solution
Plaster
Alcohol swabs or cotton balls soaked in alcohol with cover
Sterile 2X2 gauze or transparent dressing (Band Aid)
Tourniquet
Clean Gloves
Splint
IV hook
Time Tape or label (for IV container)
Arm board (if needed)

PATIENT ASSESSMENT AND PREPARATION:

1. Review accuracy and completeness of health care provider’s order for type and amount of IV fluid,
medication additives, infusion rate, and length of therapy. Follow six rights of medication administration.
2. Assess patient’s knowledge of procedure, reason for prescribed therapy, and arm placement preference.
3. Assess for clinical factors/conditions that will respond to or be affected by administration of IV solutions.
A. Body weight
B. Clinical markers of vascular volume:
(1) Urine Output
(2) Vital signs
(3) Distended neck veins
(4) Auscultation of lungs
(5) Capillary refill
C. Clinical markers of interstitial volume
(1) Skin turgor (Pinch skin over sternum or inside of forearm.)
(2) Dependent edema (pitting or nonpitting) 1+ indicates barely detectable edema; 4+ indicates deep pitting.
(3) Oral mucous membrane between cheek and gum
D. Thirst
E. Behavior and level of consciousness
4 Determine if patient is to undergo any planned surgeries or procedures.
5 Assess laboratory data.
6 Assess patient’s history of allergies, especially to iodine, adhesive, or latex.
PLANNING
1 Expected outcome following completion of procedure:
• Fluid and electrolyte balance returns to normal.
- Proper solution is infused at proper rate and monitored, resolving fluid and electrolyte imbalance
(Alexander et al., 2010).
• Vital signs are stable and within normal limits for patient.
- Demonstrates response of circulatory system to fluid and electrolyte replacement
(Alexander et al., 2010).
• No redness, drainage, swelling, or pain present at venipuncture site.
- Ensures that catheter is without infusion-related complications (INS, 2011).
• Patient is able to explain purpose and risks of IV therapy.
- Demonstrates learning (Alexander et al., 2010; INS, 2011).

IMPLEMENTATION
PROCEDURE RATIONALE
IV SETTING UP
1. Identify patient using two identifiers (i.e., name and
birthday or name and account number) according to
agency policy.
2. Verify physicians order for IV insertion, type and
amount of IV fluid, medication additives, infusion rate,
and length of therapy.
3. Check IV solution using 10 rights of medication
administration
4. Explain procedure to reassure patient and/or
significant other, secure consent if necessary. Assess
patient’s knowledge of the procedure and reason for
prescribed therapy.
5. Help patient to comfortable sitting or supine position.
Provide adequate lighting.
6. Assess patient's vein; choose appropriate site, location,
size/condition.
7.Do hand hygiene before and after the
procedure. Prepare necessary materials for procedure.
8. Check the sterility and integrity of the IV solution, IV
set and other devices. Check solution for color, clarity,
and expiration date. Check bag for leaks.
9. Place IV label on IVF bottle duly signed by RN who
prepared it (patient’s name, room no, time and date etc.)
10. Open IV administration set aseptically following the
infection control measures.
11. Place roller clamp about 2 to 5 cm (1 to 2 inches)
below drip chamber and move roller clamp to “off”
position.
12. Remove protective sheath over IV tubing port on
plastic IV solution bag or top of IV bottle.
13. Remove protective cap from tubing insertion spike
(not touching spike) and insert spike into port of IV bag
or clean rubber stopper on IV bottled solution with
single-use antiseptic and insert spike into black rubber
stopper of IV bottle. Bottles need special vented tubing.
14. Compress drip chamber and release, allowing it to fill
one-third to one-half full.
15. Prime infusion tubing by filling with IV solution:
Remove protective cap on end of tubing (you can prime
some tubing without removal) and slowly open roller
clamp to allow fluid to travel from drip chamber through
tubing to needle adapter. Invert Y connector to displace
air. Return roller clamp to “off” position after priming
tubing (filled with IV fluid). Replace protective cap on
end of infusion tubing.
16. Expel air bubbles if any and put back the cover to the
distal end of the IV Set. To remove small air bubbles,
firmly tap IV tubing where air bubbles are located.
Check entire length of tubing to ensure that all air
bubbles are removed.
17. Maintain sterility of end of connector and set aside
for attaching to catheter hub after successful
venipuncture.
CHANGING IV SOLUTION
ASSESSMENT
1.Verify doctor's prescription in doctor's order sheet for
patient name and correct solution: type, amount,
additives, rate and duration of IV therapy; countercheck
IV label, IV card, infusate sequence, type, amount,
additive (if any), and duration of Infusion
2.Observe 10R's of Drug Administration.
3. Explain procedure to reassure the patient and
significant others and assess the IV site for redness,
swelling, pain etc.
4.Note date and time when IV tubing and solution were
last changed. Change the IV tubing and cannula if 48-72
hours has lapsed after IV insertion
5.Prepare necessary materials, place on an IV tray.
6.Check sterility and integrity of IV solution. Check the
IV solution for integrity including, but not limited to,
discoloration, cloudiness, leakage, expiration date.
Determine compatibility of all IV fluids and additives by
consulting approved online database, drug reference, or
pharmacist.
7.Assess patency of current venous access device (VAD)
site, observing for any signs or symptoms of
complications such as redness, swelling, complaints of
discomfort.
8.Assess IV tubing for puncture, contamination, or
occlusions.

PLANNING
1.Expected Outcomes following completion of
procedure:
• IV solution is correct.
• VAD remains patent.
• Patient and family caregiver can explain
purpose of IV solution change.
IMPLEMENTATION
1.Gather the equipment. Have next solution prepared at
least 1 hour before needed. If solution is prepared in
pharmacy, ensure that it has been delivered to patient
care unit. Allow solution to warm to room temperature if
it has been refrigerated. Check that solution is correct
and properly labeled. Check solution expiration date.
Ensure that any light sensitivity restrictions are followed.
2.Place IV label on the bottle
3.Identify patient using two identifiers (i.e., name and
birthday or name and account number) according to
agency policy.
4.Change solution when fluid remains only in neck of
container (about 50 mL) or when new type of solution
has been ordered.
5.Wash hands before the procedure
6.Prepare new solution for changing. If using plastic bag,
hang on IV pole and remove protective cover from IV
tubing port. If using IV bottle, remove cap.
7.Close roller clamp on existing solution to stop flow
rate. Remove tubing from Electronic Infusion Device (if
used). Then remove old IV fluid container from IV pole.
Hold container with tubing port pointing upward for bags
and downward for bottle.
8.Quickly remove spike from old solution container and,
without touching tip, insert spike into new container.
9.Hang new container of solution on IV pole.
10.Close the roller clamp.
11.Check for air in tubing. If air bubbles have formed,
remove them by closing roller clamp, stretching tubing
downward, and tapping tubing with finger (bubbles rise
in fluid to drip chamber)
12.Make sure drip chamber is one-third to one-half full.
If drip chamber is too full, level can be decreased by
removing bag from IV pole, pinching off tubing below
drip chamber, inverting container, squeezing drip
chamber (see illustration), releasing and turning solution
container upright, and releasing pinch on tubing.
13.Calibrate new IV bottle according to duration of
infusion as per prescription by using roller clamp on
tubing or programming EID.
14.Place time label on side of container and label with
time hung, time of completion, and appropriate intervals.
If using plastic bags, mark only on label and not
container.
15.Reiterate assurance to patient and significant others.
16.Discard all waste materials according to Health Care
Waste Management (DOH/DENR)
17.Document and endorse accordingly. (Record amount
and type of solution infused, amount and type of solution
started, and flow rate according to agency policy. Record
solution and tubing change on patient’s record. Use
parenteral (IV) therapy flow sheet, if available.)
 EVALUATION
1.Observe functioning, intactness, and patency of IV
system and flow rate.
2.Observe patient for signs of fluid volume deficit (FVD)
or fluid volume excess (FVE) to determine response to
IV therapy
3.Assess patient for signs and symptoms of IV-related
complications. Palpate skin for temperature, edema, or
tenderness.
DISCONTINUATION
PROCEDURE
1.Verify written doctor's order to discontinue IV
including IV
2.Observe 10RS of drug Administration.
3. Assess and inform the patient of the discontinuation of
IV Infusion
4.Prepare the necessary materials: IV tray or injection
tray with sterile cotton balls with alcohol, sterile 2x2
gauze, plaster, pick up forceps in antiseptic solution,
kidney basin and band aid.
5.Wash hands before and after procedure.
6.Close the roller clamp of the IV administration set.
7.Moisten adhesive tapes around the IV catheter with
cotton ball with alcohol, remove plaster gently.
8.Use pick-up forceps to get cotton ball with alcohol and
without applying pressure, remove needle or IV catheter
then immediately apply pressure over the venipuncture
site.
9. Inspect IV catheter for completeness.
10. Place sterile gauze dressing over the venipuncture
site.
11.Discard all waste materials including the IV cannula
according to Health Care Waste Management
(DOH/DENR).
12. Reassure patient.
13.Wash hands after the procedure.
14.Document time of discontinuance, status of insertion
site and integrity of IV catheter and endorse accordingly.

Reference: "Nursing Standards on intravenous Practice 3" Edition (2006). Association of Nursing Service Administrators of the Philippines, Inc. (ANSAP)

Perry, A. G., Potter, P. A., & Ostendorf, W. R. (2014). Clinical Nursing Skills and Techniques (8th ed.). Elsevier.
Name: _________________________________________________ Section____________________________
Clinical Instructor (Return Demo): __________________________ Date of Return Demo________________

PERFORMANCE CHECKLIST
INTRAVENOUS SET UP, INSERTION, CHANGE AND DISCONTINUATION

Criteria for evaluation or rating the student’s performance:

1 - Performs the step or procedure independently, correctly and appropriately. Shows excellent attitude and gives
the correct rationale of the step/ procedure to be performed. Answers the question/s correctly and analyzes the
situation on or before performing the procedure.
2 – Performs more independently with increasing dependability but occasionally needing assistance. Shows very
satisfactory attitude and gives the correct rationale of the step/ procedure to be performed but occasionally needing
follow-up instructions and explanations.
3 – Performs expected step/ procedure but needs supervision, follow-up instructions and explanations. Has
knowledge about the topic, step or procedure but needs reinforcement.
4 – Performs with close supervision. The student needs repeated, specific, detailed guidance and direction to be
able to perform the step/ procedure correctly and appropriately. There is a need to improve performance.
5 – Performs with very close supervision. The student shows poor or no interest in the step/ procedure to be
performed; cannot answer the question raised by the supervising clinical instructor based on the step or
procedure to be performed; unable to grasp understanding of the topic or procedure; unable to perform the
required step and state the rationale after being instructed, guided or directed. Student’s behavior is
inappropriate and potentially harmful to the client.

SETTING UP
Steps of the Procedure 1 2 3 4 5
ASSESSMENT
1. Identify the patient and verify the physician's order for IV
procedure.
2. Assess patient’s knowledge of procedure, reason for prescribed
therapy, and arm placement preference.
3. Assess for clinical factors/conditions that will respond to or be
affected by administration of IV solutions.
4 Determine if patient is to undergo any planned surgeries or
procedures.
5 Assess laboratory data.
6 Assess patient’s history of allergies, especially to iodine,
adhesive, or latex.

PLANNING:
1. Prepare the materials needed
2. Explain the procedure to the patient and significant others and
secure consent
3. Choose appropriate site, location, size/condition.
4. Observe the ten Rights in giving medication

IMPLEMENTATION:
1. Do hand hygiene before and after the procedure.
2. Check the sterility and integrity of the IV solution, IV set and
other devices
3. Place IV label on IVF bottle duly signed by RN who prepared
it pts name, room no solution, time & date).
4. Open / administration set aseptically following the infection
control measures
5. Open IV administration set aseptically and close the roller
clamp and spike the infusate container aseptically.
6. Fill drip chamber to at least half & prime it with IVF
aseptically
7. Expel air bubbles if any and put back the cover to the distal
end of the IV set.

CHANGING IV SOLUTION
Steps of the Procedure 1 2 3 4 5
ASSESSMENT
1.Verify doctor's prescription in doctor's order sheet for patient
name and correct solution: type, amount, additives, rate and
duration of IV therapy;
countercheck IV label, IV card, infusate sequence, type,
amount, additive (if any), and duration of Infusion
2.Observe 10R's of Drug Administration.
3. Explain procedure to reassure the patient and significant
others and assess the IV site for redness, swelling, pain etc.
4.Note date and time when IV tubing and solution were last
changed. Change the IV tubing and cannula if 48-72 hours has
lapsed after IV insertion
5.Prepare necessary materials, place on an IV tray.
6.Check sterility and integrity of IV solution. Check the IV
solution for integrity including, but not limited to, discoloration,
cloudiness, leakage, expiration date. Determine compatibility of
all IV fluids and additives by consulting approved online
database, drug reference, or pharmacist.
7.Assess patency of current venous access device (VAD) site,
observing for any signs or symptoms of complications such as
redness, swelling, complaints of discomfort.
8.Assess IV tubing for puncture, contamination, or occlusions.

PLANNING
1.Expected Outcomes following completion of procedure:
• IV solution is correct.
• VAD remains patent.
• Patient and family caregiver can explain purpose
of IV solution change.
IMPLEMENTATION
1.Gather the equipment. Have next solution prepared at least 1
hour before needed. If solution is prepared in pharmacy, ensure
that it has been delivered to patient care unit. Allow solution to
warm to room temperature if it has been refrigerated. Check that
solution is correct and properly labeled. Check solution
expiration date. Ensure that any light sensitivity restrictions are
followed.
2.Place IV label on the bottle
3.Identify patient using two identifiers (i.e., name and birthday or
name and account number) according to agency policy.
4.Change solution when fluid remains only in neck of container
(about 50 mL) or when new type of solution has been ordered.
5.Wash hands before the procedure
6.Prepare new solution for changing. If using plastic bag, hang on
IV pole and remove protective cover from IV tubing port. If using
IV bottle, remove cap.
7.Close roller clamp on existing solution to stop flow rate.
Remove tubing from Electronic Infusion Device (if used). Then
remove old IV fluid container from IV pole. Hold container with
tubing port pointing upward for bags and downward for bottle.
8.Quickly remove spike from old solution container and, without
touching tip, insert spike into new container.
9.Hang new container of solution on IV pole.
10.Close the roller clamp.
11.Check for air in tubing. If air bubbles have formed, remove
them by closing roller clamp, stretching tubing downward, and
tapping tubing with finger (bubbles rise in fluid to drip chamber)
12.Make sure drip chamber is one-third to one-half full. If drip
chamber is too full, level can be decreased by removing bag from
IV pole, pinching off tubing below drip chamber, inverting
container, squeezing drip chamber (see illustration), releasing and
turning solution container upright, and releasing pinch on tubing.
13.Calibrate new IV bottle according to duration of infusion as
per prescription by using roller clamp on tubing or programming
EID.
14.Place time label on side of container and label with time hung,
time of completion, and appropriate intervals. If using plastic
bags, mark only on label and not container.
15.Reiterate assurance to patient and significant others.
16.Discard all waste materials according to Health Care Waste
Management (DOH/DENR)
17.Document and endorse accordingly. (Record amount and type
of solution infused, amount and type of solution started, and flow
rate according to agency policy. Record solution and tubing
change on patient’s record. Use parenteral (IV) therapy flow
sheet, if available.)

EVALUATION
1.Observe functioning, intactness, and patency of IV system and
flow rate.
2.Observe patient for signs of fluid volume deficit (FVD) or fluid
volume excess (FVE) to
3.determine response to IV therapy
4.Assess patient for signs and symptoms of IV-related
complications. Palpate skin for temperature, edema, or
tenderness.
DISCONTINUING AN IV INFUSION
Steps of the Procedure 1 2 3 4 5
1. Verify written doctor's order to discontinue IV including IV
medications.
2. Observe 10RS.
3. Assess and inform the patient of the discontinuation of IV
Infusion
4. Prepare the necessary materials: IV tray or injection tray with
sterile cotton balls with alcohol, sterile 2x2 gauze, plaster, pick
up forceps in antiseptic solution, kidney basin and band aid.
5. Wash hands before and after procedure.
6. Close the roller clamp of the IV administration set.
7. Moisten adhesive tapes around the IV catheter with cotton ball
with alcohol, remove plaster gently.
8 Use pick-up forceps to get cotton ball with alcohol and without
applying pressure, remove needle or IV catheter
then immediately apply pressure over the venipuncture site.
9. Inspect IV catheter for completeness.
10. Place sterile gauze dressing over the venipuncture site.
11. Discard all waste materials including the IV cannula
according to Health Care Waste Management (DOH/DENR).
12. Reassure patient.
13. Document time of discontinuance, status of insertion site and
integrity of IV catheter and endorse accordingly.

Comments:

Rating: ______

________________________________________
Signature Over Printed Name of CI
Name: _________________________________________________ Section____________________________
Clinical Instructor (Lecture Demo): __________________________ Date of Lecture Demo________________

ASSISTING WITH BLOOD TRANSFUSIONS

CONCEPT
Transfusion therapy or blood replacement is the intravenous (IV) administration of whole blood, its components
or a plasma-derived product for therapeutic purposes (Alexander et al., 2010).

OBJECTIVES:
1. To restore intravascular volume
2. To restore the oxygen-carrying capacity of blood

Materials:
IV tray with 0.9% NaCl (Normal Saline) IV Solution
Y-type Blood Administration set (In-line filter) (NOTE: Depending on blood product, special tubing and filter
are necessary)
Prescribed Blood Product
Forceps soaked in antiseptic solution
Plaster tape
Alcohol swabs or cotton balls soaked in alcohol with cover
Clean Gloves
IV hook
Vital sign equipment: Thermometer, blood pressure cuff, and stethoscope
Time Tape or label (for IV container)
Arm board (if needed)
Signed transfusion consent form

Optional Equipment
❏ Rapid infusion pump
❏ Electronic infusion device (EID) (Verify that pump can be used to deliver blood and
blood products)
❏ Leukocyte-depleting filter
❏ Blood warmer
❏ Pressure bag
❏ Pulse oximeter

PATIENT ASSESSMENT AND PREPARATION:

1. Verify health care provider’s order for specific blood or blood product, date, time to begin transfusion,
duration, and any pretransfusion or posttransfusion medications to administer.
2. Obtain patient’s transfusion history and note known allergies and previous transfusion reactions. Verify
that type and crossmatch have been completed within 72 hours of transfusion.
3. Verify that IV cannula is patent and without complications such as infiltration or phlebitis.
a. Administer blood or blood components to an adult, using a 14- to 24-gauge short peripheral catheter.
b. Transfuse a neonate or pediatric patient using a 22- to 24-gauge device (INS, 2011a).
c. A 1.9 Fr is the smallest central venous access device (CVAD) that can be used (INS, 2011a).
4. Assess laboratory values such as hematocrit, coagulation values, platelet count.
5. Check that patient has properly completed and signed transfusion consent before retrieving blood.
6. Know indications or reasons for transfusion (e.g., packed red blood cells [PRBCs] for patient with low
hematocrit level from gastrointestinal bleeding or surgery blood loss).
7. Obtain and record pretransfusion baseline vital signs (temperature, respirations, and blood pressure). If
patient is febrile (temperature greater than 37.8°C [100°F]), notify health care provider before initiating
transfusion.
8. Assess patient’s need for IV fluids or medications while transfusion is infusing.
9. Assess patient’s understanding of procedure and rationale.

PLANNING
1. Expected outcomes following completion of the procedure:
• Patient verbalizes understanding of rationale for therapy.
• Patient experiences improved activity tolerance.
• Patient’s cardiac output returns to baseline.
• Patient’s systolic blood pressure improves, and urine output is 0.5 to 1 mL/kg/hr
• Patient’s laboratory values improve in targeted areas (e.g., hematocrit, coagulation values,
platelet count).
2. Explain procedure to patient and family caregiver.

IMPLEMENTATION
PROCEDURE RATIONALE
1.Pre-administration Protocol:
a. Obtain blood component from blood bank following
agency protocol. Blood transfusion must be initiated
within 30 minutes after release from laboratory or blood
bank (INS, 2011a).
b. Check blood bag for any signs of contamination (i.e.,
clumping/clots, gas bubbles, purplish color) and
presence of leaks.
c. Verbally compare and correctly verify patient, blood
product, and type with another person considered
qualified by your agency (e.g., RN or LPN) before
initiating transfusion. Check the following:
i. Identify patient using two identifiers (i.e., name and
birthday or name and account number) according to
agency policy. Compare identifiers in MAR/medical
record with information on patient’s identification
bracelet and/or ask patient to state name.
ii. Transfusion record number and patient’s
identification number match.
iii. Patient’s name is correct on all documents. Check
identification number and date of birth on identification
band and patient record.
iv. Check unit number on blood bag with blood bank
form to ensure that they are the same.
v. Blood type matches on transfusion record and blood
bag. Verify that component received from blood bank is
same component that health care provider ordered (e.g.,
packed red cells, platelets) (see illustration).
vi. Check that patient’s blood type and Rh type are
compatible with donor blood type and Rh type (e.g.,
Patient A+: Donor A+ or 0+).
vii. Check expiration date and time on unit of blood.
viii. Just before initiating transfusion, check patient
identification information with blood unit label
information (see illustration). Do not administer blood
to patient without an identification bracelet.
ix. Both individuals verify patient and unit identification
record process as directed by agency policy.
d. Review purpose of transfusion and ask patient to
report any changes that he or she may feel during the
transfusion.
e. Empty urine drainage collection container or have
patient void.
1.Administration:
a. Perform hand hygiene. Apply clean gloves.
b. Open Y-tubing blood administration set for single
unit. Use multiset if multiple units are to be transfused.
c. Set all clamp(s) to “off” position.
d. Spike 0.9% normal saline IV bag with one of Y-
tubing spikes. Hang bag on IV pole and prime tubing.
Open upper clamp on normal saline side of tubing and
squeeze drip chamber until fluid covers filter and one
third to one half of drip chamber.
e. Maintain clamp on blood product side of Y-tubing in
“off” position. Open common tubing clamp to finish
priming tubing to distal end of tubing connector. Close
tubing clamp when tubing is filled with saline. All three
tubing clamps should be closed. Maintain protective
sterile cap on tubing connector.
f. Prepare blood component for administration. Gently
agitate blood unit bag, turning back and forth, upside
down. Remove protective covering from access port.
Spike blood component unit with other Y connection.
Close normal saline clamp above filter, open clamp
above filter to blood unit, and prime tubing with blood.
Blood will flow into drip chamber. Tap filter chamber to
ensure that residual air is removed.
g. Maintaining asepsis, attach primed tubing to patient’s
VAD. Open common tubing clamp and regulate blood
infusion to allow only 2 mL/min to infuse in initial 15
minutes.
h. Remain with patient during first 15 minutes of
transfusion. Initial flow rate during this time should be 2
mL/min or 20 gtt/min (using macrodrip of 10 gtt/mL).
i. Monitor patient’s vital signs at 5 minutes, 15 minutes,
and every 30 minutes until 1 hr after transfusion
(AABB, 2011) or per agency policy.
j. If there is no transfusion reaction, regulate rate of
transfusion according to health care provider’s orders.
Check drop factor for blood tubing.
k. After blood has infused, clear IV line with 0.9%
normal saline and discard blood bag according to
agency policy. When consecutive units are ordered,
maintain IV patency with 0.9% normal saline at keep
vein open (KVO) rate and retrieve subsequent unit for
administration.
l. Appropriately dispose of all supplies. Remove gloves
and perform hand hygiene.
EVALUATION
1. Observe IV site and status of infusion each time vital
signs are taken.
2. Observe for any changes in vital signs and any signs
of transfusion reactions such as chills, flushing, itching,
dyspnea, or rash.
3. Observe patient and assess laboratory values to
determine response to administration of blood
component.
4. Documentation:
• Record pretransfusion medications, vital signs,
location and condition of IV site, and patient
education.
• Record the type and volume of blood
component, blood unit/ donor/recipient
identification, compatibility, and expiration date
according to agency policy, along with patient’s
response to therapy. Document on the
transfusion record, nurses’ notes, electronic
health record (EHR), medication administration
record, flow sheet, and/or intake and output
sheet, depending on agency policy.
• Record volume of normal saline and blood
component infused.
• Report signs and symptoms of a transfusion
reaction immediately to the health care provider.
• Record amount of blood received by
autotransfusion and patient’s response to
therapy.
• Report to health care provider any
intratransfusion/ posttransfusion deterioration in
cardiac, pulmonary, and/or renal status.
• Record vital signs before, during, and after
transfusion.

Reference: "Nursing Standards on intravenous Practice 3" Edition (2006). Association of Nursing Service Administrators of the Philippines, Inc. (ANSAP)
Perry, A. G., Potter, P. A., & Ostendorf, W. R. (2014). Clinical Nursing Skills and Techniques (8th ed.). Elsevier.
Name: _________________________________________________ Section____________________________
Clinical Instructor (Return Demo): __________________________ Date of Return Demo________________

PERFORMANCE CHECKLIST
ASSISTING WITH BLOOD TRANSFUSIONS
Criteria for evaluation or rating the student’s performance:
1 - Performs the step or procedure independently, correctly and appropriately. Shows excellent attitude and gives
the correct rationale of the step/ procedure to be performed. Answers the question/s correctly and analyzes the
situation on or before performing the procedure.
2 – Performs more independently with increasing dependability but occasionally needing assistance. Shows very
satisfactory attitude and gives the correct rationale of the step/ procedure to be performed but occasionally needing
follow-up instructions and explanations.
3 – Performs expected step/ procedure but needs supervision, follow-up instructions and explanations. Has
knowledge about the topic, step or procedure but needs reinforcement.
4 – Performs with close supervision. The student needs repeated, specific, detailed guidance and direction to be
able to perform the step/ procedure correctly and appropriately. There is a need to improve performance.
5 – Performs with very close supervision. The student shows poor or no interest in the step/ procedure to be
performed; cannot answer the question raised by the supervising clinical instructor based on the step or procedure
to be performed; unable to grasp understanding of the topic or procedure; unable to perform the required step and
state the rationale after being instructed, guided or directed. Student’s behavior is inappropriate and potentially
harmful to the client.
Steps of the Procedure 1 2 3 4 5
1.Pre-administration Protocol:
a. Obtain blood component from blood bank following agency
protocol. Blood transfusion must be initiated within 30 minutes after
release from laboratory or blood bank (INS, 2011a).
b. Check blood bag for any signs of contamination (i.e.,
clumping/clots, gas bubbles, purplish color) and presence of leaks.
c. Verbally compare and correctly verify patient, blood product, and
type with another person considered qualified by your agency (e.g.,
RN or LPN) before initiating transfusion. Check the following:
i. Identify patient using two identifiers (i.e., name and birthday or
name and account number) according to agency policy. Compare
identifiers in MAR/medical record with information on patient’s
identification bracelet and/or ask patient to state name.
ii. Transfusion record number and patient’s identification number
match.
iii. Patient’s name is correct on all documents. Check identification
number and date of birth on identification band and patient record.
iv. Check unit number on blood bag with blood bank form to ensure
that they are the same.
v. Blood type matches on transfusion record and blood bag. Verify
that component received from blood bank is same component that
health care provider ordered (e.g., packed red cells, platelets) (see
illustration).
vi. Check that patient’s blood type and Rh type are compatible with
donor blood type and Rh type (e.g., Patient A+: Donor A+ or 0+).
vii. Check expiration date and time on unit of blood.
viii. Just before initiating transfusion, check patient identification
information with blood unit label information (see illustration). Do
not administer blood to patient without an identification bracelet.
ix. Both individuals verify patient and unit identification record
process as directed by agency policy.
d. Review purpose of transfusion and ask patient to report any
changes that he or she may feel during the transfusion.
e. Empty urine drainage collection container or have patient void.

1.Administration:
a. Perform hand hygiene. Apply clean gloves.
b. Open Y-tubing blood administration set for single unit. Use
multiset if multiple units are to be transfused.
c. Set all clamp(s) to “off” position.
d. Spike 0.9% normal saline IV bag with one of Y-tubing spikes.
Hang bag on IV pole and prime tubing. Open upper clamp on normal
saline side of tubing and squeeze drip chamber until fluid covers
filter and one third to one half of drip chamber.
e. Maintain clamp on blood product side of Y-tubing in “off”
position. Open common tubing clamp to finish priming tubing to
distal end of tubing connector. Close tubing clamp when tubing is
filled with saline. All three tubing clamps should be closed. Maintain
protective sterile cap on tubing connector.
f. Prepare blood component for administration. Gently agitate blood
unit bag, turning back and forth, upside down. Remove protective
covering from access port. Spike blood component unit with other Y
connection. Close normal saline clamp above filter, open clamp
above filter to blood unit, and prime tubing with blood. Blood will
flow into drip chamber. Tap filter chamber to ensure that residual air
is removed.
g. Maintaining asepsis, attach primed tubing to patient’s VAD. Open
common tubing clamp and regulate blood infusion to allow only 2
mL/min to infuse in initial 15 minutes.
h. Remain with patient during first 15 minutes of transfusion. Initial
flow rate during this time should be 2 mL/min or 20 gtt/min (using
macrodrip of 10 gtt/mL).
i. Monitor patient’s vital signs at 5 minutes, 15 minutes, and every 30
minutes until 1 hr after transfusion (AABB, 2011) or per agency
policy.
j. If there is no transfusion reaction, regulate rate of transfusion
according to health care provider’s orders. Check drop factor for
blood tubing.
k. After blood has infused, clear IV line with 0.9% normal saline and
discard blood bag according to agency policy. When consecutive
units are ordered, maintain IV patency with 0.9% normal saline at
keep vein open (KVO) rate and retrieve subsequent unit for
administration.
l. Appropriately dispose of all supplies. Remove gloves and perform
hand hygiene.

EVALUATION
1. Observe IV site and status of infusion each time vital signs are
taken.
2. Observe for any changes in vital signs and any signs of transfusion
reactions such as chills, flushing, itching, dyspnea, or rash.
3. Observe patient and assess laboratory values to determine response
to administration of blood component.
4. Documentation:
• Record pretransfusion medications, vital signs, location and
condition of IV site, and patient education.
• Record the type and volume of blood component, blood unit/
donor/recipient identification, compatibility, and expiration
date according to agency policy, along with patient’s response
to therapy. Document on the transfusion record, nurses’ notes,
electronic health record (EHR), medication administration
record, flow sheet, and/or intake and output sheet, depending
on agency policy.
• Record volume of normal saline and blood component
infused.
• Report signs and symptoms of a transfusion reaction
immediately to the health care provider.
• Record amount of blood received by autotransfusion and
patient’s response to therapy.
• Report to health care provider any intratransfusion/
posttransfusion deterioration in cardiac, pulmonary, and/or
renal status.
• Record vital signs before, during, and after transfusion.
Name: _________________________________________________ Section____________________________
Clinical Instructor (Lecture Demo): __________________________ Date of Lecture Demo________________

Nasogastric Tube Insertion (Infant and Older Children)

Basic Concept: A long, thin and hollow tube called nasogastric tube is passed or introduced through the nostril,
into the throat down in the stomach.
Objectives:
1. To administer medications or supplemental Fluids
2. To give feedings.
3. To remove fluid and gas or decompression.
4. To irrigate or lavage stomach.
5. To prevent nausea and gastric distention following surgery.
Materials/ Equipment:
Naso gastric Tube
Non-Sterile gloves
Sterile water- or water-soluble lubricating jelly
Hypoallergenic Adhesive Tape
Marking Pen ( Optional)
Feeding Tube
Ph paper/strip
Small towel
Tray

Preparation:

1. Check doctor’s Order for inspection

2. Explain the procedure to the patient and or family caregiver
3. Wash Hands
4. Gather needed materials
5. Insert Tube before feeding to prevent risk of aspiration
6. Determine the appropriate nostril to insert the tube. Select nostril without obstruction or more patent
7. Assess for the degree of assistance needed.
 STEPS RATIONALE
1. Position the infant in supine position with towel or
pillow under the shoulders. (Feeding)
Position the infant in a sitting position, if possible
2. Place towel over chest of the child.
3. Put on gloves
4. Do not hyperextend or hyperflex the infant’s neck
5. Determine the length of tubing to use by measuring
from the tip of the nose, to the earlobe down midway
between the umbilicus and xiphoid process.
6. Mark the length on the tube with tape or a marking
tape.
7. Lubricate the end of the tube to be inserted with
water soluble lubricating jelly.
8. Insert tube nasally. Advance tube if resistance is felt
stop advancing the tube.
9. Check tube that it is not coiled in the pharynx or
mouth, if tube is coiled, pull back the tube.
10. Confirm placement by radiologic confirmation. If X-
Ray is not possible ,check placement by aspiration
of gastric contents and the color of aspirated fluid;
checking the ph.
A. Aspirate 3-5 ml of gastric contents for neonate
and 20-50ml for children.
B. Observe color aspirated (Grassy Green-white or
tan color)
C. Check ph using the strip
11. Secure the placement on child’s nose
12. Further secure tubing by placing tube cheek or
behind the ear
13. Document procedure and care rendered including
the size, length of the tube inserted and length of
visible tubing.
Name: _________________________________________________ Section____________________________
Clinical Instructor (Return Demo): __________________________ Date of Return Demo________________

PERFORMANCE CHECKLIST
Infant NGT Insertion
Criteria for evaluation or rating the student’s performance:
1 - Performs the step or procedure independently, correctly and appropriately. Shows excellent attitude and gives
the correct rationale of the step/ procedure to be performed. Answers the question/s correctly and analyzes the
situation on or before performing the procedure.
2 – Performs more independently with increasing dependability but occasionally needing assistance. Shows very
satisfactory attitude and gives the correct rationale of the step/ procedure to be performed but occasionally needing
follow-up instructions and explanations.
3 – Performs expected step/ procedure but needs supervision, follow-up instructions and explanations. Has
knowledge about the topic, step or procedure but needs reinforcement.
4 – Performs with close supervision. The student needs repeated, specific, detailed guidance and direction to be
able to perform the step/ procedure correctly and appropriately. There is a need to improve performance.
5 – Performs with very close supervision. The student shows poor or no interest in the step/ procedure to be
performed; cannot answer the question raised by the supervising clinical instructor based on the step or procedure
to be performed; unable to grasp understanding of the topic or procedure; unable to perform the required step and
state the rationale after being instructed, guided or directed. Student’s behavior is inappropriate and potentially
harmful to the client.
1 2 3 4 5
ASSESSMENT
1. Check doctor’s order for insertion
2. Determines the appropriate nostril to insert the tube. Selects the nostril without
obstruction or more patent
3. Assess for the degree of assistance needed
PLANNING
1. Check doctor’s Order for inspection
2. Explain the procedure to the patient and or family caregiver
3. Wash Hands
4. Gather needed materials
5. Insert Tube before feeding to prevent risk of aspiration
6. Determine the appropriate nostril to insert the tube. Select nostril without
obstruction or more patent
7. Assess for the degree of assistance needed.
IMPLEMENTATION
1. Positions the infant in supine position with towel or pillow under the
shoulders. (Feeding)
Position the infant in a sitting position, if possible
2. Places towel over chest of the child.
3. Puts on gloves
4. Does not hyperextend or hyperflex the infant’s neck
5. Determines the length of tubing to use by measuring from the tip of the nose,
to the earlobe down midway between the umbilicus and xiphoid process.
6. Marks the length on the tube with tape or a marking tape.
7. Lubricates the end of the tube to be inserted with water soluble lubricating
jelly.
8. Inserts tube nasally. Advance tube if resistance is felt stop advancing the tube.
 9. Checks tube that it is not coiled in the pharynx or mouth, if tube is coiled,
pull back the tube.
10. Observes for change in color, coughing or gasping
11. Confirms placement by radiologic confirmation. If X-Ray is not possible,
check placement by aspiration of gastric contents and the color of aspirated
fluid; checking the ph.
A. Aspirate 3-5 ml of gastric contents for neonate and 20-50ml for children.
B. Observe color aspirated (Grassy Green-white or tan color)
C. Check ph using the strip
12. Secures the placement on child’s nose using adhesive tape, to the cheek and
insert it to the back of the ear
13. Removes gloves and wash hands
14. Document procedure and care rendered including the size, length of the tube
inserted and length of visible tubing.
EVALUATION
6. Applies previously learned concepts and principles
7. Performs the procedure with ease and deftness
8. Displays a positive attitude of an Urian student nurse (punctual, prepared,
caring and confident, etc)
9. Keeps the patient safe throughout the performance of procedure
10. Has kept the patient free from injury or complication

Comments:

Rating: ______

________________________________________
Signature Over Printed Name of CI
Name: _________________________________________________ Section____________________________
Clinical Instructor (Lecture Demo): __________________________ Date of Lecture Demo________________

Nasogastric Tube Feeding

Basic Concept: NGT feeding is the introduction of formula, solution, supplemental fluids or medications through
the inserted nasogastric tube.
Objectives:
1. To restore and maintain nutritional status
2. To administer medication
Materials/Equipment:

1. Feeding tube/ Catheter Tip syringe

2. Prescribed amount and type of feeding formula or solution
3. Prescribed medication
4. Kidney Basin
5. Gloves
6. Ph Strips
7. Water

Preparation:

1. Check doctor’s Order for formula, rate, route and frequency of feeding
2. Explain the procedure to the patient and or family caregiver
3. Assess the bowel sounds, any problem that suggest lack of tolerance from previous feeding and for any
food allergies.
4. Assess the mucosal irritation
5. Determine degree of assistance
6. Prepare tube feeding at room temperature. Check the date of expiration
7. Swaddle Baby as necessary
 STEPS RATIONALE
1. Verify client’s identity
2. Assist side lying with head chest slight elevated or
Elevate the crib
Elevate the head and shoulder by placing a rolled
towel behind the neck
Turn baby into right position if possible
Position infant into your lap.
3. Put on gloves
4. Pinch the proximal end of the naso gastric tube and
attach or insert the feeding tube.
5. Assess the tube placement
A. ASPIRATE GASTRIC CONTENT
B. CHECKING THE PH
C. CHECK THE LENGTH OF TUBE INSERTED
WITH THE INSERTION MARK.
6. Measure and return aspirated stomach content. In a
very small child Subtract this amount from the
amount ordered for that particular feeding.
7. Infuse feeding
A. Fill syringe with measured amount if formula
B. Release the tube and hold above 6-8 inches above
the tube point of insertion
C. Refill and repeat until prescribed amount has been
delivered.
D. Slowly administer feeding over 15-30 minutes
8. Offer Pacifier
9. Observe sign of distress (grasping air or cough)
10. Flush with5ml of water tube
11. Clamp the naso gastric tube before water is infused
12. Burp the infant
13. Position Right side for atleast 1 hour
14. Discard any left over feeding at the completion of the
procedure
15. Observe condition of child after feeding
16. Note any vomiting or abdominal distention
17. Note activity of the infant
18. Remove gloves
19. Document the following
A. Date and Time of feeding
B. Verify method of placement and tube patency
C. Type and amount of content aspirated
D. Type and amount of feeding given
E. Childs response or tolerance of procedure
F. Position of child following feeding.
Name: _________________________________________________ Section____________________________
Clinical Instructor (Return Demo): __________________________ Date of Return Demo________________

PERFORMANCE CHECKLIST
Infant NGT Feeding
Criteria for evaluation or rating the student’s performance:
1 - Performs the step or procedure independently, correctly and appropriately. Shows excellent attitude and gives
the correct rationale of the step/ procedure to be performed. Answers the question/s correctly and analyzes the
situation on or before performing the procedure.
2 – Performs more independently with increasing dependability but occasionally needing assistance. Shows very
satisfactory attitude and gives the correct rationale of the step/ procedure to be performed but occasionally needing
follow-up instructions and explanations.
3 – Performs expected step/ procedure but needs supervision, follow-up instructions and explanations. Has
knowledge about the topic, step or procedure but needs reinforcement.
4 – Performs with close supervision. The student needs repeated, specific, detailed guidance and direction to be
able to perform the step/ procedure correctly and appropriately. There is a need to improve performance.
5 – Performs with very close supervision. The student shows poor or no interest in the step/ procedure to be
performed; cannot answer the question raised by the supervising clinical instructor based on the step or procedure
to be performed; unable to grasp understanding of the topic or procedure; unable to perform the required step and
state the rationale after being instructed, guided or directed. Student’s behavior is inappropriate and potentially
harmful to the client.
1 2 3 4 5
ASSESSMENT
1. Checks doctor’s order for formula, rate, route frequency of feeding
2. Assesses bowel sounds, any problems that suggests lack of tolerance to previous
feeding and for any food allergies
3. Assesses for mucosal irritation
4. Determines degree of assistance needed
5. Checks expiration date for formula feeding
6. Prior to feeding, verify client’s identity
PLANNING
1. Explains the procedure to the family or caregiver
2. Prepares the feeding at room temperature
3. Recalls related principles or concepts
IMPLEMENTATION
1. Verifies client’s identity
2. Assists side lying with head chest slight elevated or
Elevate the crib
Elevate the head and shoulder by placing a rolled towel behind the neck
Turn baby into right position if possible
Position infant into your lap.
3. Puts on gloves
4. Pinches the proximal end of the naso gastric tube and attach or insert the
feeding tube.
5. Assesses the tube placement
A. ASPIRATE GASTRIC CONTENT
B. CHECKING THE PH
C. CHECK THE LENGTH OF TUBE INSERTED WITH THE
INSERTION MARK.
 6. Measures and return aspirated stomach content. In a very small child Subtract
this amount from the amount ordered for that particular feeding.
7. Infuses feeding
A. Fill syringe with measured amount if formula
B. Release the tube and hold above 6-8 inches above the tube point of
insertion
C. Refill and repeat until prescribed amount has been delivered.
D. Slowly administer feeding over 15-30 minutes
8. Offers Pacifier
9. Observes sign of distress (grasping air or cough)
10. Flushes with5ml of water tube
11. Clamps the naso gastric tube before water is infused
12. Burps the infant
13. Positions Right side for atleast 1 hour
14. Discards any leftover feeding at the completion of the procedure
15. Observes condition of child after feeding
16. Note any vomiting or abdominal distention
17. Note activity of the infant
18. Remove gloves
19. Document the following
A. Date and Time of feeding
B. Verify method of placement and tube patency
C. Type and amount of content aspirated
D. Type and amount of feeding given
E. Childs response or tolerance of procedure
F. Position of child following feeding.

EVALUATION
1. Applies previously learned concepts and principles
2. Performs the procedure with ease and deftness
3. Displays a positive attitude of an Urian student nurse (punctual, prepared,
caring and confident, etc)
4. Keeps the patient safe throughout the performance of procedure
5. Has kept the patient free from injury or complication
Comments:

Rating: ______

________________________________________
Signature Over Printed Name of CI
Name: _________________________________________________ Section____________________________
Clinical Instructor (Lecture Demo): __________________________ Date of Lecture Demo________________

INFANT BASIC LIFE SUPPORT (BLS)

Basic Concept
Basic Life Support is the level of medical care which is used for victims of life-threatening illnesses or injuries
until they can be given full medical care at the hospital
Cardiopulmonary Resuscitation is a combination of techniques; including chest compressions, designed to
pump the heart to get blood circulating and deliver oxygen to the brain until definitive treatment can stimulate
the heart to start working again.
If the heart stops pumping, it is known as cardiac arrest
Assessment:
1. Scene size up
2. Initial observation or investigation of what happened
3. Check for medical tags for indications of allergies or contraindications
4. If not sure of the incident’s history assume all patient has spine injury
5. Rescuer’s safety is priority

PROCEDURE RATIONALE

1. Verify if the scene is safe by quickly scanning the

infant’s location and surrounding for imminent
threats such as toxic and electrical hazards.

2. Assess the infant to determine whether he or she is

responsive. Gently tap the infant’s foot and ask
loudly, “Are you okay?” Call out the infant’s
name if you know it. If the infant is unresponsive,
activate the emergency response system

3. Check to see whether the infant is apneic or only

gasping and simultaneously check for a pulse. To
check for a pulse, palpate the brachial artery,
located inside the infant’s upper arm between the
elbow and shoulder. Palpate for no longer than 10
seconds.

4. If breathing is absent or the infant is only gasping

and you don’t feel a within 10 seconds or the pulse
rate is less than 60 beats per minute and the infant
has signs of poor perfusion, such as pallor,
cyanosis or mottling, place the infant in supine
position on a firm, flat surface and begin chest
compressions.
1-RESCUER CPR
1. Perform Chest Compressions
a. To begin chest compressions, place two fingers in
the center of the infant’s chest just below the
nipple line. Push hard and fast. Depress the
sternum at least one-third of the anterior-posterior
chest diameter, approximately 1 ½ “ (4cm) at a
rate of 100 to 120 compressions per minute.
Compression to breaths ratio for infants is 30:2
for one-rescuer CPR.

5. When performing chest compressions, take care to

ensure smooth motions and allow the chest to
recoil after each compression. Keep your fingers
on the infant’s chest at all times.
6. Minimize interruptions in chest compressions

B. Rescue Breathing
When performing rescue breathing on an infant, the
rescuer should cover the infant’s mouth and nose:

1. Open the airway using the head-tilt/chin-lift

maneuver. Be sure not to hyper-extend the
neck. However, if a cervical fracture is suspected,
open the airway using jaw thrust maneuver.
2. Create a seal using your lips to surround the
infant’s nose and mouth
3. Gently blow into the infant’s nose and mouth for
one second . If you cannot see the chest rise, re-
adjust the tilt of their head.
4. Give an additional breath and watch for the
infant’s chest to rise.
5. Give an additional breath and watch for the chest
to rise

2 –RESCUER CPR
Rescuer 1: Chest Compressions
1. To begin chest compressions, use the two-thumbs
encircling hands technique. Push hard and fast.
Depress the sternum at least one-third of the
anterior-posterior chest diameter, usually 1 ½ “
(4cm) at a rate of 100 to 120 compressions per
minute. Compression to breaths ratio for infants is
15:2 for two-rescuer CPR.
2. When performing chest compressions, take care to
ensure smooth motions and allow the chest to
recoil after each compression. Keep your fingers
on the infant’s chest at all times.
3. Minimize interruptions in chest compressions
 Rescuer 2: Rescue Breathing
1. Place the bag-valve- mask over the infant’s mouth
and nose.
2. Open the airway by performing the head-tilt/chin-
lift maneuver. However, if a cervical fracture is
suspected, open the airway using jaw thrust
maneuver.
3. Ensure a good seal between the mask and face
using the E-C clamp technique. Three fingers of
one hand lift the jaw (they form the “E”) while the
thumb and index finger hold the mask to the face
making a (“C”)
4. Squeeze the bag to give breaths (1 sec
each) while watching for chest rise. Deliver all
breaths over 1 sec.
5. Deliver breaths that produce visible chest rise
6. Avoid excessive ventilation
7. Switch roles with the first rescuer every two
minutes to minimize fatigue, taking less than 5
seconds to do the switch.
When to STOP CPR:
S- Patient Starts breathing and has a pulse
T- Transferred to EMT
O- You are Out of strength
P- Physician declares patient dead
Name: _________________________________________________ Section____________________________
Clinical Instructor (Return Demo): __________________________ Date of Return Demo________________

PERFORMANCE CHECKLIST
INFANT BASIC LIFE SUPPORT (BLS)

Criteria for evaluation or rating the student’s performance:

1 - Performs the step or procedure independently, correctly and appropriately. Shows excellent attitude and gives
the correct rationale of the step/ procedure to be performed. Answers the question/s correctly and analyzes the
situation on or before performing the procedure.
2 – Performs more independently with increasing dependability but occasionally needing assistance. Shows very
satisfactory attitude and gives the correct rationale of the step/ procedure to be performed but occasionally needing
follow-up instructions and explanations.
3 – Performs expected step/ procedure but needs supervision, follow-up instructions and explanations. Has
knowledge about the topic, step or procedure but needs reinforcement.
4 – Performs with close supervision. The student needs repeated, specific, detailed guidance and direction to be
able to perform the step/ procedure correctly and appropriately. There is a need to improve performance.
5 – Performs with very close supervision. The student shows poor or no interest in the step/ procedure to be
performed; cannot answer the question raised by the supervising clinical instructor based on the step or procedure
to be performed; unable to grasp understanding of the topic or procedure; unable to perform the required step and
state the rationale after being instructed, guided or directed. Student’s behavior is inappropriate and potentially
harmful to the client.
1 2 3 4 5
ASSESSMENT/PLANNING
1. Scene size up
2. Initial observation or investigation of what happened
3. Check for medical tags for indications of allergies or contraindications
4. If not sure of the incident’s history assume all patient has spine injury
5. Rescuer’s safety is priority
IMPLEMENTATION
1. Verifies if the scene is safe by quickly scanning the infant’s location and
surrounding for imminent threats such as toxic and electrical hazards.
2. Assesses the infant to determine whether he or she is responsive. Gently tap
the infant’s foot and ask loudly, “Are you okay?” Call out the infant’s name
if you know it. If the infant is unresponsive, activate the emergency
response system
3. Checks to see whether the infant is apneic or only gasping and
simultaneously check for a pulse. To check for a pulse, palpate the brachial
artery, located inside the infant’s upper arm between the elbow and
shoulder. Palpate for no longer than 10 seconds.
4. If breathing is absent or the infant is only gasping and you don’t feel a
within 10 seconds or the pulse rate is less than 60 beats per minute and the
infant has signs of poor perfusion, such as pallor, cyanosis or mottling,
place the infant in supine position on a firm, flat surface and begin chest
compressions.
1-RESCUER CPR
a.Performs Chest Compressions
b.To begin chest compressions, place two fingers in the center of the
infant’s chest just below the nipple line. Push hard and fast. Depress the
sternum at least one-third of the anterior-posterior chest diameter,
approximately 1 ½ “ (4cm) at a rate of 100 to 120 compressions per
minute. Compression to breaths ratio for infants is 30:2 for one-rescuer
CPR.

5. When performing chest compressions, take care to ensure smooth motions

and allow the chest to recoil after each compression. Keep your fingers on
the infant’s chest at all times.
6. Minimize interruptions in chest compressions

B. Rescue Breathing
When performing rescue breathing on an infant, the rescuer should cover the
infant’s mouth and nose:

7. Open the airway using the head-tilt/chin-lift maneuver. Be sure not to

hyper-extend the neck. However, if a cervical fracture is suspected, open the
airway using jaw thrust maneuver.
8. Create a seal using your lips to surround the infant’s nose and mouth
9. Gently blow into the infant’s nose and mouth for one second . If you cannot
see the chest rise, re-adjust the tilt of their head.
10. Give an additional breath and watch for the infant’s chest to rise.
11. Give an additional breath and watch for the chest to rise

2 –RESCUER CPR
Rescuer 1: Chest Compressions
12. To begin chest compressions, use the two-thumbs encircling hands
technique. Push hard and fast. Depress the sternum at least one-third of the
anterior-posterior chest diameter, usually 1 ½ “ (4cm) at a rate of 100 to 120
compressions per minute. Compression to breaths ratio for infants is 15:2
for two-rescuer CPR.
13. When performing chest compressions, take care to ensure smooth motions
and allow the chest to recoil after each compression. Keep your fingers on
the infant’s chest at all times.
14. Minimize interruptions in chest compressions

Rescuer 2: Rescue Breathing

15. Place the bag-valve- mask over the infant’s mouth and nose.
16. Open the airway by performing the head-tilt/chin-lift maneuver. However,
if a cervical fracture is suspected, open the airway using jaw thrust
maneuver.
17. Ensure a good seal between the mask and face using the E-C clamp
technique. Three fingers of one hand lift the jaw (they form the “E”) while
the thumb and index finger hold the mask to the face making a (“C”)
18. Squeeze the bag to give breaths (1 sec
each) while watching for chest rise. Deliver all breaths over 1 sec.
19. Deliver breaths that produce visible chest rise
20. Avoid excessive ventilation
Switch roles with the first rescuer every two minutes to minimize fatigue, taking less
than 5 seconds to do the switch.
 1 2 3 4 5
EVALUATION
1. Applies previously learned concepts and principles
2. Performs the procedure with ease and deftness
3. Displays a positive attitude of an Urian student nurse (punctual, prepared,
caring and confident, etc)
4. Keeps the patient safe throughout the performance of procedure
5. Has kept the patient free from injury or complication
Comments:

Rating: ______

________________________________________
Signature Over Printed Name of CI
Name: _________________________________________________ Section____________________________
Clinical Instructor (Lecture Demo): __________________________ Date of Lecture Demo________________

Caring for a Patient on Isolation Precaution (CD TECHNIQUE)

Basic Concept: Isolation Precaution is the second tier of the prevention isolation guidelines (CDC,2007), which
are based on the mode of transmission of the disease. Isolation precautions or transmission based precautions
are categorized to airborne, droplet and contact precautions. The category determines the choice of barrier
devices or protection that health worker needs. It includes the appropriate use of personal protective equipment
(PPE) such as gowns, gloves, masks, eyewear and other protective devices or clothing.
Objectives:
1. To prevent and control infection and its spread.
2. To reduce and/or eliminate sources and transmission of infection.
3. To help protect client and health care provider from disease.
Materials/Equipment:
Soap in soap dish or liquid soap in dispenser
Paper towel
Clean gown
Disposable gloves
Eyewear or goggles / Face shield
Bonnet
Clean tissue
IV stand
Trash Bag
Puncture-proof container/hub

Preparation:
1. Assess isolation indication.
2. Review agency policies and precautions necessary for specific isolation systems and consider measures
you will perform while in the patient’s room.
3. Review nurse’s notes or speak with colleagues regarding patient’s emotional state and adjustment to
isolation.
4. Assess client’s knowledge and significant others for the need to wear a gown and gloves during the care.
5. Perform hand hygiene and prepare all equipment needed to take into patient’s room.
6. Prepare for entrance in the isolation room.
IMPLEMENTATION
Steps Rationale
1. Put on the bonnet applying the correct
technique, being sure to tuck hair under the
bonnet.
2. Apply either surgical mask or respirator
around mouth and nose.
If needed apply eyewear or goggles snugly
around eyes and face. If prescription glasses
are worn, side shield may be used.
3. Apply cover gown, being sure that it covers
all outer garments.
4. Pull sleeves down to wrist.
5. Tie securely at neck and waist.
6. Apply clean gloves over gown sleeves.
7. Enter patient’s room.
Use clean tissue to open the door knob.
8. Explain purpose of isolation and necessary
precautions to patient and family.
9. Offer opportunity to ask questions.
10. Assess for evidence of emotional problems
that occur from isolation.
11. Arrange supplies and equipment for use. If
equipment will be removed for reuse, place
clean paper towel.
12. Assess vital signs.
a. If patient is infected or colonized with
resistant organism, equipment remains in
the room whenever possible. This
includes stethoscope and BP cuff.
b. If the stethoscope is to be reused, clean
diaphragm or bell with alcohol. Set aside
on clean surface.
c. Use individual or electronic or disposable
thermometer. If disposable thermometer
indicates a fever, assess for other
signs/symptoms. Confirm fever using
electronic thermometer.
13. Administer medications
a. Give oral medications in wrapper or cup.
b. Dispose of wrapper or cup in plastic lined
receptacle.
c. Administer injection.
d. Discard safely needle in sharp containers
and syringe in appropriate receptacle.
14. Administer hygiene, encouraging patient to
discuss questions or concerns about isolation.
Provide informal teaching at this time.
a. Avoid allowing gown to become wet.
b. Avoid leaning over from wet surfaces.
c. Remove linen from bed; avoid contact
with gown. Place inlinen baf according to
agency policy.
d. Remove gloves and perform hand
hygiene. Wear another gloves, if further
care is necessary.
15. Collect specimens.
a. Place specimen containers on clean paper
towel in patient’s bathroom. Follow
procedure for collecting specimen of body
fluids.
b. Transfer specimen to container without
soiling outside of the container. Place
container in plastic bag and place label on
outside of the bag or per facility policy.
c. Label specimen per facility policy.
d. Perform hand hygiene and wear another
gloves, if additional procedures are
needed.
16. Dispose linens and trash bag as they become
full.
a. Use sturdy, moisture resistant single bags
to contain soiled particles. Use double bag
if outside bag is contaminated.
b. Tie bags securely at top in knot.
17. Remove all reusable pieces of equipment.
Clean any contaminated surfaces with
hospital approved disinfectant.
18. Explain to client when you plan to return to
room. Ask whether client requires any
personal items.
19. Leave isolation room. Remember order of the
removal of protectives barriers depends on
what is worn in room. This sequence
describes steps to take if all barriers were to
be worn.
a. Remove gloves. Remove one glove
grasping cuff and pulling glove inside out
over hand. Discard glove. With ungloved
hand, tuck finger inside cuff of remaining
glove and pull it off, inside out.
b. Untie neck strings, then back strings of
gown. Allow gown to fall from shoulders.
Remove hands from sleeves without
touching outside of gown. Hold gown
inside at shoulder reams and fold inside
out; discard in laundry bag.
c. Untie top mask string and then bottom
strings, pull mask away from face and
drop into trash receptacle (do not touch
outer surface of mask).
d. Remove bonnet and discard.
e. Perform hand hygiene for a minimum 10
seconds.
f. Leave room and close door if necessary.
Door should be closed if client is in
negative airflow room.
20. Do documentation of nursing care rendered to
the patient
Name: _________________________________________________ Section____________________________
Clinical Instructor (Return Demo): __________________________ Date of Return Demo________________

PERFORMANCE CHECKLIST
Caring for a Patient on Isolation Precaution
Criteria for evaluation or rating the student’s performance:
1 - Performs the step or procedure independently, correctly and appropriately. Shows excellent attitude and gives
the correct rationale of the step/ procedure to be performed. Answers the question/s correctly and analyzes the
situation on or before performing the procedure.
2 – Performs more independently with increasing dependability but occasionally needing assistance. Shows very
satisfactory attitude and gives the correct rationale of the step/ procedure to be performed but occasionally needing
follow-up instructions and explanations.
3 – Performs expected step/ procedure but needs supervision, follow-up instructions and explanations. Has
knowledge about the topic, step or procedure but needs reinforcement.
4 – Performs with close supervision. The student needs repeated, specific, detailed guidance and direction to be
able to perform the step/ procedure correctly and appropriately. There is a need to improve performance.
5 – Performs with very close supervision. The student shows poor or no interest in the step/ procedure to be
performed; cannot answer the question raised by the supervising clinical instructor based on the step or procedure
to be performed; unable to grasp understanding of the topic or procedure; unable to perform the required step and
state the rationale after being instructed, guided or directed. Student’s behavior is inappropriate and potentially
harmful to the client.

Steps 1 2 3 4 5
Assessment/Preparation:
1. Assesses isolation indication.
2. Reviews agency policies and precautions necessary for specific
isolation systems and consider measures you will perform while in
the patient’s room.
3. Reviews nurse’s notes or speak with colleagues regarding
patient’s emotional state and adjustment to isolation.
4. Assesses client’s knowledge and significant others for the need to
wear a gown and gloves during the care.
5. Performs hand hygiene and prepare all equipment needed to take
into patient’s room.
6. Prepares for entrance in the isolation room.
Implementation
1. Puts on the bonnet applying the correct technique, being sure to
tuck hair under the bonnet.
2. Applies either surgical mask or respirator around mouth and nose.
If needed apply eyewear or goggles snugly around eyes and
face. If prescription glasses are worn, side shield may be
used.
3. Applies cover gown, being sure that it covers all outer garments.
4. Pulls sleeves down to wrist.
5. Tied securely at neck and waist.
6. Applied clean gloves over gown sleeves.
7. Enters patient’s room. Uses clean tissue to open the door knob.
8. Explains purpose of isolation and necessary precautions to patient
and family.
9. Offers opportunity to ask questions.
10. Assesses for evidence of emotional problems that occur from
isolation.
11. Arranges supplies and equipment for use. If equipment will be
removed for reuse, place clean paper towel.
12. Assesses vital signs.
a. If patient is infected or colonized with resistant organism,
equipment remains in the room whenever possible. This includes
stethoscope and BP cuff.
b. If the stethoscope is to be reused, clean diaphragm or bell with
alcohol. Set aside on clean surface.
c. Use individual or electronic or disposable thermometer. If
disposable thermometer indicates a fever, assess for other
signs/symptoms. Confirm fever using electronic thermometer.
13.Administers medications
a. Give oral medications in wrapper or cup.
b. Dispose of wrapper or cup in plastic lined receptacle.
c. Administer injection.
d. Discard safely needle in sharp containers and syringe in
appropriate receptacle.
14.Administers hygiene, encouraging patient to discuss questions or
concerns about isolation. Provide informal teaching at this time.
a. Avoid allowing gown to become wet.
b. Avoid leaning over from wet surfaces.
c. Remove linen from bed; avoid contact with gown. Place inlinen
baf according to agency policy.
d. Remove gloves and perform hand hygiene. Wear another gloves,
if further care is necessary.
15.Collects specimens.
a. Place specimen containers on clean paper towel in patient’s
bathroom. Follow procedure for collecting specimen of body fluids.
b. Transfer specimen to container without soiling outside of the
container. Place container in plastic bag and place label on outside
of the bag or per facility policy.
c. Label specimen per facility policy.
16.Performs hand hygiene and wear another gloves, if additional
procedures are needed.
17.Disposes linens and trash bag as they become full.
a. Use sturdy, moisture resistant single bags to contain soiled
particles. Use double bag if outside bag is contaminated.
b. Tie bags securely at top in knot.
c. Remove all reusable pieces of equipment. Clean any contaminated
surfaces with hospital approved disinfectant.
18.Explains to client when you plan to return to room. Ask whether
client requires any personal items.
19.Leaves isolation room. Remember order of the removal of
protectives barriers depends on what is worn in room. This sequence
describes steps to take if all barriers were to be worn.
20.Removes gloves. Remove one glove grasping cuff and pulling
glove inside out over hand. Discard glove. With ungloved hand, tuck
finger inside cuff of remaining glove and pull it off, inside out.
21.Unties neck strings, then back strings of gown. Allow gown to
fall from shoulders. Remove hands from sleeves without touching
outside of gown. Hold gown inside at shoulder reams and fold inside
out; discard in laundry bag.
22.Unties top mask string and then bottom strings, pull mask away
from face and dropped into trash receptacle (do not touch outer
surface of mask).
23.Removes bonnet and discard.
24.Performs hand hygiene for a minimum 10 seconds.
25.Leaves room and close door if necessary. Door should be closed
if client is in negative airflow room.
26.Does documentation of nursing care render to the patient
EVALUATION
1.Applies previously learned concepts and principles
2.Performs the procedure with ease and deftness
3.Displays a positive attitude of an Urian student nurse (punctual,
prepared, caring and confident, etc)
4.Keeps the patient safe throughout the performance of procedure
5.Has kept the patient free from injury or complication

Comments:

Rating: ______

________________________________________
Signature Over Printed Name of CI