SCHOOL OF NURSING

NURSING
MANUAL OF
CLINICAL
NCMPROCEDURES
1237: FUNDAMENTALS OF NURSING
RELATED LEARNING EXPERIENCE (RLE)

LEVEL 1

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 ATENEO DE DAVAO UNIVERSITY
STRONG IN FAITH THAT DOES JUSTICE
VISION

The Ateneo de Davao University is a Catholic, Jesuit, and Filipino University.

As a university it is a community engaged in excellent instruction and formation, robust
research, and vibrant community service.
As Catholic, it proceeds ex corde ecclesiae, from the heart of the Church.
As Jesuit, it appropriates the mission of the Society of Jesus and the spirituality of St. Ignatius
of Loyola.
As Filipino, it contributes to and serves Mindanao.

MISSION

It participates in the reconciliation by the Father

of humanity with Himself
of human beings with one another,
of humanity with the environment.
It strengthens faith. It promotes humane humanity.
It engages in intercultural, interreligious,
and inter-ideological dialogue especially in Mindanao.
It responds to the needs of the Bangsamoro, the Bangsamoro Autonomous Region in Muslim
Mindanao,
as well as the needs of Lumad communities.
It promotes the creation of wealth and its equitable distribution.
It strengthens its science and technology instruction, research, and technopreneurship in
Mindanao.
It promotes cultural understanding and friendship with its Asian neighbors.
It promotes lifelong learning and the dialogue between academe and the world of work.
It protects and promotes the environment as “our common home.”
It develops ADDU sui generis leaders who appropriate this mission for life.
It treasures and works with its alumni.

TABLE OF CONTENTS

Foreword -------------------------------------------------------------------------------------------------------- iii

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RLE Policies (Level 1) ----------------------------------------------------------------------------------------- iv

PROMOTING ASEPSIS & PREVENTING INFECTION------------------------------------------------ 1

Promoting Asepsis & Preventing Infection--------------------------------------------------------- 2
Hospital Housekeeping ------------------------------------------------------------------------------- 9
Care of Hospital Equipment-------------------------------------------------------------------------- 11
Medical Handwashing -------------------------------------------------------------------------------- 14
Donning and Doffing of Gloves (Open Method) --------------------------------------------- 17
Environment and Patient Safety ------------------------------------------------------------------- 18

ACTIVITY AND EXERCISE --------------------------------------------------------------------------------- 23

Body Mechanics and Positioning-------------------------------------------------------------------- 24
Assisting the Client with Ambulation--------------------------------------------------------------- 26
Range of Motion Exercises--------------------------------------------------------------------------- 27
Transfer Skills------------------------------------------------------------------------------------------ 30
Katz Index of Independence in Activities of Daily Living --------------------------------------- 25

Barthel Index ----------------------------------------------------------------------------------------- 37

FACILITATING HYGIENE, PROMOTING REST & SLEEP, THERMOREGULATION----------- 42

Bedmaking--------------------------------------------------------------------------------------------- 43
 Unoccupied ---------------------------------------------------------------------------------- 44

 Obstetric (OB) Bed-------------------------------------------------------------------------- 45

 Surgical Bed---------------------------------------------------------------------------------- 46
 Occupied Bed ------------------------------------------------------------------------------- 46
 Stripping-------------------------------------------------------------------------------------- 48
Hygiene ------------------------------------------------------------------------------------------------ 49
 Shampoo in Bed ---------------------------------------------------------------------------- 50
 Cleansing Bed Bath (CBB) ----------------------------------------------------------------- 52
 Tepid Sponge Bath (TSB)------------------------------------------------------------------ 55
 Back Rub and Massage--------------------------------------------------------------------- 56
 Oral Care for Dependent Client ----------------------------------------------------------- 58
 Foot Care------------------------------------------------------------------------------------- 60
 Perineal Care--------------------------------------------------------------------------------- 61
 Hot Sitz Bath--------------------------------------------------------------------------------- 63

ELIMINATION------------------------------------------------------------------------------------------------- 67
Urinary Catheterization ------------------------------------------------------------------------------ 68
Intake and Output Monitoring ---------------------------------------------------------------------- 70
Enema -------------------------------------------------------------------------------------------------- 72

OXYGENATION------------------------------------------------------------------------------------------------ 74
Oxygen therapy --------------------------------------------------------------------------------------- 75
Oxygen Administration
 Administering Oxygen by Nasal Cannula ------------------------------------------------ 76
 Administering Oxygen by Mask ----------------------------------------------------------- 77
Collecting a Sputum Specimen --------------------------------------------------------------------- 78
Tracheostomy Care ---------------------------------------------------------------------------------- 78
Suctioning --------------------------------------------------------------------------------------------- 79
 Oropharynx and Nasopharynx Suctioning ---------------------------------------------- 80
 Suctioning of the Tracheostomy or Endotracheal Tube ------------------------------ 81

VITAL SIGNS-------------------------------------------------------------------------------------------------- 86
Vital Signs --------------------------------------------------------------------------------------------- 87
 Temperature -------------------------------------------------------------------------------- 88
 Pulse------------------------------------------------------------------------------------------ 91
 Respiration ---------------------------------------------------------------------------------- 94
 Blood Pressure ------------------------------------------------------------------------------ 98

PAIN ASSESSMENT------------------------------------------------------------------------------------------ 99
NUTRITION---------------------------------------------------------------------------------------------------- 101
Nasogastric Tube (NGT) Insertion------------------------------------------------------------------ 102

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 Nasogastric Tube Feeding--------------------------------------------------------------------------- 105

MEDICATION ADMINISTRATION----------------------------------------------------------------------- 108

Principles of Medication and Administration------------------------------------------------------ 109
Medication Administration
 Oral and Sublingual Medications ---------------------------------------------------- 115
 Ophthalmic Medications--------------------------------------------------------------- 119
 Otic Medications------------------------------------------------------------------------ 121
 Ear Irrigation --------------------------------------------------------------------------- 122
 Nasal Drops and Inhaled Medications----------------------------------------------- 123
Preparing Injectables
 Preparing Medications from Ampules ----------------------------------------------- 124
 Preparing Medications from Vials ---------------------------------------------------- 125

 Mixing Medications in One Syringe -------------------------------------------------- 126

Administering Parenteral Medication
 Intradermal Administration ----------------------------------------------------------- 128
 Subcutaneous Injections -------------------------------------------------------------- 130
 Intramuscular Injections -------------------------------------------------------------- 132
Starting an IV Line ------------------------------------------------------------------------------------ 133
 Medications via Intravenous thru Tubing-------------------------------------------- 134
 Medications thru Soluset -------------------------------------------------------------- 135

Common Medical Terminologies ------------------------------------------------------------------------------ 136

References ------------------------------------------------------------------------------------------------------- 140

Summary of Return Demonstration Grades ----------------------------------------------------------------- 141

Rubric for Return Demonstration ----------------------------------------------------------------------------- 142

Rubric for Oral Presentation (Simulation) ------------------------------------------------------------------- 143

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 FOREWORD

The Ateneo de Davao University School of Nursing, continuously strive hard

to ensure that the Fundamentals of Nursing Practice, such as expertise in carrying out

clinical procedures are given high priority.

The School of Nursing Manual of Clinical Nursing Procedures illustrates that

clinical procedures are given high priority. Because of some significant changes in the

context of care, nursing health care providers have statutory duty for quality

improvement to further enhance the overall standard of care while reducing variations

in the outcome of services based on what is known to be effective.

Thus, this manual of Clinical Nursing Procedure, a guidance of care, has been

developed. Although setting clear standards for practice is only the first step in clinical

effectiveness, we continually ensure knowledge, skills and attitude. Competence

through making every learning opportunity happen whether in school, hospital and

community settings we go to, this is our way, the Ateneo de Davao University's brand

of commitment to excellence.

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 RELATED LEARNING EXPERIENCE POLICIES
Level 1

STUDENT ATTENDANCE

A. ABSENCE
A student is considered ABSENT for any of the following reasons:
1. Failure to show up for the RLE class
2. Lateness beyond 30 MINUTES after the circle time
3. Unprescribed hair/haircut
4. Unprescribed nursing uniform and shoes

Note:
 Excused absences require medical certificate
 The student may apply/request for a special quiz/Return Demonstration (RD) when
absences are excused and due to any of the following reasons:
1. Illness that requires bed rest
2. Hospitalization
3. Death of an immediate family member (those living with the student in their home)
4. With communicable disease
5. Official school representation

B. TARDINESS
A student is considered late for any of the following reasons:
1. Once the circle time have started and the student is not physically around
2. Arrives after the circle time
3. Lateness not beyond 30 minutes

Note: Three (3) accumulated tardiness is equivalent to one-day absence. These accumulated
number of tardiness are counted to evaluate Failure Debarred (FD)

PRESCRIBED UNIFORM
 Type C Uniform with white socks and shoes
 No tattoos are allowed. Students with tattoos prior to admission to the course, are
required to cover it with white arm sleeves
 No colored hair, mustache and unprescribed haircut are allowed
 Hair, who does not clear the collar, should be tied back
 No other jewelry may be worn except a flat wedding band.
 Body piercing: removal of all nose, lip, and eyebrow rings in all RLE activities
 Nails must be short (fingertip length). NO NAIL POLISH OR NAIL TIPS.

CEILING GRADE
1. In case a student is absent during an RD, the student is entitled to perform the missed
procedure, provided that the rubric grade will be computed on the ceiling grade of 85%
2. Students who will be allowed to present based on the applicable requirements mentioned above
are only those with the following reasons:
a. Illness that requires bed rest
b. Hospitalization
c. Death of an immediate family member (those living with the student in their home)
d. With communicable disease
e. Official school representations

GUIDELINES FOR ORAL SIMULATION

1. As the student approaches the CI, let him/her pick one paper from the set of situations provided.
2. Give the student 5 minutes to identify the needed materials to be used.
3. Allow the student to perform/demonstrate the procedure correctly within 10-15 minutes.
4. CIs can ask questions in between the procedure

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CHEATING DURING MAJOR EXAMS

RLE Major Exams are as follows:

1. Shifting Exams / Periodical Exams
2. Oral Revalida
3. Simulation
4. Case Presentations

Sanctions for cheating in a major exam

1. The student gets a failing grade in the course
2. He/she will be suspended during the succeeding semester. If the student intends to continue
studies in the University, he/she will not be allowed to "cross-enroll" in another school during the
suspension period.
However, if the student chooses to transfer to another school, he/she may be granted "honorable
dismissal" but will not be re-admitted in some future date to finish collegiate studies in the
university.
3. After the suspension, a subsequent violation of the rules on cheating in major examination will
mean a failing mark in the course and dismissal from the university at the end of the school term.

GRADING SYSTEM

Quizzes 30%
Return Demonstration 40%
Examination 30%
------------------------
Total 100%

Average of Prelim + Midterm + Finals = 75%

Simulation grade = 25%
--------------------
FINAL NCM 1237 GRADE

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PROMOTING
ASEPSIS AND
PREVENTING
INFECTION

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 PROMOTING ASEPSIS AND PREVENTING INFECTION

Guidelines
A. Standard Precautions
B. Transmission-based Precautions
 Airborne
 Droplet
 Contact
C. Principles of Infection Control
D. Basic Guidelines to Maintain Surgical Asepsis
E. The Chain of Infection

How Do Infections Occur?

An infection occurs when germs enter the body, increase in number, and cause a reaction of the body.
Three things are necessary for an infection to occur:
1. Source: Places where infectious agents (germs) live (e.g., sinks, surfaces, human skin)
A Source is an infectious agent or germ and refers to a virus, bacteria, or other microbe.
In healthcare settings, germs are found in many places. People are one source of germs including:
 Patients
 Healthcare workers
 Visitors and household members
People can be sick with symptoms of an infection or colonized with germs (not have symptoms of an
infection but able to pass the germs to others).
Germs are also found in the healthcare environment. Examples of environmental sources of germs
include:
 Dry surfaces in patient care areas (e.g., bed rails, medical equipment, countertops, and tables)
 Wet surfaces, moist environments, and biofilms (e.g., cooling towers, faucets and sinks, and
equipment such as ventilators)
 Indwelling medical devices (e.g., catheters and IV lines)
 Dust or decaying debris (e.g., construction dust or wet materials from water leaks)
2. Susceptible Person with a way for germs to enter the body
A susceptible person is someone who is not vaccinated or otherwise immune, or a person with a
weakened immune system who has a way for the germs to enter the body. For an infection to occur,
germs must enter a susceptible person’s body and invade tissues, multiply, and cause a reaction.
Devices like IV catheters and surgical incisions can provide an entryway, whereas a healthy immune
system helps fight infection.
When patients are sick and receive medical treatment in healthcare facilities, the following factors can
increase their susceptibility to infection.
 Patients in healthcare who have underlying medical conditions such as diabetes, cancer, and
organ transplantation are at increased risk for infection because often these illnesses decrease
the immune system’s ability to fight infection.
 Certain medications used to treat medical conditions, such as antibiotics, steroids, and certain
cancer fighting medications increase the risk of some types of infections.
 Lifesaving medical treatments and procedures used in healthcare such as urinary catheters,
tubes, and surgery increase the risk of infection by providing additional ways that germs can
enter the body.
Recognizing the factors that increase patients’ susceptibility to infection allows providers to recognize
risks and perform basic infection prevention measures to prevent infection from occurring.

3. Transmission: a way germs are moved to the susceptible person

Transmission refers to the way germs are moved to the susceptible person.
Germs don’t move themselves. Germs depend on people, the environment, and/or medical equipment to
move in healthcare settings.
There are a few general ways that germs travel in healthcare settings – through contact (i.e., touching),
sprays and splashes, inhalation, and sharps injuries (i.e., when someone is accidentally stuck with a used
needle or sharp instrument).
 Contact moves germs by touch (example: MRSA or VRE). For example, healthcare provider hands
become contaminated by touching germs present on medical equipment or high touch surfaces
and then carry the germs on their hands and spread to a susceptible person when proper hand
hygiene is not performed before touching the susceptible person.

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  Sprays and splashes occur when an infected person coughs or sneezes, creating droplets which
carry germs short distances (within approximately 6 feet). These germs can land on a susceptible
person’s eyes, nose, or mouth and can cause infection (example: pertussis or meningitis).
o Close range inhalation occurs when a droplet containing germs is small enough to
breathe in but not durable over distance.
 Inhalation occurs when germs are aerosolized in tiny particles that survive on air currents
over great distances and time and reach a susceptible person. Airborne transmission can occur
when infected patients cough, talk, or sneeze germs into the air (example: TB or measles), or
when germs are aerosolized by medical equipment or by dust from a construction zone
(example: Nontuberculous mycobacteria or aspergillus).
 Sharps injuries can lead to infections (example: HIV, HBV, HCV) when bloodborne pathogens
enter a person through a skin puncture by a used needle or sharp instrument.
(CDC, 2016)

A. STANDARD PRECAUTIONS

Standard Precautions are used for all patient care. They’re based on a risk assessment and make use of
common-sense practices and personal protective equipment use that protect healthcare providers from
infection and prevent the spread of infection from patient to patient.

✓ Perform hand hygiene

✓ Use personal protective equipment (PPE) whenever there is an expectation of possible

exposure to infectious material
✓ Follow respiratory hygiene/cough etiquette principles

✓ Ensure appropriate patient placement

✓ Properly handle and properly clean and disinfect patient care equipment and
instruments/devices
✓ Clean and disinfects the environment appropriately

✓ Handle textiles and laundry carefully

✓ Follow safe injection practices

✓ Wear a surgical mask when performing lumbar punctures

✓ Ensure health care worker safety including proper handling of needles and other sharps

(CDC, 2016)

Standard precautions are meant to reduce the risk of transmission of bloodborne and other pathogens
from both recognized and unrecognized sources. They are the basic level of infection control
precautions which are to be used, as a minimum, in the care of all patients.

KEY CONCEPT:
➢ To assume that all body fluids and substances are potentially infectious

Components of Standard Precaution

1. Hand Hygiene

Key Elements:

➢ Hand washing (40–60 sec): wet hands and apply soap; rub all surfaces; rinse hands and
dry thoroughly with a single use towel; use towel to turn off faucet.
➢ Hand rubbing (20–30 sec): apply enough antiseptic/disinfectant product to cover all
areas of the hands; rub hands until dry.

Indications:

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 ▪ Before and after any direct patient contact and between patients, whether gloves are
worn or not.
▪ Immediately after gloves are removed.

▪ Before handling an invasive device.

▪ After touching blood, body fluids, secretions, excretions, non-intact skin, and
contaminated items, even if gloves are worn.
▪ During patient care, when moving from a contaminated to a clean body site of the
patient.
▪ After contact with inanimate objects in the immediate vicinity of the patient.

2. Use of Personal Protective Equipment (PPE)

Key Elements:
➢ Gloves

▪ Wear when touching blood, body fluids, secretions, excretions, mucous

membranes, non-intact skin.
▪ Change between tasks and procedures on the same patient after contact with
potentially infectious material.
▪ Remove after use, before touching non-contaminated items and surfaces, and
before going to another patient. Perform hand hygiene immediately after
removal.
➢ Facial protection (eyes, nose, and mouth)

▪ Wear (1) a surgical or procedure mask and eye protection (eye visor, goggles) or
(2) a face shield to protect mucous membranes of the eyes, nose, and mouth
during activities that are likely to generate splashes or sprays of blood, body
fluids, secretions, and excretions.
➢ Gown

▪ Wear to protect skin and prevent soiling of clothing during activities that are
likely to generate splashes or sprays of blood, body fluids, secretions, or
excretions.
▪ Remove soiled gown as soon as possible and perform hand hygiene.

➢ Prevention of needle stick and injuries from other sharp instruments

Use care when:
▪ Handling needles, scalpels, and other sharp instruments or devices.

▪ Cleaning used instruments.

▪ Disposing of used needles and other sharp instruments.

3. Respiratory Hygiene and Cough Etiquette

➢ Persons with respiratory symptoms should apply source control measures:

▪ Cover their nose and mouth when coughing/sneezing with tissue or mask,
dispose of used tissues and masks, and perform hand hygiene after contact with
respiratory secretions.

➢ Health-care facilities should:

▪ Place acute febrile respiratory symptomatic patients at least 1 meter (3 feet)

away from others in common waiting areas, if possible.

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 ▪ Post visual alerts at the entrance to health-care facilities instructing persons with
respiratory symptoms to practice respiratory hygiene/cough etiquette.
▪ Consider making hand hygiene resources, tissues and masks available in
common areas and areas used for the evaluation of patients with respiratory
illnesses.

B. TRANSMISSION-BASED PRECAUTIONS

Transmission-Based Precautions are the second tier of basic infection control and are to be used in
addition to Standard Precautions for patients who may be infected or colonized with certain infectious
agents for which additional precautions are needed to prevent infection transmission.

Airborne Precautions
Use Airborne Precautions for patients known or suspected to be infected with pathogens transmitted by
the airborne route (e.g., tuberculosis, measles, chickenpox, disseminated herpes zoster).
 Source control: put a mask on the patient.
 Ensure appropriate patient placement in an airborne infection isolation room
(AIIR) constructed according to the Guideline for Isolation Precautions. In settings where
Airborne Precautions cannot be implemented due to limited engineering resources, masking the
patient and placing the patient in a private room with the door closed will reduce the likelihood of
airborne transmission until the patient is either transferred to a facility with an AIIR or returned
home.
 Restrict susceptible healthcare personnel from entering the room of patients known or
suspected to have measles, chickenpox, disseminated zoster, or smallpox if other immune
healthcare personnel are available.
 Use personal protective equipment (PPE) appropriately, including a fit-tested NIOSH-
approved N95 or higher-level respirator for healthcare personnel.
 Limit transport and movement of patients outside of the room to medically necessary
purposes. If transport or movement outside an AIIR is necessary, instruct patients to wear a
surgical mask, if possible, and observe Respiratory Hygiene/Cough Etiquette. Healthcare
personnel transporting patients who are on Airborne Precautions do not need to wear a mask or
respirator during transport if the patient is wearing a mask and infectious skin lesions are
covered.
 Immunize susceptible persons as soon as possible following unprotected contact with
vaccine-preventable infections (e.g., measles, varicella or smallpox).

Droplet Precautions
Use Droplet Precautions for patients known or suspected to be infected with pathogens transmitted by
respiratory droplets that are generated by a patient who is coughing, sneezing, or talking.

 Source control: put a mask on the patient.

 Ensure appropriate patient placement in a single room if possible. In acute care hospitals, if
single rooms are not available, utilize the recommendations for alternative patient placement
considerations in the Guideline for Isolation Precautions. In long-term care and other residential
settings, make decisions regarding patient placement on a case-by-case basis considering
infection risks to other patients in the room and available alternatives. In ambulatory settings,
place patients who require Droplet Precautions in an exam room or cubicle as soon as possible
and instruct patients to follow Respiratory Hygiene/Cough Etiquette recommendations.
 Use personal protective equipment (PPE) appropriately. Don mask upon entry into the
patient room or patient space.
 Limit transport and movement of patients outside of the room to medically necessary
purposes. If transport or movement outside of the room is necessary, instruct patient to wear a
mask and follow Respiratory Hygiene/Cough Etiquette.

Contact Precautions
Use Contact Precautions for patients with known or suspected infections that represent an increased risk
for contact transmission

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  Ensure appropriate patient placement in a single patient space or room if available in acute
care hospitals. In long-term and other residential settings, make room placement decisions
balancing risks to other patients. In ambulatory settings, place patients requiring contact
precautions in an exam room or cubicle as soon as possible.
 Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear
a gown and gloves for all interactions that may involve contact with the patient or the patient’s
environment. Donning PPE upon room entry and properly discarding before exiting the patient
room is done to contain pathogens.
 Limit transport and movement of patients outside of the room to medically necessary
purposes. When transport or movement is necessary, cover or contain the infected or colonized
areas of the patient’s body. Remove and dispose of contaminated PPE and perform hand hygiene
prior to transporting patients on Contact Precautions. Don clean PPE to handle the patient at the
transport location.
 Use disposable or dedicated patient-care equipment (e.g., blood pressure cuffs). If
common use of equipment for multiple patients is unavoidable, clean and disinfect such
equipment before use on another patient.
 Prioritize cleaning and disinfection of the rooms of patients on contact precautions
ensuring rooms are frequently cleaned and disinfected (e.g., at least daily or prior to use by
another patient if outpatient setting) focusing on frequently touched surfaces and equipment in
the immediate vicinity of the patient.

C. PRINCIPLES OF BASIC INFECTION CONTROL

1. Microorganisms move on air currents.
2. Microorganisms are transferred from one when one surface to another whenever objects
touch.
3. Microorganisms are transferred by gravity when one item is held above another.
4. Microorganisms are released into the air on droplet nuclei whenever a person breathes or
speaks.
5. Microorganisms move slowly on dry surfaces but quickly through moisture.
6. Proper handwashing removes many of the microorganisms that can be transferred by the
hands from one item to another.
7. Blood-borne infections may be spread to another person through contact between blood and
body substances contain blood-borne organism and open wounds, sores or mucous
membranes and through penetrating injuries with contaminated items.
8. Some body substances, such as feces, urine, nasal secretions, vomitus, and sputum, do not
contain blood-borne organisms, but they may contain such large quantities of bacteria that
their removal through handwashing alone is difficult.

D. PRINCIPLES OF ASEPTIC TECHNIQUE

Asepsis is the freedom from disease-causing microorganisms. To decrease the possibility of transferring
microorganisms from one place to another, aseptic technique
is used.
 Medical asepsis includes all practices intended to confine a specific microorganism to a specific
area, limiting the number, growth, and transmission of microorganisms.
 Surgical asepsis, or sterile technique, refers to those practices that keep an area or object free
of all microorganisms; it includes practices that destroy all microorganisms and spores

1. The patient is the center of the sterile field.

2. Only sterile items are used within the sterile field.

a. Examples of items used.
b. How do we know they are sterile? (Wrapping, label, storage)

3. Sterile persons are gowned and gloved.

a. Always keep hands at waist level and in sight.
b. Keep hands away from the face.
c. Never fold hands under arms.
d. Gowns are considered sterile in front from chest to level of
sterile field, and the sleeves from above the elbow to cuffs.
Gloves are sterile.

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 e. Sit only if sitting for entire procedure.

4. Tables are sterile only at table level.

a. Anything over the edge is considered unsterile, such as a suture or the table drape.
b. Use non-perforating device to secure tubing and cords to prevent them from sliding to the
floor.
5. Sterile persons touch only sterile items or areas; unsterile persons touch only unsterile
items or areas.
a. Sterile team members maintain contact with sterile field by wearing gloves and gowns.
b. Supplies are brought to sterile team members by the circulator, who opens wrappers on sterile
packages. The circulator ensures a sterile transfer to the sterile field. Only sterile items touch
sterile surfaces.

6. Unsterile persons avoid reaching over sterile field; sterile persons avoid leaning over
unsterile area.
a. Scrub person sets basins to be filled at edge of table to fill them.
b. Circulator pours with lip only over basin edge.
c. Scrub person drapes an unsterile table toward self-first to avoid leaning over an unsterile
area. Cuff drapes over gloved hands.
d. Scrub person stands back from the unsterile table when draping it to avoid leaning over an
unsterile area.
7. Edges of anything that encloses
sterile contents are considered
unsterile.
a. When

opening sterile packages, open away from you first. Secure

flaps so they do not dangle.
b. The wrapper is considered sterile to within one inch of the
wrapper.
c. In peel-open packages, the edges where glued, are not
considered sterile.

8. Sterile field is created as close as possible to time of use.

a. Covering sterile tables is not recommended.

9. Sterile areas are continuously kept in view.

a. Sterility cannot be ensured without direct observation. An unguarded sterile field should be
considered contaminated.

10. Sterile persons keep well within sterile area.

a. Sterile persons pass each other back-to-back or front to front.
b. Sterile person faces a sterile area to
pass it.
c. Sterile persons stay within the sterile
field. They do not walk around or go
outside the room.
d. Movement is kept to a minimum to
avoid contamination of sterile items or
persons.

11. Unsterile persons avoid sterile areas.

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 a. Unsterile persons maintain a distance of at least 1 foot from the sterile field.
b. Unsterile persons face and observe a sterile area when passing it to be sure they do not
touch it.
c. Unsterile persons never walk between two sterile fields.
d. Circulator restricts to a minimum all activity near the sterile field.

12. Destruction of integrity of microbial barriers results in contamination.

a. Strike through is the soaking through of barrier from sterile to non-sterile or vice versa.
b. Sterility is event related.

13. Microorganisms must be kept to irreducible minimum.

a. Perfect asepsis is an idea. All microorganisms cannot be eliminated. Skin cannot be sterilized.
Air is contaminated by droplets.

E. BASIC GUIDELINES TO MAINTAIN SURGICAL ASEPSIS

1. Only a sterile object can touch another sterile object. Unsterile touching sterile is
contamination.
2. Open sterile packages so that the first edge of the wrapper is directed away from the worker
to avoid the possibility of a sterile surface touching unsterile clothing. The outside of the
sterile package is considered contaminated.
3. Avoid spilling any solution on a cloth or paper used as a field for a sterile set up. The
moisture penetrates through the sterile cloth or paper and carries organisms by capillary
action to contaminate the field. A wet field is contaminated if the surface immediately below
it is not sterile.
4. Hold sterile objects above the level of the waist. This will help ensure keeping the object
within sight and prevent accidental contamination.
5. Avoid talking, coughing, sneezing, or reaching over a sterile field or object. This will help to
prevent contamination by droplets from the nose and the mouth or by particles dropping
from the worker’s arm.
6. Never walk away from or turn your back on a sterile field. This will prevent possible
contamination while the field is out of the worker’s view.
7. All items brought into contact with broken skin or used to penetrate the skin or in order to
inject substances into the body, or to enter normally sterile body cavities, should be sterile.
These items include dressings used to cover wounds and incisions, needles for injection, and
tubes used to drain urine from the bladder.
8. Use dry, sterile forceps when necessary. Forceps soaked in disinfectant are not considered
sterile.
9. Consider the outer 1 inch of a sterile field to be contaminated.
10. Consider an object contaminated if you have any doubt as to its sterility.

F. THE CHAIN OF INFECTION

Chain of Infection – describes the development of an infectious process. An interactive process

involving an agent, host and environment is required.

SIX ESSENTIAL LINKS (elements) IN THE CHAIN OF INFECTION

I. AGENT – entity that can cause disease. Agents that cause diseases are as follows.
▪ Humans Biologic agents: living organisms that invade the host, causing
disease, such as bacteria, virus, fungi, protozoa, and rickettsia.
▪ Chemical agents: substances that can interact with the body, causing disease,
such as food additives, medications, pesticides, and industrial chemicals
▪ Physical agents: factors in the environment that can cause disease, such as
heat, light, noise, and radiation

II. RESERVOIR – is a place where the agent can survive. The most common reservoir is:
▪ Humans

▪ Animals

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 ▪ Environment

▪ Fomites

Carriers – have the infectious disease but are symptom free

III. PORTAL OF EXIT – is the route by which an infectious agent leaves the reservoir to be
transferred to a susceptible host. The agent leaves the reservoir through body secretions
including
▪ Sputum, from the respiratory tract

▪ Semen, vaginal secretions, or urine, from the genitourinary tract

▪ Saliva and feces, from gastrointestinal tract

▪ Blood

▪ Draining wounds

▪ Tears

IV. MODES OF TRANSMISSION – is the process of the infectious agent moving from the
reservoir or source through the portal of exit to the portal of entry of the susceptible new host
▪ Contact transmission – involves the transfer of an agent from an infected,
indirect contact with the infected person through fomite, or close contact with
contaminated secretions.
▪ Airborne transmission – occurs when a susceptible host contacts droplet
nuclei or dust particles that are suspended in the air.
▪ Vehicle transmission – occurs when an agent is transferred to a susceptible
host by contaminated inanimate objects such as water, food, milk, drugs, and
blood.
▪ Vector-borne transmission – occurs when the agent is transferred to a
susceptible host by animate means such as mosquito, fleas, ticks, lice and other
animals.

V. PORTAL OF ENTRY – is the route by which an infectious agent enters the host. Portals of
entry include the following
▪ Integumentary system – through break in the integrity of the skin or mucus
membranes (surgical wounds)
▪ Respiratory tract – by inhaling contaminated droplets (such as colds,
influenza, measles
▪ Genitourinary tract – through the contact with infected vaginal secretions or
semen (as in STI)
▪ Gastrointestinal tract – by ingesting contaminated food or water (typhoid
hepatitis A)
▪ Circulatory system – through the bite of insects (such as mosquito bite
resulting in malaria)
▪ Transplacental – through transfer of microorganisms from mother to fetus via
the placenta and umbilical cord (including HIV, hepatitis B.

VI. HOST – is an organism that can be affected by an agent. A human being is usually
considered a host.
▪ Susceptible host – person who has no resistance to an agent and thus is
vulnerable to disease (ex. No vaccine)
▪ Compromised host – person whose normal body defense are impaired and is
therefore susceptible to infection (ex. Cold, or superficial burns)

9
 Breaking the Chain of Infection
 Hand hygiene is the first line of defense against infection and is the single most
important practice in preventing the spread of infection

TERMS
a. Disinfection – is the elimination of pathogens, excepts spores, from inanimate objects
b. Concurrent – after the discharge of infectious material from the body of an infected person or
after soiling the articles
c. Terminal – at the time the person is no longer source of infection
d. Disinfectants are chemical solutions used to clean inanimate objects
e. Germicide is a chemical that can be applied to both animate (living) or inanimate objects to
eliminate pathogen
f. Sterilization is destroying all microorganisms including spores (autoclaving) but not boiling
water (clean)
g. Isolation is the separation of infected person from other persons during period of
communicability
h. Quarantine is the limitation of freedom of movement of persons or animals equal to the longest
usual incubation period of the disease
i. Fumigation is any process which the killing of animal forms in accomplished with the use of
gaseous agents

Types of infection

1. Localized infections – are limited to a defined area or single organ with symptoms that
resemble inflammation (redness, tenderness, and swelling,)
2. Systemic infections – affect the entire body and involve multiple organs, such as AIDS

CHAIN OF INFECTION

10
(Image source: http://www.iahcsmm.org/Recertification/LessonPlans/images/Lesson_403_figure_1.gif

HOSPITAL HOUSEKEEPING

A. BASIC CLEANSING OPERATION

1. Sweeping
2. Dusting
3. Washing
4. Mopping
5. Scrubbing
6. Waxing

SWEEPING

Definition: Sweeping is basic cleansing operation which removes dirt from the floor area.

Equipment:
 Floor brush or broom
 Sweep

11
  Dustpan
 Dust box

PROCEDURE RATIONALE
1. Gather all equipment to the area to be
To save time and energy.
swept.
2. Place the dustpan and dust box where the
To keep dust box out of traffic.
swept articles or dirt will be accumulated.
2. Start sweeping using lone strokes from the Dirt is accumulated and collected at the center of
corners to the center of the room. the room where the dustpan and box await.
3. Tap broom or brush on the floor at the end
To free the brush or broom from dirt.
of every stroke.
4. Inspect area swept for any signs of
unremoved dirt.
5. Proceed to other cleaning operation. If no
other cleaning operation is done, return
equipment to proper places.

DUSTING

Definition: Dusting is a basic cleaning operation used in removing dirt from furniture.

Types of Dusting:
1. Low Dusting: Done daily to remove dirt form places easily reached while standing on the
floor.
2. High Dusting: done periodically to remove dirt from high areas like ceilings, windows, etc.

Equipment:
 Basin or Pail with water
 Laundry Soap
 Newspaper
 Dusting Clothes
 Brush or duster or Chicken Feathers.

PROCEDURE RATIONALE
1. Gather all equipment to the area to be
To save time and energy.
dusted.
2. Bring the dusting tray to the room and place Newspaper prevents the furniture from getting
it on the table over a newspaper lining. wet.
3. Start dusting from the entrance and around Long straight strokes prevent skipping of corners
the room using long straight strokes. and edges.
4. Dusting should be done in sequence from so that any dust that falls can be wiped clean or
highest to lowest area to the floor. vacuumed once the dusting is complete.
5. Choose furniture that are not injured by
This would avoid flicking dust over other furniture.
moisture and wipe this furniture with damped
cloth.
6. Dust in the small crevices of the furniture
should be removed by dusters with a stick
end wrapped in cloth.
3. Inspect area swept for any signs of It should appear bright and free from streaks.
unremoved dirt.

12
4. Proceed to other cleaning operation. If no
other cleaning operation is done, return
equipment to proper places.

WASHING

Definition: It is a basic cleaning operation to remove dirt using water and soap. It includes removing
loose dirt, washing, rinsing, and drying.

Equipment:
 Basin or Pail
 Cleaning solution
 Paper lining
 Dust clothes

PROCEDURE RATIONALE
1. Gather all equipment to the washing area. To save time and energy.
2. Line floor with newspaper. To protect floor from dripping.
3. Dust or wipe any loose dirt on the furniture.
4. Dip cloth in the cleansing solution and
To prevent dripping on the floor.
squeeze out.
5. Wash area in small circular motion. Rinse the
furniture using another cloth.
6. Dry the area washed.
7. Continue washing, rinsing, and drying over Overlapping strokes would prevent streaks over
entire area overlapping strokes. furniture.
8. Change water as often as possible. Dirty water causes streaks over washed area.
5. Inspect area swept for any signs of
unremoved dirt.
6. Proceed to other cleaning operation. If no
other cleaning operation is done, return
equipment to proper places.

Other Basic Cleansing Operations:

 MOPPING – Mopping is a basic cleansing operation to rub or wipe the floor.
 SCRUBBING – Scrubbing is the removal of dirt through application of friction.
 WAXING – Waxing is the application of protective coating over surfaces usually floor which is
usually polished by scrubbing.

CARE OF HOSPITAL EQUIPMENT

CARE OF BEDPANS AND URINALS

Equipment
 Disinfectant Solution
 Dutch Cleanser of Detergent
 Bedpan Brush

PROCEDURE RATIONALE
1. Gather all equipment to the washing area. To save time and energy.
2. Empty the contents into the toilet bowl and
rinse with water.
3. Soak bedpan in disinfectant solution for two
Soaking is one way of killing microorganisms.
hours
To remove the dirt and odor which had adhered
4. Brush the insides of the bedpan.
in the bedpan & urinals.

13
5. Wash the outside of the bedpan using
To remove stains.
washcloth and cleanser.
6. Rinse, wipe and dry in the rack.

7. Inspect for any signs of unremoved dirt.

CARE OF THE RUBBER GOODS

CATHETER & TUBES

PROCEDURE RATIONALE
1. Place under the faucet and let cold water run
through it.
2. Use syringe bulb to flush the lumen. Syringe bulb is used to flush small lumen.

3. Rinse using warm water.

4. Wipe with cloth by pressing between thumbs
and fingers.
5. Allow to boil for at least 5 minutes. Boiling is a method of killing microorganisms.

6. Apply powder, coil and wrap using a gauze

RUBBER RINGS & KELLY PADS

PROCEDURE
1. Clean with soap, rinse and dry.

2. Disinfectant is used if the Kelly pad had been used in infectious cases.

3. Hang to dry.

RUBBER GLOVES
PROCEDURE
1. Wash with soap inside out.
2. Rinse with water.
3. Hang inverted for at least one hour.
4. Apply powder
5. Pack for sterilization.

RUBBER SHEET
PROCEDURE
1. Wash with soap

2. Rinse with clean water

3. Dry the rubber sheet

4. Roll and store in the proper place.

5. If used in infectious cases, apply disinfectant.

ICE CAPS
PROCEDURE RATIONALE
1. Empty the contents
Moisture is a favorable medium for growth of
2. Wipe outside to dry
microorganism
To prevent the two surfaces from coming in
3. Inflate before closing
contact with each other

14
HOT WATER BAG
PROCEDURE RATIONALE
1. Empty the content after use

2. Wipe outside to dry. Moisture is a favorable growth for microorganism

3. Hang with opening downward. To drain all water content.

4. If used in infectious cases, soaked in liquid
To kill microorganisms
disinfectant for an hour then rinse.

CARE OF THE UNIT/ROOM UPON DISCHARGE OF THE PATIENT

Purposes:
1. To free the room from microorganisms.
2. To prevent cross infections.
3. To maintain order in the ward.
4. To prepare the room for the new patient.

STRIPPING AND AIRING THE BED

PROCEDURE RATIONALE
1. Open the window of the room to allow entry Proper ventilation prevents growth of
of air into the unit. microorganisms
2. Place a chair with the back at the foot of the
Allows room for the nurse to work.
bed.
3. Strip the pillowcase from the pillow and use
this pillowcase as a laundry bag.
4. Loosen the beddings all starting at the
center of the part raising the mattress with
Dust carries microorganisms.
one hand and drawing out the linen with the
other hand without raising the dusts.
Microorganisms can be transmitted by air currents
5. Roll the linen away from the uniform.
or by direct contact.
6. Place soiled linen into the laundry bag
2. Turn mattress from top to bottom and arch
its upper and lower side for 30 minutes

CARE OF THE BED

Equipment:
 Basin with water
 Dust cloth
 Soap or any detergent
 Paper lining / old newspaper
 Mattress brush

PROCEDURE RATIONALE
1. Place cleansing equipment on bedside table
To prevent from wetting the floor
with paper lining.
2. Spread paper lining under the bed.
3. Move mattress crosswise and towards the
Allows for cleaning half of the bed.
lower half of the bed.
4. Clean upper side of mattress with
dampened brush
5. Use long strokes away from you.

15
 6. Raise headset. With long rinsed in soapy
solution. Wash springs and bed frame.
7. Rinse and dry thoroughly.

3. Lower headrest.
4. Turn mattress with clean side down to the
upper part of the bed.
5. Clean the other side of the mattress.

6. Place rubber sheet on springs

7. Dry well.

8. Turn the mattress and wash the other side.

9. Hang mattress over the head of the bed. Allow space to clean pillows & rubber sheet
10. Place pillows on the spring and clean with
damp cloth.
11. Rinse knee rest of the bed. Wash the lower
half of the bed frame and springs.
12. Take cleaning equipment to utility room and
do after care.

MEDICAL HAND WASHING

Definition: Hand washing refers to washing hands with soap and water

Purpose:
➢ To reduce the number of microorganisms on the hands.

➢ To reduce the risk of transmission of microorganism to clients.

➢ To reduce the risk of cross-contamination among clients

➢ To reduce the risk of transmission of infectious organisms to oneself.

Equipment:
 Soap
 Warm running water
 Sanitized towels or Paper towels

16
 PROCEDURE RATIONALE
Short, natural nails are less likely to harbor
1. Nails should be kept short microorganisms, scratch a client, or puncture
gloves.
Microorganisms can lodge in the settings of
2. Remove all jewelry jewelry under rings. Removal facilitates proper
cleaning of the hands and forearms.

A nurse who has open sores may be at risk for

3. Check hands for breaks in the skin, such as
transmission of infectious organisms due to the
hangnails or cuts.
chance of acquiring or passing an infection.

4. If you are washing your hands where the

client can observe you, introduce yourself
and explain to the client what you are going
to do and why it is necessary.
5. Turn on the water and adjust the flow.

There are five common types of faucet

controls.
a. Hand-operated handles
b. Knee levers. Move these with the knee to
regulate flow and temperature.
c. Foot pedals. Press these with the foot to
regulate flow and temperature.
d. Elbow controls. Move these with the
elbow instead of hands.
e. Infrared control. Motion in front of the
sensor causes water to start and stop
flowing automatically.

6. Adjust the flow so that the water is warm

Warm water removes less of the protective oil
of the skin than hot water.

7. Wet the hands thoroughly by holding them The water should flow from the least
under running water. Hold the hands lower contaminated to the contaminated area; the
than the elbows so that the water flows from hands are generally considered more
the arms to the fingertips. contaminated than the lower arms.

17
 8. If the soap is liquid, apply 4 to 5 mL (1 tsp).
If it is bar soap, granules, or sheets, rub
them firmly between the hands.

9. Thoroughly wash and rinse the hands.

Use firm, rubbing, and circular movements to
wash the palm, back, and wrist of each hand.
Be sure to include the heel of the hand.
Interlace the fingers and thumbs and move
the hands back and forth.
The circular action creates friction that helps
a.Right palm over left dorsum with remove microorganisms mechanically. Interlacing
interlaced fingers and vice versa the fingers and thumbs cleans the interdigital
b.Palm to palm with fingers interlace spaces.
c. Backs of fingers to opposing palms with
fingers interlocked
d.Rotational rubbing of left thumb clasped
in right palm and vice versa.
 Continue these motions for about 20
seconds
10. Rub the fingertips against the palm of the The nails and fingertips are commonly missed
opposite hand. during hand hygiene.
11. During rinsing, hands should be higher than the
wrist/elbow. Start from one hand, first from the
fingertips with the flow of water going down the
wrist. If there is no more soap, then proceed to
the other hand. Keep both hands higher than the
wrist level until drying.
12. Dry one hand at a time from the fingertips down
to the wrist. Once at wrist dispose tissue. If there
is a need to dry again the fingers, then get a new Moist skin becomes chapped readily as does dry
paper towel. Thoroughly dry hands thru patting. skin that is rubbed vigorously; chapping produces
Dry hands and arms thoroughly with a paper lesions
towel without scrubbing. Discard paper towel
in the appropriate container.
13. Turn off water. Use new paper towel to This prevents the nurse from picking up
grasp a hand-operated control faucet. microorganism from the faucet handles.
.

18
MEDICAL HANDWASHING
(image source: WHO)

19
 DONNING AND REMOVING STERILE GLOVES (OPEN METHOD)
Purposes:
➢ To enable the nurse to handle or touch sterile objects freely without contaminating them.

➢ To prevent transmission of potentially infective organisms from the nurse's hands to clients at
high-risk infection.

Equipment:
Packages of sterile gloves (Ensure the sterility of the package of gloves)

PROCEDURE RATIONALE
1. Prior to performing the procedure, introduce Use non-latex gloves whenever possible.
self and verify the client's identity using
agency protocol. Explain to the client what
you are going to do and why it is necessary.
Check client record and ask about latex
allergies.
2. Perform hand hygiene and observe other Refer to handwashing procedures
appropriate infection prevention procedures.
3. Provide for client privacy.
4. Open the package of sterile gloves.
a. Place the package of gloves on a clean, Any moisture on the surface could contaminate
dry surface the gloves
b. Some gloves are packed in an inner as
well as an outer package. Open the outer
package without contaminating the gloves
or the inner package
c. Remove the inner package from the outer
package
d. Open the inner package. Open the flaps The inner surfaces, which are next to the sterile
and folded tabs to grasp for the opening gloves, will remain sterile.
flaps. Do not touch the inner surfaces.
5. Put the first glove on the dominant hand
a. If the gloves are packaged so that they lie The hands are not sterile. By touching only the
side by side, grasp the glove for the inside of the glove, the nurse avoids
dominant hand by its folded cuff edge (on contaminating the outside
the palmar side) with the thumb and first
finger of the non-dominant hand. Touch
only the inside of the cuff.
b. Move one step back away from the table
c. Insert the dominant hand into the glove If the thumb is kept against the palm, it is less
and pull the glove on. Keep the thumb of likely contaminates the outside of the glove
the inserted hand against the palm of the
hand during insertion
d. Leave the cuff in place once the unsterile Attempting to further unfold the cuff likely to
hand releases the glove contaminate the glove.
6. Put the second glove on the non-dominant
hand.
a. Pick up the other glove with sterile gloved This helps prevent accidental contamination of the
hand, inserting the gloved fingers (thumb glove by the bare hand
should be abducted) under the cuff and
holding the gloved thumb close to the
gloved palm
b. Pull on the second glove carefully. Hold In this position, the thumb is less likely to touch
the thumb of the gloved firsthand as the arm and become contaminated
far as possible from the palm
c. Adjust each glove so that it fits smoothly,
and carefully pull the cuffs up by sliding
the fingers under the cuffs.
REMOVING GLOVES
7. Remove and dispose of used gloves.

20
 a. If they are soiled with secretion, remove them by turning them inside out.
b. Perform hand hygiene.
8. Document that sterile technique was used in the performance of procedure.

DONNING STERILE GLOVES (OPEN METHOD)

(Image source: https://www.saintlukeskc.org/health-library/step-step-sterile-technique-putting-gloves)

REMOVING OF STERILE GLOVES

21
(Image source: https://www.saintlukeskc.org/health-library/step-step-sterile-technique-putting-gloves)

ENVIRONMENT AND PATIENT SAFETY

A. SAFE STAFF BEHAVIOR

1. Use Good Body Mechanics. As you carry out your duties, which require much standing and
walking, an erect posture in good body alignment protects you from stain. Stretching and
reaching, as well as carrying or moving heavy objects, can take their toll on poorly aligned
muscles.

2. Walk; Avoid Running. Running is risky and leads to falls. For safe movement, well-fitting shoe
are essential. Clogs and other ill-fitting shoes can prove hazardous, particularly if running
becomes necessary, because they may slip off and tip the wearer.

3. Keep to the Right in Hallways. It is easy to run into someone else whose attention diverted.
Therefore, as a general practice, always walk to the right. This provides for a smoother flow of
traffic.

4. Turn Corners Carefully. Most collisions take place when two people are rounding a corner.
Always keep to the right, slow your pace, and turn corners carefully. This is of particular
importance when you are pushing a stretcher or cart. I some hallways, mirrors are placed high
on the intersecting walls to allow you to see around the corner and avoid such collisions.

5. Open Doors Slowly. An opening door may easily strike someone on the other side. If it is
opened slowly, it is less likely to cause injury.

6. Use Stretchers Properly. When pushing on a stretcher, keep the patient’s head toward your
body and the feet in front. This is done so that the head, which highly vulnerable to impact
injury, is protected and the feet, which are less vulnerable, are outward.

7. Use Brakes on Beds, Wheelchairs and Stretchers. When beds, wheelchairs, and stretchers
are stationary, apply the brake or brakes. When a patient is being transferred to one of these
pieces of equipment or when it is standing still, the braking action prevents accidental movement
that may lead to injury.

8. Place Elevators on “Hold” when Loading or Unloading. When you are pushing a patient in
a wheelchair or stretcher, place elevator operating buttons on “hold”. This will keep the doors
open until you and the patient are safely in or out of the elevator. Back into the elevator with an

22
 occupied wheelchair so that if the door does not hold with the hold request button and suddenly
closes you, rather than the patient, will receive the impact.

B. SAFETY IN WORKING SPACES, HALLS AND CORRIDORS

1. Lighting. These spaces should always be lighted well enough to allow objects and people to be
seen clearly.

2. Floor Surfaces. Cracked tiles, raised linoleum, or torn carpeting can easily lead to falls. Highly
polished floors can also cause skidding, falls, and injury. Dropped materials such as tissues or
food substances should be retrieved immediately, because they also can cause a staff member, a
visitor, or a patient to skid. It is very important to wipe up spills of liquids immediately. Calling a
custodian or maintenance person could a delay long enough to expose someone to the danger of
a fall. If mopping is in progress, “Danger, Wet Floor” signs should always be posted.

3. Electrical Appliances. It is essential that all appliances being used be in good working order
and have a cord weight that is adequate for the appliance. A frayed or damaged cord or plug
should never be used because it may cause sparks or fire, injuring the operator or endangering
the surrounding area. All plugs should be of the three-pronged ground type so that the third
prong carries any unexpected, potentially dangerous bursts of electricity to the ground. When an
appliance, such as an electric floor polishing machine is being used in a hallway or work area, the
cord should not lie in such a way that people can trip over it. Cords that have to remain in place
should be taped to the floor away from the walking areas. Unused electrical outlets should have a
safety cover in place to protect children and others from electrical shocks.

4. Needles and Other Sharp Objects. Hospital personnel should not manually recap
contaminated needles. This is done to reduce the chance of needle sticks and the risk of
exposure to diseases transmitted by blood and body fluids. Carrying an uncapped needle down a
hallway is a violation. Razor blades, scalpels, and other small sharp instruments may also be
placed in these receptacles.

5. Dangerous or Caustic Substances or Materials. All products, regardless of where they are
used, should be clearly labeled to warn of any risks or dangers. They should never be left within
easy reach of others in hallways or workspaces, including nurse's stations. They should be
ingested by children or by persons who are confused or incompetent. A liquid substance could be
spilled, causing burns or injury.

6. Uncluttered Hallways. In a fire or emergency, such equipment could block access of

emergency personnel and equipment and the evacuation of patients and staff.

C. SAFETY IN PATIENTS' ROOM

1. Lighting. Patient rooms need enough light to allow the patient who is ambulatory to easily see
objects that maybe in the way and to allow staff to work without difficulty. At night, most patients
who have slept in complete darkness at home are not disturbed by the use of the nightlight. This
light helps to orient both the bedridden patient and the patient who is able to get out of bed to
use the bathroom.

2. Floor surface. Again, floor surfaces should be smooth, whether they are of tile, linoleum, or
carpeting. Liquids should be mopped or wiped up immediately and foreign items picked-up and
disposed of. The unsteady patient can slip even more easily than an abled-bodied visitor or staff
member. Provide non-slip mats for use on the floor of a shower or on the bottom of a bathtub to
prevent slipping. Handrails and a call cord within reach can ensure the safety of the patient.

3. Oxygen. If oxygen is in use, special precautions must be taken to ensure that sparks and flames
never occur in the vicinity. While oxygen, as a gas, does not itself explode, it supports very
combustion, and materials will burn at an explosive rate in its presence. A “No Smoking” sign is
posted on the door of the room to remind the patient and visitors o tot smoke. Electrical
appliances, including electric razors, are mot to be used when oxygen therapy is being done for
the patient. These precautions are utmost importance for safety.

23
4. Electrical Appliances. All cords and plugs used on equipment in the patient’s room should be
examined. All should be grounded with a three-pronged plug. It is essential that all electrical
equipment be in proper working order, particularly when a patient is receiving oxygen. A spark in
this environment could cause a fire and endanger the patient.

5. Furniture. All furniture in the patient’s room should be arranged to allow easy access to the wash
basin, bathroom, closet area, and door. This protects both ambulatory patients and staff members
from bumps or falls.

6. Medication and Dangerous Substances. Medications and dangerous substances should be

removed from the patient’s bedside. If a liquid used in treatment, such as saline or hydrogen
peroxide solution, is to be kept at the bedside, the container to prevent a visitor or someone for
whom they were not intended from ingesting them.

7. Doors. Entrance doors and bathroom, closet, and cabinet doors should always be either fully
open or fully closed to eliminate the possibility of people running into them. If latches are not pair,
have them fixed or replaced.

24
 BODY MECHANICS AND POSITIONING

Body Mechanics involves the coordinated effort of muscles, bones, and the nervous system to maintain
balance, posture, and alignment during moving, transferring, and positioning patients. Proper body
mechanics allows individuals to carry out activities without excessive use of energy and helps prevent
injuries for patients and health care providers (Perry, Potter, & Ostendorf, 2014).

Musculoskeletal Injuries
A musculoskeletal injury (MSI) is an injury or disorder of the muscles, tendons, ligaments, joints
or nerves, blood vessels, or related soft tissue including a sprain, strain, or inflammation related to a
work injury. MSIs are the most common health hazard for health care providers (WorkSafeBC, 2013).

FACTORS THAT CONTRIBUTE TO AN MSI

Factor Special Information

Ergonomic Risk Factors Repetitive or sustained awkward postures, repetition, or forceful exertion.

Poor work practice; poor overall health (smoking, drinking alcohol, and
Individual Risk Factors

ACTIVITY AND
obesity); poor rest and recovery; poor fitness, hydration, and nutrition.

EXERCISE
Data source: Perry et al., 2014; Workers Compensation Board, 2001; WorkSafeBC, 2013

Elements of Body Mechanics

2. Body Alignment is achieved by placing one body part in line with another body part in a
vertical or horizontal line. Correct alignment contributes to body balance and decreases strain on
muscle-skeletal structures. Without this balance, the risk of falls and injuries is increased.

3. Center of Gravity is the center of the weight of an object or person. A lower center of gravity
increases stability. This can be achieved by bending the knees and bringing the center of gravity
closer to the base of support, keeping the back straight. A wide base of support is the foundation
for stability.

4. Wide Base of Support is achieved by placing feet in a comfortable, shoulder width distance
apart. When a vertical line falls from the center of gravity through the wide base of
support, body balance is achieved. If the vertical line moves outside the base of support, the
body will lose balance.

25
 PRINCIPLES OF BODY MECHANICS

Action Principle

Assess the weight of the load before lifting and determine if

Assess the environment.
assistance is required.

Plan the move; gather all supplies and clear the area of
Plan the move.
obstacles.

Avoid stretching, reaching, and twisting, which may place the

Avoid stretching and twisting.
line of gravity outside the base of support.

Keep stance (feet) shoulder-width apart.

Tighten abdominal, gluteal, and leg muscles in anticipation of
Ensure proper body stance.
the move.
Stand up straight to protect the back and provide balance.

Place the weight of the object being moved close to your

center of gravity for balance.
Stand close to the object being
Equilibrium is maintained if the line of gravity passes through
moved.
its base of support.
Hold objects close to your center of gravity

Face direction of the movement. Facing the direction prevents abnormal twisting of the spine.

Turning, rolling, pivoting, and leverage requires less work

than lifting.
Avoid lifting.
Do not lift if possible; use mechanical lifts as required.
Encourage the patient to help as much as possible.

Keep all work at waist level to avoid stooping.

Work at waist level. Raise the height of the bed or object if possible.
Do not bend at the waist.

Reduce friction between surfaces so that less force is required

Reduce friction between surfaces.
to move the patient.

26
 Bending the knees maintains your center of gravity and lets
Bend the knees.
the strong muscles of your legs do the lifting.

It is easier to push an object than to pull it.

Push the object rather than pulling it
Less energy is required to keep an object moving than it is to
and maintain continuous movement.
stop and start it.

Use assistive devices (gait belt, slider boards, mechanical lifts)

Use assistive devices. as required to position patients and transfer them from one
surface to another.

The person with the heaviest load should coordinate all the
Work with others.
effort of the others involved in the handling technique.
Data source: Berman & Snyder, 2016; Perry et al., 2014; WorkSafeBC, 2013

POSITIONING

Positioning a patient in bed is important for maintaining alignment and for preventing bed sores
(pressure ulcers), foot drop, and contractures. Proper positioning is also vital for providing comfort for
patients who are bedridden or have decreased mobility related to a medical condition or treatment. When
positioning a patient in bed, supportive devices such as pillows, rolls, and blankets, along with
repositioning, can aid in providing comfort and safety (Perry et al., 2014).

PURPOSES
1. To promote comfort to the patient
2. To relieve pressure on various parts
3. To stimulate circulation
4. To provide proper body alignment
5. To carry out nursing intervention
6. To perform surgical and medical interventions
7. To prevent complications caused by immobility
8. To promote normal physiological functions

BASIC PRINCIPLES IN POSITIONING OF PATIENTS

1. Maintain good patient body alignment. Think of the patient in bed as though he were standing.
2. Maintain the patient's safety.
3. Properly handle the patient's body to prevent pain or injury.
4. Keep in mind proper body mechanics for the practical nurse.
5. Obtain assistance, if needed, to move heavy or helpless patients.
6. Follow specific physician's orders for ambulation and positioning.
7. Make sure the mattress is firm and level yet enough to give to fill in and support natural body
curvatures.
8. Ensure that the bed is clean and dry
9. Place support devices in specified areas according to the client's position
10. Avoid placing one body part, particularly one with bony prominences, directly on top on top of
another body part
11. Avoid friction and shearing
12. Plan a systematic 24-hour schedule for position changes
13. Always obtain information from the client to determine which position is most comfortable and
appropriate

BASIC BODY POSITIONS

27
 Position in which the patient lies on the abdomen
with the head turned to one side with one small
pillow under the ankle.
INDICATIONS:
 Post operatively; Patient with pressure
sores, burns, injuries and operations on
the back;
 To relieve abdomen distension;
Prone  Renal biopsy;
 Examine the back;
 For patients after 24 hours of amputation
of lower limbs
The patient lies on his back with his head and
shoulders are slightly elevated.
INDICATIONS:
 Examination of the chest and abdomen;
 Post-operative recovery from anesthesia;
Spine surgeries
Supine

It is a sitting position in which the head is

elevated, and the client knees are slightly
elevated, avoiding pressure on the popliteal
vessels. Backrest and two pillows are used for the
back and head. Pillows can be used to maintain
natural alignment of the hands, wrist and
Fowler's forearms.
INDICATIONS:
 To relieve dyspnea;
 To improve circulation;
 To relax the muscles of the abdomen,
back and thighs;
 To relieve tension on abdominal stature.

Semi-fowler's
This position involves the patient lying on either
her right or left side. Right lateral means the
patient’s right side is touching the bed, while left
lateral means the patient’s left side is touching
the bed. A pillow is often placed in between the
legs for patient comfort.
INDICATION:
 Helps relieve pressure on the coccyx
Lateral
 Routine turn to sides for bedridden
patients

In this position the client lies on either the right or

left side. The lower arm behind the body and
upper arm is bent at the shoulder and elbow. The
knees are both bent, with the upper most leg
more acutely bent. These positions similar to the
lateral position except that the patient’s weight is
on the anterior aspect of the patient’s shoulder
girdle and hip.
INDICATIONS:
Sim's  Vaginal and rectal examination;
 Administration of enema and suppository;
 Used for relaxation in antenatal exercises;
 Position for sigmoidoscopy and

28
 proctoscopy

The patient lies on the back with the head low.

The foot of the bed is elevated at 45˚ angle.
Entire frame of bed is tilted with head of bed
down.
INDICATIONS:
 Used in emergency situations like shock,
hemorrhage and hypotension;
 Postural drainage;
 Patients with deep vein thrombosis
Trendelenburg

A supine position with the patient on a plane

inclined with the head higher than the rest of the
body and appropriate safety devices such as a
footboard.
INDICATIONS:
 Used in surgery, especially of the
abdomen and genitourinary system.

Reverse Trendelenburg
Patient lies on back, knees fully flexed, thighs
flexed and externally rotated feet flat on the bed.
In this position clients with painful disorders are
more comfortable with knees flexed. This position
should not be used for abdominal assessment
because it promotes contraction of abdomen
muscles.
INDICATIONS:
 Catheterization.
 Vaginal douche, vulvar, vaginal and rectal
examination.
The client lies supine with hips flexed. The legs
are separated, and thighs are flexed. The
patient’s buttocks are kept at the edge of the
table and legs are supported by stirrups.
INDICATIONS:
 For delivery of baby.
 For rectal examination & surgeries.
 For vaginal examination & hysterectomy

The patient rests on the knees and the chest. The

body is at 90˚ angle to the hips with back
straight, the arm above the head, and the head
turned to one side. The abdomen remains
unsupported.
INDICATIONS:
 Used for vaginal and rectal examination.
 Used in first aid treatment in cord
prolapse or retroverted uterus.
 As exercise for postpartum and
Knee-chest gynecology patients.

29
 High fowler’s position with over bed table to be
placed across the front of the patient. Patient to
rest both hands-on over bed table/on pillow
placed in it and leans forward. Leaning forward
facilitates respiration by allowing maximum chest
expansion by reducing pressure of abdominal
organs on diaphragm.
INDICATIONS:
 Patients with severe dyspnea.
 Cardiac patients.
 Position for thoracentesis.
Orthopneic  Patient with chest drainage tubes

ASSISTING THE CLIENT WITH AMBULATION

Clinical situations in which you may encounter these skills

The client who has been confined to bed or who is weak who may need assistance with
ambulation. If the client is unsteady, a second nurse should assist. The client may complain of dizziness
or faintness. If this happens, help the client to sit down or return to bed.

Adverse Responses
The client complains of dizziness or faintness.

Anticipated Responses
The client is able to ambulate without injury.
The client does not complain of dizziness or faintness.

Equipment:
 Slippers
 Ambulation (Gait) Belt (optional)

PROCEDURE RATIONALE

1. Perform medical handwashing.

2. Provide patient privacy.

3. Introduce yourself to the patient. Gain cooperation and be able to establish rapport

4. Check identity of your patient using 2 patient

identifiers. Check client’s medical diagnosis
and any other medical problems that might be
contraindicated to planned procedure.
5. Explain procedure to the client and ask how
long did he or she last walk and how far.
Assist you in determining any problems that may
encountered.
Helps you to determine how far the client may be
able to work.

6. Clear the path of any obstacles. Obstacles present a safety hazard to the client.

30

7. Lock the wheels of the bed.
8. Lower the client’s bed to the lowest position
and lower the side rail nearest to the nurse.
9. Position the bed in fowlers position and help
the client to sit on the side of the bed.
Prevents the bed from rolling when the client is
moved.
Ensures the client’s safety
Helps the client to overcome any dizziness before
standing or prevent orthostatic hypertension.

10. Allow the patient to sit still for a few minutes

Prevent orthostatic hypotension
and encourage deep breathing

11. Put on patient gown or housecoat.

12. Ask patient to move his or her feet up and

down and in circles.

Slippers protect the client’s feet. The shoes should

13. Help the client to put on nonskid slippers or
have no slip soles. Patient’s gown provides privacy
shoes.
and comfort to the patient

14. Ask patient if he/she is feeling dizzy or

lightheaded.

15. Apply an ambulation (gait) belt if needed. Helps you support the client.
16. Hand around his or her waist or grasp the
The client is still adjusting with his/her strength
ambulation belt. If the client has weaknesses
and balance and may need your assistance.
on one side, you should support that side.

17. Ask patient if he/she feels dizzy or

lightheaded.

18. After the walk is completed, help the client to

return to bed.
19. Assess how well the client tolerated the walk
These data are necessary for charting whether
and whether any dizziness was experienced.
the client experienced any problems.
Check vital signs.
20. Wash your hands Decreases the transmission of microorganisms.
Communicates to the other members of the
health care team and contributes to the legal
21. Record the procedure
record by documenting the care given to the
client.

ASSISTING WITH RANGE-OF-MOTION (ROM) EXERCISE (PASSIVE)

Definition: The movement of a joint to the extent possible without causing pain

Purposes:

1. Promote and maintain joint mobility

2. Prevent contractures and shortening of muscles and tendons
3. Increase circulation to extremities
4. Facilitate comfort for the patient

Types of ROM:

1. Active ROM Exercises – Movement produced on a segment upon active contraction of the
muscles crossing the joint within the unrestricted range of motion

31
 2. Passive ROM Exercises – Movement produced by an external force within the unrestricted
range of motion of a segment
3. Active Assisted ROM Exercises – Assistance is provided by an outside force (manual or
mechanical), as the prime mover muscles are unable to complete the motion

Types of Body Movements

1. Flexion – movement in the saggital plane that

decreases the angle of the joint and brings two
bones closer together
2. Extension – opposite of flexion; movement in
the saggital plane that increases the angle of
the joint or distance between two bones or
parts of the body
3. Rotation – movement of a bone around its
longitudinal axis
4. Abduction – moving a limb away in the frontal
plane from the median plane of the body,
spreading the fingers apart
5. Adduction – opposite of abduction; movement
of a limb toward the body midline
6. Circumduction – a combination of all the
movements, commonly seen in ball and socket
joints where the proximal end of the limb is
stationary while the distal end moves in a circle
7. Supination – forearm rotation laterally so that
the palm is facing anteriorly, and the radius and
ulna are parallel
8. Pronation – forearm rotation medially so that
the palm faces posteriorly, and the ulna and
radius are crossed
9. Inversion – turning the sole of the foot
medially
10. Eversion – Turning the sole of the foot laterally
11. Hyperextension - extension greater than 180
degrees
12. Dorsiflexion – lifting the foot so the superior
surface approaches the shin, standing on the
heels
13. Plantar flexion – pointing the toes Image source: ( www.medical-dictionary.thefree dictionary.com/range+ofmotion+exercise)

14. Opposition – touching the thumb to other fingers

RANGE OF MOTION OF VARIOUS JOINTS

32
 MOVEMENTS
JOINT EXAMPLE
POSSIBLE
Flexion Move chin down to rest on chest

HEAD Extension Return head to normal upright position

Lateral Flexion Tilt head as far as possible toward each shoulder

Rotation Move the head from side bringing chin toward
shoulder

Flexion Start with arm at side and lift arm from forward to
above head

Abduction Start with arm at side and move laterally to upright

NECK position above head.

Adduction Lower arm to original position and move across body

as far as possible.

Internal & external Raise arm at side until upper arm is online with
rotation shoulder. Bend below at 90-degree angle and move
forearm upward and downward.
Flexion Bend elbow and move lower arm and hand upward
toward shoulder.
ELBOW
Extension Return arm and hand to original position while
straightening elbow.
Supination Rotate arm and hand so palm is up
FOREARM
Pronation Rotate lower arm and hand so palm is down.
Flexion Bend fingers in to make a fist

Extension Straighten fingers out.

FINGERS
Abduction Spread fingers apart.

Opposition of thumb to Touch thumb to each finger on hand.

fingers
Flexion With leg extended, lift upward

Extension Return leg to original position next to other leg.

HIP Abduction Lift leg laterally away from body

Internal rotation Turn foot and leg toward other leg.

External rotation Move foot and leg outward way from other leg.
Flexion Bend leg, bringing heel toward back of leg.
KNEE
Extension Return to straight position
Dorsiflexion Move foot up and back until toes are upright.

Plantar flexion Move foot with toes pointing downward

ANKLE
Inversion Turn sole foot toward the middle.

Eversion Turn sole of foot outward

Flexion Curl toes downward

Extension Straighten toes out.

TOES
Abduction Spread toes apart

Adduction Bring toes together

33
 PROCEDURE
1. Explain the procedure to the patient.
2. Perform hand hygiene
3. Raise the bed to your waist level. Adjust to
flat position or as low as patient can tolerate.
4. Begin ROM exercises at the patient’s head
and move down one side at a time.
5. Perform each exercise two to five times,
moving each joint in smooth and rhythmic
manner.
6. Protect joint during ROM exercise.
7. Progress through ROM exercises for each
joint.
8. Return patient to comfortable position.
9. Readjust the bed height and position and
raise side rail if it is appropriate. Ensure that
call bell is within patient’s reach.
10. Perform hand hygiene
TRANSFER SKILLS
Consideration: Safety and comfort are key concerns when the nurse assists the patient out of bed.
Purposes:
1. To enable the nurse to change client’s surroundings as well as position.
2. To enhance ability of the patient to independence and promote exercise.
3. To increase client’s opportunities for socialization.
BED TO CHAIR: ONE PERSON MAXIMAL ASSIST
PROCEDURE
1. Know the patient’s diagnosis.
2. Assess the capabilities of the patient by
checking with other nurses and staff.
3. Find out what equipment is available for
moving patients.
4. Identify the patient
5. Explain to the patient what you intend to do
and how you intend to help.
6. Close the door or curtain. Wash your hands
7. Lock the wheels of the bed and lower the
bed.
8. Move other room equipment as necessary to
make room for the chair/wheelchair.
9. Remove siderail closest to the nurse. Assist
patient to move to the near side of the bed.
10. Raise the head of the bed so that the patient
is in semi-sitting position and cross the
patient’s arm across the chest if possible.
11. Slide one arm under the patient’s legs and
placed the other arm behind the patient’s
RATIONALE
This facilitates the patient’s cooperation.
Hand hygiene deters the spread of
microorganisms.
This position minimizes strain on the nurse
Systematic progression ensures that all body parts
are exercised
Repeated movement of muscles and joints
improves flexibility and increases circulation to the
body part.
This prevents muscles strain or injury to the point.
This promotes rest and sleep
This ensures the patient’s safety
Hand hygiene deters the spread of
microorganism.
RATIONALE
To find out any restrictions to be observed.
Asking the patient is not always the best way to
get this information; some patients may not be
able to provide accurate information.
To be sure you are carrying out the procedure for
the correct patient.
Reduces patient anxiety and increases
cooperation.
Provide privacy. Hand hygiene deters the spread
of microorganisms.
Requires less effort to move the patient.
Ensures patient safety and facilitates transfer.
Locked wheels prevent the bed from moving if the
patient stands against it.
It will be easier to assist patient to sitting position
than having the patient from supine to sitting
position. Having the patient cross his/her arms
across the chest minimizes the risk of injury.
This is to give those assisting with the activity a
way holds onto the patient firmly.
34
 back. Swing the patient’s legs over the side of
the bed while pivoting the patient’s body, so
that the patient ends up sitting on the edge of
the bed with the feet hanging down.
12. Allow the patient to sit and dangle feet for a This prevents lightheadedness or orthostatic
few minutes. hypotension, which can occur with any sudden
change in circulation caused by lowering the legs.
13. Assists the patient to put on a patient’s gown Firm-soled give the patient a sense of security
and slippers. and prevent slipping.
14. Put on a Gait belt on the patient’s waist Make sure that the gait belt perfectly snugs the
patient’s waist.
15. Transfer the patient from the bed to This arrangement will allow the patient to pivot on
wheelchair or armchair. the stronger leg.
a. Angle the wheelchair or armchair to Minimizes transfer distance, remove barriers
the bed so that the chair is on the
patient’s stronger side. If the footrests
are removable, remove them at this
time; otherwise, fold them out.
b. Lock the wheelchair. Be sure the
patient sees the chair and its position.
c. Position the patient’s feet firmly on To protect yourself from injury, do not let the
the floor and slightly apart, with the patient hold you above the neck.
patient’s hands on the bed or on your
shoulders.
d. Take a wide stance, bend your knees, Increases stability and minimizes strain on back.
and grasp the patient at the side of
the belt.
e. Inform the patient that he or she will To gain cooperation
be assisted to a standing position on a
count of three ready “one, two, three,
stand!”
f. On the count, straighten your knees,
assisting the patient to a standing
position.
g. Assist the client to pivot until back of This allows the nurse and client to extend the
knees touches the chair. joints and provide the nurse with opportunity to
ensure the client is stable.
h. Let client hold or to arm of chair while
assisting to set at the count of 3.
i. Be sure the patient’s body is For good posture and makes the client
positioned straight and firmly back in comfortable and safe on the chair.
the seat for good posture.
j. Record in nurse’s note patient’s safe For documentation purposes.
transfer to chair.

BED TO CHAIR: ONE PERSON WITH MINIMAL ASSIST

Proceed as you would for the one-person, maximal assist transfer, with two exceptions. It is not
necessary to brace the patient’s knees, nor is a transfer belt usually necessary. You will be primarily
providing balance, not lifting the patient’s weight.

BED TO CHAIR: TWO PERSON MAXIMAL ASSIST

PROCEDURE RATIONALE
1. Put the bed in the flat position and lock it. Ensures the clients safety.
2. Position the wheelchair or armchair next to Locked wheels prevent the bed from moving of
the bed. At a 45 angle, with the seat facing the patient stands against it.
toward the bed. Secure the brakes.
3. Help the patient to a sitting position on the
edge of the bed as described in the one-
person maximal assist.
4. Nurse 1 stands between the wheelchair and Requires less effort to move the patient.

35
 bed, with one knee on the bed, and grasps
the transfer belt at the patient’s back.
5. Nurse 2 stands in front of the patient (one-
maximal assist), grasping the belt at the sides
6. Nurse 1 informs the patient that he or she will
move on a count of three
7. Nurse 1 signals ready “one, two, three, lift!”.
Both assistants lift and pivot the patient at the
To gain cooperation.
same time then lower the patient into the
wheelchair.
8. Be sure the patient’s body is positioned
For good posture.
straight and firmly back in the wheelchair.
9. Adjust the patient’s position using pillow
where necessary. Drape the lower extremities
of the patient and use restraint if necessary.
Position the call bell so it is available for use.
Hand hygiene deters the spread of
10. Perform hand hygiene.
microorganism.
11. Document the patient’s tolerance of the
procedure and length of time in the chair.
CHAIR TO CHAIR: TWO-PERSON LIFT

Transfer the patient from chair to chair or commode. The transfer belt is not used for this transfer
technique.

PROCEDURE RATIONALE
1. Place the chairs (or commode and chair) side
by side, facing in the same direction
2. Remove the footrests from the wheelchair or Locking the wheelchair prevents moving during
fold them out of the way, and lock or brace the transfer.
the chair (or commode).
3. The taller nurse (1) stands behind the chair.
4. The shorter nurse (2) stands facing the
patient.
5. Nurse 1 folds the patient’s arms across the
patient’s chest. The nurse then reaches under
the patient’s arm from behind the patient and
grasps the opposite wrists.
6. Nurse 2 bends knees and hips, adopting a Two people lifting the patient distribute weight
squatting position, and grasps the patient and decreases the effort needed for transfer.
under the knees to support the legs.
7. Nurse 1 informs the patient that he or she will To gain cooperation
be moved on a count of three, ready “one,
two, three, lift!”
8. Nurse 1 counts (one, two, three, lift!”), and Nurse 1 controls the timing because he or she will
both lift at the same time. bear the greatest weight.
9. Adjust the patient’s position using pillows
when necessary. Drape the patient and use
restraint if necessary. Position the call bell so
it is available for use.
10. Perform hand hygiene Hand hygiene deters the spread of microorganism
11. Document the patient’s tolerance of the This provides accurate documentation and
procedure and length of time in the chair. ensures continuity of care.

HORIZONTAL LIFT: THREE OR FOUR-PERSON ASSIST

(Transferring a patient from bed to stretcher)
You are more likely to use this transfer in a long-term care setting where patients usually have fewer
tubes and attachments that you can see in acute care settings.

36
 PROCEDURE RATIONALE
1. Explain the procedure to the patient This facilitates the cooperation of the patient.

2. Perform hand hygiene Hand hygiene deters the spread of microorganism

3. Move the bed and equipment to make room This facilitates transfer movement and provides
for the stretcher. Make sure that the privacy of the patient.
assistants are available. Close the door or
curtain.
4. Raise the bed to the same height as the Pushing pulling require in less effort than lifting.
stretcher and adjust the head of the bed to This position facilitates moving the patient.
the flat position if the patient can tolerate it.
Lower side rails. Place the stretcher on the
foot part of the bed forming L.
5. Move the patient to one side of the bed.
6. Team leader command a show of hands and To check for presence of jewelry, long nails that
position. may possibly scratch or injure the client.
7. Nurse 1, the tallest, stands at the patient’s
head and slides his on her arms under the
patient’s neck and shoulder.
8. Nurse 2, the next tallest nurse, stands at the
patient’s waist and hips and slides both arms
under the patient.
9. The shortest nurse, nurse 3, stands at the
patient’s knees and slides both arms under
the lower legs and thighs. If a fourth nurse is
used, nurse 2 is at the waist and back of
chest, nurse 3 is at the hips, and nurse 4 is at
the knees and legs
10. Nurse 1 instructs the patient that he or she
will be lifted on a count of “one, two, three,
lift!”
11. Ensures correct position of heads and ensure
client’s body alignment.
12. Using the elbows as levers, all nurses roll the
patient toward themselves in a hugging
motion. Then the patient is lifted on the count
of three, ready “one, two, three, lift!”
13. Holding the patient against their bodies, the
nurses walk together, with synchronized
steps, moving backward then forward towards
the stretcher.
14. At the count (“one, two, three, down!”), the
patient is placed on the stretcher

If transferring using a draw sheet in 3-person assist

PROCEDURE
1. Perform hand hygiene
2. Provide privacy
3. Introduce self and identify patient
4. Explain the procedure to the patient
5. Move the bed and equipment to make room
for the stretcher. Make sure that assistants
are available. Close the door or curtain.
RATIONALE
Hand hygiene deters the spread of
microorganisms
Use 2 identifiers (Complete name and Date of
birth)
This facilitates the cooperation of the patient.
This facilitates transfer movement and provides
privacy of the patient.

37
6. Raise the bed to the same height as the Pushing pulling require less effort than lifting. This
stretcher and adjust the head of the bed to position facilitates moving the patient.
the flat position if the patient can tolerate it.
Lower side rails.
7. Lock the wheels of the bed and lower the side Patient safety and fall precautions
rails making sure that the nurse won’t leave
at the patient side while the side rails are
down.
8. Place the slide board under the draw sheet by The slide board will prevent the nurses from lifting
rolling the patient to one side. If the slide the patient. The slide board will help ease the
board is not available, the draw sheet can be transfer from bed to stretcher.
used to move the patient.

9. Position stretcher next to the bed and parallel Positioning of the stretcher and locking the
to it. Lock wheels on the stretcher and bed. wheels facilitates safe transfer of patient.
Remove the pillow from the bed and place it
on the stretcher.

10. To move the patient:

a. Place the arms of the patient across To prevent arm, shoulder and leg injury during
his/her chest also with the legs the transfer
b. The two nurses are positioned on the
opposite side of the stretcher and
reaches the sliding board.
c. At a signal given by the first nurse Working in unison distributes the work of moving
(count to three), the second and third the patient and facilitates the transfer.
nurse pulls while the first nurse pushes
the patient from the bed to the
stretcher.
11. Secure the patient on the stretcher. Place side This ensures patient safety and comfort.
rails. Remove the slide board.

12. Assists the patient to a comfortable position

with the covering in place. Leave the draw
sheet in place for transfer back to bed.

Hand hygiene deters the spread or

13. Perform hand hygiene. microorganisms.
14. Record in the nurse’s notes the patient’s safe For documentation purposes.
transfer from bed to stretcher or vice versa.

KATZ INDEX OF INDEPENDENCE IN ACTIVITIES OF DAILY LIVING

The Katz Index of Independence in Activities of Daily Living, commonly referred to as the Katz ADL, is the
most appropriate instrument to assess functional status as a measurement of the client’s ability to
perform activities of daily living independently. Clinicians typically use the tool to detect problems in
performing activities of daily living and to plan care accordingly.

Normal aging changes and health problems frequently show themselves as declines in the functional
status of older adults. Decline may place the older adult on a spiral of iatrogenesis leading to further
health problems. One of the best ways to evaluate the health status of older adults is through functional
assessment which provides objective data that may indicate future decline or improvement in health
status, allowing the nurse to plan and intervene appropriately.

The Index ranks adequacy of performance in the six functions of

1. Bathing,

38
 2. Dressing
3. Toileting
4. Transferring
5. Continence
6. Feeding

Clients are scored yes/no for independence in each of the six functions.
A score of 6 indicates full function, 4 indicates moderate impairment, and 2 or less indicates severe
functional impairment.

TARGET POPULATION: The instrument is most effectively used among older adults in a variety of care
settings, when baseline measurements, taken when the client is well, are compared to periodic or
subsequent measures.

VALIDITY AND RELIABILITY: In the forty-eight years since the instrument has been developed, it has
been modified and simplified and different approaches to scoring have been used. However, it has
consistently demonstrated its utility in evaluating functional status in the elderly population. Although no
formal reliability and validity reports could be found in the literature, the tool is used extensively as a flag
signaling functional capabilities of older adults in clinical and home environments.

STRENGTHS AND LIMITATIONS: The Katz ADL Index assesses basic activities of daily living. It does
not assess more advanced activities of daily living. Katz developed another scale for instrumental
activities of daily living such as heavy housework, shopping, managing finances and telephoning.
Although the Katz ADL Index is sensitive to changes in declining health status, it is limited in its ability to
measure small increments of change seen in the rehabilitation of older adults. A full comprehensive
geriatric assessment should follow when appropriate. The Katz ADL Index is very useful in creating a
common language about patient function for all practitioners involved in overall care planning and
discharge planning.

BARTHEL INDEX (BI)

The Barthel Index (BI) measures the extent to which somebody can function independently and has
mobility in their activities of daily living (ADL) i.e. feeding, bathing, grooming, dressing, bowel control,
bladder control, toileting, chair transfer, ambulation and stair climbing. The index also indicates the need
for assistance in care. The BI is a widely used measure of functional disability. The index was developed
for use in rehabilitation patients with stroke and other neuromuscular or musculoskeletal disorders,
but may also be used for oncology patients.

General Guidelines for the Barthel Index of Activities of Daily Living General
1. The Index should be used as a record of what a patient does, NOT as a record of what a patient
could do.
2. The main aim is to establish degree of independence from any help, physical or verbal, however
minor and for whatever reason.
3. The need for supervision renders the patient not independent.
4. A patient's performance should be established using the best available evidence. Asking the
patient, friends/relatives, and nurses will be the usual source, but direct observation and common
sense are also important. However, direct testing is not needed.
5. Usually the performance over the preceding 24 – 48 hours is important, but occasionally longer
periods will be relevant.
6. Unconscious patients should score '0' throughout, even if not yet incontinent.
7. Middle categories imply that the patient supplies over 50% of the effort.
8. Use of aids to be independent is allowed.

Bowels (preceding week)

 If needs enema from nurse, then 'incontinent.'
 'Occasional' = once a week.

Bladder (preceding week)

 'Occasional' = less than once a day.

39
  A catheterized patient who can completely manage the catheter alone is registered as 'continent.'

Grooming (preceding 24 – 48 hours)

 Refers to personal hygiene: doing teeth, fitting false teeth, doing hair, shaving, washing face.
 Implements can be provided by helper.

Toilet use
 Should be able to reach toilet/commode, undress sufficiently, clean self, dress, and leave.
 'With help' = can wipe self and do some other of above.

Feeding
 Able to eat any normal food (not only soft food). Food cooked and served by others, but not cut up.
 'Help' = food cut up, patient feeds self.

Transfer
 From bed to chair and back.
 'Dependent' = NO sitting balance (unable to sit); two people to lift.
 'Major help' = one strong/skilled, or two normal people. Can sit up.
 'Minor help' = one person easily, OR needs any supervision for safety.

Mobility
 Refers to mobility about house or ward, indoors. May use aid. If in wheelchair, must negotiate
corners/doors unaided.
 'Help' = by one untrained person, including supervision/moral support.

Dressing
 Should be able to select and put on all clothes, which may be adapted.
 'Half' = help with buttons, zips, etc. (check!), but can put on some garments alone.

Stairs
 Must carry any walking aid used to be independent.

Bathing
 Usually the most difficult activity.
 Must get in and out unsupervised, and wash self.
 Independent in shower = 'independent' if unsupervised/unaided.
DEFINITION AND DISCUSSION OF SCORING

1. FEEDING 10 = Independent. The patient can feed himself a meal

from a tray or table when someone puts the food within his
reach. He must put on an assistive device if this is needed,
cut up the food, use salt and pepper, spread butter, etc. He
must accomplish this in a reasonable time.

5 = Some help is necessary (with cutting up food, etc.,)

2. MOVING FROM WHEELCHAIR TO
BED AND RETURN
15 = Independent in all phases of this activity. Patient can
safely approach the bed in his wheelchair, lock brakes, lift
footrests, move safely to bed, lie down, come to a sitting
position on the side of the bed, change the position of the
wheelchair, if necessary, to transfer back into it safely, and
return to the wheelchair.

10 = Either some minimal help is needed in some step of

this activity or the patient needs to be reminded or
supervised for safety of one or more parts of this activity.

5 = Patient can come to a sitting position without the help

of a second person but needs to be lifted out of bed, or if
he transfers with a great deal of help.

3. DOING PERSONAL TOILET
5 = Patient can wash hands and face, comb hair, clean
teeth, and shave. He may use any kind of razor but must
put in blade or plug in razor without help as well as get it
from drawer or cabinet. Female patients must put on own
makeup, if used, but need not braid or style hair.

40
4. GETTING ON AND OFF TOILET
5. BATHING SELF
6. WALKING ON A LEVEL SURFACE
6a. Propelling a Wheelchair
7. ASCENDING AND DESCENDING
STAIRS
8. DRESSING & UNDRESSING
9. CONTINENCE OF BOWEL
10. CONTROLLING BLADDER
10 = Patient is able to get on and off toilet, fasten and
unfasten clothes, prevent soiling of clothes, and use toilet
paper without help. He may use a wall bar or other stable
object for support if needed. If it is necessary to use a bed
pan instead of a toilet, he must be able to place it on a
chair, empty it, and clean it. Patient needs help because of
imbalance or in handling clothes or in using toilet paper.
5 = Patient may use a bath tub, a shower, or take a
complete sponge bath. He must be able to do all the steps
involved in whichever method is employed without another
person being present.
15 = Patient can walk at least 50 yards without help or
supervision. He may wear braces or prostheses and use
crutches, canes, or a walkerette but not a rolling walker. He
must be able to lock and unlock braces if used, assume the
standing position and sit down, get the necessary
mechanical aides into position for use, and dispose of them
when he sits. (Putting on and taking off braces is scored
under dressing.)
10 = Patient needs help or supervision in any of the above
but can walk at least 50 yards with a little help.
5 = If a patient cannot ambulate but can propel a
wheelchair independently. He must be able to go around
corners, turn around, maneuver the chair to a table, bed,
toilet, etc. He must be able to push a chair at least 50
yards. Do not score this item if the patient gets score for
walking.
10 = Patient is able to go up and down a flight of stairs
safely without help or supervision. He may and should use
handrails, canes, or crutches when needed. He must be able
to carry canes or crutches as he ascends or descends stairs.
5 = Patient needs help with or supervision of any one of the
above items.
10 = Patient is able to put on and remove and fasten all
clothing, and tie shoelaces (unless it is necessary to use
adaptations for this). The activity includes putting on and
removing and fastening corset or braces when these are
prescribed. Such special clothing as suspenders, loafer
shoes, dresses that open down the front may be used when
necessary.
5 = Patient needs help in putting on and removing or
fastening any clothing. He must do at least half the work
himself. He must accomplish this in a reasonable time.
Women need not be scored on use of a brassiere or girdle
unless these are prescribed garments.
10 = Patient is able to control his bowels and have no
accidents. He can use a suppository or take an enema when
necessary (as for spinal cord injury patients who have had
bowel training).
5 = Patient needs help in using a suppository or taking an
enema or has occasional accidents.
10 = Patient is able to control his bladder day and night.
Spinal cord injury patients who wear an external device and
leg bag must put them on independently, clean and empty
bag, and stay dry day and night.
5 = Patient has occasional accidents or cannot wait for the
41
 bed pan or get to the toilet in time or needs help with an
external device.

 A score of 0 is given in all of the above activities when the patient cannot meet the criteria as
defined above.

 The advantage of the BI is its simplicity. It is useful in evaluating a patient's state of

independence before treatment, his progress as he undergoes treatment, and his status when he
reaches maximum benefit. It can easily be understood by all who work with a patient and can
accurately and quickly be scored by anyone who adheres to the definitions of items listed above.

 The total score is not as significant or meaningful as the breakdown into individual items, since
these indicate where the deficiencies are.

 Any applicant to a chronic hospital who scores 100 BI should be evaluated carefully before
admission to see whether such hospitalization is indicated. Discharged patients with 100 BI
should not require further physical therapy but may benefit from a home visit to see whether any
environmental adjustments are indicated. Encouragement by family and others may be necessary
for a patient to maintain his degree of independence.

Scoring

Sum the patient's scores for each item. Total possible scores range from 0 – 20, with lower scores
indicating increased disability. If used to measure improvement after rehabilitation, changes of more than
two points in the total score reflect a probable genuine change and change on one item from fully
dependent to independent is also likely to be reliable.

BI can be interpreted as follows:

 score of 80–100, independent
 score of 60–79, needs minimal help with ADL
 score of 40–59, partially dependent
 score of 20–39, very dependent
 score of < 20, totally dependent.

42
 FACILITATING
HYGIENE,
PROMOTING REST &
SLEEP, AND
THERMOREGULATION

43
 BED MAKING

Definition
 Bed making is the proper adjustment of bed linens and the preparation of the hospital beds in
different ways or in a specific purpose.
 The ability of the nurse to keep the bed clean and comfortable.
 The technique of preparing different types of bed in making patients/clients comfortable in
his/her suitable position for a condition.
 It requires keen inspection to be sure that the linens are clean, dry and wrinkle-free.

Purposes
1. It helps maintain a clean, orderly and comfortable room which contributes to the patient’s sense
of well-being.
2. Helps the patient secure proper rest and comfort which are essential for health. Refresh the
client by providing cleanliness.
3. It helps prevent or avoid microorganisms to come in contact with the patient which could cause
tribulations.
4. It minimizes the sources of skin irritation by providing smooth, wrinkle-free bed foundation.

Types of Bed
1. Standard hospital bed – with firm mattress on metal frame which can be raised or lowered
horizontally and can be adjusted to variety of positions. Can be controlled electronically or
manually.
2. Special hospital bed – this is for clients indicated for maintaining strict body alignment, with an
axis to turn the client from supine to prone or vice versa.
a. Stryker wedge frame – manually operated; turns client laterally through side lying
position. Indicated for those with spinal injuries or surgery requiring immobility.
b. Circo-electric bed – electrically operated; using a push button rotates the patient
vertically through the standing position. It permits frequent turning of the securely
injured or immobilized patient with minimal trauma and strenuous movement to prevent
or treat decubitus ulcer, as well as respiratory and circulatory complications.

Parts of Bed
1. Side rails – to protect the client from fall.
2. Wheel locks – to prevent accidental movement of the bed.
3. Patient’s signal – device to call for assistance from health personnel.
4. Electronic or manual control (cranks) – to change the position of the bed.

Commonly used bed positions

1. Flat (Supine) – mattress is completely in horizontal position. To maintain spinal alignment for
clients with spinal injuries.
2. Fowler’s position – semi-sitting position in which head of bed is raised to angle of at least 45
degrees. Knees may be flexed or horizontal. To promote lung expansion for clients with
respiratory problem.

44
 3. Semi-fowler’s position – head of bed raised only to 30-degree angle.
Purpose: a. Relief from lying position.
b. To promote lung expansion.
4. Trendelenburg’s position – head of bed lowered, and the foot raised in a straight incline. To
promote venous circulation in certain client’s; provides postural drainage of basal lung lobes
5. Reverse Trendelenburg’s position – head of bed raised and the foot lowered. Straight tilt in
direction opposite to Trendelenburg's position; promotes stomach emptying and prevent
esophageal reflex in clients with hiatal hernia

Kinds of Linens
2. Blanket – a large piece of cloth often soft, woolen and is used for warmth as a bed cover
3. Top sheet – used to cover the patient to provide warmth, made of thick cotton, thermal material
4. Cotton drawn sheet – a piece of cloth that covers the rubber sheet and is used to absorb and
protect moisture
5. Bottom sheet – used to cover the bed after mattress cover
6. Rubber sheet – used to protect the bottom sheet from soothing due to patient secretions and
prevent the patients from getting bedsore. It is usually placed over the center of the bottom sheet
7. Mattress cover – a piece of cloth to cover the mattress
8. Woolen blanket – a large rectangle piece of cloth of soft fabric often either bound edge used
especially for warmth as a bed covering. It should be light, warm and large enough to cover the
shoulder and to tuck in well at the foot and to extend over sides.

Principles in Bed Making

1. Body Mechanics – it is important for the nurse to observe the correct body mechanics in order
to prevent exhaustion, back problems and muscle pain.
2. Anatomy & Physiology – the conscious knowledge of the normal state and condition of certain
parts of the body wherein one would be able to tell any abnormality. The body exerts uneven
points of pressure against different areas of the mattress. The sacrum may become the site for
pressure sore because of the weight of the patient’s body and a reduced blood supply to the
tissues over bony prominence.
3. Chemistry – woolen blanket fibers may cause irritation to the patient’s skin; there must always
be a sheet that separates the blanket from the patient. Strong detergent soap and bleaches used
in commercial laundries may cause skin irritation especially if the linens are not thoroughly
rinsed.
4. Microbiology – pathogenic microorganism may be transferred from one source to the other
through contaminated linen. Hands should be washed before and after making bed.
Bed linen should be folded away from the body to minimize the transfer of microorganism to the
clothing. Fanning of bed linens stirs up bacteria in the air thus making it another method of
transmission.
5. Physics – friction can irritate the skin and cause rashes. It is therefore appropriate to keep the
linens smooth and wrinkle-free. Stability of body (center of gravity over its base) should always
be observed to avoid accidents and injuries.
6. Psychology – use skill and efficiency in making the bed to minimize undue exertion and fatigue
for the patient and the nurse. If the procedure brings comfort and relaxation thus attitude will
also improve.
7. Sociology – the nurse should know how to talk to patients. The nurse should also know the
subject of conversation which interests the patient including his condition, family, and work.

Guidelines in Bedmaking
1. Wash hands thoroughly after handling client’s bed linen.
2. Hold soiled linens away from the body.
3. Linen for one client is never placed on another client’s bed.
4. Soiled linen is placed directly in a portable linen hamper or tucked into a pillowcase at the end of
the bed before it is gathered up for disposal in the linen hamper or in linen chute. Pillowcase is
then tied and labeled with name, room number, communicable/non-communicable
5. Linens is never shaken in air.
6. When stripping and making a bed, conserve time and energy by stripping and making up one
side as completely as possible before working on the other side.
7. Gather all needed linen before starting to strip the bed.
8. Keep the patient’s environment as clean and as neat as possible.

COMMON TYPES OF BED MAKING

1. UNOCCUPIED BED
1. Aesthetic and functional arrangement of bed elements while the patient is out of bed.

45
 a. Open Bed – a bed being used by a patient; the top sheet is folded down.
b. Closed Bed – a bed not being used by a patient; the top sheet is left to cover the
bed.

2. OBSTETRICAL BED
1. a bed prepared for a patient who has given birth.

3. POSTOPERATIVE BED
 Also known as recovery bed or anesthetic bed.
 Used not only for clients who have undergone surgical procedures but also for clients
who have given anesthetics for a certain examination.
 Used for a patient with a large cast or other circumstance that would make it difficult for
him to transfer easily into bed.

4. OCCUPIED BED
 the occupied bed is made when the patient is not able or not permitted to get out of the
bed
 the important part of making an occupied bed is to get the sheets smooth and tight
under the patient so that there will be no wrinkles to rub against the patient’s skin.
 the client’s privacy, comfort and safety are important when making the bed

UNOCCUPIED BED

Purposes:
1. To prepare for newly admitted client who has not yet arrived in the unit.
2. To provide clean, neat environment for the client.
3. To reduce transmission of microorganism
4. To promote the client’s comfort.
5. To provide a smooth, wrinkle-free bed foundation, thus minimizing sources of skin irritation.

Equipment:
 Pillow
 Pillowcase
 Top sheet
 Draw sheet
 Rubber sheet
 Bottom sheet

PROCEDURE RATIONALE

1. Performs medical hand washing It deters the spread of microorganism

2. Prepare the necessary equipment Promotes efficient time management

3. Folds each linen correctly Provides easy access to items.

4. Place materials on the bedside chair/table
which is positioned on foot part of the side of
the bed. Do not use another client’s bed.
5. Assess the condition of the bed/lock wheels.
6. Remove attached equipment from the bed,
such as the call light.
7. Raise the bed to a working height.
8. Place the bottom sheet of the mattress with
the centerfold at the midline of the bed and
larger hemline at the foot part.
9. Spread the sheet from the foot part to the
head part. Make sure that the end of the
sheet with the bigger hem is at the foot of the
bed. Its hem should be in line with the edge
of the mattress.
This prevents cross contamination- the movement
of microorganisms from one client to another via
soiled linen
To promote stability of the bed.
This prevents possible accidents while performing
the procedure.
Prevents straining of back muscles.
Proper positioning of linen will ensure that
adequate linen available to cover opposite side of
the bed.

46

10. Tuck and miter the corner of the bottom
sheet.
11. Put the rubber sheet approximately 18 inches
from the head part with the centerfold at the
midline of the bed.
Secures sheet tightly to the mattress, with the
triangular fold providing a smooth tuck to keep
the linen in place.
Fitted sheets do not require mitering.
The rubber sheet will prevent soiling the bottom
sheet

12. Unroll the rubber sheet.

13. Place the draw sheet over the rubber sheet The draw sheet prevents the patient’s skin from
with the centerfold at the midline of the bed getting in contact with the rubber sheet thus
and approximately enough to envelop the preventing irritation.
rubber sheet.
14. Spread the draw sheet open. Fanfold the
other half of the draw sheet towards the
midline of the bed.
15. Tuck the bottom sheet, the rubber sheet, and
draw sheet altogether underneath the To remain securely in place
mattress starting at the mitered corner.
16. Place the top sheet on the bed with the
centerfold at the midline of the bed and the
larger hemline towards the head part.
17. Spread the top sheet then tucks and miters
the corner edge at the foot part of the bed.
18. Insert the pillow into pillowcase, work at the
foot part of the bed
19. Put the pillow at the head part of the clean
side of the bed with the opening positioned For neater appearance
away from the entrance
20. Go to the other side of the bed. Working on one side of the bed at a time saves
Pass at the foot part. time.
21. Pull the bottom sheet from the head to the
foot part.
22. Smoothen out wrinkles and miter then tuck
the corners of the bottom sheet.
23. Unroll the rubber sheet toward the nurse
24. Pull the draw sheet and envelop the rubber
sheet.
25. Tuck the bottom sheet, the rubber sheet and
the draw sheet altogether underneath the
mattress starting at the head part to the foot
part.
26. Pull the top sheet at the foot part, grab the Having linen opened makes it more convenient for
mattress and miter the corner. the client to get into bed
27. Position the pillow at the midline of the head
part of the bed.
28. Cover the entire bed with top sheet.
(for closed bed).
29. Fold the top sheet approximately 16 inches Having linen opened makes it more convenient for
away from the head part. the client to get into bed

OB BED

Equipment:
 Same equipment as an unoccupied bed
 Additional cotton draw sheet

47
  Extra pillow

PROCEDURE RATIONALE
1. Repeat procedure of unoccupied bed 1-30
except step #29.
Facilitates easy entrance and placement of patient
2. Fanfold the top sheet towards the foot part.
on bed
This facilitates slight flexion of the knees which
3. Place the pillow underneath the rubber sheet.
relaxes abdominal muscles.
4. Add one cotton draw sheet over the cotton
sheet or if there is no available additional
The cotton draw sheet protects the linen from
cotton draw sheet, fold the available one into
getting soiled
3 and put in place where the buttocks will
rest.
POST-OP BED

Equipment: Same equipment as an unoccupied bed

 Gown
 Suction Machine and catheter
 Droplight (optional)
 Kidney Basin
 Mouth Wipes / wash cloth
 IV stand oxygen
 Padded tongue depressor
 O2 tank prepared with necessary connections

PROCEDURE RATIONALE

1. Untuck the top sheet at the foot part. To facilitate easy transfer of surgical patients.
2. Fold back top sheet at the head part and
To prevent head injury upon patient transfer.
fanfold top sheet away from the entrance.
3. Place the pillow against the headboard

4. Place hot water bag on the foot part.
5. Place kidney basin, mouth wipes and padded
tongue depressor at the bedside table.
6. Position call light at the head part of the bed.
To keep the patient warm and prevent chilling.
post op clients usually vomit as side effect of the
anesthesia
Having the signal device within the patient’s reach
makes it possible for him to call for assistance as
necessary

OCCUPIED BED

Purposes
1. To conserve client’s energy and maintain current health status.
2. To provide a clean, neat environment for the client
3. To provide a smooth, wrinkle free foundation thus minimizing sources of skin irritation.
4. To promote client’s comfort.

Equipment:
 Bed
 Chair
 2 Bottom Sheet
 1 Rubber Sheet
 Pillowcase
 Cotton Draw Sheet

48
 PROCEDURE RATIONALE
1. Assess client’s activity and capacity to
Checking if limitations helps minimize the risk for
participate with the changing of linens. Check
injury
for special needs and limitations in the chart.
2. Introduces self and explain the procedure to To establish rapport and promote client’s
the client. cooperation.
3. Perform medical hand washing. It deters the spread of microorganism
Organization promotes efficient time
4. Prepare the necessary equipment.
management.
5. Fold each linen correctly.

Provides easy access to items.

6. Place materials on the bedside chair/table
This prevents cross contamination- the movement
which is positioned on foot part of the side of
of microorganisms from one
the bed. Do not use another client’s bed.
client to another via soiled linen
7. Provide privacy by pulling the curtains and/ or
closing the door.
8. Remove attached equipment from the bed,
such as the call light.
To keep patient’s safely and prevent accidents.
Assess the condition of the bed. Lock the
wheels.

9. Raise the bed to a working height. Prevents straining of back muscles

10. Loosen / untuck all linen at the sides of the Facilitates easy removal of linen.
bed then raise the side rails. Promotes patient’s safety
11. Let the client move towards the nurse.

12. Logroll the client facing away the nurse. Positions client off of soiled linen.

13. Secure the client’s position by placing pillow. Protects client from falling.

14. Raise the side rail. Promotes patient’s safety

15. Move to the other side of the bed.

16. Roll the draw sheet towards the midline/ back
of the client.
17. Roll the rubber sheet towards the midline/
back of the patient, keeping contaminated
portion contained.
18. Roll the bottom sheet towards the midline/
back of the patient
19. Place the centerfold of the new bottom sheet
at the bottom part of the mattress with bigger
hemline at the foot part.
20. Tuck and miter the corner of the bottom Mitering the corners secures the linen while client
sheet. moves on the bed.
21. Put the new rubber sheet. Unroll half towards
the nurse.
22. Place the new draw sheet over the rubber
sheet with the centerfold at the midline of the
bed.
23. Fanfold the other half of the draw sheet
towards the back of the patient.

49
24. Envelope the rubber sheet. Tuck the bottom
sheet, rubber sheet, and draw sheet together.
25. Place the top sheet with the centerfold at the
midline and the bigger hemline at the head
part of the bed.
26. Spread the top sheet, tuck, and miter the
corner of the top sheet.
27. Ask permission from the patient to replace the
pillowcase.
28. Invert the soiled pillowcase and hang it at the
back of the bedside chair.
29. Put the pillow with the new pillowcase at the
head part of the made side of the bed.
30. Instruct the patient to move to the clean side This allows you to change the linen on the half of
of the bed. See to it that patient will not lie on bed.
the new top sheet by letting the client hold Holding the top sheet secures it while the used
the clean top sheet. top sheet is being removed
31. Log roll the patient towards the nurse, raise
To promote patient’s safety
side rails or place pillow.
Doing one side of the bed completely before
32. Move to the other side of the bed. Lower the
starting the other side saves nurse’s time and
side rails.
energy
33. Remove and roll the soiled top sheet from
head part to foot part. Make sure that soiled This prevents cross contamination
linen will not touch your uniform.

34. Roll and remove the draw sheet

35. Roll the rubber sheet towards the back of the

client then remove
36. Roll and remove the bottom sheet.

37. Place the soiled linen in the pillowcase.

38. Pull back bottom sheet, miter and tuck the
corner.
39. Pull back the rubber sheet and draw sheet.
40. Tuck the bottom sheet, rubber sheet and
draw sheet together.
41. Spread the top sheet and miter the corner. This protects the client from falling
42. Allow the client to assume the supine position
and realign the client at the midline of the
bed.
43. Make sure the client is safe and comfortable.
Raise the side rails.
44. Do after care.

45. Perform medical hand washing.

Bed making is not normally recorded. Record any

nursing assessments, such as the client’s physical
46. Document and report pertinent data.
status and pulse and respiratory rates before and
after being out of bed as indicated.

STRIPPING THE BED

Definition: Removal of used linen and the airing of the mattress.

50
 PROCEDURE
1. Place chair at the foot of the bed.
2. Remove pillowcase from pillow. Place pillow on chair. Place soiled pillowcase on lower bar of
the bed.
3. Loosen all bed linens starting at center of head of bed, raising the mattress with one hand and
drawing out bed clothes with other
4. Remove sheets separately. Fold each linen with soiled part inside. Wrap them all in a sheet
and place on lower bar of the bed
5. Roll rubber sheet and place on chair.
6. Remove mattress cover.

HYGIENE

HYGIENE is the science of health and its maintenance. Personal hygiene is the self-care by which
people attend to such functions as bathing, toileting, general body hygiene, and grooming. Hygiene is a
highly personal matter determined by individual values and practices. It involves care of the skin, feet,
nails, oral and nasal cavities, teeth, hair, eyes, ears, and perineal-genital areas. (Berman, et al, 2018)

Types of Hygienic Care

1. Early Morning Care – is provided to clients as they awaken in the morning. It consists of
providing a urinal or a bedpan to the client confined to bed, washing the face and hands, and
giving oral care.
2. Morning Care – is often provided after clients have breakfast, although it may be provided
before breakfast. It includes providing for elimination needs, a bath or shower, perineal care,
back massages, and oral, nail, and hair care. Making the client's bed is part of morning care.
3. Hour of Sleep or PM Care – is provided to clients before they retire for the night. It usually
involves providing for elimination needs, washing face and hands, giving oral care, and giving a
back massage.
4. As-needed (PRN) care – is provided as required by the client.
Example: A client who is diaphoretic may need more frequent bathing and change of clothes and
linen.

Importance of Hygiene and Care

1. The bath stimulates circulation in the skin and underlying tissues
2. It cleans and refreshes, promoting health and comfort
3. It provides some exercise for the patient
4. Provides excellent opportunities for observation of the patient’s physical and emotional condition
and for patient-centered conversation to promote good interpersonal relationships.

Nursing Knowledge Base

1. Personal preferences for hygiene
While a patient's hygiene practices could change with their social environment, patients
who have their own stand about hygiene would maintain their personal care preferences. For
example, they may have preferences in using certain care products in shaving, bathing and
washing hair.
2. Hygiene care is never routine
No two individuals perform hygiene in the same manner; it is important to individualize
the patient's care based on knowing about the patient's unique hygiene practices and
preferences. Hygiene care is never routine; this care requires intimate contact with the patient
and communication skills to promote the therapeutic relationship. In addition, during hygiene,
the nurse should take time to learn about the patient's health promotion practices and needs,
emotional needs, and health care education needs
3. During hygiene
 Assess physical status and limitations
 Assess client’s readiness to learn
 Provide privacy

51
  Foster physical well being

Factors Influencing Hygiene

1. Body image
 A person’s subjective concept of their appearance
2. Social practices
 Social groups and family practices
3. Socioeconomics
4. Cultural variables
5. Personal preferences
 Some people prefer showers, other prefer tub baths
 Frequency – Some bathe in the morning, some at bedtime
 Preferred products
 Some people cannot afford soap, deodorant, shampoo, toothpaste or other hygienic
products
6. Physical condition
 Lack of physical energy
 Loss of dexterity
7. Knowledge about importance of hygiene

SHAMPOO IN BED

Definition: Washing of the hair with the use of shampoo or bath soap as often as necessary to keep it
clean. It is the washing of hair while the patient is in bed.

Purposes:
1. To stimulate the blood circulation to the scalp
2. To distribute hair oils and provide a healthy sheen
3. To increase the client's comfort
4. To assess or monitor hair or scalp problems

Equipment:
 comb/brush
 shampoo
 shampoo trough
 2 rubber sheets/waterproof pad
 3 bath towels
 cotton balls
 face towel
 1 bath blanket
 gown (optional)
 pail
 2 pitchers with water 1 for warm water and 1 foe cold water)
 basin / dipper
 paper lining

PROCEDURE
1. Verify the doctor's order.
a. Determine whether the physician's order
is needed before shampoo can be given.
RATIONALE
Reviewing the medical record and plan of care
validates the correct patient and correct
procedure. Assessment helps identify problem
areas to minimize the risk for injury.

d. Determine the type of shampoo to be

used.
c. Determine the best time of the day for
Usually, the best time for this procedure is when
shampoo

52
 the patient has rested.

Minimizes harmful microorganisms.

2. Wash your hands before the procedure
3. Provide for client privacy by drawing the Hygiene is a personal matter
curtains around the bed or closing the door of
the room
4. Identify the client and establish rapport Dialogue also encourages patient participation
and allows for individualized nursing care

5. Explain the procedure to the client. This promotes reassurance and provides
knowledge about the procedure.

6. Bring all the equipment to bedside and Saves time and energy.
arrange accordingly

7. Position and prepare the client appropriately

a. Place patient on supine position Prevents muscle strain and fatigue to the nurse.

b.

8. Arrange equipment.
This protects the sheets from getting wet.
a. Put rubber sheet/waterproof pad under
the clients’ head

c. Place shampoo trough / shampoo board

under the client's head with the end
directed into the pail/basin.
d. Protect the floor or bedside table with
paper lining (newspaper) and place the
pail/basin over it.
e. Place a rolled towel under the client’s
neck
f. Put a towel over the shoulders and
chest.

g. Remove pins and ribbons from the hair,

brush, and comb it to remove tangles.

Plugging ears prevents water from entering the

9. Cover client's eyes with folded face towel and
plugs ear with cotton balls. ears.

10. Make sure the temperature of the water is not This prevents from burns and chilling.
too warm or cold.
11. Pour water slowly and carefully from pitcher Careful outpour of water prevents water on
over the hair entering the ears.

12. Apply soap or shampoo on the hair or scalp,
reaching all areas. Make a good lather while
massaging the scalp.
13. Rinse hair with clean water.
Shampoo/soap will help remove dirt or oil.
Massaging the scalp stimulates circulation.
Remaining shampoo may irritate the scalp and
hair.

14. Repeat the washing and rinsing two or three This thoroughly removes the shampoo from hair.
more times as required. Shampoo left in hair may cause pruritus. If hair is
still dirty another shampoo treatment may be
needed.

15. Squeeze as much water as possible from the

hair with hands.

53
16. Remove ear plugs and dry forehead and ears
with towel.
17. Wrap hair with towel. To remove excess water from the hair.

18. Remove shampoo trough or Kelly pad

19. Rub the client's head with towel. Comb hair. Helps hair to dry faster and prevents patient from
becoming chilled. Combing hair improves patient’s
self-image.

20. Change the patient's gown if damped. If patient’s gown is damp, patient will feel cold

21. Assist patient in a comfortable position.

22. Do after care of the equipment used in the

procedure in the utility room.
23. Perform medical handwashing / hand hygiene

24. Document accurately the time and type of Careful record is important for planning and
treatment given, condition of client and individualizing the patient’s care.
significant observations.

CLEANSING BED BATH

Definition
1. Cleansing bed bath – a complete hygienic measure administered while the patient is in bed.
2. Complete bed bath – the nurse washes the entire body of a dependent client in bed

2 General Categories
1. Cleaning – given for hygienic purposes
a. Shower – requires minimal assistance from the nurse
b. Tub bath – a bath given in a tub
c. Self-help bath – client confined to bed can bath themselves with help from the nurse for
washing the back and perhaps the feet
d. Complete bed bath – washing of the entire body.
e. Partial bath – only the part of the client’s body that might cause discomfort or odor.
f. Bag bath – a bath commercially prepared product that contains 10 to 12 presoaked
disposable wash clothes that contain no rinse cleanser solution.
2. Therapeutic Baths – are given for physical effects, such as to soothe irritated skin or to treat
on area. Medication may be place in the water and usually ordered by physician.
a. Saline for cooling effect
b. Oatmeal soothes skin irritation
c. Cornstarch soothes skin irritation

Purposes
1. To remove transient microorganism, body secretions and excretion and dead skin.
2. To refresh the patient.
3. To stimulate circulation and prevent bedsore
4. To exercise muscles, and joints.
5. To provide tactile stimulation.
6. To promote comfort and relaxation.
7. To produce a sense of well being
8. To facilitate head-to-toe assessment

Special Considerations
1. Ensure privacy.
2. Bed bath can be given 1 hour before meals or 1 hour after meals
3. Everything should be ready before giving the bath.
4. If the patient is weak all assistance should be given to free the patient from exertion.
5. Unnecessary exposure or chilling must be avoided.

54
 6. Special attention must be given to regions behind the ears, axillae, umbilicus, the pubis, and
groins, spaces between fingers and toes and areas where 2 skin surfaces come in contact.
7. During the bath, the patient must be observed for objective signs such as rashes, swelling,
discoloration; pressure sores discharges, abrasions, lice, burns, etc. The findings should be
recorded in the nurse’s notes and reported to the physician if they seem important.
8. All treatments such as enema, douches or preparation for fields of operation should be done
before the bath so that the patient will remain clean and undisturbed afterwards
9. The nurse may usually work quickly but it should be in a quiet soothing and fashion. Strokes
should be smooth and firm and ends of the washcloth should not be allowed to dangle

Equipment
 Bedpan or urinal
 bath blanket (1)
 2 basins with water (1 for warm and 1 for cold water)
 wash cloth (2)
 bath towel (2)
 soap
 lotion/powder
 deodorant
 gown and underwear
 comb
 linen

PROCEDURE RATIONALE
1. Perform medical handwashing. Prevents the spread of microorganism
2. Prepare the client and the environment.
a. Provide privacy by drawing the curtains To maintain privacy
or closing the windows and door.
b. Turn off the electric fan (s) or air Protects from chills during bath.
conditioning.
3. Introduce self to the client. To establish rapport.

4. Identify and explain the procedure to the
client.
5. Assess tolerance for bathing and activity,
comfort level, cognitive ability and
musculoskeletal function. Determine
shortness of breath before or during the
bath and the condition of the skin.
6. Offer the client bedpan or urinal or asks
whether the client wishes to use the toilet
or commode.
7. Gather and prepare all equipment at the
bedside and arrange it according to use
8. Prepare the bed and position the client
appropriately.
a. Place the bed in a working height.
b. Move the client to the side of the bed
near you. Place on supine position
c. Remove the top linen and replace it with
a bath blanket.
d. Untie and remove the gown.
e. Prepare the water according to
temperature preference of the patient.
To identify the right patient, and enhances
cooperation
This will provide the nurse the needed data for
what precautions to look after during the
procedure and what other intervention to apply
on those concerns noted to the patient.
Voiding & defecating before the bath lessens the
likelihood that the bath will be interrupted. Warm
bath water may stimulate the urge to void.
Bringing everything to the bedside conserves time
and energy. Arranging items nearby is convenient,
saves time and avoids unnecessary stretching and
twisting of muscles on the part of the nurse.
Prevents unnecessary reaching. Facilitates use of
good mechanics.
Prevents unnecessary reaching.
Prevents exposure of a client. Promotes privacy.
Protects from chills.
This provides uncluttered access during the bath.
Prevents accidental burns and chills.
To ensure patient’s comfort. Warm water (43oC to
46oC or 110oF to 115oF) is comfortable & relaxing

55

f.Place a bath towel under the client's
head and another towel across the
client's chest.
9. Make a bath mitt with washcloth.
10. Wash the face
a. Wash the client's eyes with water only.
Wipe from inner to outer canthus. Use
separate portion of the washcloth from
one eye to the other
b. Wash, rinse and dry the patient face,
ears and neck.
to the patient. It also stimulates circulation and
provides for more effective cleansing
Prevents ends of the washcloth from dragging
across skin. Promotes friction during the bath.
Having loose ends of cloth drag across the
patient’s skin is uncomfortable. Loose ends cool
quickly and feel cold to the patient.
Some client’s may not use soap on the face.
Using separate corners of the washcloth reduces
the risk of transmitting microorganisms. Patting
dry reduces skin irritation and drying.
To remove dirt from patient face

11. Wash the arms and hands.

a. Place the bath towel lengthwise under Bath towels protect the bed from getting wet.
one arm (near arm).
b. Wash, soap, rinse and dry the arm using Long strokes promote circulation
long firm strokes from distal to proximal Strokes directed distal to proximal promotes
area (from the point farthest from the venous return.
body to the point closest).
c. Place a folded towel directly on the bed Washing removes dirt and odor from axilla
& put the basin on it. Place the client's
hands on the basin. Wash, soap, rinse,
& dry the hands paying attention to the
spaces between the fingers.
d. Allow hand to soak about 3 to 5 Some dirt may accumulate between fingers, so
minutes. Wash hands inter digit area, special care is given to it.
fingers, fingernails.
e. Move to the other side of the bed.
Repeat the procedure in washing,
soaping, rinsing and drying the arms,
hands and axilla of the other arm of the
patient.
f. With the arms raised, wash, soap, rinse Soaking hands soften nails and loosens soil from
and dry the axilla. Apply deodorant if skin and nails.
requested by the patient.

12. Wash the chest and abdomen.

a. Cover the client’s chest with a bath Draping exposes only the necessary areas and
towel and fold the bath blanket down to provide privacy.
the umbilicus
b. wash, rinse, and dry the chest giving Skin fold areas may be sources of odor and skin
special attention to skinfolds under the breakdown if not cleansed and dried properly.
breast. Perspiration and soil collect within skin folds.
c. Place a bath towel across the patient’s
abdomen and fold the bath blanket up
to the pubic region. Wash and rinse the
abdomen area.
d. Assist the patient in wearing a new
gown or may cover back patient with
the bath blanket if gown is opted to be
worn later.
13. Wash the legs and feet.
a. Expose one leg by folding the bath Promotes privacy and prevents chills
blanket toward the midline while
keeping the perineum covered.

56
 b. Arrange the bath towel lengthwise The towel protects linen & prevents the patient
under the leg. from feeling uncomfortable from a damp/wet bed.
c. Wash the leg using long firm strokes
from the ankle to the knee then from
the knee to the thigh. Thoroughly rinse
and dry the leg.
d. Wash the foot and if necessary, soak
the foot in a basin of water (10
minutes). Pay attention on the spaces
between the toes. Rinse and dry the
foot. Apply lotion if available and if
preferred by the patient.
e. Remove the towel and move to the
other side of the bed. Wash and rinse
the other side of the leg paying
attention on the spaces between the
toes. Apply lotion if necessary.
14. Wash the back and then the perineum.
a. While on supine position, determine
whether the client can wash his/her
genital area.
b. Obtain fresh warm bath water and wear
Water may become dirty. It must be kept clean
a new pair of gloves
c. Assist the client to turn to prone or side
Positioning the towel and blanket protects the
lying position facing away from you and
patient’s privacy and provide warmth. Bath towel
place the towel lengthwise alongside the
protects the bed from getting wet
back and buttocks.
Fecal material near the anus may be a source of
d. wash and dry the back, buttocks, anus microorganisms. Prolonged pressure on the sacral
(front to back), and upper thigh. Pay area or other bony prominences may compromise
attention on the gluteal folds. circulation & lead to development of decubitus
ulcer.
15. Give patient a back massage if ordered.
16. Help the client to put on a new gown
17. Assist patient with his/her grooming. This prevents irritation of the respiratory tract.
18. Change bed linen when necessary Damp linen may cause patient to chill.
Equipment may serve as reservoir for
19. Do after care of the equipment used in the
microorganisms. After care will prevent further
procedure in the utility room.
spread of infection
20. Document pertinent data For record and legal purposes
a. Type of bath given
b. Reaction of the client
c. Any unusualities such as redness and
skin ulcers.

TEPID SPONGE BATH

A patient whose temperature reaches 102.2ºF will usually develop flush color, very warm and moist skin,
and an accompanying headache. A tepid sponge bath may be recommended to reduce body
temperature. Desired temperature reached is 99.6ºF.

Equipment
 Bath basin
 Tepid water (37ºC; 98.6ºF)
 Washcloth (5)
 Bath thermometer
 Bath blanket
 Patient thermometer
 Gloves

57
 PROCEDURE RATIONALE

1. Observe patient for elevated temperature.

Review physician’s orders.

2. Explain the procedure to the client This helps gain cooperation

3. Wash your hands

4. Gather equipment at the bedside of the This saves time and energy of the nurse
patient

5. Provide privacy

6. Put working gloves

7. Change top sheet with bath blanket To prevent contracting an infection from the client

8. Assists the client in removing his clothes To expose areas for sponging

9. Fill the basin with tepid water and immerse

the towel
10. Apply for a few minutes to the following
Axillae, groin and forehead are areas which
areas:
contains large blood vessels.
a. Forehead (1)
Sponge bath should take for at least 30 minutes
b. Axillae (2 face towel)
c. Groin (2 face towel)
11. Gently pat the washcloth on each patient’s Too much covering can elevate body temperature
extremity for 5 minutes. Proceed with the
back, buttocks for 5-10 minutes.

Note: Abdomen and chest are not usually

included
12. Pat dry each body part after sponging with Friction of rubbing may raise the body
bath towel and cover with the bath blanket. temperature and covering prevents exposure to
draft.

13. Monitor client vital signs hourly after the Blood vessels are located deeper, and TSB is not
procedure, until the temperature stabilized effective to reduce temperature.

14. Put on the light clothing and replace soiled Too much covering can elevate body temperature
linen.

15. Remove gloves and wash your hands

16. Chart procedure done and reaction of the Provide information to other caregivers and
patient facilitates continuity of care.

BACK RUB

Definition: Stimulation of the skin and underlying tissues with varying degrees of hand pressure.

Purposes
a. To provide an opportunity to assess the skin on the back
b. To communicate concern in a non-verbal way.
c. To relax tense muscles thereby relieving pain.
d. To promote rest or sleep.
e. To stimulate blood flow to the skin and underlying tissues.

Strokes Used
1. Effleurage – are smooth, long rhythmical movements that are used in moving the hands up in
the spine and then lightly down the sides. This technique is also called deep down stroking.

58
2. Petrissage – using the thumb and forefinger knead and stroke half the back and upon arms by
taking large pinches of about 3 inches of skin and muscles.

3. Friction – using a circular thumb stroke, massage from the buttocks to the shoulders. Then
using a smooth stroke return to the buttocks.

4. Tapotement – using the edges of the hand, perform in a hacking motion over the surface of the
back.

59
image source: http://www.healthline.com/galeimage?contentId=gea2_03_00513&id=gea2_03_img0258

Equipment
 Lotion
 Bath towel
 Linen

PROCEDURE RATIONALE

1. Perform hand hygiene Handwashing prevents spread of microorganism

2. Provide privacy by closing the doors and
curtains.
3. Identify yourself to the patient. To establish rapport
This will encourage patient cooperation and
4. Assess the level of pain or discomfort and
determine appropriate intervention fit to the
explain the procedure to the patient.
needs of the patient.
5. Bring all equipment to bedside and
This saves time and energy
arrange according to use.

6. Assist the patient to move on the side of Working with client near you avoids undue
the bed near you. reaching and strains
7. Place patient in the prone position. If
impossible, place him on side-lying
position.
8. Check for presence of allergies to lotion
9. Untie patients’ gown and drape the
patient with a folded sheet. Expose only
the area to be massage.
10. Assess skin and apply gloves if necessary.
Back rub preparations are usually cold and
11. Warm the lotion in your hands before
uncomfortable to the patients. Holding it for a few
applying to patients back.
moments warms the solution slightly
12. Plan a variety of strokes depending on what
pain the patient has. (Effleurage, Petrissage,
Friction Rub or Tapotement)
13. Move your hands up the center of the back Rubbing would promote circulation especially in
and then over the scapulae bony areas like sacral and scapulae

14. Move your hands down in the side of back.

60
15. Massage the areas over the right and left
Rubbing would promote circulation especially in
iliac. Repeat steps 9 to 12 for four minutes
bony areas like sacral and scapulae
and step 8 as often as necessary

Vigorous massage over bony prominences can

16. Massage areas gently
increase damage to the underlying tissues.

17. Pat dry any excess lotion with a bath towel Towel absorbs excess solution and prevent chills
18. Position patient back to supine making sure
that the patient is comfortable. Place back Precautionary measures to prevent fall and
the bed to its lowest position. Place side rails accident.
up
19. Evaluate patients pain level post massage.

20. Perform hand hygiene post procedure.

21. Document the patient’s response and comfort

level.

ORAL CARE FOR THE UNCONSCIOUS CLIENT

Definition: Hygiene measures administered to maintain clean and healthy teeth.

Purposes:
1. To maintain the integrity of the lips, tongue and mucous membranes of the mouth (by
maintaining moisture and integrity of the oral tissue).
2. To prevent infections
3. To clean and moisten the mucus membranes of the mouth and lips
4. To refresh the mouth
5. To relieve discomfort from inflamed lesion.
6. To improve self-concept.

Equipment:
Tray containing:
 cotton tipped applicators / toothette sponge
 mouth wipes, tissue or towel
 lubricants or cold cream (petroleum jelly) for the lips
 cup with tepid water
 rubber tip bulb syringe/Asepto Syringe)
 Emesis basin (Kidney basin)
 Wall mount suction (if available)
 Waste receptacle
 Toothbrush / Toothpaste / Mouthwash
 Gown (optional)

61
 PROCEDURE RATIONALE
1. Introduce yourself to the patient.

2. Identify patient To verify correct procedure to be done to the

patient especially unconscious patients.
3. Verify doctor’s order

4. Explain the procedure to the client This alleviates anxiety of client thus facilitates
cooperation.

5. Wash your hands This prevents spread of microorganisms

6. Provide patient privacy

7. Bring all equipment to bedside and arrange This saves time and energy
according to use.
8. Raise the bed to a comfortable working
height.
9. Put on a clean working glove.

10. Use the penlight and tongue depressor to

check for gag reflex and assess oral
cavity.
11. Remove gloves and dispose in the waste
receptacle.
12. If suctioning is needed prepare the
suction tubes within reach.
13. Position the client on the side near you by
To work conveniently and easily with the patient.
slightly elevating the head of the bed (30
Raising the head when introducing oral fluid
degrees) then turn the patient to side facing
prevents the patient from being aspirated.
the nurse if not contraindicated.
14. Place a towel under the patient’s head To avoid soiling the bed linens
15. Put on a new working glove
16. Place the kidney basin (curve side) Towel will absorb the drops of water and avoid
beneath the chin to catch the drained fluid soiling the beddings and gown of the patient.
from the mouth.
17. Suction retained secretion in the mouth
using the wall mount suction or if not
available the suction bulb/asepto syringe.
18. Moisten toothbrush or applicator
(toothette sponge) with water then apply
toothpaste or dip it to a cup with mouthwash
or any antibacterial solution. Fingers should not be used in opening the mouth
to avoid possible injury
NOTE: If necessary, to open patient’s mouth,
used a padded tongue depressor or mouth
guard.
19. Clean the teeth, tongue and inner surface of This removes dirt and microorganism from the
the mouth. Clean one part of the mouth at a teeth.
time; discard applicator (toothette sponge)
and replace with a new one if needed and Tongue should be cleared gently (avoid
continue until all areas are cleansed. stimulation of gag reflex).
If toothbrush is being used, brush in circular
vibrating motion
20. Rinse the client’s mouth using a plain water or Mouth constantly harbors microorganisms, and it
alcohol-free mouthwash. should be kept clean and moist
21. Aspirate the rinsing solution out of the mouth Fluid remaining into the mouth may be aspirated
using asepto syringe or if available the wall into the lungs.
mount suction.
22. Wipe patient’s mouth with a towel.
23. Apply a thin coat of lubricant to the lips. Lubrication prevents cracking and subsequent
infection.
24. Place patient back to a comfortable position.
Raise side rails up and lower the bed to its
lowest position.
25. Do after care of the equipment. Remove tray; Equipment may serve as reservoir for
discard the waste, rinse emesis basin with microorganism. After care will further prevent
soap and water. spread of infection and injury.
62
26. Remove and discard gloves and wash hands.
27. Document the procedure done and any For record and legal purposes.
unusuality observed such as blooding and
inflammations and swelling of the gums.
 FOOT CARE

Purposes
1. to maintain foot function
2. to prevent foot odors
3. to prevent foot infection

Equipment
 Washbasin  Lotion and foot powder
 Towels  Bed protector
 Soap  Gloves
 Nail cutter

PROCEDURE RATIONALE

1. Wash your hands Handwashing deters the spread of pathogens

2. Explain the procedure the client This alleviates anxiety of the client

3. Gather the equipment to the bed side of the

This saves time and energy of the nurse.
client.

4. Assists the client into a sitting position

5. Wear gloves Gloves protects self from contracting any infection

from the foot of the client

6. Place the wash basin at the foot of the bed Bed protector protects the bed from getting wet
lined with a bed protector. during the washing

7. soak each foot of the patient and wash it with

soap

8. Rinse well removes the soap Soap can dry skin and may cause skin crack
9. Remove the foot from the basin. Dry it
This is a common area of fungal infections
thoroughly paying special attention to the
interdigital spaces of the toes

Changing water promotes both cleanliness and

10. Change the water between care of each foot
comfort

Lotion or powder prevents moistening of the foot

11. Apply lotion or powder
which is a favorable medium for bacterial growth

Long nails harbor microorganisms and are more

12. Trim nails as required
difficult to clean

13. Document any unusualness noted on the foot

of the patient

63
 PERINEAL CARE

Definition: It is the washing of the genitals and anal area with plain water or medicated solutions

Purposes:
1. To cleanse the area of secretions and excretions.
2. To reduce unpleasant odors
3. To prevent skin irritations and excoriation.
4. To control the potential for infection
5. To promote comfort.

Equipment:
 bath blanket
 bath towel
 flushing can with sterile water
 cotton balls in soap-suds solutions
 cotton balls in antiseptic solutions (preparation for catheterization)
 dry cotton balls
 Bedpan
 rubber sheet
 pick-up forceps in disinfectant solution
 working forceps in disinfectant solution
 waste receptacle
 clean underwear/ diaper
 toilet paper (optional)
 paper lining (newspaper)
 working gloves

PROCEDURE RATIONALE

Patient identification validates the correct patient

1. Identify the patient and explain the procedure
and correct procedure. Discussion and explanation
correctly and clearly to the patient.
help allay anxiety and prepare the patient for
what to expect.

2. Wash hands Prevents the spread of microorganisms.

Bringing everything to the bedside conserves time

3. Gathers all needed materials and pieces of
and energy. Arranging items nearby is convenient,
equipment at bedside.
saves time and avoids unnecessary stretching and
twisting of muscles on the part of the nurse.

4. Provide privacy by closing door and pulling

Provides privacy.
curtains

5. Change the top sheet with the bath blanket. Maintains warmth of the patient.

6. Place the rubber sheet, and line it with a bath

Protects bed linens.
towel under the patient's hips.

7. Fold patient's gown towards hypogastric area.

Don working gloves. Remove the underwear
or diaper
8. Position client in dorsal recumbent position.
Promotes client’s comfort. Minimum exposure
Drape the patient. Place bedpan on the client
lessens embarrassment and helps to provide
perineal area.
warmth.

Secretions that tend to collect around the labia

9. Flush the perineal area with warm water
minora facilitate bacterial growth.
10. Cleanse the area with cotton balls in soap Using different cotton balls prevents the

64
 suds solution in the following order:
1- mons veneris
2 - far labia majora then thigh
transmission of microorganisms from one area to
3 - near labia majora then thigh
the other. Wipe from the area of least
4- far labia minora
contamination to that of greatest.
5 - near labia minora
6- from symphysis pubis to vaginal orifice
7- from symphysis pubis to anus
11. Rinse the area well with warm water.

Note: The preparation of catheterization

Cleanse the area with cotton balls in betadine
solution in same order as no. 10, then
proceed to catheterization.
12. Dry the area with dry cotton balls in the same
manner.

Residual moisture provides an ideal environment

13. Perform treatment if indicated.
for the growth of microorganisms.

14. Remove bedpan and place it under the bed

with paper lining. Remove the bath towel and
rubber sheet.

15. Replace the bath blanket with the clean top

sheet.

16. Pull down the patient's gown and put on the

Promotes client’s comfort.
clean under-wear or diaper.

17. Make the patient comfortable

Promotes proper disposal of contaminated

18. Do the after care. Bring all equipment to the materials thus deterring the spread of
utility room. microorganisms and preparing the equipment for
the next user.

19. Remove gloves and wash hands

20. Document the performance of the procedure,

Documentation promotes continuity of care and
the objective and subjective findings and the
communication.
patient's response.

HOT SITZ BATH

65
Purposes
1. To relieve muscle spasm
2. To soften exudates
3. To hasten the suppuration process
4. To hasten healing
5. To reduce congestion and provide comfort in the perineal area

INDICATIONS: Hemorrhoids, Perineal wounds, Episiorrhaphy.

NURSING ALERT
1. Warm water should not be used if considerable congestion is already present.
2. The patient should be observed closely for signs of weakness and faintness.
3. After the patient is in the tub or the chair, check to see whether or not there is pressure
against the patient’s thighs or legs.
4. Support patient’s back in the lumbar region.

CHARTING
1. Type of solution
2. Length of time of application
3. Type of heat application
4. Condition and appearance of wound
5. Comfort of patient

EQUIPMENT
 Towels and bathmat
 Bath blanket
 Inflatable ring
 Patient’s clean clothes
 Available bathroom with appropriate size tub for patient.

PROCEDURE RATIONALE
1. Check the patient’s order Reduces the risk for errors
2. Wash your hands Prevents the spread of microorganism
3. Prepare the equipment Save time and energy
4. Explain the procedure to the client This helps alleviate client’s anxiety
5. Measure the temperature of water using the
To determine if the desired temp of 34-37C has
bath thermometer and pour from the pail into
been obtained, the bath thermometer is used
the sitz bath chair.
6. Test the water temperature against the back This is to check if the water temp is suitable for the
of the hand of the patient client
Warm water relaxes the urinary sphincter and may
7. Instruct client to void before the procedure.
induce voiding
8. Remove pants and underwear and assist the
client into the tub
9. Provide bath blanket for the client. This prevents the client from chills
10. Observe the client closely during the bath for
signs of faintness, dizziness, weakness
accelerated pulse rate and pulse.
11. Assist the client out of bath and dry.
12. Assist the client to put in new underwear and
This would promote comfort.
fresh clothes.
13. Wash your hands. Hand washing prevents spread of microorganisms.
14. Chart procedure done and reaction of the Provides information to other caregivers and
patient. facilitate continuity of care.

66
ELIMINATION

URINARY CATHETERIZATION

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Definition: It is the introduction of catheter into the urinary bladder.

Purposes

1. To relieve urinary retention

2. Bladder outlet obstruction (To irrigate the Bladder)
3. Aids in the diagnosis of GU bleeding
4. To obtain a sterile urine specimen
5. To instill medication
6. To manage incontinence
7. To drain the bladder before surgery
8. To monitor urine output

Contraindications:

1. Presence of urethral trauma

Complications:

1. Trauma

2. Infections (Pyelonephritis, nephro-cysto-lithiasis, renal inflammation)

Note: Perineal flushing is done for females before catheterization.

Types of catheters:

1. Foley catheter

2. Straight catheter

3. Condom catheter

Catheter materials

1. Teflon

2. Latex

3. Silicon

4. PVC

Equipment

1. Sterile catheter of appropriate size

2. Catheterization kit or individual sterile items
a. Sterile gloves
b. Sterile drapes
c. Antiseptic solution
d. Cotton balls
e. Forceps
f. KY Jelly
g. Collection bag/ Urobag
h. 10 cc syringe with sterile water
3. Plaster

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FOR URINARY CATHETERIZATION

PROCEDURE RATIONALE
Reduces the risk of committing error and
1. Check the client’s chart for the physician’s order verify doctor’s order

2. Wash your hands Prevent the spread of microorganism

To gain cooperation and helps alleviate
3. Explain the procedure to the client.
anxiety.
4. Gather equipment to the bedside To save time and energy
5. Assist patient into supine position with legs
spread (Knees flexed) or dorsal recumbent For proper visualization of perineal area.
position
It provides privacy by preventing undue
6. Drape the Client
exposure of the client.
7. Open catheterization kit and catheter. Prepare
sterile field, Place sterile syringe & catheter inside
the sterile area.

8. Pour the antiseptic solution over the cotton balls Working on the bedside prevents reaching
and put on the sterile gloves contained in it. across sterile field; thus, maintaining sterility

9. Once gloved, check balloon for patency (For To make sure that there are no leaks on the
retained catheter) balloon.

10. For Specimen collection

a. Lubricate the insertion tip of catheter and

Lubrication facilitates smooth insertion
place the other end into the mouth of the
of the catheter into the meatus.
sterile specimen bottle.

11. For retained catheterization

a. Adjust kidney basin or catheter kit near

perineum and lubricate catheter
w/lubricant at least 3 inches from the tip.

12. For female

a. locate the meatus

b. Using the non-dominant hand, put thumb
and index finger to separate labia minora,
paints area with CB soaked in betadine.
Discard CB. Keeps labia separated.
Deep breathing relaxes the sphincter; thus,
c. Locate the meatus and instruct the client to
facilitating ease in insertion.
take deep breath and insert catheter 1 1/2-
Forceful insertion may cause trauma to the
3 inches.
membranes and tissues.
d. When the urine flow, hold the catheter in
place 2 cm in the meatus

13. For male

a. Grasp the penis firmly behind the glans

with the non-dominant hand and spread Firm grasp prevents stimulating an erection.
the meatus between thumb and fingers. If
uncircumcised, retract the foreskin

b. Lift the penis in a position perpendicular to This position straightens the downward
the body and exert slight pulling upward. curvature of the urethra.

69
Note: If for straight catheterization, (for urine collection) pinches
catheter and remove it quickly and gently after the urine has been
collected.

Note: For retained catheterization, the type of

catheter used is the foley catheter, where a syringe
with water is attached to the balloon valve and
inject the fluid. Attach the foley catheter to the
urobag.
14. Inflate balloon, using correct amount of sterile The injected water would inflate the balloon
liquid (usually 10 cc or according to and
manufacturer’s instruction. Always check actual anchor the foley catheter inside the bladder.
balloon size)

15. Gently pull catheter until inflation balloon is snug

against bladder neck

16. Connect catheter to drainage system / uro bag.

17. Secure catheter to abdomen or thigh, without

tension on tubing

18. Place drainage bag below level of bladder

19. Evaluate catheter function and amount, color,

odor, and quality of urine patient's response to
procedure, and assessment of urine

20. Keep the client dry and comfortable. Label

specimen properly
Hand washing deters spread of
21. Remove gloves dispose equipment appropriately
microorganisms
and wash your hands.

22. Document the amount and characteristics of the

Accurate documentation facilitates continuity
urine, the procedure done, size of catheter.
of care.
Amount of water inflated and the reaction of the
client.

FOR CONDOM CATHETER

PROCEDURE RATIONALE

1. Follow steps 1-8.

2. Clean the meatus with CB with Betadine This prevents infection

3. Apply condom by rolling smoothly over the

This space prevents the irritation of the tip of the
penis, leaving 2.5cm between the end of the
penis and allows full drainage of the urine.
penis and the rubber.

4. Secure condom firmly, but not too tightly.

Ordinary should not be used in lieu of Velcro
Wrap an elastic tape around the base of the
since ordinary tape are not elastic and can impair
penis. Connect it to urobag the other end of
blood flow
the condom.

5. Remove gloves and wash your hands. Hand washing deters spread of microorganisms
6. Document the amount and characteristics of
Accurate documentation facilitates continuity of
the urine, the procedure done, and the
care.
reaction of the client.

INTAKE AND OUTPUT MONITORING

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Definition: Measurement and recording of all fluid intake and output (I&O) during a 24-hour period.

Purpose:

1. Provides important data about a client's fluid and electrolyte balance

2. To evaluate the effectiveness of diuretic or rehydration therapy.

Guidelines in I&O monitoring

1. The unit used to measure I&O is the milliliter (mL).

2. It is important to inform clients, family members, and all care givers that accurate measurement
of I&O is required.
3. Instruct the client not to put toilet tissue into the container with urine
4. Clients who wish to be involved in recording the I&O need to be taught how to compute the
values and what foods are considered fluids.

All of the following fluids need to be recorded:

1. Oral fluids: Water, milk, juice, soft drink, coffee, tea, cream, soup, and any other beverages
2. Ice chips: Record the fluid volume as approximately one half of the volume of the ice chips.
3. Foods that are or become liquid at room temperature: Ice cream, custard, sherbet,
and gelatin.
4. Tube feedings: Include volume of water used for flushes before and after medication
administration, intermittent feedings, residual checks, or any water given via feeding tube.
5. Parenteral fluids: The exact amount of IV fluid administered must be recorded.
6. IV medications: IV medications that are administered as an intermittent or continuous
infusion must be included.
7. Catheter or tube irrigants: Fluids used to irrigate urinary catheters, nasogastric tubes,
and intestinal tubes must be recorded if not immediately withdrawn as part of the irrigation.

Measure all the following fluid output:

1. Urinary output:
2. Vomitus and liquid feces: The amount and type of fluid and the time need to be specified
3. Tube drainage: Includes gastric or intestinal drainage
4. Wound and fistula drainage: Drainage may be recorded by documenting the type and
number of dressing or linen saturated with drainage, or by measuring the exact amount of
drainage collected in a vacuum drainage or gravity drainage system.

Image source: https://www.math-salamanders.com/liquid-measurement-chart.html

Equipment:

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  I and O sheet
 Calibrated cup or glass
 Graduated container for output
 Bedpan or urinal
 Working gloves

PROCEDURE RATIONALE
1. Wash hands Prevents the spread of microorganisms.
2. Explain the procedure to the patient
including the following information:
a. All fluids taken orally must be
recorded.
b. Form of recording must be used.
c. Voiding into the bedpan or urinal
and not into toilet is a must.
Note: If in the toilet
a. Place a specimen bottle under
the toilet seat to collect urine.
b. Client with mobility problem: use
bedpan or urinal to collect urine
output.
c. Client with fracture: use a
fracture pan for clients with
fracture of the pelvis, lower
back, or legs or for clients who
have casts, splints, or braces on
their legs.
3. Place I&O sign over the patient’s bed
INTAKE
1. Measure all the oral fluids using a graduated Provides consistency of measurements
container or instruct client/watcher to do so.
2. Record time and amount of all fluid intake in Documents fluid intake
the designated space.
3. Measure all fluid intakes including all oral
drinks, soup, parenteral infusions like IV and
blood transfusions etc.
OUTPUT
1. Put on working gloves. Prevents spread of organisms
2. Empty urinal/bedpan into the graduated
container, including catheter drainage bag
or other drainage collection device. Take
note of the reading.
4. In ICUs, urine output is often measured
hourly. If a client is incontinent for urine,
estimate and record these outputs.
5. Infants: Weigh diapers that are dry and
then subtract this weight from the weight of
the soiled diapers. Each gram of weight left after subtracting is
If urine is frequently soiled with feces, the equal to 1 mL of urine.
number of voiding’s may be recorded rather
than the volume of urine.
6. Empty or discard the output appropriately.
7. Remove gloves and wash hands Prevents cross-contamination
8. Record time and amount of output, color, Provides information to the health care team
odor, clarity, and abnormal constituents, on regarding the client’s response to the treatment
the output side of the I&O sheet. and legal record of care given
ENEMA

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Definition: a solution introduced into the rectum and sigmoid colon mainly to remove feces or flatus.

Purposes

1. To stimulate peristalsis and remove feces and flatus.

2. To soften feces and lubricate colon and rectum.
3. To clean the colon and the rectum in preparation for an examination.

Equipment

 Bedpan
 Cleansing solution
 Enema set containing:
o Enema can
o Tubing
o Rectal tip
o Clamp
 Lubricant
 Gloves
 Towel

PROCEDURE RATIONALE

1. Check the patient’s chart for physician’s

Counterchecking reduces the risk for errors.
orders.

2. Gather equipment This saves time and energy for the nurse.

3. Explain the procedure to the client. This alleviates anxiety.

4. Place a waterproof pad under the patient’s

This prevents soiling of the linen.
buttocks.
This position facilitates flow of the solution into
5. Assist the client in a left lateral position.
the sigmoid and descending colon by gravity.
6. Hang the enema can depending on the
The height determines the rate at which the
order (low pressure – 12”, or high pressure
enema solution flows into the rectum.
– 18” from the rectum)
7. Allow the fluid to flow through the tubing Flow of the solution through the tube removes
and through the rectal tube clamp. the air in the tube.

8. Lubricate 5cm of the rectal tube Lubrication facilitates insertion

9. Don gloves and insert 7-10cm of the rectal
The angle follows the normal contour of the
tube into the anus smoothly and slowly,
rectum.
directing towards the umbilicus.

10. Slowly administer the enema solution. This indicates that the fluid inside the rectum is
Clamp once the client complains of fullness. in enough amount.
11. After instilling the enema and when the
The nurse should observe the characteristics of
client cannot hold it anymore, withdraw the
the stool.
rectal tube and place in clean tissue.
12. Assist the client to defecate.

13. Wash your hands.

14. Record and relevant data

73
OXYGENATION

74
 OXYGEN THERAPY

Definition: Is the administration of oxygen as a therapeutic modality. It is prescribed by the physician,

who specifies the concentration, method of delivery, and liter flow per minute.

Benefits of Oxygen Therapy:

 Increased clarity
 Relieves dyspnea
 Can prevent heart failure in people with severe lung disease
 Allows the body organs to carry out normal functions

Long-Term Benefits of Oxygen Therapy:

 Prolongs life by reducing heart strain
 Relieves shortness of breath
 Makes exercise more tolerable
 Results in fewer days of hospitalization

OXYGEN DELIVERY SYSTEMS

1. Nasal Cannula

 Also called nasal prongs.

 Is the most common inexpensive device used to administer oxygen.
 It is easy to apply and does not interfere with the client’s ability to eat or
talk.
 It delivers a relatively low concentration of oxygen which is 24% to 45%
at flow rates of 2 to 6 liters per minute.

2. Face Mask

 It covers the client’s nose and mouth may be used for oxygen inhalation.
 Exhalation ports on the sides of the mask allow exhaled carbon dioxide to escape.

Types of Face Masks:

1. Simple Face Mask - Delivers oxygen

concentrations from 40% to 60% at liter flows
of 5 to 8 liters per minute, respectively

2. Partial Rebreather Mask – Delivers oxygen

concentration of 60% to 90% at liter flows of
6 to 10 liters per minute, respectively.

3. Non-Rebreather Mask – Delivers the

highest oxygen concentration possible 95% to
100% – by means other than intubation or
mechanical ventilation, at liter flows of 10 to
15 liters per minute.

4. Venturi Mask – Delivers oxygen

concentrations varying from 24% to 40% or
50% at liter flows of 4 to 10 liters per minute.

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3. Face Tent

 It can replace oxygen masks when masks are poorly tolerated by

clients.
 It provide varying concentrations of oxygen such as 30% to 50%
concentration of oxygen at 4 to 8 liters per minute.

4. Transtracheal Oxygen Delivery

 It may be used for oxygen-dependent clients.

 The client requires less oxygen (0.5 to 2 liters per minute) because all of the low delivered enters
the lungs.

Oxygen Therapy Safety Precautions:

1. For home oxygen use or when the facility permits smoking, teach family members and
roommates to smoke only outside or in provided smoking rooms away from the client.
2. Place cautionary signs reading “No Smoking: Oxygen in use” on the client’s door, at the foot or
head of the bed, and on the oxygen equipment.
3. Instruct the client and visitors about the hazard of smoking with oxygen use.
4. Make sure that electric devices (such as razors, hearing aids, radios, televisions, and hearing
pads) are in good working order to prevent the occurrence of short-circuit sparks.
5. Avoids materials that generate static electricity, such as woolen blankets and synthetic fabrics.
Cotton blankets should be used, and clients and caregivers should be advised to wear cotton
fabrics.
6. Avoid the use of volatile, flammable materials such as oils, greases, alcohol, ether, and acetone
(e.g., nail polish remover), near clients receiving oxygen.
7. Ground electric monitoring equipment, suction machines and portable diagnostic machines.
8. Make known the location of the fire extinguishers, and make sure personnel are trained in their
use.

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 ADMINISTERING OXYGEN BY NASAL CANNULA

Purposes:
1. To reduce the work of breathing and to relieve dyspnea.
2. To reduce or prevent hypoxemia and hypoxia (maintaining arterial blood oxygen level).
3. To alleviate the anxiety association with the struggle to breath.

Equipment
 Flowmeter connected to oxygen supply
 Humidifier with sterile distilled water or piped oxygen (optional with low flow system)
 Nasal cannula and tubing (ADULT Fr.12-14; CHILDREN Fr 8-10)
 Gauze to pad tubing over ears (optional)
 Gauze pad for potential areas of pressure (optional)

PROCEDURE RATIONALE
1. Determine the need for oxygen therapy
and verifying the order for the therapy.
2. Introduce self and verify client’s identity.
3. Explain procedure to patient and review
To gain cooperation and understanding from
safety precautions necessary when oxygen
the client. Also relieves anxiety.
is in use.
4. Place “No Smoking” signs in appropriate Oxygen supports combustion.
areas.
5. Perform hand hygiene Prevents the spread of microorganism
6. Set up oxygen equipment and humidifier.
a. Attach the flow meter to the wall
outlet or tank. The flow meter
should be turned off.
b. Attach humidifier bottle to the base
of the flow meter.
c. Connect the nasal cannula to the
oxygen setup with humidification if
one is in use. Adjust the flow rate
as ordered by the physician. Check
that oxygen is flowing out of the
prongs.
d. There should be no kinks in the
tubing and the connections should
be airtight.
e. There should be bubbles in the
humidifier as the O2 flows through.
7. Place the prongs in the patient’s nostrils.
Adjust according to type of equipment. Correct placement of the prongs and fastener
a. Over and behind each ear with facilitates oxygen administration and comfort
adjuster comfortably under chin or for the patient.
b. Around the patient’s head
8. Use gauze pads at ear beneath the tubing Pads reduce irritation and pressure and protect
as necessary. the skin.
9. Encourage patient to breathe through his Nose breathing provides for optimal delivery of
or her nose with mouth closed. oxygen to patient.
Hand hygiene deters the spread of
10. Perform hand hygiene
microorganisms.
11. Assess the client and chart the date, time Patient’s respirations, color, breathing pattern,
O2 therapy started and patient response to and chest movements indicate effectiveness of
therapy. oxygen therapy.
12. Remove the mask and dry the skin every The continued presence of the cannula causes
2-3 hours if the oxygen is running irritation and dryness of the mucous
continuously. Do not powder around the membranes. Water-soluble lubricants can be
mask. Check nares for evidence of used to counteract drying effects of oxygen.
irritation or bleeding

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 ADMINISTERING OXYGEN BY MASK

Equipment:
 Flowmeter connected to oxygen supply
 Humidifier with distilled water
 Prescribed face mask of the appropriate size
 Gauze to pad elastic band (optional)

PROCEDURE RATIONALE

1. Determine the need for oxygen therapy

and verifying the order for the therapy.

2. Introduce self and verify client’s identity.

3. Explain procedure to patient and review

safety precautions necessary when oxygen
is in use.

4. Place “No Smoking” signs in appropriate

Oxygen supports combustion.
areas.

Hand hygiene deters the spread of

5. Perform hand hygiene
6. Attach the face mask to the oxygen setup
with humidification. For a mask with a
reservoir, allow oxygen to fill the bag
before placing the mask over the patient’s
nose and mouth.
7. Guide the mask toward the client’s face
and apply it from the nose downward.
Adjust it with the elastic strap so that the
mask fits snugly but comfortably on the
face.
8. Use gauze pads to reduce irritation to the
patient’s ears and over bony prominences
of the face
microorganisms.
Oxygen forced through a water reservoir is
humidified before it is delivered to the patient,
thus preventing dehydration of the mucous
membranes. Low flow oxygen does not require
humidification.
A loose or poorly fitting mask will result in
oxygen loss and decreased therapeutic value.
Masks may cause feeling of suffocation, and
patient needs frequent attention and
reassurance
Pads reduce irritation and pressure and protect
the skin

Hand hygiene deters the spread of

9. Perform hand hygiene
microorganisms.

10. Remove the mask and dry the skin every 2
to 3 hours if the oxygen is running
continuously. Do NOT powder around the
mask
11. Assess and chart patient’s response to
therapy.
The tight-fitting mask and moisture from
condensation can irritate the skin on the face.
There is danger of inhaling powder if it is
placed on the mask.
Patient’s respirations, color, breathing pattern,
and chest movements indicate effectiveness of
oxygen therapy.

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 COLLECTING A SPUTUM SPECIMEN

Definition: Sputum is the mucous secretion from the lungs, bronchi and trachea.

Purposes:
1. For culture and sensitive test
2. To identify cancer in the lung and its specific cell type
3. To identify the presence of acid-fast bacilli

Equipment:
1. A sterile container with a cover.
2. Disinfectant and CB to cleanse the outside of the container and tissue paper to dry it.
3. A completed label for the container, with identifying information about the client.
4. A completed requisition to accompany the specimen to the laboratory.
5. Mouthwash

PROCEDURE RATIONALE
An explanation provides reassurance and
1. Explain the procedure to the client.
promotes cooperation.
So that specimen will not be contaminated with
2. Offer mouth care.
microorganism from the mouth
3. If the client can expectorate (spit out) the
sputum directly into the sputum cup. Leave
the container with the client it assistance is
not required.
4. If assistance is needed ask the client to sit Containing the sputum within the cup restricts
and to breathe deeply thrice. the spread of microorganisms to others.
5. Ask the client to hold the sputum cup (or
hold it) and expectorate (spit out) into it,
about 1-2 tbsp (15-30 ml) of sputum or
depending on the specified amount.
Making sure that sputum does not come in
contact with the outside of the container if
does not contaminate, wash it with
disinfectant after the collection.
Covering the container prevents the
6. Cover the container immediately.
inadvertent spread of microorganisms.
7. Determine the respiration rate and any
abnormalities or difficulty in breathing.
8. Assess the color of the client’s skin
This indicated the impaired blood oxygenation.
especially any cyanosis.
9. Wipe the outside of the container with
disinfectant if the sputum contacted the Prevents the spread of microorganisms.
outside surface
10. Place the completed label on the container
Labeling ensures the proper identification of
(name, room number, purpose, specimen
the specimen.
series number
11. Provide the client with water to rinse the
This removes unpleasant taste.
mouth or offer mouthwash.
Overgrowth of other organisms can interfere
12. Together with the laboratory requisition
with the test results if the specimen remains at
slip, send the specimen to the laboratory
room temperature for an extended prior of
within 20 minutes.
time.
13. Document collection of the sputum
specimen on the client’s chart. Include the A written summary provides accurate
color, consistency amount, presence of documentation of the procedure
hemoptysis and color of sputum. Chart any
discomfort experienced by the client.

Note: Collect the sputum specimen (not saliva) early in the morning before breakfast to obtain an overnight accumulation of the
secretion.

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 TRACHEOSTOMY CARE

Purposes:
1. To prevent infection at tracheostomy site
2. To promote comfort of the client.
3. To promote oxygenation
4. For hygienic purposes

Equipment:
 Cotton applicator
 Dressing Pack
 Kidney basin
 Sterile Scissors
 Gloves
 Suction Machine with catheter
 OS (4x4)Betadine
 Sterile NSS or disinfectant
 Tracheostomy tie

PROCEDURE RATIONALE
Hand washing prevents spread of
1. Wash your hands
microorganisms.
2. Prepare equipment at bedside This saves time and energy of the nurse.
3. Assist the client to the semi-flower’s
This position facilitates chest expansions.
position.
4. Pour sterile saline in the kidney basin Glove serves as barrier for infection

5. Glove one hand

Tracheostomy care can stimulate patients to
6. Suction secretions inside the tracheostomy cough. Suctioning is done prior to
and suction secretions tracheostomy care to prevent escape of
secretion during dressing.
7. Remove the inner cannula of the
Soaking loosens secretions which had adhered
tracheostomy and soak it in the kidney
to the inner cannula
basin with sterile NSS.
8. Remove the OS surrounding in the
tracheostomy.
9. Wipe the rim and surroundings of the
To keep the area less at risk for infection.
stoma with betadine.
10. Apply OS with slit around the tracheostomy OS absorb mucus from the stoma to keep the
site. surrounding skin dry.
11. Untie the knot holding tracheostomy one
Too tight application of the tie can choke the
side at a time. Change with new ones.
client, too loose application defeats its purpose.
Make sure that one finger can be inserted
between the tie and neck.
12. Clean the insides of the inner cannula with
cotton applicator.
13. Rinse with Sterile NSS and place back into
the tracheostomy.
14. Do after care This deters the spread of pathogens

15. Wash your hands

The purpose of this is to check if the
16. Assess the client for any signs of dyspnea. tracheostomy is still in correct placement and if
the suctioning has been effective.
This ensures continuity of care and for keeping
17. Document relevant data
track of the patient’s status.
SUCTIONING

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Definition: It is the aspiration of secretions through a catheter connected to a suction machine or wall
suction outlet.

Purposes
1. To remove secretions that obstructs the airway
2. To facilitate ventilation (adequate gas of change)
3. To obtain secretions for diagnostic purposes (e.g. sputum culture)
4. To prevent infection that may result from accumulated secretions (e.g. pneumonia and
atelectasis)
5. To remove excess saliva or emesis from the oral cavity
6. To relieve respiratory distress.

Indications
1. Audible or visual signs of secretions in the tube
2. Signs of respiratory distress
3. Suspicion of a blocked or partially blocked tube
4. Inability by the child to clear the tube by coughing out the secretions
5. Vomiting
6. Desaturation on pulse oximetry
7. Changes in ventilation pressures (in ventilated children)
8. Request by the child for suction (older children)

Safety considerations
1. Tracheal damage may be caused by suctioning. This can be minimized by using the appropriately
sized suction catheter, appropriate suction pressures and only suctioning within the tracheostomy
tube.
2. The depth of insertion of the suction catheter needs to be determined prior to suctioning. Using a
spare tracheostomy tube of the same type and size and a suction catheter insert the suction
catheter to measure the distance from the length of the tracheostomy tube 15mm connector to
the end of the tracheostomy tube. Ensure the tip of the suction catheter remains with-in the
tracheostomy tube.
3. Record the required suction depth on the tape measure placed at the bedside and in the patient
records. Attach the tape measure to the cot/bedside/suction machine for future use.
4. Use pre-measured suction catheters (where available) to ensure accurate suction depth
5. The pressure setting for tracheal suctioning is 80-120mmHg (10-16kpa). To avoid tracheal
damage the suction pressure setting should not exceed 120mmHg/16kpa.
6. It is recommended that the episode of suctioning (including passing the catheter and suctioning
the tracheostomy tube) is completed within 5-10 seconds.

Lifespan Considerations
1. INFANTS: A bulb syringe is used to remove secretions from an infant's nose or mouth. Care
needs to be taken to avoid stimulating gag reflex.
2. CHILDREN: A catheter is used to remove secretions from an older child's mouth or nose.
3. OLDER ADULTS: Older adults often have cardiac and/or pulmonary disease, thus increasing
their susceptibility to hypoxemia related to suctioning. Watch closely for signs of hypoxemia. If
noted, stop suctioning and hyper oxygenate.

Size of suction catheter Duration of suctioning

Newborn: Fr 6 3-5 seconds
Infant: Fr 6-8 5-8 seconds
Child: Fr. 8-10 8-10 seconds
Adult: Fr. 12-16 10-15 seconds

OROPHARYNX AND NASOPHARYNX SUCTIONING

81
Equipment:
 Portable or wall suction unit with tubing
 Sterile suction catheter with Y port
 Sterile water or saline
 Sterile disposable container
 Sterile gloves
 Towel or waterproof pad

PROCEDURE RATIONALE
Suctioning should be done only when
secretions have accumulated, or adventitious
1. Determine the need for suctioning.
breath sounds are audible. This minimizes
Administer pain medication before
trauma to airway mucosa. Suctioning
suctioning to postoperative patient
stimulates coughing, which is painful for
patients with surgical incisions.
This provides reassurance and promotes
2. Explain procedure to patient
cooperation.
3. Assemble equipment This provides for organized approach
Hand hygiene deters the spread of
4. Perform hand hygiene
microorganisms
Having the patient in a sitting position helps
5. Adjust bed to comfortable working
him or her to cough and makes breathing
position. Lower side rail closer to you.
easier. Gravity also facilitates the insertion of
Place the patient in a semi-Fowler’s
the catheter. Lateral position allows the tongue
position if conscious. An unconscious
to fall thus preventing the airway from
patient should be placed in lateral position
becoming obstructed and promotes drainage of
facing you
secretions
6. Place a towel or waterproof pad across
This protects the bed linen
patient’s chest
7. Turn suction to appropriate pressure:
a. Wall unit:
 Adult: 100 to 120 mmHg
 Child: 95 to 110 mmHg
Negative pressure must be at safe level or
 Infant: 50 to 95 mmHg
pneumothorax may occur.
b. Portable unit
 Adult: 10 to 15 mmHg
 Child: 5 to 10 mmHg
 Infant: 2 to 5mmHg
8. Open sterile suction package. Set up Sterile normal saline or water is used to
sterile container, touching only the lubricate the outside of the catheter, thus
outside surface, and pour sterile saline or minimizing irritation of mucosa as it is being
water into it introduced
Handling the sterile catheter with a hand
9. Don sterile gloves. The dominant hand
wearing a sterile glove helps prevent
that will handle the catheter must remain
introducing organisms into the respiratory tract
sterile, while the non-dominant hand is
and the clean glove protects the nurse from
considered clean rather than sterile
microorganisms
10. With sterile gloved hand, pick up sterile
catheter and connect to suction tubing Sterilization must be maintained
that is held with unsterile hand
11. Moisten the catheter by dipping it into the
container of sterile saline. Occlude Y tube This reduces and eases insertion
to check suction
12. Estimate the distance from the ear lobe to
the nostril and place thumb and forefinger Proper measurement ensures that catheter
of gloved hand at that point on the remains in pharynx rather than trachea
catheter
13. Gently insert the catheter into either nares Using suction while inserting the catheter can

82
 with suction off by leaving the vent on the
Y connector open. Slip the catheter gently
along the floor of an unobstructed nostril
cause trauma to the mucosa and removes
toward the trachea to suction the
oxygen from the respiratory tract. Coughing is
nasopharynx. Or insert the catheter along
introduced when the trachea is touched. This
the side of the mouth toward the trachea
helps this helps the patient raise secretion
to suction the oropharynx. Never
introduce the suction as the catheter is
introduced. Do not force the catheter
through the nares.
14. Apply suction by occluding the suctioning Turning the catheter as it is withdrawn helps all
port with your thumb and gently rotate surfaces of respiratory passageways.
the catheter as it is being withdrawn. Do Suctioning the patient for longer than 10 to 15
not allow the suctioning to continue for seconds robs the respiratory tract of oxygen,
more than 10 to 15 seconds a time which may result in hypoxia
15. Rinse and flush the catheter with saline
Flushing cleans and clears catheter and
and repeat suctioning as needed and
lubricates it for next insertion
according to the patient’s toleration of
procedure.
16. Allow at least 20 to 30 second intervals if
additional suctioning is needed. The nares Normal breathing between suctioning helps
should be alternated when repeated compensate for any hypoxia induced by
suctioning is required. Encourage patient previous suctioning.
to cough and deep breath between Applying suctioning for too long may cause
suctioning. Limit suctioning to 5mins. In secretions decrease the client’s oxygen supply
total
17. When suctioning is completed, remove
Hand hygiene prevents transmission of
gloves, catheter and container with
microorganisms.
solution in proper
18. Use auscultation to listen to chest and
breathing sound to assess the Listen to chest and breathing sounds helps
effectiveness of suctioning. Observe skin determine whether the respiratory
color, dyspnea, level of anxiety, and passageways are clear secretions
oxygen saturation level
Respiratory secretions that are allowed to
accumulate in the mouth are irritating to
19. Offer oral hygiene after suctioning
mucous membranes and unpleasant for the
patient
20. Record the time of suctioning and the
nature and amount of secretions. Also
Records of nursing measures used help assess,
note the character of the patient’s
evaluate and coordinate care
respirations before and after the
suctioning

SUCTIONING OF THE TRACHEOSTOMY OR ENDOTRACHEAL TUBE

83
Equipment:
 Portable or wall suction device with connecting tubing
 Sterile suction kit containing the following or gathered separately: Sterile suction catheter of
appropriate size with Y port.
 Infants: 2-8 F
 Children:8-10 F
 Adults: 12-16
 Sterile container
 Sterile gloves
 Towel or waterproof pad
 Sterile normal saline
 Clean towel or sterile drape (optional).
 Goggles (or glasses) and mask
 Gown (Optional)
 Resuscitation bag connected to 100% oxygen

PROCEDURE RATIONALE

1. Determine the need for suctioning

2. Explain procedure to patient and reassure

Explanation facilitates cooperation and provides
him or her that you will interrupt procedure
reassurance for patient. Any procedure that
if the patient indicates respiratory difficulty.
compromises respiration is frightening for the
Administer pain medication before
patients with surgical infections
suctioning to postoperative patient.

3. Gather equipment and provide privacy for

This provides for organized approach to task
patient

Hand hygiene deters the spread of

4. Perform hand hygiene
5. Assist the patient to a semi-Fowler’s or
Fowler’s position if conscious. An
unconscious patient should be placed in
the lateral position facing you
6. Place clean towel, if being used, across
patient’s chest. Don goggles, mask, and
gown, if necessary
microorganisms
Sitting position helps patient to cough and
breathe more easily. These positions also use
gravity to aid in the insertion of catheter.
Lateral position prevents the airway from
becoming obstructed and promotes drainage to
tracheal mucosa may occur
Towel protects patient and linens. Wearing
protective equipment prevents contamination
of caregiver’s mucous membranes

7. Open sterile kit or set up- equipment, and

prepare to suction

8. Place sterile drape, if available across Drape protects patient and bed linens, this
patient’s chest maintains sterile setup

9. Open sterile container and place on beside

table or over bed table without Sterile technique helps prevent introduction of
contaminating inner surface. Pour sterile organism into respiratory tract.
saline into it

10. Hyper oxygenate patient manual

This prevents hypoxemia that can occur during
resuscitation bag or sigh mechanism on
suctioning.
mechanical ventilator
11. Don sterile gloves or one sterile glove on
Gloves maintaining sterility of procedure and
dominant hand and clean glove on non-
protect the nurse from microorganisms
dominant hand
a. Turn suction to appropriate pressure: Negative pressure must be safe level of
Wall Unit damage to tracheal mucosa may occur

84
  Adult:100 to 120 mm Hg
 Child: 95 to 110 mm Hg
 Infant: 50 mm Hg
Portable Unit
 Adult:10 to 15 mm Hg
 Child: 5 to 10 mm Hg
 Infant:2 to 5 mm Hg
b. Connect sterile suction catheter to
suction tubing that is held with Silicone catheters do not require lubrication
unsterile gloved hand
8. Moisten the catheter by dipping it into the
Lubricating the inside of the catheter with
container of sterile saline unless it is one of
saline helps move the secretion in the catheter.
the newest silicone catheters that do not
Silicone catheter do not require lubrication
require lubrication

9. Remove oxygen delivery setup with This exposes tracheostomy tube without
unsterile gloved hand if it is still in place contaminating sterile gloved hand
10. Using sterile gloved hand, gently and
quickly insert catheter into trachea. Using section when inserting catheter can
Advance about 10 to 12.5 cm (4 to 5 cause trauma to mucosa and removes oxygen
inches) or until patient coughs. Do not from the respiratory tract
include Y port when inserting catheter
11. Apply intermittent suction by occluding Y
port with thumb of unsterile gloved hand.
Turning the catheter while withdrawing it helps
Gently rotate the catheter with thumb and
clean surfaces of respiratory tract and prevents
index finger of sterile glove as catheter is
injury to tracheal mucosa. Suctioning for longer
being withdrawn. Do not allow suctioning
than 10 seconds may result in hypoxia.
to continue for more than 10 seconds.
Hyperventilation re-oxygenates the lungs
Hyperventilate 3 to 5 times between
suctioning or encourage patient to cough
and deep breath between suctioning.
12. Flush the catheter with saline and repeat Flushing cleans and clears catheter and
suctioning as needed and according to lubricates it for next insertion. Allowing time
patient’s toleration of procedure. Allow interval and replacing oxygen delivery setup
patient to rest at least 1 minute between helps compensate for hypoxia induced by the
suctioning and replace oxygen delivery previous suctioning. Irritation from multiple
setup if necessary. Limit suctioning events suctioning results in an increased amount of
to three times secretions
13. When procedure is completed, turn off
suction and disconnect catheter from
suction tubing. Remove gloves inside out
This prevents transmission of microorganisms
and dispose of gloves, catheter, and
container with solution in proper
receptacle. Perform Hand Hygiene
Auscultation helps determine whether
14. Adjust patient’s position. Auscultate chest
respiratory passageways are cleared of
to evaluate breath sound
secretions
15. Record the time of suctioning and the
This provides accurate documentation and
nature and amount of secretions. Also
provides for comprehensive care
note the character of patient’s
respirations before and after suctioning
Respiratory secretions that accumulate are
16. Offer oral hygiene irritating to mucous membranes and
unpleasant for the patients

85
VITAL SIGNS

VITAL SIGNS

86
Definition: Vital signs also known as cardinal signs include body temperature, pulse respiration and
blood
pressure. These signs are used to determine the functioning of the body.

Purposes:
1. Can identify the existence of an acute medical problem.
2. Are a means of rapidly quantifying the magnitude of an illness and how well the body is coping
with the resultant physiologic stress. The more deranged the vitals, the sicker the patient.
3. Are a marker of chronic disease states (e.g., hypertension is defined as chronically elevated blood
pressure).

Guidelines on when to assess the vital signs

1. On admission to a health care agency to obtain baseline data
2. When a client has a change in health status or reports symptoms such as chest pain or feeling
faint.
3. According to a nursing or medical order.
4. Before and after surgery or an invasive diagnostic procedure.
5. Before and/or after the administration of a medication that could alter the respiratory or
cardiovascular systems.
6. Before and after nursing intervention that could affect the vital signs.

BODY TEMPERATURE

Definition: Temperature is the balance between the heat produced by the body and heat loss from the
body measured in head units called degrees.

Types of body temperature

1. Core Temperature – Temperature of deep tissues of the body such as abdominal cavity or
pelvic cavity.
2. Surface Temperature - Temperature of skin, subcutaneous tissue and fat.

Factors affecting body temperature

1. Age. Extreme ages such as very young and very old are susceptible to hypothermia
2. Diurnal Variation. Body temperature varies within the day peaking at around 4-6 PM and
lowest during 4-6 AM.
3. Exercise. Increased muscle activity raises body temperature by heat production.
4. Hormones. In women, progesterone secretion increases body temperature during ovulation.
5. Stress. Simulation of sympathetic nervous system can increase the production of epinephrine,
thereby increasing the metabolic temperature which can affect the person's temperature
regulatory systems.
6. Environment. Extremes environmental temperature can affect a person’s temperature
regulatory systems.

Definition of terms commonly associated with body temperature

1. Radiation. Is the transfer of heat from the surface of one object to the surface of another
without contact between the two objects, mostly in the form of infrared rays.
2. Conduction. Is the transfer of heat from one molecule to a molecule of lower temperature.
3. Convection. Is the dispersion of heat by air currents.
4. Evaporation. The continuous vaporization of moisture from the respiratory tract and from the
mucosa of the mouth and from the skin.
5. Pyrexia. A body temperature that is above the usual range. Also known as hyperthermia or
fever (layman's term).
6. Hypothermia. Is a core body temperature below the lower limit of normal.

Types of Thermometers
a. Electronic thermometer
b. One-piece home electronic thermometer
c. Infrared thermometer

87
Measuring Body Temperature

Sites Descriptions Normal Values

➢ Measurements of body temperature are obtained by
inserting the thermometer in the mouth.
➢ Most accessible and most convenient;
ORAL contraindicated for children and clients with 370C (98.60F)
convulsive disorders
➢ Accuracy is affected by temperature of the food
recently eaten, and by oral and nasal surgery
➢ Temperature is obtained via the rectum.

➢ Most accurate but inconvenient to clients who are

unable to turn to sides.
RECTAL
➢ It could injure a recent rectal surgery. 37.50C (99.50F)

➢ Presence of stool may interfere with thermometer

placement.
➢ Obtaining patient’s temperature via the axilla.

➢ Most preferred since it is accessible and has a few

AXILLA disadvantages.
36.70C (980F)
➢ It is the safest and most noninvasive but has to be
left for a longer period of time for a more accurate
reading.
➢ Core temperature is measured via ear.
TYMPANIC
➢ It is readily accessible, but equipment is expensive 37.50C (99.50F)
MEMBRANE
and involves risk in injuring the ear drum.

INDICATIONS & CONTRAINDICATIONS

SITE INDICATIONS CONTRAINDICATIONS

1. Unconscious clients
2. Irrational clients
3. Clients who breathe through the mouth
4. Clients who had recently undergone
ORAL
nasal or oral surgery
5. Clients who had taken or hot food or
liquid
6. Infants and children
1. Irrational clients 1. Clients who had recently undergone
2. Infants and neonates rectal surgery
3. Unconscious patients 2. Clients with rectal health problems
3. Clients with diarrhea
RECTAL
4. Clients with cardiovascular alteration
because the thermometer may
stimulate the vagus nerve causing
bleeding.
1. Use when oral and rectal are both 1. Recently washed axillae
AXILLA
contraindicated

TEMPERATURE SCALES

Fahrenheit to Celsius Celsius to Fahrenheit

C = (Fahrenheit temperature – 32) x 5/9 F = (Celsius temperature x 5/9) + 32

Example: When Fahrenheit reading is Example: When Celsius reading is 40

100 88
F = (40 x 5/9) + 32
C = (100 – 32) x 5/9 = (72 + 32)
= (68) x 5/9 = 104OF
= 37.8OC
 ASSESSING BODY TEMPERATURE

Purposes:
1. To establish baseline data for subsequent evaluation.
2. To identify if the body temperature is within the normal range
3. To determine changes in the body temperature in response to specific therapies
4. To monitor clients at risk for alterations in body temperature.

Equipment:
 Watch with second hand
 Notepad and pen
 Tray Containing
o Thermometer (oral, rectal, axillary, tympanic)

o Lubricant (rectal)
o Towel or tissue
o Disposable gloves (rectal)
o Container with cotton balls soaked in soap-suds solution or alcohol pad
o Container with cotton balls soaked in water
o Waste receptacle

PROCEDURE RATIONALE
Checking the chart validates the correct
2. Check the chart and explain the procedure to
patient. Explaining the procedure would help
the client.
gain cooperation
3. Perform handwashing Washing prevents cross infection
4. Prepare the equipment and place it at the
This would save time and energy
beside of the client.
This ensures accurate reading and allows time
5. Ascertain if method of taking temperature is
to elapse between eating, smoking, and
appropriate for the client.
measuring
6. Determine the time of the client last took hot
It could affect and mask client's temperature
or cold food or liquid.
7. Clean the thermometer using the CB with
Wiping the thermometer from the cleanest to
water in a firm twisting motion from the bulb
the dirtiest limits the spread of microorganism.
to stem and dry using the same motion
8. Place the thermometer
- apply a protective sheath or probe cover if
available or needed.

9. Wait for the appropriate amount of time.

Electronic and tympanic thermometers will
indicate that the reading is complete through
light or tone. Check package instructions for
length of time to wait prior to reading
thermometers
ORAL METHOD
a. Place the bulb of thermometer under the
client’s tongue in the sublingual area either

89
 in the right or left frenulum
b. Ask the client to close the lip but not the
teeth
c. Leave the thermometer in place for 2
This allows sufficient time to measure the body
minutes (or as per manufacturer's direction
temperature

AXILLARY METHOD
a. Expose the client's axilla. If the axilla is
Friction created by rubbing can raise the
moist, dry it with towel, or tissue using a
temperature of the axilla
patting motion.
b. Place the thermometer in the client's
center of the axilla; bring the client's arm This position would keep the thermometer in
down close to his body and place his place
forearm over his chest
c. Leave the thermometer in place until a
sound is heard. That means the
temperature taking is completed.
RECTAL METHOD
a. Place the client in lateral position (sims
To ensure visualization of the anus
position)
b. Drape client before exposing the rectal
area to expose the buttocks
c. Wear disposable gloves on both hands.
Place some lubricant on a piece of tissue
The lubricant facilitates insertion of the
then apply lubricant to the thermometer of
thermometer without irrigating the mucous
about 5 cm the bulb. (Or place the
membrane
lubricant in the non-dominant hand about 5
cm.)
d. With the non-dominant hand, raise the
upper buttock to expose the anus and hold
the thermometer with your dominant hand
e. Ask the client to take deep breath and
insert the thermometer into the anus about Taking a deep breath often relaxes the external
1.5 for adult or 3.5 cm; infant 1.2cm (0.5 sphincter muscle, thus easing insertion
inch)
Inability to insert thermometer in newborn
f. Do not force insertion of the thermometer could indicate that the rectum is not patent.
if resistance is felt Forced insertion can lead to bleeding of the
anal area.
g. Hold the thermometer in place until a
This ensures enough time for the thermometer
sound is heard. That means the
to register the temperature
temperature taking is completed.
Wiping the thermometer from area with fewer
9. Remove the thermometer and wipe it at once
or no microorganism to area where they may
with dry CB/ tissue from stem down to the
be present reduces the risk for spreading
mercury bulb in a firm twisting motion
microorganism.
10. Read the temperature and record it on your
worksheet. If the temperature is obviously too Record the temperature reading immediately
high, too low, or inconsistent with the client's on your jot down notebook to avoid forgetting
condition, recheck it with a thermometer the result.
known to be functioning properly.
11. Clean the thermometer, if necessary, with
cotton balls in soap sud solution or alcohol pad
and return it to the storage.
12. Wash your hands
13. Document accurately the result on the
Immediate recording ensures it is not forgotten
patient's chart

90
 PULSE

Definition: It is the wave of blood created by contraction of the left ventricle of the heart.

Factors Affecting the Pulse

1. Age. As age increases, the pulse rate gradually decreases overall.
2. Sex. After puberty, the average male's pulse rate is slightly lower than the females.
3. Exercise. The pulse rate normally increases with activity. The rate of increase in professional
athletes is often less than the average person because of greater cardiac size, strength, and
efficiency.
4. Fever. The pulse rate increases: (a) in response to the lowered blood pressure that results from
peripheral vasodilation associated with elevated body temperature and (b) because of the
increase metabolic rate.
5. Medications. Some medications decrease the pulse rate, and others increase it.
6. Hypovolemia/Dehydration. Loss of blood from the vascular system increases the pulse rate.
In adults, the loss of circulating volume results in an adjustment of the heart rate to increase
blood pressure as the compensates for the loss of blood volume.
7. Stress. In response to stress, sympathetic nervous stimulation increases the overall activity of
the heart. Stress increases the rate as well as the force of the heartbeat. Fear and anxiety as
well as the perception of severe pain stimulate the sympathetic system.
8. Position. When a person is sitting or standing, blood usually pools in dependent vessels of the
venous system. Pooling results in a transient decrease in the venous blood return to the heart
and a subsequent reduction in blood pressure and increase in heart rate.
9. Pathology. Certain diseases such as some heart conditions or those that impair oxygenation
can alter the resting pulse rate.

VARIATIONS IN PULSE AND RESPIRATIONS BY AGE

PULSE AVERAGE RESPIRATIONS AVERAGE
AGE
(AND RANGES) (AND RANGES)
Newborn 130 (80-180) 35 (30-80)
1 year 120 (80-140) 30 (20-40)
5-8 years 100 (75-100) 20 (25-25)
10 years 70 (50-90) 19 (15-25)
Teen 75 (50-90) 18 (15-20)
Adult 80 (60 -100) 16 (12-20)
Older Adult 70 (60-100) 16 (15-20)
Source: Berman, A., Synder, S., Frandsen, G. (2018). Kozier's & Erb's Fundamentals of Nursing 10 th ed

Definition of terms commonly associated with pulse

1. Peripheral pulse. Pulse located away from the heart (e.g., foot or wrist)
2. Tachycardia. An excessively fast hear rate.
3. Bradycardia. A heart rate in adults of less than 60 beats/min.
4. Pulse rhythm. Patterns of the beats and the intervals between the beats.
5. Dysrhythmia/Arrythmia. A pulse with an irregular rhythm.

91
PULSE SITES

Image source: http://www.larrypatten.com/pulses/

Reasons for Using Specific Pulse Site

Pulse Site Reason for Use

Temporal  Used when radial pulse is not accessible

 Used during cardiac arrest/shock in adults
Carotid
 Used to determine circulation of the brain
 Routinely used for infants and children up to 3 years of age
Apical  Used to determine discrepancies with radial pulse
 Used in conjunction with some medications
 Used to measure blood pressure
Brachial
 Used during cardiac arrest for infants
Radial  Readily accessible
 Used in cases of cardiac arrest/shock
Femoral
 Used to determine circulation to a leg
Popliteal  Used to determine circulation to the lower leg

Dorsalis Pedis  Used to determine circulation of the foot

92
Posterior Tibial  Used to determine circulation of the foot
Source: Berman, A., Synder, S., Frandsen, G. (2018). Kozier's & Erb's Fundamentals of Nursing 10 th ed

ASSESSING PERIPHERAL PULSE

Purposes
1. To establish baseline data for subsequent evaluation
2. To identify whether the pulse rate is within normal range
3. To determine the pulse volume and whether the pulse rhythm is regular
4. To determine the equality of corresponding peripheral pulses on each side of the body
5. To monitor and assess changes in the client's health status
6. To monitor clients at risk for pulse alterations (e.g., those with a history of heart disease or
experiencing cardiac arrhythmias, hemorrhage, acute pain, infusion of large volumes of fluids, or
fever)
7. To evaluate blood perfusion to the extremities

Equipment
 Watch with a sweep second hand
 If using a Doppler ultrasound stethoscope (DUS): stethoscope headset, transmission gel and
tissue/wipes.

PROCEDURE RATIONALE
1. Introduce self and verify client's identity
2. Perform hand hygiene
3. Provide for client's privacy
4. Select the pulse point.
Normally, the radial pulse is taken, unless it
cannot be exposed or circulation to another
body area is to be assessed
5. Assist the client to a comfortable resting
position.
 When the radial pulse is assessed,
with the palm facing downward, the
client's arm can rest alongside the
body, or the forearm can rest at a 90-
degree angle across the chest.
 For the client who can sit, the forearm
can rest across the thigh, with the
palm of the hand facing downward or
inward.
6. Palpate and count the pulse.
 Place two or three middle fingertips Using the thumb is contraindicated because the
lightly and squarely over the pulse nurse's thumb has a pulse that could be mistaken
point for the client's pulse.
 Count for a full minute. If an irregular
pulse is found, also take the apical
pulse.
7. Assess the pulse rhythm and volume
 Assess the pulse rhythm by noting the
A normal pulse has equal time periods between
pattern of the intervals between the
beats.
beats.
 Assess the pulse volume. A normal pulse can be felt with moderate

93
 pressure, and the pressure is equal with each
beat. A forceful pulse volume is full; an easily
obliterated pulse is weak.
8. Document the pulse rate, rhythm, and
volume.

RESPIRATION

Definition
 It is the act of breathing.
 It is the act of inhaling and exhaling of air in order to exchange oxygen for carbon dioxide

Factors affecting respirations

1. Exercise
2. Stress
3. Increased environmental temperature, and lowered oxygen concentration at increased altitudes
4. Decreased environmental temperature
5. Certain medications
6. Increased intracranial pressure (ICP)
7. Body position

Definition of terms commonly associated with pulse

1. Tidal volume. During a normal inspiration and expiration, an adult takes in about 500 mL of air
2. Hyperventilation. Refers to very deep, rapid respirations
3. Hypoventilation. Refers to very shallow respirations
4. Respiratory rhythm. It is the regularity of the expirations and the inspirations.
5. Respiratory Quality. Refers to those aspects of breathing that are different from normal,
effortless breathing.

ALTERED BREATHING PATTERNS & SOUNDS

BREATHING PATTERNS BREATH SOUNDS
Rate
 Tachypnea – quick, shallow breaths
 Bradypnea – abnormally slow breathing
 Apnea – cessation of breathing
Volume
 Hyperventilation – overexpansion of
the lungs characterized by rapid and
deep breaths
 Hypoventilation – under expansion of
the lungs, characterized by shallow
respirations
Rhythm
 Cheyne-Stokes breathing – rhythmic
waxing and waning of respirations,
from very deep to very shallow
breathing and temporary apnea
Ease or Effort
 Dyspnea – difficult or labored breathing
during which the individual has a
persistent, unsatisfied need for air and
feels distressed
 Orthopnea – ability to breathe only in
upright sitting or standing positions
Audible Without Amplification
 Stridor – A shrill, harsh sound heard during
inspiration with laryngeal obstruction
 Stertor – snoring or sonorous respiration,
usually due to a partial obstruction of the
upper airway
 Wheeze – continuous, high-pitched musical
squeak or whistling sound occurring on
expiration and sometimes on inspiration when
air moves through a narrowed or partially
obstructed airway
 Bubbling – gurgling sounds heard as air
passes through moist secretions in the
respiratory tract.
CHEST MOVEMENTS
 Intercostal retraction – indrawing between
the ribs
 Substernal retraction – indrawing beneath the
breastbone
 Suprasternal retraction – indrawing above the
clavicles
SECRETIONS AND COUGHING
 Hemoptysis – the presence of blood in the
sputum

94
  Productive cough – a cough accompanied by
expectorated secretions
 Nonproductive cough – a dry, harsh cough
without secretions

ASSESSING RESPIRATIONS

Purposes
1. To acquire baseline data against which future measurements can be compared
2. To monitor abnormal respirations and respiratory patterns and identify changes
3. To monitor respirations before or after the administration of a general anesthetic or any
medication that influences respirations
4. To monitor clients at risk for respiratory alterations

Equipment
 Watch with a sweep second hand

PROCEDURE RATIONALE

1. Introduce self and verify client's identity

2. Perform hand hygiene

3. Provide for client's privacy

4. Observe and count the respiratory rate

a. Place a hand against a client's chest to
feel the chest movements with
breathing, or place the client's arm
across the chest and observe the chest The client's awareness that the nurse is counting
movements while supposedly taking the the respiratory rate could cause the client to
radial pulse purposefully alter the respiratory pattern.
b. Count the respiratory rate for 60
seconds. An inhalation and an
exhalation count as one respiration
5. Observe the depth, rhythm, and character of
respiration
During deep respirations, a large volume of air is
a. Observe the respirations for depth by
exchanged; during shallow respirations, a small
watching the movement of the chest
volume is exchanged
b. Observe the respirations for regular or
Normally, respirations are evenly spaced.
irregular rhythm
c. Observe the character of respirations –
the sound they produce and the effort Normally, respirations are silent and effortless
they require

6. Document the respiratory rate

95
 BLOOD PRESSURE

Definition: It is a measure of the pressure exerted by the blood as it flows through the arteries
a. SYSTOLIC PRESSURE – the pressure of the blood because of contraction of the
ventricles, that is, the pressure of the height of the blood wave.
b. DIASTOLIC PRESSURE –the pressure when the ventricles are at rest.
c. PULSE PRESSURE – difference between the diastolic and the systolic pressures

Factors Affecting Blood Pressure

1. Age
2. Exercise
3. Stress
4. Race
5. Sex
6. Medications
7. Obesity
8. Diurnal variations
9. Medical conditions
10. Temperature

Definition of terms commonly associated with blood pressure

1. Hypertension. A BP that is persistently above normal.
2. Hypotension. Is a BP that is below normal, that is, a systolic reading consistently between 85
and 110 mmHg in an adult whose normal pressure is higher than this.
3. Orthostatic hypotension. Is a BP that decreases when the client sits or stands.

CLASSIFICATION OF BLOOD PRESSURE

Systolic BP Diastolic BP
Category
(mmHg) (mmHg)
Normal < 120 and < 80
Prehypertension 120-139 or 80-89
Hypertension, stage 1 140-159 or 90-99
Hypertension, stage 2 > 160 or >100

NOTE:
1. If this is the initial nursing assessment of a patient, take the blood pressure on both arms. It is
normal to have a 5-to 10-mm Hg difference in the systolic residing between arms. Use the arm
with the higher reading for subsequent pressure.

2. When having difficulty hearing blood pressure sounds, the following technique is recommended.
a. With cuff in place raise the client's arm, over his or her head for 15 seconds before
rechecking the blood pressure.
b. Inflate the cuff while the arm is elevated, and gently lower the arm while continuing to
support it.
c. Position the stethoscope and deflate the cuff at the usual rate while listening for Korotkoff
sounds.

3. Raising the arm over the head helps relieve congestion of blood in the limb, increases pressure
differences, and makes the sounds louder and more distinct when blood enters the lower arm.

96
 a. Use cuff size appropriately for limb circumference. Inform client that cuff sizes range from a
pediatric cuff to a large thigh cuff and that a poorly fitting may result in an accurate
measurement.
b. Inform patients about availability of digital blood pressure monitoring equipment. Though
costly, most provide an easy-to-read recording of systolic and diastolic measurements.

ASSESSING BLOOD PRESSURE

Purposes:
1. To obtain baseline data
2. To determine client's hemodynamic status
3. To identify and monitor changes in BP

Equipment
 Sphygmomanometer
 Stethoscope

PROCEDURE RATIONALE

1. Identify the patient

Reduces patient apprehension and encourages
2. Explain the procedure to the patient
patient cooperation.
3. Gather equipment Provides organized approach to task

4. Perform hand hygiene. Deters the spread of microorganisms

5. Delay obtaining the blood pressure if the

patient is emotionally upset, is in pain, or just Factors such as emotional upset, exercise, can
exercised unless it is urgent to obtain the alter usual blood pressure measurement.
blood pressure

6. Select appropriate arm for application of cuff

Measurement of blood pressure may temporarily
(no IV infusion, breast or axilla surgery on
impede circulation to a diseased or compromised
that side, cast, arteriovenous shunt, or injured
extremity.
or diseased limb).

7. Have the patient assume a comfortable lying

This position places the brachial artery on the
or sitting position with the forearm supported
inner aspect of the elbow, so that the bell or
at the level of the heart and the palm of the
diaphragm of the stethoscope can rest on easily.
hand upward.
Clothing over the artery interferes with the ability
8. Expose the area of the brachial artery by
to hear sounds and may cause inaccurate blood
removing garments, or move a sleeve, if it is
pressure readings. Tight clothing on the arm
not too tight above the area where the cuff
causes congestion of blood and possibly
will be placed.
inaccurate reading.
Pressure in the cuff applied directly to the artery
9. Center the bladder of the cuff over the
provides the most accurate readings. If the cuff
brachial artery, about midway of the arm, so
gets in the way of the stethoscope, readings are
that the lower edge of the cuff is about 2.5 (1
likely to be inaccurate. A cuff placed upside down
inch) above the inner aspect of the
with the tubing towards the client's head may
elbow/antecubital space.
give a false reading.
10. Wrap the cuff around the arm smoothly and
A smooth cuff and snug wrapping produce equal
snugly and fasten it securely or tuck the end
pressure and help promote an accurate
of the cuff well under the preceding wrapping.
measurement. A cuff too loosely wrapped results
Do not allow any clothing to interfere with
in inaccurate reading.
proper placement of the cuff.
11. Check that a mercury manometer is in a Tilting a mercury manometer, inaccurate
vertical position. The mercury must be within calibration, or improper height for reading the

97
 the zero area with gauge at eye level. If an
gauge can lead to errors in determining the
aneroid gauge is used, the needle should be
pressure measurements
within the zero mark.
12. Use the fingertips to palpate the pulse at the
Palpation allows for measurements of the
brachial or radial artery by pressing gently
approximate systolic reading.
with the fingertips.
The bladder within the cuff will not inflate if the
13. Tighten the screw valve on the air pump.
valve is open.
The point where the pulse disappears provides an
14. Inflate the cuff while continuing to palpate the estimate of the systolic pressure. To identify the
artery. Note the point on the gauge where the first Korotkoff sound accurately, the cuff must be
pulse disappears. inflated to a pressure above the point at which
the pulse can no longer be felt.
15. Deflate the cuff and wait 1 to 2 minutes.
Before inflating the cuff again while waiting, Allowing a brief pause before continuing permits
clean the diaphragm of the stethoscope and the blood to refill and circulate through the arm.
the earpieces with alcohol swab.
16. Assume a position that is no more than 3 feet A distance of more than about 3 feet can interfere
away from the gauge. with accurate readings of numbers on the gauge.
17. Place the stethoscope earpieces in the ears.
Proper placement blocks extraneous noise and
Direct the eartips forward into the canal and
allows sound to travel more clearly.
not against the ear itself.
Having the bell or diaphragm directly over the
artery makes more accurate reading possible.
18. Place the bell or diaphragm of the stethoscope
Heavy pressure on the brachial artery distorts
firmly but with as little pressure as possible
the shape of artery and the sound. Placing the
over the brachial artery. Do not allow the
bell of diaphragm away from the clothing and the
stethoscope to touch clothing or the cuff.
cuff prevents noise, which will distract from the
sounds made by blood flowing to artery.
19. Pump the pressure 30 mmHg above the point
Increasing the pressure above where the pulse
at which the systolic pressure was palpated
disappeared ensures a period before hearing the
and estimated. Open the valve on the
first sound that corresponds with systolic
manometer and allow air to escape slowly
pressure. It prevents misinterpreting phase II
(allowing the gauge to drop 2-3 mm per
sound as phase I.
heartbeat).
Systolic pressure is the point at which the blood in
the artery is first able to force its way through
20. Note the point on the gauge at which there is
the vessel as a similar pressure exerted by the air
an appearance of the faint, but clear, sound
bladder in the cuff. The first sound is phase I of
that slowly increases in intensity. Note this
Korotkoff sounds.
number as the systolic pressure.
It is common practice to read blood pressure to
the closest even number.
21. Read the pressure to the closest even number
Reinflating the cuff while obtaining blood pressure
22. Do not re-inflate the cuff once the air is is uncomfortable for the patient and may cause
being released to recheck the systolic pressure inaccurate reading. Reinflating the cuff ca-uses
reading. congestions of blood pressure in the lower arm,
which lessens the loudness of Korotkoff sounds.
The point at which the sound changes correspond
to phase IV of Korotkoff sound and is considered
23. Note the pressure at which the sound first
the first diastolic pressure reading. According to
becomes muffled. Also observe the point at
the American Heart Association, this is using a
which the sound completely disappears. These
diastolic pressure recording in children. The last
may occur separately or at the same point.
sound heard is the beginning of phase V and is
the second diastolic measurement.
24. Allow the remaining air to escape quickly.
Repeat any suspicious reading but wait 1-2
False readings are likely to occur if there is
minutes between readings to allow
congestion of blood in the limb while obtaining
normal circulation to return in the limb. Be
repeated readings.
sure to deflate the cuff completely between
attempts to check blood pressure.

98
25. Remove the cuff, and clean and store
Equipment that must be shared among personnel
equipment. If gloves are worn, discard them
should left in a manner ready for use.
in the proper receptacle.
26. Record findings on paper, flow sheet, or
computerized record. Report abnormal
Provides accurate documentation and reporting.
findings to the appropriate person. Identify
site of assessment if other than brachial.

PAIN ASSESSMENT
TOOLS

99
 PAIN ASSESSMENT

Pain has been identified as the fifth vital signs by Australian and New Zealand College of Anesthetists and
the Chronic pain Coalition in an attempt to facilitate accountability for pain assessment and management
(Chronic Pain Policy Coalition, 2007; ANZCA, 2005).

Definition

Pain is an unpleasant feeling that is conveyed to the brain by sensory neurons. The discomfort signals
actual or potential injury to the body. However, pain is more than a sensation, or the physical awareness
of pain; it also includes perception, the subjective interpretation of the discomfort. Perception gives
information on the pain's location, intensity, and something about its nature. The various conscious and
unconscious responses to both sensation and perception, including the emotional response, add further
definition to the overall concept of pain.

General Classification

1. Acute pain — Pain in response to injury or another stimulus that resolves when the injury heals,
or the stimulus is removed.
2. Chronic pain — Pain that lasts beyond the term of an injury or painful stimulus. Can also refer
to cancer pain, pain from a chronic or degenerative disease, and pain from an unidentified cause.

Specific Types

1. Bearing-down pain – pain accompanying uterine contractions during the second stage of
labor.
2. False pains – ineffective pains resembling labor pains, not accompanied by cervical dilatation.
3. Growing pains – recurrent quasi-rheumatic limb pains peculiar to early youth.
4. Hunger pain – pain coming on at the time for feeling hunger for a meal; a symptom of gastric
disorder.
5. Intermenstrual pain – pain accompanying ovulation, occurring during the period between the
menses, usually about midway.
6. Labor pains – the rhythmic pains of increasing severity and frequency due to contraction of the
uterus at childbirth.
7. Phantom limb pain – pain felt as though arising in an absent (amputated) limb.
8. Psychogenic pain – symptoms of physical pain having psychological origin.
9. Referred pain – pain felt in a part other than that in which the cause that produced it is
situated.
10. Rest pain – a continuous burning pain due to ischemia of the lower leg, which begins or is
aggravated after reclining and is relieved by sitting or standing.

100
Factors Affecting the Pain Experience

1. Ethnic and cultural values

2. Developmental stage
3. Environment and support people
4. Previous pain experiences
5. Meaning of pain

PAIN ASSESSMENT TOOLS

1. The Wong Baker Faces Pain Scale combines pictures and numbers to allow pain to be rated by
the user. It can be used in children over the age of 3, and in adults. The faces range from a smiling
face to a sad, crying face. A numerical rating is assigned to each face, of which there are 6 total.

2. The

numerical rating scale offers the individual in pain to rate their pain score. It is designed to be
used by those over the age of 9. In the numerical scale, the user has the option to verbally rate their
scale from 0 to 10 or to place a mark on a line indicating their level of pain. 0 indicates the absence
of pain, while 10 represents the most intense pain possible.

The Numerical Rating Pain Scale allows the healthcare provider to rate pain as mild, moderate or
severe, which can indicate a potential disability level.

3. FLACC stands for face, legs, activity, crying and consolability . It is an observer rated pain
scale, performed by a healthcare practitioner such as a doctor or a nurse. The FLACC pain scale was
designed for children between the ages of 2 and 7. However, some practitioners in adult settings
may use the FLACC pain scale for people who are unable to communicate their pain. FLACC provides
a pain assessment scale between 0 and 10. Then compares the result to the numeric rating pain
scale.

101
4. The CRIES Pain Scale is often used in the neonatal healthcare setting. CRIES is an observer-rated
pain assessment tool which is performed by a healthcare practitioner such as a nurse or physician.
CRIES assesses crying, oxygenation, vital signs, facial expression and sleeplessness. The CRIES Pain
Scale is generally used for infants 6 months old and younger. The total score is compared to the
numeric rating pain scale.

102
NUTRITION

103
 ENTERAL NUTRITION

Definition: Alternative feeding methods that ensure adequate nutrition include enteral (through the GI
system) methods.

A nasogastric tube (NGT) is inserted through one of the nostrils, down the nasopharynx, and into the
alimentary tract.

Classification
1. Open System
a. Use open-top container or a syringe for administration
b. Osterized feeding/ powdered formula reconstituted with sterile water.
c. After 8-12 hours, the remaining formula should be discarded.
d. Bag and tubing should be replaced every 24 hrs.
2. Closed system
a. Consist of a refilled container that is spiked with enteral tubing and attached to the
enteral access device.
b. can be hang safely for 48 hours if sterile technique is used.

Types
1. Intermittent = administration of 300 to 500 mL of enteral formula several times a day, which is
administered over at least 30 minutes; preferred site is stomach.
2. Continuous = administered over a 24-hour period using an infusion pump (kangaroo pump)
that guarantees a constant flow rate; administered in the small bowel.
3. Cyclic Feedings = continuous feedings that are administered in less than 24 hours (e.g. 12 to
16 hours); often at night, allowing the client to attempt to eat regular meals through the day

INSERTING A NASOGASTRIC TUBE

Purposes
1. To administer tube feedings and medications to clients unable to eat by mouth or swallow a
sufficient diet without aspirating food or fluids into the lungs.
2. To establish a means for suctioning stomach contents to prevent gastric distention, nausea and
vomiting
3. To remove stomach contents for laboratory analysis
4. To lavage (wash) the stomach in case of poisoning or overdose of medications

Equipment
 Nasogastric tube of desired size
 Non-allergenic adhesive tape
 Clean gloves
 Water-soluble lubricant
 Facial tissue
 Glass of water and drinking straw
 Syringe bulb
 Kidney basin
 Flashlight
 Stethoscope

104
 PROCEDURE RATIONALE

1. Introduce self and verify the client’s identity.

2. Perform hand hygiene

3. Provide for client privacy

4. Assist the client to a high-Fowler’s position if

It is often easier to swallow in this position and
his/her health permits, and support the head
gravity helps the passage of the tube.
on a pillow

5. Assess the client’s nares

a. Apply clean gloves

b. Ask the client to hyperextend the head,

and, using a flashlight, observe the
intactness of the tissues of the nostrils,
including any irritations or abrasions
c. Select the nostril that has the greater
airflow
6. Prepare the tube

7. Determine how far to insert the tube

a. Use the tube to mark off the distance from

the tip of the client’s nose to the tip of the This length approximates the distance from the
earlobe and then from the tip of earlobe to nares to the stomach.
the tip of the xiphoid.
b. Mark this length with adhesive tape if the
tube does not have markings.
8. Insert the tube
A water-soluble lubricant dissolves if the tube
a. Lubricate the tip of the tube well with accidentally enters the lungs. An oil-based
water-soluble lubricant or water to ease lubricant, such as petroleum jelly, will not dissolve
insertion and could cause respiratory complications if it
enters the lungs.
b. Insert the tube, with its natural curve
downward, into the selected nostril. Ask
Hyperextension of the neck reduces the curvature
the client to hyperextend the neck, and
of the nasopharyngeal junction
gently advance the tube toward the
nasopharynx.
c. Direct the tube along the floor of the Directing the tube along the floor avoids the
nostril and toward the midline projection (turbinates) along the lateral wall
d. Slight pressure and a twisting motion are
sometimes required to pass the tube into Tears are a natural body response. Provide the
the nasopharynx, and some client’s eyes client with tissues as needed.
may water at this point
e. If the tube meets resistance, withdraw it, The tube should never be forced against resistance
relubricate it, and insert in the other nostril because of the danger of injury
f. Once the tube reaches the oropharynx
Tilting the head forward facilitates passage of the
(throat), the client will feel the tube in the
tube into the posterior pharynx and esophagus
throat and may gag. Ask the client to tilt
rather than into the larynx; swallowing moves the
the head forward, and encourage the client
epiglottis over the opening to the larynx
to drink and swallow.
g. If the client gags, stop passing the tube
momentarily. Have the client rest, take a
few breaths, and take sips of water to calm
the gag reflex

105
 h. In cooperation with the client, pass the
tube 5 to 10 cm (2 to 4 in.) with each
swallow, until the indicated length is
inserted.

i. If the client continues to gag and the tube

The tube may be coiled in the throat. If so,
does not advance with each swallow,
withdraw it until it is straight, and try again to
withdraw it slightly, and inspect the throat
insert it.
by looking through the mouth

9. Ascertain correct placement of the tube

a. A stethoscope is place over the client’s
epigastrium and inject 10 to 30 mL of air
into the tube while listening for a
whooshing sound. This method does not
guarantee tube position
b. Aspirate stomach contents, and check the Testing pH is reliable way to determine location of
pH, which should be acidic. a feeding tube.
c. NGT position can be confirmed by X-ray.
This is the definitive method of verifying
feeding tube tip placement. If X-ray is not
available, at least the two other methods
should be used.
Taping this manner prevents the tube from
10. Secure the tube by taping it to the bridge of
pressing against and irritating the edge of the
the client’s nose
nostril
11. Document relevant information: the insertion
of the tube, the means by which correct
placement was determined, and client
response.

106
 FEEDING THROUGH NASOGASTRIC TUBE

Definition: Administration of feeding/medications via an NGT or OGT for patients who are unconscious,
too weak or unable to take feeding /medications orally

Purposes:
1. To restore or maintain nutritional status
2. To administer medications.

Equipment:
 Correct type and amount of feeding solution.
 60-mL catheter-tip syringe/ syringe bulb
 Emesis basin (kidney basin)
 Clean gloves
 pH test strip or meter
 Water (60 mL unless otherwise specified) at room temperature
 Clean towel
 Infusion pump for feeding tube

PROCEDURE RATIONALE
1. Check for physician’s order. Introduce self and Verify correct type, amount and expiration date of
verify client’s identity. feeding solution
Inform client that the feeding should not cause any
2. Explain to the client the procedure
discomfort but may cause a feeling of fullness
3. Perform hand hygiene Observe appropriate infection control procedures
4. Provide privacy, if client desires it Tube feedings are embarrassing to some people
5. Assist client to a Fowler’s position (or 30
The positions enhance gravitational flow of the
degrees elevation) in bed or a sitting position.
solution and prevent aspiration of fluid into the
If sitting position is contraindicated, a slightly
lungs
elevated right side-lying position is acceptable
6. Assess correct tube placement
a. Aspirate gastrointestinal secretions.
Gastric secretions tend to be a grassy-
green, off-white or tan color; intestinal
fluid is stained with bile and has a golden
yellow or brownish green color.
b. Measure pH of aspirated fluid. Gastric
aspirates tend to be acidic and have a pH
of 1 to 4 but may be as high as 6 if the
client is receiving medications that control
gastric acid.
Small intestine aspirates generally have a
pH equal to or higher that 6.
Respiratory secretions are more alkaline
with values of 7 or higher.

c. Auscultate the epigastrium while injecting

5 to 20 mL of air and listen for a gurgling
sound.
NOTE: Radiographic verification is the most effective method,
however, not feasible and costly.
This is done to evaluate absorption of the last
feeding. At some agencies, a feeding is delayed
7. Assess residual feeding contents
when the specified amount (about 150 ml) or more
of formula remains in the stomach
8. In administering the feeding, using the Syringe Pinching or clamping the tube prevents excess air
Open System remove the plunger from the from entering the stomach and causing distention
syringe and connect the syringe to a pinched

107
 or clamped NGT.
Feeding solution should be warm to room
9. Clamp the feeding tube and add the feeding
temperature. Cold feeding may cause abdominal
solution to the syringe barrel
cramps
10. Release the clamp and permit the feeding to
flow slowly at the prescribed rate. Raise (about
12 inches) or lower the syringe to adjust the Quickly administered feedings can cause flatus,
flow as needed. Pinch or clamp the tubing to cramps, and /or vomiting
stop the flow for a minute if the client
experiences discomfort
11. Administer ordered amount of formula and Water flushes the lumen of the tube, preventing
instill 50 to 100 mL of water through the tubing future blockage by sticky formula
12. When giving medication:
a. Feed the client first before giving his/her If not contraindicated. To prevent gastric irritation.
medications
b. Allow the feeding to run into the stomach Gives the stomach time to accommodate the
by itself feeding and decrease GI distress
c. Give the exact/prescribe medication Prevent regurgitation and abdominal distention
d. Flush the tubing with water
13. Clamp the feeding tube before all the water is Clamping prevents leakage and air from entering
instilled the tube
14. Ensure client comfort and safety. Secure the
This minimizes pulling of the tube, thus preventing
tubing to the client’s gown or head part of the
discomfort and dislodgment
bed
15. Ask the client to remain sitting upright, These positions facilitate digestion and movement
Fowler’s position or in a slightly elevated right of the feeding from the stomach and prevent of
lateral position for at least 30 minutes aspiration of the feeding into the lungs
16. Clean the equipment used with the use of
Prevent built up of microorganism
dishwashing liquid and let it dry
17. Change the equipment every 24 hrs. or
according to agency policy
18. Document the feeding, including the amount
and kind of solution taken, duration of the
feeding, and assessment of the client

108
 MEDICATION
ADMINISTRATION

ADMINISTRATION OF THERAPEUTIC AGENTS

Definition: It is the administration of a substance for the diagnosis, cure, treatment, relief or prevention
of disease.

GENERAL INFORMATION ABOUT DRUG ADMINISTRATION

1. Doctor should order in writing the name of the drug, amount, time and frequency of giving as
well as the method of administration.
2. Verbal order should be accepted only in extreme emergencies. A written order must be obtained
as soon as the emergency has been controlled.
3. If a physician orders a drug over the telephone, a registered nurse must take down the
information. On the next visit, the physician signs the written record of the verbal order.
4. The nurse should inform the doctor of any known patient’s allergies.

109
 5. The nurse should recognize commonly used abbreviations and symbols utilized in medication
administration.
6. The nurse should bear in mind that accuracy in the measurement of drugs is vital especially in
pediatric doses where a relatively small error becomes magnified.
7. The nurse should know the usual therapeutic as well as side effects of each drug.
8. The physician should be notified immediately in case of errors.
9. The nurse should question an order in which in her judgment is erroneous. She should tactfully
clarify the order with the physician who made it.
10. The nurse should be knowledgeable of the patient’s diagnosis or tentative diagnosis.
11. Each type of drug preparation usually requires a specific method of administration.
12. The route of administration of drug affects the optimal dosage of the drug. (Optimal dosage of
drugs administered by injection maybe different from those administered orally).
13. The administration of medication requires a knowledge of anatomy and physiology as well as
knowledge of the drug and the reason it has been prescribed.
14. The method of administration of drug is partially determined by the age of the patient, level of
consciousness, and the disease process. Any difficulties encountered when administering
medicines should be reported.
15. Appropriate precautionary measures should be taken to avoid errors and accidents in the
preparation and administration of therapeutic agents.
16. Physiologic activities of the body can be maintained, improved or in some instances restored by
administration of therapeutic agents.
17. Persons vary in the way they metabolize injected or ingested agents or the way they react to
agents applied externally.
18. Each patient has his own needs for explanation and support with respect to the administration of
medicines. Some people want to know about their medicines, others prefer not to. The amount
of knowledge that a person requires is dependent upon individual circumstances.

GENERAL RULES IN THE ADMINISTRATION OF MEDICINES

1. Observe the "10 RIGHTS" in giving each medication (Joyce Kee)
1.
2. Right Patient
3. Right Drug
4. Right Dose
5. Right Time
6. Right Route
7. Right Assessment
8. Right Documentation
9. Patient's Right to Educate
10. Right Evaluation
11. Patient's Right to Refuse

110
NUTRITION

111
ENTERAL NUTRITION

Definition: Alternative feeding methods that ensure adequate nutrition include enteral (through the GI
system) methods.

A nasogastric tube (NGT) is inserted through one of the nostrils, down the nasopharynx, and into the
alimentary tract.

Classification
1. Open System
c. Use open-top container or a syringe for administration
d. Osterized feeding/ powdered formula reconstituted with sterile water.
e. After 8-12 hours, the remaining formula should be discarded.
f. Bag and tubing should be replaced every 24 hrs.
2. Closed system
g. Consist of a refilled container that is spiked with enteral tubing and attached to the
enteral access device.
h. can be hang safely for 48 hours if sterile technique is used.

Types
1. Intermittent = administration of 300 to 500 mL of enteral formula several times a day, which is
administered over at least 30 minutes; preferred site is stomach.
2. Continuous = administered over a 24-hour period using an infusion pump (kangaroo pump) that
guarantees a constant flow rate; administered in the small bowel.
3. Cyclic Feedings = continuous feedings that are administered in less than 24 hours (e.g. 12 to 16
hours); often at night, allowing the client to attempt to eat regular meals through the day

INSERTING A NASOGASTRIC TUBE

Purposes

1. To administer tube feedings and medications to clients unable to eat by mouth or swallow a
sufficient diet without aspirating food or fluids into the lungs.
2. To establish a means for suctioning stomach contents to prevent gastric distention, nausea and
vomiting
3. To remove stomach contents for laboratory analysis
4. To lavage (wash) the stomach in case of poisoning or overdose of medications

Equipment
 Nasogastric tube of desired size
 Non-allergenic adhesive tape
 Clean gloves
 Water-soluble lubricant
 Facial tissue
 Glass of water and drinking straw
 Syringe bulb
 Kidney basin
 Flashlight
 Stethoscope

PROCEDURE RATIONALE
1. Introduce self and verify the client’s
identity.
2. Perform hand hygiene

3. Provide for client privacy

4. Assist the client to a high-Fowler’s position

It is often easier to swallow in this position and
if his/her health permits, and support the
gravity helps the passage of the tube.
head on a pillow

112
5. Assess the client’s nares

6. Apply clean gloves

7. Ask the client to hyperextend the head,

and, using a flashlight, observe the
intactness of the tissues of the nostrils,
including any irritations or abrasions
8. Select the nostril that has the greater
airflow
9. Prepare the tube

10. Determine how far to insert the tube

11. Use the tube to mark off the distance from

the tip of the client’s nose to the tip of the This length approximates the distance from the
earlobe and then from the tip of earlobe to nares to the stomach.
the tip of the xiphoid.
12. Mark this length with adhesive tape if the
tube does not have markings.
13. Insert the tube
A water-soluble lubricant dissolve if the tube
14. Lubricate the tip of the tube well with accidentally enters the lungs. An oil-based
water-soluble lubricant or water to ease lubricant, such as petroleum jelly, will not dissolve
insertion and could cause respiratory complications if it
enters the lungs.
15. Insert the tube, with its natural curve
downward, into the selected nostril. Ask
Hyperextension of the neck reduces the curvature
the client to hyperextend the neck, and
of the nasopharyngeal junction
gently advance the tube toward the
nasopharynx.
16. Direct the tube along the floor of the Directing the tube along the floor avoids the
nostril and toward the midline projection (turbinates) along the lateral wall
17. Slight pressure and a twisting motion are
sometimes required to pass the tube into Tears are a natural body response. Provide the
the nasopharynx, and some client’s eyes client with tissues as needed.
may water at this point
18. If the tube meets resistance, withdraw it, The tube should never be forced against resistance
relubricate it, and insert in the other nostril because of the danger of injury
19. Once the tube reaches the oropharynx
Tilting the head forward facilitates passage of the
(throat), the client will feel the tube in the
tube into the posterior pharynx and esophagus
throat and may gag. Ask the client to tilt
rather than into the larynx; swallowing moves the
the head forward and encourage the client
epiglottis over the opening to the larynx
to drink and swallow.
20. If the client gags, stop passing the tube
momentarily. Have the client rest, take a
few breaths, and take sips of water to calm
the gag reflex

21. In cooperation with the client, pass the

tube 5 to 10 cm (2 to 4 in.) with each
swallow, until the indicated length is
inserted.

22. If the client continues to gag and the tube

The tube may be coiled in the throat. If so,
does not advance with each swallow,
withdraw it until it is straight, and try again to
withdraw it slightly, and inspect the throat
insert it.
by looking through the mouth

23. Ascertain correct placement of the tube

24. A stethoscope is place over the client’s
epigastrium and inject 10 to 30 mL of air
into the tube while listening for a
whooshing sound. This method does not
guarantee tube position
25. Aspirate stomach contents, and check the Testing pH is reliable way to determine location of
pH, which should be acidic. a feeding tube.

113
 26. NGT position can be confirmed by X-ray.
This is the definitive method of verifying
feeding tube tip placement. If X-ray is not
available, at least the two other methods
should be used.
Taping this manner prevents the tube from
27. Secure the tube by taping it to the bridge
pressing against and irritating the edge of the
of the client’s nose
nostril
28. Document relevant information: the
insertion of the tube, the means by which
correct placement was determined, and
client response.

FEEDING THROUGH NASOGASTRIC TUBE

Definition: Administration of feeding/medications via an NGT or OGT for patients who are unconscious,
too weak or unable to take feeding /medications orally

Purposes:
1. To restore or maintain nutritional status
2. To administer medications.

Equipment:
 Correct type and amount of feeding solution.
 60-mL catheter-tip syringe/ syringe bulb
 Emesis basin (kidney basin)
 Clean gloves
 pH test strip or meter
 Water (60 mL unless otherwise specified) at room temperature
 Clean towel
 Infusion pump for feeding tube

PROCEDURE RATIONALE
1. Check for physician’s order. Introduce self and Verify correct type, amount and expiration date of
verify client’s identity. feeding solution
Inform client that the feeding should not cause any
2. Explain to the client the procedure
discomfort but may cause a feeling of fullness
3. Perform hand hygiene Observe appropriate infection control procedures
4. Provide privacy, if client desires it Tube feedings are embarrassing to some people
5. Assist client to a Fowler’s position (or 30
The positions enhance gravitational flow of the
degrees elevation) in bed or a sitting position. If
solution and prevent aspiration of fluid into the
sitting position is contraindicated, a slightly
lungs
elevated right side-lying position is acceptable
6. Assess correct tube placement
7. Aspirate gastrointestinal secretions. Gastric
secretions tend to be a grassy-green, off-white
or tan color; intestinal fluid is stained with bile
and has a golden yellow or brownish green
color.
8. Measure pH of aspirated fluid. Gastric aspirates
tend to be acidic and have a pH of 1 to 4 but
may be as high as 6 if the client is receiving
medications that control gastric acid.
Small intestine aspirates generally have a
pH equal to or higher than 6.
Respiratory secretions are more alkaline
with values of 7 or higher.

9. Auscultate the epigastrium while injecting 5 to

20 mL of air and listen for a gurgling sound.
NOTE: Radiographic verification is the most effective method,

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however, not feasible and costly.
This is done to evaluate absorption of the last
feeding. At some agencies, a feeding is delayed
10. Assess residual feeding contents
when the specified amount (about 150 ml) or more
of formula remains in the stomach
11. In administering the feeding, using the
Syringe Open System remove the plunger Pinching or clamping the tube prevents excess air
from the syringe and connect the syringe to a from entering the stomach and causing distention
pinched or clamped NGT.
Feeding solution should be warm to room
12. Clamp the feeding tube and add the feeding
temperature. Cold feeding may cause abdominal
solution to the syringe barrel
cramps
13. Release the clamp and permit the feeding to
flow slowly at the prescribed rate. Raise
(about 12 inches) or lower the syringe to Quickly administered feedings can cause flatus,
adjust the flow as needed. Pinch or clamp the cramps, and /or vomiting
tubing to stop the flow for a minute if the
client experiences discomfort
14. Administer ordered amount of formula and
Water flushes the lumen of the tube, preventing
instill 50 to 100 mL of water through the
future blockage by sticky formula
tubing
15. When giving medication:
a. Feed the client first before giving his/her If not contraindicated. To prevent gastric irritation.
medications
b. Allow the feeding to run into the stomach Gives the stomach time to accommodate the
by itself feeding and decrease GI distress
c. Give the exact/prescribe medication Prevent regurgitation and abdominal distention
d. Flush the tubing with water
16. Clamp the feeding tube before all the water is Clamping prevents leakage and air from entering
instilled the tube
17. Ensure client comfort and safety. Secure the
This minimizes pulling of the tube, thus preventing
tubing to the client’s gown or head part of the
discomfort and dislodgment
bed
18. Ask the client to remain sitting upright, These positions facilitate digestion and movement
Fowler’s position or in a slightly elevated right of the feeding from the stomach and prevent of
lateral position for at least 30 minutes aspiration of the feeding into the lungs
19. Clean the equipment used with the use of
Prevent built up of microorganism
dishwashing liquid and let it dry
20. Change the equipment every 24 hrs. or
according to agency policy
21. Document the feeding, including the amount
and kind of solution taken, duration of the
feeding, and assessment of the client

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 MEDICATION
ADMINISTRATION

116
 ADMINISTRATION OF THERAPEUTIC AGENTS

Definition: It is the administration of a substance for the diagnosis, cure, treatment, relief or prevention
of disease.

GENERAL INFORMATION ABOUT DRUG ADMINISTRATION

1. Doctor should order in writing the name of the drug, amount, time and frequency of giving as
well as the method of administration.
2. Consult a clinical instructor or a head nurse if a written order is not clear as to meaning, not
legible or not signed by the doctor.
3. Wash hands thoroughly before measuring and preparing medications.
4. Make certain that all equipment is clean.
5. When giving pills/tablets, place in proper container directly from the bottle. Do not touch them
with your hands.
6. Determine if medication is to be delayed or omitted for a specific length of time, as for x-ray
examination or basal metabolic test, blood chemistry, and/or in case where the drug/s can
adversely affect the patient’s vital signs or condition.
7. Never leave the medicine cabinet unlocked. Never leave your cart of medicine tray out of your
sight.
8. Do not return to stock any excess medicine or medicine refused by a patient.
9. Do not use a drug which is discolored, precipitated, is contaminated or outdated.
10. Provide drinking straws for irritating drugs and for those likely to stain the teeth e.g., iodine
preparations.
11. Do not pour a drug from one bottle to another.
12. Never give two or more drugs at one time, unless ordered.
13. Do not permit a patient to carry medicine to another patient.
14. Know the minimum and maximum doses for the medication being given.
15. Report immediately to the C.I. or nurse in-charge any error in medication.
16. Always provide a drink of fresh water to the patient immediately after giving an oral medication,
unless water is contraindicated.
17. The nurse who prepares a medicine should give it to the patient and do the necessary recording.
18. Do not recap needles instead use the fish-hook technique (infection control).
19. Enteric coated drugs should never be powdered and crushed before administration.

Rules in measuring medication

1. Measure the exact amount of drug ordered with a calibrated equipment.
2. Do not converse with anyone while preparing a medication.
3. Ensure adequate lighting.
4. Medicine glass should be dry before pouring or measuring a medication
5. Cleanse the mouth of every bottle after use and before replacing the cap.
6. Hold the medicine glass at eye level and place thumb nail of the hand holding the glass at the
level of the scale of the desired fluid volume.
7. Measure accurately liquid medication. Check if the scale is even with the fluid level at its surface
or base of meniscus.
8. Use of dropper: The size of the drops varies according to the size of the dose in the medicine
dropper, the angle at which the dropper is held and the viscosity of the liquid
Use of syringe: Draw up small volumes (less than 10 ml) with syringe without needle, unless drug
has its own specific measuring device.

Rules regarding labels

1. Give medications only from clearly labeled containers.
2. For each dose of medicine prepared, read the label three times: before removing the bottle from
the medicine cabinet, before pouring the desired amount of drug and before returning the bottle
in medicine cabinet.
3. Never give a drug from an unmarked bottle or box.
4. Pour medicine from the bottle on the side opposite the label.
5. Labels on medicine containers should be changed only by the pharmacist.
6. If a drug has two commonly used names, it should appear in the label.
7. Take note of the expiry date marked on the label.

Rules for giving medications

1. Give the medication at the time for which it is ordered.
2. Always identify the patient before giving the medication.
3. If the medication is refused or cannot be administered, notify the C.I. / head nurse, and record
accordingly on the patient’s chart.
4. Remain at the bedside until the patient has taken the medicine.
5. Administer only those medicines which you have prepared.

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 6. Never give two drugs together, unless specifically ordered to do so. Different drugs taken at the
same time may form a chemical compound that can be injurious to the patient or will render the
drug inactive or less effective.
7. When the patient goes to the Operating Room, all orders for medication are automatically
discontinued. New orders for post-operative medication will be written by the doctor.
8. When a special test is being done, medications due at the time are omitted. They are resumed
when the next dose is due. (This is true of BID, TID, QID orders, etc.). Medications given once a
day are also administered.
9. Nurse should listen carefully to the patient who questions the addition or deletion of the
medication. If a patient questions the drug or dose you prepared to administer, recheck the
order.

Rules of recording drug administered

1. Record if an ordered medication is refused and if cannot be administered for whatever reason.
2. Record each dose of medicine soon after it is administered.
3. Use standard abbreviations in recording medications.
4. Never record medication before it has been administered.
5. Record only those medicines which you have administered.
6. Record time, kind, dose and route of drug given.
7. Record effect (beneficial or untoward of effects medication).
8. Affix your initial on the appropriate space of the medication sheet for those medications you
actually have administered. If delayed or the first dose of drug is to be given, indicate the time
above your initial.
IMPROVING MEDICATION SAFETY
(WHO Patient Safety Curriculum Guide, 2011)

Some definitions
 Side-effect: side-effect is a known effect, other than that primarily intended, relating to the
pharmacological properties of a medication.
 Adverse reaction: a reaction occurs when unexpected harm results from a justified action,
when the correct process was followed for the context in which the medication was used.
 Adverse drug event: an event involving medication (an adverse drug event) may be
preventable (e.g., the result of an error) or may not be preventable (e.g. an unexpected allergic
reaction in a patient taking a medication for the first time, as described above).
 Adverse drug reaction: any response to a medication that is noxious and unintended. This
WHO definition includes injuries that are judged to be caused by the drug and excludes drug-
related injuries that are caused by error.

Prescribing
A prescription is an order to take certain medications. In many countries, the prescriber has legal
responsibility for the clinical care of the patient, as well as a role in monitoring the safety and efficacy of
the drug(s). Prescribing a medication requires the health professional to make a decision about the drug,
the drug regimen, the documentation of the drug in the health-care records, and the ordering.

Medication error
Any preventable event that may cause or lead to inappropriate medication use. A medication error may
result in:
 an adverse event, in which a patient is harmed.
 a near miss, in which a patient is nearly harmed.
 neither harm nor potential for harm or patient harm.

Manufacturing, distribution and marketing

Before drugs can be used on humans, they must be tested to make sure they are safe. The development
and manufacturing of drugs is highly regulated in most countries.

Steps in using medication

1. Prescribing: the prescribing health-care professional must choose an appropriate medication for
a given clinical situation, taking the individual patient’s factors into account. The prescriber needs
to select the most appropriate administration route, dose, time and regimen.
2. Dispensing: a pharmacist will transcribe and check the prescription written by the prescribing
health professional and will then pick the medication and document the process.
3. Administering: administering a medication may include obtaining the medication and having it
in a ready-to-use form. This may involve counting, calculating, mixing, labeling or preparing the
drug in some way. Administering always includes the need to check for allergies and to make
sure that the correct dose of the correct medicine is given to the correct patient via the correct
route at the correct time.
4. Monitoring: involves observing the patient to determine whether the medication is working,
being used correctly and not causing harm.

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Risks of medication use
1. Prescribing
a. Inadequate knowledge about drug indications, contraindications and drug interactions
can lead to prescribing errors.
b. Failure to consider physical, cognitive, emotional and social factors that might alter
prescribing, such as allergies, pregnancy, co-morbidities, health literacy and other
medications the patient may be taking is another source of potential errors.
c. It is not possible for an individual health-care professional to remember all the relevant
details necessary for safe prescribing, without referring to reference materials.
d. Errors may involve prescribing for the wrong patient, the wrong dose, the wrong drug,
the wrong route or the wrong time for drug administration.
e. Other sources of prescribing errors are inadequate communication, illegible writing of
prescriptions and mathematical errors made in calculating dosages and concentration of
medications.
f. These errors can be a result of carelessness or fatigue but can also be the result of a lack
of training and unfamiliarity with how to manipulate volumes, amounts, concentrations
and units and/or a lack of access to updated parameters. A calculation error can occur
when transposing units (e.g., from micrograms to milligrams). This type of miscalculation
may result in a 1000 times error.
2. Dispensing
a. High pharmacy workload, defined as the number of prescriptions dispensed per
pharmacist work hour, can lead to increased risk of dispensing a potentially unsafe
medication. The following steps can be taken by pharmacists to decrease the risk of a
dispensing error:
b. ensure correct entry of the prescription.
c. confirm that the prescription is correct and complete.
d. beware of look-alike, sound-alike drugs (similar drug names account for one-third of
medication errors).
e. be careful with zeros and abbreviations.
f. organize the workplace.
g. reduce distraction when possible.
h. focus on reducing stress and balancing heavy workloads.
i. take the time to store drugs properly.
j. thoroughly check all prescriptions.
k. always provide thorough patient counseling.

3. Administering
a. Classic administration errors are the wrong drug being used, or the wrong dose of a drug
being given to the wrong patient, by the wrong route, at the wrong time. Not
administering a prescribed drug is another form of administration error. Other
administration errors include inadequate communication & documentation or calculation
mistakes e.g., for IV drugs.

4. Monitoring
a. Errors in this area include inadequate monitoring for side-effects, not ceasing medication
once the prescribed course has been completed or is clearly not helping the patient, and
not completing a prescribed course of medication. There is a particular risk of a type of
communication failure when a patient changes or moves from hospital to community
setting or vice versa.

Contributory factors for medication errors

1. Patient factors: certain patients are particularly vulnerable to medication errors. These include
patients with specific conditions (e.g. pregnancy, renal dysfunction, etc.); patients taking multiple
medications, particularly if these medications have been prescribed by more than one health-care
provider; patients with a number of health problems; and patients who do not take an active
interest in being informed about their own health and medications.

2. Staff factors: include inexperienced personnel; rushing, as in emergency situations;

multitasking; being interrupted mid-task; fatigue, boredom, and lack of vigilance. A lack of
checking and double-checking habits can also lead to medication errors, as do poor teamwork,
poor communication between colleagues and a reluctance to use memory aids.

3. Workplace design factors: include the absence of a safety culture in the workplace, e.g., lack
of reporting systems, failure to learn from past near misses and adverse events, inadequate or
untrained staffing.

4. Medication design factors: some medications can be easily confused: pills are similar in
appearance (e.g., color, shape), have similar names or ambiguous labelling. Different
preparations or dosages of similar medication may have similar names or packaging or
differentiate themselves from the usual preparation only by using a pre- or suffix. Other possible

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 risks may result from very small print, so difficult to read labeling, difficult-to-read dose
information on vials or lack of measuring instruments (e.g., spoons for syrups).

5. Technical design: for example, identical connectors for IV lines and intrathecal lines allow for
drugs to be given via the wrong route.

Some ways to make medication use safer

1. Use generic names. Medications have both trade names (brand name) and generic names
(INN, active ingredient). To minimize confusion and simplify communication, it is helpful if staff
use only generic names.

2. Tailor prescribing to individual patients. Factors to consider include allergies, pregnancy,

breastfeeding, co-morbidities, other medications the patient may be taking, and the size and
weight of the patient.

3. Learn and practice collecting complete medication histories. Medication histories should
be taken by both prescribing health professionals and pharmacists.

4. Know which medications used in your area are associated with high risks of adverse
events. Some medications have a reputation for causing adverse drug events. This may be
due to a narrow therapeutic window, particular pharmacodynamics or the complexity of dosing
and monitoring (e.g., insulin, oral anticoagulants, neuromuscular-blocking agents, digoxin,
chemotherapeutic agents, IV potassium and aminoglycoside antibiotics).

5. Be very familiar with the medications you prescribe. Never prescribe a medication you do
not know much about. Become familiar with medications frequently used, including
pharmacology, indications, contraindications, side-effects, special precautions, dosages, and
recommended regimens for these medications.

6. Use memory aids. With the growth in the number of medications and the increasing complexity
of prescribing, relying on memory alone is not sufficient. Health-care professionals should
become familiar with selecting independent, evidence-based memory aids and should view
relying on memory aids as a marker of safe practice rather than a sign that their knowledge is
inadequate. Examples of memory aids include pocket-sized textbooks, pharmacopoeias, and
information technology, such as computer software (decision/dispensing support) packages and
digital assistants.

7. Remember the 5Rs. Use 5Rs when dispensing or administering medication.

The 5 Rs for medication safety:

 right drug
 right route
 right time
 right dose
 right patient
Add-ons: right documentation and the right (of staff,
patient and carer) to question medication orders.

8. Communicate clearly. Clear, unambiguous communication will help to minimize assumptions

that can lead to errors among a health-care team. When communicating about medications, state
the obvious, as often, what is obvious to the doctor or pharmacist may not be obvious to the
patient or nurse and vice versa.
Bad handwriting can lead to dispensing errors. Health professionals should write clearly and
legibly including their name and contact details.

9. Develop checking habits. Checking should be an important part of prescribing, dispensing and
administering drugs. Health professionals are responsible for every prescription they write and
every drug dispensed or administered. Check the 5 Rs and for allergies. High-risk medications
and situations require extra vigilance with checking and double-checking, for example, when very
potent emergency drugs are being used to treat a critically ill patient. Double-checking own and
colleagues’ actions contributes to good teamwork and provides additional safeguards.
Computerized prescribing does not remove the need for checking. Computerized systems solve
some problems (e.g., illegible handwriting, confusion around generic and trade names,
recognizing drug interactions), but also present a new set of challenges
Patients should be encouraged to be actively involved in their own care and medication process.
They should be educated about their medication(s) and contribute significantly to improving the
safety of medication use.

10. Report and learn from medications. Whenever an adverse drug event or near miss occurs,
there is an opportunity for learning and improving care. The reporting of errors is facilitated when
trust and respect have been established between health-care professionals. For example,
pharmacists are more likely to report and explain near-miss errors when prescribers are open to
listening to explanations.

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 ROUTES OF ADMINISTRATION OF THERAPEUTIC AGENTS

How therapeutic agent is administered Terms used to describe route

(Route)
1. Having patient swallow Oral administration
2. Placing therapeutic agent under the tongue Sublingual
3. Having patient inhale the therapeutic agent Inhalation
4. Inserting therapeutic agent into
a. Vagina Vaginal administration
b. Rectum Rectal administration
5. Placing the therapeutic agent on the skin Topical
6. Dropping therapeutic agent into the mucous
Instillation
membrane
7. Flushing mucous membrane with large
Irrigation
amounts of the therapeutic agents
8. Injecting therapeutic agent into the: Parenteral Administration
a. Corium Intracutaneous or intradermal injection
b. Subcutaneous tissue Hypodermic/subcutaneous injection
c. Muscle tissue Intramuscular injection
d. Vein Intravenous injection
e. Subarachnoid space of spinal canal Intrathecal or intraspinal
f. Peritoneal cavity Intraperitoneal
g. Heart Intracardiac
h. Cavity of a joint Intra-articular

Common sites of Injection

1. Intradermal Injection
Sites: 1.a. Inner lower arm
1.b. Upper Chest
1.c. Back beneath the scapulae

2. Subcutaneous Injection
Sites: 2.a. An outer aspect of the upper arm
2.b. Anterior aspect of the thigh
2.c. Abdomen
2.d. Scapular areas of the upper backs
2.e. Upper ventrogluteal
2.f. Dorsogluteal area

3. Intramuscular Injection
Sites: 3.a. Ventrogluteal site
3.b. Vastus Lateralis
3.c. Dorsogluteal
3.d. Deltoid
3.c. Rectus Femoris

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 ADMINISTERING ORAL MEDICATIONS

Definition: Administration of therapeutic agents given through the mouth

Purpose: To provide a medication that has systematic effects or local effects on gastrointestinal tract
or both

Contraindications
1. Client is vomiting
2. Client with gastric or intestinal secretion
3. Unconscious
4. Unable to swallow

Equipment
 Dispensing System
 Disposable medication cups: small paper or plastic cups for tablets and capsules, waxed or plastic
calibrated medication cups for liquids
 MAR or computer print-out
 Pill crusher/cutter
 Straws to administer medications that may discolor the teeth or to facilitate the ingestion of liquid
medication for certain clients.
 Drinking glasses and water or juice
 Applesauce or pudding to use for crushed medications for clients who may choke on liquids

Assessment
1. Allergies to medication(s)
2. Client's ability to swallow medication
3. Presence of vomiting or diarrhea that would interfere with the ability to absorb the medication
4. Specific drug action, side effects, interactions, and adverse reaction
5. Client's knowledge of and learning needs about the medication
6. Perform appropriate assessment (e.g., vital signs, laboratory results) specific to the medication
7. Determine if the assessment data influence administration of the medication

PROCEDURE RATIONALE
1. Perform hand hygiene and observe other
appropriate infection control procedure
2. Unlock the dispensing system
3. Obtain appropriate medication
a. Read the MAR and take the appropriate
medication from the shelf, drawer, or
refrigerator. The medication may be
dispensed in a bottle, box, or unit-dose
packaged
b. Compare the label of the medication
This a safety checks to ensure that the right
container or unit-dose package against the
medication is given
order on the MAR or computer print-out
c. Check the expiration date of the
medication. Return expired medications to Outdated medications are not safe to medication
the pharmacy
d. Use only medications that have clear,
legible labels to ensure accuracy
4. Prepare the medication
a. Calculate the medication dosage accurately
b. Prepare the correct amount of medication
for the required dose, without Aseptic technique maintains drug cleanliness
contaminating the medication
c. While preparing the medication, recheck
This second safety check reduces the chance of
each prepared drug and container with
error
the MAR again
TABLETS OR CAPSULES
The wrapper keeps the medication clean. Not
a. Place packaged unit-dose capsules or removing the medication facilitates identification of
tablets directly into the medicine cup. Do the medication in the event the client refuses the
not remove the medication from the drug or assessment data indicate to hold the
package until at the bedside medication. Unopened unit-dose packages can
usually be returned to the medication cart

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 b. If using a stock container, pour the
required number into the bottle cap, then
transfer the medication to the disposable
cup without touching the tablets
c.
Keep narcotics and medications that This reminds the nurse to complete the needed
require specific assessments, such as pulse assessment in order to decide whether to give the
measurements, respiratory rate or depth, medication or to withhold the medication if
or blood pressure, separate from the others indicated.
d. Break only scored tablets if necessary to
obtain the correct dosage. Use a cutting or
splitting device if needed. Check the
agency policy as to whether unused
portions of a medication can be discarded
and, if so, why and how they are to be
discarded
e. If the client has difficulty swallowing, crush
the tablets to a fine powder with a pill
crusher or between two medication cups.
Mix the powder with a small amount of soft
food.
Some medication should not be crushed.
f. If the tablet is crushed, the client gets a
surge of action in the first two hours, and
then may start having severe pain again in
4 to 6 hours, as the effects wear off too
soon. The crushing of these tablets causes
an uneven effect, and the long action of
the medication is lost
LIQUID MEDICATION
a. Thoroughly mix the medication before
pouring. Discard medicine that has
changed color or turned cloudy
b. Remove the cap and place it upside down
on the countertop to avoid contaminating
the inside of the cap
c. Check the label of the bottle This reduces the chance of error
d. Hold the bottle so the label is next to your
This prevents the label from becoming soiled and
palm and pour the medication away from
illegible as a result of spilled liquids.
the label
e. Place the medication cup on a flat surface
at eye level and fill it to the desired level,
This method ensures accuracy of measurements.
using the bottom of the meniscus to align
with the container scale
f. Before capping the bottle, wipe the lip with
This prevents the cap from sticking.
a paper towel
g. When giving small amounts of liquids, Any oral solution removed from the original
prepare the medication in a sterile syringe container and placed into a syringe should be
without the needle or in a special designed labeled to avoid medications being given by the
oral syringe. Label the syringe with the wrong route. This practice facilitates client safety
name of the medication and the route (PO) and avoids tragic errors.
h. Keep unit-dose liquids in their package and
open them at the bedside
ORAL NARCOTICS
a. If an agency uses a manual recording
system for controlled substances check the
narcotic record for the previous drug count
and compare it with the supply available.
Some medications, including narcotics, are
kept in plastic containers that are sectioned
and numbered
b. Remove the next available tablet and drop
it in the medicine cup
c. After removing a tablet, record the
necessary information on the appropriate
narcotic control record and sign it
Note: Computer-controlled dispensing systems allow access
only to the selected drug and automatically record its use

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ALL MEDICATIONS
1. Place the prepared medication and MAR
together on the medication cart
2. Recheck the label on the container before
returning the bottle, box, or envelope to its This third check further reduces the risk of error.
storage place
3. Avoid leaving prepared medications This precaution prevents potential mishandling
unattended errors.
4. Lock the medication cart before entering This is safely measure because medication carts
the client’s room are not to be left open when unattended
5. Check the room number against the MAR if
the agency does not allow the MAR to be
removed from the medication cart
5. Provide client privacy
6. Prepare the client
This ensures that the right client receives the
a. Check the client's identification band
medication.
b. Assists the client to a sitting position or, if These positions facilitate swallowing and prevent
not possible to a side lying position aspiration.
c. If not previously assessed, take the
required assessment measures, such as
pulse rate before administering digitalis Narcotics depress the respiratory center. Digitalis
preparations. Take blood pressure before increases heart muscle contraction. Anti-
giving antihypertensive drugs. Take the hypertensive drugs lower the BP
respiratory rate prior to administering
narcotics
7. Explain the purpose of the medication and how
it help, using language that the client can Information can facilitate acceptance of and
understand. Include relevant information about compliance with the therapy
effects
8. Administer the medication at the correct time
a. Take the medication to the client within the
period of 30 minutes before or after
scheduled time
b. Give the client sufficient water or preferred
juice to swallow the medication. Before Fluids ease swallowing and facilitate absorption
using juice, check for any food and from the gastrointestinal tract
medication incompatibilities
c. If the client is unable to hold the pill cup,
Putting the cup to the client's mouth maintains the
use the pill cup to introduce the
cleanliness of the nurse's hands. Giving one
medications into the client's mouth, and
medication at a time eases swallowing
give only one tablet or capsule at a time
d. If an older child or adult has difficulty
swallowing ask the client to place the Stimulation of the back of the tongue produces the
medication at the back of the tongue swallowing reflexes
before taking the water
e. If the medication has an objectionable
taste, ask the client to suck few ice chips The cold of the ice chips will desensitize the taste
beforehand, or give the medication with buds, and juices or bread can mask the taste of the
juice, applesauce, or bread if there are no medication.
contraindications
f. If the client says that the medication you
are about to give is Most clients are familiar with appearance of
client has been receiving do not give the medications taken previously. Unfamiliar
medication without first checking the medications may signal a possible error
original order
The nurse must see the client swallow the
g. Stay with the client until all medications
education before the drug administration an be
have been swallowed
recorded.
9. Document each medication given. Record the
medication given dosage, time, any complaints
or assessments of the client, and your
signature
10. Dispose of all supplies appropriately
a. Replenish stock and return the cart to the
appropriate place
b. Discard used disposable supplies

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11. Evaluate the effects of medication
a. Return to the client when the medication is
expected to take effect (usually 30
minutes) to evaluate the effects of the
medication on the client.

OPTHALMIC MEDICATIONS

Definition: Medication administered to the eye using irrigations or instillations.

• Eye irrigation – administered to wash out the conjunctival sac to remove secretions or
foreign bodies or to remove chemicals that may injure the eye
• Maybe in the form of liquids or ointments
• Must be labeled: for ophthalmic use

Equipment:
• Clean gloves
• Sterile absorbent sponges soaked in sterile NSS
• Medication
• Sterile eye dressing pad
For irrigation
• irrigating solution,
• dry sterile absorbent sponges,
• moisture-resistant towel
• basin

PROCEDURE RATIONALE

1. Check the MAR (drug name, dosage, strength,

site: OU, OS, OD; report discrepancies, unclear
info)
2. Know the reason why the client is receiving the
drug, drug classification, C/I, S/E, dose,
nursing considerations
3. Compare the label on the medication
tube/bottle w/ the med record and check
expiration date

4. Calculate the dosage

Optic meds usually are not painful, often soothing

5. Explain the procedure to the client (what, why,
to the eye but some may sting initially
how the client can cooperate)
Minimize contamination
6. Wash hands

7. Provide privacy

8. Prepare the client

Ensures that the right client receives the right
a. check name
medication
b. assist to a comfortable position

9. Clean the eyelids and eyelashes

a. Put on clean gloves

b. Use sterile CB moistened w/ sterile Prevents contamination of the other eye and the
irrigating solution or NSS and wipe from lacrimal duct
the inner canthus to the outer canthus
10. Administer the eye medication.
Check the preparation – name, strength, and To prevent medication error
dose
11. Draw the correct number of drops into the The first bead from an ointment is considered
shaft of the dropper. If ointment is used, contaminate
discard the first bead
Less likely to blink if looking up, also the cornea is
12. Instruct client to look up to the ceiling.
partially protected by the upper eyelid

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 To wipe excess ointment from the eyelashes and to
13. Give the client a dry, sterile absorbent sponge
press on the nasolacrimal duct
14. Expose the lower conjunctival sac by placing
Minimizes the possibility of touching the cornea,
the thumb of fingers of your non-dominant
avoids putting pressure on the eyeball, & prevents
hand on the cheekbone just below the eye and
the person from blinking or squinting
gently draw down the skin on the cheek. If
edematous, handle carefully to avoid damage
15. Approach the eye from the side & instill the
Less likely to blink inside approach; won’t harm the
correct amount or drops into the outer third of
cornea; dropper must not touch cornea/sac
the lower conjunctival sac. Hold dropper 1-2
cm above the sac
Closing spreads the medicine over the eyeball.
16. Instruct to close eyelids but not to squeeze
Squeezing can injure the eye & push out the
them shut
medication
Variation: IRRIGATION
a. Place absorbent pads under head, neck,
shoulders. Place emesis basin next to the
eye to catch drainage

Note: some eye meds can cause systemic reaction like

confusion, ↓BP, ↓HR

17. Hold lower lid down, then hold upper lid up

a. Exert pressure on bony prominences of the Prevents blinking, pressing the eyeball and
cheekbone and beneath the eyebrow when discomfort
holding the eyebrows
b. Fill & hold the eye irrigator about 1in or At this height, the pressure of the solution will not
2.5cm Irrigate the eye, directing the damage eye tissues, and the irrigator won’t touch
solution unto the lower conjunctival sac the eye
and from inner canthus- outer canthus
c. Irrigate until the solution leaving the eye is
clear, or until all the solution has been used
d. Instruct to close and move the eye
periodically
18. Clean and dry the eyelids PRN. Wipe the
Helps to move secretions from the upper-lower
eyelids gently from the inner –outer canthus to
conjunctival sac.
collect excess medication
19. Apply an eye pad PRN
20. Asses the client’s response immediately after
the procedure
21. Document all relevant assessment &
interventions – Drug name, the strength, dose,
time, and reactions

OTIC MEDICATIONS

Definition: It is the Instillation or irrigation of the external auditory canal

Purposes
a. Generally, for cleaning purposes.
b. To soften earwax so that it can be readily removed at a later time

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 c. To provide local therapy to inflammation, destroy infective organism in the external ear canal or
both
d. To relieve pain

Equipment
• Clean gloves
• Cotton-tipped applicator, cotton fluff
• Correct medicine bottle w/ a dropper
• For irrigation: add
• Irrigating solution, dry sterile absorbent sponges, moisture-resistant towel, basin, asepto syringe

PROCEDURE RATIONALE
1. Check the medication administration record
2. Know the reason why the client received the
meds
3. Compare the label on the medication container
with the medication record and check for
expiration date
4. If needed, calculate the drug
5. Explain the procedure to gain cooperation.
explain that it is not usually painful
6. Wash hands
7. Provide patients privacy
8. Prepare the client by:
a. assisting client to a comfortable position
b. For eardrops, lying with the ear being
treated uppermost
9. Clean the pinna of the ear and the meatus of
the ear canal
a. don gloves if suspected infection
Removes any discharge present before the
b. use cotton tipped applicators and solution
instillation so that won’t be washed into the ear
to wipe the pinna and auditory meatus
canal
10. Administer ear medication
a. Warm the medication container in your
Promotes client’s comfort
hand, or place in warm water for a short
time.
b. partially fill the ear dropper with medication
c. Straighten the auditory canal. Pull the It is straightened so that the solution can flow the
pinna upward and backward for clients entire length of the canal
over 3 years old
d. Instill the correct number of drops along
the side of the ear canal
e. Press gently but firmly a few times on the
tragus of the ear
f. Ask the client to remain in the side-lying
position for about 5mins.this prevents the
It assists the flow of medication into the ear canal
drops from escaping and allows the meds
to reach all sides of the canal cavity
g. Insert a small piece cotton fluff loosely at Cotton helps retain the meds when the client is up.
the meatus of the auditory canal for 15-20 Cotton will interfere with action of the drug and the
minutes. Do not press the canal outward movement of the normal secretions

EAR IRRIGATION

PROCEDURE RATIONALE

1. Explain to the client that he may feel fullness,

warmth, and occasionally, discomfort when the
fluid comes in contact with the tympanic
membrane

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2. Assist client in a sitting position with the head The solution can then flow from the ear canal to a
tilted toward the affected ear basin
3. Place the moisture resistant towel around the
client’s shoulder under the ear to be irrigated,
and place the basin under the ear to be
irrigated
4. Fill the syringe with solution or hang up the
Solution is run through to remove air from the
irrigation container, and run through the tubing
tubing and nozzle
and the nozzle

5. Straighten the ear canal

The solution will flow around the entire canal and

6. Insert the tip of the syringe into the auditory
out at the bottom. Solution is instilled gently
meatus, and direct the solution gently upward
because strong pressure from the fluid can cause
against the top of the canal
discomfort and damage the tympanic membrane
7. Continue instilling the fluid until all the solution
is used or until the canal is cleaned, depending
on the purpose of the irrigation. Take care not
to block the outward flow of the solution with
the syringe
8. Assist the client to a side lying position on the Lying in the affected side down helps drain the
affected side excess fluid by gravity
9. Place a cotton fluff in the auditory meatus to
absorb the excess fluid
10. Assess the client’s response and the character
and amount of discharge appearance of the
canal, discomfort, and so on, immediately after
the instillation and again when the medication
is expected to act. Inspect the cotton ball for
any drainage
11. Document all nursing assessments and
interventions relative to the procedure. Include
the name of the drug or irrigation solution, the
strength, the number of drops (if liquid meds),
the time, and response of the client

ADMINISTRATION OF NOSE DROPS AND SPRAYS

PROCEDURE

1. Have client blow nose

2. Have client tilt head back for drops to reach frontal sinus and tilt head to affected side to reach
ethmoid sinus
3. Administer prescribed number of drops or sprays. Some sprays have instructions to close one
nostril, tilt head to closed side, and hold breath, or breathe through nose for 1 minute

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 4. Have client keep head tilted backward for 5 minutes after instillation of drops

ADMINISTRATION OF NOSE DROPS AND SPRAYS

PROCEDURE

1. Handheld nebulizers deliver a very fine-sized particle spray of medication

2. Hand-held metered-dose devices are a convenient method of administration for these
medications
3. Spacers are devices used to enhance the delivery of medications from the metered-dose inhaler
(MDI)

NASAL MEDICATIONS

Purposes
1. Nose drops and sprays usually are instilled for their astringent effect (to shrink swollen mucus
membranes)
2. To loosen secretions and facilitate drainage, or to treat infections of the nasal cavity or sinuses.

PROCEDURE
1. Supine position with the head tilted back, the client holds the tip of the container just inside the
nares and inhales the spray enters the nasal passages
2. Children: head in an upright position to prevent excess spray from being swallowed

PREPARING MEDICATIONS FROM AMPULES

Equipment
• MAR
• Ampule of sterile medication
• File and small gauze
• Antiseptic swabs
• Needle and syringe

PROCEDURE RATIONALE
1. Check the MAR

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 a. Check the label on the ampule carefully
against the MAR to make sure that the
correct medication if being prepared.
b. Follow the three checks for administering
medication. Read the label on the
medication: (1) when it is taken from the
medication cart, (2) before withdrawing
the medication, and (3) after the
medication.
2. Organize the equipment
3. Perform hand hygiene and observe other
appropriate infection prevention procedures
4. Prepare the medication ampule for drug
withdrawal
a. Flick the upper stem of the ampule This will bring all medication down to the main
several times with a fingernail. portion of the ampule

b. Use an ampule opener or place a piece of

sterile gauze or alcohol wipe between
The sterile gauze protects the fingers from the
your thumb and the ampule neck and
broken glass, and any glass fragments will spray
break off the top by bending it toward
away from the nurse
you to ensure the ampule is broken away
from yourself and away from others.

c. Dispose of the top of the ampule in the

sharp’s container.
5. Withdraw the medication
a. Place the ampule on a flat surface
b. Remove the cap of the syringe and insert
the needle into the center of the ampule.
This will keep the needle sterile
Do not touch the rim of the ampule with
the needle tip or shaft.
c. Withdraw the amount of drug required
for the dosage.

PREPARING MEDICATIONS FROM VIALS

Equipment
• MAR
• Vial of sterile medication
• Antiseptic swabs
• Needle and syringe
• Filter needle / withdrawing needle
• Sterile water / normal saline solution (if the drug is in powdered form)

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 PROCEDURE RATIONALE
1. Follow the same preparation as described in
preparing the medication from ampule
(Numbers 1 & 2)
2. Perform hand hygiene and observe other
appropriate infection prevention procedures
3. Prepare medication vial for drug withdrawal
Some vials contain aqueous suspensions, which
a. Mix the solution by rotating the vial
settle when they stand. In some instances,
between the palms of the hands, not by
shaking is contraindicated because it may cause
shaking
the mixture to foam
b. Remove the protection cap, or clean the
The antiseptic cleans the cap and reduces the
rubber cap in a circular motion with an
number of microorganisms
antiseptic swab or CB
4. Withdraw the medication
a. Replace injecting needle with an
aspirating needle
b. Ensure that the needle is firmly attached
to the syringe
c. Remove the cap from the needle, then
draw up into the syringe the amount of
air equal to the volume of the medication
withdrawn
d. Carefully insert the needle into the
upright vial through the center of the
rubber cap, maintaining the sterility of
the needle
The air will allow the medication to be drawn out
e. Inject the air into the vial, keeping the easily because negative pressure will not be
bevel of the needle above the surface of created inside the vial. The bevel is kept above
the medication the medication to avoid creating bubbles in the
medication.
f. Hold the syringe and vial at eye level to
determine that the correct dosage of
drug is drawn into the syringe. Eject air
remaining at the top of the syringe into
the vial.
g. When the correct volume of medication
is obtained, withdraw the needle from
the vial, and replace the cap over the
needle using the scoop method, thus
maintaining its sterility
h. Replace aspirating needle with an
injecting needle
i. If necessary, tap the syringe barrel to The tapping motion will cause the air bubbles to
dislodge any air bubbles present in the rise to the top of the syringe where they can be
syringe. ejected out of the syringe.

MIXING MEDICATIONS IN ONE SYRINGE

Equipment
• MAR
• 2 vial/ampule
• Antiseptic swabs
• Sterile syringe and needle
• Additional sterile needle
• File / bandage scissors
• Medication tray

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 PROCEDURE RATIONALE
1. Check the MAR
a. Check the label on the ampule carefully
against the MAR to make sure that the
correct medication if being prepared.
b. Follow the three checks for administering
medication. Read the label on the
medication: (1) when it is taken from the
medication cart, (2) before withdrawing
the medication, and (3) after the
medication.
c. Before preparing and combining the
medications, ensure that the total volume
of the injection is appropriate for the
injection site.
2. Organize the equipment
3. Perform hand hygiene and observe other
appropriate infection prevention procedures
4. Prepare the medication ampule or vial for
drug withdrawal
a. Inspect the medication for clarity. Note,
Preparations that have changed in appearance
however, that some medications are
should be discarded.
always cloudy
Mixing ensures an adequate concentration and
b. If using insulin, thoroughly mix the solution thus an accurate dose. Shaking insulin vials can
in each vial prior to administration make the insulin frothy, making precise
measurement difficult.
c. Clean the tops of the vials with antiseptic
swabs
5. Withdraw the medication

MIXING MEDICATIONS FROM TWO VIALS

a.Clean the tips of both vials with an alcohol
prep pad (note: some experts omit this
step for single-dose vials).
b.Draw up the same amount of into the
syringe as the total medication doses for
both vials (e.g., if the order is for 0.5ml for
vial A and 1ml for vial B, then draw up 1.5
ml of air)
c. Keeping the tip of the needle (or vial
access device) above the medication, inject
an amount of air equal to the volume of
drug to be withdrawn from the first vial
(e.g., 0.2 ml for vial A in step 2); then
inject the rest of the air into the second
vial
Note all pharmaceutical companies guarantee the
sterility of the rubber top on vials, even when they
are first opened. However be aware that once your
fingers touch the alcohol pad, it is no longer
sterile, either; so you are not sterilizing, but rather
are cleaning the vials tops, removing any tiny
particles that might be on them.
Makes withdrawing the medication easier by
creating positive pressure. For small unit-dose
vials, it may be possible to withdraw the
medication without instilling air, but you will need
to maintain a slight backward the pressure on the
plunger until the needle is completely withdrawn.
If you release the plunger, the negative pressure in
the vial will pull the medication back in. therefore,
it is always safer to install air
This is an extra precaution to prevent
contamination of the multi dose vial with
medication from the single-dose vial. However, the
needle tip should stay above the medication at all
times in step 3 anyway

Note: If the other vial is a multi-dose, inject

air into the single-dose vial first, and
change the needle before injecting air into
the multi dose vial. You must first withdraw
medication from the multiple-dose vial
before withdrawing from the single dose.

Note: if you are mixing two types of insulin

put air into regular insulin last.

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 d.Without removing the needle (or access
device) from the second vial (B), invert the
vial and withdraw the ordered amount of
medication. Expel any air bubbles and
measure the dose. Remove the needle
from the vial, and then pull back on the
plunger enough to pull all medication out
of the needle (or access device) into the
syringe. Read the dose at eye level. Tip the
syringe horizontally if you need to eject
any medication
e.Insert the needle into the first vial, invert,
and withdraw the exact ordered amount of
medication. Be very careful not to
withdraw excess medication; keep your
index finger or thumb on the flange of the
syringe to prevent it being forced back by
pressure. If this occurs, you must discard
medication in the syringe and start cover
f. Remove the needle from the vial, and then
recap the needle, using a needle capping
device or the one-handed scoop method
g.Put a new sterile needle on the syringe for
the injection. Hold the needle vertically to
expel all air and recheck the dosage (the
total for both medications). If you have
used a filter needle or vial access device
MIXING MEDICATIONS FROM ONE VIAL AND ONE AMPULE
This allows you to withdraw all the medication.
Keeping the needle in the medication and slowly
withdrawing the medication will help prevent
withdrawing excess air into the syringe and
prevent bubbles
Because the medications are mixed withdrawing
extra from the second vial makes the entire
mixture incorrect. If you eject excess medication
from the syringe, you know how much either
medication you have injected; so even if you had
the correct amount of fluid you would not know
how much of that is medication A and how much
of its medication
There is no need to change the needle before step
5 because even if one vial is a multi-dose vial, you
would have withdrawn the medication from the
first (in step 4). It will not matter if you track
medication into the single-dose vial.
Although recapping a sterile needle does not
present a threat of blood borne pathogen
exposure, using a mechanical recapping device or
the one-handed method helps develop safe habits.
As a rule, we do not recommend using the one-
handed scoop for sterile needles; however, this
needle will be discarded anyway, so if it is
accidentally contaminated with one-handed scoop,
it will not be a major error
By the time you are finished withdrawing both
medications, you will have put the needle through
a rubber vial top at least three times. This dulls the
needle. A sharp needle causes fewer traumas to
the patent on injection. A new needle also
prevents tracking of the medication through the
skin and subcutaneous tissues
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 a. Begin with the vial. Cleanse the stopper of
a multiple-dose vial. Draw the same
volume of air as the dose of medication
ordered for the vial. Inject air into the vial
and withdraw the medication.
b. Remove the injection needle, and place it
on opened, sterile alcohol pad
c. Attach the filter needle or straw to the
syringe. Flick or tap the top of the ampule
(or snap your wrist) to remove medication
from the neck to the ampule
d. Open the ampule by wrapping the neck
with a gauze pad or an unopened alcohol
wipe or use an ampule snapper. Snap
open away from you.
e. Withdraw the exact ordered amount of
medication from the ampule into the
syringe. Be very careful in drawing up the
second medication; if the total amount of
the two medications is incorrect, you must
discard the syringe contents and star over
f. Draw about 0.2ml of air into the syringe to
clear the filter needle. Remove the filter
needle or straw and discard it in sharps
container. Replace the filter needle with an
administration needle
g. Confirm the dose is correct
h. Recap the needle using a needle capping
device or the one-handed technique.
USING A PRE-FILLED CARTRIDGE AND SINGLE-DOSE VIAL FOR INTRAVENOUS
ADMINISTRATION
a. Cleanse the vial thoroughly with an alcohol
prep pad
b. Assemble the prefilled cartridge and holder
c. Remove the needle cap from the prefilled
cartridge, expel the air, and measure the
correct dose of medication
d. Holding the cartridge with the needle up
withdraw an amount of air equal to the
volume of medication you need from the
vial
Because you do not need to add air to ampules
before drawing up the medication, you should
draw from the vial first. Additionally, if it is a multi-
dose vial, you would contaminate it with the
medicine if you withdrew from the ampule first
(unless you change the needle, and that is an
unnecessary expense).
Injecting air into the vial makes withdrawing the
medication easier. For small unit-dose vials, it may
be possible to withdraw the medication without
instilling air, but you will need to maintain a slight
backward pressure on the plunger until the needle
is completely withdrawn. If you release the
plunger, the negative pressure in the vial will pull
the medication back in. therefore, it is safer always
to instill air.
Keeps the needle sterile; you will reuse it.
The use of a 5 µm filter needle minimizes the
possibility of withdrawing small glass fragments
Prevents you from accidentally cutting your fingers
or spraying glass fragments toward your face. Do
not used an opened alcohol wipe to break the
ampule, because it is not thick enough to prevent
injury.
1. Prevent needle stick injury.
2. You cannot draw the dose accurately with a
filter needle. You should not eject medication
through the filter needle because of risk of
breaking the filter
Ensures that the total volume in the syringe equals
the ordered amount of both medications plus 0.2
ml of air.
Although recapping a sterile needle does not
present a threat of blood borne pathogen
exposure, using a mechanical recapping device or
the one-handed method helps develop safe habits.
Nevertheless, some scoop techniques pose a
significant risk of contaminating the needle, so you
must watch that you maintain sterile technique
You must confirm that the dose of the first
medication is correct before you mix it with the
second medication
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 e. While continuing to hold the syringe with
needle straight up (vertically), insert the
needle into the inverted vial, and inject the
Makes medication easier to withdraw.
air into the vial. Maintain pressure on the
plunger so that air and/or medication does
not flow back into the syringe.

f. While maintaining pressure on the plunger,

allow the pressure in the vial to push the
medication into the syringe. Withdraw the
ordered amount the vial medication, being
careful not to withdraw any excess

g. The pressure will generally push a little Withdrawing any excess will result in an altered
than you need, so withdraw the correct dose, so you would need to discard the syringe
amount and start over.

h. Recap the needle (use a one-handed

The cannula prevents needle stick injury. Unless
method), and if possible, remove the
there is a needle safety device for the prefilled
needle from the prefilled syringe and
syringe, it is not recommended fro IM injections.
replace with an injection cannula for
intravenous administration.

ADMINISTERING AN INTRADERMAL INJECTION FOR SKIN TESTS

Definition: Is the administration of a drug into the dermal layer of the skin just beneath the epidermis.

Purpose: To provide a medication that the client requires for allergy testing and TB screening.

Equipment:
 Vial or ampule of the correct medication
 Sterile 1-ml syringe calibrated into hundredths of a milliliter
 Alcohol swabs
 2-in. x 2-in. sterile gauze (optional)
 Clean gloves (according to agency protocol)
 Bandage (optional)
 Epinephrine on hand in case of allergic anaphylactic reaction

PROCEDURE RATIONALE
To make sure that the correct medication is being
1. Check MAR
prepared
a. Check the label on the medication
carefully against the MAR
b. Follow the 3 checks for administering
medications
2. Organize equipment
3. Perform hand hygiene and observe other
appropriate infection control procedures
4. Prepare the medication from the vial or ampule
for drug withdrawal
a. Assemble all needed materials and pieces
of equipment
b. Read ticket and removes medicine from
the box reading the label for the first
time.
c. Changes injecting needle into an
aspirating needle
d. Disinfect rubber stopper of sterile water
e. Aspirates .9cc of sterile water
f. Withdraws .9cc of sterile water
g. Reads ticket and drug label for the second
time

135
 h. Disinfects rubber stopper of drug
i. Changes aspirating needle into an
injecting needle
j. Place the prepared medication together
with the ticket on the tray
k. reads drug label for the third time and
returns to box.
l. Disposes trash and sharps properly
5. Prepare the client
a. Prior to performing the procedure,
This ensures that the right client receives the
introduce self and verify the client's
medication.
identity using agency protocol
b. Explain the client that the medication will
produce a small wheal, sometimes called a
bleb. A wheal is a small, raised area, like a
blister
c. The client will feel a slight prick as the
needle enters the skin. Some medications
are absorbed slowly through the
capillaries into the general circulation, and
the bleb gradually disappears. Other drugs
remain in the area and interact with the
body tissues to produce redness and in
duration, which will need to be interpreted
at a particular time. This reaction will also
disappear.
6. Provide privacy
7. Select and clean the site
a. Select a site
b. Avoid using sites that are tender, inflamed,
or swollen and those that have lesions

c. Put on gloves as indicated by agency policy

d. Cleanse the skin at the site using a firm

circular motion starting at the center and
widening the circle outward allow the area
to dry thoroughly
8. Prepare the syringe for the skin test
a. Remove the needle cap while waiting for
the antiseptic to dry
b. Expel any air bubbles from syringe. Small
bubbles that adhere to the plunger are of A small amount of air will not harm the tissues
no consequences.
c. Grasp the syringe in your dominant hand The possibility of the medication entering the
close to the hub holding it between thumb subcutaneous tissue increases when using an
and forefinger. Hold the needle almost angle greater than 15 degrees. The bevel up
parallel to the skin surface, with the bevel position provides more comfort for the nurse and
of the needle up is faster to administer.
9. Inject the fluid
a. With the non-dominant hand, pull skin at Taut skin allows for easier entry of the needle
the site until it is taut and less discomfort for the client.
b. Insert the tip of the needle far enough to
place the bevel through epidermis into the
dermis. The outline of the bevel should be
visible under the skin surface
c. Stabilize the syringe and needle. Inject the
This verifies that the medication entered the
medication carefully and slowly so that it
dermis.
produces a small wheal on the skin
d. Withdraw the needle quickly at the same
time angle at which it was inserted.
Activate the needle safety device. Apply a
bandage if indicated
Massage can disperse the medication into the
e. Do not massage the area
tissue or out through the needle insertion site.
f. Dispose of the syringe and needle into the
sharp’s container

136
 g. Remove gloves
h. Circle the injection site with ink to observe
for redness or in duration (hardening), per
agency policy
10. Document all relevant information. Record the
testing material given, the time, dosage, route,
site and nursing assessments.

ADMINISTERING A SUBCUTANEOUS INJECTION

Definition: Drugs administered just beneath the skin or in the adipose tissues

Purposes
1. To provide a medication the client requires
2. To allow slower absorption of a medication compared with either the intramuscular or
intravenous route.

Equipment:
 Client's MAR or computer printout
 Vial or ampule of the correct sterile medication
 Syringe and needle
 Antiseptic swabs
 Dry sterile gauze for opening an ampule (optional)
 Clean gloves

PROCEDURE RATIONALE

1. Assess allergies to medication

2. Specific drug action, side effect and adverse

reactions
3. Check client's knowledge and learning needs
about the medication

4. Check MAR
To make sure that the correct medication is being
a. Check the label on the medication
carefully against the MAR prepared

b. Follow the 3 checks for administering

medications

5. Organize equipment

6. Perform hand hygiene and observe other

appropriate infection control procedures
7. Prepare the medication from the ampule or vial
for drug withdrawal

8. Provide client privacy

9. Prepare the client

a. Prior for performing the procedure, This ensures that the right client receives the
introduce self and verify the client's medication
identity using agency protocol
b. Assist the client to a position in which A relaxed position of the site minimizes discomfort
the arm, leg or abdomen can be
relaxed, depending on the site to be
used
This prevents injury due to sudden movement after
c. Obtain assistance in holding an
uncooperative client needle insertion

10. Explain the purpose of the medication and Information can facilitate acceptance of and
how it helps using language that the client can compliance with the therapy
understand. Include relevant information about
effects of the medication

137
11. Select and clean site
These conditions could hinder the absorption of
a. Select a site free of tenderness,
the medication and may also increase the
hardness, swelling, itching, burning, or
localized inflammation. Select a site that likelihood of injury and discomfort at the injection
has not been used frequently. site

b. Put on clean gloves

c. As agency protocol indicates, clean the The mechanical action of swabbing removes skin
site with an antiseptic swab. Start at the secretions, which contain microorganism
center of the site and clean in a
widening circle about 5cm (2 in.). Allow
the area to dry thoroughly
d. Place and hold swab between the third Using the technique keeps the swab readily
and fourth fingers of the non- accessible when the needle is withdrawn
dominant hand, or position the swab on
the client's skin above the intended site
12. Prepare the syringe for injection
a. Remove the needle cap while waiting The needle will become contaminated if it touches
for the antiseptic to dry. Pull the cap anything but the inside of the cap, which is sterile
straight off to a void contaminating the
needle by the outside edge of the cap
b. Dispose of the needle cap

13. Inject the medication

a. Grasp the syringe in your dominant
hand by holding it between your
thumb and fingers. With palm facing to
the side or upward for 45-degree angle
insertion or with the palm downward for
90-degree angle insertion prepare to
inject
b. Using the non-dominant hand, pinch or
spread the skin at the site, and insert
the needle using the dominant hand
and a firm steady push
c. When the needle is inserted, move your
dominant hand to the end of the
plunger. Some nurses find it easier to
move the non-dominant hand to the
end of the plunger
Holding the syringe steady and injecting the
d. Inject the medication by holding the
medication at an even pressure minimizes
syringe steady and depressing the
plunger with a slow, even pressure discomfort for the client

e. It is recommended that with many

subcutaneous injections, especially
insulin, the needle should be embedded
within the skin for five seconds after
seconds complete depression of the
plunger to ensure complete delivery
of the dose
14. Remove the needle

a. Remove the needle smoothly, pulling
along the line of insertion while
depressing the skin with your non-
dominant hand
b. If bleeding occurs, apply pressure to the
site with dry sterile gauze until it stops
15. Dispose of supplies appropriately.
Depressing the skin places countertraction and
minimizes the client's discomfort when the needle
is withdrawn
Bleeding rarely occurs after subcutaneous injection
Proper disposal protects the nurse and others from
injury and contamination.

a. Activate the needle safely device or

discard the uncapped needle and
attached syringe into designated

138
 receptacles
b. Remove gloves and perform hand
hygiene
16. Document all relevant information

a. Document the medication given,

dosage, time, route, and any
assessments.
b. Many agencies prefer that medication
administration be recorded on the
medication record. The nurse's notes
are used when prn medications are
given or when there is a special problem
17. Assess the effectiveness of the medication at
the time it is expected to act and document it

ADMINISTERING AN INTRAMUSCULAR INJECTION

Definition: Injection into muscle tissues

Purpose: To provide a medication the client requires

Equipment:
 MAR (Medication Administration Record)
 Sterile Medication (usually provided in an ampule or vial or prefilled syringe)
 Syringe and needle of a size appropriate for the amount and type of solution to be administered
 Antiseptic Swabs
 Clean Gloves

PROCEDURE RATIONALE
1. Perform hand hygiene and observe other
appropriate infection control procedure
2. Prepare the medication from the ampule or vial
for drug withdrawal
a. Whenever feasible, change the needle on Because the outside of a new needle is free of
the syringe before the injection. medication, it does not irritate subcutaneous
tissues as it passes into the muscle
b. Invert the syringe needle uppermost and
expel all excess air
3. Provide for client privacy
4. Prepare the client
a. Prior to performing the procedure, This ensures that the right client receives the
introduce self and verify the client's medication
identity using agency protocol
b. Assist the client to a supine, lateral, Appropriate positioning promotes relaxation of the
prone, or sitting position, depending on target muscle
the chosen site. If the target muscle is
the gluteus medius (ventrogluteal site),
have the client in supine position flex the
knee(s); in the lateral position, flex the
upper leg; and in the position, toe in
c. Obtain assistance in holding an This prevents injury due to sudden movement after
uncooperative client needle insertion
5. Explain the purpose of the medication and how Information can facilitate acceptance of and
it helps using language that the client can compliance with the therapy
understand. Include relevant information about
effects of the medication
6. Select, locate, and clean the site
a. Select a site free of skin lesions,
tenderness, swelling, hardness, or
localized inflammation and one that has
not been used frequently
b. If injections are to be frequent, alternate This is to reduce the discomfort of intramuscular
sites. Avoid using the same site twice injections
in a row
c. Locate the exact site for injection
d. Put on the gloves
e. Clean the site with an aseptic swab.
Using a circular motion, start at the

139
 center and move outward about 5cm. (2
in.) Discard the use swab in waste
receptacle
f. Place and hold a swab between the third This will help reduce the discomfort of the injection
and fourth fingers of your non-dominant
hand in readiness for needle withdrawal,
or position the swab on the client's skin
above the intended site. Allow skin to dry
prior to injecting medication
7. Prepare syringe for injection
a. Remove the needle cover and discard
without contaminating the needle
b. If using a prefilled unit-dose medication, Medication left on the needle can cause pain when
take caution to avoid dripping medication it tracked through the subcutaneous tissue
on the needle prior to injection. If this
does occur, wipe medication off the
needle with sterile gauze. Some sources
recommend changing the needle if
possible
8. Inject the medication using Z-track technique
a. Use the ulnar side of a non-dominant Pulling the skin and subcutaneous tissue or
hand to pull the skin approximately 2.5 pinching the muscle makes it firmer and facilitates
cm (1 inch) to the side. Under some needle insertion
circumstances, such as for an emaciated
client or an infant, the muscle may be
pinched
b. Holding the syringe between the thumb Using a quick motion lessen the client's discomfort
and forefinger (as if holding pencil),
pierce the skin quickly and smoothly at a
90 degree angle, and insert the needle
into the muscle
c. Hold the barrel of the syringe steady with If the needle is in a small blood vessel, it takes
your non-dominant hand and aspirate by time for the blood to appear
pulling back on the plunger with your
dominant hand. Aspirate for 5 to 10
seconds
d. If blood appears in the syringe, withdraw This step determines whether the needle has been
the needle, discard the syringe and inserted into the blood vessel.
prepare a new injection
e. If blood does not appear, inject the Injecting medication slowly promotes comfort and
medication steadily and slowly allows time for tissue to expand and begin
(approximately 10 seconds per milliliter) absorption of the medication. Holding the syringe
while holding the syringe steady steady minimizes discomfort
f. After injection, wait 10 seconds to permit
the medication to disperse into the
muscle tissue, thus decreasing the
client's discomfort
9. Withdraw the needle
a. Withdraw the needle smoothly at the This minimizes tissue injury
same angle of insertion
b. Release the skin
c. Apply gentle pressure at the site with a Use of an alcohol swab may cause pain or burning
dry sponge sensation
d. If bleeding occurs, apply pressure with
dry sterile gauze until it stops
10. Activate the needle safety device or discard the
uncapped needle and attached syringe into the
proper receptacle
11. Remove gloves. Perform hand hygiene
12. Document all relevant information. Include the
time of administration, drug name, dose, and
route and the client's reactions
13. Assess effectiveness of the medication at the
time it is expected to act

STARTING AN IV LINE

Purposes:

140
 1. To administer fluids and electrolytes needed by the patient.
2. For hyperalimentation
3. For fluid replacement in case of dehydration.
4. To provide access for the administration of emergency drugs and other medication.
5. To provide access for blood transfusion.

Equipment:
 IV solution
 IV tubing
 IV stand
 IV label
 Venflon or Butterfly
 Tourniquet
 Cotton balls with alcohol
 Plaster
 Arm board

PROCEDURE RATIONALE
1. Check the physician’s order for the type of This reduces the risk of medication error
solution to be used
2. Wash your hands Washing of hands is the most effective way of
preventing spread of infection
3. Prepare the prescribed solution and IV tubing.
a. Place the IV bottle on a flat surface
b. Remove the metal cap or plastic cap of
the IV solution
c. Clamp tubing. Uncap spike and insert it Clamping the tubing prevents unregulated flow of
into the bottle the solution
d. Invert the IV bottle and squeeze the drip Half-filled chamber prevents air entering the tubing
chamber filling it halfway and ensures continuous flow
e. Remove the cap at the other end of the
tubing
f. Release the clamp and let the solution Drainage on flow of solution through the tubing
flow filling the tubing removes air from the tubing
4. Close the clamp and recap the tubing This maintains sterility on the solution and tubing
5. Bring the equipment to the patient’s bedside This serves energy and time of nurses.
for the physician or the trained nurse to insert
6. Explain the procedure to the client This alleviates anxiety and gains cooperation of the
client
7. Position the client comfortably ask him to
extend his arms
8. Suspend the bottle or bag to the IV stand The height of the bottle should be sufficient about
18-24 inches
9. Hand the tourniquet to the physician Anticipate the needs of the doctor
10. Release the tourniquet once the needle is The tourniquet causes backflow by increasing
inserted into the vein venous pressure
11. Anchor immediately the needle onto the patient
skin
12. Uncap the end of the tube and connect it with
the IV needle after the doctor removed the
style
13. Regulate the flow of the IV as indicated. Overloading is an dangerous the IV needle from
Observed it flowing freely being dislodged by limiting the arm movement
14. Anchor the arm with IV site to an arm board
15. Label the table Labeling reduces error in medication

16. Do after care of the equipment

17. Document the procedure

ADMINISTERING MEDICTION THROUGH IV PUSH

Purpose: To Achieve immediate maximum effect

Equipment:
 IV solution
 Syringes with needle
 IV medication
 Cotton Balls with alcohol

141
For IV Heplock:
 2 syringes with needles
 NSS for flushing or Heparin

PROCEDURE RATIONALE
Washing of handle is the most effective way of
1. Wash your hands
preventing spread of infection
2. Check the physician’s order This reduces the risk of medication error
3. Prepare the prescribed solution from vial or
ampule
4. Identify the patient by letting the patient state
This reduces the risk of error in medication
his name

FOR IV PUSH
a. Locate the Y-tube of the IV line and wipe
with CB soaked with 70% alcohol
b. Check the patency of the IV line by
bringing the bottle below the level of the
IV site or draw back plunger and watch for
backflow in the tubing
c. Insert the needle in the Y-tube and slowly
administer the medication
Wiping the Y-tube with antiseptic prevents
pathogen from entering into the solution
To ensure that the solution goes directly into the
bloodstream to achieve optimal effect
Rapid administration of drugs may irritate and
cause patient discomfort

FOR HEPLOCK
a. Insert the needle into the heplock

b. Flush with plain NSS

c. Remove syringe
d. Using syringe with medication, introduce
medication and remove syringe
e. Flush the heplock with plain NSS or
heparin solution, if indicated
5. Do after care of the equipment
6. Record immediately and completely the drug
given
This flushes remaining medication from the
heplock. Administration of heparin is done to
prevent clotting and ensures patency for the
subsequent doses
This serves as reference for the treatment receive
from the patient

USING SOLUSET TO ADMINISTER INTRAVENOUS MEDICATION

Purposes:
2. For diluting irritating drugs
3. To administer drug of specific amount at specific time
4. To ad mister IV drugs that cannot be mixed with the primary solution because of incompatibility.

Equipment:
 Medication label
 Syringe with needle
 Cotton balls with alcohol
 IV solution
 Soluset
 Medication

PROCEDURE RATIONALE
Washing of hands is the most effective of
1. Wash your hands
preventing spread of infection
2. Check the physician’s order This reduces the risk of medication error
3. Prepare the prescribed solution from vial or
ampule

SOLUSET AS MAIN LINE

142
 a. Infuse specified amount of IV fluid into the
soluset
b. Locate the medication port and clean it with
cotton ball antiseptic
c. Introduce the prescribe amount of medicine
into the soluset containing IV fluid
d. Invert the soluset to mix the solution
The specific amount will serve as diluent to the
drug to be infused
Prevents entry of pathogens into the medication
Irritating solutions may cause extreme discomfort
when given as IV push
This distributes the drug evenly

e. Regulate the flow rate as indicated

f. After the infusion of the diluted drug, refill To run IV solution. Soluset may also prevent
the soluset with the IV solution and regulate overloading and under loading with IV fluid

SOLUSET AS SIDE DRIP

a. Locate the Y-tube on the mainline and clean
It prevents entry of pathogens to IV solution
it
b. Hook the soluset to the Y-tube and secure it This prevent detaching the side trip from the
using sterile gauze and plaster mainline and spilling the medication
c. Proceed in the manner of using the soluset
as in the mainline
d. Close the mainline and run the soluset flush
Incompatible solutions when mixed may cause
with a saline solution before running the
some crystallization, which is dangerous for
soluset if the solution is incompatible with
patient’s health
the mainline
e. After administration of drug, close the side
trip of retained or removed and keep set
sterile for the next infusion. If the solution
infused, was incompatible flush the IV
tubing with saline solution before running
the mainline
f. Regulate mainline as indicated

4. Documentation should follow after

143
 COMMON
MEDICAL
ABBREVIATIONS
&
TERMINOLOGIES

COMMON MEDICAL ABBREVIATIONS

144
TERM MEANING TERM MEANING TERM MEANING
A CV Cardiovascular ES emotional support
ABI Ankle/Brachial Index CVA cerebrovascular accident ESR erythrocyte sedimentation rate
ABG arterial blood gas CVC central venous catheter ESRD end stage renal disease
a.c. before meals CVP central venous pressure ET endotracheal
AC ANTECUBITAL CT computerized tomography ETA Estimated time of arrival
ACLS Advanced cardiac life support C&S culture and sensitivity ETOH ethyl alcohol
ADL activities of daily living C/S Cesarean Section ext. external or extremities
ad. Lib as desired CX culture F
AED Automatic External Defibrillator CXR chest x-ray F French
AFB Acid-fast bacilli D FA forearm
AGA appropriate for gestational age D5W Dextrose in 5% Water FBS fasting blood sugar
AKA above knee amputation DA Double Armed FFP fresh frozen plasma
ALS Advanced Life Support D&A Drug and Alcohol FH family history
a.m. morning DB deep breathing FHR fetal heart rate
AMA against medical advice DBP diastolic blood pressure FS finger stick
amb ambulance/ambulatory D&C dilation and curettage ft foot
ant anterior D&E Dilation & Evacuation FUO fever of unknown origin
AP anteroposterior D/C discontinue Fx fracture
ASAP as soon as possible DDI dressing dry & intact G
B dL deciliter g gram(s)
B bilateral DM diabetes mellitus G Gastrostomy
BFR Blood Flow Rate DNI do not intubate GCS Glasgow coma scale
b.i.d. two times per day DNR do not resuscitate Gge Guage
BKA below knee amputation D/NS dextrose in normal saline GI gastrointestinal
BLS basic life support DOA dead on arrival glu glucose
BM bowel movement DOE dyspnea on exertion gr grain
BMI Body Mass Index Drge drainage GTTS drops
BP blood pressure drsg dressing GU genitourinary
bpm beats per minute DTV due to void Gyne gynecology
BS bowel sounds or breath sounds DVT deep vein thrombosis H
BUN blood urea nitrogen D/W dextrose in water Hct hematocrit
C Dx disease HDL High density lipoprotein
0
C celcius E HEENT Head, ears, eyes, nose, throat
C&DB cough and deep breath EBL estimated blood loss Hgb hemoglobin
CAD coronary artery disease ECG Hr/s Hg mercury
Cap. capsule ECT h.s. HIV Human Immunodeficiency Virus
Cath catheter ED ht. HNV has not voided
CBC complete blood count EDC estimated time of confinement HOB head of bed
CC chief complaint EEG electroencephalogram HPI history of present illness
CHF congestive heart failure EGD Esophagogastroduodenoscopy HPV human papilloma virus
CHO Cholesterol EGG Electogastrography h/o history of
CI cardiac index EJ external jugular HR heart rate
CLR CLEAR EKG electrocardiogram Hr/s Hour/s
Electronic medication
cm centimeter e-MAR HS hours of sleep
administration record
c/o complaining of ENT ears, nose and throat Ht Height
CO cardiac output EOM extraocular muscles HTN hypertension
constant positive airway
CPAP EOMI extraocular muscles intact Hx history
pressure
CPR Cardiopulmonary resuscitation Eos Eosinophil hyper above or high
CPT chest physiotherapy EPI epinephrine hypo Below or low
I LUL left upper lobe NPO nothing by mouth
Noninvasive positive pressure
I independent LUQ left upper quadrant NPPV
ventilation
ICP intracranial pressure LV left ventricle O
ICU intensive care unit M O objective
ID infectious disease MAE moves all extremities O2 oxygen
medication administration
I&D incision and drainage MAR O2 Sat oxygen saturation
record
insulin dependent diabetes
IDDM mcg microgram OB obstetrics
mellitus
IgE Immunoglobulin E MD Medium OBS organic brain syndrome

145
IgG Immunoglobulin G MDI Multiple dose inhaler OCD Obsessive – compulsive Disorder
I&O intake and output Med. medical OG orogastric
IM intramuscular mEq milliequivalent(s) OOB out of bed
IMP impression mg milligram OP Outpatient
IOI intraosseous infusion MI myocardial infarction OPA Outpatient with Anesthesia
IOL Intraocular lens min minute OPER Outpatient with Extended Recovery
It Inspiration time mL milliliter OR Operating Room
IV intravenous mmol millimole(s) ORIF open reduction internal fixation
IVC inferior vena cava Mm Hg millimiters of mercury ORTHO Orthopedics
IVF Intravenous Fluids Mono Monocyte OT occupational therapy
J MRI magnetic resonance imaging P
Methicillin-resistant
J Jejunostomy MRSA PCRA patient controlled regional analgesia
Staphylococcus aureus
JVD jugular vein distention MS medical-surgical PCV Pressure-controlled ventilation
K MSE Mental status exam PCWP pulmonary capillary wedge pressure
kcal kilocalorie MVP mitral valve prolapse PDA patent ductus arteriosus
kg kilogram N PE Physical exam /pulmonary embolus
pupils equal and reactive to light
KUB kidney, ureter, bladder NS normal saline PEARLA
and accommodation
KVO keep vein open NSR normal sinus rhythm PED Pediatric
L NST Non-Stress Test PEEP positive end expiratory pressure
normal spontaneous vaginal percutaneous endoscopic
(L) left NSVD PEG
delivery gastrostomy
L liter NTG nitroglycerin PMFSH past medical, family, social history
Lat. lateral NV nausea & vomiting PMH past medical history
Laparoscopically Assisted
LAVH NWB non-weight bearing PNB Peripheral Nerve Block
Vaginal Hysterectomy
lb. pound N/A Not applicable PND paroxysmal nocturnal dyspnea
LBBB left bundle branch block NAD no acute distress po by mouth (per os)
L&D labor and delivery NBN newborn PO2 partial pressure of oxygen, arterial
LE lower extremity NC nasal cannula POA power of attorney
LFA left forearm Neb nebulizer POC Point of Care
LGA large for gestational age neg/- negative POD Post-op Day
LIFA left inner forearm Neut Neutrophil pos/+ positive
LLL left lower lobe NG nasogastric Post. posterior
LLQ lower left quadrant ng nanogram POV privately owned vehicle
L/M liters per minute NIBP Non- Invasive Blood Pressure pp post partum
LMP last menstrual period NICU Neonatal Intensive Care Unit PP peripheral pulses
non-insulin dependent diabetes
LOC Loss of consciousness NIDDM ppd packs per day
mellitus
LOFA left outer forearm NKA no known allergies PPN peripheral Parenteral nutrition
LOR loss of resistance nl normal PPTL post partum tubal ligation
Pneumococcal Polysaccharide
LP lumbar puncture No. number PPV
Vaccine
LR lactated ringers NOS Not Otherwise Specified PR per rectum

Prn when required S TPN Total parenteral nutrition

Pro temperature, pulse, and
prothrombin time S Subjective TPR
time respiration
premature rupture of
PROM
membranes
SBP systolic blood pressure U
PT physical therapy SCI spinal cord injury U/A Urinalysis
Pt Patient sec Second UE upper extremity
PWB partial weight bearing SGA small for gestational age U/O urinary output
Q SH social history URI upper respiratory infection
q. Every SICU surgical intensive care unit UTI urinary tract infection
q.i.d. four times per day SL Sublingual V
q.s. quantity sufficient SO significant other VC Vital Capacity
R SOB shortness of breath Vent Ventilator
(R) Right sol. Solution VF ventricular fibrillation
RA rheumatoid arthritis S/P status post VIT Vitamin
RBC red blood cell sp gr specific gravity V.O. verbal order

146
Reg Regular Strep Streptococcal VS vital signs
RESP Respirations subQ Subcutaneous VSS vital signs stable
RFA right forearm susp. Suspension W
RIFA right inner forearm SUT Suture WBAT weight bearing as tolerated
RLL right lower lobe SVC superior vena cava WBC white blood cell
RLQ right lower quadrant SVD spontaneous vaginal delivery W/C wheelchair
R/O rule out Sx Symptoms wks. weeks
ROFA right outer forearm syr. Syrup w/o without
ROM range of motion T wt. weight
ROS review of systems T Temperature
RR respiration rate tab Tablet
RUL right upper lobe TAH total abdominal hysterectomy
RUQ right upper quadrant TC & DB turn, cough & deep breath
RV right ventricle TF tube feeding
Rx Treatment t.i.d. three times a day
Source: http://pennstatehershey.org/c/document_library/get_file?folderId=301860&name=DLFE-4627.doc

Per Joint Commission on Accreditation of Healthcare Organization (JCAHO) and Healthy Medical
Consultancy (HMC) policy the following abbreviations are NOT permitted to be written in the
patient’s chart. This includes ALL written orders and notes. Please write out the words as listed
in the right column.

WRONG CORRECT
AD right ear
AS left ear
AU each ear
cc mL
DPT DTaP
IU international units
OD right eye
os po
OS left eye
OU each eye
QD daily
QOD every other day
sc or sq subQ or subcutaneous
u units
μg mcg
MS or MSO4 morphine or morphine sulfate
MgSO4 magnesium sulfate

Always use a leading zero, e.g., 0.1mL and Never use a trailing zero, e.g., 1.0mL

REFERENCES

Berman, A., Snyder, S., and Frandsen, G. (2018). Kozier & Erb's Fundamentals of Nursing C

Concepts, Process, and Practice, Tenth Edition. Singapore:Pearson Education South Asia Pte Ltd

Delaune, Sue and Patricia K Ladner. Fundamentals of Nursing, 2nd edition ed. Australia: Delma

147
 Thomas Learning, 2006.

Esters, Mary Ellen Zator, Health Assessment and Physical Examination 2nd edition. Delmar

Thomas Learning 2005

Kozier, Barbara et. al. Fundamentals in Nursing, 8th edition Singapore: Pearson Education South

Asia Pte Ltd. 2008

Peterson, Veronica Fundamentals in Nursing 6th edition, Elsevier (Singapore) Pte. Ltd 2006

Phillips, Berry and Kohn’s Operation Room Technique 10th edition. Mosby, Inc 2004

Pilliteri, Adele Maternal and Child Health Nursing 4th edition. Lippincott Williams and Wilkins 2003

Taylor, Lillis, LeMone. Fundamentals in Nursing 6th edition. Lippincott Williams and Wilkins, 2008

World Health Organization & WHO Patient Safety. (2011). Patient safety curriculum guide: multi-

professional edition. World Health

Organization. http://www.who.int/iris/handle/10665/44641

Wilison, Leuven Fundamentals of Nursing Theory, Concepts and Applications F.A. Davis

Company, Philadelphia. A, 2007

SUMMARY OF RETURN DEMONSTRATION GRADES

PROCEDURE DATE PERFORMED GRADE CI's SIGNATURE

Medical Handwashing

Gloving

148
 Transfer Skills

Bed Bath

Shampoo in Bed

Bed Making

Perineal Flushing

Hot Sitz Bath

Urinary Catheterization

Enema

Oxygen Administration

Suctioning

Vital Signs

Oral Administration

Intramuscular

Intradermal

Subcutaneous

_______________________________________
Student's Signature

_______________________________________
RLE Coordinator

Ateneo de Davao University

School of Nursing

RETURN DEMONSTRATION RUBRIC

Name of Student: ____________________________________ Date: _____________________________

Year. & Section: ________________________________________ RD Grade: _________________________
Procedure: ________________________________________ RD Instructor: ______________________

149
 TRAIT Exemplary Accomplished Improving Developing Beginning
SCORE
CONTENT (40%) 5 4 3 2 1
KNOWLEDGE
AND MASTERY
60%
ORGANIZATION
30%
LENGTH OF
PRESENTATION
10%

PSYCHOMOTOR
5 4 3 2 1 SCORE
40%
DEMONSTRATION
50%
DEXTERITY
20%
PURPOSEFUL
MOVEMENT
10%
COMPOSURE
10%
EYE CONTACT
10%

VERBAL SKILLS
5 4 3 2 1 SCORE
10%
ELOCUTION
70%
VOCALIZED PAUSES
(uh, well, uh, um)
30%

AFFECTIVE
5 4 3 2 1 SCORE
10%
INTEGRITY
30%
RESPECT
30%
EMPATHY
20%
ENTHUSIASM
10%
APPEARANCE &
PERSONAL HYGIENE
10%

Content x 40% =
Psychomotor x 40% =
Verbal Skills x 10% =
Affective x 10% =
Total: (RD GRADE)

Name & Signature of RD Instructor Name & Signatureof Student

ATENEO de DAVAO UNIVERSITY

School of Nursing

ORAL PRESENTATION RUBRIC

NAME of STUDENT Date

Year and Section GRADE

150
Evaluator

EXEMPLAR IMPROVIN DEVELOPIN BEGINNIN SCOR

TRAIT ACCOMPLISHED
Y G G G E
CONTENT (70%) 5 4 3 2 1

Knowledge and Mastery

(50%)

Accuracy (20%)

Organization (20%)

Length of Presentation
(10%)

VERBAL SKILLS (20%)

Elocution (80%)

Vocalized Pauses (20%)

NON-VERBAL (10%)

Eye Contact (25%)

Purposeful Movement
(25%)

Composure (25%)

Creativity (25%)

Content x 70%
Verbal Skills X 20%
Non-Verbal Skills X 10%
(ORAL PRESENTATION
Total
GRADE)

Name & Signature of Clinical Instructor Name & Signatureof Student

NURSES' PRAYER

Guide me to be the nurse I ought to be,

Whom, with great care and compassion,
With gentle touch and affection,
Nurse those whom you entrust to me.

If in the journey of my profession,

I stumble, fall, and wither,

151
SCHOOL OF NURSING
ADMINISTRATORS
DR. PATRIA V. MANALAYSAY, RN, MAN
Dean
Email: pvmanalaysay@addu.edu.ph
Tel. No.: (082) 221-2411 loc 8365
DR. LIZA G. FLORESCA, RN, MAN
Academic Coordinator
Email: lgfloresca@addu.edu.ph
Tel. No.: (082) 221-2411 loc 8364
MAGNOLIA MAY A. JADULANG, RN, MN
RLE Coordinator
Email: mmajadulang@addu.edu.ph
Tel. No.: (082) 221-2411 loc 8364
MA. NELIA C. RUTA, RN, MN
Community Engagement and Advocacy
Coordinator
Email: mncruta@addu.edu.ph
Tel. No.: (082) 221-2411 loc 8364
Produce sui generis graduates and an Ateneo de Davao
University School of Nursing Community rooted in faith, who
would:
Lift me, assist me, carry me,
And be my source of strength, courage and divinity
Let every word, deed and thought
Be filled with patience, love and serenity.
Lead me the way, Oh Lord,
To the path, not to selfishness but to generosity
And that, through me, may this calling be,
A vocation and an offering to you,
The Great Miracle Worker. AMEN
FLORENCE NIGHTINGALE'S PLEDGE
I solemnly pledge myself before God and in the
presence of this assembly
to pass my life in purity and to practice my
profession faithfully.
I will abstain from whatever is deleterious and
mischievous
and will not take or knowingly administer any
harmful drug.
I will do all in my power
to maintain and elevate the standard of my
profession
and will hold in confidence all personal matters
committed to my keeping,
and all family affairs coming to my knowledge in
the practice of my profession.
With loyalty, will I endeavor to aid the health team
in their works and devote myself to the welfare of
those committed to my care.
PROGRAM OUTCOMES
 Apply appropriate knowledge of physical, social, natural,
and health sciences and humanities in the practice of
nursing, especially for Mindanao. 152
 Demonstrate safe, appropriate, humanistic care to
individuals, families, population groups, and community
with the use of the nursing process.