Nursing Procedure Manual Word LATEST1

SETTING A CLIENT’S UNIT
Adapted from Delaune and Ladner(2011). Fundamentals of Nursing;

Christensen and Kockrow (2011). Foundations and Adult Health Nursing.
I. DEFINITION
Environment – the sum total of the external surroundings and influences.
Client’s Unit – is a space or room consisting of a hospital bed, mattress, mattress cover, pillow, bedside
table, chair, utensils, and other equipment which are prepared for client’s use while staying in the
hospital.
Therapeutic Environment – an environment which helps a client grow, learn and return to health; it is
an atmosphere in which an individual is supported in his perceptions of himself as a person of worth.
A. Client’s Physical Environment – consists of physical aspects such as the furniture, drapes, lighting,
fixtures, other elements of the furnishings, or noise.
B. Client’s Psychosocial Environment – includes the members of the health teams, family and
significant others, as well as the hospital’s environment such as its cleanliness, color scheme,
orderliness and over-all environment.
Care of Client’s Environment – is the process of preparing the client’s unit for admission, maintaining its
cleanliness while the client is in the hospital, and cleaning the unit after the client has been discharged
from the hospital.
II. RATIONALE
1. To provide the client with the necessary space and articles needed for his / her recovery.
2. To provide an atmosphere that simulates home and eventually giving emotional satisfaction to the
client.
3. To attend to the safety, security and hygiene needs of the client.
III. EQUIPMENT
A. For Admission
Newly Cleaned Room Bed Mattress Mattress Cover
Pillow with Pillow Case Complete Set of Bedsheets
Foot Stool Bedside Table
Chair Utensils (for meals)
Flowers in a Vase
Admission Kit (Toilet Tissue, Thermometer, Face Towel, Soap in a Soap Dish)
Wash Basin
B. For Daily Maintenance of the Unit

Broom Dustpan
Feather Duster or Dusting Rug Fresh Flowers in a Vase

Air Freshener (as per hospital policy) New Set of Linens (as per hospital policy)
C. After Discharge
Broom Dust Pan
Dusting Rug Air Freshener
Pail with Antiseptic Solution Step Ladder
Floor Mop Fumigating Solution / Chemical (as needed)
IV. PLANNING AND IMPLEMENTATION
Special Considerations:
1. The nurse has the responsibility to adjust the environment to suit the client’s needs.
2. The health care team has a big role to play in providing a therapeutic environment for the client.
3. Prevention of noise is a must in the hospital. There are special materials used on the walls, floors,
and ceilings to absorb sound.
4. Nursing units or stations should not be too near a client’s room or ward so as noise will not reach
the client.
5. Room or ward decoration should consider colors that could affect the psychological status of clients.
Pastel colors are considered more therapeutic than dark ones. White usually threatens clients.
6. Furniture should be of the right size and height. Example: Hospital bed should be 3 feet in width, 6
feet 6 inches in length and 26 inches in height.
7. Preparation for a private room is different from a general ward only in terms of equipment being
supplied but basically the same for both in terms of considering the therapeutic effects on the
clients.
8. A firm mattress is of utmost importance for client’s comfort and for maintaining good body
alignment.
A. FOR ADMISSION
ACTION RATIONALE
1. Check if the client’s room is newly cleaned. To remove possible sources of infection.
Furniture should be free from dust.
2. Open the windows and adjust window drapes. To improve room’s ventilation and lighting.
3. Adjust air – conditioning units (for private rooms) To promote client’s comfort and recovery.
to desired coolness if natural climate cannot
maintain the usual temperature of 69 – 72°F.
(follow hospital policy)
4. Check if furnitures are complete and properly
assembled in their appropriate places. Utensils
should be arranged either on top of the bedside
To make the bed ready for client’s admission.
table or in the drawer.
5. Use a new set of clean linens, make a closed bed.
(follow procedure for bedmaking)
To enhance the therapeutic effect of the
6. Arrange flowers on a vase and place on top of the
environment.
bedside table.
7. Adjust artificial lighting depending on the time
when the client comes in. Provide a reading light
as needed, (as per hospital policy)
8. Check if comfort room has been properly To promote hygiene and sanitation.
cleaned, disinfected, and provided with the
necessary articles.
9. Leave the unit untouched until the client is To prevent possible contamination.
admitted. Minimize entry of hospital personnel.
B. FOR DAILY MAINTENANCE OF THE UNIT
1. Do daily sweeping and dusting. Be careful not

To maintain
to the cleanliness of the room.
disturb the client and not to let the dust reach
him/her. (This task can be delegated to the
hospital janitorial services)
2. Change linens as per hospital policy.
3. Change flowers if withered. For aesthetic purpose.
4. Keep the bath and comfort rooms clean and

disinfected.
5. Use air freshener if not hazardous to the client’s

condition.
To promote hygiene and sanitation.
6. Arrange furniture and equipment regularly.
To improve the odor of the room.

7. Keep the signal light within the person’s reach at
all times on the person’s strong side.
8. Interact with the client as necessary.

To keep the room neat and tidy.
9. Dispose of the garbage properly.

To signal that the person needs help and attention.
To promote therapeutic communication.
To prevent contamination.
C. AFTER THE CLIENT’S DISCHARG
1. Remove contraptions if they were used To

andremove equipment which can become a possible
place them properly in the utility room or source of contamination.
nurse’s station.
Linens are considered soiled once the client is

discharged from the unit.
2. Strip the bed and discard the linens on the
hamper and send to the laundry department
(follow procedure for stripping the bed; follow
hospital policy for sending linens to the laundry
Exposure to sunlight is a way of disinfecting pillows and
department). Expose mattress and pillows to mattresses.
sunlight. Remove drapes.
3. Place furniture in their respective places. To maintain orderliness.
4. Turn off lights and air-conditioning unit (if there

To avoid power wastage.
is any).
5. Close the windows and door. To keep room sanitary.
Note: Cleaning tasks can be delegated to the janitor. Follow hospital policy if fumigation of the room is
needed.
V. EVALUATION
1. Cleanliness and tidiness of the unit
2. Aesthetic appearance of the unit
3. Hygiene and sanitation of the unit
4. Over – all therapeutic effect of the unit on the client
MAKING A BED FOR A CLIENT
I. DEFINITION
Bedmaking – a procedure wherein bed linens are changed to make the client comfortable during the
entire stay in the hospital or health care setting.
Unoccupied Bed – a hospital bed which is made ready for admission or wherein the client is out of bed
ambulating around. It can either be a closed or open bed.
Closed Bed – an unoccupied bed wherein the top sheet, blanket, and bedspread are drawn up to the
top of the bed.
Open Bed – an unoccupied bed wherein the top covers of the bed are folded back to make it easier for a
client to lie on.
Occupied Bed – a bed occupied by a client who cannot get out of bed for some reasons.
Surgical Bed – a bed made for a client who is undergoing a surgical or diagnostic procedure that
requires the use of an anesthetic agent.
Fracture Bed – a bed made for a client who is suffering from a fracture or other musculo - skeletal
disorders.
Stripping the Bed – is a procedure wherein used linens are removed from the bed and the bed mattress
is aired.
II. RATIONALE
1. To provide comfort and safety.

2. To provide a clean bed for the client.
3. To make a bed that is comfortable and neat while being occupied by a client.
4. To help maintain proper body alignment.
5. To help immobilize a body part.
III. EQUIPMENT
Mattress Cover Top Sheet

Bottom Sheet Blanket (if needed / optional)
Rubber Sheet Bedspread (if needed / optional)
Cotton Draw Sheet Hamper for soiled linens
Additional Equipment for Making a Surgical Bed

Emesis Basin Wash Cloth
Tissue Wipes IV Stand
Tongue Depressor Hot Water Bag (2)
Suction Machine (if needed) Bath Towel
Sphygmomanometer and Stethoscope
Additional Equipment for Making a Fracture Bed

Bedboards Footboards
Cradles
A. Asepsis in Bedmaking
1. Handle linens carefully. Avoid shaking them. Place soiled linens inside the laundry hamper and
not on the floor. To prevent the spread of microorganisms which move through space in air
currents. The floor is the most contaminated area in the hospital.
2. Hold both soiled and clean linens away from your uniform. To prevent contamination.
Microorganisms are transferred from one surface to another whenever one object touches
another.
3. Wash hands before and after the procedure. To prevent the spread of microorganisms.
B. Body Mechanics in Bedmaking

1. Raise the bed to a comfortable height (hip level). Bend your knees and not your back. To prevent
fatigue. A person or an object is more stable if the center of gravity is close to the base of
support.
2. See to it that the entire body is facing in the direction that you are moving and avoid twisting
the body. To lessen the susceptibility of the back to injury.
3. Make the bed completely on one side before moving to the other side. Organize your work and
move with moderate speed. To save time and effort. Smooth, rhythmical movements at
moderate speed require less energy.
C. Other Considerations
1. Place client on a safe position when the linens are completely changed. To prevent accidents.
2. Be certain the wheels of the bed are locked. To keep the bed from moving.
3. Remove attached equipment (call light, waste bag, personal items) before starting the
procedure. To save time and effort. One can perform better and movements are easy when the
work area is clear.
4. Side rails should be in the down position and in the case of an occupied bed, only at the side
where you are working. To promote easy movement and at the same time to prevent accident
in cases of occupied beds.
5. When making the bed, seams should always be toward the mattress or away from the client.
The smooth surface should be in contact with the client. To prevent skin irritation. There are
clients who are hypersensitive to rough surfaces.
ACTION RATIONALE
QUALITY OF LIFE
Remember to:
 Knock before entering the person’s room
 Address the person by name
 Introduce yourself by name and title
MAKING AN UNOCCUPIED CLOSED BED
Pre-procedure
1. Bring necessary clean linens to the bedside. To save time and energy.
2. Place linens on a clean chair or on the over bed To prevent cross - contamination. Having linens in
table in the same order in which they will be order in which they will be used saves time and
placed on the bed. Do not place the linens on effort.
another client’s bed.
3. Strip the bed, in case the bed is not stripped.

Raise the bed for proper body mechanics. (Refer
to procedure in Stripping the Bed)
Procedure
4. From the foot of the bed, place the folded bottom To allow the top of the sheet to remain securely in
sheet along the edge of the mattress with its place especially if the head of the bed is elevated.
center fold on the center of the mattress and the
seam toward the mattress. The smooth surface
should be in contact with the client. Unfold the
sheet over the bed and allow a sufficient amount
of sheet at the top to tuck under the mattress.
5. Move to the head of the bed on the same side To anchor the sheet firmly.
and tuck the sheet under the head part of the
mattress and miter the top corner (refer to
procedure on how to make a mitered comer).
Tuck the remaining sheet under the side of the
mattress all the way to the foot of the bed.
6. Working from the same side, place the rubber To protect the bottom sheet from soiling. Draw
draw sheet on the center third of the bed over sheets can also be used in moving and lifting the
the bottom sheet. The centerfold is at the center client.
line of the bed. Place the cotton draw sheet (seam
in contact with the rubber sheet) in the same
manner over the rubber sheet. Unfold the sheets
over the bed and tuck them under the mattress.
7. From the same side, place the top sheet at the To avoid unnecessary moving about the bed. To
top edge of the mattress, centerfold of the sheet save time and effort.
at the center line of the bed and seam side up.
Unfold the entire sheet and tuck under the foot
end of the bed. Miter the bottom corner of the
top linen at the foot of the bed but do not tuck
the sides. Allow it to hang freely unless toe pleats
are provided.
To provide additional room for the client’s feet.
Optional: Make a vertical or horizontal toe pleat
on the sheet.
Vertical Toe Pleat: Make a fold on the sheet 5 to
10 cm (2 to 4 in) perpendicular to the foot of the
bed.
Horizontal Toe Pleat: Make a fold on the sheet 5
to 10 cm (2 to 4 in) across the bed near the foot.
8. If using a blanket and a bedspread, follow the To provide warmth when the weather is cold.
same procedure as the top sheet, but place the
top edges about 15 cm (6 in) from the head of the
bed. Tuck at the foot of the bed and miter the
corner together with the top sheet.
9. Move to the other side of the bed to tuck the To save time and effort.
linens on that side in the same manner as the
other side. Pull the sheets firmly so that there are To prevent discomfort.
no wrinkles.
10. If using a blanket and a bedspread, fold the top of To make it easier for the client to pull the covers up.
the sheet down over the spread, providing a cuff
of about 15 cm (6 in).
11. Put a clean pillowcase on the pillow. To promote comfort. A smoothly fitting pillowcase is
more comfortable than a wrinkled one.
- Grasp the closed end of the pillowcase at the
center with one hand.
- Gather the case from top to bottom with the
second hand.
- Grasp the center of one short side of the pillow
through the pillowcase.
- With the free hand, pull the pillowcase over the
pillow.
- Adjust the pillowcase so that the pillow fits into
the corners of the case and the seams are
straight.
12. Align and place the pillows at the head of the bed To provide a neat appearance.
in the center, with the open ends of the pillow
case facing away from the door of the room.
Post-procedure
13. Replace all attached equipment (call light, waste To provide easy access for the client in case needed.
paper bag)
14. Leave bed in high position until admission comes To provide an easy access in case the client comes in
or until the client comes back. by stretcher.
15. Do after care. To prevent the spread of microorganisms.
MAKING AN UNOCCUPIED OPEN BED
- Follow the procedure in Making Unoccupied

Closed Bed.
- To make the bed an Open Bed, either fold back To make it easier for the client to get into the bed.
the top covers at one side or fanfold them down
to the center of the bed.
MAKING A SURGICAL OR ETHER BED
1. Follow steps 1 -6, and 9 of the procedure in

Making Unoccupied Closed Bed.
2. Spread the bath towel over the head part of the To protect the linens.
bed.
3. Spread the top covers of the bed. Do not tuck To facilitate easy transfer of the client from
them in, miter the corners, or make a toe pleat. stretcher to bed with minimum motion and
discomfort.
4. Fold the hanging edges of the top covers up over To promote ease in transferring the client into the
the top of the bed so that the folds are at the bed.
mattress edge (fold the sides first, then the top
and bottom). Fanfold them lengthwise at one side
of the bed or cross - wise at the bottom of the
bed.
5. Place hot water bag in between folds of the top To warm the bed.
linen.
6. Follow step 11 of the procedure in Making an

Unoccupied Closed Bed.
7. Place pillow(s) on a table or chair, or on top of the To protect the client from injury.
fan - folded linen or against the head rails of the
bed.
8. Leave the bed in high position to receive the To facilitate easy transfer of the client from the
client. stretcher to the bed.
9. Place emesis basin, tissues, IV stand, and other To provide easy access when needed.
necessary items appropriately at the bedside.
10. Do after-care. To prevent the spread of microorganisms.
MAKING A FRACTURE BED
1. If bed board is used, place directly under the To promote good body alignment and comfort.
mattress.
2. Make an unoccupied bed.
3. Place a footboard at the foot of the bed. To prevent the client from sliding to the foot of the
bed. To provide a firm surface for foot exercise. To
prevent foot drop.
4. If a cradle is used, arrange the top linen over the To keep the linen off the client’s feet and lower legs
device and pin it in place or simply tuck as as in cases of edema, leg ulcers, and burns.
securely as possible around the frame.
MAKING AN OCCUPIED BED
1. Bring all materials to the bedside. Place on a chair or To avoid the transfer of microorganisms.
on the over bed table. Arrange the linens in the To save time and energy.
same order in which they will be placed on the bed.
2. Explain the procedure to the client. Use a screen To gain the client’s cooperation and to provide
if the client is in the ward. privacy.
3. Adjust the bed to a comfortable working height To prevent unnecessary strain on the nurse’s back.
and place in a flat position if the client's health
permits. Remove the pillow(s), if permissible.
4. Loosen all the top linen at the foot part of the To promote ease and comfort during the procedure.
bed. Remove the spread and blanket, if used by To provide warmth and privacy for the client.
the client. Leave the top sheet over the client.
5. Assist the client to turn on the far side of the bed To give the nurse more room to make one side of
facing away from the side where the clean linen the bed first.
is. Reposition the client in a side-lying position. Be
sure the side rail is up in the far side of the bed. To prevent accidental fail.
6. Loosen the bottom sheet, draw sheet, and cotton To save time and effort.
draw sheet on the side where you are working.
7. Fanfold the draw sheet, rubber sheet, and bottom To limit the transfer of microorganisms from the
sheet towards the center of the bed and tuck soiled linen to the clean one.
them under the client's back and buttocks. To make it easier to pull the linen at the other side
of the bed.
8. Lay the clean bottom sheet lengthwise on the To make sure that the linens are placed and tucked
bed, unfold it so that its centerfold is at the center equally on the bed.
of the bed, the bottom hem is in line with the
bottom edge of the mattress. Fanfold half of the
sheet lengthwise to the center of the bed.
9. Tuck the sheet under the mattress at the head To anchor the linen securely.
part of the bed and miter the top comer on that
side.
10. Place the rubber sheet and cotton draw sheet on To conserve time and effort.
the bed in similar fashion as you did with the
bottom sheet. Together with the bottom sheet,
tuck them snugly and smoothly under the side of
the mattress.
11. Assist the client to roll over toward you onto the To facilitate making the other side of the bed.
clean side of the bed. The client rolls over the fan-
folded linen at the center of the bed.
12. Move the pillow to the clean side for client’s use, To provide comfort.
if not removed from bed. Raise the side rail To prevent the client from having an accidental fall.
before leaving the side of the bed.
13. Move to the other side of the bed and lower the To promote ease and comfort during the procedure.
side rail.
14. Loosen and remove the soiled linen and place it in To limit the spread of microorganisms.
the hamper.
15. Pull the fan-folded linen, rubber sheet, and cotton To provide comfort and protect the client from skin
draw sheet from the center of the bed. Beginning irritation.
with the head part of the bottom sheet, smooth
out the sheet, tuck it at the top of the mattress,
miter the top corner of that side and tuck under
the side of the mattress together with the rubber
sheet and cotton draw sheet.
16. Assist the client to the center of the bed. To promote client’s comfort.
Determine what position the client requires or
prefers and assist the client to that position.
17. Spread the fan-folded top sheet over the client’s To provide privacy while removing the soiled linen.
chest. Remove the soiled top sheet by asking the
client to hold the top edge of the clean sheet or
tuck it under the shoulders, if the client is unable
to hold it, as you pull it together with the soiled
top sheet from the top to the bottom. Place the
soiled linen in the hamper.
18. Tuck the top sheet at the foot part and make a To ensure that the linen is anchored securely.
square corner.
19. If blanket and spread are used, follow the same To provide warmth.
procedure as the top sheet and tuck them
together at the foot part with the top sheet.
20. Remove the pillow(s) and change the pillow

case(s) (follow step 11 of the procedure in Making
an Unoccupied Closed Bed). Position the pillow(s)
appropriately for client’s use.
21. Place the bed in low position and adjust the side To prevent injury.
rails.
STRIPPING THE BED
1. Wash hands. To prevent the spread of microorganisms.
2. Obtain a laundry or hamper bag. To be used for the soiled linens.
3. Place a chair at the foot part of the bed. To be used for the pillow(s) after removing the
pillow case(s).
4. Remove the pillow case(s) from the pillow(s). To limit the transfer of microorganisms.
Place the pillow(s) on the chair and the soiled
pillow case(s) on the low bar of the bed or in the
laundry / hamper bag.
5. Check bed linens for any of the client’s misplaced To prevent losses of client’s personal items and to
personal items, and detach the call bell or any promote ease and comfort in doing the procedure.
drainage tubes from the bed linen.
6. Loosen the top and the bottom linen from the To prevent stretching and reaching and possible
mattress, moving around the bed from head to muscle strain.
foot on one side and foot to head on the opposite
side.
7. Remove the rubber draw sheet and discard if it is To prevent the spread of microorganisms.
soiled.
8. Roll all soiled linen inside the bottom sheet, hold To prevent the transfer of microorganisms.
it away from your uniform, and place it directly in
the linen hamper.
9. Remove the mattress cover, discard it into the To allow the mattress to be exposed to sunlight and
linen hamper and turn the mattress over. air.
10. Do after - care and wash your hands. To prevent the spread of microorganisms.
TO MAKE A MITERED CORNER
1. Pick up the side edge of the sheet approximately

12 inches from the comer of the mattress. Hold it
straight up and down, parallel to the side of the
mattress.
2. Lay the upper part of the sheet on the bed.
3. Tuck the part of the sheet that is hanging below

the mattress smoothly under the mattress.
4. 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 SQUARED CORNER
1. Pick up the sheet to form a 45 - degree angle

(step 1 of how to make a mitered comer).
2. Lay the upper part of the sheet on the bed. See to

it that when the folded edge is placed on the top
of the mattress before tucking, it is even with the
bottom edge of the mattress.
3. Tuck the part of the sheet that is hanging below

the mattress smoothly under the mattress.
4. Bring the folded edge at the top of the mattress

down and let the sides of the top sheet hang
freely.
V. EVALUATION AND DOCUMENTATION
Evaluation is done using the following criteria:
Unoccupied Bed
1. smooth, wrinkle - free surface
2. tight corners
3. correct position (high or low) for the client’s needs
4. necessary equipment (call light, waste paper bag) attached in appropriate place
Post - op or Surgical Bed

2. top covers folded back out of the way
3. necessary items at the bedside
4. bed in high position
Fracture Bed
2. client’s comfort
3. proper placement of devices
Occupied Bed
1. client’s comfort
3. tight comers
4. bed and side rails in correct position
5. bed in low position
6. call light and other personal items within client’s reach
Documentation on the ff:

1. Tolerance of the client’s being out of bed, in case of unoccupied bed
2. Any assessment data or change in the client’s clinical status
VI. ILLUSTRATION
Mitering the Corner of a Bed A Horizontal Toe Pleat
ADMITTING A CLIENT
Adapted from Potter and Perry (2011). Clinical Nursing Skills and Techniques;
Altman, Gaylene Bonska (2010). Fundamentals and Advanced Nursing Skills.
I. DEFINITION
Admitting a Client - a process of getting a client signed into the hospital.
II. RATIONALE
1. To provide a comfortable and aesthetically pleasing environment for the client.

2. To maintain asepsis by preventing the spread of microorganisms.
3. To provide the client some control over the client’s immediate environment.
4. To provide the client with an opportunity to verbalize his/her feelings about hospitalization.
5. To encourage the client to participate in his/her plan of care.
III. EQUIPMENT
Admission Kit for Personal Hygiene Thermometer

Blood Pressure Apparatus and Stethoscope
Urine Container
Kardex and Patient Care Plan
Patient Chart
2 TYPES OF ADMISSION
1. Routine Admission - this is scheduled in advance

2. Emergency Admission - this has no prior planning
PHASES OF ADMISSION
1. Immediate Needs of the Person - should be the first concern

a. Physical Needs – if the client is in acute pain, contact the physician immediately regarding
orders for medication and care; meanwhile, institute nursing measure to relieve the pain.
b. Emotional Needs – if the client is upset or distraught, spend time listening and talking to the
client. This can facilitate the transition to the hospital environment.
2. Introduction and Orientation – greet the client; introduce yourself and call the client by his/her
name. Orient the client to the unit. This relieves the anxiety created by fear of the unknown.
3. Baseline Assessment – information to be gathered in baseline assessment varies from one facility to
another.
a. Admission Sheet
b. TPR, BP, Height, Weight
c. Physical Examination
d. Laboratory Examination
e. History
4. Care of Belongings and Personal Property - most facilities have a routine for checking and noting all
personal items a client brings to the facility. Items that are not needed can be sent home with the
family members.
5. Record Keeping - recording all parts of the admission process is essential for legal records.
ACTION RATIONALE
1. Introduce yourself to the client and begin to To establish rapport with the client and his/her
establish therapeutic nurse - client relationship. family. To ease fear of the unknown.
Introduce the client to his/her roommates, if
present.
2. Provide for privacy. Ask relatives to leave unless To provide privacy.

they will assist with undressing the client.
3. Help the client undress and assist him/her in To promote comfort and to prevent accidents such
putting on the hospital gown. Assist him/her to a as falling.
comfortable position in bed. To prepare client in receiving care.
4. Take care of the client’s clothing and valuables. To prevent loss of valuables which can be a legal
Follow agency procedure. problem.
5. Explain equipment and hospital routine. To promote ease and comfort.
6. Place the signal device and other equipment so For easy accessibility in case the client wants to call
that these will be convenient for the client’s use. for help.
7. Obtain the client’s vital signs and blood pressure. To obtain baseline data.
Obtain a urine specimen at a time that is
convenient during the admission procedure.
8. Inform the relatives that they may return to the This makes the family and relatives free of worry
client’s room/bedside. seeing that the client is settled and comfortable.
9. Notify the attending physician that the client has Informing the attending physician is an important
been admitted and obtain orders if policy responsibility of the nurse.
permits.
10. Do necessary recording on the client’s record, Client’s record is an important part of the client’s
following the agency policy. admission and all care given to the client should be
documented on his/her record.
V. DOCUMENTATION AND EVALUATION
1. Time, date, and client’s status on admission

2. Emergency measures done, if any
3. Medical and Nursing care rendered
4. Laboratory procedures done
5. Client’s status after all necessary care and tests were done
DISCHARGING A CLIENT
I. DEFINITION
Discharge Planning – a systematic process for preparing a client to leave the health care agency and for
continuity of care.
II. RATIONALE
1. To prepare the client for leaving the health care agency.

2. To transfer a client whose condition necessitates care to other health care facility.
3. To provide an environment, either home or another community agency or facility, that best meet
the needs of the client.
4. To allow the client to verbalize his/her feelings about discharge and identify the client’s strength and
weaknesses.
5. To help the client become aware of potential changes in the environment and lifestyle due to
his/her disability or limitation.
III. EQUIPMENT
Educational Pamphlets
Telephone Numbers & Information regarding Clinic Appointments or Special Groups such as Stroke Club
or Diabetic Club
Specific Equipment needed upon discharge such as wheelchair or commode
Medications
Materials for changing dressings (if indicated) or anti – embolytic stockings
ACTION RATIONALE
1. Check to see that the client has a This is a must before discharging a client as this is the
discharge order. responsibility of the physician to give discharge order.
2. If the client is leaving withoutA the
client cannot be legally held in an agency against his/her
physician’s consent, check to see that the proper decision.
form has been completed. To relieve the health care agency of any legal
responsibility in case problem will arise because the
client refused further care.
3. Check if the client or a family Pre – discharge instructions are necessary for the full
member or a relative has been given discharge recovery of the client.
instructions such as medication, out – patient
check – up, treatment at home, etc.
4. Check that all necessary equipment

To save time and effort.
and supplies are ready for the client to take
home like medication. Obtain missing items as
necessary.
5. Check to see that proper financial To avoid legal financial problems.

arrangements have been made by the client or
family member, or relative. Obtain client’s
clothing and valuables. Observe agency policy on
this matter.
6. Assist the client to dress and To

pack
conserve the client’s strength.
his/her belongings. See to it that all his/her To avoid loss of belongings and further problems in
belongings are given to them. the future.
7. Transport the client and his/her To show concern and interest to the client.
belongings to the car or any mode of
transportation he/she is taking. Assist him/her as
necessary.
1. Pre – discharge health teachings given

2. Medical and nursing care rendered before discharge
3. Date, time, and status of the client upon discharge
4. Accompanying person and mode of transportation upon discharge
BATHING A CLIENT
Lippincott Manual of Nursing Practice (2010).
I. DEFINITION
Bedbath – is a type of bath given to a client who cannot perform his / her own personal hygiene or
who can but in a very limited way. The client is required to remain in bed as part of the
therapeutic regimen.
II. RATIONALE
1. To promote cleanliness.
2. To provide comfort and relaxation.
3. To improve the client’s self - image.
4. To condition the client’s skin.
5. To stimulate the peripheral circulation of the client.
6. To provide an opportunity to strengthen a helping nurse – client relationship, to observe the client’s
physiological and emotional status and to teach the client, as needed.
III. EQUIPMENT
Bath Towels (2)

Washcloths (2)
Soap in a Soap Dish
Basin with Hot Water (between 43°C and 46°C / 110°F and 115°F)
Hygienic Supplies such as Lotion, Powder, and Deodorant
Bath Blanket
Clean Gown or Pajamas
Clean Bed Linens and Towels, if needed
Bedpan or Urinal
Hamper for Soiled Linens
Gloves (optional)
Special Considerations: Apply the principles of asepsis and body mechanics in bedmaking.
ACTION RATIONALE
QUALITY OF LIFE
Remember to:
Pre-procedure
1. Prepare the client and the environment.
1.1. Explain the procedure to the client. To gain the client’s cooperation.
1.2. Before beginning the bath, determine To prevent undue fatigue to the client.
(a)other care the client is receiving such as
x – ray or physiotherapy so that the bathTo determine the extent of care needed by the client.
can be coordinated with those activities;
and (b) aspects of the client’s health that
affect the bathing process such as limited
ROM, muscle pain, or a cast or IV therapy.
1.3. Close the windows and doors. To minimize loss of heat from the body by convection.
1.4. Close the door or draw the curtains or place

To provide client’s privacy.
a screen.
1.5. Offer the client a bedpan or a urinal orTo

askpromote comfort. Voiding is also advisable before
whether the client wants to use the toilet or cleaning the perineum.
commode.
Procedure
2. Prepare the bed and position the client

appropriately.
2.1. Place the bed in high position. To avoid undue strain on the nurse’s back.
2.2. Place a fan – folded bath blanket overTo theprevent unnecessary exposure of the client.
client’s chest and ask the client to hold the
top edge of the bath blanket. Grasp To theprevent the spread of microorganisms.
bottom of the bath blanket and the top
edge of the top sheet and pull the top sheet
and bath blanket together to the foot of the
bed. If the bed linen is to be reused, place it
over the bedside chair. If it is to be changed,
place it in the linen hamper.
2.3. Assist the client to move near you. To prevent undue reaching and straining.
2.4. Remove the client’s gown.
2.5. During the bath, assess each area of To thedetect any skin irritation, a break in the skin or reddened
skin. area.
3. Give oral care if not done yet. (refer to specific

procedure)
4. Make a bath mitt with the washcloth. To allow the water and heat to be retained better.
4.1. Triangular Method: (a) Lay your hand on the

washcloth; (b) fold the top corner over your
hand; (c) fold the side corners over your
hand; (d) tuck the second corner under the
cloth on the palmar side to secure the mitt.
4.2. Rectangular Method: (a) Lay your hand on

the washcloth, and fold one side over your
hand; (b) fold the second side over your
hand; (c) fold the top of the cloth down,
and tuck it under the folded side against
your palm to secure the mitt.
5. Wash the face.
5.1. Place one towel across the client’s chest.To protect the client from getting wet in case the water drips.
5.2. Wash the client’s eyes with water only, and To prevent eye irritation.
dry them well. Use a separate corner of the To prevent the transmission of microorganisms from
washcloth for each eye. Wipe from the one eye to the other.
inner to the outer canthus. To prevent the secretions from entering the nasolacrimal
ducts.
5.3. Ask whether the client wants soap usedToondetermine the client’s preference because soap has a
the face. drying effect especially on the face.
5.4. Wash, rinse, and dry the client’s face, neck,

and ears. You may use soap when washing
the neck and ears.
6. Wash the arms and hands.
6.1. Place the bath towel lengthwise under To

theprotect the bed from becoming wet and to prevent heat
arm. loss from evaporation.
6.2. Wash, rinse, and dry the arm using long, To increase venous blood return.
firm strokes from distal to proximal areas.
To prevent leaning over or dirty water from dripping on the
Wash the axilla well. Repeat for the other part that has already been washed.
arm. Do the far arm first.
6.3. Exercise caution if an intravenous infusion

To ispromote accuracy of IV flow.
present, and check its flow after moving the
arm.
6.4. Place a towel directly on the bed and put To protect the bed.
the basin on it. Place the client’s hands in
the basin. Wash, rinse, and dry the hands
To clean thoroughly these areas which are considered the
paying particular attention to the spaces dirtiest part.
between the fingers, and around and under
the nails.
6.5. Discard the water from the basin and

replace it with a clean one.
7. Wash the chest and abdomen.

7.1. Fold the bath blanket down to the client’s
To provide privacy.
pubic area and place the towel alongside
the chest and abdomen.
7.2. Wash, rinse, and dry the chest, giving To clean thoroughly the areas which are dirty and
special attention to the skinfold under the are prone to irritation.
breasts. Wash the abdomen with long, firm
strokes giving special attention to To theprovide privacy, prevent heat loss and promote comfort.
umbilicus. Rinse and dry. Keep the chest
and abdomen covered with the towel
between the wash and the rinse.
7.3. Replace the bath blanket when the areasTo provide privacy.
have been dried.
7.4.
8. Wash the legs and feet.
8.1. Wrap one of the client’s legs and feet with
Same as 6.1 and 6.2
the bath blanket, ensuring that the pubic
area is well covered. Place the bath towel
lengthwise under the other leg and wash
that leg. Use long, smooth, firm strokes,
washing from the ankle to the knee to the
thigh.
8.2. Rinse and dry that leg, reverse the covering Same as 6.2
and repeat for the other leg. Do the far leg
first.
8.3. Place the basin near the feet with the towel Same as 6.4
under it. Flex the leg at the knee and while
supporting the heel with the cup of your
hand, wash one foot at a time in the basin.
Pay particular attention to the spaces
between the toes. Rinse, place on the
towel, and dry.
8.4. Remove the basin. Discard the water and

obtain fresh, warm bath water.
9. Wash the back and perineum.

9.1. Assist the client to turn to a prone position
To provide privacy.
or side - lying position facing away from
you, and place the bath towel lengthwise
alongside the back and buttocks.
9.2. Expose the back and the buttocks. WashSame as 7.2

and dry the back, buttocks, and upper
thighs, paying particular attention to the
gluteal folds. Give a back rub (refer to
specific procedure for backrub). Avoid
undue exposure of the client.
9.3. Assist the client to the supine position Toandprovide privacy.

determine whether the client can wash the
genital - perineal area independently. If the
client can do so, place the basin (with newly
replaced water), washcloth and towel
within easy reach so the client can wash the
genital area or assist the client as necessary.
If the client cannot do so, drape the client
and wash the genital area (refer to specific
procedure).
9.4. Discard the used washcloth, towel, To

andprevent contamination.
water.
10. Assist the client with grooming aids such as

powder, lotion, or deodorant.
10.1. Use powder sparingly, To prevent its accumulation.
10.2. Help the client to put on a clean gownToorpromote comfort.

pajama.
10.3. Assist the client with hair, mouth, and nail

care. Some people prefer or need mouth
care prior to the bath.
Post-procedure
11. Make an occupied bed (refer to specific

procedure).
12. Do after - care of equipment and supplies. To prevent the spread of microorganisms.
13. Lower the bed to its lower position.
14. Unscreen the person.
15. Decontaminate your hands.
1. Evaluation is done in terms of fatigue manifested by the client, feelings about comfort and
cleanliness, and objective signs of cleanliness.
2. Document pertinent data: Assessment findings such as excoriation in the folds beneath the breasts
or reddened areas over bony prominences and progress in relief of previous problems; Type of bath
given; Client’s preferences or ability to participate.
VI. ILLUSTRATION
Making a Bath Mitt Draping One Leg of a Client
SHAMPOOING THE HAIR OF A CLIENT
I. DEFINITION
Hair Shampoo – washing of the hair to keep it clean.
II. RATIONALE
1. To clean the hair and increase the client’s sense of well – being.
2. To stimulate the blood circulation to the scalp through massage.

III. EQUIPMENT
Comb and Brush Bath Blanket
Plastic Sheet or Pad Receptacle for the shampoo water
Two Bath Towels Cotton Balls (optional)
Shampoo Basin or Inflated Kelly Pad Pitcher of Water
Washcloth or Pad Bath Thermometer
Liquid or Cream Shampoo Hair Dryer
ACTION RATIONALE
QUALITY OF LIFE
Remember to:
Pre-procedure
1. Determine whether a physician’s order is needed

Some agencies require an order.
before a shampoo can be given.
2. Determine the type of shampoo to be used. Some clients have allergies.
3. Determine the best time of the day for To

thebe able to schedule the procedure so the client can rest
shampoo. Discuss this with the client. after.
Procedure
4. Provide for client privacy by drawing the curtains
To promote client’s comfort.
around the bed or closing the door to the room.
5. Position and prepare the client appropriately.

- Assist the client to the side of the bed from which
To prevent the nurse from reaching over.
you will work.
- Remove pins and ribbons from the hair, and brushTo remove any tangles.
and comb it.
6. Arrange the equipment.

- Put the plastic sheet or pad on the bed underTo
theprotect the bedding from getting wet.
head.
- Remove the pillow from under the client’s head, To hyperextend the neck.
and place it under the shoulders unless there is
some underlying condition (e.g. neck surgery,
neck arthritis)
- Tuck a bath towel around the client’s shoulders. To keep the shoulders dry.
- Place the shampoo basin under the head, putting To prevent undue strain and discomfort since the muscles of
a folded washcloth or pad where the client’s neck the neck are supported by a pad.
rests on the edge of the basin. In the absence of a
shampoo basin, an inflated Kelly pad can be used.
If the client is on a stretcher, the neck can rest on
the edge of the sink with the washcloth as
padding.
- Fanfold the top bedding down to the waist, To andkeep the top bedding dry and the bath blanket will keep
cover the upper part of the client with the bath the client warm.
blanket.
- Place the receiving waste receptacle on a table Toorprevent the water from dripping all over the area.
chair at the bedside. Put the spout of the
shampoo basin or the tail of the Kelly pad over
the receptacle.
7. Put on gloves and observe other appropriate

To prevent the spread of microorganisms.
infection control procedures as needed.
8. Shampoo the hair.

- Wet the hair thoroughly with the water.
- Apply shampoo to the scalp. Make a good lather Massaging stimulates the blood circulation in the scalp. The
with the shampoo while massaging the scalp with pads of the fingers are used to prevent the nails
the pads of your fingertips. Massage all areas of from scratching the scalp.
the scalp systematically, for example, starting at
the front and working toward the back of the
head.
- Rinse the hair briefly, and apply shampoo again.
To clean the hair thoroughly.
- Make a good lather and massage the scalp as
before.
- Rinse the hair thoroughly this time to removeToallprevent the hair from drying and getting irritated if all the
shampoo. shampoo is not removed.
- Squeeze as much water as possible out of the Tohairprevent the hair from dripping.
with your hands.
Post-procedure
9. Remove and discard the gloves (if used).
Decontaminate your hands.
10. Provide comfort.
11. Lower the bed to its lowest position.
12. Raise or lower bed rails. Follow the care plan.
13. Place the signal light within reach.
14. Unscreen the person.
15. Clean and return equipment to its proper place.

Discard disposable items.
16. Follow agency policy for dirty linen.
Evaluate and document using the following criteria:
- Client’s comfort
- Client’s condition after the procedure
- Objective signs of cleanliness
- Any problem identified
PROVIDING ORAL CARE / BRUSHING / FLOSSING THE TEETH
Adapted from Altman, Gaylene Bonska (2010). Fundamentals and Advanced Nursing Skills;
I. DEFINITION
Oral Care - is a procedure performed to keep the mouth clean and refreshed.
Brushing and Flossing the Teeth – is a mechanical action of removing food particles from the mouth
and teeth that can harbor and incubate bacteria.
II. RATIONALE
Oral Care
1. To maintain the intactness and health of the lips, tongue, and mucous membranes of the mouth.
2. To prevent oral infections.
3. To clean and moisten the membranes of the mouth and lips.
Brushing and Flossing
1. To remove food particles from around and between the teeth.

2. To remove dental plaque.
3. To enhance the client’s feelings of well - being.
4. To prevent sores and infection of the oral tissues.
III. EQUIPMENT
Towel Denture Container as needed

Curved Basin (Emesis Basin) Mouthwash
Disposable Clean Gloves Rubber - Tipped Bulb Syringe
Bite block to hold the mouth open and teeth Suction
apart Catheter with Suction Apparatus (optional)
(optional) Foam Swabs and Cleaning Solution for cleaning the
Toothbrush mucous membranes
Cup of Tepid Water Petroleum Jelly (Vaseline)
Dentifrice or Denture Cleaner Dental Floss
Tissue or Piece of Gauze to remove dentures
(optional)
ACTION RATIONALE
QUALITY OF LIFE
Remember to:
Pre-procedure
1. Explain the procedure to the client. To gain client’s cooperation.
2. Wash hands and observe other appropriate To prevent contamination.

infection control procedures such as wearing of
disposable gloves.
3. Provide for client privacy by drawing the curtains

To make the client comfortable during the procedure.
around the bed or closing the door to the room.
4. Prepare the client.

- Assist the client to a sitting position in bed,
To ifprevent any liquid from draining down the client’s throat.
health permits. If not, assist the client to a
side - lying position with the head turned.
5. Prepare the equipment.

- Place the towel under the client’s chin. To prevent the client from getting wet.
- Put on disposable gloves. To prevent contamination.
- Moisten the bristles of the toothbrush with To allow the dentifrice or toothpaste to stick to the
tepid water and apply the dentifrice or toothbrush.
toothpaste to the toothbrush.
- Use a soft toothbrush (a small one for a child)
To promote comfort.
and the client’s choice of dentifrice.
- For the client who must remain in bed, place Theor basin will serve as waste receptacle.
hold the curved basin under the client’s chin,
fitting the small curve around the chin or neck.
- Inspect the mouth and teeth. To check for possible problems.
Procedure
6. Brush the teeth.

- Hand the toothbrush to the client, or brush
the client’s teeth as follows:
a. Hold the brush against the teeth with This the sulcular technique removes plaque and cleans under
bristles at a 45 - degree angle. The tips of the the gingival margins.
outer bristles should rest against and
penetrate under the gingival sulcus. The brush
will clean under the sulcus of two or three
teeth at one time.
b. Move the bristles up and down using a
vibrating or jiggling motion from the sulcus to
the crowns of the teeth.
c. Repeat until all outer and inner surfaces of the
teeth and sulci of the gums are cleaned.
d. Clean the biting surfaces by moving the brush
back and forth over them in short strokes.
e. If the tongue is coated, brush it gently withTo
theremove accumulated materials and coatings.
toothbrush.
- Hand the client the water cup or mouthwash Vigorous rinsing loosens food particles and washes out
to rinse the mouth vigorously. Then ask the already loosened particles.
client to spit the water and excess dentifrice
into the basin.
- Repeat the preceding steps until the mouth is

free of dentifrice and food particles.
- Remove the curved basin and help the client
wipe the mouth.
Post-procedure
7. Ensure client comfort.

- Remove the basin, and dry around the client’s
mouth with the towel. Replace artificial To promote comfort.
dentures, if indicated.
- Lubricate the client’s lips with petroleum jelly.
If the client is on Oxygen therapy, do not To
useprevent cracking and subsequent infection. Applying
petroleum jelly but instead use another petroleum jelly to client’s lips who are on oxygen
product that does not have petroleum in it. therapy can cause burns to the skin and mouth.
1. Evaluate the following:

- extent of client’s self – care abilities
- client’s usual mouth care practices
- any deviation from normal
- presence of oral problems
2. Document all assessments and evaluation done.

PERFORMING THERAPEUTIC MASSAGE
Adapted from Lippincott Manual of Nursing Practice (2010).
I. DEFINITION
Massage – a manual manipulation of tissues aimed at increasing circulation, promoting relaxation and
healing, and restoring mobility.
Back Massage / Back Rub – is a nursing measure done to promote relaxation or to act as a stimulant or both
which generally follows a client’s bath.
Effleurage – is a type of massage consisting of long, slow, gliding strokes.
Petrissage / Pressure Manipulation – is a type of massage consisting of pinching the skin, subcutaneous
tissue, and muscles as the hands are moved up and down usually at the client’s back.
Tapotement / Percussion Manipulation – is a type of massage consisting of alternate stroking of the

fleshy part of the hands on skin surface while moving the hands up and down and allowing them to work
alternately.
II. RATIONALE
1.To relieve muscle tension.

2.To promote physical and mental relaxation.
3.To relieve insomnia.
4.To improve the flow of blood and lymph, stretch joints, relax muscles, and relieve pain and
congestion.
5.To evacuate excessive secretions from the respiratory tract.
6.To stimulate the immune system, thereby help the body combat disease.
7.To relieve anxiety and provide a sense of relaxation and well – being.
8.To provide a sense of harmony and balance within the body.
III. EQUIPMENT
Lotion / Cream / Powder

Towel
Drapes
The massagist must possess the following qualifications:

1. A basic knowledge of human anatomy, physiology and pathology.
2. Must be in good health.
3. Muscles must be firm and strong.
4. Fingers must be soft and pliant with fingernails cut short.
5. Attitude should be orderly, pleasant and unhurried.
Contraindications for massage:

1. Presence of skin diseases
2. Temperature above 100 °F (37.8 °C)
3. Presence of varicosities
4. Nephritis (no back or abdominal massage)
5. Pregnancy (no back or abdominal massage)
6. Menstruation (no back or abdominal massage)
7. Recent injuries
8. Tuberculosis of the Lungs
9. Burns
10. Hypersensitive skin
ACTION RATIONALE
QUALITY OF LIFE
Remember to:

Pre-procedure
To maintain client’s body heat and provide privacy and

relaxation.
1. Set room temperature at approximately 75oF. To prevent backstain.

Provide low or indirect lighting, privacy, and
background music.
2. Prepare the massage table or hospital bed by To avoid scratching the client and prevent transmission
placing a clean sheet on the surface. Adjust of microorganisms.
the surface light.
3. Remove rings and watch. Wash hands /

perform hand hygiene. To prepare the client for treatment and appropriate
position enables the nurse to apply the
4. Explain the procedure to client. necessary amount of pressure without causing
discomfort.
5. Assist the client to assume either a prone,
Sim’s, supine, or sitting position, depending on
client’s condition.
To expose the affected body part and provide privacy.
6. Loosen or remove clothing from the client’s

back and arms. Drape the client with a sheet
to cover areas not being treated directly.
Procedure
7. Squeeze a small amount of lotion or oil into

the palm of the hand to warm before applying
to the client.
8. Begin with light to medium effleurage and

other massage techniques.
To prevent damage to internal structures. Stimulates
circulation and promote relaxation.
A. EFFLEURAGE
1. Mold hands to the part being treated.

2. Apply long, slow, gliding strokes while maintaining an even pressure.
3. Use the fingers or the thumb in small areas as the hands, foot, or face.
B. PETRISSAGE / PRESSURE MANIPULATION
a. Kneading
1. Alternately press the muscles and subcutaneous tissues inward and upward.
2. Squeeze, compress and release in a rhythmical manner.
3. Let the hands glide imperceptibly over the area during the relaxation phase.
4. Speed and depth can be varied.
5. Treat small areas with the tip of the fingers and thumb.
6. Modification can be applied such as:
6.1. Squeezing Kneading – tissues are squeezed on the operator’s hands.
6.2. Reinforced Kneading – one hand is placed on top of the other to increase the depth of
manipulation.
b. Picking – up
1. Use one or both hands.

2. Grasp the tissues, lift, squeeze, and release.
3. During the lift, the fingers and thumb should be controlled by the intrinsic muscles of the
hands.
4. Always keep the palm of your hands in contact with the client’s skin.
c. Wringing
1. Using both hands, grasp the tissues and lift.

2. Move the hands alternately backward and forward across the long axis of the muscles thus
stretching the tissues.
d. Skin Rolling
1. Lay both hands flat on the surface of the client’s skin.

2. Grasp the skin and subcutaneous tissues between your fingers and thumb.
3. Roll the tissues backward and forward against your fingers and thumb.
C. FRICTION
1. With the tip of the thumb, move the part treated in circular or transverse direction.
2. Vary the depth of localized penetrating movements depending on the affected part.
3. When circular friction is applied, progressively increase the depth while in case of a transverse
friction; maintain an even pressure all throughout.
D. TAPOTEMENT / PRESSURE MANIPULATION
a. Hacking
1. Strike the body with the use of the ulnar border of the little finger supplemented by the
other fingers.
2. Extend the wrist and move in pronation and supination.
b. Clapping
1. Cup the hands and pronate the forearm.

2. Flex and extend the wrist alternately bringing the hands sharp into contact with the body
and resulting in a deep toned tapping sound.
c. Beating
1. Similar to clapping, but loosely clutch the hands.

2. Allow the dorsal aspect of the fingers and the base of the hands to come in contact with the
part treated.
d. Pounding
1. Similar to hacking, but loosely clinch the fist.

2. Strike the part treated with the ulnar border of the hands.
e. Shaking
1. Hold the body part with one or both hands.

2. Move it fully from side to side or up and down.
f. Vibration
1. Using the hands or fingertips, apply a fine form of tremor to a body part.
9. Finish treatment with effleurage. To assist with relaxation and provide a sense of
completion.
10. Wipe any excess lotion or oil from skin To promote and maintain skin integrity.
with towel, or use a small amount of
warm soap and water to clean client’s
skin, taking care to dry completely.
To allow client to fully experience therapeutic

benefit of massage.
11. Assist client into comfortable position for
a period of rest or sleep. To communicate pertinent data to other
members of treatment team; to promote
continuity of care.
To reduce transmission of microorganisms.

12. Document treatment, client’s response,
and skin assessment data.
13. Wash hands/hand hygiene.
V. AFTER CARE
1. Return lotion or cream or powder to its proper storage area.

2. Leave the client in a comfortable and safe position.
VI. EVALUATION AND DOCUMENTATION
1. Client’s skin condition

2. Reaction to treatment
3. Other significant observations
APPLYING HEAT OR COLD
I. DEFINITION
Dry Heat / Dry Cold – a method of heat or cold application which is free from moisture.
Moist Heat / Moist Cold – a method of heat or cold application which is damp and involves moisture.
The application of heat/cold produces physiologic changes in the temperature of tissues, size of the
blood vessels, blood pressure, and capillary surface for exchange of fluids and electrolytes and tissue
metabolism.
II. RATIONALE
HEAT APPLICATION
1. To increase circulation in a compromised area of the body.

3. To relieve pain from muscle spasms and affected joints.
4. To reduce swelling and accompanying discomfort.
5. To warm a body part.
6. To promote healing.
COLD APPLICATION
1. To prevent edema and reduce inflammation.

2. To reduce pain and bleeding.
3. To be used as a first - aid treatment in minor burns.
III. EQUIPMENT (Refer to Specific Procedure)

Special Considerations: To apply heat and cold safely, you should be aware of the following precautions
and guidelines:
1. Explain the procedure to the client.

2. Assess the area to which the heat or cold procedure will be applied.
3. Determine the client’s ability to tolerate the therapy as tolerance differs from client to client.
4. During the heat or cold procedure, check the area at frequent intervals, at least every 15 minutes.
Stop the application if any problem occurs.
5. Ask the client to report any discomfort.
6. Remove the equipment at the designated time and dispose of it appropriately.
7. Examine the area to which the heat or cold was applied and record the client’s response.
8. Identify conditions that might contraindicate treatment.
A. Applying Dry Heat Measures: Hot Water Bottle, Electric Heating Pad, Aquathermia Pad,
Disposable Hot Pack
Equipment:
Hot water bottle (bag) Hot water bottle with a stopper
Cover Hot water and a thermometer
Electric heating pad Electric pad control
Gauze ties (optional) Aquathermia pad
Pad Distilled water
Control unit Cover
Gauze ties or tape (optional) Disposable hot pack
Cover (waterproof if there will be moisture on the pad when it is applied)
One or two commercially prepared disposable hot packs
GENERAL PROCEDURE FOR APPLYING HEAT OR COLD
ACTION RATIONALE
1. Check the order for the specific type of heatToorensure accuracy.

cold treatment ordered.
2. Assess the general condition of the client, noting

To establish a baseline information for comparison.
especially the age, diagnosis, circulatory status,
level of awareness, and amount of body fat.
Measure the vital signs. Assess the local site,
noting the condition and color of the skin.
3. Check the client’s room to see what equipment

To isbe able to plan ahead and to save time and effort.
already there and the space needed for any
temperature treatment device.
4. Wash your hands. To prevent infection.
HOT WATER BAG
a pouch used as container for hot water which is a common source of dry heat.
III. EQUIPMENT
Hot Water Bag Bath Thermometer

Hot Water (Normal Adult & Child over 2 years: 46 to 52°C /115 to 125°F; Debilitated or Unconscious
Adult or Child under 2 years: 40.5 to 46°C / 105 to 115°F)
ACTION RATIONALE
QUALITY OF LIFE
Remember to:
Pre-procedure
Follow Steps 1 to 4 of the General Procedure in Applying Heat

or Cold
Procedure
1. Test the temperature of the water with a bath

To prevent injury to the client’s skin and tissues.
thermometer before pouring into the bag.
2. Fill the bag about 2/3 full. Expel remaining air

Toinhelp keep the bag light in weight and maintain the
the bag using either one of the following temperature of the water for a period of time.
methods:
- Place the bag on a flat surface, allow the water
to flow near the opening of the bag and then
close the bag.
- Hold the bag up, twist the unfilled portion to
remove air and then close the bag.
3. Hold the bag upside down after securing the cap.

To test for leaks.
4. Apply a flannel cover over the bag before applying

To prevent the client from burning. The cover acts as
it. The cover must be warm. insulator which is a poor conductor of heat.
5. Check the client’s skin at regular intervals while
To assess the condition of the skin and the effect of
the bag is being used. prolonged use of heat.
6. Change the water in the bag approximately every

To maintain the desired water temperature.
hour as needed.
Post-procedure
1. Perform a follow-up examination. To determine the effectiveness of the therapy.
ELECTRIC HEATING PAD
An electric device wherein water is maintained at a constant temperature while circulating through the coils of the
plastic pad which provide a constant, even heat.
III. EQUIPMENT
Electric Heating Pad

Moisture – Proof Covering
Special Considerations: In addition to the above special considerations, the nurse should follow the
following guidelines:
1. Do not insert sharp objects into the pad (e.g. using pins to secure the pad). This could damage the
wire and cause an electric shock. Do not crease the pad.
2. Ensure that the body area dry unless there is a water proof cover on the pad. Electricity in the
presence of water can cause a shock.
3. Use pads with a preset heating switch so a client cannot increase the heat.
4. Do not place the pad under the client. Heat will not dissipate and the client may be burned.
ACTION RATIONALE
QUALITY OF LIFE
Remember to:

Pre-procedure
Follow Steps 1 to 4 of the General Procedure in

Applying Heat and Cold
Procedure
1. Dry the skin area where the pad is to be applied.

To avoid electric shock.
2. Warm the pad and place anterior or lateral to

To aprevent the client from burning as heat cannot dissipate
body part to be treated. if the pad is placed under the client.
3. Place a moisture – proof covering on the pad.

To avoid electric shock.
Prevent moisture around the pad or prevent the
pad from getting wet. The pad should not be
covered heavily.
To allow the heat to dissipate appropriately, preventing the

client from getting burned.
To assess client’s reaction to the treatment.
4. Check the client’s skin at regular intervals.
To prevent errors.
5. Be sure to observe agency policy for use of

heating pads.
Post-procedure
AQUATHERMIC PAD / K-PAD
- this is a device consisting of a waterproof plastic or rubber pad connected by two hoses to an
electrically powered control unit that has a heating element and motor.
III. EQUIPMENT
Aquathermic Pad
Towel Tape
ACTION RATIONALE
QUALITY OF LIFE
Remember to:

Pre-procedure

Procedure
1. Check that the reservoir of the unit is 2/3 full

Toofprevent air bubbles from impeding the flow.
distilled water and free of air bubbles.
2. Place reservoir container at the bedside in a stand

To allow the water to circulate through the system. If the
and plug into an electrical outlet. reservoir is placed below the bed level, the water
will not circulate.
3. Turn on the switch. Allow the water to circulate
To warm the pad.
through the pad. Adjust the temperature setting
and see to it that it does not exceed 40.5°C
(105°F).
4. Cover the pad with a towel and place it on To

theprovide an insulator which will prevent burning.
area to be treated. If an arm or leg is to be
treated, the pad may be tied around the
extremity using a towel and tape.
5. Remove the pad after 15 - 30 minutes depending

To ensure a maximum therapeutic effect.
on the order or agency protocol.
6. Keep the client comfortable. To promote client’s comfort.
Post-procedure
DISPOSABLE INSTANT HOT PACKS

- These are available commercially and are used in a variety of settings. They come in a number of sizes
and shapes, including one made especially for use in the perineal area. These packs deliver a specific
amount of heat for a specified length of time as indicated by the manufacturer’s instructions. To use the
pack, strike, shake, or knead the package with your hands being careful not to puncture the outer
covering. This creates a chemical reaction that releases the heat.
III. PLANNING AND IMPLEMENTATION
ACTION RATIONALE
QUALITY OF LIFE
Remember to:
Pre-procedure
and Cold
Procedure
1. Prepare commercially prepared hot packs To follow specific guidelines for preparation and application.
according to manufacturer’s directions
(microwave, strike, squeeze or knead the pack).
To prevent skin injury.
2. Wrap in a towel or enclose in a cover prior to
application.
3. Do not insert any sharp, pointed object into the

pad or pack.
To avoid leakage of hot water and to prevent injury.

4. Leave the heat in place for only the designated
period of time usually 30 minutes.
To avoid the rebound phenomena. The degree of heat felt

shortly after application will decrease, because the
5. Check the application and skin area after 5 to 10 body’s temperature receptors quickly adapt to the
minutes. temperature.
To avoid tissue injury.
Post-procedure
To determine the effectiveness of the therapy.

1. Perform a follow-up examination.
B. Applying Dry Cold Measures: Ice Bag, Ice Collar, Disposable Cold Pack
ICE BAG / ICE CAP

- This is a larger bag made of rubber, plastic, or some other leakproof material. It comes in variety of sizes
and shapes; one specifically is designed for the head. Other shapes are rectangular and square. It may
be disposable or reusable.
ICE COLLAR
- This is a long, narrow bag made of rubber, plastic, or some other material that is leakproof. Some are
made to be disposable, other are reusable. Some ice collars come with ties attached to make it easier to
keep them in place. These devices are designed for use around the neck but can be used for other small
areas of the body as well. These are prepared for use in the same way as the ice cap or ice bag.
DISPOSABLE INSTANT COLD PACK
- These are used in the same way as disposable instant hot packs. They come in a variety of sizes and
shapes, including a shape similar to an ice collar and one made especially for use in the perineal area.
These packs deliver a specific amount of cold for a specified length of time, as indicated by the
manufacturer’s instructions.
III. EQUIPMENT
Ice Cap or Ice Bag Ice Chips
Wash Cloth
ACTION RATIONALE
QUALITY OF LIFE
Remember to:

Pre-procedure

Procedure
1. Fill the bag or cap with ice chips to about 2/3 full.
To make the bag or cap light in weight and to allow it to
mold into the body part.
2. Remove air from the ice bag or cap in the same

Air in the bag acts as insulator and therefore, reduces the
manner as removing air from a hot water bag. effectiveness of cold application.
3. Secure the cap or bag cover and test for leaks.To prevent the client from getting wet.
4. Follow Steps 6 to 9 of the General Procedure in

Applying Heat and Cold.
5. Cover the ice bag or cap with a washcloth. To provide comfort as the washcloth absorbs moisture that
may accumulate outside of the bag.
6. Apply to the affected part. Remove after an hour

To prevent prolonged exposure to cold which may cause
before reapplying it. The duration of treatment injury.
depends on the doctor’s order.
7. After the treatment, pat dry the affected part To
andcheck for any possible problem.
assess its condition.
Post-procedure
8. Place client in a comfortable position. To promote comfort.
9. Do after care of equipment. To prevent contamination.
C. Applying Compresses and Moist Packs
Compress – consists of several layers of moist gauze folded to cover a body area. A washcloth can be used when
a small unsterile compress is needed while a towel can be used to cover a larger area. Pre-moistened
sterile compresses are available commercially.
III. EQUIPMENT
Sterile compress or Washcloth or Towel Sterile or Clean Basin

Sterile Solution or Hot Water 40.5 °C - 46.1°C / 105 °F - 115 °F
Sterile Gloves Heating Device (Hot Water Bag, Electric Heating Pad)
Wringer Moisture - proof material
Water Thermometer / Bath Thermometer

ACTION RATIONALE
QUALITY OF LIFE
Remember to:
Pre-procedure
and Cold
Procedure
1. Place a moisture - proof pad under the area toTobeprotect the bed from moisture.
treated. Assess the area. Drape as necessary.
a. Moisten the compress in hot water (40.5°C -

46.1°C / 105°F - 115°F). Wring it out, so that it
remains moist but does not drip. Apply it to
the area to be treated, cover it with plastic,
and cover with further insulation such as a
towel.
b. Place a water - flow heating pad or other To maintain the heat.

heating device on the outside if necessary.
c. Hold the compress in place with ties or

To aprevent the compress from being displaced.
gauze wrap.
2. Cover the area with a cloth and plastic covering.

To retain the heat.
3. Return to the client at frequent intervals (at least
To check for adverse reactions and to see that the compress
every 5 minutes). is still in place.
To promote comfort.
Post-procedure
1. Place client in a comfortable position.

2. Do after care of equipment.
D. Using Thermal Blanket for Warming or Cooling
Thermal Blanket (Warming) – This blanket is similar to the water – flow heating pad except that it is of
blanket size. This is most commonly used for warming after major surgery or trauma.
Thermal Blanket (Cooling) – It is commonly referred to as a hypothermia blanket. This is used to induce hypothermia
during surgery in order to slow circulation and thus decrease the potential for bleeding or to decrease
metabolic activity and thereby reduce Oxygen requirements. It is also used to reduce persistent high fever.
III. EQUIPMENT
Thermal Blanket Top Linen

Bath Blanket Thermometer
ACTION RATIONALE
QUALITY OF LIFE
Remember to:
Pre-procedure
1. Remove heavy clothing from the client. AssessTo

theensure accuracy.
client’s room for space for the unit and safe
electrical outlets.
2. Place a bath blanket over and under the client.To absorb the client’s perspiration.
Procedure
3. Set the control to the desired setting and turnToonallow it to reach the desired temperature and to ensure
the unit for approximately 30 minutes. that it is operating properly.
4. Roll the client onto the thermal blanket. A second

To accelerate the warming effects.
blanket is sometimes placed on top of the client.
5. If a skin sensor probe is used, carefully place itToonmonitor the client’s temperature during the treatment.
the client’s skin and secure it with a tape.
Otherwise, measure the client’s temperature
every 30 minutes until the desired temperature is
reached.
6. Cover the client with top line over the bath

To prevent undue exposure of the client.
blanket or hyper - / hypothermia blanket.
7. Assess the client’s vital signs and pupil reaction

Toat monitor the client’s condition and to identify
least every 15 minutes (or more frequently, if complications as soon as they occur.
indicated) until the temperature has stabilized at
the desired level. Monitor skin condition, intakeTo promote comfort.
and output, and comfort hourly. Reposition the
client hourly unless contraindicated. Apply extra
cover to the arms or feet if the client complaints
of discomfort from the cold.
8. Turn off the controls, leaving the client To save time and effort in case the treatment is to be
temporarily on the blanket. Monitor the client’s continued.
temperature after the blanket has been turned
off.
Post-procedure
9. Examine the client’s skin and general condition.

To identify any problem.
PERFORMING RANGE-OF-MOTION EXERCISES

Adapted from Altman, Gaylene (2010). Fundamentals and Advanced Nursing Skills;
I. DEFINITION
Range of Motion – is the degree of movement possible for each joint.
Passive Range of Motion – the nurse or another person moves each of the client’s joints through their
complete range of movement, maximally stretching all muscle groups within each plane over each joint.
Active Range of Motion – the client moves each joint in the body through its complete range of
movement, maximally stretching all muscle groups within each plane over the joint.
Active - Assistive Range of Motion – is carried out with the client and the nurse participating. The client
is encouraged to carry out as much of each movement as possible, within the limitations of strength and
mobility.
I. RATIONALE
1. To improve or maintain joint function.

2. To restore joint function that has been lost due to a disease, injury, or lack of use.
3. To improve or maintain muscle tone and strength.
4. To help maintain cardiorespiratory function in an immobilized client.
5. To prevent contractures.
6. To prepare the client for ambulation.
II. EQUIPMENT
Hospital Bed Sturdy Non – Slip Shoes or Slippers
QUALITY OF LIFE
Remember to:
PRE-PROCEDURE
III. ASSESSMENT
1. Assess the client’s joint mobility and activity status to determine the need for ROM exercises.
2. Assess the client’s general health status to determine whether any contraindications to ROM
exercises are present.
3. Assess the client’s ability and willingness to cooperate in ROM exercises.
IV. PLANNING
1. Plan when ROM exercises should be done.

2. Plan whether exercises will be active, active - assistive, or passive as well as which joints are to be
included.
PROCEDURE
V. IMPLEMENTATION
Basic Guidelines:
I. Start gradually and work slowly.
II. Avoid overexertion and using exercises to the point that the client develops fatigue.
III. Move each joint until there is resistance but not pain.
IV. Support the part being exercised at the proximal part of the joints.
V. After each movement, return the part to its correct anatomic position.
VI. Keep friction to a minimum when moving to avoid injuring the skin.
VII. Use range of motion exercises regularly as prescribed to build up muscle and joint capabilities.
VIII. Expect the client’s respiratory rate and heart rate to increase during the activity.
IX. Use passive exercises as necessary but encourage active exercise of the same kind if the client’s
health condition permits.
General Guidelines for Providing Passive Exercises:

A. Ensure that the client understands the reason for doing ROM exercises.
B. If there is a possibility of hand swelling, make sure rings are removed.
C. Clothe the client in a loose gown and cover the body with a bath blanket.
D. Use correct body mechanics when providing ROM exercises to avoid muscle strain or injury to both
yourself and the client.
E. Position the bed at an approximate height.
F. Expose only the limb being exercised to avoid embarrassing the client.
G. Support the client’s limbs above and below the joint as needed to prevent muscle strain or injury.
H. Use a firm, comfortable grip when handling the limb.
I. Move the body parts smoothly, slowly, and rhythmically.
J. Avoid moving or forcing a body part beyond the existing range of motion.
K. If muscle spasticity occurs during movement, stop the movement temporarily but continue to apply
slow, gentle pressure on the part until the muscle relaxes; then proceed with the motion.
L. If contracture is present, apply slow, firm pressure without causing pain to stretch the muscle fibers.
M. If rigidity occurs, apply pressure against the rigidity and continue the exercise slowly.
N. For elderly clients, it is not essential to achieve full range of motion in all joints but instead,
emphasize achieving a sufficient range of motion to carry out ADLs.
ACTION RATIONALE
1. Wash your hands. To prevent the spread of microorganisms.
2. Identify the client. To be sure you are carrying out the procedure for
the correct client.
3. Close the door or pull curtains around the bed. To provide privacy.
4. Explain to the client what you are about to do. To gain the client’s cooperation.
5. Position the bed. Lower the head of the bed. To position the client in a supine position.
Raise the entire bed to a comfortable working To avoid stretching and reaching.
level for you.
6. Maintain your own proper body mechanics as you To avoid undue strain.
carry the exercises for the client.
7. Follow the procedure below to administer ROM.

Complete ROM on joints you have determined
should be exercised.
TEMPROMANDIBULAR JOINT (TMJ)
TMJ Opening: Open mouth
TMJ Closure: Close mouth
Protrusion: Jut chin out.(Figure 1)

Figure 1
Retrusion: Tuck chin in. (Figure 1)
Lateral Motion: Move jaw from side to side. (Figure 2)
NECK Figure 2
Flexion: Move the head from the upright midline
position forward, so that the chin rests on the chest.
(Figure 3)
Extension: Move the head from the flexed position to Figure 3

the upright position. (Figure 3)
Hyperextension: Move the head from the upright

position back as far as possible.
Figure 4
Lateral Flexion: Move the head laterally to the right
and left shoulders while facing front. (Figure 4)
Rotation: Turn the face as far as possible to the right

and left. (Figure 5)
SHOULDER
Flexion: Raise each arm from a position by the side

forward and upward to a position beside the head.
(Figure 6) Figure 5
Extension: Move each arm from a vertical position

beside the head forward and down to a resting
position at the side of the body. (Figure 6)
Hyperextension: Move each arm from a resting side
position to behind the body. (Figure 6) Figure 6
Abduction: Move each arm laterally from a resting
position at the sides to a side position above the head,
palm of the hand away from the head. (Figure 7) Figure 7
Adduction (anterior): Move each arm from a position

beside the head downward laterally and across the
front of the body as far as possible. (Figure 8)
Adduction (posterior): Move each arm from a position

beside the head downward laterally and across behind
the body as far as possible. (Figure 8)
Figure 8
Horizontal Flexion: Extend each arm laterally at
shoulder height and move it through a horizontal plane
across the front of the body as far as possible. (Figure 9)
Horizontal Extension: Extend each arm laterally at

shoulder height and move it through a horizontal
plane as far behind the body as possible. (Figure 9)
Figure 9
Circumduction: Move each arm forward, up, back, and
down in a full circle. (Figure 10)
External Rotation: With each arm held out to the side

at the shoulder level and the elbow bent to a right
angle, fingers pointing down, move the arm upward so
that the fingers point up. (Figure 11)
Figure 10
Internal Rotation: With each arm held out to the side
at shoulder level and the elbow bent to a right angle,
fingers pointing up, bring the arm forward and down
so that the fingers point down. (Figure 11)
ELBOW Figure 11
Flexion: Bring each lower arm forward and upward so

that the hand is at the shoulder. (Figure 12)
Extension: Bring each arm forward and downward,

straightening the arm. (Figure 12)
Rotation for Supination: Turn each hand and forearm Figure 12

so that the palm is facing upward. (Figure 13)
Rotation for Pronation: Turn each hand and forearm

so that the palm is facing downward. (Figure 13)
WRIST
Figure 13
Flexion: Bring the fingers of each hand toward the
inner aspect of the forearm. (Figure 14)
Extension: Straighten each hand to the same plane as

the arm. (Figure 14)
Figure 14
Hyperextension: Bend the fingers of each hand back as
far as possible. (Figure 15)
Circumduction: Move the wrist in a circular motion.
Radial Flexion (abduction): Bend each wrist laterally Figure 15

toward the thumb side with hand supinated. (Figure
16)
Figure 16
Ulnar Flexion (adduction): Bend each wrist laterally
toward the fifth finger with the hand supinated.
HAND and FINGERS

Figure 17
Flexion: Make a fist with each hand. (Figure 17)
Extension: Straighten the fingers of each hand. (Figure

17) Figure 18
Hyperextension: Bend the fingers of each hand back as
far as possible.
Abduction: Spread the fingers of each hand apart. Figure 19

(Figure 18)
Adduction: Bring the fingers of each hand together.

(Figure 18)
THUMB
Figure 20
Flexion: Move each thumb across the palmar surface
of the hand toward the fifth finger. (Figure 19)
Extension: Move each thumb away from the hand.
Abduction: Extend each thumb laterally. (Figure 20)

Figure 21
Adduction: Move each thumb back to the hand.
Opposition: Touch each thumb to the tip of each finger

of the same hand. The thumb joint movements
involved are abduction, rotation, and flexion. (Figure
21)
Circumduction: Move the thumb in a circular motion. Figure 22
HIP
Flexion: Move each leg forward and upward. The knee

may be extended or flexed. (Figure 22)
Extension: Move each leg back beside the other leg.

(Figure 23) Figure 23
Hyperextension: Move each leg back behind the body.

(Figure 23)
Abduction: Move each leg out to the side. (Figure 24)
Adduction: Move each leg back to the other leg and Figure 24
beyond in front of it. (Figure 24)
Circumduction: Move each leg backward, up, to the

side, and down in a circle. (Figure 25)
Internal Rotation: Turn each foot and leg inward so

that the toes point as far as possible toward the other
leg. (Figure 26)
External Rotation: Turn each foot and leg outward so Figure 25

that the toes point as far as possible away from the
other leg. (Figure 26)
KNEE Figure 26
Flexion: Bring each leg bringing the heel toward the

back of the thigh. (Figure 27)
Extension: Straighten each leg, returning the foot to its

position beside the other foot. (Figure 27)
ANKLE Figure 27
Extension (plantar flexion): Point the toes of each foot

downward. (Figure 28)
Flexion (dorsiflexion): Point the toes of each foot

upward. (Figure 28)
Eversion: Turn the sole of each foot laterally. (Figure Figure 28

29)
Inversion: Turn the sole of each foot medially.
FOOT and TOES
Flexion: Curve the toe joints of each foot downward.

Extension: Straighten the toes of each foot. (Figure 30)
Abduction: Spread the toes of each foot apart.

Figure 30
Adduction: Bring the toes of each foot together.
TRUNK
Flexion: Bend the trunk toward the toes. (Figure 31)
Extension: Straighten the trunk from a flexed position.

Hyperextension: Bend the trunk backward.

Lateral Flexion: Bend the trunk to the right and to the
left. (Figure 32)
Rotation: Turn the upper part of the body from side to

side. (Figure 33)
Figure 32
Figure 33
POST-PROCEDURE
1. Evaluate the client in terms of the following:

b. fatigue
c. joint discomfort
d. joint mobility
2. Document and report the following:
a. unexpected problems or notable changes in the client’s movements such as rigidity
b. type of exercise, body parts involved, duration, client’s tolerance
c. other assessment findings
BODY MECHANICS: MOVING AND LIFTING
I. DEFINITION
Moving and Lifting - is the procedure involved in turning, positioning, and transferring a client in and
out of bed with the use of proper body mechanics.
Body Mechanics - is the term used to describe the efficient, coordinated, and safe use of the body to
move objects and carry out the activities of daily living.
II. RATIONALE
1. To provide greater comfort.

2. To provide optimal lung expansion and ventilation.
3. To help maintain intact skin and prevent complications of immobility.
4. To prevent injury due to improper movement.
5. To prevent contractures due to constant joint flexion.
6. To promote optimal joint movement.
7. To move or lift a client employing considerable care so as to prevent injury to the client and undue
strain on the part of the nurse or caregiver.
III. EQUIPMENT
Hospital Bed
Drawsheets
Pull Sheet / Turning Sheet
Chair / Wheelchair
Assistive Device such as Overhead trapeze, Transfer Bar or Sliding Bar
1. Know the client’s diagnosis, capabilities, ability to understand instructions, medications, extent of
injury, and any movement not allowed for him / her. To obtain a thorough information as to the
client’s condition.
2. Decide exactly what you will do when you plan to move or lift a client. To be able to utilize
appropriate moving and lifting techniques.
3. If indicated, use pain relief modalities or medications prior to moving the client. To provide client’s
comfort.
4. Explain the procedure to the client and assess his / her ability to assist you. To solicit the client’s
cooperation and to promote ease and comfort.
5. Remove obstacles that may make moving and lifting inconvenient. To prevent injury and to promote
ease and comfort.
6. Elevate the bed as necessary so that you are working at a height that is comfortable and safe for
you. To prevent back injury on the part of the nurse or caregiver.
7. Lock the wheels of the bed, wheelchair, or stretcher. To prevent them from sliding about during the
procedure.
8. Observe the principles of body mechanics while you work. To prevent injuring yourself.
9. Be sure the client is in good body alignment while moving and lifting him / her. To protect him / her
from strain and muscle injury.
10. Support the client’s body well. Avoid grabbing or holding an extremity by its muscles. To prevent
injury.
11. Avoid causing friction on the client’s skin during the move or lift. To prevent the skin from getting
injured or irritated.
12. Move your body in a smooth, rhythmic motion. To promote ease and comfort.
13. Use supportive device such as turning sheet when available. To provide assistance during the
procedure thereby promoting ease and comfort.
14. Be realistic about how much you can safely perform the procedure without injury. Ask for assistance
from other health care personnel when needed. To prevent injury.
I. MOVING A CLIENT UP IN BED
ACTION RATIONALE
1. Explain the procedure to the client. To solicit client’s cooperation.
2. Wash hands and observe other appropriate To prevent the spread of microorganisms.
infection control procedures.
3. Provide for client’s privacy. To promote comfort.
4. Adjust the bed and the client’s position.

- Adjust the head of the bed to a flat position To prevent back strain on the part of the nurse or
or as low as the client can tolerate. caregiver. Moving the client upward against gravity
requires more force.
- Raise the bed to the height of your center of To prevent undue strain.
gravity.
- Lock the wheels on the bed and raise the rail To prevent accidental falls.
on the side of the bed opposite you.
- Remove all pill ows, then place one against To protect the client’s head from injury against the
the head of the bed. top of the bed during the move.
5. Elicit the client’s help in lessening your workload.

- Ask the client to flex the hips and knees and To prevent friction during movement and to ensure
position the feet so that they can be used use of large muscle groups in the client’s legs when
effectively for pushing. pushing, thus increasing the force of movement.
- Ask the client to: To provide additional power to overcome inertia
and friction during the move.
a. Grasp the head of the bed with both
hands and pull during the move, or
b. Raise the upper part of the body on the
elbows and push with the hands and
forearms during the move, or
c. Grasp the overhead trapeze with both
hands and lift and pull during the move.
6. Position yourself appropriately and move the

client.
- Face the direction of the movement, and then To promote stability during the move.
assume a broad stance with the foot nearest
the bed behind the forward foot, with your
weight on the forward foot. Lean your trunk
forward from the hips. Flex hips, knees, and
ankles.
- Place your near arm under the client’s thighs. To provide support to the heaviest part of the body.
Push down on the mattress with the far arm. The far arm acts as a lever during the move.
- Tighten your gluteal, abdominal, leg, and arm To ensure a stable move.
muscles and rock from the back leg to the
front leg and back again. Then, shift your
weight to the front leg as the client pushes
with the heels and pulls with the arms so that
the client moves toward the head of the bed.
VARIATION: A CLIENT WHO HAS LIMITED STRENGTH

OF THE UPPER EXTREMITIES
 Assist the client to flex the hips and knees as in To keep the arms and head off the bed surface, thus
Step 5. Place the client’s arms across the chest. preventing friction during movement.
Ask the client to flex the neck during the move
and keep the head off the bed surface.
 Position yourself as in Step 6 and place one arm This placement of the arms distributes the client’s
under the client’s back and shoulders and the weight and supports the heaviest part of the body.
other arm under the client’s thighs. Shift your
weight as in Step 6.
VARIATION: TWO NURSES USING A HAND – FOREARM

INTERLOCK. Two people are required to move clients
who are unable to assist because of their condition or
weight.
 Using the technique described in Step 6, with the To allow the client’s weight to be distributed and
second staff member on the opposite side of the the heaviest part of the body to be supported by
bed, both of you interlock your forearms under two staff members.
the client’s thighs and shoulders and lift the client
up in bed.
VARIATION: TWO NURSES USING A TURN SHEET.

Two nurses can use a turn sheet to move a client up in
bed.
 Place a draw sheet or a full sheet folded in half To distribute the client’s weight more evenly,
under the client, extending from the shoulders to decrease friction, prevent injury to the client’s skin,
the thighs. Each person rolls up or fanfolds the and exert a more even force on the client during the
turn sheet close to the client’s body on either move.
side.
 Both individuals grasp the sheet close to the To allow a smoother movement. This draws the
shoulders and buttocks of the client. Follow the weight closer to the nurse’s center of gravity and
method of moving clients with limited upper increases the nurse’s balance and stability.
extremity strength as described earlier.
7. Ensure client’s comfort.

- Elevate the head of the bed and provide To promote client’s comfort.
appropriate support devices for the client’s
new position.
II. TURNING A CLIENT TO THE LATERAL OR PRONE POSITION IN BED
Movement to the lateral (side – lying) position may be necessary when placing a bedpan beneath the client,
when changing the bed linen, or when repositioning the client.
ACTION RATIONALE
Follow Steps 1 to 3 of Moving a Client Up in Bed.
1. Position yourself and the client appropriately.

- Move the client closer to the side of the bed To ensure that the client will be positioned safely in
opposite the side the client will face when the center of the bed after turning.
turned. Use a pull sheet beneath the client’s
trunk and thighs to pull the client to the side
of the bed. Roll up the sheet as close as
possible to the client’s body and pull the
client to the side of the bed. Adjust the
client’s head and reposition the legs
appropriately.
- While standing on the side of the bed nearest To facilitate the turning motion and to prevent the
the client, place the client’s arm across the arm from being caught beneath the client’s body
chest. Abduct the client’s far shoulder slightly during the roll.
from the side of the body and externally
rotate the shoulder.
- Place the client’s near ankle and foot across To prevent unnecessary reaching.
the far ankle and foot.
- Raise the side rail next to the client before To avoid accidental fall.
going to the other side of the bed.
- Position yourself on the side of the bed To promote ease during the turn.
toward which the client will turn, directly in
line with the client’s waistline and as close to
the bed as possible.
- Lean your trunk forward from the hips. Flex To prevent undue strain on the nurse.
your hips, knees, and ankles. Assume a broad
stance with one foot forward and the weight
placed on this forward foot.
2. Pull or roll the client toward you to the lateral

position.
- Place one hand on the client’s far hip and the To provide greater control in movement during the
other hand on the client’s far shoulder. roll.
- Tighten your gluteal, abdominal, leg, and arm To promote the client’s sense of security.
muscles; rock backward, shifting your weight
from the forward to the backward foot, and
roll the client onto the side of the body to
face you.
- Position the client on his / her side with arms To promote client’s comfort in his / her new
and legs positioned and supported properly. position.
VARIATION: TURNING THE CLIENT TO A PRONE

POSITION
To turn the client to the prone position, follow the

preceding steps, with two exceptions:
 Instead of abducting the far arm, keep the client’s To prevent the arm from being pinned under the
arm alongside the body for the client to roll over. client when he / she is rolled.
 Roll the client completely onto the abdomen. To ensure that the client will be lying on the center
Never pull a client across the bed while the client of the bed after rolling and to prevent injury on the
is in the prone position. woman’s breasts or a man’s genitals.
III. LOGROLLING A CLIENT
Logrolling is a technique used to turn a client whose body must at all times be kept in straight alignment (like a
log). This technique requires two nurses or, if the client is large, three nurses.
ACTION RATIONALE
Follow Steps 1 to 3 of Moving a Client Up In Bed
1. Position yourselves and the client appropriately

before the move.
- Stand on the same side of the bed, and To obtain a stable stance.
assume a broad stance with one foot ahead of
the other.
- Place the client’s arms across the chest. To prevent injury on the arms.
- Lean your trunk, and flex your hips, knees,
and ankles.
- Place your arms under the client, depending To center the client’s major weight area between
on the client’s size. the nurse’s arms.
- Tighten your gluteal, abdominal, leg, and arm
muscles.
2. Pull the client to the side of the bed.

- One nurse counts: One, two, three, go. Then, To maintain the client’s body alignment when
at the same time, all staff members pull the moving in unison.
client to the side of the bed by shifting their
weight to the back foot.
- Elevate the side rail on this side of the bed.
3. Move to the other side of the bed, and place To prevent accidental fall.
supportive devices for the client when turned.
- Place a pillow where it will support the To prevent lateral flexion of the neck and to ensure
client’s head after the turn. alignment of the cervical spine.
- Place one or two pillows between the client’s To prevent adduction of the upper leg and to keep
legs to support the upper leg when the client the legs parallel and aligned.
is turned.
4. Roll and position the client in proper alignment.

- All nurses flex their hips, knees, and ankles To establish a stable stance.
and assume a broad stance with one foot
forward.
- All nurses reach over the client and place To center a major weight area of the client between
hands at the far side of the client. each nurse’s arms.
- One nurse counts: One, two, three, go. Then, To maintain the client’s body alignment.
at the same time, all nurses roll the client to a
lateral position.
- Support the client’s head, back, and upper To promote client’s comfort in his / her new
and lower extremities with pillows. position.
- Raise the side rails and place the call bell To provide a safe and convenient environment for
within the client’s reach. the client.
VARIATION: USING A TURN OR LIFT SHEET
 First, stand with another nurse on the same side To help maintain the client’s alignment when
of the bed. Assume a broad stance with one foot turning.
forward, and grasp half of the tanfolded or rolled
edge of the turn sheet. On a signal, pull the client
toward both of you.
 Before turning the client, place pillow supports To ensure good alignment in the lateral position.
for the head and legs as described in Step 3. Then,
go to the other side of the bed (farthest from the
client), and assume a stable stance. Reaching over
the client, grasp the far edges of the turn sheet,
and roll the client toward you. The second nurse
(behind the client) helps turn the client and
provides pillow supports.
IV. ASSISTING THE CLIENT TO SIT ON THE SIDE OF THE BED (DANGLING)
The client assumes a sitting position on the edge of the bed before walking, moving to a chair or wheelchair,
eating, or performing other activities.
ACTION RATIONALE
Follow Steps 1 to 3 of Moving A Client Up In Bed
1. Position yourself and the client appropriately

before performing the move.
- Assist the client to a lateral position facing
you.
- Raise the head of the bed slowly to its highest To decrease the distance the client needs to move.
position.
- Position the client’s feet and lower legs at the To allow ease during the move.
edge of the bed.
- Stand beside the client’s hips and face the far To establish a stable stance.
corner of the bottom of the bed (the angle in
which movement will occur). Assume a broad
stance, placing the foot nearest the client
forward. Lean your trunk forward from the
hips. Flex your hips, knees, and ankles.
2. Move the client to a sitting position.

- Place one arm around the client’s shoulders To prevent the client from falling backward, to
and the other arm beneath both of the reduce friction of the thighs against the bed surface,
client’s thighs near the knees. and to increase the force during the movement.
- Tighten your gluteal, abdominal, leg, and arm
muscles.
- Lift the client’s thighs slightly. To reduce friction against the bed surface.
- Pivot on the balls of your feet in the desired To prevent twisting of the nurse’s spine, to increase
direction facing the foot of the bed pulling the downward movement of the client’s lower body and
client’s feet and legs off the bed. to help make the client’s upper body vertical.
- Keep supporting the client until the client is To ensure client’s safety.
well balanced and comfortable.
- Assess client’s vital signs as indicated by the To assess client's health status.
client’s health status.
VARIATION: TEACHING A CLIENT HOW TO SIT ON THE

SIDE OF THE BED INDEPENDENTLY
Instruct the client to:

 Roll to the side and lift the far leg over the near To facilitate movement.
leg.
 Grasp the mattress edge with the lower arm and To increase the force of the movement.
push the fist of the upper arm into the mattress.
 Push up with the arms as the heels and legs slide To allow an increase in the downward movement of
over the mattress edge. the lower body.
 Maintain the sitting position by pushing both fists To help make the client’s upper body vertical and to
into the mattress behind and to the sides of the maintain the sitting position.
buttocks.
V. TRANSFERRING A CLIENT BETWEEN BED AND CHAIR / WHEELCHAIR
ACTION RATIONALE
Follow Steps 1 to 3 of Moving a Client Up In Bed
1. Position the equipment appropriately.

- Lower the bed to its lowest position and lock To allow the client’s feet to rest flat on the floor.
the wheels of the bed. To prevent the bed from rolling.
- Place the chair / wheelchair parallel to the To allow more room for you to assist the client.
bed as close to the bed as possible. Put the To make it easier for the client to grasp the handle
chair / wheelchair on the side of the bed that and swivel into the chair.
allows the client to move toward his or her To prevent accidental movement of the chair during
stronger side. If a wheelchair is used, lock the the transfer.
wheels and raise the footplate.
2. Prepare and assess the client.

- Assist the client to a sitting position on the To help the client overcome dizziness before
side of the bed. standing.
- Assess the client for orthostatic hypotension To prevent the client from fainting during the move.
before moving the client from the bed.
- Assist the client in putting on a bathrobe and To provide comfort and ensure client’s safety.
nonskid slippers or shoes.
- Place a transfer belt snugly around the client’s To aid in transferring the client safely.
waist. Check to be certain that the belt is
securely fastened.
3. Give explicit instructions to the client. Ask the
client to:
- Move forward and sit on the edge of the bed. To bring the client’s center of gravity closer to the
nurse’s.
- Lean forward slightly from the hips. To bring the client’s center of gravity more directly
over the base of support.
- Place the foot of the stronger leg beneath the To enable the client to use the stronger leg muscles
edge of the bed and put the other foot to stand and power the movement. A broader base
forward. of support provides more stability.
- Place the client’s hands on the bed surface or To provide additional force for the movement and
on your shoulders so that the client can push reduce the potential for strain on the nurse’s back.
while standing. The client should not grasp
your neck for support.
4. Position yourself correctly.

- Stand directly in front of the client. Lean the To prevent loss of balance during the transfer.
trunk forward from the hips. Flex the hips,
knees, and ankles. Assume a broad stance,
placing one foot forward and one back.
Mirror the client’s feet, if possible.
- Encircle the client’s waist with your arms, and To provide a secure handle for holding on to the
grasp the transfer belt at the client’s back client and controlling the movement. Downward
with thumbs pointing downward. placement of the thumb prevents potential wrist
injury.
- Tighten your gluteal, abdominal, leg, and arm To provide a stronger force for the movement.
muscles.
5. Assist the client to stand, and then move together

toward the wheelchair.
- On the count of three, ask the client to push To allow the use of the client’s weight and good
with the back foot, rock to the forward foot body mechanics to help him / her stand. Rocking
and extend (straighten) the joints of the lower uses both client’s and nurse’s weight to gain
extremities. Push or pull up with the hands, momentum and move the client.
while pushing with the forward foot, rock to
the back foot, extend the joints of the lower
extremities, and pull the client (directly toward
your center of gravity) into a standing position.
- Support the client in an upright standing To ensure that the client is stable before moving
position for a few moments. away from the bed.
- Together, pivot or take a few steps toward Pivoting allows for greater movement with least
the wheelchair. expenditure of energy.
6. Assist the client to sit.

- Ask the client to:
a. Back up to the chair / wheelchair and To minimize the risk of the client from falling when
place the legs against the seat. sitting down.
b. Place the foot of the stronger leg slightly To support the body weight during the movement.
behind the other.
c. Keep the other foot forward. To provide a broad base of support.
d. Place both hands on the chair / To increase stability and lessen the stain on the
wheelchair arms or on your shoulders. nurse.
- Stand directly in front of the client. Place one To provide stability.
foot forward and one back.
- Tighten your grasp on the transfer belt, and To provide for the use of your body to move the
tighten your gluteal, abdominal, leg, and arm client.
muscles.
- On the count of three, have the client shift To allow the use of the client's weight and good
the body weight by rocking to the back foot, body mechanics to help him / her sit.
lower the body onto the edge of the chair /
wheelchair seat by flexing the joints of the
legs and arms. Place some body weight on the
arms, while shifting your body weight by
stepping back with the forward foot and
pivoting toward the chair / wheelchair while
lowering the client onto the seat.
7. Ensure client’s safety.

- Ask the client to push back into the seat. To provide a broader base of support and greater
stability and minimize the risk of falling from the
wheelchair.
- Lower the footplates of the wheelchair and To promote comfort.
place the client’s feet on them.
- Apply a seat belt as required. To ensure safety.
VARIATION: ANGLING THE WHEELCHAIR/ CHAIR
 For clients who have difficulty walking, place the To enable the client to pivot into the chair and
chair / wheelchair at a 45 – degree angle to the lessen the amount of body rotation required.
bed.
VARIATION: TRANSFERRING WITHOUT A BELT
 For clients who need minimal assistance, place To allow the nurse to hold the client securely and be
the hands against the sides of the client’s chest able to control the movement.
(not at the axillae) during the transfer.
 For clients who require more assistance, reach To prevent injury on the client especially clients with
through the client’s axillae and place the hands on paralysis since they cannot feel the degree of
the client’s scapulae during the transfer. Avoid pressure applied.
placing hands or pressure on the axillae,
especially for client’s who have upper extremity
paralysis or paresis.
 Follow the steps described previously.
VARIATION: TRANSFERRING WITH A BELT AND TWO

NURSES
 When the client is able to stand, position To prevent loss of balance during the transfer.
yourselves on both sides of the client, facing the
same direction as the client. Flex your hips, knees,
and ankle. Grasp the client’s transfer belt with the
hand closest to the client and with the other hand
support the client’s elbows.
 Coordinating your efforts, all three of you stand To assist the client to move in unison, thereby
simultaneously, pivot, and move to the chair / maintaining good body alignment.
wheelchair. Reverse the process to lower the
client onto the seat.
VARIATION: TRANSFERRING A CLIENT WITH AN

INJURED LOWER EXTREMITY
 When the client has an injured lower extremity, To allow the client to use the unaffected leg most
movement should always occur toward the effectively and safely.
client’s unaffected (strong) side. For example, if
the client’s right leg is injured and the client is
sitting on the edge of the bed preparing to
transfer to a chair / wheelchair, position the
chair / wheelchair on the client’s left side.
VARIATION: USING A SLIDING BOARD
 For clients who cannot stand, use a sliding board To help promote client’s sense of independence and
to help them move without nursing assistance. preserve your energy.
VI. TRANSFERRING BETWEEN BED AND STRETCHER
ACTION RATIONALE
Follow Steps 1 to 3 of Moving a Client Up in Bed
1. Adjust the client’s bed in preparation for the

transfer.
- Lower the head of the bed until it is flat or as To promote ease and comfort.
low as the client can tolerate.
- Raise the bed so that it is slightly higher than To make it easier for the client to move down a
the surface of the stretcher. slant.
- Ensure that the wheels on the bed are locked. To prevent the bed from rolling during the move.
- Pull the drawsheet out from both sides of the To promote ease.
bed.
2. Move the client to the edge of the bed and

position the stretcher.
- Roll the drawsheet as close to the client’s side To make it easier to pull the client.
as possible.
- Pull the client to the edge of the bed and To maintain comfort.
cover the client with a sheet or bath blanket.
- Place the stretcher parallel to the bed next to To prevent the stretcher from rolling during the
the client and lock the stretcher wheels. transfer.
- Fill the gap that exists between the bed and To prevent the possibility that the client may be
the stretcher loosely with the bath blankets trapped in the space between the bed and
(optional). stretcher.
3. Transfer the client securely to the stretcher.

- In unison with the other staff members, press To prevent the stretcher from moving.
your body tightly against the stretcher.
- Roll the pull sheet tightly against the client. To achieve better control over the client’s
movement.
- Flex your hips and pull the client on the pull This requires less force than pulling along a flat
sheet in unison directly toward you and onto surface.
the stretcher.
- Ask the client to flex the neck during the move, To prevent injury to these body parts.
if possible, and place the arms across the
chest.
4. Ensure the client’s comfort and safety.

- Make the client comfortable, unlock the wheels, To promote comfort.
and move the stretcher away from the bed.
- Immediately raise the stretcher side rails and / To prevent accidental falls.
or fasten the safety straps across the client.
VARIATION: USING A TRANSFER BOARD

The Transfer Board is a lacquered or smooth
polyethylene board measuring 45 to 55 cm (18 to 22
in.) by 182 cm (72 in.) with handholds along its edges.
The device may be used by one nurse alone or up to
four nurses together.
 Turn the client to a lateral position away from

you, position the board close to the client’s back, To promote ease when moving the client.
and roll the client onto the board.
 Pull the client and the board across the bed to the To ensure safety.
stretcher. Safety belts may be placed over the
chest, abdomen, and legs.
VARIATION: USING A THREE – PERSON CARRY (USE

CAUTION)
 Three people of about equal height stand side by To distribute the client’s weight appropriately.
side facing the client. Recommendations vary as
to which staff member lifts a specific area of the
client. Often, the strongest supports the heaviest
part of the client or the tallest person with the
longest reach supports the head and shoulders.
 The stretcher or bed to which the client will be To promote ease during the transfer.
moved is placed at a right angle at the foot of the
bed.
 The wheels of the bed and stretcher are locked. To prevent the bed and stretcher from rolling during
the move.
 Each person flexes the knees and places the foot To allow the nurses to provide a stronger force.
nearest to the stretcher slightly forward.
 The arms of the lifters are put under the client at To ensure good body alignment.
the head and shoulders, hips and thighs, and
upper and lower legs.
 On the count of three, the lifters roll the client This technique ensures good body alignment and
onto their chests and step back in unison. They use of body mechanics.
then pivot around to the stretcher and lower the
client by flexing their knees and hips until their
elbows are on the surface of the stretcher. The
client is then released on the stretcher surface
and is aligned and covered.
 The stretcher side rails are raised. To prevent accidental falls.

- skin integrity of the pressure areas from the previous position
- proper alignment after the position
- client’s comfort
- all required safety precautions are in place
- client’s tolerance of the activity particularly the first time the client changes position
2. Document the following relevant information:

- time and change of position moved from and position moved to
- any signs of pressure areas
- use of support devices
- ability of the client to assist in moving and turning
- response of the client to moving and turning
VI. ILLUSTRATION
Moving a Client to a Lateral Position

Moving a Client Up in Bed
P l a c e m e n t f o r L
Correct Hand
Two Nurses Using a Hand-Forearm Interlock
Assisting a client to a sitting position on the edge of the bed
Moving to a sitting position independently
Lowering a Client Who

Feels Faint to the Floor
Using a Turn
Sheet Using a Transfer
Belt
to Support A Client
Transferring Without a Belt
Using a transfer belt
Turning a client
MOVING AND POSITIONING A CLIENT

Adapted from Potter and Perry (2011). Clinical Nursing Skills and Techniques
I. DEFINITION
Positioning a client – is placing a client in positions that are anatomically correct as well as comfortable.
II. RATIONALE
1. To maintain correct alignment of all body parts so they remain functional and unstressed.
2. To prevent contractures.
3. To stimulate circulation and to help prevent thrombophlebitis, pressure sores, and edema of the
extremities.
4. To promote lung expansion and drainage of respiratory secretions.
5. To relieve pressure on a body area.
III. EQUIPMENT
Pillows
Footrest
Footboard
Linen or washcloth for hand rolls
Sheet or bath towel or bath blanket for trochanter rolls
1. One should have a knowledge of anatomy and physiology and good body alignment.
2. One should remember that correct body mechanics are essential for both the client and the nurse.
3. Know the client’s diagnosis, capabilities, extent of injury, and any movement not allowed for
him/her.
4. Remove obstacles that may make positioning inconvenient and unsafe for the client.
ACTION RATIONALE
2. Identify the client. To ensure accuracy.

3. Explain the procedure to the client. To gain the client’s cooperation.
4. Assess the client’s need to move. To be able to plan the client’s activity.
5. Assess the client’s ability to move unaided. To identify the extent of assistance the client needs.
6. Check on the assistive devices that are available. To identify any assistive device needed by the client
which may not be available.
7. Plan the moving technique. To prevent undue strain on the part of the nurse as
well as the client.
8. Obtain any needed supportive device or To maintain alignment and to prevent stress on the
assistance. client’s muscles and joints.
9. Provide for client privacy. To promote comfort on the part of the client.
10. Raise the bed to an appropriate high position. To promote good body mechanics and prevent
undue strain on the part of the nurse.
11. Place the bed in a flat position if possible. To prevent working against the pull of gravity.
12. Correctly and comfortably position the client

using any appropriate position described below.
Supporting a Client in Dorsal Recumbent Position
Position the client to the supine position.

- The client lies on her back with the spine in To provide comfort and to facilitate healing
straight alignment. following certain surgeries.
- The arms positioned at the client’s side with the
hands pronated.
Provide supportive devices.

- Place a pillow of suitable thickness under the To prevent hyperextension of the neck.
client’s head and shoulders as needed.
- Place a pillow under the lower legs from below To prevent hyperextension of the knees, keep the
the knees to the ankles. heels off the bed, and reduce lumbar lordosis.
- Place trochanter rolls laterally against the femurs. To prevent external rotation of the hips.
- Place a rolled towel or small pillow under the To support the lumbar curvature and prevent flexion
lumbar curvature if you feel a space between the of the lumbar spine.
lumbar area and the bed.
- Put a footboard or rolled pillow on the bed to To prevent plantar flexion or footdrop.
support the feet.
- If the client is unconscious or has paralysis of the To promote comfort and prevent edema.
upper extremities, elevate the forearms and Pillows are not placed on the upper arm, to prevent
hands (not the upper arm) on pillows. shoulder flexion.
- If the client has actual or potential finger and To prevent flexion contractures of the fingers.
wrist flexion deformities, use handrails (with a
circumference of 13 -15 cm.) or wrist/hand
splints.
Supporting a Client in the Prone Position
Position the client.

- The client lies on his/her abdomen with the head To promote drainage from the mouth.
turned to one side.
- The hips are not flexed. To prevent flexion contractures of the hips & knees.

- Place a small pillow under the head, aligning the To prevent flexion of the neck laterally.
head with the trunk. If drainage from the mouth is
encouraged, omit the pillow entirely. To reduce the incidence of lumbar lordosis.
- Avoid placing the pillow under the shoulders. To prevent hyperextension of the lumbar curvature,
Place a small pillow or roll under the abdomen in difficulty of breathing, and pressure on the breasts
the space between the diaphragm or breasts of a for some women.
woman and the iliac crests.
- Place a pillow under the lower legs from below To raise the toes off the bed surface and to reduce
the knees to just above the ankles. plantar flexion and excessive pressure on the
Or patellae.
Position the client on the bed so that the feet are
extended in a normal anatomic position over the To prevent pressure on the toes.
lower edge of the mattress.
Supporting a Client in Fowler’s Position

- Have the client flex the knees slightly before To prevent the person from sliding toward the foot
raising the head of the bed. of the bed as the bed is raised.
- Be certain the client’s hips are positioned directly To ensure that the client will be sitting upright when
over the point where the bed will bend when the the head of the bed is raised.
head is raised.
- Raise the head of the bed to 45 degrees or the To position the client appropriately as this is the
angle required by or ordered for the client. recommended position for clients with breathing
difficulty or cardiac problem.
- Place a small pillow or roll under the lumbar To support the lumbar curvature and prevent flexion
region of the back if you feel a space in the of the lumbar spine.
lumbar curvature.
- Place a small pillow under the client’s head. To support the cervical curvature of the vertebral
Alternatively, have the client rest the head against column. To prevent neck flexion contracture.
the mattress.
- Place one or two pillows under the lower legs To provide a broad base of support, prevent
from below the knees to the ankles. Make sure uncomfortable hyperextension of the knees, and
that no pressure is exerted on the popliteal space reduce pressure on the heels. To prevent damage
and that the knees are flexed. on the nerves and vein walls. To prevent the person
from sliding down in the bed.
- Avoid using the knee gatch of a hospital bed to To prevent pressure on the popliteal space and
flex the client’s knees. beneath the client’s calves
- Put a trochanter roll lateral to each femur. To prevent external rotation of the hips.
- Support the client’s feet with a foot board, allow To prevent plantar flexion and pressure on the toes
it to protrude several inches above the toes. The by the top bedding.
footboard should be placed 1 inch away from the To prevent undue pull on the Achilles tendon and
heels. discomfort.
- Place pillows to support both forearms and hands To prevent shoulder and muscle strain, dislocation
up to the elbow. of the shoulder, edema of the hands and arms, and
flexion contracture of the wrist.
Supporting a Client in the Lateral Position

- The client lies on one side of the body, flexing the To reduce lordosis and promote good back
top hip and knee and placing this leg in front of alignment. This is the position good for resting and
the body. sleeping clients.

- Place the pillow under the client’s head so that To prevent lateral flexion and discomfort of the
the head and neck are aligned with the trunk. major neck muscles.
- Have the client flex the lower shoulder and To prevent disruption of circulation.
position it forward so that the body does not rest
on it. Rotate it into any position of comfort.
- Place a pillow under the upper arm. If the client To prevent internal rotation and adduction of the
has respiratory difficulty, increase the shoulder shoulder and downward pressure on the chest that
flexion and position the upper arm in front of the could interfere with chest expansion during
body off the chest. respiration.
- Place two or more pillows under the upper leg To approximate correct standing alignment and
and thigh so that the extremity lies in a plane prevent internal rotation of the thigh and adduction
parallel to the surface of the bed. of the leg. To prevent pressure on the lower leg by
the weight of the top leg.
- Ensure that the two shoulders are aligned in the To prevent twisting of the spine.
same plane as the two hips. If they are not, pull

one shoulder or hip forward or backward until all
four joints are aligned in the same plane.
- Place a folded towel under the natural hollow at To prevent postural scoliosis of the lumbar spine
the waistline. Take care to fill in only the space at and to prevent undue pressure against the rib cage
the waistline. or iliac crests.
- Place a rolled pillow alongside the client’s back. To stabilize the position.
May not be needed if the client’s upper hip and
knee are appropriately flexed.
Supporting a Client in Sim’s Position
Turn the client as for the prone position.

- Place a small pillow under the client’s head, To prevent lateral flexion of the neck and cushion
unless drainage from the mouth is being the cranial and facial bones and the ear.
encouraged. Contraindicated if drainage from the mouth is
encouraged.
- Place the lower arm behind and away from the To prevent damage to the nerves and blood vessels
client’s body in a position that is comfortable and in the axillae.
does not disrupt circulation.
- Position the upper shoulder so that it is abducted To prevent internal shoulder rotation and adduction
slightly from the body and the shoulder and and to maintain alignment of the upper trunk.
elbow are flexed. Place a pillow in the space
between the chest and abdomen and the upper
arm and bed.
- Place a pillow in the space between the abdomen To prevent internal rotation and adduction of the
and pelvis and upper thigh and bed. hip and to reduce lumbar lordosis.
- Ensure that the two shoulders are aligned in the To prevent twisting of the spine.
same plane as the two hips. If they are not, pull
one shoulder or hip forward or backward until all
four joints are aligned in the same plane.
- Place a support device against the lower foot. To prevent footdrop.
Supporting a Client in a Sitting or Chair Position

- The client sits in a chair, feet flat against the floor To promote good body alignment.
with the knees and hips at right angles.
- The buttocks should rest firmly against the back of
the chair and the spine should be in straight
alignment.

- Support the client’s elbows with arm rests. To promote comfort.
- Place hand rolls, if needed. To prevent flexion contractures of the fingers.
- Support feet with foot rest, if needed. To prevent plantar flexion.
- Avoid placing pillows at the back. To prevent flexion of the lumbar spine.
Supporting a Client in Orthopneic Position

- The client sits either in bed or on the side of the To facilitate respiration by allowing maximum chest
bed with an overbed table across the lap. expansion.
- The client leans forward and rests the head and

arms on the table.

- Place one or two pillows on the overbed table. To act as padding on the overbed table.
- Elevate the overbed table to an appropriate To promote comfort.
height.
- Provide supportive device appropriately as in
Fowler’s position.
Supporting a Client in a Knee - Chest Position or

Genupectoral Position

- The client kneels on the bed, leans forward with
the torso at a 90-degree angle to the hips and the
head and chest on the bed.
- The head is turned to one side and the arms are To facilitate breathing.
held above the head.

- Place a pillow under the client’s head. To promote comfort.
- A pillow can be placed under the client’s chest if To prevent undue strain on the chest muscles.
you feel a space between the chest and the bed.
Supporting a Client in a Lithotomy Position

- Assist client to a supine position.
- Both knees are flexed simultaneously so that the To facilitate easy visualization of the perineum as
feet are brought close to the hips. this position is used in examination of the perineum
and rectum as well as in labor and delivery.
- The legs are separated widely and are supported
in stirrups.
- The hips should be in line with the edge of the
bed or table.

- Place a pillow under the client’s head. To promote comfort.
- Pad the stirrups before positioning the client’s To prevent pressure on the legs.
legs.
Supporting a Client in Trendelenberq Position

- Assist client to a dorsal or supine position.
- The head of the bed is lowered and the foot of To promote circulation towards the heart and to
the bed is elevated in a straight incline. promote postural drainage.
Provide supportive devices as in dorsal recumbent

position.
Supporting a Client in a Reverse Trendelenberg

Position

- Assist client to a dorsal or supine position.
- The head of the bed is elevated and the foot of To promote arterial circulation to the legs.
the bed is lowered in a straight incline.
Provide supportive devices as in dorsal recumbent

position.
13. Clean and return equipment properly. To prevent contamination.
1. Time and change of position according to agency protocol.

2. Any signs of pressure areas of contractures.
3. Any difficulty the client has with breathing.
4. Use of support devices.
5. Any other signs and symptoms indicative of an alteration from normal.
VI. ILLUSTRATIONS
Orthopneic Position Semi-Fowler’s Position
Dorsal Recumbent Lateral Position
Sim’s Position Prone Position

Lithotomy Trendelenburg’s
Knee-chest
SERVING AND REMOVING BEDPAN AND URINAL

Adapted from Lippincott Manual of Nursing Practice (2010);
Potter and Perry (2011). Clinical Nursing Skills and Techniques.
I. DEFINITION
Bedpans – are made of either metal or plastic and come in two sizes, (the smaller designed for pediatric
clients) which serve as receptacle for urine and feces for clients who are restricted to bed.
Urinal – is used by male clients for urination. It is made of plastic or metal with a bottle – like
configuration. A flat side allows it to rest without tipping. They are available with or without
attached tops or lids.
II. RATIONALE
1. To provide a receptacle for elimination of waste materials for clients who are confined to bed.
2. To obtain a urine or stool specimen for laboratory examination.
3. To obtain an accurate measurement or assessment of the client’s urine or stool.
III. EQUIPMENT
Clean Bedpan Bedpan Cover

Toilet Tissue Plastic Bag or Waste Receptacle
Basin of Water, Soap, Washcloth and Towel (for client’s use in washing hands after)
ACTION RATIONALE
1. Check the client’s activity order and physical To determine whether a bedpan is necessary.
status.
2. Review the client’s past use of such equipment To plan on what technique to use.
and note any problems encountered.
3. Decide how much assistance the client currently
needs and get the help needed.
4. Plan for the specific procedure or technique to be
used. (Refer to Step 10 for options)
5. Wash your hands and put on clean gloves. Use the To protect both the client and yourself.
principles of infection control throughout.
6. Explain in general how you plan to proceed. If the
client verbalizes the need to eliminate, do not go
into detail.
7. Close the door or the bed curtain. To provide privacy.
8. Raise the bed to the high position and put up the To be able to perform the procedure with
side rail on the opposite side of the bed from convenience and to provide for client’s safety.
where you plan to stand.
9. Take the bedpan, cover, and toilet tissue out of
the bedside storage unit. Set the cover and tissue
aside. A fracture pan or emesis basin can be used
in the same way as a conventional bedpan.
10. Put the client on the bedpan, using one of the
following methods, depending on the client’s
condition and ability to assist you;
- With the client in a recumbent position and To provide support.

your hand under the small (lumbosacral area) of To allow ease and comfort in placing the pan in
the back, ask the client to raise the buttocks by place.
raising up with the feet as you push the pan into
position under the client.
Or if using the urinal for male clients: The urinal
is properly placed between slightly spread legs
with the bottom of the urinal resting on bed.
- Ask the client who is able to assume the sitting To ensure stability.
position to simply lift the body by pushing down
with the hands and feet as you place the pan in
position.
- Roll a more immobilized client onto the pan. For To relieve pressure on the client's buttocks.
this maneuver, elicit the client’s cooperation.
Ask the client to grasp the side rail on the
opposite side of the bed (across from where
you are standing) as you roll the client away
from you in one plane. Place the pan against the
client, in position. You may want to pad the pan
with a towel. Now, hold the pan firmly in place
as you roll the client back. Finally, check the
position of the pan. If the client must remain
flat, you may want to place a small pillow above
the bedpan under the client’s back for support.
Note: If the client’s bed has a trapeze, make use
of this device for placing and removing the
bedpan. Have the client use the trapeze to lift
the hips.
11. Raise the side rail nearest you. To ensure safety.
12. Elevate the head of the bed to mid - or high - This provides a position that approximates what is
Fowler’s position, if not contraindicated, as the normal for elimination.
client grasps the rails.
13. Place the toilet tissue and the call bell within the To allow the client to call for help in case needed.
client’s reach.
14. Leave the client. If the client is safe, it is best to To provide privacy during elimination.
leave the client for a time; if this is not possible,
you might step just outside to be within calling
distance if the client suddenly needs assistance.
15. When the client signals, return promptly. If a To ensure safety and comfort.
client does not signal you within a reasonable
amount of time, return to the client.
16. Put on clean gloves if you remove your gloves To provide for infection control.
after you place the pan in place.
17. If necessary, clean the genital area with toilet To minimize the chance of contaminating the
tissue. Most alert clients will be able to clean urinary tract with fecal microorganisms.
themselves adequately. Some who are
incapacitated may need further assistance.
Always clean with fresh tissue from the anterior
(urinary) to the posterior (rectal) region.
18. Remove the bedpan, reversing the method that To prevent the contents from spilling.
you used when you placed the client on the
bedpan. If you used the rolling technique, hold
onto the pan firmly or get help.
19. Cover the pan. For aesthetic purpose.
20. Carry the pan to the bathroom and, if ordered, To ensure accuracy.
measure the urine. If the client is on intake and To identify significant findings.
output, a measuring container is usually kept in
the bathroom. You must estimate as accurately as
possible, taking into account the amount of toilet
tissue used. Do further assessment of the urine or
feces.
21. Collect a specimen of urine or feces, if ordered.
(Refer to specific procedure)
22. Empty the contents into the toilet and flush.
23. Thoroughly clean the pan with cold water. Health To be used in cleaning the bedpan.
regulations require that a container of
disinfectant solution and a long - handled brush
be kept in the bathroom. Wash and rinse the pan
thoroughly. Use paper towels for drying. Then
return the pan on the client’s storage unit.
24. Remove and dispose of gloves.
25. Give the client a basin of warm water, washcloth, To prevent the spread of microorganisms.
soap, and a towel, or a packaged moist towelette.
Allow the client to wash the hands and perineal
area, if desired.
26. Place the bed back in the low position and lower To promote safety and comfort.
the rail on the stand side, if appropriate. Make
the client comfortable.
27. Dispose of the equipment. To prevent contamination.
28. Wash your hands. To prevent infection.
1. Note the efficiency of the technique used and how suitable it was for the client.
2. Identify any specific problems and possible improvements.
3. Record any problems or unusual observations.
VI. ILLUSTRATION
Two types of bedpans: A. the high-back, or regular pan; B. the slipper, or fracture pan.
Two types of urinals: A. male urinal; B. female urinal.
Placing a bedpan against a client’s buttocks.
PERFORMING URINARY CATHETERIZATION

I. DEFINITION
Urinary Catheterization – is the introduction of a catheter through the urethra into the urinary bladder.
Straight Catheter – is a single – lumen tube with a small eye or opening about 11/4 cm (1/2 in) from the
insertion tip.
Retention or Foley Catheter – is a double – lumen catheter. The larger lumen drains urine from the
bladder and the smaller lumen is used to inflate a balloon near the tip of the catheter to hold
the catheter in place within the bladder.
II. RATIONALE
1. To relieve discomfort due to bladder distention or to provide gradual decompression of a distended

bladder.
2. To assess the amount of residual urine if the bladder empties incompletely.
3. To obtain a urine specimen.
4. To empty the bladder completely prior to surgery.
5. To facilitate accurate measurement of urinary output for critically ill clients whose output needs to
be monitored hourly.
6. To provide for intermittent or continuous bladder drainage and irrigation.
7. To prevent urine from contacting an incision after perineal surgery.
8. To manage incontinence when other measures have failed.
III. EQUIPMENT
Sterile Catheter (catheters are measured by French system; average adult sixe F16 or 18 and pediatric
size F10-12-14)
Catheterization Kit or Individual Sterile Items:
- Pair of Sterile Gloves
- Waterproof Drape
- Antiseptic Solution
- Cleansing Balls
- Forceps
- Water Soluble Lubricant
- Urine Receptacle
- Specimen Container
For an Indwelling Catheter:
- Syringe prefilled with Sterile Water in Amount Specified by Catheter Manufacturer
- Collection Bag and Tubing
Water-soluble lubricant
Disposable Clean Gloves
Supplies for Performing Perineal Cleansing
Bath Blanket or Sheet for Draping the Client
Adequate Lighting (obtain a flashlight or lamp if necessary)
Catheterization in Infants and Children

1. Adapt the size of the catheter for pediatric clients.
2. Ask a family member to assist in holding the child during catheterization, if appropriate.
Catheterization in Elders
3. When catheterizing older adults, be very attentive to problems of limited movement, especially in
the hips. Arthritis or previous hip or knee surgery, may limit their movement and cause discomfort.
Ask for assistance of another nurse if necessary.
ACTION RATIONALE
Preparation
 If using a catheterization kit, read the label To be sure all necessary items are included.
carefully. Perform routine perineal care. For
women, use this time to locate the urinary To cleanse the meatus from gross contamination.
meatus relative to surrounding structures.
Performance
1. Explain to the client what you are going to do, why To gain the client’s cooperation.
it is necessary, and how he / she can cooperate.
2. Wash hands and observe appropriate infection To prevent the spread of microorganisms.
control procedures.
3. Provide for client privacy. To promote comfort.
4. Place the client in the appropriate position and To prevent undue exposure of the client.
drape all areas except the perineum.
a. Female: Supine with knees flexed and

externally rotated
b. Male: Supine, legs slightly abducted
5. Establish adequate lighting. Stand on the client’s To promote ease and comfort.
right if you are right – handed, on the client’s left
if you are left – handed.
6. If using a collecting bag and it is not contained with Since one hand is needed to hold the catheter once
the catheterization kit, open the drainage package it is in place, open the package while two hands are
and place the end of the tubing within reach. still available.
7. Open the catheterization kit. Place a waterproof To protect bed linen.

drape under the buttocks (female) or penis (male)
without contaminating the center of the drape
with your hands.
8. Apply sterile gloves. To prevent contamination.

9. Organize the remaining supplies. To save time and effort.
- Saturate the cleansing balls with the

antiseptic solution.
- Open the lubricant package.
- Remove the specimen container and place it
nearby with the lid loosely on top.
10. Attach the prefilled syringe to the indwelling If the balloon malfunctions, it is important to
catheter inflation hub and test the balloon. replace it prior to use.
11. Lubricate the catheter (1 to 2 in. for females, 6 to To facilitate insertion.

7 in. for males) and place it with the drainage end
inside the collection container.
12. If desired, place the fenestrated drape over the To prevent undue exposure of the body part.
perineum, exposing the urinary meatus.
13. Cleanse the meatus. Note: The nondominant To reduce the presence of microorganisms in the
hand is considered contaminated once it touches area and prevent infection.
the client’s skin.
a. Female: Use your dominant hand to spread

the labia. Establish a firm but gentle position.
The antiseptic may make the tissues slippery
but the labia must not be allowed to return
over the cleaned meatus. Pick up a cleansing
ball with the forceps in your dominant hand
and wipe one side of the labia majora in an
anteroposterior direction. Use great care that
wiping the client does not contaminate this
sterile hand. Use a new ball for the opposite
side. Repeat for the labia minora. Use the last
ball to cleanse directly over the meatus.
b. Male: Use your nondominant hand to grasp To help straighten the urethra.
the penis just below the glans. If necessary,
retract the foreskin. Hold the penis firmly
upright, with slight tension. Pick up a
cleansing ball with the forceps in your
dominant hand and wipe from the center of
the meatus in a circular motion around the
glans. Use great care that wiping the client
does not contaminate this sterile hand. Use a
new ball and repeat three more times. The
antiseptic may make the tissues slippery but
the foreskin must not be allowed to return
over the cleaned meatus nor should the penis
be dropped.
14. Insert the catheter.

- Grasp the catheter firmly 2 to 3 in. from the To allow enough time for the sphincter to relax.
tip. Ask the client to take a slow deep breath
and insert the catheter as the client exhales.
Slight resistance is expected as the catheter
passes through the sphincters. If necessary,
twist the catheter or hold pressure on the
catheter until the sphincter relaxes.
- Advance the catheter 2 inches further after To be sure it is fully in the bladder.
the urine begins to flow through it.
- If the catheter accidentally contacts the labia To help avoid mistaking the vaginal opening for the
or slips into the vagina, it is considered urethral meatus.
contaminated and a new sterile catheter must
be used. The contaminated catheter may be
left in the vagina until the new catheter is
inserted.
15. Hold the catheter with the nondominant hand. In

males, lay the penis down onto the drape, being
careful that the catheter does not pull out.
16. For an indwelling catheter, inflate the retention

balloon with the designated volume.
- Without releasing the catheter, hold the To ensure that the catheter will be in place and to
inflation valve between two fingers of your prevent the catheter from getting pulled out.
nondominant hand while you attach the
syringe (if not left attached earlier when There is a possibility that the catheter is not yet in
testing the balloon) and inflate with your the bladder.
dominant hand. If the client complains of
discomfort, immediately withdraw the
instilled fluid, advance the catheter further,
and attempt to inflate the balloon again.
- Pull gently on the catheter until resistance is To ensure that the balloon has inflated and to place
felt. it in the trigone of the bladder.
17. Collect a urine specimen if needed. Allow 20 to 30

ml to flow into the bottle without touching the
catheter to the bottle.
18. Allow the straight catheter to continue draining. If To allow urine to drain by gravity.
necessary, attach the drainage end of an
indwelling catheter to the collecting tubing and
bag.
19. Examine and measure the urine. In some cases, To prevent sudden decompression of the bladder.
only 750 to 1000 ml of urine are to be drained
from the bladder at one time. Check agency policy
for further instructions if this should occur.
20. Remove the straight catheter when urine flow To allow usual movement and at the same time
stops. For an indwelling catheter, secure the secure the drainage system.
catheter tubing to the inner thigh for female
clients or the upper thigh / abdomen for male
clients with enough slack. Also secure the
collecting tubing to the bed linens and hang the
bag below the level of the bladder. No tubing
should fall below the top of the bag.
21. Wipe the perineal area of any remaining To promote comfort.

antiseptic or lubricant. Return the client to a
comfortable position.
22. Discard all used supplies in appropriate To prevent the spread of microorganisms.
receptacles and wash your hands.
1. The catheterization procedure including catheter size, character of urine and amount
2. Any findings that deviated from what is expected or considered normal for the client
3. Correlation of findings to previous assessment data
4. Any instructions given to the client or family member regarding catheter care
5. Whether a specimen was obtained and sent to the laboratory
VI. ILLUSTRATION
PROVIDING CATHETER CARE
I. DEFINITION
Providing Catheter Care – procedure done on clients with indwelling catheter for the purpose of
preventing ascending infection.
II. RATIONALE
To prevent the spread of microorganisms and urinary tract infection.

To provide comfort and hygienic care.
III. EQUIPMENT
Antiseptic Solution Swabs or Cotton Balls

Sterile Gloves Paper Bag
Sterile Catheter Care Kit
ACTION RATIONALE
1. Identify the client. To prevent error.
2. Explain procedure. To gain client’s cooperation.
3. Provide privacy (drapes, curtains). To promote comfort.
4. Place client in a supine position and expose the To prevent undue exposure.
perineal area. Drape appropriately.
5. Open sterile catheter kit or assemble equipment To save time and effort.
within easy reach.
6. Put on sterile gloves. To protect both the client and the nurse.
7. Pour antiseptic solution over the cotton balls or

open package of cleansing swabs.
8. Open antibiotic ointment and place a small

amount on sterile swab or cotton ball.
9. Cleanse urinary meatus using a circular motion To prevent microorganisms from entering the
moving from the middle toward the outside with urinary meatus.
antiseptic - soaked cotton ball or swab.
10. Gently pull the catheter taut and cleanse with To reduce the presence of microorganisms around
new swab or cotton ball from catheter insertion the catheter site.
site down to catheter tubing approximately 4 to 5
inches toward the drainage bag.
11. Apply ointment around the catheter at the To disinfect the area.
meatus and down the catheter tubing about ½ to
1 inch.
12. Return client to a comfortable position. To promote comfort.
13. Do after – care of equipment and wash hands. To prevent the spread of microorganisms.
1. Status of the perineal area

2. Status of the catheter and the area around
3. Unusual findings such as discharges, redness on the skin around, or swelling, etc.
APPLYING AN EXTERNAL CATHETER
I. DEFINITION
Applying an External Catheter / Condom Catheter – is the use of a condom or external catheter connected
to a drainage system which is used to drain urine from the bladder. This is commonly prescribed
for incontinent males.
II. RATIONALE
1. To collect urine and control urinary incontinence.

2. To permit the client physical activity without fear of embarrassment because of leaking urine.
3. To prevent skin irritation as a result of urine incontinence.
III. EQUIPMENT
Leg Drainage Bag with Tubing / Urinary Drainage Bag with Tubing
Condom Sheath
Bath Blanket or Similar Drape
Clean Gloves
Basin of Warm Water and Soap
Washcloth and Towel
Elastic Tape or Velcro Strap
ACTION RATIONALE
Preparation
• Assemble the leg drainage bag or urinary

drainage bag for attachment to the condom
sheath.
To facilitate easier application.
• Roll the condom outward onto itself. On some To prevent the reflux of urine.
models, an inner flap will be exposed. This flap is
applied around the urinary meatus.
To promote ease and comfort.
• Position the client in either a supine or a sitting
position.
Performance
To gain the client’s cooperation.
1. Explain to the client what you are going to do,
why it is necessary, and how he can cooperate.
2. Wash hands, apply clean gloves, and observe To prevent the spread of microorganisms.
appropriate infection control procedures.
3. Provide for client privacy.
- Drape the client appropriately with the
bath blanket, exposing only the penis. To prevent unnecessary exposure.
4. Inspect and clean the penis.

- Clean the genital area and dry it thoroughly.
5. Apply and secure the condom.
- Roll the condom smoothly over the penis, To minimize skin irritation and excoriation after
leaving 2.5 cm (1 in) between the end of the the condom is applied.
penis and the rubber or plastic connecting
tube.
- Secure the condom firmly, but not too tight,
to the penis. Some condoms have an To prevent irritation of the tip of the penis and to
adhesive inside the proximal end that provide for full drainage of urine.
adheres to the skin of the base of the penis.
Many condoms are packaged with special
tape. If neither is present, use a strip of
elastic or Velcro around the base of the Ordinary tape is contraindicated because it is not
penis over the condom. flexible and can stop the blood flow.
6. Securely attach the urinary drainage system.

- Make sure that the tip of the penis is not
touching the condom and that the condom
is not twisted.
- Attach the urinary drainage system to the
condom.
- Remove the gloves and wash your hands.
- If the client is to remain in bed, attach the
urinary drainage bag to the bed frame.
- If the client is ambulatory, attach the bag to
the client’s leg.
To prevent obstruction of urine flow.
7. Teach the client / family member about the
drainage system.
- Instruct the client or a family member to

keep the drainage bag below the level of the To prevent infection.
condom and to avoid loops or kinks in the
tubing. To ensure proper placement of the drainage bag.
8. Inspect the penis 30 minutes following the

condom application, and check urine flow. To help control the movement of the tubing and
to prevent twisting of the thin material of the
- Assess the penis for swelling and condom appliance at the tip of the penis.
discoloration.
- Assess urine flow if the client has voided.
Normally, some urine is present in the tube
if the flow is not obstructed. To ensure proper flow of urine.
This indicates that the condom is too tight.

9. Change the condom daily and provide skin To check for obstruction and proper functioning
care. of the drainage system.
- Remove the plastic or Velcro strip, apply
clean gloves, and roll off the condom. To prevent infection.
- Wash the penis with soapy water, rinse, and
dry it thoroughly.
- Assess the foreskin for signs of irritation,
swelling, and discoloration.
- Reapply a new condom.
1. Effects of the treatment on the client’s condition

2. Significant deviations from normal
3. Pattern of urine flow
VI. ILLUSTRATION
REMOVING AN INDWELLING / FOLEY CATHETER
I. DEFINITION
Removing an Indwelling / Foley Catheter – is the process of pulling out an indwelling or Foley catheter
from the bladder as part of the client’s treatment.
II. RATIONALE
To remove an indwelling or Foley catheter as ordered by the physician.
III. EQUIPMENT
10 – ml Syringe
Paper Towels to wrap the soiled catheter after removal
Padding and a Small Container to catch the fluid
Clean Gloves
ACTION RATIONALE
1. Verify the order to discontinue the indwelling To ensure accuracy.

catheter.
2. Determine whether a urine specimen is needed. This may be ordered to assess the urine.
3. Wash your hands. For infection control.
4. Obtain the necessary equipment. To save time and effort.
5. Identify the client. To ensure accuracy and prevent errors.
6. Explain to the client that the catheter is to be To be able to gain the client’s cooperation.
removed and that the procedure is not painful.
Health teachings should include the following:
a. A mild burning sensation may accompany This is due to the irritation caused by the catheter.
urination for a short time. If this persists, it
should be reported to the physician.
b. Voiding may be more frequent and in smaller This is because the bladder has been kept empty
amounts than normal at first. Again, if this and may have to learn how to respond to a
persists, it should be reported to the sensation of fullness.
physician.
c. For the first 24 hours after the catheter is To facilitate assessment.
removed, the nurse should be called to
measure each voiding. If the client can go to To give time to the client to void when there are
the bathroom explain how measurement is more staff for assistance and assessment.
carried out. As much as possible, removal
should be done during the daytime.
d. It is essential to continue increased fluid To maintain proper kidney and bladder function.
intake.
7. Close the door or draw curtains and prepare the To provide privacy.
client. Raise the bed and drape the covers back. To expose the catheter.
Put on clean gloves. To prevent infection.
8. Grasp the catheter near the meatus and gently
withdraw the catheter.
- Place paper towels under the catheter. To protect the linens.
- Use the syringe to remove sterile water from To facilitate deflation of the balloon.
the balloon.
- Pinch the catheter and pull it out smoothly. To prevent leakage.
This action should not cause discomfort but
will be felt. Ask the client to breathe in and
out through the mouth while you withdraw
the catheter.
- With your free hand, wrap the end of the To prevent contamination while trying to prevent
catheter in paper towel while you keep the leakage.
catheter itself pinched closed.
- Hold the end of the catheter up. To allow urine to drain from the tubing into the bag.
9. Assist the client to a comfortable position, and To promote comfort.

straighten and lower the bed.
10. Measure urine output. To do assessment.
11. Dispose of the equipment. To prevent contamination.
12. Remove gloves and wash your hands. To prevent the spread of microorganisms.
1. Catheter removed without difficulty

2. Client voiding in adequate amounts at regular intervals
3. Amount of fluid intake, whether it is increased
4. Client’s response to the procedure
ADMINISTERING ENEMA
I. DEFINITION
Enema – is a solution introduced into the rectum and large intestine. The action of an enema is to
distend the intestine and sometimes to irritate the intestinal mucosa, thereby increasing
peristalsis and excretion of feces and flatus.
II. RATIONALE
Cleansing Enema
1. To prevent the escape of feces during surgery.
2. To prepare the intestine for certain diagnostic tests such as x – ray or visualization tests
(e.g. colonoscopy)
3. To remove feces in instances of constipation or impaction.
Carminative Enema
4. To release gas.
5. To distend the rectum and colon, thus stimulating peristalsis.
Retention Enema
- Oil Retention Enema
6. To soften the feces.
7. To lubricate the rectum and anal canal, thus facilitating the passage of the feces.
- Antibiotic Enema
8. To treat infections locally.
- Anthelmintic Enema
9. To kill helminthes such as worms and intestinal parasites.
- Nutritive Enema
10. To administer fluids and nutrients to the rectum.
Return – Flow Enema

11. To expel flatus.
12. To relieve abdominal distention.
III. EQUIPMENT
Disposable Linen – Saver Pad Large – Volume Enema:

Bath Blanket
Bedpan or Commode Solution Container with Tubing of Correct
Clean Gloves Size and Tubing Clamp
Water – Soluble Lubricant if tubing not Correct Solution, Amount, and Temperature
prelubricated IV Pole
Paper Towel Small – Volume Enema:
Prepackaged Container of Enema Solution
with Lubricated Tip
ACTION RATIONALE
Preparation
 Lubricate about 5 cm (2 in) of the rectal tube To facilitate insertion through the sphincters and
(some commercially prepared enema sets to minimize trauma.
already have lubricated nozzles).
 Run some solution through the connecting To expel any air in the tubing which when
tubing of a large – volume enema set and the instilled into the rectum, may cause unnecessary
rectal tube and then close the clamp. distention.
Performance
1. Explain to the client what you are going to do,

why it is necessary, and how he / she can To gain the client’s cooperation.
cooperate.
2. Wash hands, apply clean gloves, and observe
3. Provide for client privacy. To prevent infection.
4. Assist the adult client to left lateral position,
with the right leg as acutely flexed as possible,
and place the linen – saver pad under the To promote comfort.
buttocks.
5. Insert the rectal tube. To facilitate the flow of solution by gravity into
- For clients in the left lateral position, lift the the sigmoid colon and descending colon. Having
upper buttock. the right leg acutely flexed provides for
adequate exposure of the anus.
- Insert the tube smoothly and slowly into the
rectum, directing it toward the umbilicus.
- Insert the tube 7 to 10 cm (3 to 4 in). To ensure good visualization of the anus.
- If resistance is encountered at the internal

sphincter, ask the client to take a deep The angle follows the normal contour of the
breath, then run a small amount of solution rectum. Slow insertion prevents spasm of the
through the tube. sphincter.
- Never force the tube or solution entry. If To place the tip of the tube beyond the anal
instilling a small amount of solution does not canal into the rectum because the anal canal is
permit the tube to be advanced or the about 2.5 to 5 cm (1 to 2 in) long in adult.
solution to freely flow, withdraw the tube. To relax the internal anal sphincter.
Check for any stool that may have blocked
the tube during insertion. If present, flush it
and retry the procedure. You may also
perform a digital rectal examination. If To prevent injury.
resistance persists, end the procedure and
report the resistance to the physician and
the nurse in charge.
6. Slowly administer the enema solution.

- Raise the solution container, and open the
clamp or
- Compress a pliable container by hand.
- During most low enemas, hold or hang the To allow the fluid to flow.
solution container no higher than 30 cm (12
in) above the rectum. During a high enema,
hang the solution container about 45 cm (18 To prevent a faster flow which may result to
in). greater pressure in the rectum. To instill the fluid
- Administer the fluid slowly. If the client further to clean the entire bowel.
complains of fullness or pain, use the clamp
to stop the flow for 30 seconds, and then
restart the flow at a slower rate. To decrease the likelihood of intestinal spasm
- If you are using a plastic commercial and premature ejection of the solution.
container, roll it up as the fluid is instilled.
- After all the solution has been instilled or
when the client cannot hold anymore and To prevent subsequent suctioning of the
feels the desire to defecate, close the clamp, solution.
and remove the rectal tube from the anus.
- Place the rectal tube in a disposable towel as
you withdraw it. To prevent contamination.
7. Encourage the client to retain the enema.

- Ask the client to remain lying down. To retain the enema. In sitting or standing,
gravity promotes drainage and peristalsis.
- Request that the client retain the solution for To obtain a maximum therapeutic effect.
the appropriate amount of time depending
on the type of enema.
8. Assist the client to defecate.

- Assist the client to a sitting position on the To facilitate the act of defecation.
bedpan, commode, or toilet. The nurse needs to observe the feces.
- Ask the client who is using the toilet not to
flush it. To be able to obtain a specimen in an easy way.
- If a specimen of feces is required, ask the
client to use a bedpan or commode. To prevent accidental spillage of feces.
VARIATION: ADMINISTERING AN ENEMA TO AN

INCONTINENT CLIENT
 Occasionally a nurse needs to administer an

enema to a client who is unable to control To allow the fluid to flow back out through the
the external sphincter muscle and thus rectal tube into the container, pulling the flatus
cannot retain the enema solution for even a with it.
few minutes. In that case, after the rectal
tube is inserted, the client assumes a supine
position on a bedpan. The head of the bed
can be elevated slightly, to 30 degrees if
necessary for easier breathing, and pillows
may be used to support the client’s head and
back.
VARIATION: ADMINISTERING A RETURN – FLOW

ENEMA
 For a return – flow enema, the solution (100
to 200 ml for an adult) is instilled into the
client’s rectum and sigmoid colon. Then the To gain the client’s cooperation and that of the
solution container is lowered. The inflow – family.
outflow process is repeated five or six times
and the solution is replaced several times Some hypertonic commercial solutions can lead
during the procedure if it becomes thick with to hypovolemia and electrolyte imbalance.
feces. Correct temperature of the solution so as to
prevent spasm from cold solutions. Correct
VARIATION: ADMINISTERING AN ENEMA TO amount of solution so as to prevent
INFANTS AND CHILDREN overdistention and to obtain a therapeutic
 Provide a careful explanation to the parents effect.
and child before the procedure.
 The enema solution should be isotonic To prevent immediate expulsion of the solution.
(usually normal saline). Enema temperature
should be 37.7°C (100°F) unless otherwise
ordered. Large – volume enemas consist of
50 to 200 ml in children less than 18 months
old; 200 to 300 ml in children 18 months to 5
years; 300 to 500 ml in children 5 to 12 years
old. This is the appropriate position since infants and
small children do not exhibit sphincter control.
 Infants and small children do not exhibit To protect the bed linen and to provide privacy.
sphincter control and need to be assisted in
retaining the enema. The nurse administers
the enema while the infant or child is lying
with the buttocks over the bedpan and the
nurse firmly presses the buttocks together.
To ensure accuracy.
 For infants and small children, the dorsal
recumbent position is frequently used.
Position them on a small padded bedpan
with support for the back and head. Secure To prevent injury.
the legs by placing a diaper under the
bedpan and then over and around the thighs.
Place the underpad under the client’s
buttocks and drape the client with bath
blanket.
 Insert the tube 5 to 7.5 cm (2 to 3 in) in the

child and only 2.5 to 3.75 cm (1 to 1.5 in) in
the infant.
 For children, lower the height of the solution

container appropriately for the age of the
child. See agency protocol.
 To assist a small child in retaining the

solution, apply firm pressure over the anus
with tissue wipes, or firmly press the
buttocks together.
VARIATION: ADMINISTERING AN ENEMA TO AN
ELDER
 Elders may fatigue easily.
 Elders may be more susceptible to fluid and
electrolyte imbalance. Use tap water enema
with great caution.
 Monitor the client’s tolerance during the
procedure, watching for vagal episodes and
dysrhythmias.
 Protect older adult’s skin from prolonged
exposure to moisture.
 Assist older clients with perineal care as
indicated.
1. Type of solution used

2. Desired effects as well as undesirable effect
3. Length of time solution was retained
4. The amount, color, and consistency of the returns
5. Relief from flatus and abdominal distention
6. Other significant observations
VI. ILLUSTRATION
Assuming a left lateral position for an enema. Note the

commercially prepared enema.
INSERTING A HIGH RECTAL TUBE
I. DEFINITION
Inserting a High Rectal tube – the introduction of a rectal tube or catheter into the anal region of the
client.
II. RATIONALE
1. To facilitate the expulsion of flatus.

2. To relieve the client of abdominal distension.
3. To provide comfort to the client.
III. EQUIPMENT
Rectal Catheter of appropriate size: 22-24 Fr for adults; 12-18 Fr for children
KY Jelly or water-soluble lubricant Kidney basin with warm water
Gloves Moisture-proof pad
ACTION RATIONALE
1. Explain the procedure to the client and To gain client’s cooperation.

family or significant others.
2. Prepare all equipment needed and bring To save time and effort.
to the client’s bedside.
To promote comfort during the procedure.
3. Provide privacy. To be able to view clearly the site of insertion.
To prevent undue exposure.
4. Place client in a Sim’s lateral position. To protect bed linens.
5. Drape the client properly exposing only To promote ease during insertion of tube.
the rectum.
To ensure that the tube is at the proper site and
to hold the tube in place.
6. Place a moisture-proof pad under the

client’s buttocks.
Warm water will relax the anal sphincter. To
allow air to be expelled.
7. Lubricate the rectal catheter.

To determine the amount of air that has been
expelled.
8. Separate the buttocks and insert the rectal To prevent irritation of the anal mucosa and
catheter 2-4 inches in adults or 1-3 inches loss of neuro-muscular response.
in children. Apply pressure over the
buttocks.
To provide comfort.
9. Place the opposite end of the catheter into

the kidney basin with warm water making To prevent trhe spread of microorganisms.
sure that the basin is below the client’s
buttocks. To prevent contamination.
10. Observe for expulsion of air through the

formation of air bubbles.
11. Leave the tube in place no longer than 20

minutes.
12. Remove rectal catheter slowly if bubbles
are no longer observed.
13. Provide perineal care as needed and place

client in a comfortable position.
14. Do after care of equipment.
15. Wash hands.
1. The procedure itself and client’s reaction

2. Amount of air expelled
3. Relief from abdominal distension and increased comfort
4. Any untoward reaction and referral to the physician
PERFORMING MANUAL FECAL EXTRACTION
I. DEFINITION
Manual Fecal Extraction – the manual removal of hardened mass of feces in the rectum
II. RATIONALE
1. To remove fecal obstruction in the rectum caused by hardened stool.

2. To facilitate the passage of normal stool.
III. EQUIPMENT
Lubricant Gloves
Bedpan Bed protector / rubber sheet
ACTION RATIONALE
1. Explain the procedure to the client. Adequate knowledge of the procedure will lessen
tension and apprehension thus gaining the client’s
cooperation towards procedure performed.
2. Have a second person to assist the The second person can assure and comfort the
procedure. client while the first person works to break up the
mass.
Enables the nurses to conduct the procedure

properly with less discomfort to the client
3. Place the patient in a side-lying position
To hold removed bits of feces.
for the convenience of the nurses.
Minimizes undue exposure and provides privacy.
4. Place a bedpan on a bed. The intestinal tract is not sterile.
The presence of the finger added to the mass

5. Drape the patient by folding top linens tends to cause discomfort to the client when
back. procedure is not done slowly and gently.
Breaking hardened stool to pieces provides easy

extraction from the rectum.
This avoids discomfort and irritation which can
6. Use clean gloves for the procedure. injure the intestinal mucosa.
This may be given before attempts are made to

break up and remove an impaction digitally.
7. Lubricate the forefinger generously to

reduce irritating the rectum and insert the
finger gently into the anal.
8. Work the finger around and into the

hardened mass, break it up and remove
pieces of it.
9. Remove the impaction at intervals if a

severe one is present.
10. Use an oil retention enema as necessary.
1. Fecal impaction is removed.

2. Comfort is provided to the client.
3. Client is able to establish regular bowel evacuation program
APPLYING PHYSICAL RESTRAINTS
Adapted from Delaune and Ladner(2011). Fundamentals of Nursing;
I. DEFINITION
Restraints – are protective devices used to limit the physical activity of the client or a part of the body.
Physical Restraints – are any manual method or physical or mechanical device, material, or equipment
attached to the client’s body; they cannot be removed easily and they restrict the client’s movement.
Chemical Restraints – are medications such as neuroleptics, anxiolytics, sedatives, and psychotropic
agents used to control socially disruptive behavior.
II. RATIONALE
1. To enable the client to receive treatment.

2. To allow the treatment to proceed without client interference.
3. To prevent the client from injuring self or others.
III. EQUIPMENT
Appropriate Type and Size of Restraints
Guidelines:
1. Obtain consent from the client or guardian.
2. Ensure that a physician’s order has been provided or, in an emergency, obtain one within 24 hours
after applying the restraint.
3. Assure the client and the client’s support people that the restraint is temporary and protective. A
restraint must never be applied as punishment for any behavior or merely for the nurse’s convenience.
4. Apply the restraint in such a way that the client can move as freely as possible without defeating the
purpose of restraint.
5. Ensure that limb restraints are applied securely but not so tightly that they impede blood circulation
to anybody area or extremity.
6. Pad bony prominences (e.g. wrists and ankles) before applying a restraint over them. The movement
of a restraint without padding over such prominences can quickly abrade the skin.
7. Always tie a limb restraint with a knot (e.g. clove hitch) that will not tighten when pulled.
8. Tie the ends of a body restraint to the part of the bed that moves to elevate the head. Never tie the
ends to a side rail or to the fixed frame of the bed if the bed position is to be changed.
9. Assess the restraint every 30 minutes. Some facilities have specific forms to be used to record
ongoing assessment.
10. Release the restraints at least every 2 to 4 hours, and provide range - of - motion exercises and skin care.
11. Reassess the continued need for the restraint at least every 8 hours. Include an assessment of the
underlying cause of the behavior necessitating use of the restraints.
12. When a restraint is temporarily removed, do not leave the client unattended.
13. Immediately report to the nurse in charge and record on the client’s chart any persistent reddened
or broken skin areas under the restraint.
14. At the first indication of cyanosis or pallor, coldness of a skin area, or a client’s complaint of a
tingling sensation, pain, or numbness, loosen the restraint and exercise the limb.
15. Apply a restraint so that it can be released quickly in case of an emergency and with the body part in
a normal anatomic position.
16. Provide emotional support verbally and through touch.
ACTION RATIONALE
1. Obtain consent from client’s guardian. Explain to To gain the cooperation of the client and the family.
the client and family what you are going to do,
why it is necessary, and how they can cooperate.
2. Wash hands and observe appropriate infection To prevent infection.

control procedures.
3. Provide for client privacy if indicated. To promote comfort.
4. Apply the selected restraint.
BELT RESTRAINT (SAFETY STRAP BODY RESTRAINT)

This is used to ensure the safety of all clients who are
being moved on stretchers or in wheelchairs. This can
also be used for certain clients confined to bed or to
chairs.
 Determine that the safety belt is in good order. If To ensure safety.
a Velcro safety belt is to be used, make sure that
both pieces of Velcro are intact.
 If the belt has a long portion and a shorter The long attached portion will then move up when
portion, place the long portion of the belt behind the head of the bed is elevated and will not tighten
(under) the bedridden client and secure it to the around the client.
movable part of the bed frame. Place the shorter
portion of the belt around the client’s waist, over
the gown. There should be a finger’s width
between the belt and the client.
Or
 Attach the belt around the client’s waist, and
fasten it at the back of the chair.
Or
 If the belt is attached to a stretcher, secure the Belt restraints need to be applied to all clients on
belt firmly over the client’s hips or abdomen. stretchers even when the side rails are up.
JACKET RESTRAINT
 Place vest on client, with opening at the front or
the back, depending on the type.
 Pull the tie on the end of the vest flap across the
chest, and place it through the slit in the opposite
side of the chest.
 Repeat for the other tie.
 Use a half - bow knot to secure each tie around This does not tighten or slip when the attached end
the movable bed frame or behind the chair to a is pulled but unties easily when the loose end is
chair leg. pulled.
Or
 Fasten the ties together behind the chair using a This does not tighten with pulling and does not slip
square (reef) knot. when pressure is released.
 Ensure that the client is positioned appropriately. To enable maximum chest expansion for breathing.
MITT RESTRAINT
This is used to prevent confused clients from using their
hands or fingers to scratch and injure themselves. This
also allows the client to be ambulatory and / or to move
the arm freely rather than be confined to a bed or a
chair.
 Apply the commercial thumbless mitt to the hand To prevent injury to the hand.
to be restrained. Make sure the fingers can be
slightly flexed and are not caught under the hand.
 Follow the manufacturer’s directions for securing
the mitt.
 If a mitt is to be worn for several days, remove it at To check the condition of the hand and to provide
least every 2 to 4 hours. Wash and exercise the care so as to prevent injury.
client’s hand, then reapply the mitt. Check agency
practices about recommended intervals for
removal.
 Assess the client’s circulation to the hands shortly Feelings of numbness or discomfort or inability to
after the mitt is applied and at regular intervals. move the fingers could indicate impaired circulation
to the hand.
WRIST OR ANKLE RESTRAINTS

These are generally made of cloth, may be used to
immobilize a limb, primarily for therapeutic reasons.
 Pad bony prominences on the wrist or ankle if To prevent skin breakdown.

needed.
 Apply the padded portion of the restraint around
the ankle or wrist.
 Pull the tie of the restraint through the slit in the
wrist portion or through the buckle.
 Using a half – bow knot (quick – release knot) or a If the ties are attached to the movable portion, the
square knot if appropriate, attach the other end of wrist or ankle will not be pulled when the bed
the restraint to the movable portion of the bed position is changed.
frame.
ELBOW RESTRAINTS
These are used to prevent infants or small children
from flexing their elbows to touch or scratch a skin
lesion or to reach the head when a scalp vein infusion
is in place. This restraint consists of a piece of
material with pockets into which plastic or wooden
tongue depressors are inserted to provide rigidity.
 Examine the restraint to make sure that the To prevent injury.

tongue depressors are intact(all in place and not
broken).
 Place the infant’s elbow in the center of the To prevent the ends of the tongue depressors from
restraint. Make sure that the padded material irritating the skin.
covers the ends of the tongue depressors.
 Wrap the restraint smoothly around the arm.
 Secure the restraint, using safety pins, ties, or To prevent injury due to obstruction in circulation.
tape. Ensure that it is not so tight that it obstructs
blood circulation.
 Optional: After the restraint is applied, pin it to To prevent it from sliding down the arm.
the child’s shirt.
MUMMY RESTRAINT
This is a special folding of a blanket or sheet around
the infant to prevent movement during a procedure
such as gastric washing, eye irrigation, or collection of
a blood specimen.
 Obtain a blanket or sheet large enough so that To ensure that it can safely restrain the infant.
the distance between opposite corners is about
twice the length of the infant’s body. Lay the
blanket or sheet on a flat, dry surface.
 Fold down one corner, and place the baby on it in
the supine position.
 Fold the right side of the blanket over the infant’s
body, leaving the left arm free. The right arm is in
a natural position at the side.
 Fold the excess blanket at the bottom up under
the infant.
 With the left arm in a natural position at the
baby’s side, fold the left side of the blanket over
the infant, including the arm, and tuck the blanket
under the body.
 Remain with the infant who is in a mummy
restraint until the specific procedure is
completed.
CRIB NET
This is simply a device placed over the top of a crib to
prevent active young children from climbing out of
the crib. At the same time, it allows them freedom to
move about in the crib. The crib net or dome is not
attached to the movable parts of the crib so that the
caregiver can have access to the child without
removing the dome or net.
 Place the net over the sides and ends of the crib. To safely secure the net.
 Secure the ties to the springs or frame of the crib.
The crib sides can then be freely lowered without
removing the net.
 Test with your hand that the net will stretch if the
child stands in the crib against it.
5. Adjust the plan of care as required, for example,
to include releasing the restraint every 2 hours,
providing skin care, and providing range – of –
motion exercises.
Evaluation
1. Need for the restraints and the client’s response

2. Circulatory status of restrained limbs
3. Skin status beneath restraints
4. Significant deviations from normal
Documentation
1. The behavior indicating the need for the restraint, all other interventions implemented in the
attempt to avoid the use of restraints and their outcomes and the time the physician was notified of
the need for restraint.
2. The type of restraint applied, the time it was applied, and the goal for its application.
3. The client’s response.
4. The times that the restraints were removed and skin care given.
5. Other assessments and interventions.
6. Explanations given to the client and significant others.
FEEDING A CLIENT
Adapted from Lippincott Manual of Nursing Practice (2010).
I. DEFINITION
Feeding – supplying food to the body.

Food – any substance, organic or inorganic, which, when ingested or eaten nourishes the body by
building and repairing tissues, supplying heat and energy, and regulating bodily processes.
Nutrition – is the combination of processes by which a living organism receives and utilizes materials or
substances needed for the maintenance of its functions and for growth and renewal of its
components.
Nutrient – a chemical component needed by the body for one or more of these functions: to provide
energy, to build and repair tissues, and to regulate life processes.
II. RATIONALE
1. To provide more nutrients than usual during illness, trauma, or wound healing.
2. To assist clients who are unable to feed themselves.
3. To be sure the client receives adequate nutrition during illness as well as during recovery from
illness.
4. To promote client’s well - being through adequate nutrition.
III. EQUIPMENT
Diet Slip
Diet Tray
Feeding Utensils
Overbed Table
Protective Covering
ACTION RATIONALE
Planning
1. Identify the type of diet ordered. To determine whether the diet is appropriate for
the
client in his/her present condition and whether
there is a need for any special feeding utensils
2. Check to see whether there is any reason why the To determine the reason and the extent of the
client’s meal should be delayed or omitted. delay.
3. Check in the nursing care plan, nursing history, or To ensure accuracy of the diet.
nursing record for the client’s previous need for
assistance, at the same time taking note of any
cultural or religious limitations, allergies, and
specific likes and dislikes.
4. Note any nursing diagnosis related to eating or To make feeding easier and more pleasant for both
feeding. client and the nurse.
5. Take into account the time food trays arrive in the To allow tasks and procedures to be scheduled away
unit. from mealtime.
6. Allot enough time for feeding so that you are free To prevent food from getting cold and the client
of other tasks and can spend uninterrupted time from feeling unattended.
with the client.
Implementation
1. Identify the client. To ensure accuracy.
2. Explain what you are going to do. To promote comfort and rapport.
3. Prepare the client’s room by removing all To make eating more pleasant and to aid in
unsightly equipment, replacing soiled linens and digestion.
arranging the bedside table.
4. Offer bedpan or urinal. To avoid interruption which may result in loss of

appetite.
5. Wash your hands. For asepsis.
6. Assist in washing client’s hands and face. To promote comfort and cleanliness.
7. Position the client comfortably in mid or high To make swallowing easier and lessen the risk of
Fowler’s position if possible. choking and aspiration.
8. If the client wears eyeglasses or dentures, be sure To allow the client to see and chew properly.
they are in place.
9. Protect the bed linen by using a suitable To protect the bed linen.
protective cover. Place a colorful napkin, if
available, over the protective linen.
10. Obtain any special utensils you have planned to To foster self - esteem by allowing clients who are
use which is appropriate for the client. partially disabled to feed themselves.
11. Make a final check of the tray, making sure that To ensure that the right food and nutrients are given
the prescribed diet corresponds with the food on to the right client.
the tray.
12. Place the food tray on the table and position the To allow the client to see the food and to promote
table so that the client can see the food. client’s comfort.
13. Assist the client prepare the food on the tray as To encourage appropriate independence.
needed. For example, cut foods into bite - size
pieces, open milk cartons and cereal boxes.
Discard all wrappers and clutter before the client
begins to eat.
14. Position yourself at the client’s eye level by To establish an unhurried atmosphere.
sitting, if possible.
15. Involve the client as much as possible. This can be To enable the client to gain a sense of participation.
done if you work from the client’s least affected
side, (see special consideration)
16. When possible, find out from the client what food To allow the client to develop a feeling of control
sequence is preferred. If not possible, feed the over his/her meal and to afford a variety of taste.
items in the order in which you would choose to
eat them.
 Feed the more nutritious items of the diet To provide adequate nutritional intake.
first.
 Feed solid and liquid foods alternately. For easy swallowing and prevent choking.
17. Continue assessment as you feed the client. To identify significant clinical manifestations.
18. Talk to the client during the meal but avoid To make mealtime a pleasant one. Digestion is
discussing stressful events or unpleasant topics. better if one is not emotionally upset.
19. Never hurry a client who is eating. Allow enough To prevent discomfort.
time to chew and swallow.
20. Allow the client to determine when enough has The client is the best person to know if enough has
been eaten. been eaten.
21. Remove the tray and provide hygiene as needed. For comfort and hygiene.
22. Reposition the client. To promote retention of food in the stomach.

- If there had been problems with digestion or To prevent vomiting.
vomiting, keep the client in high position.
- Turn the client’s head to one side. To prevent aspiration.
23. Provide a quiet environment. To enable the client to relax and therefore promote
digestion.
SPECIAL CONSIDERATIONS
A. WHEN FEEDING A BLIND CLIENT
1. Identify the placement of the food as one describes the time on the clock. For instance, you can tell
the client that the soup is at 12 o’clock, the meat at 3 o’clock, the rice at 6 o’clock, and the dessert
at 9 o’clock.
2. Tell the client which food you are giving him/her so that he/she will know what to expect.
3. Encourage independence and provide assistance as needed.
B. WHEN FEEDING AN ANOREXIC CLIENT
1. Make the food tray as attractive as possible to stimulate appetite.

2. Relieve illness symptoms that may result in loss of appetite prior to mealtime. For example, give
analgesic for pain or an antipyretic for fever or allow rest for fatigue.
3. Provide familiar food that the person likes or allow members of the family to serve the tray.
4. Select small portions so as not to discourage the anorexic client.
5. Avoid unpleasant or uncomfortable treatments immediately before or after meal.
6. A tidy, clean environment that is free of unpleasant sights and odors is important. A soiled dressing,
a used bedpan, an uncovered irrigation set, or even used dishes can destroy appetite.
7. Reduce psychological stress. A lack of understanding of therapy, the anticipation of an operation,

and fear of the unknown can cause anorexia. Often the nurse can help by discussing feelings with
the client, giving information and assistance, and allaying fears.
8. Give oral hygiene before meals as necessary and make sure the client is comfortable.
C. WHEN FEEDING A HANDICAPPED CLIENT (AMPUTEE)
1. Use special feeding utensils such as “Octopus” suction cups for securing plates, metal food guard or
spoon and fork with modified handles.
2. Assist client as necessary.
D. WHEN FEEDING A TODDLER
1. Offer small portions. It is more effective to give small helpings than to insist that he/she eats a
specified amount.
2. Provide eating equipment that are colorful and unbreakable.
3. Avoid bribes or force feeding because this reinforces negative behavior.
4. Encourage independence but provide assistance when necessary.
E. WHEN FEEDING AN ELDERLY CLIENT
1. If possible, when sending request to the dietary department, emphasize that food preparation
should be adapted to the client’s age. For example, chop fruits and vegetables finely, shred green
leafy vegetables, and select ground meat, poultry or fish.
2. Mealtime is commonly a social activity. When possible, make arrangements to promote appropriate
social interaction at meals.
3. Eat essential foods first and follow with limited foods in moderation afterwards.
4. Some elderly clients who have difficulty eating because of poorly fitting dentures often may prefer
to mix eggs, fruit, cereal and toast together.
5. Avoid giving tea, coffee, or other stimulants in the evening and see to it that the major meal is at
lunch so as to decrease difficulty sleeping at night.
V. AFTER CARE
1. Remove food tray from the room.

2. Wash your hands for aseptic purposes.
VI. EVALUATION
1. Note the amount and specific food items eaten.

2. Document the following: appetite, food intake (specific items and amount), tolerance to diet, any
untoward reaction after the meal (for example, nausea and vomiting).
PROVIDING POST – MORTEM CARE
I. DEFINITION
Care of the dead human body before transporting to the morgue.
II. RATIONALE
The nurse is responsible for taking care of the body after the physician has pronounced the client dead.
1. To maintain the best possible natural appearance of the body by preventing skin damage and
discoloration.
2. To maintain the dignity of the deceased by safeguarding belongings and handling the body with
respect and care.
III. EQUIPMENT
Clean gown
Pen and paper to list down client’s valuables and envelops for their safekeeping
Paper bag or plastic bag for client’s clothing
Sheets to wrap the body
Two identification tags (one attached to the ankle and one to the sheet)
Absorbent pads
Masking tape to fasten the sheet.
1. Prioritize workload if necessary.
2. Notify appropriate people, physician, clergy, morgue, and family.
3. Review institutional policy regarding post-mortem care.
4. Talk to the family for any plans for the deceased.
5. Do institutional policy for handling client’s belongings and possessions.
6. Assemble equipment needed.
7. Consider necessary precautions to avoid the spread of microorganisms.
8. Provide privacy to the deceased or prevent clients from seeing the deceased if possible.
ACTION RATIONALE
1. Provide privacy for the deceased by To show respect for the dead and at the same time
closing the door or pulling the curtain not to upset other patients.
around the bed.
2. Remove valuables and personal effects. To prevent loss and to protect the nurse from any
Place them in an envelope, seal and label legal liability.
properly according to agency policy.
Client’s clothing should be placed in a
separate bag. Document the safekeeping
and endorsement to the family.
3. Position client’s body in good alignment in To prevent contractures and pooling of blood in
supine position with head slightly elevated the upper portion of the body.
by a pillow.
4. Close the client’s eyelids (if open) by To close the eyes before muscle contraction or
gently pressing them with the fingertips or rigor mortis occurs.
use of moistened cotton on each eyelid for
few seconds.
5. If with dentures, place them in the client’s To avoid a sunken appearance of the jaw.
mouth if possible or send to the mortician
to be inserted in place.
6. If the mouth does not remain close, place To close the mouth before the muscles contract.
a small rolled towel beneath the chin. Do Tying the jaw may leave a permanent mark which
not put a tie around the jaw and the head. is unsightly.
7. Detach I.V. tubes, drainage tubes and To clear the work area and to absorb the
bottles, or any other contraptions. If there discharges that may drain out when there is
are body discharges, put absorbent pads relaxation of muscles after death.
on the drainage area.
8. Soiled areas of the body are washed with To clean the body and prevent odor caused by
plain water; hairpins are removed and hair microorganisms.
is combed. To prevent damage to the body caused by sharp
objects.
9. A clean gown is put on the client if the To practice aesthetic purposes.

family will view the body.
10. Attach identification tag to the body by To provide accurate identification.

tying one ID band around the waist and To prevent confusion.
one around the ankle. The ID band
includes:
a. Client’s name
b. Age
c. Address
d. Physician’s name
e. Cause of death
To protect the body and provide privacy.
11. Wrap the body as prescribed by the
institution.
To confirm client’s identification.
12. Attach another ID tag outside the wrapped
body.
To have the family and relatives identify the dead
13. Pack all remaining personal belongings in a body easily.
container and label accurately for relatives
to claim.
To give time for the family and relatives to
14. Arrange for the transport of the body to accomplish the necessary papers before leaving
the morgue. the hospital.
After-care: To protect other patients and the housekeeping

1. After the body is transported to the personnel from possible contamination.
morgue, the bed is stripped.
To prevent the spread of microorganisms.To
2. Wash hands thoroughly. prepare the room for the next client.
3. Notify proper personnel that the room is
ready to be cleansed and disinfected.
1. The events that happened leading to death.

2. The exact time physician was informed and death was pronounced.
3. Post mortem care given.
4. Personal items and valuables endorsed to the family.
5. Family members or significant others notified.
6. Necessary papers and hospital documents signed by the family member and concerned
physician.
7. Time the hospital personnel brought the body to the morgue.
TAKING A TEMPERATURE
Adapted from Delaune and Ladner(2011). Fundamentals of Nursing Standards and Practice;
I. DEFINITION
Vital Signs – also termed as Cardinal Signs; reflects the body’s physiological status and provides
information critical to evaluating homeostatic balance. It includes four critical assessment areas:
temperature, pulse, respiration and blood pressure.
Body Temperature – is a balance between heat produced by the body and heat lost from the body.
Body temperature is affected by age, weather, exercise, emotions, stress and illness.
Thermometers – are used to measure temperature. It is measured using Fahrenheit (F) and Centigrade
or Celsius (C) scale. Types of thermometers include a.) Infrared Thermometers / Battery-
Operated Thermometers which measure temperature in a few seconds; b.) Temperature
Sensitive Tape applied on the forehead or abdomen which changes color in response to body
heat; and c.) Electronic Thermometer Unit with a digital probe.
II. RATIONALE
1. To determine if core temperature is within normal range.

2. To provide baseline data for further evaluation.
3. To determine alteration in disease condition.
4. To determine changes in body temperature in response to specific therapies.
ORAL TEMPERATURE
III. EQUIPMENT
Thermometer Tray containing:

Thermometer (digital or temperature sensitive tape)
Container with thermometer wipes
Waste receptacle
Thermometer probe and cover
1. Oral temperature is taken when a client is conscious and can hold the thermometer securely under
his tongue and can breathe through his / her nose.
2. If hot or cold drink has been taken or client has been smoking, allow 15 minutes to lapse before
taking the oral temperature.
3. Contraindications for taking the temperature orally are:
a. disease of the oral cavity
b. surgery of the mouth and throat
c. infants and children under 1 0 years old
d. unconscious or irrational client
e. client on suture precaution
f. clients who are unable to keep their mouth closed for any reason
g. clients who have obstruction of both nostrils
ACTION RATIONALE
3. Position the client in a comfortable position and

provide for privacy.
To prevent the spread of microorganisms and
to protect the caregiver.
4. Put on gloves if contact with blood, body fluids,

secretions is likely.
5. Place the thermometer probe with cover in the To allow the thermometer to come in contact
client’s mouth under the tongue and ask the with superficial blood vessels under the
client to hold the lips closed. tongue.
6. Leave it in place for 2 to 3 minutes or for the To allow sufficient time for accurate reading.
length of time recommended by the agency/
equipment.
7. Instruct the client not to bite the thermometer, to To avoid accidental breakage of the
close his/her lips gently and, to breathe through thermometer and harm to the client.
the nose.
8. Place the client’s wrist across the chest and take To enable the nurse to take the pulse and
the client’s pulse and respiration. (Refer to respiration while waiting to read the
procedure in taking the pulse and respiration) thermometer.
9. Remove the thermometer from the mouth.
10. Eject the thermometer bulb/ probe cover in a To prevent contamination.

garbage can.
11. Hold the thermometer digital display that To facilitate reading of the thermometer.
registers the client’s body temperature.
12. Wipe the thermometer equipment with an To disinfect the thermometer.

antiseptic swab and return to its container.
13. Take the tray to the utility room and empty the To maintain cleanliness and reduce the
waste receptacle. spread of microorganism.
AXILLARY TEMPERATURE
III. EQUIPMENT
Same as in Oral Temperature except that an axillary thermometer is used.
1. This method should be used only when there is no other way of obtaining the body temperature.
Axillary temperature is considered to be the least reliable method.
2. This procedure can also be adapted when no individual clean oral thermometer is available.
ACTION RATIONALE
1. Follow steps 1 - 4 of taking oral temperature.

2. Assist the client to a comfortable position and To prevent increase in temperature caused by
expose the axilla. Pat the axilla dry of friction if the axilla is rubbed.
perspiration.
3. Place the thermometer in the client’s axilla and To secure the thermometer in place.
lower the arm down across the chest. Take the
pulse and respiration. (Refer to procedure in
taking pulse and respiration)
4. Leave the thermometer in place for 9 minutes (in To ensure accurate reading.
adults) or 5 minutes (in infants and children) or
for the length of time recommended by the
agency.
5. Remain with the client and hold the thermometer To prevent the thermometer from falling out
in place if the client is irrational or very young. of place.
6. Remove the thermometer from the axilla.
7. Follow steps 11-13 of taking oral temperature.
RECTAL TEMPERATURE
III. EQUIPMENT
Same as that of a standard thermometer tray as in taking oral temperature except that a rectal
thermometer is used.
Lubricant
1. Rectal temperature is indicated for clients who are:
a. critically ill, disoriented, senile and unconscious
b. dyspneic, unable to keep the mouth closed for any reason
c. on suture precaution or has brain tumor or increased intracranial pressure
2. Rectal temperature is contraindicated to clients with:
a. coronary precaution
b. rectal or perineal surgery or inflamed rectum
c. eye surgery
ACTION RATIONALE
1. Follow steps 1 – 4 of taking oral temperature.
2. Provide privacy. Instruct and assist client to turn To promote client’s comfort and easy
on side facing away from you with knees slightly visualization of the rectum.
flexed. A newborn maybe placed in a lateral
position or prone position or supine position with
both legs raised to expose the anus.
3. Lubricate the tip of the thermometer with To facilitate insertion of the thermometer
lubricant on paper tissue. without irritating the mucous membrane.
4. Fold back bed linen to expose the client’s To provide unnecessary exposure of the
buttocks. client’s body parts.
5. Don a disposable glove on the dominant hand. To prevent the spread of microorganism and
With your non – dominant hand, raise the client’s to protect the caregiver.
upper buttocks to expose the anus.
6. Ask the client to take a deep breath and insert the To relax the external sphincter muscle and
thermometer into the anus anywhere from 1.5 – ease insertion.
4 cm depending on the age and size of the client.
7. Do not force insertion of the thermometer if To prevent injury or irritation. In case of

there is a resistance. inability to insert the thermometer into a
newborn may indicate that the rectum is not
patent.
8. Hold the thermometer in place for 2 minutes or To prevent the thermometer from getting
for the length of time recommended by the displaced and to ensure accuracy.
agency.
9. Remove the thermometer from the rectum.
10. Follow steps 11 – 13 in taking oral temperature.
TYMPANIC MEMBRANE TEMPERATURE
Special considerations: Do not use thermometer in infected or drawing ear, or if adjacent lesion or incision
exists.
ACTION RATIONALE
1. Follow steps 1 – 4 of taking oral temperature.
2. Attach disposable probe sheath and press To ensure accurate reading of temperature.
firmly until baking frame of probe cover
engages base of probe.
To prevent ear injury.
3. Position client so that the probe can be safely

inserted in ear. To straighten ear canal’s natural curve and provide
access to tympanic membrane.
To seal ear canal and close tympanic membrane

for accurate reading.
4. Pull pinna back and up.
To record core body temperature.
To maintain cleanliness and reduce the spread of
microorganisms.
5. Place probe in client’s ear and advance into
ear canal to make a firm seal.
6. Press and hold temperature switch until signal

light flashes and temperature reading displays
(approx. 3 seconds)
7. Remove thermometer and discard probe

cover.
1. Check the client’s temperature and interpret appropriately.

2. Document the client’s temperature as per policy of the agency.
3. Document any nursing intervention done, if alteration of temperature is present.
PALPATING THE PULSE
I. DEFINITION
Pulse – is a wave of blood caused by the rhythmic expansion of the artery with each heartbeat. Is the
beat of the heart felt at an artery as a wave of blood passes through the artery. It is an index of
the heart’s rate and rhythm.
Pulse Rate – is the number of heartbeats felt in one minute. When counting pulse rate, one pays
attention to: a.) rate, b.) rhythm, and c.) pulse strength.
Peripheral Pulse – is a wave of blood caused by the rhythmic expansion of the artery with each
heartbeat which can be felt over any artery that lies near the surface of the body and over a
bone or other firm tissue.
Assessing Apical-Radial Pulse – is a method of measuring the apical and radial pulse simultaneously.
Apical Pulse – is the central pulse located at the apex of the heart.
Radial Pulse – is the pulse located at the radial artery.
II. RATIONALE
1. To determine if the pulse is within the normal range and if the rhythm is regular.
2. To monitor and evaluate changes in the client’s health status.
3. To reflect functioning of vital organs.
III. EQUIPMENT
Watch with second hand

Stethoscope
Doppler Ultrasound
ACTION RATIONALE
PALPATING THE RADIAL PULSE / PERIPHERAL PULSES
1. Wash your hands.

To prevent the spread of microorganism.
2. Assess the client. To assess factors and conditions that may affect the
rate and rhythm of the pulse.
- Ascertain the client’s emotional status and Anxiety and increased activity level can increase the
activity level. pulse rate.
- Assess the color and warmth of the foot if Color and warmth reflect the adequacy of blood
taking the pedal pulse. supply to the area.
- Assess the client for facial pallor and any This can affect the adequacy of generalized blood
cyanosis of the lips and nail beds. flow.
3. Explain the procedure to the client and assist To gain the client’s cooperation. To promote the
him/her in a comfortable resting position client’s comfort.
4. Select the pulse site as recommended for the To gather relevant and appropriate data.
client.
5. When the radial pulse is assessed, the arms can
rest alongside the client with the palm facing
downward or the forearm can rest at a 90 –
degree angle across the chest with the palm
downward.
6. Palpate and count the pulse. To ensure accuracy.

- Place two or three middle fingertips lightly Using the thumb is contraindicated because it has a
and squarely over the pulse point. Use the pulse which can be mistaken as the client’s pulse.
pads of the fingers in palpating.
- Count the pulse for 30 seconds and multiply An irregular pulse requires a full minute count for a
by 2 if the pulse is regular. If it is irregular or if correct assessment.
this is the first time the client’s pulse is taken
or when obtaining baseline data, count for a
full minute.
Other sites:
 Dorsalis pedis
 Brachial
 Femoral
 Carotid
TAKING PERIPHERAL PULSE WITH DOPPLER
1. Follow steps 1- 4 of palpating the radial pulse /

peripheral pulses.
2. Using Doppler ultrasound, the peripheral pulse To assess the pulse characteristics.
may be absent or weak, the amplitude can be
determined.
To promote ultrasound beam travel and best
3. Apply conductive gel to client’s skin. conductivity with gel.
To facilitate detection of swooshing pulse sounds.
4. Position probe over pulse site. Keep in direct

contact with skin at a 90 o angle to the blood vessel
being assessed. To ensure accurate measurement and establishment
of a rhythmic pattern.
To facilitate future assessments.

5. Count for 1 full minute. Start to count lub-dub
sound as one beat. Note regularity of rhythm and
note irregular beats. To take care of equipment used.
6. Clean area and mark where pulsations were

heard.
7. Return Doppler probe to its original location.
TAKING THE APICAL PULSE

To promote ease and comfort.
Special Consideration:
The apical site is used for infants and children To ensure accuracy of heart sounds.
younger than 2 years old and for cardiac
patients.
1. Follow steps 1 - 4 of palpating the radial pulse /

peripheral pulses.
To obtain adequate cardiac information on rate,
2. Using a stethoscope, warm the diaphragm in your rhythm and strength.
hand.
3. Place the client in a supine position with chest

exposed. Palpate 2nd intercostal space (ICS) with
index finger.Middle finger on the 3rd ICS and
continue to move downward to 5 th ICS to mid-
clavicular line.
4. Count rate for 1 full minute apical pulse. Start to

count while looking at second hand of watch.
Count lub-dub sound as one beat.
1. Document the pulse rate, rhythm, and volume, and the condition of the arterial wall.
2. Evaluate the findings appropriately.
3. Document and report pertinent data such as pale skin, irregularity in the rate, rhythm and volume.
VI. ILLUSTRATION
COUNTING RESPIRATION
I. DEFINITION
Respiration – is the act of breathing. It includes the intake of Oxygen (inhalation) and output of carbon
dioxide (exhalation).
II. RATIONALE
1. To note the client’s respiratory rate, rhythm, and depth.

2. To establish baseline data upon admission to the unit.
3. To monitor abnormal respiration and respiratory patterns.
4. To identify alterations in respiratory pattern resulting from a disease condition.
5. To assess respiration before and after the administration of a medication.
6. To monitor client’s at risk for respiratory alteration.
III. EQUIPMENT
Watch with a second hand
1. An infant or child who is crying will have an abnormal respiratory rate and will need quieting before
respiration can be accurately assessed.
2. Young children are diaphragmatic breathers, so observe the rise and fall of the abdomen.
3. For the elderly, ask the client to remain quiet or count respiration after taking the pulse.
ACTION RATIONALE
3. Provide for client’s privacy. To promote comfort.
4. Place the client’s hand across the abdomen and To help determine what constitutes a breath. Hand
the nurse’s hand over the client’s wrist. rises and falls with inspiration and expiration.
5. Start counting with first inspiration while looking To reveal volume of air movement into and out of
at the second hand of a watch. Observe the the lungs.
depth, rhythm, and character of respirations. To ensure accuracy of findings.
- Observe the respiration for depth by watching During deep respiration, a large volume of air is
the movement of the chest. exchanged; during shallow respiration, a small
volume of air is exchanged.
- Observe the respiration for regular or Normal respiration is evenly spaced.

irregular rhythm.
- Observe the character of respiration, the Normally, respiration is silent and effortless.
sounds they produce and the effort they
require.
6. Assist the client in a comfortable and safe position To ensure safety and comfort.
before leaving.
1. Evaluate and document the respiratory rate, depth, rhythm, and character on the appropriate
record.
2. Document any nursing intervention done.
MEASURING BLOOD PRESSURE
I. DEFINITION
Blood Pressure – is the force exerted by blood against the arterial walls as it flows within the blood
vessel.
Systolic Pressure – is the pressure of the blood against the arterial walls when the ventricles of the
heart contract.
Diastolic Pressure – is the pressure of the blood against the arterial walls when the ventricles of the
heart are at rest.
Pulse Pressure – is the difference between the diastolic and systolic pressures.
II. RATIONALE
1. To provide a baseline measure of arterial blood pressure for subsequent evaluation.

2. To determine the client’s hemodynamic status.
3. To identify and monitor changes in the blood pressure resulting from a disease process and medical
therapy.
4. To determine the client’s safety in performing activity after an extended bedrest or recovery from
anesthesia.
5. To assess the client’s general health status.
III. EQUIPMENT
Stethoscope
Blood Pressure Cuff of Appropriate Size
Sphygmomanometer
Aneroid
Mercury
Electronic (Electronic Robotic Unit or Continuous-Monitoring device)
Alcohol or Recommended Disinfectant
1. Ensure that the equipment is intact and functioning properly. To prevent errors or alteration in
findings.
2. Make sure that the client has not smoked or ingested caffeine within 30 minutes prior to
measurement. To ensure accuracy of findings.
3. Do not take blood pressure on an arm with an I.V. infusion, a cast, or a dialysis access site. If a
person had breast surgery, do not take blood pressure on that side.
4. Let a person rest for 10-20 minutes before measuring blood pressure.
5. Take note of BP cuff sizes:
a. Standard – (12-14 cm wide) for the average adult
b. Narrower cuff for infant, child, or adult with thin arms
c. For children (younger than 13 years old), the bladder should be large enough to encircle the arm
completely (100%)
d. Wider cuff (18-22 cm) for clients with obese arms of for thigh pressure readings
ACTION RATIONALE

2. Bring equipment to the bedside. To save time and effort.
3. Explain the procedure to the client and provide To gain the client’s cooperation.
privacy.
4. Position the client appropriately. To ensure an accurate result.

- The adult client should be sitting unless Knees crossed at the knee result in elevated systolic
otherwise specified. Both feet should be flat and diastolic pressures.
on the floor.
- The elbow should be slightly flexed with the The blood pressure increases when the arm is below
palm of the hand facing up and the forearm the heart level and decreases when the arm is above
supported at heart level. the heart level.
- Expose the upper arm.
5. Wrap the deflated cuff evenly around the upper To allow the bladder of the cuff to compress the
arm. Locate the brachial artery and apply the artery.
center of the bladder directly over the artery. For
an adult, place the lower border of the cuff
approximately 2.5 cm above the antecubital
space.
6. If this is the client’s initial examination, perform a To prevent underestimation of the systolic pressure
preliminary palpatory determination of systolic or overestimation of the diastolic pressure.
pressure.
- Palpate the brachial artery with fingertips.
- Close the valve on the pump by turning the
knob clockwise.
- Pump up the cuff until you no longer feel the To give an estimate of the maximum pressure
brachial pulse. Note the pressure on the required to measure the systolic pressure.
sphygmomanometer at which the pulse is no
longer felt.
- Release the pressure completely in the cuff To give time for the blood trapped in the veins time
and wait for 1 to 2 minutes before making to be released, therefore false high systolic reading
further measurements. will not occur.
7. Position the stethoscope appropriately.

- Cleanse the earpieces with alcohol or To prevent the spread of microorganisms.
recommended disinfectant.
- Insert the ear attachments of the stethoscope To be able to hear a clear sound.
in your ears so that they tilt slightly forward.
- Ensure that the stethoscope hangs freely from To prevent the stethoscope from rubbing against an
the ears to the diaphragm. object which can obliterate the sounds of blood
within an artery.
- Place the bell side of the amplifier of the To ensure accuracy. Blood pressure is a low -
stethoscope over the brachial pulse. Hold the frequency sound which is best heard with the bell -
diaphragm with the thumb and index finger. shaped diaphragm.
8. Auscultate the client’s blood pressure.

- Pump up the cuff until the To prevent error in measurement.
sphygmomanometer is 30 mmHg above the
point where the brachial pulse disappeared.
- Release the valve on the cuff carefully so that To permit blood trapped in the veins to be released.
the pressure decreases at the rate of 2 to 3
mmHg/second.
- As the pressure falls, identify the manometer
reading when the first tapping sound is heard
and when the sounds become inaudible.
- Deflate the cuff rapidly and completely.
- Wait 1 to 2 minutes before making further
measurements.
- Repeat the above steps once or twice as
necessary.
9. If this is the client’s initial examination, repeat the To obtain an accurate findings.
procedure on the client’s other arm. There should
be a difference of no more than 10 mmHg
between the arms. The arm with the higher
reading should be used for subsequent
examinations.
10. Remove the cuff from the client’s arm and wipe it To prevent contamination
with an approved disinfectant.
11. Return all equipment properly.

VARIATION: LOWER EXTREMITY BLOOD PRESSURE
1. Thigh Pressure
Measure blood pressure in thigh by using large cuff with bladder placed over posterior midthigh.
Listen at the popliteal fossa of client.
2. Lower Leg Pressure

Wrap cuff smugly and smoothly around lower leg with cuff’s distal edge at malleolus and dorsalis
pedis.
1. Evaluate and document all measurements and pertinent findings.

2. Document any variation from normal.
3. Document any nursing intervention done.
HANDWASHING / HAND HYGIENE
(Taylor, Willis and Le Mone; Fundamentals of Nursing, 2005, 5 th ed., pp. 660-661)
I. DEFINITION
Handwashing – is the most important way to prevent the spread of infection. A procedure wherein the
lower hands, fingers and nails are washed using indicated antimicrobial agents applying the correct
technique of washing.
II. RATIONALE
1. Helps in preventing the spread of pathologic microorganisms.

2. Reduces the number of microorganisms present in the hands.
3. Protects the nurse from contaminating his/her hands.
4. Prevents cross contamination to other clients and significant others.
III. EQUIPMENT
Liquid/powdered soap Nail file or orangewood stick
Cloth or paper towels Lotion (if indicated)
Running water Waste container
Nursing Considerations:
1. An antimicrobial soap product is recommended before an invasive procedure and after exposure to blood or
body fluids. The length of handwashing will vary based on the need.
2. Sinks with various faucet controls (knee, foot or elbow controls) are generally used in a surgical setting.
3. Children at their early age should be instructed on the proper handwashing technique.
4. Wearing gloves does not eliminate the need for proper hand hygiene (the warmth and moisture inside the
gloves an ideal environment for bacteria to multiply).
ACTION RATIONALE
1. Stand in front the sink. Do not allow your clothing To avoid contamination on the clothing as it may
to touch the sink during the washing the carry organisms from one place to another.
procedure.
2. Remove any jewelry and secure them in a safe

place or allow plain wedding band to remain in
place.
To facilitate proper cleansing. Microorganisms

may accumulate in settings of jewelry. If jewelry
was worn during care, it should be left on during
handwashing.
3. Turn on water and adjust flow of water. Regulate

the temperature until warm.
To avoid skin injury. Warm water is more comfort able

and has fewer tendencies to open pores and
remove oils from the skin. Organisms can lodge in
roughened and broken areas of chopped skin.
4. Wet the hands and wrist area. Keep hands lower

than elbows to allow water to flow towards the
fingertips.
To ensure water should flow from the cleaner towards the
5. Use about 1 teaspoon of liquid soap from the more contaminated area. Hands are more
dispenser or rinse bar of soap and lather contaminated than the forearms.
thoroughly. Cover all areas of hands with the
soap product. Rinse soap bar again and return to
soap dish.
6. With firm rubbing and circular motion, wash the

palms and back of the hands, each finger, the To rinse the soap before and after use removes
areas between the fingers, the knuckles, wrists the lather that may contain microorganisms.
and forearms. Wash at least 1 inch above the
areas of contamination. If hands are not visibly
soiled, wash to 1 inch above the wrists.
7. Continue this friction motion for at least 15 To cause friction and firm rubbing and circular
seconds. motions helps in removing dirt and
microorganisms that may have lodge between
8. Use fingernails of the other hand or a clean the fingers, in skin crevices of knuckles, on palms
orangewood stick in cleaning that part of the and back of hands, and on the wrists and
hands under the fingernails. forearms. Cleaning less contaminated areas
(wrists and forearms) after cleaning the hands
9. Rinse thoroughly. prevents the spread of microorganisms.
To understand that ength of handwashing is

determined by degree of contamination.
10. Dry hands, beginning with the fingers and

moving upward towards the forearms, with a
paper towel and discard it immediately. Use
another clean towel to turn off the faucet.
Discard the towel immediately without To clean area under nails has high microorganism
touching the other clean hand. count, and organisms may remain under the nails
where they can grow and spread.
11. Use lotion on hands if desired.
To allow running water rinses organisms and dirt

into the sink.
To dry the skin well prevents skin chopping. Dry

hands first because the cleanest and least
contaminated area. Turning the faucet off with a
clean towel protects the clean hands from
contact with a soiled surface.
To keep the skin soft and prevents chopping. It is

best to apply after patient care is complete. Oil-
based lotions should be avoided because they
can deteriorate the gloves.
V. EVALUATION
1. Risk of transmission and spread of microorganisms is reduced.

2. Number of microorganisms on hands are reduced.
CONDUCTING A PHYSICAL EXAMINATION

I. DEFINITION
Physical Assessment – is a comprehensive orderly manner of examining a client. This involves 4 primary
techniques which are inspection, palpation, percussion, and auscultation.
II. RATIONALE
1. To obtain a baseline data on the client’s functional abilities.

2. To supplement, confirm, or refute data obtained in the nursing history.
3. To obtain data that will help establish nursing diagnoses and plan of care.
4. To evaluate the physiologic outcomes of health care and thus the progress of a client’s health.
5. To make clinical judgments about a client’s health status.
6. To identify areas for health promotion and disease prevention.
III. EQUIPMENT
Flashlight or Penlight
Thermometer
Watch with Second Hand
Sphygmomanometer and Stethoscope
CONDUCTING A “15 – MINUTE HEAD – TO – TOE” ASSESSMENT

At the beginning of the shift in an acute or chronic care facility, you will need to do a thorough, but abbreviated,
physical assessment on each person for whom you will be providing care. This assessment will be focused
toward the particular problems or concerns of each person. Each assessment can be individualized by omitting
some parts or adding special techniques as necessary. Always include the environment in your assessment,
noting all items in the room and how they relate to this person’s care and concerns.
ACTION RATIONALE
1. Assemble the equipment you will need. Aside To save time and effort.
from the equipment mentioned above, you may
need special items related to individual needs.
2. Enter the room, identify and greet the client and To be sure that you are going to examine the correct
introduce yourself and your role. client.
3. Meet any immediate needs of the client before To prevent discomfort during the procedure.
beginning the assessment.
4. Explain what you plan to do. To gain the client’s cooperation.
IMPLEMENTATION
5. Measure the client’s temperature and blood pressure, assess the radial pulses bilaterally, and assess
respiration.
6. Inspect and palpate the hands, noting the skin, nails, capillary refill, joints, and range of motion (ROM). Test
grips bilaterally. If there is an intravenous (IV) line present, assess the site. Note cyanosis.
7. Inspect the head, face and eyes. Assess facial skin. Note facial symmetry. Note whether the client looks at
you with both eyes and assess eye movement. Check sclerae and conjunctivae and corneal reflexes, as
necessary. Check pupils for size as well as response to light and accommodation. Note visual acuity and any
visual aids necessary.
8. Inspect the mouth and lips. Note the color and condition of the skin and mucous membranes. Note the
presence or absence and condition of the teeth. Assess the gag reflex as necessary.
9. Assess the external ears. Note hearing acuity and use of any hearing aid(s).
10. Assess neck veins for distention.
11. Observe chest expansion and antero-posterior diameter. Auscultate anterior chest. Note whether the client
is a mouth breather, and assess for shortness of breath or dyspnea. Note presence and character of cough
as well as presence, amount, and character of any sputum produced. If Oxygen is in use, note route and
liters per minute being delivered. Note whether an incentive spirometer is in use.
12. Auscultate the heart sounds and count the apical pulse. Compare the apical pulse with the radial pulse as
well as with the most recent apical rate recorded and baseline.
13. Auscultate the posterior thorax. Note sacral edema.
14. Inspect, auscultate, and palpate the abdomen. Ask about any difficulty with urination and when the last
bowel movement occurred.
15. Assess the perineal area as needed. Note presence of urinary catheter, condition of the skin, and odor.
16. Assess the lower extremities. Note condition, color, and temperature of skin, especially of heels, feet, and
toes. Assess capillary refill, edema, sensation, pedal pulses, and mobility. Note presence and distribution of
hair. Check Homan’s sign and perform strength testing.
CONDUCTING A “3 – MINUTE HEAD – TO – TOE” ASSESSMENT

It will be necessary for you to do “mini – assessments” or specific assessments at times other than the beginning
of the shift when you are caring for individuals in acute or chronic care facilities. In some situations this may be
near the middle of the shift and in others more frequently as the circumstances indicate. Again, you will focus
the assessment according to the individual needs and concerns of the client.
IMPLEMENTATION
Follow Steps 1 to 4 of the Procedure Conducting a “15 - Minute Head - to - Toe Assessment”
1. Vital Signs. Measure vital signs as indicated.
2. Upper Extremities. Note color and temperature of extremities as well as capillary refill, radial pulses, and
grips.
3. Head. Inspect skin and symmetry of face. Check conjunctivae, external ears, lip color, oral mucous
membranes, and neck vein distention. If client has altered level of consciousness (LOC), check pupil size and
response to light and accommodation.
4. Anterior Chest. Auscultate heart and lung sounds. Check apical pulse and compare with radial pulse.
5. Anterior Torso. Auscultate bowel sounds in all four quadrants, palpate for tenderness and bladder
distention.
6. Posterior Chest. Auscultate lung sounds and check for sacral edema.
7. Lower Extremities. Note color and temperature of extremities, capillary refill, pedal pulses, edema, Homan’s
sin, strength testing.
GENERAL PROCEDURE FOR A COMPREHENSIVE NURSING PHYSICAL ASSESSMENT

The assessment described below may be more comprehensive than that required in your setting. It is presented
to give an overview of the kind of nursing physical assessment often required of nurses in nursing homes, clinics,
and independent practice.
IMPLEMENTATION
Follow Steps 1 to 4 of the Procedure Conducting a “15 - Minute Head - to - Toe” Assessment
 ARMS, HANDS, and FINGERS
1. Ask the client to extend both arms out in front of the body. Inspect the musculature for asymmetry and
palpate for turgor. Range the arms, hands, and fingers to assess agility.
2. Inspect the skin for lesions, spotting, and general color.
3. Inspect the hands and fingers for color and palpate for temperature.
4. Inspect and palpate the joints for nodules and enlargements. Observe the hands for any tremors. Note
any deviation of alignment in the fingers.
5. Inspect the nails for hardness and general condition and assess for capillary refill.
6. Test the grip of each hand.
 HEAD and NECK
Head
1. Palpate the cranium with the fingers for lumps, abrasions, and asymmetry.
2. Inspect the condition of the hair. It should be shiny, with distribution appropriate to the age and sex of
the person.
Neck
1. Palpate the neck for asymmetry, abnormal lymph nodes, and enlarged thyroid.
2. Perform range of motion of the neck to detect any limitations.
3. Inspect neck veins for distention.
4. Auscultate over the carotid artery to listen for bruits (abnormal sounds resulting from circulatory
turbulence).
Face
1. Inspect facial skin for moisture, lesions, and ecchymosis.
2. Inspect the face for asymmetry.
3. Ask the client to smile and then to stick out the tongue. The smile should be generally equal on each
side, and the tongue should not deviate to one side.
4. Note the presence of ptosis (drooping of the eyelids) along with any conditions such as inflammation of
the lids.
Eyes
1. If inspecting the eyes, do so at this time. Use a flashlight or ophthalmoscope to observe for papillary
response.
2. With the ophthalmoscope, inspect each eye for corneal, lens, or vitreous abnormalities while the client
gazes straight ahead. Assess the optic disc for shape and color. The disc should be mushroom shaped
and a lemon yellow color.
3. Retract each eyelid to observe the color and condition of the conjunctiva. The conjunctivae should be
pink without lesions or drainage.
4. Check visual acuity using Snellen chart. This chart has lines of block letters that decrease in size as the
reader moves downward. An adaptation of this chart using three - pronged symbols randomly facing in
different directions can be used for children and illiterate adults. The Blackbird chart uses a modified E
to resemble a flying bird and children are asked to identify which way the bird is flying. If corrective
lenses (glasses or contact lenses) are worn, check vision with and without the corrective lenses in place.
Ask the client if there have been any recent vision changes.
Nose
1. With the client’s head tilted slightly back, inspect each inner nostril using a nasal speculum. Some
examiners use the light from the ophthalmoscope instead of room light or a flashlight.
2. Inspect the nares for color and condition of the mucosa, bleeding, and the presence of foreign bodies or
masses.
Ears
1. With the client’s head turned, examine each ear with the otoscope for evidence of excess cerumen
(earwax), growths, or redness. Assess the eardrum (tympanic membrane) for signs of swelling or color
change and perforations. Palpate the area around the outer ear for tenderness.
2. Test hearing by striking a tuning fork and holding it an equal distance from each ear to test for air
conduction. Then place the struck tuning fork on each mastoid process, just below and behind the ears,
and on the center top of the cranium to test for bone conduction of sound. A more definitive hearing
test may be performed using electronic equipment.
3. If the client uses a hearing aid or aids, check to see that they have working batteries, are free from wax
build up, and are properly placed in the ears. Ask the client if there have been any recent changes in
hearing ability.
Mouth
1. Ask the client to open the mouth, and inspect it with a flashlight and tongue depressor. The tongue
should be medium red, and appear smooth at the margins and rough in the center. When the tongue is
lifted, inspect carefully because this area is often the site of cancerous lesions. Examine the back of the
throat for swelling, redness, bacterial or viral patches, and the position and size of the uvula. Have the
client say “Ah” and inspect the tonsils for redness and swelling.
2. Inspect the teeth for looseness and the presence of caries. Observe the mucosa of the inner mouth for
color and the presence of lesions. Ask the client to clench the teeth and smile, which helps in assessing
bite and facial musculature. Note the color and smoothness of the lips.
 THORAX
Back
1. Place the client in either the prone position or in a sitting position in bed with the back facing you.
Expose the back and examine the skin for spots or lesions.
2. Note the curvature of the spine and palpate the vertebral column. Check school – age children for
scoliosis (lateral curvature of the spine) by: 1) looking for asymmetry of shoulders and hips while
observing the standing child from behind, and 2) observing for asymmetry or prominence of the rib cage
while watching the child bend over the back is parallel to the floor.
3. With the stethoscope, auscultate all lobes of the lungs, anteriorly and posteriorly. Ask the client about
and observe for the presence of cough, sputum, and dyspnea on exertion (DOE).
Chest: Remove the gown or pajama top from the male client. Because a female client may feel modest
about exposing her breasts, untie and part her gown for the chest examination. If more exposure is needed,
drop the gown to the waist.
1. With either a male or female client, observe the levels of the shoulders for equality while the client is
sitting and facing you. Inspect the pectoralis muscles of each side of the chest for symmetry as the client
presses the palms together and lifts the hands over the head. Note any abnormal dimpling, color, or
discharge of the nipples.
2. Ask the female client to lie in the supine position. Examine each breasts as described in the procedure
Performing Breast Examination. A male client should also have his breasts examined for lumps and
masses.
Heart
1. With the client in the supine position, inspect the neck veins for normal filling.
2. Auscultate the heart sounds.
 ABDOMEN: Keep the client in the supine position for this assessment.
1. Observe the abdomen for general contour, distention, and asymmetry. Grasp the skin between the
fingers to test for turgor. Auscultate for bowel sounds in all four quadrants.
2. Ask the client about frequency of bowe! movements, any recent changes in bowel habits, and when the
last bowel movement occurred. Percuss and palpate for areas of tenderness, for the presence of fluid,
and for the loss of normal dullness of tone.
3. With the client breathing deeply and with the knees flexed, palpate the abdomen for organs and
masses. On expiration, feel for the position of abdominal structures.
 LEGS, FEET, ANKLES, and TOES

Legs
1. With the client still in the supine position, palpate each leg for muscle bulk.
2. Observe for color, temperature, and skin condition. Skin integrity is particularly important in the feet
and lower legs, especially if the client is diabetic.
Feet
1. Dorsiflex each foot to check for calf pain (Homan’s sign), which is a possible sign of thrombophlebitis.
2. Palpate and compare pedal pulses on each foot.
Ankles
1. Palpate the ankles with the fingers to assess for edema.
2. Inspect the malleoli, the bones on each side of the ankle, for enlargement.
3. Rotate the ankle to check for mobility.
Toes
1. Inspect the toes for proper alignment. Also check for calluses and bunions.
2. Inspect the nails, which should be without ridges. If thickening is present, it could be a sign of fungal
infection of the toes.
Assess capillary refill bilaterally. Test the strength of the leg by having the client press the sole of the foot
against your palm.
 REFLEXES: Depending on the situation, you may test only a few of the more prominent reflexes or proceed
with an abbreviated neurologic examination.
Reflexes are usually recorded using the following symbols:

0 = no response
1+ = hypoactive
2+ = normal
3+ = hyperactive
4+ = very hyperactive
Corneal Reflex (Blink): Touch the cornea with a soft, small wad of cotton; the client should blink.
Biceps Reflex: Place your thumb on the biceps tendon, which is located just above the antecubital fossa.
Striking the biceps tendon at the elbow will cause contraction of the biceps muscles.
Triceps Reflex: Support the upper arm at a right angle to the body and allow the forearm to hang freely.
Strike the triceps tendon with the reflex hammer just above the elbow. Extension of the forearm should
occur.
Brachioradial Reflex: Strike the radius slightly above the wrist with the reflex hammer; this should cause
flexion and supination of the forearm.
Quadriceps Reflex: Ensure that the client’s lower leg is relaxed and hanging freely from the knee. Strike the
patellar tendon, which is just below the knee, with the reflex hammer. Extension of the lower leg should
occur.
Achilles Reflex: Hold the foot in a position of dorsiflexion. Strike the Achilles tendon at the back of the ankle
with the reflex hammer. This should cause plantar flexion of the foot (the toes bending downward).
Babinski Reflex: Using the end of the reflex hammer or the sharper edge of a tongue blade, stroke the sole
of the foot from heel to toe. The negative response is plantar flexion. This is normal from the age of 6
months on.
Skin Sensation: You may choose to test sensation by using a pinwheel that can be rolled over broad skin
areas or by using cotton – tipped applicator. The client is asked to state, without looking at the device,
whether he / she can feel the sensation.
 GENITALIA
Female Client: Examine female clients in the lithotomy position with the knees flexed. Drape the client as
you would for catheterization, using a clean sheet or bath blanket. Cover both legs, exposing only the
perineum. It is preferable to use an examination table with stirrups, but you can examine the client in bed or
on an examining table. Provide for adequate light.
1. Put on clean gloves and lubricate the outside of a vaginal speculum. Do not lubricate the inside because
lubricating jelly interferes with the accuracy of the Papanicolau (Pap) test. To perform this test, obtain
secretions from the cervical os on a swab. Put the secretions on a glass slide, preserved with a fixative,
and send it to the laboratory to be examined for the presence of abnormal cells. After inspecting the
cervix with the speculum, withdraw the speculum.
2. Next, lubricate the index and middle fingers of one hand. Insert these fingers into the vagina and push
downward on the client’s abdomen with the other hand to palpate the uterus and ovaries. Assess these
organs for location, size, outline, masses, and tenderness.
Male Client: Examine male clients in the standing position, if possible.
1. Wearing clean gloves, palpate the inguinal ring to check for herniation.
2. Retract the foreskin of the penis and inspect for irritation, ulceration, and lesions.
3. Palpate the testes to assess for size, position, and masses.
 RECTUM
Female Client: This examination is usually done after the genital examination has been completed.
1. Evaluate the anal area for the presence of external hemorrhoids.
2. With your hand gloved and lubricated, insert your middle finger and palpate for size of lumen, masses,
internal hemorrhoids, and tenderness.
Male Client: The same examination is performed on the male client, with the client either bending over the
side of the bed or positioned in lithotomy with the penis and testes held aside. The knee – chest
position can also be used.
1. Inspect the anal area for the presence of external hemorrhoids.
2. With your hand gloved and lubricated, insert your middle finger and palpate for size of lumen, masses,
internal hemorrhoids, and tenderness.
3. Assess the prostate gland for size and tenderness; this is commonly done by a physician performing
digital rectal examination.
- Significant findings and client’s reaction

- Any referral done or intervention done
WEIGHING A CLIENT
(Dillon, Patricia M., Nursing Health Assessment, 2007, 2 nd ed., p. 54)
(White, Lois, Foundation of Nursing, 2005, 2 nd ed., pp. 549-552)
(Wolster, Kluwer, Lippincott Williams and Wilkins, 2010, Manual of Nursing Practice, 9 th ed., p. 742)
I. DEFINITION
Weight – is a force with which the body is attracted by the earth
Scale – is a system of measurement based on instruments bearing marks at regular intervals
II. RATIONALE
1. Determine physical growth according to age and weight.

2. Monitor the nutritional needs of a client based on the daily weight taken.
3. Used as a baseline comparison in monitoring the nutritional status from the day of admission
until discharge.
III. EQUIPMENT
Weighing Scale:
Standing / balance beam scale (for clients who can stand with assistance)
Sling / bed scale (for clients confined to bed)
Floor scale (for clients in wheelchair)
Mass Index
1. General background information:
Family composition, age, socioeconomic status and occupation
2. General health status and any chronic condition associated with dietary restrictions
3. Cultural and religious factors influencing dietary patterns
4. Food habits
5. Food purchases and preparation
6. Nutritionally related problems
7. Physical examination observing for a variety of physical findings associated with nutritional status
8. Weight should be measured using a consistent and reliable scale and at a consistent time
9. Assess the client’s ability to stand independently and safely on a scale.
10. Determine if clothing is similar to that worn during the previous weight measurements.
ACTION RATIONALE
1. Check client’s identification band.
2. Explain the procedure. To obtain participation of the client and significant

others.
Standing Scale
1. Cleanse hands. To reduce transmission of microorganisms.
2. Place the scale near the client. Reduces risk of fall or injury.
3. Turn on the scale and calibrate to zero. To ensure accurate reading.
4. Ask client to remove shoes/slippers if To obtain weight.

necessary. Step up on the scale and stand
still.
To ensure accurate reading.
Electronic Scale
 Read weight after the digital numbers have
stopped fluctuating
Balanced scale To reduce risk of injury if client needs assistance

 Slide the larger weight to the notch so as the
balance rest in the middle. Add the two .
numbers for the client’s weight
5. Ask the client to step down. Assist the client To reduce risk of spread of infection.
back to the bed/chair if necessary.
6. Wipe the scale with appropriate disinfectant.
7. Cleanse hands.
Sling Scale
8. Cleanse hands and put on gloves if needed.

To reduce risk of nosocomial infection.
9. Place plastic covering on sling if available.
To reduce risk of spreading infection among clients.
To ensure that accurate weight will be obtained by

10. Remove pillows. Turn the client to one side leaving no other bedding between the client and
and place half of sling on bed next to client, sling.
with remaining half rolled, up against the
clients back.
To maximize client’s comfort.
To ensure that equipment is used safely so as to

11. Turn the client to the other side, and unroll avoid any injury.
the rest of the sling so it lays flat beneath the
client. To ensure accurate reading.
To attach sling to scale to obtain measurement.
12. Roll the scale over the bed such that legs of
the scale are underneath the bed. Open and To ensure accurate weight.
lock the legs of the scale.
13. Turn on scale and calibrate to zero.

To prepare for the removal of sling.
14. Lower arms of the scale and slip hooks To allow for removal of equipment that obstructs
through the holes in the scale. proximity to the client, thereby facilitating the
removal of sling.
To facilitate removal of sling.
15. Pump scale until sling rests completely off the

bed. To ensure comfort and privacy.
16. Remind the client to remain still. Read weight
after digital numbers have stopped To reduce risk of infection.
fluctuating
17. Lower the client back to bed and remove
arms of the scale from sling. To reduce spread of microorganisms.
18. Unlock scale legs, return to their original

position, and remove scale from bed.
19. Turn the client on his/her side, roll up sling,

and turn the client to the other side.
20. Realign the client with pillows and cover.
21. Remove plastic covering from the sling and

discard as per hospital policy.
22. Remove gloves and cleanse hands.
V. DOCUMENTATION
Record the date, time, and weight of the client on the appropriate flow sheet.
VI. EVALUATION
1. Compare weight obtained to previously recorded weight. Repeat weight if large discrepancy is
noted.
2. If large discrepancy still remains, notify appropriate health team care members.
3. The weight is recorded and evaluated basing on the BMI (Body Mass Index).
POSITIONING AND DRAPING DURING PHYSICAL EXAMINATION
I. DEFINITION
Draping - is the manner of arranging the covering in order to expose the part being examined.
II. RATIONALE
To provide comfort and privacy during examination.
III. EQUIPMENT
Draping sheet
Things to remember:
1. The methods of draping vary with the condition of the client, the position of client, the examination
to be done and the room temperature.
2. The draping should be loose enough to allow quick change of position.
ACTION RATIONALE
1. Explain the procedure to the client. This reduces the anxiety of the client.
2. Adjust height of bed or the table.
I. ERECT (STANDING/UPRIGHT)
1. Assist the client to stand with either slippers on or This position facilitates examination.
with bare foot on a piece of paper.
2. Untie the gown and leave upper most tape. Fold Such procedure facilitates examination of the body
back the gown over both shoulders towards the contours.
front.
3. Place the double folded sheet around the body, This provides convenience and privacy during the
passing it under the axillae. Leave one side open examination.
and secure it in place with a safety pin.
II. HORIZONTAL RECUMBENT (DORSAL)
1. Replace the top sheet with a draping sheet (top This provides privacy and facilitates change of
sheet may be used in the absence of a draping position.
sheet). Cover the client from the shoulders to the
foot part with a sheet hanging loose at the sides.
2. Assist the client to lie flat on his back with the legs This affords better muscle relaxation.
together, extended or slightly flexed.
3. Place one pillow under the head and a smaller This gives comfort and prevents hyperextension of
one may be placed under the sides. the knees.
4. Place the arms along the sides of the body or This provides comfort and prevents interference
comfortably flexed on the sides. during the examination of the lower extremities
especially when the arms are flexed.
III. DORSAL RECUMBENT
1. Replace the top sheet with the draping sheet. This position is indicated to examine the abdomen,
pelvic and perineal areas. This is also done when
performing perineal care and treatment.
2. Assist the client to lie flat on his back.
3. Separate the legs and flex the knees so that the

soles of the feet are flat on the bed. Place the
arms either above the head with the hands on the
chest.
4. Place one pillow under the head. This is done for comfort.
5. Bring the client to the edge of the bed. Working close to the client prevents overstraining of
the back muscles.
6. Place the draping sheet diagonally on the client so Folding back the top corner over the chest prevents
that the opposite comers cover the legs. Fold the inconvenience and smothering of the client.
top corner over the chest.
7. Wrap the corner on the right side around the This prevents exposure of the lower extremities and
right foot. Do the same with the left side. holds the drape in place.
8. Fold the lower corner of the sheet back on the Having the lower corner of the sheet loose
abdomen to expose the part to be examined facilitates exposure of the part to be examined
when the physician is ready to do so. when the doctor arrives.
IV. DORSAL LITHOTOMY
1. Assist client to lie on his back. Dorsal lithotomy position is for examination of the
abdomen, pelvic and perineal areas.
2. Insert the legging or stockinettes. Stockinettes provide warmth and cover for the legs,
protect the skin from irritation.
3. Adjust the stirrups according to the size of the Properly adjusted stirrups prevent injury and
client. discomfort.
4. Separate the legs and flex the thighs deeply Such a position allows good exposure of the vulva.
towards the abdomen. Elevate the lower legs and
support them with the stirrups.
5. Draw down the buttocks to the edge of the This facilitates the insertion of instruments.
broken table.
6. Raise the arms above the head or flex them with To relax abdominal muscles.
the hands on the chest.
7. Drape as in dorsal recumbent. Preferably use the

lithotomy drape.
V. SIMS (LATERAL)
1. Assist the client to lie on either side preferably For rectal examination, colon irrigation enema.
the left with the body inclined forward.
2. Extend the left arm behind the back and flex the This position provides comfort and prevents injury.
elbow of the right arm forward.
3. Flex the right thigh towards the abdomen with This facilitates the separation of the buttocks
the knee drawn up higher than the left knee thereby allowing better exposure of the arms.
which is only slightly flexed.
4. Lay out the draping sheet as in horizontal Proper draping provides comfort and privacy.
recumbent position. Fold back and or gather a
side of the sheet to expose the area to be
examined.
VI. PRONE
1. Help the client to assume the horizontal

recumbent position.
2. Assist him to turn over onto the abdomen.
3. Turn the head to one side. To prevent smothering.

4. Place the arms at the sides flexed or extended This provides comfort and prevents interference
upwards. during examination.
5. Allow the feet to hang over the edge of the This is for support and convenience.
mattress or support them on pillow high enough
to keep the toes from touching the bed.
6. Drape as in dorsal position.
VII. FOWLERS
1. Place the client in a horizontal recumbent This is to provide comfort and facilitate various
position. procedures.
2. Elevate the head of the bed to approximately 45 Flexion prevents hyper-extension of the knees.
degrees angle.
3. Flex the knees slightly and support them with

knee roll.
4. Drape as in dorsal horizontal.
VIII. TRENDELENBURG
1. Assist the client to a horizontal recumbent This is done for certain types of shock r surgical
position. procedures and postural drainage.
2. Elevate the foot of the bed so that the lower

trunk is higher than the head and shoulder.
3. Support the shoulders and knee. The weight of the body is pulled downward by
gravity. Support will prevent the client from slipping
out of the bed.
4. Drape as a horizontal recumbent.
IX. KNEE CHEST
1. Place the client on a prone position.
2. Assist him to kneel with the knees slightly This is preparatory to assuming the desired position.
separated.
3. Bend forward so that the chest is resting on the This is for rectal and vaginal examination and as a
bed and thighs are perpendicular to the legs. form of exercise for some gynecological conditions.
4. Turn the head to one side and place the arms This is for support, convenience and prevention of
either above the head or flex at the elbow and smothering.
rest along the side of the head.
5. Drape the patient properly so that only the area This is to provide privacy.
to be examined is exposed.
V. EVALUATION
1. Comfort and privacy was provided during the examination.
VI. ILLUSTRATION
Horizontal Recumbent Dorsal Recumbent
Dorsal (supine) Sitting
Knee Chest Lithotomy

\
POSITIONING CLIENTS FOR
CAUTIONS
May be contraindicated for clients who have

cardio – pulmonary problems.
Sims
Prone
POSITIONING CLIENTS FOR PHYSICAL EXAMINATION
CAUTIONS POSITION AREAS ASSESSED
May be uncomfortable and tiring for elderly DORSAL RECUMBENT

BreastsLungsAnterior thoraxAxillaeHead and neck
people and often embarrassing.
Female Reproductive TractRectumFemale genitals
AREAS ASSESSED
PHYSICAL EXAMINATION
LITHOTOMY
POSITION
SIM’S
COLLECTING STOOL SPECIMEN

I. DEFINITION
Collecting Stool Specimen – is the process of obtaining a stool for diagnosing dysfunction in bowel
elimination which may be related to invasion of the GIT by microorganism, or to some organic pathology
of the GIT.
II. RATIONALE
1. To obtain stool specimen for diagnosing dysfunction in bowel elimination.

2. To assess for perforation or bleeding from a gastric ulcer.
3. To defect presence of parasites and pinworms.
4. To detect presence of bacteria through cultures.
III. EQUIPMENT
Paper towel
Gloves
Wooden applicator
Container with cover
Clean Bedpan or Bedside Commode
For Hemoccult Test:

Cardboard Hemoccult Slide
Hemoccult developing solution
For Hematest:
Hematest tablets (must be protected from any moisture, heat and light)
Guaiac paper (reagent tablet turns blue reaction on Guaiac paper if fecal smear contains blood)
Sink with running water
1. Assess client or family members’ understanding of the need for stool test.
2. Determine client’s ability to cooperate with procedure and collect specimen.
3. Obtain client’s medication history. Note any drugs that can cause gastrointestinal mucosal bleeding.
4. Refer to physician’s order for medications or restrictions before the test.
ACTION RATIONALE
A. Collecting Adult Stool Specimen
1. Explain procedure to client and or family To be able to obtain specimen independently with
members. Discuss reasons for specimen collection patient’s cooperation. Also prevents accidental
and how client can show cooperation. Explain disposal of the specimen.
that feces must be free from urine and tissue
paper.
To ensure accuracy of test results.
2. Arrange for any needed dietary or medication
restrictions
3. Perform hand hygiene and apply clean gloves. To reduce transmission of microorganisms.
4. Check client’s identification band. To ensure proper identification and prevent
exchange of specimens with other patients.
5. Before collecting stool specimen, ask client to To avoid contamination of the stool and to yield a
void. Instruct client not to void on the specimen. reliable result. (If with urine, the waste products of
urine will also be examined and mistaken as stool
findings).
6. Clean out all urine from the bedpan or bedside

commode.
7. Raise the head of the bed, or help the client sit on To assume squatting position on the bedpan or
the bedside commode. bedside commode.
8. Provide privacy until client passes stool.

9. Remove the bedpan or bedside commode. If
necessary, help the client clean the perineum. To protect the nurse’s hands from contamination.
10. Use tongue blade to obtain specimen and place a

small portion of the formed stool in a container.
To ensure proper identification and prevent

exchange of specimen with other clients’ specimen.
11. Clean bedpan or bedside commode while wearing
gloves. To guide the laboratory personnel to be guided with
the ordered test and to gain reliable results.
12. Wash hands.
13. Label the specimen container with complete

name of the client.
14. Fill up the laboratory request form for

appropriate test, and send the specimen to the
laboratory immediately.
B. Collecting Stool to Detect Parasites
1. Follow the steps for collecting stool specimen.
2. Collect exudates, mucus, and blood with all

specimens.
3. Keep specimen at body temperature to be To allow rganisms must be seen in active stages, as
examined within 30 minutes. loose, fluid stools are likely to contain trophozoites
or intestinal amoebas and flagellates.
Note:
There is usually no need to maintain well-formed or
semi formed stool specimen at body temperature or
to examine them quickly even though they may
contain ova or cystic forms of parasites.
4. When the presence of tapeworm is suspected, all

stool must be examined entirely in order to find
the head of the parasites.
5. Do not use barium, oil and laxatives containing To reveal ova or cyts.
heavy metals that interfere with the extraction
process for seven days prior to exam.
6. Use only normal saline solution or tap water if an To use soap suds or other substances can alter the
enema must be administered to collect specimen. result of the test.
Do not use soap suds or other substances.
7. Do not contaminate the specimen with urine. To avoid urine from killing amoeba.
8. Collect 3 random, normally passed stool To ensure accurate test results.

specimen.
C. Testing for Occult Blood
1. Follow steps for collecting stools.
2. Use tip of wooden applicator to obtain small Small specimen is sufficient for measuring blood
portion of the feces. content.
3. Perform hematocrit slide test:

a. Open flap of slide, and apply thin smear of Guaiac paper inside box is sensitive to fecal blood
stool on paper in the first box. contact.
b. Obtain second fecal specimen from different Occult blood from upper GIT is not always equally
portion of stools, and apply thinly to slide’s dispersed throughout the stool. Findings of occult
second box. blood are more conclusive for GIT bleeding when
entire specimen is found to contain blood.
c. Close slide cover and turn slide over to reverse Developing solution penetrates underlying fecal
side. Open cardboard flap and apply two drops specimen. Blood is indicated by change in the color
of Hemoccult developing solution on each box of Guaiac paper.
of Guaiac paper.
d. Read results of the test after 30-60 seconds. Bluish discoloration indicates occult blood (Guaiac
Note color changes. positive). No change in color indicates a negative
Guaiac test result.
e. Dispose of test slide in proper receptacle. To reduce transfer of microorganisms.
D. Test for Occult Blood Using Hematest Tablet
1. Follow steps for collecting stools.
2. Place stool on Guaiac paper and Hematest tablet Tablet contains solid form of developing solutions.
on top of stool specimen.
Tap water dissolves Hematest tablet thus dispenses

developing solution over specimen on Guaiac paper.
3. Apply 2-3 drops of tap water to tablet, allowing
water to flow into the Guaiac paper. Bluish discoloration indicates a positive result. Do
not read color change after 2 minutes. False finding
may occur.
4. Observe color of Guaiac paper within 2 minutes.
To reduce spread of infection.
5. Dispose of tablet and paper into proper

receptacle.
6. Wrap wooden applicator in paper towel and

dispose in proper receptacle.
7. Perform hand hygiene after removing and

discarding gloves.
V. RECORDING AND DOCUMENTATION
1. Record results of test in the nurses’ notes

2. Record any unusual characteristics of stool
3. Report results to physician
VI. EVALUATION
1. Ask client to explain the collection procedure (Document level of learning).

2. Note color changes in the Guaiac paper (Reveals blood in feces).
3. Note character of stool specimen (Certain abnormal constituents of the stool may be visible).
COLLECTING URINE SPECIMEN
CLEAN-CATCH MIDSTREAM URINE SPECIMEN
(Wolster Kluwer, Lippincott Williams and Wilkins, 2010, Manual of Nursing Practice, 9 th ed., pp. 776-777)
I. DEFINITION
Clean-catch Midstream Specimen – is a clinically effective method of securing a voided specimen for
urinalysis.
II. RATIONALE
To have an accurate diagnostic laboratory examination and directly confirms treatment given to the
client.
III. EQUIPMENT
Sterile specimen container

Antiseptic solution or liquid soap
Water
4x4 gauze pads
Disposable sterile gloves for nurse in assisting female client
1. Freshly voided urine provides the best results for routine urinalysis; some test may require first
morning specimen.
2. Obtain a sample of about 30 cc.
3. Urine culture and sensitivity tests are typically performed using the same specimen obtained for
urinalysis, therefore use clean-catch or catheterization technique.
4. Patients with urinary diversions, especially ileal conduit diversions, require special techniques to
obtain urine that is not contaminated with bacteria from the intestinal diversion.
ACTION RATIONALE
A. FEMALE CLIENT:
1. Ask the client to cleanse the area around the The urethral orifice is colonized by bacteria, urine
urinary meatus with 4x4 sponges soaked with readily become contaminated during voiding and
antiseptic/soap solution (or its equivalent). Rinse collection.
thoroughly.
2. Instruct client to separate her labia to expose the Keeping the labia separated prevents labial or
urethral orifice. If no one is available to assist the vaginal contamination of the urine specimen. By
client, she may sit backward on the toilet seat standing in the toilet seat/bedpan, the patient*s
facing the water tank or sit on (straddle) the wide labia are separated apart for cleansing.
part of the bedpan.
3. Allow initial urinary flow to drain into the bedpan The first portion of urinary flow washes out the
or toilet then catch the midstream specimen in urethra.
the sterile container.
4. Remember to keep the labia separated while This eliminates further urethral contamination.
urine collection is going on.
B. MALE CLIENT:
1. Instruct client to expose glands and cleanse area The area of the glands in the male is where most
around meatus. Wash thoroughly the area with bacteria are colonized, thus thorough cleansing is
an antiseptic/soap solution (or its equivalent). advisable.
Rinse.
2. Allow the initial urinary flow to escape. The first portion of urinary flow washes out the
urethral tip.
3. Collect the midstream urine in the sterile
container while continually exposing the glands,
avoiding to cover or touch the urethral orifice.
4. Remind the male client to avoid collecting the last Prostate secretion maybe introduced with urine at
few drops of urine. the end of the urinary stream.
C. PEDIATRIC CLIENT
1. Emphasize to mother/watcher to cleanse area Active participation of the client’s watcher ensures
and urethral meatus thoroughly with antiseptic/ proper urine collection.
soap solution (or its equivalent). Rinse and dry the
area with a clean piece of cloth.
2. Place clean/sterile receptacle around the child’s Pediatric clients do not verbalize when they are
genital area. going to urinate or they do not have control over
bladder urge at this stage.
3. Secure the plastic receptacle by an adhesive tape. This technique ensures urine specimen is collected
Do not include the anal area. by the time the child urinates.
D. 24 HOUR URINE COLLECTION
Additional Equipment:
- adequate size of urine specimen container
- additive, if required, obtained from laboratory
- soaking container with ice chips
1. Explain procedure to client. Stress the importance Orient client/watcher to this method of urine
of saving all urine in a 24 hour period. collection. Active participation and cooperation
ensures completion of the procedure.
2. Place sign/notice while the client’s specimen is in Conscious reminder can be placed strategically as all
progress with date and time due. urine in a specific time as required.
3. Discard the first voided urine when the collection The first specimen is considered “old urine” that was
time started. in the bladder before the test begins. Refrigeration
is discouraged in some hospital settings to avoid
having the urine mistaken as juice even if proper
label is placed.
4. Depending on hospital protocol, the specimen
may be refrigerated or left in the patient’s
bathroom soaked in container with ice chips for a
24 hour period.
5. If a specimen is clinically discarded, obtain a new A need to restart the procedure establishes
container. Note the new date and time and continuity in collection of urine specimen.
restart the procedure.
V. AFTER CARE
1. After the urine specimen is placed in the container, cover and send entire specimen to the
laboratory with the label and proper request form.
2. Send the urine specimen to the laboratory immediately as a longer interval between collection and
analysis may distort results.
VI. EVALUATION
1. The urine specimen is obtained without contamination.

2. The urine is collected and transferred to the collection bottle without any loss of urine.
COLLECTING SPUTUM SPECIMEN
(Wolster Kluwer, Lippincott William and Wilkins, 2010, Manual of Nursing Practice, 9 th ed., pp. 203, 206)
I. DEFINITION
Sputum – is the mucous secretion from the lungs, bronchi, and trachea. It is obtained for evaluation of
gross appearance, microscopic examination, culture and sensitivity, gram stain, acid-fast bacillus and
cytology.
II. RATIONALE
1. For culture and sensitivity to identify a specific microorganism and its drug sensitivities.
2. For cytology to identify the origin, structure, function, and pathology of cells. For this purpose, it
requires serial collection of three early – morning specimens.
3. For acid – fast bacillus (AFB), which also requires serial collection, often for 3 consecutive days, to
identify the presence of tuberculosis (TB).
4. To assess the effectiveness of a therapy.
III. EQUIPMENT
A pair of Gloves
Sputum Specimen Container with label
Mouth Care Kit
Culture Swab and Tongue Depressor
1. Patients receiving antibiotics, steroids, and immunosuppressant drugs for a prolonged time may
have periodic sputum examination because these agents may give rise to opportunistic pulmonary
infection.
2. It is important that the sputum be collected correctly preferably in the morning, and that the
specimen be sent to the laboratory immediately.
3. Allowing the specimen to stand in a warm room will result to overgrowth of microorganisms,
making identification of pathogens difficult and alter cell morphology.
4. A series of these early morning specimens is needed for acid-fast bacillus examination.
5. Cytology specimen should be collected in a container with fixative agent.
6. Sputum can be obtained through various methods:
Deep breathing and coughing

Patient in upright or sitting position (unless contraindicated). Instruct patient to take several deep
breaths, exhale and perform a series of deep coughs and expectorate the sputum in a sterile
container.
Induction through the use of ultrasonic or hypertonic saline nebulization

Nebulization increased the moisture content of air going to lower tract; particles will condense in
tracheobronchial tree and aid in expectoration.
Suctioning
Aspiration of secretions via mechanical means; through nasotracheal, endotracheal, or
tracheostomy tube.
Bronchoscopy with broncho-alveolar lavage
In which 60-100 is instilled and aspirated from various lung segments.
Gastric aspiration
Nasogastric tube is inserted; approximately 50 cc of sterile water is instilled, and swallowed
pulmonary secretions are siphoned out.
Transtracheal aspiration
Involves passing a needle and then a catheter through a percutaneous puncture of the
cricothyroid membrane, and transtracheal aspiration is done.
Generally, 15 ml of sputum sample is adequate.
Lifespan Considerations:
Infants
1. Avoid occluding an infant’s nose because normally they breathe only through the nose.
Children
2. The young child will need to be restrained gently while the throat specimen is collected. Allow the
parents to assist and explain that the procure will be over quickly.
3. Cooperative children can be asked to put their hands under their buttocks, open their mouth, and
laugh or pant like a dog.
4. Observe for signs of ear infection. A child’s short respiratory tract allows bacteria to migrate easily to
the ears.
Elders
5. Elders may need encouragement to cough because a decreased cough reflex occurs with aging.
6. Allow time for elders to rest and recover between coughs when obtaining a sputum specimen.
ACTION RATIONALE
1. Identify the correct client. To ensure accuracy.
2. Explain the procedure to the client or to a family To gain the client’s cooperation.
member.
3. Wear gloves. Follow special precautions if To prevent contamination and droplet infection.
tuberculosis is suspected, obtaining the specimen
in a room equipped with a special airflow system
or ultraviolet light, or outdoors. If these options
are not available, wear a mask capable of filtering
droplet nuclei.
4. Offer mouth care. To prevent the specimen from getting

contaminated with microorganisms from the
mouth.
5. Ask the client to breathe deeply and then cough
up 1 to 2 tablespoons or 15 to 30 ml of sputum.
6. Ask the client to expectorate (spit out) the To prevent the spread of microorganisms.
sputum into the specimen container. Make sure
the specimen does not contact the outside of the
container. If the outside of the container does
become contaminated, wash it with a
disinfectant.
VARIATION: THROAT CULTURE
 Let the client sit upright if health permits, open To expose the pharynx and control the gag reflex.
the mouth, extend the tongue, and say “ah”.
 Insert the swab into the oropharynx and run the
swab along the tonsils and areas on the pharynx
that are reddened or contain exudates.
 If the posterior pharynx cannot be seen, use a To help visualize the pharynx.
light and depress the tongue with a tongue blade
or depressor.
7. Following sputum collection, offer mouthwash. To remove any unpleasant taste.
8. Label and transport the specimen to the To prevent inaccurate results.

laboratory immediately. Ensure that the
specimen label and the laboratory requisition
contain the correct information.
1. Color, odor, consistency of the specimen collected

2. Presence of hemoptysis
3. Any measure needed to obtain the specimen
4. Any discomfort experienced by the client
COMMONLY USED ABBREVIATIONS
ABG Arterial Blood Gas

AMI Acute Myocardial Infarction
ANST After Negative Skin Test
ALT Alanine Transferase
ARF Acute Renal Failure
AST Aspartate T ransferase
BE Barium Enema
BMR Basal Metabolic Rate
BPH Benign Prostatic Hypertrophy
BUN Blood Urea Nitrogen
C/S Culture and Sensitivity
CAP Community Acquired Pneumonia
CHF Congestive Heart Failure
CHO Carbohydrate
CNS Central Nervous System
CO Carbon Monoxide
C02 Carbon Dioxide
COPD Chronic Obstructive Pulmonary Disease
CPR Cardiopulmonary Resuscitation
CRF Chronic Renal Failure
DAMA Discharged Against Advice
DHF Dengue Hemorrhagic Fever
DNR Do not Resuscitate
DPT Diphtheria Pertussis Tetanus
EDD Expected Date of Delivery
EEG Electroencephalogram
ESR Erythrocyte Sedimentation Rate
FBS Fasting Blood Sugar
FHR Fetal Heart Rate
FNAB Fine Needle Aspiration Biopsy
FWB Fresh Whole Blood
G/S Gram Stain
H+ Hydrogen Ion
HBT Hepato Biliary Tree
HBV Hepatitis B Virus
HDL High Density Lipoprotein
HEPA High Efficiency Particulate Air
HGT Hemo GlucoTest
HPI History of Present Illness
ICU Intensive Care Unit
IDDM Insulin Dependent Diabetes Mellitus
IPPB Intermittent Positive Pressure Breathing
IVF Intravenous Fluid
IVP Intravenous Pyelography
IVTT Intravenous Through Tubing
KUB Kidney Ureter Bladder
KVO Keep Vein Open
LDL Low Density Lipoprotein
LLQ Left Lower Quadrant
LUQ Left Upper Quadrant
Ml Myocardial Infarction
MICU Medical Intensive Care Unit
MRI Magnetic Resonance Imaging
MRIC Medical Resident in Charge
MS Multiple Sclerosis
NCP Nursing Care Plan
NCS Nursing Care Study
NICU Neonatal Intensive Care Unit
NST Negative Skin test
OGTT Oral Glucose Tolerance Test
OREF Open Reduction External Fixation
ORIF Open Reduction & Internal Fixation
OTC Over the Counter
PD Postural Drainage
PERRLA Pupils Equal, Round, & Reactive to Light & Accommodation
PICU Pediatric Intensive Care Unit
PID Pelvic Inflammatory Disease
PMH Previous Medical History
POST MN Post-Midnight
PNSS Plain Normal Saline Solution
PRBC Packed Red Blood Cells
PT Prothrombin Time
PTT Partial Thromboplastin Time
PTB Pulmonary Tuberculosis
PVC Premature Ventricular Contraction
RBC Red Blood Cells
R/O Rule Out
ROM Range of Motion
SARS Severe Acute Respiratory Syndrome
SIDS Sudden Infant Death Syndrome
SGPT Serum Glutamic Pyruvic Transaminase
SGOT Serum Glutamic Oxaloacetic Transaminase
SNO See New Order
STD Sexually Transmitted Disease
T/C To consider
TAH Total Abdominal Hysterectomy
TAT Tetanus Antitoxin
TCVS Thoracic Cervical Vertebral Spinal
TPN Total Parenteral Nutrition
TSB Tepid Sponge Bath
U/A Urinalysis
UGIS Upper Gastrointestinal Series
URI Upper Respiratory Infection
UTI Urinary Tract Infection
UTZ Ultrasound
VD Venereal Disease
VDRL Venereal Disease Research Laboratory
WBC White Blood Cells
V/s Versus
aa of each
ac before meals
ad lib freely, as desired
agit shake, stir
amp COMMON
ampule ABBREVIATIONS USED IN MEDICATIONS
aq water
aq dest distilled
when water
needed
bid twiceevery
a day
c withevery morning
cap capsule
every hour
comp compound
every 2 hours
dc discontinue
every 3 hours
dil dissolve,
everydilute
4 hours
elix elixirevery 6 hours
h an hour
every 8 hours
hs at bedtime
every twelve hours
IM intramuscular
every night at bedtime
IV intravenous
four times a day
M or m mix every other day
no. or # numbersufficient quantity
non rep do notmayrepeat
be repeated
OD righttake
eye
OS or ol left eye
OU both eyes
Pc after meals
po by mouth
pm without
q subcutaneous
qAM label
qh (q1h) if it is needed
q2h one half
q3h at once
q4h suppository
q6h suspension
q8h three times a day
q12h tincture
qhs
qid
qod
qs
rept
Rx
s
sc
Sig or S
sos
ss or ss
stat
sup or supp
susp
tid
Tr or tinct
COMMON USED SYMBOLS
SYMBOL TERM SYMBOL NUMBER
> greater than

< less than
= equal to
↑ Increased
↓ Decreased
♀ Female
♂ Male
° Degree
# Number
Ʒ Dram
℥ Ounce
X Times
@ At
COMMONLY USED ABBREVIATIONS

abd moderate
abdomen
ABO the
negative
main blood group
ac none
system
ADL before
nothingmeals
by mouth
ad lib normal saline
activities of daily living
adm as
Oxygen
desired
A.M. daily
admitted or admission
amb morning
right eye: overdose
amt out of bed
ambulatory
approx amount
mouth
bid left eye
approximately
BM (bm) twice
after meals
daily
BP physical
bowel examination
movement
BR blood
by or through
pressure
c ̅ (C)̅ afternoon
bed rest
C with
by mouth / per orem
CBC postoperative(ly)
Celsius (centigrade)
CBR preoperative(ly)
complete blood count
CI preparation
complete bed rest
c/o client
when necessary
DAT patient of
complains
dc (disc) diet
everyas tolerated
drsq everyday
discontinue
Dx dressing
every hour
ECG (EKG) every two hours, three hours,
diagnosis
F electrocardiogram
etc
fld every night at bedtime
Fahrenheit
GI fluid
four times a day
GP requisition
gastrointestinal
gtt general
right practitioner
h (hr) seriously ill
drops
H2O hour
specimen
hs at once, immediately
water
I &O at
three
bedtime
times a day
IV team leader
intake and output
Lab intravenous
tender loving care
liq temperature, pulse, respirations
laboratory
LMP liquid
tincture
lt (L) verbal
last order period
menstrual
meds left
vital signs
ml (mL) within normal limits
medications
milliliter
Weight
mod
neg
nil
NPO (NBM)
NS (N/S)
O2
od
OD
OOB
os
OS
pc
PE (PX)
per
P.M.
po
postop
preop
prep
prn
pt
q
qd
qh (g1h)
q2h,q3h,etc
qhs
qid
req
Rt (rt. R)
SI
spec
stat
tid
TL
TLC
TPR
Tr.
VO
VS (vs)
WNL
wt
COMMON GYNECOLOGIC AND OBSTETRIC ABBREVIATIONS
Gyne Gynecology
OB Obstetric
G Gravida
P Para/Parity
A/Ab Abortion
FHB Fetal Heart Beat
FH Fundic Height
OA Occiput Anterior
OP Occiput Posterior
LOA Left Occiput Anterior
ROA Right Occiput Anterior
LOP Left Occiput Posterior
ROP Right Occiput Posterior
RSA Right Sacral Anterior
LSA Left Sacral Anterior
RSP Right Sacral Posterior
LSP Left Sacral Posterior
LMA Left Mentum Anterior
LMP Left Mentum Posterior
TAH Total Abdominal Hysterectomy
TAHBSO Total Abdominal Hysterectomy with Bilateral Salpingo-Oophorectomy
GPTPALM Gravida, Para, Term, Preterm, Abortion, Live birth, Multiple gestation
EDC Expected Date of Confinement
EDD Expected Date of Delivery
AOG Age of Gestation
LMP Last Menstrual Period
Px Pelvic exam
CHARTING
I. DEFINITION
Charting - is the process of making an entry on a client record.
II. RATIONALE
1. To discuss reasons for keeping clients record.

2. To compare and contrast different documentation methods.
3. To identify guidelines for effective recording that meets legal and ethical standards.
Different Documentation Methods
A. Source-Oriented Record
Source-Oriented Record (SOR) is a traditional client’s record. Each person or department makes notations in a
separate section or sections of the client’s chart.
Example:
The admissions department has an admission sheet; the physician has a physician’s order sheet, a physician’s
history sheet, and progress notes; nurses use the nurses’ notes; and other departments or personnel have
their own records. In this type of record, information about a particular problem is distributed throughout
the record.
Components of Source-Oriented Record
FORM INFORMATION
Admission (face) sheet Legal name, birth date, age, gender

Social Security Number
Address
Marital Status; closest relatives or person to notify in case of emergency
Date, time and admitting diagnosis
Food or drug allergies
Name of admitting physician
Insurance information.
Any assigned diagnosis-related group (DRG)
Findings from the initial nursing history and physical health assessment.
Initial nursing
assessment Body temperature, pulse rate, respiratory rate, blood pressure, daily weight
and special measurements such as fluid intake and output and Oxygen
Graphic record saturation.
Activity, diet, bathing and elimination records.
Daily care record Examples: fluid balance record, skin assessment
Special flow sheet Name, dosage, route, time, date of regularly administered medications
Name or initials of person administering the medication.
Medication record Pertinent assessment of client.

Specific nursing care including teaching and client’s responses.
Client’s complaints and how client is coping.
Past and family medical history, present medical problems, differential or
Narrative nurse’s notes current diagnosis, findings of physical examination by the physician.
Medical orders for medications, treatments and so on.
Medical history and Medical observations, treatments, client progress, and so on.
physical
examination
Reports by medical and clinical specialists.
Physician’s order sheet
Examples: laboratory reports, x-ray reports, CT scan reports.
Physician’s progress notes
Reports by medical and clinical specialists.
Consultation records
Started on admission and completed on discharge; includes nursing
Diagnostic reports problems, general information.
Consultation reports
Client discharge plan and

referral summary
B. Narrative Charting
It is a part of source-oriented record and it consists of written notes that include routine care, normal
findings, and client problems. There is no right or wrong order to the information, although chronological
order is frequently used.
NURSING NOTES
DATE TIME
6/6/05 2:OO PM Passive ROM exercises provided for R arm and leg. Active assistive exercises to L
arm and leg. Has scratch marks on L and R fore arms. States, “My skin on my back
and arms has been itchy for a week.” Rash not evident. No previous history of
pruritus. Is allergic to elastoplast but has not been in contact. Dr. J. Wong notified.
2:30 PM Tom Ritchie, RN
Applied calamine lotion to back and arms. Incontinent of urine. Is restless.

Tom Ritchie, RN
An example of narrative notes
C. Problem-Oriented Medical Record
The problem-oriented medical record (POMR), or problem-oriented record (POR) are data arranged
according to the problems the client has rather than the source of the information. Members of the health
team contribute to the problem list, plan of care and progress notes. Plans for each active or potential
problem are drawn up, and progress notes are recorded for each problem.
The POMR has four basic components:

a. Database
b. Problem list
c. Plan of care
d. Progress notes
A No. Date Entered Date Inactive Client Problem
#1 5/9/05 CVA resulting in Rt hemiplegia and left-side weakness
#1A 5/9/05 Self-care deficit (hygiene. Toileting, grooming, feeding)
#1B 5/9/05 Impaired physical mobility (unable to turn and position
self)
#1C 5/9/05 Redefined 4/5/05
#1D 5/9/05 Total urinary incontinence; Redefined 3/16/05
#2 5/9/05 Progressive dysphasia
#3 5/9/05 Constipation r/t immobility; redefined 12/16/04
#4 5/9/05 6/8/05 History of depression
#5 6/6/05 Essential hypertension
#2 6/10/05 Pruritus
#1C 7/20/05 Risk for constipation r/t insufficient fiber intake
#1B 7/25/04 Urge urinary incontinence at night
Impaired physical mobility (needs 2-person assistance to
transfer and walk)
client’s problem list in the POMR. Note that problems 1B, 1C, and 2 were redefined on the dates indicated and
listed subsequently.
D. SOAPIE
The SOAPIE is an acronym for subjective data, objective data, assessment, planning, intervention, and
evaluation.
SOAPIE FORMAT
6/6/05 #5 Generalized pruritus

2:00 PM S – “My skin is itchy on my back and arms, and it’s been like this for a week.”
O – Skin appears clear – no rash or irritation noted. Marks where client has scratched noted on
left and right forearms. Allergic to Elastoplast but has not been in contact.
A – Altered comfort (pruritus: cause unknown).
P – Instruct not to scratch skin.
Apply calamine lotion as necessary.
Cut nails to avoid scratches.
Assess further to determine whether recurrence associated with specific drugs or foods.
Refer to physician or pharmacist for assessment.
I – Instructed not to scratch skin.
Applied calamine lotion to back and arms at 2:30 PM.
Notified physician and pharmacist of problem.
4:00 PM E – States, “I’m still itchy. That lotion didn’t help.”
E. Focus Charting
Focus charting is intended to make the client and client concerns and strengths the focus of care. Three
columns of recording are usually used: date and time, focus, and progress notes. The focus may be a
condition, nursing diagnosis, a behavior, a sign or symptom, an acute change in the client’s condition, or
client strength.
The focus charting system provides a holistic perspective of the client and the client’s needs. It also
provides a nursing process framework for the progress notes. The progress notes are organized into (D)
data, (A) action, and (R) response, referred to as DAR.
EXAMPLE:
Date/Hour Focus Progress Notes
6/11/05 Pain D: Guarding abdominal incision. Facial grimacing. Rates pain at “8” on
9:00 AM scale of 0-10.
A: Administered Morphine Sulfate 4mg IV.
9:30 AM R: Rates pain at “1”. States willing to ambulate.
F. Charting by Exception
Charting by Exception (CBE) is a documentation system in which only significant findings or exceptions to
norms are recorded. CBE incorporates three key elements:
1. Flow sheets
Examples of flow sheets include a graphic record, fluid balance record, daily care record, client teaching
record, client discharge record, and skin assessment record.
2. Standards of nursing care

Documentation by reference to the agency’s printed standards of nursing practice eliminates much of the
repetitive charting of routine care.
3. Bedside access to chart forms
In the CBE system, all flow sheets are kept at the client’s bedside to allow immediate recording and to
eliminate the need to transcribe data from the nurse’s worksheet to the permanent record.
G. Computerized Documentation
Computerized clinical record systems are being developed as a way to manage the huge volume of
information required in contemporary health care. Nurses use computers to store the client’s database,
add new data, create and revise care plans and document client progress.
Computers make care planning and documentation relatively easy. To record nursing actions and client
responses, the nurses either choose from standardized list of terms or types narrative information into the
computer. Automated speech recognition technology now allows nurses to enter data by voice for
conversion to written documentation.
Documentation Strategies
a. Write neatly and legibly
b. Use proper spelling and grammar
c. Use authorized abbreviation
d. Chart promptly
e. Follow the procedure in correcting erroneous entries
f. Signatures
g. Sequence
h. Appropriateness
i. Completeness/ conscientiousness
j. Re-evaluation of nursing intervention
Advantages of System Charting
1. Conscientiously monitors and evaluates condition.
2. Easily identifies developing complications.
3. Enhance students’ assessment skills and increases awareness of patients’ care.
4. Maximizes time.
5. Enables students to learn how to prioritize their responsibilities.
6. Enhances rapport between a student and a patient.
LOC
- Awake? Coherent? Lethargic? Stuporous? Oriented to time and place? Anxious?
- GCS
- Responsive to both verbal and painful stimuli.
HENT
- Tenderness of maxillary and frontal sinuses.
- Visual disturbances?
- Symmetry of face? Swelling of scalp?
- Nystagmus? Nasal septum deviation? Nasal discharge?
- Exopthalmia
- Mucous membranes pink? Mucous membranes score?
- Conjunctival discharge?
- PERLA (Pupils Equals React to Light and Accommodation)
- Redness/Lesion/Swelling on external ear canal?
Cardiovascular
- Rhythm regular? Irregular or arrhythmia?
- Rate tachycardic? Bradycardic?
- Peripheral pulses present?
- Pulse-bouncing? Moderate or normal? Weak/feeble? Absent?
- Neck vein distention?
- Chest pain? Radiating? Duration?
- Edema noted?
- CR rate?
- Good capillary refill?
- Clubbing of fingers?
- S1 & S2 normal?
RESPIRATORY
- Breathes spontaneously to room air?
- CO2 at 2L or 3L? Nasal cannula
- Hyperresonance (lobe) COPD
- c ̅ ET to ambubag in line c ̅ 02 at 10L/min.?
- c ̅ ET to ventilator / respirator?
- Wheezing? Crackles? Rales?
- Dyspneic as claimed?
- Tachypneic? Rate/deep, slow?
- Shallow, rapid/deep, slow?
- Cheyne stokes? Blots breathing?
- Tubings (CTT/H20 Sealed bot.) output?
GIT
- Change in bowel habits
- Able to defecate? Color? Consistency? Amount? Parasites present?
- Hypoactive? Hyperactive bowel sounds? What quandrant?
- Abdominal pain?
- Vomited/emesis? Amount? Color?
- Tympany?
- Abdominal distention/girth?
GUT
- Voids difficulty? Burning? Bladder distention?
- c foley catheter? Color? Amount? Blood? Cloud? Urgently? Pain?
Musculoskeletal
- Able to move S difficulty? Or against gravity?
- c Assistance?
- Presence of contractures?
- Foot drop
- Presence of cast, tractions, weights
- Muscle pain? Joint pain? Swelling? Difficulty in balance?
SKIN
- Dry? Intact?
- Presence of tubing? Drains?
- Color?
- Bums? Rashes? And all forms of elevation (macular, papule, vesicular, crust)
- Skin pigmentation
LOC
- On bed awake, restless
Cardiovascular
- CR = 120/min
- BP = 150/90
- Cyanotic nailbeds/clubbing of fingers
Respiratory
- Labored rapid breathing
- RR of 40 cycles/min.
- Use of accessory muscles
- Wheezing noted on both lobes
GIT
- c ̅ Normoactive bowel sounds
GUT
- Voids freely, amber colored urine
Musculoskeletal
- Able to move both upper and lower extremities S̅ difficulty
Skin
- T = 36.3, Cool clammy skin
- Good skin turgor
Nursing Activities
1:00 – Visited by Dr. Andres, c ̅ new orders; instructed to have soft diet C̅ aspiration precaution, patient
and relative informed.
2:00 RR = 20/min, slight wheezing still noted at both lower lobes
Sample Charting (Systems Charting)
LOC
- unresponsive to both painful and verbal stimuli
HEENT
- pupils bilateral dilated (4 mm) fixed and non reactive
Cardiovascular
- BP = 180/100 mmhg.
- Weak, regular pulse.
- PR = 68/min.
Respiratory – Cheyne-stokes respiration

- c ̅ ET to ventilator C̅ the following parameters: FIO2 100% Frequency = 22/min.
GIT
- c ̅ normal active bowel
- c ̅ NGT in place and patent for medication and feeding
GUT
- c ̅ Foley catheter attached to urobag draining to dark colored urine.
Musculoskeletal
- Decerebrate
- Foot drop
Skin
- Warm to touch
- T = 39.8°C
- Dirty nails
- Yellowish
- Clammy
- Incision site dry?
- Temperature? Warm to touch?
- Cyanotic?
- Dry lips
- Burns? Classify size, cm, length
- If skin reacts to hot or cold weather
- Notice easy bruising? Bleeding?
- Change in wart and mole?
SAMPLE CHARTING
ON RECEIVING THE CLIENT

• On bed with mainline IVF #1 D5LR 1L infusing well at 31 gtts/min with 550 ml left; side drip of Dopamine 250
ml running at 30 mcggts/min as piggyback, 200ml left.
• With bloodline IVF #2 NSS 1L infusing well to KVO rate with 450ml remaining.
• With patent Foley Catheter attached to urine bag draining to 30 ml of amber colored urine.
• With O2 inhalation on at 3L/min via nasal cannula
• With drain attached to asepto syringe at negative pressure draining to about 5cc of bloody discharges,
discharges.
• With patent NG tube draining about 50cc of yellow-colored discharges
• Abdominal dressings dry and intact
ON VITAL SIGNS
• Vital signs taken and recorded.
ON DOCTOR’S ORDER
• Seen and examined by Dr. Catot. New orders given. Carried out.
ON MEDICATIONS
• Due oral medications given.
• Starting dose Cefuroxime 300mg/amp 1 amp given IVTT ANST by staff nurse Chua.
ON FOLLOWING UP IVF’S
• Above mainline IVF consumed. Followed up with IVF #2 D5NM 1L and made to run for 8 hours as ordered.
FOR RADIOLOGY
• Brought to Radiology Department per stretcher for chest x-ray PA view.
• Brought back to ward thereafter. Made comfortable in bed.
ON ENDORSEMENT
• On bed; awake.
IN CASES OF FEVER
• Febrile with T = 39.9 oC. Referred to staff nurse. TSB done.
• PRN medication of Paracetamol 300mg IVTT given by staff Nurse Chua.
Nursing Activities
7:00 Elevated bed to high fowler’s position

c ̅ O2 inhalation @ 2L/min via nasal cannula
Placed on NPO; instructed
Side rails up
Informed Dr. Lemoncito, promised to see pt.
7:10 Started salbutamol ÷ nebule administered as nebulization
10:00 Claimed relief of dyspnea RR=25/min. slight wheezing still noted at R lower lobe.
12:00 Slept at short intervals

ADMINISTERING MEDICATIONS TOPICAL MEDICATIONS
I. DEFINITION
Topical Medications include dermatologic medications in the form of lotions, pastes, ointments or
liniments and occasionally powders, and irrigations and instillations.
II. RATIONALE
1. To relieve pruritus / itching.

2. To lubricate or soften the skin.
3. To cause local vasoconstriction or vasodilation.
4. To increase or decrease secretions from the skin.
5. To provide a protective coating to the skin.
6. To apply an antibiotic or antiseptic to treat or prevent infection.
7. To promote a local anesthetic effect to special parts of the body.
8. To provide a sustained systemic effect (nitroglycerin patches and anti – motion sickness preparation).
APPLYING OINTMENTS AND SALVES
I. DEFINITION
Ointment – a greasy preparation, which may or may not contain medication, for use on skin or mucous
membrane.
Salves – an oily or waxy substance applied to the skin to heal, soothe, or protect.
II. RATIONALE
Refer to rationale for Topical Medication
III. EQUIPMENT
Medication Cart
Medication in a Tube or Jar
2x2 pads for Cleaning
Tongue Blade
Gloves
Sterile Dressing / Gauze (Vaselinized)
ACTION RATIONALE
1. Obtain the client’s medication record. Medication To find out the right drug to be given to the patient.
record may be a drug card, medication sheet or
drug kardex, depending on the method of
dispensing medications of the facility.
2. Compare the medication record with the most To ensure accuracy.
recent physician’s order.

4. Gather necessary equipment including gloves or To save time and effort.
tongue blade as needed.
5. Remove the medication from the drug box or tray To prevent medication error.
on the medication cart. Compare the label on the
medication tube or jar with the medication
record.
6. Place the medication tube or jar (include a tongue

blade with jar) in a tray if not using a medication
cart.
7. Take the medication to the client’s room. Check To ensure that the right medication is administered
the room number and client’s ID band against the to the right client.
medication card or sheet. Ask the client to state
his/her name.
8. Provide privacy and explain the procedure to the To reduce client’s anxiety and enhance cooperation.
client.
9. Don a pair of gloves, as needed. To prevent contact with blood and body fluids.
10. With a patting motion, wash and carefully dry the To remove substances that may cause local infection
area to be treated using 2X2 pads. or may prevent the absorption of medication.
11. Squeeze the medication from a tube or using a To prevent contamination of medication.
tongue blade, take the ointment out from a jar.
12. Spread a small amount of medication evenly and To prevent further irritation on the area.
smoothly over the skin surface using your gloved To protect the nurse’s hand from coming in contact
fingers or a tongue blade. with microorganisms.
13. Cover the skin surface with a dressing or To protect the affected area and prevent the
vaselinized gauze. medication from being rubbed off.
14. Place the client in a comfortable position. To promote client’s comfort.
15. Do after - care of supplies and equipment. To prevent the spread of microorganisms.
16. Wash hands.
1. Document on the client’s chart or medication record the name of the medication administered, time
of administration, dosage, site of administration and the client’s reaction to the medication.
2. Note the condition of the skin and any findings / abnormalities observed.
APPLYING OINTMENT TO BURNS

III. EQUIPMENT
Medication container Medication in a Tube or a Jar

2x2 pads for cleaning Tongue blade
Sterile gloves Sterile gauze
Commercially prepared burn dressings
ACTION RATIONALE
Follow Steps 1 - 9 (Applying Ointments and Salves)
1. Squeeze the medication from the tube or using a To prevent contamination of medication.
tongue blade, take the ointment out of the jar.
2. If no dressing is ordered, apply the drug directly To provide an occlusive effect.

to the burn area using sterile gloves and tongue
blade. Cover the entire burn area with
medication.
3. If dressing is ordered, use sterile gloves to rub the To protect the burn area from possible
drug directly into the sterile gauze. Apply the contamination.
medicated gauze on the bum area. Commercially
prepared pre-medicated gauze dressings can be
applied directly to the burn area.
4. Place the client in a comfortable position. To promote comfort.
5. Do after - care of supplies and equipment. To prevent the spread of microorganisms.
6. Wash hands.
1. In the nurse’s notes, document the skin condition, any areas of irritation, erythema, etc.
2. Document the type of treatment given, time given, and reaction of the client to the treatment.
APPLYING MEDICATION TO THE MUCOUS MEMBRANE
I. DEFINITION
Administration of medication through the sublingual and buccal routes.
Sublingual Administration – a drug may be placed under the tongue until it dissolves.
Buccal Administration – a medication is held in the mouth against the mucous membrane of the cheeks
until it dissolves.
II. RATIONALE
1. To prevent destruction or transformation of drugs in the stomach or small intestines.

2. To provide more appropriate surface for absorption.
3. To promote rapid absorption of drugs in the blood stream.
4. To ensure greater potency (drug directly enters the blood and bypasses the liver).
5. To provide local anesthetic to a specific body part so as to relieve pain and discomfort.
III. EQUIPMENT
Medication Container
Medication (as prescribed)
Tongue Blade
Gloves (non-sterile)
ACTION RATIONALE
1. Obtain patient’s medication record. To determine the kind of drug to be given.

3. Wash hands. To prevent the spread of infection.
4. Gather the necessary equipment. To save time and effort.
5. Remove the medication from the drug box or tray To prevent confusion.
on the medication cart.
6. Compare the label on the medication bottle, To ensure accuracy.

packet, tube or jar to the medication record.
7. Place medication bottle, packet, tube or jar on a To prevent contamination of drug.

tray if not using medication cart.
8. Check the drug information to determine if To ensure the client’s safety.

appropriate for application to mucous
membranes.
9. Wash your hands and wear non-sterile gloves. To prevent exposure to blood and body fluids.
10. Assess the client’s knowledge of the drug and its To identify the extent of explanation needed by the
action. client.
11. Explain the procedures to the client, and allow To reduce anxiety and to gain cooperation.
the client to ask questions.
12. Offer sips of water before administering the drug Liquid may affect the effectiveness of drug
and explain to the client that liquids cannot be absorption.
taken until the drug is completely dissolved /
absorbed.
13. Administer the medication. Correct method of administration ensures effective

drug absorption.
- Sublingual: Place the drug under the tongue,
let it dissolved and be absorbed.
- Buccal: Place the drug in the mouth, held

against the mucous membrane of the cheek
until it is dissolved / absorbed.
14. Instruct the client on the following:

- Not to smoke before the drug has completely Nicotine has a vasoconstricting effect that may slow
dissolved /absorbed. down drug absorption.
- Not to chew or touch the drug with the To prevent accidental swallowing of the drug.
tongue.
15. Remove gloves and dispose in a proper receptacle To prevent the spread of microorganisms.
and wash hands.
1. Document the medication administered on the nurse’s notes indicating the status of the mucous
membrane, patient’s tolerance to the medication, observed effects of the medication, time of
administration, dosage and name of drug.
2. When the patient is receiving repeated doses of a buccal medication the nurse should indicate the
site, such as right buccal cavity, to prevent irritation of the same site.
INSTILLING NASAL DROPS
I. DEFINITION
Administering a prescribed medication via the nasal route.
Instillation – is the insertion of a medication into a body cavity.
II. RATIONALE
1. To shrink swollen mucous membranes.

2. To loosen secretions and facilitate drainage.
3. To treat infections of the nasal cavity or sinuses.
III. EQUIPMENT
Medication Tissue Wipes Dropper

Emesis Basin Gloves (optional)
ACTION RATIONALE
1. Obtain client’s medication record, it may be a To determine the drug to be given at a particular
drug card, medication sheet or drug kardex time to a particular client.
depending on the method of dispensing
medications in the facility.


5. Remove the medication from the drug box or tray To promote ease in drug preparation.
on the medication cart.
6. Compare the label on the medication bottle or To prevent medication error.

tube with the medication record.
7. Check the drug information if it is appropriate for To ensure the client’s safety.
nasal instillation.
8. Place the medication bottle or tube in a To prevent the medication from contamination.
medication tray.
9. Take the medication to the client’s room, check To ensure accuracy.

the room number against the medication card or
sheet.
10. Check the client’s ID band and ask the client to To ensure that the right client is given the right
state his / her name. medication.
11. Explain the procedure to the client and provide To reduce client’s anxiety and to gain his / her
privacy. cooperation.
12. Don a pair of gloves. To prevent contamination.
13. Provide tissue wipes to the client and instruct him To clear the nasal passages of mucus and secretions.
/ her to blow the nose.
14. Position the client properly and comfortably: To facilitate instillation of the drug.
Sitting position with the head tilted back or back –
lying position with the neck hyperextended over a
pillow.
15. Fill the dropper with the prescribed amount of To ensure accurate dosage.
medication.
16. Elevate the nares by pressing the thumb against To facilitate instillation of the drug.
the tip of the nose, the dropper is held just above
the nostril, and the drops are directed toward the
midline of the superior concha of the ethmoid
bones as the client breathes through the mouth.
17. Instruct the client not to sneeze and to remain in So that the solution will come in contact with all of
this position for 1 minute. the nasal surface.
18. Discard any unused medication remaining in the To prevent contamination.

dropper before returning the dropper to its
container.
19. Place client in a comfortable position. Provide To promote comfort.

with emesis basin and tissue wipes.
20. Do after – care of supplies and equipment To prevent the spread of microorganisms.
properly and wash your hands.
1. Document the name of drug, dosage, method of administration, time administered, and the site
where the drug was instilled (left, right or both nostrils).
2. Status of the mucous membrane, patient’s tolerance to the medication and effects of the
medication.
VI. ILLUSTRATION
Ethmoid and Sphenoid Sinuses
ADMINISTERING OPHTHALMIC IRRIGATION AND INSTILLATION

I. DEFINITION
Ophthalmic Irrigation – is the washing out of the conjunctival sac.
Ophthalmic Instillation – is the insertion of a medication in the form of liquids or ointments into the
eyes.
II. RATIONALE
1. To lubricate the eye or socket of a prosthetic eye.

2. To anesthetize the eye, dilate the pupil and stain the cornea (to identify abrasions and scars or
provide means of eye evaluation)
3. To decrease intraocular pressure (glaucoma).
4. To provide direct route for local effect.
5. To obtain desired therapeutic effect.
6. To remove foreign material.
III. EQUIPMENT
For an Instillation:
Medication
Dry sterile absorbent sponges
Sterile absorbent sponges soaked in sterile
For an Irrigation: normal saline
Sterile eye dressing / paper eye tape
Sterile gloves
Sterile container for the irrigating solution
Sterile eye syringe or irrigator (eyedropper)
Irrigating solution
Sterile kidney basin
Sterile cotton balls
Sterile normal saline (optional)
Sterile gloves
ACTION RATIONALE
1. Verify the medication or irrigation order. To ensure accuracy in drug administration.

For an instillation:
- Check the physician’s order for the
preparation, strength, and number of drops.
- Also confirm the prescribed frequency of the
instillation and which eye to be treated.
- Abbreviations are frequently used to identify
the eye: OD (right eye), OS (left eye), OU
(both eyes).
For an irrigation:
- Check the type, amount, temperature, and
strength of the solution and the frequency of
the irrigation.
2. Wash your hands. To prevent contamination.

- Explain the technique to the client. To reduce the client’s anxiety.
- Assist the client to a comfortable position, To promote comfort.
either sitting or lying. Tilt the client’s head So that the solution will run from the eye to the
toward the affected eye. Ensure that the light basin and not to the other eye.
source does not shine into the client’s eyes. To protect the eye.
- Place the drape and position the basin against To protect the client and the bedclothes.
the cheek below the eye on the affected side.
4. Assess the eye.

- Assess the eye for redness, the location, and This serves as a basis for future assessment and
nature of any discharge, lacrimation, and evaluation.
swelling of the eyelids or of the lacrimal gland.
- Note any complaints like itching, burning,

pain, blurring of vision, etc.
- Observe the client’s behavior like squinting,

blinking excessively, frowning, or rubbing the
eyes.
5. Clean the eyelid and eyelashes.

- Use sterile cotton balls moistened with sterile Material on the eyelid and lashes, if not removed,
irrigating solution or sterile normal saline, and can be washed into the eye.
wipe from the inner canthus to the outer To prevent contamination of the other eye and the
canthus. lacrimal duct.
6. Administer the irrigation or eye medication.

For an irrigation:
- Expose the lower conjunctival sac by separating To prevent blinking reflex.
the lids with the thumb and forefinger. Or, to To minimize the possibility of pressing the eyeball
irrigate in stages, first hold the lower lid down, and causing discomfort.
then hold the upper lid up. Exert pressure on the
bony prominences of the cheekbone and
beneath the eyebrow when holding the eyelids.
- Fill and hold the eye irrigator about 2.5 cm At this height, the pressure of the solution will not
above the eye. damage the eye tissue and the irrigator will not
touch the eye.
- Irrigate the eye, directing the solution onto To prevent possible injury to the cornea.
the lower conjunctival sac and from the inner To prevent contamination.
canthus to the outer canthus.
- Irrigate until the solution leaving the eye is To ensure accuracy.
clear (no discharge is present) or until all the
solution has been used.
- Instruct the client to close and move the eye To promote movement of secretion from the upper
periodically. Dry around the eye with cottonballs. to the lower conjunctival sac.
- Check the ophthalmic preparation as to To prevent a medication error.
name, strength, and number of drops if a The first bead of ointment from a tube is considered
liquid is used. Draw the correct number of contaminated.
drops into the shaft of the dropper if a
dropper is used. If an ointment is used,
discard the first bead.
- Instruct the client to look up to the ceiling. To prevent the client from blinking while the top
Give the client a piece of tissue. eyelid partially protects the cornea.
- Expose the lower conjunctival sac by placing the To minimize the possibility of touching the cornea,
thumb or fingers of your non-dominant hand on to avoid putting pressure on the eyeball, and to
the client’s cheekbone just below the eye and prevent the person from blinking or squinting.
gently drawing down the skin on the cheek.
- Using a side approach, instill the correct To prevent the client from blinking.
number of drops onto the outer third of the To prevent harm to the cornea.
lower conjunctival sac. Hold the dropper 1 to
2 cm above the sac.
Or
Holding the tube above the lower conjunctival
sac, squeeze 3 cm of ointment from the tube
into the lower conjunctival sac from the inner
canthus outward.
- Instruct the client to close the eyelids but not To spread the medication over the eyeball.
to squeeze them shut. Squeezing can injure the eye and push the
medication out.
- For liquid medications, press firmly or have To prevent the medication from running out of the
the client press firmly on the nasolacrimal eye and down the duct.
duct for at least 30 seconds. Check agency
practice.
7. Wipe the eyelids gently from the inner to the To prevent contamination while collecting excess
outer canthus. medication.
8. Apply an eyepad if needed, and secure it with To protect the eye, as needed.
paper eye tape.
9. Assess the client’s response. To assess the client’s reaction.
10. Do after – care of supplies and equipment and To prevent the spread of microorganisms.
wash your hands.
1. Assess the responses immediately after the instillation or irrigation and again after the medication
should have acted.
2. Record all nursing assessments and interventions relative to the instillation or irrigation including the
name of the drug, the strength, the number of drops if a liquid, the time and response of the client.
VI. ILLUSTRATION
Lower conjunctival sac
Exposing the lower conjunctival sac Instilling an eye drop into the lower conjunctival
sac
Instilling an eye ointment into the Pressing on the nasolacrimal duct

lower conjunctival sac
ADMINISTERING ORAL MEDICATION

I. DEFINITION
Administering medication prescribed by the physician to the client either in tablet, capsule, or liquid
form via the oral route.
II. RATIONALE
1. For drugs intended to be absorbed in the stomach and small intestine.
2. Offers convenience, economy and safety.
III. EQUIPMENT
Medicine cart or tray

Medication card
Medicine glass (for liquids)
Plastic medicine cups (for tablets and capsules)
Medicine dropper (for liquids less than 1 ml)
Drinking Straw (for liquid iron preparation and for clients who are unable to sit)
Wipes or tissues
Medication stick (to stir powdered medication mixed with water or any liquid)
Mortar and Pestle (to crush tablets to a fine powder)
ACTION RATIONALE
1. Organize the supplies. To save time and to reduce the chance of error.
- Assemble the medication tray and cups or
glass in the medicine room, or place the
medication cart outside the client’s room.
- Plan to give medications first to clients who

do not require assistance and last to those
who do. Arrange the medication cards or
records in this order.
- Assemble the medication cards or records for

each client together so that medications can
be prepared for one client at a time.
2. Verify the client’s ability to take the medication This serves as a basis in the plan of care.
orally. Determine whether the client can swallow,
is on NPO, is nauseated or vomiting, or has gastric
suction.
3. Verify the order by comparing the medication To ensure accuracy.

record with the physician’s written order. Report
any discrepancies in the order depending on the
agency policy.
4. Obtain the appropriate medication.

- Take the appropriate medication from the To prevent error in medication administration.
shelf, drawer, or refrigerator. The medication
may be dispensed in the bottle, box, or unit
dose package.
- Compare the label of the medication

container or unit dose package against the
order on the medication record or card.
5. Wash your hands.
6. Prepare the medication.

- Prepare the correct amount of medication for Aseptic technique maintains drug cleanliness.
the required dose without contaminating the
medication.
- While preparing the medication, recheck each This second check reduces the chance of error.
medication card or record with the prepared
drug and container.
For tablets or capsules from a bottle:

- Pour the required number into the bottle cap To prevent the medication from contamination.
and transfer to the medicine cup without
touching the tablets or capsules. Usually all
tablets or capsules to be given to the client
are placed in the same cup.
- Keep the medications that require specific To enable the nurse to withhold the medication if
assessments (PR, RR, BP) separate from the indicated.
others.
- If the client has difficulty swallowing, crush the For easy swallowing.
tablets to a fine powder in the mortar and
pestle or between 2 medication cups or
spoons. Then mix with a small amount of soft
food, water, or juice using the medication
stick.
For liquid medication:

- Shake the container, if needed. Mixes the medication thoroughly, when needed.
- Remove the cap and place it upside down on To avoid contaminating the cap.
the countertop.
- Hold the bottle with the label next to your This prevents the label from getting soiled and
palm and pour the medication away from the illegible due to spilled liquids.
label.
- Hold the medication cup at eye level and fill it To ensure accuracy of measurement.
to the desired level using the bottom of the
meniscus as the measurement guide.
- Before capping the bottle, wipe the lid with a To prevent the cap from sticking.
paper towel.
For an oral narcotic:

- Check the narcotic record for the previous Narcotics are carefully administered due to its
drug count and compare it with the supply potent effect and side effects.
available. Some narcotics are kept in specially
designed plastic containers that are sectioned
and numbered.
- Remove the next available tablet and drop it

in the medicine cup.
- Record the necessary information on the To control the dispensing of narcotics.

appropriate narcotic control record and sign
it.
For a unit – dose medication:

- Place the unwrapped unit – dose medications The wrapper keeps the medication clean and
directly into the medicine cup. facilitates identification.
For all medications:

- Place the prepared medication and To prevent error.
medication card together on the tray or cart.
- Return the bottle, box, or envelope to its This third check further reduces the risk of error.
storage place, and recheck the label on the
container.
- Avoid leaving prepared medications To prevent accidental disarrangement of the

unattended. medication.
7. Administer the medication at the correct time.

- Identify the client by comparing the name on To ensure accurate identification of the client.
the medication card with the name on the
client’s ID band or by asking the client to state
his / her name.
- Explain the purpose of the medication and To reduce the client’s anxiety and to facilitate
how it will help. Include relevant information acceptance and compliance with the therapy.
about the effects.
- Assist the client to a sitting position or, if not To facilitate swallowing and to prevent aspiration.
possible, to a lateral position.
- Take the required assessment measures (PR, Some medications require assessment measure
RR, BP). Report any abnormalities depending before giving the drug as part of precautionary
on the policy of the agency. measures.
- Give the client sufficient water or juice to For ease in swallowing and to facilitate absorption.
swallow the medication. Liquid medications
are generally diluted with 15 ml of water.
- If the client is unable to hold the pill cup, use To maintain cleanliness of the nurse’s hands.
the pill cup to introduce the medication into To ease swallowing.
the client’s mouth, and give only one tablet or
capsule at a time. A drinking straw can be
used for the water or juice if the client cannot
drink directly from the glass.
- If the client has difficulty swallowing, ask the To stimulate the swallowing reflex.
client to place the medication on the back of
the tongue before taking the water.
- If the medication has an objectionable taste, The cold will desensitize the taste buds and juices or
ask the client to suck a few ice chips bread can mask the taste of the medication.
beforehand, or give the medication with juice, To prevent staining of the teeth.
applesauce, or bread. For liquid iron
preparation, ask the client to use a drinking
straw.
- If the client says that the medication you are Unfamiliar drugs may signal a possible error.
about to give is different from what the client
has been receiving, do not give the
medication without checking the original
order.
- Stay with the client until the medication has The nurse must see the client swallow the
been swallowed. medication before the drug administration can be
recorded.
8. Dispose of supplies appropriately.
- Return the medication cards or records to the To prevent confusion and error.
appropriate file for the next administration
time.
- Replenish stock. To save time and effort.
1. Record promptly the medication given, dosage, time, any complaints or assessments of the client,
and your signature.
2. If the medication was refused or omitted, record this fact on the appropriate record, and document
the reason when possible. Endorse properly those medicines that were due but not given.
3. Return to the client when the medication is expected to take effect (usually 30 minutes) to evaluate
the effects of the medication.
ADMINISTERING OTIC IRRIGATION AND INSTILLATION
I. DEFINITION
Administering a prescribed medication to the client’s ears applied either as an irrigation or an

instillation. Solutions ordered to treat the ear are often referred to as otic (ear) drops or irrigations.
II. RATIONALE
1. To soften earwax.
2. To relieve pain.
3. To produce anesthesia.
4. To treat infection or inflammation.
5. To facilitate the removal of a foreign body.
6. To apply heat.
III. EQUIPMENT
For instillation:
For irrigation: Correct medication bottle with a dropper

Cotton – tipped applicator
Flexible rubber tip for the end of the dropper
Cotton fluff
Container for the irrigating solution
Irrigating solution, as ordered
Rubber bulb or Asepto syringe
Kidney basin
Moisture – resistant towel
Applicator swabs
Absorbent cotton balls
Gloves (optional)
ACTION RATIONALE
1. Verify the medication or irrigation order.
- Check the physician’s order for the kind of To ensure accuracy in drug administration.
medication or irrigation; the time, amount,
and dosage (if it is an instillation) or strength
and temperature (if it is an irrigation); and
which ear is to be treated.

For an irrigation:
- Explain that the client may experience a To gain the client’s cooperation.
feeling of fullness, warmth, and, occasionally,
discomfort when the fluid comes in contact
with the tympanic membrane.
- Assist the client to a sitting or lying position The solution can flow from the ear canal to a basin.
with head turned toward the affected ear.
- Place the moisture – resistant towel around To protect the client’s clothing and bedclothes.
the client’s shoulder under the ear to be
irrigated, and place the basin under the ear to
be irrigated.
- Assist the client to a side lying position with So that the medication will not flow out of the
the ear being treated at the uppermost. auditory canal.
3. Assess the pinna of the ear and the meatus of the This serves as a basis for future assessment and
external auditory canal for signs of redness, evaluation.
abrasions, or any discharge.
4. Don gloves if indicated. To prevent contact with blood and body fluids.
5. Clean the pinna of the ear and the meatus of the To prevent any discharges to be washed into the
ear canal by using cotton – tipped applicator and ear. The ear is cleaned before an instillation to
solution to wipe the pinna and auditory meatus. remove any drainage.
6. If doing an irrigation, prepare the equipment.

(Omit this step for an instillation.)
- Fill the syringe with solution Or
- Hang up the irrigating container, and run the To remove air from the tubing and nozzle.
solution through the tubing and the nozzle.
7. Administer the irrigation or ear medication.

For an irrigation:
- Straighten the auditory canal. For an infant, So that the solution can flow the entire length of the
gently pull the pinna downward. For an adult, canal.
pull the pinna upward and backward.
- Insert the tip of the syringe into the auditory The solution will flow around the entire canal and
meatus, and direct the solution gently upward out at the bottom. Gentle pressure is used to
against the top of the canal. prevent discomfort and damage to the tympanic
membrane.
- Continue instilling the fluid until all the To prevent obstruction in the flow of the solution.
solution is used or until the canal is cleaned,
depending on the purpose of the irrigation.
Take care not to block the outward flow of
the solution with the syringe.
- Dry the outside of the ear with absorbent To absorb the excess fluid.
cotton balls. Place a cotton fluff in the
auditory meatus.
- Assist the client to a side – lying position on To help drain the excess fluid by gravity.
the affected side.
- Warm the medication container in your hand, To promote the client’s comfort.
or place it in warm water for a short time.
- Partially fill the ear dropper with medication.
- Straighten the ear canal. To allow the flow of medication into the entire
length of the canal.
- Instill the correct number of drops along the To allow the medication to flow slowly into the
side of the ear canal. canal.
- Press gently but firmly a few times on the To assist the flow of medication into the ear canal.
tragus of the ear.
- Ask the client to remain in the side – lying To prevent the medication from escaping and to
position for about 5 minutes. allow the medication to reach all sides of the canal
cavity.
- Insert a small piece of cotton fluff loosely at To help retain the medication.
the meatus of the auditory canal for 15 to 20 Pressing the cotton fluff may interfere with the
minutes. Do not press it into the canal. action of the drug.
8. Assist client to a comfortable position. For client’s comfort.
9. Do after – care of equipment and supplies. To prevent the spread of microorganisms.
For an irrigation:
1. Assess the client for any discomfort and the appearance and odor of the fluid returns.
2. Document all nursing assessments and interventions relative to the procedure including the time of
administration, and the type, concentration, amount, and temperature of the solution used.
1. Assess the character and amount of discharge, appearance of the canal, discomfort and so on,
immediately after the instillation and again when the medication is expected to act. Inspect the
cotton ball for any drainage.
2. Document all nursing assessments and interventions relative to the procedure including the
medication, the time, the dose, and any complaints of pain.
VI. ILLUSTRATION
Normal position- Straighten the ear canal

of a child by pulling the pinna down and back
ADMINISTERING RECTAL INSTILLATION AND SUPPOSITORY

I. DEFINITION
The insertion of a suppository in the rectal canal.
II. RATIONALE
1. To provide an alternate route when there is irritation in the upper GI tract. (i.e. vomiting)
2. To offer an alternate route when the drug has an offensive taste or odor.
3. To maintain the chemical integrity of drug when digestive enzymes change the chemical properties
of the drug.
4. To improve the absorption of the drug.
5. To provide higher blood stream levels (titers) of medication.
6. To assist in bowel elimination.
III. EQUIPMENT
Prescribed rectal suppository KY jelly

Non-sterile gloves Tissue wipes
ACTION RATIONALE
1. Carefully check the physician’s order for the To ensure accuracy.

specific medication ordered, its dosage, and the
time of administration.
3. Prepare the necessary equipment. To save time and effort.

4. Remove the medication from the drug box or tray
in the medication cart.
5. Compare the medication label with the To ensure that it is the right drug.
medication record.
6. Place the medication and KY jelly (if needed) on a To prevent contamination of the medication.
tray if not using a medication cart.
7. Bring the medication to the client’s room.
8. Check the client’s room number against the To avoid error.

medication card.
9. Check the client’s ID band and let the client state To ensure that the right drug is given to the right
his / her name. client.
10. Ask the client if he / she needs to void. To reduce discomfort.
11. Explain the procedure to the client. To gain cooperation from the client.
12. Assist the client to a Sim’s (left lateral) position To facilitate insertion of the suppository.
with the upper leg flexed and drape To provide privacy.
appropriately. Provide privacy and comfort.
13. Unwrap the suppository and place it on the

opened wrapper.
14. Wear non – sterile gloves. May don a glove only To prevent contamination of the nurse’s hand by
on the hand that will insert the suppository. rectal microorganisms and feces.
15. Lubricate the smooth rounded end of the To prevent anal friction and tissue damage.
suppository and the gloved index finger.
16. Instruct the client to breathe through the mouth To promote relaxation of the client’s anal sphincter.
while the suppository is inserted gently into the
anus and along the wall of the rectum with the
gloved index finger.
In adults, suppositories are inserted to a depth of To enhance effectivity.
10 cm (4 in) and in infants or children, 5 cm (2 in)
or less.
17. To dispel the client’s urged to expel the To prevent the suppository from being expelled by
suppository, press the client’s buttocks together the client.
for a few seconds.
18. Once the gloved index finger has been To contain the rectal microorganisms and to
withdrawn, remove the glove by turning it inside prevent their spread.
out and place it on a paper towel.
19. Instruct the client to remain in the left lateral For effective results.
position for at least 15 minutes.
20. Do after – care and wash hands. To prevent the spread of microorganisms.
1. Assess the client’s response when the medication is expected to act.

2. Assess the condition of the rectal area.
3. Record any assessment and intervention done including name of the drug, the time of
administration, the dosage, and all other data just like with other medications.
VI. ILLUSTRATION
Inserting a rectal
suppository beyond the
internal sphincter and
along the rectal wall
PARENTERAL MEDICATIONS
GENERAL PROCEDURE IN GIVING INJECTIONS
I. DEFINITION
Parenteral means the administration of substances into the body other than through the mouth;
applied, for example, to the introduction of drugs or other agents into the body by injection.
II. RATIONALE
For quick absorption of a drug by the body.
III. EQUIPMENT
Medication tray Hypotowel

Medication cards Alcohol wipes
Syringes with appropriate needles Vials or ampules of medication
Diluent (when necessary) Dry gauze pads or cotton balls
Band-aid (optional)
ACTION RATIONALE
1. Obtain the client’s medication record. It may be a To determine the drug to be given.
medication card, medication sheet or drug kardex
medication in your facility.
2. Compare the medication record with the most To ensure that the drug to be given was not
recent physician’s order. discontinued.
3. Check the label on the ampule or vial carefully To make sure that the correct medication is being
against the medication record. prepared.
5. Gather all equipment for injection. Assemble To save time and effort.
things while maintaining sterility.
6. Select appropriate syringe and needle size. For accuracy and comfort.
Consider the site and route of administration and
viscosity of the medication.
PREPARING AND WITHDRAWING MEDICATION FROM AN

AMPULE
1. Hold the ampule and lightly flick its upper stem To prevent spillage of the drug which is trapped at
until all fluid flows into the main portion / lower the upper stem of the ampule.
chamber of the ampule.
2. If the ampule is not scored, partially file its neck For ease in breaking the ampule.
to start a clean break.
3. Place a sterile gauze or alcohol wipe around the To shield the nurse’s fingers from the sharp edges of
neck of the ampule. the broken ampule.
4. Firmly grasp the neck of the ampule and quickly To direct glass fragments away from the nurse’s face
snap the top off away from your body. Place the and fingers. To prevent spillage of medication.
ampule on a flat surface.
5. Withdraw the medication from the ampule, To prevent the transmission of microorganisms.
maintaining a sterile technique.
- Check the connection of the needle to the To ensure an airtight system.
syringe by turning the barrel to the right while
holding the needle guard.
- Remove the needle guard and hold the syringe To promote dexterity.
using the dominant hand.
- With your non-dominant hand, grasp the To provide access to medication.
ampule and turn it upside down or stabilize the
ampule on a flat surface.
- Insert the needle into the center of the To prevent contamination of the needle tip or shaft.
ampule; do not allow the needle tip or shaft to
touch the rim of the ampule.
- Keep the needle tip below the level of the To prevent air from entering the syringe and fluid
meniscus. from leaking out while the ampule is inverted.
- Aspirate the medication by gently pulling on To allow the medication to enter the syringe.
the plunger.
- If air bubbles are aspirated, remove the needle To prevent loss of medication from the ampule
from the ampule. Hold the syringe with the caused by air pressure.
needle pointing up and tap the sides of the To move air bubbles above the fluid level.
syringe. Draw back slightly on the plunger and Only air is ejected from the syringe.
gently push upward to eject air. Reinsert the
needle into the ampule and continue to
withdraw the medication.
6. Remove excess air from the syringe and check if For accuracy.
the amount of drug in the syringe is the same
amount to be administered. Recap.
7. Change the needle and properly discard the used To reduce the risk of irritation on the tissues caused
needle. Secure the needle to the syringe by by the presence of the drug on the used needle.
turning the barrel to the right while holding the
needle guard.
PREPARING MEDICATION IN A VIAL
1. Premixed liquid medication.

- Mix the solution, if necessary, by rotating the Shaking may cause the mixture to foam.
vial between the palms of the hands, not by
shaking.
2. Powdered medication.
- Read the manufacturer’s directions. For accuracy.
- Withdraw an equivalent of air from the vial To allow the solvent to be introduced easily since a
before adding the solvent, unless otherwise negative pressure is created.
indicated by the directions.
- Add the amount of sterile water, saline, or To prepare a solution.
solvent prescribed in the directions.
- Mix the solution by rotating the vial between Shaking may cause the mixture to foam.
the palms of the hands, not by shaking.
- If a multidose vial is reconstituted, label the Time is an important factor to consider in the
vial with the date and time it was prepared, expiration of these medications.
the amount of drug contained in each milliliter The amount of drug prepared and the person who
of solution and your initials. prepared the drug are also important factors to
consider.
WITHDRAWING MEDICATION FROM A VIAL
1. Prepare the vial. Open the alcohol wipe.

- New vial: Remove the protective metal cap To prevent surface contamination.
and clean the rubber cap with alcohol wipe by
rubbing in a rotary motion.
- Used vial: Clean the rubber cap with alcohol

wipe by rubbing in a rotary motion.
2. Prepare the syringe.

- Grasp the needle with cap and turn the barrel To ensure a closed system.
of the syringe to the right.
- Remove the needle cap; then draw up into the To prevent the formation of a vacuum in a sealed
syringe the amount of air equal to the volume vial.
of the medication to be withdrawn.
3. Inject the air into the vial, keeping the bevel of The air will allow the medication to be drawn out
the needle above the surface of the medication. easily since a positive pressure is created inside the
vial. To avoid creating bubbles in the medication.
4. Invert the vial, hold it at eye level while For accuracy.
withdrawing the correct dosage of the drug into
the syringe. The bevel of the needle should be
below the fluid level.
5. Expel air from the syringe while the needle The tapping motion will cause the air bubbles to rise
remains within the inverted vial by tapping the to the top of the syringe.
side of the syringe with your fingers.
6. Check the amount of medicine in the syringe. To ensure an accurate dose.
7. Turn the vial upright and remove the needle. To prevent the leakage of the solution from the vial.
8. Replace the needle cap. Open the sterile package To prevent needle sticks.
of the new needle. Remove used needle and
dispose properly. Attach the new needle to the For client’s comfort.
syringe.
9. Compare the amount of medication in the syringe To ensure an accurate and correct dosage.
with the prescribed dose.
ADMINISTERING INTRADERMAL / INTRACUTANEOUS INJECTION
I. DEFINITION
An intradermal injection is the administration of a drug into the dermal layer of the skin just beneath the
epidermis.
II. RATIONALE
1. To identify allergy and sensitivity reaction.

2. To administer tuberculin test and vaccines.
III. EQUIPMENT
Tuberculin syringe with a short bevel G-26 ½” needle Medication as prescribed

Diluent or distilled water Clean gloves (optional)
Alcohol wipes Dry cotton balls
Ballpen (black or blue)
ACTION RATIONALE
1. Check with the client and the chart for any known To prevent the occurrence of hyper-sensitivity
allergies. reaction such as hives, urticaria, or anaphylactic
shock.
2. Wash hands. To reduce the transmission of microorganisms.
3. Follow the 6 “Rights” in drug administration. For accuracy and safety on the part of the client.
4. Prepare the medication from an ampule or vial Saves time and effort.
(refer to the general procedure in giving
parenteral medication / injection). Take the To protect the medication from contamination. The
prepared medication (in a medication tray) to the client’s bed is considered contaminated.
client’s room and place on a clean surface, not on
the client’s bed.
5. Check the client’s name, bed / room # or ID band. For accuracy.
6. Explain the procedure to the client. To reduce the client’s anxiety and enhance
cooperation.
7. Place the client in a comfortable position; provide To promote comfort.
privacy.
8. Wash hands and don a pair of gloves (optional). To decrease contact with blood and body fluids.
9. Select and cleanse the site.

- Assess the client’s skin for bruises, redness, or This serves as a basis for future evaluation.
broken tissue.
- Select an appropriate site (usually the inner Sensitivity reaction can easily be detected on these
aspect of the forearm, upper chest or scapular sites.
area of the back).
- Cleanse the site with an alcohol wipe using a To reduce the presence of microorganism; done
firm circular motion, from the center outward. from the cleanest to the least clean area.
Allow the alcohol to dry.
10. Prepare the syringe for injection.

- Remove the needle guard. To ensure accurate and correct dosage of
medication.
- Express any air bubbles from the syringe.
- Check the amount of solution in the syringe.
11. Inject the medication.

- Hold the syringe with your dominant hand. For ease.
- With the non-dominant hand, grasp the To facilitate needle insertion.

client’s dorsal aspect of the forearm and gently
pull the skin taut on the ventral forearm.
- Insert the needle at a 10 to 15 - degree angle To ensure accurate administration of the drug.
with the bevel facing upward until resistance is
felt, advance the needle approximately 3 mm
below the skin surface.
- Administer the medication slowly until a bleb This indicates that the medication was injected into
or wheal is formed. the dermis.
- Withdraw the needle.
- Pat the area gently and lightly with a dry To prevent skin irritation.
cotton ball.
- Do not massage the area. To prevent the medication from dispersing through
the needle site.
12. Draw a circle around the perimeter of the bleb / To facilitate assessment of reaction and ensure
wheal with a ballpen. accuracy of findings.
13. Return the client to a comfortable position. For client’s comfort.
14. Discard gloves and other supplies properly. To protect the nurse and others from injury and
contamination.
1. Record the medication, injection site, and the client’s reaction.
2. Assess the site after 30 minutes for redness or swelling. If present, immediate referral to the
physician is done.
VI. ILLUSTRATION
ADMINISTERING A SUBCUTANEOUS INJECTION

I. DEFINITION
Administering a subcutaneous injection is a technique in parenteral drug administration wherein the
drug is introduced into the subcutaneous tissue, between the dermis and the muscle.
II. RATIONALE
To produce a sustained effect of the drug.
III. EQUIPMENT
3 cc. syringe with a 5/8-inch or 1/2-inch g. 25 needle; 3/8-inch needle for children and 1 -inch needle for
obese patients
Medication as prescribed Alcohol wipes
Medication card Clean gloves (optional)
ACTION RATIONALE
1. Check with client and the chart for any known To prevent the occurrence of hypersensitivity
allergies. reaction.
2. Verify the medication order. To promote accuracy.
3. Wash hands. To prevent the transmission of microorganisms.
4. Follow the 6 “Rights” in giving medication. To promote client’s safety.
5. Prepare the medication from an ampule or vial. To ensure correct and accurate preparation of
Refer to general procedure in giving medication. medication.
Take the medication (placed on a medication tray)
to the client’s room and place on a clean surface, To prevent contamination.
not on the client’s bed.
6. Check the client’s ID band or bed number. To accurately identify the client.
7. Explain the procedure to the client. To reduce client's anxiety and enhance cooperation.
8. Place the client in a comfortable position. Provide To promote comfort and relaxation.
privacy.
9. Don a pair of clean gloves. To decrease contact with blood and body fluids.
10. Select and clean the site.

- Select a site free of bruises, redness, hard Drugs are well-absorbed when injected into a
tissue, tenderness, or broken skin. healthy tissue.
- Clean the site with an antiseptic / alcohol wipe To remove surface microorganisms.
in a circular motion, from the center of the site
moving outward. Allow it to dry.
11. Prepare for the injection.

- Remove the needle cap / guard while waiting To prevent the needle from getting contaminated.
for the antiseptic / alcohol to dry. Pull the cap
straight off.
- Expel any air bubbles from the syringe by To prevent the injection of air into the tissues.
inverting the syringe and gently pushing on the
plunger until a drop of solution can be seen in To promote accuracy.
the needle bevel. If air bubbles still remain,
flick the side of the syringe barrel. Check if the
amount of solution in the syringe is the exact
dosage needed for injection.
- Grasp the syringe in your dominant hand by For ease and comfort in administering the injection
holding it like a dart between your thumb and correctly.
fingers with palm facing to the side or upward
for a 45 – degree angle insertion (if needle The angle of insertion depends on the length of the
length is 5/8-inch) or with the palm downward needle to ensure that the medication is injected in
for a 90 – degree angle insertion (if needle the subcutaneous tissue.
length is ½-inch; shorter needles, 3/8-inch for
children and longer needles, 1-inch for very The length of the needle depends on the amount of
obese clients). tissues on the site.
- Using the non-dominant hand, pinch or spread Pinching the skin lessens the sensation of needle
the skin at the site (depending on the firmness insertion while spreading the skin facilitates needle
of the client’s tissue). insertion.
12. Administer the injection.

- Insert the needle at a 45 – degree angle or 90 – To allow the needle to reach the subcutaneous layer
degree angle (depending on the needle and not on the muscles.
length).
- Release the subcutaneous tissue and grasp the To check if the needle is in a blood vessel.
barrel of the syringe with the non-dominant Omitted with Heparin injection to prevent bleeding
hand. and severe bruising.
- With the dominant hand, aspirate by pulling If blood appears in the syringe, the needle is in a
back on the plunger gently (except with blood vessel.
Heparin injection). If blood appears in the
syringe, withdraw the needle, discard the
syringe and prepare a new injection. If blood
does not appear, continue to administer the
medication.
- Inject the medication by holding the syringe To minimize discomfort for the client.
steady and depressing the plunger with a slow
even pressure.
- Remove the needle quickly, pulling along the This places countertraction on the site and
line of insertion while depressing the skin with minimizes client’s discomfort.
your non-dominant hand.
- Massage the site lightly with a sterile antiseptic To hasten absorption.

alcohol wipe or apply slight pressure on the
medication site. This is not done with Heparin To prevent bleeding and ecchymoses.
and Insulin injections.
13. Position the client in a comfortable position. To promote comfort.
14. Dispose used supplies appropriately. To protect the nurse and others from injury and
contamination.
1. Record on the medication chart the route, site and time of administration.
2. Observe the client for any side or adverse effects and assess the effectiveness of the medication at
the appropriate time.
VI. ILLUSTRATION
ADMINISTERING AN INTRAMUSCULAR INJECTION

I. DEFINITION
An intramuscular injection is a method of drug administration wherein the medication is introduced into
the muscles of the body.
II. RATIONALE
1. It enhances rapid absorption of the drug because of the greater blood supply to the muscles.
2. It provides an alternative route when drug is irritating.
3. It allows introduction of a larger volume of fluid without discomfort; although amount varies with
muscle size and condition.
4. It allows drug administration to unconscious patients, those with gastric disturbances, and those on
NPO.
III. EQUIPMENT
Medication as prescribed 3 or 5 cc. syringe with G-22 to 23 1” to 1 ½” needle

Alcohol wipes Medicine card
Clean gloves (optional)
ACTION RATIONALE
1. Check with the client and the chart for any known To prevent the occurrence of hypersensitivity
allergies. reaction.
2. Verify the medication order. For accuracy.
4. Follow the 6 “Rights” in drug administration. To promote client’s safety.
5. Prepare the medication from an ampule or vial To promote accuracy.

(refer to the general procedure in giving
parenteral medication).
6. Take the prepared medication (placed in a To protect the medication from contamination. The
medication tray) to the client’s room and place on client’s bed is considered contaminated.
a clean firm surface (not on the client’s bed).
7. Check the client’s ID band and have the client To accurately identify the client.
state his / her name.
8. Explain the procedure. To reduce anxiety and enhance cooperation.
9. Place the client in a comfortable sitting, side - To provide easy access to the site. To promote
lying, supine, or prone position depending on the comfort and reduce client’s anxiety.
chosen site. Provide privacy
10. Don a pair of gloves. To prevent contact with blood and body fluids.
11. Select, locate, and clean the site.

- Assess the client’s skin for redness, scarring, To avoid potential problem that may affect drug
breaks in the skin and palpate for lumps or absorption.
nodules.
- Select the site using the anatomic landmarks. To prevent hitting large nerves and blood vessels.
Remember to alternate sites each time an
injection is given.
- Cleanse the area with an alcohol wipe from the To reduce surface contamination.
center of the site moving outward using friction.
Allow it to dry. To prevent the introduction of alcohol into the
tissues.
12. Prepare the syringe for the injection.
- Remove the needle cap without contaminating To protect the needle from contamination until it is
the needle. ready for use.
- Invert the syringe and expel excess air, leaving This is referred to as the air-lock or air-bubble
only 0.2 ml of air. technique. This prevents the tracking of the
medication through the sensitive subcutaneous
tissues.
13. Inject the medication.
- Use the non-dominant hand to spread the skin To make the muscle firmer and to facilitate
at the site. If the client is emaciated or an insertion.
infant, the muscle may be pinched.
- Holding the syringe between the thumb and To ensure that the needle is injected into the
forefinger, quickly insert the needle at a 90- muscles.
degree angle or dart-like motion. Quick motion lessens the client’s discomfort.
- Aspirate by holding the barrel of the syringe To determine whether the needle is in a blood
steady with the non-dominant hand and by vessel.
pulling back on the plunger with the dominant
hand. Observe for blood. If present, withdraw The presence of blood indicates that the needle is in
the needle, discard the syringe and prepare a a blood vessel.
new injection.
- If blood does not appear, inject the medication To allow the medication to disperse into the muscle
steadily and slowly. tissue.
- Withdraw the needle quickly while applying To decrease tissue irritation.

pressure at the injection site. Use gentle
pressure with alcohol wipe.
14. Position the client in a comfortable position. To promote absorption of the medication.
Encourage clients receiving injections at the
ventrogluteal site to do leg exercises (flexion and
extension).
15. Do after - care of supplies and discard properly. To prevent injury and contamination.
1. Document on the medication record the dosage, route, site and time of administration.
2. Evaluate and document the client’s response to medication.
VI. ILLUSTRATION
DORSOGLUTEAL SITE VENTROGLUTEAL SITE
An intramuscular needle inserted into the muscle layer.

VASTUS LATERALIS SITE RECTUS FEMORIS MUSCLE
D E L T O I D M
VASTUS LATERALS MUSCLE
ADMINISTERING AN INTRAMUSCULAR
INJECTION
USING THE Z-TRACK METHOD
I. DEFINITION
Method of injecting medications intramuscularly when only minute quantity of solution is used / needed
or when an iron preparation is administered.
II. RATIONALE
1. To prevent staining and bruising the skin.

2. To prevent the escape of solution from the injection site.
III. EQUIPMENT
Syringe and needle for intramuscular injection Alcohol wipes

Medication as prescribed Clean gloves
ACTION RATIONALE
1. See the general procedure in giving intramuscular This allows the nurse to perform the procedure
injection. correctly.
2. Place the client in a comfortable and appropriate Proper site can be mapped out.
position, preferably in a prone position.
3. Cleanse the area with alcohol wipe in a circular To remove surface microorganisms.
motion, from the center of the site moving
outward.
4. Pull the skin and subcutaneous tissue about 2.5 To prevent the medication from seeping into the
cm to 3.5 cm to one side away from the injection subcutaneous tissue.
site.
5. Insert the needle at a 90 – degree angle, To ascertain placement of the needle.

withdraw the plunger with the dominant hand
while holding the syringe. If there is blood,
withdraw the needle, discard and prepare a new
injection. If there is no blood, inject the
medication slowly while maintaining the traction.
6. Withdraw the needle and then permit the skin to To prevent tissue irritation and damage.
return to its normal position (release the
traction). Do not massage the site of injection.
7. Discard used supplies properly. To protect the nurse and others from injury and
contamination.
1. Record the medication, site of injection, route, and amount on the medication chart.
2. Evaluate and record the client’s response to the medication.

VI. ILLUSTRATION
ADMINISTERING NEBULIZATION THERAPY

(Phroehl Jean A., Emergency Nursing Procedures, 2004, 3 rd ed.)
I. DEFINITION
Nebulizer Therapy – is also known as “Neb”, “updraft”, “SVN” (small volume nebulizer), or “acorn neb”.
A method of administering medications directly to the respiratory tract or site of action (the lungs).
II. RATIONALE
1. Nebulizers use baffles to break down particles to a size small enough to be inhaled into more distal
parts of the tracheobronchial tree.
2. Delivery of nebulized medications to the lungs is very rapid, so the onset of action is faster than with
the subcutaneous or oral route.
3. The delivery of nebulized medications also humidifies inspired air, which helps loosen bronchial
secretions.
III. EQUIPMENT
Nebulizer machine/ O2 compressor Mouthpiece

Prescribed medication/s Tissue paper / paper towel
Connecting tube Short, corrugated tubing
Nursing considerations:
1. An unconscious or confused patient who cannot cooperate with the procedure may require a mask; but
the mask lessens the effectiveness significantly.
2. Chronic Obstructive Pulmonary Disease patients should generally receive nebulization with compressed
air instead of Oxygen.
3. Nebulized medications are contraindicated in the presence of absent or severely diminished breath
sounds unless the nebulized medications are delivered through an endotracheal tube that uses positive
pressure. A patient with decreased air exchange may not be able to move the medications adequately
into the respiratory tract.
4. Use catecholamines with caution in patients with cardiac irritability. When inhaled, they increase the
cardiac rate and may precipitate dysrhythmias.
5. Never administer nebulizer treatments to a crying child; crying completely prevents absorption of
nebulized medication.
ACTION RATIONALE
1. Explain the procedure to client. To gain client’s cooperation.
2. Place the client in a comfortable upright or To allow for greater diaphragmatic expansion and
semi-fowler’s position. lung compliance.
To create baseline data. Bronchodilators and/or

catecholamines may produce tachycardia and may
3. Assess the heart rate of the client (before, precipitate dysrhythmias, dizziness, nausea, and
during, and after the procedure) diaphoresis.
4. Assemble the nebulizer and the tubing and

instill the prescribed medication into the
nebulizer.
If flow is too forceful, a stream is generated and

5. Add the amount of sterile normal saline to the medication may be wasted.
the nebulizer as prescribed (2.5 ml is a
common volume for diluent)
6. Attach the nebulizer to a source of
compressed gas (a rate of 6-8 L/min can be
used) then adjust the flow until a light mist
is created.
To encourage optimal dispersion of the medication
and will ensure that medication is deposited below
the level of the oropharynx.
7. Attach the corrugated tubing to the
nebulizer.
To allow forceful coughing and facilitate
expectoration of secretions.
8. Give patient the mouthpiece or put on

patient’s mask.
To facilitate movement of secretions for easy
expectoration.
9. Coach the patient in the correct breathing To determine any changes in the client’s heart rate
technique. Instruct to exhale and take in a and breathing sounds.
deep breath from the mouthpiece, hold
breath briefly then exhale. Too keep the nebulizer and other equipment ready
for use for the next 24 hours and to prevent
spread of microorganisms at the same time.
10. Observe expansion of the client’s chest to

ascertain that he/she is taking deep
breaths.
11. Instruct client to breathe slowly and

deeply until all medication is nebulized.
12. Encourage client to deep breathe and

cough after completion of the treatment.
13. Reassess vital signs and breathing sounds.
14. Do after care of equipment (disassemble

and clean nebulizer).
 Note: connecting tube and mouthpiece
are replaced every 24 hours
1. Record the medication used, the time and dosage.

2. Document characteristics of secretions, the amount, color and consistency.
3. Breathing sounds are improved.
4. Whether patient experiences less labored or normal, comfortable breathing.
METERED DOSE INHALER
I. DEFINITION
Metered-Dose Inhaler – also known as MDIs or “puffers”. They dispense medications into the lungs
through the use of an aerosol spray, mist, or fine powder.
II. RATIONALE
1. To administer medications directly to the pulmonary structures.

2. To assist in the relief of bronchospasm in reversible obstructive airway disease.
3. To prevent exercise-induced bronchospasm.
4. To decrease likelihood of systemic side effects and an immediate relief of symptoms.
III. EQUIPMENT
Metered-dose inhaler Prescribed medication

Spacer (example is Aerochamber) – optional Facial tissues
Wash basin or sink with warm water Paper towel
1. Improper techniques result in medication not reaching the bronchial tubes or air passages.
2. Remember to remove the mouthpiece cap and shake the canister to mix the medication properly.
3. The patient may be unable to use an MDI because of altered mental status, an elderly, and the very
young or with deterioration of clinical condition.
ACTION RATIONALE
1. Explain the type of medication
To gain client’s participation.
administration to client and significant
others.
2. Assess breath sounds, heart rate, and

respiratory rate.
3. Place client in an upright position.
4. Prepare equipment needed at client’s

bedside.
To create baseline data. Medications like bronchodilators
5. Warm by rolling in hands and shake the may cause increased cardiac rate that may lead to
inhaler canister immediately before using. dysrhythmias.
Remove the protective cap and make sure
the metal canister is firmly seated in the
plastic case.
To allow greater expansion of the lungs and diaphragm

6. Hold the mouthpiece 1-2 inches from the thereby increasing ventilation.
mouth, keeping the canister in an upright
position.
7. At the end of expiration, depress the metal

canister (with two of your fingers on top of
the canister and your thumb on the bottom
To allow easy reach of the nurse and limit unnecessary
of the plastic metered-dose inhaler) while
the patient inhales deeply and slowly movements.
through the mouth.
8. Have the patient hold the breath as long as

possible, at least 4-10 seconds.
9. Wait for 30-60 seconds and then repeat

To mix properly the medications ready for use.
steps 6 to 8, as ordered.
10. To use a spacer, insert the canister into

the spacer and put the mouthpiece into
the patient’s mouth before activating the
MDI.
11. Encourage the client to perform deep

breathing and coughing after medication.
12. Reassess the vital signs and breathing
sounds.
13. Do after care of articles used. Clean the

MDI plastic canister after each use and
dry it thoroughly.
To ensure that medication can directly enter the lower

respiratory tract.
To provide adequate ventilation of the lungs.

To trap the medication mist inside the chamber, allowing
the patient to inhale and exhale slowly several
times without removing the mouth from the spacer.
This ensures maximal medication delivery.
To facilitate movement and expectoration of secretions.
To determine improvement or changes in vital signs and

breathing sounds after taking the medication.
To prevent clogging of the valve in the mouthpiece and

prevents the spread of microorganisms.
1. Notify the physician if shortness of breath or dyspnea persists after the metered-dose inhaler is
used.
2. Record the reaction of the client to medication.
3. Record the medication and time of administration.
4. Note and record any changes in the vital signs and breathing sounds.
ASSISTING IN INTRAVENOUS FLUID THERAPY THROUGH VENIPUNCTURE USING
NEEDLE/CATHETER
(Wolters Kluwer, Lippincott Manual of Nursing Practice, 2010, 9 th ed.)
I. DEFINITION
Intravenous Therapy – is the administration of fluids into a vein. It can be administered centrally (into a
large vein in close proximity to the heart) or peripherally (into the veins of the extremities or scalp).
II. RATIONALE
1. Maintain or replace body stores of water, electrolytes, vitamins, proteins, fats, calories in the
patient who cannot maintain an adequate intake by mouth.
2. Restore acid-base balance.
3. Restore blood component volume.
4. Administer safe and effective infusion of medications by using the appropriate vascular access.
5. Provide nutrition while resting the GI tract.
6. To establish lifeline for emergency medications.
III. EQUIPMENT
Tourniquet (non-latex preferably) I.V. tubing

Disposable gloves Adhesive/non-allergic tape
Desired I.V. cannula and size Prescribed I.V. solution
Winged (butterfly) needle of desired size arm splint (if necessary)
Antiseptic swab (alcohol, iodine, povidone-iodine, chlorhexidine)
Desired catheter (Teflon, Silastic Polyurethane or Polyvinyl Chloride)
General Guidelines:
1. Before starting an I.V. therapy, consider the duration of therapy, type of infusion, condition of veins,
and medical condition of the patient to assist in choosing I.V. site and type of catheter.
2. Ensure that you are competent in initiating the type of I.V. therapy decided on and familiar with
facility policy, and procedure before initiating therapy.
3. After initiation of I.V. therapy, monitor the patient frequently for:
 Signs of infiltration or sluggish flow
 Signs of phlebitis or infection
 Correct solution, medication, volume and rate
 Dwell time of catheter and need to be replaced
 Condition of catheter dressing and frequency of change
 Fluid and electrolyte balance status of patient
 Signs of fluid overload and dehydration
 Monitor patient’s satisfaction with mode of therapy
4. Know the type of I.V. fluid, its component and effects
Types of I.V. fluids:
a. Isotonic – a solution that exerts the same osmotic pressure as that found in plasma.
Examples are: 0.9% NaCl (Plain Normal Saline Solution)

Lactated Ringer’s Solution
Blood components (Albumin 5%, Plasma)
Dextrose 5% in water (D5W)
b. Hypotonic – a solution that exerts less osmotic pressure than that of blood plasma.
Administration of this fluid generally causes dilution of plasma solute concentration and force
water to move into cells to reestablish intracellular and extracellular equilibrium; cells will then
expand or swell.
Examples are: 0.45% NaCl (Half Normal Saline Solution)
0.33% NaCl (1/3 Normal Saline Solution)
c. Hypertonic – a solution that exerts a higher osmotic pressure than that of blood plasma.
Administration of this fluid increases the solute concentration of plasma, drawing water out of
the cells and into the extracellular compartment to restore osmotic equilibrium; cells will then
shrink.
Examples are: D5W in Normal Saline Solution D5W in Half Normal Saline Solution
D10W D20W
3% or 5% Sodium Chloride Solution Hyperalimentation Solutions
D5W in Lactated Ringer’s Solution Albumin 25%
Composition of I.V. fluids:

 Saline Solutions – water and electrolytes (Na + and Cl-)
 Dextrose Solutions – saline water and calories
 Lactated Ringer’s – water and electrolytes (Na +, K+, Ca++, Cl-, lactate)
 Balanced Isotonic Solution - water, some calories, and electrolytes (Na+, K+, Cl-,
Mg++, HCO3-, gluconate)
 Whole Blood and Blood Components

 Plasma Expanders – Albumin, Mannitol, Dextran, Plasma Protein Fraction 5% (Plasmanate),
Hetastarch (Hespan); exert increase oncotic pressure, pulling fluid from the interstitium into the
circulation and temporarily increasing blood volume
 Parenteral Hyperalimentation – fluid, electrolytes, amino acids, and calories
ACTION RATIONALE
1. Wash hands. To prevent possible transfer of bacteria.

It is required before handling sterile supplies and
venipuncture.
To help alleviate anxiety. Start the infusion in the opposite

arm if possible.
2. Verify the order.
To prevent infusion of air and potential air embolism.
3. Explain the procedure. Ascertain whether the
patient is left or right handed.
4. Clear I.V. and winged needle tubing with air

To comply with CDC requirements to minimize passing of
(clear air with fluid from infusing tubing by
blood-borne pathogens between the patients.
attaching a needle, or by irrigating the needle
with saline in a sterile syringe).
To prevent possible complications or injury. A suitable I.V
site is recommended for comfort of the patient.
The vein must be visible or palpable before venipuncture is

attempted. The tourniquet should be applied not
too tightly so it does not interfere with the arterial
blood flow.
5. Put on gloves.
To increase blood flow in the area and a tourniquet may
not be necessary on greatly distended veins.
To prevent trauma to the arm from extended application

of the tourniquet. It can be reapplied later.
To reduce the number of skin microorganisms and

6. Select a site for insertion. minimizes risk of infection. Alcohol may be used
alone if the patient is allergic to iodine; otherwise
it should be used as part of a two-step process.
7. Apply a tourniquet 2-6 inches (5-15 cm) above

the desired insertion site and ascertain
satisfactory distension of the vein. Distal If 1%-2% iodine is used, it should be used before alcohol
pulses should remain palpable. for 30-60 seconds and allowed to dry.
Chlorhexidine is an alternative agent that can be
8. Have the patient open and close his fist several used alone.
times.
9. Remove the tourniquet.

To facilitate catheter insertion.
10.Clean the site:

a. Clip hair if the site is too obscured.
To stabilize the vein and facilitate successful cannulation.
b. Clean the skin with an alcohol swab in a
circular motion outward from the site for at
least 30 seconds.
To allow for the smallest and sharpest point of the needle

to enter the vein first.
c. Prepare the skin with a povidone-iodine

swab for 1 minute, working from the center
of the proposed site to the periphery until a
circle of 2-4 inches (5-10 cm) has been
disinfected.
To check if satisfactory penetration is evidenced by a
sudden decrease in resistance and by the
appearance of blood coming back into the
catheter.
To prevent puncturing the vessel wall.
d. Allow the area to air dry.
11.Reapply a tourniquet.
To ensure entry into the vein.
To prevent inadvertent puncture of the vein and provides

stability of catheter for insertion.
PERFORMANCE PHASE: CATHETER INSERTION
To start again than to cause further damage to the vessel.
The catheter may have become dislodged.
Flow of flush solution may advance catheter.

1. Remove the needle guard.
2. Hold the patient’s arm so your thumb is

positioned approximately 2 inches
3. the site. Exert traction on the skin in the

To reduce the blood leakage while removing the needle
direction of your hand.
and connecting tubing to the infusion set.
4. Insert the needle, bevel up, through the skin at

an angle. Use a slow, continuous motion.
5. If the vessel rolls, it may be necessary to
penetrate the skin at a 20-degree angle and
then apply a second thrust parallel to the skin.
6. When the vein is entered, lower the catheter

to skin level.
7. When inserting, always hold the catheter by

the clear plastic flashback chamber and not by
the colored hub.
8. Advance the catheter approximately ¼ to ½

inch into the vein.
9. Pull back on needle to separate needle from

the catheter about ¼ inch and advance the
catheter into the vein.
To secure the I.V. catheter and prevents infection.
10.If resistance is met while attempting to thread
the catheter, stop, release the tourniquet, and
carefully remove both the needle and To theprevent tension on the I.V. catheter itself.
catheter. Attempt another venipuncture with
a new catheter. Labeling the dressing is dictated by facility policy. Such a
 Alternately, if the catheter does not freely practice provides information useful in
advance, attach IV tubing or a heparin lock determining the next dressing change and the
and flush, attempting to float the catheter capability of the needle to accommodate various
into the vein. types of infusion.
11.Apply pressure on the vein beyond the
catheter tip, with your little finger; release the
tourniquet and slowly remove the needle
while holding the catheter hub in place.
12.If continuous infusion, attach the cleared

administration set to the hub of the catheter
and adjust the infusion flow at the prescribed
rate.
13.If an intermittent access device; attach lock

cap and extension set, taking care to maintain
sterility of the set. Flush with 0.5 ml Heparin or
normal saline solution.
14.Apply transparent dressing to the site or use

dressing according to agency protocol.
15.Loop tubing and tape to dressing or arm.
16.Label the strip of the tape with an arrow

indicating the path and size of catheter, date
and time of insertion, and your initials. Affix
the tape to dressing. Prepare a similar label
with each dressing change.
NOTE:
Standard dwell time for a short peripheral

catheter is 3 days. However, exceptions may
be made due to patient’s venous access, type
of solution or catheter material.
A facility that does not maintain a phlebitis
rate of 5% or less should use a 48 hour site
rotation interval. If the catheter is not rotated
according to facility policy, document the
reason.
a.

1. Record the type, name, and time of I.V. insertion.
2. The I.V. needle is inserted without difficulty into the client’s vein.
3. I.V. fluid flows and enters the vein with less or no discomfort to the client.
4. The client understood the purpose and the effects of I.V. therapy.
PERFORMING IMMEDIATE NEWBORN CARE

(Department of Health Unang Yakap Essentials of Newborn care)
I. DEFINITION
Immediate Newborn Care – early management of the newborn baby in the delivery or nursery room
after or within few minutes after birth.
II. RATIOANALE
1. The newborn is unique, fragile being, who experiences the transition from comfortable uterine
environment to external environment.
2. Newborn should be regarded as individual and not just another new baby and receive the amount of
care that his condition demands so as to:
a. Establish and maintain respiration
b. Prevent aspiration
c. Maintain a stable temperature within normal range
d. Prevent infection
e. Establish an accurate identification
III. EQUIPMENT
1 pair of scissors Rectal thermometer 2 pairs of forceps

Tape measure Cord tie / cord clamp Prescribed ophthalmic ointment
Bulb syringe Sterile gauze Sterile glove
ID band Suction apparatus Betadine antiseptic
Vitamin K InjectableStamp pad Weighing scale
Gauge 26 or 25 NGT Fr. 5, 6, lor 8 Drop light
Baby’s layette/diaper/close cap/mittens Tuberculin syringe with needle
Nursing considerations:
1. Wear a prescribed nursery gown, mask, and close cap.
2. Aseptic technique should be observed at all times.
ACTION RATIONALE
TEN ESSANTIALS OF NEWBORN CARE:
1. Establish airway To prevent meconium aspiration which results to

a. Right after the extension of newborn’s lung infection (aspiration pneumonia).
head, before the chest is delivered, the
mouth and nose should right away be
cleared.
b. Position on his back or side. To keep the airway open and unobstructed.
c. Suction gently and briefly (start with To prevent laryngospasm. Longer suctioning may
the mouth, then nose). also aspirate much needed air from the newborn.
 Deflate the rubber ball of the bulb
syringe before inserting into the
mouth and nosetril
 Preterm: <5 seconds/suction
 Full term: 5-10 seconds/suction
2. Keep the newborn warm To stabilize newborn’s temperature at birth (37.3
o
a. Dry the newborn right away with a C) drops quickly (35.5oC) owing to mechanisms of
sterile towel. heat loss either by convection, radiation, or
b. Wrap the body and promote flexion to conduction.
minimize the body surface exposed to
cool air and cool surface.
c. Cover the table and line the surface
with a towel.
d. Get the initial temperature through the To detect for any congenital anomaly:
rectum. imperforated anus.
Note: Provide immediate care under drop To maintain warm temperature of the body.
light or floor lamp.
3. Do APGAR Score To evaluate the newborn during the first and 5

minutes of life after birth.
4. Identify the newborn To ensure identification is done as soon as possible

a. Place a wristlet or anklet with the after birth. Proper identification is the legal and
gender and family name of the baby, moral responsibility of the newborn.
and mother’s complete name.
b. Take the newborn’s foot prints.
5. Provide skin care To cleanse the skin of mucus, blood, or at times

 Mild soap and water bath for normal meconium thus preventing infection.
and full term babies; oil bath for
preterm and high risk newborn.
6. Give Crede’s Prophylaxis

a. Apply prescribed ophthalmic To prevent eye infection transmitted from the
medication to both eyes of the mother like Ophthalmia Neonatorum or
newborn by holding the clipper lid gonorrheal conjunctivitis.
upward with index finger and the leaver
lid downward with a thumb.
b. Squeeze the eye ointment tube and
deposit 1 cm of medication to the inner
canthus of the eyelid without touching
the eyeball.
7. Perform cord dressing

a. Applying antiseptic technique by a To prevent occurrence of Tetanus Neonatorum.
prescribed antiseptic solution (inner to
outward direction)
b. While performing cord dressing, check
for presence of three blood vessels,
bleeding, redness and foul discharges. To ascertain completeness of blood vessels.
c. Ensure that about 1 inch of the length
of the cord is left from the base. To assure baby’s normal condition.
8. Inject Vitamin K intramuscularly (vastus

lateralis). To prevent newborn bleeding problems.
9. Take Anthropometric Measurements Newborn parameters:

a. Weight 3,000 grams to 3,400 grams with the lowest limit
normal of 2,500 grams.
b. Height (heel to crown measurement) Height of 19-21 inches or an average of 50 cm.
The head is the biggest; about ¼ of the body

weight. It is about 33-35 cm in diameter.
c. Head circumference
Less than 2 cm than that of the head; 31-33 cm.
d. Chest circumference To promote mother and child bonding.
10. Provide gentle, minimal handling, and

watchful eyes To promote mother and child bonding.
a. Promote Rooming In and Breastfeeding.
b. Check the baby’s chart if there’s an

order for Rooming In. To romote and support R.A. 7600, Rooming In and
Breastfeeding Act of 1992, for Maternal and Child
Health.
c. Bring the baby to the mother. Be sure

to check the baby’s identification with
the mother.
d. Give instructions to the mother

regarding breastfeeding and care of the
baby.
1. Record the assessment result of the APGAR score.

2. Absence of respiratory distress.
3. Free of infection and other complications.
4. The baby is identified correctly and with complete and correct data.
5. Recording of the dose, route, and time the Vitamin K and ophthalmic ointment is administered.
6. Recording of V/S, anthropometric measurements, and unusualties.
ASSESSING NEWBORN USING APGAR SCORING
I. DEFINITION
Apgar Scoring – is a tool for quick and accurate assessment of the condition of the newborn at birth.
It was devised by Dr. Virginia Apgar in 1952.
II. RATIONALE
1. The first – minute Apgar scoring is done to assess the well – being of the newborn and to determine
if there is a need for immediate resuscitation.
2. The five – minute Apgar scoring is done to:
• Assess the capacity of the newborn to adjust to the extra uterine environment.
• Evaluate the effectiveness of resuscitation measures, if done.
• Enable the nurse to formulate a plan of care for the newborn.
III. EQUIPMENT
Stethoscope Clean linen or layette

Nasogastric tube Fr 8 Apgar Score Chart
ACTION RATIONALE
1. Place the newborn in a crib or table lined with a To protect the newborn from contamination
blanket or linen. and injury.
2. Evaluate the heart rate. A significant index to cardiovascular functioning.

- Observe the pulsation of the cord at the
abdomen if the cord is still uncut.
- Listen to the heart beat using a stethoscope.
3. Observe for respiratory effort. Is the cry

vigorous? To determine if the newborn is responding well
- Is there difficulty of breathing? or has respiratory difficulty.
- Is there any presence of external retraction
or nasal flaring?
- Is the respiration “regular”?
To assess for muscular tonicity.
4. Observe for muscular tonicity.
- Are the extremities well - flexed?
- Do they resist efforts to extend them? To check for reflex irritability.
- Are they flaccid and limp?
5. Evaluate the reflex irritability.

- How does the baby respond to gentle
slapping of the sole of the feet? To
suctioning?
- Is there no response at all? To evaluate the cardiovascular functioning.
- Is the cry weak or merely makes a grimace? Color is an index to tissue perfusion and
Oxygenation of blood.
6. Inspect the newborn’s entire body for color.
V. ILLUSTRATION
ADAPTATION 0 1 2 1 min 5 min
HEART RATE Absent Less than 100 bpm Over 100 bpm
RESPIRATORY EFFORT Absent Slow, regular, weak cry Good, strong cry
MUSCLE TONE Flaccid, Limp Some flexion of Well-flexed extremities

extremities
REFLEX IRRITABILITY No response Weak cry, grimace Vigorous cry
COLOR Blue, Pale Body pink, extremities Completely pink

blue
TOTAL
1. Evaluation of the newborn based on the five adaptation areas following any sequence.
2. Score for each adaptation area.
3. Use of the Apgar Scoring chart for one minute and five minutes.
- A score of 7 to 10 indicates good condition with minimal special precaution to be taken.
- A score of 4 to 6 means the baby is in fair condition and certain recommended procedures are
to be followed.
- A score of 0 to 3 means the newborn is in extremely poor condition and resuscitation is needed
immediately.
INSTRUCTING POST PARTUM MOTHER ON BREASTFEEDING
I. DEFINITION
Breastfeeding – is the sucking of an infant at the mother’s breast to provide him/her with nourishment.
II. RATIONALE
1. To establish rapport between the mother and the infant.

2. To provide psychological and emotional satisfaction for the infant and the mother.
3. To feed the infant with natural and ideal food that will supply him/her with adequate nutrients as well
as immunologic and anti-infection properties.
4. To provide protection to the infant (prevents gastrointestinal disturbances and allergies) and the
mother (prevents breast cancer).
5. To have milk which is readily available at the right temperature.
III. EQUIPMENT
Clear Water Cotton Balls
ACTION RATIONALE
Planning
1. Provide the mother and infant with an To provide the mother and infant with an
environment that is quiet and as private as opportunity to continue to develop their
possible and free from interruptions. relationship.
2. Provide the mother with a comfortable Proper and comfortable position of the mother
armchair or pillow so that she can assume a will enable her to hold the baby correctly and
comfortable position during the feeding. support him/ her while he/she is being fed. This
Provide also foot stool to support the can also promote good let-down reflex.
mother’s feet.
If the infant is awake and comfortable, he/she
will settle down and feed better.
3. The infant should be awake and dry before If the infant is awake and comfortable, he/she
the feeding is started. will settle down and feed better.
To remove any old milk that may have leaked

and dried which can be good medium for
4. Dress the infant appropriately so that he/she bacterial growth that can cause GIT disturbances
is neither too warm nor too cold during the in infants. Use of alcohol and soap will cause dry
feeding. and cracked nipples.
5. Have the mother wash her hands, then her To provide the infant with comfort and security
nipples with clear water and cotton balls. and to make it easier for him / her to suck and
swallow. This makes the nipple more easily
accessible to the infant’s mouth and prevents
obstruction of nasal breathing.
To allow the infant get a firm grasp of the nipple

and areola.
6. Position the infant in a semi-sitting position

with his/her face close to the breast and To stimulate rooting reflex so that the infant
supported by one arm and hand. The breast turns his/her head toward the breast with
may be supported by the mother’s other his/her mouth open.
hand.
To allow an effective sucking action and

complete emptying of the collecting sinuses, as
well as prevent nipple pain and trauma.
Implementation An obstructed nasal pathway will cause the

infant to stop sucking.
7. When beginning breastfeeding, have the The infant’s sucking is most rigorous at the
mother “point up” the nipple by gently beginning of breastfeeding. Alternating the
pressing it between the thumb and breast being used first at each feeding will
forefinger. ensure that each breast is completely emptied at
every other feeding.
8. Let the mother touch the baby’s cheek with
her breast. Empties each breast and maintains milk supply.
9. Make sure the infant has both the areola and Frequent feedings maintain the milk supply and
nipple in his/her mouth. prevent overly vigorous sucking on the nipple
which may cause nipple trauma.
To prevent or lessen nipple trauma.
10. Make sure the infant’s nasal pathway is open.

Releasing air in the infant’s stomach will make
If the infant’s nose is flat against the mother’s
him/ her more satisfied and less fretful.
breast, have her indent her breast near the
nose to ensure an open breathing space.
11. Have the mother alternate the breast being

used as she begins breastfeeding with each
feeding. Start with the breast with which she
fed last in the previous feeding.
12. Have the mother use both breast at each

feeding. Begin 5 minutes at each breast
allowing the infant to suck actively. Pin a
safety pin to the bra as a reminder of which
breast to start with at the next feeding.
13. Have the mother breastfeed frequently and

on a demand schedule.
14. To break suction, instruct the mother to place

her finger at the corner of the infant’s mouth
or gently pull the chin down.
15. Have the mother bubble the infant at the end

or midway through feedings. Please see step
#7 of artificial nipple feeding.
V. AFTER CARE
1. Change infant’s diaper if it is soiled to provide comfort for restful sleep and to prevent diaper rash.
2. Position the infant on his/her right to facilitate emptying of the stomach.
3. Provide the mother with health instructions regarding advantages of breastfeeding, adequate rest,
avoidance of tension, fatigue and a stressful environment and avoidance of drugs and medications
unless prescribed by the doctor.
4. Have the mother air dry her nipple for 15-20 minutes after each feeding.
VI. EVALUATION
1. Time, length, and manner of feeding

2. Infant’s reaction after feeding; observe any untoward reaction
3. Breast or breasts used; which breast was emptied first and which breast was nursed from thereafter
CARING FOR A NEWBORN ON PHOTOTHERAPY

(Hockenberry, Marilyn; Wong’s Essentials of Pediatric Nursing, 2005, 7 th ed., pp. 264-267.)
I. DEFINITION
Phototherapy – a lamp that gives off therapeutic doses of infrared light and heat which lowers bilirubin
in the tissues.
II. RATIONALE
1. To reduce bilirubin levels of the newborn.

2. To provide an optimum thermal environment to reduce metabolic needs.
3. To prevent physiologic and breastfeeding jaundice with early introduction of feedings if without
supplementation.
III. EQUIPMENT
Heating lamp / Bililamp Opaque mask or eyeshield

Diaper Rolled blankets or towels
1. The infant under phototherapy is placed nude and repositioned frequently to expose all body surface
areas to the light.
2. Frequent serum bilirubin level is monitored every 4-12 hours after initiation of phototherapy because
visual assessment of jaundice is no longer valid.
3. Eyeshields are removed during feeding to opportunity for visual and sensory stimulation.
4. Infants who are in open crib must have protective plexi glass shield to protect from accidental bulb
breakage and minimize the amount of undesirable ultraviolet light.
ACTION RATIONALE
1. Explain the therapy to significant others. Lessens anxiety of mother and significant
others, and to gain their cooperation.
2. Assemble the things/articles to be used For easy access on the part of the nurse.
near the infant’s crib or bililamp table.
To reduce spread of microorganisms.
3. Perform hand hygiene. To ensure maximum therapeutic effect.
To ensure baby’s safety and expose all body

surfaces.
4. Keep the infant’s skin clean and dry.
To prevent exposure to light and to maintain a

patent airway.
5. Undress the baby and position
comfortably with two rolled towels or
blankets on both sides.
To prevent the skin from burning.

To determine presence of discharges, pressure
6. Cover both eyes with an opaque mask or on the eyelid, corneal irritation.
eye shield with proper size and shape not
occluding the nares. The infant’s eyelids To determine hyperthermia and to assess any
are closed before applying the shields. changes on skin like drying or burning.
7. Position the lamp approximately 45 cm (18

inches) from the skin and 60 cm (24
inches) if the bulb is large.
8. Check the baby frequently (every 15

minutes) especially the eyes.
9. Note skin color changes (every 15 minutes)

and body temperature every 2-4 hours.
1. Document the time when phototherapy has started and stopped.

2. The type and number of lamps used and distance between surface of the lamps and infant.
3. Photometer measurement of light intensity and occurrence of side effects in the infant.
4. Monitored and recorded the level of infant’s bilirubin.
SUCTIONING A NEWBORN
(Hockenberry, Marilyn; Wong’s essentials of Pediatric Nursing, 2005, 7th ed., pp. 774-775.)
I. DEFINITION
Suctioning – is a method of removing excessive secretions from the airway. It may be applied to the
oral, nasopharyngeal, or tracheal passages.
II. RATIONALE
1. To provide patent airway to improve ventilation.

2. To remove mucus secretions in the upper airway increase tissue Oxygenation.
III. EQUIPMENT
Suction apparatus Sterile gloves Lubricant

Tongue depressor Container with sterile water or normal saline
Suction catheter with vent
Size 5-6 for preterm
Size 6-8 for fullterm
1. Apply suction for 5-10 seconds only per suction to prevent suctioning of excessive Oxygen from the
lower airway.
2. Suction the orotracheal first then the nasotracheal or nasopharynx to prevent swallowing of
secretions that may escape to trachea during crying.
3. Perform gentle suctioning as the mucus membrane of the upper and oral airway is very thin and
sensitive that may lead to trauma and injury.
ACTION RATIONALE
Orotracheal Suctioning:
1. Gather equipment including catheter of To save time and energy. Equipment should be
appropriate size. Connect collection bottle near the newborn area to be used in emergency
and tubing to vacuum source. cases.
2. Inform the parents or significant others To allay fear and anxiety.

about the procedure if necessary.
To reduce the number of microorganisms thus

preventing infection.
3. Wash hands thoroughly.
To avoid any delay.

4. Fill basin with sterile water or normal
saline.
To aid in pooling and draining the secretions.
5. Turn on suction machine to check the

system and regulate the pressure if
indicated and if equipment is functioning.
To keep the hands clean.
6. Position the infant on his right side, with

his head slightly lowered. If necessary, To check the patency of the system, lubricate
seek for assistance in maintaining his the catheter, and allow some water in the
position. collection bottle which will prevent aspirated
secretions from sticking to it.
To prevent blocking of the catheter by

7. Don gloves. Connect the catheter to the compression of the lips.
suction tubing.
To avoid over stimulation of the gag reflex thus
preventing vomiting.
8. Place catheter tip in the basin and draw

sterile water through it. To remain in one place, the mucous membrane
will be drawn against it. This will occlude the
catheter and may injure the tissues.
To use about 50 cc of saline can adequately

clean the catheter with secretions.
9. Use padded tongue depressor to separate To avoid prolonged suctioning as it can lead to
the upper and lower lips. laryngospasm, bradycardia and cardiac
arrhythmias from vagal stimulation and loss of
Oxygen.
10. Leave vent open to air and introduce

catheter into the area to be suctioned. To avoid delay of work.
Insert the catheter 2-4 inches into the oral
cavity.
To lessen anxiety.
11. Occlude vent with thumb and slowly move

To elevate the bronchial passage on the
the catheter in circular motion in the area
opposite side, making the catheter insertion
to be suctioned.
easier.
12. Dip catheter in and out of the container of

sterile water or saline.
To avoid tracheal injury. Entry into the trachea

is often difficult; less change in arterial O 2 may
13. Repeat steps 9 to 12 if necessary. be caused by leaving the catheter in the trachea
Suctioning should be no longer than 10 rather than initiating repeated catheter
seconds at a time allowing 1-3 minute insertions.
interval between suction periods.
Nasotracheal Suctioning
1. Ascertain that the suction apparatus is To allow re-Oxygenation of the newborn.
functional. Place suction tubing and other
articles within easy reach.
2. Inform the parents or significant others if

necessary. To prevent suctioning of O2 deposits in the
lower airways.
3. Position the newborn’s head slightly

higher than the body. To apply gentle motion and good oxygenation.
 For left bronchial suctioning, turn the
newborn’s head to the right, chin up.
 For right bronchial suctioning, turn the
newborn’s head to the extreme left,
chin up.
4. Never apply suction until catheter is in

trachea. Once correct position is
ascertained, apply suction and gently
rotate catheter while pulling it slightly
upward. Do not remove the catheter from
the trachea.
5. Disconnect the catheter from the suction

machine after 5-15 seconds. Apply O 2 by
placing a facemask over the nose and
mouth.
6. Reconnect to suction source and repeat

suctioning when necessary within 10
seconds per suctioning; and 3-4 suctions
per suction episode.
7. During the last suction, remove the

catheter while applying suction in rotating
motion gently. Apply O2 when catheter is
removed.

1. The newborn has a clear, patent oral/pharyngeal airway.
2. The newborn has an adequate Oxygenation as evidenced of having pinkish color, normal ABG
results.
3. The newborn has no signs of respiratory distress.
PERFORMING GASTRIC GAVAGE
I. DEFINITION
Gastric Gavage – the introduction of liquid feeding through the tube into the stomach.
II. RATIONALE
1. Prevent fatigue or cyanosis that is apt to occur from bottle feeding.

2. It can provide a safe method of feeding hypotonic infants, experiencing respiratory distress
(respiratory rate greater than 60 cpm).
3. Infants with uncoordinated suck and swallow, intubated, debilitated and those with anomalies of
upper and lower digestive tract.
III. EQUIPMENT
Sterile rubber or plastic catheter, rounded tip, French 5-12 (Argyle feeding tube)
Clear, calibrated reservoir for feeding fuid 5-10 ml. syringe
Stethoscope Sterile water or normal saline
Hypoallergenic tape Feeding fluid at room temperature
Pacifier
ACTION RATIONALE
Preparatory Phase
1. Perform hand hygiene. To establish proper standard precaution.
2. Position client with a rolled diaper placed under To allow easy passage of the catheter, facilitate
shoulders. observation, and help avoid airway obstruction.
 A mummy restraint may be necessary to
help maintain this position.
3. Measure the distance from the tip of the To provide a guideline as to how far to insert the
patient’s nose to the earlobe and to the xiphoid catheter.
process of the sternum. Mark the length on the
feeding tube with a tape.
4. Have suction apparatus readily available. To clear the airway and prevents aspiration if
regurgitation occurs.
To emphasize that we do not use oil because of

Performance Phase the danger of aspiration.
5. Lubricate the catheter with sterile water,
normal saline solution or water soluble
lubricant.
6. Stabilize the patient’s head with one hand; use

the other hand to insert the catheter. To follow the nares’ passageway into the
pharynx. Positioning in the nares may cause
partial airway obstruction. Avoid this route if
there’s critical airway compromise.
a. Insertion through the nares

 Slip catheter into patient’s nostril and To go with swallowing motions will cause
direct it toward the occiput in a horizontal esophageal peristalsis which opens the cardiac
plane along the floor of the nasal cavity. sphincter and facilitates passage of the catheter.
Do not direct the catheter upward. Perforation may occur with very little pressure.
Observe for any respiratory distress.
b. Insertion through the mouth Because of cardiac sphincter spasm, resistance
 Pass the catheter through the patient’s may be met at this point. Pause a few seconds,
mouth towards the back of the throat, and then proceed. The vagal nerve pathway lies
with head tilted slightly forward. from the medulla through the neck and thorax to
the abdomen. Above the stomach arch, the left
and right branches unite to form the esophageal
plexus. To stimulate nerve branches with the
7. If the patient swallows, passage of the catheter catheter will directly affect the cardiac and
may be synchronized with swallowing. Do not pulmonary plexus.
push against resistance. Gently try rotating the
tube if resistance is met. To prevent movement of the catheter from the
pre-measured, pre-established correct position.
8. If there is no swallowing, insert the catheter
smoothly and quickly. Observe for any signs of Alternative method: Loop narrow cloth tape
vagal stimulation like apnea or bradycardia. around the tube just below the nostril, then
secure it above the lip or nose with a tape. Some
movement of the tube may be seen with
swallowing.
To aid in ensuring proper location of the

catheter. Failure to obtain aspirate does not
9. When the catheter has been inserted to the mean improper placement, there may not be any
pre-measured length, tape the catheter to the stomach content or the catheter may not be in
patient’s face. contact with the fluid. A pH of 5 or less suggests
correct placement of tube.
To secure placement, adhesive tape should not

loosen easily and should be washable, because it
may be exposed to secretions.
To verify correct placement of tube.
This position allows the flow of fluid by gravity.

10. Test for correct position of the catheter in the The use of pacifier will relax the infant, allowing
stomach, according to institutional guidelines for easier flow of fluid as well as provide for
(either by injecting air into the catheter while normal sucking needs.
auscultating for a whooshing sound over the
stomach; however the preferred method is to
aspirate a small amount of gastric contents
and test for acidity). To monitor for appropriate fluid intake, digestion
time, and overfeeding. Notify the other health
care team members of a large residual, and
document any residual amount after each
aspiration.
11. Secure the tube into the patient’s cheek by
using tape.
12. If unsure of the catheter’s placement, obtain

an abdominal x-ray.
To flow by gravity. The pressure of the fluid itself

increases the rate of flow.
13. Position the infant at right side-lying or supine
position with head and chest elevated at about
30o. Attach the reservoir to catheter and place To avoid abdominal distention.
fill with feeding fluid. Encourage the infant to
suck on a pacifier during feeding and hold the
infant when possible.
14. Aspirate the tube before feeding begins to Clamp the catheter before the air enters the
assess for residual contents and remove any stomach that causes abdominal distention.
air. Clamping also prevents fluids from dripping from
the catheter into the pharynx, causing the infant
to gag and aspirate.
15. a. If a small residual is obtained, return it to

the stomach and subtract that amount from
the total amount of formula to be given.
b. If over ½ of the previous feeding was To allow expulsion of air swallowed or ingested
aspirated, withhold the next feeding. Do not will decrease abdominal distention and allow
return aspirate back to the stomach then better tolerance to the feeding.
notify healthcare provider.
To facilitate gastric emptying and prevent
16. The flow of the feeding should be slow. Do not regurgitation and aspiration.
apply pressure. Elevate the reservoir 6-8
inches (15-20 cm) above infant’s head.
a. Feeding given too rapidly may interfere

with peristalsis, causing abdominal To prevent vagal stimulation.
distention, regurgitation, or vomiting.
b. Feeding time should approximately be 5

ml / 5-10 minutes or should last for 15-20
minutes.
17. When feeding time is completed, the catheter

is irrigated with clear sterile water. Before the
fluid reaches the end of the catheter, clamp it
off and withdraw it quickly or keep in place for
the next feeding.
18. Discard the feeding tube and any left-over

solution.
Follow-up Phase
19. Burp the infant.
20. Place on his right side for at least one hour.

21. Observe patient’s condition after feeding;
bradycardia and apnea may occur.
22. Note infant’s activity and readiness to feed by

nipple. Observe sucking activity and sleep-
wake cycle in relation to feeding.

1. Accurately describe and record procedure, including tape and size of tube used.
2. Verification of placement, time of feeding, type of gavage tube feeding, type and amount of feeding
fluid given and amount of retained or vomited.
3. Tolerance to feeding and activity before, during and after feeding.
PERFORMING GASTRIC LAVAGE
I. DEFINITION
Gastric Lavage – the aspiration and washing out of the stomach contents by means of a gastric tube.
II. RATIONALE
1. To remove swallowed discharges and amniotic fluid during delivery.

2. To wash out the stomach of ingested meconium stained amniotic fluid.
III. EQUIPMENT
Irrigating syringe (5-10 cc) Water soluble lubricant

Emesis basin Container for specimen
Nasogastric tube:French 5-6 for Pre-Term
French 8 for Full Term
ACTION RATIONALE
1. Follow steps in insertion of nasogastric

tube in performing gastric gavage (steps 1-
10).
2. Another way of checking the accuracy of To check for tube placement. If the tube is in the
placement is to submerge free end of the lungs, the water will bubble with each
tube below water level at the time of exhalation.
client’s exhalation.
To remove stomach contents.
3. Aspirate the stomach contents with

syringe attached to the tube before
instilling sterile water or antidote. Save To feed adequate amount only. Overfilling of the
specimen for analysis. stomach may cause regurgitation and aspiration,
or force the stomach contents through the
pylorus.
4. Remove syringe. Attach the funnel to the

stomach tube or use 5 or 10 cc syringe to
put lavage solution to the gastric tube. The
volume of fluid introduced into the
stomach should be in small amount.
5. Elevate the funnel above client’s head and To save specimen for diagnostic analysis.
pour approximately 5-10 ml of solution
(usually normal saline) into the funnel.
To diminish absorption of toxic substances.
6. Lower the funnel and siphon the gastric

contents into the kidney basin.
To facilitate the movement of the ingested
foreign substance through the intestinal tract.
To prevent aspiration and initiation of gag reflex.

7. Save samples of the first two washings.
8. Repeat lavage procedure until the returns

are relatively clear and no particulate
matter is seen.
9. At the completion of lavage, stomach may

be left empty.
10. A saline cathartic may be instilled in the
tube and allow to remain in the stomach.
11. Pinch off the tube during removal or

maintain suction while the tube is being
withdrawn.
12. Discard all disposable materials and

perform after-care of other equipment.
1. Record the amount and characteristics of gastric contents obtained.

2. Any abnormalities noted in the gastric contents; bleeding, color, or solid materials.
3. General condition of the infant including vital signs.
FEEDING WITH MILK FORMULA /BOTTLE FEEDING
I. DEFINITION
.
Artificial or bottle feeding - is a method of supplying nutrients to the infant by oral feedings of
commercial formula using a bottle and an artificial nipple.
II. RATIONALE
1. To provide the baby adequate fluid and nutrient intake to support growth and maintain life
processes.
2. To supplement breast-feeding with formula or water.
3. To provide additional fluid intake between feedings.
III. EQUIPMENT
Sterile nipple and bottle

Sterile formula feeding fluid
1. When feeding a premature infant, allow him/her some rest periods. Use a soft nipple so that less
energy is needed since premature infants tire easily.
2. To stimulate the infant to suck, the nurse can brush the infant’s cheek with her finger.
3. Adequate feeding time needed is at least 30 minutes.
ACTION RATIONALE
Planning
1.Baby should be awake and hungry. Change To enable the baby to feed well and to provide
soiled diaper. comfort.
2.Check formula for correct type, amount and To prevent error and to prevent infants from
temperature. burning.
3.Sit in a comfortable chair. Position infant in a To enhance warmth and physical closeness that
cradle-hold position in which the mother is occurs with breastfeeding and to prevent
sitting upright, with the infant’s head held in the aspiration and retention of air bubbles.
crook of the arm and its buttocks cradled in the
hand.
Implementation
1.Let the baby root for the nipple by touching the To stimulate the rooting reflex so that it is easier
corner of his mouth with the nipple. When he to insert the nipple.
opens his mouth, insert the nipple.
2.Hold the bottle at an angle to completely fill the To prevent the baby from sucking and
nipple with fluid. swallowing an excessive amount of air.
3.Never prop the bottle or leave the baby To prevent aspiration of formula.
unattended during feeding.
4.The bottle should be held properly so as not to To prevent GIT problems because of
contaminate the nipple or fluid. contaminated formula.
5.Position baby so that eye contact can be To promote bonding if the mother is feeding the
established. baby or rapport if the nurse is giving the feeding.
6.Baby’s feeding will vary from 10-25 minutes To ensure that adequate formula has been
depending upon the baby’s age and how received by the baby.
vigorously he sucks.
7.Bubble the baby at least once during the feeding To aid in expelling air and thus prevent
and at the end of the feeding. abdominal distention, discomfort and
regurgitation.
a.Place the baby gently in prone position on
nurse’s shoulder and gently pat or rub his/her Vigorous patting or handling may result in
back. spitting up or regurgitating the feeding.
b.Place the baby in sitting position in nurse’s lap,
tilt him/her slightly forward and gently rub or
pat his/her back or abdomen.
c. Place the baby in prone position on nurse’s lap
and gently rub or pat his/her back.
8.Take the nipple out of the mouth periodically. To allow the baby to rest and to allow air to
enter into the bottle so that the nipple does not
collapse.
V. AFTER CARE
1. Change wet or soiled diaper and place the baby on his/her abdomen or right side to aid in emptying
the stomach and to prevent regurgitation.
2. Check the baby in a few minutes. If he/she is restless pick him/her up and bubble him/her.
3. Wash and sterilize nipples and feeding bottles as necessary.
1. Type and amount of formula

2. Baby’s tolerance
3. Note any regurgitation or emesis (amount and material)
4. Length and time of feeding
5. Sucking reflex and baby’s behavior before, during and following feeding
PERFORMING LEOPOLD’S MANEUVER
I. DEFINITION
Leopold’s Maneuver – is a series of steps of abdominal palpation which is done to determine fetal
presentation, position, attitude and lie.
Fetal Attitude – is the relationship of the fetal parts to one another. Also known as “Habitus”
Fetal Lie – is the relationship between the long axis of the fetal body and the long axis of the woman’s
body.
Presentation – denotes the fetal part which enters the pelvis first or will cover the internal cervical os.
Position – is the relationship of the presenting part to a specific quadrant of the woman’s pelvis.
II. RATIONALE
To determine the fetal presentation, position, attitude and lie through systematic observation and
palopation of the abdomen.
III. EQUIPMENT
Appropriate Drape or Linen to cover the client
ACTION RATIONALE

• Explain the procedure to the client. To gain client’s cooperation.
• Let the client empty her bladder first. To promote client’s comfort during the
procedure and therefore, obtain a more
productive result. The bladder is located anterior
to the fundus.
• Provide for privacy.
To promote comfort.
• Place client in a supine position with knees
slightly fixed. The abdominal muscles will be relaxed in this
position.
• Wash hands. Be sure hands are warm and
not cold. Cold hands cause the abdominal muscles to
contract and tighten.
2. Begin by observing the client’s abdomen and
asking yourself the ff. questions:
• What is the longest diameter in
appearance? Is it horizontal or vertical? The long axis is the length of the fetus.
• If the fetus is active, where is the
movement apparent? The activity probably reflects the position of the
3. Perform the Leopold’s Maneuver. feet.
A. FUNDAL PALPATION
 Stand at the foot of the client, facing
her, and place both hands flat on her
abdomen.
 Palpate sides of the uterus and fundus.
 Head feels hard and round, freely
movable and ballotable; breech feels To determine if fetal head or breech is in the
large, nodular, and softer. uterine fundus.
B. LATERAL PALPATION
 Face client and place hands on the sides
of the abdomen to identify the location
of the back and small parts.
 One hand is held stationary on one side
of the uterus while palpates down sides
of the uterus applying gentle but deep To determine the position of the fetal
pressure. extremities, the fetal back and the anterior
 On the side of the fetal back, a long shoulder.
continuous structure will be felt; side
with fetal extremities will feel nodular,
reflecting portions of fetal extremities.
C. PAWLIK PALPATION
 Gently grasp the lower uterine segment
between the thumb and fingers of one
hand to feel the presenting part. If
presenting part is movable, engagement
has not occurred yet; if engagement has
occurred, fetal part feels fixed in the
pelvis. To determine the portion of the uterus that is
presenting and if engagement has occurred.
D. DEEP PELVIC PALPATION
 Turn and face the woman’s feet. Gently
move the fingers down the sides of the
uterus. The cephalic prominence is felt
on the side where there is greater to the
descent of the fingers into the pelvis.
4. Place client in a comfortable position, To confirm the findings of the third maneuver
preferably Sim’s position or left lateral position. and to determine the flexion of the vertex.
5. Wash hands.
This position improves fetal circulation.
1. Fetal presentation, position, attitude and lie

2. Any unusual findings
COMPUTING EXPECTED DATE OF CONFINEMENT (EDC)
I. DEFINITION
Expected Date of Confinement (EDC) – the predicted date of a pregnant woman’s delivery.
Pregnancy lasts approximately 266 days, or 38 weeks from the day of fertilization, but is considered
clinically to last 280 days, or 40 weeks, or 10 lunar months, or 9 1/3 calendar months from the first day
of the last menstrual period (LMP).
II. EQUIPMENT
Paper and pencil/pen Calculator Chair and table
ACTION RATIONALE
1. Explain the purpose of knowing the expected To gain the cooperation of the client.
date of confinement.
2. Be ready with a pen, paper, table and chair for To prevent unnecessary movement and keep
you and the client. yourself and the client comfortable.
To determine the health status and health

problems, and establish rapport at the same
3. Start by asking the client about her concerns. time.
To be able to obtain the main data for computing

the EDC.
4. Focus your questions on pregnancy related

data, particularly about her last menstrual
period, which is the first day of the last menses.
5. Example: If the woman has an LMP of June 10,
2012, compute the EDC by applying this
formula.
NAEGELE’S RULE
- Add 7 DAYS to the first day of the last menstruation, subtract 3 MONTHS, then add 1 YEAR (for the
months of April-December)
Example: LMP is June 06, 2012
06 / 06 / 2012
-3 +7 +1
03 / 13 / 2013 EDC
LMP is June 10, 2012
06 / 10 / 2012
-3 +7 +1
03 / 17 / 2013 EDC
Note: If LMP is from January to March 24, use the ff. formula.
- Add 7 DAYS to the first day of the LMP and add 9 MONTHS, then bring down the YEAR.
Example: LMP is February 02, 2012
02 / 02 / 2012
+9 +7
11 / 09 / 2012 EDC
LMP is January 31, 2012
1
01 / 31 / 2012
+9 +7
11 / 08 / 2012 EDC
LMP is March 24, 2012
03 / 24 / 2012
+9 +7
12 / 31 / 2012 EDC
COMPUTING AGE OF GESTATION (AOG)
I. DEFINITION
Age of Gestation – age of the developing fetus or embryo from the first day of the last menstruation
when a woman is diagnosed as pregnant.
II. RATIONALE
1. To determine the age of gestation.

2. To guide with the plan of care for both the mother and the fetus.
III. EQUIPMENT
Paper, pencil/pen Calculator Chair/table
ACTION RATIONALE
1. Explain the purpose of taking the AOG. To ensure participation and cooperation of the
client.
2. Complete the things needed during the To have a systematic and limit physical and mental
computation. efforts to both the nurse and the client.
To clarify if the client is in doubt of the date.
3. Start by asking pertinent questions in

relation to pregnancy.
Example: A pregnant woman has an LMP of June 10, 2012 and the assessment date is
September 15, 2012. June has 30 days, so subtract the date of the first day of
the LMP which is 10.
So, 30 days
- 10
June 20 remaining days
July 31
August 31
September 15 (day of assessment)
97 days
Divide the sum (97 days) into 7 to get the AOG in weeks.
97 / 7 = 13.8 13 weeks and 8 days 14 WEEKS AND 1 DAY (AOG)
LMP: February 05, 2012 and the woman delivered the baby on November 15, 2012
February has 28 days

-5
February 23 remaining days
March 31
April 30
May 31
June 30
July 31
August 31
September 30
October 31
November 15
283 days / 7 = 40.4 40 WEEKS AND 4 DAYS (AOG)
MEASURING FUNDIC HEIGHT
I. DEFINITION
Measurement of the height of the fundus from the notch of the symphysis pubis to the upper end of the
uterine fundus with the use of centimeter tape measure during the first and third trimester of
pregnancy.
Measuring the fundic height during this two specific can approximately correlate with age of gestation in
weeks, particularly when the pregnant woman’s LMP is unknown or in doubt.
II. EQUIPMENT
Tape measure Examining table / bed

Drape or sheet to cover the client Pillows
ACTION RATIONALE
1. Explain the procedure to client. To gain cooperation and participation of client.
To prevent spread of microorganisms.

2. Perform hand hygiene.
To have easy access with the articles and
facilitate progress of care given by care
provider.
3. Gather equipment near the examining table. This position provides comfort to the client
and allows the abdominal muscles to relax.
To provide privacy.
The distance of the height of the uterine

4. Place the client in supine position with two fundus is from the notch of the symphysis
knees flex. pubis to the top of the uterine fundus.
To have an accurate record of fundic height

measurement.
5. Cover the client with a drape exposing only the
area to be examined.
ANATOMICAL LANDMARK
6. Place the tip of the tape measure at the level Slightly above the symphysis pubis
of the notch of the symphysis pubis to the top
end of the uterine fundus. Level of the umbilicus
Below the xiphoid process
7. Take note of the number in centimeters of the

tape measure at the level of top end of uterine
fundus, and record.
Same level due to lightening on the 40 th week
8. Compute the age of gestation using the fundic

height in centimeters.
a. Mac Donald’s Rule – applies from 22-34 weeks

of gestation
 No. of cm multiplied by 8/7 = AOG in weeks

 No. of cm multiplied by 2/7 = AOG in
months
b. Bartholomew’s Rule of 4’s – estimates

the AOG in weeks by the relative position
of the uterus in the abdominal cavity by
palpation
AOG
12 weeks
20 weeks
36 weeks
32 and 40 weeks
ASSISSTING IN VAGINAL EXAMINATION
I. DEFINITION
The inspection and palpation of the female genitalia that forms a canal, from the orifice through the
vestibule to the uterine cervix.
II. RATIONALE
To determine cervical readiness, fetal position and presentation.
III. EQUIPMENT
Sterile gloves Drape

Perineal washing tray that contains the following 1 pitcher with sterile water
 1 pick-up forcep
 1 handling forcep
 Antiseptic solution
 Cotton balls1 pitcher with sterile water
ACTION RATIONALE
1. Perform hand hygiene then explain the To prevent spread of microorganisms and
procedure to client. explanation of procedure enhances cooperation
and compliance.
2. Provide privacy. To enhance client’s self-esteem.
Organization and planning improve efficiency of

work.
3. Assess client status and adjust plan of care
to client’s need. Organization and planning improve efficiency of
work.
This position allows for good visualization of the

perineum.
4. Assemble equipment.
To prevent contamination of birth canal, and
perineal washing reduces the number of
microorganisms on the external genitalia.
5. Position the woman onto her back with To ensure that quantity used will not be
knees flexed (dorsal recumbent position). contaminated, discard the first drop
To prevent the spread of organisms from the

perineum to the birth canal.
6. Perform perineal washing and put on
sterile gloves. To allow for good visualization of the perineum.
Presence of any lesions may indicate an infection
and possibly preclude vaginal birth.
7. Discard one drop of clean lubricating Amniotic fluid implies membrane rupture and
solution then drop an ample amount on possible cord prolapse. Bleeding may be a sign of
tips of the gloved fingers. placenta previa. Do not perform vaginal
8. Pour antiseptic solution over vulva using examination if a possible placenta previa is
present.
non-dominant hand.
To stabilize the uterus by placing your non-
9. Place non-dominant hand on the outer dominant hand on the woman’s abdomen.
edges of the woman’s vulva and spread
her labia while inspecting the external
genitalia for lesions. Look for red, irritated
mucous membranes; open, ulcerated
sores; clustered, pinpoint vesicles.
The cervix feels like a circular rim of tissue
around a center depression. Firmness is similar
to the tip of a nose. Softness is as pliable as an
10. Look for escaping amniotic fluid or the earlobe. The anterior rim is usually the last
presence of umbilical cord or bleeding. portion to thin.
To estimate the degree of dilatation. An index

finger averages about 1 cm. A middle finger
about ½ cm. if they can both enter the cervix, the
cervix is dilated 2 ½ - 3 cm. If there would be
room for double the width of your examining
11. If there is no bleeding or cord visible,
fingers in the cervix, the dilation is about 5 – 6
introduce the index and middle finger of
cm. when the surface is four times the width of
your dominant hand gently into the
your fingertips, dilation is as complete (10 cm).
vagina, directing toward the posterior
Measure the width of your fingertips on a
vaginal wall.
centimeter scale if you are going to do a vaginal
examination, so you know how wide your index
and middle fingers are at the tip.
12. Touch the cervix with your gloved To estimate effacement in percentage depending
examining fingers. on thickness. A cervix before labor is 2 to 21/2
cm thick. If it is only 1 cm thick, it is 50% effaced.
If it is as thin as tissue paper, it is already 100%
effaced. In a 100% effaced cervix, it is difficult to
a. Palpate for cervical consistency and rate if feel the dilatation because the edges of the
firm or soft. cervix are so thin.
The membranes (with a small amount of

amniotic fluid in front of the presenting part) are
like the shape of a watch crystal. With
b. Measure the extent of dilation. Palpate for contraction, they bulge forward and become
the anterior lip, or the rim of the cervix. prominent and can be felt much more readily.
To identify the presenting part confirms findings

obtained with Leopold’s Maneuver. Ischial spines
are palpated as notches at the 4 and 8 o’clock
positions at the pelvic outlet. Station is the
number in centimeters above or below the
spines where the presenting part is.
Differentiating a vertex from a breech may be
more difficult than would first appear. A vertex
has a hard, smooth surface. Fetal hair may be
palpable but massed together and wet; it may be
13. Estimate the degree of effacement. difficult to appreciate through gloves. Palpating
the two fontanelles, one diamond and one
triangular shaped, helps the identification.
Buttocks feel softer. Identifying the anus may be
possible because the sphincter action will “trap”
the index finger.
The fontanelle palpated is invariably the

14. Estimate whether membranes are intact. posterior one because the fetus maintains a
flexed position, presenting the posterior, not the
anterior fontanelle.
In ROA position, the triangular fontanelle will

point toward the right anterior pelvic quadrant.
In an LOA position, the posterior fontanelle will

point toward the left anterior pelvis.
In breech presentation, the anus can serve as a

15. Locate the ischial spines. Identify and rate
marker for position. When the anus is pointing
the station of the presenting part.
toward the left atrium quadrant of the female’s
pelvis, the position in LSA.
Use a gentle technique with withdrawal as with

insertion. Wiping front to back prevents moving
rectal contamination forward to the vagina. Side-
lying is the best position to prevent supine
hypotension syndrome in labor.
16. Establish the fetal position.

17. Withdraw your hand. Wipe the perineum
from front to back to remove secretions or
examining solution. Leave client
comfortable and turned to side.
1. Document procedure and assessment findings of the ff:

a. Appearance of external genitalia
b. Cervical dilatation
c. Status of labor
d. Fetal presentation and position
2. Document the reaction of the client and how the client tolerated the procedure.
MONITORING PROGRESS OF LABOR (UTERINE CONTRACTIONS)
I. DEFINITION
Labor – a series of physiological and mechanical processes by which the products of conception are
expelled from the woman’s body.
Duration – from the beginning of one contraction to the end of the same contraction.
Interval – from the end of one contraction to the beginning of the next contraction.
Frequency – from the beginning of one contraction to the beginning of the next contraction.
Intensity – the strength of a uterine contraction or the degree of tension.
Assessment of Uterine Contraction – is observing and timing the degree of tension felt on the uterine
muscles.
II. RATIONALE
1. To evaluate the progress of labor by continuously monitoring the duration, frequency, interval, and
intensity of uterine contraction.
2. To assess fetal condition.
III. EQUIPMENT
Watch with second hand Sheet to drape the patient

Pen and uterine contraction sheet
ACTION RATIONALE
1. Review the client’s admission history. To determine the onset, frequency, duration and
intensity of contractions.
2. Wash hands. To prevent spread of microorganisms.
To lessen discomfort.
3. Explain palpating procedure to client. To relieve pressure on the inferior vena cava and
promote utero-placental circulation.
To provide privacy.
4. Assist client to a comfortable, side-lying

position. To assess contractions and uterine tightening.
5. Drape client with a sheet. Expose only the part

to be palpated.
To determine the consistency of the uterine

fundus at the peak of a contraction.
6. Place fingertips on the uterine fundus and
palpate lightly.
Each contraction has 3 phases:
a. Increment – the building up of a To assess for the presence of prolonged

contraction contractions.
b. Acme – the peak of a contraction
To determine progress of labor.
c. Decrement – the period of letting down
7. Check intensity by pressing fingertips on the
uterine fundus when it tightens. The intensity To help in determining the interventions/choices
can be described as follows: of care and provide ongoing emotional support
a. Mild – feels like a person’s chin; the fundus in any event.
indents easily
b. Moderate –feels like a person’s tip of the
nose To evaluate whether she needs an analgesic,
c. Strong - feels like a person’s forehead; the anesthetic, or other appropriate measures such
uterine wall cannot be indented as repositioning or back massage.
8. Take the duration simultaneously. Seconds are

included when timing the duration.
9. Check the frequency of contractions.
10. Document and continue assessing the

contractions at least hourly during the latent
phase and continuously during the active
phase and the second stage of labor.
11. Determine how the client copes with

discomfort by assessing her breathing and
relaxation techniques.
12. Observe the client’s response to contractions.
DATE TIME STARTED TIME ENDED DURATION INTERVAL FREQUENCY INTENSITY
1. Contraction timing as to frequency, duration, interval, and intensity.

2. Client’s status whether she is in true or false labor.
3. Progress of labor based on the intensity, duration, frequency of contraction.
4. Client’s coping mechanism towards discomfort of labor.
5. Any deviation from expected responses to normal labor and if appropriate referral was done
MONITORING FETAL HEART BEAT
I. DEFINITION
Fetal Heart Beat / Fetal Heart Rate – monitoring the number of heart beats of the fetus that occur in a
given unit of time.
II. RATIONALE
1. It provides confirmatory information about fetal position and conversely fetal position aids in
locating fetal heart sounds.
2. To determine the health status of the fetus during labor and delivery, particularly first and second
stage of labor.
III. EQUIPMENT
Stethoscope / Fetoscope / Doppler Drape Lubricant gel
1. Determine fetal heart beat every 30 minutes during beginning of labor, every 15 minutes during
active labor, and every 5 minute during the second stage of labor.
2. Fetal heart sounds are transmitted best through the convex portion of the fetus, because this is the
part that lies in the closest contact with the uterine wall.
a. In cephalic presentations, they are heard loudest in the lower abdomen. In an ROA, the sounds
are heard best in the right lower quadrant. In LOA, in the left lower quadrant. In posterior
positions (LOP and ROP), the sounds are best heard in the mother’s sides.
b. In breech presentations, fetal heart sounds are heard most clearly high in the uterus at the
woman’s umbilicus or above it.
c. In face presentation, the back becomes concave, so the sounds are best heard through the more
convex thorax.
3. Check the FHB/FHR during relaxation period of uterine contraction.
ACTION RATIONALE
1. Perform hand hygiene. Explain the To prevent the spread of microorganisms.

procedure to client and provide privacy. Explanation of the procedure will enhance
cooperation and privacy promotes self-esteem.
2. Gather the things to be used. To lessen unnecessary movement and improve

efficiency of work.
3. Position the pregnant woman on her back To relax the abdominal muscles.
(recumbent position) with knees flexed.
To guide in locating the site of FHB.
4. Locate the back or position of fetus by

Leopold’s Maneuver. To use the bell part of the stethoscope that is
more sensitive to heart sounds. To ensure that the
unit is effective and can provide accurate results.
5. When stethoscope is used, adjust the bell

of the stethoscope. When Doppler is used,
To understand normal parameters. Clear fetal
check the unit if it is functioning well.
heart sounds can be counted accurately.
Apply a lubricant gel on the abdomen
where the FHB is expected to be heard.
Fetal heart beat could be heard through Doppler
by 10-12 weeks gestation and through a
stethoscope by 18-20 weeks gestation.
6. Move the device on the abdomen until a Normal FHR is 120-160 bpm.
clear fetal heart sounds are heard. Taking
note of other sounds that can possibly be Funic Souffle – rushing of blood to the umbilical
heard aside from the FHB. arteries, synchronous with FHR.
Uterine Souffle – sound of blood passing through

the uterine blood vessels, synchronous with
maternal pulse.
Fetal Bradycardia - <120 bpm and may indicate

prolapsed of the cord.
Fetal Tachycardia - >160 bpm and may indicate

maternal stress or fetal hypoxia.
To lessen the anxiety and give assurance to

mother.
To prevent a messy abdomen and left side-lying

position to promote utero-placental circulation.
7. Allow the client to listen to her baby’s fetal

heart beat.
8. Wipe off gel from the abdomen and

encourage left side-lying position.

1. Document fetal heart rate.
2. Document the time, rhythm and any unusualties.
3. Record the reaction and participation of the client.
PROVIDING PERINEAL CARE

I. DEFINITION
Perineal Care – cleansing of the perineum.
Perineum – the region of the body between the anus and the urethral opening.
II. RATIONALE
1. To remove normal perineal secretions and odors.

2. To prevent infection.
3. To render the perineum clean before and after childbirth as well as any treatment, surgery or
procedure involving the perineal area.
III. EQUIPMENT
Sterile pitcher with sterile water Sterile forceps

Sterile sponges soaked in a recommended disinfecting solution
Bedpan Rubber sheet lined with a cotton draw sheet
Bath blanket or bed sheet Waste receptacle
Disposable gloves
ACTION RATIONALE
1. Check to see specific physician’s orders to To ensure accuracy.

be followed.
3. Prepare all necessary equipment. To save time and effort.

4. Provide client privacy. To promote comfort.
5. Place client in a dorsal recumbent To prevent unnecessary exposure of the client.

position with knees flexed and separated.
Drape the client appropriately.
6. Place the rubber sheet lined with cotton To prevent the beddings from getting wet.
draw sheet under the client’s buttocks.
7. Position the client on a bedpan. To prevent any liquid from spilling.
8. Clean the perineum.

To avoid discomfort. Some clients will feel
• Pour warm sterile water gently over uncomfortably cold when the solution is not
the vulva. warm.
• With a sponge held by a pair of forceps This technique allows a thorough cleaning of the
and soaked in a recommended perineum while preventing contamination.
disinfecting solution, clean the
perineal area gently and thoroughly.
Use a top down direction (follow the
illustration below when using the 9 -
cotton ball technique). Discard used
sponges into the waste receptacle. To wash out any remaining disinfecting solution.
• Rinse with sterile water. To promote comfort.
• Dry the perineal area with a dry
sponge. Apply a clean perineal pad as
needed. To ensure client’s comfort.
9. Return client to a comfortable and safe

position.
1. Any complaints of irritation or discomfort and their location.

2. Any inflammation or swelling observed.
3. Presence of unusual odor.
4. Other significant findings especially on clients with indwelling catheter.
VI. ILLUSTRATION
DONNING AND REMOVING GLOVES
(Mosby’s Pocket Dictionary of Medicine, Nursing and Health Professions, 5 th ed.)
(Sorrentino, Sheila S., Mosby’s textbook for Nursing Assistant, 2004, 6 th ed., pp. 214-215, 228-229.)
I. DEFINITION
Gloves - sterile or clean filled coverings of hands, with separate sheath of each finger and thumb. Sterile
gloves are worn when there is contact with sterile instruments or patients sterile part. Clean gloves are
worn to protect the health care provider from urine, stool, blood, saliva, and drainage from wound and
lesions, and protect patient from health personnel who may have cuts.
II. RATIONALE
1. To provide a protective barrier and prevent gross contamination of the hands of the health care
provider.
2. To reduce the transmission of microorganisms to patients.
III. EQUIPMENT
Sterile gloves, a working space and a table/tray
a. Wearing gloves does not replace the need for hand hygiene, because the gloves may have small
defects or maybe torn during use, and hands can be contaminated from these leaks.
b. Gloves also must be changed between procedures on the same patient.
c. Examination gloves must not be worn outside the patient’s room except for certain procedures.
d. Once sterile glove is worn, its sterility is maintained throughout the entire procedure.
e. Be aware of what glove to wear, the size, sterile or clean.
f. Replace the gloves that are torn, cut or punctured during the procedure.
g. Some gloves that are made from latex may cause allergy.
h. Before performing or assisting a certain procedure that requires gloving, you must know the
procedure to be performed first and the reason for it.
ACTION RATIONALE
1. Hand hygiene. To reduce transmission of microorganisms.
2. Set up a sterile field.
To check sterility and safety to use.
3. Inspect the package of gloves giving

attention to its expiration date, if it is dry
and free from any tear, puncture, holes
and watermarks. To make sure one has enough space.
To facilitate easy opening of the package.
4. Arrange a work surface.

To maintain asepsis.
5. Open the package, grasp the flaps and

gently peel them back.
To facilitate easy donning of the gloves while
applying smoothly the sterile technique.
6. Remove the inner package and place it in

the work surface. To follow the principles of sterility. Edges of
anything that contains sterile articles are
7. Read the manufacturer’s instructions to considered unsterile.
the inner package.
To ensure that the inside of the package
including the gloves are sterile.
8. Arrange the inner package for left, right,

up, and down. The cuffs are near you and
the fingers are pointing away. To ensure that sterile technique is being
followed.
9. Grasp the folded edges of the inner To be reminded not to use your ungloved hand
package using index finger and thumb of to straighten the gloves. Do not let the outside of
each hand. the glove touch any non-sterile surface.
10. Fold back the inner package to expose the
gloves. Do not touch or otherwise
contaminate the inside of the package or
the gloves. The gloves on hand should be smooth and feel
comfortable.
11. Note that each glove has a cuff about 2 – 3

inches wide.
To follow aseptic principles. A glove to glove
technique, wherein both outside surfaces of the
glove will only touch each other to prevent
12. Put on the right glove if you are right- contaminating the hands of soiled gloves.
handed. Put on the left glove if you are
left-handed.
 Pick up the glove with your other

hand. Use your thumb, index and
middle finger.
 Touch only the cuff and the inside of
the glove.
 Turn the hand to be gloved, palm side
up.
 Lift the cuff up. Slide your fingers and
hand into the glove.
 Pull the glove up over your hand. If
some fingers get stuck, leave them To prevent contaminating hands with soiled
that way until the other glove is on. gloves.
 Leave the cuff toward down.
To prevent spread of microorganisms in case the
13. Put on the other glove. Your gloved hand hands are contaminated.
cannot touch the cuff or any surface. Hold
the thumb of your first gloved hand away
from your gloved palm.
14. Adjust each glove with the other hand.
15. Slide your fingers under the cuffs to pull

them up.
16. Touch only sterile items until the

procedure is over.
On Removing the Gloves:
1. Make sure that glove touches only glove.
2. Grasp a glove just below the cuff. Grasp it

on the outside part.
3. Pull the glove down over your hand, so it is

inside out.
4. Hold the removed glove with your other

gloved hand.
5. Reach inside the other glove. Use the first

two fingers of the ungloved hand.
6. Pull the glove down (inside out) over your

and the other glove.
7. Discard the gloves. Follow agency policy.
1. Principle of aseptic technique in opening and wearing a sterile glove is applied and practiced.
2. Sterility of the gloves is maintained throughout the procedure.
3. Contamination of a hand is prevented while removing a soiled glove.
DONNING AND REMOVING A GOWN
(Sorrentino, Sheila S., Mosby’s textbook for Nursing Assistant, 2004, 6 th ed.)
I. DEFINITION
Worn as a protective barrier from blood, body fluids, or other potentially infectious fluids.
II. RATIONALE
1. Water-resistant gowns are worn to prevent contamination of clothing with infectious agents and to
protect the skin of personnel from blood and body fluids exposures and organisms like lice or
scabies.
2. Water-impermeable gowns provide greater protection when large splashes of blood and body fluids
are possible or with exposure to large quantities of infectious material.
3. Gowns are also worn during the care of patients infected with pathogens to reduce contamination
of nurse’s clothing, which can then carry these pathogens to other patients. These gowns must be
removed when leaving the patient’s room or environment, and appropriate hand hygiene must be
performed.
III. EQUIPMENT
Gown (sterile or clean)

Waste receptacle
1. Gowns must completely cover the clothing, long sleeves have tight cuffs. The gowns open at the
back. It is tied at the neck and waist. The inside and neck are clean. The outside and waist strings are
contaminated.
2. Gowns are used at once. A wet gown is contaminated. It is removed and a dry one is put on.
3. Disposable gowns are made of paper. They are discarded after use.
ACTION RATIONALE
1. Remove your watch and jewelry. To prevent contamination of gown and facilitate
the gowning technique.
2. Roll up uniform sleeves.
4. Put on mask if required.
5. Hold a clean/sterile gown in front of you.

Let the gown unfold. Do not shake it. To ensure the gown is fit comfortably.
To avoid contaminating the uniform.
6. Put your hands and arms through the

sleeves. Make sure the gown covers the
entire uniform. It should be snug at the
neck. To prevent contamination, the gown is worn for
further protection.
7. Tie the strings at the back of the neck.

To prevent spread of microorganisms from
patient to health care giver and to other persons.
8. Overlap the back of the gown. Make sure

it covers your uniform.
9. Tie the waist strings at the back.
10. Put on gloves and proceed to procedure to

be done.
On Removing a Gown
1. Remove and discard gloves.
Decontaminate hands. Follow correct
procedure in removing gloves.
2. Remove the mask and discard it following

agency protocol.
3. Decontaminate hands.
4. Remove the gown:

a. Untie the waist strings.
b. Decontaminate hands.
c. Untie neck strings. Do not touch the
outside of the gown.
d. Pull the gown from the shoulder.
e. Turn the gown inside out as it is
removed. Hold it at the inside shoulder
seams, and bring your hands together.
5. Roll up the gown away from you. Keep it

inside out.
6. Discard the gown. Follow agency policy.
7. Decontaminate hands.
8. Open the door using a paper towel.

Discard it as you leave.
1. Correct techniques of donning and removing a gown are practiced without contaminating it.
2. Used or soiled gown is discarded to proper waste receptacle.
DRAPING THE CLIENT FOR DELIVERY
I. DEFINITION
Draping – a specific manner in covering the woman for delivery applying the sterile technique.
II. RATIONALE
1. To provide a sterile area during delivery.

2. To prevent post-partum and neonatal infection.
III. EQUIPMENT
Delivery table with stirrups

Draping sheet (Gyne Sheet)
ACTION RATIONALE
1. Explain the procedure to client. To gain participation and cooperation.
2. Assist patient to the delivery table, place in

lithotomy position.
To adjust the stirrups properly, thus prevent

injury and discomfort.
3. Adjust the stirrups according to the size of
the client. To facilitate insertion of instrument.
To relax abdominal muscles.

4. Instruct and assist client to place her
buttocks at the edge of the delivery table
and hands on her sides.
To reduce microorganisms and prevent
contamination.
5. Separate the legs and flex the thighs.

Elevate the legs and support them with
stirrups.
To facilitate draping of the client.

6. Perform perineal care.
Draping A Client With Sterile Gown

To maintain sterility of the gloved hand and of
1. Grasp the folded gyne sheet at the center the outside surface of the sheet.
placed on the sterile mayo tray.
2. Transfer hand at the edge of the folded

gyne sheet and let the other end hang
freely at your waist level.
To ensure a wider sterile area during delivery.

3. Spread the gyne drape and look for the
hole where right and left legs are to be
inserted.
4. Transfer your both hands at the outside

part of the gyne drape which is considered
to be sterile.
5. Insert the other hole of the leg into the

right leg, then the other hole into the left
leg. Instruct the client to elevate the leg
while inserting and not to touch the sheet. To cleanse the perineum with blood and other
discharges during delivery.
6. Overlap the half part of the sheet over the

abdomen and allow the other half hanging
below the posterior perineum.
7. Fix the gyne sheet without touching the

edges.
NOTE: If draping the client with a clean To keep the client dry and comfortable.
hands, the same steps are followed except
your ungloved hands should remain
holding the inside part. (This is the part
that would be contaminated because this
would be the area of the sheet that
directly touches the patient.)
On Removing the Drape
1. Perform perineal washing.

2. Still with the gloved hands, pull out slowly
the half portion of the sheet overlapping
the abdomen in the direction toward the
perineum.
3. Remove the sheet covering the right leg,

then on the left leg. Instruct the client to
elevate each leg while the drape is
removed. When the client is weak or
unconscious, ask somebody to elevate the
patient’s leg while you are removing the
drape/sheet.
4. Fold the sheet once at the center (keeping

the soiled part inside) and place under the
buttocks. Instruct the client to elevate her
buttocks while placing the dry part of the
sheet.
5. Keep the client dry and comfortable. Apply

an adult diaper.
1. Correct technique of draping is applied without contaminating other sterile area.

2. The client is kept dry and comfortable after delivery.
3. Post-partum and neonatal infection are prevented.
CARING FOR A CLIENT DURING DELIVERY
I. DEFINITION
Preparation and procedure done by a nurse who is actually handling the delivery.
II. RATIONALE
1. To maintain the sterility of the area during delivery.

2. To prevent post-partum and neonatal infection.
3. To provide safety for the mother and the baby by applying correct procedures and techniques.
4. To assess the responses and coping mechanism of the mother to the delivery of the baby.
III. EQUIPMENT
1 DR pack (prepared by the circulating nurse on the Mayo Tray) which contains the ff:
 2 forceps
 1 latex band (to tie the cord)
 1 pair of gloves (1 pair of gloves is added if C.I. and student will handle the case)
 Several O.S. or gauze
 1 gyne sheet
 Scissors (to cut the cord)
NOTE: These are the instruments and articles prepared only if the case is multipara or gravida 2, with previous home
delivery/deliveries.
ACTION RATIONALE
Before Delivery:
1. Put on cap and mask. To protect self from discharges and prevent the spread of
microorganisms.
2. Scrub hands and fingers for 5 minutes.
3. Put on sterile gloves.
To lessen or eliminate bacteria from the skin.
To maintain sterility in the area and to protect self and the

4. Together with the circulating nurse, drape the client from infection.
client with sterile gyne sheet.
To provide a sterile field.

5. Arrange the instruments on the mayo tray
prepared by the circulating nurse. Slip the latex
board on the curve forceps.
6. Stay in front of the perineal area. Keep your eye

Everything on the tray should be ready for the delivery.
on the perineum. Support the perineum when
the client pushes.
To keep watch on the perineum because the client may

bear down anytime.
During Delivery:
1. Coach the client to bear down when there is

contraction. Support the perineum with towel
or OS when it bulges.
2. Apply a modified ritgen’s maneuver as the

head starts to deliver until the head is out of
the vagina.
To facilitate pushing of the fetal head and prevent perineal

3. Instruct the client to stop pushing, open her lacerations.
mouth and breathe through it.
4. Wipe out the mucus and other secretions from

the mouth and nose of the baby.
This maneuver is apple in cephalic presentation.
5. Observe for cord around the neck of the baby.

If there is any, insert fingers to ease pressure
and slip cord over baby’s shoulder. If the cord
is very tight on the neck, apply two clamps on
the cord at least 1 inch apart, then cut the
cord between the clamps.
To provide safety for the mother and the baby, facilitate

external rotation and prevent laceration.
6. Observe for complete rotation of the shoulder;

facilitate the turning of the head with your
hands, until the shoulders are in line with the
anterior and posterior diameter of the
mother’s pelvis. To establish an immediate patent airway.
7. Deliver the anterior shoulder slowly by lateral

flexion then the posterior shoulder by lateral
flexion upward.
Very tight cord coil on the baby’s neck will alter O 2 supply of
the baby.
8. Hold the baby’s neck gently with your right

hand while simultaneously exerting a pulling
pressure to expel the whole body supporting it
with your other hand.
9. Check the time of delivery and gender of the

baby with the circulating nurse.
10. Place the baby on mother’s abdomen lined

with sterile gyne sheet or towel in side-lying
position, head downward.
This is to facilitate easy delivery of the shoulders of the baby
without the mother pushing harder.
11. Wipe off secretions from the mouth and nose,

if necessary.
12. Assess the condition of the baby using the

APGAR scoring for the first one minute of life
with the circulating nurse.
To facilitate complete expulsion and to ensure safety of the

baby.
13. Wipe the baby’s body with gauze while

waiting for the cord pulsation to stop.
14. Apply the first clamp with latex band at a
distance about 2 inches from the navel.
15. Hold the cord with the first clamp with your
left hand while the right index finger To
andfacilitate complete expulsion of fetus.
thumb milk the cord from the first clamp
towards the placenta.
16. Apply and lock the second clamp at a distance

of one inch from the first clamp.
For correct documentation.
17. Then cut the cord between the 2 clamps, just

above the clamp with the latex band.
To facilitate cutting of the cord and draining of discharges

18. Place the second clamp attached to the cord from the mouth and nose.
at the side of the mother’s abdomen.
19. Pull the string attached to the latex band and

slip towards the tip of the second clamp,
gently pull and adjust the latex band until it
To establish a patent airway and respiration of the baby.
reaches the base of the cord. Make sure the
skin is not included.
Using the scale in APGAR scoring in evaluating the condition

of the baby provides an objective assessment for
20. Cut the string and pull out while he clamp is
planning newborn management.
still in place. Trim the cord approximately one
inch above the navel, and then remove the
first clamp.
Rubbing the body not only removes discharges but also

stimulates the baby to cry and facilitate expansion.
21. Hold the baby and show to the mother. Let
the mother hold the baby. Inform her if there
is any abnormality.
To give adequate allowance in cutting the cord and allow
only a short distance to slip the tie.
22. With the circulating nurse, bring the baby to

the newborn area of the nursery and endorse
properly. Milking the cord will prevent blood from spurting when the
cord is cut.
23. Go back to the mother and deliver the

placenta when signs of placental separation
are observed.
To give enough space when cutting the cord.

24. Check the time and mechanism of placental
expulsion with the circulating nurse.
25. Inspect the placenta for completeness.

To facilitate slipping of the latex band.
26. Inspect the perineum, vagina, and cervix for

any laceration. Explore the uterus and
evacuate placental fragments and blood clots.
To maintain asepsis and to protect the baby from harm.
27. Palpate the fundus of the uterus. Massage

gently if needed.
To apply pressure on the cord, therefore, preventing
bleeding from the cord.
28. Scrub the perineum with betadine soap and

water.
29. Remove the drape and place under the
buttocks of the client.
30. Remove the legs from the stirrups and make

the client feel comfortable.
To eliminate any source of infection.
31. Do after care of the articles and equipment.
To promote bonding.
To make the mother aware, in case there is any

abnormality.
For accurate identification of the baby.
For further newborn care and management.

To prevent uterine inversion and bleeding.
To determine the duration of the third stage of labor.
To prevent retention of placental fragments.
To prevent massive bleeding.
To check the consistency of the uterus.

To prevent infection.
To keep the client dry.
To promote comfort.

1. Aseptic technique used during the delivery.
2. Correct and safe technique in handling the delivery.
3. Responses and coping mechanism of the mother.
CARING FOR A CLIENT DURING DELIVERY
I. DEFINITION
A procedure and preparation done by the nurse in assisting the delivery.
II. RATIONALE
1. To prepare all sterile equipment and articles to be used in the delivery.

2. To provide holistic care and safe delivery of the baby.
3. To prevent post-partum and neo-natal infection.
4. To record accurately all information pertaining to the delivery of the baby.
5. To assess the health status of both the mother and the baby.
III. EQUIPMENT
1 DR pack (prepared by the circulating nurse on the Mayo Tray) which contains the ff:
• 2 forceps
• 1 latex band (to tie the cord)
• 1 pair of gloves (1 pair of gloves is added if C.I. and student will handle the case)
• Several O.S. or gauze

Instruments and articles to be added to the DR set:
For Primipara and Segundi
2 scissors (1 straight, one curve) 1 needle holder
1 tissue forceps with teeth 1 5cc syringe with needle g23
1 chronic 2-0 suture Xylocaine 2% 5cc
1 pair of gloves 1 gyne sheet
For Multipara and Sugundi with home delivery:
1 gyne sheet 1 pair of scissors
1 pair of gloves
ACTION RATIONALE
Before Delivery:
1. Upon receiving the client from the labor

For accurate assessment.
room, identify whether she’s a primipara,
multipara, segundi who had prior home
delivery by reading the chart and by
interviewing the client. Take note of all
information endorsed by the LR
nurse/personnel.
2. Put on a mask and a closed cap.
3. Accompany the client to the delivery room.
4. Place a Kelly pad on the DR table and a pail on

the floor. Make sure that the tail of the Kelly
pad is directly at the center of the pail.
5. Assist the client in a lithotomy position.
To provide emotional support.
6. Do perineal flushing. Paint with Betadine

aseptic; if an episiotomy is to be done.
To maintain a clean and neat area.
7. Drape the client with a sterile gyne sheet.
This is the ideal position during delivery.
8. Check with the scrub nurse the time when the

cervix was completely dilated, the status of
the membranes, and the color of the amniotic
To lessen the amount of microorganisms.
fluid, if there is ruptured BOW.
9. Coach the client on when to bear down as
well as on breathing techniques.
To provide a sterile field.
During Delivery:
For accurate recording.

1. Record all pertinent information about the
client and her delivery such as the time of
delivery, gender of baby, presentation,
position, and type of delivery.
2. While the cord is being cut, hold the baby

using sterile drapes and at the same time
assessing his/her condition through the use of
APGAR scoring.
3. Wrap the baby with a diaper and place

him/her on the mother’s breast. To provide assistance and emotional support.
4. Check and record time and mechanism of

placental expulsion.
For accurate recording.

5. Check the client’s BP.
6. If BP is 120/80 mmHg or below, administer

Methergin 1 ampule IM; and if the BP is
130/90 mmHg or above, incorporate 10 units
Oxytocin to 1 liter of IV fluids as ordered.
After delivery: To anticipate a plan of care for the newborn.
1. Assess the consistency of the uterus.
2. Clean the client’s perineum while observing

for any bleeding.
3. Remove the drape and place the client’s

buttocks.
To keep the baby warm.
To promote bonding.
4. Remove the client’s legs from the stirrups.
For accurate recording and assessment.

5. Accomplish the Obstetrical and Nursery
Records.
6. Endorse the client and the chart to the Head

Nurse or Staff Nurse in the ward.
To determine what oxytoxic drug to administer/
7. Do after care of equipment and articles.

To prevent bleeding since oxytoxic drug stimulates uterine
contraction.
To assess if bleeding is present.
To keep the client dry.
To provide comfort.
To provide a basis for the plan of care for the mother and
the baby.
To provide accurate information which can be used for the
plan of care.
To prevent the spread of microorganism.

1. Record of OB history and present pregnancy.
2. Aseptic technique used during the process of labor and delivery.
3. Objective assessment and appropriate referral of any abnormal observations
4. Condition of the mother and the newborn baby during and immediately after delivery.
5. Appropriate nursing care to the mother and the newborn baby.
APPLYING ABDOMINAL BINDERS
I. DEFINITION
Binder – a type of bandage, sworn snugly around the trunk or body that provides support.
II. RATIONALE
1. To provide protection and support to the abdomen.

2. To protect suture lines from tension or stress.
III. EQUIPMENT
Straight and scultetus binders
ACTION RATIONALE
1. Fanfold half of the binder lengthwise. To make placement of the binder under the client
easier.
2. Raise the side rails opposite you.
To prevent the client from falling off the bed.

3. Help the client to roll onto his/her side
facing the raised side rail.
4. Place a folded binder under the client and

have the client roll back onto the binder and
to the other side.
To help you to place the binder under the client.
5. Help the client to assume a supine position
with his or her head slightly elevated and
knees slightly bent.
6. Apply binder.
To apply a straight abdominal binder: To conserve your energy and facilitates application of
the binder.
7. Pull the sides of the binder together to meet

vertically in the middle.
To reduce tension and stress on the abdominal suture

NOTE: The binder should be between the client’s line.
symphysis pubis and the lower rib cage.
8. Secure the binder with Velcro or with safety

pins.
To apply scultetus abdominal binder:
9. Starting at the left bottom tail of the binder,

pull the tail to the midline. Maintain tension
and overlap the tail with the bottom right
tail.
10. Continue overlapping each pair of tails with
tension until all are secured in the midline.
11. Secure the top set of tails with a safety pin.
12. Record the procedure and include your

evaluation of the client.
To maintain continuous and even support to the

abdominal wall and suture line.
To maintain continuous and even support to the

abdominal wall and suture line.
1. The bandage is applied in a smooth manner with even pressure to the body part.
2. The client is comfortable and does not have signs of nervous impairment such as pain, numbness, or
tingling of the bandaged areas.
ASSESSING A POSTPARTUM CLIENT

I. DEFINITION
Immediate Postpartum Care – care given to the mother for the first 2 hours immediately after delivery.
Postpartum Care – care given to the mother after delivery of the baby or after giving birth.
II. RATIONALE
1. To provide emotional and physical comfort to the mother.
2. To prevent postpartum complications like uterine atony, postpartum bleeding, and infection.
3. To identify nursing diagnoses related to physiological and psychological changes of the postpartum
period.
III. EQUIPMENT
Paraphernalia for taking vital signs:
 BP apparatus
 Thermometer
 Wristwatch with second hand
Scultetus binder
IV. PLANNING AND INTERVENTION
ACTION RATIONALE
2. Check vital signs every 15 minutes for the first

Decreased BP and increased pulse rate indicate
hour, every 30 minutes for the next 4 hours and postpartum bleeding. Elevated temperature for
every 8 hours thereafter. the first 24 hours indicates dehydration and
possible infection after this period.
The fundus should be firm and hard midline at the level of

the umbilicus or slightly above. A boggy or soft
3. Palpate the fundus every 15 minutes for the first uterus denotes uterine atony or retained placental
hour, then every 30 minutes for the next 4 tissues resulting in excessive vaginal bleeding.
hours, every 8 hours for 48 hours, then daily. If
boggy or soft, gently massage the fundus while
assessing the amount of bleeding.
• Oxytocin stimulates the uterus to contract.

If the uterus is still boggy or soft after gentle
massage, report to the physician. Observe
closely. Give Oxytocin as ordered.
4. Assess lochial discharges (color, odor, and

quantity) every 15 minutes for the first hour,
Oozing bright red lochia may indicate a clot occluding the
every 30 minutes for the next 4 hours, then 8 cervical opening. Foul odor may indicate infection.
hours for 48 hours, daily.
5. Assess breast and nipples daily.
To detect sore or crackled nipples and if breast is beginning

to engorge.
6. Assess the bladder an hour after delivery, then

every 4 hours for 48 hours, and every 8 hours
thereafter.
To assess for bladder distention and presence of pain or
discomfort upon voiding. A distended bladder may
7. Assess the perineum if episiotomy wound is interfere with effective uterine contraction.
intact, free of swelling and discoloration. Overdistended bladder may cause damage to
bladder function.
8. Assess bowels and check bowel sounds.

Swelling, bruising and discoloration indicate hematoma
and non-healing of wound.
To find out if client has bowel movements 2-3 days after

delivery. Absence of bowel movements can be
attributed to slowing down of peristalsis if client is
just confined to bed, or other high risk GIT
problems.
9. Apply scultetus binder if indicated.
To support the uterus, relieve pain and discomfort and

secure dressing in case the client had C-section.
10. Do after care and wash hands.

1. Vital signs, within normal range or any alteration.
2. Color, odor, and quantity of lochia, whether the color follows a normal progressive pattern
indicative of a normal involution of the uterus (red to pinkish to whitish lochia).
3. Findings in the assessment of the uterus, breast, nipples, perineum, episiotomy or lacerated wound,
bladder and bowel function and pattern of voiding.
4. Referrals done for any alteration from normal.
5. Nursing and medical management done.
USING PERILIGHT FOR EPISIOTOMY CARE
I. DEFINITION
Perilight Exposure – a method of heat application which is free from moisture that gives off therapeutic doses
of infrared light.
II. RATIONALE
1. To increase circulation in a compromised area of the body.

3. To relieve pain from muscle spasms and affected joints.
4. To reduce swelling and accompanying discomfort.
5. To warm the body part and promote healing.
III. EQUIPMENT
Infrared light bulb (number of watts as prescribed)
Pillows
Drape/blanket
ACTION RATIONALE
1. Read the doctor’s order. To ensure accuracy of the procedure.
2. Explain the procedure to client.
3. Prepare the procedure to client.

To establish trust and participation of the client.
4. Check the infrared light. See if it is functioning
well.
5. Position the client in dorsal recumbent (knee

flexed and abducted).
This facilitates the implementation of the procedure.
6. Check the perineal if clean and dry.
7. Place the lamp approximately 45 cm (18 inches)

from the skin and 60 cm (24 inches) if the bulb is
large.
To prevent accidents and injury to client.

8. Cover the pelvic area including lower extremities
with a sheet or blanket.
9. Instruct the client not to change position nor

touch the lamp. Check the client every 5 minutes.
10. Note skin color changes every 15 minutes. The

client should experience a pleasant warm
sensation not a hot uncomfortable feeling.
This is the recommended position to facilitate exposure of
the perineum to heat.
11. Carry out procedure as prescribed as to duration

of exposing the perineal area.
To ensure maximum therapeutic effect.
12. After the procedure, remove lamp and place
client in a comfortable position.
13. Decontaminate the equipment and store in its

proper place.
14. Hand hygiene. To prevent skin from burning.
To provide privacy.
To ensure client safety.
To assess for any possible signs of burning or injury to

client’s skin.
To ensure safety of dosage and the therapeutic effect.
To eliminate microorganisms in the equipment and hands.

1. Evaluate and record the reactions of the client about the procedure.
2. No signs of burning and injury in the perineal area.
3. Perineal episiotomy / laceration is dry and in healing process.
PERFORMING RESCUE BREATHING AND
CARDIO PULMONARY RESUSCITATION (INFANT/CHILD)
(Adapted from Philippine National Red Cross, 2012)
I. DEFINITION
CPR – is the basic life-saving skill that is used in the event of cardiac, respiratory, or cardio-pulmonary arrest to
maintain oxygenation by providing external cardiac compressions and/or artificial respiration.
II. RATIONALE
1. This life-saving skill is initiated in the event that an individual is found with or develops the absence of
a pulse or respiration or both.
2. CPR must be initiated immediately once cardiac or pulmonary arrest has occurred. Lack of O2 to the
tissue can result to permanent cardiac and brain damage within 4-6 minutes.
3. The basic goals of CPR, which are referred to as the ABCD of emergency resuscitation:
a. Establish airway
b. Initiate breathing
c. Maintain circulation
d. Defibrillate
III. EQUIPMENT
Outside clinical or hospital setting:
Hard, flat surface
Body substance isolation items (gloves, face shield, mask, etc.)
Automated external defibrillator
Clinical setting:
- Hard, flat surface (chest compression board)

- Personal protective equipment (gloves, face shield, mask, etc.)
- Ambu-bag
Oral airway (varied sizes)
Emergency drugs
Emergency resuscitation cart including defibrillator
General Guidelines:
1. Differentiate between emergency resuscitation that occur in the hospital setting versus those
occurring in the non-clinical environment.
2. Maintain an ongoing assessment of the cardiac and respiratory status throughout emergency
resuscitation efforts.
3. Be aware of the emergency response systems available in each new environment.
4. Face masks with one way valves are recommended for trained rescuers.
5. Use a pediatric dose attenuating system for children 1-8 years of age. If not available, and child is in
cardiac arrest, a standard AED may be needed.
6. There is no recommendation for or against the use of an AED in infants less than one year of age.
7. All clients in cardiac arrest receive resuscitation unless a “do not resuscitate” order is present.
Consider the comparison on Cardiopulmonary Resuscitation for child and infant:
CHILD INFANT
COMPRESSION AREA CENTER OF THE CHEST ON TOP OF THE IMAGINARY TABLE
DEPTH 1 – 1 ½ INCHES ½ - 1 INCH
HOW TO COMPRESS HEEL OF ONE HAND OR 2 HANDS 2 FINGERS
RATE APROXIMATELY 100 PER MINUTE

COMPRESSION-VENTILATION 30:2 FOR 1 RESCUER
RATIO 15:2 FOR 2 RESCUERS
NUMBER OF CYCLES PER 5 CYCLES FOR 1 RESCUER
MINUTE 10 CYCLES FOR 2 RESCUERS
COUNTING FOR 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26
STANDARDIZATION PURPOSES 27 28 29 AND 1 – THEN BREATHE, BREATHE; UP TO 5 CYCLES;
BREATHE, BREATHE
Consider the comparison on Rescue Breathing for child and infant:
CHILD INFANT
OPENING OF AIRWAY (HEAD NATURAL PLUS POSITION NEUTRAL POSITION
TILT-CHIN LIFT)
LOCATION FOR CHECKING THE CAROTID PULSE BRACHIAL PULSE
PULSE
METHOD MOUTH-TO-MOUTH OR MOUTH-TO-MOUTH- AND NOSE
MOUTH-TO-NOSE
BREATHS NORMAL BREATH (1 SECOND PER BREATH)
RATE 40 BREATHS FOR 2 MINUTES (1 BREATH FOR EVERY 3 SECONDS)
COUNTING FOR BREATHE – 1, 1001, BREATHE
STANDARDIZATION PURPOSES: 1, 1002, BREATHE
MNEMONIC OF 1 BREATHE 1, 1003, BREATHE
EVERY 3 FOR CHILD OR INFANT 1, 1004, BREATHE
1, 1005, BREATHE
1, UP TO 1040, BREATHE
ACTION RATIONALE
CPR: ONE RESCUER – CHILD (ONE YEAR OF AGE

TO ONSET OF ADOLESCENCE)
1. Assess responsiveness by tapping or gently To prevent injury and assist in assessing the level of
shaking client while shouting “are you okay?” consciousness and possible etiology of crisis.
assess for possible injury to neck before
moving the victim.
To prevent paralysis. Respiratory arrest is more
2. If unresponsive, activate the local emergency common in children than cardiac arrest. The
response system if outside the hospital. If in child is more likely to benefit from initiation of
hospital setting, initiate agency policy for CPR.
calling a code.
To facilitate successful cardiac massage.
3. Position client in a supine position on hard, flat
surface or cardiac board. To prevent infection.
4. Apply appropriate body substance isolation
items if available.
To initiate a patent airway for successful artificial
5. Open airway by slight head tilt-chin lift respirations.
method.
To prevent potential injury, CPR should not be
6. Assess for breathing: look, listen, and feel for administered to a client with spontaneous
air movement (10 seconds). respirations or pulse.
To prevent air leakage.

7. Give rescue breaths if the victim is not
breathing. Occlude nostrils with the thumb To confirm open airway.
and index finger of the hand on the forehead
that is tilting the head. Form a seal over
victim’s mouth or appropriate respiratory
assistive device and give two breaths that
make the client rise.
To prevent injury, chest compressions should be
8. Palpate carotid pulse for 10 seconds. If absent, avoided to clients with pulse.
begin external cardiac compressions.
To prevent irreversible brain and tissue damage. Proper
9. External cardiac massage are performed as positioning and technique is essential to allow
follows: for maximum compression of the heart and to
a.Kneel at client’s side, parallel to client’s reduce risk of fractures. Incomplete chest recoil
sternum. is associated with decreased coronary and
b.Remove clothing to visualize chest. cerebral perfusion.
c. Place heel of one hand on the client’s
sternum at the nipple line. Other hand over
the forehead.
d.Keep arms straight with shoulders directly
over your hands.
e.Compress chest 1 to 1 ½ inches at a rate of
100 compressions / min.
f. Allow chest to recoil completely after
compressions.
10. After 5 cycles of 30 compressions andTo2 prevent irreversible brain and tissue damage.
ventilations, allow AED to analyze the rhythm.
If AED does not detect a rhythm and needs
schock, continue chest compressions.
11. Continue CPR and rhythm analysis until

emergency response providers arrive or when
the client begins to move.
12. Place in recovery position (side-lying).
CPR: TWO RESCUERS – CHILD
13. Follow actions for one rescuer CPR for a child.

Give cycles of 15 compressions and 2 rescue
breaths. Use AED after 5 cycles of
compressions and breaths
CPR: ONE RESCUER – INFANT (UNDER 1 YEAR OF

AGE)
Refer to rationale of steps 1 -7 for a child.
1. Assess responsiveness.
a. Activate EMS.
b. Position on a flat surface.
c. Apply appropriate body substance isolation.
d. Position self and open airway.
e. Assess respirations.
To initiate emergency assistance and provide
3. If unresponsive, activate EMS and get AED if oxygenation and circulation.
available. Send second rescuer (if available) to
do this, while you stay with the infant.
To prevent irreversible brain and tissue damage.
4. If respirations are absent, begin rescue
breathing.
a. Avoid overextension of the infant’s neck. Proper positioning is essential for the following reasons:
b. Make a tight seal over both the infant’s
nose and mouth and gently administer a. It is believed that overextension of infant’s
artificial respirations. head can cause closing or narrowing of the
c. Give two rescue breaths (I second each) airway.
with visible chest rise. b. Making a complete seal over the infant’s
mouth and nose prevents air leakage.
5. Assess circulatory status using the brachial

pulse. If no pulse, perform external chest
compressions.
To ensure proper positioning.
6. Perform cardiac compressions:
a. Allows maximum compression of the heart
a. Maintain position parallel to the infant. between sternum and vertebrae.
b. Position on a flat surface. b. Compressions over xiphoid process can
c. Position the hands by drawing an lacerate the liver.
imaginary line between nipples. Place two c. Keeping other fingers and hands off the
fingers on the breastbone, just below this chest during compressions reduces risk of rib
line. Press chestbone down ½ to 1 inch the fractures.
depth of chest. Deliver 100 compressions d. Keeping one hand on the infant’s forehead
per minute. Allow chest to recoil after helps maintain an open airway.
each compression.
To prevent further injury. Respiratory arrest is more
common in children and infants than cardiac
7. After 5 cycles of CPR (30 compressions: arrest.
2 ventilations), activate EMS.
To prevent irreversible brain and tissue damage.
8. Resume CPR until emergency response

providers arrive or the infant begins to move.To keep in mind that etiology of respiratory and cardiac
arrest is different for infants and requires
9. Place in recovery position (cuddle). modification of CPR sequence.
CPR: TWO RESCUERS – INFANT
10. Follow actions for the procedure “CPR One
Rescuer for Infants” with the following
changes.
a. Provide 15 compressions to 2 ventilations.

b. Use two thumb-encircling hands technique
for compressions. Place both thumbs side
by side in the center of the infant’s
breastbone, just below the nipple line.
Encircle infant’s back with both hands and
use thumbs to depress the breastbone ½
inch to 1 inch depth of infant’s chest.
1. Client experienced improved clinical status, as evidenced by patent airway with spontaneous
respirations and return of cardiac circulation.
2. Client does not have damage inflicted by incorrect positioning for CPR.
3. Note the time and condition when the client was found.
4. Record interventions implemented including time, results of implementations, orders received from
physician, vital signs, time of incident and general status of client afterwards.
5. Record any medication given.
6. If incident occurred in a non-institutional setting, report for findings and interventions to aid
personnel when they arrive.
PERFORMING A HEIMLICH MANEUVER
FOR UPPER AIRWAY OBSTRUCTION
(Adapted from Philippine National Red Cross, 2012)
I. DEFINITION
Heimlich Maneuver – a procedure designed to dislodged a foreign object that obstructs the throat.
II. RATIONALE
To remove any foreign object that has lodged in the victim’s trachea.
III. EQUIPMENT
Examination gloves (if available)
ACTION RATIONALE
Managing the Conscious Victim
1. If choking is suspected, ask the victim “Can you

To determine if FBAO is present and complete.
speak?”
2. If the victim is coughing effectively, stay with

To remove the foreign body manually may lodge it
him or her but do not attempt to clear the deeper in the trachea, resulting in a complete
obstruction manually. obstruction. Remain with the victim until the
obstruction is cleared, since he or she may
become fatigued and experience respiratory
distress.
3. Attempt to relieve the obstruction:
a. Infant (up to age 1): Position the infant with

his or her trunk and face down. AdministerTo5 avoid trauma to the abdominal organs, chest thrusts
back blows followed by 5chest thrusts. are used instead of abdominal thrusts in infants.
b. Adult or child over 1 year: Apply 5 abdominal
thrusts (Heimlich Maneuver). Use chest To displace abdomen through abdominal thrusts,
thrusts as an alternative procedure when the forcing air from the lungs upward and creating
client is very obese, or when trauma or an artificial cough.
complications might arise from abdominal
thrusts.
4. Repeat step 3 as needed until the victim’s

airway is cleared or the victim becomes
unconscious.
Managing the Conscious Victim Who Becomes

Unconscious
5. Call for help. Activate EMS or code system of

your hospital.
To initiate more advanced life support measures.
To prevent obstruction by the victim’s tongue and

facilitate ventilation.
6. Place the victim in the supine position and open
the victim’s airway using the head tilt – chin lift
or jaw thrust method.
To prevent cardiopulmonary arrest from inadequate
7. Attempt to ventilate the victim’s airway using
delivery of oxygen.
mouth-to-mouth rescue breathing, a pocket
mask or bag-valve-mask device.
To evaluate whether or not the ventilation efforts were
8. Place your face against the victim’s mouth and
successful.
look at the chest for rise and fall, listen and feel
for air to escape from the victim’s mouth.
To prevent improper head positioning which is the most
9. If you are unable to ventilate the victim,
common cause of inability to ventilate.
reposition the head and reattempt ventilation.
10. If you are still unable to ventilate the victim:

To displace abdomen through abdominal thrusts,
a. Adult or child (aged 1 -7 years old):
forcing air from the lungs upward and creating
Position yourself astride the victim’s thighs
an artificial cough.
and apply 5 manual thrusts, or chest thrusts
if abdominal thrusts are contraindicated.
To avoid trauma to the abdominal organs, chest thrusts
b. Infant (up to 1 year old): Apply back blows are used instead of abdominal thrusts in infants.
followed by 5 chest thrusts.
11. Open the victim’s mouth by grasping the

victim’s tongue and lower jaw (mandible)
between your thumb and fingers. Look to see
if the obstructing object can be visualized. If
the object is at the level of the epiglottis To
or prevent obstruction by the victim’s tongue and
higher, use the first two fingers of your other facilitate ventilation.
hand to sweep the victim’s mouth and
remove the object. Wear maximum gloves if
available to perform the finger sweep.
12. Reposition the victim’s head, open the To prevent cardiopulmonary arrest from inadequate
victim’s airway, and attempt to ventilate the delivery of oxygen.
victim.
13. Repeat steps 10 to 12 until the obstruction is

cleared.
To ensure that CPR procedures should not be performed

Managing the Unconscious Victim (Undetermined on a sleeping person.
Cause)
To initiate more advanced life support measures.
To open the airway and prevent the victim’s tongue

14. Confirm unresponsiveness by shaking the from obstructing the flow of air.
victim and asking “Are you okay?”
15. Activate the EMS system.
16. Logroll the victim into a supine position. Keep

To assess for presence and effectiveness of ventilation.
the victim’s head and neck stable if neck
injury is suspected. Open the victim’s airwayTo prevent cardiopulmonary arrest from inadequate
using the head tilt-chin lift method. If a neck delivery of oxygen.
injury is suspected, use the jaw thrust
method.
17. Look, listen, and feel for air movement.
18. Attempt to ventilate the victim. If you are

unable to ventilate the victim, follow steps 8
to 13 for “Managing the Conscious Victim
Who Becomes Unconscious.”
1. Foreign object/food is removed easily.

2. Client is adequately oxygenated.
ADMINISTERING VAGINAL IRRIGATIONS AND INSTILLATIONS
(Sorrentino, Sheila S., Mosby’s textbook for Nursing Assistant, 2004, 6 th ed.)
I. DEFINITION
Vaginal Irrigation (douche) – is the washing of the vagina by a liquid at a low pressure. It is similar to the
irrigation of the external auditory canal in that the fluid returns immediately after being inserted.
Vaginal Medication / Instillation – is the administration of medication via the vaginal canal. Medications
are either in the form of a cream, jelly, foam, or suppository. Vaginal foams, jellies, and creams are
applied by using a tubular applicator with a plunger.
II. RATIONALE
1. To treat or prevent infection.

2. To reduce inflammation.
3. To prevent hemorrhage.
4. To relieve vaginal discomfort.
5. To remove offensive or irritating discharges.
III. EQUIPMENT
For a vaginal irrigation: For a vaginal instillation

Vaginal irrigation set: nozzle, tubing Prescribed vaginal suppository or cream
with a clamp, and solution container Disposable gloves
Moisture – resistant drape Lubricant for a suppository
Irrigating solution Applicator for vaginal cream
Thermometer Paper towel
Moisture – proof pad Clean perineal pad & T-binder/sanitary belt
Bedpan
Tissues
Gloves
IV pole
1. Drugs, heat and cold can be applied with douche.

2. Douching is not done during menstruation, nor is it done during late pregnancy or during the first 6-
8 weeks after childbirth.
3. A full bladder can cause discomfort during douche, therefore, a woman is encouraged to void before
procedure.
4. A douche kit has a bag, connecting tube and a nozzle.
5. To give a douche, the genital area is exposed and touched. This area is sexual and some people do
not like being touched. They may interpret the purpose of touch in a wrong way. (Culture, religion
and personal values and beliefs affect the meaning touch).
6. Perform the procedure with skill and in a professional manner. Explain the procedure properly to
client, get consent, and protect client’s privacy. Be careful of what you say and do. Some words may
mean different to the client. Also, take note that non-verbal communication is important.
ACTION RATIONALE
1. Verify the medication or irrigation order by To ensure accuracy.

carefully checking the physician’s order for the
specific medication or solution ordered, its
dosage, and time of administration.

- Explain to the client that a vaginal irrigation or To reduce the client’s anxiety and gain her
instillation is normally a painless procedure cooperation.
and, in fact, may bring relief from itching and
burning if an infection is present.
- Provide privacy and ask the client to void. To reduce discomfort and injury during the
treatment.
3. Position and drape the client appropriately.
For an irrigation:
- Assist the client to a back – lying position with So that the solution will flow into the posterior
the hips higher than the shoulders. fornix of the vagina.
- Position the client on a bedpan, and provide The bedpan will catch the irrigating solution that
comfortable support for the lumbar region of will flow from the vagina. To provide client’s
the back with a roll or pillow. comfort.
- Place the waterproof drape under the To protect the bedding.
bedpan.
- Provide a drape for the legs so that only the To provide privacy.
perineal area is exposed.
- Assist the client to a back - lying position with For easy viewing of the perineal area.
the knees flexed and the hips rotated
laterally.
- Drape the client appropriately so that only To provide privacy.
the perineal area is exposed.
4. Prepare the equipment.

For an irrigation:
- Clamp the tubing. Hang the irrigating At this height, the pressure of the solution is not
container on the IV pole so that the base is enough to injure the vaginal lining.
about 30 cm (12 in) above the vagina.
- Run the fluid through the tubing and nozzle To remove air from the tubing and to moisten the
into the bedpan. nozzle.
- Unwrap the suppository and put it on the To prevent contamination of the medication.
opened wrapper.
Or
- Fill the applicator with the prescribed cream,
jelly, or foam. Directions are provided with
the manufacturer’s applicator.
5. Assess and clean the perineal area.

- Don gloves. To prevent contamination.
- Inspect the vaginal orifice for inflammation, This serves as a basis for future assessment and
note any odor or discharge from the vagina, evaluation.
and ask about any vaginal discomfort.
- Provide perineal care to remove To decrease the chance of movement of
microorganisms. microorganisms into the vagina.
6. Administer the irrigation or vaginal suppository,

cream, foam, or jelly.
For an irrigation:
- Run some fluid over the perineal area, then To test the temperature of the solution and to
insert the nozzle carefully into the vagina. reduce the discomfort of the client since the
Direct the nozzle toward the sacrum, direction of the nozzle is based on the anatomical
following the direction of the vagina. structure of the vagina.
- Insert the nozzle about 7 to 10 cm (3 to 4 in), To irrigate all parts of the vagina.
start the flow, and rotate the nozzle several
times.
- Use all the irrigating solution, permitting it to Obstructing the return flow could result to injury of
flow out freely into the bedpan. the tissues from pressure.
- Remove the nozzle from the vagina.
- Assist the client to a sitting position on the To help drain the remaining fluid by gravity.
bedpan.
For a suppository:
- Lubricate the rounded (smooth) end of the To facilitate insertion.
suppository, which is inserted first.
- Lubricate your gloved index finger.
- Expose the vaginal orifice by separating the
labia with your non-dominant hand.
- Insert the suppository about 8 to 10 cm (3 to To promote an effective result.
4 in) along the posterior wall of the vagina, or
as far as it will go.
- Withdraw the finger, and remove the gloves, To prevent the spread of microorganisms.
turning them inside out and placing them on a
paper towel.
- Ask the client to remain lying in the supine To allow the medication to flow into the posterior
position for 5 to 10 minutes following fomix after it has melted.
insertion. The hips may also be elevated on a
pillow.
For a vaginal cream, jelly, or foam: For an effective result.

- Gently insert the applicator about 5 cm (2 in).
- Slowly push the plunger until the applicator is To prevent the spread of microorganisms.
empty.
- Remove the applicator and place it on a paper To prevent the spread of microorganisms.
towel.
- Remove the gloves turning them inside out,
and place them on a paper towel.
- Ask the client to remain in bed in a supine To allow the medication to flow into the posterior
position for 5 to 10 minutes following the fornix.
instillation.
7. Ensure client’s comfort.

- Dry the perineum with tissues as required. To promote client’s comfort.
- Remove the bedpan if used.
- Remove the moisture – resistant pad and
drape.
- Apply a clean perineal pad and a T – binder if
there is excessive drainage.
- Assist the client to a comfortable position.
8. Do after – care of equipment and supplies and To prevent the spread of microorganisms.
wash hands.
1. Assess the client’s response to an instillation in terms of discharge, discomfort and so forth when
the medication is expected to act.
2. Record the instillation and assessments as you would with other medications and instillations.
3. Record the administration of the irrigation, note when it was administered; the amount, type,
strength, and temperature of the irrigating solution; and all nursing assessments.
VI. ILLUSTRATION
Using a vaginal applicator Inserting a vaginal suppository
ASSISTING IN INSERTION OF CONTRACEPTIVE DEVICES
I. DEFINITION
Insertion or application of device to a man’s or woman’s genital in order to obstruct the passage of sperm or
ovum therefore preventing fertilization to occur.
II. RATIONALE
1. To prevent the passage of sperm or ovum that may lead to fertilization.

2. To keep the woman safe from getting impregnated.
III. EQUIPMENT
Prescribed contraceptive device (Condom, Diaphragm, Cervical Cap, Intrauterine Device)
Sterile gloves
1. Contraception’s effectiveness depends on motivation, which is a result of education, culture, religion

and personal situation.
2. It is best to include both partners in any contraception decision and secure the signed consent of
both partners.
3. Nurses should be familiar with contraceptive methods and educate patients with moral judgment.
4. Warn the clients who use condoms, diaphragms, and cervical caps that latex sensitivity may be a
problem. Watch for itching, swelling, and generalized reactions.
5. Hand hygiene, gloving and perineal washing are a must before insertion of contraceptive devices.
ACTION RATIONALE
CONDOM – latex, poly-urethane, or processed

collagenous tissue sheath, placed over erect
penis to prevent semen from entering the
vagina.
1. Place condom over erect penis.
To facilitate insertion of condom.
2. Leave dead space at the tip of condom (from

which air has been expelled).
To allow room or space for ejaculated semen.
3. Use spermicide on exterior.
To add protection from live sperm.

4. Grasp ring around condom at withdrawal.
DIAPHRAGM – rubber cap shaped like a dome with
To aavoid leaving condom in vagina.
flexible rim.
1. Check for holes.
2. Place spermicide inside the dome.
To ensure safety.
3. Place diaphragm against and covering

cervical opening, behind lower edge of pubic
bone. To provide further protection from the semen to enter
the genital tract.
To preserve integrity of the rubber.
4. Leave in place for at least 6 hours after

intercourse.
5. Wash hands with soap and water, dry and

stored in safe place.
CERVICAL CAP – a rubber cap, shaped like a cup with a

tall dome and flexible rim.
1. Place a spermicide inside cap.
2. Place cervical cap over cervical opening.
To provide additional protection from the semen to enter

the genital tract.
3. Clean with soap and water, dried and store

safely after intercourse.
To prevent the entry of semen in the cervical opening.
INTRAUTERINE DEVICE – a small device made of plastic

with exposed copper or progesterone-release
system; acts to inhibit uterine wall implantation.
To preserve the integrity of the material.
1. Health care provider inserts device slowly

and usually at a time of menses.
2. Check intrauterine device string regularly at

least once a month or after each intercourse.
3. Instruct the client for possible risksToorensure that device is inserted slowly for correct
complications and to see the health care placement and to prevent trauma to mucous
provider for any unusualties noted. membrane.
To monitor if it is properly inserted or if it is in place.
To provide instructions, thus preventing the severity of

side effects or any complications.
1. Record the information and health instructions about the use of contraceptive devices.
2. Allow the client to verbalize concerns, reaction about the use of devices and record.
PERFORMING BAG TECHNIQUE
Adapted from Cuevas et al (2007), Public Health Nursing in the Philippines
I. DEFINITION
BagTechnique - a tool making use of a community health bag through which the nurse, during her home visit can
perform nursing procedures with ease and deftness, saving time and effort with the end result of
rendering effective nursing care.
Community Health Bag – is an essential and indispensable equipment of the community health nurse which she
has to catty along with her when she goes out for a home visit. It is composed of basic articles which are
necessary for giving nursing care.
II. RATIONALE
To render effective nursing care during home visit in the community.
III. EQUIPMENT (contents of the Bag)
Paper lining Paper squares Plastic lining Apron
Kidney basin Waste receptacle Hand towel in a plastic bag / wrapper
Thermometer in case Tape measure Blood pressure apparatus (optional)
Dressings (OS, cotton ball, plastic or adhesive tape in plastic bag)
6 small bottles with solutions / medicines (uniform in size if possible)
 70% alcohol
 Betadine
 Zephiran solution

1. The bag should contain all the necessary articles, supplies, and equipment which may be used to
answer emergency needs.
2. The bag and its contents should be cleaned as often as possible, supplies replaced and ready for use
at any time.
3. The bag and its contents should be well protected from contact with any particle in the home of
patients. Consider the bag and its contents clean and/or sterile while any article belonging to the
patient as dirty and contaminated.
4. The arrangement of the contents of the bag should be one which is most convenient to the user to
facilitate efficiency and avoid confusion.
5. Hand washing is done as frequently as the situation calls for since it helps minimize or avoid
contamination of the bag and its contents.
6. The bag when used for a communicable case should be thoroughly cleansed and disinfected before
keeping and reusing.
7. The use of the bag technique should minimize, if not totally prevent the spread of infection from
individuals to families, hence, to the community.
8. Bag technique should save time and effort on the part of the nurse in the performance of nursing
procedure.
9. Bag technique should not overshadow concern for the patient but rather should show effectiveness
of total care given to an individual or family.
10. Bag technique can be performed in a variety of ways depending upon agency policies, actual home
situation, etc., as long as the principles of avoiding the spread of infection are carried out.
ACTION RATIONALE
1. Upon arriving at the client’s home after a short

To prevent the bag from contamination.
interaction, place the bag on the table or any flat
surface lined with paper lining (inserted beneath
the cover of the bag), clean side out (folded part
touching the table). Insert the handles/ straps of
the bag beneath it.
2. If a faucet is n not available, ask for a basin and a

glass of water. If a faucet is available, ask only for
a glass of water. Place them outside the work
area.
3. Open the bag, take the plastic lining and spread
over the paper lining, clean side in contact with
the paper lining (folded part out).
To be used for handwashing and cleaning of the
thermometer, in case a thermometer technique is
used.
4. Take out the hand towel, soap dish and apron.

To protect the work area from being wet.
Leave their plastic wrappers in the bag. Place
them at one corner of the work area, within the
confines of the plastic lining.
To provide a non-contaminated work area.
5. Do handwashing (medical asepsis technique).

Wipe hands with towel.
6. Put on the apron, right side out and wrong side

with crease touching the body, sliding the head
into the neck strap. Neatly tie the waist straps at
To prepare for handwashing.
the back.
7. Put out things needed for the case/procedure

and place them at one corner of the work area.
8. Place paper waste receptacle outside of the work

area.
9. Close the bag.
To protect the nurse’s uniform. Keeping the crease in

creates an aesthetic appearance.
10. Proceed to the specific nursing care or treatment.
11. After completing the nursing care, clean and

apply alcohol on the equipment used.
To make them readily accessible.
12. Do handwashing again (medical asepsis

technique).
To prevent the work area from possible contamination.
13. Open the bag and return all articles in their

proper places.
To prevent the contents of the bag from possible

contamination.
14. Remove the apron, folding away from the body
so that the soiled is folded inward and the clean
side outward. Place it inside the plastic wrapper
and return it to the bag.
To provide necessary treatment needed by the client.

15. Fold the plastic lining, clean side out (folded part
inward). Place it in the bag and close the bag.
To protect the bag and its contents from possible

contamination.
16. Get the bag from the table/flat surface, foldTo theprotect the caregiver from contamination.
paper lining (the side which is in contact with the
table is folded inward), and insert in between the
flaps and cover of the bag.
17. Make a post-visit conference on matters relevant To prevent the spread of microorganisms.
to health care. Record all significant findings.
18. Make an appointment for the next visit (either

home or clinic), taking note of the date, time and
place.
To protect the bag and its contents from possible

contamination.
The side which is in contact with the table is considered
contaminated.
To be used as reference for future visits.
For follow-up care.
1. All relevant findings about the client
2. Environmental factors affecting the client’s health
3. Nurse-patient interaction and if rapport was established
4. Nursing care / treatment / procedure done

TAKING TEMPERATURE / VITAL SIGNS
(Utilized in the bag technique)
I. DEFINITION
It is a method of checking a client’s temperature with due attention given to the cleanliness of the thermometer
that is used.
II. RATIONALE
1. To check a client’s temperature and assess any significant finding.
2. To keep the thermometer aseptically clean so as to prevent transfer of infection from one client to
another.
3. To protect other contents of the bag by keeping the thermometer aseptically clean.
III. EQUIPMENT
 same as bag technique
ACTION RATIONALE
1. Identify your client and explain the procedure.

To prepare the client and relieve anxiety.
2. Using the bag technique lay out, put out Totheprevent contamination.
thermometer leaving the case inside the bag.
3. Check if digital thermometer is functioning.
For accurate findings.
4. Insert the thermometer into the client’s axilla

and take the temperature, pulse, and
respirations following the procedure in taking
vital signs.
5. Remove the thermometer from the patient’s

axilla and wipe with one dry cotton ball from
your fingers down to the bulb in a twisting
motion. Discard cotton ball used.
Wiping is done from a clean to a dirty area.
6. Read the thermometer.
7. Clean the thermometer in a downward spiral

motion from your fingers to the bulb, holding it
over the wastepaper bag using the following
technique.
 1st - 3 cotton balls moistened with soap.

Discard.
 2nd - 3 cotton balls moistened with water.

Discard.
Thermometers are cleansed with soap and water before
disinfecting to minimize the presence of
 3rd – 1 cotton ball moistened with alcohol, microorganisms.
then wrap around the bulb of the
thermometer and lay it inside the kidney
basin.
8. After a few minutes, remove the cotton ball

wrapped around the bulb of the
thermometer. Wipe with a dry cotton ball
and return to case.
To allow time for disinfection.
1. Client’s temperature
2. Intervention done
3. Health teachings given
4. Client’s condition
PREPARING HERBAL MEDICATION (AMELOI)
Adapted from Bailon-Reyes (2006). Community Health Nursing.

I. DEFINITION
Ameloi – a herbal liniment preparation made from extracts of ginger roots, coconut oil, oil of
wintergreen and agua bendita.
II. RATIONALE
To relieve pain. (indicated for clients with arthritis, abdominal pain, muscle pain)
III. EQUIPMENT
Agua Colonia 240 cc
Oil of Wintergreen 240 cc
Coconut Oil ¼ kilo of the total volume of the mixture
Ginger Roots 2 kilograms
120 cc bottle containers

ACTION RATIONALE
1. Wash the ginger very well, do not peel. To remove the dirt and clean the ginger.
2. Grate the ginger. To make extraction of juice easier.
3. Extract the juice of ginger by straining To

andprevent contamination, a clean cloth is used.
squeezing in a clean cloth.
4. Catch the juice in a clean container and add

Agua Colonia and Oil of Wintergreen, then
measure the volume. To ensure the correct proportions of ingredients.
5. Pour the coconut oil and stir lightly. (coconut

oil ¼ of the total volume)
To disperse the solution.

6. Pour the mixture into the pan in a low fire. Do
not boil. Just warm the mixture.
7. When the mixture is warm, be ready to transfer
To prevent curdles of the mixture resulting from too much
the mixture into the bottle containers with heat.
labels.
To prevent drug error.
V. EVALUATION
1. Pain is relieved.
PRAPARING ORAL REHYDRATION SOLUTION (ORESOL)
Adapted from Bailon-Reyes (2006). Community Health Nursing.

I. DEFINITION
ORESOL – a solution which can replace the lost fluids in the body due to continuous discharge of watery
stools
II. RATIONALE
1. To replace loss of large amounts of fluid from the body.
2. To prevent dehydration, especially in children, and avoid shock and death.
III. EQUIPMENT
Clean pitcher or container with a wide mouth Distilled water
ORESOL pack (commercially prepared) Measuring / tablespoon

ACTION RATIONALE
1. Clean pitcher, bottle, or container with a wide

mouth which can hold the recommended amount
of distilled water (as recommended by ORESOL
pack).
2. If water is not safe for drinking, let it boil for 5

minutes and let it cool.
To prevent gastrointestinal diseases.

3. Pour recommended amount of water into the
container.
4. Open ORESOL pack and pour all contents into the

water.
5. Stir well until solution is ready to drink.
6. The ORESOL is given according to the age of the

client.
To dissolve well the solution.
a. Below 2 years old - 50 to 100 mL
b. Older children - 100 to 200 mL To let the significant others know the corresponding dosage
of the solution.
c. Adults - as much as they can tolerate
7. ORESOL solution is good for 24 hours only.
NOTE:
• If the child vomits, wait for ten minutes then continue giving the solution slowly.
• Volume per volume replacement for gastrointestinal losses is ordered by the physician.
DO NOT ADD SUGAR, JUICE OR SOFTDRINKS. THE SOLUTION IS GOOD FOR 24 HOURS ONLY. AFTER 24 HOURS,
DISCARD THE PREPARATION.
HOME MIXTURE: SSS (Salt sugar solution)

Proportions:
Department of Health (DOH)
One teaspoon of salt: eight teaspoon of sugar: one liter of water - 24 hours
Control of Diarrheal Diseases (CCD)
One pinch salt: one heap teaspoon sugar: Nescafe regular glass with tap water (200 cc)
OR:
One heap teaspoon salt: 4 teaspoon sugar: one liter water - 24 hours
Dosage:
¼ - ½ glass young children
½ - one medium glass older children
Adults, usually after BM let them drink the solution as much as they can tolerate
PERFORMING ACUPRESSURE
Adapted from Christensen and Kockrow (2011). Fundamentals and Advanced Nursing Skills.
I. DEFINITION
• An Oriental type of therapy based on the belief that there is a form of energy or Qi (life force) that
flows through the body along meridians (channels of energy). These meridians or channels can
become blocked, thus causing illness or discomfort.
• It uses gentle pressure applied with a finger and sometimes with a small, blunt object. Therapy
involves stimulating the channels to open up the dam in the flow of energy through a meridian
allowing the Qi to flow freely and relieving the pain and discomfort (Christensen Kochrow, pp. 427-
424).
II. RATIONALE
1. To relieve tension and stress, enabling patient’s comfort and relaxation

2. To increase circulation, activating the body’s defenses and energy to heal
3. To treat a disease, promoting wellness as it gets rid of toxins and body wastes
III. POINTS TO REMEMBER
1. Should be done on a flat, firm surface
2. Position of the therapist – standing/sitting; Client – sitting up / lying down
3. Apply pressure during the exhalation
4. Clothing – thin, loose, comfortable
5. Therapist – clean hands, short nails, relaxed, mastery of technique
6. Client in a correct position
7. Press at the correct Meridian Line and proper length of time
8. Observe client’s reaction
9. Treat the client for only 30 - 45 minutes
10. No lotion, alcohol or powder during treatment (as slippery hands prevent hitting the correct
pressure points)
DON’T’S IN ACUPRESSURE
1. If client has a full stomach; wait for 1 – 2 hours
2. When client’s stomach is empty
3. Not done on drug dependents
4. Not done when there is fracture
5. Not done on persons with serious illness
6. Not done on persons with contagious disease
7. Not done on persons who have had recent surgery
8. Not done on persons who have inflamed / swollen areas
TECHNIQUES IN PRESSING
1. Very light – infants = 1 second
2. Light – children = 3seconds
3. Pleasant – normal = 5 seconds
4. Strong = 10 seconds (for back, thighs, hard surfaces of the body)

BEFORE DOING ACUPRESSURE
1. Orient the client
2. Take the client’s BP
3. Diagnose – basic acupressure technique for blockage
4. Teat – acupressure
Prepare hands – “Exercise”
 Press one hand against the other with palms flat and all the fingers together
 Press one hand against the other with the thumbs separated from the other fingers
 Bend fingers back on each hand, using the other hand
Repeat for 4 – 6 times
DIFFERENT METHODS OF PRESSING

1. Sliding
2. Rolling
3. Grasping
4. Pressure
5. Wiping
6. Rotating
7. Kneading
8. Tapping / Chopping
9. Pinching
10. Palm on Palm
11. Thumb on Thumb
12. Alternate Thumb

ADMINISTERING PREOPERATIVE CARE
Adapted from Altman (2010); Fundamental and Advanced Nursing Skills
Perry & Potter (2006), Clinical Nursing Skills Techniques
I. DEFINITION
Preoperative (before surgery) Phase – This phase starts when the client first considers surgery and ends when
the client enters the operating room. Preparing the client for surgery involves activities that help
decrease anxiety, ensure client safety, and decrease the risks of complications.
II. RATIONALE
1. To place the client in the best possible condition for surgery through careful assessment and
thorough preparation.
2. To allay the client’s fears by preparing the client mentally and physically for surgery.
3. To determine the client’s level of understanding regarding the surgery and what to expect post
operatively.
4. To make sure that the client has been properly prepared for the next stage of surgery, the intra-
operative period.
III. EQUIPMENT:
Blood Pressure Cuff Stethoscope
Flashlight Preoperative Checklist
Container for dentures, glasses Surgical consent form
Intravenous fluids, needles and equipment as needed
Preoperative Medications Appropriate storage for valuables and clothes
Information packets regarding surgery Trolley
IV. PLANNING AND IMPLEMENTATION:
ACTION RATIONALE
I. ASSESSMENT
1. Verify the client by checking name tag and

To provide safety and legal protection.
asking name.
2. Check whether the client and his family have
To decrease anxiety. Clients who are uninformed may be
any questions regarding the surgery and more vulnerable and at higher risk for
understand the procedure and explain complications.
accordingly.
3. Perform physical examination. Focus on body

To provide baseline data for future assessments and
systems likely to be affected by surgery. interventions. Also confirms or disputes
information from history and may uncover new
information.
4. Collect nursing history, and identify risk

To allow for anticipation of possible complications and
factors. planning for interventions to reduce risks.
Allergies, particularly to latex, can be life
threatening.
5. Review clients’ preoperative orders. To identify specific procedures and diagnostic tests to be
done and medications to be given.
6. If client is a same-day admit or ambulatory

To prevent perioperative or post-operative complications.
client, validate that preoperative Failure to complete preparation could lead to
preparations were completed as ordered. perioperative or post-operative complications
Specific preparations to review include NPO and may necessitate the postponement or
status, administration of medications, skin cancellation of surgery.
preparation, and bowel preparation if
applicable.
II. PLANNING
7. Prepare client’s chart using preoperative

To ensure that all preoperative procedures will be
checklist, and assemble equipment needed. completed.
8. Explain procedures and allow client, family

To help decrease anxiety and increase cooperation.
members, and significant others to ask
questions and express concerns.
III. IMPLEMENTATION
9. Orient client to room or pre-surgical (holding) To decrease anxiety and promote feelings of
area. control.
10. Physician obtains consent. Act as client To provide legal basis for surgery. Surgery cannot be
advocate as needed; include considering any legally performed without client receiving
cultural sensitive issues. Witness form if information about need and extent of the
allowed by agency. surgery, alternatives, risks, and benefits.
 Clients who are illiterate can sign with a

mark if properly witnessed.
 Minors, unless married or declared

emancipated, or individual considered
incompetent cannot legally sign a consent
form. Parent or legal guardian must
provide consent.
 Some cultures do not allow female

members to give consent.
11. Check medical record, and review To

or ensure that pertinent laboratory and diagnostic test
complete preoperative checklist. results are available and that all preoperative
preparations are completed.
12. Provide preoperative teaching, including To decrease anxiety and promote cooperation in care.
explanation of postoperative exercises, pain
control measures, and postoperative care in
recovery room.
13. Instruct client on need and rationale for NPO

To decrease risk of vomiting and aspiration. GI tract
for period specified before surgery. should be empty to decrease risk of vomiting and
aspiration.
 Client may brush teeth but should not

swallow the water.
 Client may take oral medications with sips

of water (30ml) if they are specially
ordered to be taken preoperatively.
 All other oral medications are withheld.
14. Assess that any preoperative orders for

To prevent delay or postponement of surgery.
enemas, douches, and skin preparations
have been followed. Insert IV and/or
indwelling catheter if ordered.
15. Provide for hygiene measures, ensuring To prevent hair from contaminating sterile surfaces and to
client privacy. Instruct client to remove all provide easy access to client’s body in OR
clothing, including undergarments, and to
apply disposable cap and hospital gown with
opening at the back.
16. Instruct client to remove hairpins, clips, To provide safety. Hairpieces and jewelry anywhere in the
wigs, hairpieces, jewelry, including rings body may become dislodged and cause injury
used in body piercing, and makeup during positioning and intubation. Rings may
(including nail polish and acrylic nails). decrease circulation in fingers. Makeup, nail
polish and false nails impede assessment of skin
and oxygenation. In addition, acrylic nails may
 Wedding rings that cannot be removed harbor pathogenic organisms.
may be taped in place. Be careful not to
create tourniquet effect with tape around
finger.
17. Assist client in removing prostheses, To provide safety. Prostheses can be lost or damaged
including dentures and oral appliances, during surgery and could cause injury. Oral
glasses and contact lenses, artificial limbs appliances may occlude airway.
and eyes, artificial eyelashes, and hearing
aids. Inventory items, and give to family
members or have security lock them.
Document list of items and their location in
preoperative checklist and/or nurses’ notes
per agency policy.
18. Secure all valuables, or give family member

To provide security for items.
or significant other. Have release from
signed if required by agency.
19. Apply anti-embolism stockings as ordered.To promote venous return and reduce risk of thrombus
formation.
20. Assess vital signs immediately before going

Abnormal vital signs may indicate conditions that increase
to OR. risk for surgery.
 Vital signs not within normal range or

client’s baseline must be reported to
physician and may require surgery to be
postponed. Document abnormal vital
signs and any action taken in nurses’
notes and/or preoperative checklist
according to agency policy.
21. If client does not have an indwelling To prevent incontinence and bladder distention during
catheter, assist him or her in voiding before surgery and urinary retention with overflow
receiving preoperative medication. postoperatively. Preoperative medication may
cause drowsiness and decreased voiding
sensation.
22. Administer preoperative medications To

as reduce pain, anxiety, respiratory secretions, and
ordered. amount of anesthesia required. To promote
relaxation. Antibiotics may be ordered
prophylactically but are given 30 to 60 minutes of
 Preoperative medications may be incision.
ordered “on call,” which means that the
nurse is notified by a member of the
surgical team when the preoperative
medication is to be given.
 After administering preoperative

medication, raise the side rails of the
gurney or bed. Instruct the client not to
get up without assistance.
23. Ascertain that preoperative checklist is

complete.
24. Transport the patient safely to appropriate

area via a stretcher or a wheelchair.
25. Inform family members where the surgical

To provide assurance to the client and family.
waiting area is and establish a way to
contact them when the surgery is
completed.
V. EVALUATION:
1. The client experienced decreased anxiety subsequent to appropriate instruction.

2. The client did not experience any adverse reactions caused by inadequate physical preparation.
3. The client did not experience any loss of belongings or possessions during the surgery or
recovery period.
4. The client did not experience any disruption or delay of the surgery caused by poor preoperative
care or planning.
PERFORMING PRE-OPERATIVE SKIN PREPARATION
Adapted from Lippincott et al (2004), Nursing Procedures
I. DEFINITION
SKIN PREPARATION – a procedure which renders the skin and around the surgical site, scrupulously clean and
free of hair which reduces the chance of introducing organisms into the surgical wound.
 The Centers for Disease Control and Prevention strongly recommends not removing hair at all
unless it would interfere with the surgery. Follow facility policy on hair removal.
 Three common methods of hair removal are: Clipping, Depilatory (hair removing cream), and Wet
Shaving.
II. RATIONALE
1. To decrease the bacteria without injuring the skin.

2. To remove the hair from the defined area.
3. To reduce the risks for infection by reducing the resident microbial count on the skin.
III. EQUIPMENT
Antiseptic soap solution Warm tap water

Bath blanket Two clean basin
Waterproof pad Adjustable light/Appropriate light
Sterile razor with sharp new blade Scissors
Clean gloves
Optional: 4x4” gauze pads, cotton tipped applicators, acetone or nail polish remover, trash bag, towel
PREPARATION OF EQUIPMENT
Use warm tap water because heat reduces the skin’s surface tension and facilitates removal of soil and hair.
Dilute the antiseptic detergent solution with warm tap water in one basin for washing, and pour plain
warm water into the second basin for rinsing.
IV. PLANNING AND IMPLEMENTATION:
ACTION RATIONALE
1. Check physician’s order and review agency

To comply with doctors order and agency policy. Hospital
policy. policies differ regarding the description of skin
areas to be prepped, or the surgeon may have
special orders.
2. Introduce self and explain the procedure,
To decrease patient’s anxiety and gain cooperation.
including the reason for the extensive
preparations.
3. Wash hands, if appropriate, don gloves. To reduce spread of microorganisms.
4. Close the door or pull curtain. To provide privacy.
5. Place the patient in a comfortable position,

To ensure privacy and avoid chilling the patient.
drape with the bath blanket, and expose the
preparation area.
 For most surgeries, the area extends 12”
(30.5cm) in each direction from the expected
incision site.
 Expose only one small area at a time while
performing skin preparation.
6. Raise bed to comfortable working level. To promote proper body mechanics.
7. Place towel or waterproof pad under the areaTotoprotect bed and linen from soiling.
be shaved.
8. Adjust lighting. To allow thorough assessment of the skin and helps

decrease chance of skin impairment
9. Assess skin condition in the preparation area

To check any break in the skin that increases the risk of
and report any rash, abrasion, or laceration to infection and could cause cancellation of the
the physician. planned surgery.
10. Lather the skin with antiseptic soap and warm

To cleanse skin, softens hair, and reduces friction from the
water. razor.
11. Hold razor at a 39-45° degree angle to skin:
This makes the hair rise and facilitates shaving.

To avoid skin irritation & achieve smooth clean shave.
To remove hair close to skin surface
To prevent abrasions particularly over bony prominences.
a. Pull the skin taut in direction opposite the
direction of hair growth.
b. Use short, smooth strokes
c. Shave hair in same direction it grows.
d. Avoid applying pressure
12. Rinse razor frequently and re apply liquid soap

To remove accumulation of hair from razor.
to the skin as needed. To keep the area moist.
13. If entire area is shaved, rinse the soap solution

To remove excess shaved hair, body oils on skin.
and loose hair from the preparation area.
Cleanse with wash cloth and clean warm water.
14. Dry the area with a clean towel, and remove the
waterproof pad.
15. Re assess skin for cuts, abrasions, nicks or hair.
16. Return patient to appropriate position. To provide patient comfort and safety.
17. Clean and properly dispose soiled equipment To reduce spread of micro-organism.
and supplies according to facility’s policy.
18. Remove soiled gloves

19. Wash hands
CLIENT TEACHING:
Give the patient any special instructions for care of the prepared area, and remind the patient to keep the area
clean for surgery.
V. DOCUMENTATION
 Record the date, time, and area of preparation; skin condition before and after preparation, any
complications, and patient’s tolerance.
 If your facility requires it, complete an incident if the patient, complete an incident report if the
patient suffers nicks, lacerations, or abrasions during skin preparation.
Area to be prep depends on the proposed surgical procedure
Skin prep set

PERFORMING A COMPLETE SURGICAL HAND SCRUB
Adapted from Perry & Potter (2006), Clinical Nursing Skills Technique
I. DEFINITION
Surgical Hand Scrub – likely to be required when you are working in the operating room, delivery room, burn
units, and invasive diagnostic areas of the hospital. Usually takes 5 to 10 minutes with either method.
Counted Stroke Scrub – may require scrubbing each area of the hands and forearms a specific number of times.
Timed Scrub – each area of the hands and forearms is scrubbed for a specific number of minutes.
II. RATIONALE
To disinfect the skin from microbes, thus keeping it as sterile as possible.
III. EQUIPMENT
Surgical cap Surgical mask
Nail cleaner Sterile towels

Antimicrobial soap and plain scrub brush impregnated with povidone-iodine (Betadine)
Deep sink sink with foot, knee, or elbow control for dispensing water and soap.
ACTION RATIONALE
1. Remove all jewelry, including your watch.To reduce microorganisms.
2. Trim your nails if needed. No nail polish or

artificial nails should be worn.
3. Apply a cap and surgical mask.

To eliminate microorganisms collect in chipped nail
polish and under artificial or long fingernails.
4. Turn water on using foot or knee control,
and adjust to comfortable temperature.
5. Prescrub wash/rinse: wet hands and arms

under running lukewarm water, and lather
with antimicrobial agent up to 2 inches
above elbows. To provide a barrier and to reduce the spread of
 Keep hands elevated above elbows. microorganisms from the hair or respiratory
Rinse hands and arms thoroughly under tract.
running water.
 Under running water, clean under nails
of both hands using file; discard file.
6. Obtain a brush and place the opened

package containing the brush near the sink.
7. Wet brush, and apply antimicrobial agent.

8. Visualize each finger, hand, and arm as
having four sides. Wash all four sides
effectively. Scrub the nails of one hand with
15 strokes. Scrub the palm, each of side of
the thumb and fingers, and posterior sideA of
short prescrub wash/rinse removes gross debris and
the hand with 10 strokes each. superficial microorganisms and is an essential
step before surgical antisepsis.
9. Divide the arm mentally into thirds; scrub
each third 10 times. Some agency policies
require scrub by time rather than 10 strokes.
10. Rinse brush, and repeat the sequence for

the other arm. A two-brush method may be
substituted. Check agency policy.
11. Discard brush; flex arms, and rinse from

fingertips to elbows in one continuous
motion, allowing water to run off at elbow.
12. Holding your hands above your elbows, wet

the skin from your fingertips to elbows.
13. Dry each hand and arm with opposite ends

of a sterile towel, working from the
fingertips toward the elbows. The outside of the package is contaminated and
14. Turn off water with foot or knee control,

with hands elevated in front of and away you should not touch it once you have begun
from body. Enter OR suite by backing into
room.
15. Approach sterile setup, and grasp towel, the surgical scrub.
taking care not to drip water on the sterile
field or you may use the bottom part of the
sterile gown (check agency policy).
16. Bending slightly at the waist, keeping hands

and arms above the waist and outstretched,
grasp one end of the sterile towel or bottom
part of the gown to dry one hand
thoroughly, moving from fingers to elbow Toinensure removal of resident microorganisms on all
a rotating motion. surfaces of the hands and arms.
17. Use the opposite end of the towel to dry the

other hand.
18. Drop towel into linen hamper or into

circulating nurse’s hand.
19. Keep your hands above waist level at all

times.
To eliminate transient microorganisms and reduce

resident hand flora.
To avoid contamination of your hands.
To prevent irritation of the skin. Dry from the cleanest to

the most contaminated area.
Hands remain cleanest part of the upper extremities.

To keep hands free of microorganisms.
To dry hands without contaminating the sterile field.
Avoids sterile towel or gown from contacting unsterile

scrub attire and transferring contamination to
hands. Dry skin from cleanest (hands) to least
clean (elbows).
To avoid transfer of microorganisms from elbow to

opposite hand.
To prevent contamination, keep hands in your line of
vision.
VARIATION: BRUSHLESS ANTISEPTIC HAND RUB
1. After prescrub wash,, dry hands and forearms thoroughly with a paper towel
2. Dispense 2 ml of antimicrobial agent hand preparation into palm of one hand. Dip the fingertips of the
opposite hand into the hand preparation, and work it under the nails. Spread the remaining hand prep
over the hand and up to just above the elbow covering all surfaces.
3. Using another 2 ml of hand preparation, repeat above procedure with the other hand.
1. Able to complete the surgical hand scrub.

2. Hands are free of microorganisms.
PREPARING A SURGICAL SITE
Adapted from Altman (2010), Fundamental & Advanced Nursing Skills
I. DEFINITION
Once the client arrives in the operating room, there are more preparations that are necessary to undertake
before surgery can begin. The client must be positioned on the operating table in a way that will
optimize the surgeon’s access to the surgical site without compromising the client’s neurovascular
status. Once the client is in position the surgical site may need to be shaved and a final cleansing
performed.
II. RATIONALE
1. To position client on the operating table according to the type of surgery to be performed that
would allow visualization of the site of operation without compromising the client’s neurovascular
status.
2. To cleanse and prepare the surgical site in a way that will reduce the possibility of infection.
III. EQUIPMENT
Gloves (clean for shaving; sterile for cleaning surgical site)

Razor and sharp blades Sterile gauze (to clean razor)
Warm water Antibacterial cleansing agent
Sterile cotton swabs Sterile cotton sponges
Transfer forceps in antiseptic solutions Solution basins
Solution for surgical site cleaning, such as 70% alcohol
Mask and protective goggles.
ACTION RATIONALE
1. Review chart for surgery to be performed and

To avoid errors regarding site to be prepped.
determine the exact area to be prepped or ask
surgeon for his or her preference.
2. Wash hands. Don appropriate personal

To reduce the transmission of microorganism.
protective equipment.
3. Assess client’s level of consciousness and

To determine client’s ability to cooperate with the skill.
mobility.
4. Explain the procedure to the client. Verify that

To provide comfort and support for the client. To
the client has no allergies, especially to iodine protect client from exposure to allergenic
and latex. materials.
5. Be sure that hairpins, jewelry, nail polish,

To ensure that removal of artifacts that may interfere
contact lenses, prostheses, and dentures were with the assessment and procedure.
removed during the preoperative preparation.
6. Assist client with transfer from wheelchair To

or ensure client safety.
stretcher to the surgical table
7. Position the client for optimal access to the To allow the surgeon access to the body part requiring
surgical site according to institutional protocol. surgery.
Several kinds of positions:

 Supine
 Trendelenburg
 Reverse Trendelenburg
 Lithotomy
 Modified Fowlers Position
 Prone Position
 Jackknife (Kraske)
 Lateral
8. Cover with blanket. To maintain body temperature and provide privacy. The
temperature in the operation room is often
lower than in the client’s room.
9. Cover hair if required. To keep loose hair from entering sterile field.
10. Assemble equipment needed. To ensure a smooth procedure.
11. Remove ring(s) and watch. Wash hand and

To reduce the transmission of microorganisms and to
apply clean gloves. provide infection control.
12. The surgical prep sites follow, depending on

the type of surgery to be performed.
Head and Neck: The site extends from above the

eyebrows, over the top of the head, and
includes the ears and both anterior and
posterior areas of the neck. The face and
eyebrows are not shaved
Chest surgery: The site extends from the neck to the

bottom of the rib cage and to the lateral
midline. The shoulder and arm of the
operative side should be included.
Abdominal surgery: The preparation site extends

from the axilla to the pubis extending
bilaterally to the lateral midline. All visible
pubic hair should be shaved.
Perineal surgery: Shave all pubic hair and the inner

thighs to the midthigh. The area starts above
the pubic bone anteriorly and extends
beyond the anus posteriorly.
Cervical spine surgery: Posteriorly from the top of the
ears to the waist. The area extends on each
side to the midaxillary line.
Lumbar spine surgery: Posteriorly from the axilla

down to the midgluteal level of the buttocks.
The area extends on each side to the
midaxillary line.
13. Arrange for adequate light on the area to To

be provide lighting for good visualization and safe
prepared. shaving.
14. Using warm water, hold the skin taut and To decrease the chance of skin irritation. Holding skin
hold the razor at a 45-degree angle. Shave taut will decrease chance of cutting the client.
the area carefully by stroking in the direction Stroking in the direction of hair growth will
of hair growth. Rinse the razor carefully to reduce ingrown hairs when the hair grows back.
remove accumulated hair from the blade. Rinsing the razor will improve performance of
the blade, and decrease the amount of skin
irritation.
15. Dry the client’s skin with a sterile towel. To prevent the spread of microorganisms.
16. Clear the shaving supplies from the

To prevent contamination of the area with used
preparation area. supplies.
17. Apply sterile gloves. To prevent the spread of microorganisms.

18. Scrub the surgical site with an antibacterial
To remove dirt and transient microbes from the skin. To
cleaner. Using a rotary movement to clean reduce the resident microbial count as much as
the skin, begin in the center and gradually possible.
enlarge the area with each rotation.
19. Continue this process for 3 to 10 minutesTo as prevent recontamination of the site.
prescribed by institutional policy. Be sure to
use a clean brush or swab whenever
returning to the center of the surgical site.
20. Clean any hidden areas in the surgical site

To decrease chance of transmission of microorganisms.
(the ear canals, under the fingernails, the
umbilicus) using cotton swabs.
21. Rinse the area with sterile water. Wait for the
To decrease chance of transmission of microorganisms.
site to dry or pat dry with a sterile towel.
22. Cover the area with sterile drapes leaving the

To provide a sterile field for the surgical procedure.
surgical site exposed. Draping depends on
what the surgical operation positioning is.
a. Make use of towels to create a

window on the area to be excised.
Some institutions may use four towels;
others use only two.
b. Secure with towel clips.
c. Long sheet may be spread from the
thigh to the foot part of the patient.
d. Another long sheet may be spread on
the chest up and over the anesthesia
screen.
e. Unfold the laparotomy sheet or lap

sheet, making sure that the hole is
placed on the operative site then
unfold the head part first, cover the
entire chest of the patient, hold up
and over the anesthesia screen.
f. Unfold towards the feet of the client.
Let the edges dangle off the table.
V. EVALUATION
1. The surgical preparation was performed without injury or trauma to the client.
2. The client voices understanding of the procedure and reason for it.
3. The client did not experience any allergic rection or skin sensitivity secondary to the surgical
preparation.
4. The client did not experience any injury secondary to perioperative positioning.
VI. DOCUMENTATION
1. Report client’s response to surgical preparation.

2. Report positioning of the client for surgery.
Common Surgical Positioning
Final skin prep at OR
DONNING A STERILE GLOVE AND GOWN via the CLOSED METHOD
Adapted from Altman. (2010), Fundamental & Advanced Nursing Skills
Berman et al. (2009,) Skills in Clinical Nursing
I. DEFINITION
“Closed Glove” – refers to a technique where, after the surgical scrub, the gown is put on first; then the gloves
are put on by grasping the gloves with the hands still in the sleeves of the gown.
II. RATIONALE
1. To decrease the risk of wound contamination.

2. To allow the nurse to move freely in the environment with sterile drapes and objects.
III. EQUIPMENT
 Sterile pack containing a sterile gown

 Sterile gloves
ACTION RATIONALE
1. Establish a sterile field. To decrease the transmission of microorganisms.
 Open a sterile pack containing a sterile gown.

 Drop the gloves in their inner sterile wrap on
the sterile field.
2. Perform surgical hand antisepsis/scrub.
3. Put on the sterile gown.
 Grasp the gown at the crease near the neck.

 Step back and allow the gown to open in front
of you. Do not allow it to touch anything.
 With the hands at shoulder level, slip both To keep the outside of the gown sterile.
arms into the gown; keep your hands inside the
sleeves of the gown.
 The circulating nurse will step up behind you
and grasp the inside of the gown, bring it over
your shoulders, and secure the ties at the neck
and waist.
To prevent the gown from touching non sterile objects; to
allow sterile items to come in contact only with
other sterile items.
To prevent any part of the gown from touching a non-

sterile object; to provide complete coverage of
undergarments.
4. Perform Closed Gloving
 With hands still inside the gown sleeves, open
the sterile glove wrapper on the sterile field.
 With your non dominant sleeved hand, grasp To maintain sterility of the gloves.
the cuff of the glove for the dominant hand.
 Lay the glove on the extended dominant
forearm, thumb side down, with the glove
opening pointed toward the fingers.
 Use the non-dominant to grasp the cuff of the

glove through the gown cuff, and firmly
anchor it.
 With the dominant hand working through its
sleeves, grasp the upper side of the glove’s
cuff, and stretch it over the cuff of the gown.
 Pull the sleeve up to draw the cuff over the
wrist as you extend the fingers of the non-
dominant hand into the glove’s fingers.
 With the gloved dominant hand, repeat the
procedure for the non-dominant hand.
V. EVALUATION
1.The client is not exposed to microorganisms from the nurses uniform, and the patient does not
experience a nosocomial infection.
2.Sterility of the gown and gloves was maintained while the nurse applied them.
PERFORMING OPEN GLOVING
Adapted from White (2005), Foundations of Nursing

I. DEFINITION
Open Method of applying gloves – is used most frequently when performing procedures that require the sterile
technique but that do not require donning a sterile gown.
II. RATIONALE
1. To manipulate sterile items without contaminating them.

2. To prevent client at risk from becoming infected by microorganisms from the nurses’ hands.
III. EQUIPMENT
Package of proper-sized sterile gloves.
ACTION RATIONALE
1. Determine if sterile gloving is necessary.
Sterile gloving is not necessary for every procedure. It

may be safe for the client and cost-effective to
use disposable, non-sterile gloves.
2. Wash hands thoroughly. To prevent transmission of microorganisms.
3. Explain to the client that sterile glovingToisreduce patient’s apprehension.

necessary for protection against infection.
4. Place the unopened package of gloves on

To a maintain sterility of the gloves. If the package
clean and dry surface. becomes wet, it is no longer considered sterile.
5. Open the outside paper covering the sterile

To avoid contamination of the sterile gloves.
gloves by grasping the tabs on top of the
package and peeling the paper open.
6. Remove the outer wrapper and lay To theprovide easy access to gloves.
exposed package of gloves on a clean, dry
surface.
7. Open the inner package containing To theavoid contamination of the sterile gloves inside the
sterile gloves by touching only the bottom of wrapper.
the package.
8. Identify right and left hand; glove dominant

To facilitate motor dexterity during gloving.
hand first.
9. Grasp the 2-inch wide cuff with the thumb To maintain sterility of the outer surfaces of the sterile
and first two fingers of the non-dominant glove.
hand, touching only the inside of the cuff.
10. Gently pull the glove over the dominant
To prevent tearing the glove material; guiding the fingers
hand, making sure the thumb and fingers fit into proper places facilitates gloving.
into the proper spaces of the gloves.
11. With the gloved dominant hand, slip your

Cuff protects gloved fingers, maintaining sterility.
fingers under the cuff of the other glove,
gloved thumb abducted, making sure the it
does not touch any part of your non
dominant hand.
12. Gently slip the glove onto your nondominant

To maintain sterility of the glove.
hand without touching your skin. Make sure
the fingers slip into the proper spaces.
13. Turn the cuffs of the gloves into your wrists

To maintain sterility of the gloves. The inside portion is
without touching the insides of the cuffs. not sterile.
14. With gloved hands, interlock fingers toTofitpromote proper fit over the fingers.
the gloves onto each finger.
VI. EVALUATION
1. Sterility of the gloves and the sterile field was maintained without breaks.
2. Sterility of the procedure was maintained.
Steps in donning sterile gloves Steps in removing gloves
(Open Method)
ASSISTING IN DRESSING A SURGICAL WOUND
I. DEFINITION
Wound Dressing – a technique of aseptically dressing a wound that involves placing a protective covering over
the wound.
Dressings – are materials used to protect the wound, provide humidity to the wound surface, absorb drainage,
prevent bleeding, immobilize, and hide the wound from view.
II. RATIONALE
1. To cover and protect the wound from injury.

2. To prevent introduction of bacteria, reduces discomfort, and speeds healing.
3. To absorb drainage that may occur.
III. EQUIPMENT
Clean gloves Sterile gloves

Gown, face shields or goggles if indicated Hypoallergenic tape or binder
Povidone Iodine swabs Moisture proof trash bag
Topical medication if ordered Soap and water
Sterile dressing set; if none is available, gather the following sterile items:
 Drape or Towel
 Gauze squares or other type of dressing materials
 Sterile cotton tipped applicators
 Container for the cleaning solution
 Antimicrobial solution
 Forceps
Additional supplies required for a particular dressing
Optional: skin protectant, acetone-free adhesive remover, sterile normal saline solution
ACTION RATIONALE
1. Ask the patient about allergies to tapes,

povidone-iodine and dressings.
2. Assemble all equipment in the patient’s room.

Check the expiration date on each sterile
package, and inspect for tears.
3. Open the waterproof trash bag, and placeToit provide a wide opening and to prevent
near the patient’s bed. Position the bag to contamination of instruments or gloves by
avoid reaching across the sterile field or the touching the bag’s edge.
wound when disposing of soiled articles. Form
a cuff by turning down the top of the trash
bag.
4. Explain the procedure to the patient. To allay his fears and ensure his cooperation.
5. Check the physician’s order for specific wound

care and medication instructions.
6. Assess patient’s condition.
7. Provide privacy and position patient To asavoid chilling.

necessary and expose only the wound site.
8. Wash hands thoroughly. Put on gown and face

shield if necessary. Then put on clean gloves.
9. Remove the old dressing.
a. Loosen the soiled dressing by holding the

patient’s skin and pulling the tape or
dressing toward the wound.
b. Moisten the tape with acetone-free
adhesive remover, if necessary.
To protect the newly formed tissue and prevent stress
c. Slowly remove the soiled dressing. If the
on the incision.
gauze adheres to the wound, loosen the
gauze by moistening it with sterile normal
saline solution.
d. Observe the dressing for the amount,
color, type, and odor of drainage.
e. Discard the dressing and gloves in the
waterproof trash bag.
To make the tape removal less painful (particularly if the

skin is hairy).
10. Caring for the wound.
a. Wash hands.
b. Establish a sterile field with all the
equipment and supplies you’ll need for
suture-line care and dressing change,
including the sterile dressing set and
povidone iodine swabs.
c. If physician has ordered ointment, squeeze

the needed amount onto the sterile field.
d. If you’re using an antiseptic from an
unsterile bottle, pour the antiseptic
cleaning agent into a sterile container so
you won’t contaminate your gloves.
e. Saturate the sterile gauze pads with the
prescribed cleaning agent. Avoid using
cotton balls.
f. Irrigate the wound, if ordered, using the
specified solution.
g. Pick up moistened gauze pad or swab, and
squeeze out the excess solution.
h. Working from the top of the incision, wipe
once to the bottom and then discard the
gauze pad. With a second moistened pad,
wipe from top to bottom in a vertical path
next to the incision.
i. Continue to work outward from the
incision in lines running parallel to it.
- Always wipe from the clean area
toward the less clean area (usually from
top to bottom). Use each gauze pad or
swab for only one stroke.
- Remember that the suture line is
cleaner than the adjacent skin and the
top of the suture line is usually cleaner
than the bottom.
j. Use sterile, cotton-tipped applicators for
efficient cleaning of tight-fitting wire
sutures, deep and narrow wounds, and
wounds with pockets.
- Remember to wipe only once with each
applicator.
k. If the patient has a surgical drain, clean the
drains surface last. Clean the skin around
the drain by wiping in half or full circles
from the drain site outward.
l. Clean all areas of the wound to wash away
debris, pus, blood, and necrotic material.
Try not to disturb sutures or irritate the
incision. Clean at least 1” beyond the end
of the new dressing. If aren’t applying a
new dressing, clean to at least 2” beyond
the incision.
m. Check to make sure the edges of the
incision are lined up properly, and check
for signs of infection (heat, redness,
swelling, induration, and odor),
To prevent irritation, infection, or adhesion caused by
dehiscence, and evisceration. If you
fibers that may be shed by a cotton ball in the
observe such signs or if the patient reports
wound.
pain at the wound site, notify the
physician.
n. Wash skin surrounding the wound with
soap and water, and pat dry using a sterile
4” x 4” gauze pad. Avoid oil-based soap.
Apply any prescribed topical medication.
o. Apply skin protectant, if needed.
p. If ordered, pack the wound with gauze
pads or strips folded to fit, using a sterile
forceps.
- Pack the wound, using the wet-to-damp
method. Soaking the packing material
in solution and wringing it out so that
it’s slightly moist provides a moist
wound environment that absorbs
debris and drainage.
- Don’t pack the wound tightly; doing so
will exert pressure and may damage the
wound.
To avoid tracking wound exudate and normal body flora

from surrounding skin to the clean areas.
To prevent cross contamination since moist drainage
promotes bacterial growth, the drain is
considered the most contaminated area.
To ensure pouch adherence.
11. Applying a fresh gauze dressing.
a. Gently place sterile 4” x 4” gauze pads

at the center of the wound, and move To prevent skin excoriation that may occur with
progressively outward to the edges of repeated tape removal necessitated by
the wound site. frequent dressing changes.
b. Extend the gauze at least 1” beyond the
incision in each direction, and cover the
wound evenly with enough sterile
dressings (usually two or three layers)
to absorb all drainage until the next
dressing change.
c. Secure the dressing’s edges to the
patient’s skin with strips of tape to
maintain the sterility of the wound site.
- Or secure the dressing with
- T-binder or Montgomery straps.
12. Make sure the patient is comfortable.
13. Properly dispose of the solutions and

trash bag, and clean or discard soiled
equipment and supplies according to
your facility’s policy.
- If your patient’s wound has purulent
drainage, don’t return unopened sterile
supplies to the sterile supply cabinet.
To prevent cross contamination of other equipment.
14. Wash hands.

 Because many physicians prefer to change the first post-operative dressing themselves to check
the incision, don’t change the first dressing unless you have specific instructions to do so. If you
have no such order and drainage comes through the dressings, reinforce the dressing with fresh
sterile gauze. Request an order to change the dressing, or ask the physician to change it as soon
as possible. Reinforced dressing shouldn’t remain in place longer than 24 hours because it’s an
excellent medium for bacterial growth.
 For the recent postoperative patient or a patient with complications, check the dressing every 15
to 39 minutes or as ordered. For the patient with a properly healing wound, check the dressing at
least once every 8 hours.
V. EVALUATION AND EVALUATION
1. There is no sign of infection and drainage.

2. The appropriate dressing was applied to the site.
3. The procedure was performed with minimal discomfort to the client.
4. Administration of pain medication before dressing change.
5. Date and time dressing done.
6. Wound appearance (size, condition of margins, presence of necrotic tissue).
ASSISSTING IN REMOVING SKIN SUTURES AND STAPLES

Adapted from Kockrow (2011), Foundations and Adult Health Nursing
Altman (2010) Fundamental and Advanced Nursing Skill
Lippincott et al (2004), Nursing Procedures
I. DEFINITION
Sutures and Staples – are surgical means of closing a wound by sewing, wiring, or stapling the edges of the
wound together. They are generally removed 7-10 days after surgery, depending on where the wound is
located and how well it is healing.
Suture Removal – is to remove skin sutures from a healed wound without damaging newly formed tissue.
II. RATIONALE
1. To decrease the risk of infection and irritation from a foreign substance.
III. EQUIPMENT
Suture removal kit or sterile forceps with sterile suture removal scissors.
Sterile gauze pads (size as appropriate for wound area to be covered)
Sterile normal saline solution, prepackaged antiseptic swabs, or gauze for cleaning, if appropriate
Sterile gauze to wipe stitches or sutures from forceps and scissors.
Waterproof trash bag Clean gloves
Sterile gloves Adhesive strips
Antiseptic cleaning agent Povidone-iodine pads
Sterile staple extractor if staples were used
Optional: butterfly strips or Steri-Strips and compound benzoin tincture or other skin protectant
ACTION RATIONALE
1. If your facility allows you to remove

sutures, check the physician’s order to
confirm details for this procedure.
2. Assemble all equipment in patient’s room.

- Check the expiration date on each sterile
package.
- Place the waterproof trash bag near the
patient’s bed.
To avoid reaching across the sterile field or the suture

line when disposing of soiled articles.
3. Check for patient’s allergies, especially to

adhesive tape and povidone or other
topical solutions or medications.
4. Explain the procedure to the patient
5. Provide privacy and place patient onToaprevent undue tension on the suture line
comfortable position.
6. Wash hands thoroughly.
7. If the patient has a dressing, put on clean

gloves and carefully remove the dressing.
Discard the dressing and the gloves in the
waterproof trash bag. Then put on sterile
gloves.
8. Assess the patient’s wound for possible

To allow determination of alterations in healing process
gaping, drainage, inflammation, signs of and collection of data for accurate
infection, and embedded sutures. documentation.
- Notify the physician if the wound has
failed to heal properly.
9. Establish a sterile work area with all the
To maintain asepsis during procedure and organize
equipment and supplies you’ll need for approach to procedure.
suture removal and wound care.
10. Using a sterile technique, clean the suture

To decrease number of microorganisms present and
line. reduce the risk of infection.
Moisten the sutures sufficiently. Soften

To ease removal of the sutures.
them further if needed with normal saline
solution.
11. Proceed according to the type of suture To determine suture removal technique (suture removal
you’re removing: technique depends on the type of sutures to be
removed).
INTERRUPTED SUTURES
- Using a sterile forceps, grasp the knot
of the first suture and raise it off the
skin.
- Place the rounded tip of sterile curved-
tip suture scissors against the skin, and
To expose a small portion only of the suture that is
cut through the exposed portion of the
below skin level.
suture.
- Then, still holding the knot with the
forceps, pull the cut suture up and out
of the skin in a smooth continuous
motion.
- Discard the suture.
- Repeat the process for every other
suture, initially; if the wound doesn’t
gape, you can remove the remaining
sutures as ordered.
CONTINUOUS SUTURES
- Cut the first suture on the side opposite
the knot.
- Next, cut the same side of the next
suture line. To avoid causing pain.
- Then, lift the first suture out in the
direction of the knot.
- Proceed along the suture line, grasping

each suture where you grasped the
knot on the first one.
STAPLES
- Position the staple extractor’s lower

jaws beneath the span of the first
staple.
- (The extractor changes the shape of the
staple and pulls the prongs out of the
intradermal tissue.)
- Squeeze the handles until they’re
completely closed.
- Lift the staple away from the skin.
12. After removing sutures, wipe the incision
gently with gauze pads soaked in an
antiseptic cleaning agent or with a
povidone-iodine pad.
13. Apply a light sterile dressing, if needed. To prevent infection and irritation from clothing.
14. According to the physician’s preference,

inform the patient that he may shower 1
or 2 days if the incision is dry and heals
well.
15. Properly dispose of the solutions and trash

bag, and clean or dispose of soiled
equipment and supplies according to your
facility’s policy.
V. EVALUATION
1. The wound is intact, edges are adhered, and there are no signs of infection.
2. The procedure was performed with a minimum of pain and trauma to the client.
CARING FOR A PATIENT

WITH WOUND DRAINAGE DEVICES
Adapted from Berman et al (2009), Skills in Clinical Nursing
I. DEFINITION
Surgical drains are inserted to permit the drainage of excessive serosanguineous fluid and purulent material and
to promote healing of underlying tissues. These drains maybe inserted and sutured through the incision
line, but they are most commonly inserted through the incision line.
Types of drainage systems:
The closed drainage system (e.g., Hemovac, Jackson Pratt) is a system of tubing or other apparatus that is
attached to the body to remove fluids in an airtight circuit that prevents any type of environmental
contaminants from entering the wound or area being drained.
The open drainage system (e.g., Penrose drain) is a tube or apparatus that is inserted into the wound and drains
out onto a dressing.
II. RATIONALE
1. To drain excess exudates
2. To promote healing of underlying tissues
3. To reduce risk of infection and skin breakdown as well as the number of dressing changes. (Closed
drainage system)
4. To provide for accurate measurement of the drainage. (Closed drainage system)
III. EQUIPMENT
Clean gloves Calibrated drainage receptacle
Moisture proof pad Alcohol sponge
Sterile 4”x4” gauze pads Sterile dressing set
IV. PLANNING & IMPLEMENTATION

ACTION RATIONALE
1. Check physicians order.
2. Introduce self and explain what you are going to

do, why it is necessary, and how he or she can
participate.
3. Perform hand hygiene and other appropriate

infection control procedures.
5. Determine the type and placement of the

To check whether the drainage tubing is placed
client’s wound drain. within wound or through small surgical
incision near major wound.
6. Assess:
a. Amount, color, consistency, clarity, and odor of
the drainage.
b. Client’s comfort level or pain on a scale of 0 to

10.
c. Clinical signs of infection

To provides baseline of client’s comfort level and
to determine response to therapy.
d. For close drainage; check tube patency. Make
sure that the tubing is free of twists, kinks and
leaks.
e. Be sure Penrose drain has a sterile safety pinTo

in ensure that the drainage system is airtight for
place. Penrose drains may be covered with a it to work properly.
gauze dressing or a wound pouch.
To prevent drain from being pulled below the

skin’s surface.
7. Empty the drainage unit (for close wound

drainage system):
a. Apply clean gloves.
b. Place the Hemovac or Jackson Pratt unit on the

waterproof pad.
c. Open the plug of the drainage unit.

d. Invert the unit and empty into the calibrated
collecting receptacle.
e. Re-establish suction
A. Hemovac:
a. Place the unit on a solid, flat surface with port

To re-establish the vacuum necessary for the
open. closed drainage system to work.
b. Place the palm of hand on unit and press the top

and the bottom together.
c. While holding the top and bottom together,

cleanse the opening and plug with alcohol swab.
d. Replace the draining plug before releasing hand

pressure.
B. Jackson-Pratt:
a. Compress the bulb with the port open.
b. While maintaining the tight compression on the

To re-establishes the vacuum necessary for the
bulb, cleanse the ends of the emptying port. closed drainage system to work.
c. Insert the plug into the emptying port
8. Secure the unit to the client’s gown To

orfacilitate drainage.
position unit on the bed.
Ensure that the unit is below the level of the wound
9. Dressing a wound with drain
a. Cleanse the wound if indicated using a circular

motion, begin at the drain site and clean
outward. If additional cleaning is required,
obtain new gauze and clean from drain site
outward.
b. Use a commercially pre-cut gauze drain

dressings, or prepare a drain dressing by using
sterile scissors to cut a slit in a sterile 4”x4”
gauze pad.
c. Fold the pad in half; then cut inward from center

of the fold edge.
d. Gently press one drain dressing close to the skin

around the drain from the opposite direction so
that the tubing fits into the slit.
e. Press the second drain dressing around the drain

from the opposite direction so that the two
dressings encircle the tubing.
f. Layer as many uncut 4” x 4” gauze pads or large

absorbent dressings around the tubing as
needed.
g. Tape dressing in place, or use T binder or

Montgomery straps.
To absorb expected drainage.
10. Discard contaminated materials, and perform

hand hygiene.
 Empty the drain and measure its contents once during each shift if drainage has accumulated,
more often if drainage is excessive. – Rationale: Removing excess drainage maintains maximum
suction and avoids straining the drain’s suture line.
1. Amount, color, odor of drainage; dressing change to drain site; appearance of drain insertion
site.
2.Record the amount and type of drainage on the intake and output
PREPARING CLIENTS FOR AN ELECTROCARDIOGRAM
(ECG / EKG)
I. DEFINITION
Electrocardiogram - is a standardized non-invasive diagnostic tool used to record the electrical activity of the
heart.
II. RATIONALE
1. To monitor a patient’s heart rate

2. To evaluate the effects of disease or injury to the heart
3. To evaluate pacemaker function
4. To evaluate response to medications (such as anti-arrhythmic)
5. To obtain a baseline recording before, during, and after a medical procedure
6. To provide information about the following:
a. Conduction disturbances
b. Electrical effects of medications and electrolytes
c. The presence of ischemic damage
III. EQUIPMENT
12-lead ECG machine with charged batteries ECG leads or electrolytes
Correct recording paper for the machine KY jelly, electrode paste
Alcohol swabs Drape

ACTION RATIONALE
1. Elicit and record the client’s age, sex, height,

To facilitate interpretation of the ECG.
weight, blood pressure, symptoms, and
medications; unusual position of the client
during the examination; and the presence of
thoracic deformities, amputation, respiratory
distress, or muscle tremors.
2. Ask the client if he/she has ever had an ECG

before. Explain that the procedure will take
only 10-15 minutes and is painless.
3. Close the door and beside curtains.
4. Assist the client to assume a supine position.
5. Drape patient as necessary.
6. Perform hand hygiene
7. Cleanse and prepare the skin; wipe skin with

alcohol.
To promote cooperation and decrease patient anxiety.

Simple explanation reduces the client’s anxiety.
8. Apply electrode paste and attach leads. If the client has had an ECG, the old ECG should
be obtained for comparison.
Extremities:
Secure electrodes on the flat inner aspects of the
client’s wrists and ankles with extremity
straps adjusted to hold the electrodes firmly
in place.
Chest leads (precordial leads): To provide client privacy.

a. V1 – at the fourth intercostal space, right
To promote accuracy of test and facilitate good
sternal border recording.
b. V2 – at the fourth intercostal space,
left sternal border
To prevent necessary embarrassment.

c. V3 – at the midpoint between V1 and V4
d. V4 – at the fifth intercostal space, at the
midclavicular line
e. V5 – at the level of V4, at the left anterior
axillary line
f. V6 – at the level of V4, at the left mid
To reduce spread of microorganism.
axillary line
9. Turn on the lead selection switch to record all

12 leads.
10. Remove the leads and wipe electrode paste

that may be remaining.
11. Place the ECG results on the chart and note

the time and condition of the client. To promote adherence of leads / electrodes to chest or
extremity.
12. Assist patient to a comfortable position.
Position of leads promotes proper display of ECG on

paper.
If the straps are placed too tightly, circulation to the

extremity could be compromised. Electrode
paste or alcohol swabs ensure good contact
between the client’s skin and the electrode.
The recording will vary according to the placement of
the leads.
Promotes the client’s comfort.
Communicates to the other members of the health care

team and contributes to the legal record by
documenting the care given to the client.
To ensure patient comfort.

Document time, test performed, and patients’ response.
Administering Oxygen Therapy
Adapted from Altman (2010); Foundations and Advanced Nursing Skills
De Laune (20110); Fundamentals of Nursing Standards & Practice
I. DEFINITION
Oxygen Therapy – is the administration of oxygen at a concentration of pressure greater than that found in the
environmental atmosphere.
II. RATIONALE
1. To increase oxygenation in patient with reduced blood oxygen-carrying capacity.
2. To enable the patient to reduce his ventilator efforts in a respiratory emergency.
3. To boost alveolar oxygen levels when lung volumes are decreased from alveolar hypoventilation such
as in cases of atelectasis or ARDS.
4. To help meet the increased myocardial workload as the heart tries to compensate for hypoxemia in a
cardiac emergency.
5. To supply the body with enough oxygen to meet its cellular needs when metabolic demand is high (in
cases of massive trauma, burns, or high fever).
III. EQUIPMENT
Stethoscope Oxygen source – portable or in-line
Oxygen flow meter Oxygen delivery device:
nasal cannula Pulse oximetry
 mask
 T-tube with adapter for artificial airway.
Oxygen tubing
Humidifier and distilled or sterile water (not needed with low flow rates per nasal cannula

ACTION RATIONALE
1. Obtain preliminary information:
- Determine client history and acute or

chronic health problems.
- Assess the client’s baseline respiratory

signs; including airway, respiratory
To determine the need for O2 therapy and to develop
pattern, depth, and rhythm, noting
baseline data if not already available.
indications of increased work or
breathing.
- Review ABG and pulse oximetry results.
To determine the client’s need for oxygen as well as

response to the therapy.
- Note lung sounds for wheezes/crackles.

Secretions will interfere with airway
patency.
- Assess nares, behind the earlobes,

cheeks, tracheostomy site, or other
places where oxygen tubing or
equipment is in constant contact with
To determine the need for therapy as well as changes in
the skin. therapy. ABG and pulse oximetry are the most
important determinants of the effectiveness of
the pulmonary system.
- The prescribing practitioner’s order for

O2 including the administering device
and the liter flow rate (L/min). To look for signs of irritation or breakdown.
To ensure correct dosage and route.
2. Give adequate explanation and

To increase compliance with procedure.
reassurance to the client and support
persons.
3. Assist the client to a semi fowler’s position

To permit easier chest expansion and hence easier
if possible. breathing.
4. Obtain equipment needed.
5. Wash hands before assembling the

To reduce transmission of microorganism to the client.
equipment.
6. Attach “No Smoking, Oxygen in Use.” SignsTo avoid any activity that might cause spark or fire since
are placed on the client’s door, at the foot oxygen is combustible.
or head of the bed, and O2 equipment.
Explain hazards to the client.
7. If using humidity, fill humidifier to fill line

To prevent drying of the clients airway.
with distilled water and close container.
8. Attach humidifier to oxygen flow meter.To allow the oxygen to pass through the water and
become humidified.
9. Insert humidifier and flow meter into To gain access to oxygen. Many institutions also have
oxygen source in wall or portable unit. compressed air available from outlets very
similar in appearance to oxygen outlets.
10. Check the equipment if it is functioning

To ensure safe and effective O2 administration.
well.
- There should be no kinks in the tubing.
- The connection should be air tight. To ensure proper functioning.
- There should be bubbles in the
humidifier as the O2 flows through the
H20.
- You should feel the 02 at the outlets of
cannula
To check for patency of the catheter.
11. Administer Oxygen
NASAL CANNULA
1. Attach the oxygen tubing and nasal cannula to

the flow meter and turn it on to the prescribed
flow rate (1-5 L/min). Use extension tubing for
ambulatory clients so they can get up to goTo to prevent drying of the nasal mucosa, flow rate should
the bathroom. not exceed 6L/min when administering oxygen
2. Place the nasal prongs in the client’s nostrils. via nasal cannula.
Secure the cannula in place by adjusting the
tubing around the client’s ears and using the
slip ring to stabilize it under the client’s chin.
3. Check for proper flow rate every 4 hours.
4. Assess client’s nostrils every 8 hours. If the
client complains of dryness or has signs of
irritation, use sterile lubricant to keep mucous
membranes moist. Add humidifier if not To deliver the amount of oxygen ordered and keep
already in place. delivery system in place.
5. Monitor vital signs, oxygen saturation, and
client condition every 4-8 hours (or as
indicated or ordered) for signs and symptoms
of hypoxia.
6. Wean client from oxygen as soon as possible
using standard protocols.
To ensure that the client receives proper dose.
To prevent drying of the mucous membrane. Dry

membranes are more prone to breakdown by
friction or pressure from nasal cannula.
To detect any untoward effects from therapy.

MASK: Venturi (High-Flow Device), Simple Mask
(Low Flow), Partial Rebreather Mask, Non
Rebreather Mask and Face Tent.
1. Attach appropriate sized mask or face tent to

oxygen tubing, and turn on flow meter to
prescribed flow rate.
a. The Venturi mask will have color-coded
inserts that list the flow
b. Rate necessary to obtain the desired
percentage of oxygen.
c. Allow the reservoir bag of the non-
rebreathing or partial rebreathing maskToto ensure proper fit; size needed is based on the client’s
fill completely. size.
2. Place the mask or tent on the client’s face,
fasten the elastic band around the client’s
ears, and tighten until the mask fit snugly.
3. Check for proper flow rate every 4 hours.
4. Ensure that the ports of the Venturi mask are
not under covers or impeded by any other
source.
5. Assess the client’s face and ears for pressure
from the mask, and use padding as needed.
6. Wean client to nasal cannula and then wean
off oxygen per protocol.
To prevent loss of oxygen from the sides of the mask.
To ensure that client is receiving the proper dose.
To provide client comfort and prevent skin breakdown.

OXYGEN via ARTIFICIAL AIRWAY (Tracheostomy
or Endotracheal tube)
1. Attach the wide bore oxygen tubing and T-

tube adapter or tracheostomy mask to the
flow meter and turn the meter to the flow rate To check the oxygen source and prime the
needed to achieve the prescribed oxygen tubing and adapter.
concentration.
- An oxygen analyzer may be used to check
the actual oxygen percentage being
delivered.
2. Check for bubbling in the humidifier and a fine

mist from the adapter.
3. Attach the T-piece to the client’s artificial

airway or place the mask over the client’s To ensure proper functioning.
airway. Be sure the T-piece is firmly attached
to the airway.
4. Position tubing so that it is not pulling client’s

airway.
5. Check for proper flow rate and patency of the

system every 1 to 2 hours depending on the
acuity of the client.
6. Suction as needed to maintain a patent To ensure that the client will not develop
airway. complications related to an interrupted oxygen
supply.
7. Monitor airway patency, vital signs, oxygen
saturation, and for signs and symptoms of
hypoxia every 2 hours, or more frequently as
necessary or as ordered. Additionally, monitor
breath sounds and tube position every 4
hours.
To provide comfort and prevent dislodgment of

the artificial airway.
To ensure that client is receiving proper dose.
To detect response to or any untoward effects

from therapy. To determine whether tube is in
place.
V. EVALUATION
1. Oxygen levels returned to normal in blood and tissues as evident by oxygen saturation is
equal or greater than 92%; skin color normal for client.
2. Respiratory rate, pattern, and depth are within the normal range.
3. The client did not develop any skin or tissue irritation or breakdown.
4. Breathing efficiency and activity tolerance are increased.
5. The client understands the rationale for the therapy.
VI. DOCUMENTATION
1. Record 02 saturation and respiratory status.

2. Note method of oxygen delivery rate.
3. Document client’s assessment parameters and response to treatment.
4. Note and record changes in mental status
PERFORMING SUCTIONING
Adapted from Altman (2010); Foundations and Advanced Nursing Skills
De Laune (20110); Fundamentals of Nursing Standards & Practice
I. DEFINITON
Suctioning – is a method of removing excessive secretions from a natural or artificial airway accomplished by
aspirating secretions through a catheter connected to a suction machine or wall suction outlet.
Oroharyngeal and Nasopharyngeal Suctioning - removes secretions from the upper respiratory tract.
Tracheal Suctioning (through an endotracheal tube or tracheostomy) – removes secretions from the trachea
and bronchi or the lower respiratory tract.
II. RATIONALE
1. To provide a patent airway

2. To remove secretions that obstruct the airway
3. To increase tissue oxygenation
4. To increase respiratory ventilation
5. To obtain secretions for diagnostic purposes
6. To prevent infection that may result from accumulated secretions
III. EQUIPMENT
Suction source (wall suction regulator with collection bottle or portable suction machine)
Appropriate suction catheter Sterile gloves
Common catheter sizes: Clean gloves as indicated
Infant:
 5 to 8 F Sterile solution container

 Children: 8 to 10 F
 Adults: 12 to 18 F Sterile normal saline or water
Sterile water soluble lubricant Extension tubing connected to suction device
Towel Oxygen or Ambu bag
Personal Protective Equipment: gown, mask, and goggles if splattering is likely
Equipment for tracheostomy care (for tracheal tube suctioning)
Sputum trap, if specimen is to be collected

ACTION RATIONALE
1. Refer to medical record, care plan or KardexTo

forprovide basis for care. Verification is ensured when you
special interventions. review medical record.
2. Assess the client’s need for suctioning.

Suctioning is an uncomfortable and traumatic
procedure and should be done only when
needed.
3. Introduce yourself. To decrease the patient anxiety.
4. Verify client’s identity using agency protocol. To ensure procedure is performed with the right patient.
5. Explain the procedure. To promotes cooperation and reduce risks and associated
- Inform client that suctioning will relieve anxiety to a minimum.
breathing difficulty and, although the
procedure is painless, it is noisy and can cause
discomfort by stimulating the cough, gag, or
sneeze reflex.
6. Perform hand hygiene and observe other

7. Provide for client privacy
8. Position patient.
- If patient is alert and conscious, place in semi-
Fowlers position with the head turned to one
side for oral suctioning or with the neck
To facilitate the insertion of the catheter and help prevent
hyperextended for nasal suctioning. aspiration of secretions.
- If the patient is unconscious, place in the
lateral position facing you.
To allow the tongue to fall forward, so that it will not

obstruct the catheter on insertion. And also to
facilitate drainage of secretions from the pharynx
and prevents the possibility of aspiration.
9. Place the towel or moisture-resistant pad over

the pillow or under the chin for oropharyngeal,
nasopharyngeal and endotracheal suctioning.
Place it across patient’s chest below
tracheostomy for tracheostomy tube suctioning.
10. Pour sterile normal saline solution into sterile For moistening and cleansing catheter.
container.
11. Turn on suction machine, and select To decrease the risk of trauma to oral and nasal
appropriate pressure. mucosa with elevated pressure setting.
Common vacuum settings for wall suction units:

• Infants: 50 to 95 mm Hg
• Children: 95 to 110 mm Hg
• Adult: 110 to 150 mm Hg
12. Use the smallest catheter that will remove the To decrease the risk of trauma to oral and nasal
secretions. mucosa.
For tracheostomy and endotracheal suctioning, the
outer diameter of the suction catheter should To allow the air to enter around the catheter
not exceed one-half the internal diameter of during suctioning so that hypoxia can be
the tracheostomy and endotracheal tube. prevented.
13. Connect suction catheter to tubing.

14. Aspirate solution through catheter by placing
To check patency of suction catheter and suction pressure
thumb over open end of the connector or over and moisten catheter for ease of insertion.
vent.
15. Insert catheter without applying suction To

yet.prevent trauma to the mucous membrane.
(Leave your finger off the port.)
A. Oral and Oropharyngeal

a. Apply clean gloves.
b. Moisten the tip of the suction catheter with
To reduce friction and facilitate ease of insertion.
water or saline.
c. Insert suction catheter into one side of Totheprevent gagging.
mouth.
d. Glide the catheter toward oropharynx by
advancing 10 to 15 cm.
e. Apply suction and move tip of catheter
around mouth until secretions are cleared.
f. Encourage patient to cough.
g. Rinse tip of catheter with water in cup or
basin until connecting tubing is cleared of
secretions.
B. Nasopharyngeal
a. Wear sterile gloves
b. Inspect the nares with a penlight to
determine patency.
c. If needed, apply or increase supplemental

oxygen
d. Lubricate and introduce the catheter. To reduce friction and facilitate ease of insertion.
To avoid trauma to the nasal turbinates.

Length of insertion:
Adults: 16 cm
Older children: 8 to 12 cm To ensure that all surfaces are reached and to prevents
trauma to any one area of the respiratory mucosa
due to prolonged suction.
Infants/young children: 4 to 8 cm
e. Lubricate catheter tip with sterile waterToorlessen the occurrence of trauma or irritation to the
saline. trachea or nasopharynx
f. Without applying suction, insert the catheter

into naris and advance it along the floor of
the nasal cavity.
f. Never force the catheter against an
obstruction. If one nostril is obstructed, try
the other.
g. Apply your finger to the suction control port
to start suction, and gently rotate the
catheter.
h. Apply intermittent suction for 5 to 10 seconds
while withdrawing the catheter.
i. Rinse the flush the catheter and tubing with
sterile water or saline.
C. Endotracheal
a. Apply goggles, mask, and gown if necessary.

Apply sterile gloves.
b. Lubricate the catheter tip in sterile saline To facilitate ease of insertion and to reduce tissue trauma
solution. during insertion. Lubricating the lumen also helps
c. If the client does not have copious secretions, prevent secretions sticking inside of the catheter.
hyperventilate the lungs with a resuscitation
bag before suctioning. (Summon an assistant
if one is available for this step).
 Turn the oxygen to 12 to 15 L/min.
 Compress the Ambu bag three to five
times, as the client inhales.
 If the client is on a ventilator, use
ventilator for hyperventilation and
hyperoxygenation.
d. If the client has copious secretions, do not
hyperventilate with a resuscitator.
To prevent hypoxia during suctioning.
(Hyperventilating a client who has copious
secretions can force the secretions deeper
into the respiratory tract).
Instead:
Keep the regular oxygen delivery device on and
increase the liter flow or adjust the FiO2 to
100% for several breaths before suctioning.
e. Wrap the catheter tubing around hand from
the tip of the catheter down to the port end.
f. Quickly and gently insert the catheter during
inspiration until resistance is met or the
client coughs; then pull back 1 cm (1/2 inch).
g. Apply suction for 5 to 10 seconds. Suction
time is restricted to a maximum of 10
seconds
h. Rotate the catheter by rolling it between
your thumb and forefinger while slowly
withdrawing it.
i. Withdraw catheter completely. To prevent damaging the mucous membranes at the
j. Hyperventilate the client bifurcation.
k. Suction again if needed
To minimize oxygen loss.

To prevent tissue trauma by minimizing the suction time
against any part of the trachea
D. Tracheal Tube
a. Apply goggles, mask, and gown if necessary.To facilitate ease of insertion and reduce tissue trauma
Apply sterile gloves. during insertion. Lubricating the lumen also helps
b. Lubricate the catheter tip in sterile saline prevent secretions sticking inside of the catheter.
solution.
c. If the client does not have copious
secretions, hyperventilate the lungs with a
resuscitation bag before suctioning.
(Summon an assistant if one is available for
this step.)
 Turn the oxygen to 12 to 15 L/min.
 Compress the Ambu bag three to five
times, as the client inhales. To prevents hypoxia during suctioning.
 If the client is on a ventilator, use
ventilator for hyperventilation and
hyperoxygenation.
d. If the client has copious secretions, do not
hyperventilate with a resuscitator. Instead:
Keep the regular oxygen delivery device on and
increase the liter flow or adjust the FiO2 to
100% for several breaths before suctioning.
e. Remove the inner cannula and place in a
basin of hydrogen peroxide to loosen
secretions
f. Wrap the catheter tubing around hand from
the tip of the catheter down to the port end.
g. Quickly and gently insert the catheter during
inspiration until resistance is met or the
client coughs; then pull back 1 cm (1/2 inch).
h. Apply suction for 5 to 10 seconds. Suction
time is restricted to a maximum of 10
seconds, preferably less
i. Rotate the catheter by rolling it between

your thumb and forefinger while slowly
withdrawing it.
j. Withdraw catheter completely.
k. Hyperventilate the client
l. Suction again if needed
m. After suctioning, clean the inner cannula
using a tracheostomy brush and rinse well in
sterile water or sterile saline. Then dry inner
cannula, reinsert and lock into place.
To allow easier passage of the suction catheter.
To prevent damaging the mucous membranes at the

bifurcation.
To minimize oxygen loss.
To prevent tissue trauma by minimizing the suction time

against any part of the trachea
To remove secretions and maintain patent inner cannula.
16. Repeat suctioning if needed. Allow 1 Totoallow patient to rest and regain oxygen supply. Time
minutes of rest between suctioning. needed for patient to rest between suctioning will
vary from 1 to 2 minutes to 20 to 30 seconds,
depending on patient’s ability to tolerate
procedure.
17. If patient is alert and is able to cooperate,

To mobilize secretions from lower airway into mouth and
request patient to breathe deeply and cough upper airway.
18. When suctioning is complete, place catheter

Toinflush secretions from catheter and tubing to maintain
solution and apply suction. patency in the event it is necessary to repeat
procedure.
19. Turn off suction and disconnect the catheter

from the suction tubing.
20. Wrap the catheter around your hand and peel

the glove off so that it turns inside out over
the catheter.
21. Discard the gloves and the catheter in the

moisture resistant bag. Perform hand hygiene.
22. Replenish the sterile fluid and supplies so that

To ensure availability of equipment at the bedside ready
the suction is ready for use again. for use since clients who require suctioning often
require it quickly.
23. Be sure that the ventilator and oxygen settings
are returned to pre-suctioning settings.
24. Promote client comfort. Perform oral care and

assist the client to a comfortable, safe position
that aids breathing.
25. Assess the effectiveness of suctioning.
1. If specimen is required, obtain specimen by using a sputum trap. Attach the suction catheter to the
tubing of sputum trap. Then, attach the suction tubing to the sputum trap air vent. After which, suction
client. The sputum trap will collect the mucus during suctioning.
2. No saline instillation. Instilling normal saline into the airway was a common practice and a routine part of
the suctioning procedure. It was thought that the saline would facilitate removal of secretions and
improve the client’s oxygenation status. Recent studies report just the opposite – that is, instillation of
saline promotes adverse effects for the client. Results indicated that oxygen saturation decreased and
took longer to return to its baseline value when saline was used. The saline can dislodge bacteria from
the inside of the artificial airway, thus predisposing the client to lower respiratory infection. Saline
instillation should not be a routine component of suctioning.
V. DOCUMENTATION
1. Date and time of suctioning
2. Method of suctioning
3. Amount, consistency, color, and odor of secretions
4. Respiratory assessment
5. Patient’s response
VI. EVALUATION
1. Conduct appropriate follow-up, such as appearance of secretions suctioned; breath sounds;

respiratory rate, rhythm, and depth; pulse rate and rhythm; oxygen saturation and skin color.
2. Compare findings to previous assessment data if available.
3. Report significant deviations from normal to the doctor.
Initiating Chest Physiotherapy (CPT)
Adapted from Lippincott et al (2004), Nursing Procedures 4th
Lippincott et al (2010), Manual of Nursing Practice
I. DEFINITION
CPT is a technique intended to promote the drainage of secretions from the lungs. It includes postural drainage,
chest percussion and vibration, and coughing and deep breathing exercises.
Postural Drainage – use of specific positions so the force of gravity can assist in the removal of bronchial
secretions from affected lung segments to central airways by means of coughing or suctioning.
Percussion – is movement done by “clapping” the chest wall in a rhythmic fashion with cupped hands or a
mechanical device directly over the lung segments to be drained.
Vibration – is the technique of applying manual compression with oscillations or tremors to the chest wall during
the exhalation phase of respiration; or is done by using a special vibrator applied to the chest wall.
II. RATIONALE
1. To promote the drainage of secretions from the lungs.

2. To improve mobilization of bronchial secretions.
3. To promote lung tissue expansion
4. To promote efficient use of respiratory muscles.
5. To prevent or treat atelectasis and may also help prevent pneumonia in bedridden patients.
III. EQUIPMENT
Pillows Sputum cup
Tilt or postural drainage table Emesis basin
Facial tissues Equipment for oral care
Stethoscope
ACTION
1. Explain the procedure to the patient, provide RATIONALE

privacy and wash your hands.
2. Auscultate the patient’s lungs. To determine baseline respiratory status.
3. Instruct the client to use diaphragmatic

To promote patient relaxation and help widen the
breathing. airways.
4. Position the patient in prescribed postural To position patient according to the area of the lung
drainage position. The spine should be straight that is to be drained.
to promote rib cage expansion
- The positions assumed are determined by

the location, severity, and duration of mucus
obstruction.
- Instruct the patient to remain in each
position for 10 to 15 minutes. During this
time, perform percussion and vibration as
ordered.
5. Percuss (or clap) with cupped hands over the To help dislodge the mucus plugs and to mobilize
chest wall for 5 minutes over each segment secretions toward the main bronchi and
for cystic fibrosis or 1 to 2 minutes for other trachea.
conditions.
- Work from:
- The lower ribs to shoulders in the back.
- The lower ribs to top of chest in the front.
- The air trapped between the operator’s
hand and chest wall will produce a
characteristic hollow sound that resembles
the sound of horses trotting.
6. Avoid clapping over the spine, liver, kidneys,To prevent injuries to the spine or internal organs.
spleen, breast, scapula, clavicle or sternum.
7. Instruct the patient to inhale slowly and

deeply. Vibrate the chest wall as the patient
exhales slowly through pursed lips.
a. Place one hand on top of the other over
affected area or place one hand on each
side of the rib cage.
b. Tense the muscles of the hands and arms
while applying moderate pressure
downward and vibrate hands and arms.
c. Relieve pressure on the thorax as the
patient inhales.
d. Encourage the patient to cough, using
abdominal muscles, after three or four
vibrations.
8. After postural drainage, percussion or To remove loosened secretions.

vibration, instruct patient to cough.
a. Tell him to inhale deeply through his nose
and then exhale in three short huffs.
b. Then have him inhale deeply again and
cough through a slightly open mouth.
c. Three consecutive coughs are highly
effective. An effective cough sounds deep,
low, and hollow; an ineffective one, high-
pitched.
To aid in the movement and expulsion of secretions.
9. Allow the patient to rest several minutes
10. Listen with a stethoscope for changes in

To evaluate effectiveness of therapy. The
breath sounds. improvement of crackles and rhonchi indicates
movement of air around mucus in the bronchi.
11. Repeat the percussion and vibration cycle

according to the patient’s tolerance and
clinical response; usually 15-30 minutes.
12. Provide oral hygiene Because secretions may have a foul taste or a stale
odor.
Special considerations:
a. Maintain adequate hydration in the patient receiving chest physiotherapy to prevent mucus
dehydration and promote easier mobilization.
b. Avoid performing postural immediately before or within 1 ½ hours after meals to avoid
nausea, vomiting, and aspiration of food and vomitus.
V. DOCUMENTATION:
1. Record the date and time

2. Positions for secretion drainage and length of time each is maintained
3. Chest segments percussed or vibrated
4. Color, amount, odor, and viscosity of secretions produced and the presence of any blood
5. Complications and nursing actions take
6. Patient’s tolerance of treatment
ASSISTING a CLIENT with an INCENTIVE SPIROMETER
Adapted from Altman (2010); Foundations and Advanced Nursing Skillsn
I. DEFINITION
Incentive Spirometry – a technique used to promote deep breathing using a device (spirometer).
Incentive Spirometer (IS) – a device that provides measurement and feedback related to breathing
effectiveness.
II. RATIONALE
1.To encourage deep breathing

2.To measure deep breaths (inspired air) while exerting maximum effort.
III. EQUIPMENT
 Stethoscope
 Incentive spirometer with appropriate mouthpiece
2 General Types of Incentive Spirometers:
1.Flow-oriented Inspiratory Spirometer – this type of incentive spirometer measures inspiration. It

contains one or more clear plastic cylinder chambers that contain freely movable, colored,
lightweight plastic balls. Patients are instructed to inhale briskly to elevate the balls to keep them
floating as long as possible.
2.Volume-oriented Spirometer – this form of incentive spirometer maintains a known volume of
inspiration. Encourage the patient to breathe with normal inspired capacity.
 Tissue
 Emesis basin
 Pillow
ACTION RATIONALE

2. Check chart for previous respiratory
To establish a baseline for comparison.
assessment.
3. Gather equipment. To ensure preparation
4. Explain procedure to client. To encourage client’s cooperation.
5. Demonstrate deep, sustained inspiration.
6. Instruct client to assume a comfortableTo promote optimal lung expansion.

semi-Fowler’s or high-Fowlers position.
7. Set pointer on Incentive Spirometer To at encourages client to reach appropriate goal.

appropriate level or point to level where
disk or ball should reached.
8. Use incentive spirometer:

a. Have client breathe in and exhale
completely before using IS.
b. Hold unit upright. To promote clearing of secretions before using the IS.
c. Have client seal lips around
mouthpiece and inhale slowly and
deeply until desired volume is
To promote effective use of the spirometer.
attained.
d. Sustain inspiration for at least 3
seconds
To allow gauge to register effective inspiration.
And to allow the alveolar sacs to open and remain

open and discourage atelectasis.
e. Instruct patient to remove the
mouthpiece, relax, and exhale.
To prevent fatigue.
f. Patient should take several normal
breaths before attempting another
one with the incentive spirometer.
9. Instruct to patient to repeat 10-20 times

To ensure that airways remain open and prevent
every 1-2 hours while awake for 72 hours atelectasis.
and as needed and note the volume on
the spirometer.
 A total of 10 sustained maximal
inspiratory maneuvers per hour during
waking hours is a typical order. May
be required longer than 72 hours.
10. Teach client to perform IS every hour and

To encourage client to take responsibility for their
verify that the client is compliant. health care.
11. Dispose of soiled equipment or tissues

and wash hands.
V. EVALUATION:
1. The client has clear breath sounds throughout lung fields, especially at the base of the
lungs.
2. The client has normal depth and rate of respiration.
3. The inspiratory lung expansion returned to client’s pre event status.
4. The client’s arterial blood gases are normal.
5. There is an absence of consolidation or atelectasis.
6. Respirations are not labored.
VI. DOCUMENTATION
1. Record lung volume in cubic centimeters (cc).

2. Record respiratory assessment, including auscultation of breath sounds and rate and depth
of respirations.
3. Note the type and amount of secretions expectorated.
ASSISTING a CLIENT with CONTROLLED COUGHING
and DEEP BREATHING

Adapted from Altman Adapted from Altman (2010); Foundations and Advanced Nursing Skills
I. DEFINITION
Teaching client controlled, effective coughing techniques is essential in the management of bronchial secretions.
It should be taught to all clients undergoing surgery and is essential for the management of excessive
respiratory secretions in clients with lung conditions from cute to chronic.
II. RATIONALE
1. To prevent atelectasis and pneumonia.

2. Deep controlled breathing reopens small airways, and coughing promotes the removal of secretions.
III. EQUIPMENT
Tissues Water pitcher and glass Gloves
Emesis basin Stethoscope
Pillows for splinting the client’s chest and abdomen

ACTION RATIONALE
2. Assess the client’s pain status.
3. Explain the purpose and the importance

To elicit client’s cooperation.
of the procedure.
4. Help the client sit in a high Fowler’s

To allow for maximal lung expansion.
position if able.
5. Auscultate lungs before procedure. To determine which areas of the lungs need more
effective coughing, deep breathing, and
repositioning.
6. Place the palms of your hands onTothe

assess effective expansion of chest.
client’s rib cage.
7. Use pillow or folded towels to splintTothe

minimize pain with deep expansion in post-operative
abdomen or chest if client has had a clients and to promote effective deep breathing
surgery. and coughing.
8. Practice deep breathing with client: To promote loosening of secretions.

- Instruct the client to cover the mouth
with tissue (use mask, gloves, and
gown for staff as needed).
- Take a deep breath in and exhale
slowly and repeat 2-3 times.
- Repeat 10 times every 1-2 hours as
needed.
To promote effective coughing up of secretions.
9. Reassess lung fields after procedure.To evaluation whether procedure should be repeated.
10. Assist the client to cough as follows:

- Follow the procedure for deep
breathing and have the client hold
breath for 1 to 2 seconds. To clear bronchial secretions, especially from lower
- Contract abdominal muscles, cough airways.
forcefully, and expectorate secretions
into tissue or basin as nurse splints
incision areas as appropriate.
- Splint the client’s abdomen and chest
as he or she coughs by pressing on
lower chest wall and abdomen with
your hands.
To propel mucus upward. The force of the air after the

deep inspiration and the muscle contractions
enable more effective coughing.
11. Repeat as necessary to clear lung fields;

To clear airways to prevent atelectasis and pneumonia.
however, be aware that excessive If excessive coughing happens, the client may
coughing can irritate the trachea and cause irritation and compromise respiratory
bronchial tree. Clients with chronic status.
respiratory problems may need to
repeat the procedure at more frequent
intervals but with fewer coughs with
each procedure.
- Adjunct therapy may be necessary.
12. Observe for dizziness, shortnessMay ofindicate hyperventilation.

breath, or other respiratory problems.
13. Dispose of all tissues and wash hands.

Reduces the transmission of microorganisms.
V. EVALUATION
1. The client is able to breathe deeply and clearly.

2. The client is able to use effective breathing techniques.
3. The client is able to cough productively if secretions are present on assessment.
4. The lung fields are clear to auscultation, that is, there is absence of atelectasis,
rales/crackles, or rhonchi.
5. The client’s respiratory rate is normal.
6. The client has good skin color and mentation
VI. DOCUMENTATION
1. Record date and time of procedure

2. Include description of secretions and amount expectorated.
3. Record results of auscultation before and after procedure.
PREPARING and MAINTAINING a CHEST DRAINAGE SYSTEM
and ASSISSTING with CHEST TUBE INSERTION
Adapted from Altman Adapted from Altman (2010); Foundations and Advanced Nursing Skills
Lippincott et al (2010), Manual of Nursing of Nursing Practice
Kockrow (2011), Foundations and Adult Health Nursing
I. DEFINITION OF TERM
Chest Drainage System – is a closed system designed to drain air or fluid from the pleural cavity while restoring
or maintaining the negative intrapleural pressure needed to keep the lungs properly expanded.
Chest tubes - are positioned strategically in the pleural space, sutured to the skin, and connected to a drainage
apparatus to remove the residual air and fluid from the pleural or mediastinal space.
II. RATIONALE
1. To continuously drain fluid, blood or air from the pleural cavity

2. For medication instillation.
3. To restore normal intrapleural pressure and facilitate expansion of lung.
III. Equipment
 Sterile Tube thoracostomy tray that includes:
Drapes 10 ml syringe Forceps
Gauze sponges 22 gauge needle
25 gauge needle #11 blade scalpel
 Two large clamps

 Suture material
 Local anesthetic
 Chest Tube (appropriate size), trocar, connector
 Personal protective equipment: cap, mask, gown
 Chest drainage system
a. Disposable Chest Tube Drainage System
 Disposable chest tube drainage system
 Suction tubing if the drainage system will be connected to suction.
b. Reusable Bottle Chest Drainage System (1 bottle, 2 bottle or 3 bottle drainage system.
 Sterile glass bottles – 1 to 3 depending on the physician’s order.
 Glass tubes – 1 to 7 depending on the physician’s order.
 Rubber tubing
 Suction tubing if the drainage system will be connected to suction
 Rubber stoppers with holes the size of the glass tubes to be used on the glass
bottles-2 with holes and 1 with three holes.

 Tape
 Sterile water or saline
 Skin cleansing solution (e.g. povidone iodine)
 Extra 4x4 gauze sponges or other occlusive bandage material
 Petrolatum gauze (optional)
ACTION RATIONALE
1. Assess patient for pneumothorax,

hemothorax, presence of respiratory
distress
2. Obtain a chest X-ray. Other means Toof evaluate extent of lung collapse or amount of
localization of pleural fluid include bleeding in pleural space.
ultrasound or fluoroscopic localization.
3. Obtain informed consent.
4. Premedicate the client for pain if needed.

To reduce pain.
5. Obtain vital signs, including oxygen

saturation, for baseline data and then
every 4 hours.
6. Set Up the drainage system (Follow strict

To prevent microorganisms from entering the system
surgical technique) and subsequently entering the client’s pleural
cavity.
Disposable Chest Drainage System
a. Open the prepackaged disposable
chest tube system.
b. Set the unit upright.
c. If only the water seal has been
ordered, pour the measured amount
of sterile water or saline into the
funnel provided.
d. If suction has been ordered, fill the
suction control chamber to the
ordered level of fluid, usually 20 cmToofallow the unit to be filled.
water.
e. If suction has been ordered, attach
suction tubing to the marked suction To provide a water seal to prevent air from entering the
port and the suction source. pleural cavity.
f. Turn the suction up until there is
gentle bubbling in the suction section
of the system.
g. Set the system up at the client’s
bedside. Keep the drainage system
below level of the client.
One-Bottle Water-Seal System

To increase the drainage of fluid or air from the pleural
cavity.
This system is generally used only
pneumothorax as one bottle is required to
act as a water seal and a drainage
system.
a. Insert a long glass tube through one

hole of a two rubber stopper.
b. Insert a short glass tube through the
other hole in the stopper.
c. Pour sterile saline or sterile water into

the glass bottle, filling it to a depth of
at least 4cm.
d. Put the rubber stopper onto the
bottle.
To provide suction to the system.
e. Do not touch the inside of the rubber
stopper and the glass tubes that will
be inside the bottle.
f. Be sure the end of the long glass tube
is submerged 2cm into the water in
the bottle.
g. If the tube does not extend deeply
enough, add more water to the
bottle. Do not fill the bottle more than
one-third full.
h. Attach rubber tubing to the outside
end of the long glass tube for
drainage from the client’s chest tube.
To prevent backflow or air or fluid into the pleural
i. Place a measuring guide on the side of
cavity.
the bottle, marking the water level
before connection to the client.
Two-Bottle Water-Seal System

This system is used when gravity drainage
is adequate but a separate drainage
container is desired for accurate
assessment of the drainage and to
prevent increased resistance as the
drainage bottle fills.
a. Insert two short glass tubes into a
two-hole rubber stopper. Place this
rubber stopper onto the drainage
bottle.
b. Insert one long glass tube and one
short glass tube into a second two-
hole rubber stopper.
c. Pour sterile water or sterile saline into
the water seal bottle to a depth of
about 4 cm.
d. Place the rubber stopper with the
long glass tube onto the water seal
bottle, being careful not to
contaminate the inside of the bottle
or the glass tubes.
e. Be sure the end of the long glass tubeTo provide a water seal.
is submerged 2 cm into the water in
the bottle.
f. Place a length of rubber tubing
between the outer end of one of the
short glass tubes on the drainage
bottle and the outer end of the long
glass tube on the water deal bottle.
g. Place a length of rubber tubing on the
outer end of the second short glass
To prevent the buildup of pressure in the bottle as fluid
tube in the drainage bottle. This tube
is connecting to the client for and air drain out of the pleural cavity. The
drainage shorter tube works as an air vent.
h. Place a measuring guide on the side of
the drainage collection bottle before
connection to the client.
Three-Bottle Water-Seal and Suction To provide a sterile water seal to prevent air return into
Control System the pleural cavity.
This method is used when significant
amounts of drainage are expected and
the client requires suction to the chest
tubes.
a. Insert short glass tubes through the

holes in one of the two-hole rubber
stoppers.
b. Insert a long glass tube through one
hole of a two-hole rubber stopper. To maintain sterility while assembling the chest
Insert a short glass tube through the drainage system.
other hole in the stopper.
c. Insert a long glass tube through the
middle hole of a three-hole rubber
stopper and a short glass tubes
through the other two holes in the
three-hole stopper.
d. Pour sterile saline or sterile water into
the suction control bottle to the
ordered depth, usually 20cm of water. To provide a water seal that prevents the return of air
e. Put the rubber stopper with the two into the pleural cavity.
short glass tubes onto the drainage
collection bottle.
f. Place the two-hole rubber stopper
with the long glass tubes onto the
water seal bottle.
g. Be sure the end of the long glass tube
is submerged 2cm into the waterToinfacilitate drainage.
the bottle.
h. Attach rubber tubing to the outside
end of one of the short glass tubes
extending from the drainage
collection bottle to attach to the
client’s chest tube.
i. Attach a length of rubber tubing from
the second short glass tube in the
drainage collection bottle to the long
glass tube in the water seal bottle.
j. Attach a length of rubber tubing to
the second short glass tube in the
water seal bottle to one of the short To provide a sealed drainage system.
glass tubes in the suction control
bottle.
k. Attach the suction tubing to the
second short glass tube in the suction
control bottle and to the suction
source.
l. Do not touch any tubing to the outer
end of the long glass tube in To themeasure amount of drainage from the chest tube.
suction control bottle.
m. Turn the suction source up until a

gentle bubbling is noted in the suction
control bottle.
n. Place a measuring guide on the side of
the drainage bottle before connection
to the client.
To allow drainage to flow into the bottle without

creating a water seal in this container.
To provide a water seal(long tube), and the shorter tube

will work as an air vent to prevent the buildup
of pressure in the bottle as fluid and air drain
out of the pleural cavity.
To provides a sterile water seal and to prevent air
return into the pleural cavity.
To maintain sterility while assembling the chest

drainage system.
To provide water seal that prevents the return of air

into the pleural cavity.
To provide continuous sealed system for drainage
without allowing air or fluid to return to the
pleural cavity.
To document the amount of drainage from the client’s

chest tube.
To allow drainage to empty into the drainage bottle

while keeping the bottle open to the water seal.
To provide a water seal (long tube), and the shorter

tube will connect to the suction control bottle.
The long tube will remain open to the air as a vent. The
two shorter tubes are connectors to the water
seal bottle and to the suction source.
To provide a sterile water seal to prevent air return into

pleural cavity.
To promote suction. If the long tube touches the

bottom of the suction control bottle, it will be
unable to vent outside air, and the suction to
the pleural cavity will be infinite.
To accurately document the amount of drainage from

the pleural cavity.
7. Tape all connections. To prevent accidental breakage of the sealed system.
8. Explain the steps of the procedure to To

theencourage cooperation.
patient.
9. Position the as for an intercostal nerve

block or according to physician
preference.
- The tube insertion site depends on the
substance to be drained, the patient’s
mobility, and the presence of
coexisting conditions.
10. Do skin preparation and assist The the area is anesthetized to make sure tube insertion
physician during introduction of local and manipulation relatively painless.
anesthesia.
11. Assist during insertion:
Needle or Intracath Technique
a. An exploratory needle is inserted.
b. The IntraCath catheter is inserted

through the needle into the pleural
space. The needle is removed, and the
To puncture the pleura and determine the presence of
catheter is pushed several centimeters
air or blood in the pleural cavity.
into the pleural space.
c. The catheter is taped to the skin; may
be sutured to the chest wall and
covered with a dressing To prevent it from being dislodged out of the chest
during patient movement or lung expansion.
Trocar Technique The chest tube clamp is removed once the
a. A trocar catheter is used for the chest tube is attached to the system.
insertion of a large-bore tube for
removal of a moderate to large
amount of air leak or for the
evacuation of serous effusion.
b. A small incision is made over the
prepared, anesthetized site. Blunt To admit the diameter of the chest tube.
dissection (with a hemostat) through
the muscle panes in the interspace to
the parietal pleura is performed.
c. The trocar is directed into the pleural
space, the cannula is removed, and the
chest tube is inserted into the pleural
space and connected to a drainage
system.
Hemostat Technique using a large-bore
chest tube.
a. An incision is made over through the
skin and subcutaneous tissue.
b. A curved hemostat is inserted into the
pleural cavity and the tissue is spread
with the clamp.
c. The tract is explored by the examining
finger.
d. The tube is held by the hemostat and
directed through the opening up over
the ribs and into the pleural cavity.
e. The clamp is withdrawn and the chest
tube is connected to a chest drainage
system.
f. The tube is sutured in place and
covered with a sterile dressing.
g. Catheter is attached to a
connector/tube and to the system. All
connections are taped.
To make a tissue tract for the chest tube.
To help confirm the presence of the tract and

penetration of the pleural cavity.
To prevents dislodgment.
12. Observe the drainage system for blood

and air. Observe for fluctuation in the
tube on respiration.
 If a hemothorax is draining through a
thoracostomy tube into a bottle
containing sterile normal saline, the
blood is available for autotransfusion.
13. Secure a follow up chest Xray. To confirm correct chest tube placement and re-
expansion of the lung
14. Maintain integrity of the chest drainage

system.
a. Ensure that the water seal chamber is
filled to the marked level.
b. Assess for an air leak by watching for
bubbling in the water seal chamber
and having the client take a deep
To prevent air from returning to the pleural cavity; if it
breath and cough.
is not maintained at the marked level, air could
c. Make sure there is fluctuation
be drawn into the cavity.
(“tidaling”) of the fluid level in the
drainage system.
To provide valuable indication of patency of the
drainage system. Fluctuation of fluid in the
tubing will stop when:
d. Assess the chest tube dressing every
shift. Change dressing every 24 to 48
hours. a. the lung has re-expanded
e. Every 1-8 hours, depending upon the
orders, assess the drainage output,
noting the color and the amount. b. a dependent loop develops.
To provide occlusive seal to the site, preventing air from

being drawn in. Changing the dressing every 24
to 48 hours will prevent infection at the site.
f. Assess that the drainage system is
safely on the floor lower than the
client.
g. Assess that the tubing is free from
kinks and dependent loops.
h. A chest tube should never be
To monitor output.
clamped, except on orders from a
physician.
i. Ensure that the chest tube is never
milked or stripped to maintain To ensure adequate drainage.
patency.
j. If it is necessary to help the drainage
move through the tubing, applyToaensure drainage of the chest tube
gentle squeeze-and-release motion to
small segments of the chest tube
between your fingers. To prevent increase of pleural pressure. If chest tube is
k. Keep chest tube clamps at bedside. clotted, notify the physician.
l. Chest tubes are not clamped
routinely. Clamps with rubber
protection are kept at the bedside for
special procedures such as changing
the chest drainage system and
assessment before removal of the
chest tubes.
15. Wash hands To reduces the transmission of microorganisms.
V. EVALUATION
1. The chest drainage system did not pose a hazard for infection or loss or air seal to the
client.
2. The chest tube and drainage system are maintained in a safe manner.
3. The amount of drainage from the chest drainage system was accurately determined and
recorded.
VI. DOCUMENTATION
1. Indicate the type of chest drainage system used.

2. Note presence or absence of leak
3. Record chest tube drainage amount and color

ASSISTING with a THORACENTESIS
Adapted from from Altman (2010); Foundations and Advanced Nursing Skills
I. DEFINITION
Thoracentesis – is the process of inserting a large-bore needle through the chest wall into the pleural cavity
(utilizing sterile technique) for the purpose of removing fluid or administering medications intra-
pleurally.
II. RATIONALE
To remove excess fluid from the pleural space for diagnostic or therapeutic purposes.
III. EQUIPMENT
Antiseptic solution Sterile gauze sponges

Sterile towels and drapes Local anesthetic (e.g. lidocaine 1%)
Fluid receptacle Sterile specimen containers
Sterile syringes and needles: Hemostat
 3-5ml with 23-25 gauge needles for administration of local anesthetic medication
 20-50ml syringes with 14-17 gauge needles 5-7 cm in length for fluid drainage
Three-way stopcock/two-way stopcock with extension tubing

ACTION RATIONALE
1. Wash hands before baseline assessment

and as necessary throughout the
preparation, procedure, and follow-up. To reduce the transmission of microorganisms.
2. Obtain baseline vital signs and medical

To assess tolerance and improvement in clinical
history. status.
3. Be sure a signed consent has been

To reduce the legal risk to the nurse, physician and
completed. hospital and ensures the client has been
informed of procedure and risks.
4. Review necessary pretests (e.g. X-ray)

To enable the physician to identify the appropriate
and have information available at site to perform the thoracentesis. To assist
bedside. the nurse in proper positioning of the
client.
5. Prepare necessary client-specific

To reduce risk of incorrect labeling or handling of
labaoratory/cytology labels and specimens obtained during the procedure.
requisitions.
6. Review client teaching and assess

To provide reinforcement of prior teaching and
anxiety. opportunity for anxiety-reducing
techniques (e.g. relaxation, guided
imagery).
7. Pre-medicate as ordered.
8. Prepare the necessary equipment and

To provides a safe, organized approach to the
sterile field. procedure and prevents introduction of
microorganisms into the pleural cavity.
9. Assist in client positioning: To ensure that the diagphragm is dependent and to

 Sitting at the edge of the bed with facilitate access to the pleural cavity
arms on the bedside table. through intercostal spaces.
 Straddling the back of a chair, with
arms supported on the back of the
chair.
 Lying on the unaffected side.
10. Assist throughout procedure with client To decrease the risk of complications (e.g. client
positioning, assessment of vital signs, moving, sterile field becoming
client reassurance, management of contaminated) and monitors client’s
supplies, and maintenance of sterile field tolerance.
and technique.
11. The physician will perform the procedure.

The nurse assists as needed as the
following are done:
a. Wash hands
b. Put on mask, goggles if required by

institution policy apply sterile gloves,
To reduces the transmission of microorganisms.
and drape the client with sterile
towel.
c. Disinfect client’s skin with povidone

iodine solution.
d. Inject local anesthetic to the

To maintain surgical asepsis.
subcutaneous tissue.
e. Needle is inserted into pleural space.
To reduce the number of microorganisms on client’s

f. Fluid is removed from the pleural
skin.
space
g. Needle is stabilized as fluid is drained

To provide access to pleural space.
from pleural space.
To prevent movement of needle during procedure.
12. Upon completion of procedure:

a. Apply occlusive sterile dressing to the
thoracentesis site.
b. Position client in comfortable To prevent the entry of microorganisms into the
position. Bed rest is recommended pleural cavity
for at least 1 hour following a
thoracentesis.
c. Appropriately dispose contaminated
disposable and reusable supplies and
equipment.
d. Label and send out specimen for
testing as ordered.
To ensure availability of laboratory data necessary

to evaluate client’s health status.
13. Remove gloves and wash hands. To reduce the transmission of microorganisms.
14. Assess vital signs every 15 minutes for To

1 monitors the client for complications of
hour, or as ordered. hemorrhage or shock.
15. Assess client for complications. To prevent complications and adverse sequelae.
V. EVALUATION
1. The client’s pain decreased or ceased.

2. Respiratory status showed no evidence of distress.
3. ABG, pulse oximetry and other diagnostics tests improved.
4. Pleural effusion was absent on follow-up diagnostic tests.
5. The client experienced minimal amount of discomfort during the procedure.
6. The client has not experienced any complicating injury or infection related to the
procedure.
VI. DOCUMENTATION
1. Record pre and post-assessments, including vital signs and other physiologic
parameters.
2. Describe the color, quantity and quality of fluid obtained from the pleural cavity.
3. Document laboratory tests sent and pending.
4. Record any adverse events that would indicate complications from the procedure.
5. Document follow-up chest x-ray.
ADMINISTERING BLOOD TRANSFUSION
Adapted from Altman (2009), Fundamentals and Advanced Nursing Skills
I. DEFINITION
Blood Transfusion – is the intravenous administration of whole blood or components of blood such platelets,
plasma or packed red cells.
II. RATIONALE
1. To increase blood volume after surgery, trauma or hemorrhage.

2. To increase the number of red blood cells in a patient with severe anemia.
3. To provide platelets to clients with platelet defects because of deficiencies or coagulation
abnormalities.
4. To replace plasma proteins such as albumin.
5. To combat infection caused by decreased or defective WBC’s or antibodies.
III. EQUIPMENT
Tape Pressure bag if needed
Blood warmer if needed Clean gloves
Blood transfusion set and filter (Y-sets or Single Tubing set)
Intravenous solution 0.9% sodium chloride (normal saline)
Infusion pump if compatible with the specific blood product
Venipuncture equipment if client doesn’t have an IV line in place

Unit of whole blood, packed RBC’s, or other component in plastic bags obtained from the blood bank
ACTION RATIONALE
1. Verify the health care doctor’s order for the

transfusion. Blood transfusion must be ordered
by the doctor.
2. Explain procedure to the client. To ensure that client understands procedure and
decreases anxiety.
 Review side effects (dyspnea, chills,

headache, chest pain, itching) with client To encourage cooperation. Prompt reporting of a side
and ask him or her to report these to the effect will lead to earlier discontinuation of transfusion
nurse. and minimize the reaction.
3. Have the client sign consent forms.
4. Obtain and record vital signs. To allow detection of a reaction by any change in vital
signs during transfusion.
 If the patient’s clinical status permits, delay
transfusion if baseline temperature is
greater than 38.7 degrees Centigrade.
5. Prepare infusion site and start the prescribed IV
solution.
 If the client has an IV line, assess the

catheter size, patency, and whether any
signs of infiltration are present. To ensure a patent and adequate IV for infusion of
 If the client doesn’t have an IV line in place, blood.
perform venipuncture (preferably on a
large vein and using a gauge 20 or larger
needle or catheter).
Smaller needles may slow the infusion and could

damage blood cells.
6. Obtain the blood product from the blood bank To prevent bacterial growth and destruction of red
within 30 minutes of initiation. In the presence blood cells. (If the start of the transfusion is
of laboratory personnel: unexpectedly delayed, return the blood to the blood
bank within 30 minutes. Do not store blood in the unit
refrigerator).
 Inspect for abnormal color, cloudiness,

clots, and excess air.
 Check expiration date. To ensure that the expiration date has not passed.
 Verify on the laboratory slip attached to the
unit of the blood the client’s name, hospital
number, blood identification number, blood To verifies that the client receives correct blood.
type, blood unit number.
7. Verify and record the blood product and To reduce the risk of administering blood products to
identify the client with another nurse at the the wrong client. If there is error during this
bedside: procedure, notify the blood blank and do not
administer the product.
 Clients name, blood group, Rh type
 Cross-match compatibility
 Donor blood group and Rh type
 Unit and hospital number
 Expiration date and time on blood bag
 Type of blood product compared with
health care provider’s order.
 Presence of clots in blood
8. Wash hands and put on gloves. To reduce the transmission of microorganism and,
therefore, risk of transmission of human
immunodeficiency virus (HIV), hepatitis, or blood-
borne bacteria.
9. Prepare the infusion equipment.
a. Close all the clamps on the Y-set: the main

flow rate clamp and both Y-line clamps.
b. Insert the spike into the saline solution.
c. Hang the container on the IV pole about 39
inches above the venipuncture site.
10. Prime the tubing with normal saline and attach To ascertain the patency of the line before beginning
to the intravenous catheter. infusion. It also clears the IV catheter of incompatible
 Open the saline and main flow rate clamps solutions or medications.
and adjust the flow rate.
11. Prepare the blood bag.
a. Invert the blood bag gently several times to

mix cells with the plasma.
b. Expose the port on the blood bag by pulling
back the tabs.
c. Insert the remaining Y-spike into the blood
bag.
d. Suspend the bag.
e. Open roller clamp. If single-tubing set is
used, prime IV tubing with normal saline
and piggyback it to the blood
administration set.
To attach the tubing to blood unit.
To avoid forcing blood cells through both needle and a

venous catheter.
12. Establish the blood transfusion.
a. Close the upper clamp below the IV saline

solution container.
b. Open the upper clamp below the blood bag
and allow tubing to fill with blood to the
hub.
c. Re adjust the flow rate with the main
clamp.
13. Observe the client closely for the first 15

minutes.
a. Run the blood slowly for the first 15

minutes at 10 to 15 drops/min.
b. Note adverse reaction.
 The earlier a transfusion reaction
occurs, the more severe it tends to be.
Promptly identifying adverse reactions
helps to minimize the consequence.
14. Monitor the client.
a. Check vital signs after 15 minutes of

initiation, if there are no signs of reaction,
establish the required flow rate.
b. Assess the client including vital signs every
15 minutes for the first hour of transfusion
and every 30 minutes thereafter until blood
transfusion is terminated. Or depending on
the agency policy.
c. Infuse the blood at a rate of 2-5 mL/min
according to the doctor’s order.
Whole blood 2-3 hours
Red Blood Cells Over 2-3 hours (<4

hours)
Platelet 20-60 min or more
Concentrates depending on total
volume
Plasma (Fresh 15-30 min depending

or Fresh on total volume
Frozen)
Cryoprecipitat 3-15 minutes

e
a. If the client has a reaction and the blood is

discontinued, send the blood bag to the
laboratory for investigation of the blood.
15. When transfusion is completed:
a. Apply gloves and clamp blood tubing.

b. Open saline infusion and flush tubing.
c. Remove blood bag and tubing.
d. Establish original IV infusion.
e. Complete transfusion record and send
blood bag and forms to blood bank.
16. Appropriately dispose tubing, gloves. Wash To reduce transmission of microorganisms.

hands.
V. EVALUATION:
1. Observe for signs of transfusion reaction.

2. Observe client and laboratory values to determine response to transfusion.
3. Monitor client for signs and symptoms of fluid overload.
VII. DOCUMENTATION:
1. Blood product administered

2. Blood unit number
3. Start and end times
4. Names of persons starting and ending the transfusion.
5. Names of individuals verifying patient
6. Amount of blood absorbed or transfused
7. Vital signs
8. Describe client’s response to transfusion
ASSISTING IN BONE MARROW ASPIRATION and BIOPSY
I. DEFINITION
A specimen of bone marrow (major site of blood cell formation) may be obtained by aspiration or needle biopsy
performed by a physician. The procedure allows evaluation of overall blood composition by studying
blood elements and precursor cells as well as abnormal or malignant cells.
II. RATIONALE
1. Aspirates aid in diagnosing various disorders and cancers, such as oat cell carcinoma, leukemia, and
such lymphomas as Hodgkin’s disease.
2. Biopsies are often performed simultaneously to stage the disease and monitor response to
treatment.
III. EQUIPMENT
For aspiration:
Povidone-iodine pads Sterile drapes

10 4x4 gauze pads 10 2x2 gauze pads
2 12-ml syringe 22 gauge 1” or 2” needle
Scalpel Sedative
Specimen containers Bone marrow needle
70% isoprophyl alcohol 1% lidocaine
26 or 27 gauge ½” needle Adhesive tape
Sterile gloves Glass slides and cover glass
Labels and laboratory biohazard transport bags
For Biopsy:
Biopsy needle such as Vim-Silverman, Jamshidi, Illinois sternal, or Western-Jensen needle

Zenker’s fixative
ACTION RATIONALE
1. Explain the procedure to the patient.
To ease his anxiety and ensure cooperation.

Inform the patient that the procedure normally takes
5 to 10 minutes.
2. Ensure that the consent form has been
signed.
3. Provide a sedative as ordered before the test.
4. Position the patient according to the selected

puncture site.
Posterior superior iliac crest:
 The patient is placed either in lateral

position with one leg flexed or in the
prone position.
Anterior iliac crest:
 The patient is placed in the supine or side

lying position. This site is used with
patients who can’t lie prone because of
severe abdominal distention.
Sternum
 Aspiration from the sternum involves the

greatest risk but may be used because the
site is near the surface. This site is seldom
used for biopsy.
5. Using sterile technique, the puncture site is

cleaned with povidone-iodine pads and
allowed to dry; then the area is draped.
6. Assist the physician during administrationToofanesthetize the tissue down to the bone.
1% lidocaine.
7. After allowing about 1 minute for the To avoid pushing skin into the bone marrow and also to
lidocaine, a scalpel may be used to make a help avoid unnecessary skin tearing to help
small stab incision on the patient’s skin to reduce the risk of infection.
accommodate the bone marrow needle.
8. Bone marrow aspiration:
a. The physician inserts the bone marrow

needle and lodges it firmly in the bone
cortex.
b. If the patient feels sharp pain instead of

pressure when the needle first touches
bone, the needle was probably inserted
outside the anesthetized area.
c. The needle is advanced by applying an

If this happens, the needle should be withdrawn slightly
even, downward force with the heel of the
and moved to the anesthetized area.
hand or the palm, while twisting it back
and forth slightly. A crackling sensation
means that the needle has entered the
marrow cavity.
d. Next, the physician removes the inner

cannula, attaches the syringe to the
needle, aspirates the required specimen,
and withdraws the needle.
e. The nurse puts on gloves and applies

pressure to the aspiration site with gauze
pad for 5 minutes to control bleeding
while an assistant prepares the marrow
slides.
f. The area is then cleaned with alcohol to

remove the povidone-iodine, the skin is
dried thoroughly with a 4” X 4” gauze pad,
and a sterile pressure dressing is applied.
g. Specimens are labeled appropriately,

placed in in laboratory biohazard
transport bags, and sent to laboratory
9. Bone marrow biopsy:
a. The physician inserts the biopsy needle into

the periosteum and advances it steadily
until the outer needle passes into the
marrow cavity.
b. The biopsy needle is directed into the

marrow cavity by alternately rotating the
inner needle clockwise and
counterclockwise.
c. Then plug of tissue is removed, the needle

assembly is withdrawn, and the marrow
specimen is expelled into a properly labeled
specimen bottle containing Zenker’s fixative
or formaldelhyde.
d. It’s then placed in the laboratory biohazard

transport bag and sent to the laboratory.
e. The nurse puts on gloves, cleans the area

around the biopsy site with alcohol to
remove the povidone-iodine solution,
firmly presses a sterile 2”x2” gauze pad
against the incision to control bleedine, and
applies a sterile pressure dressing.
Special Considerartion:
 Faulty needle placement may yield too little aspirate. If no specimen is produced, the needle must be
withdrawn from the bone (but not from overlying soft tissue), the stylet repl;aced, and the needle
inserted into a second site within the anesthetized field.
 Bone marrow specimens’ shouldn’t be collected from irradiated areas.
 Bleeding and infection are potentially life threatening complications of aspiration or biopsy at any
site.
 If hematoma occurs around the puncture site, apply warm soaks. Give analgesics for site pain and
tenderness.
V. DOCUMENTATION
1. Chart the time, date, location, and patient’s tolerance of the procedure and the specimen
obtained.
MAINTAINING INTRAVENOUS FLUID INFUSIONS
Adapted from Berman et al (2009), Skills in Clinical Nursing
I. DEFINITION
Once an intravenous infusion has been established, it is the nurse responsibility to maintain the prescribed flow
rate and to prevent complications associated with IV therapy.
II. RATIONALE
1. To monitor the solution drip rate and maintain the infusions as ordered.
2. To infuse the amount of prescribed solution.
3. To maintain the patency of IV catheter.
4. To prevent complications associated with IV therapy.
III. EQUIPMENT
None
ACTION RATIONALE
1. Explain the procedure to the client. To gain patient’s cooperation.
2. Perform hand hygiene and observe other To prevent transfer of microorganism.

3. Expose the IV site but provide privacy.
4. Ensure that the correct solution is being

infused. Compare the label on the container
(including added medication) to the order.
a. If the infusion is incorrect, slow the rate

of flow to a minimum to maintain
patency of the catheter.
b. If the infusing infusion is contraindicated

for the client, stop the infusion and
saline-lock the catheter.
c. Change the solution to the correct one,

using new tubing if indicated.
d. Document and report the error according

to agency protocol.
5. Observe the rate of flow every hour.
a. Compare the rate of flow at least hourly

against the infusion schedule.
b. Observe the position of the solution To promote flow by gravity of the solution into the
container. If it is less than 3 ft. above IV vein.
site, readjust it to the correct height of
the pole.
c. If too much fluid has infused in the timeTo prevent complication of fluid overload.
interval, check agency policy. The doctor
may need to be notified.
 In some agencies, you will slow the
infusion to less than the ordered rate
so that it will be completed at the
planned time.
 Assess for manifestations of
hypervolemia: dyspnea, rapid labored
breathing, cough, crackles,
tachycardia, and bounding pulses.
 In other agencies, if the order is for a
specified amount of fluid per hour, the
IV may be adjusted to the correct rate
and the client monitored for signs of
fluid overload. In this case, make the
appropriate revisions on the container
time strip.
d. If the rate is too slow, adjust the IV to the

prescribed rate.
 Some agencies permit nursing
personnel to adjust an IV that Tois supply sufficient fluid, electrolytes, or medication
behind time by a specified percent. for a client’s needs.
Adjustment above this amount may
require a doctor’s order.
e. If the prescribed rate of flow is 150mL/h

or more, check the rate of flow more
frequently, for example, every 30
minutes.
6. Inspect the patency of the IV tubing and

needle.
a. Observe the chamber. If it is less than half

full, squeeze the chamber to allow
correct amount of fluid to flow in.
To check patency of the IV line. Rapid flow of fluid into
b. Open the drip regulator and observe for a the drip chamber indicates patency of the IV
rapid flow of fluid from the solution line. Closing the drip regulator to the
container into the drip chamber. Then prescribed rate of flow prevents fluid
close the drip regulator to reestablish the overload.
prescribed rate of flow.
c. Inspect the tubing for pinches, kinks, or

obstructions to flow. Arrange the tubing
so that it is lightly coiled and under no
pressure. Sometimes the tubing becomes
caught under the client’s arm and the
weight of the arm blocks the flow.
d. Observe the position of the tubing. If it is

dangling below the venipuncture site, coil
it carefully on the surface of the bed.
e. If the infusion is dripping at less than the

To check patency of IV line. A return flow of blood
prescribed rate even when adjusted, indicates the needle is patent and in the vein.
lower the solution container below the Blood returns because venous pressure is
level of the infusion site, and observe for greater than the fluid pressure in the IV tubing
a return flow of blood from the vein. (siphoning). Absence of blood return indicates
that the needle is no longer in the vein or that
the tip of the catheter is partially obstructed
f. If the infusion is dripping at less than the by a thrombus, the vein wall, or a valve in the
prescribed rate even when adjusted, vein.
determine whether the bevel of the
catheter is against the wall of the vein.
 Carefully raise or lower the hub of the
needle. If the flow rate improves, tape
a sterile gauze pad under or over the
hub to secure the modified position of
the catheter bevel.
g. If there is leakage, locate the source.

 If the leak is at the catheter
connection, tighten the tubing into the
catheter.
 If the leak is elsewhere in the tubing,
slow the infusion and replace the
tubing.
 Estimate the amount of solution lost, if
it was substantial.
 If fluid is leaking at the insertion site,
the needle may be blocked. Checked
agency policy regarding irrigating
potentially clotted needles.
7. Inspect the insertion site for fluid infiltration

(presence of intravenous fluids within the
subcutaneous space surrounding a
venipuncture site).
a. If infiltration is present, stop the infusion

and remove the catheter. Restart the
infusion at another site.
b. Apply warm compress to the site To
of promote comfort and vasodilation, facilitating
infiltration. absorption of the fluid from interstitial tissues.
8. Inspect the infiltration site for phlebitis

(inflammation of a vein).
 Phlebitis can occur as a result of

mechanical trauma or chemical irritation
(such as from intravenous electrolytes,
especially potassium and magnesium, and
certain medications).
 Signs of phlebitis are redness, warmth,
and swelling at the intravenous site and
burning pain along the course of the vein.
 If phlebitis is detected, discontinue the
infusion, and apply warm compresses to
the venipuncture site. Do not use this
injured vein for further infusions.
9. Inspect the intravenous site for bleeding.
 Oozing or bleeding into the surrounding

tissues can occur while the infusion is
freely is freely flowing but is more likely
to occur after the needle has been
removed from the vein.
 Observation of the venipuncture site is
extremely important for clients who
bleed readily, such as those receiving
anticoagulants.
V. EVALUATION
1. Perform follow-up based on findings or outcomes that deviated from expected or normal for the
client. Consider urinary output compared to intake, tissue turgor, specific gravity of urine, vital signs,
and lung sounds compared to baseline data.
2. Regularly check the client for intended and adverse effects of the infusion. Report significant
deviations from normal to the doctor.
VI. DOCUMENTATION
1. Record the status of the IV insertion site and any adverse responses of the client.
2. Document the client’s IV fluid intake at least every 8 hours according to agency policy.
3. Include the date and time; amount and type of solution used; container number; flow rate; and the
client’s general response.
NURSING INTERVENTIONS FOR LOCAL COMPLICATIONS OF IV THERAPY
Complication Signs & Symptoms Possible Causes Nursing Interventions

 Tenderness at the tip  Poor blood flow  Remove venous access device
of and proximal to around venous access  Apply warm soaks.
Phlebitis venous access device device.  Notify physician if patient has
 Redness at tip of  Friction from cannula fever.
cannula and along movement in vein  Document patient’s condition and
vein.  Venous access device your interventions.
 Vein hard on left in vein too long.
palapation  Clotting at cannula tip
 Elevated temperature. (thrombophlebitis) Prevention:
 Drug or solution with
high or low pH or high
osmolarity.  Restart infusion using larger vein
for irrigating solution, or restart
with smaller gauge device to
ensure adequate blood flow.
 Tape device securely to prevent
motion.
 Swelling at and above  Venous access device  Stop infusion.

IV site (may extend dislodged from vein,  Apply ice (early) or warm soaks
Extravasation along entire limb). or perforated vein. (later) to aid absorption. Elevate
 Discomfort, burning or limb.
pain at site (may be  Check for pulse and capillary refill
painless) periodically to access circulation.
 Tight feeling at site  Restart infusion above infiltration
 Decreased skin site or in another limb.
temperature around  Document patient’s condition and
site. you interventions.
 Blanching at site
 Continuing fluid
infusion even when Prevention:
vein is occluded
(although rate may
decrease)  Check IV site frequently.
 Absent backflow of  Don’t obscure area above site
blood. with tape.
 Teach patient to observe IV site
and report pain or swelling.
 Loose tape  Loosened tape, or  If no infiltration occurs, retape
 Cannula partly backed tubing snagged in bed without pushing cannula back
Cannula out of vein linens, resulting in into vein. If pulled out, apply
Dislodgment  Solution infiltrating. partial retraction of pressure to IV site with sterile
cannula; pulled out by dressing
confused patient.
Prevention:
 Tape venipuncture device

securely on insertion.
 No increase in flow  IV flow interrupted

rate when IV container  Heparin lock not  Use mild flush injection. Don’t
is raised. flushed force it. If unsuccessful, reinsert
IV line.
 Blood backflow in line  Blood backflow in line
 Discomfort at insertion when patient walks
site  Line clamped too
long. Prevention:
Occlusion
 Maintain IV flow rate

 Flush promptly after intermittent
piggyback administration
 Have patient walk with his arm
bent at elbow to reduce risk of
blood backflow.
 Pain during infusion  Solution with high or  Decrease the flow rate
 Possible blanching if low pH or high  Try using an electronic flow
Vein irritation or vasospasm occurs osmolarity, such as 40 device to achieve steady flow.
pain at IV site  Red skin over vein mEq/L of potassium
during infusion chloride, phenytoin,
 Rapidly developing and some antibiotics Prevention:
signs of phlebitis. (Vancomycin,  Dilute solutions before
erythromycin) administration. (Refer to your
facility’s policy)
 If long term therapy of irritating
drug is planned, ask physician to
use central IV line.
 Tenderness at  Vein punctured  Remove venous access device.

venipuncture site through opposite wall  Apply pressure and warm soaks
Hematoma  Bruised area around at time of insertion. to affected area.
site  Leakage of blood from  Recheck for bleeding.
 Inability to advance or needle displacement.
flush IV line  Inadequate pressure
applied when cannula Prevention:
is discontinued
 Choose a vein that can

accommodate the size of venous
access device
 Release tourniquet as soon as
insertion is successful.
 Painful, reddened, and  Injury to endothelial  Remove venous access device;

swollen vein. cells of vein wall, restart infusion in opposite limb if
Thrombosis  Sluggish or stopped IV allowing platelets to possible.\
flow. adhere and thrombi  Apply warm soaks.
to form.  Watch for IV therapy – related
infection; thrombi provide an
excellent environment for
bacterial growth.
Prevention:
 Use proper cenipuncture

techniques to reduce injury to
vein.
DISCONTINUING INTRAVENOUS LINE AND

CONVERT TO A SALINE OR HEPARIN LOCK
Adapted from Altman (2010), Fundamental and Advanced Nursing Skills
I. DEFINITION
HEPARIN LOCK or SALINE LOCK – also known as an intermittent infusion device, is a small plastic device with a
resealing rubber entry that is screwed onto the hub of the existing IV catheter or butterfly needle
tubing. Filled with dilute heparin or saline solution to prevent blood clot formation, the device maintains
venous access in patients who are receiving IV medication regularly or intermittently but who do not
require continuous infusion.
II. RATIONALE
1. To maintain patent access to the vein without necessity of running IV fluids in the body.
2. To help improve client mobility, as client can walk and move without the IV stand, pump or tubing.
3. To prevent blood clot formation.
III. EQUIPMENT
Intermittent infusion cap or device
Clean gloves
Antiseptic swab (usually alcohol)
Sterile saline for injection or heparin flush solution (10units/ml or 100 units/ml), in a syringe.
Tape or Transparent dressing, if required.
ACTION RATIONALE
1. Check health care provider’s orderToto

ensure accurate placement of saline lock.
discontinue IV and insert a saline or
heparin lock.
2. Wash hands and put on clean gloves. To reduce the number of micro-organism.
3. Verify the client’s identity using agency

To ensure that correct procedure is performed for the
protocol. client.
4. Explain procedure and reason Tofor
provide information thus decreases anxiety.
discontinuing IV to client.
5. Prepare supplies at bedside. To ensure smooth procedure.
6. Stop IV infusion. To stop the flow of the fluid in the IV tubing.
7. Place the intermittent infusion device:
 Stabilize the IV catheter with your

nondominant hand and use little finger
to place slight pressure on the vein
above the end of catheter.
 Loosen IV tubing and remove
 Screw intermittent infusion device into

the hub of tubing.
8. Check for patency of IV:
 Clean the intermittent infusion device

with antiseptic solution.
 Insert saline syringe with 25-gauge

needle into center of diagphragm.
 Pull back gently and watch for blood
return.
 Inject saline slowly into lock.
 Assess client’s pain at site.
9. Keep lock patent with heparin or normalTo maintain patency.

saline every 8 hours:
 Per agency protocol, instil saline or
heparin to maintain patency of the
intermittent infusion device.
 Use only heparin if prescribed as “flush
with heparin” or if institutional policy
requires it.
 Clean the rubber diaphragm with an

antiseptic swab.
 Insert the syringe with heparin or

saline into the diaphragm.
 Inject heparin or saline slowly into lock.
10. Remove syringe from the diaphragm To andreduce transmission of microorganisms. And reduce
swab it with an antiseptic swab. Discard risk of needle stick injury.
needle in sharps container.
11. Assess the site for any signs of leakage,

To detect problems with the site that needs additional
irritation or infiltration. assessment and intervention.
12. Remove gloves and dispose with all used
materials.
13. Wash hands. To reduce transmission of microorganisms.
1. The IV is discontinued and the intermittent infusion device is placed without complications.
2. Examine site at regular intervals. Note patency and ease of flushing.
3. Document date and time IV was discontinued and saline lock was placed and any unusual findings at
insertion site.
INFUSING TOTAL PARENTERAL NUTRITION (TPN)
Adapted from Altman (2010), Fundamental and Advanced Nursing Skills

I. DEFINITION
Total Parenteral Nutrition (TPN) – formerly called hyperalimentation, the intravenous infusion of a solution
containing dextrose, amimo acids, fats, essential fatty acids, vitamins and minerals through a central
venous catheter usually inserted into the superior vena cava.
Peripheral Parenteral Nutrition (PPN) – is the intravenous administration of nutritionally balanced isotonic or
mildly hypertonic solutions via a peripheral vessel, used for short term (3 weeks or less). It cannot
handle as concentrated a solution as central lines but can accommodate lipids.
II. RATIONALE
TPN formulas are used for client’s who, because of their disease process or treatment, are unable to
receive adequate nutrition through the gastrointestinal tract. The following are examples of disease
states that require this type of nutritional intervention:
 Short bowel syndrome

 Inflammatory bowel disease
 Gastrointestinal fistula
 Hypermetabolic state (severe burns)
 Intractable diarrhea
 Serious acute alimentary disease (pseudomembranous colitis)
 Chronic idiopathic intestinal pseudo-obstruction
 Renal or hepatic failure
III. EQUIPMENT
TPN solution Timing tape
Infusion Pump Tubing with filter
Disposable gloves IV infusion tubing
ACTION RATIONALE
1. Confirm the order for TPN
2. Obtain vital signs, including recent body

temperature, client’s weight, fluid balance,
and any allergy to contents of the TPN
solution.
3. Inspect and prepare the solution.

 Remove the ordered TPN solution from
the refrigerator 1 hour before use, and
check each ingredient and the proposed To prevent pain, hypothermia, and venous spasms and
rate against the order on the chart. constriction caused by infusion of a cold
 Inspect the solution for cloudiness or solution.
presence of particles, and ensure that the
container is free from cracks.
 For lipids, examine the bag for separation
of emulsion, fat globules, or froth.
 Check its expiration date. Most solutions
must be used within 24 hours of
To administer a clear solution without clouding. If there
preparation, unless they are refrigerated.
is any problem with the solution, notify
 Two licensed nurses need to check the
pharmacy and receive a new product.
nutrients in the bag with the order written
by the doctor.
 Apply a timing tape on the solution
container.
4. Explain the procedure to the client. To elicit cooperation.
5. Assist the client to a comfortable position,

To promote comfort.
either sitting or lying.
6. Perform hand hygiene and observe To reduce the transmission of microorganisms.

7. Using aseptic technique, change the solution

container to the TPN solution ordered.
 Ensure that correct placement of the
central line catheter has been confirmed
by x-ray examination.
 Ensure that the tubing has an in-line filter
connected to the end of the TPN tubing.
Plain TPN – 0.22 micron filter
TPN with lipids – 1.2 microns filter
Plain lipids – without filter
 Attach and connect the tubing to an
infusion pump.
 Attach the TPN solution to the IV
administration tubing. If a multiple-lumen
tube is in place, attach the infusion to the
appropriate lumen. If possible, a lumen To trap bacteria and particles that can form in the TPN.
should be dedicated to TPN use only.
To eliminate the changes in flow rate that occur with

alterations in the client’s activity and position.
8. Regulate and monitor the flow rate based on

client’s nutritional and metabolic needs.
 Establish the prescribed rate of flow and
monitor the infusion at least every 30
minutes.
 Never accelerate an infusion that has
fallen behind schedule. To prevent wide fluctuations in blood glucose that can
 Never interrupt or discontinue the infusion occur if the rate of TPN infusion is irregular.
abruptly. If TPN solution is temporarily
unavailable, infuse a solution containing at
least 5% to 10% dextrose.
 During the initial stage of a lipid infusion

To prevent rebound hypoglycemia.
(i.e., the first hour), closely monitor vital
signs and side effects (e.g., fever, flushing,
diaphoresis, dyspnea, cyanosis, headache,
nausea or vomiting)
 Start lipid infusions very slowly according to
the doctor’s orders, the manufacturer’s
directions, and agency policy.
 For 10% emulsion, start at 1mL/min for the
first 5 minutes then up to 4mL/min for the
next 25 minutes. If well tolerated, set ordered
rate thereafter.
9. Monitor the client for complications.

 Change the administration set and
filter every 24 hours.
 Monitor vital signs every 4 hours. If
fever or abnormal vital signs occur,
notify the primary care giver.
 Assess fingerstick blood glucose levels
every 6 hours according to agency
protocol.
To detect earliest indication of catheter-related sepsis.
 For hyperglycemia supplementary

insulin may be ordered
To check blood glucose level. Blood glucose is tested to
subcutaneously or added directly to
make certain the infusion is not running too
the TPN solution per doctor’s order.
rapidly for the body to metabolize glucose or
 For hypoglycemia the infusion rate
too slowly for caloric needs to be met.
may need to be increased.
 Measure the daily fluid intake and
output and calorie intake.
To administer precise replacement of fluid and
electrolyte if deficits are readily determined.
10. Wash hands. To reduce the transmission of microorganism.
11. Assess weight. Weigh the client dailyToatreport a gain of more than 0.5 kg per day indicates
the same time. fluid excess and should be reported.
V. EVALUATION
1. Monitor the client’s response hourly, assessing for complications such as allergic reactions, fluid
overload, occlusion of the line, and electrolyte imbalance (mental status changes)
2. Monitor blood glucose frequently per facility routines.
3. Monitor electrolytes.
4. Monitor weight daily and intake and output.
VI. DOCUMENTATION
1. Initiation of therapy
2. Type and amount of infusion and rate of infusion.
3. Vital signs every 4 hours.
4. Fingerstick blood glucose levels as ordered.
5. Client’s daily weight

ASSISTING IN NASOGASTRIC TUBE INSERTION
Adapted from DeLaune et al (2011), Fundamentals of Nursing Standards and Practice
White (2005), Foundations of Nursing
I. DEFINITION
Nasogastric Tube (NGT) – a flexible tube made of rubber or plastic that is inserted through one of the nostrils
down the nasopharynx and esophagus down into the alimentary tract. In some instances, the tube is
passed through the mouth and pharynx, although this route may be more uncomfortable for the adult
client and may cause gagging.
Nasoenteric Tube – a longer tube (at least 40 inches for an adult) inserted through one nostril down into the
upper small intestine.
II. RATIONALE
1. To administer tube feedings and medications to clients who are comatose, semiconscious, or unable
to consume sufficient nutrition orally.
2. To establish a means for suctioning stomach contents to prevent gastric distention, nausea, and
vomiting.
3. To obtain gastric specimens for analysis.
4. To lavage (wash) the stomach in case of oral ingestion of poisonous substance or overdose of
medications.
III. EQUIPMENT
Hypoallergenic tape Clean gloves

Water-soluble lubricant Tissues and towel
Glass of water and drinking straw Basin pH chemstrip
Stethoscope Suction apparatus if required
Penlight
Number 6, 8 or 12 French tube for gastric suction (Levine, Salem sump or Anderson)
Small-bore feeding tube 8 or 12 French tube (Keofeed, Dobbhoff, Moss)
Guidewire or Stylet for small-bore tube
Solution basin filled with warm water (if plastic tube is used) or Ice (if rubber tube is used)
20 – 50 ml syringe with an adapter or Asepto Syringe with small-bore tube
ACTION RATIONALE
1. Review client’s medical record and history. To confirms doctors order for inserting a nasogastric
tube; history of nasal or sinus surgery or
problem.
2. Gather the equipment. To facilitate an efficient procedure.
4. Check client’s armband; explain procedure, To verify correct client; explanation of procedure
showing items. reduces anxiety and increases client
cooperation.
5. Raise the bed the bed and place it in a high To facilitate passage of the tube into the esophagus
Fowlers position (45 to 60 °) or assist the client and swallowing.
to a Fowlers position, at least a 45° angle or
higher, with a pillow behind client’s shoulder;
provide for privacy.
 Place comatose clients in semi-Fowler’s
position.
6. Place towel over patient’s chest, with tissues To prevents soiling of gown and bedding and protects
in reach. Don gloves. nurse from contamination with bodily fluids;
lacrimation can occur during insertion through
nasal passages.
7. Examine nostrils with penlight and assess To

as determine the most patent nostril to facilitate
client breathes through each nostril. insertion.
8. Using the NG tube, measure the distance fromTo approximate length of tube needed to reach
the of the nose to the earlobe and then to the stomach.
xiphoid process of the sternum and mark this
distance on the tube with a piece of tape.
 If tube is to go below stomach
(nasoduodenal or nasojejunal), add an
additional 15 to 20 cm.
9. Have client below nose, and encourage To help clears nasal passage without pushing
swallowing of water if level of consciousness microorganisms into inner ear; to facilitate
and treatment plan permit. passage of tube.
10. Lubricate first 4 inches of tube with water-
To facilitate passage into the nares.
soluble lubricant.
11. Ask patient to slightly flex the neck backward.

To make insertion easier.
12. Insert tube as follows:
a. Gently insert the tube into nostril; aim tubeTo promote passage of tube with minimal trauma to
toward back of throat and down. mucosa.
b. Ask client to tip the head forward once the To facilitate passage of the tube into the esophagus
tube reaches the nasopharynx – this is instead of the trachea. Tube may stimulate gag
usually where the client starts to gag. reflex.
c. If client continuous to gag, stop a moment. To allow client rest, reduce anxiety and prevent
d. When client feels tube in back throat, use vomiting.
flashlight or penlight to locate tip of tube.To ensure tip’s placement. Tube may be coiled or
e. Advance the tube several inches at a time kinked.
as the client swallows ice chips or water.
f. If resistance is met, rotate tube slowly withTo assist in advancing the tube past the oropharynx.
downward advancement toward client’s The action of swallowing facilitates the
closest ear; do not force tube. insertion process. With each swallow; the
g. Withdraw the tube immediately if there are tracheal opening is closed to prevent
signs of respiratory distress. inspiration.
h. Advance the tube until the taped mark is
reached To prevent trauma to the bronchus or lung. To
enable the tube to reach the stomach.
13. Secure the tube by taping it to the bridgeTo of prevent tube displacement.
the client’s nose.
a. Wipe body oils off tip of nose and allow

drying.
b. Split a 4 inch strip of tape lengthwise 2
inches.
c. Place the intact portion of the tape on the
bridge of the nose and wrapping the split
ends around the tube.
d. Tape to cheek as well if desired.
14. Check placement of tube: To ensure correct placement in the stomach.
a. Attach syringe to free end of tube and To ensure correct placement in the stomach. A
rapidly inject 30cc of air and at the same “whoosh” sound will be heard if the tube is
time auscultate over the epigastric area. correctly placed. Amount of air varies for
pediatric patient or if patient has had gastric
surgery.
b. Aspirate gastric contents; assess color and

pH below 4, tube is in stomach; pH range of 6 to 7
quality of the content. If required, measure indicates intestinal sites or pleural fluid from
with pH indicator strip. Follow protocol tracheobronchial tree.
regarding insertion of contents versus
discarding.
c. If prescribed, obtain x-ray; keep client To
on prevent leakage of gastric contents.
the right side until x-ray is taken. To confirm correct placement; if nasoduodenal or
nasojejunal feedings are required, passage
through pylorus may require several days.
15. Connect the distal end of the tube to suction,

To establish an appropriate pathway for intervention.
draining bag, or adapter according to the
purpose of this nursing intervention.
16. Secure the tube with tape, or with rubber

To enhance the level of comfort and to secure the
band and safety pin, to client’s gown. tubing system.
17. Instruct client about movements that can

To reduce anxiety and to teach client how to prevent
dislodge the tube. tugging on tube with head movement.
18. Gastric decompression: To perform decompression as prescribed by the

doctor; intermittent or continuous suctioning
a. Remove syringe from free end of the tube, is determined by type of tube inserted.
and connect tube to suction tubing; set
machine on type of suction and pressure as
prescribed.
b. Levine tubes are connected to intermittent
low pressure.
c. Salem sump or Anderson tube is connected
to continuous low suction.
d. Observe nature and amount of gastric tube
To provides information about patency of tube and
or drainage. gastric contents.
e. Assess client for nausea, vomiting, and

abdominal distention.
19. Provide oral hygiene and cleanse nares withToa promote comfort.
tissue.
20. Remove gloves, dispose of contaminated

To prevent the spread of microorganisms; protect
materials in proper container, and wash other workers from coming into contact with
hands/hand hygiene. objects contaminated with body fluids.
21. Position client for comfort, and place call light

To promote comfort and safety.
within easy reach.
VARIATION:
INSERTING A NASOINTESTINAL TUBE:
a. Add 3 to 4 cm (8 to 10cm) to the length

measured for the nasogastric tube and
mark it with tape.
b. After inserting the tube into the stomach, To enable advancement of the tube through the
position the client bon his / her right side pyloric sphincter.
c. When the tube has advanced to the To determine placement in the intestine.
premarked point, test the pH to as the
aspirate.
d. Have proper placement confirmed by x-ray
and tape the tube in place when
confirmation is received.
V. EVALUATION DOCUMENTATION
1. The reason for the tube insertion

2. The type of tube inserted
3. If suction is applied: the type (intermittent or continuous) of suctioning and pressure setting
4. The nature and amount of aspirate and drainage
5. The client’s tolerance of the procedure
6. The effectiveness of the intervention, such as nausea relieved
ADMINISTERING TUBE FEEDINGS
I. DEFINITION
Tube feedings involved delivery of a liquid feeding formula directly to the stomach (known gastric gavage),
duodenum, or jejunum.
II. RATIONALE
1. To restore or maintain nutritional status of patient who can’t eat normally because of dysphagia
or oral or oral or esophageal obstruction or injury.
2. To administer nutrition to unconscious or intubated patient, or patient recovering from GI tract
surgery who can’t ingest food orally.
3. To administer medications
III. EQUIPMENT
For Gastric Feedings For Duodenal or Jejunal For Nasal and Oral Care
Feedings
 Feeding formula
 Graduated container  Feeding formula  Cotton-tipped
 120 ml of water of  Enteral applicators
water administration set  Water soluble
 Gavage bag with containing a gavage lubricant
tubing and flow container, drip  Petroleum jelly
regulator clamp chamber, roller
 Towel or linen-saver clamp or flow
pad regulator and tube
 60-ml syringe connector
 Stethoscope  IV pole
 60 ml syringe with
adapter tip
 Water
*A bulb syringe or large catheter tip syringe may be substituted for a gavage bag after the
patient demonstrated tolerance for gravity drip infusion.
ACTION RATIONALE
1. Explain the procedure. Inform the patient
that he’ll receive nourishment through the
tube. If possible give him a scheduleToofgain cooperation.
subsequent feedings.
2. Wash hands
3. Provide privacy.
4. If the patient has a nasal or oral tube,

cover his chest with a towel or linen-saver
pad.
5. Assess the patient’s abdomen for bowel

sounds and distension.
DELIVERING A GASTRIC FEEDING
To promote comfort.
6. Assist client to semi-Fowler’s or high

Fowlers position on bed or a sitting
position in a chair, the normal positionTo
forprotect him and the bed linens from spill.
eating. If contraindicated, a slightly
elevated right side-lying position is
acceptable.
7. Check placement of feeding tube.
To enhance the gravitational flow of the solution and

prevent aspiration by gastroesophageal reflux.
 Attach the syringe to the open end of
the tube and aspirate alimentary
secretions. Check the pH.
 Allow 1 hour to elapse before testing
the pH if the client has received a
medication.
 You may also check tube patency by
removing plug from the feeding tube,
and use the syringe to inject 5 to 10 cc
of air through the tube. At the same
time, auscultate the patient’s stomach
To be sure it hasn’t slipped out since the last feeding.
with the stethoscope. Listen for
whooshing sound.
To check if feeding tube is in place.
8. Assess gastric emptying.
 Aspirate and measure residual gastric

contents.
 Hold feedings if residual volume is
greater than the predetermined
amount specified in the doctor’s order
(usually 50 to 100ml). Reinstill Toanyensure accuracy.
aspirate obtained.
 If the client is on continuous feeding,

check the gastric residual every 4 -6
hours according to agency protocol.
To confirm tube positioning in the stomach.
9. Administer the feeding.
 Before administering, check the

expiration date and warm the feeding
solution to room temperature. To evaluate the absorption of last feeding; that is,
 FEEDING BAG (OPEN SYSTEM) whether undigested formula from a previous
feeding remains.
To determine if feeding is to be given or withheld, and

the amount of feeding to be given depending on
a. Hang the bag from an infusion pole about the agency policy.
30 cm (12 inches) above the tube’s point
of insertion into the client.
b. Clamp the tubing and add the formula to
the bag.
c. Open the regulator clamp, run the formula
through the tubing, and re-clamp the tube.
The formula will displace the air in the
tubing.
d. Attach the bag to the nasogastric /
nasoenteric tube and regulate the drip by
adjusting the clamp to the drop factor on
the bag.
SYRINGE (OPEN SYSTEM)
a. Remove the bulb or plunger from the

syringe and attach the syringe to a
pinched-off or clamped nasogastric tube.
b. Add the feeding to the syringe barrel.
c. Permit the feeding to flow in slowly at the
To prevent disturbance in the client’s electrolyte balance.
prescribed rate. Raise or lower the syringe
to adjust the flow as needed. Pinch or
clamp the tubing to stop the flow for a
minute if the client experiences
discomfort.
d. When the syringe is three-quarters empty,
pour more formula into it. Never allowTothedetermine gastric absorption.
syringe to empty completely.
PREFILLED BOTTLE WITH DRIP CHAMBER (CLOSED

SYSTEM)
a. Remove the screw – on cap from the

container and attach the administration
set with the drip chamber and tubing.
b. Close the clamp on the tubing.
c. Hang the container on an intravenous pole
about 30 cm (12 inches) above the tube’s
insertion point into the client.
d. Squeeze the drip chamber to fill it to one-
third to on- half of its capacity.
e. Open the tubing clamp, run the formula
through the tubing and re-clamp the tube.
f. Attach the feeding set tubing to the
feeding tube and regulate the drip rate to
deliver the feeding over the desired length
of time. Pre-filled tube feeding sets canTobe avoid giving of expired feeding and minimize
attached to a feeding pump to regulate abdominal cramps.
the flow.
To regulate the rate of flow, not too slow or too fast.

10. After administering the appropriate
amount of formula, flush the tubing by
adding about 60 ml of water to the to the
gavage bag or bulb syringe, or manually
flush it using a barrel syringe.
To prevent the formula from running through the tube
 Be sure to add water before the feeding and may possibly flow out of the tube.
solution has drained from the neck of a
syringe of from the tubing of an
administration set. Before adding water
To prevent the instillation of excess air into the client’s
to a feeding bag or prefilled tubing set, stomach or intestine.
first clamp and disconnect both the
feeding and administration tubes.
 If you are using a continuous feeding,
flush the tube every 4 hours and
monitor gastric emptying every 4 hours.
To deliver the feeding as ordered.

11. To discontinue gastric feeding (depending
on the equipment you’re using), close the
regulator clamp on the gavage bag tubing,
disconnect the syringe from the feeding
tube, or turn off the infusion controller.
12. Cover the end of the feeding tube with its

plug or cap.
13. Leave the patient in semi-Fowlers or high

Fowlers position for at least 30 minutes.
Ensure client comfort and safety.
.
14. Dispose of equipment properly.
 If the equipment reusable, wash

thoroughly with warm water. Dry it and
store it in a convenient place for the
next feeding.
 Change the equipment every 24 hoursToorprevent excess air from entering the stomach and
according to agency policy. causing distention.
DELIVERING A DUODENAL OR JEJUNAL

FEEDING
To prevent administering the feeding quickly that may

cause flatus, cramps, and / or reflux vomiting.
1. Elevate the head of the bed and place the

patient in low Fowler’s position.
2. Open the enteral administration set and

hang the gavage container on the IV pole.
3. If you’re using a nasoduodenal tube,

measure its length. Remember that you
may not get any residual when you
aspirate the tube.
To prevent air from entering the tube and the patient’s
stomach.
4. Open the flow clamp and regulate the flow

to the desired rate. To regulate the rate
using a volumetric infusion pump follow
the manufacturer’s directions for setting
up the equipment. Most patients receive
small amounts initially, with volumes
increasing gradually once tolerance is
establish.
5. Flush the tube every 4 hours with water.

A needle catheter jejunostomy tube may
require flushing every 2 hours.
At this point the formula should run at a safe rate into

the stomach or intestine.
To displace the air in the tubing, thus preventing the

instillation of excess air.
To maintain the tube’s patency by removing excess

formula, that could occlude the tube.
To prevent the instillation of air into the stomach or
intestine and thus prevents unnecessary
distention.
To help prevent tube occlusion.
To prevent leakage and contamination of the tube.

To facilitate digestion and movement of feeding from the
stomach along the alimentary tract and prevent
the potential aspiration of the feeding into the
lungs
To check tube placement.
To maintain patency and provide hydration.

To prevent formula build up inside the tube.
 Be sure to refrigerate formulas prepared in the dietary department or pharmacy. Refrigerate

commercial formulas only after opening them. Use powdered formula within 24 hours of mixing.
 If feeding solution doesn’t initially flow through a bulb syringe, attach the bulb and squeeze it gently to
start the flow. Then remove the bulb. Never use the bulb to force the formula through the tube.
 If the patient becomes nauseated or vomits, stop the feeding immediately. The patient may vomit if the
stomach becomes distended from overfeeding or delayed gastric emptying.
 To reduce oropharyngeal discomfort from the tube, allow the patient to brush teeth or care for his
dentures regularly, and encourage frequent gargling. If patient is unconscious, administer oral care with
lemon-glycerin swabs every 4 hours. Use petroleum jelly on dry, cracked lips.
 Drugs can be administered through the feeding tube. Except for enteric-coated drugs or sustained-
release medications, crush tablets or open and dilute capsules in water before administering them. Be
sure to flush the tubing afterward to ensure full instillation of medication. Keep in mind that some drugs
may change the osmolarity of the feeding formula and cause diarrhea.
1. Perform a follow-up examination of the following:

a. Tolerance of feeding
b. Regurgitation and feelings of fullness after feedings
c. Weight gain or loss
d. Fecal elimination pattern
e. Skin turgor
f. Urine output
g. Glucose and acetone in urine
h. Relate findings to previous assessment data if available, and report significant deviations from
normal findings to physician
2. Document the following:
a. The feeding, including amount and kind of solution taken, duration of the feeding, and
assessments of the client.
b. Volume of the feeding and water administered on the client’s intake and output record.
CARING FOR COLOSTOMY

I. DEFINITION
COLOSTOMY – a temporary or permanent opening of the colon through the abdominal wall.
STOMA – that part of the colon that is brought above the abdominal wall in a colostomy and
becomes the outlet for discharge of intestinal contents.
II. RATIONALE
1. To collect fecal matter

2. To help control odor
3. To protects the stoma and peristomal skin
III. EQUIPMENT
Skin barrier Pouch clip or rubber band
Skin paste Disposable gloves

Soap and washcloth Warm water
Appropriate pouch (Pouching system may be drainable or closed bottomed, disposable or reusable, adhesive-
backed, and one-piece or two-piece.
ACTION RATIONALE
1. Gather equipment.
2. Explain the procedure to client. As you

perform each step, explain what you are
doing and why.
To promote cooperation and because the patient will

eventually perform the procedure himself.
3. Wash hands/hand hygiene; put on gloves and To reduce risk of contamination.

provide privacy.
APPLYING OR CHANGING THE POUCH:
a. Assist client to a standing (preferable) or To facilitate application of pouch by reducing wrinkles.

sitting position.
b. Remove the soiled pouch by gently pressing To avoid trauma to the peristomal skin.
on the skin while pulling the pouch.
c. Dispose of the pouch in a plastic bag after To minimize odor associated with the pouch change.
removing the clip used to seal the pouch.
d. Wipe the stoma and peristomal skin gently

with a facial tissue.
e. Carefully wash with mild soap and water by To remove fecal material and pathogens and to
patting gently. Allow the skin to dry prepare the skin for pouch reapplication.
thoroughly.
f. Inspect the peristomal skin and stoma. Notify To check for unusual appearance of the stoma or
the physician of any skin irritation, peristomal area.
breakdown, rash,
g. If necessary clip surrounding hair in a To promote a better seal and avoid skin irritation from
direction away from the stoma. hair pulling against the adhesive.
h. Inspect the pouch opening and ensure that it To ensure appropriate-sized pouch and to protect the
fits the stoma. peristomal skin.
i. Apply a skin sealant or skin paste if indicated; To promote an effective seal and to protect the
apply skin barrier. peristomal skin.
j. Gently apply the pouch and press into place. To prevent leakage of effluent from the pouch.
 Remove the paper backing from the

adhesive side of the pouching system and
center the pouch opening over the stoma.
 Press gently to secure.
 Encourage the patient to stay quietly in
position for about 5 minutes.
 Attach an ostomy belt to further secure
the pouch, if desired.
 Apply a closure clamp if necessary.
To improve adherence. The patient’s body warmth

also helps to improve adherence and soften a rigid skin
barrier.
k. Remove gloves and discard; wash To reduce risk of transfer of microorganisms.

hands/hand hygiene.
EMPTYING THE POUCH:
a. Tilt the bottom of the pouch upward and

remove the closure clamp.
b. Turn up the cuff on the lower end of the

pouch and allow it to drain and allow it to
drain into the toilet or bed pan.
c. If desired, the bottom of the pouch can be To prevent loosening the seal on the skin
rinsed with cool tap water. Don’t aim
water up near the top of the pouch.
d. Release flatus through the gas release valve if
the pouch has one. Otherwise, release
flatus by tilting the pouch bottom upward,
releasing the clamp, and expelling the
flatus.
e. Never make a pinhole in a pouch to release

as. This will destroy the odor proof seal.
4. Remove gloves and wash hands. To reduce risk of contamination.
 All pouching systems need to be changed immediately if a leak develops, and every pouch must be
emptied when it’s one-third to one-half full.
 Naturally, the best time to change the pouching system is when the bowel is least active, usually
between 2 and 4 hours after meal.
V. DOCUMENTATION
1. Date and time of stoma care.

2. Condition of stoma and the area around the stoma, include any sign of skin breakdown.
3. Drainage amount, consistency and odor.
PERFORMING COLOSTOMY IRRIGATION
I. DEFINITION
Irrigation is a means of regulating some colostomies. It may begin as soon as bowel function resumes
after surgery or until the bowel movements are more predictable.
II. RATIONALE
1. To allow a patient with distending or sigmoid colostomy to regulate bowel function.

2. To clean the large bowel before and after tests, surgery, or other procedures.
III. EQUIPMENT
Colostomy irrigation set that contains: Water

Irrigation drain or sleeve Ostomy pouching system
Water soluble lubricant Line-saver pad
Drainage pouch clamp Appropriate personal protective equipment
Irrigation bag with clamp, tubing and cone tip Optional: bedpan or chair; mild non
Normal Saline Solution (for cleansing enemas moisturizing soap, rubber band or clip,
1,000 ml of tap water irrigant warmed at 38.8°C small dressing or bandage, stoma cap
IV pole or wall hook
Wash cloth and towel
ACTION RATIONALE
1. Explain procedure.
To elicit cooperation.
2. Provide privacy and wash hands. To reduce transmission of microorganisms.
3. If the patient is in bed, place a linen saver

To protect the sheets from soiling.
ad under him.
4. Apply clean gloves and personal protective

equipment.
5. Assemble irrigation kit. Attach cone To

or ensure that all equipment is ready to use.
catheter to irrigation bag tubing.
6. Fill irrigation bag with 1000 cc tepid tap

water. (The colon is already filled with
microorganisms, so the use of sterile
water is not necessary).
7. Open clamp and let water from the

To eliminate any air bubbles that can cause intestinal
irrigation bag fill the tubing. cramping.
8. Hang bottom of irrigation bat at heightTo

of prevent increase intestinal cramping when hanging
client’s shoulder, or 18 inches above the the irrigation bag too high, and hanging the
stoma if the client is supine. irrigation bag below shoulder level will cause
poor results. This height provides resistance of
back pressure from flatus.
9. Lubricate small finger with water-solubleTo determine the bowel angle at which to insert the
lubricant and insert the finger into orifice cone safely.
of stoma.
10. Place irrigation sleeve over stoma and

To provide a vehicle for containment for irrigant and
hold in place with belt. stool
11. Spray inside of irrigation sleeve and

To help decrease or eliminate odor from stool as it is
bathroom with odor eliminator (usual passed from the bowel.
dose is 2 sprays).
12. Cuff end of irrigation sleeve and place into

To facilitate drainage of water and stool into a suitable
toilet bowl (if client is in bathroom) or container.
bedpan (if client is in bed or on chair).
13. Lubricate the cone end of irrigation tubing

To prevent cone from causing trauma to intestinal
and insert into orifice of stoma through lumen.
the top opening of irrigation sleeve.
14. Close top of irrigation sleeve over the

To prevent water and stool from splashing outside the
tubing. irrigation sleeve.
15. Slowly run water through tubing into To alleviate intestinal cramping. If cramping should
colon. start, immediately stop and allow client to rest
 If you don’t have the clamp to control for a few minutes.
the irrigant’s flow rate, pinch the tubing
to control the flow.
16. Remove cone after all water has emptied

out of irrigation bag.
17. Close end of irrigation sleeve by attaching

To maintain a closed system for any remaining stool and
it to the top of the sleeve. irrigant to empty into.
18. Encourage client to ambulate. To facilitate emptying of remaining stool from colon.
19. Remove irrigation sleeve after 20 to 30

minutes or when stool is no longer
emptying the colon.
 If the irrigation was intended to clean

the bowel, repeat the procedure with
warmed normal saline solution until the
return solution appears clear.
20. Cleanse stoma and skin with warm tap

To prevent injury to the mucosa.
water. Rinse and pat dry with a clean
towel.
21. Apply a clean pouch. If the patient hasToa protect both the client’s clothing and the stoma from
regular bowel elimination pattern, place irritation.
gauze pad over stoma to absorb mucus
from stoma.
22. Secure gauze with hypoallergenic tape. To ensure that the gauze remains in place.
23. Remove gloves and wash hand/hand

To reduces transmission of microorganisms.
hygiene.
- Irrigation may help regulate bowel function in patients with a descending or sigmoid colostomy because
this is the bowel’s stool storage area. However, a patient with an ascending or transverse colostomy won’t
benefit from irrigation.
- If diarrhea develops, discontinue irrigations until stools form again.
- If patient has a strictured stoma that prohibits cone insertion, remove cone from the irrigation tubing and
replace it with a soft silicone catheter. Angle the catheter gently 2” to 4” into the bowel to instill the
irrigant. Don’t force the catheter into the stoma, and don’t insert it further than the recommended length
because you may perforate the bowel.
V. DOCUMENTATION
1. Record date and time of irrigation and the type and amount of irrigant.
2. Note the stomas color and the character of drainage, including the drainage color, consistency, and
amount.
ADMINISTERING SITZ BATH

I. DEFINITION
A sitz bath involves immersion of the pelvic area in warm or hot water.
II. RATIONALE
1. To relieve discomfort, especially after perineal or rectal surgery or childbirth.

2. To promote wound healing
3. To reduce inflammation
4. It helps relax local muscles
III. EQUIPMENT
Bath mat Rubber mat

Bath (utility) thermometer Two bath blankets
Towels Patient gown
Sitz tub, portable sitz bath, or regular bathtub; or a disposable sitz bath kit for single use that includes a plastic
basin that fits over a commode and an irrigation bag with tubing and clamp.
Gloves, if patient has an open lesion or has been incontinent
Optional: rubber ring, foot stool, overbed table, IV pole, wheelchair or cart, dressings
ACTION RATIONALE
1. Check the physician’s order, and assess

patient’s condition.
3. Make sure the sitz tub, portable sitz bath,

or regular bathtub is clean and disinfected.
Or, obtain a disposable sitz bath kit from
the central supply department.
To prevent falls
4. Position the bath mat next to the bathtub,

sitz tub or commode. If you are using a
tub, place a rubber mat on its surface.
To serve as a seat for the patient. Keeping the patient

elevated improves water flow over the wound
Place the rubber ring on the bottom of the tub, site and avoids unnecessary pressure on tender
and cover the ring with a towel for tissues.
comfort.
If you are using a commercial kit, open the package

and familiarize yourself with the
equipment.
5. Fill the tub or bathtub one-third to one-

half full, so that the water will reach the
seated patient’s umbilicus.
Use warm water (34 to 37 degrees Celsius) for

relaxation or wound cleaning and healing
and hot water (43 to 46 degrees Celsius)
for heat application.
Measure the water temperature using the bath

temperature.
Because it will cool while the patient prepares for the

bath.
6. Run the water slightly warmer than
desired.
7. If you’re using a commercial kit, fill the

basin to the specified line with water at
the prescribed temperature. Place the
basin under the commode seat, clamp the
irrigation tubing to block water flow, and
fill the irrigation bag with water of the
same temperature as that in the basin. To
create flow pressure, hang the bag above
the patient’s head on a hook, towel rack or
IV pole.
8. Once preparation of equipment is done,

wash hands thoroughly and put on gloves.
9. Have the patient void.
10. Assist the patient to the bath area, provide

privacy, and make sure that the area is
warm and free of drafts. Help the patient
undress, as needed.
11. Assist the patient into the tub or onto the

commode, as needed. Instruct him to use
the safety rail for balance.
12. Explain that the sensation may be

unpleasant initially because the wound is
already tender. Assure patient that this
discomfort will soon be relieved by the
warm water.
To decrease pressure on local blood vessels.
13. For any apparatus except a regular

bathtub, if the patient’s feet don’t reach
the floor and the weight of his legs presses
against the edge of the equipment, place a
small stool under the patient’s feet.
To prevent discomfort and promote correct body

alignment.
14. Place a folded towel against the patient’s
lower back.
To avoid chills that causes vasoconstriction.
15. Drape the patient’s shoulders and knees

with bath blankets.
To allow a stream of water to flow continuously over

the wound site.
16. If you’re using the sitz bath kit, open the
clamp on the irrigation tubing.
Refill the bag with water of the correct

temperature as needed, and encourage
the patient to regulate the flow himself. To provide support and comfort.
Place the patient’s overbed table in front of him.
To prevent dizziness and loss of balance.
17. If you’re using a tub, check the water

temperature frequently with the bath
thermometer. If the temperature drops
significantly, add warm water. For
maximum safety, first help the patient
stand up slowly.
Then, with the patient holding the safety rail for

support, run warm water into the tub.
Check the water temperature. When the
water reaches the correct temperature,
help the patient sit down again to resume
the bath.
18. If necessary, stay with the patient during

the bath. If you must leave, show him how
to use the call button, and ensure his
privacy.
19. Check the patient’s color and general
condition frequently.
If he complains of feeling weak, faint, or nauseated

or shows signs of cardiovascular distress,
discontinue the bath, check the patient’s
pulse and blood pressure, and assist him
back to bed.
Use a wheelchair or cart to transport the patient to

his room if necessary. Notify the physician.
To prevent dizziness and to allow him regain his

equilibrium.
20. When the prescribed bath time has
elapsed – usually 15 to 20 minutes, tell the
patient to use the safety rail for balance,
and help him to standing position slowly.
21. If necessary, help the patient dry himself.

Re-dress the wound as needed, and assist
the patient to dress and return to bed or
back to his room.
22. Dispose of soiled materials properly.

Empty, clean, and disinfect the sitz tub,
bathtub, or portable sitz bath. Return the
commercial kit to the patient’s bedside for
later use.
SPECIAL CONSIDERATIONS:
Because the application of heat to the extremities

causes vasodilation and draws blood away from
 Use a regular bathtub only if a special the perineal area.
sitz tub, portable sitz bath, or
commercial sitz bath kit is unavailable. A
To help detect vasodilation that could make him feel
regular bathtub is less effective for local
treatment than sitz device. faint when he stands up.
 If the patient will be sitting in a bathtub
with his extremities immersed in the hot
water, check his pulse before, during, Because of the risk of infection.
and after the bath.
 Tell the patient never to touch an open
wound.
V. DOCUMENTATION
1. Record the date, time, duration, and temperature of the bath; wound condition before and after
treatment, including color, odor, and amount of drainage; any complications; and the patient’s
response to treatment.
MEASURES IN MEETING THE NEEDS OF CLIENTS WITH ALTERATION IN ENDOCRINE

FUNCTION
Adapted from Nettina (2010), Lippincott Manual of Nursing Practice 9th Edition
Adapted from Berman et al (2009), Skills in Clinical 6th Edition
I. DEFINITION
Blood Glucose Monitoring and Ketones
Capillary Blood Glucose (CBG)

Specimen is often taken to measure the current blood glucose level when frequent tests are
required or when a venipuncture cannot be performed.
II. EQUIPMENT
2x2 gauze Clean gloves

Blood Glucose Meter (glucometer) Antiseptic swap
Blood Glucose Reagent strip compatible with the meter
Sterile lancet (a sharp device to puncture the skin)

Sterile lancet (a sharp device to puncture the skin)
Lancet injector (a spring-loaded mechanism that holds the lancet)
ACTION RATIONALE
Preparation
Review the type of meter and the manufacturer’s
instructions. Assemble the equipment at the
bedside.
Performance
1. Prior to performing the procedure, introduceTo prevent performing an invasive procedure on the
self and verify the client’s identity using wrong client and promotes accuracy of results
agency protocol. Explain to the client what
you are going to do, why it is necessary, and
how he or she can participate. Discuss how
results will be used in planning further care or
treatments.
2. Perform hand hygiene and observe otherTo reduce transmission of microorganisms.

appropriate infection control procedures
(e.g., gloves)
3. Assemble the equipment at bedside. CalibrateTo allow for smooth procedure.

the meter and run a control sample according
to the manufacturer’s instructions.
4. Select and prepare the puncture site. To prevent irritation.
5. Clean the site with antiseptic swab or soap
and water and allow it to dry completely.
To ensure that it is in a perpendicular position relative to
6. Obtain the blood specimen the skin.
a. Apply clean gloves
b. Place the injector against the site, and

release the needle, thus permitting it to
pierce the skin. Make sure the lancet is
perpendicular to the site. To prevent contamination.
c. Gently squeeze (but do not touch) the

puncture site until a large drop of blood
forms. The size of the drop of blood can
vary depending on the meter. To have accurate result.
7. Transfer the drop of blood to the reagent strip

by carefully moving the site over the strip. The
droplet should transfer without smearing.
(Note: Some meters require that the blood
droplet be applied to the strip that is already in
the meter.) Follow instructions on monitor
selected because they may vary. To ensure proper timing, to produce accurate results.
Always check the manufacturer’s instructions
8. Quickly press the timer on the meter and lay the because the technique varies between meters.
strip next to the meter on a clean, dry surface.To stop the bleeding at the site.
9. Apply pressure to the puncture site. To ensure that the step are followed which is specific to
certain meters (e.g., Accu-Check III) that require
10. After 60 seconds, wipe the blood from the test the strip to enter the meter dry.
pad with a cotton ball; place the strip into the
meter. (Note: This step may vary with the type
of meter.) Allow the timer to continue.
11. Read the meter for the results found on the unit
To reduce contamination by blood to other individuals;
display. sharps must always be handled properly to
protect others from accidental injury.
12. Turn off the meter and properly dispose of the
test strip, cotton ball, and lancet.
To reduce contamination of microorganisms.

13. Remove disposable gloves and place them in
the appropriate receptacle. To promote participation in health care.
14. Wash hands To properly have treatment plan for the patient.
15. Review tests results with the client.

16. Notify the health care provider of the test
results.
17. Wash hands.

IV. EVALUATION AND DOCUMENTATION
1. Reinspect the puncture site for bleeding and tissue injury.

2. Compare the glucose reading to the client’s previous glucose results.
3. Compare the client’s results to normal blood-glucose levels.
4. Client’s understanding of the procedure and ability to demonstrate the technique
5. Medications administered
ASSISTING CLIENTS ON INSULIN THERAPY
I. DEFINITION
Insulin Therapy
The administration of synthetically produced insulin extract from the pancreas of slaughtered pigs and
cows. It is given to persons who do not have adequate indigenous insulin and administered through
subcutaneous route to lower blood glucose level.
II. RATIONALE
To lower the blood sugar level by facilitating the uptake and utilization of glucose by body cells or energy
production.
III. EQUIPMENT
Prescribed bottle of insulin Alcohol swabs/ sponge

Insulin syringe (units 40, 80, 100) Small tray for supplies
Hypodermic needles (G25,26, 1-2cm (1/2 inch) long
ACTION RATIONALE
For One-Insulin Solution

1. Check medication order, injection site used To ensure correct administration of the medication;
previously as reflected in the rotation chart. keep in mind the 10 Rights in giving
medication.
2. Follow the usual procedure and principles in
giving injections in general:
a. Wash hands prior to preparation. To prevent nosocomial infection.
b. Gather equipment, obtain specific insulin

Insulin syringes are calibrated in units of 40, 80, and
syringe for strength of insulin being 100.
administered.
This brings the solution into suspension for insulin
c. Rotate insulin bottle between hands. other than regular.
d. Remember: Do not inject air directly into
To prevent air bubbles. Air bubbles in the solution can
insulin solution. alter the actual dosage being administered.
To prevent error in giving medication.
e. Double check the medication card, insulin
bottle and dose with another nurse.
A suggested rotation chart is attached to the client’s
f. Give insulin only by subcutaneous route. chart to guide the nurse of the injection sites
Position hand on a 45 degree angle and used.
hold the subcutaneous tissue in place.
Involve client and family about client’s care. The
g. Observed and teach client what specific family’s knowledge and cooperation contribute
signs and symptoms to watch out for while to better quality of care.
on insulin therapy.
For Two- Insulin Solutions:
1. Follow the above guidelines and steps in

insulin administration.
The technique generally prevents cloudy insulin from
2. Keep in mind: Regular or clear insulin is contaminating the clear insulin.
withdrawn into the insulin syringe first:
followed by the intermediate-acting (NPH,
Lente) of long-acting (PZI, Ultra Lente) insulin
which are cloudy in preparation.
3. This can avoid by putting gentle “pullback”The total insulin dose will include the amount of
pressure on plunger with your small finger regular insulin already drawn up into the
when inserting the needle into the bottle. syringe.
4. Emphasize to the patient that he is receiving Refer the table provided below.
two insulin solutions with different peak and
duration effects in the body.

1. Place an open insulin bottle in the refrigerator.
2. Dispose of the insulin syringe and needle after use.
3. Chart medication and injection site in the nurse’s notes.
4. Desired effect would be relief of pain, lowered blood sugar or decreased urine glucose.
TYPE ONSET PEAK DURATION

Rapid-acting
Regular ½ to 1 2-4 hours 6-8 hours
Semi Lente ½ to 1 4-8 hours 6-10 hours
Humulin R ½ to 1 2-4 hours 5-7 hours
Intermediate -acting
NPH 1 to 1 ½ 8-12 hours 24 hours
Lente 1 to 1½ 8-12 hours 24 hours
Humulin N 1 ½ to 3 ½ 8-12 hours 18 to 24 hours
Long-acting 4 to 8 14-20 hours 24-36 hours
Protamine Zinc (PZI) 4 to 8 16-24 hours 36 hours
Ultralente
TEACHING DIABETIC CLIENTS SELF –INJECTION OF INSULIN

I. EQUIPMENT
Prescribed bottle of insulin Cotton ball and alcohol or alcohol wipe

Disposable insulin syringe and needle or insulin pen injection device with insulin cartridge
II. IMPLEMENTATION
ACTION RATIONALE
To inject insulin
1. Give the patient the syringe or insulin pen
device containing the prescribed dose of
insulin.
2. Have patient select a clean area of

subcutaneous tissue.
To help accurately target the injection site.
3. Instruct the patient hold the syringe as he
would hold a pencil.
4. Show the patient how to select an area of skin
from the anterior thighs and form a skin fold by
picking up subcutaneous tissue between the
thumb and forefinger if the patient is thin.
5. Select areas of upper arms, abdomen, and

upper buttocks for injection after patient
becomes proficient with needle insertion
6. Assist the patient to insert the needle with a

quick thrust to the hub at a 45 to 90 degree
angle to the skin surface.
To prevent bruising.
7. Instruct the patient to release the “pinched”
skin and inject the insulin with slow, consistent
pressure.
To allow time for insulin absorption. To prevent trauma
8. Have the patient count to 5 and then withdraw to the insertion site.
the needle in the same direction it was
inserted.
To load the syringe

1. If insulin is in a suspension (NPH), gently shake,
rotate, or roll the insulin bottle to mix well.
2. Do not wipe off the top of the vial with alcohol;

instead, make sure that vial is stored in its
original carton and is kept clean.
3. Inject approximately the same volume of air

into the insulin vial as the volume of insulin to
be withdrawn.
4. If insulin pen is advice is being used, follow
manufacturer’s instructions for dialing the
dosage and changing cartridges.
To fill a syringe with long and short acting insulin

mixture
1. Inject air equal to the number of units to To be create positive pressure in vial, so that insulin will be
injected into each vial. Use the same sequence withdrawn from each vial without mixing.
each time, for example, always NPH insulin first.
2. After injecting air into the second vial, keep

needle in vial and withdraw prescribed amount
of that type of insulin, then withdraw needle.
3. Withdraw prescribed amount of insulin from

the second vial.
FOLLOWING HAND HYGIENE PROTOCOL

I. DEFINITION
Hand washing - is a procedure wherein thorough cleaning of the hand using soap is done by rubbing briskly in a
rotary motion.
II. RATIONALE
1. To remove transient micro-organisms that might be transmitted to the nurse, clients, visitors, or
other health care personnel.
2. To deliver client care with pathogen free hands
3. To protect clients from cross contamination
4. To protect the nurse
III. EQUIPMENT
Warm running water Paper towels or similar items
Optional: fingernail brush, plastic sponge brush, nail file Trash basket
Soap or detergent (use non-antimicrobial soap for routine hand washing), (use an antimicrobial agent or
waterless antiseptic agent to control outbreaks or hyperendemic infections)
IV. PLANNING
• Trim long fingernails so they are less than ¼ inch long.
Rationale: Short, natural nails are less likely to harbour microorganisms, scratch a client, or puncture gloves.
• Remove all jewelry; a plain, smooth wedding band can be worn.
Rationale: Microorganisms can lodge in the settings of jewelry and under rings. Removal facilitates proper
cleaning of the hands and arms.
• Check hands for breaks in the skin, such as hangnails or cuts.
Rationale: open sores may increase risk of transmission of infectious microorganisms.

V. IMPLEMENTATION
ACTION RATIONALE
1. If you are washing your hands where the client

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

Serves as a wetting agent and facilitate lathering.
the water is warm
There are five common types of faucet controls:
a. Hand-operated handles
b. Knee levers – move these with the knee

to regulate flow and temperature.
c. Foot pedals – press these with the foot to

regulate flow and temperature.
d. Elbow controls – move these with the

elbow instead the hands.
e. Infrared control – motion in front of the

sensor causes water to start and stop
flowing automatically.
ADMINISTERING CARE FOR CLIENTS UNDER
ISOLATION PRECAUTIONS
Adapted from Perry & Potter: Clinical Nursing Skills Technique
Berman et al.(2009), Skills in Clinical Nursing
White (2005), Foundations of Nursing
I. DEFINITION
When a client has a known source of infection, he must be placed in isolation to prevent the spread of an
infectious process and health care workers follow specific infection control practices and take preventive
actions.
II. RATIONALE
To decrease the risk of transmitting infectious disease among clients or health care workers.
III. EQUIPMENT
Disposable gloves, mask, eyewear or goggles, and gown

Other client care equipment (as appropriate)
Impermeable bags (for soiled linen and trash)
Isolation sign
ACTION RATIONALE
1. Assess client and review medical history To
for ascertain type and degree of precautions to be
possible indications for isolation. followed, mode of transmission of infectious
microorganism must be determined.
2. Review laboratory test results To be informed of the type of microorganism for which
client is being isolated. Body fluid in which it was
identified, and whether client is
immunosuppressed.
3. Consider types of care measures to To

be enable nurse to organize care items for procedures
performed while in client’s room (e.g., and time spent in client’s room.
medication administration or dressing
change).
4. Review NCP, or confer with colleagues

To determine client’s need for emotional support and
regarding client’s emotional state and teaching.
reaction/adjustment to isolation.
5. Determine from nursing care plan, medical To determine client’s level of knowledge and need for
record, or significant other if client and family instruction/reinforcement.
understand the purpose of isolation or
procedures to anticipate.
6. Place appropriate isolation supplies outside

To ensure ataff follows isolation protocol and alerts
the client’s room and place isolation sign on visitors to check with the nurses’ station before
the door. entering the room.
Prepare all equipment needed to be taken into client’s

To prevent nurse from making more than one trip into
room. room.
7. Determine appropriate barriers to apply based

To ensure adequate protection to prevent transmission
upon isolation category and activities to be of infection.
performed to client.
8. Perform hand hygiene. To reduce transmission of microorganisms.
9. Prepare for entrance into isolation room. To ensure nurse is protected from microorganism
Choice of barrier protection depends on type exposure.
of isolation and facility policy. For example, if
client is on airborne precautions, apply only a
special mask and keep door closed.
A. Apply the face mask
 Locate the top edge of the mask. The

mask usually has a narrow metal strip
along the edge.
 Hold the mask by the top two strings or

loops.
 Place the upper edge of the mask over

the bridge of the nose, and tie the upper
ties at the back of the head or secure the
loops around the ears. If glasses are worn,
fit the upper edge of the mask under the
glasses.
 Secure the lower edge of the mask under

the chin, and tie the lower ties at the
To lessen the likelihood of clouding of the glasses.
nape of the neck.
 If the mask has a metal strip, adjust this

firmly over the bridge of the nose.
 Wear the mask only once, and do not

wear any mask longer than the
manufacturer recommends or once it
becomes wet.
To be effective, a mask must cover both the nose and the

mouth, because air moves in and out of both.
 Do not leave a used face mask hanging
around the neck.
To prevent both the escape and the inhalation of

microorganisms around the edges of the mask
and the fogging of eyeglasses.
B. Apply cap to cover hair and ears

completely, if policy requires cap.
C. Apply a clean gown
 Pick up a clean gown, and allow it to

unfold in front of you without allowing it
to touch any area soiled with body
substances.
 Slide the arms and the hands through the

sleeves.
 Fasten the ties at the neck to keep the

gown in place.
 Overlap the gown at the back as much as
possible and fasten the ties or belt.
To securely cover the uniform at the back. Waist

ties keep the gown from falling away from
the body, which can lead to inadvertent
soiling of the exposed uniform.
D. Apply clean gloves
 Inspect gloves for perforations. To prevent pathogenic microorganism from

entering through perforation in gloves.
 If wearing a gown, pull the gloves up to

cover the cuffs of the gown, pull the cuffs To ensure full coverage of the wrists.
up over the wrist.
E. Don goggles and face shield.
To provide adequate protection.
10. Enter client’s room with all gathered supplies. To prevent extra trips into and out of the room.
11. Explain purpose of isolation and precautions To improve client’s and family’s ability to participate
necessary to client and family. Offer in care and minimizes anxiety.
opportunity to ask questions. Assess for
emotions that may be related to the isolation,
such as loneliness or boredom, and for
signs/symptoms of depression, for example,
lack of appetite or difficulty sleeping.
12. Assess vital signs.
a. If client is infected or colonized with a

resistant organism (e.g. MRSA), equipment
taken into the room remains in the room or
is thoroughly disinfected when removed
from the room.
b. Avoid contact of stethoscope or blood

pressure cuff with infective material. Wipe
off with disinfectant as needed.
c. If stethoscope is to be reused, clean

diaphragm or bell with 70% alcohol or
liquid soap. Set aside on clean surface.
d. Individual or disposable thermometers

should be used.
To decrease risk of infection being transmitted.
To minimize chance of spreading infectious agents

between clients.
To prevent cross contamination.
13. Administer medications:
a. Give oral medication in wrapper or cup. To minimize transfer of microorganisms.
b. Dispose of wrapper or cup in plastic-lined

receptacle.
c. Administer injection, being sure gloves are

worn.
To reduce the risk of exposure to blood.
d. Discard disposable syringe and uncapped or

sheathed needle into designated sharps
container.
To reduce risk of needle stick injury.
14. Administer hygiene, encouraging the client to To minimize transfer of microorganisms.

verbalize any questions or concerns regarding
isolation. Informal teaching may be done at
this time.
a. Avoid allowing isolation gown to become

wet; carry wash basin outward away from
gown; avoid leaning against wet tabletop.
b. Assist client in removing own gown; discard Moisture allows organisms to travel through gown
in impervious linen bag. to uniform.
c. Remove linen from bed; avoid contact with

isolation gown. Place in impervious bag.
d. Provide clean bed linen and set of towels
To reduce transfer of microorganism.

e. Change gloves and perform hand hygiene if
they become excessively soiled and further
care is necessary.
To prevent contact with clean items.
15. Collect specimens
a. Place specimen containers on clean paper To prevent contamination of outer surface.

towel in client’s bathroom.
b. Follow procedure for collecting specimen of

body fluids
c. Transfer specimen to container without

soiling outside of container. Place container Specimens of blood and body fluids are placed in
in a plastic bag, and label the outside of the well-constructed containers with secure lids
bag or as per agency policy. to prevent leaks during transport.
d. Check label on specimen for accuracy. Send
to laboratory (warning labels may be used,
depending on hospital policy).
16. Dispose of linen, trash, and disposable items:
a. Use single bags that are impervious to

moisture and sturdy to contain soiled
articles. Use double-bagging if necessary
for heavily soiled linen or heavy wet trash. To prevent leakage of contaminated materials,
thereby preventing spread of infection.
b. Tie bags securely at top in knot.
c. Label correctly according to contents.

To warn other personnel that the contents are
infectious.
17. Remove all reusable pieces of equipment. All items must be properly cleaned, disinfected, or
Clean any contaminated surfaces with hospital sterilized for reuse.
approved disinfectant.
18. Resupply room as needed. Have staff To limit trips of personnel into and out of room thus
colleague hand new supplies to you. reduces nurse’s and client’s exposure to
microorganisms.
19. Before leaving, let the client know when you To decrease client’s feeling of abandonment.
will return and make sure call light is
accessible.
20. Leave isolation room. Remember, order of

removal of protective barriers depends on
what is worn in room. This sequence
describes step to take if all barriers were
A. Remove gloves first since they are the

most soiled.
 If wearing a gown that is tied at the

waist, undo the ties before removing
the gloves.
 Remove the first glove by grasping it

on its palmar surface, taking care to
touch only glove to glove.
 Pull the first glove completely off by

inverting or rolling the glove inside
out.
 Continue to hold the inverted

removed glove by the fingers of the
remaining gloved hand. Place the
first two fingers of the bare hand
inside the cuff of the second glove.
 Pull the second glove off to the

fingers by turning it inside out. This
pulls the first glove inside the
second glove.
 Using the bare hand, continue to

remove the gloves, which are now
inside out, and dispose of them in
the refuse container.
 Perform hand hygiene.
B. Remove the mask. (If a client has an

airborne-spread disease, the mask
may be removed last.)
 Remove the mask at the doorway

to the client’s room. If using a
respirator mask, remove it after
leaving the room and closing the
door.
 If using a mask with strings, first

untie the lower strings of the mask.
 Untie the top strings and, while

holding the ties securely, remove
To reduce the chance of transferring any
the mask from the face.
microorganisms by direct contact.
 If side loops are present, lift the

side loops up and away from the
ears and face. Do not touch the
front of the mask.
 Discard a disposable mask in

appropriate container.
To prevent cross contamination.

C. Remove the gown when preparing to
leave the room. Unless a gown is
grossly soiled with body substances,
no special precautions are needed to
remove it. If the gown is grossly soiled:
 Release neck ties of the gown and

allow the gown to fall forward.
 Avoid touching soiled parts on the

outside of the gown, if possible.
 Grasp along the inside of the neck

and pull down over the shoulders.
Do not shake the gown.
 Roll up the gown with the soiled

part inside, and discard it in the
appropriate container.
D. Remove protective eyewear and

dispose of properly or place in the
appropriate receptacle for cleaning.
E. Remove cap by slipping your finger

under the cap and removing from
front to back and dispose of it.
To prevent the top part of the mask from falling

onto the chest.
To protect other health care workers.
21. Perform hand hygiene again.
22. Record vital sign values on notepaper.
23. Leave room and close door, if necessary.

Door should be closed if client is in
negative airflow room.
V. EVALUATION
1. The appropriate type of isolation was instituted.

2. The client and family express understanding of the client’s condition and the reason for isolation.
VI. DOCUMENTATION
1. Date, time, and type of isolation instituted.

2. Document procedures performed and client’s response to social isolation in nurses’ progress notes.
3. Document any client education performed and reinforced.
COMPLYING WITH COMMUNICABLE DISEASE CONTROL AND PREVENTION
GUIDELINES FOR ISOLATION PROCEDURES:
Adapted from Breman et al (2009), Skills in Clinical Nursing
I. DEFINITION OF TERMS
ISOLATION PRECAUTIONS: Are guidelines created to prevent transmission of microorganisms in hospital.
2 Tiers of Isolation Precautions:
First Tier: STANDARD PRECAUTIONS – Designed for the care of all patients in the hospital regardless of
diagnosis or infection status and is the primary strategy for preventing hospital acquired infections.
Second Tier: TRANMSMISSION BASED PRECAUTIONS – Designed for the care of patients with known or
suspected infectious diseases spread by Airborne, Droplet or Contact routes.
II. USING STANDARD PRECAUTIONS
STANDARD PRECAUTIONS – A set of guidelines set forth by the CDC to reduce the risk of transmission of
blood borne pathogens and pathogens from moist body substances.
Standard Precaution applies to (a) blood; (b) all body fluids, excretions and secretions except sweat; (c) non-
intact or broken skin; and (d) mucous membranes.
The Elements of Standard Precautions include:
1. Hand Hygiene
2. Use of Personal Protective Equipment (e.g. gloves, mask)
3. Proper Handling of Patient Care Equipment & Linen
4. Environmental Control
5. Prevention of injury from sharp devices
6. Patient placement (i.e. room assignments) within health care facilities
They are to be used in conjunction with other transmission-based precautions: airborne, droplet, and
contact precautions.
III. EQUIPMENT:
Depending on the specific aspects of the procedure, have available PPE:
Gloves Masks
Goggles Face Shields
Gowns
ACTION RATIONALE
1. Consider the procedures about to be

performed and determine which aspects
require standard precaution.
2. Remove or secure all loose items such as

name tags or jewellery.
3. If PPE will be used, explain to the client why
To prevent client from feeling alienated, fearful, or even
this is necessary and that Standard ashamed when staff members use this equipment.
Precautions is performed with all clients.
4. Perform hand hygiene after contact with To help the client to understand that Standard Precautions
blood, body fluids, secretions, excretions, are used to protect both clients and health care
and contaminated objects (linens, workers.
dressings, instruments or any other item
that have come in contact with potentially
infective material) whether or not gloves
are worn.
 Wash hands after the removal of PPE
Gloves can develop invisible holes during use. Moisture that

collects on hands under gloves promotes the growth
of micro-organisms.
5. Wear gloves during contact with blood,

body fluids, secretions, excretions, and
contaminated objects.
6. Wear mask, eye protection, or face shield
and a clean, waterproof gown if client care
is likely to involve splashes or sprays of
blood, body fluids, secretions, excretions.
7. Ensure that objects that have come in

contact with blood, body fluids, secretions,
or excretions are disposed of or cleaned
properly.
 Check labels and/or institutional

procedure manuals for details regarding
proper disposal or decontamination.
8. Handle used needles and other sharp

To reduce the risk of accidental injury or infection.
instruments carefully.
 Don’t bend, break, reinsert them into

their original sheaths, remove needles
from syringes, or unnecessarily handle
them.
 Discard them intact immediately after

use into a puncture-resistant container.
 Use tools to pick up broken glass or
other sharp objects.
9. Immediately notify your employee health To allow investigation of the incident and appropriate care
provider of all needle-stick or other sharp and documentation.
object injuries, mucosal splashes, or
contamination of open wounds or non-
intact skin with blood or body fluids.
10. Handle all soiled linen as little as possible.

Do not shake it. Bundle it up with the
clean side out and dirty side in, and hold
away from self so that the nurse’s uniform
or clothing is not contaminated.
11. Place all laboratory specimens collected

from patients in leak proof container
properly labelled.
12. While wearing the appropriate PPE,

promptly clean all blood and body fluid
spills with detergent and water followed
by EPA-registered disinfectant if
necessary.
 Standard precautions, such as hand hygiene and appropriate use of PPE, should be routine infection
control practices.
 Keep mouthpieces, resuscitation bags, and other ventilation devices nearby to eliminate the need
for emergency mouth-to-mouth resuscitation, thus reducing the risk of exposure to body fluids.
V. DOCUMENTATION:
1. Record any special needs for isolation precautions on the nursing care plan and as otherwise
indicated by your facility. Document patient and family teaching about isolation precautions.
IMPLEMENTING TRANSMISSION-BASED PRECAUTIONS
I. DEFINITION OF TERMS
Transmission-Based Precautions – are used in addition to standard precautions when those precautions do not
completely block the chain of infection and the infections are spread in one of three ways: by airborne
or droplet transmission, or by contact.
AIRBORNE PRECAUTIONS
In addition to Standard Precautions, use airborne precautions for patients known or suspected to have
serious illnesses transmitted by airborne droplet nuclei smaller than 5 microns.
II. RATIONALE:
Prevents the spread of infectious diseases transmitted by airborne pathogens that are sneezed, or
coughed into the environment.
III. EQUIPMENT:
 Respirators (either disposable N95 or HEPA respirators or reusable HEPA respirators or PAPR’s)
 Surgical masks
 Isolation door card
 Other PPE as needed for Standard Precautions
 Additional supplies such as thermometer, stethoscope, and blood pressure cuff.
PREPARATION OF EQUIPMENT:
 Keep all airborne precaution supplies outside the patient’s room in a cart or anteroom.
Depending on the specific aspects of the procedure, have available PPE:
Gloves Masks
Goggles Face Shields
Gowns
VI. PLANNING AND IMPLEMENTATION
ACTION RATIONALE
1. Introduce self and verify the client’s identity

using agency protocol.
2. Explain to the client what you are going Ittois extremely important that clients and family members
do, why it is necessary, and how he or she understand the rationale for the use of barriers to
can participate. infection transmission. They must be given the
opportunity to ask questions and express feelings.
Hospitalized clients are already socially isolated from

others and use of additional barriers can initiate
negative feelings such as depression &
withdrawal.
3. Use standard precautions.
4. Perform hand hygiene using soap and water

if the hands are visibly soiled. Otherwise, use
alcohol-based hand rub.
5. Situate the patient in a negative-pressure

A negative pressure ventilated rooms are ideal for
room. airborne precautions.
 If possible, the room should have Ifannegative pressure room is not available, place patient
anteroom. in a well-ventilated single room with door kept
close.
 If a private room is not available, place the

client with another client who is infected
with the same organism.
6. Keep the patient’s door (and the anteroom
To maintain the negative pressure and contain the
door) closed at all times. airborne pathogens.
7. Put the airborne precautions sign on the

door to notify anyone entering the room.
8. Wear a respiratory device and put it on

according to the manufacturer’s directions
when entering the room.
9. Instruct the patient to cover his nose and

mouth with a facial tissue while coughing or
sneezing.
10. Tape an impervious bag to the patient’s

So that patient can dispose of facial tissues correctly.
bedside.
11. Make sure all visitors wear respiratory

protection while in the patient’s room.
12. Limit the patient’s movement from the So that the precautions will be maintained and the
room. If he must leave the room for patient can be returned to the room
essential procedures, make sure he promptly.
wears a surgical mask over his nose
and mouth. Notify the receiving
department or area of the patient’s
isolation precautions.
 Before leaving the room, remove gloves (if worn) and wash your hands. Remove your
respirator outside the patient’s room after closing the door.
 Depending on the type of respirator and recommendations from the manufacturer, follow
your facility’s policy and either discard your respirator or store it until the next use.
 If your respirator is to be stored until the next use, store it in a dry, well-ventilated place (not a
plastic bag) to prevent microbial growth.
 Non disposable respirators must be cleaned according to the manufacturer’s

recommendations.
V. DOCUMENTATION:
Record the need for airborne precautions on the NCP and as otherwise indicated by your facility.
Document initiation and maintenance of the precautions, the patient’s tolerance of the
procedure, and any patient or family teaching. Also document the date the airborne
precautions were discontinued.
DROPLET PRECAUTIONS
In addition to Standard Precautions, use droplet precautions for clients known or suspected to
have serious illnesses transmitted by particle droplets larger than 5 microns.
Rationale: Prevent the spread of infectious diseases transmitted by contact of nasal or oral
secretions (droplets arising from coughing or sneezing) from the infected patient with the
mucous membranes of the susceptible host.
EQUIPMENT:
 Masks
 Gowns, if necessary
 Gloves
 Plastic bags
 Droplet precautions door card

 Additional supplies such as thermometer, stethoscope, and blood pressure cuff.
PREPARATION OF EQUIPMENT:
 Keep all droplet precaution supplies outside the patient’s room in a cart or anteroom.
PLANNING AND IMPLEMENTATION:
ACTION RATIONALE
1. Introduce self and verify the client’s identity

using agency protocol.
2. Explain to the client what you are going to It is extremely important that clients and
do, why it is necessary, and how he or she family members understand the rationale for
can participate. the use of barriers to infection transmission.
They must be given the opportunity to ask
questions and express feelings.
Hospitalized clients are already socially

isolated from others and use of additional
barriers can initiate negative feelings such as
depression & withdrawal.
4. Place the patient in a single room with

private toilet facilities and an anteroom if
possible.
 The door doesn’t need to be closed.

5. Put a droplet precautions card on the door. To notify anyone entering the room.
6. Wash your hands before entering and

leaving the room and during care as
indicated.
7. Wear mask when entering the room if you

will be working within 3 feet of the client.
8. Instruct the patient to cover his nose and

mouth with a facial tissue while coughing or
sneezing.
9. Tape an impervious bag to the patient’s So that the patient can dispose of facial tissues
bedside correctly.
10. Make sure all visitors wear masks
when in close proximity with the patient
(within 3’) and, if necessary, gowns and
gloves.
11. If he must leave the room for essential So that the precautions will be maintained and
procedures, make sure he wears a surgical the patient can be returned to the room
mask over his nose and mouth. Notify the promptly.
receiving department or area of the
patient’s isolation precautions.
 Before removing the mask, remove your gloves (if worn) and wash your hands.
 Untie the strings and dispose of the mask, handling it by the strings only.
DOCUMENTATION:
Record the need for droplet precautions on the NCP and as otherwise indicated by your facility.
procedure, and any patient or family teaching. Also document the date the airborne precautions
were discontinued.
CONTACT PRECAUTIONS
In addition to Standard Precautions, use contact precautions for clients known or suspected to
have serious illnesses easily transmitted by direct client contact or by contact with items in the
client’s environment.
Rationale: Prevent the spread of infectious diseases transmitted by contact with body
substances containing the infectious agent or items contaminated with the body substances
containing the infectious agent.
EQUIPMENT:
 Gloves
 Gowns
 Masks, if necessary
 Isolation door card
 Plastic bags
 Additional supplies such as thermometer, stethoscope and BP cuff
PREPARATION OF EQUIPMENT
 Keep all droplet precaution supplies outside the patient’s room in a cart or anteroom.
PLANNING AND IMPLEMENTATION
ACTION RATIONALE
1. Introduce self and verify the client’s

identity using agency protocol.
2. Explain to the client what you are going to It is extremely important that clients and
do, why it is necessary, and how he or she family members understand the rationale for
can participate. the use of barriers to infection transmission.
They must be given the opportunity to ask
questions and express feelings.
Hospitalized clients are already socially

isolated from others and use of additional
barriers can initiate negative feelings such as
depression & withdrawal.
4. Situate the patient in a single room with

private toilet facilities and an anteroom if
possible.

5. Place a contact precautions card on the To notify anyone entering the room.
door.
6. Wash your hands before entering and

after leaving the patient’s room and after
removing gloves.
7. Apply clean gloves. Change gloves and
perform hand hygiene after contact with
infectious material.
8. Wear a gown when entering the patient’s

room if there will be any client contact
with potentially contaminated areas.
9. Bag contaminated articles.
a. Identify and separate items that are

disposable from those that are reusable.
b. Place garbage and disposable items

such as dressings or single-use equipment
in the plastic bags that line the waste
basket and tie the bag.
c. Place used disposable sharps (e.g.,

needles, scalpels, syringes) directly into
designated sharps containers. Do not
disassemble or recap sharps.
d. Place contaminated reusable items in

an impermeable bag and send to the
proper area for decontamination.
e. Place soiled linen directly in the linen

hamper. Close the bag and send to the To decrease the chances of sustaining a
laundry as specified by policy. puncture injury.
f. Place any laboratory specimens in

impervious, labelled containers, and send
them to the laboratory at once. Attach a
requisition slips to the outside of the
container.
g. Food dishes and silverware require no

special handling.
10. Instruct visitors to wear gloves and a gown

while visiting the patient and to wash their
hands after removing the gown and
gloves.
11. Remove PPE at the doorway before

leaving the room or in the anteroom, in
the proper sequence and disposed of
properly.
a. Remove gloves without touching the

hands to the outside of the gloves.
b. Remove googles or face shield.
c. Remove gown without touching hands

to the outside of the gown.
d. Make sure uniform does not contact
possible contaminated surfaces.
e. Remove mask grasping only the ties or

elastic.
f. Cleanse hands immediately.
12. Limit the patient’s movement from the So that the precautions will be maintained and
room. If the patient must be moved, cover the patient can be returned to the room
any draining wounds with clean dressings. promptly.
Notify the receiving department or area of
the patient’s isolation precautions.
 Cleaning and disinfection of equipment between patients is essential.
 Try to dedicate certain reusable equipment (thermometer, stethoscope, BP cuff) for the
patient in contact precautions to reduce transmitting infection to other patients.
 Remember to change gloves during patient care as indicated by the procedure or task.
Wash hands after removing gloves and before putting on new ones.
DOCUMENTATION:
Record the need for contact precautions on the NCP and as otherwise indicated by your facility.
procedure, and any patient or family teaching. Also document the date the airborne precautions
were discontinued.
MONITORING NEUROLOGIC VITAL SIGNS
I. DEFINITION
Neurologic Vital Signs – supplement the routine measurement of temperature, pulse rate, and respirations by
evaluating the patient’s level of consciousness (LOC), papillary activity, and orientation to person,
place and date. They provide a simple, indispensable tool for quickly checking the patient’s neurologic
status.
Glasgow Coma Scale - provides a standard reference for assessing or monitoring level of consciousness in a
patient with a suspected or confirmed brain injury. This scale measures 3 responses to stimuli – eye
opening response, motor response, and verbal response – and assigns a number to each possible
response within these categories.
CHARACTERISTIC RESPONSE SCORE
Eye Opening response Spontaneous 4
To verbal stimuli 3
To pain 2
No response 1
Best Motor Response Obeys commands 6
To painful stimuli
-localizes pain ; pushes stimulus away 5
-flexes and withdraws 4
-abnormal flexion 3
-extension 2
-no response 1
Best Verbal Response Oriented and converses 5

(arouse the patient with
painful stimuli if necessary
Disoriented and converses 4
Uses inappropriate words 3
Makes incomprehensible sounds 2
No response 1
Total: 3 to 15
Assess each of the 3 areas separately, and give a number for the patient’s correct response. Total
the three numbers.
A score of 3 is the lowest and 15 is the highest.
A score of 7 or less indicates coma.
II. EQUIPMENT
Penlight Thermometer
Stethoscope Sphygmomanometer
Pupil Size Chart. Sterile Cotton Ball or Cotton Tipped Applicator
ACTION RATIONALE
1. Explain the procedure to the patient even if he

is unresponsive.
2. Wash hands and provide privacy.
3. Assess LOC and orientation: Use standard

method such as the Glasgow Coma Scale (see
above).
a. Begin by measuring patient’s response to

verbal, light tactile (touch), and painful (nail
bed pressure) stimuli.
 Ask the patient his/her full name, if

he/she responds appropriately; assess
his/her orientation to person, place and
date.
 Ask him where he is and then what day

and year it is.
Expect disorientation to affect the sense of date first,

then time, place, caregivers and finally self.
 When he/she responds verbally, assess

the quality of speech to determine if it is
clear and concise.
 Assess the patient’s ability to

understand and follow one stepTo check whether patient has difficulty with thought
commands that require a motor processing and organization.
response. For example, ask him to open
and close his eyes or stick out his
tongue.
 If the patient doesn’t respond Totonote whether the patient can maintain his LOC. If
commands, apply painful stimuli. (With you must gently shake him to keep him
moderate pressure, squeeze the nail focused on your verbal commands, he may
beds on the fingers and toes, and note have sustained neurologic compromise.
his response).
To check motor responses bilaterally to rule out

monoplegia and hemiplegia.
4. Examining Pupils and Eye Movement
a. Ask the patient to open his eyes. If To

heevaluate the pupil size more precisely, use a chart
doesn’t respond, gently lift his upper showing the various pupil sizes. (Normal
eyelids. diameter: 2-6mm).
b. Inspect each pupil for size and shape, and
compare the two for equality.
c. Also check whether the pupils are

positioned in, or deviate from, the midline.
Pupil size varies considerably, and some patients have
normally unequal pupils (anisocoria).
d. Test the patient’s direct light response.
Normally, the pupil constricts immediately. When you

 Darken the room, then hold each eyelid remove the penlight, the pupil should dilate
open in turn, swing the penlight from immediately.
the patient’s ear toward the midline of
the face. Shine the light directly into the
eye.
 Wait about 20 seconds before testing

the other pupil
e. Test consensual light response.
 Hold both eyelids open, but shine the

light into one eye only. Watch To forallow it to recover from reflex stimulation.
constriction in the other pupil, which
indicates proper nerve function of the
optic chiasm.
f. Brighten the room and have the conscious

patient open his eyes.
 Observe the eyelids for ptosis or

drooping.
 Check for extraocular movements:
 Hold up one finger, and ask the patient

to follow it with his eyes alone. As you
move the finger up, down, laterally, and
obliquely, see if the patient’s eyes track
together to follow your finger (conjugate
gaze).
 Watch for involuntary jerking or

oscillating eye movements either
laterally or vertically upon moving eyes
(nystagmus).
g. Check accommodation:
 Hold up one finger midline to the

patient’s face and several feet away.
Have the patient focus on your finger.
Gradually move your finger toward his
nose while he focuses on your finger.
h. Test the corneal reflex by touching a wisp

of cotton ball to the cornea. Repeat for the
other eye.
i. If the patient is unconscious, test the

oculocephalic (doll’s eye) reflex.
 Hold the patient’s eyelids open. Then

quickly but gently turn his head to one
side and then the other. If the patient’s
eyes move in the opposite direction
from the side to which you turn the
head, the reflex is intact.
To assess pupil accommodation. This should cause his

eyes to constrict equally.
To assess corneal reflex. This normally causes an
immediate blink reflex.
Never test the doll’s eye reflex on an awake, alert

patient or if you know or suspect that the
patient has a cervical spine injury.
5. Evaluating motor function:
a. If the patient is conscious, test his grip

To test the grip strength that is usually slightly
strength in both hands. Extend your hands, stronger in the dominant hand.
ask him to squeeze your fingers as hard as
he can, and compare the strength of each
hand.
b. Test arm strength by having the patient

close his eyes and hold his arms straight out
in front of him with the palms up.
c. Test leg strength by having the patient raise

his legs, one at a time, against gentle
To check if either arm drifts downward or pronates
downward pressure from your hand. Gently
push down on each leg at the midpoint of (pronator drift), indicating muscle weakness.
the thigh.
d. If decorticate or decerebrate posturing

develops in response to stimuli, notify the
physician immediately.
DECORTICATE
(abnormal flexion) To evaluate muscle strength.
-In the decorticate posture, the patients arms are

abducted and flexed, with the wrists and
fingers flexed on the chest. The legs may be
stiffly extended and internally rotated, with
plantar flexion of the feet.
DECEREBRATE
(abnormal extension)
-In the decorticate posture, the patient’s arms are

adducted and extended with the wrists
pronated and the fingers flexed. One or both
of the legs may be stiffly extended, with To examine for decorticate posture, that may indicate
plantar flexion of the feet. a lesion of the frontal lobe, internal capsule,
or cerebral peduncles.
e. Flex and extend extremities on both sides.

f. Test the plantar reflex in all patients. Stroke
the lateral aspect of the sole of the
patient’s foot with your thumbnail or
another moderately sharp object.
 Watch for Babinski sign - dorsiflexion

of the great toe with fanning of the
other toes.
To examine for decerebrate posture, that may

indicate lesions of the upper brain stem.
To evaluate muscle tone.
Normally this elicits flexion of all toes.
This indicates an upper motor neuron lesion.
Normal in patients younger than age 2

6. Completing the neurologic examination
a. Take the patients temperature, pulse rate,

To assess for e widening pulse pressure that can
respiratory rate, and blood pressure. indicate increasing ICP.
b. Check pulse pressure
IV. DOCUMENTATION
Record assessment as your facility’s policy directs
ASSESSING THE CRANIAL NERVES FUNCTION
Adapted from Smeltzer et al (2011), Medical Surgical Nursing
I. DEFINITION
Assessment of the cranial nerve function is an important part of the neurologic assessment. The 12 pairs of
cranial nerves transmit sensation from the body to the spinal cord and brain. They also transmit
impulses from the brain and spinal cord to the body’s muscles.
NERVE FUNCTION
I. Olfactory Smell
II. Optic Vision
III. Oculomotor Extraocular eye movement (up, down, and medial);
Papillary;Control (pupillary constriction), Upper lid elevation
IV. Trochlear Extraocular eye movement; including downward and lateral
movements
V. Trigeminal Sensations of face, scalp, and teeth; chewing movements

VI. Abducens Lateral eye movements
VII. Facial Facial muscles around eyes, mouth and forehead
Taste receptors (anterior two thirds of tongue); salivary
and lacrimal glands
VIII. Acoustic Hearing; sense of balance

IX. Glossopharyngeal Secretion of saliva; swallowing movements
Sensations of throat; taste receptors (posterior one
third of tongue
X. Vagus Swallowing movements; voice production

XI. Spinal Accessory Shoulder movements (trapezius muscle)
and turning movements of head (sternocleidomastoid muscle)
XII. Hypoglossal Tongue movements

II. EQUIPMENT
2 Test tubes or small bottles Cotton ball
Cotton swab
3 Substances with familiar and distinct odors such as coffee, tobacco, soap
Ophthalmoscope Otoscope
Pencil Penlight
Reflex hammer Safety pin
Tongue depressorTuning Fork
ACTION RATIONALE
1. Assessing patient’s olfactory nerve: Olfactory nerve controls the sense of smell.
a. Obtain three substances with distinctive,

You may use items that are available in your patient’s
but familiar odors; for example: coffee, room such as flowers, a bar of soap etc.
tobacco and detergent.
b. Explain the procedure.
c. Have patient sit at the edge of the bed, or
on a chair.
d. Examine both his nostrils with a penlight
to be certain they are not constricted. In
Suppose your patient’s unable to identify one or more
addition, ask him to alternately occlude
test substances correctly. He may have olfactory
each nostril and inhale through the mouth
nerve impairment. Possible causes: temporal
e. Ask patient to close his eyes and occlude
lobe lesion, cold, allergies, head trauma resulting
his left nostril with his finger. Then, hold
in parosmia (perversion of the sense of smell);
one of the substances under his right
compression of the olfactory bulb by
nostril and ask him to identify the odor.
menangiomas or anterior fossa aneurysm; and
f. Follow this procedure with the other two
tumor infiltration in the frontal lobe.
substances.
g. Repeat the entire test on his left nostril.
2. To test visual fields:
 Instruct your patient to cover his right

eye with his hand. Take care he’s not
pressing in on the eye. Close your left
eye.
 Position yourself at eye level with your
patient, and approximately 24” away.
 Then, ask your patient to look directly
into your open eye.
 Hold a test object, such as a pencil or
finger, at arm’s length above your head.
 Next, lower the pencil from the periphery
into your patient’s field of vision. Ask him
to indicate when he first sees the pencil.
 Compare this point to the point where
you first see the pencil, and note any
differences.
 Repeat this test for each different
direction.
 Repeat the entire examination on
patient’s right eye.
a. Darken the room and use an
ophthalmoscope to examine your patient’s
internal eye structure.
Evaluate the patient’s fundus (retina and disc).

Expect the retina to be transparent,
This sensory nerve helps provide your patient’s visual
although pigmentation may vary with acuity, visual fields, and internal eye structure.
race and complexion. The optic disc
should appear yellowish and round and
oval shaped.
If his vision’s normal, he’ll be able to read the line

marked 20/20. If he can’t, note the smallest line
he can read.
If your patient has difficulty performing visual field tests,

he may have a visual field disorder.
Suppose the disc appears elevated and pink or engorged

with blood (hyperemic) from retinal vessels.
Suspect papilledema or choked disc, which is a
swelling of the optic nerve tissues caused by
increased intracranial pressure.
3. Assessing your patient’s oculomotor, These nerves help innervate the muscles needed for eye
trochlear, and abducens nerves. movements. In addition, the oculomotor nerve
(Remember, these nerves operate as a unit, also innervates the muscles which help regulate
you’ll test and evaluate them together.) pupil constriction and eyelid movement.
b) Begin by familiarizing yourself with the
six cardinal fields of gaze.
c) Hold a pencil or your finger about 12” in
front of your patient’s nose.
d) Ask patient to hold his head still and
follow the pencil’s movement with his
eyes. As you slowly move the pencil to his
right, watch his eyes simultaneously.
e) When the pencil’s about 24” from the
starting point -or the movement in either
of patient’s eyes stops-hold the pencil
still. Note the position of your patient’s
iris in relation to each eyes midline.
f) Repeat this procedure for each of the
remaining cardinal fields of gaze.
g) Assess patient’s extrinsic eye muscles:

 Hold the pencil about 17” in front of
his nose and note his ability to focus
on the pencil.
 Keeping the pencil in place, test his
accommodation and convergence.
 Ask your patient to keep his head
still and follow the pencil with his
eyes as you move it.
 Then, move the pencil toward the
bridge of your patient’s nose. Both
your patient’s eyes should converge
on the pencil at the same level and
distance. When they do, expect his
pupils to constrict and remain
constricted.
h) Test pupillary light responses which
include direct and consensual reflexes.
 Note each pupil’s size and shape,
and their equality.
 Then, darken the room. Test your
patient’s direct light reflex; instruct
him to cover his left with his hand.
Hold his right eyelid open with your
hand.
 Holding the penlight at an angle,
direct the light into his right pupil.If you see eye jerking, oscillation, sluggish eyelid
 Repeat the procedure on your movement, or if your patient’s eyes are not
patient’s left pupil with his right eye tracking together, suspect possible extraoccular
covered. muscle problems.
 To assess consensual light reflex,
keep the room darkened. Instruct
him to keep both eyes open.
 Angle the penlight in front of his
right eye. Then, turn on the penlight
and note the reaction of the left
pupil.
 Check his right pupillary response by
placing the penlight in front of his
other eye.
 Ask patient if he is experience
diplopia (double vision) as you
performed these test.
If everything’s okay, your patient will be able to sustain

his gaze when the pencil is 2’ to 3” from the
bridge of his nose.
His pupil should constrict quickly and remain so until
the light’s removed.
Expect both pupils to constrict bilaterally until you

remove the light.
Diplopia may indicate oculomotor, trochlear, or
abducens nerve damage.
If you observe either of the patients’s eyes deviating

inward toward his nose, suspect abducens
nerve damage.
If patient is unable to move either eye down or laterally,

suspect trochlear nerve damage.
If you note ptosis; a dilated pupil unreactive to light;

nystagmus; or an inability to move either eye
medially, or up or down normally; it may
indicate oculomotor nerve damage.
Some additional causes of oculomotor, trochlear and

abducens nerve damage may be: trauma,
multiple sclerosis, tumor or aneurysm at the
base of the skull, botulism or lead poisoning.
4. Assessing patient’s trigeminal nerve.
a. Gather the following equipment: To assess patient’s facial sensitivity.
2 test tubes or small bottles, safety
pin, and reflex hammer, cotton ball.
 Instruct patient to close his eyes and

keep them closed until you tell him to
open them.
 Use a cotton wisp to touch first one
side of his forehead, and then the
other. Ask your patient to tell you when
and where he feels the cotton. Repeat
the test on his cheeks and jaw.
b. Test patient’s temperature sensitivity.
 Fill one test tube with hot water and

the other with cold water.
 First, touch the test tube filled with hot
water to one side of the patient’s face.
Hold it there for 1 second.
 Repeat the procedure on the opposite
side of the patient’s face.
 Ask him to tell you what he feels, and
where he feels it.
c. Assess patient’s facial sensation:
 Gently touch one side of his forehead

with the sharp end of a safety pin, ask
him to tell you what he feels, and
where he feels it.
 Touch the same side of his forehead
with the pins dull end. Ask the patient
what he is feeling, including whether
the sensation is sharp or dull.
 Repeat the test on both sides of your

patient’s cheeks and jaw, and compare
your findings.
 Instruct your patient to open his eyes.
d. Assess patient’s corneal reflex:
If patient’s sensory perception’s normal, he’ll be able to

 Ask patient to look up. Approaching distinguish between hot and cold.
from his side, gently touch his cornea-
but not the conjunctiva-with a cotton
wisp
 Repeat the test on his left cornea.
He should experience pain if everything’s okay.

e. Instruct patient to clench his teeth.
 Palpate his temporal muscles on his

right and left temples.
f. Palpate his masseter muscles, located

on either side of his jaw joints.
g. As patient continues to clench his

If his sensory perceptions normal, he’ll be able to
teeth, test your patient’s pterygoid
muscle strength. Grasp his lower jaw distinguish between sharp and dull sensations
with one hand and pull downward. equally on both sides.
h. Assess patient’s maxillary reflex, or jaw

jerk.
 Tell patient to unclenched his teeth and

open his mouth slightly.
 Tap the side of his chin with a reflex
hammer.
Be careful not to touch his eyelashes or his sclera.
The ability to clench your teeth indicates an intact motor

function.
These muscles should be equal in size and strength.
If everything’s okay, your patient will be able to keep his

teeth clenched, resisting your efforts.
You should see a sudden, slight closing of his jaw.

You should see a sudden, slight closing of his jaw.
Absence of any of these test responses may indicate a

trigeminal nerve tumor.
Trigeminal nerve damage can be caused by trauma,

trigeminal neuralgia (tic douloureux), a
meningeal infection, an intracranial aneurysm,
or multiple sclerosis.
5. Assessing patient’s facial nerves. To assess patient’s facial expressions and sense of taste.
If you notice facial asymmetry, abnormal movements

(such as tics), or both during this part of the
assessment, suspect a facial nerve lesion.
a. Observe your patient’s face while at rest
and as he talks. Then, ask him to raise his
eyebrows, frown, smile, and puff out his
cheeks. Note any asymmetry or abnormal
movements.
b. Test the upper motor portion of patient’s
facial nerve. Ask patient to close his eyes
tightly. Tell him to keep them closed
while you try to open them.
c. Test the lower portion of your patient’s

facial nerve by having him puff out his
cheeks. Instruct him to resist your efforts
to collapse them.
d. Check the sensory portion of your

Note: If your patient’s sense of smell is impaired, he may
patient’s facial nerve. Do this by dipping a
lose his ability to taste
cotton swab into sugar. Then ask patient
to stick out his tongue. Touch the swab
to one side of the anterior part of his
tongue on each side. Tell him to keep his
tongue out until he taste the flavor.
Then, ask him to identify the flavor.
e. Instruct patient to rinse his mouth with

In many cases, an inability to correctly identify both
water. Repeat procedure (c) substituting
salt. flavors indicates a lesion in the facial nerve
sensory fibers or sensory nucleus.
Facial injury may result from trauma to peripheral nerve

branches, mastoid surgery complications,
temporal bone fracture, intracerebral bleeds,
parotid area lacerations, or contusions. Other
possible causes: intracranial tumor, meningitis,
herpes zoster, Bell’s palsy.
6. Assess patient’s acoustic nerve The acoustic nerve consists of the cochlear nerve, which
provides hearing ability, and the vestibular nerve
which controls equilibrium.
a. Begin by examining his ear canal with an
otoscope to rule out any abnormalities
which may affect his hearing or
equilibrium.
b. Determine patient’s normal hearing
ability:
 Place a ticking watch close to his right
ear.
 Ask him to tell you when he can no
longer hear the ticking.
c. Test for lateralization (Weber Test) He should hear the ticking a maximum of 4” to 6” from
 Place the base of the tuning fork on top his ear.
of your patient’s forehead.
 Ask patient if the tone is centralized or
referred to the left or the right side.
d. Perform the Rinne test.
 Touch the base of the vibrating tuning
fork to your patient’s right mastoid
process. If all’s well, he’ll hear the tone
immediately. Ask him to tell you when
he no longer hears the tone, and note He should hear the same tone (volume and intensity) in
this amount of time. each ear. If he does, document the result as
 Then, without vibrating the fork again, Weber negative. But if hears the tone louder in
assess air conduction by holding the one ear, ask him which ear has the louder tone.
vibrating prongs ½” next to your Then, document this result as Weber right or
patient’s right external ear canal. Make Weber left.
sure the prongs are in front of, but not
touching, the ear canal.
 Ask him to tell you when he no longer
hears the tone. Also, note this length of
time.
This test compares the strength of hearing through bone

conduction to that of air conduction.
Normally, your patient will hear the tone carried by air
conduction twice as long as the tone carried by
bone conduction.
Tinnitus, decreased hearing, or deafness may indicate

cochlear nerve damage. Possible causes of
abnormal test findings: Inflammation,
intracranial tumor, drug toxicity, and middle
fossa skull fracture.
7. Assessing patient’s glossopharyngeal and

These nerves help regulate gag and palatal reflexes and
vagus nerves. work as a unit. So, you’ll always test these
nerves together.
a. Ask patient to say “ah.” As he does,

observe his soft palate and uvula for
upward movement, and his posterior
pharynx for inward movement. Note any
asymmetry.
b. Then, ask the patient to speak and

swallow.
c. Assess patient’s gag reflex:
 Ask him to open his mouth. Then, hold
down his tongue with a tongue
depressor.
 Use a cotton swab to touch each side of
his pharynx.
d. Assess patient’s palatal reflex:
 Instruct him to open his mouth again.
Touch each side of the uvula with a
cotton swab. Voice should be clear and without hoarseness.
Gag reflex should be immediate.
The uvula should rise.
If voice is hoarse or nasal sounding, suspect nerve

damage.
Causes of 9th cranial nerve damage: acute anterior

poliomyelitis, intramedullary lesions, vascular
lesions, multiple sclerosis.
Causes of 10th cranial nerve damage: infection or
intracranial tumors.
8. Assessing patient’s spinal accessory nerve: Test his trapezius and sternocleidomastoid muscles
which allow his head to rotate and nod.
a. Begin by testing the strength of your

patient’s trapezius muscles. Stand facing
your patient and place your patient and
place your hands on your patient’s
shoulders.
b. Instruct patient to raise his shoulders as
you apply downward pressure.
c. Test patient’s sternocleidomastoid
muscle strength, remain standing and
place your left hand on the right side of
your patient’s face.
d. Tell him to turn his head on the left side
of his face.
If either the trapezius or sternocleidomastoid muscle

seems abnormally weak, or if the muscle on one
side seems longer than one the other side,
suspect a lesion.
Other possible causes of abnormalities include: occipital

bone necrosis, inflammation, amyotropic lateral
sclerosis.
9. Assessing patient’s hypoglossal nerve: To test patient’s tongue movement and strength.
a. Ask your patient to open his mouth.

Examine his tongue as it lies on the floor
of his mouth. It should lie flat with no
tremors or twitching.
b. Ask your patient stick out his tongue. It
should protrude centered between his
lips. Note any tremor or atrophy.
c. Next, tell your patient to quickly dart his
tongue in and out of his tongue.
d. Have him stick out his tongue and move it
from side to side as quickly as he can. The
tongue movements should be smooth
and fast.
e. To test your tongue strength, you’ll need
a tongue depressor. Hold the tongue
depressor on one side of his mouth and
ask him to push against it with his tongue.
Then repeat the procedure on the other
side of his mouth.
If patient is unable to move his tongue toward one side

of his mouth or the other, or if you have noted
fasciculation, tremors, or an increased wrinkling
of the tongue’s surface, suspect a nerve lesion.
Other causes of abnormalities: amyotrophic lateral

sclerosis, alcoholism, or cerebrovascular
accident.
IV. DOCUMENTATION
Document all findings or results in your nurses’ notes.

EXAMINING THE REFLEXES
I. DEFINITION
The motor reflexes are involuntary contractions of muscles or muscle groups in response to abrupt stretching
near the site of the muscle’s insertion. The tendon is struck directly with a reflex hammer or indirectly
by striking the examiner’s thumb, which is placed firmly against the tendon.
II. RATIONALE
To assess involuntary reflex arcs that depend on the presence of afferent stretch receptors, spinal synapses,
efferent motor fibers, and a variety of modifying influences from higher levels.
III. EQUIPMENT
Reflex hammer
Applicator stick
Clean wisp of cotton
ACTION RATIONALE
1. Obtain equipment needed.
2. Explain each test to your patient. Encourage him

Valid findings depend on several factors: proper use of
to relax each part of his body as you test it. reflex hammer, proper positioning of the
extremity and a relaxed patient.
3. Assess your patient’s deep tendon reflexes:
a. Biceps Reflex
 Slightly flex his right elbow.
 Then, with your thumb pressed firmly
against his biceps muscle tendon, hold
your patient’s elbow.
 Keeping the reflex hammer held loosely
between your thumb and fingers, strike
your thumb.
 Repeat the test on your patient’s left
bicep.
b. Triceps Reflex
 To do this, have him flex his arm at the
elbow.
 Then, hold his arm at the wrist.
 With the reflex hammer, strike the
triceps tendon directly over his elbow.
 Repeat the test on the other elbow. Allowing it to swing freely.
Expect your patient’s biceps muscle to contract, flexing

his arm at the elbow.
c. Brachioradialis Reflex
 Have him rest his forearm in his lap. His
palm should be facing down.
 With the wide end of the reflex hammer,
strike the radius, usually located about
1” to 2” above the wrist.
 Repeat the test on his other forearm.
The triceps muscle should contract, extending your
patient’s arm at the elbow.
d. Patellar Reflex
 Using the reflex hammer, briskly strike
his patellar tendon just below the
patella.
 Repeat this on his other knee.
e. Achilles Tendon Reflex

 Hold your patient’s right foot with your
left hand.
 Gently rotate his foot outward and strike
his Achilles tendon with the reflex
hammer.
 As you do, watch the plantar flexion on
his ankle.
 Then, observe quickly the muscle relaxes
after contraction.
 Repeat the test on his left Achilles
tendon.
If all’s well, your patient’s forearm will flex, so his palm

turns upward.
Expect to see knee extension, causing his leg to swing
forward.
If this relaxation period is slowed, suspect

hypothyroidism.
4. Assess superficial reflexes:
a. Abdominal
 Assist patient to lie on the bed in a
supine position.
 His legs should be slightly flexed at the
knees.
 Tell to keep both arms at the side during
the test.
 Expose his abdomen.
 Instruct patient to exhale. As he does,
gently pull the applicator stick across his
upper right abdomen, from the outer
side toward his umbilicus.
 Repeat this test on his lower abdomen.
b. Plantar
 Lightly scratch the lateral aspect of his
foot, from the heel up.
 Repeat the test on his other foot.
c. Cremasteric (for men only)

 If your patient’s male, you’ll need to test
the cremasteric reflex.
 Gently draw the stick down the upper
portion of his right inner thigh.
 Repeat the test on your patient’s left
side
 Normally, the umbilicus will move up and toward the
d. Corneal area being touched. If your patient has an upper
 It is tested carefully using a clean wisp of or lower neuron disturbance, his abdominal
cotton. reflex may be absent.
 Lightly touch the outer corner of each
eye on the sclera.
e. Gag or Swallowing
 Elicited by gently touching the back of
the pharynx with a cotton-tipped Expect the umbilicus to move down.
applicator.
 First on one side of the uvula and then
the other.
If everything’s okay, his toes will curl downward.
Dorsiflexion of the great toe and fanning of the other

toes (Babinski sign) is an abnormal response.
Expect cremasteric muscle to contract and the right
testicle to rise slightly.
Absence of cremasteric reflex may be present in upper

and lower neuron disturbances.
Conditions such as CVA or coma might result in loss of

this reflex, either unilaterally or bilaterally.
Positive response is an equal elevation of the uvula and

“gag” with stimulation.
Absent response on one or both sides can be seen

following a CVA and requires careful evaluation.
V. EVALUATION AND DOCUMENTATION:
Deep tendon reflex responses are often graded on a scale of 0 to 4+.
4+ Hyperactive reflex (hyperreflexia); often indicating pathology

3+ Increased (may be interpreted as normal)
2+ Indicates an average or normal response
1+ Diminished (hypoactive)
0 No response
Some examiners prefer to use the terms present, absent, and diminished when describing reflexes.
Superficial reflexes are graded differently than the motor reflexes and are noted to be present (+) or
absent (-).
MEASURES IN MEETING THE NEEDS OF CLIENTS WITH ALTERATION IN VISUAL AND
AUDITORY
Adapted from Altman (2010), Fundamentals & Advanced Nursing Skills, 3rd Edition
Adapted from Berman et al (2009) Skills in Clinical Nursing 6th Edition
I. DEFINITION
A. Eyes and Ears Medications

Refers to drops, ointment, and disks. These drugs are used for diagnostic and therapeutic purposes- to
lubricate the eye or socket for a prosthetic eye and to prevent or treat eye conditions such as glaucoma
(elevated pressure within the eye) and infection.
Safety Measures to prevent cross-contamination

1. Each client should have his or her own bottle of eye drops.
2. Discard any solution remaining in the dropper after instillation.
3. Discard the dropper if the tip is accidentally contaminated, as by touching the bottle or any part of
the client’s eye.
B. Ear Medications
Solutions ordered to treat the ear are often referred to as otic (pertaining to the ear) drops or irrigation.
External auditory canal irrigations are usually performed for cleaning purposes and less frequently for
applying heat and antiseptic solutions.
II. RATIONALE
EYE MEDICATION
1. Diagnostically, eye drops can be used to anesthetize the eye
2. Dilate the pupil, and stain the cornea to identify abrasions and scars.
EAR MEDICATION
1. To soften ear wax
2. To produce anesthesia
3. To treat infection or inflammation
4. To facilitate removal of a foreign body such as insect
III. EQUIPMENT
Eye Medication
Medication Administration Record (MAR)
Eye medication
Tissue or cotton ball
Nonsterile latex-free gloves (if needed)
Ear Medication
Otic Medication
Cotton-tipped applicator
Tissue
Nonsterile latex-free gloves (if needed)
IV. IMPLEMENTATION
Special Considerations
a. When administering eye medication, make sure the client is not wearing contact lenses. In addition,
wearing contact lenses may be prohibited within 30 minutes after the eye medication has been
administered as medication may damage the contact lenses.
b. Some eye medications cause pupil dilation and make the client’s eyes sensitive to light and,
therefore, require protective measures such as sunglasses. Most often after the pupils are dilated, it
is difficult for the client to read for several hours. Proper client education should be addressed to
promote client comfort and safety.
ACTION RATIONALE
Eye Medication
1. Check with the client and the chart for any
known allergies or medical conditions that
would contraindicate use of the drug. To prevent occurrence of adverse reactions.
2. Gather the necessary equipment
3. Follow the 10 Rights of Drug Administration

To promote efficiency.
4. Take the medication to the client’s room

To promote safety.
and place on a clean surface.
5. Check client’s identification armband. To decrease risk of contamination of bottle cap.
6. Explain the procedure to the client; inquire

if the client wants to instill medication. To
If accurately identifies client.
so, assess the client’s ability to do so.
To reduce client’s anxiety and enhances collaboration;
7. Wash hands, don nonsterile latex-free some clients are used to instilling their own
gloves, if needed medication.
8. Place client in a supine position with the

To decrease contact with bodily fluids.
head slightly hyperextended.
Instilling Eye Drops To minimize drainage of medication through a tear

9. Remove cap from eye bottle and place cap duct.
on its side.
10. Squeeze the prescribed amount To
of prevent contamination of the bottle cap.
medication into the eyedropper.
11. Place a tissue below the lower lid. To ensure correct dose.
12. With dominant hand, hold eyedropper one- To absorb the medication that flows from the eye.
half to one-third inch (1/2 - 1/3 inch) above
the eyeball; rest hand on client’s forehead
to stabilize.
To reduce risk of dropper touching eye structure, and
13. Place hand on cheekbone and expose lower prevents injury to the eye.
conjuctival sac by pulling down on cheek.
14. Instruct the client to look up and drop

prescribed number of drops into center To
of stabilize hand and prevents systemic absorption of
conjunctival sac. eye medication.
15. Instruct client to gently close eyes and

move eyes. Briefly place fingers on either
To reduce stimulation of the blink reflex; prevents
side of the client’s nose to close the tear injury to the cornea.
ducts and prevent the medication from
draining out of the eye.
To distribute solution over conjunctival surface and
16. Remove gloves; wash hands. anterior eyeball.
17. Record on the Medication Administration

Record (MAR) the route, site (which eye),
and time administered.
18. Repeat Action 1 to 8.
19. Lower lid: To provide documentation that the medication was

a. With nondominant hand, gently separate given.
client’s eyelids with thumb and finger and
grasp lower lid near margin immediately
below the lashes; exert pressure
downward over the bony prominence To of provide access to the lower lid.
the cheek.
b. Instruct the client to look up.
c. Apply eye ointment along inside edge of

the entire lower eyelid, from inner to
outer canthus. To reduce stimulation of the blink reflex and keeps
cornea out of the way of the medication.
20. Upper lid: To ensure drug is applied to entire lid.
a. Instruct client to look down.
b. With nondominant hand, gently grasp

client’s lashes near center of the upper lid
with thumb and index finger, and draw lid To keep cornea out of the way of medication.
up and away from eyeball. To ensure medication is applied to entire
length of lid.
c. Squeeze ointment along upper lid starting
at inner canthus.
21. Repeat Actions 16 and 17.
Medication Disk
22. Repeat Actions 1 to 8. See Rationales 16 and 17.
23. Open sterile package and press dominant,

sterile gloved finger against the oval disk so
See Rationale 1 to 8.
that it lies lengthwise across fingertip.
24. Instruct the client to look up. To promote sticking of disk to fingertip.
25. With nondominant hand, gently pull the

client’s lower eyelid down and place the To reduce stimulation of the blink reflex and keeps
disk horizontally in the conjunctival sac. cornea out of the way of the medication.
a. Then pull the lower eyelid out, up and
over the disk. To secure the disk in the conjuctival sac.
b. Instruct the client to blink several times.To allow the disk to settle into place.
c. If disk is still visible, repeat steps.

Ensures correct placement of the disk.
d. Once the disk is in place, instruct the
client to gently press the fingers against To secure disk placement of the disk.
the closed lids; do not rub eyes or move
the disk across the cornea. To preserve medication. This is not a sterile
procedure. Health care provider must wear
e. If disk falls out, pick it up, rinse under cool gloves to pick up disk.
water, and reinsert
To ensure both eyes are treated at the sane time.
26. If the disk is prescribed for both eyes (IU), See rationale 15 to 17.
repeat Actions 23 to 25.
Repeat action 15 to 17.

See rationale 3 and 5 to 8.
Removing an eye Medication Disk
Repeat action 3 and 5 to 8. To expose the disk for removal.
Remove the disk: To safely move the disk to the lower conjunctival sac.
a. With nondominant hand, invert the lower
eyelid and identify the disk.
b. If the disk is located in the upper eye, To safely remove the disk without scratching the
instruct the client to close eye, and place cornea.
your finger on the closed eyelid. Apply
gentle, long, circular strokes; instruct
client to open eye. Disk should be
located in corner of eye. With your
fingertip slide the disk to the lower lid,
and then proceed.
To reduce transmission of microorganism.
c. With dominant hand, use the forefinger
to slide the disk onto the lid and out To
of provide documentation that the disk was removed.
the client’s eye.
Remove gloves; wash hands.

To prevent the occurrence of hypersensitivity.
Record the removal of the disk on the MAR.
To ensure accuracy in identification of the

Ear Medication medication.
1. Check with client and chart for any known

To reduce the transfer of microorganisms.
allergies.
To ensure the administration of the correct dose.
2. Check the MAR against the health care To ensure correct client.
provider’s written orders.
3. Wash your hands. To enhance cooperation.
4. Calculate the dose. To facilitate the administration of medication.
5. Use the identification armband to properly

identify the client To open the canal and facilitates introduction of the
medication.
7. Place the client in a side-lying position with

the affected ear facing up. To prevent injury to the ear canal.
8. Straighten the ear canal by pulling the pinna

down and back for children less than 3 years
of age or upward and outward in adults and To Allow for distribution of medication.
older children.
9. Instill the drops into the ear canal by holding

To prevent the medication from escaping when the
the dropper at least ½ inch above the ear client changes to a sitting or standing position.
canal. To reduce the transmission of microorganisms.
10. Ask the client to maintain the position forTo

2 document the actions of the nurse will reduce the
to 3 minutes number of medication errors.
11. Place a cotton ball on the outermost part of

the canal.
12. Wash hands.
Document the drug, number of drops, time administered

and ear medicated.
1. The right client received the right dose of the right medication via the right route at the right time.
2. The procedure was performed with minimum trauma and/or discomfort to the client.
3. The client received maximum benefit from the medication.
4. All the prescribed medication went into the eye or ear and none was spilled.
Documentation
1. Record the date, time, location, and dosage of medication administered
2. If an ordered medication was not given, note this, usually by circling the time of the missed
medication.
Nurses’ Notes
1.If an ordered medication was not given, record the reason.
2.If an as-needed medication was given, note the reason for giving medication and the client’s
response.
3.Document on appropriate flow sheet or electronic medical record (EMR).
Ear Drops
INSTILLING NASAL DROPS
I. DEFINITION
Administering a prescribed medication via the nasal route

Instillation- is the insertion of a medication into a body cavity.
II. RATIONALE
1. To shrink swollen mucous membranes.

2. To loosen secretions and facilitate drainage.
3. To treat infections of the nasal cavity or sinuses.
III. EQUIPMENT
Medication Tissue
Dropper Emesis Basin
Gloves (optional)
ACTION RATONALE
1. Obtain client’s medication record. It mayTobedetermine

a the drug to be given at a particular time to a
drug card, medication sheet or drug Kardex particular client.
medications in the facility.
2. Compare the medication record withTothe

ensure accuracy.
most recent physician’s order.
3. Wash your hands. To prevent the spread of microorganism.
5. Remove the medication from the drug box

To promote
or ease in drug preparation.
tray on the medication cart.
6. Compare the label on the medication bottle

To prevent medication error.
or tube with the medication record.
7. Check the drug information if it is appropriate

To ensure client’s safety.
for nasal instillation.
8. Place the medication bottle or tube To

inprevent
a medication from contamination.
medication tray.
9. Take the medication to the client’s room,

To ensure accuracy.
check the room number against the
medication card or sheet.
10. Check the client’s ID band and ask the To

client
ensure that the right client is given the right
to state his/her name. medication.
11. Explain the procedure to the clientToand

reduce client’s anxiety and to gain his/her cooperation.
provide privacy.
12. Don a pair of gloves.
To clear the nasal passages of mucus and secretions.
13. Provide tissue wipes to the client and
instruct him/her to blow the nose. To facilitate instillation of the drug.
14. Position the client properly and

comfortably; Sitting position with the head
tilted back or back-lying position with the
neck hyperextended over a pillow. To ensure accurate dosage.
15. Fill the dropper with the prescribed amount

of medication. To facilitates instillation of the drug.
16. Elevate the nares by pressing the thumb

against the tip of the nose, the dropper is
held just above the nostril, and the drops
are directed toward the midline of the
superior concha of the ethmoid bones as
the client breathes through the mouth.To let the solution come in contact with the
entire nasal surface.
17. Instruct the client not to sneeze and to
remain in this position for 1 minute. To prevent contamination.
18. Discard any unused medication remaining

in the dropper before returning the dropper
to its container. To promote comfort.
19. Place client in a comfortable position.

Provide emesis basin and tissue wipes.To prevent the spread of microorganisms.
20. Do after-care of supplies and equipment

properly and wash your hands.
1. Document the name of drug, dosage, method of administration, time administered, and the site
where the drug was instilled (left, right or both nostrils).
2. Status of the mucous membrane, patient’s tolerance to the medication and effects of the
medication.
APPLICATION OF EYE PATCH, EYE SHIELD, PRESSURE DRESSING

Adapted from Altman (2010), Fundamentals & Advanced Nursing Skills, 3rd Edition
Adapted from Berman et al (2009) Skills in Clinical Nursing 6th Edition
I. RATIOANALE
One or both eyes may need shielding for the following reasons:
1. To keep an eye at rest, thereby promoting healing
2. To prevent the patient from touching the eye
3. To absorb secretions.
4. To protect the eye
5. To control or lessen edema
II. EQUIPMENT
Eye covering to be used (shield, oval patches) Tape

Scissors Skin Protectant (optional)
III. IMPLEMENTATION
ACTION RATIONALE
Preparatory Phase
1. Wash hands To prevent contamination
2. Explain procedure to patient. To allay fear and ensure cooperation.
3. Verify patient and eye to be patched. To prevent error.
4. Instill ointment, if directed, prior to patching.

To protect the cornea from abrasion or prevent
infection.
5. Shave the male face and apply skin protectant
as indicated. To enhance ability to stick and protect the skin from
tape.
Performance Phase
For eye patch:
a. Instruct patient to close both eyes
b. Place patch over affected eye. To immobilized both eyes
c. Secure the patch with two or more strips
of tape applied downward and diagonally
from midforehead to cheek.
For eye shield

a. Apply over dressing or directly over the
undressed eye, fastening with twoToorprotect the eye.
more strips of tape.
b. Be sure there are no rough edges against
the skin. To prevent abrasion. Use skin protectant as indicated.
For pressure dressing

a. Have the patient close both eyes tightly.
To prevent eye from opening before dressing is secured.

b. Fold patch in half (short end to short end)
To provide pressure dressing bulk.
and place over closed eyelid (with fold
line at eyebrow). Cover with additional
unfolded patches.
c. Apply strips of tape firmly from checkTotosecure dressing and apply pressure.
forehead, overlapping each strip.
1. Trim tape and monitor for security of patch or shield.

2. Advised patient that because depth perception will be impaired, he should perform activities
carefully and report any foreign body sensation.
Evidence Base:
American Ophthalmic Association of Registered Nurses. (2007). Ophthalmic Procedures for the Office or
Clinic.
ASSISTING IN THE APPLICATION OF CAST
(PLASTER OF PARIS and FIBERGLASS CAST)
I. DEFINITION
Cast
A mold mad of plaster of Paris or fiberglass which is used to immobilize the trunk or any body part so
that a fracture of a bone, a dislocation or an injury to soft tissue can heal.
Plaster of Paris.
A hard but fairly light substance. Crinoline (a firmly woven cotton fabric) rolls impregnated with plaster
of Paris are immersed in water and molded to a body part to form a cast.
Fiberglass Cast
Also referred to as a ‘light” cast because of its light weight. It is a roll of synthetic cast material that is in
sealed moisture-proof packages that begin to harden as soon as the package is opened. These materials
come in a wide variety of colors.
II. RATIONALE
1. To immobilize the trunk or a body part.

2. To allow healing of a bone fracture, a dislocation, or a soft tissue injury.
III. EQUIPMENT
Casting material depending on the type of cast to be applied

Cast saw in case windowing is needed Stockinette
Adhesive cloth tape Large, heavy-duty scissors
Plastic apron and gloves Cast Padding
Cast knife for trimming Rolls of plaster of Paris
Wadding sheet (cotton cast padding) A bucket of water
Synthetic Cast Padding Can of Fiberglass material for finishing
cast
ACTION RATIONALE
1. Review the client’s record To determine the kind of injury and read the physician’s
notes about casting.
2. Inspect the skin over which the cast is to

To assess the condition of the skin so as to anticipate
be applied for any abrasions or possible problems.
interruptions in skin integrity. Look for
signs of edema that may intensify
pressure caused by the cast.
To clarify any information that has been given.
3. Find out what the client knows about theTo alleviate any anxiety or discomfort.
procedure. Determine if the physician
has ordered a sedative to be given 30
minutes before casting.
4. Wash your hands.
To save time and effort.
5. Gather equipment on a cart.
To assess that the procedure is performed to the right
6. Identify the client. patient.
To provide privacy and protect the linen from moisture
7. Drape the client. Place a plastic-covered and casting materials.
sheet or pillow under the part to be
casted.
To lessen anxiety.
8. Offer emotional support and reassurance
to the client
9. Assist the physician in applying the cast.
10. When the cast is completed, remove To prevent irritation.

excess material from the client’s skin.
11. Position the client to support the cast. To prevent indentations on the wet or damp cast.
To dry the cast and to keep the cast from pulling on
12. Handle the cast until it is completely dry. muscles.
Use the flat side of the palm of your
hands.
To prevent swelling of the tissues and excessive
13. Elevate the extremity slightly higher than tightness of the cast.
the heart.
14. Leave the cast uncovered during drying

period.
15. Provide client teaching as to

16. Monitoring of the cast area
17. Length of time for the cast to dry.
18. Importance of reporting feelings of pain,

pressure, or altered sensation.
19. Aftercare of equipment. Wash your
hands.

a. Client’s comfort
b. Condition of the cast
c. Neurovascular status, including circulation, motion, and sensation of the affected part.
2. Document the type of cast applied, the date and time, the client’s comfort and neurovascular status.
ASSISTING CLIENTS TO USE MECHANICAL AIDS FOR WALKING
I. DEFINITION
Crutches – used by clients who cannot bear any weight on one leg, clients who can only bear partial
weight on one leg, and clients who have full weight bearing ability on both legs. There are several types
of crutches available, depending on the length of time the client will require the assistance and the
client’s upper body weight.
Cane – used by clients who can bear weight on both legs but one leg or hip is weaker or impaired. There
are several types of canes as well. The standard, straight cane is used most often. There are also canes
with three to four legs on the end, called quad canes, to increase a client’s stability when walking.
Walker – used by clients who require more support than a cane provides. Walkers are available with or
without wheels. Walkers without wheels provide the most stability but they must be lifted with each
step. Walkers with wheels are somewhat less stable but a client who does not have the upper body
strength to lift the walker repeatedly can push it along while walking.
II. RATIONALE
1. To assess the reason why the client requires an assistance device.

2. To assess the client’s physical limitations.
3. To assess client’s physical environment.
4. To assess the client’s ability to understand and follow directions regarding use of an assistive device.
III. EQUIPMENT
Gait belt Assistive device: crutches, cane, walker

Tape measure Nonslip footwear
ACTION RATIONALE
Crutch Walking
1. Inform client that you will be assisting with

To reduce anxiety and gain client’s cooperation.
ambulation using the device chosen.
2. Assess client strength, mobility, rangeToof determine client’s capabilities and amount of
motion, visual acuity, perceptual difficulties assistance required.
and balance.
3. Measure client for size of crutches and adjust

To increase client safety and comfort.
crutches to fit. While supine, measure client
from heel to axilla.
4. Provide a robe or other covering as wellToasprovide privacy.

nonslip foot coverings or shoes.
5. Lower the height of bed.
6. Dangle the client at the side of the bedToforallow stabilization of blood pressure, thus preventing
several minutes. Assess for vertigo or nausea. orthostatic hypotension; also increases client
comfort.
7. Apply gait belt around client’s waist if balance

To provide support and promote safety.
and stability are unreliable.
8. Instruct client on method of holding crutches

To increase comprehension and cooperation.
while he or she remains seated. This should
be with elbows bent 30 degrees while hands
are on the hand grips and pads 1.5 to 2 inches
below axilla. Instruct client to position
crutches 4 -5 inches laterally and 4 – 6 inches
in front of feet.
9. Assist the client to a standing positionTobyallow stability while promoting independence.
placing both crutches in the non-dominant
hand. Then, using the dominant hand, push
off from bed while using the crutches for
balance. Once erect, the extra crutch can be
moved into the dominant hand.
To promote client comfort, support and safety.
10. Instruct client to remain still for a few
seconds while assessing for vertigo or
nausea. Stand to the client to support as
needed. While client remains standing,
check for correct fit of the crutches. The
client’s body weight should be supported
on the hands and arms, not in the axillary
area.
Four-Point Gait To provide greater stability.
11. Position the crutches 4.5 to 6 inches to the

side and in front of each foot. Move the
right crutch forward 4 to 6 inches and move
the left foot forward, even with the left
crutch. Move the left crutch forward 4 to 6
inches and move the right foot forward,
even with the right crutch. Repeat the four-
point gait.
To provide a strong base of support.
Three-Point Gait
12. Advance the crutches and the weaker leg

forward together 4 to 6 inches. Move the
stronger leg forward, even with the
crutches. Repeat the three-point gait.
To provide a strong base of support.
Two-Point Gait
13. Move the left crutch and right leg forward

4-6 inches. Move the right crutch and left
leg forward 4-6 inches. Repeat the two-
point gait.
To permit a faster pace. This gait requires greater

Swing-Through Gait balance and more practice.
14. This step is basically the same as the three-

point gait. The difference is that on the
swing, whichever leg is moving will go past
the stationary point and set down in front.
To prevent weight bearing on the weaker leg. When
Walking Upstairs ascending stairs, crutches should follow the
legs, thereby allowing stability if the client
15. Stand beside and slightly behind client. S weight shifts down the stairs while moving. This allows
Instruct to position crutches as if walking. the client to catch himself instead of falling
Place body weight on hands. Place the backward.
strong leg on the first step. Move the
crutches and the weak leg up to the first
step. Repeat pattern for all steps.
To provide greater stability and prevent weight bearing
Walking Downstairs on the weaker leg.
16. Position the crutches as if walking. Place

weight on the strong leg. Move the crutches
down to the next lower step. Place partial
weight on hands and crutches. Move the
weak leg down to the step with the
crutches. Put total weight on arms and
crutches. Move strong leg to same step as
weak leg and crutches. Repeat for all steps.
17. Set realistic goals and opportunities To

forcollaborate with the physical therapist who is the
progressive ambulation using crutches. expert for crutch-walking techniques.
18. Consult with a physical therapist for clients

learning to walk with crutches.
19. Wash hands. To promote less turning, better stability, and increase
safety.
Sitting with Crutches
20. Instruct client to back up to chair until felt

with the back of legs. To promote safety.
Sitting with Crutches
21. Place both crutches in the non-dominant

hand and use the dominant hand to reach
To lessen pain and possible injuries.
back to the chair.
22. Instruct client to lower slowly into the chair.

See rationales 1 – 7.
Walking with a Cane

To promote safety, cooperation and client’s sense of
23. Repeat actions 1 – 7. autonomy.
24. Have the client hold the cane in the hand

opposite the affected leg. Explain the safety
and body mechanics underlying use of To apromote autonomy as well as increase upper body
cane on the strong side. strength.
25. Have the client push up from the sitting

position while pushing down on bed with
To allow client to gain balance.
arms.
26. Have the client stand at the bedside for

To aprovide for a better muscle strength and support
few minutes. than if the arm is straight.
27. Assess the height of the cane. With the
cane placed 6 inches ahead of the client’s
body, the top of the cane should be at wrist
To allow the nurse to provide stability.
level with the arm bent 25% to 30% at the
elbow.
28. Walk to the side and gently behind the

client, holding the gait belt if needed for
stability. To provide a wide base of support.
The Cane Gait
29. Move the cane and the weaker leg forward

at the same time for the same distance.
Place weight on the weaker leg and the
cane. Move the strong leg forward. Place
weight on the strong leg. To provide additional support as client lowers self into
the chair.
Sitting with a Cane
30. Have the client turn around and back up to

the chair. Have client grasp the arm of the
chair with free hand and lower self into the
chair. Be sure to place cane out of the way
but within reach.
To collaborate with the physical therapist who is the
31. Set realistic goals and opportunities for expert for crutch-walking techniques.
progressive ambulation using a cane.
learning to walk with cane.
See rationales 1 -7.
33. Wash hands.
Walking with a Walker To provide stability when the client is standing.
Repeat actions 1 – 7.
Place the walker in front of the client.

To encourage independence.
36. Have the client put the dominant hand on

the front bar of the walker or on the
handgrip for that hand, whichever is more
comfortable. Then, using the dominant
hand to push off from bed and the non- To maintain balance while transferring weight.
dominant hand for stabilization, help the
client to an erect position. To provide maximum support from arms while
ambulating.
37. Have the client transfer hand to the walker
handgrips.
38. Be sure the walker is adjusted so To theallow the nurse to provide greater stability or
handgrips are just below waist level and the assistance if the client needs.
client’s arms are slightly bent at the elbow.
39. Walk to the side and slightly behind the

client, holding the gait belt if needed for
stability. To provide support for a weak or nonweight-bearing leg
by using arm and upper body strength.
Walker Gait
40. Move the walker and the weaker leg

forward at the same time. Place as much
weight as possible or as followed on the
weaker leg. Move the strong leg forward
and shift the weight to the strong leg. To provide a more stable support.
Sitting with a Walker
41. Have the client turn around in front of chair

and back up until the back of the legs touch
the chair. Have client place hands on the
chair armrests, one hand at a time, and
then lower self into the chair using the
armrests for support. To collaborate with the physical therapist who is the
expert for crutch-walking techniques.
42. Set realistic goals and opportunities for
progressive ambulation using a walker. To reduce transmission of microorganisms.

learning to walk with a walker.
44. Wash hands.
1. The client was able to demonstrate safe and independent ambulation with the assistance of
crutches, a cane, or a walker.
2. The client was confident and safe while using the assistive device.
3. Document the type of device the client is using, the level of understanding regarding the use of
device, how far the client is able to walk using the device, and the client’s response to the activity.
CARE OF CLIENT WITH IMMOBILIZATION DEVICES
Adapted from Nettina (2010), Lippincott Manual of Nursing Practice 9th Edition
Adapted from Perry et al (2006) Clinical Nursing Skills & Techniques 6th Edition
1. DEFINITION
Immobilization Devices increases stability, support a weak extremity, or reduce the load on weight-
bearing structures such as hips, knees or ankles. Legs in an abducted position.
Splint
Immobilizes and protects a body part
Temporary Splint
Reduces pain and prevent tissue damage from further motion immediately after injury such as a fracture
or sprain. Examples are: Air splint, Thomas splint, and improvised splint
Slings
Are used to support splints, casts, or injured upper extremities
Abduction Splint
Used after hip replacement surgery, maintains the client’s.
Immobilizers (cloth & Foam splints)

Prevent pressure from the brace/ splint/ sling or Provides long-term immobilization. It treats sprains
and in a cast or dislocations that do not require complete and continuous immobilization in a cast or
traction. Often used following orthopedic surgery. Common types are cervical collar, (soft or hard),
belt-type shoulder immobilizers, and vinyl wrists forearm splints.
Delegation Considerations
1. Review the purpose of brace/ splint/ sling as it applies to the client.
2. Review correct application of the brace/splint/sling and positioning of any ties or straps
3. Review prescribed schedule of wear and activities permitted while in the brace/ splint/ sling
4. Instruct assistive personnel to alert the nurse if client complains of pain, rubbing, or if a change
occurs in client’s skin condition
II. EQUIPMENT
Brace/ splint/ commercially prepared sling or triangular bandage and safety pin
Cotton shirt or gown
ACTION RATIONALE
1. Expected outcomes following completion of

procedure:
a. Client’s skin remains in good condition

Indicates no friction or pressure from device that lead to
without circulatory impairment. skin breakdown or circulatory impairment
Encourage cooperation and minimizes risks and anxiety

b. Client/significant other verbalize purpose, of procedure.
correct application, and care of devices.
Indicates proper fit of device and permit safer
c. Client rates pain at 2 or less (scale 0 to 10). ambulation.
Reveals there are no changes in neurovascular status

d. Circulation and sensation distal to brace/ following application.
splint is maintained.
Demonstrates that proper immobilization promotes
e. Client uses the device correctly, including healing and safe ambulation without injury.
schedule of wear, activity limitations, and
positioning. Reveals that client is confident in abilities and willing to
try different strategies to enhance appearance.
f. Client demonstrates adjustment to
changes in physical appearance or
function.
Reduces transmission of microorganism
Applying Splint/ Braces/ Sling Teaching and demonstration enhance learning, reduce
anxiety and encourage cooperation.
Client’s position will depend on the type of brace/
2. Explain reasons for the brace/splint/sling, and splint/ sling being used. Upper-extremity
demonstrate how the device works. braces/splints/slings are applied best with the
client sitting upright. Lower extremity braces
3. Assist the client to a comfortable position, are applied best with client lying down.
preferably sitting or lying down.
This protects the skin, absorbs moisture, and keeps the
brace/splint/ sling clean.
4. Prepare the skin that will be enclosed in the

brace/ splint/ sling by cleaning the skin with
soap and water; rinse, pat, dry and change
any dressings (if present). If applying a back
brace, put a thin cotton shirt or gown on the
client. Ensure that there are no wrinkles
causing pressure.
Critical Decision Point

1. Instruct the client to inform the health care
provider if there is a feeling of pressure, pain,
numbness, rubbing, or if the skin becomes
reddened.
Proper application of brace/ splint/ sling is important to
2. Inspect the device for wear, damage, or rough avoid breakdown, pressure ulcers,
edges. neurovascular compromise, calluses, or
worsening of the deformity.
3. Apply the brace/ splint/ sling as directed by
physician, orthotist, physical therapist,Prevent
or trapping of blood distal to immobilization
occupational therapist. If securing splint with device.
elastic bandage:
a. Apply even tension as bandage for splint

is wrapped from distal to proximal.
b. Prevent padding from gathering This or position cradles the arm.
bunching.
4. If applying sling using triangular bandage:
a. Position one end of the bandage over the

shoulder of the unaffected arm.
b. Take the remaining bandage, and place

the material against the chest, then under
and over the affected arm, cradling the
arm. This prevents skin irritation to the back of the neck.
c. Position the pointed end of the triangle

toward the elbow.
d. Tie the two ends of the triangle at the

side of the neck.
e. Fold the pointed end of the sling at the

elbow in the front, and secure with Thisa prevents pressure on the radial artery, which can
safety pin closing the end of the sling. impair circulation.
f. Adjust the length of the sling by adjusting

the amount of material in the knot. Proper use of the brace/ splint/ sling will facilitate
healing and mobility and reduce pain and stress.
g. Ensure the sling supports the limb
comfortably without interfering with
circulation.
5. Teach the client the prescribed schedule of

wear and allowed activities while in Brace/ the splint/ sling may need to be adjusted.
brace/ splint/ sling as directed by physician,
physical therapist or occupational therapist.
Metal braces should be stored upright. Splint of molded
6. Reinforce the signs of skin breakdown, materials should be stored away from heat.
pressure or rubbing to report. Leather materials should be treated with a
leather preservative to prevent drying or
7. Teach the client how to care for the brace/ cracking. Most slings can be gently washed to
splint/ sling. remove any soiling.
8. Assist client with ambulating with brace/

This will determine if client is able to ambulate safely.
splint/ sling in place.
Promotes client independence; demonstration confirms
level of learning skill.
9. Have the client apply and remove the brace/

splint/. Client may need assistance with
application and removal of sling.
IV. EVALUATION
1. Inspect areas of the skin underneath the brace/ splint/ sling for sign of pressure, including redness
or breakdown.
2. Observe the client using the brace/splint/sling.
3. Ask the client to rate level of comfort while the brace/ splint/ sling.
4. Palpate pulse and test sensation of extremity distal to position of brace/ splint/ sling.
5. Ask the client/ family the ease with which ADLs are performed while wearing the brace/ splint/ sling.
6. Client states confidence in academic; physical and social abilities related to wearing immobilizing
device and is willing to try different strategies to enhance appearance.
Documentation
1. Document type of brace/ splint/ sling applied, schedule of wear, activity level and movement
permitted and client’s tolerance of procedure in progress notes.
2. Record specific assessment related to skin integrity and neurovascular status.
3. Document instructions given to client and family.
4. Record observations regarding client’s ability to apply, ambulate with, and remove the brace/splint/
sling.
5. Immediately report any injury sustained while using the brace/ splint/ sling.
BANDAGING A CLIENT
I. DEFINITION
Bandage – a strip of cloth used to wrap some part of the body. Bandages are available in various widths, most
commonly 1.5 to 7.5 cm (0.5 to 3 inches).
II. RATIONALE
1. To immobilize a joint.
2. To secure a dressing or piece of equipment in place (such as Bucks traction); position an extremity.
3. To apply pressure (example: elastic bandages apply pressure to the lower extremities to improve
venous blood flow).
4. To retain warmth (example: a flannel bandage on a rheumatoid joint).
III. EQUIPMENT
Clips, safety pins, or tape to secure the bandage in place
Bandage material as needed for the type of bandage to be used:

For an arm For a circular For a spiral For a spiral For a figure of For a recurrent
sling: wrap: wrap: reverse wrap: eight wrap: wrap:
Triangular 1 inch wide roll 1 inch wide roll 1 inch wide roll Elastic 1 inch wide roll
muslin cloth of gauze of gauze or of gauze or bandage of gauze
elastic elastic
bandage bandage
Safety pin Scissors Scissors Scissors

¼ inch tape ¼ inch tape ¼ inch tape ¼ inch tape ¼ inch tape
ACTION RATIONALE
1. Introduce yourself to the client and explain the

To reduce anxiety and apprehensions.
procedure.
2. Assess the area to be bandaged to determine

To determine the type of material to be used.
the bandaging materials needed.
3. Assess the skin to be bandaged for broken

To provide a means of comparison when the bandage
areas, redness, or swelling. is removed.
4. Apply the bandage.
APPLYING AN ARM SLING
1. Place the open sling across the client’s chest

To reduce anxiety and apprehension.
with the apex of the triangle extending beyond
the client’s elbow on the affected side.
2. Place the upper point of the triangle across the

To determine the type of material to be used.
client’s clavicle on the unaffected side and
behind the client’s neck.
3. Help the client to position his or her arm at an
To prevent dependent edema in the hands and fingers.
80-degree angle.
To provide support for the forearm and hand.
4. Bring the sling over the client’s forearm and
hand.
To allow the sling to be tied around the client’s neck.
5. Extend the lower point of the sling around the
client’s neck on the affected side. To ensure adjustments in the angle of the arm.
6. Reassess the angle of the client’s arm. To prevent the sling from becoming loose. This knot
prevents pressure and discomfort at the
7. Secure the sling with a square knot or safety client’s neck.
pin at a point on the upper anterior chest wall.
To enclose the client’s elbow with the extra material.
8. Fold the remaining cloth extending from the To promote comfort.

client’s elbow and secure it with a safety pin.
To ensure the sling is providing support to the arm and
9. Place padding under the knot if needed. prevents pressure on the device.
10. Inspect the clavicle area and check the angle of

the client’s arm.
APPLYING A BANDAGE USING CIRCULAR TURNS To promote ease in applying pressure.
1. Hold the roll of gauze in your dominant hand.

To allow the gauze to be applied smoothly.
2. Place the flat surface of gauze on the anterior
surface to be bandaged.
To provide even pressure to the body part being
3. Unroll the gauze. Overlap and circle it two bandaged.
times around the digit or wrist being
bandaged.
4. Cut the gauze with scissors.

To keep the gauze from unrolling.
5. Fold the end under.
6. Secure the end of the gauze with tape.
APPLYING A BANDAGE USING SPIRAL TURNS To secure the bandage in place.
1. Circle the bandage two times around distal

end of the body part being bandaged. To allow the entire area to be covered.
2. Apply the dressing from the distal to the

proximal border by overlapping the previous
turn one-half to three quarters the width of
the bandage. To prevent uneven pressure from the excess bandage
material.
3. Cut the end of the bandage with scissors.
To keep the bandage from unrolling.
4. Secure the dressing in place.
APPLYING A BANDAGE USING SPIRAL REVERSE

TURNS To anchor the bandage.
1. Circle the bandage two times around the distal

end of the body part being covered.
2. Apply the bandage from the distal border to
the proximal border at a 30-degree angle. To hold the bandage in place.
To form the “reverse” spiral portion of the dressing.
3. Placing your thumb on the anterior surface of
To cover the bandage.
the bandage.
4. Folding the bandage onto itself so the folded
edges form an inverted “V”. To secure the bandage.
5. Wrapping the bandage around the posterior
aspect of the body part.
6. Complete the bandaging with two circular

To keep the bandage from unrolling.
turns.
7. Secure the dressing with tape.
APPLYING A BANDAGE USING THE FIGURE OF

To secure the bandage.
EIGHT TURN
1. Circle the bandage two times around the distal

To form the top of the figure of eight.
end of the body part being bandaged.
2. Advance the bandage above the joint and To form the bottom of the figure of eight.
circle it around the posterior aspect of the
joint.
To ensure entire joint is covered for support.
3. Bring the bandage down. Cross over the
anterior aspect of the joint.
4. Continue wrapping the bandage above and To secure the bandage in place.
below the person’s joint to form the figure of
eight turns until the joint is completely
wrapped. To keep the dressing from loosening.
5. Complete the bandaging with two circular

turns.
6. Secure the dressing with tape.

To secure the bandage in place.
APPLYING A BANDAGE USING RECURRENT TURNS
1. Wrap the bandage around the proximal area To

in allow the head to be covered evenly and smoothly.
two circular turns.
2. In the center front, make a reverse turn and

advance the gauze towards the back of the
body part being covered and end in the center
back.
3. Reverse the turn in the back and advance the

gauze over the body part being covered,
ending in the center front.
4. Continue the reverse turns until the entire
body part is covered.
5. Complete the procedure with two circular

turns.
To communicate the findings to other members of the
6. Secure dressing with tape. health care team and contribute to the legal
record by documenting the care given to the
client.
7. Record the procedure and include your
evaluation.
V. EVALUATION
1. The bandage is applied in a smooth manner with even pressure to the body part.
2. The client is comfortable and does not have any signs of nervous impairment such as pain,
numbness, or tingling of the bandaged area or areas distal to the bandage.
PERFORMING BREAST EXAMINATION
Adapted from Altman (2010), Fundamentals & Advanced Nursing Skills, 3 rd Edition
I. DEFINITION
Breast Examination - an inspection or an investigation of the breast as a means of diagnosing abnormalities or

diseases
II. RATIONALE
a. To detect abnormalities in the breast

b. To teach the client how to perform breast self-examination
III. EQUIPMENT
A good lamp
ACTION RATIONALE
1. Review personal history, medications,

allergies, and family health history.
To identify risk factors and previous baseline (or
lack of). Identifies allergies to latex.
2. Ask the client to disrobe to the waist and put

To provide easy access while maintaining
on a gown with opening in the front. maximum privacy.
3. Wash hands. Apply glove if required To

by prevent microorganism transfer and possible
institutional policy. contact with discharge when palpating
nipples.
4. Assist the client to a sitting position facing

To allow comparison of breast bilaterally.
you and expose chest and breast.
5. Inspect breast, areola, and nipples: To observe for flesh color, slight inequities in size
- With client’s arms at sides and symmetry, rounded shape, and
- With client’s arms raised smooth skin surface.
- With client’s hands pressed on hips
- With client’s arms extended straight
Redness, blue hue, retraction, dimpling, enlarged
ahead as client leans forward (may omit
this position for male unless pores, edema, lumps, lumps, lesions,
gynecomastia is present) rashes, ulcers, and discharge are
abnormal. Supernumerary nipples along
the milk line are a normal variant.
6. Palpate adjacent lymph nodes;

To check if nodes is less than 1 cm in diameter
supraclavicular, infraclavicular, and and nontender.
subclavian
7. Palpate breast: Using the pads of the palmar

To observe the breast for warm temperature,
surfaces of the fingertips, palpate the right elasticity, tenderness, pain, erythema,
breast by gently compressing the mammary masses or nodules which are abnormal.
tissues against the chest wall. Palpation may
be performed from the periphery to the
nipple, in either concentric circles or in
wedge sections.
Explain the procedure to the client as you examine.
8. Teach breast examination as you examine. To teach the client during the examination and
Teach the client to use the right hand to reinforces the need for and
palpate the left breast and the left hand to understanding of breast exams and
palate the right breast. During part of the enables the client to identify normal
exam, place the client’s fingers under the breast tissue and abnormal tissue if
practitioner’s fingers. present.
To increase the client’s confidence in performing

breast examination.
9. Palpate areola and nipple by using a similar
To observe for any abnormalities such as
circular technique as with breast. Pay inflammation discharge, nodules,
special attention to sub- areolar area and fissuring, or lesions.
gently press the nipple between your
fingers.
10. Palpate into axilla, starting at anterior

To identify posterior axillary, central axillary,
axillary line and continuing at an angle to anterior axillary and lateral axillary node
the midaxillary line and up into the axilla locations. Nodes should be less than 1
(using same circular fingertip motion). cm and nontender.
Have client place arm at side and palpate
deep into the axilla.
11. Repeat action 7 to 9 on the left breast,

To identify normal versus abnormal as with the
nipple, and axilla. right breast. Compare breast bilaterally.
12. Assist the client to the supine position.

To position, spreads breast tissue over the chest
Place arm on examination side under head wall, maximizing palpation accuracy.
and place a small pillow under the same
side scapula.
13. Palpate breast, areola and nipple asToinreevaluate examination in second position.
Action 7 to 10.
14. Assist the client to a sitting position.

To provides more comfort for client. Evaluate
Review the steps and ask the client to success of your teaching.
return-demonstrate breast self-
examination.
15. Allow client to dress. To provide comfort.
16. Remove gloves and wash hands. To reduce transmission of microorganisms.

17. Give the client written materials To to reinforce teaching. To provide a readily
reinforce teaching. Instruct the client available form to client for reference
when to schedule the next clinical when at home.
examination.
1. Client is able to perform monthly breast examination.

2. Client returns for clinical breast examination at prescribed time.
3. Any abnormalities are identified early for referral evaluation and possible treatment.
4. Record the date and time.
5. Document findings of abnormalities and absence of abnormalities
6. Record the client’s response to findings and teaching.
7. Record a follow-up plan, if necessary.
TEACHING THE CLIENT BREAST SELF-EXAMINATION
I. DEFINITION
Breast Self- Examination
Is the inspection and palpation of the breast following a guided procedure.
This is done by the client herself.

II. RATIONALE
To detect early any abnormalities in the breast resulting to a greater chance of cure and less complex treatment.
III. EQUIPMENT
Mirror
Special Consideration
1. All women 20 years of age and older need monthly breast self-examination even after menopause.
2. Cancer of the breast is one of the leading causes of death among women.
3. Breast self-examination is ideally done one week following menstruation.
4. Proper explanation to the client of the importance of this procedure must be done.
5. Clients must be instructed to promptly report any changes noted to the health care provider.
Implementation
Inspection before a mirror
Look for any change in the size or shape; lumps or thickenings; any rashes or other skin irritations; dimpled or
puckered skin; any discharge or change in the nipples (e.g. position or asymmetry). Inspect the breasts
in all of the following positions:
a. Stand and face the mirror with your arm relaxed at your sides or hands resting on the hips; then turn
to the right and the left for a side view (look for any flattening in the side view).
b. Bend forward from the Waist with arms raised over the head.
c. Stand straight with the arms raised over the head and move the arms slowly up and down at the
sides. (Look for free movement of the breasts over the chest wall.)
d. Press your hands firmly together at chin level while the elbows are raised to shoulder level.
Palpation: Lying position
a. Place a pillow under your right shoulder and place the right hand behind your head. This position
distributes breast tissue more evenly on the chest.
b. Use the finger pads (tips) of the three middle fingers (held together) on your left hand to feel for
lumps.
c. Press the breast tissue against the chest wall firmly enough to know how your breast feels. A ridge
of firm tissue in the lower curve of each breast is normal.
d. Use small circular motions systematically all the way around the breast as many times as necessary
until the entire breast is covered. (Refer to illustrations in Performing Breast examination)
e. Bring your arm down to your side and feel under your armpit, where breast tissue is also located.
f. Repeat the examination on your left breast, using the finger pads of your right hand.
Palpation: Standing or Sitting
a. Repeat the examination of both breasts while upright with one arm behind your head. This position
makes it easier to check the area where a large percentage of breast cancers are found, the upper
outer part of the breast and toward the armpit.
b. Optional: DO the upright BSE in the shower. Soapy hands glide more easily over wet skin.
1. Client’s performance
2. Significant findings as claimed by the client
ASSISTING MALE CLIENTS IN EXAMINATION
Adapted from Altman (2010), Fundamentals & Advanced Nursing Skills, 3 rd Edition
I. DEFINITION
A prostate exam is a physical examination of the prostate gland of a male. The prostate gland is a gland that
surrounds the duct that connects the male genitalia to the bladder. The main function of the gland is to
produce and store seminal fluid, which is why it is found only in males. The gland is prone to various
cancers and the exam thus attempts to detect those conditions.
II. RATIONALE
1. To examine rectum for any abnormalities e.g.: neoplasm, hemorrhoids, polyps, fistula, fissure or
faecal impaction.
2. To aid in diagnosis of acute appendicitis, enlarged prostate and pelvic disorders.
III. EQUIPMENT
Disposable gloves Equipments – protoscope, forcep e.g., sponge holding

forcep, probe - optional
Lubricant Specimen container if needed
Protective sheet Clinical waste
Tissue paper/gauze Domestic waste
Torch light
IV. IMPLEMENTATION
ACTION RATIONALE
Penile Examination
1. Ask then client to disrobe completely and

To provide easy access for the exam.
to put on a gown.
2. Explain the procedure to the client To decreases the client’s anxiety level.
3. Wash hands and apply clean gloves. To perform clean technique.
4. Have the client stand and hold up his gown

To provide best exposure for examination.
to expose the genitalia.
5. Inspect the penis and pubic hair To check skin color: tanner stage in boys; note
distribution. Check the skin at the base of size, color, integrity (lesions, rash, and
the penis for rash, lesion, nits or lice. pustules).
6. Retract, or have the client retract, the

To determine uncircumcised male client will
prepuce (foreskin), if present. have foreskin of the glans, which
should be easily retracted. It is
necessary to retract the prepuce to
detect chancres or carcinoma.
Smegma, a cheesy secretion, may
accumulate normally under the
foreskin.
7. Observe the glans penis and the urethral To take note that the skin of the glans penis
meatus. Open the urethral meatus by should be smooth and without
compressing the glans gently between ulceration. The urethral meatus is
your index finger above and thumb below. normally located ventrally on the end of
Note the location of the urethral meatus the penis. There is normally no
as well as any discharge, ulcers, scars, discharge. If discharge is present,
nodules, lesions or signs of inflammation. obtain a culture for gonorrhea and
Chlamydia.
8. Palpate the entire length of the penis

To assess for any tenderness, induration, or
between your thumb and the first two masses. Palpation of the shaft may be
fingers. omitted in a young asymptomatic client.
Replace the foreskin, if retracted,
before continuing with the exam.
Scrotal Examination
9. Inspect the scrotum for erythema, To check abnormalities in the scrotum can be
discoloration, swelling and skin integrity. indicative of local trauma,
inflammation, hernias, or systemic
conditions, such as heart or renal
failure.
10. Elicit the cremaster reflex on both sides. To check for the presence or absence of this
reflex. It may be the most sensitive
physical finding for torsion of the
testicle. It is performed by gently
stroking or pinching the superior
medical aspect of the thigh, resulting
in brisk ipsilateral testicular torsion or
retraction.
11. Palpate each testis and epididymis To evaluate if the left testicle normally sits
between the thumb and first two fingers. slightly lower than the right testicle.
Note their size, lie (high or low within the The testicles are rubbery and
scrotum), shape, consistency, and approximately equal in size.
tenderness. The length of a normal testis
should be greater than 4cm and the
volume greater than 20 ml. Pressure on the testis normally produces a deep
visceral pain. Twisting or torsion of the
testis causes venous obstruction,
edema, and eventually arterial
obstruction (rarely seen in clients older
than 20-30 years of age). It is a
Note: Testicular Torsion is a Surgical Emergency. significant cause of sterility and
morbidity in men.
12. Palpate each spermatic cord, including the To assess for any swelling in the scrotum.
vas deferens within the cord, between Shine a beam of light (flashlight) from
your thumb and fingers from the behind the scrotum through the mass.
epididymis to the inguinal ring. Note any Normal testes do not transilluminate.
nodules or swelling. Look for transmission of light as a red
glow: swellings that contain serious fluid
(hydrocele, spermatocele)
transilluminate.
Hernia Examination
13. Inspect the inguinal and femoral areas. To assess if there is a bulge that presents
Ask the client to strain down or cough on straining suggests a hernia.
while you continue your observation.
14. Palpate for a femoral hernia by placing To determine presence of lymph nodes.
your fingers on the anterior thigh in the Small (1.0cm), freely mobile lymph nodes
region of the femoral canal. Ask the client may normally be found in the inguinal
to bear down or cough as you note any area.
palpable masses, tenderness or swelling.
15. Palpate for an inguinal hernia. Using your To assess if present, a herniating mass
right hand for the client’s right side and will generally be felt against the side of
your left hand for the client’s left side, just the finger.
above the testicle, invaginate the loose
scrotal skin with your index finger. Follow
the spermatic cord upward to find a
triangular slit-like opening of the external
inguinal ring. If the inguinal ring is
enlarged enough to admit your finger,
then gently follow the inguinal canal and
ask the client to cough. Note any
herniating mass felt against the finger.
Rectal Examination
16. If the client is standing after the To position the client for ease of
completion of the genital examination, examination.
have him bend and lean on the exam table,
with legs slightly apart, exposing the
rectum to the examiner. OR:
Ask the client to lie in a lateral decubitus position,
on his left side, placing his buttocks close
to the edge of the table nearest the
examiner. Flex the client’s hips and knees
to stabilize the client and improve
visibility.
17. Provide a warm, quite environment with To decrease the client’s anxiety and provides
appropriate lighting. Drape the client so privacy. Gentle, slow movement of
that only his buttocks are exposed. Explain the examiner’s finger accompanied
the procedure to the client. by explanation and a calm demeanor
will ensure a successful exam.
18. Wash hands and apply clean gloves. To prevent spread of microorganism.
19. Spread apart the buttocks and examine theTo assess adult perianal skin; normally more
anus, perianal area, and sacral region for pigmented and coarser than the skin
any scars, lesions, nodules, inflammation, over the buttocks.
ulcerations, or abnormalities. Ask the
client to bear down as you assess for any
bulges. As the client strains down, note any tissue
protrusions or hemorrhoids.
Reassure the client that sensations of
urinations and defecation are
normal.
20. Lubricate the gloved index finger. Ask the

To ease in the insertion. The anal canal is
client strains down, rest the pad of the approximately 2.5 cm long. It is
finger over the anus. As the sphincter bordered by the external and internal
relaxes, slowly insert the finger into the anal sphincters, which normally are firm
anal canal, with the finger facing the and smooth.
umbilicus. Note sphincter tone and any
masses, nodule, or tenderness.
21. Insert the finger as far as possible into the

To assess the wall of the rectum, it should be
rectum. Rotate your hand to palpate the smooth and moist.
walls of the rectum laterally and
posteriorly while rotating your index
finger.
22. Anteriorally palpate the two lobes of the To inform the client that he may feel the urge to
prostate gland and its sulcus. Note the urinate when you examine the prostate,
size, shape, and consistency of the that this is a normal sensation, and that
prostate as you identify any irregularities he will not void.
such as nodules, masses, or tenderness.
The male prostate gland is approximately 2.5 cm

long. It is smooth, nonmovable,
nontender, and rubbery to the touch.
23. If possible, extend your finger above the To assess for presence of swelling. Note for
prostate region and palpate the superior nodules, cysts or tenderness.
portion of the lateral lobe to the region of
the seminal vesicles and the peritoneal
cavity.
24. Gently withdraw your finger. Note the To assess for any abnormalities
color of any fecal material on your glove
and test for occult blood.
25. Offer the client tissue or wipe excess To provide client comfort.
lubricant/ stool from anus.
1. Any abnormalities are identified early for treatment and/or referral evaluation.
2. The client is able to perform monthly testicular self-examinations
3. The client returns to his health care provided for regular checkups.
4. Record the date and time of the examination.
5. Include the client’s physiologic findings of abnormalities and absence of abnormalities.
6. Record the client’s response to the findings.
7. Document instruction and return demonstration of testicular self-examination.
8. Record a follow-up plan, if necessary.
TEACHING THE CLIENT TESTICULAR SELF-EXAMINATION
I. DEFINITION
Testicular Self-Examination is the inspection and palpation of the scrotum and testicles. This is done by the
client himself.
II. RATIONALE
To detect testicular abnormalities early and therefore allow a greater chance of cure.
III. EQUIPMENT
Mirror
Special Consideration
a. All males 15 years and older should develop the habit of doing testicular self-examination once a
month.
b. It may be wise for both may and female nurses to request permission from a parent or guardian
before teaching testicular self-examination to teenage boys.
c. The best time to perform this procedure is after a shower when the scrotum is warm and relaxed
and testicles are easier to examine.
d. Explanation of the importance of the procedure should be done to the client before teaching this
procedure.
e. Instruct clients to report immediately to the health care provider any changes or findings noted.
Implementation
1. Choose one day of each month (e.g., the first or last day of each month) to examine yourself.
2. Examine yourself when you are taking a warm shower or bath.
3. Support the testicle underneath with one hand. Place the fingers of the other hand under the
testicle and the thumb on top. (This may be easier to do if the leg on that side is raised.
4. Roll each testicle between the thumb and fingers of your hand, feeling for lumps, thickening, or a
hardening in consistency.
5. Palpate the epididymis, a cordlike structure on the top and back of the testicle. The epididymis
should feel soft and not as smooth as a testicle.
6. Locate the spermatic cord, or vas deferens, which extends upward from the scrotum toward the
base of the penis. It should feel firm and soft.
7. Using a mirror, inspect your testicles for swelling, any enlargement, or lumps in the skin of the
testicle.
1. Client’s performance
2. Any lumps or changes as claimed by the client.
ASSISTING IN PELVIC EXAM/ PAP SMEAR
I. DEFINITION
Papanicolau Test/ Pap Smear involves scraping secretions from the cervix, spreading them on
the slide, and immediately coating the slide with fixative spray or solution to preserve specimen cells for
nuclear staining. Pap smear also permits cytologic evaluation of the vaginal pool.
II. RATIONALE
1. To assess the pelvic cavity for the presence of conditions which include signs of inflammation,
irritation, ulceration, infection, or any discharges.
2. To evaluate cervicovaginal cells for pathology that might indicate cancer.
3. To detect cervical cancer early
III. EQUIPMENT
Bivalve vaginal speculum Fixative ( a commercial spray or 95% ethyl alcohol

solution)
Gloves Adjustable lamp
Pap Stick (wooden spatula) Drape
Long cotton tipped applicator Laboratory request forms
Three glass microscope slides Laboratory biohazard transport bag
Preparation of Equipment
1. Select a speculum of the appropriate size, and gather the equipment in the examining room
2. Label each glass slide with the patient’s name, and the letter “E”, “C”, or “V” to differentiate
endocervical, cervical and vaginal specimens.
IV. IMPLEMENTATION
ACTION RATIONALE
1. Explain the procedure to the patient and

To gain cooperation. To prevents the spread of
wash your hands. microorganism.
2. Place the client in the lithotomy position To facilitate relaxation of the abdominal
muscles and visualization of pelvic
cavity and external genitalia.
3. Drape the client by covering her abdomenTo provide privacy.

extending her legs, exposing only the part
to be examined.
4. Perform perineal washing applying the

To eliminate or lessen the presence of
nine strokes. microorganisms on the part to the
examined.
5. Wear sterile gloves. To minimize the spread of microorganisms.
6. Inspect the external genitalia. To check for presence of irritation, inflammation

or redness in the surrounding genitalia.
7. Press the anterior wall of the vagina with

To assess the Skene’s glands.
your finger.
8. Palpate the Bartholin’s glands at 5 to To

7 assess the Bartholin’s glands.
o’clock applying a little pressure on the
site.
9. Request the client to bear down. While To assess for the presence of rectocele or
the client is bearing down, separate the cystocele.
labia with your fingers to view the vaginal
walls.
10. Lubricate the vaginal speculum with To prevent inaccurate result (Lubricant can
warm water rather than lubricating jelly if interfere with cytologic studies). Warm
a specimen is to be taken. water is used to prevent contraction of
the vaginal muscles.
11. Insert the index and middle fingers of the

To prevent discomfort on the part of the client.
nondominant hand 2.5 cm into the vaginal
entrance. Spread these fingers and exert
pressure down on the posterior wall.
12. Hold the speculum in the opposite hand

with the blades between curled index and
middle fingers.
13. Ask the client to bear down. To help to open the vaginal orifice more and to
relax the perineal muscles.
14. Insert the speculum obliquely and To facilitate the insertion. and prevents trauma
downward at a 45-degree angle toward to the vaginal wall.
the posterior wall with the blades in closed
position. (The crease of the blades is
directed to 4 to 8 o’clock).
15. Rotate the speculum slowly to horizontal

To facilitate easy visualization of the cervix.
position
16. Open the blades of the speculum and

To steady the open position of the speculum for
tighten the screw at the side. easy visualization of the pelvic cavity
17. Assess the cervix and record the

following:
a. Shape of the os.
b. Color
c. Size
d. Position
e. Surface Characteristics.
To differentiate the normal from the
f. Discharges
normal.
18. Obtain a specimen for Pap smear. To further assess.
19. Remove the speculum by loosening the

To prevent discomfort on the part of the client.
screw, and closing it back to oblique
position.
20. Dispose of equipment appropriately. To prevent the spread of microorganism.
21. Remove the drape. Clean and dry the To provide comfort.
client’s perineum. Assist her as needed
to a sitting position on the examining
table.
1. Normal and abnormal findings.

2. Date and time the procedure was done.
3. Person who performed the procedure.
PRACTICING SAFETY BARRIERS IN CHEMOTHERAPY
Adapted from Nettina (2010), Lippincott Manual of Nursing Practice 9 th Edition
I. DEFINITION
Chemotherapy is the use of antineoplastic drugs to promote tumor cell destruction by interfering with
cellular function and reproduction.
It includes the use of various chemotherapeutic agents and hormones.
II. RATIONALE
1. To reduce exposure of the nurse when handling the drug.

2. To handle and prepare drugs in a class II biological safety cabinet.
III. EQUIPMENT
Prescribed drug or drugs IV solution
Patient medication record and chart Diluent if necessary
Long sleeve-gown Compatibility reference source
Latex powder-free surgical gloves Medication labels
Face shield or goggles Class II biological safety cabinet
Eyewash Disposable towel
Plastic absorbent pads Hydrophobic filter or dispensing pin
Sterile gauze pads 18g needle

Shoe covers Syringes and needles of various sizes
Impervious containers labeled CAUTION: IV tubings with luer-lock fittings

BIOHAZARD for disposal of any unused drug
or equipment
IV controller pump (if available)
Chemotherapeutic Spill Kit
Water-resistant, nonpermeable, long-sleeved gown Two disposable pads puncture proof, leak-
with cuffs and back closure proof container labeled
BIOHAZARD WASTE
Container of desiccant powder or granules Container of 70% alcohol for cleaning the
spill area
( to absorb wet contents)
Two pairs of gloves (for double gloving) Plastic scraper (for collecting broken glass)
Goggles Plastic backed or absorbable towels
Mask Shoe covers
Disposable dustpan
Preparation
1. Verify drug, dosage, and administration route.

2. Make sure you know the immediate and delayed adverse effects.
3. Follow administration guidelines.
IV. IMPLEMENTATION
ACTION RATIONALE
1. Wash hands before and after preparationTo prevent spread of microorganism

and administration
2. Assess patient’s physical condition and

medical history.
3. Determine best site to give drug. To avoid extravasation.
4. Continuous infusion of a vesicant drug

should be done through a central venous line
or a vascular access device.
Alert: Don’t mix chemotherapeutic drugs with other drugs. If you have questions or concerns,
talk with the physician or pharmacist before giving the drug.
5. Double- check chart for the complete To prevent errors.

chemotherapy protocol order, including
patient’s name, drug’s name, dosage, route,
rate, and frequency of administration.
6. Wear gloves through all stages of handling the

drug.
7. Before giving drug, perform a new venipuncture

proximal to the old site.
Alert:
Avoid using an existing IV line. Never test vein patency with a chemotherapeutic drug.
If you suspect extravasation, stop infusion immediately. Leave IV catheter in place and notify physician.
A. Managing Extravasation
Extravasation
The infiltration of a vesicant drug into the surrounding tissue – can result from a punctured vein or
leakage around a venipuncture site. There is presence of local tissue damage, may cause prolonged
healing, infection, and cosmetic disfigurement and loss of function and may necessitate multiple
debridement and possible amputation.
Equipment
Ice pack
Warm compress
Implementation
ACTION RATIONALE
1. Stop the IV flow, aspirate the

remaining drug in the catheter, and
remove the IV line, unless there is a
need for the needle to infiltrate the
antidote.
2. Estimate the amount of extravasated

solution and notify the physician.
3. Instill the appropriate antidote

according to facility’s protocol.
4. Elevate the extremity.
5. Record the extravasation site, patient’s

symptoms, estimated amount of
infiltrated solution and treatment.
Include the time you notified the
physician and the physician’s name.
Continue documenting the appearance
of the site and associated symptoms.
6. Depending on facility’s protocol, apply

either ice packs or warm compresses
to the affected area. Ice pack applied
to all extravasated areas for 15-20
minutes every 4-6 hours for about 3
days. For etoposide and vinca
alkaloids, heat is applied.
To prevent further tissue damage and injury.
7. If skin breakdown occurs, apply

dressing as ordered.
8. If severe tissue damage occurs, plastic

surgery and physical therapy may be
needed.
Patient Teaching
1. Teach the patient about possible adverse reactions to chemotherapy.

2. Let the patient know that the drug can be given to treat some of the adverse reactions.
3. Explain to the patient the type and sequence of drugs he’ll receive
B. Disposal of supplies and unused drugs

ACTION RATIONALE
a. Do not clip or recap needles or breakTo avoid needle prick injuries

syringes
b. Place all supplies used intact in a leak proof,

puncture proof container. Label
appropriately
To prevent aerosolization/ spillage of drug.
c. Dispose of containers filled with

chemotherapeutic supplies and unused
drugs in accordance with regulations of
hazardous wastes.
C. Management of chemotherapeutic spills
Chemotherapy spills should be cleaned up immediately by properly protected personnel trained in the
appropriate procedure. A spill should be identified with a warning sign so that other person will not
be contaminated.
Spill on hard surface
1. Restrict area of spill

2. Obtain drug spill kit
3. Put on protective gown, gloves, goggles
4. Open waste disposal bags
5. Place absorbent pads gently on the spill; be careful not to touch spill.
6. Place absorbent pad in waste bag
7. Cleanse surface with absorbent towels using detergent solution and wipe clean with clean tap
water.
8. Place all contaminated materials in the bag.
9. Wash hands thoroughly with soap and water.
Spill on personnel or patient
1. Restrict area of spill

2. Obtain drug spill kit
3. Immediately remove contaminated protective garments or linen
4. Wash affected skin area with soap and water
5. If eye exposure-immediately flood the affected eye with water for at least 5 mins., obtain medical
attention promptly
6. Notify the physician if drug spills on patient
7. Document the spill
1. Document drug dosage, site and any occurrence of extravasation including estimated
amount of drug,
2. Indicate needle type and size

3. Report amount and type of flushing solution
4. Describe site’s condition after treatment
5. Document adverse reactions.
6. Note patient’s tolerance of treatment
7. Record topics discussed with patient and family
PRACTICING SAFETY BARRIERS IN RADIATION
I. DEFINITION
Radiation therapy (also called radiotherapy is the treatment of benign and malignant diseases with ionizing
radiation.
II. RATIONALE
1. To deliver a precisely measured dose of irradiation to a defined tumor volume with minimal
damage to surrounding healthy tissues
2. To allow effective palliation or prevention of symptoms of cancer,with minimal morbidity.
III. EQUIPMENT
Film badge or pocket dosimeter long-handled forceps
RADIATION PRECAUTION sign for door male T-binder and two sanitary napkins with
safety pin (if Burnett applicator is
being used)
RADIATION PRECAUTION Optional: lead shield and lead strip.
warning label
masking tape lead-lined container
Preparation of equipment
1. Place the lead-lined container and long-handled forceps in a corner of the patient's room.
2. Mark a safe line on the floor with masking tape
i. (1.8 m) from the patient's bed to warn visitors to keep clear of the patient to minimize
their radiation exposure.
3. If desired, place a portable lead shield in the back of the room to use when providing care.
4. Place an emergency tracheotomy tray in the room if an implant will be inserted in the oral cavity or
neck.
IV. IMPLEMENTATION
ACTION RATIONALE
1. Explain the treatment and its goals to

the patient. Before treatment begins,
review radiation safety procedures, To prepare the patient thus increasing tolerance
visitation policies, potential adverse to the drug.
effects, and interventions for those
effects. Also review long-term concerns
and home care issues.
2. Place the RADIATION PRECAUTION sign

To avoid exposure to radiation
on the door
3. Check to see that informed consent has To minimize administration errors.

been obtained.
4. Ensure that all laboratory tests are

performed before beginning treatment.
5. Affix a RADIATION PRECAUTION warning

label to the patient's identification
wristband.
6. Affix warning labels to the patient's

chart and Kardex
7. Wear a film badge or dosimeter at waist

To minimize exposure to radiation, use the
level during the entire shift. three principles of time, distance, and
shielding. Each nurse must have a
personal, nontransferable film badge or
ring badge.
8. Provide essential nursing care only; omit

bed baths. If ordered, provide perineal
care, making sure that wipes, sanitary
pads, and similar items are bagged
correctly and monitored. (Refer to
facility's radiation policy.)
9. Dressing changes over an implanted

area must be supervised by the
radiation technician or another
designated caregiver.
10. Before discharge, a patient's

temporary implant must be removed
and properly stored by the radiation
oncology department
A. Ensuring Protection from Radiation
ACTION RATIONALE
1. To avoid exposure to radiation while the

patient is receiving therapy, consider the
following:
a. Time – exposure to radiation is
directly pproportional to the time
spent within specific distance to the
source.
b. Distance – amount of radiation
reaching a given are decreases as
resistance increases.
c. Shield – Sheet of absorbing material
placed between the radiation source
and the nurse decreases the amount To avoid exposure to radiation
of radiation exposure.
2. If exposed to penetrating radiation To prevent further contamination.

(X-ray or gamma rays), wear film
badges on the front of the body.
3. Take appropriate measure To follow directives on precautions.

associated with sealed sources of
radiation implanted within a patient
(sealed internal radiation)
4. Do not linger longer than necessary To protect self from exposure.

in giving patient care, even though
all precautions are followed.
5. After the patient is discharged fromTo properly dispose all remaining materials
the facility, it is a good policy for the contaminated with radiation.
radiologist to check the room with a
radiograph or survey meter to be
certain that all radioactive materials
have been removed.
Special considerations:
1. Nurses and visitors who are pregnant or trying to conceive or father a child must not attend patients
receiving radiation implant therapy
2. If the patient must be moved out of his room, notify the appropriate department of the patient's
status to give receiving personnel time to make appropriate preparations to receive the patient.
3. The patient's room must be monitored daily by the radiation oncology department, and disposables
must be monitored and removed according to facility guidelines.
4. If a code is called on a patient with an implant.
- Notify the code team of the patient's radioactive status
- Notify the radiation oncology department
- Cover the implant site with a strip of lead shielding if possible
- Don't allow anything to leave the patient's room until it's monitored for radiation
- The primary care nurse must remain in the room
5. If an implant becomes dislodged, notify the radiation oncology department staff and follow their
instructions. Typically, the dislodged implant is collected with long-handled forceps and placed in a
lead-shielded canister.
6. Tell the patient who has had a cervical implant to expect slight to moderate vaginal bleeding after
being discharged.
7. Refer the patient for sexual or psychological counseling if needed.
8. If a patient with an implant dies on the unit, notify the radiation oncology department so they can
remove a temporary implant and store it properly.
9. If the implant was permanent, radiation oncology staff members will determine which precautions to
follow before post-mortem care can be provided and before the body can be moved to the morgue.
1. Document drug dosage, and monitor for any adverse reaction.

2. Radiation precaution maintained
ASSISTING IN TRACHEOSTOMY INSERTION
Adapted from Wiegand et al (2005), ACCN Procedure Manual for Critical Care, 5 th Edition
Adapted from Acello (2007), Advanced Skills for Health Care Providers, 2 nd
I. DEFINITION
Tracheostomy - is a surgically created opening in the trachea through the second, third or fourth
tracheal ring to allow ventilation when there is an upper airway obstruction. It may be permanent or
temporary.
II. RATIONALE
1. To facilitate prolonged artificial ventilation

2. To facilitate removal of excessive or tenacious respiratory secretions
3. To prevent aspiration of blood secretions such as food into the lungs
4. To bypass serious upper respiratory obstruction
5. To prevent easier access to lower airways if not possible through the nose or mouth
III. EQUIPMENT
Tracheostomy tube (size 6 to 9 mm for mostShave prep kit

adults)
Sterile instrument: hemostat, scalpel and blade,Resuscitation bag and mask with oxygen
forceps, suture material, scissors source
Sterile gown and drapes, gloves Local anesthetic and syringe
Cap and face shield Sedation
Antiseptic prep solution Suction source and catheters
Gauze pad Respiratory support available for post-

tracheostomy (mechanical
ventilation, tracheal oxygen
Syringe for cuff inflation (5ml) mask, CPAP, T-piece)
Parts of a Tracheostomy Tube

1. Outer tube – the tube that is inserted into the windpipe
2. Inner tube - Fits inside the outer tube; removed for cleaning or replacement.
3. Neck Flange - Flat plastic plate attached to outer tube; has holes on either side for securing neck ties.
4. 15mm outer diameter connector - Fits all ventilator and respiratory equipment.
5. Obturator - a guide used to insert the tracheostomy tube
All remaining features are optional:
1. Cuff – balloon on the end of the tracheostomy tube; forms a seal against the windpipe
2. Air inlet valve – where the syringe is connected to inflate or deflate the cuff.
3. Air inlet line – thin plastic tubing; route for air from air inlet valve to cuff.
4. Pilot cuff – a small plastic balloon on the end of the inflation line; indicates whether the cuff is
inflated or not
5. Fenestration - Hole situated on the curve of the outer tube; single or multiple
6. Speaking valve/tracheostomy button or cap – used to occlude the tracheostomy tube opening.
IV. IMPLEMENTATION
ACTION RATIONALE
Performance Phase

To lessen apprehension.
Discuss a communication system with
the patient.
2. Obtain consent for operative procedure.
3. Shave neck region (optional) To prevent contamination. Hair and beard May
harbour microorganism.
4. Assemble equipment. Using aseptic To ensures that the cuff is functioning before
technique, inflate tracheostomy cuff and insertion.
evaluate for symmetry and volume
leakage. Deflate maximally.
5. Position the patient (in supine position

To bring the trachea forward.
with head extended and a support under
the shoulders).
6. Obtain an order for and apply soft wrist

To preserve aseptic technique.
restraints if patient is confused.
7. Give medication if ordered. To sedate the patient.
8. Position the light source.
9. Assist with antiseptic source
10. Assist with gowning and gloving

11. Assist with sterile draping
12. Put on face shield. To protect self from blood and body fluid spills.
13. During procedure, monitor the patient’s

To assess the patient for any untoward signs
vital signs, suction as necessary, give and symptoms of bradycardia.
medication as ordered and be prepared Bradycardia may result from vagal
to administer emergency care. stimulation due to tracheal
manipulation, or hypoxia. Hypoxia may
also cause cardiac irritability.
14. Immediately after the tube is inserted,

To ensure ventilation of both lungs.
inflate the cuff. The chest should be
auscultated for the presence of bilateral
breath sounds.
15. Secure the tracheostomy tube with

tapes or other securing device and apply
dressing.
16. Apply appropriate respiratory assistive

device (mechanical ventilation)
17. Check the tracheostomy tube cuff

To relieve the cuff of excessive pressure that
pressure. may cause tracheal damage.
18. “Tie sutures” or “stay sutures” of silk

To secure the tracheotomy tube in place.
may have been placed through either
side of the tracheal cartilage at the
incision and brought out through the
wound. Each is to be taped to the skin
at 45-degree angle laterally to the
sternum.

1. Assess vital signs and breath sounds; note tube, size used, physician performing procedure, type,
dose, and route of medications given.
2. Obtain chest X-ray.
3. Document proper tube placement.
4. Assess and chart condition of stoma: bleeding, swelling and subcutaneous air.
PERFORMING TRACHEOSTOMY CARE
I. RATIONALE
1. To facilitate removal of excessive or tenacious respiratory secretions

2. To prevent aspiration of blood secretions such as food into the lungs
II. EQUIPMENT
Assemble the following equipment or obtain a prepackage tracheostomy care kit:
Sterile towel Sterile gloves Antiseptic solution and ointment

(optional)
Sterile gauze pads (10) Hydrogen peroxide Tracheostomy tie tapes or

commercially available
tracheostomy securing
device
Sterile cotton swabs Sterile water Face shield

Assessment
ACTION
RATIONALE
1. Observe for signs and symptoms of need

to perform tracheostomy care: excess
intratracheal secretions, soiled or dampTo assess for signs and symptoms
tracheostomy ties, soiled or damp
tracheostomy dressing, diminished airflow
through tracheostomy tube, or signs and
symptoms of airway obstruction requiring
suctioning.
2. Observe for factors (e.g. hydration,To allow the nurse to accurately assess need to
humidity, infection, nutrition, ability tom perform tracheostomy care.
cough) that normally influence
tracheostomy airway functioning.
3. Assess client’s understanding of and abilityTo allows the nurse to identify potential need for
to perform own tracheostomy care. instruction.
4. Check when tracheostomy care was lastTo provide tracheostomy care (at least every 8-
performed. 12 hours and more often if indicated )
Planning
ACTION RATIONALE
1. Expected outcomes following completion

of procedure:
- Inner cannula and outer cannula of To evaluate patency.
trach tube are free of secretions; ties
are clean, secured snugly, and tied in
double square knot.
- Stoma site is pink, does not bleed, and
is free of secretions.
2. Have another nurse or family member To prevent accidental extubation of

assists in this procedure. tracheostomy tube.
3.Explain procedure and client’s To encourage cooperation, minimizes risks,

participation. and reduces anxiety.
4.Assist client to position comfortable for To promote client comfort and prevents
both nurse and client (usually supine nurse muscle strain.
or semi-fowler’s).
5.Place towel across client’s chest. To reduce transmission of microorganism.
Implementation
ACTION RATIONALE
1. Perform hand hygiene, and apply gloves
and face shield if applicable.
2. Suction tracheostomy. Before removing To remove secretions to avoid occluding outer

gloves, remove soiled tracheostomy cannula while inner cannula is
dressing, and discard in glove with coiled removed. Reduces need for client to
catheter. cough
3. While client is replenishing oxygen stores,

To prepare equipment and allows for smooth,
prepare equipment on bedside. organized completion of
tracheostomy care.
4. Apply gloves. Keep dominant hand sterile

throughout procedure.
5. Remove oxygen source. Apply oxygen To help to reduce the amount of desaturation.
source loosely over tracheostomy if client
desaturates during procedure.
CRITICAL DECISION POINT:
For tracheotomy tube with no inner cannula or Kistner button, continue with Step 8.
6. Tracheostomy with Inner Cannula Care
a. While touching only the outer aspect
of the tube, remove the inner cannula
with nondominant hand. Drop inner To remove inner cannula for cleaning.
cannula into hydrogen peroxide Hydrogen peroxide loosens secretions
basin. from inner cannula.
b. Place tracheostomy collar, T tube or
ventilator oxygen source over outer
cannula (Note: T tube and ventilator
oxygen devices cannot be attached to
all outer cannulas when the inner
cannula is removed.) To maintains supply of oxygen to client.
c. To prevent oxygen desaturation, in
affected clients, quickly pick up inner
cannula, and use small brush To to remove secretions and hydrogen peroxide
remove secretions inside and outside from inner cannula.
inner cannula
d. Hold inner cannula over basin, and
rinse with normal saline, using
nondominant hand to pour normal
saline.
e. Replace inner cannula, and secure To secure inner cannula and re-establishes
“locking” mechanism. Reapply oxygen supply.
ventilator or oxygen sources.
7. Tracheostomy with disposable inner

cannula
a. Remove cannula from manufacturer’s
packaging.
b. While touching only the outer aspect
of the tube, withdraw inner cannula,
and replace with new cannula. Lock
into position.
c. Disposed of contaminated cannula in
appropriate receptacle, and apply
ventilator or oxygen sources.
8. Using hydrogen peroxide-saturated

cotton-tipped swab, clean exposed outer
cannula surfaces and stoma under
faceplate extending 5 to 10 cm (2-4
inches) in all directions from stoma.
Clean in circular motion from stoma site
outward using dominant hand to handle
sterile supplies.
9. Using normal saline-saturated cotton-

tipped swabs, rinse hydrogen peroxide
from tracheostomy tube and skin
surfaces.
10. Using dry 4x4 inch gauze, pat lightly at

skin an exposed outer cannula surfaces.
11. Secure tracheostomy. To promote hygiene and reduces transmission

a. Trach tie method of microorganisms. Secures trach
1. Instruct assistant, if available, to tube. Reduces risk of incidental
apply gloves and securely hold extubation.
tracheostomy tube in place.
With assistant holding
tracheostomy tube, cut old ties.
2. Take prepared tie and insert one
end of the tie through faceplate
eyelet, and pull ends even.
3. Slide both ends of tie behind the
head and around neck to other
eyelet, and insert one tie
through second eyelet.
4. Pull snugly.
5. Tie ends securely in double
square knot, allowing space for
only one loose or two snug
finger widths in tie.
6. Insert fresh tracheostomy
dressing under clean ties and
faceplate.
b. Trach tube holder method
1. While wearing gloves, maintain a
secure hold on tracheostomy
tube. This can be done with an
assistant or, when an assistant is
not available, leave the old trach
tube holder in place until the
new device is secure.
2. Align strap under client’s neck.
Be sure that the Velcro
attachments are positioned on
either side of the tracheostomy
tube.
3. Place narrow end of the ties
under and through the faceplate To ensure tracheostomy will not come out.
eyelets. Pull ends even, and
secure with the Velcro closures.
4. Verify that there is space for only
one loose or two snug finger
width(s) under neck strap
To absorb drainage. Dressing prevents
pressure on clavicle heads.
12. Position client comfortably, and assess

To promote comfort. Some clients may
respiratory status. require post-tracheostomy care
suctioning.
13. Replace any oxygen delivery sources.
14. Remove gloves and face shield, and To reduce transmission of microorganism.
discard in appropriate receptacle. Contaminated gloves should not
touch clean supplies.
15. Replace cap on hydrogen peroxide and

normal saline bottles. Store reusable
liquids and unused supplies in
appropriate place.
16. Perform hand hygiene. To reduce transmission of microorganisms

among clients.
VI. EVALUATION
1. Compare assessments before and after tracheostomy care.
2. Assess comfort of new tracheostomy ties.
3. Inspect inner and outer cannulas for secretions.
4. Assess stoma for signs of infection or skin breakdown.
ASSISTING IN ENDOTRACHEAL TUBE INTUBATION
I. DEFINITION
Endotracheal Tube Intubation
Is a measure that provides complete control over the airway. Commonly called intubation. An
Endotracheal tube is passed through the mouth, or less commonly the nose, into the patient’s lungs.
II. RATIONALE
1. To provide a means of delivering 100 percent oxygen directly to the lungs.

2. Provides a method for delivering positive pressure ventilation in a code or other emergency in
which the patient requires ventilation assistance.
3. To protect the airway in patients who are at risk for aspiration.
4. To maintain a patent airway in patients with burns, inhalation injuries, or ingestion of caustic
substances that cause swelling in the throat or lower airway.
5. To provide a pathway through which the health care professional can suction the lungs.
III. EQUIPMENT
Mask, face shield or other personal protective

Tape, 1 and 2 inch sizes, or endotracheal tube
equipment depending on the patients holder
situation and facility policy
Oral airway
Disposable examination gloves
Stethoscope
Sterile towel or drape
Bag-Valve-Mask
Laryngoscope handle and blades
Endothracheal tubes, assorted sizes Humidified oxygen source
Stylette (a wire inserted through the tube to reduce

Sterile gauze pad
flexibility
Sterile water
10 ml syringe
Sterile basin
Water soluble lubricant
Kelly clamp or other hemostat
Suction set up with flexible catheter
Assessment
ACTION RATIONALE
1. Assess immediate history of trauma

when spinal cord injury is suspected or
cranial surgery To allow for selection of the most appropriate
method for intubation, helping reduce
the risk for secondary injury.
2. Assess level of consciousness, anxiety and
To determine needs for sedation or use of
respiratory difficulty. paralytic agents and the patient’s
ability to lie flat and supine for
intubation.
3. Assess Nothing-by-mouth (NPO) status

To prevent increased risk of aspiration and
and signs of gastric distention. vomiting occurs with accumulation of
air, food or secretions. If a patient who
has gastric distention or who has eaten
recently needs to be intubated, use of
cricoids pressure decreases the risk for
aspiration.
4. Assess vital signs
5. Assess need for premedication
Implementation
ACTION RATIONALE
1. Wash hands, and don on personal To reduce transmission of microorganism and

protective equipment, including eye body secretions; standard precaution
protection.
Protective eyewear should be worn to avoid

exposure to secretions.
2. Attach patient to pulse oximeter and

cardiac monitor.
3. Set up and check equipment for To verify that equipment is functional; prepares
intubation. Place it in a convenient tube for insertion.
location on a sterile towel or drape,
close to the patient’s head.
4. Check the light on the laryngoscope To ensure that t is bright, white and steady, and
blade. Snap the blade onto the handle, working.
and then fold it up and down. When
pulled up, the light should go on.
Folding it down turns the light off.
5. Set up suction apparatus and connect To prepare for oropharyngeal suctioning as

rigid suction tip catheter to tubing. needed.
6. Open the sterile package containing the

endotracheal tube. Leave the tube
within the package, removing only the
inflation port for the cuff. The tube
must remain sterile.
7. Lubricate the entire stylette, and place

it on the table next to the endotracheal
tube.
8. Tear the tape and place it over the edge
of the table, or in another convenient
location.
9. Squeeze water-soluble lubricant onto a

sterile gauze pad.
10. Prepare the humidified oxygen
11. Position the patient’s head by flexing

To allow for visualization of the vocal cords by
the neck forward and extending the aligning the mouth, pharynx, and
head. (Sniffing position- only if neck trachea.
trauma is not suspected.)
12. Apply gloves
13. Check the mouth for dentures and

remove if present. Suction mouth and
pharynx as needed.
14. Assist the physician as directed as he or

she performs the intubation procedure.
You may be asked to ventilate the
patient before the procedure.
15. After the tube has been inserted, note

and record the centimeter mark on the
tube where it exits the mouth. Record
the volume of air used to inflate the
cuff.
16. After insertion, call X-ray for a portable
X-ray for tube placement.
17. Perform procedure completion actions.

Connect the endotracheal tube to
oxygen source or mechanical ventilator.
18. Secure endotracheal tube in place To prevent inadvertent dislodgement of tube.
19. Remove gloves. Wash hands To decrease the risk and transmission of
microorganism.
1. Record placement of patent artificial airway
2. Properly positioned and secured airway
3. Improved oxygenation and ventilation
4. Facilitation of secretion clearance.

PERFORMING ENDOTRACHEAL TUBE CARE
I. RATIONALE
1. To monitor the patient frequently and anticipating his/her needs.
2. To provide oral and nasal care as directed.
3. To remove oral secretions and secure the endotracheal tube.
4. To reduced oral colonization (ventilator associated pneumonia)
II. EQUIPMENT
Towel Clean 2x2 inch gauze
Endotracheal and oropharyngeal suction equipment Toothbrush, toothpaste (optional)
1 or 2 ½ inch wide adhesive or waterproof tape or Mouthwash-soaked clean gauze

commercial ET tube holder and mouthguard secured on tongue depressor 0r
(follow manufacturer’s instructions for sponge-tipped applicator
securing)
Clean gloves (2 pairs) Skin prep pad
Adhesive tape remover swab or acetone on cotton One wet, one soapy washcloth or
ball paper towels
Tongue blade (optional) Face shield, if indicated

III. IMPLEMENTATION
ACTION RATIONALE
1. Perform hand hygiene. Apply face shield

if indicated.
2. Administer endotracheal,
To remove secretions. Diminishes clients need to
nasopharyngeal, and oropharyngeal cough during procedure.
suction.
3. Connect oral suction catheter to suction

To prepare client for oropharyngeal suctioning.
source.
4. Apply gloves. Instruct assistant to apply

pair of gloves and hold ET tube firmly at Maintains proper tube and prevents
client’s lips or nares. Note the number incidental extubation.
marking on the ET tube at the gum line.
Do not allow assistant to hold the tube away from the lips or nares. Doing so allows too much
“play” in the tube and increases the risk of tube movement and incidental extubation. Never
let go of the ET tube, even for a moment. Client could move or cough, and the tube could
become dislodged.
5. Remove old tape or device.

a. Tape. Carefully remove tape from ET
tube and client’s face. If tape is difficult
to remove, moisten with (soapy) wetTo provide nurse with access to skin under tape
washcloth, water, or adhesive tape for assessment and hygiene. Reduces
remover. Discard tape in appropriate transmission of microorganism.
receptacle if nearby.
b. Commercially available device.
Remove Velcro strips from ET tube, and
remove ET tube holder from the client.
To avoid the need for tape and the resultant skin

breakdown and are easily applied in the
presence of facial hair.
6. Remove any secretions or adhesive fromTo promote hygiene. Adhesive can cause damage
the client’s face. Use adhesive remover to skin. Prevents poor adhesion of new
swab to remove excess adhesive left on tape.
face after tape removal. Wash adhesive
remover from the face.
7. Remove oral airway or bite block, To

if provide access to and complete observation of
present, and place on towel. client’s oral cavity.
Do not remove oral airway if client is actively biting ET tube. Wait until tape is partially or completely
secured to ET tube.
8. Clean mouth, gums, and teeth opposite

To promote hygiene and reduces risk of infection to
ET tube with non-alcohol based teeth and gums. Alcohol-based
mouthwash solution and 4x4 inch gauze, mouthwashes dry oral mucosa.
sponge-tipped applicators, or saline
swabs. Brush teeth as indicated. If
necessary, administer oropharyngeal
suctioning with Yankauer suction
catheter.
9. For oral ET tube: Remembering “cm”ToETprevent formation of pressure sores at sides of
tube marking at lips or gum line, with help client’s mouth. Ensures correct position of
of assistant move ET tube to opposite side tube.
or center of mouth. Do not change tube
depth.
10. Repeat oral cleaning as in step 9 on

To remove secretions from mouth and oral
opposite side of the mouth. pharynx.
11. Clean face and neck with soapy

washcloth, rinse, and dry. Shave male
client as necessary.
12. Secure ET tube
Tape method To position tape to secure ET tube in proper

position.
a. Slip tape under client’s head and

neck, adhesive side up. Take care not
to twist tape or catch hair. Do not
allow tape to stick to it. It helps to
gently stick tape to tongue blade,
which serves as a guide. Then slide
tongue blade under client’s neck.
Center tape so that double-faced
tape extends around back of neck
from ear to ear.
b. On one side of face, secure tape from

ear over lip to ET tube. Tear
remaining tape in half lengthwise,
forming two pieces that are ½ to ¾
inch wide. Secure bottom half of
tape across upper lip to opposite ear.
Wrap top half of tape around tube
and up from bottom. Tape should
encircle tube at least two times Tofor secures tape to face. Using top tape to wrap
security. prevents downward drag on ET tube.
c. Gently pull other side of tape firmly
to pick up slack, and secure to
opposite side of face and ET tube the
same as the first piece. NOTE: ET To secure tape to face and tube. Endotracheal
tube is secured. Assistant can tube should be at same depth at lips or
release hold. gum line. Check earlier assessment for
verification of tube depth in centimeters.
13. If already done, remove and clean oral

To promote hygiene. Reduces transmission of
airway in warm soapy water, and rinse microorganisms.
well. Hydrogen peroxide can aid in
removal of crusted secretions. A
mouthwash rinse will freshen client’s
mouth. Shake excess water from oral
airway.
14. Reinsert oral airway without pushing

Prevents client from biting ET and allows access
tongue into oropharynx, and secure for oropharyngeal suctioning.
with tape.
15. Discard soiled items in appropriate Reduces transmission of microorganisms.

receptacles. Remove towel, and place in
laundry
16. Reposition client. Promotes comfort.
17. Remove gloves and face shield, discard

Reduces transmission of microorganisms.
in receptacle and perform hand hygiene.
1. Compare respiratory assessment before and after ET tube care.

2. Observe depth and position of ET tube according to physician recommendation.
3. Assess security of tape by gently tugging at tube.
Assess skin around mouth and oral mucous membranes for intactness and pressure
areas.
Monitoring / ECG Interpretation
Adapted from Mc Cann(2005), ECG Interpretation

Adapted from Aehlert (2011), ECGs Maade Easy
I. DEFINITION
Electrocardiogram
Is a standardized noninvasive diagnostic tool used to record the electrical activity of
the heart.
Continuous Cardiac Monitoring
Cardiac monitoring is performed to provide continuous observation of the heart in patients who are at risk of
developing dysrhythmias, and those with unstable medical conditions.
Cardiac monitoring is done using three or five electrodes. The chest leads are most commonly used for
monitoring because these appear upright and are easiest to read.
2 Types of Monitoring
1. Hardwire Monitoring
The patient’s heart rhythm is displayed on both a monitor at bedside and another at the nurse’s
station.
2.Telemetry
Enables the patient to be ambulatory. A small transmitter sends a signal to a location, where them
patient’s cardiac rhythm is displayed on a monitor screen.
The ECG provides a continuous graphic picture of cardiac electrical activity. The ECG can be used for diagnostic,
documentation and treatment purposes.
II. RATIONALE
1. To records the electrical activity of a large mass of atrial and ventricular cells as specific waveforms
and complexes.
2. To detect current flow as measured on the patient’s skin.
III. EQUIPMENT
Cardiac Monitor
ACTION RATIONALE
Assessment
1. Assess the patient’s peripheral pulses,
vital signs, heart sounds, level of
consciousness, lung sounds, neck vein
distention, presence of chest pain To
orprovide baseline data.
palpitations, and for peripheral
circulatory disorders (i.e. clubbing,
cyanosis, and dependent edema)
2. Assess if the patient has a history To

of provide baseline data and may guide selection of
cardiac dysrhythmias or cardiac monitoring leads
problems.
3. Assess landmarks for identificationTo ofensure accurate placement for accurate

correct placement of electrodes. interpretation.
Patient Preparation
1. Ensure that the patient and family

understand preprocedural teaching.
To evaluate and reinforces the understanding of
previously taught information
2. Assist the patient to the supine position.To position enables easy access to the chest for
electrode placement.
Implementation
1. Wash hands To reduce the transmission of microorganism;

standard precaution.
2. Make sure there are no loose pins in the

end of the ECG cable and no frayed or
broken cable or lead wires. Make sure
the monitor has an adequate paper
supply.
3. Connect the ECG cable to the machine.

Connect the lead wires to the ECG cable
(if not already connected). Turn the
power on to the monitor. Adjust
contrast on the screen if necessary.
4. Open package of ECG electrodes. Make

sure the electrodes gel in the electrodes
to be used is moist. Attach an electrode
to each lead wire.
5. Prepare the patient’s skin to minimize

distortion of the ECG tracing. Do this by
briskly rubbing the skin with a dry gauze
pad. If electrodes will be applied to the
patient’s chest instead of limbs, shave
small amount of chest hair if needed
before applying electrodes to ensure
good contact.
6. Remove the backing from the pregelled

To allow for impulse transmission.
electrodes and test the center of the
pads for moistness.
7. Apply electrodes to the sites, ensuring

To aprevent external influences from affecting the
seal. Avoid pushing on the gel pads. ECG.
8. Evaluate the ECG monitor pattern forTo themake accurate judgments about the patient’s
presence of P waves, QRS complexes, a status and treatment.
clear baseline, and absence of artifact or
distortion. Obtain a rhythm strip on
admission, every shift (as per institution
protocol), and with rhythm changes.
9. Assess the ECG pattern continually To
forassess changes in the ECG pattern may indicate
dysrhythmias, assess patient tolerance significant problems for the patient and
of the change, and provide prompt may require immediate intervention or
nursing intervention. additional diagnostic test, such as 12-lead
ECG.
10. Evaluate skin integrity around To thehave a clear picture of the ECG. Replacing
electrodes on daily basis, and change the electrodes every 48 hours prevents drying
electrodes every 48 hours. Rotate sites of the gel and may prevent skin breakdown.
when changing electrodes. Monitor the It may be necessary to change to different
skin for any allergic reaction to the leads if sites become irritated. Electrode
adhesive or gel. Change all electrodes if resistance changes as the gel dries, so
a problem occurs with one. changing all electrodes at once prevents
differences in resistance between
electrodes.
11. Check electrode placement every shift.

To have accurate interpretation of many
dysrhythmias depends on proper
placement of the electrodes and knowing
which lead is being viewed.
12. Obtain tracing and inspect resulting To provides for review of ECG by cardiologist.
printout for clarity. Repeat the
procedure if tracings contain artifact.

1. It is important to note and document if the client is experiencing any chest discomfort during the
procedure.
2. Report any unexpected outcomes immediately.
CENTRAL VENOUS PRESSURE MONITORING
Adapted from Nettina (2010), Lippincott Manual of Nursing Practice 9 th
I. DEFINITION
Refers to the measurement of right atrial pressure or the pressure of the great veins within the
thorax (normal range: 5 to 10 cm H2O or 2 to 8mmHg).
a. Right-sided cardiac function is assessed through the evaluation of CVP.

b. Left-sided heart function is less accurately reflected by the evaluation of CVP, but may be useful in
assessing chronic right-and left-sided heart failure and differentiating right and left ventricular
infarctions.
Requires the threading of a catheter into a large central vein (subclavian, internal jugular, median
basilica, or femoral). The catheter tip is then positioned in the right atrium, upper portion of the
superior vena cava, or the inferior vena cava (femoral approach only).
II. RATIONALE
a. To serve as a guide for fluid replacement.
b. To monitor pressure in the right atrium and central veins.
c. To administer blood products, total parenteral nutrition, and drug therapy contraindicated for
peripheral infusion.
d. To obtain venous access when peripheral vein sites are inadequate.
e. To insert a temporary pacemaker.
f. To obtain central venous blood samples.
III. EQUIPMENT
Venous pressure tray IV pole Heparin flush system and

pressure bag (if transducer
to be used)
Cutdown tray Arm board (for antecubital Manometer level (for

insertion) establishing zero point)
Gowns, masks, caps, and ECG monitor Sterile dressing and tape
sterile gloves
Infusion solution/infusion set with CVP manometer

(Electronic CVP monitoring does not use a
manometer
Nursing Alert: A CVP line is a potential source of septicemia.

IV. IMPLEMENTATION
A. To Measure CVP
ACTION RATIONALE
Preparatory Phase (By Nurse)
1. Assemble equipment according to the

To assess for coagulapathies or anemia.
manufacturer’s directions. Evaluate
the patient’s Prothrombin Time (PT),
Partial Thromboplastin time (PTT),
and Complete Blood Count (CBC).
2. Explain the procedure to the patient

and ensure that informed consent is
obtained.
a. Explain to patient how to perform To gain cooperation from the patient
the Valsalva maneuver.
b. NPO 6 hours before insertion.
3. Position patient appropriately.

a. Place in supine position.
i. Arm vein – extend arm and To provide maximum visibility of veins.
secure on arm board. Trendelenburg’s position reduces the
ii. Jugular veins – place patient in risk of air emboli. Anatomic access
Trendelenburg’s position. and clinical status of the patient are
Place a small rolled towel considered in site selection.
under shoulder (subclavian
approach).
4. Flush IV infusion set and manometer

(measuring device) or prepare heparin
flush for use with transducer. Secure
all connections to prevent air emboli
and bleeding.
a. Attach manometer to IV pole. The
zero point of the manometer
should be on a level with the
patient’s right atrium.
b. Calibrate/ zero transducer and
level port with patient’s right
atrium.
a. To level the manometer. The

level of the right atrium is at
the fourth intercostals space
midaxillary line.
b. To mark midaxillary line with

indelible ink for subsequent
readings to ensure
consistency of the zero level.
5. Institute electrocardiogram To note any dysrhythmias during insertion as

monitoring. catheter is advanced.
Insertion Phase (By physician)
1. Physician puts on gown, cap andTo maintain sterility.

mask.
2. The CVP site is surgically cleaned. TheTo protect against risk of air embolus,
physician introduces the CVP catheter patient may be asked to perform the
percutaneously or by direct venous Valsalva maneuver
cutdown.
3. Assist the patient in remaining

motionless during insertion.
4. Monitor for dysrhythmias, tachypnea,To assess signs of pneumothorax or arterial

and tachycardia as catheter is puncture.
threaded to great vein or right atrium.
5. Connect primed IV tubing/heparinTo verify catheter placement before

flush system to catheter and allow IV hypertonic or blood products can be
solution to flow at a minimum rate to administered.
keep vein open (25 ml maximum).
6. The catheter should be sutured inTo prevents inadvertent catheter

place. advancement or dislodgement.
7. Place a sterile occlusive dressing over

site.
8. Obtain a chest x-ray. To verify correct catheter position and

absence of pneumothorax.
B. To Measure CVP
ACTION RATIONALE
1. Place the patient in a comfortable

position.
To have a baseline position.
2. Position the zero point of the To eliminate the effect of hydrostatic

manometer at the level of the right pressure on the transducer.
atrium.
3. Turn the stopcock so the IV solution

To eliminate the effects of atmospheric
flows into the manometer, filling to pressure.
about the 0-to25-ml level. Then
turn stopcock so solution in
manometer flows into patient.
4. Observe the fall in the height of the

To check for patency of the line. The
column of fluid in manometer. column of fluid will fall until it
Record the level at which the meets an equal pressure. The CVP
solution stabilizes or stops moving reading is reflected by the height of
downward. This is CVP. Record CVP a column of fluid in the manometer
and the position of the patient. when there is open communication
between the catheter and the
manometer. The fluid in the
manometer will fluctuate slightly
with the patient’s respirations.
This confirms that the CVP line is
not obstructed by clotted blood.
5. CVP catheter maybe connected to a
transducer and an electrical monitor
with either digital or calibrated CVP
wave readout.
6. CVP may range from 5-12 H2O To differentiate readings. The change in
(absolute numeric values have not CVP is more useful indication of
been agreed on) or 2 to 6 mm Hg. adequacy of venous blood volume
All values should be determined at and alterations of cardiovascular
the end of expiration. function. The management of the
patient is not based on one
reading, but on repeated serial
readings in correlation with
patient’s clinical status.
7. Assess the patient’s clinical

To have a baseline data. CVP is interpreted
condition. Frequent changes in by considering the patient’s entire
measurements (interpreted within clinical picture: hourly urine
the context of the clinical situation) output, heart rate, blood pressure,
will serve as a guide to detect and cardiac output measurements.
whether the heart can handle its
fluid load and whether hypovolemia
or hypervolemia is present.
8. Turn the stopcock again to allow IV To keep line open.

solution to flow from solution bottle
into the patient’s veins. Use an IV
pump, and monitor the infusion at
least hourly.
1. Prevent and observe for complications.

a. From catheter insertion: Pneumothorax, hemothorax, air embolism,
hematoma, and cardiac tamponade.
b. From indwelling catheter: infection, air embolism, central venous thrombosis.
2. Make sure the cap is secure on the end of the CVP monitor and all clamps are
closed when not in use.
3. If air embolism is suspected, immediately place patient in left lateral

Trendelenburg’s position and administer oxygen
4. Carry out ongoing nursing surveillance of the insertion site and maintain aseptic
technique.
a. Inspect entry site twice daily for signs of local inflammation and phlebitis.
Remove the catheter immediately if there are signs of infection.
b. Make sure sutures are intact.
c. Change dressings as prescribed.
d. Label to show date and time of change.
Send the catheter tip for bacteriologic culture when it is removed.
5. When discontinued, remove central line.

a. Position patient flat with head down.
b. Remove dressing and sutures.
c. Have patient take a deep breath and hold it while catheter is gently pulled out.
d. Apply pressure at catheter site and apply dressing.
e. Monitor site and vital signs for signs of bleeding or hematoma formation.
ADVANCED CARDIAC LIFE SUPPORT
I. DEFINITION
A. Defibrillation
Is the use of electrical energy, delivered over a period, temporarily depolarize the heart. When it repolarizes
it has a better chance of resuming normal activity.
B. Synchronized Cardioversion
Is the use of electrical energy that is synchronized to the QRS complex so as not to hit the T wave during
cardiac cycle, which may cause ventricular fibrillation.
C. Defibrillator
Is an instrument that delivers an electric shock to the heart to convert the dysrhythmia to normal sinus
rhythm. (Defibrillator is not used to convert other abnormal and rapid cardiac rhythms).
There are several types of defibrillators:
a. Direct current defibrillators contain a transformer, an alternating-current-direct-current converter, a

capacitor to store direct current, a charge switch, and a discharge switch to the electrodes to
complete the circuit.
b. Portable defibrillators have a battery as a power source and must be plugged in at all times when
not in use.
c. Automatic external defibrillator (AED) maybe used inside the facility or in the community to deliver
electric shock to the heart before trained personnel arrive with a manual defibrillator. AEDs are
accurate to be used by less trained individuals because the device has a detection system that
analyzes the person’s rhythm, detects the presence of ventricular fibrillation or tachycardia and
instructs the operator to discharge a shock.
Indications
Defibrillation
1. Ventricular fibrillation
2. Ventricular tachycardia without a pulse
Synchronized Cardioversion
1. Atrial fibrillation
2. Atrial flutter
3. Supraventricular tachycardia
4. Ventricular tachycardia with a pulse
Evidence Base:
Electrical therapies: Automated external defibrillators, defibrillation, Cardioversion and pacing.(2005).

Circulation 1 12:IV-35-IV-46.
ASSISTING IN DIRECT CURRENT DEFIBRILLATION FOR
VENTRICULAR FIBRILLATION
I. EQUIPMENT
Direct current defibrillator with paddles or multifunctional defibrillator pads
Highly conductive multipurpose electrolyte gel
II. IMPLEMENTATION
ACTION RATIONALE
Monitored Patient
1. If ventricular fibrillation is witnessed,To minimize cerebral ischemia and potentially

precordial thump may be considered restart cardiac rhythm.
2. Immediately implement
To ensure blood supply to the cerebral and
cardiopulmonary resuscitation (CPR) coronary arteries. CPR is essential
until defibrillator is available. before and after defibrillation
Unmonitored Patient
1. Expose anterior chest and move jewelryTo prevent interference. Jewelry may interfere
and transdermal patches away from the with electrical current and cause
area. serious burns
2. Immediately implement CPR untilTo provide oxygenated blood supply to the

defibrillation is available. If response cerebral and coronary arteries.
time is greater or equal to 5 minutes,
perform 2 minutes of CPR prior to
defibrillation.
3. Apply multifunctional defibrillator padsTo have better conduction.

or paddles with conductive gel to
patient’s bare chest.
4. Apply paddles or multifunctional pads.
5. Remove oxygen from immediate area. To prevent danger of fire or exploration.
6. Turn on defibrillator to the prescribedBiphasic is preferred over monophasic. Means

setting. AHA recommends that initial that the machine delivers current that
defibrillation should be 200 joules for flows in one direction for a specified
biphasic or 360 joules for monophasic. duration then reverses the current to
flow in the other direction. Significantly
lower energy levels are required with
biphasic defibrillators.
7. For paddles: To prevent getting shocked.
b. Grasp the paddles only by the
insulated handles.
c. Charge the paddles. Once paddles
are charged, give the command
“ALL CLEAR”. Look around quickly
to make sure everyone is clear from
the patient and bed.
d. Push the discharge buttons located
on both of the handles of the
paddles while simultaneously
exerting 25 lb of pressure to each
of the paddles.
8. For multifunctional pads: Multifunctional pads provide hands-free

a. Press the charge button on the defibrillation.
defibrillator machine. Once the
charge is reached, give the
command “ALL CLEAR.” Look
around quickly to make sure
everyone is clear from the patient
and bed.
b. Push the shock button on the
defibrillator machine.
9. Resume CPR immediately after To oxygenate the patient and restore

defibrillation circulation.
III. EVALUATION AND DOCUMENTATION
1. After the patient is defibrillated and rhythm is restored, antiarrhythmic are usually given to prevent
recurrent episodes.
2. Continue with intensive monitoring and care.
SYNCHRONIZED CARDIOVERSION
I. Equipment
Direct current defibrillator with paddleHighly

or conductive multipurpose electrolyte gel
multifunctional pads
II. Implementation
ACTION RATIOANALE
1. If the procedure is elective, it is

advisable to have the patient ingest
nothing by mouth 12 hours before the To prevent patient from vomiting and
cardioversion. Make sure to have aspiration.
working suction equipment available.
a. Reassure the patient and make
sure that informed consent has
been obtained.
b. Make sure the patient has not
been taking digoxin and that
serum potassium level is normal.
To prevent post-shock dysrhythmias.
2. Make sure IV line is secure To properly administer emergency medications.
3. Obtain a 12-lead electrocardiogram

To not that the patient has not had a recent MI
(ECG) before and after cardioversion prior to cardioversion.
with ECG machine.
4. Make sure oxygen is readily available.
5. Placement of paddles or
multifunctional pads by the physician.
6. Turn the machine to the synchronize

mode. Set to the appropriate joules as
ordered.
7. Monitor the ECG after cardioversion

To assess further the patient and report for any
occurs. Vital signs should be check abnormalities.
every 15minutes for one hour or
according to hospital policy.
1. Record the time, the numbers of joules administered and the medication given.
2. Monitor the patient for the first 3 hours until vital signs stabilizes.
AUTOMATED EXTERNAL DEFIBRILLATOR (AED)
I. EQUIPMENT
Automatic external defibrillator (AED)
Defibrillator pads
II. IMPLEMENTATION
ACTION RATIONALE
1. Assess unresponsiveness and pulselessness
2. Position patient in the supine position
3. Start cardiopulmonary resuscitation (CPR)

To have early restoration of oxygenation and
while automated external defibrillator perfusion is imperative in enhancing the
(AED) is being applied. resuscitative effort.
4. Place pads in the anterolateral position.

Apply one paddle/pad just to the right of
the sternum below the clavicle and the
other paddle/pad just to left of the cardiac
apex.
5. Turn on AED.
6. Follow audio and/ or visual instructions

To determine the need for defibrillation based on
from the AED. that analysis. It will then the operator knows
how to proceed.
7. Suspend CPR or any movement of the

External movement will impair the AED’s accuracy in
patient during the analysis. analyzing the rhythm.
8. If, after analyzing the rhythm, a shock External

is movement will impair the AED’s accuracy in
advised, the AED will instruct the operator analyzing the rhythm.
to prepare for a shock. It will charge the
unit, give the warning to “STAND CLEAR”
and then deliver the shock or prompt the
operator to push the shock button.
9. After the first shock, resume CPR for To2 provide oxygenation to the patient.
minutes before reanalyzing the rhythm per
American Heart Association (AHA)
guidelines.
10. If no shock is indicated, continue CPR forA2 shock will only be delivered if ventricular
minutes, and then allow the AED to analyze fibrillation or tachycardia is present.
the rhythm. Proceed as above if a shock is
now indicated. If a shock is still not
indicated, continue CPR and reanalyze the
rhythm every 2 minutes.
1. Vital signs stable; pacing spikes rated on ECG tracing.

2. Breath sounds noted throughout; respirations unlabored.
3. Document procedure done.
MANAGING THE CLIENTS ON MECHANICAL VENTILATION AND READING PARAMETERS
I. DEFINITION
Mechanical Ventilator Device

Functions as a substitute for the bellows action of the thoracic cage and diaphragm. The
mechanical ventilator can maintain ventilation automatically for prolonged periods.
Clinical Indications
Mechanical Failure of Ventilation

1. Neuromuscular disease
2. CNS disease
3. CNS depression (drug intoxication, respiratory depressants, cardiac arrest)
4. Inefficiency of thoracic cage in generating pressure gradients necessary for ventilation (chest injury,
thoracic malformation)
5. When ventilator support is needed post postoperatively.
Disorders of Pulmonary Gas Exchange
1. Acute respiratory failure

2. Chronic respiratory failure
3. Left-sided heart failure
4. Pulmonary disease resulting in diffusion abnormality
5. Pulmonary disease resulting in V/Q mismatch
6. Acute lung injury
Underlying Principles
1. Variables that control ventilation and oxygenation include:
a. Ventilator Rate Adjusted by rate setting.
b. VT Volume of gas required for one breath (ml/kg)
c. Fraction of inspired oxygen

Set on ventilator and measured with an
concentration (FiO2) oxygen analyzer.
d. Ventilator dead space Circuitry (tubing) common to inhalation and

exhalation; tubing is calibrated.
e. PEEP (Positive End-Expiratory

Set within the ventilator or with 5the use of
Pressure) external PEEP device; measured at
the proximal airway.
2. CO2 elimination is controlled by VT, rate and dead space.

3. Oxygen tension is controlled by oxygen concentration and PEEP (also by rate and VT)
4. In most cases, the duration of inspiration should not exceed exhalation.
5. The inspired gas must be warmed and humidified to prevent thickening of secretions and decrease
in body temperature. Sterile or distilled water is warmed and humidified. By way of a heated
humidifier.
Modes of Operation
Controlled Ventilation
1. Patient receives a set number and volume of breaths/ minute.

2. Provides a fixed level of ventilation, but will not cycle or have gas available in circuitry to respond to
patient’s own inspiratory efforts. This typically increases work of breathing for patient attempting to
breath spontaneously.
3. Generally used for patients who are unable to initiate spontaneous breaths.
Assist/Control
1. Inspiratory cycle of ventilator is activated by the patient’s voluntary inspiratory effort and delivers a
preset full volume.
2. Ventilator also cycles at a rate predetermined by the operator. Should the patient not initiate a
spontaneous breath, or breathe so weakly that the ventilator cannot function as an assistor; this
mandatory baseline rate will provide a minimum respiratory rate.
3. Indicated for patients who are breathing spontaneously, but who have the potential to lose their
respiratory drive or muscular control of ventilation. In this mode, the patient’s work of breathing is
greatly reduced.
Intermittent Mandatory Ventilation (IMV)
1. Allows patient to breathe at their own rate and volume spontaneously through ventilator circuitry.
2. Periodically, at preselected rate and volume or pressure, cycles to give a “mandated” ventilator
breath.
3. Ensures that a predetermined number of breaths at selected tidal volume are delivered each
minute.
4. Gas provided for spontaneous breaths usually flows continuously through the ventilator.
5. Indicated for patients who are breathing spontaneously, but at a VT and/ or rate less than adequate
for their needs. Allows the patient to do some of the work of breathing.
Synchronized Intermittent Mandatory Ventilation (SIMV)

1. Allows patient to breathe at their own rate and volume spontaneously through the ventilator
circuitry.
2. Gas provided for spontaneous breathing flows continuously through the ventilator.
3. Indicated for patients who are breathing spontaneously, but at a VT and/ or rate less than adequate
for their needs. Allows the patient to do some of the work of breathing.
Pressure Support
1. Augments inspiration to a spontaneously breathing patient.
2. Maintains a set positive pressure during spontaneous inspiration.
3. The patient ventilates spontaneously, establishing own rate, VT, and inspiratory time.
4. Pressure support may use independently as a ventilator mode or used in conjunction with CPAP or
SIMV.
Positive-End-Expiratory Pressure (PEEP)
Maneuver by which pressure during mechanical ventilation is maintained above atmospheric at end of
exhalation, resulting in an increased functional residual capacity. Airway pressure therefore positive
throughout the entire ventilator cycle.
II. RATIONALE
To increase functional residual capacity (or the amount of air left in the lungs at the end of
expiration).
Continuous Positive Airway Pressure (CPAP)
1. Assist the spontaneously breathing patients to improve oxygenation by elevating the end-expiratory
pressure in the lungs through the respiratory cycl.
2. Can be delivered through ventilator circuitry, rate is “0” or maybe delivered through a separate CPAP,
does not require the use of ventilator.
3. Indicated for patients who are capable of maintaining an adequate VT but who have pathology
preventing maintenance of adequate levels of tissue oxygenation or for sleep apnea.
Newer Modes of Ventilation
A. Inverse Ratio Ventilation
Pressure Regulated volume control ventilator mode is a volume-targeted mode used in acute respiratory
failure that combines the advantages of the decelerating inspiratory flow pattern of a pressure- control
mode with the ease of use of a volume-control (VC) mode.
1. I:E ratio is greater than 1, in which inspiration is longer than expiration

2. Uncomfortable for patients; need to be heavily sedated.
B. Airway Pressure Release Ventilation

1. Ventilator cycle between two different levels of CPAP.
2. The baseline airway pressure is the upper CPAP level and the pressure is intermittently
released.
3. Uses a short expiratory time.
4. Used in severe ARDS/Acute lung injury.
C. Non-Invasive Positive Pressure Ventilation
Uses a nasal or face mask, or nasal pillows. Delivers air through a volume or pressure controlled ventilator.
Used successfully during acute exacerbations. Can be used in the home setting. Equipment is portable
and easy to use. Eliminates the need for intubation, preserves normal swallowing, speech and the
cough mechanism.
MANAGING THE PATIENT REQUIRING MECHANICAL VENTILATION
I. EQUIPMENT
Artificial airway (Endotracheal tube or tracheostomy) Humidifier
Manual self-inflating resuscitation bag Suction equipment

Pulse oximeter Mechanical Ventilator
Ventilation Circuitry
II. IMPLEMENTATION
A. Attaching Patient to Mechanical Ventilator
ACTION RATIONALE
Preparatory Phase
1. Obtain baseline samples for blood gas To have baseline measurement that will serve as a
determination (pH, PaO2, PaCO2, HCO2) guide in determining progress of therapy.
Performance Phase
1. Give a brief explanation to the patient and

To emphasize that mechanical ventilation is a
family. temporary measure. The patient should be
prepared psychologically for weaning at the
time the ventilator is first used.
2. Premedicate as needed. To promote cooperation through mild sedation.

3. Establish the airway by means of a cuffed
A closed system between the ventilator and patient’s
ET or tracheostomy tube. lower airway is necessary for positive
pressure ventilation.
To have all equipment and settings in place before

applying to patient.
4. Prepare the ventilator (Respiratory
Therapist does this in many facilities)
a. Set up desired circuitry.
b. Connect oxygen and compressed air
source.
c. Turn on power
d. Set VT (usually 6 to 8 ml/kg body
weight [Morton]).
e. Set oxygen concentration.
f. Set ventilator sensitivity.
g. Set rate at 12-14 breaths/minute
(variable).
h. Set inspiratory-expiratory (I:E) times

Adjusted according to pH and PaCO2
(varies depending on the ventilator).
Adjust flow rate (velocity of gas flow
during inspiration). Usually set at 40
to 60 L/min. Depends on rate and
VT.
Adjusted according to PaO2
i. Select mode of ventilation.
j. Check machine function-measure VT, This setting approximates normal ventilation. These
rate, I:E ratio, analyze oxygen, check machines’ settings are subject to change
all alarms. according to the patient’s condition and
response, and the ventilator type being used.
The slower the flow, the lower the peak airway

pressure will result from set volume delivery.
To ensures safe function.
5. Couple the patient’s airway to the

To make sure all connections are secure. Prevent
ventilator ventilator tubing from “pulling” on artificial
airway, possibly resulting in tube
dislodgement or tracheal damage.
6. Assess patient for adequate chestTo ensure proper function of equipment.

movement and rate. Note peak airway
pressure and PEEP.
7. Set airway pressure alarms according to

To assess alarm activation that indicates inability to
patient’s baseline. build up airway pressure because of
a. High pressure alarm disconnection or leak, and changing
b. Low pressure alarm compliance and resistance.
Assess frequently for change in respiratory status

by evaluation of ABGs, pulse oximetry,
spontaneous rate, and use of accessory
muscles, breath sounds, and vital signs.
Other means of assessing are through the
use of exhaled carbon dioxide or “oxygen
saturation monitoring”. If change is
noted, notify the physician.
8. Monitor and troubleshoot alarm
To prioritize ventilation and oxygenation of patient.
conditions. Ensure appropriate In alarm conditions that cannot be
ventilation at all times. immediately corrected, disconnect the
patient from the mechanical ventilation and
manually ventilate with resuscitation bag.
9. Check for secure stabilization of artificial

To reduces risk of inadvertent extubation.
airway.
10. Positioning:
a. Turn patient from side to side every 2
hours or more frequently if possible.
Consider kinetic therapy as early Long-term Ventilation, this may result in sleep
intervention to improve outcome. deprivation. Follow a turning schedule best
b. Lateral turns are desirable; from right suited to a particular patient’s condition.
semiprone to left semiprone. Repositioning may improve secretion
c. Sit the patient upright at regular clearance and reduce atelectasis.
intervals if possible.
Nursing Alert:
For patients in severe compromised respiratory state or who are unstable hemodynamically,
consider use of specialty bed with kinetic therapy.
11. Carry out passive range-of-motion To prevent contractures.

exercises of all extremities for patients
unable to do so.
12. Assess for need of suctioning at least

Patients with artificial airways on mechanical
every 2 hours. ventilation are unable to clear secretions and
stimulate the cough reflex.
13. Assess breath sounds every 2 hours. Auscultation of the chest is a means of assessing
airway patency and ventilator distribution. It
also confirms the proper placement of the ET
or tracheostomy tube.
14. Provide mouth care every 1-4 hours andTo reduced risk of infection and provide comfort
assess for development of pressure areas
from ET tubes.
15. Report intake and output precisely and
Positive fluid balance resulting in increase in body
obtain accurate daily weight to monitor weight and interstitial pulmonary edema is a
fluid balance. frequent problem in patient requiring
mechanical ventilation.
16. Monitor nutritional status and GI

Patient on mechanical ventilation require inflation of
function artificial airway cuffs at all times.
Mechanically ventilated patients are at risk
for development of stress ulcers.
1. Maintain a flow sheet to record ventilation

To establish means of assessing effectiveness and
patterns, ABGs, venous chemical progress of treatment.
determinations, hemoglobin and hematocrit,
status of fluid balance, weight, and
assessment of patient’s condition.
2. Change ventilator circuitry per facility To prevent contamination of lower airways.

protocol; assess ventilator’s function every 4
hours or more frequently if problem occurs.
DRUG ALERT:
Never administer paralyzing agents until the patient is intubated and on mechanical ventilation.
Sedatives should be prescribed in conjunction with paralyzing agents, because the patient may
not be able to move but can still have awareness of his surroundings and inability to move.
Evidence Base:
Chulay, M., and Burns, S. (2006). AACN essentials of critical care nursing. New York: McGraw-Hill.
Morton, P., et al. (2005). Critical care nursing: A holistic approach (8 th Ed). Philadelphia:
Lippincott Williams & Wilkins.
B. Weaning Patient from Mechanical Ventilator
I. EQUIPMENT
Varies according to technique used Intermittent mandatory ventilation (IMV) or

SIMV set up in addition to ventilator or
incorporated ventilator and circuitry
Briggs T-piece Pressure support
II. IMPLEMENTATION
ACTION RATIONALE
Preparatory Phase
1. For weaning to be successful, the patient

To provide baseline; ensures that patient is capable
must be physiologically capable of of having adequate neuromuscular control
maintaining spontaneous respirations. to provide adequate ventilation.
Assessment must ensure that:
a. The underlying disease process is
significantly reversed, as evidenced by
pulmonary examination, ABGs, chest x-
ray.
b. The patient can mechanically perform
ventilation. Should be able to
generate a negative inspiratory
pressure less than 20 cm H2O; have a
vital capacity 10 to 15 mL/kg; have a
resting minute ventilation less than 10
L/min; and be able to double this; have
a spontaneous respiratory rate of less
than 25 breaths/min; without
significant tachycardia; be
normotensive; have optimal
hemoglobin for condition; have
adequate nutritional status.
2. Assess for other factors that may cause Weaning is difficult when these conditions
respiratory insufficiency. are present.
a. Acid-base abnormality
b. Nutritional depletion
c. Electrolyte abnormality
d. Fever
e. Abnormal fluid balance
f. Hyperglycemia
g. Infection
h. Pain
i. Sleep deprivation
j. Decreased LOC
3. Assess psychological readiness Patient
for must be physically and psychologically ready
weaning. for weaning.
Performance Phase
1. Ensure psychological preparation. Explain

To decrease anxiety and promote cooperation
procedure and that weaning is not always
successful on the initial attempt.
2. Prepare appropriate equipment
3. Position the patient in sitting or semi-

To increase lung compliance, decreases work of
Fowler’s position. breathing.
4. Pick optimal time of day, preferably early

Patient should be rested.
morning.
5. Perform bronchial hygiene necessary The to patient should be in best pulmonary condition
ensure that the patient is in best for weaning to be successful.
condition (postural drainage, suctioning)
before weaning attempt.
T-piece
This system provides oxygen enrichment and humidity to a patient with an ET or tracheostomy tube
while allowing completely spontaneous respirations.
1. Discontinue mechanical ventilation and

Stay with the patient during weaning time to
apply T-piece adapter. decrease patient anxiety and monitor for
tolerance of procedure.
2. Monitor the patient for factors indicating

To indicate tolerance of weaning procedure.
need for reinstitution of mechanical
ventilation
3. Increase time off ventilator with each The patient will progress as he becomes mentally
weaning attempt as the patient’s condition and physically able to perform adequate
indicates. Evaluate for tolerance before spontaneous ventilation.
moving to the next increment.
4. Institute other techniques helpful Provides

in motivation and positive feedback.
encouraging weaning.
5. When patient tolerates 40 to 60 minutes

of continuous weaning, weaning
increment can increase rapidly.
6. When the patient can maintain

spontaneous ventilation throughout day,
begin night weaning.
CPAP Weaning
1. The principles and technique This for weaning technique is preferred for patients
continuous positive airway pressure prone to atelectasis when placed on a T-
(CPAP) weaning are the same as for T- piece.
piece weaning.
2. The patient breathes with CPAP at low

level (2.5 to 5 cm H2O), rather than with
the T-piece, for periods that increase in
length.
IMV or SIMV Weaning
1. Set ventilator to IMV or SIMV mode
2. Set rate interval. To determines the time interval between machine-

deliveed breaths, during which the patient
will breathe on his own.
3. If the patient is on continuous flow IMV The gas flow rate into the bag must be adequate to
circuitry, observe reservoir bag to be sure prevent the bag from collapsing during
that it remains mostly inflated during all inspiration. Flow rates of 6 to 10 L/min are
phases of ventilation. usually adequate.
4. If gas for the patient’s spontaneous breath

To aid in decreasing work of breathing necessary tom
is delivered via a demand valve regulator, open demand valve.
ensure that machine sensitivity is at
maximum setting.
5. Evaluate for tolerance of procedure If the patient does not tolerate the procedure, the
PaCO2 will rise and pH will fall.
Pressure Support
1. May be beneficial adjunct to IMV or SIMV

weaning.
2. The amount of pressure support (cm H2O)

provided to the airway is progressively
decreased over time, allowing the patient
to increase role in supporting own
spontaneous ventilation.
1. Record each weaning interval: heart rate, BP, respiratory rate, FiO2, ABG, pulse oximetry value,
respiratory and ventilator rate (if IMV or SIMV), or length of time
2. Provides record of procedure and assessment of progress.
C. Extubation
I. EQUIPMENT
Tonsil suction (surgical Face mask connected to large- Gloves

suction bore tubing, humidifier,
instrument) and O2 source
10m ml syringe Suction catheter Face shield
Resuscitation bag and Suction source

mask with O2
flow
II. IMPLEMENTATION
ACTION RATIONALE
Preparatory Phrase
1. Monitor heart rate, lung expansion, To assess respiratory muscle function and
and breath sounds before extubation. adequacy of ventilation.
Record tidal volume (VT), vital capacity
(VC), negative inspiratory pressure
(NIP).
2. Assess the patient for other signs To

of have adequate muscle strength is necessary
adequate muscle strength. to ensure muscle strength for
a. Instruct the patient to tightly spontaneous breathing and coughing.
squeeze the index and middle
fingers of your hand. Resistance
to removal of your fingers from
the patient’s grasp must be
demonstrated.
b. Ask the patient to lift head from
the pillow and hold for 2 to 3
seconds.
Nursing Alert:
Keep in mind that patient’s underlying problems must be improved or resolved before
extubation is considered. Patient should also be free from infection and malnutrition.
Performance Phase
1. Obtain orders for extubation and

Do not attempt extubation until postextubation
postextubation oxygen therapy. oxygen therapy is available and
functioning at the bedside.

a. Artificial airway will be removed.
b. Suctioning will occur before
extubation.
c. Deep breath should be taken on
command.
d. Instruction will be given to cough
after extubation. To increase patient cooperation.
3. Prepare necessary equipment. HaveSyringe, bag-mask unit, and oxygen by way of

ready for use tonsil suction, suction face mask.
catheter, 10 ml
4. Place the patient in sitting position To

or increase lung compliance and decreases work
semi-fowler’s position (unless of breathing. Facilitates coughing.
contraindicated.
5. Put on face shield. To protect self from spillage.
6. Put on gloves. Loosen tape or ET

tube-securing device. Suction ET.
Suction oropharyngeal airway above
ET cuff as thoroughly as possible.
Deflate the cuff.
7. Extubate the patient:

a. Ask the patient to take a deep
breath as possible (if patient is
not following commands, give a
deep breathing with resuscitation
bad).
b. At peak inspiration, deflate the
cuff completely and pull the tube
out in the direction of the curve
(out and downward).
8. Once the tube is fully removed, askTo assess for old blood that is seen in the
the patient to cough or exhale secretions of newly extubated patients.
forcefully to remove secretions. Then Monitor for the appearance of bright red
suction the back of the patient’s blood due to trauma occurring during
airway with the tonsil suction. extubation.
9. Apply oxygen therapy as ordered

10. Evaluate immediately for any signs Immediate
of complications:
airway obstruction, stridor, or difficult
breathing. If the patient develops
any of these problems, attempt to a. Laryngospasm may develop, causing
ventilate the patient with the obstruction of the airway.
resuscitation bag and mask and b. Edema may develop at the cuff site.
prepare for reintubation. (Nebulized Signs of narrowing airway lumen are
treatments may be ordered to avoid high-pitched crowing sounds,
having to reintubate the patient.) decreased air movement, and
respiratory distress.
1. Note and record patient tolerance of procedure, upper and lower airway sounds
postextubation, description of secretions.
2. Observe and record the patient closely postextubation for any signs and
symptoms of airway obstruction or respiratory insufficiency.
3. Observe character of voice and signs of blood in sputum.
4. Provide supplemental oxygen using face mask.

Evidence Base:
AARC. (2002). Clinical practice guidelines: Removal of endotracheal tube.

MONITORING A CLIENT UNDERGOING DIALYSIS
Adapted from Berman (2009), Skills in Clinical Nursing 6 th Edition
I. DEFINITION
Dialysis refers to the diffusion of solute molecules through a semipermeable membrane, passing from
the side of higher concentration to that of lower concentration.
II. RATONALE
1. To maintain the life and well-being of the patient.
2. Serve as a substitute for some kidney excretory functions but does not replace the kidneys’ endocrine
and metabolic functions
Methods of Dialysis
1. Peritoneal dialysis
a. Intermittent peritoneal dialysis (acute or chronic)
b. Continuous ambulatory peritoneal dialysis
c. Continuous cycling peritoneal dialysis
Uses automated peritoneal dialysis machine overnight with prolonged dwell time during day.
2. Hemodialysis
3. Continuous renal replacement therapy (CRRT)
III. EQUIPMENT
For Infusing the Dialysate For Changing the Catheter Site Dressing
Container of peritoneal solution at body temperature, of Sterile gloves and masks (gowns and goggles
the amount and kind ordered by the primary care as needed)
provider. Bags range in size from 1 to 3 liters.
Sterile cotton-tipped applicators
IV Pole
Chlorhexidine gluconate, povidone-iodine
Sterile peritoneal dialysis administration set (separate or solution, or soap and water as specified
combined pieces):
Y connector Povidone-iodine ointment
IV-type tubing for dialysate
Drainage bag with tubing Precut sterile 2x2 gauze or slit transparent
occlusive dressing
Povidone-iodine swabs (or other antiseptic per agency
protocol). Some agencies recommend a sterile Nonallergenic tape
bowl and antiseptic for soaking the transfer set
tubing.
Mask and goggles
IV. IMPLEMENTATION
A. Conducting Peritoneal Dialysis

Preparation
Determine when the last dressing change was performed. The dressing should be changed when wet,
soiled, and loose or at intervals specified by agency policy.
ACTION RATIONALE
Performance
1. Prior to performing the procedure,To gain cooperation and trust.

introduce self and verify the client’s identify
using agency protocol. Explain to the client
the procedure.
2. Perform hand hygiene and observe otherTo prevent spread of microorganism

4. Prepare the solution and the tubing.

a. Examine the label on the container and
dialysate itself.
The dialysate solution should be clear and the seals
unbroken. Check the expiration date.
Warmed solution enhances exchanges and is more

b. Warm the dialysate using an approved comfortable for the client.
warmer (not a microwave oven) to at
least body temperature.
c. Add any prescribed medication to the
dialysate solution. Heparin is sometimes
added.
To prevent the accumulation of fibrin in the catheter.
Potassium is often added. This prevents excessive
loss of potassium.
d. Spike the solution container, close

the clamp, and hang the container on the IV
pole.
e. Prime the tubing: Remove the

protective cap and hold the tubing over
a cup or basin. Maintain the sterility of
the end of the tubing and the cap. Open
the clamp and let the fluid run through
To get rid the tubing of air that could enter the peritoneal
the tubing, removing all bubbles. Close
cavity, causing discomfort and preventing free
the tubing clamp.
drainage outflow.
5. Connect the solution to the catheter.

a. Apply clean gloves, mask, and goggles.
b. Free the catheter end from the dressing
if necessary.
c. Cleanse or soak the transfer set
connections with povidone-iodine or
other specified disinfectant for the time
listed in the agency protocol (usually 5
minutes). Remove the cap from the
transfer set and attach the Y connector
and end of the tubing from the solution
to the catheter.
d. Connect the drainage receptacle to the
outflow tubing. Close the outflown
tubing clamp.
e. If necessary, cover the catheter site with
the precut sterile gauze, and tape the
dressing in place.
f. Remove and discard gloves. Perform
hand hygiene
6. Infuse the peritoneal dialysate.

a. Open the clamp on the inflow tubing so
that the dialysate can flow into the
peritoneal cavity for the time specified
by the order. If no rate specified, the
client can usually tolerate a steady
open flow.
b. After the fluid has infused, clamp the
inflow tubing.
c. Leave the fluid in the cavity for the
designated time.
To prevent air from entering the peritoneal cavity. With the

tubing clamped.
7. Ensure client comfort and safety.

a. Assist the client into a comfortable
position.
b. Monitor the client’s vital signs.
c. Periodically assess the client’s comfort
during the dwell time.
8. Remove the fluid.

a. Unclamp the outflow tubing, and
permit the fluid to drain into the
drainage bag by gravity for about 30
minutes.
b. If the fluid does not drain freely, assist
the client to change position, or raise
the head of the bed. If specified, drain
only the amount ordered.
9. Assess the outflow fluid.

a. Observe the appearance of the outflow
fluid.
To check for any abnormalities. A cloudy, pink-tinged or
blood-tinged return may indicate peritonitis
(infection/ inflammation of the peritoneal cavity).
During the first two to four exchanges, the return
may be blood tinged but should quickly progress
to a straw-color return.
b. Apply cleave gloves.

c. Measure the amount of outflow fluid,
and discard the fluid and used supplies
in an appropriate area.
10. Calculate the fluid balance for each

exchange.
a. Compare the amount of outflow fluid
with the amount of solution infused for
each exchange.
b. If more fluid was infused than removed,
the client’s fluid balance is positive (+);
if more fluid was removed than infused,
the fluid balance is negative (-).
Example:
+ 2,000 ml dialysate solution infused
- 1,500 ml fluid returned in drainage bag

= 500ml balance for this exchange
c. Repeat steps for each exchange.
11. Calculate the cumulative fluid balance. The

cumulative fluid balance should be
negative.
Example:
Previous cumulative exchange balance + 100 ml
Present exchange balance - 500 ml
Cumulative exchange balance - 400 ml
12. Check the dressing at the catheter site if

present.
a. Assess the dryness or wetness of the
dressing.
b. To change the catheter site dressing,
use the supplies listed. Do not forcibly
remove crusts or scabs.
To keep dressing dry during dialysis.
This may irritate skin and increase the risk of exit site
infection. Dressing may not be necessary for well-
healed insertion sites.
13. Disconnect the catheter from the tubing,This allows the catheter to remain in place between each of
and cover the end of the catheter with a the exchanges without the contamination of the
new sterile cap. catheter.
14. Removed and discard gloves. Perform hand

hygiene.
1. Document findings in the client record using forms or checklist supplemented by narrative
notes when appropriate.
2. Include the time during which the fluid infused; exchange number; dialysate and additives
used; details of the exchange balance; color of outflow dialysate return from client; client’s
response.
3. Evaluate appearance of exit site and dressing; and client’s weight before and after the set of
exchanges (daily). .
4. Perform detailed follow-up based on findings that deviated from expected or normal for the
client. Relate and record findings to previous assessment data if available.
5. Report and record significant deviation from normal.
B. Care of Patient Undergoing Hemodialysis

I. EQUIPMENT
Povidone-iodine swabs or antiseptic solution as Alcohol swabs

determined by institution protocol
Sterile and nonsterile gloves Transparent dressing or gauze dressing supplies
Heparin (concentration depends on hospital

policy for flushing
II. IMPLEMENTATION
ACTION RATIONALE
Arteriovenous Fistula: Shunt or Graft
1. Wash hands. Prevents the spread of microorganism.
2. Position extremity so that you can easily Prevent trauma to fistula.

palpate the fistula.
3. Palpate gently over the area withTest for adequate blood flow through the fistula.
fingertips or palm of your hand to feel
for thrill (vibration).
4. Auscultate over the area with Tests a for adequate blood flow through the fistula.
stethoscope to detect a bruit (swishing Notify the health care provider if bruit and
noise). thrill are absent. Surgical interventions
may be necessary to restore flow.
5. Palpate pulses distal to the fistula andTo check for adequate blood flow and perfusion to
observe capillary refill in the extremity. the fistula extremity.
6. Assess for symptoms of infection,To monitor form potential complications.

bleeding, or sensation impairment in
the area around the fistula and the
entire extremity.
7. Post signs in the client’s room to let allTo prevent restriction of flow and possible clotting
caregivers know to avoid venipuncture or rupture of fistula. Reduces chances for
and blood pressure in the fistula infection.
extremity.
8. Inform client to avoid any activities thatPrevents unnecessary loss of access site because
will restrict flow or cause injury to the of occlusion or infection.
affected extremity.
9. Once the surgical incision is healed, theTo prevent infection at the puncture sites.
skin over the fistula or graft requires
only routine care with soap and water.
Arteriovenous Fistula: Shunt or Graft
11. Fill two 5-ml syringes with heparin andTo use to fill both lumens of catheter at end of site
saline per institution protocol. care. Actual volume used may vary, but
most catheter hold <3ml.
12. If changing caps, prime with heparinTo prevent air from entering the system.
and saline.
13. Open central line care kit or assembleTo maintain sterile technique.
needed supplies and place on sterile
field.
14. Put on mask and nonsterile gloves. To protect site from expired pathogens and used
in removal of dressing as part of Standard
Precautions.
15. Remove old transparent dressing andTo Comply with Standard Precautions.
discard with gloves in appropriate
receptacle.
16. Put on sterile gloves. To maintain sterile techniques.
17. Cleanse site with alcohol and assessTo remove pathogens from the skin and prepares
site for any redness, swelling or the skin for a new dressing.
drainage.
18. Cleanse area surrounding the catheterTo remove pathogens from the skin and prepares
site with povidone-iodine swabs the skin for a new dressing.
beginning at insertion site and going out
in a circular motion. Repeat for a total
of three times.
19. Let air dry and apply transparentTo allow the iodine solution to complete the
dressing. disinfectant process and ensures that the
dressing will adhere tightly to the skin.
20. Close clamp to both lumens andTo prevent air from entering the system when the
remove and discard old male adapters client inspires and creates a negative
(caps). pressure.
21. Cleanse ends of catheter with alcoholTo remove any old blood or drainage.
pads and then attach new primed male
adapters.
22. Unclamp lumens and flush withTo create a positive pressure within the catheter,
heparin and saline per agency protocol. thereby preventing backup of blood into
Close clamp as the last 0.5 cc is being the catheter.
injected.
23. Note: Some institutional policies willTo prevent over-anticoagulating the client, who
include aspirating the heparin solution may already have bleeding tendencies.
in the catheter before flushing. The
permanent catheters may also require
flushing with normal saline before theHeparin maintains patency of dialysis catheters.
heparin depending on the frequency of
dialysis.
Normal saline is never used without heparin

unless the client has an allergy to
heparin.
II. EVALUATION/ DOCUMENTATION

1. Assess and document catheter site for signs of infection or bleeding
2. Determine if catheter or fistula is patent and provides adequate blood flow for dialysis
3. Determine client understanding of rationale for fistula/catheter and related care.
MEASURE IN MEETING THE NEEDS OF CLIENT WITH FIRST AID, EMERGENCY &
DISASTER NURSING.
Adapted from Altman (2010), Fundamentals & Advanced Nursing Skills. 3 rd Edition
A. Performing Foreign Body Obstruction Management – Adult
I. DEFINITION
Foreign Body Obstruction
Is a condition when solid materials like chunked foods, coins, vomitus, small toys etc. are blocking the
airway.
Causes of Airway Obstruction
1. Improper chewing of large pieces of food
2. Excessive alcohol intake
a. Relaxation of tongue back into the throat
b. Aspirated vomitus (stomach content)
3. Presence of loose upper and lower dentures

4. For children who are running while eating
For smaller children of hand-to-mouth sage left unattended
Two types of Obstruction
a. Anatomical Obstruction
It happens when the tongue drops back and obstructs the throat. Other causes are acute asthma, croup,
diphtheria, swelling, and cough (whooping).
b. Mechanical Obstruction
When foreign objects lodge in the pharynx or airways; fluids accumulate in the back of the throat.
Classification of Signs Rescuer Action
Obstruction
As long as good air exchange continues:
a. Encourage the victim to

A. Mild a. Good air exchange continue spontaneous
Obstruction b. Responsive and can cough coughing and breathing
forcefully
efforts.
c. May wheeze between coughs.
d. Has increased respiratory b. Do not interfere with the
difficulty and possibly victim’s own attempts to
cyanosis. expel the foreign body, but
stay with the victim and
monitor his or her condition.
c. If mild airway obstruction

persists, activate the
emergency response system
a. Poor or no air exchange a. Ask the victim if he or she is

b. Weak or ineffective cough or choking.
no cough at all b. If the victim nods and
c. High-pitched noise while cannot talk, severe airway
inhaling or no noise at all obstruction is present and
d. Increased respiratory you must activate the
B. Severe Obstruction difficulty emergency response system
e. Cyanotic (turning blue) and AED once the victim
f. Unable to speak becomes unconscious.
g. Clutching the neck with the
thumb and fingers making
the
universal sign of choking.
h. Movement of air is absent
Abdominal thrusts
Is an emergency procedure for removing a foreign object lodged in the airway that is preventing a person
from breathing.
REMEMBER :
Abdominal Thrusts should not be used in infants under 1 year of age due to risk of causing injury.
Foundation Facts:
Complications from Abdominal Thrusts
1. Incorrect application of the Abdominal Thrust can damage the chest, ribs and internal organs.
2. May also vomit after being treated with the Abdominal Thrust.
3. They should be examined by a Physician to rule out any life-threatening complications.
Self-Administration of Abdominal Thrusts
a. To apply the Abdominal Thrust maneuver to oneself:

b. Make a fist with one hand and place it in the middle of the body at a spot above the navel and
below the breastbone, then grasp the fist with the other hand and push sharply inward and
upward.
If this fails,
The victim should press the upper abdomen over;
- the back of a chair,
- edge of a table,
- Porch railing or something similar and thrust up and inward until the object is dislodged.
PERFORMING ABDOMINAL THRUSTS UNDER SPECIAL CIRCUMSTANCES
OBVIOUSLY PREGNANT AND VERY OBESE PEOPLE

 The main difference in performing the Abdominal Thrust on this group of people is in the placement of
the fists.
 Instead of using abdominal thrusts, chest thrusts are used.
 The fists are placed against the middle of the breastbone and the motion of the chest thrust is in and
downward, rather than upward.
 If the victim is unconscious, the chest thrusts are similar to those used in CPR.
Caution: Pregnant and Obese Victims
If the victim is pregnant or obese, perform chest thrusts instead of abdominal thrusts.
Management of Foreign-Body Airway Obstruction
I. EQUIPMENT
An individual with training to perform this procedure
Standard precaution supplies, including gloves, masks, gowns, and protective eyewear, should always be easily
accessible (if available)
1. Assess air exchange
A foreign body obstruction can be complete or partial.

Partial airway obstruction will have some air exchange. If the client can cough, this should be encouraged
and the nurse should not interfere with the client’s efforts. In the event of partial airway
obstruction, the client will usually be able to cough but may wheeze between coughs.
If the client has complete airway obstruction as indicated by a weak, ineffective cough, high- pitched
inspiratory noises (stridor), and signs of respiratory distress (cyanosis, loss of consciousness),
intervention is necessary.
2. Establish airway obstruction. The universal sign of airway obstruction is “hand clutching the throat”
In addition, the inability to talk or breathe as well as cyanosis and the progressions to an
unconscious state are indicative of airway obstruction. Determine the problem.
3. In the pediatric client differentiate between infection and airway obstruction. Fevers, gradually
increasing respiratory distress, retractions, stridor, and drooling are all signs of infection. In this
situation it is important to maintain an upright position, keep the child as calm as possible, and seek
immediate medical attention. The Heimlich maneuver is not appropriate in these cases.
Delegation Tips:
The Heimlich maneuver may be performed by nay trained individual. A technique adjustment may need to be
demonstrated in pregnant women.
II. IMPLEMENTATION
ACTION RATIONALE
1. Determine scene safety.

Introduce yourself patient, guardian and or
bystander.
2. Ask the client “Are you choking?” AssessIf there is a good air exchange and the client is
airway for severe airway obstruction. able to forcefully cough, you should not
Hands’ clutching the throat is the intervene or interfere with the client’s
universal choking sign. attempt to expel the foreign body.
Encourage attempts to cough and
breathe, as attempts to cough will
provide a more forceful effort. If severe
airway obstruction is apparent, the
Heimlich maneuver or alternative method
of subdiaphragmatic thrusts should be
performed immediately.
3. Activate medical assistance andProvides follow-up care by professionally trained

transport facility, if there is respiratory personnel.
distress or complete blockage, for
example asks a bystander to call 911.
4. Let the client lean forward and deliver 5

back slap
5. Stand behind the client. Proper positioning is necessary to provide an
effective subdiaphragmatic thrust.
6. Wrap your arm around the client’s waist
7. Make a fist with one hand. Place theCorrect hand placement is important to prevent
thumb side of your fist against the internal organ damage.
client’s abdomen. The first should be
placed midline, above the navel and
below the xiphoid process. Grasp fist
with other hand
8. Press fist into abdomen with a quickThis subdiaphragmatic thrust can produce an
upward thrust; each thrust should be artificial cough by forcing air from the
separate and distinct lungs.
9. Repeat this process until the clientAttempts to dislodge food or a foreign body to
either expels the foreign body or loses relieve airway obstruction should be
consciousness. continued as long as necessary because
of the serious consequences of hypoxia.
10. If client is obese or in later stages of

pregnancy, perform chest thrusts:
Rescuer may not be able to wrap arms around the

client/s waist. Performing abdominal
thrusts in late stages of pregnancy can
cause injury.
a. Stand behind the client.
Proper positioning is necessary to provide effective

b. Wrap your under arm pits around the thrusts.
client’s chest.
c. Make a fist with one hand. Place Proper positioning is necessary to provide effective
thumb side of fist in the middle of the thrusts.
sternum. Grasp fist with other hand.
Proper hand placement is necessary to avoid

d. Press fist into chest and deliver thrusts damage to internal organs.
back and upward.
To create pressure to force object out. Chest

e. Repeat this process until the client thrusts may not be effective on the first
either expels the foreign body or loses attempts
consciousness.
Unconscious Client – Adult and children > 1 Year of Age
11. When the client becomes unconscious,To avoid injury to head. Places the client in the
lower client to floor. Protect the client’s most effective position to apply
head. Place in supine position. intervention.
12. Activate emergency medical systemTo activate assistance from personnel trained in
(EMS), if not previously done. advanced life support.
13. Open client’s mouth. Use one hand toDraws the tongue away from any foreign body
grasp the lower jaw and tongue between lodged in the back of the throat.
your thumb and finger. Lift the jaw. If
you see an object, remove it.
14. Open the airway and provide 2 breathsThe brain can suffer irreversible damage if it is
and look for chest to rise. If chest does without oxygen for 4-6 minutes.
not rise, reposition client’s head, reopen
the airway and provide 2 breaths.
15. If unable to ventilate, begin CPR To perform life-saving procedure.
16. Every time you give breaths, open theTo remove object blocking the airway.
mouth. If you see an object, remove it.
17. Continue to provide CPR untilTo perform life-saving procedure.

emergency response arrives or the client
begins to move.
18. If patient has sign of spontaneous

circulation and breathing, properly place
in recovery position.(Do log roll)
Evidence Base. AHA. (2006). ACLS Provider Manual. Dallas: AHA
1. The client demonstrates improved clinical status as evident by airway clearance or establishment
of a patent airway.
2. The client demonstrates improved gas exchange as evident by absence of signs and symptoms of
partial or complete airway obstruction (e.g., cough, wheezing, stridor, loss of consciousness,
cyanosis).
3. The client experience minimal discomfort during the Heimlich maneuver or other method of
airway clearance.
4. The client did not experienced complication related to airway obstruction/ hypoxia.
Documentation
1. If the airway obstruction occurs in the health care setting, document the following in the
narrative notes and in the emergency procedure notes if needed:
a. Time and date of onset of symptoms
b. Presentation including onset and type of symptoms.
c. Type (Complete or partial) and cause of obstruction, if known
d. Intervention used to alleviate obstruction
e. Results of interventions.
2. If the airway obstruction occurs in an alternate setting (e.g., restaurant, home) , provide the
following information to the responding health care providers for documentation:
a. Presentation including onset and type of symptoms
b. Type (complete or partial), and cause of obstruction, if known
c. Intervention used to alleviate obstruction
d. Length of time with airway obstruction
e. Result of interventions.
3. Document on appropriate flow sheet or electronic medical record (EMR).
B. Performing Rescue Breathing and CPR
I. DEFINITION
Is a technique of basic life support for the purpose of oxygenating the brain and heart until appropriate,
definitive medical treatment can restore normal heart and ventilatory action. Management of foreign-
body airway obstruction or cricothyroidotomy may be necessary to open the airway before CPR can be
performed.
Evidence Base AHA. (2006). ACLS provider manual 2006. Dallas: American Heart Association.
Indications
A. Cardiac Arrest B.Respiratory Arrest

1. Drowning
2. Stroke
1. Ventricular fibrillation 3. Foreign-body airway obstruction
2. Ventricular tachycardia 4. Smoke inhalation
3. Asystole 5. Drug overdose
6. Electrocution/ injury by lightning
7. Suffocation
8. Accident/ injury
9. Coma
10. Epiglottitis
Assessment
1. Immediate loss of consciousness

2. Absence of breath sounds or air movement through nose or mouth.
3. Absence of palpable carotid or femoral pulse; pulselessness in large arteries.
Complications
1. Postresuscitation distress syndrome (secondary derangements in multiple organs)

2. Neurologic impairment, brain damage
Nursing Alert:
The patient who has been resuscitated is at risk for another episode of cardiac arrest.
C. Cardiopulmonary Resuscitation
I. EQUIPMENT
Arrest Board IV setup Electrocardiograph machine
Oral Airway Defibrillator Intubation equipment
Bag and mask device Emergency cardiac drugs Suction
Oxygen Cardiac monitor
II. IMPLEMENTATION
ACTION RATIONALE
Responsiveness/airway
1. Determine unresponsiveness: tap orThis will prevent injury from attempted

gently shake patient while shouting, resuscitation on a person who is not
“Are you okay?” unconscious.
2. Activate emergency medical service
(call local emergency telephone
number or 911) if outside facility.
3. Place the patient supine on a firm, flatThis enables the rescuer to perform rescue
surface. Kneel at the level of the breathing and chest compression without
patient’s shoulders. If he has suspected changing position.
head or neck trauma, he should not be
moved unless it is absolutely necessary
(eg, at the site of an accident, fire, or
other unsafe environment).
4. Open the airway.

a. Head-tilt/chin-lift maneuver: Place
one hand on the patient’s forehead
and apply firm backward pressure a. In the absence of sufficient muscle
with the palm to tilt the head back. tone, the tongue or epiglottis will
Then, place the fingers of the other obstruct the pharynx and larynx. This
hand under the bony part of the support the jaw and helps tilt the head
lower jaw near the chin and lift up back
to bring the jaw forward and the
teeth almost to occlusion.
b. Jaw-thrust maneuver: Grasp the
angles of the patient’s lower jaw
and, lifting with both hands, one on
each side; displace the mandible
forward, while tilting the head
backward.
b. The jaw-thrust technique without head
tilt is the safest method for opening
the airway in the presence of
suspected neck injury.
Breathing
1. Place ear over patient’s mouth andTo determine presence or absence of spontaneous
nose while observing the chest, look for breathing.
the chest to rise and fall, listen for air
escaping during exhalation, and feel for
the flow of air.
2. Perform rescue breathing by mouth-to-This prevents air from escaping from the patient’s
mouth, using a ventilation barrier nose. Adequate ventilation is indicated by
device. While keeping the patient’s seeing the chest rise and fall, feeling the
airway open, pinch the nostrils closed air escape during ventilation, and hearing
using the thumb and index finger of the the air escape during exhalation.
hand you have place on his forehead.
Take a deep breath, open your mouth
wide, and place it around the outside
edge of the patient’s mouth to create
an airtight seal. Ventilate the patient
with two full breaths (each lasting 1
second), taking a breath after each
ventilation. If the initial ventilation
attempt is unsuccessful, reposition the
patient’s head and repeat rescue
breathing.
Circulation
Determine presence or absence of pulse.
1. While maintaining head-tilt with oneCardiac arrest is recognized by uselessness in the

hand on the patient’s forehead, palpate large arteries of the unconscious,
the carotid pulse for no more than 10 breathless patient. If the patient has a
seconds. If pulse is not palpable start palpable pulse, but is not breathing,
external chest compressions. initiate rescue breathing at rate of 12
times per minute (once every 5 seconds)
after two initial breaths.
External Chest Compressions
This procedure consists of serial, rhythmic application of pressure over the lower half of the
sternum.
1. Kneel as close to side of patient’s chestThe long axis of the heel of the rescuer’s hand
as possible. Place the heel of one hand should be placed on the long axis of the
on the lower half of the sternum, 1 ½ sternum so that the main force of the
inches (3.8cm) from the tip of thee compression is on the sternum, thereby
xiphoid. The fingers may either be decreasing the chance of rib fracture.
extended or interlaced but must kept
off the chest.
2. While keeping your arms straight,

elbows locked, and shoulder positioned
directly over your hands, quickly and
forcefully depress the lower half of the
patient’s sternum straight down one-
third the depth of the chest or, 1 ½- 2
inches (3.8-5cm).
3. Release the external chest compressionRelease of external chest compression allows

completely and allow the chest to blood flow into the heart.
return to its normal position after each
compression. The time allowed for
release should equal the time required
for compression.
4. For cardiopulmonary resuscitationRescue breathing and external chest compressions

(CPR) perform by one rescuer, do 30 must be combined. Check for return of
compressions at a rate of 100 per carotid pulse. If absent, resume CPR with
minute and then perform two two ventilations followed by
ventilations; reevaluate the patient. compressions. For CPR performed by
After four cycles of 30 compressions health professionals, mouth-mask
and two breaths each, check the pulse; ventilation is an acceptable alternative to
check again every few minutes rescue breathing.
thereafter. Minimize interruptions of
chest compressions.
5. For CPR performed by two rescuer, the
compression rate is 100 per minute.
The compression-ventilation ration is
30:2. Once an advanced airway is
place, the compressing rescuer should
give continuous chest compression at
the rate of 100 without pauses for
ventilation. The rescuer delivering
ventilation provides 8 to 10 breaths per
minute.
6. While resuscitation proceeds,Definitive care includes defibrillation,

simultaneous efforts are made to pharmacotherapy for dysrthmias and acid-
obtain and use special resuscitation base disturbances, and ongoing
equipment to manage breathing and monitoring and skilled care in an intensive
circulation and provide definitive care. care unit.
7. Utilizes the automated externalThe American Health Association supports the use
defibrillator (AED) as soon as possible. of AEDs in public places as well as medical
Special circumstances affecting use of team.
AEDs include:
a. AEDs should not be used on
children younger than age 8. The default energy level of AEDs is too high for
children younger than age 8.
b. The victim should not be lying in
water when using an AED. Make
sure the patient’s chest is dryUsing an AED when patients are wet or lying in
before attaching the AED. water may result in burns and shocks to
the rescuer.
c. Do not place the AED electrode

directly over an implanted
pacemaker.
Placing an AED pad directly over an implanted

pacemaker may reduce the effectiveness
of the defibrillation.
d. Remove any transdermal
medication patches from the
patient before using the AED.
Placing an AED pad over a transdermal medication

patch may make the defibrillation less
effective and causes a burn.
8. The four basic steps used in AED

operation are:
a. Turn the power on.
b. Attach the AED pads to the
patient’s chest, using the diagrams
on the pads to show you exactly
where to place them.
c. Analyze the patient’s rhythm by
pushing the button on the AED
labeled ANALYZE. During this time,
no one should touch the patient.
d. Charge the AED and deliver the
shock if indicated by the AED.Touching the patient could create artifact and
Make sure that no one is touching interfere with analysis.
the patient. Push the shock button;
the AED provide visual and voice
prompts to tell you what to do.
If the machine delivered a shock, anyone touching

the patient would feel it.
Evidence Base. AHA.(2005). American Heart Association 2010 Guidelines for CPR and ECC. Circulation 112
(Suppl 1). Australian Research Council (2006). Guidelines 7. Cardiopulmonary Resuscitation ARC.
Table of Comparison on Cardiopulmonary Resuscitation for Adult, Child and Infant
Adult Child Infant
Compression Just below the nipple line

Landmark (lower half of sternum)
Lower half of sternum, between the nipples
Compression Depth Approximately 1.5 to 2 Approximately 1/3 to ½ Approximately 1/3 to ½ the

inches (4 to 5 cm) the depth of the chest depth of Infant chest
Compression Heel of one hand with Heel of one hand with LR: 2 finger technique
method (Push hard hand of the other on hand of the other on top
and fast, Allow top
Complete recoil)
HCP (Lone and 2-rescuer): 2-
thumbs hand encircling
technique
Compression rate Approximately 100 Compressions per minute
Compression- Lone Rescuer (Lay rescuer and HCP): 30:2

Ventilation Ratio
Two Lay Rescuer or HCP with a Lay rescuer: 30:2
HCP (Two-rescuer): 15:2
Counting for 1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20, 1,2,3,4,5,6,7,8,9,1 (1, 2, 3,4, and 5)

Standardization
Purpose
1. Immediately report and document arrest, indicating exact location of victim.

2. In community setting, activate the emergency medical response system.
3. Cardiopulmonary arrest requires precise documentation. Most hospitals use a form designed
specifically for in-hospital arrests.
4. Document in nurses’ notes or on designated CPR worksheet: onset of arrest, time and number of AED
shocks, time and energy level of manual defibrillation, medication given, procedure performed,
cardiac rhythm, use of CPR, and the client’s response.
IMPLEMENTING PERSONAL PROTECTIVE EQUIPMENT
Adapted from Perry et al (2006), Clinical Nursing Skills & Techniques, 6 th Edition
Adapted from Altman (2010), Fundamentals & Advanced Nursing Skills. 3 rd Edition
A. Caring of Client after Biological Exposure
I. DEFINITION
Bioterrorism or biological attack
Is the result of the release of a biological agent into a specified environment.
Delegation Consideration
The nurse provides assistive personnel with information, assistance, and direction including:
1. Appropriate use of PPE to prevent exposure.

2. Techniques for handling a body after death to prevent contamination.
II. EQUIPMENT
Choices of equipment depend on the route of transmission of the infecting agent. The following is a general
list of supplies needed in the event of release of the most contagious biological agents. Not all of the
following equipment will be needed in all situations
Biohazard bags with label Face shield
Soap and water Head cover
0.5% diluted bleach or Environment Protective Negative-pressure room (high-efficiency

Agency (EPA) – approved germicidal particle air filtration maybe required)
agent with anteroom
Gloves Mask
- Standard face mask

- N95 mask
Gown Shoe covers
Critical Decision point
A biological event should be considered when large numbers of ill persons presents who have
unexplained yet similar symptoms; when there are unexplained deaths, particularly among young and
healthy populations; when there is unusual pattern associated with the symptoms (e.g., geographical,
season, client population); when the client fails to respond to traditional therapy; when a single client
presents with symptoms suggestive of an uncommon agent (e.g., anthrax or smallpox).; Once a
biological event is suspected, incident command must be notified immediately.
III. IMPLEMENTATION
ACTION RATIONALE
1. Perform hand hygiene. To reduce transmission of microorganism
2. Institute transmission-based isolationTo reduce transmission of microorganisms and the

precaution. likelihood of additional secondary sites of
contamination Reduces transmission of
microorganism.
3. Administer appropriate antibiotics and/orVarious biological agents are commonly treated

antitoxins. with Ciprofloxacin and/or Doxycycline (e.g.,
anthrax, plague, typhoidal tularemia), and
botulism requires supportive care and use
of antitoxin.
4. Administer immunization (e.g., smallpox) There is no specific treatment of smallpox after the
onset of illness other than
palliative/supportive care.
5. Administer fluid and nutrition therapy. Various biological agents commonly cause
gastrointestinal (GI) disturbances that may
result in dehydration.
6. Administer oxygen therapy. Various biological agents commonly cause

respiratory symptoms that may result in
altered gas exchange.
7. Provide supportive care (e.g., comfortSome victims of a biological attack will not survive;
measures, including pain management) supportive palliative care is essential.
8. Counsel client and family on both acuteReaction of clients to exposure will include shock,
and potential long term psychological immobilization, and fear. Long-term
effects of exposure. Offer access to psychological effects could arise without
trained counselors. proper counseling. (CDC, 2004).
Collaborate with the physician and other rescue workers for an ongoing plan for managing the client
exposed to a biological agent while also caring for other clients who may already be present in the
health care agency seeking care for illness unrelated to the current MCI.
IV. EVALUATION AND DUCOMENTATION
1. Observe for improved airway breathing, circulation, level of consciousness, and neurological
functioning.
2. Inspect the condition of client’s skin; note character of remaining lesions
3. Evaluate the client for changes that suggest either improvement or deterioration of psychological
status; ask client, “How do you feel right now?” Check levels of orientation and ability to conduct
conversation
4. Report and document cases of a biological incident to physician or emergency officer.
5. Record client’s status and response to treatment and/or comfort measures.
6. Report any unexpected outcome to physician.
(SEE TABLE FOR SUMMARY OF SELECTED CLASS A BIOLOGICAL WARFARE AGENTS)

B. Caring OF THE CLIENT AFTER CHEMICAL EXPOSURE
I. DEFINITION
Chemical Disaster
Is defined as the dispersal of a toxic chemical agent into the environment.
Summary of Selected Chemical Warfare Agents
Chemical Agent Onset of Symptoms Untreated Course of Chemical Exposure
“Lethal” agents – nerve Symptoms are generally immediate Pinpoint pupils and shortly thereafter
agents (tabun, salivation, runny nose, dyspnea,
sarin, soman, and chest tightness, nausea, muscle
VX) twitching, coma, seizures, and
death
“Blood” agents – hydrogen

Rapid onset of symptoms through
cyanide cyanide poisoning is often
associated with the smell of
bitter almonds. Death due to asphyxiation
“Blister” agents - mustard

Symptoms may be immediate or
and lewisite delayed
Coughing choking, and disruption in

“Choking” agents Symptoms
– can be immediate or may be pulmonary function that can lead
phosgene and delayed up to 24 hours, to death
chlorine
a. Appropriate use of PPE to prevent exposure

b. Techniques for handling a body after death to prevent contamination
II. EQUIPMENT
The following is a general list of supplies needed in the event of release of the most toxic chemical
agents.
a. Decontamination room or area (adult decontamination rooms may not meet the needs of
children requiring decontamination; decontamination areas for ambulatory victims will not meet
the needs of those who are not ambulatory).
b. Scissors or some other tool to cut off clothing rather than further contaminating the individual by
pulling the clothing over the victim’s head
c. Biohazard bags with labels
d. Large volumes of water
e. Appropriate PPE for use by trained personnel
III. IMPLEMENTATION
ACTION RATIONALE
1. Assess the client’s symptoms. Perform Symptoms identification and clustering of

appropriate focused physical examination data is the first step to accurate
(pulmonary, skin, gastrointestinal, identification of client’s problem and
neurological) response.
2. Observe for presence of liquid on client’s skin Common conditions present when
or clothing and odor (e.g., chlorine) chemical exposure has occured
3. Assess the client for preexisting medical Clients with preexisting medical
conditions that would complicate the effects conditions may require additional
of the toxic chemical exposure. treatment or may be at greater risk for
death.
A toxic chemical event should be considered when large numbers of ill persons present who have
unexplained yet similar symptoms; the primary objective for initial care is decontamination.
Decontamination is the process used to remove harmful contaminants from the surface of the skin.
It is achieved by removing clothing, scrubbing the skin, and by hydrolysis, a process of chemical
dilution using large volumes of water.
4. Assess client’s immediate psychologicalAids the nurse in being able to provide
response following exposure. Individual appropriate crisis intervention and
responses to chemical exposure will vary. stress management. Remaining calm
Clients may present with dissociative and projecting confidence while
symptoms, disorientation, depression, assessing individuals for clinical
anxiety, psychosis, and inability to care for symptoms versus feelings of panic will
self. Even without direct exposure to a go a long way in reducing the anxiety of
chemical agent many individuals, spurred the ill and worried well as they
by feelings of fear and doom, will present experience the general sense of panic
for emergency services. These worried associated with chemical exposure.
well can quickly overwhelm available
emergency services.
5. Identify resources available (e.g., criticalExpert resources can assess extent of

incident stress debriefing teams, psychological impact of disorders.
counselors, psychiatric/ mental health
nurse practitioners)
ACTION RATIONALE
1. Perform hand hygiene. To reduce transmission of and damage from

toxic chemicals.
2. Only trained personnel using required To reduce likelihood of secondary toxic chemical
PPE decontaminate clients with toxic contamination to untrained personnel
chemical contaminations attempting decontamination.
Hold victim outside decontamination area until preparations are completed for decontamination procedure.
If client is grossly contaminated, consider decontamination before entry into building.
3. Provide for client privacy by closing room To prevent discomfort and

curtains or closing door. embarrassment when clothing is
removed.
4. Decontaminate the client:

a. Act quickly; avoid touching
contaminated parts of clothing as
much as possible.
b. Remove all of client’s clothing.
Caution: Do not pull over the client’s
head; instead, cut garments off.
c. Use copious amounts of soap and
water to wash the clients thoroughly.
d. If eyes are burning or vision is blurred,
rinse eyes with plain water for 10 to 15
minutes. If the client wears contacts,
remove and place with contaminated Cutting off clothing prevents contamination of
clothing; do not reinsert in eyes. Wash head and hair.
eyeglasses with soap and water;
reapply when completed (CDC, 2004).
5. Dispose of client’s contaminated To reduce the likelihood of secondary chemical

clothing in an appropriate biohazard contamination.
bag and seal. Then place bag in
another plastic bag and seal (see
agency policy).
6. Initiate treatment for chemical agent Appropriate chemical agent protocol will vary with
using appropriate chemical agent client exposure (e.g., linesterase, nerve agent,
protocol. chlorine, lewisite)
7. Control bleeding Various chemical agents cause extensive bleeding.
8. Administer fluid and nutrition Various chemical agents commonly cause GI

therapy disturbances that may result in dehydration.
9. Establish airway if needed; administer Various chemical agents commonly cause

oxygen therapy. respiratory symptoms that may result in
altered gas exchange.
10. Provide supportive care (e.g., comfort Some victims of a chemical attack will not
measures, including pain survive; it is essential for the nurse to
management). provide palliative symptom control.
11. Counsel client and family on both Reaction of clients to exposure will include
acute and potential long-term shock, immobilization, and fear. Long-
psychological effects of exposure. term psychological effects could arise
Offer access to trained counselors. without proper counseling.
Collaborate with physician and other rescue workers for an ongoing plan to manage clients exposed to a
toxic chemical agent while also caring for other clients who may already be present in the health
care agency seeking care for illness unrelated to the current MCI.
IV. EVALUATION
1. Observed for improved airway maintenance, breathing, circulation, level of consciousness, and
neurological functioning.
2. Inspect condition of skin; note extent of blistering.
3. Evaluate client’s level of orientation, ability to problem solve, and perception of condition.
4. Report and document suspected cases of a toxic chemical event to physician or emergency
officer.
5. Record status and response to treatment and/or comfort measures
6. Report and document any unexpected outcome.
C. Caring of the Client after Radiation Exposure
I. DEFINITION
Radiological event is the dispersal of radioactive material via a “dirty bomb” or by deliberate contamination of
food, supplies, water supplies, or over the terrain.
1. Appropriate use of PPE to prevent exposure.

2. Technique for handling a body after death to prevent contamination.
II. EQUIPMENT
The following is a general list of supplies needed in the event of release of the most radiological exposure.
1.Decontamination room or area (Adult decontamination rooms may not meet the needs of children
requiring decontamination; decontamination of ambulatory victims will not meet the needs of
those who are not ambulatory.)
2. Scissors or some other tool to cut off clothing.
3. Depending on the type of radiological exposure, containers for clothing will be needed
4. Appropriate PPE for use by trained personnel
5. Equipment for select specimen collection
III. IMPLEMENTATION
ACTION RATIONALE
1. Perform hand hygiene. Reduces transmission of microorganism.
2. Only trained personnel use required PPEReduces likelihood of secondary radiological

to decontaminate clients with radiological contamination to untrained personnel
contamination. attempting decontamination.
3. Decontaminate the client:

a. Remove client’s clothing.
Removal of clothing should eliminate 70% to 90%

of contamination.
b. Wash client’s skin thoroughly with

water and soap, taking care not to
abrade or irritate the skin. Do not
allow radioactive material to beUse of copious amounts of water is critical in
incorporated into any wounds. decontamination.
c. Have radiation technician resurvey
the client after washing. Rewash as
necessary.
d. Isolate and cover any area of the skin

that is positive for radiation by using a
plastic bag or wrap.
4. Client’s contaminated clothing is baggedReduces the likelihood of secondary chemical

and tagged for further evaluation and contamination when containers designed
placed in an appropriate biohazard to contain the radiological particle are
container. used.
Collaborate with the physician and other rescue workers for an ongoing plan to manage clients exposed
to radiological materials while also caring for other clients who may already be present in the health
care agency seeking care for illness unrelated to the current nuclear or radiological event.
5. Prepare for possibly obtaining a completeCBC establishes baseline to determine client’s

blood count (CBC), urinalysis, fecal immunological status over time. When
specimen, and swabs of body orifices. internal contamination is suspected,
collection of urine, feces, and body orifice
swabs will be ordered to analyze for
radionuclides.
6. Treat symptoms according to ordinaryClient exposed to radiation is at risk for GI

treatment practices; provide intravenous alterations and fluid imbalance. Potassium
(IV) fluid support, antidiarrheal therapies, iodide reduces risk of thyroid cancer from
antiemetic medications, and potassium radioactive exposure.
iodide tablets.
IV. EVALUATION
1. Observe for improved fluid balance, GI status, level of consciousness and neurological functioning,
and further improvement of other radiological agent-specific symptoms.
2. Monitor CBC and other appropriate laboratory tests.
3. Evaluate client’s level of consciousness, orientation, and ability to relate events. Ask if client
remembers what has occurred; observe affect.
4. Document and report client’s status and response to treatment and/or comfort measures.
5. Report any unexpected outcomes to physician.

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SETTING A CLIENT’S UNIT

Adapted from Delaune and Ladner(2011). Fundamentals of Nursing;

Environment – the sum total of the external surroundings and influences.

B. For Daily Maintenance of the Unit

Feather Duster or Dusting Rug Fresh Flowers in a Vase

IV. PLANNING AND IMPLEMENTATION

B. FOR DAILY MAINTENANCE OF THE UNIT

1. Do daily sweeping and dusting. Be careful not

2. Change linens as per hospital policy.

3. Change flowers if withered. For aesthetic purpose.

4. Keep the bath and comfort rooms clean and

5. Use air freshener if not hazardous to the client’s

6. Arrange furniture and equipment regularly.

To improve the odor of the room.

8. Interact with the client as necessary.

9. Dispose of the garbage properly.

To promote therapeutic communication.

C. AFTER THE CLIENT’S DISCHARG

1. Remove contraptions if they were used To

Linens are considered soiled once the client is

4. Turn off lights and air-conditioning unit (if there

5. Close the windows and door. To keep room sanitary.

1. To provide comfort and safety.

Mattress Cover Top Sheet

Additional Equipment for Making a Surgical Bed

Additional Equipment for Making a Fracture Bed

IV. PLANNING AND IMPLEMENTATION

B. Body Mechanics in Bedmaking

MAKING AN UNOCCUPIED CLOSED BED

3. Strip the bed, in case the bed is not stripped.

15. Do after care. To prevent the spread of microorganisms.

MAKING AN UNOCCUPIED OPEN BED

- Follow the procedure in Making Unoccupied

MAKING A SURGICAL OR ETHER BED

1. Follow steps 1 -6, and 9 of the procedure in

6. Follow step 11 of the procedure in Making an

10. Do after-care. To prevent the spread of microorganisms.

MAKING A FRACTURE BED

2. Make an unoccupied bed.

5. Do after-care. To prevent the spread of microorganisms.

MAKING AN OCCUPIED BED

20. Remove the pillow(s) and change the pillow

22. Do after-care. To prevent the spread of microorganisms.

STRIPPING THE BED

1. Wash hands. To prevent the spread of microorganisms.

2. Obtain a laundry or hamper bag. To be used for the soiled linens.

TO MAKE A MITERED CORNER

1. Pick up the side edge of the sheet approximately

2. Lay the upper part of the sheet on the bed.

3. Tuck the part of the sheet that is hanging below

4. Holding the sheet in place against the mattress

TO MAKE A SQUARED CORNER

1. Pick up the sheet to form a 45 - degree angle

2. Lay the upper part of the sheet on the bed. See to

3. Tuck the part of the sheet that is hanging below

4. Bring the folded edge at the top of the mattress

Evaluation is done using the following criteria:

Post - op or Surgical Bed

Documentation on the ff:

Admitting a Client - a process of getting a client signed into the hospital.