HAND WASHING

Definition
It is the act of cleaning the hands with or without the use of water or another liquid, or with the
use of soap, for the purpose of removing soil, dirt, and/or microorganisms

Purposes
• To remove possible harmful bacteria from the skin.
• To loosen and remove soil and grime, body secretions, dead skin cells, and germs.

Equipments
• Disinfectant or soap
• Towel
• Water
• Tissue

Implementation

STEPS
1. Consider the sink, including the faucet
controls, contaminated.
2. Avoid touching the sink.
3. Turn water on using a paper towel and
then wet your hands and wrists
4. Work soap into a lather.
5. Vigorously rub together all surfaces of
the lathered hands for 15 seconds. Friction
helps remove dirt and microorganisms.
Wash around and under rings, around
cuticles, and under fingernails
RATIONALE
This site is unsterile so do not touch it may
cause transfer of microorganisms.
The inside of the sink and its surfaces are
usually littered with microorganisms
To avoid touching the faucet
Helped most to wash away the
microorganisms
Provides complete access to fingers,
hands, and wrists. When you wear rings, it
increases the number of microorganisms
on your hands which can then be passed
on to patients.

6. Apply the handwashing techinques Do handwashing technique as follows

7. Palm to palm
8. Right palm over the left dorsum and left
palm over the right dorsum
9. Palm to palm with finger interlaced
10. Back of the fingers opposing palms
with fingers interlocked.

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11. Rotational rubbing of the right thumb
clasped in left palm and vice versa.
12. Rotational rubbing backwards and
forwards with clasped finger of right hand
in left palm and vice versa.
13. Rinse hands thoroughly under a Rinsing mechanically washes away dirt
stream of water. Running water carries and microorganisms.
away dirt and debris. Point fingers down so
water and contamination won't drip toward
elbows
14. Dry hands completely with a clean dry Drying from cleanest (fingertips) to least
paper towel. clean (forearms/wrists) area avoids
contamination. Drying hands prevents
chapping and roughened skin.

15. Use a dry paper towel to turn faucet
off.
16. To keep soap from becoming a
breeding place for microorganisms,
thoroughly clean soap dispensers before
refilling with fresh soap.
17. When handwashing facilities are not
available at a remote work site, use an
appropriate antiseptic hand cleaner or
antiseptic towelettes. As soon as possible,
rewash hands with soap and running
water.
To avoid touching the non sterile area
Soap is needed because it works by
emulsifying fat and oil and lowering surface
tension, thus ridding your hands of large
amounts of microorganisms. Antiseptic or
antibacterial soaps generally help to rid
your hands of even larger amounts of
microorganisms
Always bring alcohol or hand sanitizer if
handwashing facilities are no available.

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DONNING AND REMOVING STERILE GLOVES (OPEN METHOD)

Purpose
• Permits the wearer to handle sterile supplies, instruments, and tissues of the surgical
sites.

Planning
1. Check client record, and ask the client about latex allergies.
2. Assemble equipment:
• Packages of sterile gloves.
3. Insure sterility of the package of gloves.

STEPS RATIONALE

1. Introduce yourself, and verify the
client’s identity. Explain to the client
what you are going to do, why it is
necessary, and how the client can
cooperate.
To ascertain that you are giving care to the
right patient and to gain his/her trust and
cooperation throughout the procedure.

2. Observe other appropriate infection The inside of the sink and its surfaces are
control procedures. usually littered with microorganisms.

3. Provide drapes and curtains. For client’s privacy.

4. Open the package of sterile gloves. Any moisture on the surface could
• Place the package of gloves on a contaminate the gloves.
clean, dry surface.
• If the gloves are packed in an inner
as well as outer package, open the
outer package without contaminating
the gloves or the inner package.
• Remove the inner package from the
outer package.
5. Put the first glove on the dominant The hands are not sterile. By touching only
hand. the inside of the glove, the nurse avoids
• If the gloves are packaged so that contaminating the outside.

3
 they lie side by side, grasp the glove
for the dominant hand by its folded
cuff edge (on the palmar side) with
the thumb and first finger of the
nondominant hand. Touch only the
inside of the cuff;
Or
• If the gloves are packaged one on
top of the other grasp the cuff of the
top glove as above, using the
opposite hand.
• Insert the dominant hand into the
glove, and pull the glove on. Keep
the thumb of the inserted hand
against the palm of the hand during
insertion.
• Leave the cuff in place once the non-
sterile hand releases the glove.
6. Put the second glove on the This helps prevent accidental
nondominant hand. contamination of the glove by the bare
hand.
• Pick up the other glove with the
sterile gloved hand, inserting the
gloved fingers under the cuff and
holding the gloved thumb close to the
gloved palm.
In this position, the thumb is less likely to
• Pull on the second glove carefully. touch the arm and become contaminated.
Hold the thumb of the gloved first
hand as far as possible from the
palm.
• Adjust each glove so that it fits
smoothly, and carefully pull the cuffs
up by sliding the fingers under the
cuffs.
7. Remove and dispose of used gloves. To maintain cleanliness.
• There is no special technique for
removing sterile gloves. If they are
soiled with secretions, remove them
by turning them inside out.
8. Document that sterile technique was To avoid any legal concerns.
used in the performance of the procedure.

Evaluation

4
Conduct any follow-up indicated during your care to the client. Ensure that adequate numbers
and types of sterile supplies are available for the next health care provider.

DONNING A STERILE GOWN AND GLOVES (CLOSED METHOD)

Purposes
• To enable the nurse to work close to a sterile field and handle sterile object
freely.
• To protect clients from becoming contaminated with microorganisms on the
nurse’s hands, arms, and clothing.

Assessment
Review the client’s record and orders to determine exactly what procedure will be performed
that requires sterile gloves. Check the client record and ask about latex allergies. Use nonlatex
gloves whenever possible.

Planning
Think through the procedure, planning which steps need to be completed before the gloves and
gown can be applied. Determine what additional supplies are needed to perform the procedure
for this client. Always have an extra pair of sterile gloves available.

Equipment
• Sterile pack containing a sterile gown
• Sterile gloves

Implementation
Preparation
Ensure the sterility of the package of gloves.

Performance
STEPS RATIONALE
1. Prior to performing the procedure, introduce To ascertain that you are giving care to the
self and verify the client’s identity using right patient and to gain his/her trust and
agency protocol. Explain to the client what you cooperation throughout the procedure.
are going to do, why it is necessary, and how
the client can cooperate. Discuss how the
results will be used in planning further care or
treatments.
2. Do hand washing. To prevent the spread of microorganisms-

5
 causing infection.
3. Provide drapes and curtains. For client privacy.
4. Open the package of sterile gloves. If the inner wrapper is not touched, it will
Remove the outer wrap from the sterile gloves remain sterile.
and leave the gloves in their inner sterile wrap
on the sterile field.
5. Unwrap the sterile gown pack.
6. Put on sterile gown.
• Grasp the sterile gown at the crease The gown will e unsterile if its outer surface
near the neck, hold it away from you, and touches any unsterile objects.
permit it to unfold freely, without touching
anything, including the uniform.
• Put the hands inside the shoulders of the
gown without touching the outside of the
gown.
• If donning sterile gloves by using the
closed method, work the hands down the
sleeves only to the beginning of the
cuffs.
Or
• If donning the sterile gloves by using the
open method, work the hands down the
sleeves and through the cuffs.
• Have a co-worker grasp the neck ties
without touching the outside of the gown
and pull the gown upward to cover the
neckline of your uniform in front and
back. The co-worker ties the neck ties.
7. Open the sterile glove wrapper while the
hands are still covered by the sleeves.
8. Put the glove on the nondominant hand. To facilitate the closed gloving first on the
• With the dominant hand, pick-up the nondominant hand.
opposite glove with the thumb and index
finger, handling it through the sleeve.
• Position the dominant hand palm upward
inside the sleeve. Lay the glove on the
opposite gown cuff, thumb side down,
with the glove opening pointing toward
the fingers.
• Use the nondominant hand to grasp the
cuff of the glove through the gown cuff,
and firmly anchor it.
• With the dominant hand working through

6
 its sleeve, 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
nondominant hand into the glove’s
fingers.
9. Put the glove on the dominant hand. To facilitate closed gloving on the dominant
• Place the fingers of the gloved hand hand.
under the cuff of the remaining glove.
• Place the glove over the cuff of the
second sleeve.
• Extend the fingers into the glove as you
pull the glove up over the cuff.
10. Completion of the Gowning. This approach keeps the ties sterile.
• Have a co-worker to hold the waist tie of
your gown, using sterile gloves or a
sterile forceps or drape.
• Make a three quarter-turn, then take the
tie and secure it in front of the gown.
• Or
• Have a co-worker take the two ties at
each side of the gown and tie them at the
back of the gown, making sure that your
uniform is completely covered.
• When worn, sterile gowns should be
considered sterile in front from the waist
to the shoulder. Once the nurse
approaches the table, the gown is
considered contaminated from the waist
or table down, whichever is higher. The
sleeves should be considered sterile
from the cuff to 2 in. above the elbow,
since the arms of a scrubbed person
must move across a sterile field.
Moisture collection and friction areas
such as the neckline, shoulders,
underarms, back, and sleeve cuff should
be considered unsterile.
11. Remove and disposed off used gown and To promote cleanliness.
gloves.
• If soiled, remove the attire by turning it
inside out.
12. If appropriate, document that sterile To avoid legal issues.

7
technique was used in the performance of the
procedure.

Evaluation
Conduct any follow-up indicated during your care to the client. Ensure that adequate numbers
and types of sterile supplies are available for the next health care provider.

ASSESSING BODY TEMPERATURE

Definition
Body temperature reflects the balance between the heat produced and the heat lost from the
body, and is measured in heat units called degrees.

Purposes
• To establish data for subsequent evaluation
• To identify whether the core temperature is within the normal range
• To determine changes in the core temperature in response to specific therapies(e.g.
antipyretic medication, immunosuppressive therapy, invasive procedure)
• To monitor clients at risk for infection or diagnosis of infection; those who have been
exposed to temperature extremes

Equipments
• Thermometer
• Thermometer sheath or cover
• Water soluble lubricant for rectal temperature
• Disposable gloves
• Towel for axillary temperature
• Tissues/wipes

STEPS RATIONALE
ASSESSMENT
1. Assess
• Clinical signs of fever
• Clinical signs of hypothermia
• Site most appropriate for
measurement
• Factors that may alter body
temperature

8
Preparation
Check that all equipment is functioning -Checking equipments before use promotes
properly accurate result
Performance

1. Prior to performing the procedure, introduce
self and verify the client using agency
protocol. Explain to the client what you are
going to do, why is it necessary, and how
he or she can cooperate. Discuss how the
results will be used in planning further care
treatments
-Introducing self to the client builds rapport.
Verifying the client ensures that the nursing
care is given to the right person. Explaining the
procedure is important so the client can
anticipate what will happen as the procedure
goes on.

2. Perform hand hygiene and observe -Hand washing is important to cleanse the
appropriate infection control procedures. hands of pathogens (including bacteria or
Don gloves if performing a rectal viruses) and chemicals which can cause
temperature. personal harm or disease

3. Provide for client privacy

4. Place the client in the appropriate

position(e.g. lateral or sim’s position for
inserting a rectal thermometer)

5. Place the thermometer

• Apply a protective sheath or cover if
appropriate
• Lubricate a rectal thermometer

6. Wait the appropriate amount of time. - To get accurate measurement, make sure to
Electronic and tympanic thermometers will wait for the appropriate amount of time.
indicate that the reading is complete
through light or tone. Check package
instructions for length of time to wait prior to
reading chemical dot or tape thermometers

7. Remove the thermometer and discard the

cover or wipe a tissue if necessary

9
8. Read the temperature and record it on your
worksheet. If the temperature is obviously
too high, too low, or inconsistent with the
client’s condition, recheck it with a
thermometer known to be functioning
properly

9. Wash the thermometer if necessary and

return it to the storage location

10. Document the temperature in the client

record.

ASSESSING A PERIPHERAL PULSE

Definition
A pulse is a wave of blood created by contraction of the left ventricle of the heart. Generally the
pulse wave represents the stroke volume output or the amount of blood that enters the arteries
with each ventricular contraction.

Purposes
• To establish baseline data for subsequent evaluation
• To identify whether the pulse rate is within the normal range.
• To determine whether the pulse rhythm is regular and the pulse volume is appropriate
• To determine the equality of corresponding peripheral pulses on each side of the body
• To monitor and assess changes in the client’s health status
• To monitor clients at risk for pulse alterations
• To evaluate blood perfusion to the extremities

Equipments
• Watch with a second hand or indicator
• If using a DUS:transducer probe, stethoscope headset, transmission gel
• Tissues/ wipes

IMPLEMENTATION RATIONALE
Preparation

If using a DUS, check that the equipment is

10
functioning normally
Performance

1. Prior to performing the procedure,
introduce self and verify the client
using agency protocol. Explain to the
client what you are going to do, why
is it necessary, and how he or she
can cooperate. Discuss how the
results will be used in planning further
care treatments
--Introducing self to the client builds rapport.
Verifying the client ensures that the nursing
care is given to the right person. Explaining
the procedure is important so the client can
anticipate what will happen as the procedure
goes on.

2. Perform hand hygiene and observe
appropriate infection control procedures
3. Provide for client privacy
-Hand washing is important to cleanse the
hands of pathogens (including bacteria or
viruses) and chemicals which can cause
personal harm or disease

4. Select the pulse point. Normally, the radial

pulse is taken, unless it cannot be
exposed or circulation to another body
area is to be assessed.

5. Assist the client to comfortable resting

position. When the radial pulse is
assessed, with the palm facing downward,
the client’s arm can rest alongside the
body or the forearm can rest at a 90-
degree angle across the chest. For a
client who can sit, the forearm can rest
across the thigh, with the palm of the hand
facing downward or inward.

6. Palpate and count the pulse. Place the -Using the thumb is contraindicated because
two or three middle finger tips slightly and the nurse’s thumb has a pulse that could be
squarely over the pulse points mistaken for the client’s pulse

• Count for 15 seconds and multiply by

4. Record the pulse in beats per
minute on your worksheet. If taking
the client’s pulse for the first time,
when obtaining baseline dta, or of the
pulse is irregular, count for a full
minute. . If an irregular pulse is found,
also take the apical pulse

11
 7. Assess the pulse rhythm and volume.
• Assess the pulse rhythm by noting
the pattern of the intervals between
the beats. A normal pulse has equal
time periods between the beats. If
this is an initial assessment, assess
for one minute.
• Assess the pulse volume. A normal
pulse volume. A normal pulse can be
felt with moderate pressure, and the
pressure is equal with each beat. A
forceful pulse volume is full; an easily
obliterated pulse is weak. Record the
rhythm and volume in your work
sheet

8. Document the pulse rate, rhythm, and

volume and your actions in the client
record.

ASSESSING RESPIRATIONS
Definition
Respiration is the acT of breathing. Inhalation or inspiration refers to the intake of air into the
lungs. Exhalation or expiration refers to breathing out or the movement of gases from the lungs
to the atmosphere.

Purposes
• To acquire baseline data against which future measurements can be compared
• To monitor abnormal respirations and respiratory patterns and identify changes
• To monitor respirations before or following the administration of a general anesthetic or
any medication that influences respirations
• To monitor clients at risk for respiratory alterations

Equipment
• Watch with a second hand or indicator

IMPLEMENTATION RATIONALE
Preparation

For a routine assessment of respirations,

12
determine the client’s activity schedule and
choose a suitable time to monitor the
respirations. A client who has been exercising
will need to rest a few minutes to permit the
accelerated respiratory rate to return to normal
Performance

1. Prior to performing the procedure, - Introducing self to the client builds rapport.
introduce self and verify the client Verifying the client ensures that the nursing
using agency protocol. Explain to the care is given to the right person. Explaining the
client what you are going to do, why is procedure is important so the client can
it necessary, and how he or she can anticipate what will happen as the procedure
cooperate. Discuss how the results will goes on.
be used in planning further care
treatments
2. Perform hand hygiene and observe -Hand washing is important to cleanse the
appropriate infection control procedures hands of pathogens (including bacteria or
viruses) and chemicals which can cause
personal harm or disease
3. Provide for client privacy
4. Observe or palpate and count the
respiratory rate
• The client’s awareness that the nurse
is counting the respiratory rate could
cause the client to purposefully alter
the respiratory pattern. If you anticipate
this, place a hand against the client’s
chest to feel the chest movements with
breathing, or place the client’s arm
across the chest and observe the chest
movements while supposedly taking
the radial pulse

• Count the respiratory rate for 30

seconds are regular. Count for 60
seconds if they are irregular. An
inhalation and an exhalation count as
one respiration
5. Observe the depth, rhythm, and character
of respirations.
• Observe the respirations for depth by • During deep respirations, a large
watching the movement of the chest volume of air is exchanged; during
shallow respirations, a small volume is
exchanged
• Observe the respirations for regular or • Normally, respirations are evenly

13
 irregular rhythm spaced

• Observe the character of respirations- • Normally, respirations are silent and

the sound they produce and the effort effortless
they require
6. Document the respiratory rate, depth,
rhythm, and character on the appropriate
record

ASSESSING BLOOD PRESSURE

Definition
Arterial blood pressure is the measure of the pressure exerted by the blood as it flows through
the arteries

Purposes
• To obtain a baseline measure of arterial blood pressure for subsequent evaluation
• To determine the client’s hemodynamic status(e.g. cardiac output; stroke volume of the
heart and blood vessel resistance)
• To identify and monitor changes in blood pressure resulting from a disease process or
medical therapy(e.g. presence or history of cardiovascular disease, renal disease,
circulatory shock, or acute pain; rapid infusion of fluids or blood products.

Equipments
• Stethoscope or DUS
• Blood pressure cuff of the appropriate size
• Sphygmomanometer

14
IMPLEMENTATION
Preparation
• Ensure that the equipment is intact and
functioning properly. Check for leaks in the
tubing of the sphygmomanometer
• Make sure that the client has not smoked
or ingested coffee within 30 minutes prior
to measurement
Performance
1. Prior to performing the procedure,
introduce self and verify the client
using agency protocol. Explain to the
client what you are going to do, why is
it necessary, and how he or she can
cooperate. Discuss how the results will
be used in planning further care
treatments
2. Perform hand hygiene and observe
appropriate infection control procedures
3. Provide for client privacy
4. Position the client appropriately
• The adult client should be sitting unless
otherwise specified. Both feed should
be flat on the floor
• The elbow should be slightly flexed
with the palm of the hand facing up the
forearm. Supported at the heart level.
Readings in any other position should
be specified. The blood pressure is
normally similar in sitting, standing, and
lying positions, but it can vary
significantly by position in certain
persons
• Expose the upper arm
RATIONALE
-Smoking constricts blood vessels, and
caffeine increases the pulse rate. Both of
these cause a temporary increase in blood
pressure
-Introducing self to the client builds rapport.
Verifying the client ensures that the nursing
care is given to the right person. Explaining the
procedure is important so the client can
anticipate what will happen as the procedure
goes on.
-Hand washing is important to cleanse the
hands of pathogens (including bacteria or
viruses) and chemicals which can cause
personal harm or disease
• Legs crossed at the knee result in
elevated systolic and diastolic blood
pressures
• The blood pressure increases when the
arm is below the heart level and
decreases when the arm is above the
heart level
15
5. Wrap the deflated cuff evenly around the
upper arm. Locate the brachial artery. Apply
the center of the bladder directly over the
artery.
6. If this is the client’s initial examination,
perform a preliminary palpatory
determination of systolic pressure
• Palpate the brachial artery with
fingertips

• Close the valve of the bulb

• Pump up the cuff until you no longer

• This gives an estimate of the systolic
feel the brachial pulse. At the pressure
pressure
the blood cannot flow through the
artery. Note the pressure on the
sphygmomanometer at which pulse is
no longer felt

• Release the pressure completely in the

cuff and wait 1 to 2 minutes before
• A waiting period gives the blood
making further assessments
trapped in the veins time to be
released. Otherwise, false high systolic
readings will ocur
7. Position the stethoscope appropriately.
• Cleanse the earpieces with antiseptic
wipe

• Insert the ear attachments of the • Sounds are heard more clearly when
stethoscope in your ears so that they the ear attachments follow the direction
tilt slightly forward. of the ear canal

• Ensure that the stethoscope hangs • If the stethoscope tubings rub against
freely from the ears to the diaphragm. an object, the noise can block the
sounds of the blood within the artery

• Place the bell side of the amplifier of • Because the blood pressure is a low-
the stethoscope over the brachial pulse frequency sound, it is best heard with
site. the bell- shaped diaphragm

• Place the stethoscope directly on the • This is to avoid noise made from
skin, not on clothing over the site. rubbing the amplifier against the cloth

16
 • Hold the diaphragm with the thumb and
the index finger

8. Auscultate the client’s blood pressure

• Pump up the cuff until the

sphygmomanometer reads 30 mmHg
above the point where the brachial
pulse disappeared.

• Release the valve on the cuff carefully

so that the pressure decreases at the • If the rate is faster or slower, an error in
rate of 2 to 3 mm Hg per second. measurement may occur

• As the pressure falls, identify the

manometer reading Korotkoff phases I, • There is no clinical significance in
IV and V. phases II and III

• Deflate the cuff rapidly and completely

• Wait 1 to 2 minutes before making

another determinations • This permits blood trapped in the veins
to be released
• Repeat the above steps to confirm the
accuracy of the reading-especially if it
falls outside the normal range.

9. If this is the client’s initial examination,

repeat the procedure on the client’s other
arm. There should be a difference of no
more than 10 mm Hg between the arms.
The arm found to have the highest pressure
should be used for subsequent examination
10. Remove the cuff
11. Wipe the cuff with an approved -Cuffs can become significantly
disinfectant. contaminated. .

12. Document and report pertinent

assessment data according to agency policy.

HEAD-TO-TOE ASSESSMENT

17
Definition

Physical assessment is an organized systemic process of collecting objective data

based upon a health history and head-to-toe or general systems examination. A physical
assessment should be adjusted to the patient, based on his needs. It can be a complete
physical assessment, an assessment of a body system, or an assessment of a body part.

Purposes

1. To obtain baseline physical and mental data on the patient.

2. To supplement, confirm, or question data obtained in the nursing history.
3. To obtain data that will help the nurse establish nursing diagnoses and plan patient care.
4. To evaluate the appropriateness of the nursing interventions in resolving the patient's
identified pathophysiology problems.
• Gloves
Equipments • Lubricants
• Flashlight or Penlight • Tongue blades
• Laryngeal or Dental mirror (deppressors)
• Nasal septum • Pencil & paper
• Ophthalmoscope • News print to read
• Otoscope • Paper clip
• Percussion (reflex) hammer • Snellen chart
• Tuning Fork • Substance to smell and
• Cotton applicators taste

Assessing Appearance and Mental Status

PROCEDURE RATIONALE
1. Introduce self and verify the client’s To promote client’s cooperation and
identity using agency protocol. Explain to participation.
the client what you are going to do, why it
is necessary, and how he or she can
cooperate. Discuss how the results will be
used in planning further care or treatments.
2. Perform hand hygiene and observe To reduce spread of microorganisms.
appropriate infection control procedures.
3. Provide for client privacy To allay fear and anxiety.
4. Observe body build, height, and weight N – proportionate, varies with lifestyle
in relation to the client’s age, lifestyle, and A – Excessively thin or obese
health
5. Observe client’s posture and gait, N – Relaxed, erect posture; coordinated

18
standing, sitting and walking.
6. Observe client’s overall hygiene and
grooming. Relate these to the person’s
activities prior to the assessment.
7. Note body breath odor in relation to
activity level.
8. Observe for signs of distress in posture
or facial expression.
9. Note obvious signs of health or illness
(e.g. in skin color or breathing).
10. Assess the client’s attitude.
11. Note the client’s affect/mood; assess
the appropriateness of the client
responses.
12. Listen for quantity of speech (amount
and space), quality (loudness, clarity,
infection), and organization (coherence of
though, overgeneralization, vagueness).
13. Listen for Relevance and organization
of thoughts.
Assessing the skin
1. Inspect skin color (best assessed under
natural light and on areas not exposed to
the sun).
2. Inspect the uniformity of skin color.
3. Assess edema, if present (i.e., location,
color, temperature, shape and degree to
which the skin remains indented or pitted
when pressed by a finger). Measuring the
movement
A – Tense, slouched, bent posture;
uncoordinated movement; tremors
N – Clean Neat
A – dirty, unkempt
N – No body odor, no breath odor
A – Foul body odor, ammonia odor
N – no distress noted
A – Bending over because of abdominal
pain, wincing, frowning, or labored
breathing
N – healthy appearance
A – Pallor, weakness; lesions
N – Cooperative, able to follow instructions
A – Negative, hostile, withdrawn
N – Appropriate to situation
A - Inappropriate to situation
N – Understandable, moderate pace; clear
tone and inflection; exhibits thought
association
A – rapid or slow pace; lacks association
N – Logical sequence; makes sense; has
sense of reality
A – Illogical sequence; flight of ideas
N – Varies from light to deep brown; from
ruddy pink to light pink; from yellow
overtones to olive
A – Pallor, cyanosis, jaundice, erythema
N – Generally uniform except in areas
exposed to the sun; areas of lighter
pigmentation (palms, lips, nail beds) in
dark skinned people
A – areas of either hyperpigmentation or
hypopigmentation
N – No edema
A – see the scale for describing edema
19
circumference of the extremity with a
millimeter tape may be useful for
comparison.
4. Inspect, palpate, and describe skin
lesions. Apply gloves if lesions are open or
draining. Palpate lesions to determine
shape and texture. Describe lesions
according to location, distribution, color
configuration, size, shape, type, or
structure.
5. Observe and palpate skin moisture.
6. Palpate skin temperature. Compare the
two feet and the two hands, using the
backs of your fingers.
7. Note skin turgor (fullness or elasticity) by
lifting and pinching the skin on an
extremity.
Assessing the Hair
1. Inspect the evenness of growth over the
scalp.
2. Inspect hair thickness or thinness.
3. Inspect hair texture and oiliness.
4. Note presence of infections or
infestations by parting the hair in several
areas, checking behind the ears and along
the hairline at the neck.
5. Inspect amount of body hair.
Assessing the Nails
1. Inspect fingernail plate shape to
determine its curvature and angle.
2. Inspect fingernail and toenail texture and N – Smooth texture
bed color.
N – Freckles, some birthmarks, some flat
and raised nevi; no abrasions or other
lesions
A – Various interruptions in skin integrity;
irregular, multicolored or raised nevi
N – Moisture in skin folds and the axillae
A – excessive moisture or excessive
dryness
N – Uniform; within normal range
A – Generalized
hyperthermia/hypothermia; localized
hyperthermia/hypothermia
N – When pinched, skin springs back to
previous state; may be slower in elders
A – Skins stays pinched or tented or
moves back slowly
N – Evenly distributed hair
A – Patches of hair loss
N – Thick hair
A – very thin hair
N – Silky, resilient hair
A – Brittle hair; excessively oily/dry hair
N – No infection or infestation
A – Flaking, sores, lice, nits (louse eggs),
and ringworm
N – Variable
A – Hirsutism in women; naturally absent
or sparse leg hair.
N – convex curvature
A – Spoon nail/clubbing
A – Excessive thickness or thinness or
presence of grooves or furrows
20
3. Inspect tissues surrounding nails.
4. Perform blanch test of capillary refill.
Press two or more nails between your
thumb and index finger: look for blanching
and return of pink color to nail bed.
Assessing the Skull and Face
1. Inspect the skull for size, shape, and
symmetry.
2. Palpate the skull for nodules or masses
and depressions. Use a gentle rotating
motion with the fingertips. Begin at the
front and palpate down the midline, then
palpate each side of head.
3. Inspect the facial features.
4. Inspect the eyes for edema and
hollowness.
5. Note symmetry of facial movements.
Ask the client to elevate the eyebrows,
frown or lower the eyebrows, close the
eyes tightly, puff the cheeks, and smile
and show the teeth.
Assessing the Eye structures and Visual acuity
1. Inspect the eyebrows for hair distribution
and alignment and skin quality and
movement.
2. Inspect eyelashes for evenness of
distribution and direction of curl.
3. Inspect the eyelids for surface
characteristics, position and relation to the
cornea, ability to blink, and frequency of
blinking. For proper visual examination of
the upper eyelids , elevate the eyebrows
with your thumb and index fingers, and
have the client close the eyes. Inspect the
lower eyelids while the client’s eyes are
closed.
N – Intact epidermis
A – hangnails; paronychia
N - prompt return of pink/usual color
A - Delayed return of pink or usual color
N – Rounded, smooth skull contour
A – lack of symmetry, increase skull size
with more prominent nose and forehead
N - Smooth, uniform consistency; absence
of nodules/masses
A – Sebaceous cysts; local deformities
from trauma; masses nodules
N – Symmetric facial features
A - Increased facial hair; thinning of
eyebrows; asymmetric features
A – Periorbital edema; sunken eyes
N – Symmetric facial movements
A - asymmetric facial movements
N – Hair evenly distributed; skin intact;
symmetrically aligned
A – Loss of hair; scaling and flakiness of
skin, unequal alignment of eyebrows
N – Equally distributed; curled slightly
outward
A - Turned inward
N – Skin intact; no discharge; no
discoloration
A – redness, swelling, flaking, crusting,
plaques, discharge, nodules, lesions
21
4. Inspect the bulbar conjunctiva for color,
texture, and the presence of lesions.
Retract the eyelids with your thumb and
index finger, exerting pressure over the
upper and lower bony orbits, and ask the
client to look up, down, and from side to
side.
5. Inspect the palpebral conjunctiva by
everting the lids. Evert both lower lids and
ask the client to look up. Then gently
retract the lower lids with the index fingers.
6. Inspect and palpate the lacrimal gland
7. Inspect and palpate the lacrimal sac and
lacrimal duct.
8. Inspect the cornea for clarity and
texture. Ask the client to look straight
ahead. Hold a penlight at an oblique angle
to the eye, and move the light slowly
across the corneal surface.
9. Perform the corneal sensitivity test to
determine the function of the fifth cranial
nerve. Ask the client to keep both eyes
open and look straight ahead. Extend your
hand behind the client’s field of vision, then
bring the gauze toward the outer canthus.
Lightly touched the cornea with a corner of
the gauze.
10. Inspect the pupils for color, shape, and
symmetry of size.
11. Assess each pupil’s direct and
consensual reaction to light to determine
the function of the third and fourth cranial
nerves.
12. Assess each pupil’s reaction to
accommodation.
N - transparent; capillaries sometimes
evident; sclera appears white
A – Jaundice sclera, excessively pale
sclera, lesions or nodules
N – Shiny, smooth and pink /red
A – extremely pale, Extremely red, nodules
or other lesions
N – No edema or tenderness over lacrimal
gland
A – swelling or tenderness over lacrimal
duct
N – No edema or tearing
A – Evidence of increase tearing
N – Transparent, shiny and smooth; details
of the iris are visible
A – opaque; surface not smooth
N – Client blinks when the cornea is
touched, indicating that the trigeminal
nerve is intact
A – one or both eyelids fail to respond
N – Black in color; equal in size; normally
3-7 mm in diameter; round, smooth border,
iris flat and round
A – Cloudiness, mydriasis, miosis,
anisocoria; bulging of iris toward cornea
N – Illuminated pupil constricts (direct
response) Nonilluminated pupil constricts
(consensual response)
A – Neither pupil constricts, unequal
responses, absent responses.
N – Pupil’s constrict when looking at near
object; pupils dilate when looking at far
object; pupils converge when near object is
moved toward nose
22

13. Assess six ocular movements to
determine eye alignment and coordination.
14. Assess near vision by providing
adequate lighting and asking the client to
read from a magazine or newspaper held
at a distance of 36cm. If the client normally
wears corrective lenses, the glasses or
lenses should be worn during the test.
15. Assess distance vision by asking the
client to wear corrective lenses, unless
they are use for reading only, i.e., for
distances of only 36cm
Assessing the Ears and Hearing
1. position the client comfortably – seated
if possible
2. Inspect the auricles for color, symmetry
of size, and position. To inspect position,
note the level at which the superior aspect
of the auricle attaches to the head with
relation to the eye.
52. Palpate the auricles for texture,
elasticity, and areas of tenderness.
3. Using an otoscope, inspect the external
ear canal for cerumen, skin lesions, pus,
and blood.
4. Inspect the tympanic membrane for
color and gloss
5. Perform weber’s test to assess bone
conduction by examining the
lateralizationof sounds.
A – One or both pupils fail to constrict,
dilate or converge
N – Both eyes coordinated, move in unison
A – Eye movements not coordinated or
parallel; one or both eyes fail to follow a
penlight in specific directions
N – Able to read newsprint
A – Difficulty reading newsprint unless due
to aging process
N – 20/20 vision on snellen-type chart
A – Denominator of 40 0r more on snellen-
type chart with corrective lenses
To make client comfortable.
N – color same as facial skin, symmetrical
A – Bluish color of earlobes, pallor,
excessive redness
N – Mobile, firm and not tender; pinna
recoils after it is folded
A – Lesions; flaky, scaly skin; tenderness
when moved or pressed
N - Distal third contains hair follicles and
glands, Dry cerumen, grayish-tan color; or
sticky, wet cerumen in various shades of
brown
A – Redness and discharge, scaling,
excessive cerumen obstructing canal
N – Pearly gray color, semitransparent
A – Pink to red, some opacity, yellow
amber, white, blue or deep red, dull
surface
N – sound is heard in both ears or is
localized at the center of the head
A - sound is heard better in impaired ear,
indicating a bone-conductive hearing loss;
or sound is heard better in ear withpout a
23

Assessing the Nose and Sinuses
1. Inspect the external nose for any
deviations in shape, size, or color and
flaring, or discharge from the nares.
2. Lightly palpate the external nose to
determine any areas of tenderness,
masses, or displacements of bone and
cartilage.
3. Determine patency of both nasal
cavities.
4. Inspect the nasal cavities using a
flashlight or a nasal spectrum.
5. Observe for the presence of redness,
swelling, growths, and discharge.
6. Inspect the nasal septum between the
nasal chambers.
7. Palpate the maxillary and frontal sinuses
for tenderness.
Assessing the Mouth and Oropharynx
1. Inspect the outer lips for symmetry of
contour, color, and texture.
2. Inspect and palpate the inner lips and
buccal mucosa for color, moisture, texture,
and the presence of lesions.
3. Inspect the teeth and gums while
examining the inner lips and buccal
mucosa.
problem, indicating a sensorineural
disturbance
N – symmetric and straight, no discharge
or flaring, uniform color
A – asymmetric, discharge from nares,
localized areas of redness or presence of
skin lesions
N – Not tender
A – Tenderness on palpation; presence of
lesions
N – Air moves freely as the client breathes
through the nares
A – Air movement is restricted in one or
both nares
To inspect the nasal passages.
N – Mucosa pink, clear, watery discharge,
no lesions
A – Mucosa red, edematous, abnormal
discharge, presence of lesions
N – Nasal septum intact and in midline
A – Septum deviated to the right or to the
left
N – Not tender
A – Tenderness in one or more sinuses
N – uniform pink color, soft, moist, smooth
texture, symmetry of contour, ability to
purse lips
A – pallor, cyanosis, blisters; generalized
or localized swelling; fissures; crusts, or
scales
N - uniform pink color, soft, moist, smooth,
elastic texture
A – Excessive dryness, pallor, leukoplakia
N – 32 adult teeth, smooth, white, shiny
tooth enamel, pink gums, moist
A – Missing teeth, ill-fitting dentures, brown
or black discoloration of the enamel,
24

4. Inspect the dentures.
5. Inspect tongue movement.
6. Inspect the base of the tongue, the
mouth floor, and the frenulum.
7. Palpate the tongue and floor of the
mouth for any nodules, lumps, or
excoriated areas.
8. Inspect salivary duct openings for any
swelling or redness.
9. Inspect the hard and soft palate for
color, shape, texture, and the presence of
bony prominences.
10. Inspect the uvula for position and
mobility while examining the palates.
11. Inspect the oropharynx for color and
texture.
12. Inspect the tonsils for color, discharge,
and size.
13. Elicit the gag reflex by pressing the
posterior tongue with a tongue blade.
Assessing the Neck
1. Inspect the neck muscles
(sternocleidomastoid and trapezius) for
abnormal swellings or masses.
2. Palpate the entire neck for enlarged
lymph nodes.
3. Palpate the trachea for lateral deviation.
4. Inspect the thyroid gland.
excessively red gums
N – smooth, intact dentures
A – ill-fitting dentures, irritated and
excoriated area under dentures
N – moves freely, no tenderness
A – Restricted mobility
N – Smooth tongue base with prominent
veins
A – sweeling, ulceration
N – smooth with no palpable nodules
A - swelling nodules
N – same as color of buccal mucosa and
floor of mouth
A – Inflammation
N – Light pink, smooth, soft palate, Lighter
pink hard palate, more irregular texture
A – Discoloration, palates the same color,
irritations
N – Positioned in midline of soft palate
A – Deviation to one side from tumor or
trauma; immobility
N – pink and smooth posterior wall
A – reddened or edematous
N – Pink and smooth, no dischargeof
normal size or not visible
A – inflamed, presence of discharge,
swollen
N – present
A – Absent
N – Muscles equal in size; head centered
A - Unilateral neck swelling, head tilted to
one side
N – not palpable
A – enlarged, palpable, possibly tender
N – central placement in midline of neck
A – deviation to one side
N – Not visible on inspection
25

5. Palpate the thyroid gland for
smoothness.
Assessing the Thorax and Lungs
1. Inspect the shape and symmetry of the
thorax from posterior and lateral views.
Compare the anteroposterior diameter to
the transverse diameter.
2. Inspect the spinal alignment for
deformities.
3. Palpate the posterior thorax.
4. Palpate the posterior chest for
respiratory excursion.
5. Palpate the chest for vocal (tactile)
fremitus.
6. Percuss the thorax.
7. Percuss for diaphragmatic excursion.
8. Ausculate the chest using the flat-disc
diaphragm of the stethoscope.
9. Inspect breathing patterns.
10. Inspect the costal angle and the angle
at which the ribs enter spine.
11. Palpate the anterior chest.
12. Palpate the anterior chest for
respiratory excursion.
A – visible diffuseness/local enlargement
N – Lobes may not be palpated
A – solitary nodules
N – Anteroposterior to transverse the
diameter in ratio of 1:2, chest symmetric,
A – Barrel chest; increased anteroposterior
to transverse diameter, chest assymetric
N – Spine vertically aligned
A – Exaggerated spinal curvatures
N – skin intact
A – Skin lesions
N – full and symmetric chest expansion
A – asymmetric/ decreased chest
expansion
N – bilateral symmetry of vocal fremitus
A – decreased or absent of fremitus
N – Percussion notes resonate, except
over scapula, lowest point of resonance is
at the diaphragm
A – Assymetry in percussion, Areas of
dullness or flatness over lung tissue
N – excursion is 3-5cm. bilaterally in
women and 5-6 cm in men
A – Restricted excursion
N – Vesicular and bronchovesicular breath
sounds
A – Adventitious breath sounds
N – quiet, rhythmic, and effortless
respirations
A – abnormal breathing patterns and
sounds
N – Costal angle is less than 90 degrees
and the ribs insert into the spine at
approximately a 45 degree angle
A – widened
N – full symmetric excursion
26

13. Palpate tactile fremitus in the same
manner as for the posterior chest.
14. Percuss the anterior chest
systematically.
15. Auscultate the trachea.
16. Auscultate the anterior chest.
Assessing the Heart and Central Vessels
1. Simultaneously inspect and palpate the
precordium for the presence of abnormal
pulsations, lifts, or heaves.
2. Auscultate the heart in all four anatomic
sites: aortic, pulmonic, tricuspid, and apical
(mitral)
3. Palpate the carotid artery. Use extreme
caution.
4. Auscultate the carotid artery.
A – Asymmetric/ decreased respiratory
excursion
N – same as posterior vocal fremitus
A – same as posterior fremitus
N – Percussion notes resonate down to the
sixth rib at the level of the diaphragmmbut
are flat over areas of heavy muscle and
bone, dull on areas over the heart and the
liver, and tympanic over the underlying
stomach
A – Asymmetry in percussion notes, areas
of dullness or flatness over lung tissue
N – Bronchial and tubular breath sounds
A – Adventitious breath sounds
N – Bronchovesicular and vesicular breath
sounds
A – Adventitious breath sounds
N – No pulsations
A – pulsations
N – S1: usually heard at all sites, usually
louder at base of heart
S2: usually heard at all sites, usually
louder at the base of heart
Systole: silent interval;slightly shorter
duration than diastole at normal heart rate
Diastole: silent interval;slightly longer
duration than systole at normal heart rates
S3: in children and young adults
S4: in many older adults
A – Increased or decreased intensity,
varying intensity with different beats,
increased intensity at aortic area,
increased intensity at pulmonic area, sharp
sounding ejection clicks, s3: in older adults,
s4: may be a sign of HPN
N – symmetric pulse volume
A – asymmetric volumes
N – no sound heard on auscultation
A – Presence of bruit in one or both
arteries
27
5. If jugular distention is present, assess
the jugular venous pressure (JVP). Locate
the highest visible point distention of the
internal jugular vein.
Assessing the Peripheral Vascular System
1. Palpate the peripheral pulses on both
sides of the client’s body individually,
simultaneously (except the carotid pulse),
and systematically to determine the
symmetry of pulse volume. If you have
difficulty palpating some of the peripheral
pulses, use a Doppler ultrasound probe.
2. Inspect the peripheral veins in the arms
and legs for the presence and/ or
appearance of superficial veins when limbs
are dependent and when limbs are
elevated.
3. Assess the peripheral leg veins for signs
of phlebitis.
4. Inspect the skin of the hands and feet
for color, temperature, edema, and skin
changes.
5. Capillary refill test: squeeze the client’s
fingernail and toenail between your fingers
sufficiently to cause blanching
Assessing the Breasts and Axillae
1. Inspect the breasts for size, symmetry,
and contour or shape while hthe client is in
a sitting position.
2. Inspect the skin of the breast for
localized discolorations or
hyperpigmentation, retraction or dimpling,
The external jugular vein is more easily
affected by obstruction or kinking at the
base of the neck
N – Symmetric pulse volumes, full
pulsations
A – Asymmetric volumes, absence of
pulsations
N – In dependent position, presence of
distention and nodular bulges at calves,
when limbs elevated, veins collapsed
A – Distended veins in the thigh or lower
leg or on posterolateral part of calf from
knee to ankle
N – Limbs not tender, symmetric in size
A – tenderness on palpation, pain in calf
muscles with forceful dorsiflexion of the
foot
N – skin color pink, temperature not
excessively warm or cold, no edema, skin
texture resilient and moist
A – cyanotic, pallor, dependent rubor, a
dusky red color when limb is lowered,
brown pigmentation around ankles, skin
cool, marked edema, skin thin and shiny or
thick, waxy with reduced hair
N – capillary refill test immediate return of
color
A – Delayed return of color
N – F: rounded shape; slightly unequal in
size; generally symmetric
M: breasts even with the chest wall; if
obese may be similar in shape to female
breasts
A – recent change in breast size; swelling;
marked asymmetry
N – Skin uniform in color, smooth and
intact, diffuse symmetric horizontal or
vertical vascular pattern in light-skinned
28
localized hypervascular areas, swelling, or
edema.
3. Inspect the areola area for size, shape,
symmetry, color, surface characteristics,
and any masses or lesions.
4. Inspect the nipples for size, shape,
position, color, discharge, and lesions.
5. Palpate the axillary, subclavicular, and
supraclavicular lymph nodes.
6. Palpate the breast for masses,
tenderness, and any discharge from the
nipples. Palpation of the breast is generally
performed while the client is supine.
7. Palpate the areola and the nipples for
masses.
8. Teach the client the technique for breast
self-examination.
Assessing the Abdomen
1. Inspect the abdomen for skin integrity.
2. Inspect the abdomen for contour and
symmetry.
3. Observe abdominal movements
associated with respiration, perstalsis, or
aortic pulsations.
4. Observe the vascular pattern.
people, striae; moles and nevi
A – Localized discoloration or
hyperpigmentation, retraction or dimpling,
swelling.
N – round or oval and bilaterally the same
color varies widely, from light pink to dark
brown
A – any asymmetry, mass or lesion
N – round, everted, and equal in size;
similar in color; soft and smooth; both
nipples point in same direction
A – asymmetrical size and color, presence
of discharge, crusts, or cracks, recent
inversion of one or both nipples
N – no tenderness, masses or nodules
A – tenderness, masse or n odules
R – in the supine position, the breast
flatten evenly against the chest wall,
facilitating palpation
N – no tenderness,masses , nodules or
nipple discharge
A – Tenderness, masses, nodules and
nipple discharge
N - no tenderness,masses , nodules or
nipple discharge
A - tenderness,masses , nodules or nipple
discharge
For client to be knowledgeable on how to
examine his/her own breast.
N – unblemished skin, uniform color, silver
white striae or surgical scars
A – Presence of rash or other lesions
N – Flat, rounded or schapoid, symmetric
contour
A – distended, asymmetric contour
N – symmetric movement caused by
respiration
A – limited movement due to pain or
disease process
N – no visible vascular pattern
29

5. Auscultate the abdomen for bowel
sounds, vascular sounds, and peritoneal
friction rubs.
6. Percuss several areas in each of the
four quadrants to determine presence of
tympany and dullness.
7. Percuss the liver to determine its size
8. Perform light palpation first to detect
areas of tenderness and/ or muscle
guarding.
9. Perform deep palpation over all four
quadrants.
10. Palpate the liver to detect enlargement
and tenderness.
11. Palpate the area above the pubic
symphysis if the client’s history indicates
possible urinary retention.
Assesing the Musculoskeletal System
1. Inspect the muscles for size.
2. Inspect the muscles and tendons for
contractures.
3. Inspect the muscles for tremors.
4. Palpate muscles at rest to determine
muscle tonicity.
5. Palpate muscles while the client is
active and passive for flaccidity, spasticity,
and smoothness of movement.
6. Test muscle strength. Compare the right
A – Visible venous pattern is associated
with liver disease, ascites & venocaval
obstruction
N – audible bowel sounds, absence of
arterial bruits, absence of friction rub
A – hypoactive, hyperactive and true
absence of sounds
N – tympany over the stomach and gas
filled bowels; dullness, especially over the
liver and spleen, or a full bladder
A – Large dull areas
N – 6-12 cmin the midclavicular line, 4-8cm
at the midsternal line
A – enlarged size
N – no tenderness
A – tenderness
N – Tenderness may be present near
xiphoid process, over cecum, and over
sigmoid colon
A – generalized/ localized areas of
tenderness, mobile or fixed masses
N – May not be palpable
A – Enlarged
N – not palpable
A – distended and palpable as smooth,
round , tense mass
N – equal size on both sides of body
A – atrophy or hypertrophy, asymmetry
N – No contractures
A – malposition of body part, e.g. foot drop
N – No tremors
A – Presence of tremor
N – normally firm
A – atonic
N – Smooth coordinated movements
A – Flaccidity/spasticity
N – equal strength on each body side
30
side with left side.
7. Inspect the skeleton for normal structure
and deformities.
8. Palpate the bones to locate any areas of
edema or tenderness.
9. Inspect the joint for swelling.
10. Assess joint range of motion.
Assessing the Neurological System
1. Determine the client’s orientation to
time, place, and person by tactful
questioning.
2. Listen for lapses in memory.
3. Apply the Glasgow Coma Scale
4. Test the cranial nerves.
I. Cranial Nerve I – Olfactory
II. Cranial Nerve II – Optic
III. Cranial Nerve III – Oculomotor
IV. Cranial Nerve IV – Trochlear
V. Cranial Nerve V – Trigeminal
VI. Cranial Nerve VI – Abducens
VII. Cranial Nerve VII – Facial
VIII. Cranial Nerve VIII – Auditory
IX. Cranial Nerve IX – Glossopharyngeal
X. Cranial Nerve X – Vagus.
XI. Cranial Nerve XI – Accesory
XII. Cranial Nerve XII – Hypoglossal
A – 25% or less of normal strength
N – no deformities
A – Bones misaligned
N – no tenderness and swelling
A – tenderness,swelling, crepitation or
nodules
N – no swelling, no tenderness
A – One or more swollen joints, tenderness
N – varies to some degreein accordance
with person’s genetic makeup and degree
of physical activity
A – limited range of motion in one or more
joints
To assess mental status of the client.
To assess the client’s ability to recall
information.
To assess client’s level of conciousness.
To identify different mild aromas, such as
coffe, vanilla, peanut butter, orange/lemon,
chocolate
To check visual fields and vision of the
client
To assess 6 ocular movements and pupil
reaction
To assess skin sensation of the client
To assess direction of gaze
Facial expression and taste
To assess client ability to hear spoken
word and vibrations of tuning fork.
To assess client ability to swallow , tongue
movement and taste
To assess client’s speech for hoarseness
To assess the head movement and
shrugging of the shoulders
To assess protrusion of tongue
31
5. Gross Motor and Balance Tests
- walking gait
- Romberg test
6. Fine Motor Tests for the Upper
Extremities.
- Finger to nose test
- alternating supination and pronation of
hands and knees
- finger to nose and to the nurses finger
- Fingers to fingers
- fingers to thumb
7. Fine Motor Tests for the Lower
Extremities.
- heel down opposite shin
- toe or ball of foot to the nurse’s finger
8. Light-Touch Sensation.
Compare the light touch sensation of
symmetric areas of the body.
N – Has upright posture and steady gait
with opposing arm swing; walks unaided,
maintaining balance
A – poor posture and unsteady, irregular,
staggering gait with wide stance; bends
legs only from hips; has rigid or no arm
movements
N – Negative Romberg: may sway slightly
but is able to maintain upright posture and
foot stance
A – positive Romberg: can’t maintain foot
stance; moves the feet apart to maintain
stance.
N – repeatedly & rhythmically touches the
nose
A – Misses the nose or give the sloe
response
N – Can alternately supinate and pronate
hands at rapid pace
A – slow, clumsy movements, and irregular
timing.
N – Performs with coordination and rapidly
A – Misses the finger and moves slowly
N – performs with accuracy and rapidity
A – Moves slowly
N – Rapidly touches each finger to thumb
with each hand
A – cannot coordinate this fine discrete
movements with either one or both hands
N – Demonstrate bilateral equal
coordination
A – tremors; awkward; heel moves off shin
N – Moves smoothly with coordination
A – misses your finger; cant coordinate
movement
Sensitivity to touch varies among different
skin areas
32
9. Pain Sensation.
10. Temperature Sensation.
11. Position or Kinesthetic Sensation.
12. Tactile Discrimination.
Assessing the Female Genitals and Inguinal Area
1. Cover the pelvic area with a sheet, or a
drape at all times when not actually being
examined. Position the client in supine,
with feet elevated on the stirrups of an
examination table. Alternately, assist the
client into the dorsal recumbent position
with knees flexed and thighs externally
rotated.
2. Inspect the distribution, amount, and
characteristics of the pubic hair.
3. Inspect the skin of the pubic area for
parasites, inflammation, swelling, and
lesions. To assess pubic skin adequately,
separate the labia majora and labia
minora.
4. Inspect the clitoris, urethral orifice, and
vaginal orifice when separating the labia
minora.
To assess pain sensation
N – Able to discriminate sharp and dull
sensation
A – Areas of reduce, heightened or absent
sensation
N – able to discriminate between hot and
cold sensations
A – areas of dulled or lost of sensation
N – can readily determine the position of
fingers and toes
A – unable to determine the position of one
or more fingers or toes
To assess client’s ability to recognize
objects by touching them
To provide privacy and comfort.
N – there are wide variations; generally
kinky in the menstruating adult, thinner and
straighter after menopause, distributed in
the shape of an inverse triangle
A – Scant pubic hair, hair growth should
not extend over the abdomen
N – pubic skin intact, no lesions, Skin of
uvula area slightly darker than the rest of
the body, labia round, full, and relatively
symmetric in adult females
A – Lice, lesions, scars, fissures, swelling,
erythema, excoriations, varicosities or
leukoplakia
N – Clitoris does not exceed 1 cm in width
and 2 cm In lengh, urethral orifice appears
as a small slit and is the same color as
surrounding tissues, no inflammation,
swelling or discharge
A – Presence of lesions, inflammation
swelling or discharge
33
5. Palpate the inguinal lymph nodes.
Assessing the Male Genitals and Inguinal Area
1. Cover the pelvic area with a sheet, or
drape at all times when not actually being
examined.
2. Inspect the distribution, amount, and
characteristics of pubic hair.
3. Inspect the penile shaft and glans penis
for lesions, nodules, swellings, and
inflammation.
4. Inspect the urethral meatus for swelling,
inflammation, and discharge.
5. Palpate the penis for tenderness,
thickening, and nodules. Use your thumb
and first two fingers.
6. Inspect the scrotum for appearance,
general size, and symmetry.
7. Palpate the scrotum to assess the status
of underlying testes, epididymis, and
spermatic cord. Palpate both testes
simultaneously for comparative purposes.
8. Inspect both inguinal areas for bulges
while the client is standing, if possible.
Assessing the Rectum and Anus
1. Inspect the anus and surrounding tissue
for color, integrity, and skin lesions.
N – No enlargement or tenderness
A – Enlargement and tenderness
To provide privacy and comfort.
N – Triangular distribution, often spreading
up the abdomen
A – scant amount or absence of hair
N – Penile skin intact, appears slightly
wrinkled and varies in color as widely as
other body skin, foreskin easily retractable
from the glans penis, small amount of thick
white smegma between the glans and
foreskin
A – Presence of lesions, nodules, swelling
or inflammation
N – pink and slitlike appearance,
positioned at the tip of the penis
A – Inflammation; discharge, variation in
meatal locations
N – smooth and semifirm, is slightly
movable over the underlying structures
A – Presence of tenderness, thickening or
nodules, immobility
N – scrotal skin is darker in color than that
of the rest of the body and is loose
A – discolorations; any tightening of skin’
N – Testicles are rubbery, smooth and free
of nodules and masses, testis is about 2 x
4 cm
A – testicles are enlarged, with uneven
surface, epididymis is nonresilient and
painful
N – No swelling or bulges
A – swelling or bulge
N – Intact perianal skin; usually slightly
more pigmented than the skin of the
buttocks Anal skin is more pigmented,
coarser, and moister than perianal skin and
usually hairless.
34

2. Palpate the rectum for anal sphincter
tonicity, nodules, masses, and tenderness.
3. On withdrawing the finger from the
rectum and anus, observe it for feces. If
ordered, perform a test for occult blood on
the stool.
4. Document findings in the client record
using forms or checklists supplemented by
narrative notes when appropriate.
A – Presence of fissures, ulcers,
excoriations, inflammations, abscesses,
protruding hemorrhoids, lumps or tumors,
fistula openings, or rectal prolapse.
N – Anal sphincter has good tone.
A – Hypertonicity/hypotonicity of the anal
sphincter
N – brown color
A – Presence of mucus blood or black tarry
stool.
N – To contribute to data collection and
fulfill procedural requirement.

BED BATH
Definition
It is a type of bath given while the client is on bed.

Purposes

1. To make client clean and fell comfortable.

2. To increase sense of wellbeing.
3. To promote muscular relaxation and relieve feelings of fatigue.

Assessment

ASSESS

35
 1. Condition of the skin ( color, texture and turgor, presence of pigmented spots,
temperature, lesions, abrasions and bruises )
2. Physical or emotional factors ( e.g., Fatigue, sensitivity to cold, need for control, anxiety
and fear ).
3. Presence of pain and need for adjunctive measures( e.g., analgesics ) before the bath
4. Need for use of clean gloves during the bath
5. Any other aspect of health that may affect the client’s bathing process ( e.g., mobility,
strength, cognition )

Planning

1. Assemble the following equipment:

1.1 Wash basin
1.2 Bath blanket
1.3 Wash cloth
1.4 Patient gown
1.5 Hamper for soiled linen
1.6 Gloves
1.7 Soap
1.8 Hygiene supplies ( lotion, powder and deodorant )
1.9 Bed pan / Urinal
2. Introduce self and verify patient’s identification.

Implementation

STEPS RATIONALE

1. Assess the client’s tolerance for the
activity.
2. Adjust the room temperature and
ventilation.
3. Perform hand hygiene, and
observe other appropriate infection
control procedure.
4. Provide privacy by drawing the
curtains and closing the door.
5. Explain the procedures.
To determine client’s ability to perform
self -care and level of assistance.
Warm room prevents rapid loss of body
heat during bathing.
To allay fear and anxiety.
To promote client’s cooperation and
participation.

36
6. Offer bedpan or urinal Client will feel more comfortable and allow
continuity of work.
7. Wash hands. To reduce spread of microorganisms.
8. Adjust bed to a comfortable height To prevent muscle strain in the part of the
position. healthcare provider.
9. Remove the top linen by placing a Blanket provides warmth and privacy.
bath blanket over the client before
removing the top sheet.
10. Remove the client’s gown while To provide full exposure of body parts
keeping the client covered with a during the procedure.
bath blanket.
NOTE:
a. If client has an IV, remove gown Undressing unaffected or uninjured side
first from arm without IV. Do not first allows easier manipulation of body
disconnect tubing. parts with reduced range of motion.
b. If any extremity is injured,
remove gown first from the
uninjured side.
11. Pull side rail up and then fill wash To maintain client safety. Warm water
basin 2/3 full of warm water. promotes comfort and relaxation of
muscles.
12. Remove pillow if allowed and place Removal of pillow makes it easier to wash
patient in a semi-Fowler’s position. client’s ear and neck.
Spread bath towel across patient’s
chest tucking it under the chin.
13. Make a mitt of the wash cloth. To protect the client’s skin from the nails of
the health care provider. Mitt retains water
and heat than a loosely held cloth.
14. Wash client’s eyes with plain water Soap will irritate the eyes.
moving from the inner canthus
(corner) of the eye to the outer
canthus of the eye. Use separate
portion of the wash cloth for the
eyes.
15. Wash client’s face, ears, neck with Soap tends to dry the face which is
or without soap as per client’s exposed to air more than any other parts of
preference. the body.
16. Place the bath towel under the arm Long firm strokes stimulate circulation.
away from you. Wash client’s arm
with soap and water using long firm
strokes from distal to proximal arm
including underarm. Rinse and pat
dry.

37
17. Repeat procedure for the client’s Washing first the arm of the client away
other arm near you. from the health care provider prevents
contamination of dirt from the arm near the
client.
18. Fold bath towel in half and lay it on To prevent soiling of bed.
bed beside the client. Wash both
hands.
19. Place bath towel over the client’s Skin folds accumulate dirt.
chest and fold bath blanket down
the pubic area. Wash, rinse and dry
chest and abdomen using long firm
strokes paying attention to skin
folds.
20. Replace bath water. For sanitary purposes.
21. Expose one leg at a time folding To provide warmth and privacy.
blanket toward midline. Place bath
towel under the calf of leg away
from you. Wash with long firm
strokes.
22. Repeat for the other leg near you. Same as above.
23. Immerse and wash feet in basin. Moisture between digits promotes
Pat dry thoroughly between toes. accumulation of microorganism.
24. Replace water. For sanitary purposes.
25. Turn patient on his/her side and Dirt accumulates on the fold of the buttocks
place towel along side of the back. and anus.
Bath beginning on the hairline and
washing downwards including the
buttocks using long firm strokes
giving special attention on the folds
of buttocks and anus.
26. If unable, place client in a supine To provide privacy and comfort.
position and cover with bath
blanket. Wash, rinse and dry
perineum from the front to the rear
giving special attention to skin
folds. If client is able, place a towel
under the buttocks and bring basin
and soap within patient’s reach.
Instruct client to complete the bath
him/herself.
27. Assist client to put on a clean To make client comfortable.
gown, comb hair. Apply deodorant,
powder and lotion if desired or
requested by the patient.

38
 28. Remove equipment used and store
them in proper place.
29. Wash hands.
30. Document the procedure.
Leaving the client’s unit clean and orderly
will prevent accidents and show respect for
the client.
To prevent spread of microorganisms.
To contribute to data collection and fulfill
procedural requirement.

Evaluation

1. Note the client’s tolerance of the procedure ( e.g., respiratory rate and effort, pulse rate,
behaviors of acceptance or resistance, statements regarding comfort )
2. Conduct appropriate follow-up, such as
a. Condition and integrity of skin ( dryness, turgor, redness, lesions, and so on)
b. Client strength
c. Percentage of bath done without assistance
3. Relate to prior assessment data, if available.

PERINEAL CARE

Definition
A cleansing procedure prescribed for cleansing the perineum after various obstetric and
gynecological procedures. Sterile and clean perineal care is practiced to remove secretions or
dried blood from a wound and to prevent contamination of the urethral and vaginal areas or
prineal wounds with fecal matter or urine.

Purposes

• To remove normal perineal secretions and odor

• To promote client comfort

Equipments

• Bath towel
• Bath blanket
• Clean gloves

39
• Bath basin with water at 43C to 46C (110F to115F)
• Soap
• Washcloth
• Cotton balls or swabs
• bed pan to receive rinse water
• Receptacle
• Perineal pad

STEPS RATIONALE

1. Prior to performing the procedure,

introduce self and verify the client’s
identity using agency protocol. Explain
to the client what you are going to do,
why it is necessary and how he/she
can cooperate.
2. Perform hand hygiene and observe
other appropriate infection control
procedures.
3. Provide for client privacy by drawing
the curtains around the bed or closing
the door of the room.
4. Prepare the client:
-fold the top of the bed linen to the foot Hygiene is a personal matter.
of the bed and fold the gown up to
expose the genital area.
The bath towel prevents the bed from
-Place a bath towel under the client’s becoming soiled.
hips
5. Position and drape the client and clean
the upper inner thighs.
FOR FEMALES:
-Position the female in a back lying
position with knees flexed and spread
well apart.
Minimum exposure lessen the embarrassment
-cover her body and legs with a bath
and helps to provide warmth.
blanket positioned so a corner is at her
head, the opposite corner at her feet,
and other on the sides. Drape the legs
by tucking the bottom corners of the
bath blanket under the inner sides of

40
 the legs
-put on gloves, wash and dry the upper
inner thighs
FOR MALES:
-position the male client in a supine
position with knees slightly flexed and
hips slightly externally rotated.
-Put on gloves, wash and dry the upper
inner thighs.

6. Inspect the perineal area.

-note particular areas of inflammation,
excoriation, or swelling especially
between the labia in females and the
scrotal folds in males.
-also note excessive discharge or
secretions from the orifices and the
presence of odors.
7. Wash and dry the perineal area.
FOR FEMALES Secretions that tend to collect around
-Clean the labia majora.Then spread the labia minora facilitate bacterial
the labia to wash the fills between the growth.
labia majora and labia minora Using seperate quarters of the wash
-Use separate quarters of the wash cloth or new wipes prevents the
cloth for each stroke, and wipe from transmission of microorganisms from
the pubis to the rectum. one area to the other.
-Rinse the area well. Wipe from the area of least
contaminated 9the pubis) to that of
greatest (the rectum).

FOR MALES
-Wash and dry the penis, using firm
under the foreskin and facilitates bacterial
strokes.
growth. Replacing the foreskin prevents
-if the client is uncircumcised, retract constriction of the penis, which may cause
the prepuce (foreskin) to expose the edema.
glans penis for cleaning. Replace the
The scrotum tends to be more soiled than the
foreskin after cleaning the glans penis.
penis because of its proximity to the rectum,
-Wash and dry the scrotum. The thus it is usually cleaned after the penis
posterior folds of the scrotum may
need to be cleaned when the buttocks
are cleaned.

41
 8. Inspect the perineal orifices for
intactness. A catheter may cause excoriation around the
-Inspect particularly around the urethra urethra.
in clients with indwelling catheters.
9. Clean between the buttocks.
-Assist the client to turn onto side
facing away from you.
-Pay particular attention to the anal
area and posterior folds of the scrotum
in males. Clean the anus with toilet
tissue before washing it, if necessary
-Dry the area well
-For post delivery or menstruating This prevents contamination of the vagina and
females, apply a perineal pad as urethra from the anal area.
needed from front to back.
10. Document any unusual findings such
as redness, excoriation, skin
abrasions, discharge or drainage, and
any localized areas of tenderness.

BED MAKING

Definition
Bed making is the preparation of hospital beds usually after client receives certain care or
whenever a bed is unoccupied. At times, however, nurses need to make an occupied bed or
prepare a bed for a client who is having surgery or whenever the need arises, especially if
linens are soiled.

I. Changing an Unoccupied Bed

Purposes

• To promote the client’s comfort

• To provide a clean neat environment for the client
• To provide a smooth, wrinkle-free bed foundation, thus minimizing sources of skin
irritation

Equipments

42
 • Two flat sheets or one fitted and one flat sheet
• Cloth drawsheet (optional)
• One blanket
• One bedspread
• Waterproof pads (optional)
• Pillowcase(s) for the head pillow(s)
• Plastic laundry bag or portable linen hamper, if available

Implementation
Steps
1. Perform hand hygiene and observe other
appropriate infection control procedures.
2. Provide for client privacy.
3. Place the fresh linen on the client’s chair or
overbed table; do not use another client’s
bed.
4. Assess and assist the client out of bed
Rationale
A universal precaution which helps prevent the
spread and transmission of infectious
organisms.
To show respect to the client and gain
cooperation
This prevents cross contamination (the
movement of microorganisms from one client
to another) via soiled linen.
To promote safety

• Make sure that this is an appropriate

and convenient time for the client to
be out of bed.

• Assist the client to a comfortable

chair
5. Raise the bed to a comfortable height. To avoid straining of the body.
6. Strip the bed.

• Check bed linens for any items

belonging to the client, and detach
the call bell or any drainage tubes
from the bed linen

• Loosen all bedding systematically,

Moving around the bed systematically
starting at the head of the bed on the
prevents stretching and reaching and possible
far side and moving around the bed
muscle strain.
up to the head of the bed on the
near side.

43
 • Remove the pillowcases, if soiled,
and place the pillows on the bedside
chair near the foot of the bed.

• Fold reusable linens, such as the

bedspread and top sheet on the bed,
Folding linens saves time and energy when
into fourths. First, fold the linen in
reapplying the linens on the bed and keeps
half by bringing the top edge, and
them clean.
then grasp it at the center of the
middle fold and bottom edges.

• Remove the waterproof pad and

discard it if soiled.

• Roll all soiled linen inside the bottom

sheet, hold it away from your
uniform, and place it directly in the These actions are essential to prevent the
linen hamper, not on the floor. transmission of microorganisms to the nurse
and others.
• Grasp the mattress securely, using
the lugs if present, and move the
mattress up to the head of the bed.
7. Apply the bottom sheet and drawsheet.

• Place the folded bottom sheet with The top of the sheet needs to be well tucked
its center fold on the center of the under to remain securely in place especially
bed. Make sure the sheet is hem when the head of the bed is elevated.
side down for a smooth foundation.
Spread the sheet out over the
mattress and allow sufficient amount
of sheet at the top to tuck under the
mattress. Place the sheet along the
edge of the mattress at the foot of
the bed and do not tuck it in. (unless
it is a fitted sheet)

• Miter the sheet at the top corner on

the near side and tuck the sheet
under the mattress, working from the
head of the bed to the foot.

• If a waterproof drawsheet is used,

place it over the bottom sheet so that
the centerfold is at the centerline of
the bed and the top of bottom edges

44
 extend from the middle of the client’s
back to the area of the midthigh or
knee. Fanfold the uppermost half of
the folded drawsheet at the center or
far edge of the bed and tuck in the
near edge.

• Lay the cloth drawsheet over the

waterproof sheet in the same
manner.
• Optional: Before moving to the other
side of the bed, place the top linens
on the bed hemside up, unfold then,
tuck them in, and miter the bottom
corners.
Completing one entire side of the bed at a time
saves time and energy.

8. Move to the other side and secure the

bottom linens.

• Tuck in the bottom sheet under the

head of the mattress, pull the sheet
firmly, and miter the corner of the
sheet.

• Pull the remainder of the sheet firmly

so that there are no wrinkles. Wrinkles can cause discomfort for the client
and breakdown of skin. Tuck the sheet in at
the side.

• Complete this same process for the

drawsheet(s).
9. Apply or complete the top sheet, blanket
and spread.
• Place the top sheet, hemside up, on
the bed so that its centerfold is at the
center of the bed and the top edge is
even with the top edge of the
mattress.

• Unfold the sheet over the bed.

45
 • Follow the same procedure for the
blanket, and the spread, but place
the top edges about 15 cm (6 in)
from the head of the bed to allow a
cuff of sheet to be folded over them

• Tuck in the sheet, blanket, and

spread at the foot of the bed, and
miter the corner, using all three
layers of linen. Leave the sides of
the top sheet, blanket and spread
hanging freely unless toe pleats
were provided.

• Fold the top of the top sheet down

over the spread, providing a cuff
The cuff of sheet makes it easier for the client
to pull the covers up.
• Move to the other side of the bed
and secure the top bedding in the
same manner.
10. Put clean pillowcases on the pillows as
required.

• Grasp the closed end of the

pillowcase at the center with one
hand.

• Gather up the sides of the pillowcase

and place them over the hand
grasping the case. Then 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
A smoothly fitting pillowcase is more
and the seams are straight.
comfortable than a wrinkled one

• Place the pillows appropriately at the

head of the bed.
11. Provide for client comfort and safety.

46
 • Attach the signal cord so that the
client can conveniently reach it.
Some cords have clamps that attach
to the sheet or pillowcase. Others
are attached by a safety pin.

• If the bed is currently being used by

a client, either fold back the top This makes it easier for the client to get into
covers at one side or fanfold them bed.
down to the center of the bed.

• Place the bedside table and the

overbed table so that they are
available to the client

• Leave the bed in the high-position if

the client is returning by stretcher or
place in the low position if the client
is returning to bed after being up
12. Document and report pertinent data.

• Bed-making is not normally recorded

• Record any nursing assessments,

such as the client’s physical status
and pulse and respiratory rates
before and after being out of bed, as
indicated.

II. Changing an Occupied Bed

Purposes

• To conserve the client’s energy

• To promote client comfort

Equipments

• Two flat sheets or one fitted and one flat sheet

• Cloth drawsheet (optional)
• One blanket

47
 • One bedspread
• Waterproof drawsheet or waterproof pads (optional)
• Pillowcase(s) for head pillow(s)
• Plastic laundry bag or portable linen hamper

Implementation

Steps
1. Perform hand hygiene and observe other
appropriate infection control procedures.
Put on disposable gloves if line is soiled
with body fluids.
2. Provide for client privacy.
3. Remove the top bedding.
Rationale
To prevent transmission of infectious
organisms and spread of infection.
To show respect to the client and gain
cooperation

• Remove any equipment attached to

the bed linen such as a signal light.
• Loosen all top linen at the foot of the
bed, and remove the spread and the
blanket
• Leave the top sheet over the client
(the top sheet can remain over the
client if it is being changed and if it
will provide sufficient warmth), or
replace it with a bath blanket as
follows:

Spread the bath blanket over

the top sheet.
a. Ask the client to hold the top
edge of the blanket
b. Reaching under the blanket
from the side, grasp the top
edge of the sheet and draw it
down to the foot of the bed,
leaving the blanket in place.
c. Remove the sheet from the
bed and place it in the soiled
linen hamper.
4. Change the bottom sheet and drawsheet.

• Assist the client to turn on the side

48
 facing away from the side where
the clean linen is.

• Raise the side rail nearest the

client. This protects the client from falling. If there is
no side rail, have another nurse support the
client at the edge of the bed.
• Loosen the foundation of the linen
on the side of the bed near the
linen supply.

• Fanfold the drawsheet and the

bottom sheet at the center of the
Doing this leaves the near half of the bed free
bed, as close to and under the
to be changed.
client as possible.

• Place the new bottom sheet on the

bed, and vertically fanfold half to be
used on the far side of the bed as
close to the client as possible. Tuck
the sheet under the near half of the
bed and miter the corner if a
contour sheet is not being used.

• Place the clean drawsheet on the

bed with the center fold at the
center of the bed. Fanfold the
uppermost half vertically at the
center of the bed and tuck the near
side edge under the side of the
mattress.

• Assist the client to roll over toward

you onto the clean side of the bed.
The client rolls over the fanfolded
linen at the center of the bed.

• Move the pillows to the clean side

for the client’s use. Raise the side
rail before leaving the side of bed.

• Move to the other side of the bed

and lower the side rail.

49
 • Remove the usesd linen and place
it in the portable hamper.

• Unfold the fanfolded bottom sheet

from the center of the bed.

• Facing the side of the bed, use

both hands to pull the bottom sheet
si that it is smooth and tuck the
excess under the side of the
mattress.

• Unfold the drawsheet fanfolded at

the center of the bed and pull it
tightly with both hands.
Pull the sheet in three sections
a. Face the side of the bed to
pull the middle section
b. Face the top far corner to
pull the bottom section
c. Face the far bottom corner
to pull the top section
• Tuck the excess drawsheet under
the side of the mattress.
5. Resposition the client in the center of the
bed.
• Reposition the pillows at the center
of the bed
• Assist the client to the center of the
bed. Determine what position the
client requires or prefers and assist
the client to that position.
6. Apply or complete the top bedding.
• Spread the top sheet over the client
and either ask the client to hold the
top edge of the sheet or tuck it
under the shoulders. The sheet
should remain over the client when
the bath blanket or used sheet is
removed.
7. Raise the side rails. Place bed in the low To promote safety.
position before leaving the bedside.

50
 Attach the signal cord to the bed linen
within the client’s reach. Put items used by
the client within easy reach.
8. Bed-making is not normally recorded.

ADMINISTERING INTRADERMAL INJECTION

Definition

It is the administration of a drug into the dermal layer of the skin just beneath the epidermis.
Usually only a small amount of liquid is used, for example, 0.1 mL. this metohd of administration
is frequently used for allergy testing and tuberculosis (TB) screening. Common sites for
intradermal injections are the inner lower arm, the upper chest, and the back beneath the
scapulae. The left arm is commonly used for TB screening and the right arm is used for all other
tests.

ADMINISTERING AN INTRADERMAL INJECTION FOR SKIN TESTS

Purposes
• To provide medication the client requires

Equipments
 Vial or ampule of the correct medication

 Sterile 1-mL syringe calibrated into hundredths of a milliliter(i.e.,tuberculin syringe) and

#25- to # 27- gauge safety needle that is ¼ to 5/8 inch long

 Alcohol swabs

51
  Clean gloves

 Bandage(optional)

 Epinephrine on hand in case of allergic anaphylactic reaction

Assessment

Assess:

• Appearance of injection site

• Specific drug action and expected response

• Client’s knowlegde of drug action and response

• Check agency protocol about sites to use for skin tests.

Planning

Delegation

• The administration of intradermal injections is an invasive technique that involves

the application of nursing knowledge, problem solving, and sterile technique. This
technique is not delegated to UAP. The nurse, however, can inform the UAP
about symptoms of allergic reactions and the necessity to report those
observations immediately to the nurse.

• Check the medication administration record (MAR)

 Check the label on the madication carefully against the MAR. to make sure that
the correct medication is being prepared.

 Follow the three checks for administering medications. Read the label on the
medication (1) when it is taken from the medication chart, (2) before withdrawing
the medication, and (3) after withdrawing the medication

• Organized the equipment

Implementation

Steps Rationales

52
 1. Perform hand hygiene and observe
other appropriate infection control
procedures
This ensures that the right client receives the
2. Prepare the medication from the vial or medication.
ampule for drug withdrawal.

3. Prepare the client

This ensures that the right client receives the
medication.
4. Explain the procedure to the client
Information can facilitate acceptance of and
compliance with the therapy.

5. Provide privacy of the client.

To avoid using of sites that are tender,
inflamed, or swollen and those that have
6. Select and clean the site
lesions.

To minimize spread of microorganism.

7. Wear disposable gloves as indicated by
agency policy.

8. Cleanse the skin at the site using a circular

motion starting at the center and widening the
circle outward.

9. Prepare the syringe for the injection.

10. Expel any air bubbles from the syringe.
Small bubbles that adhere to the plunger are
of no consequence.
11. Grasp the syringe in your dominant hand,
close to the hub, holding it between thumb and
forefinger. Hold the needle almost parallel to
the skin surface, with the bevel of the needle
up.
a small amount of air will not harm the tissues.
The possibility of the medication entering the
subcutaneous tissue increases when using an
angle greater than 15 degrees. The bevel up
position provides more comfort for the nurse
and id faster to administer.

Taut skin allows for easier entry of the needle

12. Inject the fluid with the nondominant hand, and less discomfort for the client.
pull the skin at the site until it is taut.
This verifies that the medication entered the

53
13. Insert the needle and inject the medication dermis.
carefully and slowly so that it produces a small
wheal on the skin.

14. Withdraw the needle quickly at the same

angle. Apply a bandage if indicated.
Massage can disperse the medication into the
tissue or out through the needle insertion site
15. Do not massage the area

Do not recap the needle in order to prevent

16. Dispose the syringe and needle into the needlestick injuries.
sharps container.

To prevent contamination.
17. Remove the gloves.
To observe for redness or induration.
18. Circle the injection site with ink.

19. Document all the relevant information.

20. Record the testing material given, the time,

dosage, route, site, and nursing assessments.

Some medications used in testing may cause

21. Evaluate the client’s response to the
allergic reations. Epinephrine may need to be
testing substance.
used.

22. Evaluate the condition of the site in 24 or

48 hours, depending on the test.

23. Measure the area of redness and

induration in millimeters at the largest diameter
and document findings.

ADMINISTERING SUBCUTANEOUS INJECTION

Definition
Under the skin. "Subcutaneous" implies just under the skin.
With a subcutaneous injection, a needle is inserted just under the skin. A drug (for example,
insulin) can then be delivered into the subcutaneous tissues. After the injection, the drug moves
into small blood vessels and the bloodstream. The subcutaneous route is used with many
protein and polypeptide drugs such as insulin which, if given by mouth, would be broken down
and digested in the intestinal tract.

54
Purposes
• To provide medication the client requires
• To allow slower absorption of a medication compared with either the
intramuscular or intravenous route
Equipments
• Client’s MAR or computer printout
• Vial or ampule of the correct sterile medication
• Syringe and needle appropriate for the client
• Antiseptic swabs
• Dry sterile gauze for opening an ampule (optional)
• Clean gloves

Steps
1. Perform hand hygiene and observe
other infection control procedure
2. Prepare the medication from the
ampule or vial for drug withdrawal
3. Provide for client’s privacy
Rationales
 To eliminate/lessen the transfer of
microoganisms
 To lessen the embarassment of the
client and for their own confidentiality

4. Prepare the client

• Prior to performing the  This ensures that the right patient
procedure, introduce self and receives the medication
verify the client’s identity using
agency protocol
• Assist the client to a position in
which the arm, leg, abdomen  A relaxed position of the site minimizes
can be relaxed, depending on discomfort
the site to be used
•Obtain assistance in holding an
uncooperative client  This prevents injury due to sudden
5. Explain the purpose of the medication movement after needle insertion
and how it will help.include relevant  Information can facilitaye acceptance
information about the effects of the of and compliance with the therapy
medication
6. Select and clean the site
• Select a site free of tenderness,
hardness, swelling, scarring,
itching or localized
inflammation. Select a site that
is not used frequently

55
  These conditions could hinder the
absorption of the medication and may
also increase the likelihood of injury
and discomfort at the inection site
• Put on clean gloves
• As agency protocol indicates,
clean the site with an antiseptic
swab. Start at the center of the  The mechanical action of swabbimg
site and clean in a widening removes skin secretions which
circle to about 5cm contains microorganisms
• Place and hold the swab
between the third and fourth
fingers of the non-dominant  Using this method keeps the swab
hand readily accessible when the needle is
withdrawn
7. Prepare the syringe for injection
• Remove the needle cap while
waiting for the antiseptic to dry.
Pull the cap straight off to avoid
 The needle will become contaminated
contaminating the needle by
if it touches anything but inside the cap
the outside edge of the cap
which is sterile
• Dispose the needle cap
8. Inject the medication
• Grasp the syringe in your
domonant hand by holding it
between your thumb and
fingers. With palm facing to the
side or upward for a 45-degree
angle insertion, or with palm
downward for a 90-degree
angle insertion, prepare to inject
• Using the non-dominant hand,
pinch or spread the skin at the
site, and insert the neddle using
the dominant hand and a firm
steady push
• When the needle is inserted,
move your non-dominant hand
to the end of the plunger.
• Inject the medication by holding
the syringe steady and
depressing the plunger with a
sloe and even pressure
• It is recommended that with
many subcutaneous injections,
the needle should be
 Holding the syringe steady and
56
 embedded within the skin for injecting the medication at an even
five seconds after complete pressure minimizes the discomfort of
depression of the plunger to the client
ensure complete delivery of the
dose
9. Remove the needle
• Remove the needle smoothly,
pulling along the line of
insertion while depressing the
skin with your non-dominant
hand.
• If bleeding occurs, apply
pressure to the site with dry
sterile gauze until it stops
 Depressing the skin places
10. Dispose the supplies appropriately countertraction on it and minimizes the
•Activate the needle safety client’s discomfort when the needle is
device or discard the uncapped withdrawn
needle and attached syringe
into designated receptacle
11. Document all relevant information
• Document the medication
given, dosage, time, route and
any assessments
• Many agendies prefer that the  Proper disposal prevents the nurse and
medication administration be others from injury and contamination
recorded at the medication
record. The nurse’s notes are
used when prn medication are
given or when there is a
special problem
12. Assess the effectiveness of the
medication at the time it is epected to
act and document it

ADMINISTERING MEDICATIONS USING IM INJECTION

Definition
An intramuscular (IM) injection is the preferred route of administering medication when fairly
rapid-acting and long-lasting dosage of medication is required. Some medications that are
irritating to the subcutaneous tissue may be given into the deep muscle tissue. Injection of
medication into muscle tissue forms a deposit of medication that is absorbed gradually into the
bloodstream. An intramuscular injection is the safest, easiest, and best tolerated of the injection
routes.

Purposes

57
 • For the delivery of certain drugs not recommended for other routes of administration, for
instance intravenous, oral, or subcutaneous.
• To offer a faster rate of absorption than the subcutaneous route, and muscle tissue can
often hold a larger volume of fluid without discomfort.

Equipments
• needle and syringe
• antiseptic pads
• adhesive bandages or cotton balls

STEPS RATIONALE

1. Checks doctor’s order. The orders are checked to ensure correct

2. Gather Equipment.
3. Wash Hands.
4. Assemble needle and syringe.
5. Check expiration date of medication.
6. Draw medication into syringe.
7. Identify patient.
8. Prepare the patient.
9. Select injection site and position the
patient.
10. Prepare injection site.
11. Remove needle guard or cover.
12. Stabilize injection site.
13. Insert needle into patient at site
selected for injection.
14. Aspirate syringe.
15. Inject medication.
medication is obtained and administered.
The correct dosage may already be
prepared by the hospital pharmacy.
Should be available in the immediate area.
To prevent contamination
To know if the medication is expired. Do
not use it if it is expired.
To allow the medication into the syringe
To know the right patient to be given i.m.
medication.
To know if the patient has medication
allergies.
To administer the medication at the perfect
site
To prevent contamination.
Avoid bending or touching the needle
Firm the injection site with the hand that is
free by pinching the skin with the thumb
and forefinger
A quick insertion of the needle will
minimize the pain for the patient.
If blood appears in the syringe do not
administer the medication.
Push the plunger into the syringe barrel
with a slow, continuous downward

58

16. Withdraw needle
17. Massage injection site.
18. Cover injection site.
19. Perform postinjection patient care
20. Dispose expended needle and syringe
movement as far as the plunger will go
Remove the needle straight out in same
direction as the injection with a quick,
outward motion.
Massaging help to disperse the medicine
so that it can absorbed more quickly.
To prevent contamination
Check the patient for any medication
reaction.
Proper disposal of equipment prevents
cross contamination, drug abuse, and
injury by needles.

ADMINISTERING MEDICATIONS USING IV PUSH

Purposes
- to achieve immediate and maximum effect of the medication.

Equipments
IV push for an existing Line
- Medication in a vial or ampule
- Sterile syringe (3 to 5 ml)
- Sterile needles #21 to #25 gauge, 2.5 cm (1 in.)
- Antiseptic swabs

59
 - Watch with a digital readout or second hand
- Clean gloves

IV Push for an IV lock

- Medication in a vial or ampule
- Sterile syringe (3 to 5 ml)
- Sterile syringe (3ml) (for the saline or heparin push)
- Vial of normal saline to flush the IV catheter or vial of heparin flush solution or both
depending on agency practice. Rationale: these maintain the patency of the IV lock.
Saline is frequently used for peripheral locks.
- Sterile needles (#21 gauge)
- Antiseptic swabs
- Watch with second hand
- Disposable gloves

Implementation

Preparation
1. check the medication administering record
- check the label on the medication carefully against the MAR to make sure that the
correct medication dose.
- Follow the three checks for correct medication and dose. Read the label on the
medication (1) when it is taken from the medication cart ,(2) before withdrawing the
medication and, (3) after withdrawing the medication.
- Calculate medication dosage accurately
- Confirm the route is correct
2. Organize the equipment

PERFORMANCE RATIONALE
1. perform hand hygiene and observe
other appropriate infection control
procedures
2. prepare the medication.
Existing Line It is important to have the correct dose and
- prepare the medication according to the the correct dilution
manufacturer’s direction.
IV Lock
a. Flushing with saline
- prepare 2 syringes, each with 1 ml
of sterile normal saline.
b. Flushing with heparin and saline

60
 - prepare 1 syringe with 1 ml of
heparin flush solution
- prepare 2 syringes with 1 ml each
of sterile, normal saline
- draw up the medication into
syringe.
3. put a small gauge syringe needle This reduces the transmission of
on the syringe if using a needle microorganisms and reduces the likelihood
system. of the nurse’s hands contacting the client’s
4. perform hand hygiene and put on blood.
clean gloves.
5. provide privacy This ensures that the right client receives
6. prepare the client the medication.
- prior to performing the procedure,
introduce self and verify the client’s
identity using agency protocol.
- If not previously assessed take the
appropriate assessment measures
necessary for the medication. If any
of the findings are above or below
the predetermined parameters,
consult the primary care provider
before administering the
medication.
7. explain the purpose of the
medication and how it will help,
using language that the client can
understand. Include relevant
information about the effects of the
medication.

8. administer the medication by IV This creates a turbulence in the flow

push
IV Lock with Needle
- clean the diaphgram with the antiseptic
swab.
-Insert the needle of syringe containing
normal saline through the center of the
diaphragm and aspirate for blood.
-Flush the lock by injecting 1ml of saline
through the catheter which reduces the
residue buildup in the line and the potency
for occlusion.
This prevents microorganisms from
entering the circulatory system during the
needle insertion.
The presence of blood confirms that the
catheter or needle is in the vein. In some
situations, blood will not return even
though the lock is patent.
This removes blood and heparin from the

61
slowly. needle and lock.
-Remove the needle and syringe. Activate
the needle and safety device.
-clean the locks diaphragm with an This prevents the transfer of
antiseptic swab. microorganisms.
Insert the needle of the syringe containing
the prepared medication through the
center of the diaphragm.
- inject the medication slowly at the Injecting the drug too rapidly can have a
recommended rate of infusion. Use a serious untoward reaction.
watch or digital readout to time the
injection. Observe the client closely for
adverse reactions. Remove the needle and
syringe when all medications have
administered.
- activate the needle safely
- clean the diaphragm of the lock.
- attach the second saline syringe, and The saline injection flushes the medication
inject 1 ml of saline through the catheter and prepares the lock
for heparin if this medication is used.
Heparin is incompatible with many
medications
-if heparin is to be used, insert the heparin
syringe and inject the heparin solely into
the lock.
IV Lock with needle system
-remmove the protective cap from the
needleless port
- insert syringe containing normal saline
into the lock.
-Flush the lock with 1 ml of sterile saline
These clears the lock of blood.
- remove the syringe
- insert the syringe containing the
medication into the valve.
- Inject the medication following the
precautions described previously.
- Withdraw the syringe.
- Repeat injection of 1ml of saline.
- Place a new sterile cap over the
lock.
Existing IV line

62
-identify the injection port closest to the An injection port must be used because it
client. Some ports have a circle indicating is self sealing. Any puncture to the plastic
the site for the needle insertion. tubing will leak.
-clean the port with an antiseptic swab.
- stop the IV flow by closing the clamp or
pinching the tubing above the injection port
-connect the syringe to the IV system
a. Needle system
- hold the port steadily.
-Insert the needle of the syringe that This prevents damage to the IV line and to
contains the medication through the center the diaphragm of the port.
of the port

c. needleless system
- remove the cap from the
needleless injection port. Connect
the tip of the syringe directly to the
port.
- Inject the medication at the order
rate. Use the watch or digital This ensures safe drug administration
readout to time the medication because a too rapid injection could be
administration. dangerous.

NASOGASTRIC TUBE INSERTION

Definition
It is a medical process involving the insertion of a plastic tube (nasogastric tube, NG tube)
through the nose, past the throat, and down into the stomach.

Purposes
• to administer tube feedings and medications to clients unable to eat by mouth or swallow
a sufficient diet without aspirating food or fluids into the lungs.
• To establish a means for suctioning stomach contents to prevent gastric distention,
nausea, and vomiting.
• To remove stomach contents for laboratory analysis
• To lavage the stomach in case of poisoning or overdose of medication.

Equipments
63
 • large or small bore tube (non latex preferred)
• non allergic adhesive tape, 2.5 cm (1 in.) wide
• clean gloves
• water soluble lubricant
• facial tissues
• glass of water and drinking straw
• 20 to 50 ml syringe with an adapter
• Basin
• pH test strip or meter
• bilirubin dipstick
• stethoscope
• disposable pad or towel
• clamp or plug
• antireflux valve for airvent if salem sump tube is used.

Implementation

Preparation
-assist the client to a high fowler’s position if his or her health condition permits, and support the
head on a pillow. Rationale: it is often easier to swallow in the position and gravity helps the
passage of the tube. Place a towel or disposable pad across the chest.

Performance Rationale
1. Prior to performing the insertion,
introduce self and verify the clients
identity using agency protocol.
Explain to the client what you are
going to do, why it is necessary,
and how he or she can cooperate.
The passage of a gastric tube is
unpleasant because the gag reflex
is activated during insertion.
Establish a method for the client to
indicate distress and a desire for
you to pause the insertion. Raising
a finger or hand is often used for
this.
2. Perform hand hygiene and observe
other appropriate infection control
procedures
3. Provide for client privacy

64
4. Assess the client’s nares.
5. prepare the tube
- if a small bore tube is being used,
ensure stylet or guidewire is secured in An improperly positioned stylet or
position. guidewire can traumatize the nasopharynx,
esophagus, and stomach.
6. determine how far to insert the
tube. this length approximates the distance from
- use the tube to mark off the distance the nares to the stomach. The distance
from the tip of the client’s nose to the varies from individuals.
tip of the earlobe and then from the tip
of the earlobe to the tip of the xyphoid.
7. insert the tube.
- put on gloves
- lubricate the tip of the tube well with a water soluble lubricant dissolves if the
water soluble lubricant or water to tube accidentally enters the lungs
ease insertion.
- Insert the tube with its natural curve hyperextension of the neck reduces the
toward the client, into the selected curvature of the nasopharyngeal junction.
nostril. Ask the client to
hyperextended the neck, and gently
advance the tube toward the
nasopharynx.
- Direct the tube along the floor of
the nostril and toward the ear on Direct the tube along the floor avoids the
the side. projections along the lateral wall.
- Slight pressure and twisting motion
are sometimes required to pass the Tears are a natural body response.
tube into the nasopharynx, and
some client’s eyes may water at
this point.
- If the tube meets resistance,
withdraw it, relubricate it, and insert
in the other nostril. The tube should never be forced against
- Once the tube reaches the resistance because of the danger of injury.
nasopharynx, the client will feel the
tube in the throat and may gag and
retch. Ask the client to tilt the head Tilting the head forward facilitates passage
forward, and encourage the client of the tube into the posterior pharynx and
to drink and swallow. esophagus rather than into the larynx.
Swallowing moves the epiglottis over the
- In cooperation with the client, pass opening of the larynx.
the tube 5 to 10 cm with each
swallow. Withdraw it slightly and
inspect the throat by looking The tube maybe coiled into the throat.
through the mouth.

65
 8. ascertain correct placement of the
tube.
- aspirate stomach contents and check Testing pH is reliable way to determine
the pH which would be acidic. location of a feeding tube.
- place a stethoscope over the client’s
epigastrium and inject 10 to 30 ml of air
into the tube while listening to a whooshing
sound.
9. secure the tube by taping it to the Taping in this manner prevents the tube
bridge of the client’s nose. from pressing against and irritating the
edge of the nostril.

10. once correct position, attach the

tube to a suction source or feeding
apparatus as ordered, or clamp the
end of the tubing.
11. secure the tube to the client’s
gown. The tube is attached to prevent it from
dangling and pulling.

12. document the type of tube inserted,

date and time of tube insertion,
type of suction used, color and
amount of gastric contents, and the
tolerance of client to the procedure.

URINARY CATHETERIZATION
Definition
Urinary catheterization is the introduction of a catheter into the urinary bladder. This is
usually performed only when absolutely necessary, because the danger exists of introducing
microorganisms into the bladder. Thus, strict sterile technique is used for catheterization.
Purposes
• To relieve discomfort due to bladder distention or to provide gradual decompression of a
distended bladder
• To assess the amount of residual urine if the bladder empties incompletely
• To obtain a sterile urine specimen
• To empty the bladder completely prior to surgery
• To facilitate accurate measurement of urinary output for critically ill clients whose output
needs to be monitored hourly
• To provide for intermittent or continuous bladder drainage and/or irrigation
• To prevent urine from contacting an incision after perineal surgery
• To manage incontinence when other measures have failed

66
 Assessment
• Determine the most appropriate method of catheterization based on the purpose and
any criteria specified in the order such as total amount of urine to be removed or size of
the catheter to be used.
• Use a straight catheter if only a spot urine specimen is needed, if amount of residual
urine is being measured, or if temporary decompression/emptying of the bladder is
required.
• Use and indwelling/retention catheter if the bladder must remain empty or continuous
urine measurement/collection is needed.
• Assess the client’s overall condition. Determine if the client is able to cooperate and hold
still during the procedure and if the client can be positioned supine with head relatively
flat.
• Determine when the client last voided or was last catheterized.
• Percuss the bladder to check for fullness or distention.
• When possible, complete a bladder scan to assess the amount of urine present in the
bladder before performing a urethral catheterization.

Planning
Allow adequate time to perform the catheterization. Although the entire procedure can require
as little as 15 minutes, several sources of difficulty could result in a much longer time. If
possible, it should not be performed just prior to or after the client eats.

Equipments
Sterile catheter of appropriate size: (An extra catheter should also be at hand.)
• Adult female: 14F or 16F
• Adult male: 18F
• Children: 8F or 10F
 Catheterization kit or individual sterile items:
1-2 pair sterile gloves
Waterproof drapes
Antiseptic solution
Cleansing balls
Forceps
Water-soluble lubricants
Urine receptacle
Specimen container
For an indwelling catheter:
• Syringe prefilled with sterile water in amount specified
by catheter manufacturer
• Collection bag and tubing

67
2% Xylocaine gel (if agency permits)
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.)

Implementation
Preparation
If using a catheterization kit, read and label carefully to be sure all necessary items are included.
Perform routine perineal care to cleanse the meatus from gross contamination. For women, use
this time to locate the urinary meatus relative to surrounding structures.
Performance

68
 STEPS RATIONALE
1) Prior to performing the procedure, To ascertain that you are giving to the right
introduce self and verify the client’s client and to gain trust and cooperation
identity using agency protocol. throughout the procedure.
Explain to the client what you are
going to do, why it is necessary,
and how he or she can cooperate.

2) Perform hand hygiene and observe To prevent infection.

appropriate infection control
procedures.

3) Provide drapes. To provide for client privacy.

4) Place the client in the appropriate To provide access for catheterization.

position.
a. Female: supine with knees flexed,
feet about 2 feet apart, and hips slightly
externally rotated, if possible.
b. Male: supine, thighs slightly
abducted or apart.
5) Establish adequate lighting. Stand To provide better viewing of the site to be
on the client’s right if you are right- catheterized.
handed, on the client’s left if you
are left-handed.

6) If using a collecting bag and it is not Since one hand is needed to hold the
contained within the catheterization catheter once it is in place, open the
kit, open the drainage package and package while two hands are still available
place the end of the tubing within
reach.
7) If agency policy permits, apply To provide local anesthetic.
clean gloves and inject 10 to 15 ml
Xylocaine gel into the urethra of the
male client. Wipe the underside of
the shaft to distribute the gel up the
urethra. Wait until 5 minutes for the
gel to take effect before inserting
the catheter. Remove gloves.

8) Open the catheterization kit. Place To promote cleanliness and avoid

a waterproof drape under the contamination throughout the procedure.
buttocks (female) or penis (male)
without contaminating the center of
the drape with your hands.

9) Put on sterile gloves. To maintain aseptic technique.

10) Organize the remaining supplies. To promote an orderly and systematic

a. Saturate the cleansing balls with procedure. 69
the antiseptic solution.
b.Open the lubricant package.
c. Remove the specimen container
and place it nearby with the lid
Evaluation
Conduct appropriate follow-up such as notifying the primary care provider of the catheterization
results. Perform a detailed follow-up based on the findings that deviated from expected or
normal for the client. Relate finding s to previous assessment data if available. Teach the client
how to care for the indwelling catheter, to drink more fluids, and other appropriate instructions.

SUCTIONING
Definition

70
Suctioning is the removal of airway secretions using negative pressure. Oropharyngeal and
nasopharyngeal suctioning is used when the client is able to cough effectively but is unable to
clear secretions by expectorating or swallowing. It is frequently used after the client coughs.
Oropharyngeal and nasopharyngeal suctioning may also be appropriate in less responsive or
comatose clients who require removal of oral secretions.

Purposes
1. To maintain a patent airway and prevent airway obstructions.
2. To promote respiratory functions (optimal exchange of oxygen and carbon dioxide into
and out of the lungs).
3. To prevent pneumonia that may result from accumulated secretions.

Assessment
1. Assess sign and symptoms of upper and lower airway obstruction including wheezes,
crackles or gurgling on inspiration or expiration; restlessness; ineffective coughing,
absent or diminished breath sounds, tachypnea, cyanosis, decreased level of
consciousness.

Planning
1. Prepare needed equipment and supplies:
1.1 Suction catheter with intermittent control port of appropriate size for the client:
10-12 years: French 14
Adults: French 12-16
1.2 Portable or wall suction apparatus:
children: 5-10 inches Hg
Adults: 7-15 inches Hg
1.3 Sterile disposable gloves
1.4 Sterile water or normal saline approximately 100ml in a container/glass
1.5 Connecting tubing(optional)
1.6 Clean towel
2. Prepare patient.
2.1 Explain to patient how procedure will help clear airway and relieve breathing
problems. Explain that coughing, sneezing or gagging is normal.
2.2 Explain importance of and encourage coughing during procedure.
2.3 Assist patient to assume position comfortable for nurse and client (usually semi-
fowler’s or sitting upright with head hyperextended, unless contraindicated). If
unconscious, lay patient on side facing nurse.
2.4 Place towel across patient chest.
3. Prepare suction apparatus.
3.1 Ascertain that the apparatus is functional. Place suction tubing within easy reach.
3.2 Turn suction device on and set vacuum regulator to appropriated negative pressure.
3.3 Connect one end of connecting tubing to suction machine and place the other end in
convenient location.

71
Implementation
STEPS
1. Wash hands and open suction catheter
package. Do not allow suction surface
other than the inside of the package.
2. Fill container with 100ml sterile normal
saline/ sterile water.
3. Aseptically glove both hands.
Designate one hand as
“contaminated”.
4. Pick up suction catheter with dominant
hand without touching non-sterile
surfaces. Pick up connecting tubing
with non-dominant hand.
5. Check if the equipment is functioning
properly by suctioning small amount of
normal saline from basin.
6. Remove oxygen delivery device, if
applicable with non-dominant hand. Do
this quickly inserting catheter with
dominant thumb and forefinger into
nares using slightly downward slant or
through mouth when client breathes in.
Do not force through nares.
7. Once correct position is ascertained,
apply suction and gently rotate catheter
while pulling it slightly upward.
8. Encourage patient to cough. Replace
oxygen device, if applicable.
9. Rinse catheter and connecting tubing
with normal saline until they are
cleared.
10. Repeat steps 6-9 as needed to clear
pharynx or trachea of secretions.
Allow adequate time between suction
passes for ventilation.
11. Monitor patient’s cardiopulmonary
status between suction passes. Ask
patient to deep breath and cough.
12. When pharynx and trachea are
RATIONALE
Hand washing prevents transmission of
microorganism.
Sterile saline/water is used to flush and
lubricate catheter.
Handling the sterile catheter with a hand
wearing a sterile glove helps prevent
introducing microorganisms into the respiratory
tract and the clean glove protects the nurse
from microorganisms.
Sterilization can be maintained.
Lubrication makes catheter insertion easier
and ensures proper functioning of suction
equipment.
Using suction while inserting the catheter can
cause trauma to the mucosa and removes
oxygen from the respiratory tract. Coughing is
induced when the trachea is touched. This
helps the patient raise secretions.
Inspiration open epiglottis and facilitates
catheter movement into trachea.
Rotation of the catheter prevents trauma to
mucous membranes from prolonged
suctioning of one area. Limiting the suction
time to 10 seconds or less prevents hypoxia.
Coughing facilitates clearing of secretions.
Prolonged suctioning can induce hypoxia.
Rinsing clears secretions from catheter.
Adequate time between suctions reoxygenates
the lungs.
Normal breathing between suctioning helps
compensates for any hypoxia induced in the
previous suctioning.
This suctions the orophrarynx after trachea
72
 sufficiently cleared of secretions, because the mouth is less clean than the
perform oral pharyngeal suctioning to trachea.
clear mouth secretions.

13. When suctioning is completed, roll This contains client’s secretions inside glove to
catheter around fingers of dominant reduce transmission of microorganisms.
hand. Pull glove off inside out so that
catheter remains coiled in the glove.
Pull off the other glove in same way.
Discard in appropriate receptacle. Turn
off suction device.
14. Reposition patient. If indicated, Accumulated respiratory secretions irritate the
readjust oxygen to original level. mucous membranes and are unpleasant for
the client.
15. Remove towel and discard remainder This reduces transmission of microorganism.
of normal saline and dispose of
disposable equipment. Wash hands.

Evaluation
1. Compare patient’s respiratory assessment before and after suctioning.
2. Measure heart rate, blood pressure, respiratory rate and oxygen saturation.
3. Record the patient’s tolerance of procedure, type and amount of secretions removed and
complications.
4. Report any patient’s intolerance of procedure (changes in vital signs, bleeding,
laryngospasm, upper airway noise).

73
OXYGEN THERAPY (OXYGEN ADMINISTRATION)
Definition
It is the administration of oxygen as a medical intervention, which can be for a variety of
purposes in both chronic and acute patient care. Oxygen is essential for cell metabolism, and in
turn, tissue oxygenation is essential for all normal physiological functions.

Purposes

• CANNULA
1. To deliver a relatively low concentration of oxygen when only minimal O2 support
is required.
2. To allow uninterrupted delivery of oxygen while the client ingests food or fluids.
• FACE MASK
1. To provide moderate O2 support and a higher concentration of oxygen and/or
humidity than is provided by cannula
a. FACE TENT
a. To provide high humidity
b. To provide oxygen when a mask is poorly tolerated.
c. To provide a high flow of O2 when attached to a Venturi system.

Assessment

1.Skin and mucous membrane color- note whether cyanosis is present

2.Breathing patterns.
3.Chest movements.
4.Chest wall configuration.
5.Lung sounds.
6.Presence of clinical signs of hypoxemia. ( tachycardia, tachypnea, restlessness,
dyspnea, cyanosis, and confusion )
7. Presence of clinical signs of hypercarbia. ( restlessness, hypertension, headache,
lethargy, tremor )
8. Presence of clinical signs of oxygen toxicity. ( tracheal irritation and cough, dyspnea, and
decreased pulmonary ventilation )
DETERMINE

1. Vital signs—especially pulse rate and quality and respiratory rate, rhythm, and depth.
2. Whether the client has COPD.
3. Results of diagnostic studies.
4. Hemoglobin, hematocrit, complete blood count.
5. Oxygen saturation levels.
6. Arterial blood gases, if available.
7. Pulmonary function tests, if available.
74
Planning

1. Assemble the following equipment:

1.1 CANNULA
1.1.1 Oxygen supply with a flow meter and adapter
1.1.2 Humidifier with distilled water or tap water, according to agency protocol
1.1.3 Nasal Cannula and tubing
1.1.4 Tape
1.1.5 Padding for the elastic band
1.2 FACE MASK
1.2.1 Oxygen supply with a flow meter and adapter
1.2.2 Humidifier with distilled water or tap water, according to agency protocol
1.2.3 Prescribed face mask of the appropriate size
1.2.4 Padding for the elastic band
1.3 FACE TENT
1.3.1 Oxygen supply with a flow meter and adapter
1.3.2 Humidifier with distilled water or tap water, according to agency protocol
1.3.3 Face tent of the appropriate size.
2. Determine the need for oxygen therapy, and verify the order for the therapy.
2.1 Perform a respiratory assessment to develop baseline data if not already available.
3. Prepare the client and support people.
3.1Assist the client to a semi-Fowler’s position if possible. Rationale: This position
permits easier chest expansion and hence easier breathing.
3.2 Explain that oxygen is not dangerous when safety precautions are observed. Inform
the client and support people about the safety precautions connected with oxygen
use.

Implementation

STEPS RATIONALE

1. Introduce self and verify the client’s To obtain the cooperation of the client.
identity. Explain the procedure.
2. Perform hand hygiene and observe
appropriate infection control
procedures.
3. Set up oxygen equipment and
humidifier.
i. Attach the flow meter to the

75
 wall outlet or tank. The flow meter
should be in the off position.
ii. If needed, fill the humidifier
bottle.
iii. Attach the humidifier bottle
to the base of the flow meter.
iv. Attach the prescribed
oxygen tubing and delivery device
to the humidifier.

4. Turn on the oxygen at the

prescribed rate and ensure proper
functioning.
a. Check the oxygen is flowing
freely through the tubing. There
should be no kinks in the tubing,
and the connections should be
airtight. There should be bubbles in
the humidifier as the oxygen flows
through. You should feel the
oxygen at the outlets of the
cannula, mask or tent.
b. Set the oxygen at the flow
rate ordered.
5. Apply the appropriate oxygen
delivery device.
CANNULA
a. Put the cannula over the client’s
face, with the outlet prongs
fitting into the nares and the
elastic band around the head.
b. If the cannula will not stay in
place, tape it at the sides of the
face.
c. Pad the tubing and band over
the ears and cheekbones as
needed.
FACE MASK
a. Guide the mask toward the
client’s face, and apply it from
the nose downward.
b. Fit the mask to the contours of The mask should mold to the face, so that
the client’s face. very little oxygen escapes into the eyes or
around the cheeks and chin.
c. Secure the elastic band around

76
 the client’s head so that the
mask is comfortable but snug.

d. Pad the band behind the ears Padding will prevent irritation from the
and over bony prominences. mask.
FACE TENT
a. Place the tent over the client’s face,
and secure the ties around the
head.

6. Assess the client regularly.

a. Assess the client’s vital signs, level
of anxiety, and ease of respirations,
and provide support while the client
adjusts to the device.
b. Assess the client in 15 to 30
minutes, depending on the client’s
condition, and regularly thereafter.
c. Assess the client regularly for
clinical signs of hypoxia,
tachycardia, confusion, dyspnea,
restlessness, and cyanosis. Review
oxygen saturation or ABG results if
they are available.
NASAL CANNULA
a. Assess the client’s nares for
encrustations and irritation. Apply a
water-soluble lubricant as required
to soothe the mucous membranes.
b. Assess the top of the client’s ears
for any signs of irritation from the
cannula strap. If present, padding
with a gauze pad may help relieve
the discomfort.
FACE MASK OR TENT
a. Inspect the facial skin
frequently for dampness or chafing,
and dry and treat it as needed.
7. Inspect the equipment on a regular
basis.
a. Check the liter flow and the level of
water in the humidifier in 30
minutes and whenever providing
care to the client.
b. Be sure that water is not collecting

77
 in dependent loops of the tubing.
c. Make sure safety precautions are
being followed.
8. Document findings in the client
record using forms or checklists
supplemented by narrative notes
when appropriate.

Evaluation
1. Perform follow-up based on findings that deviated from expected or normal for the client.
Relate findings to previous data if available ( e.g., check oxygen saturation to evaluate
adequate oxygenation )
2. Report significant deviations from normal to the primary care provider.

PROVIDING TRACHEOSTOMY CARE

Definition

78
 A tracheostomy is a surgically created opening in the trachea. A tracheostomy tube is placed in
the incision to secure an airway and to prevent it from closing. Tracheostomy care is generally
done every eight hours and involves cleaning around the incision, as well as replacing the inner
cannula of the tracheostomy tube. After the site heals, the entire tracheostomy tube is replaced
once or twice per week, depending on the physician's order.

Purposes
• To maintain airway patency.
• To maintain cleanliness and prevent infection
• To facilitate healing and prevent skin excoriation
• To promote comfort

Equipments
• Sterile disposable tracheostomy cleaning kit
• Towels or drapes
• Sterile suction catheter kit
• Sterile normal saline
• 2 pairs of sterile gloves
• Clean gloves
• Moisture proof bag
• 4x4 gauze dressing
• Clean scissors
Steps Rationales
1. Prior to performing the procedure,  To make sure that you are going to
introduce self and verify the client’s perform the procedure to the
identity using agency protocol appropriate client

2. Perform hand hygiene and observe  To eliminate/lessen the transfer of

other infection control procedures microoganisms

3. Provide for client’s privacy  To lessen the embarassment of the

client and for their own confidentiality
4. Prepare the client and the equipment

• Assist the client to a semi-  To promote lung expansion

Fowler’s or Fowler’s position
• Open the tracheostomy kit or
sterile basins. Pour the
soaking solution and sterilr
normal saline into separate
containers

79
 • Establish a sterile field
•
Open other sterile supplies as
needed including sterile
applicators, suction kit, and
tracheostomy dressing
5. Suction tracheostomy tube if needed.
6. Clean the inner cannula
 To remove secretions and maintain
• Removethe inner cannula from the airway
soaking solution
• Clean the lumen and the entire
inner cannula thouroughly using the
brush or pipe cleaners moistened
with sterile normal saline
• Rinse the inner cannula
thouroughly in the sterile normal
saline
• After rinsing, gently tap the cannula
against the inside edge of the
sterile saline container. Use a pipe
cleaner folded half to dry only the
inside of the cannula; do not dry the  This removes excess liquid from the
outside. cannula and prevents possible
7. Replace the inner cannula, securing it aspiration by the client, while leaving a
in place. film of moisture on the outer surface to
lubricate the cannula for reinsertion.
• Insert the inner cannula y
grasping the outer flange and
inserting the cannula in the
direction of its curvature
• Lock the cannula in place by
turning the lock (if present) into
position to securethe flange of
the inner cannula to the outer
cannula
8. Clean the incision site and tube flange
• Using sterile applicators or
gauze dressings moistened with
sterile saline, clean the incision
site
• Hydrogen peroxide may be
used to remove crusty
secretions. Thouroughly rinse  This avoids contaminating a clean area
the cleaned area using gauze with a soiled gauze dressing or
squares moistened with sterile applicator
normal saline
• Clean the flange of the tube in

80
 the same manner  Hydrogen peroxide can be irritating to
• Touroughly dry the client’s skin the skin and inhibit healingif not
and tube flanges with dry gauze thoroughly removed
squares
9. Apply sterile dressings
• Use commercially prepared
tracheostomy dressing of non-
raveling material or open and
refold a 4x4 gauze into a V
shape
• Place the dressing under the
flange of the tracheostomy tube
• While applying the dressing,
ensure that the tracheostomy  Cotton lint or gauze fibers can be
tube is securely supported aspirated by the client, potentially
10. Change the tracheostomy ties creating a tracheal abscess
• Change as needed to keep the
skin clean and dry
• Twill tape and specially
manufactured velcro ties are
available. Twill tape is  Excessive movement of the
inexpensive and readily tracheostomy tubirritates the trachea
available; however it is easily
soiled and can trap moisture
that leads to irritation of the skin
of the neck. Velcro ties are are
becoming commonly used.
They are wider more
comfortable and cause less skin
abrasions

Two-strip Method (Twill tapes)

• cut two unequal strips of twill tapes,
one approximately 10in. and the other
20in. long
• Cut 0.5in. lengthwise slit approximately
1in. from one end of each strip. To do
this, fold the end of the tape back onto
itself about 1in. , then cut a slit in the
middle of the tape from its folded edge
• Leaving the old ties in place, thread the
slit end of one clean tape through the
eye of the tracheostomy flange from
the bottom side; then thread the long
 Cutting one tape longer than the other
end of the tape through the slit, pulling
allows them to be fastened at the side
it tight until it is securely fastened to the

81
 flange of the neck for easy access and to
• If old ties are very soiled, have an avoid pressure at the back of the neck
assistant put on sterile gloves and hold
the tracheostomy in place while you
replace the ties.
• Repeat the process for the second tie
• Ask the client to flex the neck. Slip the
longer tape under the client’s neck,
 Leaving the old ties in place while
place a finger between the tape and
securing the clean ties prevents
the client’s neck
inadvertent dislodging of the
tracheostomy tubes

• Tie the ends of the tape using square

knots. Cut off any long ends, leaving
approximately 0.5in.
• Once the clean ties are secured,
remove the soiled ties and discard  Flexing the neck increases its
circumference the way coughing does.
Placing a finger under thr ties prevent
One-strip Method (twill tape) making the tie too tight, which could
• Cut a length of twill tape 2.5 times the interfere with coughing or place
length needed to go around the neck pressure to the jugular veins
from one tube flange to the other
• Thread one end of the tape to the slot
on one side of the flange
• Bring both ends of the tape together
• Thread the end of the tapr to the  Adequate ends beyond the knot
client’s neck through the slot from back prevent the knot from untying
to front
• Have the client flex the neck, tie the
loose ends with a square knot at the
side of the client’s neck, allowing for
slack by placing two fingers under the
ties. Cut off lomg ends

11. Tape and pad the tie knot

• Place a 4x4 gauze under the tie
knot, and apply tape over the
knot.
12. Check the tightness of the ties

82
 • Frequently check the tightness
of the tracheostmy ties ans
position of the tracheostomy
tube
13. Document all the relevant information.
• Record suctioning,
tracheostomy care, and the
dressing change, noting your
assessment

 This reduces ckin irritation from the

knot and prevents from confusing the
knot with the client’s gown ties

 Swelling of the neck may cause the ties

to become too tight, interfering with
coudhing and circulation

INTRAVENOUS FLUID THERAPY

Definition
83
This is essential when client are unable to take foods and fluids orally. It is an efficient and
effective method of supplying fluids directly into the intravascular fluid compartment and
replacing the electrolyte losses.

Purposes
• To supply fluid when clients are unable to take in an adequate volume of fluids by mouth
• To provide salts and other electrolytes needed to maintain electrolyte balance

Equipments
• infusion set
• sterile parenteral solution
• IV pole
• Adhesive or nonallergenic tape
• Clean gloves
• Tourniquet
• Antiseptic swab
• IV catheter
• Sterile gauze dressing
• Arm splint
• Towel or pad

STEPS RATIONALE

1. Perform hand hygiene. Identify the

client and verify the client’s identity
also verify for the order to start an
intravenous line.
2. Open and prepare the infusion set.
-remove tubing from the container
and straighten it out.
-slide the tubing clamp along the
tubing until it is just below the drip
chamber to facilitate its access.
-Close the clamp
This will maintain the sterility of the tubing.
-Leave the ends of the tubing until
the infusion is started.
3. Spike the solution container
- remove the protective cover
from the entry site of the bag.
-Remove the cap from the spike

84
 and insert the spike into the
insertion site of the bag or bottle.
Follow the manufacturer’s
instructions.
4. Apply a timing label on the solution
container The label is applied upside down so it can
-The timing label may be applied at be read easily when the container is
the time the infusion is started hanging up.
5. Hang the solution container on the
pole. This height is needed to enable gravity to
-Adjust the pole so that the overcome venous pressure and facilitate
container is suspended about 3 ft flow of the solution into the vein.
above the client’s head.

6. Partially fill the drip chamber with

solution
-Squeeze the chamber gently until
it is half full solution

7. Prime the tubing.

8. Remove the protective cap and
hold the tubing over a container.
Maintain the sterility of the end of
the tubing and the cap.
-release the clamp and let the fluid
run through the tubing until all
bubbles are removed. Tap the The tubing is primed to prevent the
tubing if necessary with your introduction of air into the client.
fingers to help the bubbles move.
9. Perform hand hygiene just prior to
client contact.
10. Select the venipuncture site.
-Use the client’s non dominant Sclerotic vein may make initiating and
hand, unless contraindicated. maintaining the IV difficult. Joint flexion
Identify possible venipuncture sites increases the risk of irritation of vein wall
by looking for veins that are by catheter.
relatively straight not sclerotic or
tortuous and avoid venous valves.
11. Dilate the vein.
-Place the extremity in a dependent
position (lower than the clients Gravity sloes venous return and distends
heart) the veins. Distending the veins makes it
-Apply a tourniquet firmly 15 to easier to insert the needle properly.
20cm (6 to 8 in) above the

85
 venipuncture site. Explain that the
tourniquet will feel tight.
The tourniquet must be tight enough to
obstruct venous flow but not so tight that it
occludes arterial flow. Obstructing arterial
flow inhibits venous filling.
Gloves protect the nurse from
contamination of the client’s blood.

12. Put on clean gloves and clean the

venipuncture site.
-use circular motion in cleaning the
site.
13. Insert the catheter and initiate the This stabilizes the vein and makes the skin
infusion. taut for needle entry. It can also make
-Use the non dominant hand to pull initial tissue penetration less painful.
the skin taut below the entry site.
-once blood appears in the lumen
of the needle or you feel the lack of
resistance , lower the angle of the
catheter until it is almost parallel
with the skin and advance the
needle and catheter approximately The catheter is advance to ensure that it,
0.5 to 1 cm farther. and not just the metal needle is in the vein.
-Release the tourniquet
-put pressure on the vein proximal
to the catheter to eliminate or
reduce blood oozong out of the
catheter.
-Remove the protective cap from
the distal end of the tubing and hold
it ready to attach the end of the
infusion tubing ti the catheter hub.
-Initiate the infusion.
14. Tape the catheter.
15. Dress and label the venipuncture
site and tubing according to agency
policy.
-Loop the tubing and secure it with
tape.
Looping and securing the tubing prevent
the weight of the tubing or any movement
from pulling on the needle or catheter

16.Ensure appropriate infusion flow.

-apply a padded arm board to splint

86
 the joint, as needed.
-adjust the infusion rate of flow
according to the order.
17. Label the IV tubing
-Date and time of attachment and The tubing is labeled to ensure that it is
your initial. changed at regular intervals

18. Document relevant data, including

assessments. Record the start of
the infusion , date and time of the
venipuncture amount and type of
the solution used, any additives.

COLOSTOMY CARE: CHANGING OF COLOSTOMY BAG

Definition

87
A colostomy is a surgical procedure that reroute the colon to an opening made in the abdomen.
Waste drains from the colon, through a stoma into a collection bag worn near the stomach,
which is emptied periodically. When injury or disease damages the colon, a colostomy allows
passage of waste from the body.

Equipments
• Clean washcloth or 4×4 gauze pads
• Warm tap water
• Clean gloves
• Lubricant or skin cream (optional)
• Scissors
• Plastic waste bag
• Ostomy Wafer
• Ostomy Drainage Bag
• Disposable bed protector

STEPS RATIONALE
1. Assess the appearance of the stoma To determine an effective strategy of changing
and the condition of the bag and the colostomy bag based on current condition.
characteristics of the fecal waste.

2. Wash hands. To reduce the transmission of microorganisms

3. Gather equipment. To promote efficiency.

4. Identify the client and explain the Ensures correct client and reinforces detailed
procedure. instructions client will need to perform self
care.

5. Provide privacy To reduce embarrassment

6. Place the disposable bed protector Protects the bed from soiling.
under the client’s hips.

7. Wear clean gloves Prevents contact with fecal matter.

8. Remove the soiled plastic stoma bag Prevents contamination of the surrounding
from the skin carefully. environment.

9. Discard soiled stoma bag in plastic Removes and promotes infection control.
waste bag.

88
 10. Remove gloves and wash hands.
11. Apply clean gloves.
12. Clean the stoma and skin with warm
tap water. Pat dry.
13. Apply a small amount of lubricant or
protective cream around the area of
the ostomy.
14. Place gauze over orifice of stoma while
preparing the wafer and pouch for
application.
15. Trace pattern onto the paper back of
wafer and cuts as traced.
16. Attach clean stoma bag or pouch to
wafer. Make sure port closure is
closed.
17. Remove gauze pad from the orifice of
stoma.
18. Remove ion of the stoma.paper
backing from wafer and place on skin
over stoma.
19. Tape wafer edges down with
hypoallergenic tape.
20. Remove disposable bed protector and
discard all used equipment.
21. Wash hands.
22. Record pertinent data.
CENTRAL VENOUS PRESSURE
Definition
To maintain aseptic technique throughout the
procedure.
Practices clean technique.
Removes feces from the stoma and skin.
Prevents irritation of the skin around the
stoma.
Ensures a good seal of the wafer to the client’s
skin.
Provides an accurate fit for the ostomy bag.
To prevent feces from leaking during the
application.
To facilitate visualization of the stoma.
Paper backing needs to be removed from
wafer to become adherent to the skin.
To prevent edges of wafer from adhering to
the client’s body.
Prevents contamination of the environment.
Reduces microorganism transfer.
To provide data needed in the care of the
client.
89
It is obtained by inserting a catheter into the external jugular, antecubital or femoral vein and
threading it into a vena cava. The catheter is attached to an IV infusion and H2O manometer by
a three way stopcock or electronic transducer. Normal range is 4-10 cm H2O or 2-6 mmHg.

Purposes
1. To reveal right atrial pressure, reflecting alterations in the right ventricular pressure.
2. To provide information concerning blood volumes and adequacy of central venous
return.
3. To provide an IV route for drawing blood samples, administering fluids or medication and
possibly inserting a pacing catheter.

Assessment
1. Assess patient. Establish baseline data, vital signs and hydration status.
2. Evaluate PT, PTT and CBC.
3. Obtain signed permission if needed.
4. Assess patient’s ability to participate in and tolerate the procedure.
5. Check the order for the insertion of a central IV line with CVP manometer.

Planning
3. Wash hands.
4. Assemble the following equipment:
4.1 infusion solution
4.2 infusion set with CVP manometer
4.3 IV pole attached to the bed
4.4 Arm board
4.5 Adhesive tape
5. Check patient’s identification and explain the procedure to the patient.

Implementation

STEPS RATIONALE

1. Place the patient in supine position. This It provides maximum visibility of veins.
is the baseline position used for (Lippincott). It facilitates the catheter
subsequent readings. insertion (Bowden and Greenberg)

2. Flush IV infusion set and manometer. The level of the right atrium is at the fourth
Secure all connection. intercostals space midaxillary line. Mark
midaxillary line with inedible ink for

90
 2.1. Attach the manometer to the IV
pole. The zero point on the manometer
should be on a level with the patient’s right
atrium.
2.2. Locate the phlebostatic axis mark.
3. The CVP site is surgically cleansed. The
physician introduces the CVP catheter
percutaneously or by direct venous
cutdown and threaded through antecubital,
subclavian or internal/ external jugular
vein. The catheter may be sutured or tape.
4. The CVP catheter is connected to a
three- way stopcock that communicated to
an IV and to a manometer.
5. Start the IV flow and fill the manometer
10 cm above the anticipated reading (or
until the level of 20 cm H2O is reached).
Turn the stopcock and fill the tubing with
fluid.
6. The infusion is adjusted to flow into the
patient’s vein by a slow continuous drip.
Measure the CVP:
7. Check the doctor’s order.
8. Place the patient in the identified
position and confirm the zero point.
9. Position the zero point of the manometer
at the level of the right atrium.
10. Turn the stopcock so that the IV
solution flows into the manometer, filling to
about 20-25 cm. Then turn the stopcock so
subsequent readings to ensure
consistency of the zero level. (Lippincott)
This reduces the number of
microorganisms. (Bowden and Greenberg)
This will provide the route for an accurate
reading of CVP.
Turning the stopcock allows the fluid to
flow from the bag to the manometer. A
required pressure must be followed for an
accurate reading.
Slow continuous drip allow fluids to flow
smoothly, thus, the pressure to be read will
not be altered.
A signed permission is needed in
measuring the CVP.
It ensures accuracy or readings by
eliminating hydrostatic forces (Bowden and
Greenberg). This is the baseline position
used for subsequent reading. (Lippincott)
Using level at right atrium reflects the blood
volume and cardiac function of patient
(Smith et.al)
Overfilling the manometer may expose the
client to contamination resulting from
overflow (Smith et.al)
91
that the solution in manometer flows into
the patient.

11. Observe the fall in the height of the Normally the pressure should be between
column of fluid in manometer. Record the 4 and 11 cm.
level at which the solution stabilizes or
stops moving downward. This is CVP.

12. Record the CVP and the position of the To provide accurate data and
patient.. documentation of patient’s care.

13. Turn the stopcock again to allow IV When readings are not being made, flow is
solution from solution bottle into patient’s from a very low microdrip to the catheter,
veins. by passing the manometer. (Lippincott)

Follow up phase: CVP is interpreted by considering the

1. Assess the patient’s clinical condition. patient’s entire clinical picture; hourly urine
output, heart rate, blood pressure, cardiac
output measurements.

2. Observe the complications: Patient’s complaints of new or different

2.1 From the catheter insertion:
pneumothorax, hemothorax, air embolism,
hematoma, cardiac tamponade.
2.2 From indwelling catheter: air
embolism, infection.
pain or shortness of breath must be
assessed closely; they may indicate
development of infection. Signs and
symptoms of air embolism include severe
shortness of breath, hypotension, hypoxia,
rumbling murmur, cardiac arrest.

3. Carry outgoing nursing surveillance of To prevent infection and further

the insertion site and maintain aseptic complications.
technique.
3.1 Inspect entry site twice daily for
signs of inflammation.
3.2 Change dressing as prescribed.
3.3 Label to show time/data of
change.
3.4 Send the catheter tip for
bacteriologic culture when it is
removed.
CARDIOPULMONARY RESUSCITATION
Definition

92
It is an emergency procedure which is attempted in an effort to return life to a person in cardiac
arrest. It is indicated in those who are unresponsive with no breathing or only gasps. It may be
attempted both in and outside of a hospital.
CPR involves chest compressions at a rate of at least 100 per minute in an effort to
create artificial circulation by manually pumping blood through the heart. In addition the rescuer
may provide breaths by either exhaling into their mouth or utilizing a device that pushes air into
the lungs. The process of externally providing ventilation is termed artificial respiration. Current
recommendations place emphasis on high quality chest compressions over artificial respirations
and a method involving only chest compressions is recommended for untrained rescuers.
CPR alone is unlikely to restart the heart; its main purpose is to restore partial flow of
oxygenated blood to the brain and heart. It may delay tissue death and extend the brief window
of opportunity for a successful resuscitation without permanent brain damage. An administering
of an electric shock to the heart, termed defibrillation, is usually needed to restore a viable or
"perfusing" heart rhythm. Defibrillation is only effective for certain heart rhythms, namely
ventricular fibrillation or pulseless ventricular tachycardia, rather than asystole or pulseless
electrical activity. CPR may however induce a shockable rhythm. CPR is generally continued
until the person regains return of spontaneous circulation (ROSC) or is declared dead.

Purposes
• To restore and maintain breathing and circulation
• To provide oxygen and blood flow to the heart, brain, and other vital organs.

Equipments
• Various types and sizes of gauze pads
• Bandages
• Tape
• Sterile eyewash
• Ice pack
• Scissors
• face shield
• Mask
• Gloves
• Watch/stop watch

STEPS RATIONALE
1.Check the scene for dangers >If you come across someone who is
unconscious, you need to quickly make sure
there are no dangers to yourself if you choose
to help them.

2. Check the victim for consciousness

>If they respond, they are conscious. They
by shaking or tapping their shoulder may have just been sleeping, or they could
and saying in a loud, clear voice, have been unconscious. If it still appears to be

93
"Are you okay? Are you okay?"
3. Send for help.
4. Check the victim’s pulse.
o To check the neck (carotid )
pulse, feel for a pulse on the side of the
victim's neck closest to you by placing
the tips of your first two fingers beside
his Adam's apple.
o To check the wrist (radial)
pulse, place your first two fingers on
the thumb side of the victim's wrist.
o Other pulse locations are the
groin and ankle. To check the groin
(femoral) pulse, press the tips of two
fingers into the middle of the groin. To
check the ankle (posterial tibial) pulse,
place your first two fingers on the
inside of the ankle.
5. Remember CAB: Chest Compressions,
Airway, and Breathing.
2. 6. Give 30 chest compressions. Place
your hands on top of each other and
place them on the sternum, or in the
center of the chest (on the breastbone)
between the two nipples. Your ring
finger should be on top of the nipple
(this will lower the chances of breaking
a rib or ribs).
o Compress the chest, with
elbows locked, by pushing straight
down at least 2 inches deep.
o Do 30 of these compressions,
and do them at a rate of at least 100
compressions per minute.
7. Make sure the airway is open. Place your
hand on the victim's forehead and two fingers
on their chin and tilt the head back to open the
an emergency situation
> The more people available for this step the
better, however, it can be done alone. Send
someone to call the Emergency Medical
Services (EMS). Do not check for more than
10 seconds. If the victim does not have a
pulse, continue with CPR and the next steps.
> Chest compressions are more critical for
correcting abnormal heart rhythms (ventricular
fibrillation or pulseless ventricular tachycardia),
and because one cycle of 30 chest
compressions only require 18 seconds, airway
opening and rescue breathing are not
significantly delayed.
> Allow complete chest recoil after each
compression. Minimize pauses in chest
compression that occur when changing
providers or preparing for a shock. Attempt to
limit interruptions to less than 10 seconds
> No control over the muscles suggests the
casualty may be unconscious. Therefore they
may be at risk of the tongue falling to the back
of the mouth and obstructing the airway.
Opening the airway prevents this. Also if they
are at risk of vomiting (e.g. after drinking a lot
of alcohol), if they vomit they will not be able to
gag and the vomit can enter the lungs, causing
death,
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airway (if you suspect a neck injury, pull the > Do abdominal thrusts to remove the
jaw forward rather than lifting the chin). If jaw obstruction.
thrust fails to open the airway, do a careful
head tilt and chin lift.

1. 8. Give two rescue breaths. Keeping

the airway open, take the fingers that
were on the forehead and pinch the
victim's nose closed. Make a seal with
your mouth over the victim's mouth and
breathe out for about one second. > You should do CPR for 2 minutes (5 cycles
Make sure you breathe slowly, as this of compressions to breaths) before checking
will make sure the air goes in the lungs for signs of life. Continue CPR until someone
not the stomach. Make sure you keep takes over for you, emergency personnel
your eye on the victim's chest. arrive, you are too exhausted to continue, an
AED is available for immediate use, or pulse
o If the breath goes in, you should and breathing return (signs of life).
see the chest slightly rise and also feel
it go in. If the breath goes in, give a
second rescue breath.
o If the breath does not go in, re-
position the head and try again. If it
does not go in again, the victim may be
choking.

8. Repeat the cycle of 30 chest compressions

and 2 breaths.

10. If the victim wakes up, you can stop CPR.

BLOOD TRANSFUSION
Definition
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Blood products are ordered by the physician to restore circulatory blood volume, improve
hemoglobin or correct serum protein levels. It is the responsibility of the physician to determine
which blood component should be administered and the reason for the transfusion.
Administration of blood or blood components is a nursing procedure.

Purpose
1. To restore blood volume after severe hemorrhage.
2. To restore capacity of the blood to carry oxygen.
3. To provide plasma factors such as antihemophilic factor (AHF) or factor VIII, or platelet
concentrates which prevent or treat bleeding.

Assessment
1. Assess integrity and intactness of present intravenous line.
2. Check that venipuncture was performed with 18 or 19 gauge angiocatheter.
3. Inspect if IV line is flowing, obstructed or infiltrated.
4. Review baseline vital signs in patient’s medical record before initiating transfusion.

Planning
1. Prepare the following equipments
1.1 Blood filter and tubing
1.2 Intravenous solution with 0.9% NaCl (Normal Saline)
1.3 Blood warmer if needed.
1.4 Pressure bag
1.5 Disposable gloves
1.6 Cotton balls

2. With another registered nurse, verify blood product and identify the patient’s:
2.1 Name and identification number (verbally and against his armband)
2.2 Blood group and Rh type
2.3 Crossmatch compatibility
2.4 Donor blood group and Rh type
2.5 Unit and hospital number
2.6 Expiration date of blood
2.7 Type of blood component
2.8 Clots in blood – if clots are present, return blood to blood bank.

3. Explain to patient procedure and its purpose.

Implementation

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 STEPS RATIONALE

1. Obtain baseline vital signs before It provides a baseline for comparison

administering transfusion. during the transfusion. (Timby)

2. Wash hands and apply disposable Handwashing deters the spread of

gloves. microorganisms. Gloves are used to
protect against accidental exposure to
patient’s blood. (Taylor)

3. Flush IV fluid line (PNSS). Infusing normal saline before initiating the
transfusion clears the IV catheter of
incompatible solutions or medications.
(Kozier)

Dextrose may lead to clumping of RBC and

hemolysis. (Taylor)

4. Open blood administration set. This complies with the standards of care
for administering blood. (Timby)

5. Change IV bottle or close IV fluid line This provides route for administering the
and infuse blood. normal saline or blood. (Timby)

6. For Y tubing only:

a. Spike 0.9 NSS intravenous bag This provides route for administering
normal saline. (Timby)

b. Spike blood or blood component unit This provides route for administering blood.
and fill drip chamber with blood. (Timby)

c. Prime tubing with 0.9 NSS Suction effect causes fluid to move into
drip chamber. It prevents also air from
moving down the tubing. (Taylor)

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7. For single tubing with administration:
a. Spike blood unit.
b. Squeeze the drip chamber, allow
filter to be filled with blood.
c. Open roller clamp and allow
infusion tubing to fill with blood.
8. Remain with patient during first 15-20
minutes of transfusion., Initial flow rate
should be 25 ml/min.
9. Monitor patient’s vital signs
appropriately: every 5 minutes for first
15minutes, every 15 minutes for next hour;
hourly unit of blood is infused.
Evaluation
Observe and document for any chill, flushing, itching, dyspnea, rash, hives or other signs of
transfusion reactions.
ESSENTIAL NEWBORN CARE
(Unang Yakap Campaign of the Department of Health)
Definiton
This provides route for administering blood.
(Timby)
Suction effect causes fluid to move into
drip chamber. It prevents also air from
moving down the tubing.(Taylor)
This removes air from tubing that in large
amounts act as an air embolus.(Taylor)
Transfusion reactions typically occur during
this period, and a slow rate will minimize
the volume of red blood cells infused. If
there has been no adverse effect during
this time, the infusion rate is increased.
(Taylor)
If complications occur, they can be
observed, and blood can be stopped
immediately. (Taylor)
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 On December 7, 2009, the Department of Health launched the Unang Yakap Campaign.
With this campaign, the DOH aims to cut down infant mortality in the Philippines by at least half.
The campaign employs Essential Newborn Care (ENC) Protocol as a strategy to improve the
health of the newborn through interventions before conception, during pregnancy, at and soon
after birth, and in the postnatal period. The ENC Protocol provides an evidence-based, low cost,
low technology package of interventions that will save thousands of lives. ENC is a simple, cost-
effective newborn care intervention that can improve neonatal as well as maternal care. It is an
evidence-based intervention that emphasizes a core sequence of actions, performed
methodically (step-by-step); is organized so that essential time bound interventions are not
interrupted; and fills a gap for a package of bundled interventions in a guideline format.

Purposes
• To help improve the health of the newborn through interventions before conception,
during pregnancy, immediately after birth, and in the postnatal period
• To ensure that all health providers know how to handle newborn babies, implement
exclusive breastfeeding, and guarantee a healthy child.
• To reduce neonatal mortality

Equipments
• Suction machine
• Suction catheter
• Saline (cool)
• Clean container for rinsing catheter
• Vitamin K ampule
• 1cc syringe
• Rectal thermometer
• Terramycin ointment
• Weighing scale
• Cord clamp
• Cotton balls
• Sterile gloves
• Sterile gauze
• 70% alcohol
• Tape measure

Implementation
Preparation (first 90 minutes; at perineal bulging; with presenting part visible)
1) Check the temperature of the delivery room. It should be 25-28°C and free of air drafts.
2) Notify appropriate staff.
3) Arrange needed supplies in linear fashion.
4) Check resuscitation equipments.

99
 5) Wash hands with clean water and soap.
6) Double glove just before delivery.

Performance

100
 STEPS RATIONALE
Time-bound Procedures
I. Immediate and thorough drying (within Immediate drying prevents hypothermia,
30 seconds) which is extremely important to survival.

1) Use a clean, dry cloth to thoroughly

dry the baby by wiping the eyes,
face, head, front and back, arms,
and legs.
2) Remove the wet cloth.
3) Do a quick check of the newborn’s
breathing while drying.
Notes:
• Do note ventilate unless the baby is
floppy/limp and not breathing.
• Do not suction unless the
mouth/nose are blocked with
secretions or other material.
• Do not put the newborn on a cold or
wet surface.
• Do not bathe the newborn earlier
than 6 hours of life.
• Do not wipe-off vernix caseosa.

If after 30 seconds of thorough drying,

newborn is not breathing or is gasping:
1) Clamp and cut the cord
immediately.
2) Call for help.
3) Transfer to a warm, firm surface.
4) Inform the mother that the newborn
has difficulty breathing and that you
will help the baby to breathe.
5) Start resuscitation protocol.

II. Early skin-to-skin contact (after thorough To provide warmth, increase the duration
drying) of breastfeeding, and allow the “good
bacteria” from the mother’s skin to colonize
the newborn.
4) Position the newborn prone on the
mother’s abdomen or chest.
5) Cover the newborn’s back with a
dry blanket.
6) Cover the newborn’s head with a
bonnet.
7) Place the identification band on the
ankle and take footprints.

III. Properly-timed cord clamping and To increase the baby’s iron reserves, 101
cutting (while on skin-to-skin contact; up to reduce the risk of Iron-Deficiency Anemia,
3 minutes post-delivery) improve blood circulation and brain
hemorrhage.
8) Remove the first set of gloves.
Evaluation
Conduct appropriate follow-up such as notifying the primary care provider of the results of the
interventions. Evaluate expected findings as well as any deviations (if any) such as birth injuries,
malformations, or defects.

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