Nursing Department Student Logbook رات العواضي

Medical Surgical Nursing Dept.
Log Book for Adult nursing I
Adult Nursing Dept. Faculty of Nursing
Log Book of Fundamental Of

Nursing
For
First Year Nursing Students
First Semester
By
Teaching Staff Members
of
Medical Surgical Nursing Department
Faculty of Nursing - Assiut University
2020/2021
1
Medical Surgical Nursing Dept. Log Book for Adult nursing I
Unit Pag
e
Content
I Body Mechanics 3
II Asepsis and infection control: 5
- Performing hand hygiene using soap and water (hand 6
washing).
- Performing hand hygiene using an alcohol-based 10
hand rub.
- Preparing a sterile field and adding sterile items to a 12
sterile field.
- Putting on sterile gloves and removing. 19
- Using personal protective equipment (PPE). 25
III Vital signs: 30
- Measuring body temperature (oral, axillary & rectal). 31
- Heat and cold measures. 48
- Assessing the pulse. 55
- Assessing respiration. 62
- Measuring blood pressure. 65
IV Oxygen Therapy:
- Using a pulse oximetry. 74
- Assisting a patient with an incentive spirometer. 77
- Administering oxygen by nasal cannula. 80
- Administering oxygen by mask. 82
V - Range of motion exercises (ROM). 85
VI Turning & Moving:
- Assisting a Patient with turning in bed. 93
- Moving a patient up in bed with the assistance. 98
VII Bed making:
- Unoccupied bed making. 103
- Occupied bed making. 110
VIII Hygienic care:
- Bed bath 114
- Oral care 119
- Denture care 123
- Mouth care for unconscious patients 126
- Shampooing a patient's hair in bed 129
- Foot and nail care 135
2
Body Mechanics
Student’s Name: Clinical Evaluator:
Mark:
Evaluation
Steps of the procedure Marks 1St 2nd Average
1-Always lock wheels on bed,
1
stretcher, or wheelchair.
2-Allow patient to assist during
2
move.
3-Use mechanical aids (e.g.,
2
lifters, slide boards.
4-When possible, slide, push, or
2
pull patient rather than lifting and
carrying.
5-Tighten abdominal and gluteal
2
muscles before moving patient.
6-Use smooth, rhythmic,
1
coordinated motions.
7-If another person is assisting,
plan your movement before 2
beginning.
8-Face patient to be moved, and
plan to pivot your entire body 2
without twisting your back.
9-Place both feet flat on floor;
bend knees slightly with one foot 2
slightly in front of the other .
10-Bend knees to lower center of
2
gravity toward patient.
11-Elevate beds to waist level &
2
lower side rails.
12-Carry objects close to body,
2
and stand as close as possible .
Total 22
3
Hand washing
Mark:
Evaluation
1. Stand in front of the sink. Do not
2
allow clothes to touch the sink.
2. Remove jewelry and securing it. 1
3. Turn on water and adjust force,
regulate the temperature until the 2
temperature is warm
4. Wet the hands and wrists area.
Keep hands lower than the 1
elbows to allow water to flow
toward fingertips
5. Use about 1 teaspoon of liquid
soap from dispenser or rinse bar
of soap and lather thoroughly. 2
Cover all areas of hands with
soap product.
6. Rinse soap bar again and return
1
to soap rack .
7. With firm rubbing and circular
motions, wash the palms and
backs of the hands, each finger,
2
the areas between the fingers,
and the knuckles, wrists and
forearms.
8. Continue this friction motion for
1
at least 20 seconds.
9. Clean under finger nails with
1
orangewood stick.
10. Rinse thoroughly with water
2
flowing toward fingertips
4
11. Pat hands dry with a paper

towel, beginning with the fingers
2
and moving upward toward
forearms, and discard the towel.
12. Use another clean towel to turn
off the faucet. Discard the paper 2
towel immediately
13. Use oil-free lotion on hands if
1
desired.
Total 20
5
Performing Hand Hygiene Using an Alcohol

Mark:
Evaluation
1.Visibly inspect hands for
2
obvious contaminants or debris.
2.Remove rings and watch or
push watch up on the forearm so 2
the wrist is clear of any jewelry.
3.When decontaminating hands
with an alcohol-based hand rub,
dispense an ample amount of the 2
product into the palm of one
hand.
4.Rub the hands together
covering all surfaces of hands 2
and fingers, up to 1 2 inch above
the wrist.
5.Rub hands together until hands
are dry, approximately 15 to 30 2
seconds.
Total
10
6
Using Personal Protective Equipment (PPE)

Mark:
Evaluation
1. Check medical record and
nursing plan of care for type of 1
precautions.
2. Plan nursing activities before
1
entering patient's room.
3. Perform hand hygiene. 1
4. Provide instruction about
1
precautions to patient.
5. Put on gown, mask, protective
eyewear, and gloves based on
the type of exposure anticipated
and precautions:
a. Put on the mask or
respirator over the nose,
mouth, and chin. Secure ties
or elastic bands at the 4
middle of the head and
neck.
b. Put on goggles.
c. Put on clean disposable
gloves.
d. Put on clean disposable
gloves.
Remove PPE:
6. Except for respirator,

remove PPE at the doorway or 1
in an anteroom. Remove
respirator after leaving the
7
patient's room and closing the

door.
7. Remove respirator after
leaving the patient's room and
closing the door:
a. If impervious gown has been
tied in front of the body at the
waistline, untie waist strings
before removing gloves.
b. Grasp the outside of one 5
glove with the opposite gloved
hand and peel off, turning the
glove inside out as you pull it
off.
c. Slide fingers of ungloved
hand under the remaining glove
at the wrist.
d. Peel off the glove over the
first glove, containing the one
glove inside the other. Discard
in appropriate container .
e. To remove the goggles or face
shield: Handle by the headband
or earpieces. Lift away from the
face
8
8. To remove gown:
a.Unfasten ties, if at the neck
and back.
b.Allow the gown to fall away
from shoulders.
c.Touching only the inside of the
5
gown, pull away from the torso.
d.Keeping hands on the inner
surface of the gown, pull gown
from arms.
e.Turn gown inside out. Fold or
roll into a bundle and discard.
9. To remove mask or
respirator:
a. Grasp the neck ties or

elastic, then top ties or elastic
and remove.
b. Take care to avoid touching 3
front of mask or respirator.
Discard in waste container.
c. If using a respirator, save for
future use in the designated
area.
10. Perform hand hygiene

immediately after removing all 1
PPE.
Total 23
9
Vital Signs
A. Measuring Body temperature(mercury)
Mark:
Evaluation
1. Check medical order for
frequency of measurement 1
and routes
2. Introduce self and verify
2
patient’s identity.
3. Explain procedure to patient. 2
4. Gather appropriate equipment. 2
5. Perform hand hygiene and wear
2
gloves
6. Maintain body mechanics 1
7. Close curtains around bed and
2
close the door to the room.
8. Ask if patient has ingested
hot/cold food or drink,
2
smoked, or chewed gum
within last 20 minutes.
9. Wipe the thermometer with
clean, soft tissue gauze using 2
a firm twisting motion
10. Wipe from the bulb toward
2
the fingers with soft gauze.
11. Hold color-coded end of glass
thermometer tightly with 2
thumb and forefinger.
11
12. Slowly rotate thermometer at eye

2
level to read mercury level.
13. If mercury is higher than desired
level, using a sharp, snapping
2
motion of the wrist, shake down
below 35C.
14. Ask patient to open mouth and
gently place thermometer at the base
of the tongue to the right or left of 1
the frenulum, in the sublingual
pocket
15. Ask patient to close the lips, not the
2
teeth, around the thermometer.
16. Wait at least 3 minutes. 2
17. Carefully remove thermometer from

1
patient mouth.
18. Wipe off thermometer using gauze
pad with one downward motion
toward bulb end.
19. Read thermometer. 1
20. Dispose of gauze in a container. 1
21. Wash thermometer in cool soapy
water. Dry and place it in a
container, shake down the 2
thermometer and return it to its
container.
22. Hand washing. 1
23. Rearrange the equipment. 1
24. Place patient in comfortable

1
position.
25. documentation .
1
Total 40
11
Measuring Oral Body temperature - Electronic

Thermometer
Mark:
Evaluation
1-Introduce self and verify
1
2-Explain procedure to patient. 2
3-Gather appropriate equipment. 2
4-Perform hand hygiene and
2
observe other appropriate
infection control procedures.
5-Maintain body mechanics. 2
6-Attach the oral probe (blue tip)
to the electronic display unit.
Grasp the top of the stem, using 1
caution not to apply pressure to
the eject button
7-Slide a clean disposable plastic
cover over the temperature probe 2
until it locks in place.
8-Ask If the patient has recently
ingested hot or cold food or
beverages or has been smoking, 2
you must wait 15 to 30 minutes
before taking the
9-Grasp the probe by the collar,
and remove it from the face of 2
the thermometer.
10-Ask the patient to open
mouth and gently place the probe
2
under the tongue, on either side
of the frenulum .
12
11-Have patient keep the probe

in place until the alarm on the
electronic thermometer sounds 1
and the temperature reading
appears on the digital display.
12- Remove the prope from the
1
patient`s mouth .
13-Return the probe to its stored

position in the thermometer unit.
2
Return the thermometer unit to
its storage base.
14-Hand washing. 1
15-Rearrange the equipment. 2
16-Place patient in comfortable

2
position.
17-Documentation: Record and
report readings to supervisor 1
immediately.
Total 28
13
Measuring Axillary Body Temperature by mercury

Mark:
Evaluation
1
4. Perform hand hygiene and
2
observe other appropriate infection
control procedures.
5. Provide for patient privacy. 2
6. Maintain body mechanics. 1
7. Position patient either sitting or
2
lying position.
8. Expose axillary area. 2
9. Pat axilla dry with the gauze
2
pads.
10. Shake down thermometer below
2
35C.
11. Place thermometer or probe into
2
axilla with bulb in center of axilla
12. Lower the arm over the

thermometer, and place the 2
patient’s forearm across the chest.
13. Wait 5 minutes, remain with the
patient and hold the thermometer 2
in place if the patient is unable .
14. Lift patient's arm at elbow and
1
remove thermometer.
15. Wipe off thermometer using
gauze pad with one downward 2
motion toward bulb end.
14
16. Read thermometer.

2
17. Dispose of gauze in a container.

2
18. Wash thermometer in cool

soapy water. Dry and place it in a
container, shake down the 2
thermometer and return it to its
container.
19. Hand washing. 1
1
position.
22. Record and report readings to
1
supervisor immediately.
Total 38
15
Measuring Axillary Body Temperature—

Electronic Thermometer
Mark:
Evaluation
1
2
7. Remove the thermometer unit
from its storage base, and attach 2
the oral (blue collar) probe to it.
8. Remove clothing from the
patient’s shoulder and arm.
Ensure that the axilla is dry. If it 2
is wet, pat it dry with a paper
towel or a gauze pad.
9. Grasp the probe by the collar,
and remove it from the face of 2
the thermometer.
10. Take the patient’s temperature
by placing the probe in the
center of the patient’s axilla. 2
Instruct the patient to hold the
arm close to the body.
16
11. hold the prope in place until

hear the tone. 2
12. Remove the probe from the

patient’s axilla. Discard the
probe cover by firmly pressing 2
the ejection button while holding
the probe over waste container.
13. Return the probe to its stored
position in the thermometer unit.
2
Return the thermometer unit to
its storage base
14. Hand washing. 1

2
position.
17. Record and report readings to
1
supervisor immediately.
Total 30
17
Measuring Rectal Body Temperature by Mercury

Thermometer
Mark:
Evaluation
1
2. Explain procedure to
2
patient.
3. Gather appropriate
2
equipment.
2
7. Assist patient into sims’
position or side-lying
position (position patient
2
lying on his side with top
knee flexed). Children may
be placed in a prone position.
8. Shake down thermometer
2
below 35C.
9. Squeeze a liberal amount
of water-soluble lubricant
onto a tissue. Lubricate
2
thermometer (2.5-4cm) for
adult and (1-1.5 cm) for
infant
10. With the non-dominant
hand, raise the patient’s upper 2
buttock to expose the anus.
18
11. Ask patient to take deep

2
breath.
12. Gently insert the

thermometer into the anus in
the direction of the umbilicus. 2
Insert the thermometer (1.5
inch) for adults.
13. Hold in place for 2
2
minutes.
14. Remove the thermometer
1
from patient's rectum.
15. Wipe off thermometer
using gauze pad with one
2
downward motion toward
bulb end.
16. Read thermometer 2
17. Dispose of gauze in a
1
container.
18. Wash thermometer in
cool soapy water and then dry
it, shake down the 2
thermometer and return it to
its container.
19. Hand washing. 1
21. Place patient in

1
comfortable position.
22. Record and report
readings to supervisor 1
immediately.
Total 37
19
Measuring Rectal Body Temperature-electronic

thermometer
Mark:
Evaluation
1
2
5-Provide for patient privacy. 1
7-Remove the thermometer unit
from its storage base. Attach the 2
rectal (red collar) probe to it.
8-Provide the patient with a
gown. Instruct the patient to
remove enough clothing to
2
provide access to the anal area
and to put on the gown with the
opening in the back.
9-Apply gloves. Position the
patient in the Sim's position, and
2
drape the patient to expose only
the anal area.
21
10-Grasp the probe by the

collar, and remove it from the
face of the thermometer. Apply 2
a lubricant to the tip of the probe
cover up to a level of 1 inch.
11-Instruct the patient to lie still.
Separate the buttocks to expose
the anal opening, and gently
insert the thermometer probe 2
approximately 1 inch into the
rectum of an adult, 5 /8 inch in
children, and ½ inch in infants.
12-Hold the probe in place until
you hear the tone. At that time,
the patient’s temperature 2
appears as a digital display on
the screen.
13-Gently remove the probe
from the rectum in the same
1
direction as it was inserted.
Avoid touching the probe cover.
14-Wipe the patient’s anal area
with tissues to remove excess
2
lubricant. Dispose of the tissues
in a regular waste container.
15- Hand washing. 1

1
position.
18-Rerecordandreport
readings to supervisor 2
immediately.
31
Total
21
Heat and Cold measures

Mark:
Evaluation
1
2. Explain procedure to patient 1
3. Gather appropriate
1
equipment.
observe other appropriate 1
infection control
procedures.
7. Warm the container of
sterile saline or tap water by
placing it in a bath basin
2
filled with hot tap water.
Sterile saline should be
warmed to 105˚ - 110˚ F.
8. Place a waterproof pad
under the body area that 2
needs the warm compress.
A thin layer of petroleum
jelly may be placed on the
2
patient's skin in the area to
be treated.
9. Pour the sterile saline into
the sterile basin soaks an
2
appropriate size piece of
gauze or a towel.
22
10. Place it on the affected

area. Wear sterile gloves if 2
there is an open wound.
11. Check the patient’s skin
periodically for signs of 2
heat intolerance.
12. Leave the compress in
place for approximately 30
2
minutes if it is tolerated,
then remove it
13. Dry the affected area.
1
14. Proper dispose of all

1
single use equipment.
15. Clean the bath basin and
thermometer. Return the
sterile basin to the 2
appropriate place for re-
sterilization.
16. Remove gloves if they
were worn and wash your 1
hands.
17. Reassess the condition of
2
the patient’s skin.
18. Clean and rearrange the
1
equipment's.
19. Hand washing. 1
20. Documentation.
1
Total 30
23
Cold Application

Mark:
Evaluation
1-Introduce self and verify patient’s
1
identity
1
observe other appropriate infection
control procedures.
7-Determine the diagnosis. Identify
whether the patient has a history of
2
circulatory impairment or
neuropathy.
8-Fill the bag three-fourths full with
ice and remove the remaining air 2
from the bag.
9-Close the bag. Check for leaks.
Wrap the bag in a towel or
2
protective cover and place it on the
affected area.
10-Fill the collar three-fourths full 2
with ice.
11-Remove the remaining air from
the collar before closing in a
2
protective cover and around the
patient’s neck.
12-Activate the pack according to
the manufacturers' direction if a 2
disposable cold pack is used.
24
13-Assessthe patient’sskin
periodically for signs of cold 2
intolerance or tissue damage.
14-Leave the cold application in
place for approximately 20-30
minutes at approximately 15 ْ C 1
(59 ْ F) if the patient can tolerate
the cold.
15-Reassess the condition of the
2
patient’s skin
16-Clean and rearrange the
1
equipment.
17-Hand washing. 1
18-Documentation: 1
Total 26
25
Assessing radial (wrist) pulse:

Mark:
Evaluation
1-Wash hands. 1
2-Inform patient of the site (s)
2
where pulse will be measured.
3-Flex patient's elbow and place
2
lower part of arm across chest.
4-Support patient's wrist by 2
grasping outer aspect with thumb.
5-Place index and middle fingers
on inner aspect of patient’s wrist
over the radial artery, and apply 2
light but firm pressure until pulse
is palpated
6-Identify pulse rhythm. 2
7-Determine pulse volume. 2
8-Count pulse rate by using
second hand on watch. For a
regular rhythm, count number of 2
beats for 30 seconds and multiply
by 2.
9-Hand washing. 1
1
position.
12-Document the pulse rate,

2
rhythm, and volume.
Total 20
26
Assessing apical pulse:

Mark:
Evaluation
Steps of the procedure Marks 1St 2nd Avera
ge
1-Wash hands 1
2-Raise patient's gown to expose
2
sternum and left side of chest.
3-Cleanse earpiece and diaphragm
2
of stethoscope with swab.
4-Locate apex of heart: With
patient lying on left side, locate 2
suprasternal notch.
5-Inform patient that his or her
heart will be listened to. Instruct 1
patient to remain silent
6-With dominant hand, put
earpiece of the stethoscope in
ears and grasp diaphragm of the 2
stethoscope in the palm of the
hand for 5 to 10 seconds.
7-Place diaphragm of stethoscope
over the PMI and auscultate for
2
sounds S1 and S2 to hear lub-dub
sound .
8-Note regularity of rhythm. 2
9-Start to count while looking at
second hand of watch. Count lub- 2
dub sound as one beat:
10-Share findings with patient. 2
11-Record the rate, rhythm, and
number of irregular beats. 2
12-Wash hands.
1
27
C. Assessing apical-radial pulse:

2
2-Explain procedure to patient.
1
3-Gather appropriate equipment.

2
4-Perform hand hygiene . 1


7-Position patient in supine or
2
sitting position.
8-Locate the apical and radial
2
pulse sites.
Two-nurse technique:
1-Place the watch where both
2
nurses can see it.
2-The nurse who is taking the
2
radial pulse hold the watch.
3-Decide on a time to begin
2
counting.
4-The nurse taking the radial pulse
2
say start at the same time
5-Each nurse counts the pulse rate
2
for 60 seconds.
6-Both nurse end the count when

the nurse taking the radial plus say 2
stop.
7-Compare the rates obtained. If a
difference is noted between the
2
rates, subtract the radial rate from
the apical rate.
28
One-nurse technique:
1-Assess the apical pulse for 60
seconds. 2
Assess the radial pulse for 60
seconds
2-Hand washing.
1
3-Rearrange the equipment.

1
4-Replace the patient’s clothing,

and Place patient in comfortable 1
position.
5-Document the pulse rate,
2
rhythm, and volume.
Total 55
29
Assessing Respiration
Mark:
Evaluation
1
patient’s identity
2-Gather appropriate equipment 1
3-Perform hand hygiene 1
6-Place the patient in a position
of comfort, preferably sitting.
Place one hand on the patient's 2
wrist as if taking the radial
pulse.
7-Place the patient's arm across
his or her chest if the
2
respirations cannot be readily
observed.
8-Count the respiration for for
30 second. Multiply this number
2
by 2 to calculate the respiratory
rate per minute .
9-Observe the respirations for
depth, rhythm, character, and 2
chest movement, if indicated.
10-Assist the patient back into
2
the comfortable position.
11-Rearrange equipment. 2
12-Hand washing. 1
13-Documentation: 2
Total 20
31
Measuring blood pressure Auscultation method using

brachial artery:
Mark:
Evaluation
1-Wash hands. 1
2-Determine which extremity is
2
most appropriate for reading.
3-Select a cuff size appropriate for
2
the patient.
4-Have the patient’s bare arm
resting on a support so themidpoint 2
of the upper arm is at the level of
the heart.
5-Make sure the bladder cuff is fully
deflated and the pump valve moves
freely. Place the manometer so the
2
center of the mercury column or
aneroid dial is at eye level and
easily visible to the observer.
6-palpate the brachial artery in the
1
antecubital spase.
7-Wrap and secure the cuff around
the patient’s bare upper arm. The
lower edge of the cuff should be 1 2
inch (2 cm) above the antecubital
fossa.
8-Insert the earpieces of the
stethoscope into the ear canals with 2
a forward tilt to fit snugly.
9-Place the bell of the stethoscope
2
over the brachial artery pulsation.
10-With dominant hand, turn the
2
valve clockwise to close.
31
11-Partially open the valve counter

clock wise to deflate the bladder at 2
2
mm/sec while listening for the pulse
sounds.
12-Inform the patient of the reading.
2
13-The systolic and diastolic

pressure should be immediately
2
recorded, rounded off (upward) to
the nearest 2 mmHg.
14-If appropriate, lower bed, raise
side rails, and place call 2
light within easy reach.
15-Put all equipment within proper
2
place.
16-Wash hands. And documentation
2
Total 30
32
Measuring blood pressure from the thigh:

Mark:
Evaluation
1.Introduce self and verify
1
2.Explain procedure to patient. 1
3.Gather appropriate
1
equipment.
4.Perform hand hygiene and 1
observe other appropriate.
5.Provide for patient privacy. 1
6.Maintain body mechanics. 1
7.Help the patient to assume
prone position if the patient
cannot measure the blood 2
pressure in a supine position
with the knee slightly flexed.
8.Expose the thigh. 1
9.Locate the popliteal artery. 2
10.Warp the cuff evenly
2
around the mid-thigh.
11.Compress bladder over the
posterior aspect of the thigh
2
and the bottom edge above the
knee
12.With dominant hand, turn
the valve clockwise to close.
Compress the pump to inflate
the cuff rapidly and steadily
2
until the manometer registers
20 to 30 mm Hg above the
level previously determined by
the palpation
33
13.Partially open the valve

counter clock wise to deflate
2
the bladder at 2 mm/sec while
listening for the pulse sounds.
14.After the last sound is
heard, deflate the cuff slowly
for at least another 10 mm Hg
1
to ensure that noother sounds
are audible; then, deflate
rapidly and completely.
15.Allow the patient to rest for
at least 30 seconds and remove
1
cuff. Take 2 or more additional
readings and average them.
16.Inform the patient of the
1
reading.
17.The systolic and diastolic
2
pressure should be recorded.
18.Hand washing. 1
19.Rearrange the equipment. 1
20.Place patient in comfortable
1
position.
21.Document the result.
1
Total
28
34
A. Measuring blood pressure by the palpation method.

Mark:
Evaluation
1.Explain the procedure to the
1
patient.
2.Wash hands. 1
3.Locate the patient’s brachial
2
or radial pulse.
4.Place the cuff on the 2
patient’s arm.
5.Palpate again for the pulse.
When the pulse is felt, 2
continue to palpate.
6.Inflate the cuff until unable
2
to palpate the pulse.
7.Inflate the cuff until the
measurement gauge is 20 mm
2
Hg past the point at which the
pulse was lost on palpation.
8.Slowly deflate the cuff at a
rate of 2 to 3 mm Hg per 2
second.
9.Note the reading on the
measurement gauge when the
2
pulse returns. Remove cuff
from the patient’s arm.
10.Documentations. 2
Total 18
35
Using a Pulse Oximetry

Mark:
Evaluation
1-Wash hands. 1
2-Select an appropriate sensor.
Sensors are commonly used for 2
the fingertips.
3-Select an appropriate site for
the sensor. Fingers are most
commonly used; however, toes 2
ear lobes, nose, forehead,
hands, and feet can be used
4-Assess for capillary refill and
proximal pulse. If the patient
has poor circulation, use an 2
earlobe, forehead, or nasal
sensor instead.
5-Clean the site with an 2
alcohol wipe.
6-Remove artificial nails or
nail polish if present or select
another site. Clean any tape 2
adhesive and use soap and
water if necessary to clean site
7-Apply the sensor and make
sure the photo detectors are
aligned on opposite sides of the 2
selected site.
8-Connect the sensor to the
oximeter with a sensor cable. 2
Turn on the machine.
9-Adjust the alarm limits for
high and low O2 saturation 2
levels according to the
36
manufacturer’s directions.
10-If taking a single reading,
move the site of spring. 2
Sensors every 2 hours.
11-Cover the sensor with a
sheet or towel to protect it 2
from exposure to bright light.
12-Notify the physician or
qualified practitioner of 2
abnormal results.
13-Record the results of O2
saturation measurements 2
according to protocol
Total 25
37
Assisting a patient with an incentive spirometer.

Mark:
Evaluation
1. Wash hands 1
2. Check chart for previous
2
respiratory assessment.
3. Gather equipment. 2
4. Explain procedure to the 2
patient.
5. Demonstrate deep, sustained
2
inspiration.
6. Instruct patient to assume a
1
semi-fowlers position.
7. Set pointer on incentive
spirometer at appropriate 1
level
8. Use incentive spirometer,
have patient breath in and
2
exhale completely before
using spirometer.
9. Hold unit upright 2
10. Have patient seal lips
around mouthpiece and
inhale slowly and deeply
2
until desired volume
incentive spirometer
attained.
11. Sustain inspiration for at
least 3 seconds & Exhale 2
slowly.
12. Repeat 10 to 20 times
every 1 to 2 hours while 2
awake for 72 hours
38
13. Teach patient to perform

incentive spirometer every 2
hour .
14. Dispose soiled equipment 1

16. Place patient in
comfortable position ,Hand 1
washing.
17. Documentations. 1
27
Total
39
41
Administering Oxygen by Nasal cannula

Mark:
Evaluation
1. Wash hands. 1
2. Verify the health care
2
provider's order.
3. Explain procedure and hazards
to the patient. Remind patients
who smoke of the reasons for 2
not smoking while oxygen is
in use.
4. If using humidity, fill
humidifier to fill line with 2
distilled water and close
container.
5. Attach humidifier to oxygen
2
flow meter.
6. Insert humidifier and flow
2
meter into oxygen source
7. Attach the oxygen tubing and
nasal cannula to the flow meter
2
and turn it on to the prescribed
flow rate
8. Check for bubbling in the
2
humidifier.
9. Place the nasal prongs in the
patient's nostrils. Secure the
cannula in place by adjusting
the tubing around the patient's 2
ear and using the slip ring to
stabilize it under the patient's
chin
41
10. Check for proper flow rate

every 4hours and when the
2
patient returns from
procedures.
11. Assess patient nostrils every
8 hours. If the patient
complains of dryness or has
signs of irritation, use sterile
2
lubricant to keep mucous
membranes moist. Add
humidifier if not already in
place.
12. Monitor vital signs, oxygen
saturation, and patient
condition every 4 to 8 hours
2
(or as indicated or ordered) for
signs and symptoms of
hypoxia.
13. Wean patient from oxygen as
soon as possible using 2
standard protocols.
Administering Oxygen by
Mask
1.Follow Standard Protocol.
a. Check Doctor’s Order.
b. Identify the patient.
c. Introduce yourself and explain
the procedure. 5
d. Provide privacy and position
comfortably.
e. Perform hand hygiene and put
on PPE.
42
2.Attach face mask to oxygen

source (with humidification, if
appropriate, for the specific
2
mask)
the flow of oxygen at the
specified rate.
3.Position face mask over the
2
patient’s nose and mouth.
4.Adjust the elastic strap so that
the mask fits snugly but 2
comfortably on the face
5.Adjust the flow rate to the
2
prescribed rat
6.If the patient reports irritation
or redness is noted, use gauze
pads under the elastic strap at
2
pressure
points to reduce irritation to ears
and scalp
7.Reassess patient’s respiratory
status, including respiratory rate, 2
effort, and lung sounds.
8.Remove PPE, if used. Perform
1
hand hygiene.
9.Remove the mask and dry the
skin every 2 to 3 hours if the 2
oxygen is running continuously.
10.Document the following:
a. Type of mask used.
b. Amount of oxygen used.
4
c. Oxygen saturation level.
d. Lung sounds and
rate/pattern of respirations
Total 47
43
Using an Oxygen Tent

Mark:
Evaluation
 Verify or Check Doctor’s
Order.
 Identify the patient.
 Introduce yourself and
5
explain the procedure.
 Provide privacy and position
comfortably.
 Perform hand hygiene and
put on PPE
2.Calibrate the oxygen analyzer
according to manufacturer’s 2
directions.
3.Roll small blankets like a jelly
roll and tuck tent edges under 2
blanket rolls, as necessary.
4.Place tent over crib or bed.
Connect the humidifier to the
2
oxygen source in the wall and
connect the tent tubing to the
humidifier.
5.Adjust flow rate as ordered by
physician. Check that oxygen is 2
flowing into tent.
6.Turn analyzer on. Place
oxygen analyzer probe in tent, 1
out of patient’s reach.
7.Adjust oxygen as necessary,
2
based on sensor readings.
44

10.Adjust oxygen as necessary,
2
based on sensor readings.
11.Once oxygen levels reach the
prescribed amount, place patient 2
in the tent.
12.Encourage patient and
family members to keep tent 2
flap closed.
13.Reassess patient’s respiratory
status, including respiratory rate, 2
effort, and lung sound.
14.Remove PPE, if used.
1
Perform hand hygiene.
15.Frequently check bedding
and patient’s pajamas for
1
moisture. Change as needed to
keep the patient dry.
a. Document amount of
oxygen Applied.
b. Respiratory rate. 2
c. Oxygen saturation level.
d. Assessment before and
after intervention.
Total 32
45
Range of motion exercises (ROM)

Mark:
Evaluation
1.Wash hands, wear gloves if
1
contact with body fluids.
2.Explain procedure to patient. 1
3.Provide for privacy, including
1
exposing only the extremity.
4.Adjust bed to comfortable height 1
for performing ROM.
5.Lower bed rail only on the side to
1
the nurse.
6.Support the limb being ranged
1
above and below the joint.
7.Apply ROM slowly,and smoothly. 1
8.Start at the patients head and
perform exercises down each side 2
of the body.
9.Repeat each ROM exercise as the
patient tolerates, to a maximum of 5 2
times.
10: Neck ROM
-Flexion: bring chin to rest on chest
- Extension: return to erect
position.
- Hyperextension: bend back as 5
far as possible.
- Lateral flexion: tilt as far as
possible toward each shoulder.
- Rotation .
11: Shoulder ROM:
-Flexion: raise arm from side 8
position forward to above.
46
- Extension: return arm to position

at side of body.
- Hyperextension: move arm
behind body keeping elbow
straight.
- Abduction: raise arm to side to
position above with palm turned
away.
- Adduction: lower arm sideways
and across body as far as
possible.
- Internal rotation: move arm to
side at shoulder level with elbow
bent at 45 degrees.
- External rotation: with elbow
flexed move arm until thumb is
upward and lateral.
Circumduction: move arm in full
circal.
12: Elbow ROM:
1. Flexion: extend the arm then
bend elbow so that lower
arm moves toward the
shoulder.
3
2. Extension: straighten elbow
by lowering hand.
3. Hyperextension: bend lower
arm back as far as possible
beyond normal extension.
13.Forearm ROM:
- Supination: turn lower arm and
hand so that palm is up .
2
-Pronation: turn lower arm so that
palm is down.
47
14. Wrist ROM:

- Flexion: move palm toward inner
aspect of forearm .
- Extension: move fingers so
fingers, hands, and forearm are in
straight line .
- Hyperextension: bring dorsal 5
surface of hand back as far as
possible .
- Abduction: bend wrist medially
toward thumb.
- Adduction: bend wrist laterally
toward fifth finger.
15. Thumb ROM:
-Flexion: move thumb across
palmer surface of the hand.
-Extension: move thumb straight a
way from hand
5
Abduction: extend thumb laterally.
- Adduction: move thumb back
toward hand .
- Opposition: touch thumb to each
finger of same hand .
16. Hip and leg ROM:
-Flexion: move leg forward and up
-Extension: move leg back beside
other leg.
-Hyperextension: move leg back
beyond normal extension.
8
-Abduction: move leg laterally
away from body.
Adduction: move leg back toward
medial position
-Internal rotation: Turn foot and
leg in ward.
48
-External rotation: Turn foot and

leg out ward.
-Circumduction: move leg in
circle.
17. Ankle ROM

-Dorsiflexion: move foot so toes
are pointed up ward. 2
-Planter flexion: move foot so toes
are pointed down ward.
18. Foot ROM:
-Inversion: turn the whole foot
inward.
-Eversion: turn the whole foot
outward. 6
-Flexion: curl toes downward.
-Extension: bend the toes upward.
-Abduction: spread toes a part.
-Adduction: bring toes together.
19: Documentation.
1
Total
56
49
Assisting A Patient with Turning in Bed

Mark:
Evaluation
 Identify the patient.
 Introduce yourself and explain
the procedure. 4
 Provide privacy.
 Perform hand hygiene and put
on PPE
2. Prepare the bed.
 Position at least one nurse
on either side of the bed.
 Place pillows, wedges, or
any other support to be
used for positioning
within easy reach. 4
 Place the bed at an
appropriate and
comfortable working
height, usually elbow
height of the caregiver.
 Lower both side rails.
3. Position a friction-reducing 1
sheet under the patient
4.Reposition the patient.
 Move the patient to the edge
2
of the bed
 Raise the side rails.
51
5. Prepare the patient for

turning.
Able patient: Have the patient 2
grasp the side rail on the side of
the bed toward which he or she
is turning.
6. Unresponsive patient:
Place the patient’s arms across
2
his or her chest and cross the far
leg over the leg nearest to the
nurse where to be turned.
7 .If available ,Activate the bed
mechanism to inflate the side of 2 the bed
behind the patient’s back
if available.
8. Use body mechanics during turning :
 The nurse on the side of the
bed toward which the patient
is turning should stand
opposite the patient’s center
with feet spread about
3
shoulder width and with one foot
ahead of the other.
 Tighten the gluteal and abdominal muscles and flex your
knees.
 Use leg muscles to do the pulling
51
9. The other nurse should

position hands on the patient’s
shoulder and hip, assisting to
roll the patient to the side.
- Instruct the patient to pull on 3
the bed rail at the same time.
- Use the friction-Reducing sheet
to gently pull the patient over on
his or her side.
10. Support the patient’s back.

- Use a pillow or other support
behind the patient’s back. 2
- Pull the shoulder blade
forward and out from under.
11. Ensure patient’s safety and
comfort.
-Make the patient comfortable
and position in proper
alignment, using pillows or
other supports under the leg and
arm, as needed.
-Readjust the pillow under the
5
Patient’s head.
-Elevate the head of the bed as
needed for comfort.
-Place the bed in the lowest
position, with the side rails up.
-Make sure the call bell and
other necessary items are Within
easy reach.
12. Remove gloves and other
PPE, if used. Perform hand
hygiene. 2
52
13. Document the following:

-Time the patient’s position
was changed.
-Use of supports.
-Any pertinent observations 4
including skin assessment -Patient’s
tolerance of the
position change; and aids used
to facilitate movement.
Total 36
53
Moving A patient up in Bed with the Assistance of

Another Caregiver
Mark:
Evaluation
1. Follow Standard Protocol.
-Identify the patient.
-Introduce yourself
-Explain the procedure. 5
-Provide privacy.
-Perform hand hygiene and put on
PPE
2.With two nurses on opposite sides
of bed, lower side rails and lock the 2
wheels on the bed.
3.Remove pillow and place against
2
headboard.
4. Place draw sheet on bed under 2
patient’s midsection.
5.Roll or bunch sheet so edges are
close to patient’s body and grasp
2
firmly next to patient’s shoulders
and hips.
6.If able to assist, have patient flex
1
knees and place feet flat on bed.
7.Facing head of bed, the nurses
stand on either side of the
2
patient’s center with knees flexed
and feet apart in a broadstance.
8.On signal, rock and shift weight
from back to front leg, one smooth 2
motion.
9.After each positioning, realign
patient, replace pillows and 2
other positioning aids.
54
10.Remove gloves and other PPE, if

2
used. Perform hand hygiene.
 Time the patient’s position was
changed.
 Use of supports.
 Any pertinent observations
4
including skin assessment
 Patient’s tolerance of the position
change; and aids used to
facilitate movement.
Total 26
55
Making a closed unoccupied adult bed

Mark:
Evaluation
1.Hand washing. 1
2.Prepare the equipment. 1
3.Raise bed to comfortable working
1
level.
4.Apply clean gloves and remove 2
solid linen
5.Maintain body mechanics. 1
6.Remove soiled line 1
7.Place pillows on bedside chair or
table after removing soiled pillow 2
slips.
8.Fold reusable linens (bedspread ,
blanket and top sheet on the bed) 2
into a fourths.
9.Remove soiled pillowcases by
grasping the closed end with one
2
hand and slipping the pillow out
with the other.
10.Fold soiled linens: head of bed to
middle, foot of bed to middle. Place
2
in linen bag or hamper, keeping
soiled linens away from uniform
11.Check mattress. If the mattress
is soiled, clean it with an antiseptic 2
solution and dry it thoroughly.
12. Remove and disposed gloves

and perform hand washing. 2
56
13.Apply the bottom sheet and draw

sheet; Place the folded bottom sheet 2 with its
center fold on the center of
the bed.
14. Miter the sheet at the top corner on the near side and tuck the
sheet under the mattress, working from the head of the bed to the
foot:
a. Tuck in the bedcover (sheet,
blanket, and /or spread) firmly
under the mattress at the bottom or
top of the bed.
b. Lift the bedcover so that it forms
a triangle with side edge of the bed
and the edge of the bedcover is
parallel to the end of the bed . 5
c. Tuck the part of the cover that
hangs below the mattress under the
mattress while holding the triangle
up or against the bed
d. Bring the tip of the triangle down
toward the floor while the other
hand holds the fold of the cover
against the side of the mattress .
e. Remove the hand and tuck the
remainder of the cover under the
mattress.
15. Move to the other side and
secure the bottom linens. Tuck in
the bottom sheet under the head of
the mattress; pull the sheet firmly
2
and with no wrinkles. And miter the
corner of the sheet.
57
16. Apply or complete the top sheet,

blanket, and spread; Place blanket
3
over top sheet, smooth out. Place
spread over blanket, smooth out.
17. Allow for toe pleat:
a. Vertical toe pleat: Make a fold in
the sheet 5 to 10 cm perpendicular
to the foot of the bed. 2
b. Horizontal toe pleat: Make a fold
in the sheet 5 to 10 cm across the
bed near the foot.
18. Fold the top of top sheet down
2
over the spread providing a cuff.
19.Put clean pillowcase on pillow as

required.
a. Grasp the closed end of the
pillowcase at the center .
b. Gathers up the sides of the
pillowcase and place them over the
4
hand grasping the case..
c. With the free hand, pull the
pillowcase over the pillow .
d. Adjust the pillowcase so that the
pillow fits into the corners of the
case .
Total 39
58
Making a surgical unoccupied adult bed

Evaluation
1- Carry out the steps from 1: 14. 14
2- Place and leave the pillow on 2
the bedside chair.
3-On the side of the bed where the
patient transferred, fold up the two
outer corners of the top linens so 2
they meet in the middle of the bed
forming a triangle
4-Pick up the apex or point of the
triangle and fanfold the
top linens lengthwise to the side of 2
the bed opposite from where the
patient will enter the bed
5-Leave the bed in high position
2
with the side rails down.
6-Lock the wheels of the bed. 2
7-Return the bed to the lowest
position and elevate the head of 2
the bed 30 to 45 degrees.
8-Assist the patient back into the
2
bed and pull the side rails.
9-Attach the call light so the

2
patient can reach it.
10-Place the bed side cabinet and
over bed table so that they are 2
available to the patient.
11-Hand washing. 4
12-Document the procedure. 2
59
Total 38
61
Making an occupied adult bed

Mark:
Evaluation
1-Hand washing. 1
2-Prepare the equipment. 1
3-Raise bed to comfortable
1
working level.
4-Apply clean gloves and 2
remove solid linen
6-Maintain patient's privacy. 1
7-Remove any equipment
attached to the bed linen, such as 2
signal light.
8-Remove blanket and
2
bedspread and loosen sheet.
9-Place bed in as flat a position
2
as the patient can tolerate
10-Leave the top sheet over the
2
patient.
11-Replace the top sheet with a
bath blanket as follows .
a. Spread the bath blanket over
the top sheet.
b. Ask the patient to hold the
top edge of the blanket.
4
c. Reaching under the blanket,
grasp the top edge of sheet
and draw it down to the foot
of the bed, leaving the blanket
in place.
d. Remove the sheet from the
61
bed and place it in the soiled

linen hamper.
12-Change the bottom sheet and

draw sheet:
a. Raise the side rail that the
patient will turn toward.
b. Assist the patient to turn on
the side away from the nurse
and toward the raised side rail.
c. Loosen the bottom linens on
the side of the bed near the
nurse.
d. Fanfold the dirty linens.
e. Place the new bottom sheet 4
on the bed, and vertically
fanfold the half to bed used on
the far side of the bed as close
to the patient as possible.
f. Place the clean draw sheet on
the bed with the center fold at
the center of the bed. Fanfold
the upper most half vertically at
the center of the bed and tuck
the near side edge under the
side of the mattress.
13-Assist patient to roll slowly
toward nurse over folds of linen
2
and go to opposite side of bed &
lower side rails.
14-Loosen and remove all
bottom linens. Discard soiled
linen in laundry bag or hamper.
2
Do not place on floor or
furniture. Do not hold soiled
linens against the uniform.
62
15-Pull bottom sheet to proper

position and miter corners.
Stretch draw sheets into place 2
and tuck under mattress. Finish
placement of top linens.
16-Cover pillow with clean
1
pillow case.
17-Tuck in all linens at foot of
bed, raise side rails & make 1
opposite side of bed.
18-Make toe pleat. 1
19-Ensure continued safety of
the patient:
a. Raise the side rail.
b. Place the bed to the lowest
3
position and elevate the head
of the bed 30 to 45 degrees.
c. Attach the call light so, the
patient can reach it
20-Hand washing. 1
21-Documentation: 1
Total 37
63
Hygienic care
Mark:
Evaluation
Bed bath:
1-Introduce self and verify 1
4-Perform hand hygiene and 2
wear gloves.
7-Lower side rail nearer to work
area and assist patient to side of
2
bed. Have patient lie on his or
her back.
8-Place bath blanket over top
sheet. Remove top sheet from
2
under bath blanket. Remove
patient’s gown.
9-Fill washbasin two-thirds full.
Permit patient to test 2
temperature of water with hand.
10-Wet the washcloth and wring
2
it out.
11-Make a bath mitten with the
2
washcloth.
12- Wash eyes use a separate

corner of the washcloth for each 2
eye, wiping from inner to outer
13-Wash face, neck and ears.
Rinse and pat dry. 2
64
14-Wash arms, forearms, and

hands. Using strokes in the
direction from distal to 2
proximal. Wash axilla. Rinse
and pat dry
15-Apply deodorant or powder if
1
desired.
16-Immerse patient’s hand into
basin of water. Allow hand to
soak about 3–5 minutes. Wash 2
hands, fingers, and fingernails.
Rinse and pat dry
17-Fold bath blanket down to
umbilicus. Wash chest using
long, firm strokes. Wash skin 2
fold under the female breast.
Rise and pat dry
18-Fold bath blanket down to
supra-pubic area. Use another
towel to cover chest area. Wash
abdomen using long, firm 2
strokes. Rinse and pat dry.
Replace bath blanket over chest
and abdomen.
19-Expose leg farthest by
folding bath blanket toward the
other leg. Wash, rinse and pat 2
dry the leg from ankle to the
knee to the thigh.
20-Assist patient into prone or
side- lying position. Wash back
2
and buttocks. Rise and pat dry.
Give back rub and apply lotion
21-Assist patient to supine
2
position. perform perineal care.
65
22-Change bed linens. Dispose

of soiled linens according to 1
agency policy.
23-Change bed linens. Dispose
of soiled linens according to 2
agency policy.
1
position with the side rails up.
25-Wash hands. 1
26-Documentation: 1
Total 42
66
Oral Care
Mark:
Evaluation
1. Brushing
1-Introduce self and verify patient’s 2
identity.
4-Perform hand hygiene, apply
1
gloves.
7-Place patient in a high fowler's
1
position.
8-Place the towel under the patient's
2
chin.
9-Moisten toothbrush in cup of
water and apply toothpaste to 2
bristles.
10-Place the emesis basin under
2
patient's chin.
11-Inspect the mouth, gums and

2
teeth.
12-Brush the patient's teeth holding
the bristles at a 45 degree angle.
2
Brush from gum line to the crown
of the tooth .
13-Move the bristles up and down
gently. Repeat until all outer and
inner surfaces of the teeth are 2
cleaned.
67
14-Brush the biting surfaces of the

teeth by moving the brush back and 2
forth on top of the tooth's surface
15-Brush tongue gently with
2
toothbrush
16-Assist patient in rinsing of
2
mouth with cup of water.
Total 26
68
2. Flossing:
Mark:
Evaluation
1-Wrap one end of the floss
around the third finger of each 1
hand .
2-Ask patient to open mouth and
2
smile to reveal teeth.
3- Gently insert floss between
2
teeth and move it back and forth
4-Move the floss up and down 2
between the teeth.
5-Assist patient to rinse mouth. 2
6-Apply lubricant to patient lips
1
as needed.
7-Remove and dispose of
2
equipment appropriately.
8-Remove and discard gloves
2
and wash hands.
2
position.
10-Document procedure and
assessment finding of the teeth, 2
tongue, gums, and oral mucosa.
Total 18
69
II- Denture care:

Mark:
Evaluation
Denture care
1-Verify patient’s identity and 1
introduce self.
2- Explain procedure to patient. 1
3-Provide privacy. 1
4-Assist patient to a high-
2
fowler’s position.
5-Assemble articles for denture
1
cleaning.
6-Wash hands . 2
7- Apply gloves 1
8- Maintain body mechanics. 1
9-Assist patient with denture
removal (Top denture): With
tissue, grasp the denture with 2
thumb and forefinger and pull
downward. Place in denture cup.
10-Assist patient with denture
removal (Bottom denture): Place
thumbs on the gums and release
the denture. 2
- Grasp denture with thumb and
forefingers and pull upward.
Place in denture cup.
71
11-Apply toothpaste to brush,

and brush dentures either with
cool water in the emesis basin or 2
under running water in the sink.
Pad sink with towel.
12-Rise denture thoroughly 1
13-Assist patient with rinsing

1
mouth and replacing dentures.
14-Reposition patient, with side
2
rails up.
15-Rinse, dry, and return articles
2
to proper place.
16-Remove gloves and wash
2
hands.
17- Documentation. 1
Total 25
71
III. Mouth care for unconscious patients:

Mark:
Evaluation
1
3-Gather appropriate
1
equipment
4-Perform hand hygiene, apply 2
gloves.
7-Place the patient in a lateral
position, with the head turned 2
toward the side.
8-Place the towel under the
2
patient's chin.
9-Place the emesis basin
against the patient's chin and 2
lower cheek.
10-Gently open the patient’s
mouth by applying pressure to
2
lower jaw at the front of the
mouth
11-Place bite block in patient's
mouth never fingers in an 2
unconscious patient's mouth.
12-Moisten toothbrush or
toothette, and brush the teeth
and gums using friction in
2
circular motion.
72
13-Rinse mouth with syringe

(do not force water into the 2
mouth)
14-Allow fluid to run out of
patient mouth into basin. If
needed, suction may be used to 2
remove excess fluid from the
mouth
15-Swab roof of mouth and
2
tongue with toothette as well.
16-Dry the patient's mouth.
2
17-Apply lip lubricant.

1
18-Raise side rails and lower

2
bed.
19-Remove and dispose of
2
equipment appropriately.
20-Remove and discard gloves
2
and wash hands.
1
position.
22-Documentation.
1
Total 36
73
Shampooing A Patient's Hair in Bed

Mark:
Evaluation
1-Identify the patient and
1
introduce self.
2-Explain the procedure to the
1
patient.
1
equipment.
5-Wash hands and don
2
disposable gloves
6-Maintain body mechanics 1
7-Lower the head of the bed.
Remove pillow and place
2
protective pad under patient’s
head and shoulders.
8-Place linen saver (or plastic
bag) covered by a towel under 2
patient’s shoulders and head .
9-Fill the large pitcher/s with
warm water (105°–110°F),
checking temperature with
2
thermometer or volar surface
of your arm. Place on bedside
table .
10-Place the shampoo tray
under the patient’s neck and
head with neck in the U-shaped 2
opening. Adjust the fan-folded
neck towel to cushion the tray .
74
11-Position pail/washbasin/trash
can in direct line with the spout
2
of the shampoo tray. Position as
close to the spout as possible.
12-Offer washcloth for patient to
hold over or above eyes and
2
cotton balls to place in ears
during shampooing..
13-Fill small pitcher with water
by dipping it into the larger 2
pitcher.
14-Place a small amount of
shampoo into your palms and
1
massage it into the hair, working
the shampoo into a lather.
15-Rinse the hair using the
pitcher to pour warm water over 2
the hair and scalp.
16-Repeat application of
shampoo and massage scalp and
2
hair gently but vigorously for a
longer period of time.
17-Rinse again using several
pitchers of water until hair and 1
scalp are free of shampoo.
18-Support patient's head while
2
remove the shampoo tray.
19-Wrap patient's hair by gently
pulling fan- folded bath towel
1
from shoulders up and over
scalp.
20-Remove the linen saver and
towel from the bed by carefully 2
folding inward .
75
21-Elevate the head of bed to

desired angle within prescribed 1
and/or patient-tolerated limits.
22-Thoroughly dry your hands
1
and/or change gloves.
23-Turn on hair dryer to warm
setting and check the 1
temperature on your inner arm.
24-Dry hair, concentrating on
one section at a time, moving
your fingers, comb, or brush 2
gently through the hair while
drying.
25-Gently comb/brush the hair. 1
26-Reposition the patient

comfortably, adjust bed as
2
requested within medical orders,
safety measures.
27-Empty the water. Remove,

1
clean, and return equipment.
28-Remove gloves and wash
2
your hands.
29- Document the following:

Assessment, significant
2
observations, and unusual
findings.
Total 45
76
Foot and nail care

Mark:
Evaluation
1-Identify the patient and
1
introduce self.
2-Explain the procedure to the
1
patient.
4-Wash hands /apply gloves. 2
1
equipment
6-Maintain body mechanics 1
7-Fill washbasin halfway with
warm water. Test water
2
temperature and place basin on
the linen saver.
8-Soak hand/foot from 2 to 10
minutes, depending on patient 2
health and tolerance
9-Wash hand/foot with scant
amount of mild antibacterial 2
soap.
10-Rinse well to be sure all
2
soap is removed.
11-Remove hand/foot from
basin and place directly onto 2
clean towel.
12- Pat and then gently rub
dry, paying close attention to
between and under the 2
fingers/toes.
77
13- Using the towel, or cuticle

stick, gently push the cuticle
2
and subungual skin back.
14-Scrub callused areas of feet

2
with washcloth
15-Apply powder between and
1
under fingers/toes.
16-Check pulses, turgor, and
2
capillary refill.
17-Empty basin and refill.
Repeat procedure with other 2
hand /foot
18-While other hand /foot
soak, perform nail care on the 2
first hand /foot.
19-Cut toenails straight across. 2
20-Lightly apply cream (not

lotion), massaging into the 1
hand/foot.
21-Remove, clean, and replace
2
equipment/supplies.
22-Dispose of gloves and wash
2
hands.
23-Documentation:
- Record the time and date care
1
was performed.
- Note any unusual finding.
Total 38
78

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Nursing Department Student Logbook رات العواضي

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Medical Surgical Nursing Dept.

Log Book for Adult nursing I

Adult Nursing Dept. Faculty of Nursing

Log Book of Fundamental Of

11. Pat hands dry with a paper

Performing Hand Hygiene Using an Alcohol

Student’s Name: Clinical Evaluator:

Using Personal Protective Equipment (PPE)

Student’s Name: Clinical Evaluator:

6. Except for respirator,

patient's room and closing the

a. Grasp the neck ties or

10. Perform hand hygiene

12. Slowly rotate thermometer at eye

17. Carefully remove thermometer from

24. Place patient in comfortable

Measuring Oral Body temperature - Electronic

11-Have patient keep the probe

13-Return the probe to its stored

16-Place patient in comfortable

Measuring Axillary Body Temperature by mercury

12. Lower the arm over the

16. Read thermometer.

17. Dispose of gauze in a container.

18. Wash thermometer in cool

Measuring Axillary Body Temperature—

11. hold the prope in place until

12. Remove the probe from the

15. Rearrange the equipment. 2

Measuring Rectal Body Temperature by Mercury

11. Ask patient to take deep

12. Gently insert the

20. Rearrange the equipment. 2

21. Place patient in

Measuring Rectal Body Temperature-electronic

10-Grasp the probe by the

16-Rearrange the equipment. 2

17-Place patient in comfortable

Heat and Cold measures

Student’s Name: Clinical Evaluator:

10. Place it on the affected

14. Proper dispose of all

Student’s Name: Clinical Evaluator:

Assessing radial (wrist) pulse:

12-Document the pulse rate,

Assessing apical pulse:

C. Assessing apical-radial pulse:

1-Introduce self and verify

3-Gather appropriate equipment.

4-Perform hand hygiene . 1

6-Maintain body mechanics. 1

6-Both nurse end the count when

3-Rearrange the equipment.

4-Replace the patient’s clothing,

Measuring blood pressure Auscultation method using

11-Partially open the valve counter

13-The systolic and diastolic

Measuring blood pressure from the thigh:

13.Partially open the valve

A. Measuring blood pressure by the palpation method.

Student’s Name: Clinical Evaluator:

Using a Pulse Oximetry

Assisting a patient with an incentive spirometer.

13. Teach patient to perform