1-FON Skill Lab Manual

TABLE OF CONTENTS
S# SKILLS PAGE
1. CPR Certifications BLS 2
2. Preparing of different beds
a. Making an Un-occupied Bed: 7
b. Making an Occupied Bed 11
c. Making a Post-operative Bed 14
3. Bathing a patient in bed 17
4. Measuring body temperature 21
5. Assessment of pulse 26
6. Assessment of Respiration 28
7. Monitoring of Blood pressure 29
8. Assisting the client with oral care 34
9. Mouth care of unconscious patient 36
10. Measurement of Height & Weigh 38
11. Application of hot water bag 40
12. Application of Cold Compresses 42
13. Applying bandages including wound dressing 44
14. Oxygen Administration 51
15. Performing Nebulization/steam therapy 53
16. Apply suction therapy 56
17. Care of drainage bags (catheter) 59
18. Sitz bath 61
19. Elimination:
A. Enema. 63
B. Suppositories. 66
C. Flatus Tube, 68
D. Manual Extract 70
20. Specimen Collection:
A. Collecting Blood Specimen 73
B. Obtaining Blood for Culture 76
C. Collecting Urine Specimen 77
D. Collecting a 24-hour Urine Specimen 78
E. Collecting a Urine Specimen from a Foley Catheter 79
F. Collecting a stool specimen 80
G. Collecting Specimen of Throat Swab 82
H. Collecting a sputum specimen 83
I. Collecting a sputum culture 84
21. Urine Testing through dipstick 86
22. Informed Consent
CPR CERTIFICATIONS BLS (BASIC LIFE SUPPORT)
CARDIO PULMONARY RESUSCITATION
Definition: Cardiopulmonary resuscitation (CPR) is the basic life-saving skill that is utilized in
the event of cardiac, respiratory, or cardiopulmonary arrest to maintain tissue oxygenation by
providing external cardiac compressions and/ or artificial respiration. This life-saving skill is
initiated in the event that an individual is found with the absence of a pulse or respiration or both.
The basic goals of CPR, which are often referred to as the ABCs of emergency resuscitation,
follow: ABCD (Airway, Breathing, Circulation, Defibrillate)
 To establish an airway
 Initiate breathing
 Maintain circulation
Purposes:
 To Restore cardio pulmonary functioning.
 To provide oxygen and blood flow to the heart, brain, and other vital organs.
 To prevent irreversible brain damage from anoxia.
Equipment:
 Hard, flat surface (e.g., chest  Oral airway
compression board)  Emergency resuscitation cart.
 Body substance isolation items  Documentation forms.
(Gloves, Mask. Oral barrier device)
 Ambo bag
Procedure:
S# Nursing Action Rational
1 Asses the Response:
Assess responsiveness by tapping or gently Confirms that client is unconscious as opposed to
shaking client while shouting, “Are you intoxicated, sleeping or hearing impaired.
OK?”
2 If unresponsive:
Activate emergency medical system. In the Activates assistance from personnel trained in
hospital, follow institutional protocol. In the advanced life support. Also, one person cannot
community or home environment, activate perform.
the local emergency response system
(e.g.1122)
3 Position client in a supine position on a hard, Proper positioning facilitates assessment of the
flat surface (e.g., floor or cardiac board). cardiac and respiratory status and successful
compression of the heart.
Use caution when positioning a client with a A client with a potential head or neck injury to
possible head or neck injury. prevent further damage.
4 Apply gloves, face shield if available. Prevents transmission of disease.
5 Position self. Face the client on your knees Proper positioning facilitates CPR by allowing the
parallel to the client, next to the head, to rescuer to move from chest compressions to
begin to assess the airway and breathing artificial breathing with minimal movement.
status.
6 Airway:
Open airway. The most commonly used A patent airway is essential for successful artificial
2
method is the head-tilt/chin-lift method respirations
Use the Head Tilt-Chin Lift maneuver:

In the event of a witnessed collapse with no The head tilt/chin lift assists in preventing the
reason to assume a cervical spine injury: tongue from obstructing the airway.
 Accomplished by placing one hand on
the client‟s forehead and applying a
steady backward pressure to tilt the head
back.
 While placing the fingers of the other
hand below the jaw at the location of the
chin and lifting the chin.
Use the Jaw Thrust Maneuver. In the event The jaw thrust is used when a head or neck injury is
of a suspected head or neck injury, this lift is suspected because it prevents extension of the neck
modified and the jaw thrust is used. and decreases the potential of further injury.
To perform the jaw thrust,
 Place hands at the angles of the lower
jaw and lift, displacing the mandible
forward while tilting the head backward.
 Additionally, if available, insert oral
airway.
7 Breathing: Assess for respirations. Cardiopulmonary resuscitation should not be

Look, listen, and feel for air movement. administered to a client with spontaneous
Watch for abnormal breathing or gasping. respirations due to the potential risk of injury.
If respirations are absent:

Commence rescue breaths immediately.
For mouth to mouth resuscitation:
 Occlude nostrils with the thumb and Occluding the nostrils and forming a seal over the
index finger of the hand on the forehead client‟s mouth will prevent air leakage and provide
that is tilting the head back. full inflation of the lungs.
 Form a seal over the client‟s mouth using
either your mouth or the appropriate
respiratory assist device (Ambo bag and
mask)
 Deliver two rescue breaths. Each rescue Excess of air volume and fast respiratory flow rate
breath should last approximately 0.5 to 2 can cause pharyngeal pressure that exceed
second allowing time for both inspiration esophageal opening pressure, allowing air to enter
stomach and result in gastric distension & increase
and expiration
the risk of vomiting.
In the event of a serious mouth or jaw injury
that prevents mouth-to-mouth ventilation,
mouth-to-nose ventilation may be used by
tilting the head earlier with one hand and
using the other hand to lift the jaw and close
the mouth.
3
8 Assess for the rise and fall of the chest: Visual assessment of chest movement helps confirm
• If the chest rises and falls, continue to next an open airway. A volume of 800– 1200 ml is
step. usually sufficient to make the chest rise in most
• If the chest does not move, assess for adults.
excessive
oral secretions, vomit, airway obstruction,
or improper positioning
9 Circulation: Check the patient for a carotid
pulse for 5-10 seconds Performing chest compressions on an individual
 If present, continue rescue breathing, at with a pulse could result in injury. Hyperventilation
the rate of 10-12 breaths/min. assists in maintaining blood oxygen levels.
 If absent, begin cardiac compressions
10 Cardiac compressions are performed as Irreversible brain and tissue damage can occur if a
follows: client is hypoxic for over 4–6 minutes. Proper
 Position the hands for compressions: positioning is essential for the following reasons:
 Using the hand nearest to the legs, use  Allows for maximum compression of the heart
the index finger to locate the lower rib between the sternum and vertebrae.
margin and quickly move the fingers up  Compressions over the xiphoid process can
to the location where the ribs connect to lacerate the liver.
the sternum.
 Place your palms midline, one over the Results are maxima in compression of heart between
other, on the lower 1/3 of the patient‟s sternum and vertebrae.
sternum between the nipples.
 Extend or interlace fingers and do not Careful attention to hand placement during cardiac
allow them to touch the chest compression prevents fractured rib and organ
trauma.
 Keep arms straight with shoulders
directly over hands on sternum and lock
elbows
 Compress the adult chest at depth of 2 to
2.4 inches (5-6cm) or more on the
patient‟s chest at the rate of 100–120
compressions per minute.
 The heel of the hand must completely
release the pressure between
compressions, but it should remain in
constant contact with the client‟s skin.
 Use the mnemonic “one and, two and,
three and . . .” to keep rhythm & timing.
 Press hard and fast. Allow for full chest  Faster rate increase the blood flow to brain and
recoil with each compression. heart.
 1 cycle of adult CPR is 30 chest
compressions to 2 rescue breaths.
 Reassess the client after 5 cycles of CPR  Determine return of pulses and respiration and
(lasts approximately 2 minutes). need to continue CPR.
11  If two providers are present: switch rolls One rescuer to perform artificial respirations while
between compressor and rescue breather the other administers chest compressions without
getting in each other‟s way.
In addition, this facilitates ease in when one of the
4
rescuers becomes fatigued.
12 Defibrillate: Power:
Turn AED on NOW! Follow verbal AED Early defibrillation is the single most important
prompts. therapy for survival of cardiac arrest and should be
done as soon as it arrives.
Attachment: Firmly place appropriate pads
to patient‟s skin to the indicated locations.
Analyze:
If the rhythm is not shock able: A short pause in CPR is required to allow the AED
Initiate 5 cycles of CPR. Recheck the rhythm to analyze the rhythm.
at the end of the 5 cycles of CPR.
If the shock is indicated:
 Assure no one is touching the patient by You or someone else could get shocked. Conductive
yelling “Clear, I‟m Clear, you‟re clear!” surfaces may transfer the shock to others.
prior to delivering a shock.
 Press the shock button
 Resume 5 cycles of CPR.
 Reevaluate the patient‟s response
13 Recovery position
(lateral recumbent or 3/4 prone position): This position is used to maintain a patent airway in
Place the patient close to a true lateral the unconscious person. Turning head allows gravity
position with the head dependent to allow to drain secretions.
fluid to drain.
Assure the position is stable. Prevents from airway obstruction
References:
 Delmar‟s fundamental and advanced nursing skills
 P. Ratna (2007).Manipal Manual of Nursing procedures, (IST Ed vol.1 Part)
5
Basic Life Support (BLS)
Mouth to Mouth Breathing Rescue breathsbreathing with Ambo bag
Access carotid pulse Chest compression
Place Appropriate Pads & Deliver Shock Resume CPR
6
BED MAKING:
MAKING AN UN-OCCUPIED BED:
Definition: A bed prepared to receive a new patient is an un-occupied bed.
Purpose
 To provide clean and comfortable bed for the patient
 To reduce the risk of infection by maintaining a clean environment
 To prevent bed sores by ensuring there are no wrinkles to cause pressure points
Equipment required:
 Mattress  Mackintosh
 Bed sheets  Draw sheet
 Bottom sheet  Blanket
 Top sheet  Non-sterile gloves
 Pillow  Laundry bag or hamper.
 Pillow cover  Trolley
Procedure:
1. Prepare all required equipment. Organization facilitates accurate skill performance.
2. Wash your hands. Hand washing prevents the spread of infection.
3. Move the chair and bed side locker It makes space and helps effective action.
4. Clean Bed-side locker: Wipe with wet & dry To maintain the cleanliness
gauze.
5. Position bed: flat, side rails down, adjust height to Promotes good body mechanics and decreases back
waist level. strain.
6. Remove and fold blanket and/or bedspread. If Keeps reusable bed linens clean.
clean and reusable, place on clean work area.
7. Remove soiled pillowcases by grasping the Allows easy removal of the pillowcases without
closed end with one hand and slipping the pillow contamination of uniform by soiled linens
out with the other. Place the soiled cases on top of and keeps pillows clean
the soiled sheet, and place the pillows on clean
work area.
8. Remove soiled linens: Start on the side of the bed Linens are folded from cleanest area to most soil to
closest to you; free the bottom sheet and mattress prevent contamination.
and rolling soiled linens to the middle of the bed.
Go to the other side of the bed, repeat action.
9. Fold soiled linens: head of bed to middle, foot of Folding linens reduces the risk of transmission of
bed to middle. Place in linen bag or hamper, infection to others.
keeping soiled linens away from uniform
10. Clean the mattress: If the mattress is soiled,
clean it with an antiseptic solution. Gather the Reduces the transmission of microorganisms.
dust and debris to the bottom Collect them into
kidney tray. Give dry wiping.
11. Remove gloves, wash hands, and apply a second Reduces the transmission of microorganisms to
pair of clean gloves. clean linens.
12. Fitted Bottom Sheet:
 Position yourself diagonally toward the head Ensures good body mechanics and efficient
of the bed. procedure.
7
 Start at the head with seamed side of the fitted Placement of seamed side toward mattress prevents
sheet toward the mattress. irritation to the client‟s skin.
 Lift the mattress corner with your hand Prevents straining of back muscles; decreases the
closest to the bed; with your other hand, pull chance that the sheet will pull out from under the
and tuck the fitted sheet over the mattress mattress.
corner; secure at the head of the bed.
 Pull and tuck the fitted sheet over the mattress
corners at the foot of the bed. It decreases the chance that the sheet will pull out
from under the mattress.
13. Flat Regular Sheet
 Place and slide the bottom sheet upward over Unfolding the sheet in this manner allows you to
the top of the bed leaving the bottom edge of make the bed on one side.
the sheet.
 Open it lengthwise with the center fold along
the bed center.
 Fold back the upper layer of the sheet toward
the opposite side of the bed.
 Tuck the bottom sheet securely under the
head of the mattress (approximately 20-
30cm).
Make a mitered corner.  A mitered corner has a neat appearance and
 Face the side of bed and lift and lay the top keeps the sheet securely under the mattress.
edge of the sheet onto the bed to form a  Forms the base for the tuck.
triangular fold.
 With your palms down, tuck the lower edge  Forms the first half of the tuck.
of sheet (hanging free at the side of the
mattress) under the mattress.
 Grasp the triangular fold; bring it down over  Will form the final portion of the mitered corner
the side of the mattress. Allow the sheet to when tucked in.
hang free at the side of the mattress.
 Place the draw sheet and mackintosh if used Provides a sheet to lift and move the client inbed
on the bottom sheet and unfold it to the without having to use the bottom sheet and remake
middle crease. the bed. Helps to keep the bottom sheet clean.
 Tuck the hanging part of the sheet under the
mattress.
 Face the side of the bed, palms of hands Keeps sheet taut, in place, and wrinkle-free,
down. Tuck both the bottom and draw sheets decreasing the risk of skin irritation.
under the mattress. Ensure that the bottom
sheet is tucked smoothly under the mattress
all the way to the foot of the bed.
14.  Go to the other side of the bed, unfold the
bottom sheet, draw sheet, if used, and grasp
the free-hanging sides of both the bottom and
draw sheets. Pull toward you, keeping your
back straight, and with a firm grasp sheets
tuck both sheets under the mattress.
15. Return to the right side.
8
Top sheet and blanket: A blanket provides warmth
 Place the top sheet evenly on the bed,
centering it in the below 20-30cm from the
top of the mattress
 Spread it downward.
 Cover the top sheet with blanket in the below
1feet from the top of the mattress and spread
downward.
 Fold the cuff (approximately 1 feet) in the Making the cuff at the neck part prevents irritation
neck part from blanket edge.
 Tuck all these together under the bottom of Tucking all these pieces together saves time and
mattress. Miter the corner. provides a neat appearance.
 Tuck the remainder in along the side
16. Repeat the same as in the above procedure in left To save time in this manner.
side.
17. Return to the right side. A pillow is a comfortable measure.
Pillow and pillow cover:
 Put a clean pillow cover on the pillow. Pillow cover keeps cleanliness of the pillow and
 Place a pillow at the top of the bed in the neat. The open end may collect dust or organisms.
center with the open end away from the door.
18. Return the bed, the chair and bed-side table to Bedside necessities will be within easy reach for
their proper place. the client
19. Replace all equipment in proper place. Discard It makes well-setting for the next.
lines appropriately. Proper line disposal prevents the spread of
infection.
20. Perform hand hygiene To prevent the spread of infection.
Nursing Alert
 Do not let your uniform touch the bed and the floor not to contaminate yourself.
 Never throw soiled lines on the floor not to contaminate the floor.
 Staying one side of the bed until one step completely made saves steps and time to do
effectively and save the time
9
10
BED MAKING
B. CHANGING AN OCCUPIED BED
Definition: The procedure that used to change linen of a hospitalized patient is an occupied bed.
Purpose:
 To provide clean and comfortable bed for the patient.
 T reduces the risk of infection by maintaining a clean environment.
 To prevent bed sores by ensuring there are no wrinkles to cause pressure points.
Equipment required:
 Mattress  Draw sheet
 Bed sheets  Blanket
 Bottom sheet  Non-sterile gloves
 Top sheet  Kidney tray or paper bag
 Pillow  Laundry bag or Bucket.
 Pillow cover  Trolley
 Mackintosh
Procedure:
Sr# Nursing Action Rational
1. Check the client‟s identification and condition. To assess necessity and sufficient condition
2. Explain the purpose and procedure to the client. Providing information fasters cooperation and
reduced patient's anxiety.
3. Prepare all required equipment. Organization facilitates accurate skill performance.
4. Perform hand hygiene Hand washing prevents the spread of infection.
5. Close the curtain or door to the room. Put screen. To maintain the client‟s privacy.
6. Remove the client‟s personal belongings from To prevent personal belongings from damage and
bed-side and put into the bed-side locker or safe loss.
place.
11
7. Lift the client‟s head and move pillow from The pillow is comfortable measure for the client
center to the left side.
8. Assist the client to turn toward left side of the Top sheet keeps the client warm and protect his or
bed. Adjust the pillow. Leaves top sheet in place. her privacy.
9. Stand in right side: Placing folded (or rolled) soiled linen close to the
Loose bottom bed linens. Fanfold (or roll) soiled client allows more space to place the clean bottom
linens from the side of the bed and wedge them sheets.
close to the client.
10. Wipe the surface of mattress by sponge cloth To prevent the spread of infection.
with wet and dry.
11. Bottom sheet, mackintosh and draw sheet: Soiled linens can easily be removed and clean linens
 Place the clean bottom sheet evenly on the are positioned to make the other side of the bed.
bed folded lengthwise with the center fold as
close to the client‟s back as possible.
 Adjust and tuck the sheet tightly under the
head of the mattress, making mitered the
upper corner.
 Tighten the sheet under the end of the
mattress and make mitered the lower corner.
 Tuck in alongside.
 Place the mackintosh and the draw sheet on
the bottom sheet and tuck in them together.
12. Assist the client to roll over the folded (rolled) Moving the client to the bed‟s other side allows you
linen to right side of the bed. Readjust the pillow to make the bed on that side.
and top sheet
13. Move to left side: Soiled linens can contaminate your uniform, which
Discard the soiled linens appropriately. Hold may come into contact with other clients.
them away from your uniform. Place them in the
laundry bag (or bucket).
14. Wipe the surface of the mattress by sponge cloth To prevent the spread of infection
with wet and dry
15. Bottom sheet, mackintosh and draw sheet:
 Grasp clean linens and gently pull them out
from under the client. Wrinkled linens can cause skin irritation.
 Spread them over the bed‟s unmade side.
Pull the linens taut
 Tuck the bottom sheet tightly under the head
of the mattress and miter the corner.
 Tighten the sheet under the end of the
mattress & make mitered lower corner.
 Tuck in alongside.
 Tuck the mackintosh and the draw sheet
under the mattress
16. Assist the client back to the center of the bed. The pillow is comfort measure for the client.
Adjust the pillow.
17. Return to right side: Tucking these pieces together saves time and
Clean top sheet, blanket: provides neat, tight corners
 Place the clean top sheet at the top side of the
soiled top sheet.
12
 Ask the client to hold the upper edge of the
clean top sheet.
 Hold both the top of the soiled sheet and the
end of the clean sheet with right hand and
with draw to downward. Remove the soiled
top sheet and put it into a laundry bag (or a
bucket).
 Place the blanket over the top sheet. Fold
top sheet back over the blanket over the
client.
 Tuck the lower ends securely under the
mattress. Miter corners.
 After finishing the right side, repeat the left
side.
18. Remove the pillow and replace the pillow cover The pillow is a comfortable measures for a client
with clean one and reposition the pillow to the
bed under the client‟s head.
19. Replace personal belongings back. Return the To prevent personal belongings from loss and
bed-side locker and the bed as usual. provide safe surroundings
20. Return all equipment to proper place. To prepare for the next procedure.
21. Perform hand hygiene. To prevent the spread of infection.
13
BED MAKING
MAKING A POST-OPERATIVE BED
Definition: a special bed prepared to receive and take care of a patient returning from surgery.
Purpose:
 To receive the post-operative client from surgery and transfer from a stretcher to a bed.
 To arrange client‟s convenience and safety
Equipment required:
 Mattress  Trolley
 Bed sheets  IV stand
 Bottom sheet  According to doctor‟s orders:-
 Top sheet Oxygen cylinder with flow meter
 Pillow  O2cannula or simple mask,
 Pillow cover Airway Tongue depressor
 Mackintosh  Suction machine with suction
 Draw sheet tube,
 Blanket  SpO2monitor (pulse oximeter)
 Infusion pump, syringe pump
 Kidney tray or paper bag
 Laundry bag or Bucket.
Procedure:
2. Assemble equipment‟s and bring bed- Organization facilitates accurate skill performance
side
3. Make foundation bed as usual with a Mackintosh prevents bottom sheet from wetting or
large mackintosh, and cotton draw soiled by sweat, drain or excrement.
sheet. Cotton draw sheet makes the client felt dry or
comfortable without touching mackintosh directly.
4. Place top bedding as for closed bed but Tuck at foot may hamper the client to enter the
do not tuck at foot. bed from a stretcher.
5. Fold back top bedding at the foot of To make the client„s transfer smooth.
bed.
6. Tuck the top bedding on one side only. Tucking the top bedding on one side stops the bed
linens from slipping out of place.
7. On the other side, do not tuck the top The open side of bed is more convenient for
sheet. receiving client than the other closed side.
 Bring head and foot corners of it at
the center of bed and form right
angles.
 Fold back suspending portion in 1/3
and repeat folding top bedding
twice to opposite side of bed.
8. Remove the pillow. To maintain the airway.
14
9. Place a kidney-tray on bed-side. To receive secretion
10. Place IV stands near the bed. To prepare it to hang I/V soon
11. Check locked wheel of the bed. To prevent moving the bed accidentally when the
client is shifted from a stretcher to the bed.
12. Place hot water bags (or hot bottles) in Hot water bags (or hot bottles) prevent the client
the middle of the bed and cover with from taking hypothermia.
fan folded top if needed.
13. When the patient comes, remove hot To prepare enough space for receiving the client.
water bags if put before.
14. Transfer the client:
 Help lifting the client into the bed To prevent the client from chilling and /or having
 Cover the client by the top sheet hypothermia.
and blanket immediately
 Tuck top bedding and miter a
corner in the end of the bed.
15. Return all equipment to proper place. To prepare for the next procedure
16. Perform hand hygiene. To prevent the spread of infection
References:
 FUNDAMENTAL OF NURSING PROCEDURE MANUAL for PCL course.
 Kozier, B. et al, Fundamentals of Nursing, Concepts, Process and Practice. 9thEd
15
16
BATHING A PATIENT IN BED
Definition: bath given to client who is in the bed (unable to bath itself).
Purpose:
 To prevent bacteria spreading on skin.
 To clean the client‟s body.
 To stimulate the circulation.
 To improve general muscular tone and joint.
 To promote client comfort level and help to induce sleep.
 To observe skin condition and objective symptoms.
Equipment required:
 Washcloths and bath towels  Warm water
 Bath blanket  Clean gown
 Soap Toiletry items (deodorant,  Laundry bag
powder, lotion, comb, hairbrush, and  Clean gloves
mouth care items toothbrush and  Washbasin.
toothpaste)
Procedure:
1. Check client identification and current In some instances a bed bath may be harmful for
condition. a client, who is in pain, hemorrhaging, or weak.
2. Assess patient‟s tolerance for bathing: Determines patient‟s ability to perform or
activity tolerance, comfort level, tolerate bathing and level of assistance required
cognitive ability, musculoskeletal (e.g., tub bath, partial bed bath).
function, and of shortness of breath.
3. Explain the purpose and procedure to Providing information fosters cooperation.
the client. If he or she is alert or oriented Encourage the client to assist with care and to
ask question the client about personal promote independence.
hygiene preferences and ability to assist.
4. Gather all required equipment and Bring Easy access to equipment prevents delay, saves
to the bed-side. time and energy.
6. Apply clean non-sterile gloves. Gloves protect the nurse from contact with
mucous membranes and body fluids.
7. Close the curtain or the door. To ensure that the room is warm &maintain the
client‟s privacy.
8. Prepare hot water (60°C). Water will cool during the procedure.
9. Offer patient bedpan or urinal. Patient feels more comfortable after voiding.
Prevents interruption of bath
10. Lock the bed, and raise bed to a Prevents bed from moving. Helps you reach
comfortable working height. Lower side patient without stretching and reaching across
rail closest to you and assist patient into bed, thus minimizing strain on back muscles.
comfortable supine position,
maintaining body alignment. Bring
patient toward side closest to you.
11.  Place bath blanket over patient and Bath blanket provides warmth and privacy
17
loosen and remove top covers during bath.
without exposing him or her. If
possible, have patient hold top of
bath blanket.
 Place soiled linen in laundry bag.
Take care to not allow linen to touch
your uniform. Optional: Use top
sheet when bath blanket is not
available or patient prefers.
12.  Remove patient‟s gown arm with IV Manipulation of IV tubing and container may
line (see illustrations). Remove IV disrupt flow rate.
tubing from pole and slide IV
container and tubing through arm of
patient‟s gown.
 Rehang IV container and check
flow rate. Regulate if necessary.
13.  Pull side rail up. Lower bed Raising side rail and lowering bed position
temporarily to lowest position and maintain patient‟s safety while you leave
raise to comfortable working height bedside. Keeping bed at working height during
on return after filling washbasin bath prevents back strain.
two-thirds full with warm water.
 Place basin and supplies on over-bed Warm water promotes comfort, relaxes muscles,
table. Check water temperature and and prevents unnecessary chilling.
also have patient place fingers in Testing temperature prevents accidental burns.
water to test temperature tolerance.
14.  Lower side rail, remove pillow if Removal of pillow makes it easier to wash
tolerated, and raise head of bed 30 to patient‟s ears and neck.
45 degrees if allowed.
 Place bath towel under patient‟s Placing towels prevents bed linen and bath
head. Place second bath towel over blanket from getting soiled or wet.
patient‟s chest.
15. Face, neck, ears: Place a towel under
the client‟s body from the head to
shoulders. Place face towel under the To prevent the bottom sheet from making wet.
chin which also covered the top sheet.
Fold washcloth around fingers of your
hand to form a mitt. Immerse mitt in
water and wring thoroughly.
 Wash patient‟s eyes with plain warm Soap irritates the eyes.
water. Use different section of mitt Washing from inner to outer corner prevents
for each eye. Move mitt from inner weeping debris into the client‟s eyes.
to outer canthus. Using a separate portion of the mitt for each eye
 Soak any crusts on eyelid for 2 to 3 prevents the spread of infection.
minutes with damp cloth before
attempting removal. Dry eyes
thoroughly but gently
18
Wash the client‟s face, neck, and ears. Soap is particularly drying to the face.
Use soap on these areas only if the client
prefers .Rinse and dry carefully.
16. Upper extremities:
 Remove bath blanket from patient‟s Towel prevents soiling of bed.
arm that is closest to you.
 Place bath towel lengthwise under Soap lowers surface tension and facilitates
arm. Bathe arm with soap and water removal of debris and bacteria. Long, firm
using long, firm strokes from distal strokes stimulate circulation; moving distal to
to proximal areas (fingers to axilla). proximal promotes venous return.
 Raise and support arm above head Movement of arm exposes axilla and exercises
(if possible) to wash, rinse, and dry normal ROM of joint.
axilla thoroughly. Alkaline residue from soap discourages growth
 Apply deodorant or powder to of normal skin bacteria. Drying prevents excess
underarms if desired or needed. moisture, which can cause skin maceration
17. Chest and abdomen:
 Fold bath blanket down to Draping prevents unnecessary exposure of body
umbilicus. Wash chest using long, parts. Towel maintains warmth and privacy.
firm strokes.
 Wash skin fold under the female Keeping skin folds clean and dry helps prevent
client‟s breast by lifting each breast. odor and skin irritation. Moisture and sediment
Rinse and pat dry. that collect in skin folds predispose skin to
 Fold bath blanket down to supra- maceration.
pubic area .Wash abdomen using
long, firm strokes. Rinse and pat
dry. Replace bath blanket.
18. Exchange the warm water. You may change water earlier if necessary to
maintain the proper temperature.
19. Lower extremities: Cover legs with
bottom of blanket. Expose near leg by
folding blanket toward midline. Be sure Prevents unnecessary exposure
to keep other leg and perineum draped
20. Place bath towel under leg, supporting Towel prevents soiling of bed linen.
leg at knee and ankle Bend patient‟s leg Support of joint and extremity during lifting
at knee; and, while grasping patient‟s prevents strain on musculoskeletal structures.
heel, elevate leg from mattress slightly
and cover bed with bath towel. Place Sudden movement by patient could spill bath
washbasin on towel. water.
21. Wash leg using long, firm strokes from Promotes circulation and venous return.
ankle to knee and from knee to thigh.
Do not rub or massage the back of the Excess massage of calf could loosen deep vein
calf. Rinse and dry well. thrombus.
Clean foot, making sure to bathe Secretions and moisture may be present between
between toes. Rinse and dry toes and toes, predisposing patient to maceration and
feet completely. breakdown.
22. Back and buttocks:
Cover the back with big towel. Uncover Skin breakdown usually occurs over bony
the back. Wash with soap and rinse. Dry prominences. Carefully observe the sacral area
19
with towel. Rub back if needed. and back for any indications.
Remove bath towel.
23. Return the client to the supine position. To make sustainable position for perianal care.
24. Perform Perineal care. Clean the perineal area to prevent skin irritation
and breakdown and to decrease potential odor.
25. Assist the client to wear clean cloth. To provide for warmth and comfort.
26. After bed bath:
 Make the bed tidy and keep the  These measures provide for comfort and
client in comfortable position. safety.
 Check the IV flow and maintain it  To confirm IV system is going properly and
with the speed prescribed if the safely.
client is given IV.
27. Document on the chart with your Documentation provides coordination of care
signature and report any findings to and maintains professional accountability.
senior staff.
References:
 Ratna (2007).Manipal Manual of Nursing procedures, (IST Ed vol.1 Part

20
TAKING VITAL SIGNS:
TEMPERATURE, PULSE, RESPIRATION, BLOOD PRESSURE
Definition: Taking vital signs are defined as the procedure that takes the sign of basic
physiology that includes temperature, pulse, respiration and blood pressure. If any abnormality
occurs in the body, vital signs change immediately.
Purpose:
 To assess the client‟s condition
 To determine the baseline values for future comparisons
 To detect changes and abnormalities in the condition of the client
Equipment required:
 Thermometer tray.  Watch with a second hand.
 Stethoscope.  Spirit swab.
 Non-sterile gloves  Record form.
 Sphygmomanometer with  Pen: blue, black, red.
appropriate cuff size.
MEASURING TEMPERATURE
Definition:
Measuring/ monitoring patient‟s body temperature using clinical thermometer
Purpose:
 To determine body temperature
 To assist in diagnosis
 To evaluate patient‟s recovery from illness
 To determine if immediate measures should be implemented to reduce elevated body
temperature or converse body heat when body temperature is dangerous low.
 To evaluate patient‟s response once heat conserving or heat reducing measures have
been implemented.
Equipment:
 Thermometer  Small kidney tray.
 Glass thermometer  Pen.
 Electronic thermometer  Watch with second hand.
 Tympanic thermometer  Blank paper / flow sheet.
with protective sheath  Gloves.
 Tissue / cotton balls.
21
Procedure:
S# Nursing action Rational
1. Check the client‟s identification. To confirm the necessity & to give care to the
correct patient.
2. Prepare all required equipment. Easy access to equipment prevents delay, saves
time and energy.
3. Explain the purpose and the procedure to Providing information fasters and reduced
the client. patient's anxiety.
4. Wash your hands. Prevents the spread of infection.
5. Provide for privacy Minimize embarrassment.
6. Position the client in a sitting or lying Promotes comfort and improves site access for all
position with the head of the bed elevated measurements. Activity and movement can
45° to 60° for measurement of all vital elevate heart and respiratory rates.
signs except those restricted.
7. Oral Temperature: Glass Thermometer:
Ensure patient has not taken hot/cold fluids
for at least 10-15 minutes (or according to To Ensures correct reading.
the policy).
8. Select correct color tip of thermometer a Identifies correct device.
blue tip denotes an oral thermometer
9. Remove thermometer from disinfectant Cleansing removes disinfectant, which can irritate
container and cleanse under cool water. Cool water, prevents expansion of the mercury.
10. Dry thermometer from bulb‟s end toward Wipe from area of least contamination to most
fingertips. contaminated area.
11. Read thermometer by locating mercury Thermometer must be below normal body
level. It should read 35.5°C (96°F). temperature to ensure an accurate reading.
12. If thermometer is not below normal body
temperature reading, grasp thermometer Shaking briskly lowers level of mercury in
with thumb and forefinger and shake column, glass thermometers break easily, make
vigorously by snapping the wrist in a sure that nothing in the environment comes in
downward motion to move mercury to a contact with the thermometer when shaking it.
level below normal.
13. Place thermometer under the tongue and The thermometer needs to reflect the core
along the gum line to the posterior temperature of the blood in larger blood vessels
sublingual pocket at a 45°c angle in a of the posterior pocket.
position that allows the bulb to rest against
the tongue tissue.
14. Instruct the client close his/ her mouth Prevent thermometer from falling & ensure
carefully with lips held firmly together accurate results by preventing environmental air
from coming in contact with the bulb.
15. Avoid biting down the thermometer Less likely to chip on the clients teeth or break
Refrain from speaking the thermometer
16. Leave in place as specified by agency Thermometer must stay in place long enough to
policy, usually 3–5 minutes. ensure an accurate reading.
17. Remove thermometer, Wipe off any Mucus on thermometer may interfere with
secretion from thermometer with cotton disinfectant solution‟s effectiveness. Wipe from
swab in rotating fashion from finger to area of least contamination to most contaminated
22
bulb end. area.
18. Read at eye level and rotate slowly until Ensures an accurate reading.
mercury level is visualized.
19. Shake thermometer down, and cleanse Mechanical cleansing removes secretions that
glass thermometer with soapy water, rinse promote growth of microorganisms. Hot water
under cold water, and return to storage may cause coagulation of secretions and cause
container. expansion of mercury in thermometer.
20. Remove and dispose of gloves. Reduces transmission of microorganisms.
Wash hands.
21. Record reading and indicate site as “OT.” Accurate documentation by site allows for
comparison of data.
22. Oral Temperature— Electronic
Thermometer:
Place disposable protective sheath over Reduces transmission of microorganisms.
probe
23. Place tip of thermometer under the client‟s Sublingual pocket contains superficial blood
tongue and along the gum line to the vessels
posterior sublingual pocket lateral to center
of lower jaw
24. Instruct client to keep mouth closed around
thermometer.
25. Thermometer will signal (beep) when a Signal indicates final temperature reading.
constant temperature registers
26. Read measurement on digital display of Reduces transmission of microorganisms.
electronic thermometer. Discard disposable Ensures that the electronic system is ready for
sheath and return probe to storage well. next use.
27. Inform client of temperature reading. Promotes client‟s participation in care
28. Remove and dispose of gloves. Wash Reduces transmission of microorganisms.
hands.
29. Record reading and indicate site as “OT.” Accurate documentation by site allows for
comparison of data.
30. Return electronic thermometer unit to Ensures charging base is plugged into electrical
charging base. outlet and ready for next use.
31. Axillary route To provide easy access to axilla.
Assist the client to a supine or sitting
position.
32. Move clothing away from shoulder and To expose axilla for correct thermometer bulb
arm. placement.
33. Be sure the client‟s axilla is dry. If it is Moisture will alter the reading. Under the
moist, pat it dry gently before inserting the condition moistening, temperature is generally
thermometer. measured lower than the real.
34. Place the bulb of thermometer in hollow of To maintain proper position of bulb against blood
axilla at anterior inferior with 45 degree or vessels in axilla.
horizontally.
35. Keep the arm flexed across the chest, close Close contact of the bulb of the thermometer with
to the side of the body. the superficial blood vessels in the axilla ensures
more accurate temperature registration.
36. Hold the glass thermometer in place for 5- To ensure an accurate reading.
23
8minutes (by agency policy)
37. Remove and read the level of mercury of To ensure an accurate reading.
thermometer at eye level.
38. Explain the result and instruct him/her if Promotes client‟s participation in care.
he/she has fever or hypothermia.
39. Shake mercury down carefully and wipe Prevents transmission of microorganisms and
the thermometer with spirit swab or breakage of glass thermometer.
cleanse glass thermometer with soapy
water, rinse under cold water, and return to
storage container.
40. Assist client with replacing gown Promotes comfort.
41. Record reading and indicate site as “AT.” Promotes accurate documentation for data
comparison.
42. Disposable (Chemical Strip)
Thermometer:
Apply tape to appropriate skin area, usually Tape must be in direct contact with the client‟s
forehead. skin.
43. Observe tape for color changes Color indicates temperature reading (refer to the
manufacturer‟s instructions).
44. Record reading and indicate method. Promotes accurate documentation for data
comparison
45. Wash hands. Reduces transmission of microorganisms
46. Tympanic Temperature:
Infrared Thermometer:
Remove probe from container and attach Prevents contamination.
probe cover to tympanic thermometer
47. Turn client‟s head to one side. For an adult, Provides access to ear canal. Gentle insertion
pull pinna upward and back; for a child, prevents trauma to external canal. Firm pressure
pull down and back. Gently insert probe is needed to ensure probe will record an accurate
with firm pressure into ear canal temperature.
48. Remove probe after the reading is Reading is displayed within seconds.
displayed on digital unit (usually 2
seconds).
49. Remove probe cover and replace in storage Protects damage to the reusable probe.
container.
50. Return tympanic thermometer to storage. Recharges batteries of unit for future use.
51. Record reading and indicate site as “ET.” Promotes accurate documentation for data
comparison.
24
52. Wash hands. Reduces transmission of microorganisms.
53. Rectal route
Put the curtains around patients' bed or To maintain the client‟s privacy.
close door (as required).
54. Place client in the Sims‟ position with Proper positioning ensures visualization of anus.
upper knee flexed. Adjust sheet to expose
only anal area.
55. Place tissues in easy reach. Apply gloves. Tissue is needed to wipe anus after device is
removed.
56. Lubricate tip of rectal thermometer or Promotes ease of insertion of thermometer or
probe (a rectal thermometer usually has a probe.
red cap).
57. With dominant hand, grasp thermometer. Aids in visualization of anus
With other hand, separate buttocks to
expose anus
58. Instruct client to take a deep breath. Insert Relaxes anal sphincter. Gentle insertion decreases
thermometer or probe gently into anus: discomfort to client and prevents trauma to
infant, 1.2 cm (0.5 inches); adult, 3.5 cm mucous membranes.
(1.5 inches). If resistance is felt, do not
force insertion.
59. Hold the thermometer in place for 3- 5 Prevents trauma to mucosa and breakage of
minutes. glass thermometer
60. Wipe secretions off glass thermometer with Removes secretions and fecal material for
a tissue. Read at eye level and rotate slowly visualization of mercury level.
until mercury level is visualized
61. Record reading and indicate site as “RT.” Promotes accurate documentation for data
comparison
62. Wash your hands. To prevent the spread of infection
63. Replace all equipment in proper place. To prepare for the next procedure.
64. Replace thermometer in antiseptic solution Storage container prevents breakage.
65. Report an abnormal reading to seniors. Promotes continuity of care.
66. Record in the client‟s chart and give Documentation provides ongoing data collection
signature on the chart. & maintains professional accountability,
25
MEASURING A RADIAL PULSE:
Definition: Checking presence rate, rhythm, and volume of throbbing of artery.
Purpose:
 To obtain a base line of heart rate and rhythm.
 To gather information about heart rhythm and pattern of beats.
 To evaluate strength of pulse.( to determine whether the pulse rhythm is regular and
pulse volume is appropriate)
 To assess clients' cardiovascular status.
 To assess response of heart to cardiac medications, activity, blood volume and gas
exchange.
 To assess vascular status of limbs (to assess heart's ability to deliver blood to distant
areas of the blood viz. Fingers and lower extremities)
Equipment:
 Watch with sweep second hand.  Pen (red ink).
 Paper or flow sheet
Assess the following peripheral pulses
 Temporal  Femoral
 Carotid  Popliteal
 Brachial  Posterior tibial
 Radial  Dorsalispedis
Procedure:
Sr# Nursing action Rational
1. Check the client‟s identification. To confirm the necessity & to give care to the
correct patient.
2. Prepare all required equipment. Organization facilitates accurate skill
performance.
3. Explain the purpose and the procedure to Providing information fasters cooperation and
the client. reduced patient's anxiety.
5. Assist the client in assuming a supine or To provide easy access to pulse sites
sitting position.
 If supine, place client‟s forearm straight Relaxed position of forearm and slight flexion
alongside body with extended straight or of wrist promotes exposure of artery to
upper abdomen with extended straight palpation without restriction.
 If sitting, bend clients elbow 90 degrees
and support lower arm on chair or on
nurse‟s arm slightly flex the wrist.
6. Count and examine the pulse
Place tips of first two or middle three The fingertips are sensitive and better able to
fingers of dominant hand over groove along feel the pulse. Do not use your thumb because
radial or thumb side of patient's inner wrist. it has a strong pulse of its own.
7. Apply only enough pressure to radial pulse. Moderate pressure facilitates palpation of the
Lightly compress against radius; press pulse pulsations. Too much pressure obliterates the
initially, and then relax pressure so pulse pulse, whereas the pulse is imperceptible with
26
becomes easily palpable. too little pressure.
8. Using watch, count the pulse beats for a full Counting a full minute permits a more
minute. accurate reading and allows assessment of
pulse strength and rhythm.
9. Examine the rhythm & strength of pulse. Strength reflects volume of blood ejected
against arterial wall with each heart
contraction.
11. Document in flow sheet and (if required) Documentation provides ongoing data
nurse's notes. Report to the senior staff if collection & maintains professional
you find any abnormalities. accountability, promotes continuity of care.
27
COUNTING RESPIRATION
Definition: monitoring the involuntary process of inspiration and expiration in a patient.
Purposes:
 To determine number of respiration occurring per minute for base line data
 To monitor abnormal respiratory status and identify changes.
 To monitor patients at risk for respiratory alterations
 To evaluate effects of medication and activity on respiratory status.
 To gather information about rhythm and depth of respiration.
Equipment:
 Watch with second hand.
 Flow sheet
 Pen (black)
Procedure:
1. Check the client‟s identification. To confirm the necessity & to give care to
the correct patient.
2. Wash your hands. Hand washing prevents the spread of
infection.
3. Prepare all required equipment. Easy access to equipment prevents delay,
saves time and energy.
4. Close the door and/or use screen. To maintain privacy.
5. Make the client's position comfortable, To ensure clear view of chest wall and
preferably sitting or lying with the head abdominal movements. If necessary, move
of the elevated 45 to60 degrees. the bed linen.
6. Prepare count respirations by keeping A client who knows are counting respirations
your fingertips on the client‟s pulse. may not breathe naturally.
7. Counting respiration: One full cycle consists of an inspiration and
Observe the rise and fall of the client‟s expiration.
(one inspiration &one expiration).
Count respirations for one full minute.) Allow sufficient time to assess respirations,
especially when the rate is with an irregular
Examine the depth, rhythm, facial Children normally have an irregular, more
expression, cyanosis, and cough and rapid rate. Adults with an irregular rate
movement accessory. require more careful assessment including
Replace bed linens if necessary. depth and rhythm.
8. Perform hand hygiene To prevent the spread of infection.
9. Report any irregular findings to the To provide continuity of care.
senior staff.
10. Record the rate on the client‟s chart. Documentation provides ongoing data
collection & maintains professional
accountability.
28
MEASURING BLOOD PRESSURE
Definition: Monitoring blood pressure using palpation and/or sphygmomanometer
Purpose:
 To obtain baseline data for diagnosis and treatment.
 To compare with subsequent changes that may occur during care of patient.
 To assist in evaluating status of patient‟s blood volume, cardiac output and vascular
system.
 To evaluate patient‟s response to changes in physical condition as a result of
treatment with fluids or medications.
Equipment:
 Sphygmomanometer (B.P)  Spirit swabs.
apparatus).  Flow sheet.
 B.P cuff (appropriate size).  Black pen
 Stethoscope
Procedure:
1. Check the client‟s identification. To confirm the necessity & to give care to
2. Explain the purpose and procedure to the Providing information fosters the client‟s
client. cooperation and understanding.
4. Wash your hands. Prevents the spread of infection
5. Cleanse the stethoscope‟s ear pieces and Cleansing the stethoscope prevents spread of
diaphragm with a spirit swab. infection
6. Have the client rest at least 5 minutes Allow the client to relax and helps to avoid
before measurement. falsely elevate readings.
7. Determine the previous baseline blood To avoid misreading of the client‟s blood
pressure, if available, from client‟s pressure and find any changes his/her blood
record. pressure from the usual.
8. Identify the factors that interfere in Exercise and smoking can cause false
accuracy of blood pressure measurement elevations in blood pressure.
like exercise, coffee and smoking.
9. Setting the position: Assist the client to Physical or interpersonal stressful
a comfortable position. Be sure room is environment can affect the blood pressure
warm, quiet and relaxing. measurement.
Position arm at heart level, extend elbow Blood pressure increases when arm is below
with palm turned upward level of heart and decreases when arm is
above level of heart.. Rotate the arm so the
brachial pulse is easily accessible.
Remove any constrictive clothing. Constricted cloths interfere to measure the
brachial pulse accurately.
29
10. Make sure bladder cuff is fully deflated Equipment must function properly to obtain
and pump valve moves freely an accurate reading.
11. Determine which extremity is most Cuff inflation can temporarily interrupt blood
appropriate for reading. Do not take a flow and compromise circulation in an
pressure reading on an injured or painful extremity already impaired or a vein
extremity or one in which an intravenous receiving intravenous fluids.
line is running.
12. Checking brachial artery and wrapping
the cuff: Locate brachial artery in the
antecubital space
Palpate brachial artery. Center the cuff‟s Center the bladder to ensure even cuff
bladder approximately 2.5 cm (1 inch) inflation over the brachial artery.
above where you palpate brachial pulse.
Wrap the cuff snugly around the client‟s Loose-fitting cuff causes false high readings
arm and secure the end approximately. appropriate way to wrap is that you can put
only2 fingers between the arm and cuff.
Check the manometer whether if it is at Improper height can alter perception of
level with the client‟s heart. reading.
13. Measure blood pressure by two step
method: Palpation identifies the approximate systolic
Palpatory method Using Brachial reading. Estimating prevents false low
or Radial Artery: readings.
 Palpate brachial pulse distal to cuff
with fingertips of no dominant hand.
 Close the screw clamp on the bulb.
 Inflate the cuff while still checking
the pulse with other hand.
 Observe the point where pulse is no
longer palpable.
 Inflate cuff to pressure 20-30 mmhg Maximal inflation point for accurate reading
above point at which pulse can be determined by palpation.
disappears.
 Deflate cuff slowly as you note on Ensures accurate reading
the manometer when the pulse is
again palpable.
 Deflate cuff rapidly and completely. Prevents arterial occlusion and client
discomfort of numbness or tingling.
 Remove cuff or wait 2 minutes before Releases trapped blood in the vessels
taking a second reading.
 Inform client of reading. Promotes client‟s participation in care.
 Record reading Ensures accuracy.
30
14. Auscultation Method Using Brachial
Artery
 Palpate brachial artery, turn valve Inflates the cuff‟s bladder with pressure and
clockwise to close and compress bulb temporarily impairs flow of blood through
to inflate cuff to 30mm Hg above artery. Provides an estimate of maximum
point where palpated pulse pressure required to measure systolic
disappears, then slowly release valve pressure
(deflating cuff ), noting reading when
pulse is felt again.
 Position the stethoscope‟s earpieces Each earpiece should follow angle of ear
comfortably in your ears (turn tips canal to facilitate hearing.
slightly forward). Be sure sounds are
clear, not muffled.
 Relocate brachial pulse with your non Proper stethoscope placement ensures
dominant hand and Place the optimal sound reception. Improperly
diaphragm over the client‟s brachial positioned sounds that often result in false
artery. Chest piece should be in direct low systolic and high diastolic readings.
contact with skin and not touch cuff
 With dominant hand, turn valve Ensure that the systolic reading is not
clockwise to close. Compress pump underestimated.
to inflate cuff until manometer
registers 30 mm Hg above the point
where the pulse had disappeared.
 Open the clamp and allow the aneroid If deflation occurs too rapidly, reading may
dial to fall at rate of 2 to 3 mmhg per be inaccurate.
second.
15. Note the point on the dial when first clear
This first sound heard represents the systolic
sound is heard. The sound will slowly pressure or the point where the heart is able
increase in intensity. to force blood into the brachial artery.
16. Continue deflating the cuff and note the This is the adult diastolic pressure. It
point where the sound disappears. Listen represents the pressure that the artery walls
for 10 to 20mmhg after the last sound. exert on the blood at rest.
17. Release any remaining air quickly in the Continuous cuff inflation causes arterial
cuff and remove it. occlusion, resulting in numbness and tingling
of client‟s arm.
18. Remove cuff or wait 2 minutes before The interval eases any venous congestion and
taking a second reading provides for an accurate reading when you
repeat the measurement.
19. Inform client of reading.. Promotes client‟s participation in care
20. Wash your hands prevents the spread of infection.
21. Clean stethoscope with spirit swab and Prevents spread of microorganism t. To
replace the instruments to proper place. prepare for the next procedure.
22. Record blood pressure on the client‟s Documentation provides ongoing data
chart. Sign on the chart. collection. Giving signature maintain
Report any findings to senior staffs. professional accountability.
31
32
33
MOUTH CARE OF UNCONSCIOUS PATIENT:
Definition: Mouth care is defined as the scientific care of the teeth and mouth.
Purpose:
 To keep the mucosa cleans, soft, moist and intact.
 To keep the lips clean, soft, moist and intact.
 To prevent oral infections.
 To remove food debris as well as dental plaque without damaging the gum.
 To alleviate pain, discomfort and enhance oral intake with appetite.
 To prevent halitosis or relieve it and freshen the mouth.
Equipment required:
 Trolley  Oral care agents: Tooth paste/
 Gauze-padded tongue depressor to antiseptic solution
suppress tongue  Kidney tray
 Torch  Mackintosh small size
 Appropriate equipment for cleaning:  Tap water
Tooth brush- Foam swabs- Cotton  Lubricants: Vaseline/ Glycerin
ball with artery forceps.  Suction apparatus with catheter
 Non-sterile gloves
ASSISTING THE CLIENT WITH ORAL CARE:
1. Check the client‟s identification. To give care to the correct patient.
4. Close door and /or put screen. To maintain privacy.
5. Perform hand hygiene and wear gloves. To prevent the spread of infection
6. If you use solutions such as sodium Solutions must be prepared each time
bicarbonate, prepare solutions required. before use to maximize their efficacy.
7. Assist the client a comfortable upright To promote effectiveness of the care
position or sitting position. including oral inspection and assessment.
8. Inspect oral cavity:
Inspect whole oral cavity, such as teeth, Comprehensive assessment is essential to
gums, mucosa and tongue, with the aid of determine individual needs.
gauze-padded tongue depressor and torch.
Take notes if you find any abnormalities, Some clients with anemia, immune-
e.g., bleeding, swollen, ulcers, sores, etc. suppression, diabetes, renal impairment
epilepsy and taking steroids should be
paid attention to oral condition.
9. Place face towel over the client. To prevent the clothing form wetting.
10. Put kidney tray in hand or assist the client To receive disposal surely.
holding a kidney tray.
34
11. Instruct the client to brush teeth
Points of instruction Effective in dislodging debris and dental
 Client places a soft toothbrush at 45° plaque from teeth and gingival.
angle to the teeth.
 Client brushes in direction of the tips of
the bristles under the gum line with
tooth paste. Rotate the bristles using
vibrating or jiggling motion until all
outer and inner surfaces of the teeth and
gums are clean.
 Also brush at biting surfaces of teeth.
 Client clean tongue from inner to outer Cleansing posterior direction of the tongue
and avoid posterior direction. may cause the gag reflex.
12. If the client cannot tolerate toothbrush When the client is prone to bleeding
swabs or cotton balls can be used. and/or pain, tooth brush is not advisable.
13. Rinse oral cavity
 Ask the client to rinse with fresh water  To make comfort and not to remain
and void contents into the kidney tray. any fluid and debris
 Advise him/her not to swallow water. If  To reduce potential for infection.
needed, suction equipment is used to
remove any excess.
14. Ask the client to wipe mouth and around it. To make comfort and provide the well-
appearance.
15. Apply lubricant to lips. To keep moisturize the lips.
16. Rinse and dry tooth brush thoroughly. To prevent growth of microorganisms.
17. Discard dirt properly. To maintain standard precautions.
18. Remove gloves and wash your hands. To prevent the spread of infection.
19. Document the care and sign on the records. Documentation provides ongoing data
collection and coordination of care.
20. Report any findings to senior staffs. To provide continuity of care.
35
PROVIDING ORAL CARE FOR UNCONSCIOUS CLIENT

1. Check the client‟s identification. To give care to the correct patient.
2. Prepare all required equipment and bring the Easy access to equipment prevents delay,
articles to the bedside. saves time and energy.
3. Wash your hands. Prevents the spread of infection
4. Be ready suction apparatus. It prevents aspiration.
5. Close the curtain/door or Put screen. It maintains the client‟s privacy.
Apply non-sterile gloves

7. The client should be in the lateral position Proper positioning prevents back strain and
with tilting the head downward encourages aspiration.
fluid to drain out of the client‟s mouth
8. Place the mackintosh and towel from the neck The towel and mackintosh protect the client
to chest. and bed from soakage.
9. Put the kidney tray over the towel and It facilitates drainage from the client‟s
mackintosh under the chin. mouth.
10. Inspect oral cavity:
Inspect whole the oral cavity, such as teeth, Comprehensive assessment is essential to
gums, mucosa and tongue, with the aid of determine individual needs.
gauze-padded tongue depressor & torch.
Take notes if you find any abnormalities, e.g., Some clients with anemia, immune-
bleeding, swollen, ulcers, etc. suppression, diabetes, renal impairment,
epilepsy and taking steroids should be paid
attention to oral condition. They may have
complication in oral cavity.
11. Clean oral surfaces:
Insert the padded tong depressor gently from The tong depressor assists in keeping the
the angle of mouth toward the back molar client‟s mouth open. As a reflex
area. You never use your fingers to open the mechanism, the client may bite your fingers
client‟s mouth.
Squeeze all cotton balls excess solution by To avoid inspiration of the solution
artery forceps and dissecting forceps.
Clean the client‟s teeth from incisors to molars Friction cleanses the teeth.
using up and down movements from gums to
crown.
36
Clean oral cavity from proximal to distal, Friction cleanses the teeth.
outer to inner parts, using cotton ball for each
stroke.
12. Discard used cotton ball. To prevent the spread of infection.
13. Rinse oral cavity: Rinse the areas using
moistened cotton balls To remove debris and make refresh.
If needed, suction equipment is used to Forcefully irrigated may cause aspiration.
remove any excess. To avoid aspiration of the solution.
14. Confirm the condition of client‟s teeth, gums, To assess the efficacy of oral care and
mucosa and tongue. determine any abnormalities.
15. Wipe mouth and around it. Apply lubricant to Lubricant prevents lips from drying and
lips by using foam swab or gauze piece with cracking.
artery forceps.
16. To provides for the client‟s comfort and
Reposition the client in comfortable position.
safety.
17. Replace all equipment in proper place. To prepare equipment for the next care.
18. Discard dirt properly and safety. To maintain standard precautions.
19. Frequency of care Oral care should be Four hourly cares will reduce the potential
performed at least every four hours. for infection from microorganisms
20. Remove gloves and perform hand hygiene. To prevent the spread of infection. Gloves
are not puncture or leak proof and hands
may become contaminated when gloves
are removed.
21. Report any findings to the senior staff. Documentation provides ongoing data
Document the care and sign on the records. collection and coordination of care.

37
MEASUREMENT OF HEIGHT & WEIGHT:
Purpose:
 To calculate body mass index (BMI) a measure of healthy versus unhealthy weight.
 To Monitoring body fat or muscle mass changes, or for monitoring hydration level.
 A sensitive indicator of current nutritional status.
 Uses reference values for age or height or both of the population.
 To provide a base line comparison in nutritional status.
 To provide a measurement of patient's fluid status.
Equipment:
 Weighing scale  Flow sheet
 Measuring tape  pen
Procedure:
Sr # Nursing Action Rational
1. Check client‟s identification and condition. Providing nursing care for the correct
client with appropriate way.
3. Prepare all required equipment and bring the
Saves time and energy.
articles to the bedside.
4. Wash hands and observe appropriate
Reduces transfer of microorganisms.
infection control procedure.
5. Height:
Ask the client to remove shoes and stand To eliminate error in measurement of
with his/her back and heels touching the height.
wall.
 Stand erect, with heels together.
 Shoulders, buttocks and heels should
touch to scale stick.
 Look straight ahead.
 Raise metal L shaped rod on weighing
scale, until it rests on top of the patient's
head.
6. Place a pencil flat on his/her head so that it This shows his/her height measured with
makes a mark on the wall. cm tape from the floor to mark on wall.
7. Weight:
Zero the scales before the client steps onto To eliminate zero error.
them.
8. Ask the client to remove any „heavy‟ items To eliminate error in measurement of
from their pockets and clothing (big jackets, weight.
woolen jerseys key‟s, wallets etc.)
9. When measuring weight – ask client to look To obtain accurate weight.
straight ahead and stay still on the scales.
Wait for the needle/digital screen to settle
before recording the measurement.
38
10.
Calculate the body mass index. Body Mass index (BMI) is used to assess
the status of nutrition using weight and
height in the world. Formula for BMI =
weight (kg)/ height (m) 2.
In adults women men
anorexia <17.5
underweight <19.1 <20.7
in normal 19.1-25.8 20.7-26.4
range
marginally 25.8-27.3 26.4-27.8
overweight
overweigh 27.3-32.3 27.8-31.1
obese >32.3 >31.1
severely 35-40
obese
morbidity 40-50
obese
11. The weight should be recorded in kilograms Documentation provides ongoing data
and should be signed /dated by the nurse collection and coordination of care.
taking the measurement.

39
APPLICATION OF HOT WATER BAG:
Definition:-
Application of heat means the use of an agent warmer than the skin, which may be applied in
either a moist or a dry form. It can be applied to produce a local or systemic effect or both.
Purpose:
 To stimulate circulation by dilating blood vessels
 To relieve pain and congestion by encouraging flow of blood.
 To supply warmth and comfort
 To promote healing
 To relieve retention of urine
 To relieve muscle spasm
 To counteract sudden drop in temperature during cold sponging
 To raise body temperature in case of hypothermia.
Physiological changes due to application of heat:-
 Vasodilatation: Increased capillary permeability,
 Increased local metabolism, increased oxygen requirement.
 Decreased blood viscosity, increased blood flow, increased lymph flow, increased
motility of leukocytes, reduce muscle tension
Equipment:
 Hot water bag with cover.  Towel.
 Boiling water Mug -to pour  Bath thermometer.
water into bag.  Vaseline or oil
 Duster
Procedure:
1. Check the client‟s identification. To confirm the necessity & To give
care to the correct patient.
2. Explain the procedure to the parents what you Providing information fosters
are going to do, why it is necessary, and how cooperation. Minimizes anxiety
they can cooperate.
3. Prepare all required equipment and bring the Easy access to equipment prevents
articles to the bedside. delay, saves time and energy.
4. Provide privacy by putting curtain. So that the This protects patient‟s privacy and
patient will not feel shy. facilitates relaxation.
5. Wash your hands. It prevents the spread of infection.
6. Assess for presence of lotion/oil over skin. Oil act as insulator.
7. Fill the hot water bag with hot water, secure the To ensure that there are no leaks and
cap and turn it upside down. pre-warms the bag.
8. Empty the bag and refill with hot water to about
two third full.
9. Place the bag on a flat surface &expel all air by
forcing the water up to neck of the bag.
10. Screw the cap tightly; dry outside of the bag To check it for leakage.
using duster.
40
11. Wipe off any moisture on the outside of the bag
.Put on the cover and take to the bedside.
12. Apply to the area as ordered; keep the bag in For the continuity of care.
place for 20 - 30 mints or as physician‟s order
by changing the position of the bag as
necessary. Refill the bag as necessary.
13. Remove the hot water bag when treatment is To make comfortable to the patient.
over& dry. Cover the area.
14. Inspect the area for redness; if redness is
present apply Vaseline or oil.
15. Dry the bag by hanging upside down. When To prepare equipment for the next care.
dried, fill it with some air, cork it and store it in
a proper place.
16. Wash hands. To prevent the spread of infection.
17. Record the procedure with date, time, the area Timely and accurate documentation
to which it is applied, the purpose of application promotes patient safety.
and reaction, if any.
41
APPLICATION OF COLD COMPRESSES:
It is a local moist cold application. It may be sterile or unsterile. Sterile cold compresses are
applied over open wounds or breaks in the skin. Cold compresses are made out of folded layers
of gauze, lint piece or old soft linen, wring out of cold or ice
Purpose:-
 To reduce inflammation.
 To relief pain.
 To prevent edema, and reduce inflammation.
 To control hemorrhage.
 To decrease metabolism and thus prevent gangrene.
 To reduce body temperature.
 To anaesthetize an area for a short period.
 To inhibit bacterial growth and prevent suppuration.
Equipment:
 Large basin with ice.
 Small basin with cold water.(65-80 degree F)
 Gauze pieces or small towels.
 A small bowl with non-absorbent cotton balls( for plugging ears if applying to forehead)
 Waterproof pad.
 Bath towel.
Procedure:
2. Explain the procedure to the parents what you Providing information fosters
are going to do, why it is necessary, and how cooperation and Minimizes anxiety
they can cooperate.
3. Prepare all required equipment and bring the Easy access to equipment prevents
articles to the bedside. delay, saves time and energy.
4. Provide privacy by putting curtain. So that the This protects patient‟s privacy and
patient will not feel shy. facilitates relaxation.
5. Wash your hands. It prevents the spread of infection.
6. Place the small basin with cold water into To maintain temperature of cold water.
large basin with ice.
7. Place the towel/gauze in the cold water.
8. Expose the area and Keep the waterproof To avoid soiling of linen.
material under the part.
9. Soak 3-4 gauze in cold water, squeeze gently
and apply into area.
10. After 2-3 mints, remove the compress and To maintain temperature at site of
apply fresh one. compression.
11. Squeeze the used compress into basin and For continuity of care.
immerse into bowl of cold water.
42
12. Check the area every 5 minutes for any Application of cold compress for larger
adverse reaction like burning, discoloration, period can interfere with circulation of
and erythema. blood.
13. Discontinue procedure if adverse reactions are This promotes patient safety.
seen.
14. Change the compress every 5 minutes or
when it becomes hot.
15. Continue the procedure for specified length of This promotes patient comfort and
time that is until desired result is obtained(15- safety.
20 mints) and repeat every 2-3 hours
16. Remove compress, dry the area. Make the patient comfortable.
17. Clean the equipment and place it in the proper For next time use.
place. Discard the used articles.
18. Wash hands. This step prevents the transfer of
microorganisms.
19. Document the care-time, site, duration of the Accurate and timely documentation and
application. reporting promote patient safety.
Cold Sponging:
 Cold sponging is used to reduce temperature in a client with hyperpyrexia.
 Large area of the body is sponged at one time permitting the heat of the body to transfer
to the cooler solution on the body surface.
 Often wet towels are applied to the neck, axillae, groin and ankles where the blood
circulation is close to the skin surface.
 Each area is dried by patting rather than by rubbing. Since the rubbing will increase the
cell metabolism and raise the heat production.
 The vital signs are checked very frequently to detect the early signs of complications.
 Cold sponging is hazardous to the client if the temperature of the body is brought down
rapidly from a high temperature to a very low temperature.
 In cold sponging, the temperature of the water is kept between 65 and 90 degree
43
DRESSING AND BANDAGE
The terms „dressing‟ and „bandage‟ are often used synonymously. In fact, the term
‘dressing’ refers more correctly to the primary layer in contact with the wound. A
bandage is a piece of material used.
 To cover wounds.
 To keep dressings in place.
 To applying pressure controlling bleeding.
 To support a medical device such as a splint,
 To restrict a part of the body.
Dressing: Dressings are used to cover wounds, prevent contamination and control bleeding.
In providing first aid we commonly used self-adhesive dressings or gauze dressings.
Adhesive dressings are used mainly for small wounds. They come in many different sizes,
including specific types for placement on fingertips.
Gauze dressings are thick, cotton pads used to cover larger wounds. They are held in place with
tape or by wrapping with a gauze strip (bandage). Dressings must be sterile and absorbent to
prevent the growth of bacteria, and should be left in place until the wound heals, unless it needs
to be regularly cleaned.
Adhesive dressing Gauze dressings
Bandage: The three major types of bandages are:

 Roller bandages.
 Tubular bandages.
44
 Triangular bandages.
Roller Bandages:
Roller bandages are long strips of material. Basically there are two types of roller bandages:
1. An elastic roller bandage is used to apply support to a strain or sprain and is wrapped
around the joint or limb many times. It should be applied firmly, but not tightly enough to
reduce circulation.
2. Cotton or linen roller bandages are used to cover gauze dressings. They come in many
different widths and are held in place with tape, clips or pins. They can also be used for
wound compression if necessary, as they are typically sterile.
Tubular Bandages:
 Tubular bandages are used on fingers and toes because those areas are difficult to
bandage with gauze.
 They can also be used to keep dressings in place on parts of the body with lots of
movement, such as the elbow or knee (support injured joints).
45
Triangular Bandages:
Triangular bandages are made of cotton or disposable paper. They have a variety of uses.
 When opened up, they make slings to support, elevate or immobilize upper limbs.
 This may be necessary with a broken bone or a strain, or to protect a limb after an
operation. Folded narrowly, a triangular bandage becomes a cold compress that can help
reduce swelling.
 They are used also for applying pressure to a wound to control bleeding.
Basic Bandaging Forms

Each bandaging technique consists of various basic forms of bandaging. The following five basic
forms of bandaging can be used to apply most types of bandages:
1. Circular bandaging
2. Spiral bandaging
3. Figure-of-eight bandaging
4. Recurrent bandaging
5. Reverse spiral bandage
Circular Bandaging:
 Circular bandaging is used to hold dressings on body parts such as arms, legs, chest or
abdomen or for starting others bandaging techniques.
 For circular bandage we used strips of cloth or gauze roller bandage or triangular bandage
folded down to form strip of bandage (cravat).
 In the circular bandaging technique the layers of bandage are applied over the top of each
other: With the roll on the inner aspect, unroll the bandage either toward you or laterally,
holding the loose end until it is secured by the first circle of the bandage.
 Two or three turns may be needed to cover an area adequately.
 Hold the bandage in place with tape or a clip.
 Almost all bandaging techniques start and end with a few circular bandaging turns.
46
Spiral bandaging:
 Spiral bandages are usually used for cylindrical parts of the body.
 An elasticated bandage can also be used to apply spiral bandaging to a tapered body part.
 Despite the increasing diameter of the body part, the elasticity will allow the bandage to
fit closely to the skin.
 With each spiral turn, part of the preceding turn is covered generally by 1/3 of the width
of the bandage.
Figure-of-eight bandage:
 Involves two turns, with the strips of bandage crossing each other at the side where the
joint flexes or extends. It is usually used to bind a flexing joint or body part below and
above the joint.
The figure-of-eight bandage can be applied using a roller bandage in two ways:
1. Following a circular turn around the middle of the joint, the bandage should fan out upwards
and downwards. The turns should cross at the side where the limb flexes.
2. Also be applied from a starting point located below or above the joint crease, working
towards the joint itself. The cross-over points will be located at either the flexing or
extending side of the joint; the side where the turns do not cross remains uncovered.
47
Reverse Spiral Bandage
 Reverse spiral bandage is a spiral bandage where the bandage is folded back on itself by
180° after each turn.
 This V-shaped fold allows the bandage to fit to the tapered shape of the body part all the
way along.
 This type of bandaging is required when using non-elasticated bandages.
 The development of elasticated fixing bandages, which are applied to tapered body parts
using the spiral technique, means that the reverse spiral technique is far less commonly
used nowadays.
48
Application
2. Explain the procedure to the parents what you are Providing information fosters
going to do, why it is necessary cooperation and understanding.
Minimizes anxiety and gains
cooperation.
3. Prepare all required equipment and bring the Organization facilitates accurate skill
articles to the bedside. performance. Easy access to
equipment prevents delay, saves time
and energy.
4. Provide privacy by putting curtain. This protects patient‟s privacy and
facilitates relaxation.
5. Wash hands. To prevent spread of microorganism.
6. Select the appropriate bandage material for injury.
 Use gauze or a flex roller for bleeding injuries
of the forearm, upper arm, thigh, and lower This will make the bandage easy to
leg. use and more likely to stay in place
 Use a flexible roller bandage for bleeding for many hours.
injuries of the hand, wrist, elbow, shoulder, The correct application technique is
ankle and foot. essential to provide comfort and
 Use an elastic roller bandage for amputations, adequate support or the affected part
arterial bleeding and sprains.
 It is best to use a bandage with some degree of
stretch in the weave.
7. Select the appropriate width of bandage Width of the bandage to use is
 Hand and fingers – 50 mm determined by the size of the part to
 Lower arm, elbow, hand and foot – 75 mm. be covered.
 Upper arm, knee and lower leg – 100 mm.
Large leg or trunk – 150 mm.
8. Prepare the patient for bandaging
 Position the body part to be bandaged a normal
resting position (position of function)
 Ensure that the body part that is to be
bandaged is clean and dry.
9. Apply the anchor wrap
Lay the bandage end at an angle across the area to
be bandaged.
10. Bring the bandage under the area back to the
starting point, and make a second turn.
11. Fold the uncovered triangle of the bandage end
back over the second turn
12. Cover the triangle with a third turn, completing
the anchor.
49
Anchor Wrap
13. Apply the bandage wrap to the injury
14. Use a circular wrap to end other bandage
patterns, such as a pressure bandage, or to cover
small dressings
15. Use a spiral wrap for a large cylindrical area

such as a forearm, upper arm, calf, or thigh. The
spiral wrap is used to cover an area larger than a
circular wrap can cover.
16. Use a spiral reverse wrap to cover small to large
conical areas, for example, from ankle to knee.
17. Use a figure eight wrap to support or limit joint

movement the hand, elbow, knee, foot.
18. Use a recurrent wrap for anchoring a dressing on

fingers, the head, or on a stump.
19. Check the circulation after application of the A bandage that is too tight can cut off
bandage .Check the pulse distal to the injury. circulation and cause tissue damage.
20. Elevate the injured extremities. To reduce swelling (edema).
21. Document procedure according to policy. Documentation provides accurate
details of response to bandage.
50
OXYGEN ADMINISTRATION
Definition: Oxygen therapy is the administration of supplementary oxygen when tissue

oxygenation is impaired.
Purpose:
 To prevent hypoxia in conditions were insufficient oxygen is available.
 To provide an atmosphere of increased oxygenation in body.
Equipment:
 Oxygen cylinder  A tray containing
 Nasal catheter  Cotton applicator and normal
 Water soluble jelly saline kidney tray and paper bag.
 Adhesive tapes  Mackintosh and towel.
 Bowl of water  Gauze pieces in container.
 Flash light and tongue depressor
Procedure:
1. Check client‟s identification against To confirm the necessity & Providing
doctor‟s orders. nursing care for the correct client.
2. Explain the procedure to the patient. Providing information fasters cooperation
and reduced patient's anxiety.
4. Provide privacy. This protects patient‟s privacy and
5. Perform hand hygiene To prevent the spread of infection
6. Position patient in fowler‟s or semi- To allow for appropriate lung expansion.
fowler‟s position unless otherwise
ordered.
7. Fill humidifier to designated level. Provide moisture in oxygen to prevent
drying of the nasopharyngeal mucosa.
8. Attach flow meter to humidifier and insert Flow meter must be properly secured to
in proper oxygen source. oxygen source.
9. Via Nasal Catheter
 Attach nasal catheter to oxygen
tubing, then attach tubing to flow
meter.
 Place catheter in cup of water and turn
on flow meter to 6 to 10 L to flush
tubing.
 Adjust flow rate to prescribed amount,
usually 2 L/mint.
 Determine depth of insertion by using Making place on catheter will assure nurse
nasal catheter to measure from for proper length of insertion.
patients‟ ear lobe to tip of nose.
 Cover tip of catheter with water
51
soluble lubricant.
 Hold catheter to observe its natural
curvature and gently insert catheter
into one side of nasal passage.
 Inspect mouth. Withdraw catheter
approximately 1cm or until it is no
longer visible.
 Tape catheter in place. It may be taped
to bridge of nose or side of cheek.
 Provide slack of tubing and secure to
patients garment.
10. Via nasal cannula/prongs
 Attach nasal cannula oxygen tubing This determines patency, removes away
and then attach to flow meter. microscopic particles that may be in tubing.
 Adjust flow rate to prescribed amount. If water bubbles, tube and prongs are patent.
Place a nasal prongs into each nares of
patient.
 Adjust straps of cannula over the ear
tighten under the chin. Place padding
between strap and ears.
11. Via face mask:
 Adjust flow rate of oxygen per
physician order.(usually 6-10L/mint)
 Place mask over bridge of nose, then
cover mouth.
 Adjust straps around patient‟s head
and over ears.
 Remove mask and clean skin and dry
1-2 hours.
12. Via oxygen Tent:
 Place oxygen machine at the head of
bed.
 Fanfold top sheet to patient‟s waist.
 Set temperature to 70 degree. Turn on
machine , adjust flow rate to 10-12
L/mt
13. Perform hand hygiene Prevents the transfer of microorganisms.
14. Repeated the procedure as it is for nasal
prongs and face mask.
15. Record the date, time, flow rate, method Accurate and timely documentation and
of oxygen delivery, respiratory reporting promote patient safety.
assessment, patient‟s response.
52
PERFORMING NEBULIZATION SKILLS
Nebulization is a process by which medications are added to inspired air and converted into a
mist that is then inhaled by the patient into their respiratory system.
Purpose: Nebulizers are commonly used for the treatment of asthma, cystic fibrosis, COPD and
other respiratory diseases or disorders.
Safety considerations:
 Dispense medication in a quiet area
 Avoid conversation with others.
 Follow agency‟s no-interruption zone policy.
 Prepare medications for ONE patient at a time.
 Follow the TEN RIGHTS of medication administration.
Procedure:
2. Explain the procedure to the patient. Providing information fasters cooperation
and reduced patient's anxiety.
3. Prepare all required equipment. Organization facilitates accurate skill
performance.
4. Provide privacy. This protects patient‟s privacy and
6. Check allergy band for any allergies. For the safety of patient.
7. Complete necessary focused assessments an
d signs document on Medicine
Administration Record.
8. Perform the TEN RIGHTS x 3 (must be Always verify any unclear or inaccurate
done with each individual medication): information prior to administering
 Right patient medications.
 Right drug
 Right dosage
 Right time
 Right route
 Right to refuse
 Right knowledge
 Right questions
 Right advice
 Right response or outcome.
9. The label on the medication must be To ensure patient safety.
checked for name, dose, and route, and
compared with at three different times:
A. When the medication is taken out of the
drawer.
B. When the medication is being poured.
53
C. When the medication is being put
away/or at bedside.
10. Assemble nebulizer as per manufacturer‟s Assembly specific to manufacturer‟s
instructions. instructions ensures proper delivery of
medication.
11. Add medication as prescribed by pouring This step ensures the proper delivery of
medication into the nebulizer cup. medication.
 Some medications may be mixed
together if there are no
contraindications.
 Some medications may require the
addition of saline per prescription for
dilution.
12. Use a mask if patient is unable to tolerate a This ensures the proper delivery of
mouthpiece and an adaptor specific to medication
tracheostomies if the patient has a
tracheostomy.
13. Position patient sitting up in a chair or in This position improves lung expansion
bed at greater than 45 degrees. and medication distribution.
14. Assess pulse, respiratory rate, breath Determine a baseline respiratory
sounds, pulse oximetry, and peak flow assessment prior to administration of
measurement (if ordered) before beginning medication.
treatment.
NOTE: Attach the nebulizer to compressed air if available; use oxygen if there is no
compressed air. If patient is receiving oxygen, do not turn it off. Continue to deliver oxygen
through nasal prongs with the nebulizer.
15. Turn on air to nebulizer and ensure that a This process verifies that equipment is
sufficient mist is visible exiting nebulizer working properly.
chamber. A flow rate of 6 to 10 L should
provide sufficient misting.
 Ensure that nebulizer chamber
containing medication is securely
fastened.
 Ensure that chamber is connected to
face mask or mouthpiece, and that
nebulizer tubing is connected to
compressed air or oxygen flow meter.
16. If mouthpiece is being used, ensure lips are Sealed lips ensure proper inhalation of
sealed around mouthpiece. medication.
17. Have patient take slow, deep, inspiratory This maximizes effectiveness of
breaths. Encourage a brief 2- to 3-second medication.
pause at the end of inspiration, and continue
with passive exhalations. If patient is
feeling dyspnea, encourage holding every
fourth or fifth breath for 5 to 10 seconds.
18. Have patient repeat this breathing pattern This maximizes the effectiveness of the
54
until medication is complete and there is no medication.
visible misting. This process takes
approximately 8 to 10 minutes.
19. Tap nebulizer chamber occasionally and at This action releases drops of medication
the end of the treatment. that cling to the side of the chamber.
20. Monitor patient‟s pulse rate during Beta-adrenergic bronchodilators
treatment, especially if beta-adrenergic have cardiac effects that should be
bronchodilators are being used. monitored during treatment.
21. Once treatment is complete, turn flow meter This promotes patient comfort and safety.
off and disconnect nebulizer.
22. Rinse, dry, and store nebulizer as per Proper care reduces the transfer of
agency policy. microorganisms.
23. If inhaled medication included steroids, Rinsing removes residual medication from
have patient rinse mouth and gargle with mouth and throat, and helps prevent oral
warm water after treatment. candidacies related to steroid use.
24. Once treatment is complete, encourage Treatments are often prescribed
patient to perform deep breathing and specifically to encourage mucous
coughing exercises to help remove expectoration.
expectorate mucous.
25. Return patient to a comfortable and safe This promotes patient comfort and safety.
position.
26. Perform hand hygiene This step prevents the transfer of
microorganisms.
27. Document treatment as per agency policy, Accurate and timely documentation and
and record and report any unusual events or reporting promote patient safety.
findings to the appropriate health care
provider.
55
ORAL SUCTIONING
Oral suction is the use of a rigid plastic suction catheter, known as a Yankauer to remove
pharyngeal secretions through the mouth. The suction catheter has a large hole for the thumb to
cover to initiate suction, along with smaller holes along the end, which mucous enters when
suction is applied.
Purpose:
 To clear secretions from the mouth in patient who are unable to remove
secretions or foreign matter by effective coughing. For example CVAs,
drooling, impaired cough reflex related to age or condition, or impaired
swallowing.
NOTE: The oral suctioning catheter is not used for tracheotomies due to its large size
Equipment:
 A suction machine or  Yankauer
suction connection  Water and a sterile basin,
 Connection tubing,  Face mask
 Non-sterile gloves  Clean towel.
Procedure:
2. Providing information fasters
Explain the procedure to the patient. cooperation and reduced patient's
anxiety.
3. Assess patient need for suctioning
Baseline respiratory assessment,
(assessment for signs of hypoxia), risk for
including an O2 saturation level, can
aspiration, inability to protect own airway,
alert the health care provider to
clear secretions adequately, which may lead
worsening condition.
to upper airway obstruction.
4. Easy access to equipment prevents
Prepare all required equipment.
delay, saves time and energy.
5. This protects patient‟s privacy and
Provide privacy.
7. Explain to patient how the procedure will This allows patient time to ask questions
help clear out secretions and will only last a and increase compliance with the
few seconds. procedure. Minimizes fear and anxiety.
8. Encourage the patient to cough to bring
If appropriate, encourage patient to cough secretions from the lower airways to the
upper airways.
9. Position patient in semi-Fowler‟s position
with head turned to the side.
This facilitates ease of suctioning.
Unconscious patients should be in the
lateral position
56
10. Perform hand hygiene, gather supplies, and
This prevents the transmission of
apply non-sterile gloves. Apply mask if a
microorganisms.
body fluid splash is likely to occur.
11. Water is used to clear connection tubing
in between suctions. Fill basin with
Fill basin with water.
enough water to clear the connection
tubing at least three times.
12.
Attach one end of connection tubing to the

suction machine and the other end to the
Yankauer.
This prepares equipment to function
effectively.
13. Turn on suction to the required level. Test Suction levels for adults are 100-150
function by covering hole on the Yankauer mmHg on wall suction and 10-15 mmHg
with your thumb and suctioning up a small on portable suction units. Always refer
amount of water. to hospital policy for suction levels
14. Remove patient‟s oxygen mask if present.
Nasal prongs may be left in place. Place
towel on patient‟s chest. (Always be The towel prevents patient from coming
prepared to replace the oxygen if patient in contact with secretions.
becomes short of breath or has decreased O2
saturation levels.)
15. Movement prevents the catheter from
suctioning to the oral mucosa and
causing trauma to the tissues.
Insert Yankauer catheter and apply suction

by covering the thumb hole. Run catheter
along gum line to the pharynx in a circular
motion, keeping Yankauer moving.
57
16. Coughing helps move secretions from
Encourage patient to cough.
the lower airways to the upper airways.
17. Apply suction for a maximum of 10 to 15
seconds. Allow patient to rest in between This saves the patient from injury.
suction for 30 seconds to 1 minute.
18. Replace oxygen to prevent or minimize
If required, replace oxygen on patient and
hypoxia.
clear out suction catheter by placing
Clearing out the catheter prevents the
Yankauer in the basin of water.
connection tubing from plugging.
19. Reassess and repeat oral suctioning if
To determine if intervention was
required. Compare pre- and post-suction
effective.
assessments
20. Reassess respiratory status and O2 This identifies positive response to
saturation for improvements. Call for help if suctioning procedure and provides
any abnormal signs and symptoms appear. objective measure of effectiveness.
21. Ensure patient is in a comfortable position
and call bell is within reach. Provide oral This promotes patient comfort.
hygiene if required.
22. Clean up supplies, remove gloves, and wash Cleanup prevents the transmission of
hands. microorganisms.
23. Document procedure according to hospital Accurate and timely documentation and
policy. reporting promote patient safety.
58
CARE OF DRAINAGE BAGS (CATHETER)
The following five principles apply to the care of drainage tubes.
A. Closed cavities of the body are sterile cavities. Insertion of any tube must be performed
with adherence to the principles of sterile asepsis.
B. A portal of entry that comes into contact with a non-sterile surface immediately renders an
otherwise sterile field non-sterile. When disconnecting drainage tubes, such as a urinary
catheter or a T-tube, the ends must be kept sterile
C. Gravity promotes the flow of drainage from a cavity. Keep drainage tubes and collection
bags at a lower level than the cavity being drained.
D. Drainage will flow out of the tubing if the lumen is not occluded. Avoid kinks and coils in
the tubing and watch that the person does not lie on the tubing. Do not clamp tubes without
a doctor‟s order.
E. Properly cleanse the site before accessing any tubing to reduce possible introduction of
microorganisms into a cavity. . An alcohol swab may be used to clean the entry point prior
to accessing the tubing.
The following four factors affect the flow of fluid through tubes.
1. Pressure difference
A fluid will flow through a tube only when a pressure difference occurs between the two
ends, with fluids moving from the region of higher pressure to the region of lower pressure.
The larger the pressure difference, the more flow there will be.
2. Diameter
The diameter of a tube is the width of its lumen or inside opening. Increasing a tube‟s
diameter increases the flow rate and vice versa.
3. Length
The length of a tube affects the rate of fluid flow. Fluid is slowed down by the friction of its
molecules against the walls of the tube. The longer the tube, the more surface area there is for
the fluid to rub against
4. Viscosity
Viscosity refers to the tendency of a fluid to resist flow because of the friction of its
molecules rubbing against each other.
Procedure:
1. Perform hand hygiene Hand hygiene reduces the risk of
infection.
2. Collect the necessary supplies.( drainage Easy access to equipment prevents delay,
measurement container, non-sterile gloves, saves time and energy.
waterproof pad, and alcohol swab)
3. Apply non-sterile gloves and goggles or face Personal protective equipment reduces the
shield according to agency protocols. transmission of microorganisms and
protects against an accidental body fluid
exposure.
59
4.  Secure tubes to the skin with tape (non-
allergenic or waterproof). When tension is applied to the tube, the
 A good method of taping is to loop the stress will be taken by the tape rather than
tape around the tubing, make a “neck” of by the tube.
tape, and secure the tape to the skin
(except for nasogastric tubes).
 This allows some gentle moving of the
tube without kinking and protects it from
the danger of being pulled out.
5. Drainage bags should be secured to This prevents undue stress on the drainage
stretchers, patient gowns. tube and/or accidental removal from the
wound or body cavity.
6. Connect tube to sterile tubing and drainage This helps keep wound or body cavity
receptacle. Do not clamp tubing unless sterile and promotes flow of drainage.
ordered.
7. To ensure continuous drainage, be sure Any kinks in tubing can stop drainage
tubing is not kinked, not caught in the bed from the patient and cause further
rails, not underneath the patient, and free complications.
from tension when turning, etc.
8. Dressing around tube, if any, should be clean This avoids irritation from tube rubbing
and dry. Sterile technique is used if it is the skin or from excessive drainage.
necessary to change the dressing.
9. If you are unsure how to empty the container Most drainage tubes must have the ends
or how to close it after a spill, seek help. kept sterile. Always follow agency
regulations on how to clean up a blood or
body fluid spill.
10. Remove gloves and perform hand hygiene Hand hygiene must be performed after
removing gloves. Gloves are not puncture-
proof or leak-proof, and hands may
become contaminated when gloves
are removed.
11. Discard drainage according to agency policy. Monitor drains frequently in the post-
operative period to reduce the weight of
the reservoir and to monitor drainage.
12. Record the number the drains if there is more
than one, and record each one separately.
If the amount of drainage increases or
changes, notify the appropriate health care
provider.
13. Record and report patency of tube and This will help inform ward staff of an
amount, color, character, and odor of unusual situation that happened in your
drainage. If an unusual situation occurs in department.
your department (i.e., if the bag is full and If amount of drainage significantly
must be emptied), call for help. If the decreases, the drain may be ready to be
contents of a drainage tube are spilled, the assessed and removed.
approximate amount must be reported.
60
SITZ BATH:
Definition:
Sitz bath or hip bath is a bath in which a patient sits in water up to the hips to relieve discomfort
and pain in the lower part of the body. Sitz bath works by keeping the affected area clean and
increasing the flow of blood.
Objectives
 To relieve muscle spasm.
 To reduce congestion and provide comfort in the perineal area.
 To aid healing a wound in the area by cleaning on discharges and slough (hasten healing).
 To induce voiding in urinary retention.
 To relieve pain, congestion and inflammation in cases of: hemorroids, rectal surgery, anal
fissures, after proctoscopic or cycloscopic exams. Sciatica, uterine and renal colic.
 To induce menstruation.
Indications:
 Hemorrhoids  Episiotomy
 Anal Fissures/Surgery  Uterine Cramps
Contraindications
 Diabetes.  Impaired peripheral sensory function
 Peripheral vascular disease  Immediate post hemorrhoidectomy.
Equipment
 Sitz tub half filled with water (105-  Medication if ordered
110 degree F 40-43 degree  Bath towel
centigrade)  Bath blanket
 Bath thermometer  Patient‟s clean clothes
 Gown
Procedure:
Sr# Nursing Action Rationale
1. Check client‟s identification against
To know if it is indicated for the patient.
doctor‟s orders.
2. Explain the procedure to the patient. Providing information fasters cooperation and
4. Provide privacy. This protects patient‟s privacy and facilitates
relaxation.
5. Assess the patient‟s condition, pain level
To collect base line data.
and ability to ambulate to the bathroom.
6. Take linen to bathroom. Fill clean tub
To save time and effort.
about one-third f with warm water.
7. Add required quantity of ordered
medication if any.
8. Test the water with a thermometer before Warm water should not be used if
the patient enters the tub. If the purpose of considerable congestion is already present. If
the sitz bath is to apply heat, water at a the purpose of the sitz bath is to produce
temperature of 43°C to 46°C for 15 relaxation or to help promote healing in a
minutes will produce relaxation of the wound by cleaning it of discharge and debris,
61
parts involved after a short contraction. then water at a temperature of 34°C to 37°C is
used
9. Assist patient in removal of any dressing
and position to sit in sitz bath basin.
10. Wrap a bath blanket around the patient‟s This protects the patient‟s from feeling chilly
shoulders, and drape ends over the tub and form exposure
11. Do not leave the patient unattended
during the procedure. Instruct patient to
contract and relax anal sphincter while
taking sitz bath.
12. Observe the patient closely for signs of Typical signs of faintness include skin pallor,
weakness and fatigue. Discontinue the a rapid pulse rate, and nausea.
bath if the patient‟s condition warrants
like weakness or pallor occurs.
13. Test the water in the tub several times, The water should be agitated by stirring it as
and keep it at the desired temperature. hot water and added to prevent burning the
Additional hot water may be added by patient.
pouring it slowly
14. Help the patient out of the tub when the
bath is completed. Normally, a hot sitz
bath should be continued for 15 to 30
minutes; Dry & cover the patient
adequately.
15. Assist the patient to his bed. To returns normal circulation.
16. Document procedure Documentation provides accurate details of
 Type of solution response to procedure and clear
 Length of time of application communication among the health care team.
 Type of heat application
 Condition and appearance of wound
 Comfort of patient
62
ELIMINATION:
ENEMA:
Definition: An enema is the introduction of fluid into the lower bowel through the rectum for the
purpose of producing bowel action or instilling medication.
Purpose:
 To clean the lower bowel before surgery.
 To soften hard fecal matter e.g., oil enema
 To introduce medication into the system.
 To soothe and treat irritated bowel mucosa.
 To stop local hemorrhage.
 To relieve gaseous distension.
 For diagnostic purpose.
Types of enema
 Cleansing(o clean the intestines when constipated, as part of the preoperative
preparation & as part of preparation for examination of the intestines)
 Medical
 Diagnostic
Equipment:
 Screen for privacy  Enema can
 Draw-sheet and mackintosh.  Plastic bag to throw waste in
 Kidney tray.  Toilet paper
 Gloves  Lubricant
 Gown
Procedure:
Sr# Nursing Procedure Rational
1. Check client‟s identification against To confirm the necessity & Providing nursing care
doctor‟s orders. for the correct client with appropriate way.
2. Explain the procedure to the patient. Providing information fasters cooperation and
time and energy.
relaxation.
5. Perform the TEN RIGHTS x 3 (must be
done with each individual medication):
 Right patient
 Right drug
 Right dosage
 Right time
 Right route
 Right to refuse
 Right knowledge
 Right questions
 Right advice
 Right response or outcome.
63
6. Check for expiry date of medication. Tom maintains safety. Expired medication may be
less effective and causes harm to the patients.
7. Calculate the dosage. Ensure patient safety.
8. If possible, have patient defecate prior to Medication should not be inserted into feces.
rectal medication administration.
9. Ensure that you have water-soluble Lubricant reduces friction as suppository enters
lubricant available for medication rectal canal.
administration.
10. Raise bed to working height. Positioning helps prevent injury to nurse
Position patient on left side with upper leg administering medication.
flexed over lower leg toward the waist
(Sims position)
11. Apply clean non-sterile gloves. Gloves protect the nurse from contact with mucous
membranes and body fluids
12. Provide privacy and drape the patient with This protects patient‟s privacy and facilitates
only the buttocks and anal area exposed. relaxation.
13. Place a drape sheet underneath the It protects linens from potential fecal drainage
patient‟s buttocks.
14. Remove wrapper tip of enema and Lubricant reduces friction as suppository/enema
lubricate and index finger of dominant enters rectal canal.
hand with lubricant.
15.  Separate buttocks with non-dominant You should feel the anal sphincter close around
hand and, using gloved index finger of your finger after insertion. Forcing enema through
dominant hand. a clenched sphincter will cause pain and,
 Expel air from enema and then potentially, rectal damage.
insert tip of enema into rectum toward
umbilicus while having patient take a
deep breath, exhale through the mouth,
and relax anal sphincter.
16. Roll plastic bottle from bottom to tip until
all solution has entered rectum and colon.
17. Remove finger and wipe patient‟s anal Wiping removes excess lubricant and provides
area. comfort to the patient.
18. Remove drape sheet underneath the Make the patient comfortable.
patient‟s buttocks
19. Ask patient to remain on side for 5 to 10 This position helps prevent the expulsion
minutes.
20. Discard gloves by turning them inside out Using gloves reduces transfer of microorganisms.
and disposing of them and any used
supplies as per agency policy.
Dispose of gloves
21. Perform hand hygiene. Gloves are not puncture-proof or leak-proof, and
64
hands may become contaminated when gloves
are removed.
22. Ensure call bell is nearby and Patient will require a bedpan/commode or close
bedpan/commode is available and close by. proximity to toilet.
23. Evaluate the effectiveness of medication Monitors patient response to treatment.
after 30 min by visiting the patient.
24. Document procedure as per agency policy Timely and accurate documentation promotes
and include patient‟s tolerance of patient safety.
administration.
65
ADMINISTERING RECTAL SUPPOSITORIES:
Purposes:
 To empty the bowel before certain type of surgery.
 To empty the bowel to relieve acute constipation.
 For diagnostic purposes.
 To sooth and treat hemorrhoids.
Equipment:
 Mackintosh.  gauze pieces
 Towel.  Lubricating jelly.
 Gloves.  suppository
Procedure:
Sr# Nursing Action. Rational
1. Check client‟s identification against doctor‟s To confirm the necessity & Providing
orders. nursing care for the correct client with
appropriate way.
3. Explain the purpose and the procedure to the Providing information fasters cooperation
client. and reduced patient's anxiety.
relaxation.
5. If patient prefers to self-administer the Patient may feel more comfortable self-
suppository give specific instructions to patient administering suppository.
on correct procedure.
6. Have patient defecate prior to rectal medication Medication should not be inserted into feces.
administration.
8. Raise bed to working height.
Position patient on left side with upper leg flexed Positioning helps prevent injury to nurse
over lower leg toward the waist (Sims position). administering medication.
9. Provide privacy and drape the patient with only This protects patient‟s privacy and facilitates
the buttocks and anal area exposed. relaxation.
10. Place a drape underneath the patient‟s buttocks. Drape protects linens from potential fecal
drainage.
11. Remove the foil or wrapper from the
suppository, if present.
12. Apply a small amount of lubricant to the Lubricant reduces friction as suppository
suppository and you‟re gloved. enters rectal canal.
13. Separate buttocks with non-dominant hand and,
using gloved index finger of dominant hand,
insert suppository (rounded tip toward patient)
into rectum toward umbilicus.
14. While having patient take a deep breath, exhale You should feel the anal sphincter close
through the mouth, and relax anal sphincter. around your finger after insertion. Forcing
the suppository through a clenched sphincter
66
will cause pain and, potentially, rectal
damage.
15. With your gloved finger, insert suppository Suppository should be against rectal mucosa
along wall of rectum about 5 cm beyond anal for absorption and therapeutic action.
sphincter. Do not insert the suppository into Inserting suppository into feces will decrease
feces. its effectiveness.
16. Remove finger squeeze buttocks together for a Wiping removes excess lubricant and
few minutes to help client hold in the provides comfort to the patient.
suppository for as long as possible and wipe
patient‟s anal area.
17. Ask patient to remain on side for 5 to 10 This position helps prevent the expulsion of
minutes. suppository
18. If the suppository is used as a laxative, instruct So that you can check on the “results”.
client to let you know when they use the
bathroom.
19. Discard gloves by turning them inside out and Using gloves reduces transfer of
disposing of them. microorganisms.
20. Evaluate the effectiveness of medication after 30 Monitors patient response to treatment.
min by visiting the patient.
21. Document procedure as per agency policy and Timely and accurate documentation
include patient‟s tolerance of administration. promotes patient safety.
NOTE: Unintended vagal stimulation may occur, resulting in bradycardia in some patients. Be
aware that the rectal route may not be suitable for certain cardiac conditions. Notify physician.
67
FLATUS TUBE:
Definition: Flatus tube or rectal tube inserted into the rectum to relive flatulence and gaseous
distension of the abdomen.
Equipment:
 Screen for privacy  Draw-sheet and mackintosh.
 A clean square tray:  Kidney tray.
 Sterile flatus tube in a bowl  Gloves
 Lubricant
Procedure:
1. Check client‟s identification against doctor‟s To confirm the necessity & Providing nursing
orders. care for the correct client with appropriate way.
2. Prepare all required equipment. Take all the articles Easy access to equipment prevents delay, saves
to right side of the patient. time and energy.
3. Explain the purpose and the procedure to the client. Providing information fasters cooperation and
understanding and reduced patient's anxiety.
4. Provide privacy by putting curtain. So that the This protects patient‟s privacy and facilitates
patient will not feel shy. relaxation.
5. Place the draw-sheet mackintosh and under his/her This step prevents soiling of bed linens.
waist.
6. Give him left lateral position on the bed.
mucous membranes and body fluids
Apply non-sterile gloves.

8. Loose the garments of the waist and expose only So that the patient will not hesitate.
the necessary portion.
9. Lubricate the flatus tube at eye side, up to 3" to 4". To prevent the friction. As the mucus membrane
of the rectum is very delicate.
10. Separate buttocks with non-dominant hand and,
using gloved index finger of dominant hand.
11. Touch the tip of flatus tube to the anus so that the
sphincter muscles of the anus constrict and
immediately relaxes, at that time insert it in anal
canal gently but quickly, keeping the free end of the
flatus tube under the lotion in kidney tray.
12. Insert the tube 7 to 10 inches and observe the
bubbles and liquid stools in the lotion.
13. When the bubbles are stopped then move the tube
little bit inside and outside, and observe for the
bubbles.
14. If the bubbles are observed more then write the
68
result 'good', if not then mark the result 'poor'.
15. Remove the draw-sheet and mackintosh. Make the patient comfortable. And neat the bed.
16. Discard gloves by turning them inside out and Using gloves reduces transfer of
disposing of them. microorganisms.
17. Perform hand hygiene. Gloves are not puncture-proof or leak-proof, and
are removed.
18. Document the procedure date, time and result of Timely and accurate documentation promotes
flatus tube. patient safety.
69
MANUAL EXTRACTION:
Definition: The Removal of faeces from rectum for the treatment of acute faecal impaction and
as a bowel management technique.
Indications
 Faecal impaction/loading.
 Incomplete defaecation.
 Inability to defaecate.
 Other bowel emptying techniques have failed.
 In patients with spinal injury as part of a bowel management program.
Equipment:
 Gloves
 Plastic bag to throw waste in
 Soap and water
 Washcloth and towel
 Toilet paper
 Lubricant
 Under-pads if done in bed
 Raised toilet seat, commode chair

1. Check client‟s identification against doctor‟s To confirm the necessity & Providing
orders. nursing care for the correct client with
appropriate way.
2. Prepare all required equipment. Take all the Easy access to equipment prevents delay,
articles to right side of the patient. saves time and energy.
3. Explain the purpose and the procedure to the Providing information fasters cooperation
client. and understanding and reduced patient's
anxiety.
4. Complete bowel assessment with the patient. To ascertain the need for digital removal of
faeces ensure:
5. Explain potential risks to the patient. Digital removal of faeces entails a possible
risk of damage to anal and rectal mucosa and
of stretching the anal sphincter.
6. Obtain informed consent and document. The patient needs to consent voluntarily
without coercion or manipulation.
7. Give the patient the opportunity to empty As a full bladder may cause discomfort
their bladder. during the procedure.
8. Provide privacy by putting curtain. So that the This protects patient‟s privacy and facilitates
dignity is maintained at all times patient will relaxation.
not feel shy.
9. Take the patient‟s pulse and blood pressure at To obtain a baseline of the patient‟s
rest before the procedure. condition before the procedure, as vagal
stimulation can slow the heart rate.
10. Assess the risk of autonomic dysreflexia of Autonomic dysreflexia is a sudden and
those spinal injury patients with injury at T6 exaggerated autonomic response to an
70
or above. unpleasant stimulus, e.g. a full rectum or
digital stimulation of the rectum during
bowel evacuation. It occurs in spinal injuries
at T6 or above.
11. Place waterproof pad under patient. It protects linens from potential fecal
drainage.
12. Ask the patient to remove clothing from the
waist down. Offer assistance if required.
13. Ask the patient to lie in the left lateral Expose anus and allow easy insertion of
position with knees flexed (if possible) finger and anal area can be easily visualized.
14. A sitting position should be avoided To prevent overstretching of the anal
sphincter and discomfort to the patient
15. Wash your hand. Put on a disposable apron Gloves protect the nurse from contact with
and gloves. mucous membranes and body fluids
16. For patients receiving this procedure on a Facilitate easier insertion of index finger.
REGULAR basis, place water-based
lubricating gel on gloved index finger.
17. If this is an ACUTE procedure, a local To reduce sensation and discomfort for the
anesthetic gel may be applied topically to the patient.
anal area.
18. DO NOT apply if you have documented Lignocaine may cause anaphylaxis,
evidence of anal damage or bleeding. hypotension, bradycardia or convulsions if
applied to a damaged mucosa.
19. Inform patient of imminent examination. To ensure the patient is ready and relaxed
20. Insert non-latex gloved, lubricated index To avoid trauma to the anal mucosa and
finger slowly and gently, encouraging the prevent forced over-dilation of the anal
patient to relax. Use one finger only. sphincter.
21. If stool is a solid mass, push finger into To relieve the patient‟s discomfort.
center, split it and remove small sections until
none remain. If stool is in small separate hard
lumps remove a lump at a time.
22. If the rectum is full of soft stool continuous To relieve the patient‟s discomfort.
gentle circling of the finger may be used to
remove stool.
23. If the faecal mass is too hard, larger than 4cm Avoid considerable pain and trauma (anal
and is impossible to break up, STOP and refer sphincter damage) to the patient.
to the medical team for a possible digital
removal of faeces under general anesthetics.
24. Precede with caution with spinal cord injury Most spinal cord injury patients will not
patients – those patients with a reflex bowel experience any pain.
may require a further rectal stimulant.
25. Observe the patient throughout the procedure Note signs of distress, pain, bleeding and
STOP if there is anal area bleeding, STOP if general discomfort.
pain persists, STOP if the patient asks you to.
26. Check patient‟s pulse STOP if heart rate Vagal stimulation can slow heart rate and
drops or rhythm changes. alter heart rhythm.
27. STOP at first sign of autonomic dysreflexia. Symptoms include headache, blurred vision,
71
nausea, sweating, bradycardia, respiratory
distress, pupil constriction and flushing.
28. Place faecal matter in an appropriate To facilitate appropriate disposal of faecal
receptacle as it is removed. matter.
29. When the procedure is completed, wash and
dry the patient‟s buttocks and anal area and
position comfortably before leaving.
30. Remove the gloves and apron disposing of It will reduce transfer of microorganisms.
them& perform Hand hygiene. Gloves are not puncture-proof or leak-proof,
and hands may become contaminated when
gloves are removed.
31. Document in nursing notes all observations, Timely and accurate documentation
findings and action. promotes patient safety.
Nursing Alerts:
 Obtain a baseline pulse and blood pressure whilst patient has rest prior to procedure.
 Record pulse and blood pressure during and after the procedure.
 Monitoring the pulse and blood pressure is especially important in spinal injured patients
and the frail elderly.
 Observe for signs and symptoms of autonomic dysreflexia –headache, flushing, sweating,
hypertension.
 Observe for distress, pain, discomfort, and rectal bleeding, collapse and stool consistency.
72
SPECIMEN COLLECTION:
You always should follow the principle steps as the following:
 Label specimen tubes or bottles with the client‟s name, age, sex, date, time MR number.
 Always perform hand hygiene before and after collecting any specimen.
 Always observe body substance precautions when collecting specimens
 Collect the sample according your hospital/agent policy and procedure.
 Clean the area involved for sample collection
 Maintain the sterile technique if needed for sample or culture.
 Transport the specimen to laboratory immediately
 Be sure specimen is accompanied by specimen form or appropriate order form
 Record the collection and forwarding of the sample to laboratory on the client‟s record
COLLECTING BLOOD SPECIMEN

PERFORMING VENIPUNCTURE
Definition: Venipuncture is using a needle to withdraw blood from a vein, often from the inside
surface of the forearm near the elbow
Purpose:
 To examine the condition of client and assess the present treatment
 To diagnose disease
Equipment required:
 Laboratory form  Dry gauze
 Sterilized syringe  Disposable Gloves if available
 Sterilized needles  Adhesive tape
 Tourniquet  Sharps Disposal Container
 Blood collection tubes or specimen  Steel Tray
vials  Ball point pen
 Spirit swabs
Procedure:
1. Check client‟s identification against doctor‟s Providing nursing care for the correct
orders. client with appropriate way.
2. Explain to the client about the purpose and the Providing explanation fosters his/her
procedure. cooperation and allays anxiety
3. Reassure the client that the minimum amount of To perform once properly without any
blood required for testing will be drawn unnecessary venipuncture
4. Assemble the necessary equipment. Easy access to equipment prevents delay,
5. Perform hand hygiene and put on gloves. To prevent the infection of spreading.
6. Positioning: Make the client to be seated To make position safe and comfortable is
comfortably or supine position. helpful to success venipuncture at one try.
Assist the client with the arm extended to form a
straight-line from shoulder to wrist.
73
7. Check the client‟s requisition form, blood To assure the Dr‟s order with the correct
collection tubes or vials and make the syringe- client and to make the procedure smoothed.
needle ready.
8. Select the appropriate vein for venipuncture. The larger median cubital, basilica and
cephalic veins are most frequently used,
but other may be necessary and will
become more prominent if the client closes
his/her fist tightly.
9. Applying the tourniquet: Apply the tourniquet To prevent the venipuncture site from
3-4 inches (8 - 10 cm) above the collection site. touching the tourniquet and keep clear
Never leave the tourniquet on for over 1 minute. vision.
If a tourniquet is used for preliminary vein Tightening of more than 1 minute may
selection, release it and reapply after two minutes. bring erroneous results due to the change
of some blood composition.
10. Selection of the vein: Feel the vein using the tip
of the finger and detect the direction, depth and To assure venipuncture at one try.
size of vein.
11. Disinfect the selected site: Clean the puncture To prevent the infection from venipuncture
site by making a smooth circular pass over the site.
site with the spirit swab, moving in an outward
spiral from the zone of penetration.
Allow the skin to dry before proceeding. Disinfectant has the effect on drying.
Do not touch the puncture site after cleaning. To prevent the site from contaminating.
After blood is drawn the desired amount, release
tourniquet and ask the client to open his/her fist.
Place dry gauze over the puncture site and
remove the needle.
Immediately apply slight pressure. Ask the client To avoid making ecchymoma.
to apply pressure for at least 2 minutes.
When bleeding stops, apply a fresh bandage or The normal coagulation time is 2-5
gauze with tape. minutes.
12. Transfer blood drawn into appropriate blood A delay could cause improper coagulation.
specimen bottles or tubes as soon as possible
using a needless syringe. Do not shake or mix vigorously.
The container or tube containing an additive
should be gently inverted.
13. Dispose of the syringe and needle as a unit into To prevent the spread of infection.
an appropriate sharps container.
14. Label all tubes or specimen bottles with name, To prevent the blood tubes or bottles from
age, sex, inpatient no., date and time. misdealing.
15. Send the blood specimen to the laboratory To avoid erroneous results.
immediately along with the laboratory form.
16. Replace equipment and disinfects materials if To prepare for the next procedure and
needed. prevent the spread of infection.
17. Put off gloves and perform hand hygiene. To prevent the spread of infection.
74
❖NURSING ALERT❖
 Extensive scarring or healed burn areas should be avoided.
 Specimens should not be obtained from the arm on the same side as a mastectomy
 Avoid areas of hematoma.
 If an I.V. is in place, samples may be obtained below but NEVER above the I.V. site.
 Do not obtain specimens from an arm having a cannula, fistula, or vascular graft.
 Allow 10-15 minutes after a transfusion is completed before obtaining a blood sample.
 Observe universal (standard) precaution safety precautions. Observe all applicable
isolation procedures.
 Contaminated surfaces must be cleaned with disinfectant.
 Needle are never recapped, removed, broken or bent after phlebotomy procedure.
 In the case of an accidental needle-stick, immediately wash the area with an antibacterial
soap, express blood from the wound, and contact your supervisor.
 A patient should never be stuck more than twice unsuccessfully by a same staff. The
supervisor or a senior staff should be called to assess the client.
75
OBTAINING BLOOD FOR CULTURE:
Definition: Collecting of blood specimen for culture is a sterile procedure to obtain blood
specimen. Sterile techniques are used in whole of the procedure.
Purpose:
 To identify s disease-causing organisms
 To detect the right antibiotics to kill the particular microorganisms
Equipment required:
 Sterilized syringes (10 mL)  Gloves
 Sterilized needles  Adhesive tape or bandages
 Tourniquet  Sharps Disposal Container
 Blood culture bottles/sterile tubes  Steel Tray
containing a sterile anticoagulant  Ball point pen
solution as required
 Dry gauze
Procedure:
1. Check client‟s identification against doctor‟s Providing nursing care for the correct client
orders. with appropriate way.
2. Explain to the client about the purpose and the Providing explanation fosters his/her
procedure. cooperation and allays anxiety
3. Reassure the client that the minimum amount of To perform once properly without any
blood required for testing will be drawn unnecessary venipuncture
4. Perform hand hygiene and put on gloves. To prevent the infection of spreading.
5. Label all tubes or specimen bottles with client To prevent the blood tubes or bottles from
name, age, sex, inpatient no., date and time. misdealing.
6. Place the arm with proper position &disinfect To prevent unnecessary injury and protect
around injection site approximate 2-3 inches. entering organisms from the skin surfaces.

7. While puncturing: drawing blood Confirm the Sometimes the blood may be placed into two
amount after obtaining sufficient blood specimen or more tubes or bottles.
place the specimen into the specimen container with To secure the sterilized condition of
strict sterile technique. container.
Close the container promptly and tightly
8. After puncturing:
 Place a sterile gauze pad and folded into a
compress tightly over the site.
 Secure firmly with tape.
 Check stop of bleeding a few minutes later. To make sure all bleeding has stopped
9. Dispose of the syringe and needle as a unit into an To prevent the spread of infection.
appropriate sharps container.
10. Send the specimen to the laboratory immediately To avoid misdealing and taking erroneous
along with the laboratory order. results.
11. Replace equipment and disinfects materials if To prepare for the next procedure and
needed. prevent the spread of infection.
12. Put off gloves and perform hand hygiene. To prevent the spread of infection.
13. Document the procedure To avoid duplication. Documentation
provides coordination of care.
76
COLLECTING URINE SPECIMEN
Definition: Urinalysis, in which the components of urine are identified, is part of every client
assessment at the beginning and during an illness.
Equipment required
 Laboratory form.  Gloves
 Bedpan or urinal  Ballpoint pen
 Container with Label.
Purpose:
 To diagnose illness
 To collect uncontaminated urine specimen for culture and sensitivity test
 To detect the microorganisms causes urinary tract infection
 To diagnose and treat with specific antibiotic
1. Check client‟s identification and condition Providing nursing care for the correct client with
appropriate way.
2. Explain the purpose and procedure to the Providing information fosters cooperation and
client. understanding.
3. Label specimen containers or bottles Reduce handling after the container or bottle is
before the client voids. contaminated.
4. Note on the specimen label if the female One of the tests routinely performed is a test for
client is menstruating at that time. blood in the urine. If the female client is
menstruating at the time a urine specimen is taken,
a false-positive reading for blood will be obtained.
5. Instruct the client:
 Instruct the client to clean perineum  Bacteria are normally present on the labia or
with soap and water penis and the perineum and in the anal area.
 Open sterilized container and leave the  The cover should be kept the state sterilized;
cover facing inside up Substances in urine decompose when exposed
 Instruct the client to void into sterilized to air. Decomposition may alter the test results.
container with wide mouth.
6. Remove the specimen immediately after  Ensure the client voids enough amount of the
the client has voided. Obtain 30-50 mL at urine for the required tests.
midstream point of voiding (for urine  Emphasize first and last portions of voiding to
culture). be discarded.
7. Close the container securely without Covering the bottle retards decomposition and it
touching inside of cover or cap prevents added contamination
8. Dispose of used equipment. To prevent the spread of infection.
Remove gloves and perform hand hygiene.
9. Send the specimen bottle or container to Organisms grow quickly at room temperature.
the laboratory immediately with the
specimen form.
10. Be sure to document the procedure. To avoid duplication. Documentation provides
coordination of care
77
COLLECTING A 24-HOUR URINE SPECIMEN
Definition: Collection of a 24-hour urine specimen is defined as the collection of all the urine
voided in 24 hours, without any spillage of wastage.
Purpose:
 To detect kidney and cardiac diseases or conditions
 To measure total urine component
Equipment required
 Laboratory form.  Clean measuring jar
 Bedpan or urinal  Gloves
 24 hours collection bottle with lid  Ballpoint pen
or cover
Procedure:
1. Explain the procedure Providing information fosters his/her
cooperation.
2. Assemble equipment and check the Ensure that the specimen collecting is
specimen form with client‟s name, date and correct.
content of urinalysis.
3. Label the bottle or container with the date, Ensure correct identification and avoid
client‟s name, and department. mistakes.
4. Instruct the client: Before beginning a 24 To measure urinal component and assess
hour urine collection, asks the client to void the function of kidney and cardiac
completely. function accuracy.
5. Document the starting time of a-24 hour The entire collected urine should be
urine collection on the specimen form and stored in a covered container.
nursing record.
6. Instruct the client to collect all the urine
into a large container for the next 24 hours.
7. Measure total amount of urine and record it
on the specimen form and nursing record.
8. Perform hand hygiene and put on gloves. Ensure the client voids enough amount of
Collect some urine as required or all the the urine for the required tests.
urine in a clean bottle with lid. Transfer it Covering the bottle retards
to the laboratory with the specimen form decomposition and it prevents added
immediately. contamination.
9. Remove gloves and perform hand hygiene. Gloves are not puncture-proof or leak-
proof, and hands may become
contaminated when gloves are removed.
10. Be sure to document the procedure in the To avoid duplication. Documentation
designated place. provides coordination of care.
78
COLLECTING A URINE SPECIMEN FROM A FOLEY CATHETER
Equipment required:
 Laboratory form  10-20-mL syringe with 22-24-gauge
 Gloves needle
 Container with label as required  Clamp or rubber band
 Spirit swabs or disinfectant swabs  Ballpoint pen
Procedure:

1. Assemble equipment. Label the container. Organization facilitates accurate skill
performance.
2. Explain the procedure to the client. Providing information fosters his/her
cooperation.
3. Perform hand hygiene and put on gloves. To prevent the spread of infection.
4. Clamp the tubing: Collecting urine from the tubing guarantees
Clamp the drainage tubing or bend the tubing afresh urine.
Allow adequate time for urine collection Long-time clamp can lead back flow of
❖Nursing Alert❖ You should not clamp urine and is able to cause urinary tract
longer than 15minutes. infection.
5. Cleanse the aspiration port with a spirit swab Disinfecting the port prevents organisms
or another disinfectant swab (e.g. Betadine). from entering the catheter.
6. Withdrawing the urine:
Insert the needle into the aspiration port. This technique for uncontaminated urine
Withdraw sufficient amount of urine gently specimen, preventing contamination of the
into the syringe. client‟s bladder.
7. Transfer the urine to the labeled specimen Care full labeling and transfer prevents
container. contamination or confusion of the urine
specimen.
8. The container should sterile. Appropriate container brings accurate
results of urinalysis.
9. Unclamp the catheter. The catheter must be unclamped to allow
free urinary flow and to prevent urinary
stasis.
10. Prepare and pour urine to the container for Proper packaging ensures that the specimen
transport to laboratory. is not an infection risk.
11. Dispose of used equipment and disinfect if To prevent the spread of infection.
needed.
12. Remove gloves and perform hand hygiene. To prevent the spread of infection. Gloves
are not puncture-proof or leak-proof, and
hands may become contaminated when
gloves are removed
13. Send the container to the laboratory Organisms grow quickly at room
Immediately. temperature.
79
COLLECTING A STOOL SPECIMEN:
Definition: Collection of stool specimen deters a process which is aimed at doing chemical
bacteriological or parasitological analysis of fecal specimen
Purpose:
 To identify specific pathogens.
 To determine presence of ova and parasites.
 To determine presence of blood and fat.
 To examine for stool characteristics such as color, consistency and odor
 To measure the volume of fecal content
 To determine intestinal Absorption problems
Equipment required:
 Laboratory form  Closed specimen container with Label
 Disposable gloves  Wooden tongue depressor
 Clean bedpan with cover.  Plastic bag for dirt
1. Check the client‟s identification. To confirm the necessity & To give care to the
correct patient.
2. Explain the purpose and procedure to the client. Providing information fosters the client‟s
cooperation and understanding.
3. Wash your hands. Hand washing prevents the spread of infection
4. Label the container. Careful labeling ensures accuracy of the report
5. Ask the client to tell you when he/she feels the Most of clients cannot pass on command.
urge to have a bowel movement.
6. Perform hand hygiene and put on gloves. To prevent the spread of infection.
7. Placing bedpan:
 Close door and put curtains/ a screen.  To provide privacy
 Give the bedpan when the client is ready.
 Allow the client to pass feces.
 Instruct not to contaminate specimen with  To gain accurate result.
urine.
8. Collecting a stool specimen: Remove the
bedpan and assist the client to clean if needed.
Use the tongue depressor to transfer a portion it is grossly contaminated
of feces to the container without any touching. To gain accurate results.
Cover the container. It prevents the spread of odor.
9. Remove and discard gloves. Perform hand Gloves are not puncture-proof or leak-proof, and
hygiene. hands may become contaminated when gloves
are removed.
10. Send the container immediately to the Stools should be examined when fresh.
laboratory. Examinations for parasites, ova, and organisms
must be made when the stool is warm.
11. Document the procedure. To avoid duplication. Documentation provides
coordination of care.
80
COLLECTION OF SPECIMEN OF THROAT SWAB
Purposes:
 To screen the presence of any pathogenic organism in the throat culture.
 To diagnose any respiratory tract infection.
Equipment:
 Clean tray containing sterile  Completed identification label
swab in in sterile culture tube  Completed laboratory
 Emesis basin or clean container requisition forms
 Tongue blade  Clean disposable gloves
 Penlight
Procedure:
S# Nursing Procedure RATIONALE
1. Check the client‟s identification. To confirm the necessity & To give care to
3. Explain the purpose and the procedure to Providing information fosters the client‟s
the client. cooperation and understanding.
4. Wash your hands. Hand washing prevents the spread of
infection.
5. While collecting throat culture Facilitate visualization of pharynx.
Instruct client to tilt head backward for
clients in bed, place pillows behind
shoulders.
6. Ask the client to open mouth and say Permits exposure to pharynx, relaxes throat
„aaahh‟ muscles, minimize gag reflex
7. If pharynx not visualized, depress tongue Area to be swabbed should be clearly
with tongue blade and not inflamed areas of visualized. Placement of tongue blade
pharynx or tonsils. Prepare anterior 1/3 of along back of tongue may likely initiates
tongue only. gag reflex.
8. Insert swab without touching lips, teeth, Touching lips or oral mucosa can
tongue and cheeks. contaminate swab with resident bacteria.
9. Gently but quickly swab tonsillar area side These areas contain most organisms.
to side making contact with inflamed or
purulent sites
10. Carefully withdraws swab without striking Retain micro-organism with culture tube
oral structure. Immediately place swab in mixing swab tip with culture media ensures
culture. life of bacteria for testing.
11. Discard tongue depressor into trash. Reduces transmission of micro-organism
12. Securely attach properly completed Incorrect identification of specimen could
identification. results in diagnostic and therapeutic errors.
13. Send specimen immediately to laboratory or Fresh specimen provides most accurate
store in refrigerator. results.
81
COLLECTING A SPUTUM SPECIMEN:
ROUTINE TEST
Definition: Collecting a sputum specimen is defined as a one of diagnostic examination using
sputum
Purpose:
 To diagnose respiratory infection
 To assess the efficacy of treatment to diseases such as TB
Equipment required:
 Laboratory form  Plastic bag for dirt
 Disposable gloves  Paper tissues as required
 Sterile covered sputum container
with Label
Procedure:
1. Check the client‟s identification. To confirm the necessity & To give care to the
correct patient.
time and energy.
4. Perform hand hygiene and put on gloves. The sputum specimen is considered highly
contaminated; you should treat it with caution.
5. Label the container. Careful labeling ensures accuracy of the report
6. Collecting the specimen:
Instruct the client to cough up secretions A sputum specimen should be from the lungs and
from deep in the respiratory passage. bronchi. It should be sputum rather than mucous.
Have the client expectorate directly into Avoid any chance of outside contamination to
the sterile container. specimen & contamination of other objects.
Instruct the client to wipe around mouth Paper tissues used by any client are considered
if needed. Discard it properly. contaminated.
Close the specimen immediately To prevent contamination
7. Remove and discard gloves. Perform To prevent the spread of infection. Gloves are not
hand hygiene. puncture-proof or leak-proof, and hands may
become contaminated when gloves are removed.
8. Send specimen to the laboratory To prevent the increase of organisms.
immediately.
9. Document the procedure. To avoid duplication. Documentation provides
82
COLLECTING SPUTUM FOR CULTURE:
Definition: Collection of coughed out sputum for culture is a process to identify respiratory
pathogens.
Purpose:
 To detect abnormalities
 To diagnose disease condition
 To detect the microorganisms causes respiratory tract infections
 To treat with specific antibiotics
Equipment required:
 Laboratory form  plastic bag for dirt
 Disposable gloves  Paper tissues as required
 Sterile covered sputum container  Ballpoint pen
with Label.
❖Nursing Alert❖
You should give proper and understandable explanation to the client
1. Give specimen container on the previous evening with instruction how to treat
2. Instruct to raise sputum from lungs by coughing, not to collect only saliva.
3. Instruct the client to collect the sputum in the morning.
4. Instruct the client not to use any antiseptic mouth washes to rinse his/her mouth before
collecting specimen.
Procedure:
Sr Nursing Action Rational
#
1. Check the client‟s identification. To confirm the necessity & To give care to
4. Label the container. Careful labeling ensures accuracy of the
report and alerts the laboratory personnel to
the presence of a contaminated specimen.
5. Perform hand hygiene and put on gloves To prevent the spread of infection. The
sputum specimen is considered highly
contaminated, so you should treat it with
caution
6. Instruct the client:
Instruct the client to collect specimen early To obtain overnight accumulated secretions
morning before brushing teeth
7. Instruct the client to remove and place lid To maintain the inside of lid as well as
facing upward. inside of container
8. Instruct the client to cough deeply and A sputum specimen should be from the
expectorate directly into specimen container lungs and bronchi. It should be sputum
rather than mucous.
83
9. Instruct the client to expectorate until you To obtain accurate results.
collect at least 10 ml of sputum
10. Close the container immediately when To prevent contamination.
sputum was collected
11. Instruct the client to wipe around mouth if Paper tissues used by any client are
needed. Discard it properly. considered contaminated.
12. Remove and discard gloves. Perform hand To prevent contamination of other objects,
hygiene including the label.
13. Send specimen to the laboratory To prevent the increase of organisms.
immediately.
14. Document procedure. Documentation provides ongoing data
collection.
84
URINE TESTING THROUGH DIPSTICK
Equipment:
 Alcohol swab.  Urine dipsticks
 Gloves  Urine sample
 Apron
Procedure:
1. Perform hand hygiene Hand hygiene reduces the risk of infection.
2. Apply non-sterile gloves and gown or face Personal protective equipment reduces the
shield according to agency protocols. transmission of microorganisms and protects
against an accidental body fluid exposure.
3. Confirm patient details are correct on the Careful labeling ensures accuracy of the report
sample bottle
4. Inspect the color of the urine: straw color normal
Dark concentrated urine dehydration
Red hematuria
Brown bile pigments
5. Inspect the clarity of the urine: Clear Normal

Cloudy /debris urinary tract
infection (UTI)
Frothy nephritic syndrome
6. Remove the sample bottles‟ cap and assess  Offensive urine – UTI
urine odor:  Sweet – glycosuria
7. Check urine dipsticks‟ expiry date For accuracy of results.
8. Remove a testing strip from the container To prevent contamination.
(avoiding touching the testing zones)
9. Insert test strip into urine sample (ensuring For accuracy of results.
all test zones are immersed)
10. Ensure test strip remains in a horizontal To avoid cross contamination of testing zones
orientation
11. Use the dipstick analysis guide on the side
of the testing strip container to interpret the pH indicates acidity of urine – e.g. ↓pH
findings in systemic acidosis
Specific indicates amount of solute dissolved
gravity in urine – ↓ in diabetes insipidus
Blood indicates number of red blood cells
in urine
Protein indicates level of protein in urine
Ketones breakdown product of fatty acid
metabolism – ↑ starvation / ↑DKA
Glucose ↑ hyperglycaemia
Bilirubin Indicates ↑ conjugated bilirubin
(water soluble) – ↑ biliary tract
obstruction
85
12. Different tests on the strip are required to be
read at different times, so ensure you
interpret the appropriate test at the correct
time interval –e.g. 60 seconds for protein
13. Once you have interpreted all of the tests,
discard the strip into the clinical waste bin
along with your gloves and apron.
14. Wash hands. Gloves are not puncture-proof or leak-proof, and
are removed.
15. Document procedure and findings. To avoid duplication. Documentation provides
86
INFORMED CONSENT
PURPOSES
 To ensure that parents /legal guardian or patient clearly Understand the procedure or
treatment to be performed.
 To ensure that any risk factor involve or alternate methods available to achieve the same
end has been explained by a health provider.
 To provide health teaching.
EQUIPMEN
 Consent form.
 Pen
PROCEDURE:
S# STEPS RATIONALE
1. Identify the patient. To take consent from the right patient
2. Identify individual responsible for making To take consent from the right person who
the decision. is legally responsible.
3. Make sure that the decision making person Age, relation and the mental status of that
appears competent to give consent. person is important for legal concern.
4. Introduce self and explain the purpose of Helps minimizing anxiety and to gain
consent. cooperation
5. Establish comfortable environment Facilitates more exchange of information
without fear and anxiety.
6. Maintain eye contact. Ensures that the parents/ legal guardian or
patient is giving maximum attention
7. The information should be presented in For clear understanding.
simple, easy-to-understand terms.
8. All questions and concern should be Minimizes anxiety and promotes
answered honestly. cooperation
9. If appropriate, an interpreter should used. To ensure clear communication.
10. Take written consent on consent form. Consent form is a legal document and
Protect legally.
11. Make sure the decision is voluntary. The person making decision must not be
coerced or forced.
12. Make sure the signature is authentic. For legal concern.
13. Record client‟s concerns or questions Communicates client understood.
14. Record any teaching as a result of nursing Facilitates communication among health
related questions by the client. care professionals
15. Record any special circumstances, such as
the use of interpreter should be
documented.
87
REFERENCES:
1. FUNDAMENTAL OF NURSING PROCEDURE MANUAL. 2. PUBLISHED BY:
JAPAN INTERNATIONAL COOPERATION AGENCY (JICA)
2. PROCEDURE CHECKLISTS FOR FUNDAMENTALS OF NURSING HUMAN
HEALTH AND FUNCTION.
3. NURSING PROCEDURES AND INTERVENTIONS TEXTBOOK FOR
BACHELOR‟S AND MASTER‟S DEGREE PROGRAMMES.
4. KOZIER, B., ERB, G., BLAIS, K AND WILKINSON, LM (1995). ASSESSING
VITAL SIGNS. (5TH CD.), FUNDAMENTALS OF NURSING: CONCEPTS
PROCESS AND PRACTICE (PP. 434-436). .NEW YORK: ADDISON WESLEY.
5. PROCEDURES THE ROYAL MARSDEN MANUAL OF NINTH EDITION
CLINICAL NURSING PROFESSIONAL EDITION.
6. CLINICAL NURSING SKILLS AND TECHNIQUES - 9TH EDITION –
ELSEVIER
7. HOW TO PERFORM A DIGITAL REMOVAL OF FAECES –
CITESEERXCLINICAL PROCEDURE FOR SAFER PATIENT CARE
88

1-FON Skill Lab Manual

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

1-FON Skill Lab Manual

Uploaded by

Copyright:

Available Formats

TABLE OF CONTENTS

Use the Head Tilt-Chin Lift maneuver:

7 Breathing: Assess for respirations. Cardiopulmonary resuscitation should not be

If respirations are absent:

Mouth to Mouth Breathing Rescue breathsbreathing with Ambo bag

Access carotid pulse Chest compression

Place Appropriate Pads & Deliver Shock Resume CPR

 Ratna (2007).Manipal Manual of Nursing procedures, (IST Ed vol.1 Part

Sr# Nursing Action Rational

Apply non-sterile gloves

 Ratna (2007).Manipal Manual of Nursing procedures, (IST Ed vol.1 Part

 Ratna (2007).Manipal Manual of Nursing procedures, (IST Ed vol.1 Part

Adhesive dressing Gauze dressings

Bandage: The three major types of bandages are:

Basic Bandaging Forms

15. Use a spiral wrap for a large cylindrical area

17. Use a figure eight wrap to support or limit joint

18. Use a recurrent wrap for anchoring a dressing on

Definition: Oxygen therapy is the administration of supplementary oxygen when tissue

Attach one end of connection tubing to the

Insert Yankauer catheter and apply suction

Apply non-sterile gloves.

Sr# Nursing Action Rational

COLLECTING BLOOD SPECIMEN

Sr# Nursing Action Rational

5. Inspect the clarity of the urine: Clear Normal

You might also like