Nursing Skills Manual

FOCUSED ASSESSMENT
OBJECTIVES: At the end of this station, the student nurse will be able to:
- Identify Level of Consciousness and Verbal response
- Perform pupil size/reaction assessment
- Evaluate Cranial nerve functioning
- Differentiate between normal from abnormal heart and lung sounds
- Verbalize and perform intervention for chest pain, dyspnea, nausea and
vomiting, pain
- Perform abdominal assessment
- Perform motor function assessment
- Evaluate skin integrity
- Interpret Glasgow Coma Scale
This is the procedure:

1. Knock on the door (not too soft nor too loud).
2. Greet patient.
3. Do small talk.
4. Explain while doing procedures
5. Wash hands prior to procedure.
6. Assess patient according to the sequences in the manual.
Pain Assessment
*Ask the patient if he/she feels pain in any part of his/her body. If yes, refer to the next sequence.
(If the location of the pain is in the thoracic/chest and abdominal, refer to the “Chest pain, Dyspnea,
and Abdominal Assessment”) If no pain noted, skip the pain assessment and proceed with the next
assessment.
1. Onset and temporal pattern -- When did your pain start? How often does it
occur? Has its intensity changed?
2. Location --Where is your pain? Is there more than one site?
3. Description -- What does your pain feel like? What words would you use to
describe your pain?
A. Assessment
of pain 4. Intensity -- On a scale of 0 to 10, with 0 being no pain and 10 being the worst
intensity and pain you can imagine, how much does it hurt right now? How much does it
character hurt at its worst? How much does it hurt at its best?
5. Aggravating and relieving factors -- What makes your pain better? What
makes your pain worse?
6. Previous treatment -- What types of treatments have you tried to relieve your
pain. Were they and are they effective?
7. Effect -- How does the pain affect physical and social function?
1. Effect and understanding of the diagnosis and
treatment on the patient and the caregiver.
2. The meaning of the pain to the patient and the family.
Psychosocial 3. Significant past instances of pain and their effect on the
B. Psychosocial
assessment should patient.
assessment
include the following: 4. The patient's typical coping responses to stress or pain.
5. The patient's knowledge of, curiosity about,
preferences for, and expectations about pain
management methods.
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6. The patient's concerns about using controlled
substances such as opioids, anxiolytics, or stimulants.
7. The economic effect of the pain and its treatment.
8. Changes in moods that have occurred as a result of the
pain (e.g., depression, anxiety).
1. Examine site of pain and evaluate common referral patterns.
C. Physical and 2. Perform Head and neck pain -- cranial nerve evaluation
neurological pertinent
examination neurological Back and neck pain -- motor and sensory function in limbs
evaluation.
LEVEL OF CONSCIOUSNESS
*Note if the patient is conscious, coherent, and ambulatory, skip the Assessment of Glasgow
Coma scale and proceed to the next assessment.
1. Establish orientation to time, place, person GLASGOW COMA SCALE SCORING Normal
and event (or situation). For instance ask: Eye Opening
- What’s your name? a. Spontaneous 4
- What year is this? b. To speech 3
c. To pain 2
- Where are you? d. No response 1
Verbal Response
2. Identify gross deficits in long term and short-a. Oriented to time, place, person 5
term memory with simple test. b. Engages in conversation, confused in content 4
c. Words spoken but conversation not sustained 3
- Long-term test: the patient is able tod. Groans evoked by pain 2
relate the past history. e. No Response 1
Motor Response
- Short-term test: stating three words fora. Obeys command 6
5
the patient to remember, asking theb. Localizes a painful stimulus
4
c. Withdraws to pain
patient to say the words immediatelyd. Abnormal flexion to pain (decorticate) 3
and ask the patient to repeat them aftere. Extensor response to pain (decerebrate) 2
a few minutes. f. No response 1
15
Interpretation:
- A score of 15 indicates normal
- A score less than 8 indicates poor prognosis
- A score of 3 indicates deep coma
Conscious Semi-conscious Unconscious

Level Alert Confused Obtunded, drowsy Stupor Light coma Deep coma
Behaviors Normal Poor Sleepy, very short Apathetic, slow Not oriented Absence,
activity, coordination, attention span, moving, blank to time, place of response
aware, delirium, ready arousal, expression, or person, to even the
mentally hallucinations, responds drooping head, response is most
functional restlessness, appropriately when staring. Arousal only by painful
excitable, may aroused, ability to only to vigorous grimace or stimuli.
be combative, respond verbally, stimuli, withdrawing
short attention fends off painful incomplete limb from
span, stimuli with arousal to painful pain,
inappropriate purposeful stimuli, no verbal primitive and
actions and movement response or disorganized
judgments, moaning, response to
decreased response to painful
verbal stimuli.
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awareness, communication is
disorientation inconsistent and
vague
ASSESSMENT OF PUPIL SIZE AND REACTION
1. Dim the lights. (Because we want to make sure that we get accurate information, I’d like to
check your pupils)
2. Stand in front of the patient; assess both eyes for size and symmetry.
3. Observe reaction to light. Open eyelid being tested and cover the opposite eye, note the
findings. And do the same thing to the other eye.
4. Observe consensual light reflex or consensual validation by holding both eyelids open, shine
light into one eye only, and observe reaction of both eyes.
Constrict
Dilate
Cranial Nerve Assessment
A commonly used mnemonic for identifying and remembering the cranial nerves is: On Old
Olympus Towering Tops, A Finn And German Viewed Some Hops. The details of the cranial
nerves are as follows.
1. CN1 – Olfactory: You have one nose, which is where CN 1 resides. Its function
contributes to the sense of smell.
2. CN II – Optic: You have two eyes, where you will find CN II. Function of this cranial
nerve is vital to vision and visual fields, and, in conjunction with CN III, pupillary
reaction.
3. CN III – Occulomotor: CN III, the eye (occulo-) movement (motor) nerve works
with CN III, IV and VI (abducens, which helps the eyeball abduct or move). The
actions of these CNs are largely responsible for the movement of the eyeball and
eyelid.
4. CN IV – Trochlear
5. CN V – Trigeminal: Three (tri) types of sensation – temperature, pain and tactile –
come from this three (tri)-branched nerve that covers three (tri) territories of the face.
For normal corneal reflexes to be present, the afferent limb of the first division of CN
V and the effect limb of CN VII need to be intact.
6. CN VI – Abducens
7. CN VII – Facial: Dysfunction of this nerve gives the characteristic findings of Bell’s
palsy (facial asymmetry, droop of mouth, absent nasolabial fold, impaired eyelid
movement).
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8. CN VIII – Auditory or vestibulocochlear: When this does not function properly,
hearing (auditory) or balance is impaired (vestibulocochlear). The Rinne test is part
of the evaluation of this cranial nerve.
9. CN IX – Glossopharyngeal: The name of this CN provides a clue that its function
affects the tongue (glosso) and throat (pharynx). Along with CN X, the function of this
nerve is critical to swallowing, palate elevation and gustation.
10. CN X – Vagus
11. CN XI – Accessory or spinal root of the accessory: Function of this CN can be
tested by evaluating shoulder shrug and lateral neck rotation.
13. CN XII – Hypoglossal- Function of this CN is tested by noting movement and
protrusion of the tongue.
CHEST PAIN ASSESSMENT
*Proceed ONLY if the patient complains pain upon the Pain Assessment.
Questions to ask the patient:

1. What are the complaints? (specific words, location, severity)
2. Are there other signs or symptoms? (Lightheaded, dizzy, nausea, palpitations, indigestion,
breathless)
3. What was the patient doing when it started?
4. Assess for any Past Medical History such as MI, Angina, Pericarditis, G.E.R.D. or chest wall
syndrome.
5. Ask the patient to describe the pain.
6. Note if Levine’s sign is present (fist over chest).
HEART SOUND ASSESSMENT
1. Wash your hands and explain every step of the procedure to the patient. Provide privacy by
closing the door or pulling the curtain around the bed. (Because we are concerned that we
maintain your privacy, I am now pulling the curtain around your bed.)
2. If possible have the patient sit on the bed, and if not, raise the bed to the nurse's waist level
then elevate the head of the bed to 45-90 degrees if not contraindicated. If the patient is in bed,
have him turn to the left side lying position. This position ensures that the heart is close to the
chest wall.
3. Loosen or remove clothing.
4. Place the diaphragm of the stethoscope at the apex of the heart (5 th intercostal space at the
left midclavicular line) and identify S1 and S2, the “lub” and “dub” sounds. Count the apical
pulse rate.
5. Using the bell of the stethoscope, auscultate in the four valve areas for abnormal sounds
(gallops, murmurs, rubs, clicks etc.)
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6. Replace clothing and make the patient comfortable. Lower the bed and raise the side rails if
they were moved.
7. Report murmurs or any sound that is different from an S1 or S2.
8. Record the apical heart rate and presence of normal or abnormal sounds.
DYSPNEA ASSESSMENT
*Proceed ONLY if the patient complains pain upon the Pain Assessment

1. When did the dyspnea begin?
2. What have you tried to relieve the dyspnea?
3. What makes your dyspnea worse?
4. Do you feel exhausted or fatigued?
5. Are you able to do your daily activities?
6. Is your shortness of breath associated with meals or daily activities, or any of the medications
you are taking?
- The use of a consistent dyspnea scale (0 = no dyspnea, 10 = worst dyspnea imaginable)
helps to best communicate the intensity of dyspnea a patient experiences.
Dyspnea Intensity Scale

0 1 2 3 4 5 6 7 8 9 10
I I I
No Dyspnea Moderate Dyspnea Worst Dyspnea
LUNG SOUND ASSESSMENT
1. Wash your hands and explain every step of the procedure to the patient.
2. Eliminate extraneous noise from the area. Ask the patient not to talk.
3. Provide privacy by drawing the curtain around the bed or closing the door to the room; adjust
the blinds if the window faces a walkway or if others can see in easily. (Because we are
concerned that we maintain your privacy, I am now adjusting the blinds of this window).
4. Help the patient assume a sitting position with the back away from the bed or chair. Raise the
bed to working height and lower the side rail.
5. Remove or loosen clothing. Do not listen over patient’s gown so that the stethoscope can be
applied to the skin in the correct locations.
6. Warm the diaphragm of the stethoscope with your hand. (Because we are concerned that you
don’t feel how cold this is, we will warm it up for you). Warming the diaphragm of the
stethoscope will promote comfort.
7. Ask the patient to breathe in and out slowly and deeply through an open mouth.
8. Apply the diaphragm of the stethoscope to the posterior of the chest and listen in each location
for full inspiration and expiration. Move the stethoscope from one side to the other. Do not listen
over bone; place the stethoscope between the scapula, beside the vertebrae, and between the
ribs.
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9. Move around to the front of the patient and auscultate the anterior and lateral areas of the lungs
in a methodical side-to-side fashion.
10. If noise from hair on the chest is heard, press the diaphragm more firmly onto the chest or wet
the hair.
11. If rhonchi or crackles are heard, ask the patient to take a couple of deep breaths and to turn
the head away and cough.
12. Compare sounds heard on the right with those on the left for each area.
13. Rearrange the patient’s clothing and turn the radio or TV back on. Lower the bed if it was raised;
replace side rails if they were lowered, and make the patient comfortable.
14. Wash your hands.
15. Document the findings.
NAUSEA AND VOMITING ASSESSMENT
*Ask the patient first if he/she feels nauseous and vomited for the past 24 hours. Skip this part if
there’s no evidence of nausea and vomiting, and proceed with the next assessment.
SYMPTOMS DIAGNOSIS SELF-CARE
See Nausea and Vomiting

1. Is the patient an Assessment for Infants and
infant or child? Children below.
2. Does the patient Go to Question 7.*.

have a fever?
3. Does the patient

have cold symptoms May be viral
Request anti-diarrheal from MD for
and fever along with GASTROENTERITIS
symptom-relief and observe for dehydration
nausea and (stomach flu).
vomiting?
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URGENT
4. Does the patient May have APPENDICITIS
Assess for bowel sounds, rebound
have abdominal pain abdominal tenderness, rectal tenderness,
or a BOWEL
in the middle or examine WBC count, and refer to MD. An
OBSTRUCTION.
lower right side? infected appendix could rupture within 24
hours if left unattended.
5. Does the patient EMERGENCY

have a headache or May have MENINGITIS, a
Assess for s/s of increased intracranial
stiff neck, and does serious infection around the
pressure. Refer to MD. Delay could result
normal light hurt the brain.
in serious injury or death.
eyes?
May have GALLSTONES or

6. Does the patient CHOLECYSTITIS, an Assess type of pain. If colicky, stones;
have pain in the right infection of the gallbladder. intense, pancreatitis. Assess location of
upper abdomen or This may also be due to pain. If RUQ radiating to R shoulder,
do greasy foods PANCREATITIS, gallstones. If epigastric radiating to lumbar,
make the pain inflammation of the pancreatitis.
worse? pancreas.
7. *Does the patient

have a burning pain Assess pain occurrence. Call MD and
May have ULCERS or
in the stomach that's request for a simple antacid. If it takes care
simple HEARTBURN or
relieved by bland of the problem, the irritation was mild. If the
GASTRITIS.
foods and upset by pain or burning continues, call MD.
spicy foods?
May have a bleeding

ULCER, a RUPTURE or URGENT
8. Have you vomited TEAR in the lining of the Call MD after assessment of bowel sounds,
blood? esophagus, or a severe presence of bleeding (i.e. hematemesis,
NOSEBLEED that may epistaxis, etc.)
need packing.
May have FOOD

9. Do the symptoms POISONING caused by a
occur shortly after toxin or bacteria from Most episodes will clear up by themselves
eating food that contaminated food. This is in six to 12 hours. Watch for s/s of
might have gone likely if someone else who dehydration
bad? ate the same food also
became ill.
10. Does the patient

have yellow May have HEPATITIS Make assessments re appetite, knowledge
discoloration in eyes, A/B/.C from a viral illness, a of transmission. Put the patient on Enteric
weight loss and drug or exposure to a Precautions if A; Standard Precautions if B
nausea, or does food chemical. or C.
taste strange, or is
the urine very dark?
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11. Is the patient taking Medicine could be causing Assess for drugs that may cause
medicine? the problem. nausea/vomiting.
12. Have the patient

missed a period May be PREGNANT. Refer to MD
and/or could be
pregnant?
Monitor blood sugar closely and check for

13. Does the patient May develop
urine for ketones. Assess for fruity odor on
have diabetes and KETOACIDOSIS, even with
breath, changes in LOC, color and moisture
vomiting? mild symptoms.
of skin.
14. Did the patient

recently hit his/her
head and now has a May have a serious HEAD
Assess for s/s of increased ICP
headache, blurred INJURY.
vision, or numbness
or tingling?
(Nausea and Vomiting Assessment for infants and children)
SYMPTOMS DIAGNOSIS SELF-CARE
This is probably
"SPITTING UP," a
1. Is the infant throwing common occurrence for The baby may be gulping air or may have
up small amounts of infants on formula. Less taken too much formula, or the formula may
formula after a common is a LACTOSE be upsetting the child's stomach.
feeding? INTOLERANCE or MILK
ALLERGY.
2. Does the infant

forcefully vomit large This type of vomiting may
amounts of formula or Refer to MD after appropriate assessment.
be from a blockage at the
fluid and is the child (presence of olive shaped mass in
end of the stomach called
under 10 weeks of age abdomen, non-bile emesis
PYLORIC STENOSIS.
or appear to be
dehydrated?
Vomiting and diarrhea

may be from VIRAL
3. Does the child have GASTROENTERITIS or Assess for fever and dehydration
diarrhea? possibly from a formula
problem.
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4.
- Has the infant (age two

years and under) been
vomiting continuously May be on the verge of
Assess for fluid and electrolyte imbalance.
for six to 12 hours? DEHYDRATION.
- Has the child (age two
and above) been
vomiting continuously
for 12 to 24 hours?
4. Does the infant have

cranberry-colored May have an Assess for high pitched sounds proximal to
diarrhea and OBSTRUCTION of the obstruction and absent bowel sounds distal
uncontrollable crying, intestines. to the obstruction. Refer to MD.
and continue to vomit
all liquids?
ABDOMINAL ASSESSMENT
1. Wash your hands and explain every step of the procedure to the patient.
2. Provide privacy by closing the door or pulling the curtains around the patient’s bed. (Because
I’m concerned about your privacy, I am now pulling the curtain around your bed.)
3. Have the patient lie in a supine position with knee flexed and remove or loosen the patient’s
clothing.
4. Inspect the general contour of the abdomen.
5. Inspect for bruising around umbilicus and over flanks.
6. Observe for scars, stretch marks, dilated veins, presence of hernia.
7. Assess circumference for intra-abdominal hemorrhage or ascites by placing a tape measure
around the largest circumference of the abdomen and drawing two lines around patient’s entire
abdomen, one line at the top of the tape measure, and one line at the bottom of the tape
measure; perform measurement when patient exhales.
8. Auscultate abdomen to assess presence and quality of bowel sounds.
9. Place diaphragm of stethoscope firmly on right lower quadrant and count sounds for 1 minute.
10. Listen at all quadrants, near the center, for 1 full minute per quadrant if sounds not heard initially.
11. Palpate abdomen to determine condition of abdominal muscles and organs beneath muscles
except if a pulsating mass is present.
12. Assist patient to relax, lie flat in bed, and flex knees.
13. Place your hand flat on patient’s abdomen, holding your four fingers together and depressing
½ inch.
14. Instruct patient to cough to determine any areas of abdominal muscles.
15. Palpate at the pubis moving upward. Palpate any problem areas last to minimize effects of
comfort.
16. Palpate all quadrants of abdomen to assess organs contain in each quadrants.
17. For superficial palpation, use slight pressure only.
18. For deep palpation: indent the abdominal wall 4-5 cm may use one hand over the other to apply
pressure.
19. Palpate liver by placing left hand behind 11th and 12th ribs with right hand on right abdomen
lateral to rectus muscle.
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ASSESSMENT OF MOTOR STRENGTH
1. Assess bilateral muscle strength. Test “handgrip” by asking patient to squeeze

your fingers.
2. Test arm strength by asking the patient to close eyes and hold out in front with palms up.
3. Assess flexion and extension strength in extremities. Stand in front of the patient, place your
hand in front of the patient, and ask the patient to push your hand away. Place your hand on
patient’s forearm and ask the patient to pull arm upward. Position patient’s leg with knee flexed
and foot resting on bed; as you try to extend leg, ask patient to keep foot down.
4. Place one hand on patient’s knee and one hand on patient’s ankle; ask patient to straighten
leg as you apply resistant force to knee and ankle.
5. Assess for muscle tone. Flex and extend patient’s upper extremities to assess how well patient
resists your movements. Flex and extend patient’s lower extremities to assess resistance.
SKIN INTEGRITY ASSESSMENT
*If there’s evidence of impaired skin integrity, proceed with the assessment. If not, skip this part and
proceed with the next procedure.
1. Identify patient’s risk for pressure ulcer formation using the Braden Scale and assign a score
for each of the subscales:
a. Sensory perception
b. Moisture
c. Activity
d. Mobility
e. Nutrition
f. Friction and shear
2. Use the risk score and evaluate based upon patient’s over all condition.
3. If any of the risk factors are found to receive low score on the risk assessment tool, consider
one or more of the interventions listed in box.
4. Perform a systematic skin assessment of bony prominences. If open areas are noted, wear
examination gloves. Look for areas of skin breakdown in the following locations
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a. Back of head h. Inner/outer ankles
b. Shoulders i. Heels
c. Ribs j. Feet
d. Hips k. Ears and nares
e. Sacral area l. Lips
f. Ischiums m. Tube sites
g. Inner/outer knees
5. When a reddened area is noted, check for the following:
a. Blanching erythema b. Non Blanching erythema
6. Assess all skin surfaces for the following:

a. Absence of superficial skin layers
b. Blisters
c. Any loss of epidermis and dermis
SELECTED REFERENCES
(For nursing procedures and images)
Clinical Nursing Skills Basic to Advanced Skills 6th Edition (by Sandra F. Smith, Donna J. Duell)
Fundamentals Concepts and Skills for Nursing (by Susan Dewit and Barbara C. Martin)
Medical-Surgical Nursing 6th Edition (by Joyce Black, Jane Hawks, Annabelle Keene)
Pocket Dictionary of Medicine, Nursing and Allied Health 4th Edition (by Mosby)
Photo Atlas of Nursing Procedures 3rd Edition (by Sweargen and Howard)
Clinical Nursing Skills and Concepts (by Susan Roe)
http://www.medused.com/images/inventory_pictures/13795-01.jpg
http://www.lymphomajournal.com/images/mycatheter.jpg
http://www.hivpositive.com/f-PainHIV/Pain/table3.html
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http://www.fpnotebook.com/NEU100.htm
http://www.bartleby.com/107/161.html
http://www.findarticles.com/p/articles
http://www.parkhurstexchange.com
http://familydoctor.org/x2558.xml
http://www.reddingmedical.com
AIRWAY MANAGEMENT
- Perform proper suctioning technique
- Insert oropharyngeal airway and nasal trumpet
- Provide tracheostomy care
- Obtain ABG specimen
- Assist in Endotracheal Tube insertion
- Demonstrate correct pulse oximetry technique
Technical Skill: Suctioning of Oropharyngeal and Nasopharyngeal

Procedure:
Demonstrations and Pictures
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16. Assess the patient’s need for suctioning. 1. Prepare the patient for suctioning.
Explain every step of the procedure to the Positioning to 30-45 degrees or in Semi-
patient. (Because we are concerned about Fowler’s, facilitates suctioning and
your breathing pattern and your comfort…) prevents increased intracranial pressure.
2. Adjust the wall suction. 3. Set up the sterile suctioning field and don
sterile gloves, goggles, and mask. For
self-protection if splash is anticipated.
4. Connect the catheter to tubing. 5. Estimate the distance for insertion.
6. Insert the catheter into nares using dominant 7. Suction intermittently by placing and
hand without applying suction. Suctioning releasing non-dominant thumb over
during insertion deprives the patient of catheter suction port. Limit suction to no
oxygen and inhibits catheter advancement. more than 5-10 seconds. Intermittent
suctioning reduces airway injury rather
than continuous suctioning. Suctioning
not more than 5-10 sec. prevents
hypoxemic complication induced by
suctioning.
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9. Assess the patient while coughing and
8. Rinse the catheter.
deep breathing.
10. Suction the oropharynx. 11. Auscultate lung sounds bilaterally and
heart rate and rhythm for changes.
Suctioning usually causes tachycardia
but hypoxemia and vagal response may
cause serious bradycaria or cardiac
arrest.
TECHNICAL SKILL: Inserting an Oropharyngeal Airway

Procedure:
1. Assure that the patient is unresponsive and has no gag reflex. Conscious patient may vomit
and aspirate or develop laryngospasm during tube insertion.
2. Wash your hands; don gloves.
3. Select appropriate size airway length should be from corner of mouth to corner of ear tragus.
4. Gently open patient’s mouth with cross finger technique. You may need to use modified jaw
thrust to insert tube.
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5. Perform oral suctioning.
6. Hold tongue down with tongue depressor and advance airway to back of tongue or advance
airway upside down (curve upward) and, as airway passes uvula, rotate the airway 180 °.
7. Check that concave curve fits over tongue. It should extend from the lips to the pharynx,
displacing the tongue anteriorly. Proper positioning helps prevent injury to lips, teeth, tongue,
and posterior pharynx.
8. Tape top and bottom of the airway in position. Stabilization of the tube prevents injury.
9. Position the patient laterally or on side.
10. Remove gloves and discard.
11. Observe position of airway and evaluate quality of the patient’s spontaneous breathing.
12. Continue to monitor.
TECHNICAL SKILL: Suctioning the Tracheostomy (Open System)

Procedure:
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1. Place the patient in semi-Fowler’s position. 2. Turn suction device to the appropriate
Proper positioning facilitates suction pressure. Higher suction pressure
procedure; hence the risk of increasing of increases risk of mucosal drainage.
intracranial pressure is reduced.
3. Don gloves, goggles, and mask in 4. Set up sterile tray.

preparation for suctioning.
5. Place waterproof pad across patient’s chest. 6. Connect the suction catheter to the
suction tubing.
7. Moisten the catheter in saline solution.
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8. Occlude Y-port to check for proper
suction.
9. Hyper-oxygenate the patient using a manual 10. Insert the catheter applying positive
resuscitation bag. (Preferably, have another pressure until the client coughs, then pull
person perform this). Suctioning depletes the catheter at least 1 inch and apply
oxygen and causes hypoxia. intermittent suction while withdrawing
catheter.
12. Remove gloves while keeping the

11. Flush catheter. catheter inside.
13. Auscultate lung sounds bilaterally and heart

rate and rhythm for changes. Suctioning
usually causes bradycardia but hypoxemia
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and vagal response may cause serious
bradycardia or cardiac arrest.
TECHNICAL SKILL: Providing Tracheostomy Care

Procedure:
1. Remove the soiled dressing. 2. Prepare the sterile field.
3. Remove oxygen source. 4. Rotate the inner cannula while

stabilizing outer cannula.
5. Remove inner cannula for cleaning. 6. Remove contaminated gloves and put
sterile gloves.
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7. Use brush to clean inner cannula. 8. Rinse cannula using an agitating motion.
9. Tap the cannula to remove excessive 10. Replace the inner cannula.
moisture.
11. Reapply the oxygen source. 12. Release the lock on the inner cannula.
13. Lock new inner cannula in place. 14. Clean with cotton-tipped applicators
under face plate.
16. Slide new tracheostomy dressing under

15. Pull skin around stoma gently. face plate.
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17. Cut the tape. 18. Pull the tape through along side old
tape.
19. Tie the ends with a double square knot. 20. Remove the old ties.
TECHNICAL SKILL: Suctioning of Endotracheal Tube (Open System)

Procedure:
1. Remove ventilator from endotracheal tube to 2. Insert suction catheter into endotracheal
suction. tube.
3. Apply suction and pull suction catheter back 4. Reconnect ventilator tubing to
with finger on thumb in a rotating motion. endotracheal tube.
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TECHNICAL SKILL: Using the Pulse Oximeter
Procedure:
1. Evaluate patient’s health status before using oximetry. Inaccurate oximetry readings can be
found in patients with:
a. Alkalosis, acidosis
b. Fever, hypothermia
c. Poor peripheral blood flow.
d. Carbon Monoxide poisoning.
e. Recent dye injection studies.
2. Obtain appropriate sensor. (Sensor probes are designated for specific sites: fingers, toes and
earlobes.)
3. Avoid placing pulse oximetry sensor on the thumb or an edematous site
1. Select an appropriate finger. Note: Remove 2. Assess the pulse.

nail polish or artificial nails. These
substances can distort readings.
3. Assess for capillary refill. 4. Clean the area.
5. Attach probe to patient’s finger and make 6. Connect sensor probe to unit.
sure that both sensor probes are aligned
directly opposite each other
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7. Check for the alarms. (Pre-determined 8. Read pulse oximeter
saturation levels or pulse rate).
Oxygen Saturation %
Findings Client Status
50-75 Life-threatening hypoxemia
75-90 Moderate hypoxemia
90-96 Mild Hypoxemia
96-100 NORMAL
Name: __________________________________________________________ Date: ________
Directions: Put a tic (√) on the appropriate box for each item.
CRITICAL ELEMENTS: Suctioning of Oropharngeal and Nasophargeal
Procedures Done Not COMMENTS

Done
1. Assess the patient’s need for suctioning.
2. Explain every step of the procedure to the patient.
3. Wash hands.
4. Gather the materials needed.
5. Prepare the patient for suctioning.
6. Adjust the wall suction.
7. Set up the sterile suctioning field.
8. Connect the catheter to tubing.
9. Estimate the distance for insertion.
10. Insert the catheter into nares.
11. Suction the nasopharynx.
12. Rinse the catheter.
13. Assess the patient while coughing and deep breathing.
14. Suction the oropharynx.
15. Auscultate lung bilateral sounds.
16. Remove gloves.
17. Discard the materials used.
18. Document the procedure and patient response.
CRITICAL ELEMENTS: Inserting Oropharngeal Airway
22 | P a g e
Done
2. Wash hands and don gloves.
3. Select appropriate size airway length.
4. Open patient’s mouth with cross finger technique and use modify jaw
thrust to insert tube.
5. Perform oral suctioning.
6. Hold tongue down with tongue depressor and advance airway to back
of tongue or advance airway upside down (curve upward) and, as airway
passes uvula, rotate the airway 180 °.
7. Check that concave curve fits over tongue.
8. Tape top bottom of airway in position.
9. Position patient on side to facilitate drainage.
10. Remove gloves and discard.
11. Observe position of airway and evaluate quality of patient’s
spontaneous breathing.
12. Document procedure and patient’s response.
CRITICAL ELEMENTS: Suctioning of Trachea (Open system)

Done
2. Place the patient in semi-Fowler’s position.
3. Turn suction device to the appropriate pressure.
4. Don gloves and mask.
5. Set up sterile tray.
6. Place waterproof pad across patient’s chest.
7. Connect the suction catheter to the suction tubing.
8. Moisten the catheter in saline solution.
9. Occlude Y-port (to check for proper suction)
10. Hyper-oxygenate the patient using a manual resuscitation bag (Ambu).
11. Apply intermittent suction while withdrawing catheter.
12. Flush catheter.
13. Remove gloves while keeping the catheter inside.
14. Discard the materials used.
15. Auscultate lung sounds bilaterally and heart rate and rhythm for
changes.
CRITICAL ELEMENTS: Providing Tracheostomy Care

Done
2. Wash hands.
3. Remove the soiled dressing.
4. Prepare the sterile field.
5. Don gloves.
6. Remove oxygen source.
23 | P a g e
7. Rotate the inner cannula while stabilizing outer cannula.
8. Remove the inner cannula for cleaning.
9. Remove the contaminated gloves and put sterile gloves.
10. Use brush to clean inner cannula.
11. Rinse cannula using an agitating motion.
12. Tapping the cannula to remove excessive moisture.
13. Replace the inner cannula.
14. Reapply the oxygen source.
15. Release the lock on the inner cannula.
16. Lock new inner cannula in place.
17. Clean with cotton-tipped applicators under faceplate.
18. Pull skin around stoma gently.
19. Slide new tracheostomy dressing under face plate.
20. Cut the tape.
21. Pull the tape through along side old tape.
22. Tie the ends with a double square knot.
CRITICAL ELEMENTS: Suctioning of Endotracheal (Open Method)

Done
2. Wash hands.
3. Don sterile gloves.
4. Remove ventilator from endotracheal tube to suction.
5. Insert suction catheter into endotracheal tube.
6. Apply suction and pull suction catheter back with finger on thumb in a
rotating motion.
7. Reconnect ventilator tubing to endotracheal tube
8. Document procedure and the patient response.
24 | P a g e
CRITICAL ELEMENTS: Pulse Oximeter

Done
2. Wash hands.
3. Select an appropriate finger.
4. Assess the pulse.
5. Assess capillary refill.
6. Clean the area.
7. Attach probe to patient’s finger and make sure that both sensor probes
are aligned directly opposite each other.
8. Connect sensor probe to unit.
9. Check for the alarms. (Pre-determined saturation levels or pulse rate).
10. Read pulse oximeter
11. Record use of pulse oximetery and oxygen saturation.
12. Record and report oxygen saturation, patient responses, and abnormal
findings.
Evaluated by:
_______________________
Signature over Printed name
(Preceptor for this station)
25 | P a g e
SELECTED REFERENCES
Clinical Nursing Skills Basic to Advanced Skills 6th Edition (by Smith, Duell, and Martin)
Pocket Dictionary of Medicine, Nursing and Allied Health 4th Edition (by Mosby)
Photo Atlas of Nursing Procedures 3rd Edition (by Sweargen and Howard)
Clinical Nursing Skills 5th Edition (by Lippincott Williams and Wilkins)
R’Notes Nurse’s Clinical Pocket Guide (by Ehren Myers)
http://connection.lww.com/Products/evans-smith/documents/c02/jpg/F1925-002-002_4.jpg
http://hkfsd.gov.hk./home/images/equipments/ambulance/images/photo
http://connection.lww.com/Products/evans-smith
http://www.mobilitydiscount.com/images/
http://www.bemedical.com
http://mcjohnson.com/
IV MANAGEMENT
26 | P a g e
- Describe and state principles and procedures in IV management
- Maintain a peripheral IV for fluid and electrolyte, medication or blood access
- Monitor and evaluate an IV infusion
- Assess and maintain patency of an IV site
- Change IV solutions, IV Tubings, IV dressings, and IV sites
- Assist in Insertion of Central Lines
- Perform Central Line dressing change
- Discontinue Central and Peripheral Lines
- Maintain and change the Hickman or Broviac CV Catheter and dressing
- Maintain the CV catheter with a Groshong valve
- Monitor and Evaluate the Peripherally Inserted Central (PICC) Line
TECHNICAL SKILL: Using an Electronic Flow-Control Device

Procedure:
1. Explain every step of the procedure to the patient. (Because we are concerned that you get the
exact volume of fluid ordered by your physician, we are using an IV pump).
2. Wash hands.
3. Spike IV Solution bag.
4. Fill drip chamber to minimum ½ full. This amount allows sufficient air space
in drip chamber.
5. Prime tubing by opening and regulating the clamp slowly and allowing
tubing to fill with IV solution. If using cassette-type tubing, follow package
instructions to connect the cassette portion of the tubing that engages into
the control device.
6. Follow manufacturer’s instructions to load administration set into device,
taking care to fit tubing and cassette into appropriate receptor sites. (The
multiple-channel pump can infuse 3 different IV solutions at one time).
7. Close device door and latch.
8. Don gloves.
9. Check that the patient’s venipuncture site is free from signs of vein irritation or infiltration.
10. Connect administration set tubing to established infusion site protective cap using a
needleless cannula.
11. Open regulating clamp on administration set.
12. Turn device ON.
13. Set device parameters for operation, again following manufacturer’s instructions or machines
setup prompts.
Parameters may include:
- Infusion (e.g. primary)
- Volume to be infused
- Rate (ml/hr)
- Pressure/ (measure can vary; e.g. mmHg, cm H2O, or PSI)
14. START device when parameters are set.
15. Observe that infusion is running properly.
16. Remove gloves and wash hands.
17. Check the patient’s infusion site frequently.
18. Document the procedure.
19. Wash hands.
TECHNICAL SKILL: Monitoring an IV infusion

Procedure:
27 | P a g e
1. Check drip chamber and time drops. 2. Check tubing for anything that might
interfere with flow rate.
3. Check the settings of the infusion device. 4. Inspect IV site.
TECHNICAL SKILL: Assessing and Maintaining the IV site

Procedure:
1. Review the physician’s order for IV therapy.

2. Review the patient’s history for medical condition or allergies.
3. Review the patient’s IV site record and intake and output record.
4. Wash your hands.
5. Obtain the patient’s vital signs. Changes in vital signs may indicate whether the patient is
having fluid retention and overload or is dehydrated.
6. Check the IV for correct fluid, additives, rate and volume at the beginning of your shift.
7. Check the IV tubing for secure connections every 4 hours.

8. Check the IV dressing hourly to be sure it is dry and intact.
28 | P a g e
9. If the gauze is not dry and intact, remove the dressing and observe the site for redness,
swelling, or drainage.
10. If an occlusive dressing is used, do not remove the dressing when assessing the site.
11. Observe the vein track for redness, swelling, warmth, or pain, hourly
12. Document the IV site findings in the nursing record or flow sheet.
13. Wash your hands.
TECHNICAL SKILL: Changing IV Solution and Tubing

Procedure:
1. Clamp the tubing on the administration set. 2. Invert the solution bag and remove the
spike.
3. Remove protective cap from the new 4. Spike the new tubing to the solution bag.
tubing.
29 | P a g e
5. Reopen the clamp and adjust the flow rate. 6. Release clamp to allow IV fluid through
tubing.
7. Reopen the clamp and adjust the flow rate

8. Open clamp on new tubing, with short
extension tubing taped in place. Label
with tape on the IV tubing to indicate the
date when to change the IV tubing.
Note: IV solutions are changed every 24 hours while IV tubing is changed every 48-72 hours
TECHNICAL SKILL: Discontinuing IV Lines

Procedure:
1. Check physician’s order.

2. Gather equipment.
5. Turn off IV infusion.
6. Loosen dressing and tape, peeled dressing edges back toward puncture site.
7. Stabilize needle or catheter while removing dressing and tape.
8. Remove needle/catheter carefully and smoothly, keeping it almost flush with the skin. Do not
press down on top of needlepoint while it is in the vein.
9. Quickly press the sterile pad over the venipuncture site and hold firmly. Pressure on site
prevents bleeding.
10. Apply clean pad and tape in place.
11. Elevate but do not bend arm. Bending elbow causes hematoma formation while elevating arm
reduces venous pressure and helps to collapse vein.
12. Observe venipuncture site for redness, swelling or hematoma.
13. Dispose of equipment and gloves according to hospital policy.
14. Wash hands.
15. Check the site again in 15 minutes.
16. Record volume infused on Input & Output sheet.
30 | P a g e
Name: __________________________________________________________ Date: ________
Directions: Put a tic (√) on the appropriate box for each item.
CRITICAL ELEMENTS: Using an Electronic Flow-Control Device

Done
2. Wash hands.
3. Spike IV Solution bag.
4. Fill drip chamber to minimum ½ full.
5. Prime tubing by opening regulating clamp slowly and allowing tubing to
fill with IV solution.
6. Close device door and latch.
7. Don gloves.
8. Check that the patient’s venipuncture site is free from signs of vein
irritation or infiltration.
9. Connect administration set tubing to established infusion site protective
cap using a needleless cannula.
10. Open regulating clamp on administration set.
11. Turn device ON.
12. Set device parameters for operation, again following manufacturer’s
instructions or machines setup prompts.
Parameters may include:
a. Infusion (e.g. primary)
b. Volume to b infused
c. Rate (ml/hr)
d. Pressure/ (measure can vary; e.g. mmHg cm H2o, or psi).
13. START device when parameters are site.
14. Observe that infusion is running properly.
16. Check the patient’s infusion set frequently.
18. Wash hands.
CRITICAL ELEMENTS: Monitoring an IV infusion

Done
2. Wash your hands.
3. Check the drip chamber and time drops.
4. Check the tubing.
5. Check the settings of the infusion device
6. Inspect IV site.
7. Document procedure, time and patient’s response.
31 | P a g e
CRITICAL ELEMENTS: Assessing and Maintaining the IV site

Done
1. Review physician’s order
3. Wash your hands.
4. Check the IV for correct fluid, additives and rate.
5. Check the IV tubing and dressings.
6. Remove the dressing and observe the site for redness, swelling, or
drainage if the gauze is not dry and intact.
7. Observe the vein track for redness, swelling and warmth.
8. Document the IV site findings in the nursing record or flow sheet.
9. Wash your hands.
CRITICAL ELEMENTS: Changing IV Solution and Tubing

Done
2. Wash hands.
3. Clamp the tubing on the administration set.
4. Invert the solution bag and remove the spike.
5. Remove protective cap from tubing.
6. Spike the new solution bag.
7. Reopen the clamp and adjust the flow rate
8. Release clamp to allow IV fluid through tubing.
9. Reopen the clamp and adjust the flow rate.
10. Open clamp on new tubing, with short extension tubing taped in place.
11. Wash hands.
12. Document procedure, time and patient’s response.
CRITICAL ELEMENTS: Discontinuing IV Lines

Done
1. Check physician’s order.
2. Gather equipment.
3. Wash hands and don gloves to the patient.
4. Explain every step of the procedure
5. Turn off infusion.
6. Loosen dressing and tape.
7. Stabilize needle or catheter while removing dressing and tape.
8. Remove needle/catheter.
9. Quickly press the sterile pad over venipuncture site and hold firmly.
10. Apply clean pad and tape in place.
11. Elevate arm to reduce venous pressure and help collapse vein. Do not
bend arm at elbow.
12. Observe venipuncture site for redness, swelling or hematoma.
32 | P a g e
13. Dispose equipment and gloves.
14. Wash hands.
15. Check the site again in 15 minutes.
16. Record volume infused on I & O sheet.
Evaluated by:
_______________________
33 | P a g e
CRITICAL ELEMENTS: Blood Transfusion

Done
1. Verify intravenous catheter to be used.
2. Obtain client’s transfusion history.
3. Review physician’s order for blood component transfusion. Check
consent.
4. Obtain VS before initiation of transfusion.
5. Explain procedure to the client.
6. Preadministration.
a. Obtain blood from the blood bank.
b. Verify product and identify patient.
b.1 Check client’s first and last name.
b.2 Check client’s blood type and Rh type. (Blood should be
freee from discoloration and clots)
b.3 Check serial number on blood bag and on the blood
bank form.
b.4 Check expiration date
b.5 Check appearance of blood product.
c. Empty urine drainage
7. Administration
a. Perform hand hygiene, apply clean, disposable gloves
b. Open blood transfusion set.
c. Set roller clamp to “OFF” position
d. Prepare blood component for administration.
i. Invert bag gently, 2 or 3 times.
ii. Spike bag, squeeze drip chamber. Fill chamber halfway.
Allow infusion tubing to fill with blood.
iii. Close roller clamp when tubing is filled
iv. Set up a piggyback infusion of 0.9% saline IV solution
using a stopcock.
e. Attached primed tubing to IV catheter.
f. Regulate the flow initially to 20gtts/min
g. Monitor VS every 5 minutes after initiation of transfusion.
Monitor IV site and status of infusion. Observe changes.
h. After infusion of blood, clear IV tubing with 0.9% normal saline
and discard blood bag according to agency policy.
i. Dispose all supplies used.
8. Observe client and assess laboratory values to determine response to
administration of blood component.
Evaluated by:
_______________________
34 | P a g e
SELECTED REFERENCES
Fundamental Concepts and Skills for Nursing (by Susan Dewit)
R’Notes Nurse’s Clinical Pocket Guide (by Ehren Myers)
http://connection.lww.com/Products/evans-smith/documents/c02/jpg/F1925-002-002_4.jpg
http://hkfsd.gov.hk./home/images/equipments/ambulance/images/photo
http://connection.lww.com/Products/evans-smith
http://www.umm.edu/imagepages/18087.htm
http://www.mobilitydiscount.com/images/
http://www.ardusmedical.com/media
35 | P a g e
TUBE MANAGEMENT
- Demonstrate Nasogastric tube insertion
- Determine proper placement of NGT
- Administer a tube feeding
- Discontinue NGT
- Maintain a chest tube
- Perform catheterization for both male and female patients (indwelling or
straight catheter)
TECHNICAL SKILL: Insertion of Nasogastric Tube

Procedure:
1. Place patient in semi-to high Fowler’s 2. Measure the NG tube from nostril-tip of
position in preparation for tube insertion. earlobe and tip of earlobe-xiphoid
Examine the nostrils and select the most process,mark the NGT with an indelible
patent nostril by having the patient breathe ink or a tape. Estimate the distance from
through each one. The nostril with greater the site of insertion to the stomach.
airflow should be chosen for insertion.
3. Lubricate the tube using KY jelly and then 4. Insert the tube through nostril until back of
begin insertion with patient positioned with throat. Suggest the patient swallow sips of
head up. Oil-based lubricant could cause water to assist tube insertion. Swallowing
respiratory complications. sips of water through a straw may aid in
advancing tube.
36 | P a g e
5. Inject 10-15 ml of air through the NG tube 6. Aspirate to obtain gastric fluid to determine
and listen with the stethoscope over gastric content. Check the pH level (Refer
stomach for a rush of air or “whoosh” to the procedure for “Checking for
sound. This is one method of checking placement of NGT” below).
that the tube has reached the patient’s
stomach.
7. Apply tape to patient’s cheek. When tube 8. Attach NG tube to wall suction. Secure the
is taped securely, tissue trauma caused by tube. (Note: Blue vent should be
pull on sides of nostril will be minimized. positioned above patient’s shoulder).
TECHNICAL SKILL: Checking for NGT placement

Procedure:
1. Identify the type of feeding tube used by the patient.
Note: The tip of the Salem sump (for irrigation) lies in the stomach while the tip of the Duofeed
(for feeding) lies in the duodenum
37 | P a g e
3. Wash hands.
4. Ask the patient to talk. If the patient is unable to speak, the tube is in the trachea.
5. Inspect posterior pharynx for presence of coiled
tube.
6. Draw up 10 to 20 ml of air into catheter-tipped
syringe and attach to end of tube.
Auscultate left upper quadrant of the patient’s
abdomen while quickly ejecting air into the
tube.
7. Aspirate gently back on syringe to obtain
gastric contents. Observe the color and
amount, if the residual volume is more than
50cc, hold feeding and make referrals to the
physician.
8. Measure pH of aspirate with color-coded pH
paper that has range of whole numbers
from 1 to 11. Return the aspirated
gastric content. Metabolic Alkalosis may occur if the gastric content/HCL is decreased.
***If medications are given during feeding time, make sure to pulverize it and check if the medications are
gastric irritants, if not you can give the medication before the feeding, check for drug compatibility and its
absorption properties first. DO NOT MIX THE MEDICATION WITH THE FEEDING FORMULA
TECHNICAL SKILL: Administering Tube Feeding

Procedure:
1. Assess the patient’s abdomen to verify 2. Clean/disinfect top of feeding container

presence of bowel sounds. Absence of with alcohol before opening it.
bowel sounds indicates lack of peristalsis,
and gastric feeding should not be given. In
addition, disconnect the syringe from
tubing.
38 | P a g e
3. Attach feeding bag tubing to NG tube. 4. Pour water into feeding bag
6. Remove plunger from a 60-cc

5. Cap NG tube after it is clamped. irrigating syringe.
7. Pour formula into syringe

8. Pour tap water into almost empty
syringe.
39 | P a g e
TECHNICAL SKILL: Discontinuing NGT
Procedure:
1. Check the physician’s order for NG tube removal.

2. Gather material needed.
4. Provide tissue and place towel over the patient’s chest.
5. Flush NG tube with 20 ml normal saline. To clear tube so that the GI contents do not
inadvertently drain into esophagus on tube removal.
6. Follow saline flush with a bolus of air. Free tube from stomach lining.
7. Unpin tube from the patient’s gown and loosen tape that secures tube to the patient’s nose.
8. Turn off suction and disconnect NG tube.
9. Plug tube or clamp it by folding it over in your gloved hand.
10. Pinch tube close to the patient’s nares, have patient take a deep breath and hold it while you
withdraw the tube. Holding breath closes glottis and helps prevent aspiration.
11. Wrap tube in paper towel to remove from the patient’s view.
12. Offer oral and nasal hygiene.
13. Empty and record the amount and character of drainage.
14. Discard disposable equipment and return reusable equipment to appropriate area.
15. Remove and dispose of gloves and wash hands.
16. Document the findings and patient response.
TECHNICAL SKILL: Chest Tube Care

Procedure:
1. Assess and identify chest tube insertion 2. Check for Bubbling (tidaling) in the
site. suction chamber. If no bubbling is noted,
the tube may be occluded or a leak is
present, or the lungs may be fully
expanded.
3. Note the level of drainage. 4. Unroll and cut the foam tape.
40 | P a g e
5. Cross clamp tube and attach tube to the 6. Applying foam tape and leave vaselinized
new drainage. gauze and two clamps at the bedside.
These are in case the tube gets
dislodged.
TECHNICAL SKILL: Inserting a Straight Catheter (Female)

Procedure:
1. Check the physician’s order.

2. Explain every step of the procedure to the patient. Gather materials needed.
3. Wash hands and don gloves and provide privacy. (Because we are concerned that your privacy
is maintained, I will pull the curtain around your bed)
4. Position the patient in supine position with knee flexed. This position provides for good
visualization of urinary meatus.
5. Open sterile package by tearing package on lined edge of plastic wrap at foot of bed for waste
disposal.
6. Place catheter tray on bed between the patient’s legs.
7. Fold back drape to expose perineum.
8. Open white outer wrap away from sterile package with last turn toward the patient.
9. Remove sterile absorbent pad and position plastic side down under the patient’s buttocks. Have
the patient lift buttocks if able. Position the pad by holding corners of pad only. Pad creates a
sterile field.
10. Put on sterile gloves.
11. Remove sterile articles from tray, and arrange conveniently on sterile field or place tray onto
field using a forceps .
12. Open package, and pour antiseptic solution over cotton balls.
13. Uncap syringe filled with lubricant, or tear open lubricant package, pick up catheter tip, and
lubricate the tip of the catheter generously. Place catheter back on tray. May place lubricant on
sterile field, put catheter tip on lubricant, and leave in place. Removing catheter from sterile
container (tray) increases risk of contamination.
14. If specimen is required, uncap sterile specimen container.
15. Move catheter tray close to the patient.
16. Place sterile fenestrated drape over perineum exposing meatus (optional).
17. Preparation of patient’s meatus:
- Separate the patient’s labia minora with your non-dominant hand. Maintain separation
throughout prep.
- With your dominant hand, use forceps to pick up an absorbent ball that has been saturated
with antiseptic solution. (If betadine swabs are used, pick up one swab).
- Cleanse patient’s meatus with one downward stroke of forceps or swab. Using a downward
stroke cleans from least contaminated to most contaminated area.
- Discard absorbent ball or swab in the plastic cover at foot of bed. Using a new cotton ball
or swab with each downward stroke prevents transfer of microorganism.
- Repeat cleaning at least 3-4 times.
41 | P a g e
- Continue to hold patient’s labia apart until you insert catheter. This prevents contamination
of urinary meatus.
18. Discard preps in plastic bag at the foot of the bed as appropriate. Using sterile gloved hand,
pick up lubricated catheter keeping drainage end in collection container, and insert 2 inches or
until urine begins to flow.
19. Move non-dominant hand from holding labia open to hold catheter in place.
20. Place sterile specimen container under drainage end of catheter if specimen is needed, and fill
container with approximately 30 ml of urine.
21. Replace catheter drainage end into collection container, and allow urine to flow until it ceases.
22. Remove drapes and dry the perineum. Tape the tube in the upper thigh.
23. Position the patient for comfort; put the bed in LOW position with the side rails up.
24. Measure and record urine output on I & O bedside record.
25. Discard gloves and equipment appropriately.
26. Wash hands.
27. Send specimen to lab if indicated and document findings.
TECHNICAL SKILL: Catheterizing the Male Urinary Bladder (Straight and Indwelling)
Procedure:
1. Check physician’s order. Gather materials 2. Lift penis to erect position with gloved
needed. Explain every step of the non-dominant hand and clean meatus in a
procedure to the patient. Prepare sterile circular motion with cotton ball held with
field. Position the patient supine with forceps in gloved dominant hand.
fenestrated drape over penis.
42 | P a g e
4. Insert the catheter about 20 cm until urine
3. Insert a syringe 3-4 inches with lubricant
flow occurs. Lift penis to a 90-degree
into urethra. (Some lubricant contains
angle/ perpendicular to the body and exert
anesthetics) This facilitates catheter
slight traction by pulling upward. This
placement by expanding and
movement straightens the urethra for
anesthetizing urethra, especially for the
easier insertion of the catheter.
patient with enlarged prostate.
5. Inflate the balloon and pull gently on the 6. Tape the tube below the umbilical area or
catheter to check that the balloon is at side of the pelvis. Place the drainage
inflated. Then push it back slightly. Ensure bag below the level of the bladder. Attach
placement of the catheter in the urinary bag to the bed frame and not on the side
bladder. rails. Placing bag below the level of the
bladder facilitates drainage. Taping the
catheter in place will relieve tension to the
urinary sphincter thus prevent pressure on
the penoscrotal angle.
43 | P a g e
SELECTED REFERENCES
http://www.mitaka-supply.com/02en_models/404m166-2/img/p_02.jpg
http://www.med.uottawa.ca/procedures/ucath/images/cath.gif
http://www.smasupport.com/equipment_list.htm
http://www.bbc.co.uk
44 | P a g e
WOUND AND OSTOMY MANAGEMENT
- Perform wound care and apply a Sterile Dressing
- Perform wound care using the clean technique
- Assess and evaluate pressure ulcers
- Apply a Fecal Ostomy Pouch
- Perform Ostomy care
TECHNICAL SKILL: Cleaning a Wound using a Sterile Technique

Procedure:
1. Loosen the dressing tape with gloved 2. Remove the dressing with gloved hands.
hands. Pulling toward the wound decreases
the pain of tape removal by not putting
pressure on the incision line.
3. Use saline to aid in removing dressing. 4. Assess incision area for erythema, edema,
or drainage. Persistent drainage, edema,
or temperature above 100.4 º F post op
indicates complication has occurred. Also,
assess color of incision. A healing incision
looks pink or red. Redness that does not
fade 48 hours after surgery may indicate
impaired healing.
45 | P a g e
5. Remove the gloves. 6. Set up the sterile field.
7. Put on sterile gloves. 8. Clean wound with dampened gauze with

gloved hand.
9. Apply the antiseptic ointment to wound with 10. Place 4x4 gauze pads over incision area,
cotton applicator and gloved hand. being careful no to touch incision or
patient with your gloves. Touching the
incision or patient contaminates the
gloves. You need to re-glove if this occurs.
11. Apply a Surgi-pad (ABD) over dressing and 12. Record the date and time of dressing
secure with tape. change.
46 | P a g e
TECHNICAL SKILL: Cleaning a Wound using the Clean Technique
Procedure:
1. Wash hands.
2. Gather all equipment needed.
3. Open sterile packages and place on overbed table. Arrange packages to ensure that you do
not cross over sterile field when using dressing.
4. Remove tape slowly by pulling tape toward wound.
5. Don clean gloves.
6. Remove soiled dressing and dispose of bag.
7. Obtain wound specimen for wound culture as ordered.
8. Remove clean gloves and discard into plastic bag.
9. Open saline solution and pour over wound. Place emesis basin next to skin surface to catch
overflow.
10. Don sterile gloves
11. Cleanse wound. When cleansing an area, always start at cleanest area and work away from
that area. Never return to an area previously cleaned.
12. Assess the wound.
13. Cleanse the edge drain and around the site with 4x4 gauze pad and cleansing solution if drain
is present.
14. Place several 4x4 gauze pads over wound. Touching the incision or patient contaminates the
gloves. You need to re-glove if this occurs.
15. Dispose of the materials properly.
16. Remove gloves and wash hands thoroughly.
17. Document procedure and the patient response.
TECHNICAL SKILL: Assessment of Pressure Ulcers

Procedure:
1. Check the physician’s order for specific positioning of the patient and dressing change
instructions.
2. Gather all of the materials you will need.
3. Identify the patient and explain every step of the procedure to the patient.
4. Wash your hands.
5. Provide for patient privacy and apply gloves.
6. Adjust the bed to your level and lower the side rail nearest you without leaving the patient
unattended.
7. Assess the patient’s risk for developing pressure ulcers by using the Braden scale or similar
risk chart.
8. Assess the patient’s skin over all pressure points such as the sacrum, ischial tuberosities,
feet, heels, elbows, back of head.
9. Assess other sites for potential areas of pressure points.
10. Change the patient’s position. Teach patient to change position as often as he/she can and
to use supportive devices between his/her bones (e.g. put a pillow or towel between their
knees when lying on their side).
11. Keep the patient’s position at 30 degrees or less.
12. Provide skin care if the area is soiled or sweaty, but don’t massage pressure points.
13. Use support devices: such a special beds, egg crates, pillows, towels, blankets, and heel
protectors to support the body. Use towels, washcloths, gloves filled with water or ice (if
the patient is not allergic to latex), pillows and blankets to keep pressure off bony
prominences. Cover the glove with ice in it with a washcloth to prevent an ice burn to the
skin.
47 | P a g e
(Heel protector) (Egg crate mattress)
14. Perform a dressing change on pressure ulcer as ordered or per policy, remembering
aseptic or sterile technique.
15. Return the side rail to the upright position and lower the bed.
16. Remove gloves and wash your hands
17. Document the appearance or pressure points and/or ulcer, including the skin care and
wound care provided and position changes.
18. Create an every 2-hour turning schedule if one is not available.
Pressure Ulcer Staging and Treatment

Stages Treatment Protocol for Pressure Ulcer Stages
Stage I: Non-blanchable erythema of Stage 1: Apply an adhesive film dressing over the red
intact skin, the heralding lesion of area. Semi permeable to oxygen and prevent bacterial
skin ulceration. invasion. Healing can occur in 24 hours.
Stage II: Partial-thickness skin loss Stage II: Apply a transparent adhesive film dressing if
involving epidermis or dermis. The ulcer is not draining. If wound is draining irrigate with
ulcer is superficial and presents normal saline and apply a hydrocolloid dressing remain
clinically as an abrasion, blister, or in place for 5-7 days, creating a moist environment that
shallow crater. Usually caused by promotes epitheliazation and restoration of the
friction or moisture plus pressure. epidermis.
Painful and may have minimal
drainage.
Stage III: Full-thickness skin loss Stage III: Irrigate with normal saline, cover with a
involving damage or necrosis of hydrocolloid dressing.
subcutaneous tissue that may
extend down to, but not through,
underlying fascia. The ulcer presents
clinically as a deep crater with or
without the undermining of adjacent
tissue. Usually caused by pressure
plus shearing forces,
Stage IV: Full-thickness skin loss Stage IV: Chemical debridement, autolysis, or surgery
with extensive destruction, tissue is required for treatment of this stage. Wet-to-damp is
necrosis, or damage to muscle, used for larger wounds.
bone, or supporting structure
(tendon or joint capsule are
examples). Undermining and sinus
tracts may be associated with this
stage ulcer,
A pressure ulcer is classified in stages by the degree observed. Accurate staging is not
possible until eschar has sloughed or wound is debrided. Reverse staging is unacceptable
48 | P a g e
Wound dressings
The 'Ideal Wound Dressing' should:
 Maintain a moist environment at wound interface

 Remove excess exudate without allowing 'strike through’ to surface of
dressing
 Provide thermal insulation and mechanical protection
 Act as a barrier to micro-organisms
 Allow gaseous exchange
 Be no adherent and easily removed without trauma
 Leave no foreign particles in wound
 Be non-toxic, non-allergenic and non-sensitizing
 No single dressing is appropriate for all wound types and all stages of healing
Hydrocolloids e.g. Granuflex
 Matrix of cellulose and other gel forming agents - gelatin and pectin
 Occlusive dressing
 Should be avoided if infection particularly with anaerobic organisms
 Promotes autolysis and aids granulation
 Can remain in place for up to a week
 Over-granulation can occur
Alginates e.g. Kaltostat
 Calcium and sodium salts of alginic acid obtained from seaweed

 Highly absorbent
 Useful in medium to heavily exudating wounds
 Secondary covering is required
 Forms a gel in contact with wound exudate
Foam dressings e.g. Lyofoam
 Useful for moderately exudating wounds

 Prevents 'strike through' of exudate to wound surface
 Desloughs wounds by maintaining a moist environment
Hydrogels e.g. Intrasite Gel
 High water content creates a moist wound surface

 Debrides wounds by hydration and promotion of autolysis
 Will absorb a light exudate
 Not appropriate for heavily exudating wounds
Debriding agents
 Remove eshcar and necrotic tissue

 Do not maintain moist environment
49 | P a g e
 Need frequent changes
 Varidase = streptokinase
 Aserbine = malic, benzoic and salicylic acids in a cream base
 Damages granulation tissue and delays healing
TECHNICAL SKILL: Applying a Fecal Ostomy Pouch

Procedure:
1. Wash hands and don clean gloves.

2. Place bath blanket over patient. Place absorbent pad or towel under the patient.
3. Observe the placement of stoma to determine normal amount of output and consistency.
Immediately after surgery, all stomas will have liquid stool and high flatus output.
4. Empty the old pouch into bedpan or toilet.
5. Remove old pouch by pushing against skin as you pull back from skin. Discard in plastic bag.
Save tail closure on bottom of pouch.
6. Measure the output, if ordered.
7. Clean the skin stoma gently with warm water and soft cloth. Oily substances can interfere with
pouch adhesive.
8. Dry skin well with soft cloth. Keep tissues available if stoma functions while pouch is off.
9. Observe skin and stoma for changes in size, ulceration, and color (stoma should be a beefy
red).
10. Measure the stoma with a measuring guide.
11. Trace measured pattern of pouch.

12. Cut pouch to pattern, making sure opening is large enough to encircle stoma without pushing
on edges. No skin should appear between the pouch edge and the stoma.
13. If using two-piece pouch, snap the wafer and pouch together.
14. Remove paper from skin barrier on pouch and save it. This may be used as pattern for next
pouch change.
15. Apply a ring of skin barrier paste to opening on pouch.
16. Remove the paper from outer ring.
17. In the center, apply pouch to clean and dry skin. Smooth edges of adhesive to skin. If adhesive
is wrinkled, it may result in leakage from pouch.
50 | P a g e
18. Pouches are applied over an incision. Incisions are sealed within 24 hours of surgery.
19. Close and secure end of pouch with tail closure.
- Ensure bowed end is next to body. This provides a better fit to body, and prevents out
pouching of clamp through clothing.
- Lay hook on top of bag and fold bag 1 inch over end of pouch.
- Squeeze clamp together to close.
20. Remove soiled pouch and tissues from bedside.

22. Position the patient in comfortable position.
23. Put away supplies and re-order as necessary
51 | P a g e
SELECTED REFERENCES
Pressure Ulcer in Adults: Prediction and Prevention, (by Rockvillle MD)
US Department of Health and Human Services/Public Health Service
Agency for Health Care Policy, Quality and Research
http://www.rockcreek.com/images_products
https://www.betterlivingnow.com/images
52 | P a g e

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What are the steps in performing a pain assessment?

What are the steps in performing a pain assessment?

What are some types of wound dressings described and what are their purposes?

What are some types of wound dressings described and what are their purposes?

FOCUSED ASSESSMENT

This is the procedure:

Conscious Semi-conscious Unconscious

Cranial Nerve Assessment

CHEST PAIN ASSESSMENT

Questions to ask the patient:

HEART SOUND ASSESSMENT

Questions to ask the patient:

Dyspnea Intensity Scale

LUNG SOUND ASSESSMENT

NAUSEA AND VOMITING ASSESSMENT

Questions to ask the patient:

SYMPTOMS DIAGNOSIS SELF-CARE

See Nausea and Vomiting

2. Does the patient Go to Question 7.*.

3. Does the patient

5. Does the patient EMERGENCY

May have GALLSTONES or

7. *Does the patient

May have a bleeding

May have FOOD

10. Does the patient

12. Have the patient

Monitor blood sugar closely and check for

14. Did the patient

(Nausea and Vomiting Assessment for infants and children)

SYMPTOMS DIAGNOSIS SELF-CARE

2. Does the infant

Vomiting and diarrhea

- Has the infant (age two

4. Does the infant have

ASSESSMENT OF MOTOR STRENGTH

1. Assess bilateral muscle strength. Test “handgrip” by asking patient to squeeze

SKIN INTEGRITY ASSESSMENT

5. When a reddened area is noted, check for the following:

a. Blanching erythema b. Non Blanching erythema

6. Assess all skin surfaces for the following:

Clinical Nursing Skills and Concepts (by Susan Roe)

Technical Skill: Suctioning of Oropharyngeal and Nasopharyngeal

Demonstrations and Pictures

4. Connect the catheter to tubing. 5. Estimate the distance for insertion.

TECHNICAL SKILL: Inserting an Oropharyngeal Airway

TECHNICAL SKILL: Suctioning the Tracheostomy (Open System)

Demonstrations and Pictures

3. Don gloves, goggles, and mask in 4. Set up sterile tray.

7. Moisten the catheter in saline solution.

12. Remove gloves while keeping the

13. Auscultate lung sounds bilaterally and heart

TECHNICAL SKILL: Providing Tracheostomy Care

Demonstrations and Pictures

1. Remove the soiled dressing. 2. Prepare the sterile field.

3. Remove oxygen source. 4. Rotate the inner cannula while

16. Slide new tracheostomy dressing under

TECHNICAL SKILL: Suctioning of Endotracheal Tube (Open System)

Demonstrations and Pictures

Name: __________________________________________________ Date: