PROCEDURESSSSSSS

Foundation University
COLLEGE OF NURSING
Dumaguete City
HAND WASHING
HAND WASHING is the rubbing together of all surfaces and crevices of the hands using a soap
or chemical and water. Hand washing is component of all types of isolation precaution and is the
most basic and effective infection control measure that prevents and controls the transmission of
infectious agents.
PURPOSES
 To reduce the number of microorganisms in the hands

 To decrease the risk of transmission t clients
 To prevent the risk of cross contamination among clients
 To reduce the risk of infection among other healthcare workers
 To lower the risk of transmission of the infectious organisms to oneself
ASSESSMENT
1. Assess the environment to establish if facilities are adequate for cleansing the hands.
2. Check hands to determine if they have open cuts, hang nails, broken skin or heavily
soiled areas.
NURSING DIAGNOSIS
Determine related factors that could influence the environment. Appropriate nursing
diagnosis may include:
1. Risk for infection
2. Effective health maintenance
PLANNING
 Determine the equipment to be used
 Wash hands for infection control
 Ensure that aseptic technique is followed
 Obtain materials needed
EQUIPMENT
Soap in a soap dish
Orange wood stick
Clean hand towel
Paper squares
Paper lining
1
IMPLEMENTATION
STEP RATIONALE
1. Prepare and assess the hands. File the Short nails are less likely to harbor
nail short. microorganisms, scratch a client, or puncture
glove. Long nails are hard to clean.
a. Remove all jewelry. Some prefer to Microorganisms can lodge in the settings of
slide their watch up above the jewelry and under rings. Its removal facilitates
elbows, or pin the watch to the proper cleansing of the hands and arms.
uniform. Otherwise remove it and
place inside the pocket.
b. Check hands for breaks or cuts in Open cuts or wounds can harbor high
the skin and cuticle. Report concentration of microorganisms which can be
condition to your instructor before passed on to clients. The risk of cross infection
beginning one’s work. Anyone who from patient to health workers is also high.
has open wounds may have to
change work assignments otherwise
one wears gloves to avoid contact
with infectious materials.
c. Check hands for heavy soiling. This will require lengthier hand washing
duration.
d. Roll sleeves above the elbows. This facilitates cleaning of the skin including
just above the elbows.
e. Carry equipment to the washing Ensure that you bring all the necessary
area. materials.
2. Turn on the water and adjust its flow or Warm water is more effective in removing
temperature. microorganisms than cold water.
Adjusting the water flow helps in conserving

the precious water without affecting the
purpose of the medical asepsis.
a. Avoid splashing water against one’s Microorganisms travel and grow in moisture
uniform. rapidly.
3. Wet the hands thoroughly by holding

them under the running water. Apply
soap to the hands.
a. Hold hands lower than the elbows Water flows from the least contaminated are.
so the water flows from the arms to The hands are generally considered more
the hands. contaminated then lower the arms.
b. Apply soap, rubbing it firmly and Initially cleanse the hands before soaping the
vigorously creating plenty of lather forearms. Soap cleanses by emulsifying fat and
in the palms, back, wrist and the oil and by lowering the surface tension.
interdigital areas.
4. Thoroughly wash and rinse the hands. Remove soap residue that causes dryness of the
skin.
2
a. Repeat (3b) rubbing firmly the Vigorous rubbing the skin enhances
palms and interdigital areas. Use the mechanical loosening and removal of the dirt
orange wood stick to remove the and microorganisms.
dirt in the fingernails. Rinse the
orange wood stick before returning. Interlacing the fingers and thumbs ensure that
all surfaces are cleansed.
Areas under the nails can be highly

contaminated which will increase the risk of
infection for the health worker and the client.
b. In a circular motion soap forearms This ensures removal of gross contaminants on
and elbows. Add more soap as the skin surface.
needed and create plenty of lather.
Do steps (4a) and (b) for about 10-
15 seconds repeatedly interlacing
fingers and rubbing palms and back
of hands with circular motion no
less than 5 times each. Keep
fingertips down to facilitate
removal of microorganism.
c. Rinse forearms, hands, and wrist Rinsing mechanically washes away dirt and
thoroughly, keeping hands down microorganisms.
and elbow up.
d. OPTIONAL: Repeat steps 4a and
b, and extend period of washing if
hands are heavily soiled.
5. Thoroughly dry the hands and arms. Drying from the cleanest (fingertips) to the
least clean (forearms) area avoids
a. Dry hands starting from fingers, to contamination. Drying hands thoroughly
wrist up to the forearms and elbows prevents chapping and roughened skin.
with the wash cloth (or paper
towels).
6. Turn off the water with dry paper It prevents from picking up microorganisms
squares or the paper towel before it is from the faucet handles.
discarded.
Wet paper and hands allow transfer of
pathogens by capillary action.
EVALUATION:
 The hand washing was adequate to control topical flora and infectious agents on the
hands.
 The hands were not decontaminated during or shortly after the hand washing.
REFERENCES:
Kozier, B. et al. (2006). Techniques in Clinical Nursing. 4th Ed. Ca: Addison Wesley
Potter,P. & Perry A. (2004). Fundamentals of Nursing. 5th Ed. St. Louis CV Mosby.
3
Roe, S. (2003). Delmar’s Clinical Nursing Skills and Concept.
COLLEGE OF NURSING
Dumaguete City
HANDWASHING
Performance Checklist
NAME: _____________________________________________ LEVEL: ________
DATE: ___________________
STEP 0 1 1.5 2 N/A COMMENT

ASSESSMENT
1. Assess the environment to establish if facilities are
adequate for cleansing the hands.
2. Assess the hands to determine if they have open
cuts, hang nails, broken skin or heavily soiled areas.
PLANNING
3. Determine what supplies or equipments are needed.
4. Wash hands for infection control.
5. Ensure that the correct technique is followed
6. Obtain the necessary equipments to use.
IMPLEMENTATION
7. Roll sleeves above the elbows.
8. Carry equipment to the washing area.
9. Turn on the water and adjust its flow or
temperature.
10. Wet the hands thoroughly by holding them under
the running water. Apply soap to the hands.
11. Hold hands lower than the elbows so the water
flows from the arms to the hands.
12. Apply soap, rubbing it firmly and vigorously

creating plenty of lather in the palms, back, wrist
and in the interdigital areas.
13. Thoroughly wash and rinse the hands.
14. Repeat (3b) rubbing firmly the palms and

interdigital areas. Use the orange wood stick to
remove dirt in the fingernails. Rinse the orange
wood stick before returning.
15. In a circular motion soap forearms and elbows. Add

more soap as needed and create plenty of lather. Do
steps (4a) and (b) for about 10-15 seconds
repeatedly interlacing fingers and rubbing palms
and back of hands with circular motion no less than
5 times each. Keep fingertips down to facilitate
removal of microorganism.
4
16. Rinse forearms, hands, and wrist thoroughly,
keeping hands down and elbows up.

17.OPTIONAL: Repeat steps 4a and b, and extend
period of washing if hands are heavily soiled.
18. Thoroughly dry the hands and arms.
19. Dry hands starting from fingers, to wrist up to the

forearms and elbows with the wash cloth (or paper
towels).
20. Turn off the water with dry paper squares or the
paper towel before it is discarded.
EVALUATION
21. The hand washing was adequate to control topical
flora and infectious agents on the hands.
22. The hands were not decontaminated during or

shortly after the hand washing.
ATTITUDE:
1. Purpose
2.Honest and sincere
3.Shows interest and willingness to learn
4.Manifests creativity
5.Shows resourcefulness
6.Possess sense of initiative
7.Shows positive attitude towards supervision
8.Systematic and conserve steps
9.well groomed
10.Applies body mechanics when performing procedure
TOTAL
Rating Scale:
1- Not done, but essentially required

2- Incorrectly done; wrong techniques and findings
1.5- correct measures, but with inadequate description of findings or not systematic in
performance
2- Correctly done, systematic according to standard; with correct findings
N/A- not applicable
5
REMARKS
COLLEGE OF NURSING
Dumaguete City
CARE OF THE CLIENT’S ENVIRONMENT
ASEPSIS is commonly defined as the absence of pathogenic microorganisms. Keeping the

client’s room clean is a way to prevent infection.
DAMP DUSTING
PURPOSES
 To reduce the number of microorganism in the clients environment.

 To keep the area neat and orderly
 To reduce the risk of transmission of organisms to oneself and among other health
workers.
ASSESSMENT
1. Assess the environment for the need of specialized materials such as hard to reach places (on
top of a shelf or below a bed)
2. Check the presence of objects within the environment that should not be dampened such as
electrical appliances.
3. Assess for the presence of hazardous objects that should be removed prior to damp dusting.
NURSING DIAGNOSIS
Determine related factors that could influence the environment. Appropriate nursing diagnosis
may include:
 Risk for infection

 Risk for injury
PLANNING
1. Determine the equipment needed.

6
3. identify and obtain the necessary equipment.
EQUIPMENT:
Basin with water
Disposable gloves
Two wash cloth
IMPLEMENTATION:
STEP RATIONALE
STEP RATIONALE
1. Gather all the equipment needed. To save time and effort.
2. Perform hand hygiene Reduces the time of transient bacteria.
3. Wear clean gloves Reduces the transmission of microorganisms.

This ensures that the medication is given to the
right person
4. Use treated cloth or dampened cloth. To avoid raising dust.
5. Clean away from yourself especially when To prevent undue articles from settling down
dusting or scrubbing articles. the hair, the face, or the uniform.
6. Do not shake linens. Dust particles constitute a means by which

bacteria may be transported from one area to
another.
7. Clean the least soiled area first and then the To prevent having the cleaner area soiled by
more soiled one. the dirtier one.
8. Wipe from up to own or start from the upper To prevent transferring the dust particles from
part going down, an area to another.
9. Wipe the surface using long strokes motions. Facilitates ease and less effort.
10. Clean and put clients unit in order. This contributes to the comfort of the patient
and helps raise the patient’s moral.
11. Rearrange the client’s thing with

permission. To enhance the patient’s participation.
7
EVALUATION
The expected outcomes are met when the client’s environment is clean and neat and it is free
from microorganisms.
REFERENCES:
Craven, Ruth F. & Constance J. Hirnle. (2003). Fundamentals of Nursing: Human Health and
Function, 4th ed. Philadelphia: Lippincott Williams & Wilkins.
Evans-Smith, Pamela (2005) Taylor’s Clinical Nursing Skills: A Nursing Process Approach.
Philadelphia: Lippincott Williams & Wilkins.
Potter, Patricia A. & Anne G. Perry.(2004) Fundamentals of Nursing, 6th ed. St. Louis Mosby,
Inc.
8
COLLEGE OF NURSING
Dumaguete City
DAMP DUSTING
NAME: ____________________________________
LEVEL:____
DATE:_______________
STEPSTEP 00 11 1.5
1.5 2 2 N/A
N/A COMMENT
COMMENT
ASSESSMENT
1.Assess the environment for the need of specialized
materials such as hard to reach places (on top of a
shelf or below a bed).
2. Check presence of objects within the environment
that should not be dampened such as electrical
appliances.
3.Assess for the presence of hazardous objects that
should be removed prior to damp dusting.
PLANNING
4. Determine what supplies or equipments are needed.
5. wash hands for infection control.
6. identify and obtain the necessary equipments to
use.
IMPLEMENTATION
7. Wear clean gloves.
8. Use treated cloth or dampened cloth.
9.Clean away from yourself especially when dusting
or scrubbing articles.
10. Do not shake linens.
11. Clean the least soiled area first and then the more
soiled one.
12.Wipefrom up to down or start from the upper part
going down.
13.Wipe the surface using long strokes.
14.Clean and put clients unit in order.
15. Rearrange the client’s thing in order with
9
permission.
EVALUATION
16. The expected outcomes are met when the client’s
environment is clean and neat and it is free from
microorganisms.
ATTITUDE:
1. Punctual
2. Honest and sincere
3.Shows interest and willingness to learn
4. Manifests creativity
5. Shows resourcefulness
6. Possess sense of initiative
10
COLLEGE OF NURSING
Dumaguete City
FLOWER ARRANGEMENT
Description
FLOWER AND FLOWERING PLANTS forms an exceeding important part of nature.

“Flowers seem intended for the solace of ordinary humanity” – John Ruskin. Almost nothing in
the world represents beauty, love, joy and color, the way flowers do. They have always
mesmerized humans with their perfumed scent, beautiful patterns and wide range of colors.
Nothing is more refreshing than a beautiful assortment of fresh flowers. Fresh flowers
arrangement is an art. The fresh flower arrangement must have an aesthetic appeal. Even though
flowers are beautiful just by themselves, they should not be arranged haphazardly.
PURPOSES
 Enhance color to the surrounding

 Gives aesthetic appearance to the environment
 Promotes the patient’s well-being through manipulation of the milieu
ASSESSMENT
1. Assess for any allergies to pollens or fresh flowering plants

2. Review patient’s records for any contraindication of placing flowers inside the room.
3. Check for procedures or treatment the patient is undergoing that comprises the immune
system.
NURSING DIAGNOSIS
Determine related factors that could influence the environment. Appropriate nursing diagnosis
may include:

2. Risk for injury
3. Altered immune response
PLANNING
1. Determine the equipment needed.

2. Perform hand washing
3. Review the methods of the different kinds of flower arrangement
4. Gather the materials essential for the procedure.
11
EQUIPMENT:
Different kinds of flower

Flower vase
Water
IMPLEMENTATION
STEP RATIONALE
1. Gather all equipment needed. To ensure saving time and efforts.
2. Perform hand hygiene. Detects the transmission of microorganisms

from one surface to another.
3. Select flower for the four varied types Maintains efficiency in accomplishing this
of arrangement task.
4. Place enough water in the flower vase. Retains the freshness of the flowers even for
how many days.
5. For single type of arrangement use Exudes simplicity without compromising the
one kind of flower and arrange it in representation of beauty.
the flower vase.
6. For mixed type arrangement, use Enhance the color of the surroundings.
varied kinds of flowers. Organize
them in the flower vase.
7. For the man, heaven, and earth type of Provides aesthetic appeal to the patient’s
flower presentation, utilize one kind of environment.
flower or more. Sort them like a
ladder and it should resemble like an
expression of beauty through art form.
8. For the Ikebana pattern, one kind of This is the key shape of Ikebana.
flower can suffice. The placement of - Certainly, beautiful patterns and wide
the flowers in asymmetrical form. range of colors creates a refreshing
look to the surroundings.
9. Discard the part of flower that has Maintains cleanliness of the working area.
been cut off like stem and fallen
petals.
10. Wipe off water dripping exteriorly out For the presentation to look deliberately
of the vase. executed with the purpose of promoting
wellness through environmental control.
11. Perform hand hygiene. Reduces the transmission of microorganisms.
12
EVALUATION
The expected outcomes are met hen the flower presentation is able to provide color to the
surroundings not only to the flower plainly but also to the vibrant color of the leaves that cover
the area and enhances the beauty to the environment.
REFERENCES:
Kozier & Erb’s Fundamentals of Nursing (Fundamentals of Nursing (Kozier)) 10th Edition
REMARKS:
13
COLLEGE OF NURSING
Dumaguete City
FLOWER ARRANGEMENT
NAME:__________________________ LEVEL: __________DATE: ____________
STEPS SATISFIE UNSATISFI COMMENTS

D ED
ASSESSMENT
1. Assess for any allergies to pollens
or fresh flowering plants.
2. Review patient’s records for any
contraindication of placing flowers
inside the room.
3. Check for procedures or treatment
the patient is undergoing that
compromises the immune system.
PLANNING
4. Determine what supplies or
equipment are needed. Determine
the equipment needed.
5. Wash hands for infection control
6. Identify and obtain the necessary
equipment to use.
7. Review the methods of different
kinds of flower arrangement.
IMPLEMENTATION
8. Selects flower for the four varied
types of arrangement.
9. Place enough water on the flower
vase.
10. For single type of arrangement use
one kind of flower and arrange it
in the flower vase.
11. For mixed type arrangement, use
varied kinds of flowers. Organize
them in the flower vase.
12. For the man, heaven, and earth
type of flower presentation, utilize
one kind of flower or more. Sort
them like a ladder and it should
resemble like an expression of
beauty through art form.
13. For the Ikebana pattern, one kind
of flower can suffice. The
14
placement of the flowers in
asymmetrical form.
14. Discard the part of flower that has
been cut off like stem and fallen
petals.
15. Wipe off water dripping exteriorly
out of the vase.
16. Perform hand hygiene.
EVALUATION
17. The expected outcomes are met
hen the flower presentation is able
to provide color to the
surroundings not only to the
flower plainly but also to the
vibrant color of the leaves that
cover the area and enhances the
beauty to the environment.
ATTITUDE:
1. Punctual
3. Show interest and willingness
to learn
7. Shows positive attitude
towards supervision
8. Systematic and conserves steps
9. Well groomed
10. Applies body mechanics when
performing procedure
TOTAL
RATING SCALE:
SATISFIED
UNSATISFIED
REMARKS
15
COLLEGE OF NURSING
Dumaguete City
BAG TECHNIQUE
BAG TECHNIQUE: A tool making which the health worker, during a home visit, can perform
procedure(s) in the home with ease and deafness, saving time and effort, with the end view of
rendering effective health care.
PUBLIC HEALTH BAG: Is an essential and indispensable equipment of the public health
nurse which he/she has to carry along when he/she goes out for a home visit. It contains basic
medications and articles which is necessary for giving care.
RATIONALE: to render effective nursing care to clients and/or members of the family during
home visit.
Principles:
1. The bag should contain all necessary articles, equipment, which may use to answer
emergency needs.
2. The bag and its contents should be washed and cleaned as soon as possible; it supplies
being replenished, and ready for use any time.
3. The bag and its contents should be well protected from contact with any article in the
home of patients. Consider the bag and its contents clean and/or sterile, while ay article
belonging to the patient as contaminated.
4. The arrangements of the bag contents should be in accordance to its sequence of use and
convenience of the user so as to facilitate efficiency and avoid confusion.
5. Handwashing is done as frequently as the situation necessitate and it should minimize
contamination of the bag and its contents.
6. If the bag was used for communicable case; the bag and its contents should be
appropriately cleaned, disinfected, and air-dried.
7. The bag technique is done as soon as you get into the home of your client.
8. Carry your PH bag in a manner that its state of cleanliness is maintained. Do not swing
them on the floor. Use the paper lining (with technique) if you have to lay open you PH
bag in a place where it might be contaminated.
9. Periodically wash the cloth lining, small towels, and wash cloth; air dry the rest of the
bag contents.
16
Contents of the Bag Reagents
BP Apparatus with Stethoscope Benedict Solution 30cc

2 clamped forceps; pean/Kelly Acetic Acid 30cc
1 bandage scissors Denatured alcohol 30cc
1 medicine glass 70% isopropyl alcohol
2 droppers
2 test tubes (5cc or 10cc) Supplies
1 test tube holder Cotton balls
1 axillary thermometer Powdered soap
1 tape measure Small tin can cover
1 functional pen light Small wide mouth glass
White cloth lining (14x24 inches) Paper waste receptacle
White wash cloth Paper lining
White apron Small size plastic bag
Orange stick Match box/ lighter
Umbrella (pleasant- color) Long cotton applicator
Glass container Test tube brush
Plastic container
ASSESSMENT
Assess the environment to establish if facilities are adequate for bag technique
IMPLEMENTATION
STEP RATIONALE
1. Upon arriving at the client’s home, place To protect the bag from contamination.
the bag on the table or any flat surface
lined paper lining, clean side out (folded
part touching the table). Put bag handles or
strap beneath the bag.
2. Open the bag, take the linen/plastic To make a non-contaminated work area.
lining and spread over work field or area.
The paper lining, clean side out (folded
part out).
3. Take out hand towel, soap dish and To prepare for handwashing.
apron and place them at the corner of the
work area (within the confines of the
linen/plastic lining).
4. Do handwashing. Wipe, dry with towel. Handwashing prevents possible infection

Leave the plastic wrappers of the towel in from care provider to the client.
the soap dish in the bag.
5. Put on apron right side out and wrong To protect the nurse’s uniform. Keeping the
side with crease touching the body, sliding creases creates aesthetic appearance.
the head into the neck strap. Neatly tie the
17
straps at the bag.
6. Put out things most needed for the

specific case (e.g. thermometer, kidney To make them readily accessible.
basin, cotton balls, waste paper receptacle)
and place at one another of the work area.
7. Place waste paper bag outside of work

area.
To prevent contamination of clean area.
8. Close the bag
To give comfort and security, maintain

9. Proceed to the specific nursing care or personal hygiene and hasten recovery.
treatment.
To prevent contamination of the bag and
10. After completing the nursing care or contents.
treatment, clean and disinfect the things
used. To protect care giver and prevent spread of
infection to others.
11. Do handwashing again.
12. Open the bag and put it back all

articles in their proper placed.
13. Remove apron folding away from the

body, with soiled side folded inwards, and
the clean side out. Place it in the bag.
14. Fold the linen/plastic lining, clean;

place it in the bag and close the bag.
15. Make post-visit conference on matters

relevant to health care, taking anecdotal
notes preparatory to final reporting. To be used as reference for future visit.
16. Make an appointment for the next visit

(either home or clinic). Taking note of the
date, time, and purpose.
For follow-up care.
AFTER CARE
1. Before keeping all articles in the bag, clean, and disinfect them.
2. Get the bag from the table, fold paper lining (and insert), and place in between the flaps
and cover the bag.
EVALUATION AND DOCUMENTATION
1. Record all relevant finding about the client and members of the family.
18
2. Take note of environmental factors which affect the clients/family health.
3. Include the quality of nurse-patient relationship.
4. Assess effectiveness of nursing care provided.
REFERENCES:
FUCN PROCEDURE MANUAL 2007
COLLEGE OF NURSING
Dumaguete City
BAG TECHNIQUE
19
Name: __________________________________ Level: ____________ Date:

______________
STEP SATIFIED UNSATISFIE COMENTS

D
1. Place bag on the table lined with
clean paper.
2. Towel or cloth spread over paper
lining.
3. Wash hands and wipe dry.
4. Bring out apron with outside part
of the chest to come in contact with
the body.
5. Put all necessary articles needed
for care relative to procedure to be
done.
6. Transfer all necessary articles on
the bedside, set-up, and bring to
bedside of patient, prn.
7. After nursing care, clean articles
used and place them on the towel
lining.
8. Wipe them dry.
9. Open bag and return articles to
their proper places.
10. Remove apron, folding inside
the soiled side. Left to right.
11. Return towel to bag and close it.
12. Record observations.
13. Gather used papers, cotton balls,
etc. and place them inside the paper
bag. Close and give to family
member for disposal.
14. Lift the bag. Fold newspaper
lining with part touching table
folded inside.
ATTITUDE:
1. Punctual
3. Shows interest and willingness to
learn
4. Manifest creativity
5. shows resourcefulness
7. Shows positive attitude towards
supervision
9. Well groomed
20
10. Applied body mechanics when
performing procedure.
TOTAL
Rating Scale:
Satisfied
Unsatisfied
REMARKS
Signature of Student Nurse over Printed Name Signature of Clinical instructor over Printed Name
21
COLLEGE OF NURSING
Dumaguete City
URINALYSIS
A. TEST for ALBUMIN HEAT METHOD

1. Spread newspaper on a flat surface table, chair, or floor.
2. Open PH bag and follow procedure in bag technique, handwashing and putting on apron
3. Remove from bag the following materials:
2 test tube Tin can cover
3 droppers Small wide-mouth glass
Test tube holder Paper waste receptacles
Test tube brush Paper lining
Cloth lining Small-sized plastic bag
Apron Match box
Cotton balls
Long cotton applicators REAGENTS:
Powdered soap Denatured alcohol
Handwashing materials Acetic acid
Benedict’s solution
4. While materials are being assemble, ask the client to void and place urine specimen in a clean
bottle.
5. Ask client to open the specimen bottle if sealed.
PROCEDURE:
1. Saturate cotton balls with denatured alcohol and place in tin can cover.
2. Fill test tube with two-thirds full of urine.
3. Light saturated cotton balls.
4. Heat upper part of the test tube and bring to boiling point.
5. Hold test tube against light and examine for a cloudy ring.
6. If there is a ring, add 3-5 drops of acetic acid and heat again
RESSULT:
 If cloudiness disappears, there is NO ALBUMIN
 If top liquid is OPAQUE, it is read as “TRACE”
 If FRANKLY CLOUDY, “+ to ++” ALBUMIN
 If ring is WHITE resembling the white of an egg, it is as “+++ ALBUMIN”
7. Pour solution into toilet bowl. Rinse test tube and medicine dropper with clean water. Then
use cotton applicator soaped with detergent to clean articles.
8. Rinse test tube well. Place on set up.
9. Return equipment to bag.
10. Record results.
11. Upon returning to FUCN/home/boarding house rewash all used equipment using test tube
brush. Dry tem thoroughly (inside of test tubes as well as outside) using cotton applicators. Then
or dry the PH bag overnight to reduce the smell of chemicals.
22
B. TEST for URINE SUGAR
1. Place about 2cc (30 gtts) of benedict’s solution in the test tube and heat over flame.
2. Add 3-5 drops of urine, shaking simultaneously and heat until it boils.
RESULTS:
 No discharge in color indicates NEGATIVE for sugar
 Blue-Green indicates TRACES of sugar
 Yellow-Green indicates + to ++
 Orange-Yellow indicates +++ to ++++
REFERENCES:
Craven, R., Hirnle, C. J. &Henshaw, C. M. (2016) Fundamentals of Nursing: Human Health and
Function. 8th ed. Philadelphia, 19103: Lippincott Williams & Wilkins.
DeLaune, S. & Ladner, P. K. (2010). Fundamentals of Nursing Standards and Practice. 4 th ed.
Clifton Park, NY: Delmar Cengage Learning.
Hall, A., Perry, A. G., Potter, P. &Stockert, P. (2016). Fundamentals of Nursing. 9 th ed. St.
Louis: Mosby, Inc.
Timby, B. (2016). Fundamental Nursing Skills and Concepts. 11th ed. Philadelphia,
19103: Lippincott Williams & Wilkins.
23
COLLEGE OF NURSING
Dumaguete City
URINALYSIS
PERFORMANCE CHECKLIST
NAME: _________________________________ LEVEL: ____________ DATE:

______________
STEP SATISFIED UNSATISFIED COMMENTS

1. Place the bag on table lined with
paper lining.
2. Spread cloth lining over paper
linin.
3. Wash hands and wipe dry.
4. Bring out apron with outside part
of the chest come in contact with the
body.
5. Put all necessary articles needed
for the procedure.
TEST FOR ALBUMIN
6. Saturate cotton balls with
denatured alcohol and place in tin can
cover.
7. Fill test tube with two-thirds full of
urine.
8. Light saturated cotton balls.
9. Heat upper part of the test tube and
bring to boiling point.
10. Hold test tube against light and
examine for a cloudy ring.
11. If there is a ring, add 3-5 drops of
acetic acid and heat again.
12. Observe the result
13. Record and inform, the client of
the interpretation of the result
TEST FOR ALBUMIN
14. Place about 2cc (30 gtts) of
benedict’s solution in the test tube
and heat over flame.
15. Add 3-5 drops of urine, shaking
simultaneously and heat until it boils.
16. Observe the result
17. Record and inform the client of
the interpretation of the result.
18. Dispose all test tube and contents
24
properly.
19. Wash and rinse test tube and
droppers thoroughly. Place on set up.
21. Open bag and return used articles.
ATTITUDE:
1. Punctual
2. Honest and Sincere
learn
supervision
9. Well groomed
TOTAL
RATING SCALE:
SATISFIED
UNSATISFIED
REMARKS
COLLEGE OF NURSING
25
Dumaguete City
VITAL SIGNS TAKING
Vital signs taking is the manner by which the patients temperature, pulse rate, respiratory rate
and blood pressure is taken and recorded.
PURPOSE
1. To afford the opportunity to observe the general condition of the patient.

2. To serve as a guide in meeting the needs of the patient.
3. To aid the physician in making his diagnosis and planning the patient’s care.
CONSIDERATION
 Before taking the vital signs, be sure that the patient has rested and is placed in a
comfortable position.
 The frequency of taking TPR depends upon the condition of the patient and the policy of
the institution.
 Inform the physician or the head nurse promptly for any significant changes in the vital
signs.
 To allay fear and anxiety, explain the procedure to the patient or significant others.
GUIDELINES FOR TAKING VITAL SIGNS
1. The nurse caring for the client is responsible for vital signs measurement
2. Equipment should be functional and appropriate for the size and age of the patient.
3. Equipment should be selected based on client’s condition.
4. The nurse should know the clients usual range of vital signs.
5. The nurse should be aware of the client’s medical history as well as the therapies and
medication prescribed.
6. The nurse controls or minimizes environmental factors affecting the client’s vital signs.
7. The nurse should be organized and systemic in taking the vital signs to ensure accuracy.
8. The nurse should approach the client in a warm and caring manner.
9. Based on the client’s condition, the nurse should collaboration with the physician
regarding the frequency of taking the vital signs.
10. The nurse uses vital signs measurement in determining medication administration.
11. The nurse analyses the result of the vital signs measurements so that proper referrals will
be made.
12. The nurse develops a teaching plan to instruct the client or caregiver in proper vital sign
taking
WHEN TO TAKE VITAL SIGNS
26
1. When admitted to a health care facility.
2. Routine schedule based on institution policy/physician’s order.
3. Before and after any surgical procedure.
4. Before and after any invasive diagnostic procedure.
5. Before, during and after the administration of medications that affect the cardiovascular,
respiratory, and temperature control function.
6. When there is a change in clients general physical condition e.g. loss of consciousness or
increases intensity of pain.
7. Before and after a nursing procedure that can affect a vital sign.
8. When the client reports a non-specific symptom of physical distress.
BODY TEMPERATURE
DEFINITION
The difference between the heat produced by the body processes and the amount of heat
lost from the body to the external environmental. (Potter & Perry, 2005)
REGULATION
Neural and vascular control; hypothalamus - control body temperature (anterior hypothalamus
controls heat loss, while posterior hypothalamus controls heat production)
Heat Production
 Heat is a by-product of metabolism

 Occurs during rest, voluntary movement, involuntary shivering, and non-shivering
thermogenesis.
Heat Loss
 Normal process are as follows: radiation, conduction, convection and evaporation

Behavioral Control: the ability of a person to control body temperature depends on (a) the degree
of temperature extremes, (b) the person’s ability to sense feeling comfortable or uncomfortable,
(c) emotions, and (d) the person’s mobility or ability to remove or add clothes.
FACTORS AFFECTING BODY TEMPERATURE
 AGE: newborns have immature temperature control mechanism

 EXERCISE: exercise increases metabolic rate thus, affecting body temperature
 HORMONE LEVELS:
o Women generally experiences greater fluctuations in body temperature
than men progesterone, thyroxine, norepinephrine, and epinephrine
increases body temperature
o Estrogen decreases body temperature.
 CIRCADIAN RHYTHYM/DIURNAL VARIATIONS: highest temperature is usually
reached between 8:00 PM to 12:00 MN; and the lowest temperature is reached between
4:00 and 6:00 AM
27
 STRESS: Sympathetic system nervous stimulation increases the production of
epinephrine and norepinephrine thereby increasing the metabolic rate and heat production
 ENVIRONMENT: infants and older adults are most likely to be affected by
environmental temperature because their temperature-regulating mechanism are less
efficient.
TEMPERATURE ALTERATIONS
1. Pyrexia – body temperature above normal range (also hypothermia, fever)

2. Hyperpyrexia – very high fever, 41C (105.8F) and above
3. Hypothermia – subnormal core body temperature, may be caused by excessive heat loss,
inadequate heat production or impaired hypothalamic function
TYPES OF FEVER
1. Intermittent Fever. The temperature fluctuates between periods of fever and periods of
normal/subnormal temperature.
2. Remittent Fever. The temperature fluctuates within a wide range over a 24 – hours period
but remains above normal range.
3. Relapsing Fever. The temperature is elevated for few days, alternated with 1 or 2 days of
normal temperature.
4. Constant Fever. Body temperature is consistently high.
 Very high temperature (41-42C) cause irreversible brain cell damage.
SPECIAL CONSIDERATIONS
 Take the body temperature by mouth unless otherwise contraindicated.

 Stay with the patient while the thermometer is in place.
 Provide individual thermometer for each patient.
 Use ORAL THERMOMETER only when taking the temperature by mouth and RECTAL
THERMOMETER for rectal temperature.
 When using the axillary method, see to it that axilla is dry and the bulb of the
thermometer is within the hollow portion of the axilla.
 Do not take an axillary temperature immediately after bathing.
 Taking the body temperature by mouth is contraindicated in children below 5 years old,
who might bite the glass thermometer.
 Taking the rectal temperature is contraindicated in patient with diarrhea, with rectal
disease, post rectal surgery, or who may be at risk of perforation from the thermometer.
 Rinse the thermometer in cold water to prevent leakage.
 Conversion:
o Celsius to Fahrenheit: F = ( C x 9/5) + 32
o Fahrenheit to Celsius: C= (F – 32) x 5/9
ADVANTAGES AND DISADVANTAGES OF SELECTED TEMPERATURE

MEASUREMENT SITES
Tympanic Membrane Sensor
Advantages
28
 Easily accessible site
 Minimal client repositioning required
 Provides accurate core reading
 Very rapid measurement (2 to 5 seconds)
 Can be obtained without disturbing or waking up the client
 Eardrum close to hypothalamus
 Sensitive to core temperature changes
 Unaffected by oral intake of food, fluids
 Can be used for tachypnea clients
Disadvantages
 Requires removal of hearing aids before measurement

 Should not be used for clients who have had surgery of the ear or tympanic membrane
 Requires disposable probe cover
 Expensive
 Does not accurately measure core temperature changes during and after exercise
 Possible distortion of temperature readings for client with otitis media
 May have lower readings with cerumen impaction
 Question about measurement accuracy in newborns
 More variability of measurement than with other core temperature devices
 Cannot obtain continuous measurement
RECTUM
Advantages
 Argued to be more reliable when oral temperature cannot be obtained
Disadvantages
 May lag behind core temperature during rapid temperature changes

 Should not be used for clients with diarrhea, rectal surgery, rectal disorder, or decreased
platelets
 Should not be used for routine vital signs in newborns
 Requires positioning and may be a source of the client’s embarrassment and anxiety
 Risk of body fluid exposure
 Requires lubrication
ORAL
Advantages
 Accessible – requires no position change

 Comfortable for client
 Provides accurate surface temperature reading
 Reflects rapid changes in core temperature
29
Disadvantages
 Affected by ingestion of fluids or food, smoke and oxygen delivery

 Should not be used with infants, small children, confused, unconscious, or uncooperative
clients
 Risk of body fluid exposure
AXILLA
Advantages
 Safe and noninvasive

 Can be used in newborns and uncooperative clients
Disadvantages
 Long measurement time

 Requires continuous positioning by the nurse
 Lags behind core temperature during rapid core temperature changes
 Requires exposure of thorax
 Not recommended to detect fever in infants and young children
SKIN
Advantages
 Inexpensive
 Provides continuous reading
 Safe and noninvasive
 Does not require disturbing the client
 Easy to read
Disadvantages
 Lags behind other sites during temperature changes, especially during hyperthermia
 Adhesion can be impaired by diaphoresis or sweat
 Can be affected by environmental temperature
 Unreliable during chill phase of fever
Clinical Signs of Fever
Onset (cold or chill stage) of Fever
 Increased heart rate

 Increased RR and depth
 Shivering
 Pale, cold skin
 Cyanotic nail bed
 Complaints of feeling cold
30
 “goose flesh” appearance of the skin
 Cessation of sweating
 Rise in body temperature
Course of Fever
 Absence of chills
 Skin that feels warm
 Feeling of being neither hot nor cold
 Increase pulse and respiratory rates
 Increased thirst
 Mild to severe dehydration
 Drowsiness, restlessness, delirium, and convulsions
 Herpetic lesions in the mouth (fever blisters)
 Loss of appetite to eat
 Malaise, weakness and aching muscles
Defervescence (fever abatement)
 Skin that appears flushed and feels warm

 Sweating
 Decrease shivering
 Possible
Normal Adult Temperature Range
Methods of Temperature Taking Ranges

1. Oral 97.6 F – 99.6 F
(36.5 C – 37.5 C)
2. Axillary 96.6 F – 98.6 F
(35.8 C – 37.0 C)
3. Rectal 98.6 F – 100.6 F
(37.0 C – 38.1 C)
4. Tympanic 98.2 F – 100.2 F
(36.8 C – 37.9 C)
NURSING DIAGNOSES
Clients with Altered Body Temperature
1. High risk for altered body temperature related to:

Illness or trauma affecting temperature regulation
Medication causing vasoconstriction, vasodilation, altered metabolism
state or sedation
Inactivity or vigorous activity
2. Hyperthermia related to:
31
Exposure to excessive warm environment
Increased metabolic rate
Dehydration
3. Hypothermia related to:
Exposure to excessively cool environment
Debilitating illness or trauma
Lack of adequate clothing or shelter
4. Ineffective thermoregulation related to:
Decreased basal metabolism secondary to aging
Trauma or illness
NURSING INTERVENTION IN CLIENTS WITH FEVER
 Monitor vital signs

 Assess skin color and temperature.
 Monitor WBC, Hot and other pertinent laboratory records
o Elevated WBC levels indicate presence of infection
o Elevated Hot indicates dehydration
 Remove excess blankets when the client feels warm; provide extra warmth when the
client feels chilled
 Provide adequate nutrition and fluids to have additional calories and to prevent
dehydration
 Measure intake and output
 Maintain prescribed IV fluids as ordered by the physician
 Promote rest. To reduce body heat production.
 Provide good oral hygiene. To prevent herpetic lesions in the mouth.
 Provide cool circulating air using a fan. To dissipate heat through convection.
 Provide dry clothing and bed linens. To ensure comfort.
 Provide TSB (temperature of water should be 80 – 98 F). To enhance heat loss by
evaporation and conduction.
 Administer antipyretics as ordered. Temperature of 38.5 C and above usually require
administration of antipyretics.
PULSE
Pulse is the expansion of the arterial walls occurring with each ventricular contraction. It is the
palpable bounding of blood flow noted at various points on the body. Pulse rate is an indicator of
the person’s circulatory status.
Physiology and Regulation

Electric impulses from the sinoatrial (SA) node travel through heart muscle to stimulate cardiac
contraction. Approximately 60 to 70 ml of blood enters the aorta with each ventricular
contraction (stroke volume). With each stroke volume ejection, the walls of the aorta distend,
creating a pulse wave that travels rapidly toward the distal ends of the arteries. When a pulse
wave reaches a peripheral artery, it can be felt by palpating the artery lightly against underlying
bones or muscles.
Cardiac Output= pulse rate x stroke volume
32
= 5000 ml of blood per minute (normal CO of an adult)
ASSESSMENT
 Radial and Carotid Arteries- commonly used; highly palpable
 Radial Pulse- used by lay individuals in monitoring their own heart rates
 Apical Pulse- used when radial pulse at wrist is abnormal or intermittent resulting from
dysrhythmias or it is inaccessible because of a cast or dressing
 Brachial or Apical Pulse- best site for assessing an infant’s or young child’s pulse, other
sites are difficult and deep to palpate.
Character of Pulse
A. RATE
 The number of beats per minute
 Temporarily increase when a person changes from a lying to a seating position or
standing position
 Factors affecting pulse rate: exercise, temperature, emotions, drugs, hemorrhage,
postural changes and pulmonary conditions
 Identification of first and second heart sounds:
S1- low pitch and dull, sound like “lub”
S2- high pitch and short, creating the sound “dub”
 two common abnormalities: tachycardia, bradycardia
 pulse deficit- the difference between apical and radial pulse rates
B. RHYTHM
 Is the regular interval between each pulse or heartbeat
 Dysrhythmia- an abnormal rhythm characterized by an early or late beat or missed
beat; identified by palpating an interruption between the heart sounds
C. STRENGTH
 A.k.a amplitude of a pulse reflects the volume of blood ejected against the arterial
wall with each heart contraction and the condition of the arterial vascular system
leading to the pulse site
D. EQUALITY
 Assessment of the pulse on both sides of the peripheral vascular system
 Pulse in one extremity may be unequal in strength or absent in many disease state
(e.g. thrombus formation, aberrant blood vessels, cervical rib syndrome or aortic
dissection)
Special Considerations
 Remember that one pulse moves or one complete rise and fall of the arterial wall is
considered as one heartbeat or count.
 Be sure that both the patient and the nurse are in comfortable position.
 When taking the pulse, note the rate, rhythm, strength and equality.
 Do not take the pulse when the patient is restless or when the child is crying.
 A patient’s pulse can be palpated or auscultated each time the heart’s left ventricular
contracts and forces blood into the aorta.
 The pulse is counted for 1 full minute.
NORMAL PULSE RATES
33
Newborn 1 month old 120-160 bpm
1 month old- 1 year old 80-140 bpm
1 year old- 2 years old 80-130 bpm
2 years old- 6 years old 75-120 bpm
6 years old- 12 years old 75-110 bpm
Adolescent-Adult 60-100 bpm
Common sites of peripheral pulses
RESPIRATION
Respiration is the mechanism the body uses to exchange gases between the atmosphere and the
blood, and the cells.
Involves the process of:
 Ventilation – The movement of gasses in and out of the lungs

 Diffusion – The movement of oxygen and carbon dioxide between the alveoli and the red
blood cells
 Perfusion – the distribution of red blood cells to and from the pulmonary arteries
Physiological Control
 Respiratory Center – located in the brain stem, regulates the involuntary control of
respirations
34
 Levels of CO2, O2, and hydrogen ion concentration – regulates ventilation
 Levels of CO2 in the arterial blood – most important factor in the control of ventilation
 Elevation causes the respiratory control system in the brain to increase the
rate and depth of breathing, thereby removing excess CO2 (hypercarbia)
MECHANICS of BREATHING
Breathing – generally a passive process; involves both inspiration and expiration process; types:
thoracic and abdominal/diaphragmatic
ASSESSMENT OF VENTILATION
Respiration Rate
 Observes a full inspiration and expiration when counting ventilation or respiration rate
 Varies with age
 Apnea Monitor – a device that needs the nurse’s assessment; uses leads attached to
client’s chest wall that sense movement; frequently used with infants
 Factors influencing characters of respirations: exercise, acute pain, anxiety, smoking,
body position, medications, neurological injury, and hemoglobin function
Ventilator Depth
 Assessed by observing the degree of excursion or movement in the chest wall

 Described as deep, normal, and shallow
 Alteration is breathing pattern: bradypnea, tachypnea,hyperpnea, apnea,
hyperventilation, hypoventilation, Cheyne-strokes respiration, Kussmaul’s respiration,
and Blot’s respiration
Ventilator Rhythm
 Determine by observing the chest or the abdomen

 Diaphragmatic breathing – usually demonstrated by healthy men and children
 Thoracic breathing – usually demonstrated by women
 Labored respiration – involved the use of accessory muscles (sternocleidomastoid,
intercostal muscles, trapezius)
 May be regular or irregular in rhythm
Special Considerations
 Count respiration after counting the pulse with the fingertips on the client’s artery.
 Report rate changes that occur suddenly. A rate of fewer than 8 or more than 40 breaths
per minute usually indicates a respiratory problem.
 Observe the client for signs of dyspnea, such as anxious facial expression, flaring nostrils,
or heavy chest wall.
 Make sure that the patient must be aware that you are already taking his respiration.
35
 One inhalation and one respiration is already counted as one respiration.
NORMAL RESPIRATORY RATES
Newborn 30 – 60 cycles per minute (cpm)

Infant (6 months) 30 – 50 cpm
Toddler 25 – 32 cpm
Child 20 – 30 cpm
Adolescent 16 – 19 cpm
Adult 12- 20 cpm
BLOOD PRESSURE
Blood pressure is the force exerted on the walls of an artery by the pulsing blood under pressure
from the heart. Systemic or arterial blood pressure is the blood pressure in the system of arteries
in the body, it is good indicator of cardiovascular health.
Because the blood moves in waves, there are two blood pressures:
Systolic pressure- the peak of maximum pressure when ejection occurs as a result of ventricular
contraction
Diastolic pressure- the pressure of the remaining blood in the arteries when the ventricles are at
rest
mmHg (millimeters in mercury)

 Standard unit of measuring blood pressure
 The measurement indicates the height to which the blood pressure can raise a column of
mercury.
Pulse Pressure- the difference between the systolic and diastolic pressure
Physiology of Arterial Blood Pressure

A. Cardiac Output: volume of blood pumped by the heart (stroke volume, SV) during 1
minute (heart rate, HR)
CO= HR x SV
The blood pressure (BP) depends on the cardiac output and peripheral vascular
resistance (R)
36
BP= CO x R
B. Peripheral Resistance: is the resistance of blood flow determined by the one of vascular
musculature and diameter of blood vessels
C. Blood Volume:
Adults- 5000 ml circulating blood volume
Increase- causes increases in blood pressure and vice versa
D. Viscosity: the thickness of blood; hematocrit or percentage of red blood cells in the
blood, determines blood viscosity; when hematocrit rises and blood flows shows, arterial
blood pressure increases
E. Elasticity: the distensibility of the arterial walls; arteriosclerosis causes the vessel walls
to lose their elasticity because of fibrous tissue replacement
Factors Influencing Blood Pressure

1. Age: relative
2. Stress: anxiety. fear, pain and emotional stress increases blood pressure
3. Ethnicity: African-American have higher BP than European-Americans
4. Gender: after puberty, males have higher BP while after menopause, women tend to be
higher
5. Diurnal Variation: lowest in the early morning, gradually rises during the morning and
afternoon and peaks in late afternoon or evening
6. Medications: antihypertensive drugs and opiod analgesics lower BP
7. Other: lifestyle, etc.
MEASUREMENTS OF BLOOD PRESSURE

A. Direct Invasive: insertion of a thin catheter into an artery
B. Indirect Non-invasive: use of sphygmomanometer and stethoscope
Sphygmomanometer- includes a pressure manometer, an occlusive cloth or vinyl cuff that

encloses an inflatable rubber valve that inflates the bladder
 Two types of manometer: aneroid manometer and mercury manometer
 Standard cuff size: cuff width 20 % more than upper arm diameter or 40
%od circumference and 2/3 of arm length.
Stethoscope- its five major parts are the earpieces, binaurals, tubing, bell chestpiece and
diaphragm chestpice.
37
Mercury Manometer Aneroid Manometer
Stethoscope
Special Considerations:
 Avoid taking blood pressure readings on an arm that in injured or has a disease, or a side
that underwent a breast surgery, has an intravenous shunt, or is wrapped in a bulky
bandage or cast.
 Be sure that the sphygmomanometer is at the eye level for accurate blood pressure
reading (always read at the lowest level of the meniscus of the mercury).
 Do not re-inflate the cuff without completely deflating it or waiting at least 30 seconds.
 Assess the pulse and respiration and check the proper functioning of the equipment, if the
patient’s blood pressure is difficult or impossible to auscultate.
REFERENCES:
Craven, R., Hirnle, C. J. &Henshaw, C. M. (2016) Fundamentals of Nursing: Human Health and
Function. 8th ed. Philadelphia, 19103: Lippincott Williams & Wilkins.
DeLaune, S. & Ladner, P. K. (2010). Fundamentals of Nursing Standards and Practice. 4 th ed.
Clifton Park, NY: Delmar Cengage Learning.
Kowalski, M. &Rosdahl, C. (2016). Textbook for Basic Nursing. 11 th ed. Philadelphia, 19103:
Lippincott Williams & Wilkins.
Lynn, P. (2014). Taylor’s Clinical Nursing Skills: A Nursing Process Approach. 4 th ed.
Philadelphia, 19103: Lippincott Williams & Wilkins.
Timby, B. (2016). Fundamental Nursing Skills and Concepts. 11 th ed. Philadelphia, 19103:
Lippincott Williams & Wilkins.
COLLEGE OF NURSING
Dumaguete City
TEMPERATURE TAKING
38
PURPOSES
1. To obtain baseline data on submission to the hospital

2. To guard against hyperthermia and hypothermia.
3. To monitor the client’s responses to a procedure or therapy.
4. To detect or follow the course of febrile illness.
ASSESSMENT
1. Assess the patient to ensure that his or her cognitive function is intact to
determine the appropriate temperature taking method use.
2. Assess whether the patient can close his or her lips around the thermometer, if
not, the select a different method.
3. Assess the oral cavity for any sores.
4. Ask the patient if he or she has recently smoked, has been chewing gum, or was
eating or drinking immediately before assessing the temperature.
5. Review the patient’s platelet level (if available) and the diagnosis when rectal
temperature is being considered.
6. If the patient has an earache, do not use the affected ear to take the tympanic
temperature.
7. Assess the patient for significant ear drainage or scarred tympanic membrane and
the patient’s ability to do the side lying position when the ear route is being
considered.
NURSING DIAGNOSIS
Determine the related factors for the nursing diagnoses based on the patient’s current status.
Appropriate nursing diagnoses may include but are not limited to the following:
1. Risk for Trauma

2. Hyperthermia
3. Hypothermia
4. Risk for altered body temperature
5. Ineffective thermoregulation
OUTCOME IDENTIFICATION
The expected outcome would be:
 Accurate temperature is assessed

 Patient experiences no trauma, during and after the procedure
Note: other outcomes may be appropriate depending on the patient’s nursing diagnosis.
PLANNING
39
1. Determine what supplies or equipment are needed.
3. Ensure that the correct technique is followed.
4. Obtains the necessary equipment to use.
EQUIPMENT
Digital, electronic, or glass thermometer (oral, axillary, rectal)

Probe covers for electronic thermometer
Pencil/ pen
Paper/ vital signs sheet
Cotton ball/ tissue paper
Soap/ antiseptic solution / alcohol
Wristwatch with secondhand
IMPLEMENTATION
Measuring temperature regardless of route
ACTION RATIONALE
1. Check the physician’s order or nursing care This provides safety
plan for the frequency and route.
2. Identify the patient. To ensure that the correct procedure is done

to correct client.
3. Explain the procedure to the patient. Reduces anxiety and promotes cooperation by
the client.
4. Ensure that the electronic or digital In improperly functioning or busted

thermometer is in operating condition. equipment may give inaccurate or false
reading.
5. Perform hand hygiene or done gloves if
appropriate or indicated. Reduces microorganisms in the hands and
reduces the risks of cross contamination
among clients.
6. Select the appropriate site.
Assess the client’s age and mental and
physical condition to ensure safety and
accuracy of measurement.
7. Take the temperature accordingly.

( follow the steps outline below)
Proper hand hygiene prevents the spread of
8. Perform hand hygiene. If gloves are worn, microorganisms
discard them in proper receptacle.
Proper documentation and referral ensures
9. Record temperature on paper, flow sheet, appropriate management or care for the client.
or computerized record. Report significant This will also serve as an evaluation for an
findings to the physician. intervention that was provided beforehand.
Assessing temperature with a glass thermometer
40
ACTION RATIONALE
1. If it is stored in a chemical solution, wipe Chemical solution may irritate mucous
the thermometer dry with a soft tissue, using a membranes and have an objectionable taste.
firm twisting motion. Twisting helps cover the entire surface.
2. Wipe from the bulb towards the fingers. Wiping from an area of few of no
microorganisms to an area where
microorganisms might be present prevents
contamination or minimizes the spread of
microorganisms to the cleaner area.
3. Grasp the thermometer firmly with the Moves the chemical back into the bulb below
thumb and the forefinger and, using strong the previous measurement to ensure accurate
wrist movements, shake it until the chemical reading.
line reaches at least 36C.
4. Read thermometer by holding it This position makes it easier for you to see
horizontally at eye level, and rotate it between the calibration or the chemical line.
your fingers until you can see the chemical
line.
5. For oral use, place the bulb of the To obtain an accurate reading.
thermometer within the back of the right or
left pocket under the patient’s tongue and tell
the patient to close the lips around the
thermometer.
6. For rectal use, place the thermometer bulb
in the rectum about 1.5 inches in an adult or 1
inch in a child. Depth of insertion must be adjusted based on
the patient’s age. Rectal temperatures are
7. For axillary use, place the thermometer normally taken in an infant.
bulb in the center of the axilla with the
patient’s arm against the chest wall. To prevent inaccurate reading.
8. Leave the thermometer in place according

to the type of method used: 2 – 3 minutes for
rectal temperature, 5 minutes for oral Time is needed for the chemicals in the
temperature, and 10 minutes for axillary thermometer to expand and accurately
temperature or according to hospital protocol. measure temperature. Axillary temperature
takes the longest time for chemicals to
expand. Staying with the patient ensures that
9. Remove the thermometer and wipe it once the thermometer remains in the correct
from the fingers down to the bulb, using a position and s not broken
firm twisting motion
Wiping the thermometer minimize the spread
of microorganisms from an area of higher
concentration to a cleaner area; friction helps
10. Dispose of the tissue in a receptacle for loosen material from the thermometer surface.
contaminated items.
Confining contaminated articles helps reduce
11. Read the thermometer to the nearest tenth the spread of pathogens.
41
of a degree.
The chemical may raise above below a bit
12. Wash the thermometer in lukewarm soapy from the calibration lines.
water. Rinse it in tap water. Dry and place the
thermometer in its container. Washing removes organic material and
organisms.
EVALUATION
The expected outcome is met when the patient’s temperature is assessed accurately and
the patient experience no trauma.
UNEXPECTED OUTCOME
 Temperature reading is higher or lower than expected based on how the patient’s skin
feels. Reassess temperature with a different thermometer. The thermometer may not be
calibrated correctly. If using a tympanic thermometer, you will get lower readings if the
probe is not inserted far enough in the ear.
 During the rectal temperature assessment, the patient reports feeling lightheaded or
passed out. Remove the thermometer immediately. Quickly assess the patient’s blood
pressure and heart rate. Notify he physician. Do not attempt to take another rectal
temperature on this patient.
INFANT AND CHILD CONSIDERATION

Small children have a limited attention span and have difficulty keeping their lips closed
long enough to obtain an accurate oral temperature reading. For children younger than 6 years,
use the axillary or tympanic site or use a temperature sensitive tape (although research is ongoing
to determine the accuracy of the measurements).
HOME CARE CONSIDERATIONS

Use axillary or tympanic site for a confused, disoriented, or comatose adult. Axillary
temperature are generally about one degree less than oral temperatures, rectal temperatures are
generally about one degree higher.
REFERENCES:
Evan-Smith, P. (2013). Fundamentals of Nursing. 8th ed. Philadelphia: Lippincott Williams &
Wilkins.
Potter, P.A. & Perry, A.G. (2013). Fundamentals of Nursing. 8th ed. Missouri: Mosby, Inc.
Smith, Pamela (2011) Taylor’s Clinical Nursing Skills: A Nurse Process Approach
Timby, Barba (2009) Fundamental Skills and Concepts in Patient Care, 9 th ed. Philadelphia:
Lippincott.
42
COLLEGE OF NURSING
Dumaguete City
TEMPERATURE TAKING
Name:____________________________________ Level: ____________ Date:

_____________
STEP SATISFIED UNSATISFIED COMMENT
43
ASSESSMENT
1. Assess the patient to ensure that
his or her cognitive function is
intact to determine the appropriate
temperature taking method use.
2. Assess whether the patient can
close his or her lips around the
thermometer, if not, the select a
different method.
3. Assess the oral cavity for any
sores.
4. Ask the patient if he or she has
recently smoked, has been
chewing gum, or was eating or
drinking immediately before
assessing the temperature.
5. Review the patient’s platelet
level (if available) and the
diagnosis when rectal temperature
is being considered.
6. If the patient has an earache, do
not use the affected ear to take the
tympanic temperature.
7. Assess the patient for
significant ear drainage or scarred
tympanic membrane and the
patient’s ability to do the side
lying position when the ear route
is being considered.
PLANNING
equipment are needed.
9. Wash hands for infection
control.
10. Ensure that the correct
technique is followed.
11. Obtains the necessary
equipment to use.
IMPLEMENTATION
12. Check the physician’s order or
nursing care plan for the
frequency and route.
13. Identify the patient.
14. Explain the procedure to the
patient.
15. Ensure that the electronic or
digital thermometer is in operating
condition.
16. Perform hand hygiene or done
gloves if appropriate or indicated.
44
17. Select the appropriate site.
18. Take the temperature
accordingly.
( follow the steps outline below)
19. Perform hand hygiene. If
gloves are worn, discard them in
proper receptacle.
20. Record temperature on paper,
flow sheet, or computerized
record. Report significant findings
to the physician.
Assessing temperature with a
glass thermometer
21. If it is stored in a chemical
solution, wipe the thermometer
dry with a soft tissue, using a firm
twisting motion.
22. Wipe from the bulb towards
the fingers.
23. Grasp the thermometer firmly
with the thumb and the forefinger
and, using strong wrist
movements, shake it until the
chemical line reaches at least 36C.
24. Read thermometer by holding
it horizontally at eye level, and
rotate it between your fingers until
you can see the chemical line.
25. For oral use, place the bulb of
the thermometer within the back
of the right or left pocket under
the patient’s tongue and tell the
patient to close the lips around the
thermometer.
26. For rectal use, place the
thermometer bulb in the rectum
about 1.5 inches in an adult or 1
inch in a child.
27. For axillary use, place the
thermometer bulb in the center of
the axilla with the patient’s arm
against the chest wall.
28. Leave the thermometer in
place according to the type of
method used: 2 – 3 minutes for
rectal temperature, 5 minutes for
oral temperature, and 10 minutes
for axillary temperature or
according to hospital protocol.
29. Remove the thermometer and
wipe it once from the fingers
45
down to the bulb, using a firm
twisting motion.
30. Dispose of the tissue in a
receptacle for contaminated items.
31. Read the thermometer to the
nearest tenth of a degree.
32. Wash the thermometer in
lukewarm soapy water. Rinse it in
tap water. Dry and place the
thermometer in its container.
ATTITUDE
1. Punctual
3. Shows interest and willingness
to learn
7. shows positive attitude towards
supervision
9. Well groomed
TOTAL
RATING SCALE:
S- Satisfied
U- Unsatisfied
C- Comments
REMARKS:
_______________________________
____________________________
Signature of Clinical Instructor over
Signature of Student Nurse over
printed name
printed name
46
COLLEGE OF NURSING
Dumaguete City
PULSE RATE TAKING
PURPOSE:
1. To obtain baseline measure of the client’s heart rate and rhythm.
2. To measure changes in the client’s cardiovascular status.
47
3. To monitor the heart’s responses to a disease, procedure, or therapy such as use of
digoxin in clients with heart failure.
4. To assess blood flow to a specific body part.
ASSESSMENT:
Assess the site where you want to take the pulse taking into consideration the age of the client.
For an adult client, the most common site is the radial or the apical pulse. For a child older than 5
years old, the radial pulse may be palpated. In younger children the brachial pulse may be
palpated, or the apical pulse may be auscultated.
NURSING DIAGNOSIS:
Determine the related actors for the nursing diagnoses based on the patient’s current status.
1. Decreased cardiac output
2. Ineffective tissue perfusion
3. Deficit fluid volume
4. Acute pain
OUTCOME IDENTIFICATION AND PLANNING:

 The client’s pulse is palpated or auscultated
 Client experiences no trauma, during and after the procedure.
Note:Other outcomes may be appropriate depending on the patient’s nursing diagnosis.
EQUIPMENT:
Hand washing materials
Stethoscope
Cotton balls
Soap/ antiseptic solution/ alcohol
Doppler ultrasound
Pencil/pen
Paper/ Vital signs sheet
IMPLEMENTATION:
For All Sites and Methods
ACTION RATIONALE
1. Check the physician’s order or nursing This provides safety to the patient.
care plan for the frequency and route.

to the correct client.
3. Explain the procedure to the patient. Reduces anxiety and promotes cooperation by
the client.
4. Gather the equipment’s needed. Having all the equipment on hand provides
for organized approach to the task.
48
5. Perform hand hygiene or done gloves Hand washing and wearing of protective
if appropriate or indicated. materials prevents the spread of
microorganisms.
6. Select the appropriate site. Different arteries may be used to assess the
pulse; apical pulse is rapid, irregular or
nonpalpable.
7. Take the temperature accordingly.

(Follow the steps outlined below)
8. Perform hand hygiene. If gloves are Proper hand hygiene prevents the spread of
worn, discard them in the proper microorganisms.
receptacle.
9. Record pulse rate and site on paper, Proper documentation and referral ensure
flow sheet or computerized record. appropriate management or care for the client.
Report any significant findings to the This will also serve as an evaluation for an
physician. intervention that was provided beforehand.
Palpating the Radial Pulse

ACTION RATIONALE
1. The patient may either be supine with This position is comfortable for the patient
the arm along side the body, wrist and convenient for the nurse.
extended, and the palms of the hand
lateral or facing down or sitting with
the forearm at a 90-degree angle to the
body resting on a support with the
wrist extended and the palm
downward or facing laterally.
2. Place your first, second and middle The area on your fingertips are very sensitive
fingers along the patient’s radial that it can feel the pulsations of the arteries.
artery, and press gently against the
radius. Rest your thumb on the back of
the patient’s wrist.
3. Apply only enough pressure so that Moderate pressure facilitates palpitation of

the artery can be felt distinctly. the pulsations. Too much pressures obliterates
the pulse while with too little pressure, the
pulse is imperceptible.
4. Using a watch with a second hand, For clients with erratic or irregular pulse rate,
count the number of pulsations felt for you should count the pulse for 1 full minute
30 seconds. Multiply this number by 2 to get the accurate pulse rate.
49
to calculate the rate for 1 minute.
However, if the rate, rhythm or
amplitude of the pulse is abnormal in
any way, palpate and count the pulse
for 1 full minute.
Auscultating the Apical Pulse Rate

ACTION RATIONALE
1. Use alcohol swab to clean earpieces Using alcohol in cleaning the stethoscope
and diaphragm of the stethoscopes. ensures that the instrument is clean and ready
to be use by the nurse to the patient.
2. Assist patient in sitting on a chair or This position of the facilitates the

on the bed and exposed the chest area. identification of the site for the placement of
For female clients, provide a screen the stethoscope. Also, providing privacy is
and drape appropriately. essential especially to female clients.
3. Hold the stethoscopes diaphragm Warming the diaphragm promotes patient

against the palm of your hand for a comfort.
few seconds.
4. Palpate the fifth intercostal space and This is the point of maximum impulse where
move to the left midclavicular line. the heart sound is heard well.
Place the diaphragm over the apex of
the heart.
5. Listen for heart sounds (“lub-dub”).

These sounds occur as the heart valves closes.
Each “lub-dub” counts as one beat.
6. Using a watch with a second hand,
count the heartbeat for 1 minute. Counting for a full minute increases the
accuracy of the assessment.
Using a Doppler to Assess the Pulse Rate

ACTION RATIONALE
1. Remove Doppler from the charger and Doppler needs to be charged and ready for
turn it on. Make sure that the volume use all times. If the volume is turned up high,
is set at low. it might alarm the patient.
2. Apply Doppler gel to the site where For Doppler to pick-up the sound waves, a
you are auscultating the pulse. medium such as gel is needed.
3. Hold the Doppler in your non- Anatomic locations may vary slightly from
dominant hand. With your dominant person to person. The Doppler may need to be
hand, place the Doppler in the gel. moved to locate the appropriate site.
Adjust the volume as needed. Move
the Doppler tip around until the pulse
is heard.
50
4. Using a watch with a second hand, Measuring for a full minute increases the
count the heartbeat for 1 minute. accuracy of assessment.
5. Removing the Doppler tip and turn the If the Doppler is left on, the battery will wear
Doppler off. Wipe the gel off the down. Removing the gel ensures the patient’s
patient’s extremity with tissues. comfort.
6. Return the Doppler to the charge base. The Doppler needs to be recharged for the use
of the next client.
EVALUATION:
The expected outcome is met when the patient’s pulse is palpated or auscultated, and the
patient experiences no trauma.
UNEXPECTED OUTCOMES:
 The pulse is irregular. Monitor the pulse for 1 full minute. If this is a change of the
patient, notify the physician immediately.
 The pulse is palpated easily but then disappears. Apply only moderate pressure to the
pulse. Applying too much pressure may obliterate the pulse.
 You cannot palpate a pulse. Use a Doppler ultrasound to assess the pulse. If this is a
ultrasound, notify the physician. If you cannot find the pulse using Doppler place a small
X over the sport where the pulse is located. This can make palpating the pulse easier
since the exact location of the pulse is unknown.
INFANT AND CHILD CONSIDERATION:

The apical pulse is the most reliable for infants and small children.
HOME CARE CONSIDERATION:

 Teach the patient and family members how to take the patient’s pulse.
 Inform the patient and family about the digital pulse monitoring devices.
 Teach family members how to locate and monitor peripheral pulse site.
SPECIAL CINSIDERATION:
 The normal heart rate varies with age.
 When palpating a carotid pulse, lightly press only one side of the neck at a time.Never
attempt to palpate both the carotid arteries at the same time.
REFERENCES:
Evan-Smith, P. (2013). Fundamentals of Nursing. 8th ed. Philadelphia: Lippincott Williams

& Wilkins.
51
Timby, Barba (2009) Fundamental Skills and Concepts in Patient Care, 9 th ed.
Philadelphia: Lippincott.
COLLEGE OF NURSING
Damaguete City
PULSE RATE TAKING
Perform Checklist
Student’s Name: ________________________________________ Level: ______ Date:
_______
STEP SATISFIED UNSATISFIE COMMENTS
52
D
ASSESSMENT
1. Assess the site where you want to
take the pulse taking into
consideration the age of the client.
PLANNING
2. Determine what supplies and
4. Obtain the needed equipment.
IMPLEMENTATION
For Foot Care
nursing care plan for the frequency
and route.
7. Explain the procedure to the patient.
8. Gather the equipment’s needed.
9. Perform hand hygiene or don
10. Select the appropriate site and count
the pulsations.
11. Perform hand hygiene. If gloves are
worn, discard them in the proper
receptacle.
12. Record pulse rate and site on paper,
flow sheet or computerized record.
Report any significant to the
physician.
ATTITUDE:
1. Punctual
learn
supervision
8. Systemic and conserver steps
9. Well groomed
TOTAL
RATING SCALE:
S- Satisfied
U- Unsatisfied
C- Comments
53
REMARKS:
_______________________________
____________________________
Signature of Clinical Instructor over
Signature of Student Nurse over
printed name
printed name
54
COLLEGE OF NURSING
Dumaguete City
ASSESSING RESPIRATION
PURPOSES
1. To obtain baseline data on respiratory rate and characteristics

2. To monitor effects of pathologic conditions on the client’s respiration.
3. To monitor the client’s response to specific intervention that affects respiration
such as oxygen therapy.
ASSESSMENT
Assess the client for signs of respiratory distress:
 Retractions
 Nasal flaring
 Grunting
 Orthopnea
 Tachypnea
NURSING DIAGNOSIS
Determine the related factors for the nursing diagnosis based on the patient’s current status.
1. Ineffective breathing pattern

2. Impaired gas exchange
3. Risk for activity intolerance
OUTCOME INDENTIFICATION AND PLANNING
 The client’s respiratory rate is counted successfully.

 The client’s respiratory rhythm and depth are observed accurately
 The clients experiences no trauma during and after the procedure.
Note: Other outcomes maybe appropriate depending on the patient nursing diagnosis.
EQUIPMENT
55
Pencil/pen
Paper/vital signs sheet
IMPLEMENTATION
ACTION RATIONALE
1. While your fingers are still in place after The client might alter the rate of respiration if
counting the pulse rate, observe the patient’s he or she is aware that they are being counted.
respiration.
A complete cycle of an inspiration and

2. Note the rise and fall of the client’s chest. expiration composes one respiration.
Sufficient time is necessary to observe the

3. Using a watch with a second hand, count rate, depth, and other characteristics.
the number of respiration for at least 30
seconds. Multiply this number by 2 to get the
respiratory rate per minute. To make sure that the rate of respiration
4. If respirations are irregular, count the assessed is accurate and this will also give an
respiration in 1 full minute. ample time to detect unequal timing between
reparations.
Hand washing and wearing of protective

5. Perform hand hygiene and remove other materials prevents the spread of
protective materials worn during the microorganisms.
procedure.
Proper documentation and referral ensures
6. Document respiratory rate on paper, flow appropriate management or care for client.
sheet or computerized record. Report any This will also serves as an evaluation for an
significant findings to the physician. intervention that was provided beforehand.
EVALUATION
The expected outcome is met when the client’s respirations are assessed without the
patient altering the rate, rhythm, and depth.
UNEXPECTED OUTCOMES AND ASSOCIATED INTERVENTION

 The client is breathing shallow respirations that you cannot count the rate. Sometimes it
is easier to count respirations by auscultating the lung sounds. Notify the physician of the
respiratory rate and the characteristics of the respirations.
INFANT CONSIDERATION
 Infants, count the respiration 1 full minute due to a normally irregular rhythm.
56
REFERENCES:
Evan-Smith, P. (2013). Fundamentals of Nursing. 8th ed. Philadelphia: Lippincott Williams and
Wilkins.
Potter, P.A. and Perry, A.G. (2013). Fundamental of Nursing. 8th ed. Missouri: Mosby, Inc.
Smith, Pamela (2011). Taylor’s Clinical Nursing Skills: A Nursing Process Approach
Philadelphia: Lippincott Williams and Wilkins.
Timby, Barbara (2009) Fundamental Skills and Concepts in Patient Care, 9th ed.
Philadelphia: Lippincott
COLLEGE OF NURSING
57
Dumaguete City
ASSESSING RESPIRATION
Name:____________________________________ Level: ____________ Date:

_____________
STEP SATIFIED UNSATISFIED COMMENT

ASSESSMENT
1. Assess the client for signs of
respiratory distress:
 Retractions
 Nasal flaring
 Grunting
 Orthopnea
 Tachypnea
PLANNING
control.
4. Ensure that the correct
technique is followed.
5. Obtains the necessary
equipment to use.
IMPLEMENTATION
6. While your fingers are still
in place after counting the
pulse rate, observe the
patient’s respiration.
7. Note the rise and fall of the
client’s chest.
8. Using a watch with a second
hand, count the number of
respiration for at least 30
seconds. Multiply this number
by 2 to get the respiratory rate
per minute.
9. If respirations are irregular,
count the respiration in 1 full
minute.
10. Perform hand hygiene and
remove other protective
materials worn during the
procedure.
11. Document respiratory rate
on paper, flow sheet or
computerized record. Report
58
any significant findings to the
physician.
ATTITUDE:
1. Punctual
3. Shows interest and
willingness to learn
6. Possess sense of
initiative
towards supervision
8. Systemic and conserver
steps
9. Well groomed
10. Applies body mechanics
when performing procedure.
TOTAL
RATING SCALE:
S- Satisfied
U- Unsatisfied
C- Comments
REMARKS:
COLLEGE OF NURSING
59
Dumaguete City
ASSESSING BLOOD PRESSURE
PURPOSE:
1. To obtain baseline blood pressure measurement.
2. To assess the client’s cardiovascular status.
3. To assess the client’s response to blood or fluid volume loss after surgery, childbirth,
trauma or burns.
4. To evaluate the client’s response to changes in his condition after treatment with fluids
medications and other interventions affecting the blood pressure.
ASSESSEMENT:
 Check if the client has an intravenous infusion.
 Assess as to which side of the client has had a breast or axilla surgery.
 Assess if the client has a cast, arteriovenous shunt, or an injured or diseased limb.
NURSING DIAGNOSIS:
1. Decreased cardiac output
2. Ineffective health maintenance
3. Ineffective therapeutic regimen management
4. Risk for falls
OUTCOME IDENTIFICATION AND PLANNING:

 The client’s blood pressure is measured accurately
Note: other outcomes may be appropriate depending on the patient’s nursing diagnosis.
EQUIPMENT;
Stethoscope
Sphygmomanometer
Blood pressure cuff of appropriate size
Pencil/pen
Paper/Vital signs sheet
Alcohol swab
Blood pressure machine (if using electronic)
Doppler (if needed) and Gel (for Doppler)
IMPLEMENTATION:
Taking the blood pressure using a blood pressure cuff and a stethoscope
ACTION RATIONALE
60
1. Check the physician’s order or nursing This action provides safety and adequacy of
care plan for the frequency. patient care.

3. Explain the procedure to the patient. Explanation reduces apprehension and

encourage cooperation.
4. Gather the equipment’s needed. Having all the equipment on hand provides
for organized approach to the task.
5. Perform hand hygiene or don gloves if Hand washing and wearing of protective
appropriate or indicated. materials prevents the spread of
microorganisms.
6. Delay obtaining the blood pressure if This could provide an inaccurate result since
the patient is emotionally upset, is in emotions, pain and exercising increase the
pain, or has just exercised (unless blood pressure.
maybe if the measurements is urgent).
7. Select the appropriate arm for Make sure that the arm selected has no
application of cuff. intravenous infusion, has not had any breast
or axilla surgery, cast arteriovenous shunt, or
injury because putting pressure on the side is
contraindicated when these conditions are
present.
8. Have the client assume a comfortable This position helps the client to relax leading
lying or sitting position with the to a more accurate result. Having the palm
forearm supported at the level of the facing upward allows for a more accessible
palm of the hand upward. brachial artery.
9. Expose the brachial artery by This would allow for maximum exposure of
removing garments, or move a sleeve, the brachial artery so that it will be heard
if it is not too tight above the area better with the stethoscope.
where the cuff will be placed.
10. Wrap the cuff around the arm Wrapping the cuff snugly on the arm will give
smoothly and snugly and fasten it you a more accurate reading of the blood
securely or tuck the end of the cuff pressure.
well under the preceding wrapping.
Do not allow any clothing to interfere
with the proper placement of the cuff.
11. Check that the needle on the aneroid If the needle is not at the zoo level, the blood
gauge is within the zero mark. If using pressure may not be accurate. Tilting the
a mercury manometer, check to see mercury manometer, inaccurate calibration, or
that the thermometer is in the vertical improper height for reading the gauge can
position and that the mercury is within lead to errors in determining the blood
the zero level with the gauge at eye pressure measurements.
61
level.
12. Palpate the pulse at the brachial or Palpation allows for measurement of the
radial artery by pressing gently with approximate systolic reading.
the fingertips.
13. Tighten the screw valve on the air The bladder within the cuff will not inflate
pump. with the valve open.
14. Inflate the cuff while continuing to The point where the pulse disappears provides
palpate the artery. Note the point on an estimate of the systolic pressure. To
the gauge where the pulse disappears. identify the first Korotkoff sound accurately,
the cuff must be inflated to a pressure above
the pint at which the pulse can no longer be
felt.
15. Deflate the cuff and wait for 15 Allowing a brief pause before continuing
seconds. permits the blood to refill and circulate
through the arm.
16. Assume a position that is more than 3 A distance of more that 3 feet can interfere
feet away from the gauge. with the accurate readings of the numbers in
the gauge.
17. Place the stethoscope earpieces in Proper placement blocks extraneous noise and
your ears. Direct the earpieces into the allows sound travel more clearly.
ear canal and not against the ear itself.
18. Place the bell or diaphragm of the Having the bell or diaphragm directly over the
stethoscope firmly but with as little artery allows more accurate readings. Heavy
pressure as possible over the brachial pressure on the brachial artery distorts the
artery. Do not allow the stethoscope to shape of the artery and the sound. Placing the
touch clothing or the cuff. bell of the diaphragm away from clothing and
the cuff prevents noise which would distract
you form the sounds made by blood flowing
through the artery.
19. Pump the pressure 30 mmHg above Increasing the pressure above the point where
the point at which the systolic pressure the pulse disappeared ensures a period before
was palpated and estimated. Open the hearing the first sound that corresponds with
valve on the manometer and allow the the systolic pressure. It prevents
air to escape slowly (allowing the misinterpretation of sounds.
gauge to drop 2 to 3 mm per
heartbeat).
20. Note the point on the gauge at which Systolic pressure is the point at which the
the faint, but clear, sound appears that blood in the artery is first able to force its way
slowly increases in intensity. Note this through the vessel at a similar pressure
number as the systolic pressure. exerted by the bladder in the cuff. The first
sound is phase I or Korotkoff sounds.
62
21. Read the pressure to the closest even It is common practice to read blood pressure
number. in the closest even number.
22. Do not re-inflate the cuff once the air Re-inflating the cuff while obtaining the
is being released to recheck the blood pressure is uncomfortable for the
systolic pressure reading. patient and may cause congestion of blood in
the lower arm which will then lessen the
loudness of the Korotkoff sounds.
23. Note the pressure at which the sound The point at which the sound changes
first becomes muffled. Also observe corresponds to phase IV Korotkoff sounds
the point at which the sound and is considered as the first diastolic pressure
completely disappears. These may reading. According to the American Heart
occur separately or at the same point. Association, this is used as the diastolic
pressure recording in children. The last sound
heard is the beginning of phase V and is the
second diastolic measurements.
24. Allow the remaining air to escape False reading is likely to occur if there is
quickly. Repeat any suspicious congestion of blood in the limb while
reading but wait 30 to 60 seconds obtaining repeated readings.
between readings to allow normal
circulation to return in the limb.
Deflate the cuff completely between
attempts to check the blood pressure.
25. Remove the cuff, and clean and store Equipment should be left ready for the next
the equipment. user.
26. Perform hand hygiene. If gloves were Proper hand hygiene prevents the spread of
worn, discard them in the proper microorganisms.
receptacle.
27. Record the findings on paper, flow Proper documentation and referral ensure
sheet or computerized record. Report appropriate management or care for the client.
any significant findings to the This will also serve as an evaluation for an
physician. Identify the arm used and intervention that was provided beforehand.
the sites of assessment if other than
brachial.
EVALUATION:
The expected outcome is met when the blood pressure is measured accurately, and the
client experiences no trauma during and after the procedure.
INFANT AND CHILD CONSIDERATIONS:

 In infants and small children, the lower extremities are commonly used for blood pressure
monitoring. The more common sites are popliteal, dorsalis pedis and posterior tibial
blood pressures obtained in the lower extremities are generally higher than if taken in the
upper extremities.
63
 In newborns, take blood pressure in all four extremities and documents. Large differences
among blood pressure readings can indicate heart defects.
HOEME CARE CONSIDERATIONS:

 Use a cuff size appropriate for limb circumstance. Inform the patient that cuff sizes range
from a pediatric cuff to large thigh cuff that a poorly fitting cuff may result in an
inaccurate measurement.
 Inform the patient about digital blood pressure monitoring equipment. Though costly,
most provide an easy-to-read recording of systolic and diastolic measurements.
REFERENCES:
Wilkins.
Timby, Barba (2009) Fundamental Skills and Concepts in Patient Care, 9 th ed. Philadelphia:
Lippincott.
64
COLLEGE OF NURSING
Dumaguete City
ASSESSING BLOOD PRESSURE
Perform Checklist
Student’s Name: ________________________________________ Level: ______ Date:
_______

D
ASSESSMENT
1. Check if the client has an
intravenous infusion.
2. Assess as to which side of the client
has had a breast or axilla surgery.
3. Assess if the client has a cast,
arteriovenous shunt, or an injured or
diseased limb.
PLANNING
equipment’s are needed.
6. Ensure that the correct technique is
followed.
7. Obtain the necessary equipment to
use.
IMPLEMENTATION
nursing care plan for the frequency.
10. Explain the procedure to the patient.
11. Gather the equipment’s needed.
12. Perform hand hygiene or don
13. Delay obtaining the blood pressure
if the patient is emotionally upset, is
in pain or has just exercised (unless
maybe if the measurement is
urgent).
14. Select the appropriate arm for
application of cuff.
15. Have the client assume a
comfortable lying or sitting position
with the forearm supported at the
level of the heart and the palm of
the hand upward.
16. Expose the brachial artery by
65
removing garments, or move a
sleeve, if it is not too tight, above
the area where the cuff will be
placed.
17. Wrap the cuff around the arm
smoothly and snugly and fasten it
securely or tuck the end of the cuff
well under the preceding wrapping.
Do not allow any clothing to
interfere with the proper placement
of the cuff.
18. Palpate the pulse at the brachial or
radial artery by pressing gently with
the fingertips.
19. Tighten the screw valve on the air
pump.
20. Inflate the cuff while continuing to
palpate the artery. Note the point on
the gauge where the pulse
disappears.
21. Deflate the cuff and wait for 15
seconds.
22. Assume a position that is more than
3 feet away from the gauge.
23. Place the stethoscope earpieces in
your ears. Direct the earpieces into
the ear canal and not against the ear
itself.
24. Place the bell or diaphragm of the
stethoscope firmly but will a little
pressure as possible over the
brachial artery. Do not allow the
stethoscope to touch clothing or the
cuff.
25. Pump the pressure the pressure 30
mmHg above the point at which the
systolic pressure was palpated and
estimated. Open the valve on the
manometer and allow the air to
escape slowly (allowing the gauge
to drop 2 to 3 mm per heartbeat).
26. Note the point on the gauge at
which the first faint, nut clear,
sound appears that slowly increases
in intensity. Note this number as the
systolic pressure.
27. Read the pressure to the closest
even.
28. Do not re-inflate the cuff once the
air is being released to recheck the
systolic pressure reading.
66
29. Note the pressure at which the
sound first becomes muffled. Also
observe the point at which the
sound completely disappears. These
may occur separately or at the same
point.
30. Allow the remaining air to escape
quickly. Repeat any suspicious
reading but wait 30 to 60 seconds
between readings to allow normal
circulation to return in the limb.
Deflate the cuff completely between
attempts to check the blood
pressure.
31. Remove the cuff and clean and
store the equipment.
32. Perform hand hygiene. If gloves
were worn discard them in the
proper receptacle.
33. Record the findings on paper, flow
sheet or computerized record.
Report any significant findings to
the physician. Identify the arm used
and the site of assessment if other
than brachial.
ATTITUDE:
1. Punctual
learn
supervision
8. Systemic and conserver steps
9. Well groomed
TOTAL
RATING SCALE:
S- Satisfied
U- Unsatisfied
C- Comments
REMARKS:
67
COLLEGE OF NURSING
Dumaguete City
BACK RUB
A general body conditioner which acts to relieve muscle tension and promote relaxation.
PURPOSES
 To improve circulation
 To decrease anxiety
 To improve sleep quality and relieve insomnia
 To help alleviate pain perception and symptom distress
 To provide an opportunity for the nurse to observe the skin for signs of breakdown
 To provide a means of communication with the patient through the use of touch
ASSESSMENT
1. Review the patient’s medical record and plan of care for information about the patient’s
status and contraindications to back massage.
2. Assess behaviors indicating potential need for back massage, such as a complaint of
stiffness, muscle tension in the back and shoulders, or difficulty sleeping related to
tenseness or anxiety.
3. Identify patients with impaired physical mobility who may benefit from back massage.
4. Assess whether is willing to have a massage.
5. Inquire about any allergies to lotions or scents.
6. Assess patient’s level of pain and check the medication and treatment record for the time
an analgesic was last administered.
7. Determine any limitations to poisoning.
NURSING DIAGNOSIS
Determine the related factors for the nursing diagnoses based on the patient’s current
status.
1. Acute pain 6. Ineffective coping

2. Chronic pain 7. Activity intolerance
3. Sleep pattern disturbances 8. Knowledge deficit
4. Risk for impaired skin integrity 9. Ineffective tissue perfusion
5. Anxiety 10. Self-care deficit
Expected outcomes:
68
1. Patient states pain is relieved
2. Patient displays decreased anxiety and improved relaxation
3. Absence of skin breakdown
4. Patient verbalizes understanding for reasons of back rub.
PLANNING
1. Ensure that you have the full amount of time available for the massage. The back rub
should be conducted in a calm and unhurried manner.
2. Determine what supplies and equipment are needed.
3. Washed your hands for infection control.
EQUIPMENT:
Lotion
Powder, if not contraindicated
Bath blanket
Towel
IMPLEMENTATION
STEP RATIONALE
1. Determine:
a. Previous assessments of the
skin.
b. Special lotions to be used.
c. Positions contraindicated for the
patients
2. Arrange for a quiet environment with To promote maximum effects for back
no interruptions. massage.
3. Prepare equipment and arrange at Organization facilitates performance of tasks.

bedside.
4. Explain to the patients what you are Allays fear and anxiety thereby promoting
going to do, why is it necessary, and patient cooperation and participation.
how he/she can cooperate. Encourage
the patient to give you feedback as to
the amount of pressure you are using
during the back rub.
5. Perform hand hygiene and observe Hand hygiene deters the spread of
other appropriate infection control microorganisms.
procedures.
69
6. Provide for patient privacy by closing Closing the door or curtain ensure privacy and
the door and curtain promote relaxation.
7. Raise the bed at the comfortable This avoids undue reaching and straining and
working height. Lock up side rail on promotes good body mechanics.
opposite side of bed from your work.
Lower the side rail on the side close to
you. Assist the patient to move near
you.
8. Assist patient to the prone or side- lying This position exposes an adequate area for the
position with the back exposed form massage Draping the patient provides privacy
the shoulders to the sacral area. Use and warmth.
bath blanket to cover remainder of the
body.
9. Warm the lotion in the palm of your Warn hands and lotion prevents startle
hand, or place the container in warm response and muscle tension from cold lotion
water. and hands.
10. Pour a small amount of lotion onto the Lubricating palms decreases friction on skin
palms of your hands and hold it for a during massage.
minute. Rub your palms together, to get
the lotion on both hands and warm it
slightly.
11. With your feet apart (the outside one

ahead of the inside one so that you can
rock back and forth while maintaining
and body mechanics), place your hands
at the sacral area, one on other side of
the spinal column.
12. Begin massage in sacral area with Continuous contact in soothing and stimulates
circular motion. Move hands upward to circulation and muscle relaxation.
shoulders, massaging over scapulae in
smooth, firm strokes. Without
removing hands from skin, continue in
smooth strokes to upper arms and
downsides of back and iliac crest.
Continue for 3 to 5 minutes. NOTE:
Use light gliding strokes (effleurage).
13. Massage the patient’s shoulder, entire

back areas over iliac crest, and sacrum A firm stroke with continuous contact
with circular stroking motions. promotes relaxation.
Continue for several minutes, applying
additional lotion as necessary.
14. While massaging, assess for broken Pressure from any massage can traumatize and
skin areas and whitish or reddened damage tissues.
70
areas that do not disappear. Avoid
pressure over areas of breakdown or
redness.
15. Knead patient’s skin by gently For additional stimulations.

alternating grasping and compression
(petrissage) ; or hacking movement
(tapotement) of the back.
16. Continue massage and move down one

side of the trunk with both hands until
you are again at the sacral area. Then,
placing your hands side by side with
palms down, rub in a figure 8 pattern
over buttocks and sacral area. Move the
figure 8 back and forth to include the
entire buttocks area, which in subjected
to ongoing pressure in the bedridden
patient.
17. Complete the massage with additional Long stroking motions are soothing and
long stroking movements that will promote relaxation; continued stroking with
eventually become lighter in pressure. gradual lightening of pressure helps extend the
feeling of relaxation.
18. Use towel to pat the patient dry and to Drying provides comfort and reduces the
remove excess lotion. Apply powder if feeling of moisture on the back.
the patient requests it.
19. Retie patient’s gown, straighten the Massage promotes patient comfort.
beddings and assists to comfortable
position.
20. Perform hand hygiene. It deters the spread of microorganisms.
21. Document the a back rub was A careful record is important for planning and
performed and the patient’s response. individualizing the patient’s care.
Record any unusual findings.
EVALUATION
The expected outcome is achieved when the patient reports a decrease in pain or control of pain;
patient verbalizes increased comfort and decreased anxiety. The patient exhibit pink, dry, intact
skin and verbalizes an understanding of the reasons for the benefits of back rub.
REFERENCES:
71
Crayon, Ruth & Constance Himle (2003). Fundamentals of Nursing: Human Health and
Function, 4th ed. Philadelphia. Lippincott Williams & Wilkins.
Evans – Smith, Pamela (2005) Taylor’s Clinical Nursing skills: A Nursing Process Approach.
Philadelphia. Lippincott Williams & Wilkins.
Potter, Patricia & Anne Perry (2005) ). Fundamentals of Nursing, 6th ed. St. Louis: Mosby, In
72
COLLEGE OF NURSING
Dumaguete City
BACK RUB
NAME: LEVEL:
DATE:

1. Assess:
a. Behaviors indicating potential need for
back rub.
b. If patient is willing to have a massage.
c. Contraindications for back massage.
2. Determine:
a. Previous assessments of the skin.
b. Special lotions to be used.
c. Positions contraindicated for the patients
3. Arrange for a quiet environment with no
interruptions.
4. Prepare equipment and arrange at bedside.
5. Explain to the patients what you are going to do,
why is it necessary, and how he/she can
cooperate.
6. Perform hand hygiene and observe other
appropriate infection control procedures.
7. Provide for patient privacy
8. Raise the bed at the comfortable working height.
Lock up side rail on opposite side of bed from
your work. Lower the side rail on the side close to
you
9. Assist the patient to move near you.
10. Assist patient to the prone or side- lying position
with the back exposed form the shoulders to the
sacral area. Use bath blanket to cover remainder
of the body.
11. Warm the lotion in the palm of your hand, or
place the container in warm water.
12. Pour a small amount of lotion onto the palms of
your hands and hold it for a minute. Rub your
73
palms together
13. With your feet apart the outside one ahead of the
inside place your hands at the sacral area, one on
other side of the spinal column.
14. Begin massage in sacral area with circular motion
Use light gliding strokes (effleurage).
15. Move your hands up to the center of the back and
then over the right and left iliac crest.
16. Massage in sacral area with circular motion. over
scapulae.
17. Move your hands down the side of the back.
18. Massage the areas over the right and left iliac
crest.
19. Apply firm, continuous pressure without breaking
contact with the patients skin.
20. Continue massaging the patient’s shoulder, entire
back, areas over iliac crest, and sacrum with
circular stroking motion for several minute
obtaining more lotion as necessary.
21. While massaging the back, assess for broken skin
areas, whitish or reddened areas that do not
disappear, of areas of decreased circulation.
Avoid pressure over areas of breakdown or
redness.
22. Knead patient’s skin by gently alternating
grasping and compression (petrissage) ; or
hacking movement (tapotement) of the back.
23. Continue massage and move down one side of the
trunk with both hands until you are again at the
sacral area. Then, placing your hands side by side
with palms down, rub in a figure 8 pattern over
buttocks and sacral area. Move the figure 8 back
and forth to include the entire buttocks area
24. Complete the massage with additional long
stroking movements that will eventually become
lighter in pressure.
25. Pat the patient dry and to remove excess lotion.
Apply powder if the patient requests it.
26. Retie patient’s gown, straighten the beddings and
assists to comfortable position.
28. Document the a back rub was performed and the
patient’s response. Record any unusual findings.
ATTITUDE:
1. Punctual
2. Honest and sincere.
3. Shows interest and willingness to learn.
74
7. Shows positive attitude towards supervision.
8. Systematic and conserve steps.
9. Well groomed
10. Applies body mechanics when performing
procedure
Total
Rating Scale:
0 – Not done, but essentially required

1 – Incorrectly done; wrong techniques and findings
1.5 – correct measures, but with adequate description of findings or not systematic in
performances
2 – correctly done; systematic according to standard; with correct findings
N/A – not applicabe
REMARKS
75
COLLEGE OF NURSING
Dumaguete City
VENTUSA
DEFINITION
Ventusa is a method of treating disease promoting health, and preventing illness through
the use of glass jar or cup.It is known as “Pa-hou-kuan” in Chinese and is often times translated
as “CUPPING” in English. In ventusa, heat is introduce inside the jar in order to create a vacuum
to suction particular parts of the body.
HISTORY
The earliest known record on ventusa could be found in china as early as the third or
fourth century B.C. It was then known as the “horn method” because of the use of animal horns.
As the technology advanced, the people began using cups made of bamboo, clay and glass.
Ventusa is a part of our indigenous medicine. It was been widely practice in the
Philippines, for it has proven to be effective. Yet, until now, no thorough research has been
conducted to evaluate the merits of healing procedure.
Today, the most commonly used ventusa jar is the glass cup. It is preferred because it is
transparent and lets the practitioner see the skin reaction of the client being treated. The ordinary
household glass could be used, as long as its rim is smooth, well rounded and does not have any
cracks which could damage the client’s skin.
PURPOSE
1. To restore and maintain the free flow of Qi.

2. To relieve pain due to the impairment in the free flow of Qi and blood.
Selecting the Size of Cup
The size of cup should be selected according to the patient’s body built and area to be
treated. Large cups are generally preferred for muscular and fleshly areas such as the back and
the thigh. These can be used for students who are in good physical condition. For old and weak
persons, for those who are asthenic, small cups are preferred. It is also indicated for less fleshy
areas of the body such the abdomen.
Choosing the Ventusa Site
76
Usually, ventusa is done on particular acupuncture points. For example, L1-15 could be
selected to treat shoulder or arm pain and CV-12 to ease abdominal pain and distention. For
cases involving excess (as in stagnant Qi) or deficient conditions, local sites or Ashi points could
be chosen.
For deficient conditions, which ma manifest as numbness, local sites could be applied
with ventusa. In this cases, the practitioner could use a single cup applied at a particular site. This
will leave a reddish make on the skin and will help promote the circulation of the Qi or blood in
that particular area.
How Does it Work
Ventusa helps to restore and maintain the free flow of Qi. It has a mild warming effect
and, hence, could be used for cases arises from an attack of cold in the exterior or interior. In
general, ventusa is used to treat pain due to the impairment to the free flow of Qi and blood.
Common Illness where Ventusa in Indicated
 Arthritis
 Paralysis
 Myalgia
 Joint pain
 Gas pain
 Muscle cramps
 Cysts
 Tumors
 Snake bites
 Abdominal distention
 Diarrhea due to dump-cold
 Abscesses (Vesiculated type)
 Other fixed masses
 External attack of wind-cold
 Retention of food in the stomach and spleen
Contraindications
In general, ventusa should not be applied to clients who are:
 Unconscious
 Convulsing or having a history of convulsions
 High febrile
 Suffering from bleeding disorders
 Pregnant
Areas To Be Avoided
 Areas overlying bony structures

 Lymph nodes
77
 Primary blood vessels
 Skin diseases
 Wounds
 Ulcers
 Hairy areas
Recommended sites
This is done to specific acupuncture sites, such as:
 L1-15: To treat shoulder or arm pain

 CV-12: To ease abdominal pain and distention
EQUIPMENT (assemble at bed side and arrange according to use)
PH bag and its contents
A thin slice of ginger
Match or lighter
Glass jar with dull, smooth and even rim
Mineral oil
Wash clothed or a piece of clean cloth (client’s own)
ASSESSMENT
1. Assess the patient to be able to know if there are contraindications to the

procedure.
2. Check the condition of the body part where you are to perform ventusa to be able
to know if there are contraindications to the procedure (e.g. hairy areas)
3. Inspect the rim of the glass to ensure safety.
PLANNING

2. Instruct client to void a few minutes before the procedureto ensure comfort and avoid
delays in the performance of the procedure.
3. Gather all the equipment needed (get this from the client)
A glass jar or cup
A piece of cloth or wash cloth
IMPLEMENATTION
78
ACTION RATIONALE
1. Lay down PH bag on a table lined with Minimize transfer of microorganisms.
paper.
2. identify the client. explain the treatment, its To reduce anxiety, ensure cooperation, and
purpose, and what to expect during the compliment the client’s self esteem. Giving an
progress. Mention the equipment (glass jar, overview of the procedure ensures favorable
wash cloth) which the client has to produce. client’s confidence and give time to clarify
doubts.
3. Ask the client to void. Attain comfort
4. Perform the bag technique. Put on n the Organization facilitates performance of the
apron. Bring out the following from the PH task. If the materials are prepared by the client
bag and set-up: then just put out your hand washing materials
 Box of matchsticks which you need after the procedure to remove
 A slice of ginger the oil from your hands.
 Bottle of baby/ mineral oil
 A piece of cotton
 Two waste receptacles
 Paper squares and lining
 Plastic bag
Gives a pleasant feeling to the client knowing
5. Borrow from the client the following
that the needed materials are readily available
materials:
in their home without added cost.
 A glass jar/cup with smooth and intact
rim
 a piece of cloth /wash cloth/ towel
Body part to be treated should be relaxed and
6. instruct the client to position himself in bed. well rested.
Provide privacy.
7. Bring all the necessary equipments to the Easy access thereby saving time and effort.
bedside.
8.Drape the client and expose only the part to Consider the client’s conservativeness
be treated.
This will serve as the wick to be lighted later.
9. Make a small cotton ball.
10. Apply a tiny film of baby oil or mineral oil To lubricate and easy maneuverability of the
over the area to be treated. glass.
11. Soak cotton ball with the baby oil. Wet enough but not dripping
12. lay the sliced ginger and put cotton ball Make sure that the cotton ball does not fall off
with oil over it. from the ginger.
13. light the cotton ball using the matchstick. Inform the client to minimize movement once
79
the cotton ball is lighted.
14. Wait for 3-5- seconds then put jar over the This will create a vacuum causing the skin to
ginger and cotton with flame. protrude.
Note: Do not wait for the flame to become big.

this will create a strong vacuum which is
painful to the skin to apply the glass, tilt it so
that part of the rim comes in contact with the
skin first then totally cover the ginger and the
cotton with flame.
15. Move glass in rotary motion inch by inch Ensure that the vacuum is maintained to
covering the intended area to be treated. attained consultant suction of the skin.
16. Ask the client if he or she feel any pain To lower the vacuum thus ensuring client’s
while moving the glass. (To lessen the vacuum, comfort.
Press the skin near the rim of the glass to
release some air.
17. Continue the process for five to ten minutes This procedure must go on until the skin
but assess client’s reaction to the procedure
such as pain or any other discomfort.
18. To end the procedure, press the skin at the

side of the glass with your finger to release the
vacuum inside.
19. With the skin with the client’s wash cloth.
20. Tell the client client to put on clothing and

not to wash himself in 30 minutes to one hour.
21. Do after care of the equipment and do hand

washing.
22. Ask the client to sit down and do some

health teaching.
23. Gather all handwashing materials and

return inside the PH bag observing the aseptic
technique.
24. Use the plastic bag to contain the bottle of

oil and matchbox.
25. Observe bag technique during after care of

equipment.
80
COLLEGE OF NURSING
Dumaguete City
PREPARATION OF HERBAL MEDICATIONS
A. SAMPAGUITA INFUSION
Indication: Sore Eyes (Conjunctivitis)

Materials:
● Sampaguita bud ( 1 handful )
● One glass of water
● Measuring glass
● Clay pot
● Cooking clay stove
Procedure:
1. Wash handful of sampaguita
2. Place in a glass
3. Boil one glass of water
4. Pour water inside the glass of Sampaguita
5. Cover the glass for 15 minutes
6. Stain in cloth strainer and let it cool
Label:
Name of Preparation: Sampaguita infusion

Indications: Sore Eyes (Conjunctivitis)
Directions: Apply to the affected eye like a washing agent
Date Prepared:
Date of Expiration:
81
B. GARLIC TINCTURE
Indications: Cleansing agent for infected wounds.

Materials:
● Garlic (5 tablespoons chopped finely)
● 1 glass of gin or tuba
● Colored container
Procedure:
1.Peel 1 garlic; chopped and measure 5 tablespoons then place in container.
2. Pour one glass of Gin or tuba. Shake 3-5 daily for 3 days.
3. After 3 days remove garlic from bottle. Place the tincture in colored container.
Warning: Not to be taken internally.
Label:
Name of Preparation: Garlic Tincture

Indication: Cleansing Agent for Infected Wounds
Directions: Apply to the Affected Site
Date Prepared:
Date of Expiration:
C. SLK SYRUP
Indication: Cough and colds; fever

Materials:
● Sampaloc leaves
● Ginger (Luy-a; 2 thumbs size)
● Kalamansi (3-5 pcs)
● Sugar ((brown) 1 glass
● Measuring glass
● Chopping board
● Long stick
● Cooking clay pot
● Colored bottle; sterilized
● Strainer (muslin cloth)
● Candle
● Water
● Wooden/bamboo ladle
82
Procedure:
1. Wash sampaloc leaves, separate leaves from stem. Measure the leaves in the glass up to
the neck. Place the leaves in the spot.
2. Wash ginger but DO NOT peel the skin. Cut into thin slices and place over the leaves.
Add 2 glasses of water, one glass at a time. Measure the level of water using the stick.
Place the pot over the fire. Cook until it becomes a decoction and only one glass of the
water remains. Do not cover the pot while cooking.
3. Strain. Press until all the liquid is extracted.
4. Measure the decoction and add sugar. For every glass of decoction, add one glass of
sugar ( 1:1 ratio )
5. Boil mixture until it is syrupy. Shortly before removing the syrup add the kalamansi
extract.
6. Place the SLK syrup into sterile, Colored bottle (s).
7. Dip the cover into the melted candle. Set is aside.
8. Label the bottle with:
Name of Preparation: SLK Syrup

Indications: Cough and colds; fever
Directions: ADULTS: 1 tablespoon 3-4 times a day
CHILDREN: 7-12 years- 1 teaspoon 3 times a day 2-6 years ½ teaspoon once a day
Date Prepared:
Date of Expiration:
Directions:
ADULTS: 1 tablespoon 3-4 times a day
CHILDREN: 7 12 years - 1 teaspoon 3 times a day
2-6 years- ½ teaspoon once a day
D. BANANA POWDER
Indications: Loose Bowel Movement

Materials:
● Green banana (latundan)
● Knife
● Plastic bag or wide open mouth container
● Nego or any circular tray
● Mortar and pestle
Procedure:
1. Peel the green banana
2. Slice into cubes
3. Pound it in a mortar until it turns into a powder form.
83
4. Keep the banana powder in a sealed bag or any wide mouth container.
5. Directions: Banana powder could be mixed in the porridge or soup.
● Two tablespoon of powder to 1 cup of soup; add 1 teaspoon of sugar
6. Label:
Name of preparation: BANANA POWDER

Indications: Loose Bowel Movement (kalibanga)
Directions: Banana Powder could be mixed in the porridge or soup
● Two tablespoons of powder to 1 cup of soup; add 1 tablespoon or
sugar
Date Prepared:
Date of Expiration:
E. BLS OIL
Indications: Arthritis, Neuralgia, Bruises Muscle pains

Materials:
● 1 glass or cup of garlic
● 1 glass or cup of siling labuyo
● 1 glass or cup of ginger
● Mortar and pestle
● Dark colored bottle
● Knife
● Cooking claypot
● Coconut or vegetable oil
Procedure:
1. Measure 1 cup of each: ginger, garlic, and sili (black pepper may do)
2. Chop ginger and garlic; mash the sili
3. Heat 3 cups of oil then placed chopped garlic, ginger, and pressed sili.
4. Heat in a low fire for 5-10 minutes
5. Strain and place in a container
6. Cool before using
Direction: Apply over affected areas 2-3 times a day

Warning: Not to be used/ taken internally
Label:
Name of preparation: BLS OIL
84
Indications: Arthritis, Neuralgia, Bruises, Muscle pains
Directions: Apply over affected areas 2-3 times a day
Date Prepared:
Date of Expiration:
F. SUNTING OINTMENT
Indications: Tinea flava, athlete’s foot, ringworm

Materials:
● Sunting leaves
● Chopping board
● Candle or pomade
● Vegetable/ coconut oil
● Measuring glass
● Flat, shallow,small containers
● Knife
● Clay pot
● Wooden/ bamboo ladle
● Cloth to strain
Procedure:
1. Wash leaves well. Cut into fine strips
2. Measure one glass of sliced sunting leaves. Place inside the pot. Measure one glass of oil.
Mix it with the leaves inside the pot (1:1 ratio). Boil for 5 minutes.
3. Strain in a net bag or cloth strainer. Scrape candle and melt. For every glass of sunting
extract, place ½ glass of melted candle. If using the pomade, mix one part of sunting
extract.
4. Set it aside until it hardens. Get a spoon and place the ointment in containers.
5. Label properly: Wrap in paper and put away from sunlight.
6. Directions: Apply to affected parts 3 times a day for 3 weeks.
Label:
Name of Preparation: SUNTING OINTMENT

Indications: Tinea flava, athlete’s foot, ringworm
Directions: Apply over affected areas 3 times a day for 3 weeks
Date Prepared:
85
Date of Expiration:
G. CALACHUCHI OINTMENT
Indications: Scabies, skin allergies, mosquito bites, tick bites, eczema, wound, or boils
Materials:
● Calachuchi branch (matured)
● Candle
● Wooden/ bamboo ladle
● Measuring glass
● Vegetable/ coconut
● Cloth strainer
● Flat, shallow,small containers
● Knife
● Clay cooking pot
● Chopping board
● Shredder/ scraper
Procedure:
1. Wash leaves well. Cut into fine strips.
2. Measure one glass of sliced sunting leaves. Place inside the pot. Measure one glass of oil.
Mix it with the leaves inside the pot (1:1 ratio). Boil for 5 minutes.
3. Strain in a net bag or cloth strainer. Scrape candle and melt. For every glass of sunting
extract, place ½ glass of melted candle. If using pomade, mix one part of sunting extract.
4. Set it aside until hardens. Get a spoon and place the ointment in containers.
5. Label properly. Wrap in paper and put away from sunlight.
6. Directions: Apply to affected parts 3 times a day for 3 weeks.
Label:
Name of Preparation: SUNTING OINTMENT

Indications: Tinea flava, Athlete’s foot, ringworm
Directions: Apply over affected areas 3 times a day for 3 weeks
Date Prepared:
Date of Expiration:
86
H. SALABAT POWDER
Indication: Sore throat, fever, cough/colds, vomiting, nausea, hyperacidity, colic
Materials:
● Ginger
● Strainer
● Grater
● 1 glass brown sugar
● cup/glass
● Cooking clay pot
● Plastic container
● wooden/bamboo ladle
Procedure:
1. Clean ginger well. Grate it.
2. Extract the juice. Measure 1 glass of ginger juice and 1 glass of brown sugar.
3. Place the mixture inside the pot. Cook in low fire.
4. Stir briskly until syrupy. Remove from fire. Continue to stir (briskly and continuously).
5. Place in a clean plastic container or bottle.
6. Direction: Place a teaspoon of powder in a glass of water.
Label:
Name of Preparation: SALABAT POWDER

Indications: Sore throat, fever, cough/colds, vomiting, nausea, hyperacidity, colic
Directions: Place a teaspoon of powder in a glass of water.
Date Prepared:
Date of Expiration:
87
COLLEGE OF NURSING
Dumaguete City
HERBAL MEDICATION PREPARATION: SLK SYRUP
NAME:__________________________________LEVEL:______DATE:__________
1. Perform hand hygiene
2. Wash and prepare the ingredients and

materials needed.
3. Place the ingredients inside the clay pot

according to desired proportion.
4. Add water and measure using the stick.
5. Boil the preparation uncovered until water

is reduced to one-half of its original
amount.
6. Strain decoction.
7. Measure decoction and add equal amount

of brown sugar
8. Boil until syrupy. Add calamansi juice just

shortly before removing the pot from the
fire.
9. Pour syrup into sterile dark colored bottles.
10. Seal and label accordingly.
11. Do after care of the equipment used and
88
work area.
ATTITUDE:
1. Punctual
3. Shows interest and willingness to learn
6. Possesses sense of initiative

supervision
9. Well groomed

procedure.
TOTAL
Rating Scale:
0-not done, but essentially required
1- incorrectly done; wrong techniques and findings
performance.
2- correctly done, systematic according to standard; with correct findings
N/A- not applicable
REMARKS
89
COLLEGE OF NURSING
Dumaguete City
HERBAL MEDICATION PREPARATION:SUNTING AND CALACHUCHI

OINTMENT
NAME:__________________________________LEVEL:______DATE:__________

materials needed.
3. Place the ingredients inside the clay pot

according to desired proportion.
4. Boil the preparation uncovered and strain.
5. Measure and mix solution with

proportionate amount of melted candle or
pomade.
6. Stir constantly until container and label.
7. Place into storage container and label.

work area.
ATTITUDE:
1. Punctual
90

supervision
9. Well groomed

procedure.
TOTAL
Rating Scale:
performance.
N/A- not applicable
REMARKS
91
COLLEGE OF NURSING
Dumaguete City
HERBAL MEDICATION PREPARATION:GARLIC TINCTURE
NAME:__________________________________LEVEL:______DATE:__________

materials needed.
3. Chop ingredients
4. Pour proportionate amount of gin or tuba.
5. Instruct how to fermentation of the mixture

for (3) days.
6. Label container properly.

work area.
ATTITUDE:
1. Punctual
92
supervision
9. Well groomed

procedure.
TOTAL
Rating Scale:
performance.
N/A- not applicable
REMARKS
93
COLLEGE OF NURSING
Dumaguete City
HERBAL MEDICATION PREPARATION: BLS OIL
NAME:__________________________________LEVEL:______DATE:__________

materials needed.
3. Chop ingredients
4. Measure according to the desired quantity
5. Heat oil together with chopped ingredients

in slow fire for 5-10 minutes.
6. Strain using a muslin cloth
7. Do aftercare of the equipment used and

work area.
8. Label the container accordingly.
ATTITUDE:
1. Punctual
94
supervision
9. Well groomed

procedure.
TOTAL
Rating Scale:
performance.
N/A- not applicable
REMARKS
95
COLLEGE OF NURSING
Dumaguete City
TEPID SPONGE BATH
DEFINITION
A sponge bath given to a patient with fever through the use of lukewarm water and application of
friction to the body’s surface.
PURPOSES:
1. To reduce fever or lower body temperature.
2. To stimulate circulation and aid in elimination.
3. To provide for patient comfort.
4. Sedative effect.
ASSESSMENT:
1. Assess vital signs to obtain baseline data.
2. Avoid unnecessary exposure and chilling.
a. Expose, sponge and dry only a part of the body at one time.
b. Avoid draft.
c. Use appropriate temperature of the water.
3. Do the bath quickly but unhurriedly, and use even, smooth but firm strokes.
4. Use adequate amount and temperature of water and change as frequently as necessary.
NURSING DIAGNOSIS:
Determine the related factors for nursing diagnoses based on the patient’s current status.
10. Risk for Imbalanced Body Temperature
11. Hyperthermia
12. Ineffective thermoregulation
13. Fluid Volume Deficit
14. Knowledge Deficit
OUTCOME IDENTIFICATION:
Expected Outcomes:
a. Temperature decreases or is within normal limit. Other vital signs are WNL.
b. Patient verbalizes increase comfort.
c. Patient verbalizes understanding for the reasons of tepid sponge bath.
96
PLANNING
A. Determine what supplies and equipment are needed.
B. Wash hands for infection control.
C. Obtain the needed equipment.
EQUIPMENT:
Pitcher filled with lukewarm water (94°- 98℉). Test by measuring with bath thermometer or by
placing several drops on your inner forearm.
Bath basin Ice bag
Two bath towels Hot water bag
Two washcloths Bed screen (if in ward)
Face towel Linen for changing the beddings
Gown or pajama Rubber sheet
Bath blanket Glooves
Bed pan or urinal Disposable clean gloves
IMPLEMENTATION:
STEP RATIONALE
1. Assess patient’s body temperature and Provides baseline for evaluating response to
other vital signs. therapy. Sudden circulatory changes may alter
pulse.
2. Check physician’s order. At times the physician will indicate to perform

TSB as an adjunct therapy for patient’s having
periodic fever.
3. Explain to the patient the purpose of Procedure can be uncomfortable. Anxiety over
sponging with tepid water is to cool procedure can increase body temperature.
body slowly. Briefly describe the steps
of the procedure.
4. Prepare necessary equipment and Facilitates efficiency of the task.

supplies.
5. Perform hand hygiene. Reduces transfer of microorganisms. Infection

are caused by pathogenic microorganisms.
6. Close room door or curtain and Ensures privacy.

windows. If in ward, use bed screen
prn. Avoid chilling the patient by
keeping the surroundings free from
draft.
7. Offer the patient a bedpan or urinal or Prevents interruption of the procedure.

ask whether the patient wishes to use
97
the toilet or commode.
8. Place waterproof pads under patient Pads prevent soiling of bed linen. Removing
and remove gown. Replace top sheet gown provides access to all skin surfaces.
with bath blanket.
9. Place ice cap to forehead and hot water Ice cap is indicated for headache which is
bag to feet (if desired). common in febrile patients. The HWB is to
provide warmth while TSB is applied to the
patient.
10. Check water temperature. Tepid water prevents sudden heat loss and
chilling.
11. Place bath towel across patient’s chest. To provide warmth to the patient.
12. Apply wet cloths under each axilla and Axillae and groin contain large superficial
cover groin prn. blood vessels. Application of washcloths
promotes cooler temperature of body’s core by
conduction.
13. Immerse washcloth in water and wring Retains water. A bath mitt prevents . ends of
gently. Make a bath mitt with the washcloth from dragging across the skin.
washcloth.
14. Sponge face gently and then pat dry. Friction stimulates circulation.
15. Gently sponge and apply friction to Prevents sudden temperature fall and
farther arm and hands for 5 minutes. minimizes risk of developing chills.
Use long, even strokes. Cover opposite
extremity. Note patient’s response.
16. Dry extremity and observe patient’s Response to therapy is monitored to prevent
response. sudden temperature change.
17. Continue sponging nearer arm and Prevents sudden temperature fall and
hands, followed by the chest, abdomen, minimizes risk of developing chills.
legs, and thighs, and back for 3-5
minutes each. Change water as
necessary.
NOTE: > When body temperature falls slightly

above normal, discontinue procedure and refer
to physician.
>Do not apply any pressure or friction
on the abdomen. Spread the washcloth
over the areas.
18. Dry extremities and body parts This aids in providing warmth.
thoroughly.
98
19. Assist patient put on a clean gown.
20. Replace bath blanket with light top Prevents chilling. Excessive heavy covering
sheet. may increase body temperature.
21. Dispose of equipment and change bed Controls transmission of infection.

linen if soiled. Wash hands.
22. Measure patient’s temperature 30 Temperature indicates response to therapy.

minutes after TSB.
23. Remove hot water bag after 20 minutes. To hinder the effect of rebound phenomenon.
Remove ice bag prn.
24. Record time procedure was started and Recording communicates care provided in
terminated, vital sign changes, patient’s accurate and timely fashion.
response, and health teachings given.
EVALUATION:
The expected outcomes are met when patient’s body temperature decreases, and other vital signs
are within acceptable range. Patient will verbalizes increase comfort and understanding for the
reasons of tepid sponge bath.
NURSE’S REMARK SHEET
DATE TIME DIET AND THERAPY NURSE’S REMARK

11/29/05 0800 H Received awake on bed. BP = 90/60 mmHg;
T = 39.5℃, warm to touch; PR = 98 bpm,
strong and regular; RR = 16 cpm, moderate in
depth and without effort. Tepid sponge bath
done for 30 minutes. Verbalized relief.
Tolerated procedure well. Incidental health
teaching given on measures to relieve
fever.________________________________
0830 H Orange juice – 1 glass-- Taken and consumed.___________________
Drop temperature = 38℃._____CM Raga,
SN
Rev: //RGV/Jll//060409
99
COLLEGE OF NURSING
Dumaguete City
TEPID SPONGE BATH
Student’s Name: _____________________________ Year: _____ Level: _____
STEPS 0 1 1.5 2 N/A COMMENTS

1. Assess patient’s body temperature and other
vital signs.
2. Check physician’s order
3. Explain to the patient what you are going to
do, why it is necessary, and he or she can
cooperate.
4. Prepare necessary equipment and supplies.
6. Close room door or curtain and windows. If in
ward, use bed screen prn. Avoid chilling the
patient by keeping the surroundings free from
draft.
7. Offer a bedpan or urinal to the patient or ask
whether he/she wishes to use the toilet or
commode prior to therapy.
8. Place waterproof pads under patient and
remove gown. Replace top sheet with bath
blanket.
9. Place ice cap to forehead and hot water bag to
feet (if desired).
10. Check water temperature.
11. Place bath towel across patient’s chest.
12. Apply wet cloths under each axilla and over
groin prn.
13. Immerse washcloth in water and wring gently.
Make a bath mitt with the washcloth.
14. Sponge face gently and then pat dry.
15. Gently sponge and apply friction to farther arm
100
and hands for 5 minutes. Use long, even
strokes. Cover opposite extremity. Note
patient’s response.
16. Continue sponging and applying friction to
nearer arms, followed by:
a. Chest
b. Abdomen – spread washcloth over
abdomen. Do not apply pressure or friction
c. Legs and thighs
d. Back
17. Change water as necessary.
18. Dry extremities and body parts thoroughly.
19. Assist patient put on a clean gown.
20. Replace bath blanket with light to sheet.
21. Dispose of equipment and change bed linen if
soiled. Wash hands.
22. Wash hands.
23. Measure patient’s temperature 30 minutes after
TSB.
24. Remove hot water bag after 20 minutes.
Remove ice bag prn.
25. Record time procedure was started and
terminated, vital sign changes, patient’s
response, and health teachings given.
ATTITUDE
1. Punctual
4. .Manifests creativity
5. .Shows resourcefulness
6. .Possess sense of initiative
7. .Shows positive attitude towards supervision
TOTAL
RATING SCALE:

performance
N/A- not applicable
REMARKS
101
COLLEGE OF NURSING
Dumaguete City
PROPER BODY MECHANICS AND SAFE LIFTING
Body Mechanics - is the efficient, coordinated and safe use of the body to move objects and
carry out activities of daily living. Its primary purpose is to facilitate the safe and efficient use of
appropriate muscle groups to maintain balance ; reduce the energy required , reduce the energy
required, reduce fatigue, and decrease the risk of injury.
Terminologies:
Center of gravity- when standing, is located in the center of the pelvis about midway between
the umbilicus and symphysis pubis.
Line of gravity - is a vertical line that passes through the center of gravity
Base of support - is the foundation that provides for an objects stability ; the wider the base of
support and the lower the center of gravity, the greater the stability of the object.
Rationale for the use of this Skill
A nurse engaged in a clinical practice daily performs a variety of physical tasks, including
reaching, stooping, lifting, carrying, pushing and pulling. Practiced incorrectly, any of these has
the potential to cause strain, fatigue or injury to the nurse or patient. With practice, using the
principles of body mechanics, the nurse will move smoothly and surely, minimizing personal
strain, conserving energy and enhancing the safety and confidence of patients.
Concepts of Body Mechanics
1. Body alignment or posture

Good posture or good body alignment, is that alignment of body parts that permits optimal
musculoskeletal balance and operation and promotes healthy physiologic functioning
102
2. Balance
A body in correct alignment ; an object’s center of gravity is close to its base of support, and
the object has a wide base of support
3. Coordinated body movement
Postural Reflexes
Labyrinthine sense - this sense of position and movement is provided by the sensory organs in
the inner ear, which are stimulated by body movement and transmit these impulses to the
cerebellum.
Proprioceptor or kinesthetic sense - this informs the brain of the locomotion of a limb or body
part as a result of joint movements stimulating special nerve ending in the muscles, tendons and
fascia.
Visual or optic reflexes - visual impressions contribute to posture by alerting the person to
spatial relationship with the environment.
Extensor or stretch reflexes - when extensor muscles are stretched beyond a certain point.
GUIDELINES RATIONALE
1. Plan the move or transfer carefully. Free Appropriate preparation prevents potential
the surrounding area of obstacles and move falls and injury and safeguards the client
required equipment near the head of foot of and equipment.
the bed.
2. Obtain assistance of other people or use The heavier an object, the greater the force
mechanical devices to move objects that needed to move the object.
are too heavy. Encourage clients to assist
as much as possible by pushing or pulling
themselves to reduce muscular effort. Use
arms as levers whenever possible to
increase lifting power.
3. Adjust the working area to waist level, Objects that are close to the center of
and keep the body close to the area. gravity are moved with the least effort.
Elevate the adjustable beds and overbed
tables or lower the side rails of beds to
prevent stretching and reaching.
4. Provide a firm, smooth and dry bed Less friction between the object moved and
foundation before moving a client in bed or the surface on which it is moved requires
use a pull sheet. less energy
103
5. Always face the direction of the Ineffective use of major muscle groups
movement occurs when the spine is rotated or twisted.
6. Start any body movement with proper Balance is maintained and muscle strain is
alignment. Stand as close as possible to the avoided as long as the line of gravity
object to be moved. Avoid stretching, passes through the base of support.
reaching and twisting, which may place the
line of gravity outside the base of support.
7. Before moving an object, increase your The wider the base of support and the
stability by widening your stance and lower the center of gravity, the greater the
flexing your knees, hips and ankles. stability.
8. Before moving an object, contract your The greater the preparatory isometric
gluteal, abdominal, leg and arm muscles to tensing, or contraction of muscles, before
prepare them for action. moving an object, the less energy required
to move it and the less the likelihood of
musculoskeletal strain and injury.
9. Avoid working against the gravity. Pull, Moving an object along a level surface
push, or turn objects instead of lifting requires less energy than moving an object
them. Lower the head of bed of the clients up an inclined surface or lifting against the
bed before moving the client up in bed. force of gravity.
10. Use your gluteal and leg muscles rather Pulling creates less friction than pushing.
than sacrospinal muscles of your back to
exert an upward thrust when lifting.
Distribute the workload between both arms
and legs to to prevent back strain.
11. When pushing an object, enlarge the The synchronized use of as many large
base of support by moving the front foot muscle groups as possible during an
forward. activity increases overall strength and
prevents muscles fatigue and injury.
12. When pulling an object, enlarge the Balance is maintained with minimal affort
base of support by either moving the rear when the base of support is enlarged in the
leg back if facing the object or moving the direction in which the movement will
front foot forward if facing away from the occur.
object.
13. When moving or carrying objects, hold The closer the lone of gravity to the center
them as close as possible to your center of of the base support, the greater the
gravity stability.
14. Use the weight of the body as a force Body weight adds force to counteract the
for pulling or pushing, by rocking on the weight of the obejct and reduces the
feet or learning forward or backward. amount of strain on the arms and back.
15. Alternate the rest periods with periods Continous muscle exertion can result in
of muscle use to help prevent fatigue. muscle strain and injury.
104
Application of Body Mechanics
1. Develop a habit of erect posture and whenever necessary, begin activities by broadening the
base of support and lowering the center of gravity.
2. Use the longest and the strongest muscles of the arms and legs to help provide the power
needed in strenous activities. The muscles of the back are less strong and more easily injured
when used improperly.
3. Use the internal girdle and a long midriff to stabilize the pelvis and to protect the abdominal
viscera when stooping, reaching, lifting or pulling. The internal girdle is made by contracting the
gluteal muscles in the buttocks downward and the abdominal muscles upward. It is helped
further by making a long midriff by stretching the muscles in the waist,
4. Work closely as possible to an object being moved, thereby permitting most of the burden to
be borne by the leg and arm muscles rather than the back.
5. Use the weight of the body as a force for pulling or pushing by rocking on the feet or leaning
forward or backward. This reduces the amount of strain placed on the arms and the back.
6. Slide, roll, push or pull an object rather than lift it to reduce the energy needed to lift the
weight against the pull of gravity.
7. Use the wight of the body to push an object by falling or rocking forward and to pull an object
by falling or rocking backward.
8. Spread the feet apart to provide a wider base of support when increased stability of the body is
necessary.
9. Flex the knees, put on the internal girdle and come down close to an object that is to be lifted.
Factors affecting body alignment and mobility
1. Development considerations
A persons age and degree or neuromuscular development markedly influence body
proportions, posture, body mass, movements and reflexes.
2. Physical health
105
Problems in the musculoskeletal or nervous systems can have a negative influence on the
body alignment and movement. Similarly, illness or trauma involving other body systems may
interfere with movement because of either the underlying pathology or the treatment regimen.
When assessing a patients response to a mobility deficit, work to:
-reinforce behaviors that promote health functioning
-correct behaviors that compound the mobility deficit over time
3. Muscular, skeletal or nervous system problems

A. Congenital or acquired postural abnormalities e.g. newborn with developmental hip
dysplasia or a clubfoot, a teenager with scoliosis
B. Problems with bone formation or muscle development
 Achondroplasia - premature bone ossification leading to dwarfism
 Osteogenesis imperfecta - excessively brittle bones and multiple fractures
 Diet related problems - rickets (Vit D deficiency)
 Disease related problems- Paget’s disease
 Age- related problem - osteoporosis
C. Problems affecting joint mobility

 Arthritis - inflammation in one or more joints and possibly pain and stiffness in
adjacent body parts
 Osteoarthritis - a non inflammatory, progressive disorder of movable joints, particularly
weight-bearing joints, characterized by the deterioration of articular cartilage and pain
with motion
 Trauma- results to sprain
D. Problems affecting the central nervous system

 Cerebrovascular disease - damage the motor cortex and produce temporary or
permanent voluntary motor impairment
 Parkinson’s disease - progressively degeneration of the basal ganglia of the cerebrum
E. Trauma to the musculoskeletal system

 Fractures - break in the continuity of a bone or cartilage, may result from a traumatic
injury or some underlying disease process
 Strain- is a stretching of a muscle
106
 Soft tissue injuries - include sprains, strains and dislocations
Nursing Responsibilities
1. Early detection of and referral for these problems.

2. Exploration and selection of patient education, counseling and support as treatment options.
3. Careful attention to positioning, transfers and exercise.
4. Education of the patient and family regarding safe self-care activities.
5. Careful collaboration with the physical and healthcare team to determine the motion capacities
of the individual.
References
Ellis, J.R. Nowlis, E.A., & Patricia M. Bentz (1996) Modules for basic nursing skills. 6th ed.
Philadelphia: Lippincott - Raven Publishers
Danierls, R. (2004) . Nursing fundamentals: Caring & clinical decision making. Thompson
Asian edition, Australia : Delmar.
Kozier, B., et al (2004). Fundamentals of Nursing:Concepts; Process and Practice. 7th ed

Pearson Education Inc., Upper saddle river, NJ.
Taylor, C. Lillis, C. & Priscilla Lemone. (2005). Fundamental of Nursing: The art and
science of nursing care. 5th ed. Philadelphia: Lippincott Williams and Wilkins.
Potter, P.A. & Perry, A.G. (2004). Fundamentals of Nursing. 6th ed. St. Louis: Mosby Inc.
107
COLLEGE OF NURSING
Dumaguete City
BASIC BODY MECHANICS
Student’s Name: ______________________ Year: _____________ Level: __________

Assessment
1. Ascertain a good status of
physical health prior to any
procedure.
2. Check for any muscular,
skeletal or nervous system
problems
3. Determine availability of
other members of the healthcare
team for anticipated assistance.
Planning
control
equipment are needed for the
procedure to be done.
6. Report and do refferals for
presence of limitations and
problems.
Implementation
108
7. Keep weight balanced above
base of support.
8. Enlarge base of support as
necessary to increase body’s
stability
9. Lower center of gravity
toward base of support as
necessary to increase body’s
stability.
10. Enlarge base of support to
direction in which force to be
applied.
11. Tighten abdominal and
gluteal muscles in separation for
all activities.
12. Face in the direction of
tasks and turn body in one
plane.
13. Bend hips and knees when
lifting.
14. Move objects on level
surface when possible.
15. Slide objects on smooth
surface when possible.
16. Hold objects close to body
and stand close to objects to be
moved.
17. Use body’s weight to assist
in lifting or moving when
possible.
18. Use smooth motions and
reasonable speed when trying
out tasks.
19. Raise the working surface to
your waist level when possible.
Evaluation
Criterion : The nurse and the
client is free from injury after
the implementation of the
procedure.
Attitude
109
1. Punctual
3. Shows interest and
towards supervision
TOTAL
Rating Scale:
1-not done,but essentially required

1-incorrectly done:wrong techniques and findings
1.5 correct measured,but with inadequete description of findings or not systematic in

performance
2- correctly done,systemstic accounting to standard: with correct findings
N/A - not applicable
REMARKS
110
COLLEGE OF NURSING
Dumaguete City
BEDMAKING
Rationale for the Use of This Skill
The bed is one of the most important part of the patient’s environment in the healthcare
setting. Knowing how to make various types of beds and how to modify them for special
situations is of paramount importance for the nurse. A clean, wrinkle-free bed that remains intact
when a patient moves does a great deal for the patient’s physical and psychological comfort.
INFECTION CONTROL IN BEDMAKING
Apply these principles of basic infection control to all bed making procedures:
5. Microorganism moves through on air currents;

Therefore, handle linen carefully. Avoid shaking it tossing it into the laundry hamper
(it should be places directly in the hamper).
6. Microorganism are transferred from one surface to another whenever one object
touches another;
Therefore, hold both soiled and clean linen away from your uniform to prevent
contamination of the linen by the uniform and contamination of the uniform by the
soiled linen. In addition, avoid placing it on the floor to prevent the spread of any
bacteria present either on the linen or on the floor.
7. Proper handwashing removes many of the microorganisms that would be

transferred by the hands from one hem to another;
Therefore, wash your hands before you begin and after you finish bed making.
BODY MECHANICS IN BEDMAKING
Apply these principles of body mechanics to all bed making procedures:
111
1. A person or an object is more stable if the center of gravity is close to the base of
support. Therefore, when you must bend, bend your knees, not your back, to keep
the center of entire body in the direction that you are moving and to avoid twisting to
prevent back strain or injury.
2. Facing in the direction of the task to be performed and turning the entire body in one
plane rather than twisting lessens the susceptibility of the back injury. Therefore,
face your entire body in the direction that you are moving and to avoid twisting to
prevent back strain or injury.
3. Smooth, rhythmical movements at moderate speed requires less energy. Therefore,
organized your work. Conserve steps by making as few trips around the bed as
possible.
4. It takes less energy to work on a surface at an appropriate height (usually waist
level) than it does to stoop or stretch to reach the surface. Therefore, raise the bed to
an appropriate height from maximum working comfort for you to prevent fatigue.
PROCEDURE FOR MAKING THE UNOCCUPIED BED
Assessment
1. Check the activity order for the patient to determine if it is possible for the patient to
be out of bed during the bed making procedure.
2. Assess the patient to determine whether there are factors present (fatigue or pain, for
example) that might affect the patient’s ability to be out of bed during the bed
making procedure.
3. Check the condition of the linen in the bed to determine which items to be replaced
or added to complete the bed making procedure.
4. Check for any of the patient’s special needs that might require extra linen or special
equipment.
Planning
5. Wash your hands for infection control

6. Obtain a laundry bag or an improvised hamper
7. Gather the linen to be used and place it in order, so that the first item to be used will be
on the bottom, the second item next, and so on. You should choose only those items that
need to be changed. Remember that preventing excessive purchase and laundry costs is
part of cost containment in the healthcare environment. Items can include:
a) Mattress pad which may already be on the bed (not used in all facilities)
b) bottom sheet( many facilities will have fitted bottom sheets)
c) 1 plastic drawsheet( may be optional)
d) 1 cloth drawsheet( A top sheet folded in half may be used in some settings. The
use of drawsheet may be optional; use one if it is needed to assist with turning or
if the patient has drainage or some other condition. It is much easier to change a
drawsheet than an entire bottom sheet.)
e) 1 top sheet
f) 1 blanket
g) 1 bedspread (optional)
h) 1 pillowcase for each pillow on the bed
If linen is stacked in this order,the stack need merely be turned over for it to be in
the correct order for use.
112
8. Obtain any other needed item or equipment. You will need to clean gloves if you will be
handling linen soiled with body temperature.
Implementation
9. Raise the bed to an appropriate working height to help prevent fatigue. Be certain the
wheels are locked to keep the bed from moving.
10. Remove attached equipment(call light, waste bag, personal items). Place side rails in the
down position. Put on gloves before handling linen soiled with body secretions.
11. Remove cases from pillows and place the pillows on a chair or bedside table.
12. Loosen the top and the bottom linen from the mattress, moving around the bed from foot
to head on the opposite side.
13. Remove any clean items to be reused (spread, blanket, sheets) one at a time. Fold each in
quarters and place across the back of a chair.
14. Remove the remaining linen and place it in a laundry hamper. If is put on gloves to
handle linen soiled with body secretion, remove them and wash your hands before
touching any clean items.
15. If the mattress is to be turned, do so at this point by grasping it, pulling toward you, and
turning it.
16. Move the mattress to the head of the bed.
17. Wash your hands after handling the soiled bed linens.
18. Place a mattress pad on the mattress and secure it smoothly.
19. Place a bottom sheet on the bed, with the center fold at the center of the bed, and the
seam toward the mattress. Spread the sheet, tucking it under at the head of the bed, if it is
a flat sheet.
20. If your facility uses fitted sheet, first fit diagonal corners over the mattress. If your
facility does not use fitted sheet, use mitered or square corners remain tucked better and
appear neater than the sheets that are simply tucked under the mattress.
To make a mitered corner:
a) Pick up the side edge of the sheet approximately 12 inches from the corner of the
mattress. Hold it straight up and down,parallel to the side of the mattress.
b) .Lay the upper part of the sheet on the bed
c) Holding the sheet in place against the mattress with one hand, use your other hand
to lift the folded part of the sheet lying on the bed and bring it down. Tuck it
under the mattress. To make a square corner, pick up the sheet to form 45° angle
(in step above) so that,when the folded edge is place on the top of the mattress
before tucking, it is even with the bottom edge of the mattress.
21. Tuck the remainder of the sheet under the side of the mattress all the way to the foot of
the bed, pulling it tightly toward the bottom of the bed as you go to create a smooth
surface.
22. If a plastic drawsheet is to be used, place it over the middle art of the bed, with the center
fold at the center. Unfold the drawsheet toward the far side of the bed. Tuck the near edge
smoothly under thr mattress
23. Place the cloth drawsheet over the plastic drawsheet, and place it on the bed, making sure
that the plastic drawsheet is completely covered.
24. Place the top sheet on the bed with the center fold at the center of the bed, seam side up.
Align the top edge of the sheet under the mattress. Unfold it toward the far side of the
bed.
113
25. .Make a toe pleat (optional- follow the procedure at your clinical facility) by folding a 2
inch pleat across the sheet about 6 to 8 inches from the foot of the bed. The tuck the end
of the sheet under the mattress. This is more comfortable for the patient in that it prevents
impingement of the top linen on the patient's toe.
26. Place the blanket on the bed, center fold at the center of the bed, so that the edge of the
blanket is about 6 inches from the top of the mattress, making a toe pleat if necessary. In
warm weather, or at the patient's request, omit the blanket or if the patient is cold, use
additional blanket.
27. Place the bedspread on the bed, with the center fold at the center of the bed. The top edge
of the spread should be about 6 inches from the top of the mattress. Unfold the remainder
of the spread toward the far side of the bed. Tuck it under the foot of the mattress, making
a toe pleat if necessary. Some nurses prefer to tuck all three - top sheet, blanket and
spread together.
28. Miter the corner of the top linen at the foot of the bed. Do not stuck in the upper portion;
allow it to hang down smoothly and freely.
29. Move to the other side of the bed. It is easier to make one entire side of the bed (both
bottom and top linen) before moving to the other side to save time and energy. Pull the
bottom linen and smoothly and tightly across the mattress and tuck the bottom sheet
under the head of the bed mattress and make a mitered or square corner.
30. Tuck the bottom sheet along the side of the bed, puling toward you and slightly toward
the bottom of the bed to make the sheet tight as you smooth, comfortable surface for the
patient.
31. Pull the center of the plastic drawsheet (if present) toward you. With palms down, tuck it
under the mattress, as snugly as possible. Grasp the top corner of the drawsheet, pull it
diagonally, and tuck it under the mattress snugly. Repeat this activity with the lower
corner of the drawsheet to obtain an absolutely wrinkle - free surface.
32. Tuck the cloth drawsheet under the mattress in the same way you tucked in the plastic
drawsheet.
33. Straighten and smooth the top sheet, blanket, and spread starting at the top of the bed and
moving toward the foot of the bed. Miter the bottom corner.
34. Fold the top sheet back over the edge of the blanket and the spread. If there is more
spread than blanket at the top of the bed, fold the excess spread over the blanket to form
an even line. Then Fold the top sheet over as described.
a) Close Bed: the upper edge of the spread is left even with the upper edge of the
mattress to designate a close bed. In healthcare facilities this may only be done
when no patient is assigned on the bed. In long-term care facilities, the bed is
usually closed during the day.
b) Open Bed: opening a bed is usually done by grasping the upper edge of the top
linen with both hands, bringing it all the way to the foot of the bed, then folding it
back toward the center of the bed. The is known as fan folding.
35. Put a pillowcase on the pillow. This is known as fan follows.
a) Grasp the pillowcase at center of the closed end of the case.
b) Gather the case up over that hand and grasp the zipper, or open end of the pillow
cover.
c) Straighten and smooth the case over the pillow and place it at the head of the bed
with the open end way from the door (for neater appearance).
d) Keep the pillow and case away from your uniform as you apply the case.
36. Replace the call light in an appropriate place and leave the bed in low position, ready for
the patient who will be turning to bed from a chair or walk.
114
Evaluation
37. Evaluate the unoccupied bed, using the following criteria:
a) Smooth wrinkle - free surface
b) tuck and tight corners
c) Correct position (high or low) for the patient's needs
d) call light attached in appropriate place
Documentation
38. Linen changes are not routinely documented but the tolerance of the patients being out of
the bed and mobility limitations are important to be recorded.
PROCEDURE FOR MAKING OCCUPIED BED

There are many instances in which a bed must be wholly or partially made with a patient
in it. In most cases this is because the patient is too ill or disabled to get out of bed.
Practice making an occupied bed, keeping the patient's safety and comfort foremost in
you mind and taking care to avoid bumping the bed or exposing the patient. If the patient cannot
participate, you may need another staff member to assist you.The order if activities mains the
same, the procedure differs from making an unoccupied bed only because a patient is in the bed.
Assessment
 Check activity orders to be sure that the patient must stay in bed as well as orders for any
position. Also check for any position that must be maintained (for example,head of bed
elevated 30°).
 Assess the patient to determine whether there are any factors (such as fatigue,shortness of
breath, or pain, for example) that might affect the ability of the patient to undergo the bed
making activity at that time.
 3 - 4. Follow the steps of the procedure for Making the Unoccupied Bed
Planning
5. Wash your hands for infection control.
6. Obtain a laundry bag or hamper
7. Gather the linen to be used and place it in order, so that the first item to be used will be
on the bottom, the second item next, and so on. You should choose only those items that
need to be changed. Remember that preventing excessive purchase and laundry costs is
part cost containment in the healthcare environment. Items can include:
a) mattress pad which may already be on the bed (not used in all facilities)
b) bottom sheet (many facilities will have fitted bottom sheets)
c) 1 plastic drawsheet ( may be optional)
d) 1 cloth drawsheet( A top sheet folded in half may be used in some settings. The use
of a drawsheet may be optional; use one if it is needed to assist with turning or if the
115
patient has drainage or some other condition. It is muvh easier to change a drawsheet
than an entire bottom sheet.)
e) 1 top sheet
f) 1 blanket
g) 1 bedspread (optional)
h) 1 pillowcase for each pillkw on the bed
If linen is stacked in this order, the stack need merely be turned over for it to be in the
correct order for use.
8. Obtain any other needed item or equipment. You will need to clean gloves if you will be
handling linen soiled with body secretions.
Implementation
9. Explain what you plan to do. The patients will greatly help you. Provide for the patient’s
privacy by closing the curtain around the patient.
10. Raise the bed to an appropriate height for you to help prevent fatigue. Be certain the
wheels are looked.
11. Removed the call light and other equipment, spread, and blanket from the bed. If the
spread and the blanket are to be reused, fold them and place over a chair. Put on gloves.
12. Before removing the top sheet, place a bath blanket over the sheet. The bath blanket will
remain in places as you remove the sheet to provide privacy and warmth for the patient.
Ask the patient, if able, to hold the top edge of the bath blanket while you pull the sheet
out from under it. Discard the top sheet if you will not be using it.
13. If the mattress must be moved towards the head of the bed, get assistance from another
person.
14. Elicit the patient’s help and roll the patient to the far side of the bed, making sure that the
pillow is moved also. If possible, the patient should be side – lying, facing away from
you. The side rail on the far side of the bed should be up far safety and comfort.
15. Loosen the foundation (bottom linen) of the bed on the near side, leaving the mattress pad
in place unless it is wet or soiled.
16. Fanfold each piece of linen toward the center of the bed, with the last fold toward the
opposite side of the bed and tucked under the patient’s back and buttock to make it easier
to reach later. If you put on gloves to handle the linen soiled with the body secretions,
remove them and wash your hands before touching any clean items.
17. Straighten the mattress pad. If you must replace the mattress pad, use the process in step
1.
18. Lay the bottom sheet lengthwise and fold it so that the center fold of the sheet is the
center of the bed, the bottom hem is at the bottom edge of the mattress. Fanfold half of
the sheet lengthwise towards the center of the bed, allowing the other half to drape over
the side towards you.
19. Place the fanfold sheet under the patient as far as possible, tucking it under the soiled
bottom sheet so that it is not against the soiled upper surface.
20. Tuck the sheet under the top, miter the top corner, and tuck it along side of the mattress to
the foot of the bed.
21. If the plastic drawsheet is in use, unfold it at this point, pull it over the folded bottom
sheets, and tuck it in snugly and smoothly.
22. Ifaplasticdrawsheetisinused,alwayscoveritwithaclothdrawsheetaswell.Ifonlya
clothdrawsheetisused,placeitsothatthecente'rfoldisatthecenterofthebed.
23. Tuckthenearsideunderthemattress.Fanfoldtheotherhalftowardthecenterofthebed,tuckingitu
nderthe patient'sbackandbuttocks.
116
24. Helpthepatientroleoverthefoldedlinen.Adjustthepillow.Putupthesiderailfor
safetyandcomfort.
25. Movetotheothersideofthebed.Lowerthesiderail.
26. Loosenthebottomlinen.Putonglovesifthelinenissoiledwithbodysecretions.Removethesoile
dlinen(bottomsheetwithclothdrawsheet)andplaceitinthelaundryhamper-
orbag.Removegloveandwashyourhandsbeforetouchinganycleanitems.
27. Straightenthemattresspad.Straighten,pull,andtuck the
bottomsheetasifmakinganunoccupiedbed.Pullthesheettightbybracingagainstthebedandpull
ingwithbothhandstomakethesheetsmoothandtightunderthepatientbeforetuckingit.
28. Ifadrawsheetisbeingused,pullandtuckitasyoudidpreviously .
29. Nowmovethepatienttothecenterofthebedinacomfortableposition.
30. Placethetopsheetonthebedasyoupulltheblanketfromthetoptothebottom.Place
thebathblanketinthelaundrvhampero·r(ifitisunsoiledanddry)folditandleaveitinpatient's
unituntilforfutureuse.
31. AddtheblanketandthespreadasintheProcedureforMakingtheUnoccupiedBed.
Insteadofmakingatoepleat;youmayhavethepatientpointthetoesupwhileyouaretuckinginthef
ootofthebed:thisallowsroomforthetoesafterbedhasbeenmade.
32. Removethepillowandputonacleanpillowcase.
33. Reattachthecalllightandanyotherequipmentyouremoved.
34. Placethebed·inthelowposition,adjustingthesiderailsaccordingtoyourfacility
'spoliciesandtheindividual situation.
Evaluation
35. Evaluate the occupied by using the following criteria:
d. Patient’s comfort
e. Smooth, wrinkle – free surface
f. tightcomers
g. bedandsiderailsincorrectposition
h. bedinthelowpositionforsafety
i. calllightandotherpersonalitemswithin patient'sreach
Documentation
36. Documentanyassessmentdataorchangeinthepatient'sclinicalstatus.
ACCESSORIESOFTHEBED
Amongthedevicesoftenaddedinthebedarethebedboard,thefootboard,andthecradle.Thesedevi
cesmaybeorderedbyaphysician, butinmanyfacilitiestheyareaddedatthenursediscretion.
Bedboard
Abedboardmaybeuseddirectlyunderamattresswhenthepatientneedsanespeciallyfirmbed.Bed
boardsareoftenusedfororthopedicpatientsorforthosewhohaveahistoryofbackproblems.Some
patientsaresimplymorecomfortablesleepingonafirmsurface.Mostmodernbedsinhealthcarefac
ilitiesdonotneedabedboardtocreateafirmsurface.
117
Footboard
Afootboardmaybeplcedonthebedtokeepthefeetatrightanglestothelegswhenthepatientissupin
eposition(lyingflatontheback)inbedandpreventprolongedplantartlexion.Thefeetarepositione
dtorestfirmlyagainstthefootboard.
Linenistuckedinaroundthefootboardandishelpupoffthepatient'sfeet.Thispreventsthetopsheet,bla
nket,andspreadfromforcingthefeetintoplantarflexion.Trochanterrollsmaybeusedtokeepthehipsfr
omexternallyrotating.
Footbo·ardsarenotallthesame.SomearemerelyboardsthatfitatthefootofthemattressSomerequireth
ataboxor"block"beadded,sothatthefeetofashorterpatientcanreachtheboard.Otherfootboardsfitun
derthem·attressandslideuptotheappropriatepointonthebed.
Onlyfootboardsthatallowthepatient'sfeettorestflatagainstthemhelptopreventfootdrop. Foot drop

is an abnormal shortening of the Archilles tendon from a prolonged period of plantar flexion.
Footdrop results in patient's inability to walk normally and requires extensive physical therapy
to correct. A footboard is only effective if the patient's feet are resting firmly against it.
Cradles
Abedcradleisadevicedesignedespeciallytokeeplinenupoffthefeetandlower
legs.ofpatientswhennessary,asincasesofedema,legulcers,andburns.Placethedeviceonthebedov
erthepatient'slegsandfeet.Arrangethetoplinenoverthedeviceandpinorclipitinplace.Somefacilities
donotallowpinningbecauseitcantearthelinen.Inthesesituations,linenmustsimplybetuckedassecur
elyaspossiblearoundtheframe.
Reference:
Ellis, J.R., Nowlis, E.A., & Patricia B. Benz. (1996). Modules for the basic nursing skills, 6th
Ed. Philadelphia: Lippincott – Raven Publishers.
118
COLLEGE OF NURSING
Dumaguete City
BEDMAKING
Student’s Name: Year: Level:
STEPS S U N/ Comments
A
1. Handle linen carefully; do not shake; place in
hamper
2. Hold both soiled and clean linen away from your
uniform.
3. Wash your hands before and after bed making.
BODY MECHANICS
1. When you must bend, bend knees, not your back
2. Face your entire body in the direction in which
you are moving and avoid twisting.
3. Organize your work and conserve steps.
4. Raise the bed to an appropriate height.
UNOCCUPIED BED:
5. Check activity order for patient.
6. Assess patient.
7. Check the condition of the linen on bed.
8. Check for patient’s special needs.
PLANNING
9. Wash your hands
119
10. Obtain laundry bags or hamper.
11. Gather linen to be used.
12. Obtain other needed items or equipment,
including gloves if linen soiled with body
secretions.
IMPLEMENTATION
13. Raise bed to an appropriate working height. Be
certain wheels are locked.
14. Removed attach equipment. Put on gloves before
handling linen soiled with body secretion.
15. Remove cases from pillow.
16. Loosen top and bottom linen from mattress.
17. Remove clean items to be reused, fold and place
across back of chair.
18. Remove remaining linen and place in hamper. If
you put on gloves, remove them and wash hands
before touching clean items.
A
19. Turn mattress if necessary.
20. Move mattress to head bed.
21. Wash your hands.
22. Place mattress pad on mattress.
23. Place bottom sheet on bed.
24. Miter top corners of bottom sheet or, if fitted
sheet, tuck diagonally.
25. Tuck remainder of sheet under.
26. Place rubber drawsheet (if used) on bed, using
center fold as guide. Tuck near edge.
27. Place cloth drawsheet over rubber drawsheet.
Tuck near edge.
28. Place and unfold top sheet on bed.
29. Make toe plate (optional).
30. Place a top blanket on bed, using center fold as
guide.
31. Place bedspread on bed; tuck all three together or
separately.
32. Miter corner of top linen at foot of bed.
33. Move to other side of bed.
34. Tuck bottom sheet.
35. Tuck rubber drawsheet (if used) snugly under
mattress.
120
36. Tuck cloth drawsheet.
37. Smooth top sheet, blanket and spread; under
mattress.
38. Fold top sheet over top edge of blanket and
spread.
39. Apply pillowcase, keeping pillow and case away
from uniform.
40. Replace call light and leave bed in appropriate
position.
EVALUATION
41. Evaluate using the following criteria:
a. Smooth, wrinkle – free surface
b. Tight corners
c. Low position
d. Call light attached in appropriate
DOCUMENTATION
42. Document linen change according to policy of
your facility.
OCCUPIED BED:
ASSESSMENT
1. Check the activity in order for patient and orders
for position restriction.
2-4. Follow Checklist steps 2-4 of the Procedure for
Making the Unoccupied Bed
PLANNING
5-8. Follow Checklist Steps 5-8 of the Procedure for
Making the Unoccupied Bed.
IMPLEMENTATION
9. Explain what you plan to do and provide for
privacy of patients.
10. Raise bed to appropriate height and lock wheels.
A
11. Remove attached equipment, spread, and blanket
from bed. Fold if to be reused. Put on gloves if
linen is soiled with body secretions.
12. Place bath blanket over top sheet, pull sheet from
under it.
13. If mattress needs repositioning, get assistance.
14. Elicits patient’s help, roll patient to other side
with side rail up.
15. Loosen bed linen.
16. Fanfold each linen item to be used toward center
of bed, tucking under patient’s back.
17. Straighten mattress.
18. Lay clean bottom sheet lengthwise. Fanfold far
121
side toward patient.
19. Tuck clean sheet so that it does not stuck used
soiled bottom sheet.
20. Miter top corner and tuck length under mattress.
21. If rubber drawsheet is used, pull over folded
bottom sheets and truck.
22. Cover rubber drawsheet (if used) with cloth
drawsheet.
23. Tuck nearest side, fanfold other portion towards
patient’s side.
24. Raising side rail, assist patient in rolling towards
you over linen, raising side rail.
25. Move the other side of the bed and lower rail.
26. Remove soiled linen and place in hamper.
Remove gloves and wash hands.
27. Straightens mattress pad.
28. Pull and tuck drawsheet, if used.
29. Move patient to center bed.
30. Place top sheet on bed, removing bath blanket.
31. Add blanket and spread, make toe plate if
appropriate, and miter bottom corners.
32. Put clean case on pillow.
33. Reattach call light and reinstate equipment.
34. Place bed in low position.
EVALUATION
35. Evaluate using the following critieia:
a. Patient’s comfort
b. Smooth, wrinkle – free surface.
c. tightcomers
d. bedandsiderailsincorrectposition
e. bedinthelowposition
f. calllightandotherpersonalitemswithin
patient'sreach
Documentation
36. Documentation any
assessmentdataorchangeinthepatient'sclinicalstatu
s.
Attitude
1. Punctual
A
122
7. Shows positive attitude towards supervision.
TOTAL
Rating Scale:
1.5 Correct measures, but with inadequate description of findings or not systematic in
performance
N/A- not applicable
Remarks
HOT APPLICATION
PURPOSES
Heat peripheral blood vessels,help to dissipate heat from the body and increasing blood flow to
the area. This increases the supply of oxygen and nutrients to the area venous congestion. Heat
application accelerates and the inflammatory response thereby promoting healing. Heat also uses
to muscle tension,relieve muscle tension,relieve muscle spasm and relieve joint stiffness. Heat
also helps relieve pain. It is used to treat infections,surgical wounds,inflammation,arthritis,joint
pain,muscle pain, and chronic pain.
Heat is applied by wet or worst and dried method. The physician's order should include the type
of application,the area to be treated, the frequency of application, and the length of time for the
application. Water is used for heat applications needs to be the appropriate temperature to avoid
skin damage: 115• to 125•F for older children for the adults while 105• to 110•F for infants,
young children, older adults, and parents with diabetes, or those who are unconscious.
Two types of external hearing device are Aquathermia pads and hot water bags, Aquathermia
pads are used in health care agencies and are safer to use than hearing pads. The temperature
setting for an Aquathermia pad should not exceed 105• to 109.4•F , depending on the institution
policy
123
Hot water bags are easy and expensive bags to use but have several disadvantages. They may
leak and pose Sanger from burns related to improper use. They are used more than often in the
home setting.
ASSESMENT
1. Asses the situation to determine appropriateness for the application of heat.

2. Asses the patient's physical and mental status and the condition of the body area to be treated
with heat.
3. Confirm the physician's order for the heat therapy, including frequency, type of therapy, body
area to be treated, and the length of time for the application
4. Check the equipment to be used, including the application of the plugs. Check for leaks.
NURSING DIAGNOSIS
Determine related factors for the nursing diagnosis based on the patient's current
status.Appropriate nursing diagnosis may include but are not limited to the following:
•Acute pain
•Chronic pain
•Impaired skin integrity
•Impaired tissue integrity
•Delayed surgical recovery
•Risk for skin integrity
•Risk for injury
•Patient pain is relieved
•Patient displays increase in comfort
•Patient verbalizes muscle spasms.
•Patient exhibits improved wound healing.
•Patients demonstrates a reduction in inflammation
•Patients remain free from injury.
•Patients verbalizes understanding of reasons behind treatment modality.
124
PLANNING
1. Determine what supplied and equipment are needed

2. Wash hands for infection control
3 .Obtain the needed equipment.
EQUIPMENT

Hot water bags with cover
Bath thermometer
Waterproof bag for under the hot water bag
Pitcher
IMPLEMENTATION
125
ACTION RATIONALE
1.Check the physician's order or nursing Reviewing the order validates the correct patient
care plan for the application of heat and the correct procedure.
therapy, including frequency, type of
therapy, body area to be reserved, and
length of time for the application.
2. Identify the patent. To ensure that the correct procedure is done to the
correct client.
3.Explain the procedure to the patent. Discussing the procedure to the patient help
allay , anxiety ,encourage patient cooperation and
prepare the patient for what to expect.
4. Assessment the condition of the skin Assessment supplies baseline data for post
where the heat is to be applied. treatment comparison and identifies conditions
that may contraindicated the application. Very
thin or damaged skin is more susceptible to injury
from heat.
5. Assessment sensitivity to temperature Determines whether the patient is insensitive to
and plan using light touch,pinprick and heat and cold extremes.
temperature sensation tests.
6.Gather the equipments needed. Preparation of the materials promotes efficient
time management and provides an organized
approach to the task.
7.Perform hand hygiene Good hand hygiene prevents the spread of
microorganisms.
8. Close the room door or curtains. Raise Closing the door or curtains provides privacy.
the bed to a comfortable working height. Proper bed positioning helps reduce back strain
while you are performing the procedures.
9.Assist the patent to a comfortable Patient positioning and use of a bath blanket
position that provides easy access to the provides comfort and warmth. Waterproof pad
area to be treated. Exposed the area and protects the patient and the bed linens.
state the patient with a bath blanket of
needed. Put a waterproof pad under the
wound area to protect the bed. If
necessary.
10. Pour glass of tap water to pitcher and Checking the temperature helps prevent skin and
follow with hot water. Check the water tissue damage.
temperature .
11.Fill the hot water bag with two-thirds Prevents the hot water from spilling over
full of water
12. Remove the air inside the hot water
bag by placing it on a flat surface and
allowing water near the opening. Close
the bag.
13. Check for the presence of leaks Leaks may cause burns to the client. Change hot
water bag if a leak is noted.
14.Wrap the hot water bag with Cover protects the skin from direct contact with
protective cover. Apply the heat source to the bag. Heat travels by conduction from one
the area indicated for the object to another. Gauze bandage or tape holds
treatment.Secure the protective cover the bag in position. Do not use pins, as they may
with a gauze bandage or tape . puncture and damage the hot water bag.
15. Assess the condition of the skin and Maximum therapeutic effects from the application
the patient's response to the heat an of occur within 20 to minutes. Using heat more
frequent intervals,according to institution than 45 minutes results in tissue congestion and
policy. Do not exceed prescribed length vasoconstriction ,which can result in an increased
of time for the application of heat. risk for burns.
16. Remove the bag after the prescribed Removal of the bag on line reduces the risk for
amount of time has lapsed. injury
17.Assist the patient to preferred Helps the client to relax.
comfortable position
18. Do aftercare of the equipment and Reduce transmission of microorganisms and
dispose solid linens. prepares the equipment for the next user.
126
19. Perform hand hygiene. Good hand hygiene prevents cross contamination.
20. Document the procedure, the Documentation promotes continuity of care and
patient's response,and your assessment of communication among health care professionals.
the area before and after procedure.
EVALUATION
The expected outcome is met when the patient,exhibits increased comfort, decreased muscle
spasms,less pain,improved wound healing or decreased information in addition the patient
remains free from injury during and after the procedure.
REFERENCES
Wilkins.
Potter, P.A. & Perry , A.G. (2005). Fundamentals of Nursing . 6th ed. Missouri: Mosby, Inc
Smith, Pamela (2005) Taylor’s Clinical Nursing Skills: A nursing process approach Philadelphia:
Lippincott Williams and Wilkins.
Timby, Barbara ( 1996) Fundamental Skills and Concepts in patient care, 6th ed.
Philadelphia;Lippincott
COLLEGE OF NURSING
Dumaguete City
HOT APPLICATION
Student’s Name: ______________________ Year: _____________ Level: __________

Assessment
1. Assess the situation to
determine appropriateness for
the application of heat.
2. Assess the the patient's
physical and mental status and
the condition of the body area to
be treated with heat.
3. Confirm the physician's order
for the heat therapy, including
frequency, type of therapy,
body area to be treated ,and the
length of time for the
application.
4. Check the equipment to be
used including the condition of
127
the plugs. Check for leaks.
Planning
5.Determine what supplies and
equipment are needed
6.Wash hands for infection
control.
7.Obtain the needed equipment
Implementation
8.Check the physician's order or
application of heat therapy,
including frequency,type of
therapy, body area to be treated
and length of time for the
application.
9.Identify the patient.
10.Explain the procedure to the
patient
11. Assess condition of the skin
where the heat is to be applied.
12.Assess sensitivity to
temperature and pain using light
touch,pinprick, and temperature
sensation tests.
13.Gather the equipment needed
14.Perform hand hygiene
15.Close the room door
curtains. Raise the bed to a
comfortable working height.
16.Assist the patient to a
comfortable position that
provides easy access to the area
to be treated. Exposed the area
and drape the patient with a
bath blanket if needed.Put a
waterproof pad under the
wound area to protect the bed,if
necessary.
17.Pour a glass of tap water to
pitcher and follow with hot
water.Check the water
temperature.
18. Fill the hot water bag with

two-thirds full of water
19. Remove the air inside the
hot water bag by placing it on a
flat surface and allowing water
near the opening. Close the bag.
128
20. Check for the presence of
leaks.
21. Warp the hot water bag with
protective cover. Apply the heat
source to the area indicated for
the treatment. Secure the
protective cover with a gauze
bandage or tape.
22. Assess the condition of the
skin and the patient's response
to the heat at frequent intervals,
according to institution policy,
Do not exceed prescribed length
of time for the application of
heat.
23. Remove the bag after the
prescribed amount of time has
lapsed.
24. Assist the patient to
preferred comfortable position.
25. Do aftercare of the
equipment and dispose soiled
linens .
27. Document the procedure,the
patient's response,and your
assessment of the ares before
and after the procedure.
Evaluation
28. Evaluate using the
following criteria:
a.The patient reports a relief of
pain and increased comfort.
b.The patient verbalizes
decreased muscle spasms
c.The patient exhibits improved
wound healing,or decreased
inflammation
d. The patient remains free from
injury during and after the
procedure.
ATTITUDE
1.Punctual
129
3.Shows interest and
4.Manifest creativity
7.Shows positive altitude
towards supervision
8.Systematic and conserves
steps
9.Well groomed
10.Applies body mechanics
when performing procedure
TOTAL
Rating Scale:
1.5 correct measured,but with inadequate description of findings or not systematic in
performance
2- correctly done,systematic accounting to standard: with correct findings
REMARKS
130
COLLEGE OF NURSING
Dumaguete City
COLD APPLICATION
PURPOSES
Cold constricts the peripheral blood vessels, reducing blood flow and to the tissues and
decreasing the local release of pain reducing substances. Cold reduces the formation of edema,
and inflammation, reduces muscle spas, and promotes by slowing the transmission of pain
stimuli. The application of cold therapy reduces bleeding and hematoma formation. The
application of cold, using ice is appropriate after direct trauma, for dental pain, for muscle
spasms, after muscle spasms, and for the treatment of chronic pain. Ice can be used to apply cold
therapy, usually in the form of an ice bag or ice collar, or in a glove. Commercially prepared cold
packs are also available.
ASSESSMENT
 Assess the situation to determine the appropriateness for the application of cold therapy.
 Assess the patient’s physical and mental status and the condition of the body area to be
treated with the cold therapy
 Confirm the physician’s order, including the frequency, type of therapy, body area to be
treated, and length of the time for application
 Asses the equipment to be used to make sure it will function properly
NURSING DIAGNOSIS
 Acute pain
 Chronic pain
 Impaired skin integrity
 Ineffective tissue perfusion
131
 Delayed surgical recovery
 Decreased inflammation
 Patient does not show signs of bleeding or hematoma at the treatment site
 Patients states that pain is reduced
 Patients verbalizes understanding the rationale for cold application
Note: Other outcomes may be appropriate depending on the nursing diagnosis.
PLANNING
 Determine what supplies and equipment are neede
 Obtain the needed equipment
EQUIPMENT
Ice
Ice bag, ice collar
Small towel or washcloth
Disposable gloves
Bath blanket
Bath towel
Waterproof pad
IMPLEMENTATION
132
ACTION RATIONALE
1.Check the physician's order or nursing care Reviewing the order validates the correct patient
plan for the application of cold therapy, and the correct procedure.
including frequency, type of therapy, body
area to be reserved, and length of time for the
application.
2. Identify the patent. To ensure that the correct procedure is done to the
correct client.
3.Explain the procedure to the patent. Discussing the procedure to the patient help
allay , anxiety ,encourage patient cooperation and
prepare the patient for what to expect.
4. Assessment the condition of the skin Assessment supplies baseline data for post
where the heat is to be applied. treatment comparison and identify conditions that
may contraindicated the application. Very thin or
damaged skin is more susceptible to injury from
heat.
5. Assessment sensitivity to temperature and Determines whether the patient is insensitive to
plan using light touch,pinprick and heat and cold extremes.
temperature sensation tests.
6.Gather the equipments needed. Preparation of the materials promotes efficient
time management and provides an organized
approach to the task.
7.Perform hand hygiene Good hand hygiene prevents the spread of
microorganisms.
8. Close the room door or curtains. Raise the Closing the door or curtains provides privacy.
bed to a comfortable working height. Proper bed positioning helps reduce back strain
while you are performing the procedures.
9.Assist the patent to a comfortable position Patient positioning and use of a bath blanket
that provides easy access to the area to be provides comfort and warmth. Waterproof pad
treated. Exposed the area and state the patient protects the patient and the bed linens.
with a bath blanket of needed. Put a
waterproof pad under the wound area to
protect the bed. If necessary.
10.Fill the bag, ice collar or glove about Ice provides a cold surface. Excess air interferes
three-fourths full with ice. Remove any with cold conduction. Fastening the end prevents
excess air from the device. Securely fasten leaks.
the end of the bag or collar.
11. Cover the device with a towel or wash The cover protects the skin and absorbs
cloth. If the device has a cloth exterior (this condensation
is not necessary)
12. Put on gloves. Remove and dispose of Use of gloves prevents the spread of
any dressing at the site, if present. microorganisms. Dressing removal allows the
access of the treatment site.
13. Check for the presence of leaks Leaks may cause burns to the client. Change hot
water bag if a leak is noted.
14. Place the device snugly on the site and Wrapping or taping stabilizes the device in the
secure it in place with a gauze wrap or tape. proper location
15. Reassess the treatment area every five Assessment of the patient’s skin necessary for
minutes or according to institution policy early detection of the adverse effects, therby
allowing prompt intervention to avoid
complications.
16. After 20 minutes of the prescribed 133 Limiting the time of application prevents injury
amount of time, remove the ice dry the skin. due to overexposure to cold. Prolonged
application to cold may result in decreased blood
flow with resulting tissue ischemia. A
EVALUATION
The expected outcome is met when the patient reports a relief p fain and increased comfort.
Other outcomes that may be appropriate include: the patient verbalizes decreased muscle spasms;
the patient exhibits a reduction in inflammation and the patient remains free of any injury,
including signs of bleeding and hematoma at the treatment site.
REFERENCES
Wilkins.
Potter, P.A. &Perry , A.G. (2005). Fundamentals of Nursing . 6th ed. Missouri: Mosby, Inc
Smith, Pamela (2005) Taylor’s Clinical Nursing Skills: A nursing process approach Philadelphia:
Timby, Barbara ( 1996) Fundamental Skills and Concepts in patient care, 6th ed.
Philadelphia;Lippincott
134
COLLEGE OF NURSING
Dumaguete City
COLD APPLICATION
NAME:__________________________ LEVEL: __________ DATE: ____________

ASSESSMENT
2. Assess the situation to
determine appropriateness for the
application of heat.
2. Assess the patient's physical
and mental status and the
condition of the body area to be
treated with heat.
3. Confirm the physician's order
for the heat therapy, including
frequency, type of therapy, body
area to be treated ,and the length
of time for the application.
4. Assess the equipment to be
used to make sure it will function
properly
PLANNING
5.Determine what supplies and
equipment are needed
6.Wash hands for infection
control.
7.Obtain the needed equipment
IMPLEMENTATION
8.Check the physician's order or
application of heat therapy,
including frequency,type of
therapy, body area to be treated
and length of time for the
application.
9.Identify the patient.
10.Explain the procedure to the
patient
11. Assess condition of the skin
135
where the ice is to be applied.
12.Assess sensitivity to
temperature and pain using light
touch,pinprick, and temperature
sensation tests.
13.Gather the equipment needed
15.Close the room door curtains.
Raise the bed to a comfortable
working height.
16.Assist the patient to a
comfortable position that
provides easy access to the area
to be treated. Exposed the area
and drape the patient with a bath
blanket if needed.Put a
waterproof pad under the wound
area to protect the bed,if
necessary.
17.Fill the bag, ice collar or glove
about three-fourths full with ice.
Remove any excess air from the
device. Securely fasten the end of
the bag or collar.
18. Cover the device with a towel

or wash cloth. If the device has a
cloth exterior (this is not
necessary)
19. Put on gloves. Remove and
dispose of any dressing at the
site, if present.
20. place the device s=lightly
against the area. Remove the ice
and assess the site for redness
after 30 seconds. Ask the patient
about the presence of burning
sensations.
21. Place the device snugly on the
site and secure it in place with a
gauze wrap or tape.
22. Reassess the treatment area
every five minutes according to
institution policy.
23. After 20 minutes of
prescribed amount of time,
remove the ice and dry the ski.
24. Apply a new dressing to the
site if necessary.
25.Assist the patient to preferred
136
26.Do aftercare of the equipment
and dispose soiled linens .
28.Document the procedure,the
patient's response,and your
assessment of the ares before and
after the procedure.
EVALUATION
29.Evaluate using the following
criteria:
a.The patient reports a relief of
pain and increased comfort.
b.The patient verbalizes
decreased muscle spasms
c.The patient exhibits improved
wound healing,or decreased
inflammation
d. The patient remains free from
injury during and after the
procedure.
ATTITUDE
1.Punctual
3.Shows interest and willingness
to learn
4.Manifest creativity
7.Shows positive altitude towards
supervision
8.Systematic and conserves steps
9.Well groomed
10.Applies body mechanics when
TOTAL
Rating Scale:
1.5 correct measured,but with inadequate description of findings or not systematic in
performance
2- correctlydone,systematic accounting to standard: with correct findings
137
REMARKS
COLLEGE OF NURSING
Dumaguete City
STEAM INHALATION
Inhalation of warmth, moist air into the mucous membranes and respiratory tract.
PURPOSE
 To relieve inflammation and congestions of the mucous membranes of the upper

respiratory tract.
 To loosen secretions and stimulations stimulate expectoration.
 To relieve spasmodic breathing
 Prevent excessive dryness of the mucous membranes.
ASSESSMENT
Assess patient’s respiratory status, including respiratory rate, effort and lung sounds establish a
baseline and determine the effectiveness of therapy.
NURSING DIAGNOSIS
 Impaired gas exchange

 Ineffective Breathing Pattern
 Ineffective airway clearance
 Acute pain
 Activity intolerance
 Knowledge deficit
Expected outcomes:
1. Respiratory status is within acceptable parameters.

2. Patient verbalizes understanding for the reasons of steam inhalation.
PLANNING
 Determine what supplies and equipment needed.

 Obtain the needed equipment.
138
EQUIPMENT:
A.PITCHER METHOD
Pitcher
Basin
Prescribe drugs (as ordered by physician)
Face towel
Paper funnel
Newspaper
B. VAPORIZED METHOD
Vaporizer
Prescribe drug (as ordered by physician)
Face towel
Paper funnel
News paper
IMPLEMENTATION
STEP RATIONALE
A. PITCHER METHOD:
1. Identify the patient and explain what To make sure that the procedures is indicated
you are doing to do, why it is to the appropriate patient.
necessary, and he or she can
cooperate.
2. Perform hand hygiene and observe other Deters the spread of microorganisms and
appropriate infection control procedures. hinders cross-contamination.
3. Pour boiling water about one-half full

in the pitcher. Add prescribe amount of the Boiling water produces steam that would
drug ordered. enlarge the airway and loosens mucus
secretions.
4. Cover pitcher
139
To avoid spillage
5. Carry equipment and supplies to
bedside. Organization of supplies saves time and
reduces the chance of error.
6. Arrange for a quiet environment with
no interruptions. Avoid drafts during To enhance the effect of steam inhalation the
treatment time. therapy should be done for 30 min. to an
hour. The water temperature should be
retained.
7. Provide for patient privacy prn.
Maintains client’s self-esteem and ensures
orderly performance of procedures.
8. Assist patient to assume convenient
position (e.g., sitting at edge of bed, low/high This facilitates adequate chest expansion and
fowlers). lung movement during the therapy.
9. With the paper funnel, direct the steam

into the patient’s face for inhalation. Protect The paper funnel and face towel protects the
patient’s eyes with the face towel. patient’s face and eyes respectively to have
direct contact with moist heat.
10. Instruct the patient to inhale the steam.
Inhalation allows entry of the moist heat to
enter the airway thereby enhances adequate
ventilation.
11. Carry out therapy for 30 min. to one
hour, morning and evening, as tolerated or as To maximize the effect of the procedure if
ordered by the physician. administered within the prescribe duration.
12. Wipe patient dry and assist to a

comfortable position on bed. Steam produces moist that adheres to the
patient’s face. Place the patient in fowler’s
position to promote adequate ventilation and
effective breathing.
13. Protect patient from drafts after
therapy. Draft causes heat loss through convection.
14. Do after care of equipment.

Proper equipment cleaning prevents the
spread of microorganisms.
Han d hygiene deters the spread of
microorganism
16. Chart
A careful record is important for planning and
individualizing the patient’s care.
B. VAPORIZED METHOD:
22. Read manual for operation and
preparation of the device. This facilitates the proper usage and
functioning of the equipment. Instructions
may vary per manufacture.
23. Do after care of the patient and
140
equipment as in pitcher method. Proper equipment cleaning prevents the
spread of microorganisms.
24. Chart.
A careful record is important for planning and
individualizing the patient’s care.
EVLUATION
TheExpected outcome is met when the patient demonstrates improved lung sounds and
ease of breathing. In addition, patient verbalizes correct information about therapy.
REFERENCES
Kennewick,R,P. Tri-City Rose Society.2002
141
COLLEGE OF NURSING
Dumaguete City
STEAM INHALATION
Performance checklist
NAME: __________________________________ DATE:_________________

LEVEL:____________________________________

1. Identify the patient and explain what you are
doing to do, why it is necessary, and he or she can
cooperate.
2. Perform hand hygiene and observe other

appropriate infection control procedures.
3. Pour boiling water about one-half full in the

pitcher. Add prescribe amount of the drug
ordered.
4. Cover pitcher
5. Carry equipment and supplies to bedside.
6. Arrange for a quiet environment with no
interruptions. Avoid drafts during treatment time.
7. Provide for patient privacy prn.
8. Assist patient to assume convenient position
(e.g., sitting at edge of bed, low/high fowlers).
9. With the paper funnel, direct the steam into the
patient’s face for inhalation. Protect patient’s eyes
with the face towel.
10. Instruct the patient to inhale the steam.
11. Carry out therapy for 30 min. to one hour,
morning and evening, as tolerated or as ordered by
the physician.
12. Wipe patient dry and assist to acomfortable
position on bed.
13. Protect patient from drafts after therapy.
14. Do after care of equipment.
16. Chart
B. VAPORIZER METHOD
1. Read manual for operation and preparation of
142
the device.
2.Do after care of the patient and equipment as in
pitcher method.
3. Chart.
ATTITUDE:
1. Punctual

7. Shows positive attitude towards supervision
8. systematic and conserve steps
9. well groomed
10. Apply boy mechanics when performing
procedure
TOTAL
Rating Scale:
0-Not done, but essentially required
1-incorrectly done; wrong techniques and findings
1.5- Correct measures, but with inadequate description of findings or not systematic in
performance.
N/A- Not applicable.
REMARKS
143
SHIATSU AND ACUPRESSURE
DEFINITION
It is a method of maintaining health, treating diseases and alleviating pain by applying pressure
or massaging certain points on the body surfaces. Pressure is applied through the thumbs, fingers
or heels of the hand. Pressure must be tolerable, firm but not heavy enough to cause pain.
INDICATIONS
1. To alleviate stress and tension.

2. To attain new vitality and stamina.
3. To relieve discomfort.
4. To booster immunity.
5. To increase self-awareness.
6. To treat other common ailments.
CONTRAINDICATIONS
Shiatsu
1. pregnancy
2. high blood pressure
3. clients with cardiac problem
Acupressure
1. presence of skin lesion, rashes, warts, and broken bones

2. menstrual flow
3. cardiac problems
4. pregnancy
EQUIPMENT
The PH bag
Table and chair or mat
Lubricant (lotion, mentholated oil, herbal remedies)
METHODOLOGY
1. Know your client and assess him/her.
2. Explain the procedure and let him void.
3. Do the bag technique.
4. Put on apron, remove wristwatch, and take out the BP apparatus.
5. Assess vital signs (pulse rate and BP)
144
6. Client should be in sitting position. Comfort, quiet and warm room with subdued light
must be observed.
7. Rub palms briskly together before starting.
8. Begin the message to the face, twice.
9. Concentrate on points CV-25, ST-4, GV-26, Si-18, Gb-1, TW-23 and Gb-14. Then run
the fingers through the hair, gently pull it, then finger massage the ears. Make concentric
circles on point CV-25, TW-17, Gb-8, GV-20. Conclude behind the midline of the skill at
Gb-20.
10. Press on the lateral side of the neck, ending with a stretch to the neck achieved by gently
elongating it by lifting the head upward and forward.
11. Press along the top of each shoulder, doing petrisage from the base of the neck to the
blades. Rotate the shoulder blades.
12. The arms should be managed one at a time. Press down the inside part with the palm
facing up using flat hand, then with the palm facing down along the tip of the shoulder to
the back of the forearm. Have a prolonged massage along Li-11 and H-7. Let fingers
travel along palm of the hand, concluding at each finger. Pull the fingers, concentrating
on the point between the thumb and the forefinger L-14. End by shaking the area to relax
it.
13. Stretch the chest by placing both hands behind the client’s neck. Stretch both arms by
pulling on the elbows, backward with the knee placed at the midpoint of the back, in
between the scapula.
14. with the client lying prone on the mat on the floor, work on the back by doing effleurage
from the top of the back down to the lumbar region, stretching to loosen light muscles
and to establish a rhythm. Apply pressure down both sides and the back shu points with
palms and thumbs.
15. Massage the shiatsu points in the sacral region, iliac crest and gluteal region.
16. Press along the center of the back of each leg. Press on the ankle points. Stretch the leg in
each direction, then crook the knee in and the foot out to press down the alter border.
“Walk” the finger along the soles of the foot making a point to massage K-1, pull each of
the toes.
17. Turn the client to the supine position. Press along the spaces between the ribs,
concentrating on K-27.
18. Work with both hands flat using a circular kneading technique on the “hara” in the lower
abdomen, then press up gently under the lower borders of the ribs and then down
midline, ending at the navel. Use a rocking motin to call the “hara”.
19. Massage the legs one at a time, working from the groin to the feel, working down the
front of the thigh. Manipulate the patella to lossen it. Knead the lower limbs down to the
calf. Concluding at Sp-6. Dorsiflex and Plantarflex the foot, making concentric circles
and conclude by Liv-3. Shake the legs to relax it.
20. Continually assess for pain, differentiating between an anshi point or a contusion or
growth.
21. Ask client about comfort. Observe any physiologic changes that client may exhibit.
22. Reassess pulse and BP. Report any significant change in the vital signs.
23. Wash hands, preferably in warm water. Continue with bag technique. Place the apparatus
and stethoscope in plastic bag. Reture them into the PH bag.
24. Record client’s response to therapy.
REFERENCES
De Domingo, G. & Wood, E. (1997). Beard’s massage (4thed). W.B. Saunders Co.
145
Libre, A. lll (2002 Revision). Acupressure; For stress management. Philippines: DOH Phis. Inst.
Of Traditional and Alternative Health Care
COLLEGE OF NURSING
Dumaguete City
SHIATSU AND ACUPRESSURE
NAME: _________________________________________ LEVEL: _________
DATE: __________________
STEPS 0 1 1.5 2 N/ COMMEN

A TS
1. Put PH bag on a table with paper lining.
2. Know your client and assess him
accordingly.
3. Ask client to prepare warm water and pull
it in the thermos or any container that will
contain its heat.
4. Perform the bag technique.
5. Wear apron, remove wristwatch and finger
ring.
6. Take out BP apparatus and assess client’s
vital signs (BP & pulse rate).
7. Ask client to sit in a stool comfortably.
(The room must be quiet, warm and with
subdued lighting.)
8. Put your palms together in a briskly manner
to warm them.
9. Put a small quantity of lotion or
mentholated oil or herbal remedies.
10. Begin the massage to the body parts
intended to be treated. (Note: If the whole
body is intended to be massaged, a mat should
be prepared where the client may lie down.)
11. From time to time, ask client for any pain.
12. Ask client about his comfort and observe
any physiologic changes that he may exhibit.
13. Reassess pulse and Bp and record any
significant changes in the vital signs.
14. One done and over with the massage, do
hand washing in a warm water prepared
earlier.
15. Continue with the bag technique.
16. Record client’s response to therapy and do
146
some health teaching
ATTITUDE
1. Punctual
3. Show interest and willingness to learn
5. Show resourcefulness
7. Show positive attitude towards supervision
TOTAL
Rating Scale:
0- not done, but essentially required

performance
2- correctly done, systematic according to standard; with correct findings N/A- not
applicable
REMARKS
147
COLLEGE OF NURSING
Dumaguete City
BED BATH
DEFINITION:
A bath given to a patient on bed.
PURPOSES:
1. To cleanse, refresh and give comfort to the patient who must remain on bed.
2. To stimulate circulation and aid in elimination.
3. To provide for an opportunity to assess the patient’s body for any signs of abnormality.
4. To provide range motion of exercises for joints.
5. To provide opportunity for nurses-patient interaction.
6. To control body odor and promote self-esteem and sense of well-being.
7. To remove transient microorganisms, body secretions and excretions and dead skin cells.
SPECIAL CONSIDERATIONS:
1. Avoid unnecessary exposure and chilling
 Expose, wash, rinse, and dry only a part of the body at one time.
 Avoid draft.
 Use appropriate temperature of the water.
2. Observe the patient’s body closely for physical signs such as rashes, swelling,
discoloration, sores, burns, abnormal discharges and bodily lice among others.
3. Give special attention to the following areas: behind the ears, axilla, under the breast,
umbilicus, pubis region, groin and the spaces between the fingers and toes.
4. Do the bath quickly but unhurriedly and use even, smooth but firm strokes.
5. Us adequate amount of water and change as frequentlyas necessary.
ASSESSMENT:
1. Assess the patient’s ability to perform self-care and amount of assistance he or she needs.
Evaluate the patient’s activity tolerance, cognitive function, musculoskeletal function and
level of discomfort to determine type of bath needed. Note: Encourage the patient to be
as independent as possible but not to become excessively fatigued. Pain should not
be intensified.
2. Asses the patient’s preferences for bathing (i.e. frequency, time of day, type of skin care
product used).
3. Review chart to determine other procedures or therapies the patient is receiving to
coordinate scheduling and prevent fatigued.
4. Identify patients with special consideration for bathing:
 Older patients: susceptible to dry skin
 Immobilized patients: pressure areas or dependent and bony parts; need for ROM
exercises on the joint areas
 Patients with altered sensation: risk for burns from hot water
148
 Obese or diaphoretic patients: excessive perspiration or moisture on skin surfaces
that against each other and provide medium for excoriation and bacteria growth
5. Review history for precautions regarding movement and positioning.
6. Assess the patient’s knowledge and practice of hygiene to determine learning needs.
7. Assess the need for use clean gloves during the bath.
NURSING DIAGNOSIS:
 Self-care deficit: Bathing/Hygiene

 Altered comfort: Acute pain
 Ineffective coping
 Knowledge deficit
 Body image disturbance
 Impaired skin integrity
 Impaired social interaction
The expected outcome should be:
 Patient state pain is relieved.

 Patient displays increased in comfort.
 Patient verbalizes decreased muscle spasms.
 Patient exhibits improved wound healing.
 Patient demonstrates reduction in inflammation.
 Patient remains free from injury.
 Patient verbalizes understanding for reasons behind treatment modality.
Note: Other outcomes may be understanding depending on the patient’s nursing diagnoses.
PLANNING:
1. Determine what supplies and equipment’s are needed.
2. Determine whether or not you will need any assistance.
EQUIPMENT:
Pitcher filed with lukewarm water (110°-115° F: 43.3°- 46.1 °C). test by measuring with bath
thermometer or by placing several drops on your inner forearm.
Bath blanket
Two bath towels
Teo washcloths
Face towel (optional)
Bath basin
Soap in soap dish
Gown or pajama
Bed pan or urinal
Bed screen (if in ward)
149
Linen for changing the beddings
Paper lining or rubber sheet
Disposable clean gloves
Personal skin-care products (deodorant, powder, lotion, cologne)
Comb (patient’s own)
Nail cutter
IMPLEMENTATION:
ACTION RATIONALE
2. Explain the patient what you are going Discussing the procedure to the patient help
to do, why it is necessary and how he allay anxiety, encourage patient cooperation,
or she can cooperate. Discuss to the and prepare the patient for whatto expect.
patient the plan for bathing and
explain may unfamiliar procedures
3. Provide for patient’s privacy by Privacy is important to maintain the patient’s

drawing the curtains around the bed or dignity.
closing the door to the room. If in
ward, use bed screen prn.
4. Prepare the patient and the

environment.
a. Invite a family member or To make the patient comfortable and this will
significant other to participate promote independence from the care giver
if desired. (nurse).
b. Close windows and door to Air currents increase the loss of heat from the
ensure the room is in a body by convection.
comfortable temperature.
c. Offer the patient a bedpan or Warm water and activity can stimulate the
urinal or ask whether the need to void. The patient will be more
patient wishes to use the toilet comfortable and relaxed after elimination.
or commode. Furthermore, it prevents interruption of the
procedure.
d. Encourage the patient to This promotes independence, exercise and

perform as much personal care self-esteem.
as possible.
5. Wash hands thoroughly. Good hand hygiene reduces the transmission

of microorganisms.
6. Raise the bed at a comfortable This avoids undue reaching and straining and
working height. Lock up side rails on promotes good body mechanics.
150
opposite side of bed from you. Lower
the side rail on the side closer to you.
Assist the client to move near you.
7. Loosen top covers at foot or bed, then Removalof top linens prevents them from
place bath blanket over top sheet. Fold becoming soiled or moist during bath.
and remove top sheet from under Blankets provide warmth and privacy.
blanket. If possible, have patient hold
bath blanket while you withdraw the
top sheet.
Proper disposable prevents transmission of
8. If top sheet is to reuse, fold it and microorganisms.
place it over the bedside chair. If it is
to be changed, dispose to a laundry
nag, taking care not to allow linen to
come in contact with your uniform.
Provides full exposure of body parts during
9. Remove patient’s gown or pajamas bathing. Undressing unaffected side first
while maintaining privacy. If allows easier manipulation of gown over body
extremity is inured or has reduced part with reduced ROM.
mobility, begin removal from the
unaffected side. If the patient has
intravenous (IV) tube, remove gown
from arm without IV first, and then
lower IV container and slide gown
covering affected arm over tubing
container. Hang the IV container back
to he IV pole and check the flow rate.
Raising side rails maintains safety as you
10. Pull the side rail up. Fill bath basin leave the bedside. Lukewarm water promotes
with two-thirds full lukewarm water. comfort and prevents chilling. Testing
Have patient place fingers to test temperature prevents accidental burning of
temperature tolerance. patient’s skin.
Removal of pillow makes it easier to wash

11. Lower side rail. Remove pillow if patient’s ears and neck. Placement of towel
allowed and raise head of bed 30° to prevents soiling of bed linen.
45°. Place bath towels under patient’s
head and across chest.
Prevents splashing.
12. Immerse wash cloth in water and
wring thoroughly.
A bath mitt retains water and heat than a cloth
13. Make bath mitt with the washcloth. loosely held and prevents ends of washcloth
from dragging across the skin.
Washing eye from inner to outer canthus

14. Cleanse eyes with water only, wiping prevents secretions from entering and
from inner to outer canthus. Use a irritating nasolacrimal ducts. Using separate
separate corner of the wash cloth for corner of each eye prevents transfer of
each eye. Soak encrustations on eyelid microorganisms from one eye to the other.
151
for 2-3 minutes with dump cloth
before attempting removal. Dry eye
thoroughly but gently.
Soap has a drying effect and the face which is
15. Determine if patient would like soap exposed to the air more than the body parts
on face. Wash, rinse and dry well tends to be drier.
forehead, cheeks, nose, neck and ears.
16. Remove bath bowel from under

patient’s head.
Prevents soiling of the bed.
17. Remove bath blanket from client’s
arm that is closest to nurse. Place bath
towel lengthwise under arm. Soap lower surface tension and facilitates
removal of debris and bacteria when friction
18. Bathe arm with soap and water using is applied during washing. Long, firm strokes
long, firm strokes from the fingers stimulate circulation and are relaxing and
towards the axilla. Raise and support more comfortable than uneven strokes.
arm above head (if possible) while Movement of arm exposes and exercises
thoroughly washing the axilla. joint’s normal ROM.
Alkaline residue from soap discouraged

growth of normal skin bacteria. Excess
19. Rinse and dry arm and axilla moisture causes maceration or softening.
thoroughly. If patient prefers, apply Deodorant controls body odor.
deodorant or talcum powder.
Soaking softens cuticles and calluses of hands
and loosens debris beneath nails. Soaking also
20. Place a folded towel on the bed next to enhances feeling of cleanliness. Thorough
the patient’s hand and put basin on it. drying removes moisture from between
Immerse patient’s hand in water and fingers.
allow to soak for 3-5 minutes. Wash,
rinse and dry hand well.
21. Raise side rail and move to other side

of bed. Lower side rail and repeat
steps for another arm. Use of warm water maintains patient’s
comfort. Raising the side rails prevents
22. Change water and check temperature accidental falls when leaving the patient to
of bath water. Side rails should be up. change water.
To keep the patient warm while preventing

unnecessary exposure of body parts.
23. Spread a towel across patient’s chest.
Lower bath blanket to patient’s
umbilical area. Exposing, washing, rinsing, ad drying one
part of the body at a time avoids unnecessary
24. With one hand, lift edge of towel exposure and chilling. Skin folds areas may
away from chest. With mitted hand, be sources of odor and skin breakdown if not
bathe chest using long, firm strokes. cleansed and dried properly.
Give special attention to skin under
152
the breasts and any other skin under
the breasts and nay well. Apply a light
dusting of bath powder under the
breasts or between skin folds. Prevents chilling and exposure of the body
parts.
25. Place bath towels horizontally across
the abdomen first and then across the
chest. Folds blanket down just above
the pubic region. Moisture and sediment that collect in skin
predispose patient to skin maceration and
26. With one hand, lift edge of towel irritation.
away from chest. With mitted hand,
bathe abdomen giving special
attention to bathing umbilicus and
abdominal folds of creases. Stroke
from side to side. Keep the abdomen
covered between washing and rinsing.
Dry well. Position the towel and bath blanket protects
patient’s privacy and provides warmth.
27. Assist patient to prone or side-lying
position facing away from you.
Position bath blanket and towel to
expose only the back and buttocks.
Place a bath towel lengthwise
alongside the back and buttocks.
Apply gloves. Fecal material near the anus may be a source
of microorganisms. Prolonged pressure on the
28. Wash, rinse and dry and buttocks area. sacral area or other bony prominences may
NOTE: Pay particular attention to compromise circulation and lead to the
cleansing gluteal folds and observe development of decubitus ulcer.
for ay redness of skin breakdown in
the sacral area. Maintains patient’s warmth and comfort.
Dressing the affected area first allows easier
29. Assist the patient don a clean gown. If manipulation of gown over body part with
one extremity is injured or reduced ROM.
immobilized, always dress the affected
side first.
30. Change water and check bath water

temperature. Side rails should be up. Prevents unnecessary exposure.
31. Cover chest and abdomen with top of

bath blanket. Expose near leg by
folding blanket over toward midline.
Be sure perineum is draped. The towel protects linens and prevents the
patient from feeling uncomfortable from a
32. Bend patient’s leg and knee by damp or wet bed. Support of joint and
positioning your arm under leg. While extremity during lifting prevents strain on
grasping patient’s heel, elevate leg musculoskeletal structures.
from mattress slightly and slide both
towel lengthwise under leg. Washing from ankle to groin with firm
153
strokes promotes venous return.
33. Using firm stroke, wash, rinse and dry
leg from ankle to knee and knee to
groin. Supporting the patient’s foot and leg helps
reduction strain and discomfort of the patient.
34. Fold a towel near patient’s foot area Placing the foot in a basin of water is
and place basin on it. Place foot in comfortable and relaxing and allows thorough
basin while supporting the ankle and cleaning of the feet and the areas between the
heel in your hand and the leg on your toes and under the nails.
arm. Wash, rinse and dry paying
particular attention to area between
toes. If skin is dry, apply location.
35. Repeat steps 31-34 for the other leg

and feet.
36. Cover patient with bath blanket. Raise Drop in water temperature during the bathing
side rail for patient’s safety and can cause chilling. Clean water reduces
change bath water. microorganism’s transmission.
37. Assess if the patient can wash genitals Maintains patient’s privacy. Patient’s capable
and perineal area independently. If the of performing partial bath usually prefer to
patient needs care, drape with blanket wash their own genitalia. Skin folds are site
so that only genitals are exposed. Don for accumulation of secretions and moisture.
disposable gloves. Using fresh water
and a new cloth. Wash, rinse and
genitalia and perineum.Give special
attention to skin folds.
38. Assist patient in washing hands

thoroughly by pouring water from the
pitcher.
39. Assist patient in putting on clean

underwear.
40. Complete care according to patient’s Involving patient in his care nurtures self-
preferences. Apply powder, lotion and esteem and self-care.
cologne as per patient’s request. Assist
with hair, nail and mouth care. Make
bed with clean linen.
41. Clean equipment and return to These actions deter the spread of
appropriate storage area. Dispose microorganisms.
gloves and perform hand hygiene.
Dispose soiled linens according to
institution policy.
42. Record any significant observations A careful record is important for planning and
on the chart and refer accordingly. individualizing the patient’s care.
154
EVALUATION:
The expected outcomes are met when the patient is clean, demonstrates some feeling of control
in his or her care; verbalizes an improved body image; and states the importance of cleanliness.
REFERENCES:
Evan-Smith, P. (2013). Fundamental of Nursing. 8th ed. Philadelphia: Lippincott Williams and
Wilkins.
Potter, P.A and Perry, A.G. (2013). Fundamentals of Nursing. 8th ed. Missouri: Mosby, Inc.
Smith, Pamela (2011) Taylor’s Clinical Nursing Skills: A Nursing Process Approach
Timby, Barbara (2009) Fundamental Skills and Concepts in Patient Care, 9th ed.
Philadelphia: Lippincott
155
COLLEGE OF NURSING
Dumaguete City
BED BATH
Perform Checklist
Student’sName:________________________________________Level:______
Date:________

D
ASSESSMENT
1. Assess the patient’s ability to
perform self-care and amount of
assistance he or she needs. Evaluate
the patient’s activity tolerance,
cognitive function, musculoskeletal
function, and level of discomfort to
determine type of bath needed.
2. Assess the patient’s preferences for
bathing (i.e. frequency, time of day,
type of skin care product used).
3. Review chart to determine other
procedures or therapies the patient is
receiving to coordinate scheduling
and prevent fatigued.
4. Identify patients with special
considerations for bathing:
 Older patients: susceptible to
dry skin
 Immobilized patients:
pressure areas or dependent
and bony parts; need for
ROM exercises on the joint
areas
 Patients with altered
sensation: risk for burns
from hot water
 Obese or diaphoretic
patients: excessive
perspiration or moisture on
skin surfaces that against
each other and provide
medium for excoriation and
bacterial growth.
156
5. Review history for precautions
regarding movement and
positioning.
6. Assess the patient’s knowledge and
practice of hygiene to determine
learning needs.
7. Assess the need for use clean gloves
during the bath.
PLANNING
9. Determine whether you will need
any assistance.
IMPLEMENTATION
13. Explain the patient what you are
going to do, why it is necessary and
how he or she cooperate. Discuss to
the patient the plan for bathing and
explain may unfamiliar procedures.
14. Provide for patient’s privacy by
drawing the curtains around the bed
or closing the door to the room. If in
ward, use bed screen prn.
15. Prepare the patient and the
environment.
a. Invite a family member or
significant other to
participate if desired.
b. Close windows and door to
ensure the room is in a
comfortable temperature.
c. Offer the patient wishes or
urinal or ask whether the
patient wishes to use the
toilet or commode.
d. Encourage the patient to
perform as much personal
care as possible.
16. Wash hands thoroughly.
17. Raise the bed at a comfortable
working height. Lock up side rail on
opposite side of bed from you.
Lower the side rail on the side closer
to you. Assist the client to move
near you.
18. Loosen top covers at foot of bed,
then place bath blanket over top
157
sheet. Fold and remove top sheet
from under blanket. If possible, have
patient hold bath blanket while you
withdraw the top sheet.
19. If top sheet is to reuse, fold it and
place it over the bedside chair. If it
is to be changed, dispose to a
laundry bag, taking care not to allow
linen to come in contact with your
uniform.
20. Remove patient’s gown or pajamas
while maintaining privacy. If
extremity is injured or has reduced
mobility, begin removal from the
unaffected side. If the patient has
intravenous (IV) tube, remove gown
from arm without IV first and then
lower IV container and slide gown
covering affected arm over tubing
container. Hang the IV container
back to the IV pole and check the
flow rate.
21. Pull the side rail up. Fill bath basin
with two-thirds full lukewarm water.
Have patient place fingers to test
temperature tolerance.
22. Lower side rail. Remove pillow if
allowed and raise head of bed 30° to
45°. Place bath towels under
patient’s head and across chest.
23. Immerse washcloth in water and
wring thoroughly.
24. Make bath mitt with the washcloth.
25. Cleanse eyes with water only,
wiping from inner to outer canthus.
Use a separate corner of the wash
cloth for each eye. Soak
encrustations on eyelid for 2-3
minutes with dump cloth before
attempting removal. Dry eye
thoroughly but gently.
26. Determine if patient would like soap
on face. Wash, rinse and dry well
forehead, cheeks, nose, neck and
ears.
27. Remove bath towel from under
patient’s head.
28. Expose patient’s near arm and place
towel lengthwise under it.
29. Bathe arm with soap and water
using long, firm strokes from the
158
fingers towards the axilla. Raise and
support arm above head (if possible)
while thoroughly washing the axilla.
30. Rinse and dry arm and axilla
thoroughly. If patient prefers, apply
deodorant or talcum powder.
31. Place a folded towel on the bed next
to the patient’s hand and put basin
on it. Immerse patient’s hand in
water and allow to soak for 3-5
minutes. Wash, rinse, and dry hand
well.
32. Raise side rail and move to other
side of bed. Lower side rail and
repeat steps for another arm.
33. Change water and check
temperature of bath water. Side rails
should be up.
34. Spread a towel across patient’s
chest. Lower bath blanket to
patient’s umbilical area.
35. With one hand, lift edge of towel
bathe chest using long, firm strokes.
Give special attention to skin under
the breasts and any other skin folds
of patient. Rinse and dry well.
Apply a light dusting of bath
powder under the breasts or between
skin folds.
36. Place bath towels horizontally
across the abdomen first and then
across the chest. Fold blanket down
just above the pubic region.
37. With one hand, lift edge of towel
bathe abdomen giving special
attention to bathing umbilicus and
abdominal folds of creases. Stroke
from side to side. Keep the abdomen
covered between washing and
rinsing. Dry well.
38. Assist patient to prone or side-lying
position facing away from you.
Position bath blanket and towel to
expose only the back and buttocks.
Place a bath towel lengthwise
alongside the back and buttocks.
Apply gloves.
39. Wash, rinse and dry back and
buttocks area. NOTE: Pay
159
particular attention to cleansing
gluteal folds and observe for any
redness of skin breakdown in the
sacral area.
40. Assist the patient don a clean gown.
If one extremity is injured or
immobilized, always dress affected
side first.
41. Change water and check bath water
temperature. Side rails should be up.
42. Cover chest and abdomen with top
of bath blanket. Expose near leg by
folding blanket over toward midline.
Be sure perineum is draped.
43. Bend patient’s leg and knee by
positioning your arm under leg.
While grasping patient’s heel,
elevate leg from mattress slightly
and slide both towel lengthwise
under leg.
44. Using long firm stroke, wash, rinse,
and dry leg from ankle to knee and
knee to groin.
45. Fold a towel near patient’s foot area
and place basin on it. Place foot in
basin while supporting the ankle and
heel in your hand and the leg on
your arm. Wash, rinse and dry
paying particular attention to area
between toes. If skin is dry, apply
lotion.
46. Repeat steps 31-34 for the other leg
and feet.
47. Cover patient with bath blanket.
Raise side rail for patient’s safety
and change bath water.
48. Assess if the patient can wash
genitals and perineal area
independently. If the patient needs
care, drape with blanket so that only
genitals are exposed. Don
disposable gloves. Using fresh water
and new cloth. Wash, rinse and
genitalia and perineum. Give special
attention to skinfolds.
49. Assist patient in washing hands
thoroughly by pouring water from
the pitcher.
50. Assist patient in putting on clean
underwater.
51. Complete care according to patient’s
160
preference. Apply powder, lotion
and cologne as per patient’s request.
Assist with hair, nail and mouth
care. Make bed with clean linen.
52. Clean equipment and return to
appropriate storage area. Dispose
Dispose soiled linens according to
institution policy.
53. Record any significant observations
on the chart and refer accordingly.
EVALUATION
a. The patient is clean.
b. The patient demonstrates some
feeling of control in his or her.
c. The patient verbalizes an improved
body image.
d. The patient states the importance of
cleanliness.
ATTITUDE:
1. Punctual
learn
supervision
8. Systemic and conserve steps
9. Well groomed
10. Apples body mechanics when
TOTAL
RATING SCALE:
S- Satisfied
U- Unsatisfied
C- Comments
REMARKS:
161
COLLEGE OF NURSING
Dumaguete City
GIVING A BED SHAMPOO
The act of washing the hair and scalp to a patient who must remain on bed.
PURPOSES:
 To clean the hair and scalp.
 To stimulate the blood circulation to the scalp through massage.
 To promote patient comfort and sense of well-being.
ASSESSMENT:
1. Assess patient’s activity level and identify positioning restrictions.
2. Assess condition of the hair and scalp.
3. Assess usual hair care practices and routinely used hair care products.
4. Assess whether wetting the hair will make it difficult to comb.
5. Assess evenness of hair growth over the scalp; hair texture, oiliness, thickness or thinness
on the scalp; presence of hirsutism.
6. Assess self-care abilities.
NURSING DIAGNOSIS:
Determine the related factors for the nursing diagnoses based on patient’s current status.
1. Self-care Deficit: Bathing/Hygiene
2. Activity Intolerance
3. Impaired Physical Mobility
4. Impaired Transfer Ability
5. Impaired Social Interaction
6. Disturbed Body Image
Expected Outcomes:
1. Patient’s hair will be clean.
2. Patient able to tolerate procedure without little or no difficulty.
3. Patient will demonstrate an improved body image.
4. Patient will state an increase in comfort.
PLANNING
1. Determine whether or not you will need any assistance.
162
EQUIPMENT:
Small pillow or rolled linen Patient’s gown
Rubber sheet (big) Linen for changing the beddings
2-3 bath towels Comb and brush (patient’s own)
Face towel Shampoo (patient’s own)
Cotton balls Disposable clean gloves (optional)
Pail or Bucket Newspaper and Waste receptacle
Pitcher filled with warm water (110°-115°F; 43.3°-46.1°C)
IMPLEMENTATION
STEP RATIONALE
1. Determine whether the physician’s To ensure that shampooing the hair is or not
order is needed before a shampoo can contraindicated for the patient.
be given.
2. Determine the type of shampoo to be

used (e.g., medicated shampoo).
3. Determine the best time of day for the

shampoo. Discuss with patient. A
person who must remain in bed may
find the shampoo tiring. Choose a
time when the patient is rested and can
rest after the procedure.
4. Prepare equipment and arrange at Organization facilities performed of tasks.

bedside.
5. Explain to the patient what you are Allays fear and anxiety thereby promoting
going to do, why it is necessary and patient cooperation and participation.
how he or she can cooperate.
6. Perform hand hygiene. If you suspect Hand hygiene deters the spread of
there are any cuts on the scalp or microorganisms. Gloves protect the nurse
blood in the hair, done disposable from any pathogens.
gloves.
7. Provide for patient privacy by drawing Privacy is important to maintain the patient’s
the curtains around the bed or closing dignity.
the door to the room. If in ward, use
bed screen prn.
8. Offer the patient bedpan or urinal or Prevent interruption of the procedure.

ask whether the patient wishes to use
9. Remove pillow. Place bath towel on

top pillow (optional).
10. Assist patient to lie diagonally across
163
bed with the head near the edge of the
bed.
11. Fanfold the top bedding down to the The folded bedding will stay dry and the bath
waist and cover the upper part of the blanket which can be discarded after the
patient with the bath blanket. shampoo, will keep the patient warm.
12. Place a bath towel underneath Keeps the shoulders dry and the bed from
patient’s head and shoulders. getting soiled.
13. Unless contraindicated, place a small This hyperextends the neck.

pillow or rolled linen under patient’s
neck. Make sure that the patient is in a
14. Make the rubber sheet into an Prevents the linen from getting soiled or wet.
improvised Kelly pad and place
underneath patient’s head.
15. Tuck a bath towel around the patient’s Keeps the shoulders dry.
shoulders.
16. Put pail or bucket on chair lined with The pail or bucket will catch he runoff water,
newspaper and place at side of bed. preventing a mess on the floor.
17. Remove pins and ribbons from the Removing tangle and distribution scalp oils
hair, and brush and comb it to remove through hair result in through cleansing.
tangles. Place combings in waste
receptacle.
18. Place cotton balls in the patient ears. These keep water from collecting in the ear
canals.
19. Place a damp washcloth over the The washcloth protects the yes from soapy
patient’s eyes. water. A damp washcloth will not slip.
20. Slowly pour warm water Warm water is comfortable and relaxing for
(approximately 110°F or 43.3°C) the patient. It also stimulates circulation and
water from the pitcher over the hair provides for more effective cleansing.
until it is completely saturated. Check
temperature by placing small amount Checking the water temperature protects the
of water on your inner forearm. face and scalp from becoming burned.
21. Apply a small amount of shampoo to Shampoo will help to remove dirt or excess il.
patient’s har. Make a good lather with
the shampoo while massaging the Massaging stimulates the blood circulation in
scalp with the pads of your fingertips. the scalp. The pads of the fingers are used so
Massage all areas of the scalp that the fingernails will not scratch the scalp.
systematically (e.g. starting at the
front and working toward the back of Systematic lathering ensures thorough
the head). Lift head slightly with one cleansing.
164
hand to wash back. Shampoo sides of
head.
22. Rinse hair with warm water. Reapply Soap residue in hair may dry and irritate the
shampoo and repeat massage prn. hair and scalp.
23. Rinse hair thoroughly with arm water.

Squeeze as much water as possible out
of the hair with your hands.
24. If patient has thick hair or requests, Conditioner moisturizes her and scallop and
apply a small amount of conditioner to eases tangles making combing easier.
hair and massage throughout.
25. Rinse with warm water and squeeze

out excess moisture from hair. Wrap
bath towel around hair. Remove
rubber sheet.
26. Pat hair dry use. Another towel if

necessary.
27. Remove equipment and wet towels

from bed. Place pillow protected with
dry towel.
28. Gently comb and brush hair, removing Removing tangles help hair to dry faster.
tangles as needed and dry with dryer if Combing/Brushing hair improves patient’s
desired. self-image.
Blow drying hair helps hair to dry faster and

prevents patient from becoming chilled.
29. Change patient’s gown prn. If patient’s gown is damp, patient will
become chilled.
30. Assist patient to a comfortable

position.
31. Do aftercare of equipment and dispose

of soiled linen.
32. Perform hand hygiene. Hand hygiene deters the spread of

microorganisms.
33. Document that hair was washed and A careful record is important for planning and
record any unusual findings and individualizing the patient’s care.
untoward reactions.
EVALUATION:
165
The expected outcomes are met when the patient’s hair is clean, the patient verbalizes a
positive body image, reports an increase in comfort level as is able to tolerate the procedure
without excessive fatigued.
SAMPLE CHARTING:
NURSES’S REMARK SHEET

NAME OF PATIENT: _____________________________________
ROOM AND BED NUMBER: _______________________________
DATE TIME DIET AND NURSES’S REMARKS

THERAPY
11/29/09 0800H Received awake on bed with D5LR at
right metacarpal vein 750 cc level. Flow
rate regulated at 22 gtts/min. BP= 110/70
mmHg; T= 36.5°C; PR= 68 bpm, strong
and without effort. Bed bath done for 30
minutes. No signs of inflammation, rashes
or excessive dryness noted. Applied
deodorant and lotion after bath. Able to
perform active ROM. Tolerated procedure
well. Hair washed using Rejoice shampoo.
Slight dandruff noted. No lesions, cuts
luce and nitsnoted on hair and scalp.
Verbalized feeling refreshed and clean
after the shampoo.
REFERENCES:
Evans-Smith, Pamela (2014) Taylor’s Clinical Nursing Skills: A Nursing Process Approach.
Kozier, Barbara et al (2016) Fundamentals of Nursing: Concepts, process and Practice, 10th
ed. New Jersey: Prentice-Hall.
Potter, Patricia and Anne Perry (2013) Fundamentals of Nursing, 8th ed. St. Louis: Mosby. Inc.
166
COLLEGE OF NURSING
Dumaguete City
GIVING A BED SHAMPOO
Perform Checklist
Student’s Name:_______________________________________ Level:______
Date:________

D
1. Assess need for bed shampoo.
2. Obtain physician’s order.
3. Prepare equipment and arrange at
bedside.
4. Explain procedure to the patient.
5. Perform hand hygiene and observe
other appropriate infection control
procedure as needed.
6. Provide for patient privacy.
7. Offer the patient bedpan or urinal
or ask whether he/she wants to use
8. Remove pillows. Place bath towel
on top pillow (optional).
9. Assist patient to lie diagonally
across bed with the head near the
edge of the bed.
10. Fanfold the top bedding down to
the waist and cover the upper part
of the patient with the bath
blanket.
11. Place a bath towel underneath
patient’s head and shoulders.
12. Place a small pillow or rolled linen
under patient’s neck. Make sure
that the patient is in a comfortable
position.
13. Form the rubber sheet into an
improvised Kelly pad and place
underneath patient’s head.
14. Tuck a bath towel around the
patient’s shoulders.
15. Places pail or bucket in chair lined
167
with newspaper and place at side
of bed.
16. Remove pins and ribbons from the
hair and brush and comb it to
remove tangles. Place combings in
waste receptacle.
17. Place cotton balls in the patients’
ears.
18. Place a damp washcloth over the
patient’s eyes.
19. Check temperature of water.
Slowly pour warm water from the
pitcher over the head making sure
that the hair is completely wet.
20. Apply a small amount of shampoo
to patient’s hair. Make a good
lather with the shampoo while
massaging deep into the scalp.
21. Rinse hair with warm water.
Reapply shampoo and repeat
massage prn.
22. Rinse hair thoroughly with warm
water. Squeeze as much water as
possible out of the hair with your
hands.
23. Apply small amount of conditioner
to hair and massage throughout.
24. Rinse with warm water and
squeeze out excess moisture from
hair.
25. Place towel around patient’s head.
Remove rubber sheet.
26. Pat hair dry use. Another towel if
necessary.
27. Remove equipment and wet towels
from bed. Place pillow protected
with dry towel.
28. Gently comb and brush hair,
removing tangles as needed and
dry with dryer if desired.
29. Change patient’s gown prn.
30. Assist patient to a comfortable
position.
31. Do aftercare of equipment and
dispose of soiled linen.
33. Document the shampoo an any
assessments.
ATTITUDE:
1. Punctual
168
learn
supervision
8. Systemic and conserves steps
9. Well groomed
10. Apples body mechanics when
TOTAL
RATING SCALE:
S- Satisfied
U- Unsatisfied
C- Comments
REMARKS:
169
COLLEGE OF NURSING
Dumaguete City
PERINEAL CARE
DEFINITION:
Perineal care involves the cleansing of the upper thighs, the labia majora, and the folds
between the labia majora and minora in women. For men, this involves washing the upper
inner thighs, the penis, and the scrotum;in uncircumcised men, the foreskin must be retracted,
and the glands penis washed. For both sexes, the buttocks are cleaned after the genitals, from a
side-lying position. Perineal care is usually part of the complete bed bath. Patients most in need
of medical care are those at greatest risk for acquiring an infection (e.g., uncircumcised males,
patients who have indwelling urinary catheters, or patients recovering from rectal or genital
surgery or childbirth). In addition, women who are having a menstrual period will require good
perineal care.
PURPOSES:
a. To remove normal perineal secretions and odors.
b. To promote patient comfort.
ASSESSMENT:
1. Identify patients at risk for developing infection of genitalia, urinary tract, or reproductive
tract (e.g., uncircumcised male, recent rectal or perineal surgery, presence of indwelling
catheter, urinary or fecal incontinence).
2. Assess for the presence of irritation, excoriation, inflammation, swelling; excessive
discharge, odor, pain or discomfort.
3. Assess patient’s cognitive and musculoskeletal function.
4. Assess perineal-genital hygiene practices and self-care activities.
NURSING DIAGNOSES:
Appropriate nursing diagnoses may include:
1. Self-care deficit: hygiene
2. Knowledge deficit
4. Impaired skin integrity
5. Risk for impaired skin integrity
The expected outcome to achieve when giving a perineal care is that the patient will be clean and
fresh, other outcomes that may be appropriate include the following: patient regains feelings of
170
control by assisting with perineal care; and patient demonstrates understanding about the need
for cleanliness.
PLANNING:
 Determine what supplies and equipment are needed
EQUIPMENT:
Wash basin Special perineal-genital care:
Soap dish with soap Cotton balls or swabs
Two or three washcloths Solution bottle, pitcher, or container
Bath towel filled with warm water or prescribed
Bath blanket solution
Moisture resistant bag or receptacle for used cotton swabs
Waterproof pad or bedpan
Toilet tissue or diaper wipes
Disposable gloves
IMPLEMENTATION:
STEP RATIONALE
1. Identify the patient and assess his or Patients at risk for infection in perineal area
her knowledge on the importance of may be unaware of the importance of
perineal hygiene. cleanliness. Reflects the patient’s need for
education.
2. Explain procedure and its purpose to Helps minimize anxiety during procedure that
patient. is often embarrassing to nurse and patient.
3. Perform hand hygiene. Hand hygiene and glowing prevent the spread
of microorganisms.
4. Prepare necessary equipment and Facilitates easy organization of tasks.

supplies.
5. Pull curtain around patient’s bed or Maintains patient’s privacy and ensures
close room door. Assemble supplies at orderly procedure.
bedside.
6. Raise bed to comfortable working Facilitates good body mechanics. Provides

position. If raised, lower side rail, and easy access to genitalia.
assist patient in assuming side-lying
procedure, placing towel lengthwise
along patient’s side and keep patient
covered with bath blanket or top sheet.
7. Apply disposable gloves.

Eliminates transmission of microorganisms.
171
8. If fecal material is present, enclose in
a fold of underpad or toilet tissue, and Cleansing reduces transmission of
remove with disposable wipes or microorganism from anus to urethra or
tissue. Cleanse buttocks and anus, genitalia.
washing front to back. Cleanse, rinse
and dry area thoroughly. If needed,
place an absorbent pad under patient’s
buttocks. Remove and discard
underpad and replace with clean one.
9. Change gloves when they are soiled.

Perform hand hygiene.
Eliminates transmission of microorganisms.
10. Fold top bed linen down toward foot
of bed and raise patient’s gown above
genital area. Prepare bed linen to Exposes perineal area for easy accessibility.
protect patient’s privacy.
“Diamond”drapethe patient by
placing the bath blanket with one
comer between patient’s legs, one Prevents unnecessary exposure of body parts
corner pointing toward each side of and maintains patient’s warmth and comfort
bed and one corner over patient’s during procedure.
chest. Tuck side corners around
patient’s legs and under hips.
11. Raise side rail. Fill washbasin with

warm water.
Prevents patient from falling. Proper water
12. Place washbasin and toilet tissue on temperature prevents burns to perineum.
overbed table. Place washcloths in
basin.
13. Provide perineal care.
FEMALE PERINEAL CARE
1. Assist patient to dorsal recumbent

position.
Provides easy access to genitalia.
2. Lower side rail and help patient flex
knees and spread legs. Note
restrictions or limitations in patient’s Provides full exposure of female genitalia.
positioning. Minimize degree of abduction in female if
position causes pain because arthritis or
3. Fold lower corner of bath blanket up reduced joint mobility.
between patient’s legs onto abdomen.
Wash and dry patient’s upper thighs. Minimizes transmission of microorganisms.
4. Wash labia majora. Use nondominant

hand to gently retract labia from thigh;
172
with dominant hand, wash carefully Skinfolds may contain body secretions that
skinfolds. Wipe in direction from harbor microorganisms. Wiping from
perineum to rectum (front to back). perineum to rectum (rectum to back) reduces
chance of transmitting fecal organism to
5. Separate labia with nondominant hand urinary meatus.
to expose urethral meatus and vaginal
orifice. With dominant hand, wash Cleansing method reduces transfer of
downward from pubic area toward microorganisms to urinary meatus. (for
rectum in one smooth stroke. Cleanse menstruating women or patients with
thoroughly around labia minora, indwelling urinary catheter, cleanse with
clitoris and vaginal orifice. cotton balls).
6.
7. If patient uses bedpan, pour warm Rinsing removes soap and microorganisms
water over perineal area. Dry perineal more effectively than wiping. Retained
area thoroughly, using front-to-back moisture harbors microorganisms.
method.
8. Fold lower corner of bath blanket back Provides full exposure of male genitalia.
between patient’s legs and over
perineum. Ask patient to lower legs
and assume comfortable position.
MALE PERINEAL CARE
a. Lower side rails and assists patient to Minimizes transmission of microorganisms.

supine position. Note restriction in Keeping the patient draped until procedure
mobility. begins minimizes anxiety. Build up to
perineal secretions can soil surrounding skin
surfaces.
b. Fold lower corner of bath blanket up
between patient’s legs and onto Towel prevents moisture from collecting in
abdomen. Wash and dry patient’s inguinal area. Gentle but firm handling
upper thighs. reduces chance of patient having an erection.
Secretions capable of harboring
microorganisms collect underneath urethra.
c. Gently raise penis and place bath
towel underneath. Gently grasp shaft Direction of cleaning moves from area of
of penis. If patient is uncircumcised, least contamination to area of most
retract foreskin. If patient has an contamination, preventing microorganisms
erection, defer procedure until later. from entering urethra.
173
d. Wash tip of penis at urethral meatus
first. Using circular motion, cleanse Tightening of foreskin around shaft of penis
from meatus outward. Discard can cause local edema and discomfort.
washcloth and repeat with clean cloth
until penis is clean. Rinse and dry
gently.
e. Return foreskin to its natural position.

Vigorous massage of penis can lead to
erection, which can embarrass patient and
nurse. Underlying surface of penis may have
greater accumulation of secretions. Abduction
of legs provides easier access to scrotal
tissues.
f. Wash shaft of penis with gentle but Pressure on scrotal tissue can be painful to
firm downward strokes. Pay special patient. Secretions collect between skinfolds.
attention to underlying surface of
penis. Rinse and dry penis thoroughly.
Instruct patient to spread legs apart
slightly.
g. Gently cleanse scrotum. Lift it

carefully and wash underlying
skinfolds. Rinse and dry.
h. Fold bath blanket back over patient’s Draping promotes comfort and minimizes
perineum and assist patient in turning patient’s anxiety. Side-lying position provides
to side lying position. access to anal area.
9. If patient has had urinary or bowel Protects the skin from excess moisture and
incontinence, apply thin layer of skin toxins from urine or stool.
barrier containing petrolatum or zinc
oxide over anal and perineal skin.
10. Remove disposable gloves, dispose in Moisture and body secretions on gloves can
proper receptacle and perform hand harbor microorganisms.
hygiene.
11. Assist patient in assuming a Patient’s comfort helps to minimize stress to

comfortable position and cover with procedure.
sheet.
12. Remove bath blanket and dispose of Reduces transmission of microorganisms.

all soiled bed linen. Return unused
equipment to storage area.
13. Inspect surface of external genitalia Thick secretions may cover underlying skin
and surrounding skin after cleansing. lesions or areas of breakdown. Evaluation
determines need for additional hygiene.
174
14. Ask if patient feels a sense of Evaluates patient’s comfort level.
cleanliness.
15. Observe for abnormal drainage or Evaluates presence of infection.

discharge from genitalia.
16. Record and report. 6/15/10 0900H Complained of itchiness at

a. Presence of any abnormal finding perineal area. Presence of redness and
(e.g., character and amount of slight excoriation noted. Perineal care
discharge or condition of genitalia). done. Tolerated procedure well. Verbalized
b. Appearance of suture line, if present. feeling clean and fresh. Health teaching
c. Any break in suture or presence of given on perineal-genital care.
abnormalities. -------------------------------
BWaldorf, RN
EVALUATION:
The expected outcome is met when the patient states that he/she feels clean and fresh and patient
regains feelings of control by assisting with perineal care; and is able to demonstrate
understanding about the need for cleanliness.
UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS:

1. Skin and genitalia may be inflamed, with localized tenderness, swelling and presence of
foul-smellingdischarge:
a. Bathe area frequently to keep clean and dry.
b. Obtain order for sitz bath.
c. Apply protective barrier.
d. Notify physician and apply prescribed antibacterial or antifungal ointment/cream.
2. Patient expresses discomfort:

a. Increase frequency of perineal care.
b. Assess perineum for signs of irritation or discharge.
3. Patient unable to perform perineal care correctly:

a. Review perineal care
b. Position patient and have him/her observe cleansing procedure.
REFERENCES:
Craven, Ruth and Constance Hirnle (2017). Fundamentals of Nursing: Human Health and
Function, 8th ed. Philadelphia: Lippincott Williams and Wilkins.
Pilliteri, Adele (2014). Maternal and Child Health Nursing: Care of the Childbearing and
Childbearing Family, 7th ed.Philadelphia: Lippincott.
Smith, Pamela (2011). Taylor’s Clinical Nursing Skills: A Nursing Process Approach.
Timby, Barbara (2009). Fundamental Skills and Concepts in Patient Care, 9th ed.
Philadelphia: Lippincott.
175
COLLEGE OF NURSING
Dumaguete City
PERINEAL CARE
Perform Checklist
Student’sName:_________________________________________Year:______
Level:________
STEPS SATISFI UNSATISFI COMMENTS

ED ED
1. Identify the patient and assess his or
her knowledge on the importance of
perineal hygiene.
2. Explain procedure and its purpose to

patient.
4. Prepare necessary equipment and

supplies.
5. Pull curtain around patient’s bed or

close room door. Assemble supplies
at bedside.
6. Raise bed to comfortable working

position. If raised, lower side rail
and assist patient in assuming side-
lying procedure, placing towel
lengthwise along patient’s side and
keep patient covered with bath
blanket or top sheet.
7. Apply disposable gloves.
8. If fecal material is present, enclose

in a fold of underpad or toilet tissue,
and remove with disposable wipes
or tissue. Cleanse buttocks and anus,
washing front to back. Cleanse, rinse
and dry area thoroughly. If needed,
place an absorbent pad under
176
patient’s buttocks. Remove and
discharge underpad and replace with
clean one.
9. Change gloves when they are soiled.

Perform hand hygiene.
10. Fold top bed linen down toward

food of bed and raise patient’s gown
above genital area. Prepare bed linen
to protect patient’s privacy.
“Diamond” drapethe patient by

placing the bath blanket with one
corner between patient’s legs, one
corner pointing toward each side of
bed and one corner over patient’s
chest. Tuck side corners around
patient’s legs and under hips.
11. Raise side rail. Fill wash basin with

warm water.
12. Place wash basin and toilet tissue on

overbed table. Place washcloth in
basin.
13. Provide perineal care.
FEMALE PERINEAL CARE

14. Assist patient to dorsal recumbent
position.
15. Lower side rail and help patient flex

knees and spread legs. Note
restrictions or limitations in patient’s
positioning.
16. Fold lower corner of bath blanket up

between patient’s legs onto
abdomen. Wash and dry patient’s
upper thighs.
17. Wash labia majora. Use

nondominant hand to gently retract
labia from thigh; with dominant
hand, wash carefully skinfolds.
Wipe in direction from perineum to
rectum (front to back).
177
18. Separate labia with nondominant
hand to expose urethral meatus and
vaginal orifice. With dominant hand,
wash downward from pubic area
toward rectum in one smooth stroke.
Use separate section of cloth for
each stroke. Cleanse thoroughly
around labia minora, clitoris and
vaginal orifice.
19. If patient uses bedpan, pour warm
water over perineal area. Dry
perineal area thoroughly, using
front-to-back method.
20. Fold lower corner of bath blanket

back between patient’s legs and over
perineum. Ask patient to lower legs
and assume comfortable position.
MALES PERINEAL CARE

21. Lower side rails and assists patient
to supine position. Note restriction
in mobility.
22. Fold lower corner of bath blanket up

between patient’s legs and onto
abdomen. Wash and dry patient’s
upper thighs.
23. Gently raise penis, and place bath

towel underneath. Gently grasp shaft
of penis. If patient is uncircumcised,
retract foreskin. If patient has an
erection, defer procedure until later.
24. Wash tip of penis at urethral meatus

first. Using circular motion, cleanse
from meatus outward. Discard
washcloth and repeat with clean
cloth until penis is clean. Rinse and
dry gently.
25. Return foreskin to its natural

position.
26. Wash shaft of penis with gentle but

firm downward strokes. Pay special
attention to underlying surface of
penis. Rinse and dry penis
thoroughly. Instruct to spread legs
apart slightly.
178
27. Gently cleanse scrotum. Lift it
carefully and wash underlying
skinfolds. Rinse and dry.
28. Fold bath blanket back over

patient’s perineum and assist patient
in turning to side lying position.
29. If patient has had urinary or bowel

incontinence, apply thin layer of
skin barrier containing petrolatum or
zinc oxide over anal and perineal
skin.
30. Remove disposable gloves, dispose

in proper receptacle and perform
hand hygiene.
31. Assist patient in assuming a

comfortable position and cover with
sheet.
32. Remove bath blanket and dispose of

all soiled bed linen. Return unusual
equipment to storage area.
33. Inspect surface of external genitalia

and surrounding skin after cleansing.
34. Ask if patient feels as sense of

cleanliness.
35. Observe for abnormal drainage or

discharge from genitalia.
36. Record and report

a. Presence of any abnormal
finding (e.g., character and
amount of discharge or condition
of genitalia).
b. Appearance of suture line, if
present.
c. Any break in suture or presence
of abnormalities.
ATTITUDE
 Punctual
 Honest and sincere
 Shows interest and willingness to
179
learn
 Manifest creativity
 Shows resourcefulness
 Possess sense of initiative
 Shows positive attitude towards
supervision
TOTAL
RATING SCALE:
S- Satisfied
U- Unsatisfied
C- Comments
REMARKS:
180
COLLEGE OF NURSING
Dumaguete City
SITZ BATH
DEFINITION
The partial immersion of the hips and buttocks in a warm water or saline solution. It comes from
the German verb “sitzen”, meaning “to sit” .
PURPOSES
c. To relieve pain after operation.
d. To cleanse, soothe, reduce inflammation, and hasten healing of perineal or vaginal area
after childbirth, vaginal or rectal surgery, or from local irritation of hemorroids and
fissures
e. To relieve cramps and spasms in the pelvic region and urinary bladder.
f. To stimulate pelvic circulation, promoting healing.
g. To relax urinary bladder and encourage nomal voiding.
ASSESSMENT
5. Cheack medical orders for a directive to administer a sitz bath.

6. Review medical record to determine systemic contraindications to immersion (e.g.,
History of MI, angina pectoris m hypotension, use of nitroglycerin transdermal patch
or ointment).
7. Assess and document vital signs and level of pain discomfort.
8. Determine patient’s ability to ambulate and maintain sitting position for 15 to 20
minutes.
9. Inspect and document perineal/rectal area of welling, drainage, redness, warmth and
tenderness
10. Assess bladder fullness and encourage patient to avoid prior to sitx bath.
11. Determine patients understanding of purpose of sitz bath, what to expect during the
procedure and how he or she can help.
NURSING DIAGNOSES
Determine the related factors for the nursing diagnoses based on the patient’s current
status.Appropriate nursing diagnoses may include:
13. Ineffective Peripheral Tissue Perfusion
14. Acute Pain
15. Impaired Tissue Integrity
16. Impaired Physical Mobility
181
17. Altered Sensory Perception: Tactile
18. Knowledge Deficit
19. Risk for Injury
20. Risk for Hypothermia
21. Risk for Infection
The expected outcome to achieve when administering a sitx bath is that the patient will state an
increase in comfort. Other outcomes tha may be appropriate include the following: the patient
will experience a decrease in healing time. Maintain normal body temperature, remain free of
any signs and symptoms of infection, and exhibit signs and symptoms of healing.
PLANNING
 Determine what supplies and equipment are needed.
EQUIPMENT
Sitz bath with sitz bath bowl with water bag

1. If not available, use one large basin that is deep enough for a person to sit in
Pitcher of water (37° to 46°C or 98° to 115°F) – tap or normal saline
Bath Thermometer
Bath Blanket
Towels
Medications as prescribed (e.g., povidone - iodine)
Clean disposable gloves
Ice pack prn
Clean disposable perineal pads
IV pole
IMPLEMENTATION
STEP RATIONALE
1. Identify the patient. To ensure that the procedure is per formed to

an appropriate patient.
2. Explain procedure to patient. Explanation facilitates cooperation.
3. Provide privacy by closing curtains or Providing privacy reduces embarrassment for

room door. the patient, and increases his or her ability to
relax.
4. Perform hand hygiene and don Hand hygiene and disposable gloves deter the
disposable gloves spread of microorganisms.
5. Assemble equipment in bathroom. Organization facilitates performance of task.
 Raise lid of toilet. Place bowl of Sitz bath will not drain approximately if placed
182
sitz bath, with drainage ports to in toilet backwards. Warm water can promate
rear and infusion port in front, in relaxation, help with edema and circulation.
the toilet. Fill bowl of sitz bath
about halfway full with warm
water ( 37° to 46°C or 98° to
115°F).
 Clamp tubing on bag. Fill bag If bag is hung lower, the rate of flow will not
with same temperature water as be sufficient and water may cool too quickly.
mentioned above. Hang bag Using correct temperature of water eliminates
above patient’s shoulder length on risk of thermal injury. Adequate flow of warm
water increases circulation to the perineum,
hook or IV pole so that a steady
thereby reducing inflammation, and aiding
stream of water will flow from the healing.
bag, through the tubing, and into
the basin.
6. If a sitz chair is not available, put a Improvising if the necessary equipment is not
large basin on the chair, with small available is acceptable with compromising the
amount of worm water. A waterproof principles of the procedure
pad should be placed underneath
basin. You may continue to gradually
add warm water to sitz basin to
patient’s tolerance.
7. Assist patient with donning on robe The robe is warm again after the procedure.
over patient’s gown and putting on This is to provide covering to the body and
slippers. preventing heat loss through convection.
8. Assist patient with ambulating to Assisting with ambulation minimizes risk of

bathroom. Remove robe and hang on injury.
back of chair.
9. Help with removal of underwear or Removing pad front to back minimizes risk of
perineal pad (remove pad from front infection transmission.
to back).
10. Assist patient to sit on basin or toilet. Proper placement ensures effectiveness of
treatment.
11. Slowly unclamp tubing and allow sitz

Continuous swirling water aids in reducing
bath to fill. edema and promoting comfort.
12. Clamp tubing once sitz bath is full. Cool water may produce hypothermia. Privacy
Instruct patient to open clamp when enhances self – esteem. Quick easy access to
water in bowl becomes cool. Use call bell allows for prompt intervention should
robe, blankets or towel to prevent problem arise.
chilling and provide for privacy.
183
Have call bell within reach.
13. Instruct patient to call if she or he Patients may become light – headed due to
feels light-headed, “spacy”, or dizzy vasodilation, so call bell should be within
reach.
or has any problems. Instruct patient
not to try standing without assistance.
14. Leave the patient alone, but recheck

at frequent intervals to add more Provide for sustained application of warm
water to the reservoir bag and check water
condition of the buttocks.
15. After 15 – 20 minutes, assist patient

After 20 minutes, heat is no longer therapeutic
to stand and gently pat bottom dry.
because vasoconstriction occurs. Proper
Help with applying a clean handling of pad prevents contamination and
underwear and pad (holding pad by possible risk of infection.
the bottom side to ends).
16. Assist patient’s with ambulating back

to room Patient may become fatigued from the
procedure or light – headed and dizzy from the
worm water, increasing the risk for falling.
17. Evaluate patient’s tolerance and
response to procedure; ask patient to
Evaluation assists with determining
report how he or she feels. Institute effectiveness of procedure and making any
health teachings, such as continuing changes. Health teaching help to promote
sitz bath when at home. continuity care after discharge.
18. Empty and disinfect sitz bath bowl

according to agency policy. Remove
gloves and perform hand hygiene. Proper equipment cleaning and hand hygiene
deter the spread of microorganism.
19. Document the sitz bath, including
water temperature, length of bath, A careful record is important for planning and
and how patient tolerated the bath. individualizing the patient’s care.
EVALUATION
The expected outcomes are met when the patient verbalizes a decrease in pain or discomfort,
patient tolerates sits bath without problem, area remains clean and dry, and patient demonstrates
signs of healing.
UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS
184
4. Patient complains of feeling light – headed or dizzy during a sitz bath: Stop sitz
bath. Do not attempt to ambulate patient by self. Use call light to summon help. Let
patient sit on toilet with face up until feeling subsides or help has arrived to assist
patient back to bed.
5. Temperature of water in uncomfortable: The water may be too warm or cold,

depending on the patient’s preference. If this happens, clamp the tubing, disconnect
the water bag, and refill it water that is comfortable for the patient.
185
COLLEGE OF NURSING
Dumaguete City
SITZ BATH
Student’s Name: Year: Level:
STEPS 0 1 1.5 2 N/A Comments

4. Identify the patient
5. If a sitz chair is not available, put a large
basin on the chair, with small amount of
warm water. A waterproof pad should be
placed underneath basin. You may continue
to gradually add warm water to sitz basin to
patient’s tolerance.
6. Explain procedure to patient.
7. Provide privacy by closing curtains or room
door.
8. Perform hand hygiene and don disposable
gloves.
9. Assemble equipment in bathroom.
4. Raise lid of toilet. Place bowl of sitz bath,

with drainage ports to rear and infusion port
in front, in the toilet. Fill bowl of sitz bath
about halfway full with warm water (37° to
46°C or 98° to 115°F)
5. Clamp tubing on bag. Fill bag with same

temperature water as mentioned above. Hang
bag above patient’s shoulder length on hook
or IV pole so that a steady stream of water
will flow from the bag, through the tubing,
and into the basin.
10. Assist patient with donning on robe over
patient’s gown and putting on slippers.
11. Assist patient with ambulating to bathroom.
Remove rob and hang on back of chair.
12. Help with removal of underwear or parineal
pad (remove pad from front to back).
186
13. Assist patient to sit on basin or toilet.
14. Slowly unclamp tubing and allow sitz bath to
fill.
15. Clamp tubing once sitz bath is full. Instruct
patient to open clamp when water in bowl
becomes cool. Use robe, blankets or towel to
prevent chilling and provide for privacy.
Have call bell within reach.
16. Instruct patients to call if she or he feels light-
headed, “spacy”, or dizzy or has any
problems. Instruct patient not to try standing
without assistance.
STEPS 0 1 1.5 2 N/A Comments
17. Leave the patient alone, but recheck at
frequent intervals to add more water to the
reservoir bag and check condition of the
buttocks.
18. After 15 – 20 minutes, assist patients to stand
and gently pat bottom dry. Help with
applying a clean underwear and pad (holding
pad by the bottom side or ends).
19. Assist patient with ambulating back to room.
20. Evaluate patient’s tolerance and response to
procedure; ask parient to report how he or she
feels, institute health teaching, such as
continuing sitz bath when at home.
21. Empty and disinfect sitz bath bowl according
to agency policy. Remove gloves and perform
hand hygiene.
22. Document the sitz bath, include water
temperature, length of bath, and how patient
tolerated the bath.
ATTITUDE
 Punctual
 Honest and sincere
 Shows interest and willingness to learn
 Manifest creativity
 Shows resourcefulness
 Possess sense of initiative
 Shows positive attitude towards supervision
TOTAL
Rating Scale:
0 – not done, but essentially required
1 – incorrectly done; wrong techniques and findings
1.5 – correct measures, but with inadequate description of findings or not systematic in
performance
2 – correctly done, systematic according to standard; with correct findings
N/A – not applicable
187
REMARKS
COLLEGE OF NURSING
Dumaguete City
SPECIMEN COLLECTION
The nurse contributes to the assessment of the client’s health status by collecting specimen of
body fluids. All hospitalized client’s have at least one laboratory specimen collected during their
stay at the health care facility. Laboratory collection of specimen such as urine, blood, stool and
sputum provides important adjunct information of diagnosing health care problems and also
provides a measure of the responses to therapy.
NURSING RESPONSIBILITIES ASSOCIATED WITH SPECIMEN COLLECTION:

 Provide client comfort, privacy and safety. Client may experience embarrassment or
discomfort when providing a specimen.
 Explain the purpose of the specimen collection and the procedure for obtaining the
specimen. Client may feel anxiety about the procedure, especially if it is perceived as
being intrusive or if they fear an unknown test result.
 Use the correct procedure for obtaining a specimen or ensure that the client or staff
follows the correct procedure.
 Note relevant information on the laboratory requisition slip.
 Transport the specimen to the laboratory promptly. Fresh specimen provides more
accurate results.
 Report abnormal laboratory findings to the health care provider in a timely manner
consistent with the severity of the abnormal results.
A.URINE SPECIMEN
The nurse is responsible for collecting urine specimen for a number of tests: clean voided
specimens for routine urinalysis, clean-catch or midstream urine specimens for urine culture and
timed urine specimens for a variety of test that depend on the client’s specific health problem.
Urine specimen collection may require collection via straight catheter insertion.
1. Clean Voided Urine Specimen

A clean voided specimen usually adequate for routine examination. Many clients are able
to collect a clean voided specimen and provide the specimen independently with minimal
instructions. Male clients are generally are able to void directly into the specimen
container, and the female clients usually sit or squat over the toilet, holding the container
between their legs during voiding. Routine urine examination is usually done on the first
voided specimen in the morning because it tends to have a higher, more uniform
concentration and a more acidic ph than the specimen later in the day.
At least 10 ml of urine is generally sufficient for a routine urinalysis. Client who ,is
seriously ill, physically incapacitated, disoriented may need to use a bedpan or urinal in
bed; others may require supervision or assistance in the bedroom. Whatever t he
situation, clear a specific direction is required.
2. Clean Catch or Midstream Urine Specimen
188
Clean-catch or midstream voided specimens are collected when a urine culture is ordered
to identify microorganisms causing urinary tract infection. Although some contamination
by skin bacteria may occur with a clean-catch specimen, the risk of introducing
microorganisms around the urinary tract through catheterization is more significant. Care
is taken to ensure that the specimen is as free as possible from contamination by
microorganisms around the urinary meatus. Clean-catch specimens are collected into a
sterile container with a lid.
3. Timed Urine Specimen

This require the collection of all urine produced and voided over a specific period of time
ranging from 1 to 2 hours to 24 hours. Timed specimens are generally refrigerated or
contain preservative to prevent bacterial growth or decomposition of urine components.
PURPOSES
 To determine the presence of microorganisms, the type of organism and antibiotics to
which the organisms are sensitive.
 To assess the ability of the kidney to concentrate and dilute urine.
 To determine disorders of glucose metabolism.
 To determine levels of specific constituents.
ASSESSMENT
 Determine the ability of the client to provide the specimen.
 Assess the color, odor, and consistency of the urine and the presence of clinical sign of
urinary tract infection.
NURSING DIAGNOSIS
Possible Nursing Diagnoses:
 Altered Urinary Elimination
 Anxiety
 Deficient Knowledge
The expected outcome to be met when collecting a urine specimen is that an adequate amount of
urine is obtained from the patient without contamination. Other outcome include the following:
the patient exhibits minimal anxiety during specimen collection and demonstrates ability to
collect a clean urine specimen.
PLANNING
 Instruct the client in the correct process of obtaining the specimen.
 Proper cleansing of the urethra should be emphasized to avoid contaminating the urine
specimen.
 Determine what supplies and equipment are needed.
 Obtain the needed equipment.
EQUIPMENTS:
Clean gloves
Antiseptic towelette, such as povidone-iodine
Sterile cotton balls or 2×2 gauze pads
Sterile specimen container
Specimen identification label
189
Complete laboratory requisition form
Urine receptacle, if the client is not ambulatory
Basin of warm water, soap, wash cloth, and towel for non-ambulatory client
URINE SPECIMEN COLLECTION
A. Timed Urine Specimen

1. Obtain a specimen container with preservative (if indicated) from the laboratory.
Label the container with identifying information of the client, the test to be
performed, time stated, and time completion.
2. Provide a clean receptacle to collect urine.
3. Post signs in the clients chart, kardex, room, bathroom alerting personnel to save all
urine during the specified time.
4. At the start of the collection of period, have the client to void and discard the urine.
5. Save all urine produced during the time collection period in the container,
refrigerating or placing the container on ice as indicated.
6. At the end of the collection period, instruct the client to completely empty the bladder
and save this voiding as part of the specimen.
7. Record collection of the specimen, time started and completed, and any pertinent
observations of the urine on appropriate records.
B. Indwelling Catheter Specimen

1. Put on disposable gloves.
2. If there is no urine in the catheter, clamp the drainage tubing for about 30 minutes.
3. Wipe the area where the needle will be inserted with a disinfectant swab. The site
should be distal to the tube leading to the balloon to avoid puncturing this tube.
4. Insert the needle at a 30 to 45 degree angle.
5. Unclamp the catheter.
6. Withdraw the required amount or urine (3 ml for urine culture or 30 ml for routine
urinalysis).
7. Transfer the urine to the specimen container.
8. Without recapping the needle , discard the syringe and needle in an appropriate sharps
container.
9. Cap the container.
10. Remove gloves and discard appropriately.
11. Label the container, and send the urine to the laboratory immediately for analysis or
refrigeration.
12. Record collection of the specimen and any pertinent observations of the urine on the
appropriate records.
IMPLEMENTATION
STEP RATIONALE
For an adult patient who is capable of self-
care:
1. Explain procedure to patient, including Cleaning perineal area or penis reduces the risk
performing of hand hygiene before and for contamination of the specimen, w hich
after specimen collection. Instruct should be as clean as possible.
patient to wipe perineal area from front
to back or meatus of penis with moist
towelette. Instruct male patient who is
190
not circumcised to retract foreskin and
clean glans penis.
2. Have patient void about 25 ml into Collecting a midstream specimen ensures that
toilet, stop stream, collect specimen (10 fresh urine is analyzed. Some urine may have
to 20 ml is more than enough) and then collected in the urethra from the last void. By
finish voiding. Tell patient not to touch voiding a little before collecting the specimen,
the inside of the container or the lid. the specimen will contain only fresh urine.
3. Have patient place lid on container. Placing a lid on container helps keep specimen
Don gloves and label container with clean and prevent spills. Glove reduce the risk
patient’s name, date, time, and person of exposure to body fluids. Labeling the
collecting specimen. container provides valuable information to the
laboratory and ensures accurate reporting of
results.
4. Place container in biohazard bag. Transporting specimen in biohazard bag

Remove gloves and perform hand prevents exposure of other health care workers
hygiene. to pathogens. Hand hygiene deters the spread
of microorganisms.
5. Transport the specimen to the If not refrigerated immediately, urine may act
laboratory as soon as possible. If unable as a culture medium, allowing bacteria to
to take specimen to laboratory multiply and skewing the results of testing.
immediately, refrigerate it. Refrigeration prevents the bacteria from
multiplying.
6. Document specimen sent odor, amount A careful record is important for planning the
(if unknown), color, and clarity of patient’s care.
urine.
For very young children and infants:

7. Explain steps to a young child, if old Explanation at the child’s level helps to
enough, and to the parents. Talk to the promote cooperation. Knowing that the
child at child’s level, stressing that no procedure is not painful helps to relieve
pain will be involved. anxiety and fear.
8. Perform hand hygiene and don Hand hygiene deters the spread of
disposable gloves. microorganisms. Gloves protect nurse from
contact with microorganisms.
9. If the child is old enough, follow the The specimen needs to be as clean as possible.
steps as for an adult. For an infant, Skin needs to be dry for adhesive bag to stick.
remove the diaper. Perform thorough
perineal care: for girl, spread the labia
and cleanse area; for boys, retract
foreskin if intact and cleanse the glans
of penis. Pat skin dry.
10. Remove paper backing from adhesive Since child cannot void on command and
191
faceplate, apply faceplate over labia or specimen needs to be as aseptic as possible
over penis. Gently push faceplate so using a urine collection bag is ales traumatic
that seal forms on skin. Take acre to not way to obtain a sterile urine specimen. At
contaminate inside of bag when times the physician may order insertion of an
applying, because it is consider sterile. intermittent ( straight) catheter to obtain a
specimen.
11. Apply clean diaper over bag. Remove Apply diaper over bag prevents child from
gloves and perform hand hygiene. removing the bag. Frequently checking is
Check bag frequently to see whether necessary to ensure as fresh a specimen as
child has voided. possible. Since the urine is not a midstream
catch and the bag comes in contact with the
child’s skin, a small amount of contaminants
may be present. To prevent these contaminants
from skewing the laboratory test, the specimen
must be refrigerated or sent to the laboratory
as soon as possible. Some specimen bags have
a divider to prevent urine from flowing back
over the child’s skin.
12. As soon as enough urine is in collection Pushing skin away from bag reduces skin
bag, perform hand hygiene and don trauma. Sterile scissors must be used to prevent
gloves. Gently remove bags by pushing the contact with any other pathogens. Do not
skin away from bag. Using sterile pour urine out of application hole because this
scissors cut corner of bag and pour area has been grossly contaminated with
urine into sterile container. epithelial cells.
13. Perform perineal care and reapply Cleansing the area will remove any adhesive
diaper. remaining from collection bag.
14. Place the urine in the container. Don

gloves and label container with
patient’s name, date, time, and person
collecting specimen.
15. Place container in biohazard bag.

Remove gloves and perform hand
hygiene.
16. Transport specimen to laboratory as

soon as possible. If unable to take
specimen on laboratory immediately,
refrigerate it.
17. Document specimen sent, odor,

amount, color and clarity of urine.
192
For patient with an indwelling catheter:
18. Explain the procedure to the patient. This provides reassurance and promotes patient
Organize equipment at bedside. cooperation. Organization improves efficiency.
19. Perform hand hygiene and don gloves. Hand hygiene deters the spread of
microorganisms. Gloves protect nurse from
any microorganisms in urine.
20. Clam or kink off drainage tubing near The drainage tubing can be clamped with the
urinary catheter distal to the port. plastic clamp provide on tubing. This ensures
Remove lid from specimen container, the collection of an adequate amount of fresh
keeping the inside of the container and urine. The container needs to remain sterile so
lid free from contamination. as not to contaminate the urine.
21. Cleanse aspiration port with alcohol Cleaning with alcohol deters the entry of
wipe and allow port to air dry. microorganisms when the needle punctures the
port.
22. Insert the blunt tipped needle into the Using blunt tipped needle prevents a needle
port. Slowly aspirate enough urine for stick. Collecting urine from the port ensure that
specimen (usually 5 ml is adequate). the specimen contains fresh urine.
Remove blunt tipped needle from port.
23. Slowly inject urine into specimen If urine is injected into the container, it may
container. Dispose off needle and splash out of the container or into the nurse’s
syringe appropriately. eyes.
24. Label container with patient’s name, Labeling the container provides valuable
date, time, and person collecting information to the laboratory and ensures
specimen. accurate reporting of results.
25. Place container in biohazard bag. Prevents exposure of other healthcare workers
Remove gloves and perform hand to pathogens.
hygiene.
26. Transport specimen to laboratory as

soon as possible. If unable to take
specimen on laboratory immediately,
refrigerate it.
27. Document specimen sent, odor, A careful record is important for planning the
amount, color and clarity of urine. patient’s care.
193
B.STOOL SPECIMEN
Analysis of stool specimen can provide information about a client’s health condition.
PURPOSES
 To determine the presence of occult (hidden) blood.
 To analyze for dietary products and digestive secretions.
 To detect the presence of ova and parasites.
 To detect the presence of bacteria and viruses.
ASSESSMENT
1. Review the patient’s chart and determine the reason for collecting the stool specimen.
2. Determine the correct method of obtaining and handling the specimen.
3. Assess the patient’s understanding of the need for the test and the requirements of the
test; ask the patient when his or her last bowel movement was.
4. Assess whether the patient can obtain the specimen without assistance.
NURSING DIAGNOSIS
Appropriate nursing diagnosis may be:
1. Deficient knowledge
2. Diarrhea and anxiety
Expected outcomes:
1. Patient is able to obtain specimen free from contamination.
2. Patient verbalizes decrease in anxiety related to stool collection.
3. Aseptic technique is maintained from handling the client’s bedpan, to transferring the
stool sample to specimen container, and when disposing of the bedpan contents.
4. Specimen label and laboratory requisition have the correct information and securely
attached to the specimen container.
PLANNING
1. Confirm and check laboratory information about proper specimen collection.
EQUIPMENT
Bedpan or bedside commode
Tissue paper
Two clean tongue depressor
194
Clean gloves
Specimen container
Specimen label
Specimen swab
IMPLEMENTATION
STEP RATIONALE
1. Gather necessary equipment. Place Organization facilitates performance of task.
disposable collection container (hat) in Placing a container in a toilet or bedside
toilet or bedside commode to catch commode aids in obtaining clean stool
stool without urine. Instruct patient not specimen uncontaminated by urine.
to discard toilet paper with stool. Tell Explanation helps to alleviate anxiety and
patient to call you as soon as bowel facilitate cooperation.
movement is completed.
2. Perform hand hygiene and put on Hand hygiene deters the spread of
gloves. microorganisms. Gloves protect nurse from
microorganisms in feces.
Random Stool Collection is needed:

3. After patient has passed a stool, use a Due to the nature of the testing, no
clean tongue blade to obtain specimen, preservatives are needed for the stool. The
and place it in dry, clean, urine-free container does not have to be sterile, since
container. stool is not sterile. To ensure accurate results,
the stool should be free of urine or menstrual
blood.
4. Collect as much of stool as possible to Different test and laboratories require different
send to the laboratory. If patient is amounts of stool. Collecting as much as
wearing a diaper, the stool may be possible helps to ensure that the laboratory has
collected from diaper. an adequate amount of specimen for testing.
5. Place lid on container, label with All specimens sent to the laboratory should
patient’s data; and place container in include the following information: patient’s
small biohazard bag. name and ID number, test ordered, date and
time collected, and the initials of person
collecting specimen. Packaging the specimen
in a biohazard bag prevents the person
transporting the container from coming in
contact with any pathogens that may be present
in stool.
6. Remove gloves from inside out. This protects nurse from contact with any
microorganisms.
7. Perform hand hygiene. Hand hygiene deters the spread of

microorganisms.
8. Transport specimen to laboratory while Most test have better results with fresh stool.
195
stool is warm. If immediate transport is Different tests require different preparation if
possible, check with laboratory the test is not immediately completed. Some
personnel or policy manual as to test will be compromised if the stool is
whether refrigeration is refrigerated.
contraindicated.
If stool is collected for presence of ova and

parasites:
9. Follow above steps. Do not refrigerate Refrigeration will affect parasites. Ova and
specimen. Some institutions require ova parasites are best detected in warm stool.
and parasite specimens to be placed in a
container filled with preservatives;
check institution policy.
10. Document amount, odor, consistency of Documentation promotes continuity of care

stool sent. and communication, alerting health care team
members that ordered test has been sent.
EVALUATION
The expected outcome is met when the patient passes a stool that is not contaminated by urine or
menstrual blood and is placed in a clean container. The specimen is transported appropriately to
the laboratory. The patient participates in stool collection and verbalizes feelings of diminished
anxiety related to procedure.
Unexpected situation and associated interventions:

Patient is menstruating or has discarded toilet paper into commode with stool: call laboratory to
discuss possible effects on test results. Not all test will be affected by contaminants. The
laboratory may accept the specimen even with the contaminant. Make notation on order card that
goes to laboratory with specimen.
Specimen is inadvertently left on the counter instead of being sent to laboratory: call laboratory
to discuss possible effects on test results. Not all test will be affected by leaving the specimen on
the counter for a period of time. The laboratory may accept the specimen even though it has been
sitting out. Make sure that the time on card is the actual time the specimen was obtained.
C.SPUTUM SPECIMEN
Sputum is the mucous secretion from the lungs, bronchi, and trachea. It is important to
differentiate it from saliva, the clear liquid secreted by t he salivary glands in the mouth,
sometimes referred to as “spit”. Healthy individuals do not produce sputum. Clients need to
cough to bring sputum up from the lungs, bronchi, and trachea into the mouth in order to
expectorate it into the collecting container.
PURPOSES
 For culture and sensitivity to identify microorganisms and its drugs sensitivities.
 For cytology to identify the origin, structure, function, and pathology of cells. Specimen
for identify cancer in the lungs and its specific cell type.
 For acid- fast bacillus (AFB), which also requires serial collection, often foe 3
consecutive day, to identify the presence of tuberculosis.
 To assess the effectiveness of therapy.
196
ASSESSMENT:
1. Assess the patient’s lung sounds. Patients with a productive cough may have coarse,
wheezing, or diminished lung sounds.
2. Assess the ability of the patient to cough, including position of patient, time for specimen
collection and sterile technique.
3. Assess the patient’s level of pain. Consider administering pain medication before
obtaining the sample, since patient will have to cough.
4. Monitor oxygen saturation level because patient with excessive pulmonary secretions
may have deceased oxygen saturation.
5. Determine if there is a need for an invasive procedure in sputum collection.
NURSING DIAGNOSIS
Determine related factors for the nursing diagnoses based on the patient’s current status.
Appropriate nursing diagnoses include the following:
2. Acute pain
3. Ineffective airway clearance
The expected outcome to achieve when collecting a sputum specimen is that the patient produces
an adequate sample from the lungs. Other outcomes that may be appropriate include the
following: airway patency is maintained; oxygen saturation increase; patient demonstrates
understanding about the need for specimen collection; and patient demonstrates improves
respiratory status.
PLANNING
3. Ensure that aseptic technique is followed.
EQUIPMENT:
Specimen container
Disposable gloves
Mask
IMPLEMENTATION
STEP RATIONALE
1. Review physician’s laboratory order fro To validate the correct patient and correct
patient’s name, kind of laboratory specimen.
order, and kind of specimen to be
collected.
2. Identify your patient; assess the

patient’s ability to expectorate.
3. Explain procedure to patient. If patient This provides for organized approach.

may have pain with coughing ,
administer pain medication if ordered.
197
If patient can perform task without
assistance after instruction, leave
container at bedside with instructions to
call nurse as soon as specimen is
produced.
4. Assemble equipment. This provides for organized approach.
5. Perform hand hygiene. Hang hygiene deters the spread of

microorganisms.
6. Don disposable gloves and goggles. The gloves and goggles prevent the spread of
pathogens to the nurse.
7. Adjust bed to the comfortable working The semi-fowler’s position will help the patient
position. Lower side rail closer to you. to cough and expectorate the sputum specimen.
Place patient in semi-fowler’s position. Water rinses the oral cavity of any food
Have patient rinse mouth with water particles.
before beginning the procedure.
8. Instruct patient to inhale deeply and The specimen will need to come from the
cough. If patient has had abdominal lungs; saliva is not acceptable. Splinting helps
surgery, assist patient to splint reduce the pain in the abdominal incision.
abdomen.
9. If patient produces sputum, open the lid The specimen needs to come from the lungs,
to the container and have patient saliva is not acceptable.
expectorate specimen into container.
10. If patient believes he or she can This give the laboratory more specimens to
produce more specimens, have patient work with.
repeat the procedure.
11. Close the lid to the container. Offer oral Oral hygiene helps to remove pathogens from
hygiene to patient. the oral cavity.
12. Remove gloves. Perform hand Hand hygiene deters the spread of
hygiene. microorganisms.
13. Label the container with patient’s This helps the laboratory to log the specimen
name, time specimen was collected, correctly.
any antibiotics administered within the
past 24 hours, rout of collection, and
any other information required by
agency policy.
14. Record the time the specimen was This provide accurate documentation and
collected and spent and the nature and provides for comprehensive care.
amount of secretions. Note the
character of patient’s respiratory before
and after sputum collection. Note on
198
the laboratory request form any
antibiotics administered in the past 24
hours.
COLLEGE OF NURSING
Dumaguete City
URINE SPECIMEN COLLECTION
NAME: _______________________________________ LEVEL: __________

DATE: _______________________
STEP 0 1 1.5 2 N/ COMMENT

A
For an adult patient who is capable of self-

care?
1. Explain procedure to patient, including
performing hand hygiene before and after
specimen collection. Instruct the patient to wipe
perineal area from front to back or meatus of
penis with moist towelette. Instruct male patient
who is not circumcised to retract foreskin and
clean glans of penis.
2. Have patient void about 25ml into toilet stop
stream, collect specimen (10 to 20 ml is more
than enough) and then finish voiding. Tell
patient not to touch the inside of the container
or the lid.
3. Have patient place lid on container. Don

gloves and label container with patient’s name,
date, time, and perform hand hygiene.
4. Place container in biohazard bag. Remove

gloves and perform hand hygiene
5. Transport the specimen to the laboratory as

soon as possible. If unable to take specimen to
laboratory immediately, refrigerate it.
6. Document specimen sent odor, amount, (if

unknown), color, and clarity of urine.
For young children and infants:

7. Explains steps to a young child, if old
enough, and to the parents. Talk to the child at
child’s level, stressing that no pain will be
199
involved.

gloves.
9. If the child is old enough, follow the steps as

for an adult. For an infant, remove the diaper.
Perform thorough perineal care: for girls, spread
labia and cleanse are; for boys, retract foreskin
if intact and cleanse the glans of penis. Pat skin
dry.
10. Remove paper backing from adhesive

faceplate. Apply faceplate over labia or over
penis. Gently push faceplate so that seal forms
on skin. Take care to not contaminate inside of
bag when applying because it is considered
sterile.

A
11. Apply clean diaper over bag. Remove
gloves and perform hand hygiene. Check bag
frequently to see whether child has voided.
12. As soon as enough urine is in collection bag.

Perform hand hygiene and don gloves. Gently
remove nag by pushing skin away from bag
using sterile scissors cut corner of bag and pour
urine into sterile container.
13. Perform perineal care and reapply diaper.
14. Place the urine in the container, don gloves

and label container with patient’s name, date,
time and person collecting specimen.
15. Place container biohazard bag. Remove

16. Transport specimen to laboratory as soon as

possible. If unable to take specimen to
laboratory immediately refrigerate it.

For patient with an indwelling urinary

catheter:
18. Explain the procedure to patient. Organize
equipment at bedside.
200
gloves.
20. Claim or kink off drainage tubing near

urinary catheter distal to the port. Remove lid
specimen container, keeping the inside of the
container and lid free from contamination.
21. Cleanse aspiration port with alcohol wipe

and allow port to air dry.
22. Insert the blunt tipped needle into the port.

Slowly aspirate enough urine for specimen
(usually 5ml is adequate). Remove blunt tipped
needle from port.
23. Slowly inject urine into specimen container.

Dispose of needle and syringe appropriately.
24. Label container with patient’s name, date,

time and person collecting specimen.
25. Place container biohazard bag. Remove

26. Transport the specimen to the laboratory as

soon as possible. If unable to take specimen to
laboratory immediately, refrigerate it.

ATTITUDE:
1.Punctual
6. possess sense attitude towards supervision
7. Shows positive attitude towards supervison
9. Well groomed

procedure
201
TOTAL
Rating Scale:
1 – Not done, but essential require.

2.5 –correct measures, but with inadequate description of findings or not systematic in
performance.
2- Correctly done, systematic according; with correct findings
N/A- not applicable
REMARKS
COLLEGE OF NURSING
Dumaguete City
STOOL SPECIMEN COLLECTION
NAME: _______________________________________ LEVEL: __________

DATE: _______________________

A
1. Gather necessary equipment. Place

disposable collection container (hat) in toilet or
bedside commode to catch stool without urine.
Instruct patient not to discard toilet paper with
stool. Tell patient to call you as soon as bowel
movement is completed.
2. Perform hand hygiene and put on gloves.
Random Stool Collection is needed:

3. after patient has passed s stool, use a clean
tongue blade to obtain specimen, and place it in
202
dry, clean, urine – free container.
4. Collect as much of the stool as possible to

send to the laboratory. If patient is wearing
diaper, the stool may be collected from diaper.
5. Place lid on container, label with patient’s

data, and place container in small biohazard
bag.
6. Removes gloves from inside out.
8. Transport specimen to laboratory while stool

is still warm. If immediate transport is
impossible, check with laboratory personel or
policy manual as to whether refrigeration is
contraindicated.
If stool is collected for presence of ova and

parasites:
9. Follow above steps. Do not refrigerate
specimen. Some institutions require ova and
parasite specimen to be placed in a container
filled with preservatives; check institution
policy.
10. Document amount, odor, consistency of

stool sent.
ATTITUDE:
1.Punctual
6. possess sense attitude towards supervision
7. Shows positive attitude towards supervison
9. Well groomed

procedure
TOTAL
203
Rating Scale:
1 – not done, but essential require.

1.5 –correct measures, but with inadequate description of findings or not systematic in
performance.
2- Correctly done, systematic according; with correct findings
N/A- not applicable
REMARKS
COLLEGE OF NURSING
Dumaguete City
SPUTUM SPECIMEN COLLECTION

Name:____________________________ Level:________
Date: ____________________________
STEP 0 1 1. 2 N COMMENT
5 A
15. Review physician’s laboratory order fro
204
patient’s name, kind of laboratory order, and
kind of specimen to be collected.
16. Identify your patient; assess the patient’s ability
to expectorate.
17. Explain procedure to patient. If patient may
have pain with coughing , administer pain
medication if ordered. If patient can perform
task without assistance after instruction, leave
container at bedside with instructions to call
nurse as soon as specimen is produced.
18. Assemble equipment.
20. Don disposable gloves and goggles.
21. Adjust bed to the comfortable working position.
Lower side rail closer to you. Place patient in
semi-fowler’s position. Have patient rinse
mouth with water before beginning the
procedure.
22. Instruct patient to inhale deeply and cough. If
patient has had abdominal surgery, assist patient
to splint abdomen.
23. If patient produces sputum, open the lid to the
container and have patient expectorate
specimen into container.
24. If patient believes he or she can produce more
specimens, have patient repeat the procedure.
25. Close the lid to the container. Offer oral hygiene
to patient.
26. Remove gloves. Perform hand hygiene.
27. Label the container with patient’s name, time
specimen was collected, any antibiotics
administered within the past 24 hours, rout of
collection, and any other information required
by agency policy.
28. Record the time the specimen was collected and
spent and the nature and amount of secretions.
Note the character of patient’s respiratory before
and after sputum collection. Note on the
laboratory request form any antibiotics
administered in the past 24 hours.
ATTITUDE:
1. Punctual
7. Shows positive attitude towards supervision
8. Systematic and conserve steps
9. Well groomed
205
procedure
TOTAL
Rating Scale:
0- not done, but essentially required

1.5- correct measures but with inadequate description of findings or not systematic in
performance
2- correctly done, systematic according to standard, with correct findings
N/A- not applicable
REMARKS
206

PROCEDURESSSSSSS

Uploaded by

Copyright:

Available Formats

PROCEDURESSSSSSS

Uploaded by

Document Information

Original Title

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

PROCEDURESSSSSSS

Uploaded by

Copyright:

Available Formats

Foundation University

 To reduce the number of microorganisms in the hands

Adjusting the water flow helps in conserving

3. Wet the hands thoroughly by holding

Areas under the nails can be highly

STEP 0 1 1.5 2 N/A COMMENT

12. Apply soap, rubbing it firmly and vigorously

13. Thoroughly wash and rinse the hands.

14. Repeat (3b) rubbing firmly the palms and

15. In a circular motion soap forearms and elbows. Add

STEP 0 1 1.5 2 N/A COMMENT

19. Dry hands starting from fingers, to wrist up to the

22. The hands were not decontaminated during or

1- Not done, but essentially required

CARE OF THE CLIENT’S ENVIRONMENT

ASEPSIS is commonly defined as the absence of pathogenic microorganisms. Keeping the

 To reduce the number of microorganism in the clients environment.

 Risk for infection

1. Determine the equipment needed.

2. Perform hand hygiene Reduces the time of transient bacteria.

3. Wear clean gloves Reduces the transmission of microorganisms.

4. Use treated cloth or dampened cloth. To avoid raising dust.

6. Do not shake linens. Dust particles constitute a means by which

11. Rearrange the client’s thing with

FLOWER AND FLOWERING PLANTS forms an exceeding important part of nature.

 Enhance color to the surrounding

1. Assess for any allergies to pollens or fresh flowering plants

1. Risk for infection

1. Determine the equipment needed.

Different kinds of flower

1. Gather all equipment needed. To ensure saving time and efforts.

2. Perform hand hygiene. Detects the transmission of microorganisms

11. Perform hand hygiene. Reduces the transmission of microorganisms.

NAME:__________________________ LEVEL: __________DATE: ____________

STEPS SATISFIE UNSATISFI COMMENTS

BP Apparatus with Stethoscope Benedict Solution 30cc

4. Do handwashing. Wipe, dry with towel. Handwashing prevents possible infection

6. Put out things most needed for the

7. Place waste paper bag outside of work

To give comfort and security, maintain

12. Open the bag and put it back all

13. Remove apron folding away from the

14. Fold the linen/plastic lining, clean;

15. Make post-visit conference on matters

16. Make an appointment for the next visit

FUCN PROCEDURE MANUAL 2007

Name: __________________________________ Level: ____________ Date:

STEP SATIFIED UNSATISFIE COMENTS

A. TEST for ALBUMIN HEAT METHOD

NAME: _________________________________ LEVEL: ____________ DATE:

STEP SATISFIED UNSATISFIED COMMENTS

VITAL SIGNS TAKING

1. To afford the opportunity to observe the general condition of the patient.

 Heat is a by-product of metabolism

 Normal process are as follows: radiation, conduction, convection and evaporation

FACTORS AFFECTING BODY TEMPERATURE

 AGE: newborns have immature temperature control mechanism

1. Pyrexia – body temperature above normal range (also hypothermia, fever)

 Take the body temperature by mouth unless otherwise contraindicated.

NAME:____________ LEVEL: DATE:

Name: ______________________ Level: Date:

NAME: _____________________ LEVEL: DATE:

Name:________________________ Level: Date: