MEDICAL ASEPSIS

Ways Through Which Microorganisms Spread:

1. Microorganisms move through space on air currents.

2. Microorganisms are transferred from one surface to another whenever one subject touches another.
3. Microorganisms move from one object to another as a result of gravity when one is held above another.
4. Microorganisms are released into the air through droplet nuclei whenever a person breathes or speaks. Coughing
and sneezing increase the number of microorganisms released from the mouth and nose.
5. Microorganisms move slowly on dry surfaces but very quickly through moisture.

ABBREVIATED HANDWASHING PROCEDURE:

This procedure is frequently used during the care of a single patient or when moving from relatively clean tasks to
new tasks. The differences are minimal.
1. Wash well above the writs; washing up to the elbows is not usually necessary.
2. Do not clean nails routinely.
3. Latter and rinse only once instead of twice.

Personal Hygiene
Obviously, in order to enhance medical asepsis, you must practice good personal hygiene. Also, it is much more
pleasant for patient to be near someone who smells fresh and who is wearing a clean uniform. Use the following important
guidelines for personal hygiene:
1. Style hair in such a way that it does not fall forward when you lean forward (as for example, when you examine a
patient). When hair falls over an area, microorganisms can drop from the hair (by gravity) onto the patient, or the
hair itself may fall onto trays wounds. Keep you hair short or restrain it in some way so that it does not fall
forward. Also avoid any style in which you are constantly brushing you hair out of your eyes. Your hair is usually
less clean that your hands because it is not washed as frequently. In addition, if your hands have been
contaminated by contact with a patient, you will transfer microorganisms from them to your hair and near your
face, where they remain until your next shampoo.

HAND WASHING

Handwashing is important in every setting where people are ill, including hospitals, clinics and in the home. It is
considered one of the most effective infection control measures. The goal of handwashing is to remove transient
microorganisms that might be transmitted to the health worker, clients, visitors, or other health care personnel.

Any client may harbormicroorganisms that are currently harmless to the client yet potentially harmful to another person or
to the same clientiftheyfindaportalofentry. It is important that hands be washed at the following times to prevent the
spread of these microorganisms, before eating, after using the bedpan or toilet, and after the hands have come in contact
with any body substances, such as sputum, or drainage from a wound or ones wares and linens. In addition, health care
workers should wash their hands before and after any direct client contact.

For routine client care, the CDC recommends a vigorous hand washing under a stream of water for the least 10 seconds or
longer using bar soap, granules soap antimicrobial liquid soap.

Hands shall be held down (below the elbows) when they are soiled with body substances and during routine handwashing
so that the microorganisms are washed directly into the sink (practice in medical asepsis). For surgical asepsis, the hands
should be held above the elbows so that the water runs from the cleanest to the least clean area. Paper towels are preferred
to dry the hands, discarding them in an appropriate container immediately after use.

Reference: Excerpts taken from: Kozier, Barbara etal. Techniques in Clinical Nursing. 10th
ed. CA: Addison Wesley. 2016.

1
 HANDWASHING
Purposes:
1. To reduce the number of microorganisms in the hands.
2. To reduce the risk of transmission to clients.
3. To reduce the risk of infection among other health care workers.
4. To reduce the risk of transmission of the infectious organisms to oneself.

Equipment:
soap in a soap dish or antimicrobial soap paper squares
orange wood stick (optional) paper lining
clean hand towel (Good Morning towel) paper waste receptacle

The Procedure:
STEPS RATIONALE
1. Prepare and assess the hands. Fingernails should Short nails are less likely to harbor
be kept short. microorganisms, scratch a client or puncture
- Remove wristwatch and roll long sleeves gloves. Long nails are hard to clean.
above wrists.
- Avoid wearing rings, if worn remove Microorganisms can lodge in the settings of
jewelry and under rings. Its removal facilitates
a. Remove all jewelry including the proper cleaning of the hands and arms.
wristwatch and place inside the pocket.

b. Check hands for breaks or cuts in the skin

or cuticle. Report condition to your Open cuts or wounds can harbor high concentration
instructor before beginning ones work. of microorganisms which can be passed on to
Anyone who has open wounds may have to health worker is also high.
change work assignments otherwise one
wears gloves to avoid contact with
infectious material.

c. Check hands for heavy soiling. This will require lengthier handwashing:

d. Roll your sleeves above your elbows. This facilities cleaning of the skin including just
above the elbows.
2.Turn on the water and adjust its flow and Warm water is more effective in removing
temperature. microorganisms than cold water.

Adjusting the water flow helps in conserving the

precious water without affecting the purpose of
medical asepsis.

Avoid splashing water against ones uniform. Microorganisms travel and grow in moisture.
3.Wet the hands thoroughly by holding them under
the running water. Apply soap to the hands. Bar
soap should be rinsed before application.

a. Hold hands lower than the elbows so the Water flows from the least contaminated to the
water flows from the arms to the hands. most contaminated area. The hands are generally
considered more contaminated than the lower arms.

b. Apply soap rubbing it firmly and Initially cleanse the hands before soaping the
vigorously creating plenty of lather in the forearms. Soap cleanses by emulsifying fat and oil
palms, back and wrist and in the and by lowering the surface tension of water.
interdigital areas.

2
 STEPS
c. Rinse soap and return to soap dish.
4. Thoroughly wash and rinse the hands.
a. Repeat 3 b rubbing firmly the palms and
interdigital areas. Use the orange wood
interdigital areas. Use the orange wood
stick to remove dirt in the fingernails.
Rinse orange wood stick before returning.
RATIONALE
 Vigorous rubbing of the skin enhances
mechanical loosening and removal of the
dirt and microorganisms.
 Interlacing fingers and thumbs ensure that
all surfaces are cleansed,
 Areas under the nails can be highly
contaminated, which will increase the risk
of infection for the health worker and the
client.

b. In a circular motion soap forearms and This ensures removal of gross contaminants on the
elbows. Add more soap as needed and skin surface.
create plenty of lather.
Do steps 4a and b for about 10-15 seconds
repeatedly interlacing fingers and rubbing
palms and back of hands with circular
motion no less than 5 times each. Keep
fingertips down to facilitate removal of
microorganisms.

c. Rinse forearms hands and wrist thoroughly,  Rinsing mechanically washes away dirt
keeping hands down and elbows up. and microorganisms.

d. Optional: Repeat steps 4a & b, and extend

period of washing if hands are heavily
soiled.
5. Thoroughly dry the hands and arms.
a. dry hands starting from fingers, to wrist up
to the forearms and elbows with the
washcloth (or paper towels).
6. Turn off the water with dry paper squares or the
paper towel before it is discarded.
- use clean, dry paper towel.
Drying from the cleanest (fingertips) to the least
clean (forearms) avoids contamination. Drying
hands thoroughly prevents chapping and roughened
skin.
 It prevents picking up microorganisms
from the faucet handles.
 Wet paper and hands allow transfer of
pathogens by capillary action.

References :
Potter, P. &Perry A. (2017). Fundamentals s of Nursing.9thed. St. Louis: CV Mosby Co.
Kozier, B. etal. (2016) Techniques in Clinical Nursing.10th ed. Ca: Addision Wesley.
Previous procedures & write-ups.

Revised by: Assoc. Prof. Ramonita M. Nakao, RN MA

Date revised: Summer 2002
Revised by: Asst.Prof.Kathleah S. Caluscusan
Date revised: June 18,2018

3
 HANDWASHING
PERFORMANCE CHECKLIST

CRITERIA SATIS- UNSATIS- REMARKS

FACTORY FACTORY
1. Inspect hands and forearms.
2. Roll sleeves above elbows and removes watch and
jewelries.
3. Turn on water and adjust flow and temperature.
4. Rinse hands holding them lower than elbows
5. Do not touch outside or inside of sink nor splash
water against ones uniform.
6. Apply soap to hands and create plenty of lather,
interlacing fingers and thumbs.
7. Rub hands firmly and vigorously paying attention to
palms, back, wrist and interdigital areas.
8. Rinse forearms and hands allowing water to fall off
from finger tips.
9. Repeat application of soap interlacing fingers and
thumbs and rotary motion to the forearms and elbows.
10. Cleanse fingernails with orange stick.
11. Add more soap while repeatedly rubbing palms,
back , thumbs, wrist, interdigital areas, forearms no less
than 5 times each.
12. Rinse thoroughly keeping hands lower than elbows.

13. Dry hands thoroughly.

14. Turn off the faucet.

Name of Students:______________________ _________________________

Signature of Clinical Instructor
Date:__________________

Comments:

4
 COLLEGE OF NURSING
SillimanUniversity
DumagueteCity

BLOOD PRESSURE

Arterial Blood Pressure –a measure of the pressure exerted by the blood as it flows through the arteries.
There are two blood pressure measures:

a. Systolic pressure – the pressure of the blood as a result of contraction of the ventricles.
b. Diastolic pressure – the pressure when the ventricles are at rest,
the lower pressure present at all times within the arteries.

Pulse Pressure – the difference between the diastolic pressure and the systolic pressure.
Blood pressure is measured in millimeters of mercury (mmHg) and recorded as a
fraction The systolic pressure is written over the diastolic pressure .

120/ 80 mmHg – the average pressure of a healthy adult.

Determinants of Blood Pressure:

A. Pumping action of the heart- when pumping action of the heart is weak, less blood is pumped into arteries (lower
cardiac output) and the blood pressure decreases. When the heart’s pumping action is strong and the volume of blood
pumped into the circulation increases (higher cardiac output), the blood pressure increases.
B. Peripheral Vascular Resistance-peripheral resistance can increase blood pressure especially the diastolic pressure.
Some factors that create resistance in the arterial system are the capacity of the arterioles and capillaries, the
compliance of the arteries and the blood viscosity. Normally, the arterioles are in a state of partial constriction,
increased vasoconstriction raises the blood pressure, decreased vasoconstriction lowers the blood pressure.
C. Blood Volume – when blood volume decreases (hemorrhage, dehydration) the blood pressure decreases because of
decreased fluid in the blood.
D. Blood Viscosity –blood pressure is high when the blood is highly viscous that is, when the proportion of RBC to the
blood plasma is high. This proportion is referred to as hematocrit.Viscosity increases when hematocrit is more than
6to 65%.

Factors Affecting Blood Pressure :

A. Age –The pressure rises with age, reaching peak at the onset of puberty then tends to decline. Older people have
rigid and elastic arteries which produces an elevated systolic pressure.
B. Exercise – physical activity increases cardiac output and so is the blood pressure. So, 20 to 30 mins. After
exercising rest is indicated before resting blood pressure can be assess.
C. Stress – stimulation of the sympathetic nervous system increases cardiac output and vasoconstriction of the
arterioles thus increasing blood pressure.
D. Race – African American males over 35 have higher blood pressure than European American males.
E. Gender – after puberty, females usually have higher blood pressure than males of the same age due to hormonal
variations.
F. Medications –medications may increase or decrease blood pressure.
G. Obesity –both childhood and adulthood obesity predispose to hypertension.
H. Diurnal variation –pressure is lowest in the morning, metabolic rate rises throughout theday and peaks in the late
afternoon or early evening.
I. Disease process – condition affecting cardiac output, blood viscosity have direct effect on the blood pressure.

5
Alterations in Blood Pressure :
Hypertension –a blood pressure that is persistently higher than normal. Usually asymptomatic, often a contributing
factor to myocardial infarction. Classified as :
Primary Hypertension – an elevated blood pressure of unknown cause.
Secondary Hypertension– an elevated blood pressure of a known cause.

Hypotension –a blood pressure that is below normal, systolic reading consistently between 85 and 110 mmHg
in an adult whose normal pressure is higher than this. Orthostatic hypotension is a blood pressure that falls when the client
sits or stands due to peripheral vasodilatation, in which blood leaves the central body organs.

Assessing Blood Pressure :

A. Blood pressure equipment
 Sphygmomanometer – indicates the pressure of the air within the bladder. Consists of a cuff and manometer.
There two types :Aneroid = a calibrated dial with a needle that points to the calibration. .mercury = is a calibrated
cylinder filled with mercury. The pressure is indicated at the point to which the rounded curve of the meniscus rises.

Blood pressure cuff – consists of a rubber bag that can be inflated with air. It is
called the bladder which comes in several sizes which should be proportional to the limb. Note : BP cuff width is
40% of the circumference and bladder should encircle at least 2/3 of the arm.

Stethoscope – an instrument used to listen body sounds. The diaphragm (flat surface) is usually used for blood
pressure taking.

 Show actual stethoscope and identify the parts: earpiece, tubing, chest piece :Bell= smaller in diameter, for
low frequency sound ; Diaphragm = large, flat side for high frequency sound.

B. Blood Pressure Sites

The blood pressure is usually assessed in the client’s arm using the brachial artery. Assessing using
the thigh is indicated on some situations.

C. Methods
Blood pressure can be assessed directly or indirectly.
A. Direct measurement ( invasive monitoring) – involves insertion of a catheter into the brachial, radial or
femoral artery and displayed on an oscilloscope, with highly accurate reading.
B. Indirect ( non-invasive) – are auscultatory method and palpatory method.
b.1 Auscultatory method- used in hospitals, clinics and homes which require
the use of sphygmomanometer, a cuff and a stethoscope. When using the stethoscope the nurse
notes the series of sounds called Korotkoff’s sounds.
b.2 Palpatory method- used when korotkoff’s sounds cannot be heard and electronic equipment to amplify is
not available. In palpatory method the use of light to moderate pressure is use to palpate the pulsations
and pressure is read from the sphygmomanometer when first pulsation is felt.

6
 SILLIMAN UNIVERSITY COLLEGE OF NURSING
DumagueteCity

ASSESSING THE BLOOD PRESSURE (ARM)

Purposes:
1. To obtain a baseline measure of arterial blood pressure (BP) for subsequent evaluation.
2. To identify and monitor changes in pressure resulting from a disease process and medical therapy (e.g.
presence or history of cardiovascular disease, renal disease, circulatory shock, or acute pain, rapid infusion or
blood products).

Equipment:
Stethoscope
A blood pressure cuff of the appropriate size
Sphygmomanometer
PH bag

The Procedure:
STEPS
1. Prepare the client and explain the procedure.
Make sure the client has not exercised, smoked or
ingested caffeine (i.e. coffee, chocolate, tea or its
preparations) within 30 minutes prior to
measurement.
RATIONALE
This reduces anxiety, which can falsely elevate
readings.
Exercise, smoking and ingestion of caffeine can
cause false elevation in BP.

2. Perform the bag technique. After putting on the To prevent the transfer of microorganisms.
apron, take out from the PH bag the following:
Sphygmomanometer
Stethoscope
Plastic bag

3. Position the client appropriately.

In a sitting position with the arm slightly flexed,
the forearm supported at the heart level and the
palm facing up.
Otherwise, a lying position may be assumed.
Be sure room is warm, quiet and relaxing.
4. Expose the upper arm. Ask client not to speak
when BP is being measured.
 The blood pressure is normally similar in
sitting, standing and lying positions, but it
can vary significantly y position in certain
persons and may need to be measured in all
three positions.
 It is important to note readings in positions
other than sitting.
 BP increases when the arm is below the heart
level and decreases when arm is above heart
level.
Talking when BP is being assessed increases
readings 10%-40%.

5. Apply the cuff with its lower border located at  The bladder inside the cuff must be directly
about 2.5 cm above the antecubital space. over the artery to be compressed if the
reading is to be accurate.
 It should be smoothly and evenly applied.

6. Position manometer vertically at eye level.
Observer should be no further than 1 meter
(approximately 1 yard) away.
 Accurate readings are obtained by looking at
the meniscus of the mercury at eye level. The
meniscus is the point where the crescent-
shaped top of the mercury column aligns with
the manometer scale.

STEPS RATIONALE
If this is the client’s initial examination, perform  The initial estimate tells the HW the maximal
preliminary palpatory determination of the pressure to which the manometer needs to be
systolic pressure. elevated in subsequent determination. It also
7

a. Palpate the brachial artery with the
fingertips.
b. Close the valve on the pump by turning the
knob clockwise.
c. Pump up the cuff until you no longer feel
the brachial pulse.
d. Not the pressure on the
sphygmomanometer at which the pulse is no
longer felt.
Release the pressure completely in the cuff and
wait 1 to 2 minutes before making further
measurements.
7. Insert the earpiece of the stethoscope in your ears
so that they tilt slightly forward. Be sure sounds
are clear, not muffled.
Ensure that the stethoscope hangs freely from the
ears to the diaphragm.
8. Relocate the brachial artery and place the
diaphragm of the stethoscope over the brachial
pulse. Use the bell-shaped or diaphragm chest
piece of the stethoscope. The bell-shaped side is
ideal for low sound reception.
9. Close valve of pressure bulb clockwise until tight.
Rapidly inflate cuff to 30 mmHg above palpated
systolic pressure.
10. Slowly release pressure bulb and allow Hg or
needle of aneroid manometer gauge to fall at a
rate of 2-3 mmHg per second.
11. Note point on manometer where first clear sound
is heard. The sound will slowly increase in
intensity.
12. Continue to deflate cuff, noting point at which
muffled or dampened sound appears.
13. Continue to deflate cuff gradually, noting point at
which sounds disappear in adults. Listen for 10-20
mmHg after the last sound and then allow
remaining to escape quickly.
Wait 1-2 minutes before further determinations.
14. Repeat the above steps once or twice as necessary.
STEPS
15. Remove the cuff from the client’s arm.
If this is the client’s initial examination, repeat the
procedure on the client’s other arm.
8
prevents underestimation or overestimation of
the systolic and diastolic pressure in case of
an auscultatory gap.
 The brachial artery is normally found in the
antecubital space.
 At this pressure, the blood can no longer flow
through the artery.
 This give an estimate of the maximum
pressure required to measure the systolic
pressure.
 A waiting period gives the blood trapped in
the veins to be released.
 Sounds are heard more clearly when the ear
attachments follow the direction of the ear
canal.
 Rubbing the stethoscope against an object can
obliterate the sounds of the blood within an
artery.
 Proper stethoscope placement ensures optimal
sound reception. Improperly positioned
stethoscope causes muffled sounds that often
result to false readings.
Tightening of valve prevents air leaks during
inflation. Inflation ensures accurate
measurement of systolic pressure.
If the rate is faster or slower, an error in
measurement may occur.
First Korotkoff sound (Phase 1) indicates the
systolic pressure.
Fourth Korotkott sound (Phase 4) involves
distinct muffling of sounds.
Beginning of the 5thKorotkoff sound (Phase 5) as
an indication of diastolic pressure in adults.
 This permits blood trapped in the veins to be
released.
 To confirm accuracy of readings.
RATIONALE
 If there is a difference, it should be no more
than 10 mmHg between the arms.
 16. Assist the client to assume a comfortable position
and cover the upper arm if it was previously
clothed.
17. Place the BP apparatus and stethoscope in a
section of the paper lining.
18. Discuss findings with client and do the health
teachings as needed.
19. Wash hands. Continue with the bag technique.
Place the BP apparatus and stethoscope in a
plastic bag. Return them into the PH bag.
20. Chart the blood pressure findings according to
agency policy.
21. Report any significant changes in the client’s BP
to either your C.I. and/or the doctor.
 The arm found to have the higher pressure
should be used for subsequent examination.
 Restore comfort and promote a sense of well-
being.
 Avoid contaminating the rest of the materials
in the bag, including the cloth lining.
 Promote client in one’s own care and
understanding one’s health status.
Reduce the transfer of microorganisms. The cuff
of the BP apparatus and the stethoscope have to
be air dried upon reaching the dorm or home for
at least an hour.
Record the date and time of assessment. Record
two pressures in the form of “130/80” where the
numerator is the systolic reading (Phase 1) and
the denominator is the diastolic reading (Phase
5). Use the abbreviations RA for right arm and
LA for left arm.
Report finding like:
a. systolic BP (of adult) above 140 mmHg
b. diastolic BP (of adult) above 90 mmHg
c. systolic BP (of adult) below 100 mmHg

References:
Kozier, B. et.al(2017) . Techniques in Clinical Nursing.9th ed. Ca: Addison-Wesley Co.
Porter, P. and Pery,(2016)A. .Fundamentals of Nursing. 10th ed. St. Louis: CV Mosby Co.

Prepared by:
Prof. Ramonita M. Nakao, RN MA
Date: Summer 2005

Revised by:Asst. Prof. Kathleah S.Caluscusan

Date: 1st sem 2018

9
 BP TAKING
Performance Checklist

CRITERIA SATIS- UNSATIS- REMARKS

FACTORY FACTORY
1. Place PH bag in a table lined by a newspaper.

2. Explain procedure to patient.

3. Perform the bag technique.

4. Wash hands. Put on apron.

5. Put out needed equipment as:

Stethoscope BP apparatus Plastic bag
6. Place patient in comfortable position with forearm
supported and palm upward.
7. Place self so that meniscus of mercury can be read at
eye level, and no more than 3 feet away.
8. Place cuff so inflatable bag is centered over brachial
artery (lies midway between anterior and medical
aspect of arm) so that the lower edge of cuff is 2 cm
above antecubital fossa.
9. Wrap cuff smoothly around arm and tucks end
securely.
10. Use finger tips to feel for pulsation in antecubital
space.
11. Place stethoscope where pulsation in noted.

12. Pump bulb of manometer until Hg rises to

approximately 30 mm above point of anticipated
systolic pressure.
13. Use valve of bulb, release air 2-3 mm per heartbeat
and notes point at which first sound is heard.
14. Continue to release air in cuff evenly and gradually.

15. Note reading on manometer when last distinct loud

sound is heard.
16. Allow remaining air to space quickly and remove
cuff.
17. Do after care of equipment.

18. Wash hands.

19. Continue with the bag technique.

20. Discard paper lining and waste receptacle with

technique.
21. Record the BP findings.

Name of Student: ____________________________ ______________________________

Date: __________________ Signature of Clinical Instructor

Remarks:

10
 COLLEGE OF NURSING
SillimanUniversity
DumagueteCity

TEMPERATURE, PULSE AND RESPIRATION RATE

The taking of TPR rate is important because it serves as an indicator of patient’s status. Most
institution have routine tines of taking TPR rate, often q 4h (every 4 hours) but a patient’s illness or
certain other conditions may indicate more frequent measurement. For example, you would make an
independent nursing decision to take the temperature of a flushed patient who complains of feeling warm.
Routine TPR is usually taken on a number of patients at one time, and the readings are recorded on paper
at the bedside. These readings are transcribed either to a central clipboard at the nurse’s station or directly
on the graphic record in the patient’s chart.

TEMPERATURE

Body temperature shows the balance between heat produced and heat lost by the body. It is
surprisingly consistent in healthy individuals, that is, a normal oral reading is 98.6 degrees Fahrenheit
(98.6oF) or 37 degrees Celsius (37oC) (sometimes called centigrade). Many factors---time of day, age,
presence of infection, temperature of the environment, amount of exercise, metabolism and emotional
status can raise or lower a patient’s temperature. If a patient has been drinking liquids that are either hot
or cold, delay taking the patient’s temperature for at least 30 minutes.

If the temperature is elevated, the patient is febrile, that is, has a fever. Depending on the
fluctuations of the temperature, it can be described as remittent or intermittent.

PULSE

Pulse rate varies greatly among adults. The American Heart Association states that a normal adult
pulse rate may be 60 to 100 beats per minute. Also, the pulse rate can increase or decrease as a result of
changes in the body temperature. Exercise, the application of heat or cold, medications, emotions,
hemorrhage, and heart disease can all affect pulse rates as well. The term bradycardia describes an adult
pulse rate below 60 beats per minute; tachycardia refers to an increase pulse rate above 100 beats per
minute.

RESPIRATION

All the factors that affect pulse rate will also cause the respiratory rate to vary. Normal adults
breathe 16 to 20 times per minute. The rate as well as the rhythm may change when the patient is
suffering from respiratory disorders. Also, the sides of the chest may not rise and fall symmetrically. Any
difficulty in breathing is called dyspnea.

It is best to count respirations after taking the pulse. By using this sequence, you can keep your
fingers on the patient’s wrist and place the patient’s arm across his or her chest. The patient should be
unaware that you are doing another procedure and thus will continue to breathe naturally. Feeling the rise
and fall of the patient’s chest, you can count for the required 30 seconds. Multiply the result by 2 to
determine the rate for a full minute. If the patient’s respiration is very irregular, you may choose to count
for a full minute for accuracy.

Don’t forget to record the patient’s breathing characteristics.

Revised 1st sem. 2018

11
 TEMPERATURE TAKING
Definition: A method of checking a client’s temperature ensuring that the thermometer is kept clean.

Purpose:
1. To check the client’s temperature and note any significant result.
2. To maintain the cleanliness of the thermometer so as to prevent the transfer of infection from one
person to another.
3. To protect the other contents of the PH bag by maintaining the cleanliness of the thermometer.

Equipment:
The PH bag if a rectal temperature is considered, add to the equipment a pair of gloves.
Lubricant

The Procedure:

STEPS RATIONALE

1. Identify the client and explain the procedure. For oral To prepare the client and be relieve of anxiety.
temperature, determine the time of last intake of any hot Allow 20-30 minutes to pass before assessing
or cold food or fluids or smoked. the temperature orally.

To prevent transfer of infection.

2. Perform the Bag Technique.

3. After putting on one’s apron, bring out the following

from the bag into the cloth lining:
 the appropriate thermometer to use;
 bottle of 70% Isopropyl alcohol;
 container of dry cotton balls;
 kidney basin;
 waste receptacle outside of paper lining.
Differences in thermometer types:
 a round bulb – for rectal temperature.
 long tip – for oral/axillary temperature.
 bringing out all necessary supplies
needed can both save time and avoid
contamination of the bag contents.

4. Prepare 7-9 dry cotton balls and lay them inside the
It reduces contamination of the bulb.
kidney basin.

5. Remove thermometer from its container

To maintain the cleanliness of the bulb.
6. With a cotton ball, wipe the thermometer in a rotating
motion. Discard used cotton ball.

8.A. For Oral Temperature
8.A.1. Ask client to open mouth. Place the
thermometer at the base of the tongue to the
right or left of the frenulum, in the posterior
sublingual pocket.
STEPS
8.A.2. Ask the client to close the lips (not the teeth)
around the thermometer.
 The thermometer should reflect the core
temperature of the blood in the larger blood
vessels of the posterior pocket.
RATIONALE
 A client who bites the thermometer can
break it and injure the mouth.
 This is the proper position of the
thermometer.

8.A.3. Leave the thermometer for 3-5 minutes.  The client has to be cautioned against
prematurely removing the thermometer to
read results for curiosity.

12
8.B. For Axillary Temperature
8.B.1. Expose the client’s axilla.
8.B.2. If axilla is moist, pat it dry using the client’s
towel.
8.B.3. Place the thermometer at the center of the
client’s axilla.
8.B.4. Assist the client to place the arm tightly across
the chest to keep the thermometer in place.
8.B.5. Leave thermometer in place for 9 minutes; for
infants – 5 minutes.
8.B.6. Remain holding the thermometer in place if
the client is irrational or is very young.
8.C. For Rectal Temperature
8.C.1. Put on gloves.
8.C.2. Place some lubricant on a cotton ball. In a
rotating motion, lubricate the thermometer up
to 2.5 cm (1 inch) from the bulb.
8.C.3. Provide privacy before draping the patient to
expose the buttocks.
8.C.4. Assist the client to assume a lateral position. A
newborn can be placed in lateral or prone
position; a young child in a lateral position
with knees flexed or in prone position across
the lap.
8.C.5. Ask the client to take a deep breath; lifting the
buttocks with the non-dominant hand, insert
the thermometer into the anus 1.5 cm to 4 cm
(0.5 to 1.5 inches) depending on the age of
Client.
STEPS
8.C.6. Hold the thermometer in place for 2 minutes
for adults and 5 minutes for a neonate.
9. After the designated length of time of assessment,
remove the thermometer. Wipe the thermometer in a
rotating manner from the stem to the bulb. Discard cotton
ball.
13
 Move clothing or gown away from shoulder
and arm.
 Friction created by rubbing can raise the
temperature of the axilla.
 Maintains proper position of the
thermometer
 Studies differ as to the appropriate length of
time for registering the temperature of the
body.
 For safety of the client.
 This is the standard precaution to protect
the caregiver from any infectious agents.
 The lubricant facilitates insertion of the
thermometer without irritating the mucous
membrane.
 Privacy reduces client’s embarrassment and
ensures one’s cooperation.
 Positioning facilitates in the assessment of
the client.
 Taking a deep breath relaxes the external
anal sphincter muscle, thus easing the
insertion.
Insertion is:
Infants – 1.5 cm (0.5 inches)
Child - 2.5 cm (0.9 inches)
Adult - 3.7 cm (1.5 inches)
Do not force insertion of the thermometer in a
newborn. This may indicate the absence of a
rectum.
RATIONALE
 Ensure that the bulb is in its proper place.
This prevents injury to the client.
 Hold the young child firmly while the
thermometer is in the rectum.
 The thermometer is wiped from the area to
the least contamination to the greatest
contamination.
 10. Read the temperature.  Hold thermometer at eye level .

11. Place the used thermometer in the waste receptacle as

need arises.

After Care of the Thermometer:

12. Bring to the washing area the following:
 Used thermometer
 2-3 cotton balls
 Soap in a soap dish  Create a good lather and rub well the
Cleanse thoroughly the thermometer with soap and water thermometer
using the cotton balls.  Ensure that any organic matter is
thoroughly cleansed in the process.

13. Return to your set-up and dry the thermometer using a

cotton ball. Discard. Remove ones gloves if using it.

14. Saturate 2-3 cotton balls with 70% alcohol and wrap it Stretch the cotton balls to make it pliable to
around the thermometer. Let this stay for awhile inside accommodate the length of the thermometer.
the kidney basin

15. Continue with your health teachings related to the

procedure.
In case the thermometer is wet – dry this using
16. Remove the used alcohol and cotton balls. Return a cotton ball.
thermometer into its case.

17. Continue with the bag technique.

18. Document findings as needed.
19. Set your appointment for the next visit.
References: Reyala, J, et al. (2000). Community Health Nursing in the Philippines. Department of
Health. 9th ed. Mla: DOH –MLGN.
Kozier, B. et al. (2016). Techniques in Clinical Nursing. 10th ed. Ca.: Addison Wesley Co.
Potter, P.& Perry, A. (2017).Fundamental of Nursing. 9th ed. St. Louis:CV Mosby

Prepared by: Prof. Ramonita M. Nakao, RN MA

Date: Summer 2002
REVISED by: Asst.Prof.Kathleah S. Caluscusan
Date: 1stsem 2018

14
 TAKING THE TEMPERATURE
PERFORMANCE CHECKLIST
CRITERIA SATIS- UNSATIS- REMARKS
FACTORY FACTORY
1. Place bag on table lined with paper.

2. Explain procedure to the patient.

3. Spread cloth lining.

4. Wash hands.

5. Put on apron.

6. Take out from the bag needed articles appropriate for

the care.

7. Place 7-9 dry cotton balls in the kidney basin.

8. Remove thermometer from its case .

9. Wipe thermometer with a cotton ball in a rotating

motion.

A. Oral Temperature
A.1 Place thermometer under patient’s tongue.

A.2 Instruct patient to close mouth and other

safety tips.

A.3 Leave in place for 3-5 minutes.

B. Axillary Temperature
B.1 Expose the client’s axilla and pat dry if
moist.

B.2 Place thermometer at the center of the axilla.

B.3 Place arm across the chest

B.4 Leave thermometer in place for 9 minutes

for adults; 5 minutes for infants.

B.5 Hold thermometer in place for special

patients.

C. Rectal Temperature
C.1 Put on gloves

C.2 Lubricate thermometer up to 1 inch above

the bulb.

C.3 Provide privacy.

15
 CRITERIA SATIS- UNSATIS- REMARKS
FACTORY FACTORY

C.4 Position patient and drape

C.5 Insert thermometer according to length.

C.6 Hold thermometer in place for 2 minutes for

adults; 5 minutes for an infant

10. Remove thermometer and wipe in rotating motion

from the stem towards the bulb.

11. Read at eye level.

12. Set aside used thermometer in the waste receptacle as

need arises.

13. Bring soap dish, 2-3 cotton balls and used

thermometer to washing area.

14. Cleanse thermometer well with soap and water.

15. Dry thermometer with a cotton ball. (Remove gloves

if using any).

16. Disinfect thermometer wrapping it with 2-3

alcoholized cotton balls: set aside inside the kidney
basin.

Following the health teachings of the client…

17. Wash hands.

18. Return thermometer into its case.

19. Return equipment into the bag.

20. Remove apron and fold.

21. Return handwashing equipment and cloth lining.

22. Lift bag and discard paper lining and waste

receptacle.

23. Document findings as needed.

Revised by: Prof. Ramonita M. Nakao

Date: June 10, 2002
Revised by: Asst.Prof.Kathleah S. Caluscusan
Date: 1stsem 2018

16
 COLLEGE OF NURSING
SillimanUniversity
DumagueteCity

ASSESSING A PERIPHERAL PULSE

Definition: A peripheral pulse is one which is located in the periphery of the body like the hand,
temple, and foot.

Purposes:
1. To identify whether the pulse rate (PR) is within normal range.
2. To identify whether the pulse rhythm is regular and the pulse volume is appropriate.

Equipment:
PH bag contents Wrist watch with a second hand

Procedure:

STEPS RATIONALE

1. Identify the client and explain the procedure. This is To prepare the client and be relieved of anxiety.
usually done with temperature taking.
For accuracy of findings.
Ensure that the client is calm and quite 10-15 minutes before
PR assessment.
To relax the client.
2. Assist the client to a comfortable supine position or to a
sitting position on a chair or at the edge of the bed.

3. Perform the bag technique. Keep your wristwatch in To prevent the transfer of infection.
place after putting on the apron.

4. Select the pulse point. Normally, the radial pulse is taken.

Rest the arm along side the body with the palm facing
down if client is supine.

Or the forearm can also rest at 90o angle across the chest
with palm downward (in supine position).
To achieve a relaxed position.
Or if client is sitting up, the forearm can rest across the
thigh, with the palm facing downward or inward or on
top of the table.
Using the thumb is contraindicated because it
5. Place two or three middle fingertips lightly and squarely has a pulse that the health worker could
over the pulse point.
mistaken for the client’s pulse.

Period of observation of the pulse’ regularity

6. Observe for the first minute the regularity of the pulse. If may be extended depending upon the
it is regular, count for 30 seconds and multiply by 2. If assessment by the health worker. Regularity of
irregular, count for one full minute. the pulse refers to the time interval between
each beat.

A normal pulse can be felt with moderate

7. Note the pulse rhythm and volume. pressure, and the pressure is equal with each
beat.
A forceful pulse volume is full. One that you
can obliterate is a weak pulse.

17
 STEPS RATIONALE

8. After obtaining the PR and the RR, proceed to wash your To reduce contamination of one’s hands.
hands.

9. Continue with your bag technique and discard waste Done for aesthetic reasons too.
receptacle and paper lining.

10. Record accordingly. Note the time of procedure, the rate, rhythm
and volume of the pulse assessed.

11. Set your appointment for the next visit.

References:
Kozier, B et. al. 2016.Techniques in Clinical Nursing. 10th ed. Ca.: Addison-Wesley Co.
Potter, P. and Perry, A. 2017.Fundamentals of Nursing. 9th ed. St. Louis: CV Mosby Co.

Prepared by: Prof. Ramonita M. Nakao, RN MA

Date: Summer 2002
Revised by: Asst.Prof.Kathleah S. Caluscusan
Date: 1st sem.2018

18
 COLLEGE OF NURSING
SillimanUniversity
DumagueteCity

ASSESSING RESPIRATION
Purposes:
1. To acquire baseline data against which future measurements can be compared.
2. To monitor abnormal respiration and identify changes.
3. To assess respiration before the administration of a medication such as morphine (an abnormally slow
respiratory rate (RR) may warrant withholding the medication).
4. To monitor respiration following the administration of a general anesthetic or any medication that
influences respiration.
5. To monitor clients at risk for respiratory alternations (e.g., those with fever, pain, acute anxiety, chronic
obstructive disease, respiratory infection, pulmonary edema, chest injury, brain and skin injury).

Equipment:
PH bag Wrist watch with a second hand

The Procedure: Usually the RR is obtained together with the temperature and pulse rate
determination procedures.

STEPS RATIONALE

1. Determine the client’s activity schedule. As need arises, One who has been exercising, climbing the
ask the client one’s activities within the 15 minute period stairs or walking will need to rest for a few
when the procedure is to be performed. minutes to permit the accelerated RR to return
to normal.

 An infant or child who is crying will

have an abnormal RR and will need
quieting before the accurate assessment of
the respiration can be made.
2. Perform the bag technique. Keep your wristwatch in
place after putting on the apron.

3. Assist the client into a comfortable sitting or supine

position as preferred. To ensure a relaxed client.

4. Place the client’s arm across the chest and observe the
chest movements, while supposedly taking the radial
pulse. For young
children, observe the rise and fall of the abdomen.
5. Use the first 60 seconds (a full minute) to observe the
characteristics of the client’s respiration.
6. Count the RR for 60 seconds or a full minute.
7. Observe the respiration for:
a. Depth by watching the movement of the
chest.
Awareness of the client on the RR assessment
could cause one to voluntarily alter the
respiratory pattern. Children are diaphragmatic
breathers.
Note the depth, rhythm and character of the
respiration.
An inhalation and exhalation counts as one
respiration.
During a deep respiration, a large volume of air
is exchanged; during a shallow respiration, a
small volume is exchanged.

19
 STEPS RATIONALE

b. Rhythm Normally, respirations are evenly spaced

regular rhythm); otherwise, it could be
irregularor unevenly spaced.

c. Character of the respiration – the sound they Normal respiration are silent and effortless.
produce and the effort they require.

8. After obtaining the RR, gather the handwashing Prevent the transfer of microorganisms.
equipment and wash hands.

9. Continue with the bag technique and discard the paper Dispose these materials in the appropriate
lining and the waste receptacle. containers.

Record the rate, rhythm, depth, and character of

10. Document the RR, depth, rhythm and character in an
the respirations.
appropriate record.
Report/refer RR which is significantly above or
below the normal range, an irregular respiratory
rhythm, inadequate depth or abnormal character
– wheezing, rales, stridor, etc. or any
complaints of dyspnea.

References:
Kozier, B et. al. 2016.Techniques in Clinical Nursing. 9th ed. Ca.: Addison-Wesley Co.
Potter, P. & Perry, A. (2017).Fundamental of Nursing. 10th ed. St. Louis: CV Mosby.

Prepared by:Prof. Ramonita M. Nakao, RN MA

Date: Summer 2002
Revised by: Asst. Prof.Kathleah S. Caluscusan
Date: 1st sem.2018

20
 PULSE AND RESPIRATION
PERFORMANCE CHECKLIST
CRITERIA SATIS- UNSATIS- REMARKS
FACTORY FACTORY
Radial Pulse

1. Place the PH bag in a paper lined table.

2. Explain procedure.

3. Do the bag technique, put on an apron and

wristwatch.

4. Position comfortably.

5. Place the arm across the chest (if supine) or over the
thighs or on the table (if sitting up).

6. Place two or three middle fingertips against the radial

artery.

7. With light, gentle pressure, feel and observe the pulse

characteristics.

8. Count for one full minute.

9. Wash hands.

10. Continue with the bag technique.

11. Discard the paper lining and waste receptacle.

12. Document/record ones findings.

Respirations

1. With the fingers still in place after taking the PR,

relax the gentle pressure and note the characteristics
of the patient’s respirations.

2. Count for 6o seconds the rise and fall of the patient’s

chest.

3. Wash hands.

4. Continue with the bag technique.

5. Lift bag and discard paper lining and waste

receptacle.

6. Document/record ones findings.

__________________________________ _________________________________
Name of Student Signature of Clinical Instructor

Date: _____________________

21
Comments:
HEALTH HISTORY

I. Biographical Data

Name of Client: Address:

Age: Date of Birth: Tel. No.:
Sex: Marital Status: Occupation:
Source of Information: Religious Affiliation:
Date and Time History was Taken: Ethnic Group/Race:

II. Chief Complaint(s)/Reason(s) for Seeking Health Care:

III. History of Present Illness:

IV. Past Health History:

Childhood Illness:
Accidents/Injuries:
Serious or Chronic Diseases:
Hospitalizations:
Operations:
Obstetric History:
Immunizations:
Last Exam Date (Dental, Vision, Hearing, EKG, Chest x-ray)
Allergies:
Current Medications:
Habits and Lifestyles:
Recent Travel:

V. Family History (Use Genogram):

VI. Personal and Social History:

VII. Review of Systems (Subjective Data):

1. General Overall Heath State:

2. Skin/Hair, Nails:
3. Head:
4. Eyes:
5. Nose/Sinuses:
6. Ears:
7. Mouth and Throat:
8. Neck:
9. Respiratory System:
10. Cardiovascular:
11. Peripheral Vision:
12. Gastrointestinal:
13. Urinary:
14. Genital/Sexual Health:
15. Musculoskeletal:
16. Neurologic:
17. Hematologic:
18. Endocrine:

22
 COLLEGE OF NURSING
SillimanUniversity
DumagueteCity

REVIEW OF SYSTEMS
A. General: Usual weight, recent weight change, any clothes that fit tighter or looser than before, weakness,
fatigue, fever.

B. Skin: Rashes/lumps, sores/itching, dryness, color change, changes in hair or nails.

C. Head: Headache, head injury

D. Eyes: Vision, glasses or contact lenses, last eye examination, pain, redness, excessive tearing, double
vision, blurred vision, spots, specks, flashing lights, glaucoma, cataracts.

E. Ears: Hearing, tinnitus, vertigo, earaches, infection, discharges, use of hearing aids.

F. Nose and Sinuses: Frequent colds, nasal stuffiness, discharge or itching, hay fever,
nosebleeds, sinus trouble.

G. Mouth and Throat: Conditions of teeth and gums, bleeding gums, dentures (if any), last
dental examination, sore tongue, dry mouth, frequent sore throat, hoarseness.

H. Neck: Lumps, “swollen glands”, goiter, pain or stiffness in the neck.

I. Breasts: Lumps, pain or discomfort, nipple discharge, self-examination.

J. Respiratory: Cough, sputum (color, quantity), hemoptysis, wheezing, asthma, bronchitis,

emphysema, pneumonia, tuberculosis, pleurisy, last x-ray film.

K. Cardiac: Heart trouble, high blood pressure, rheumatic fever, heart murmurs, chest pain of discomfort,
palpitations, dyspnea, orthopnea, edema, past Electrocardiogram or other heart results.

L. Gastrointestinal: Trouble swallowing, heartburn, appetite, nausea, vomiting,

regurgitation, vomiting of blood, indigestion, frequency of bowel movements, constipation,
diarrhea, abdominal pain, food intolerance, excessive belching or passing of gas, jaundice, liver or
gallbladder trouble, hepatitis.

M. Urinary: Frequency of urination, polyuria, nocturia, burning pain on urination, hematuria, incontinence,
urinary infections, stones.

N. Genital:
Males: Hernias, discharge from or sores on the penis, testicular pain or masses, history of sexually
transmitted disease (STD) and their treatments, sexual problems.

Females: Age of menarche, regularity and duration of periods, amount of bleeding, bleeding between
periods or after intercourse, last menstrual period, dysmenorrhea, age of menopause,
menopausal symptoms, postmenopausal bleeding, discharge, itching, sores, lumps, STD
and their treatment, number of pregnancies, number of deliveries, number of abortions
(spontaneous and induced), complications of pregnancy, birth control methods, sexual
problems including dyspareunia.

O. Musculoskeletal: Muscle or joint pains, stiffness, arthritis, backache, if present describe location and symptoms
(swelling, redness, pain, tenderness, stiffness, weakness, limitation of motion or activity).

23
 COLLEGE OF NURSING
SillimanUniversity
DumagueteCity

PHYSICAL ASSESSMENT CHECKLIST

PA CHARTING
U S U

S
PREPARATION:
1. Proper explanation given.
2. Adequate light provided.
3. Appropriate attire provided.
4. Ask the patient to empty bladder.
GENERAL SURVEY:
1. State of awareness.
2. Obvious signs of distress, pain, anxiety.
3. Gait.
4. Posture.
5. Body movements.
6. Hygiene/grooming, odor.
7. Speech.
8. Mood and affect.
VITAL SIGNS/MEASUREMENTS:
1. Temperature
2. Pulse
3. Respirations
4. Blood Pressure
5. Height
6. Weight
INTEGUMENTARY SYSTEM
1. Skin – A) Inspect
a.1 color
a.2 lesions
a.3 edema
B) Palpate
b.1 mobility/turgor
b.2 texture
b.3 temperature
2. Nails – A) Inspect
a.1 color
a.2 thickness
a.3 shape
a.4 angle
HEAD
1. Inspection – Separate hair with use of comb and check scalp for
presence of nits, dandruff, scaliness; assess hair for
quantity, distribution, texture.
2. Palpate for lesions, deformities, lump.
FACE
1. Inspect
A. Contour
B. Symmetry
C. Involuntary movements
D. Edema
2. Palpate – masses

24
 PA CHARTING
U S U

S
EYEBROWS
1. Inspect – quantity, scaliness
2. Palpate – masses
EYES
1. Visual Acuity – Instruct client to wear eyeglasses if he/she has
One
A. Near Visual Acuity - Instruct client to read a printed material about one
foot away.

B. Far Vision – Snellen’s Test

b.1 measure 20 feet distance from Snellen’s Chart

b.2 instruct client to cover one eye with opaque material

b.3 let client read letters in Snellen’s Chart

b.4 repeat procedure with other eye

b.5 repeat procedure with both eyes

b.6 note and record findings

2. Conjunctiva and Sclera

A. Depress lower lid with thumb or index finger

B. Inspect for color, swelling, nodules

C. Instruct client to look up

NOTE: Upper eyelid can be everted prn.

3. Cornea and Lens

4. Pupils

A. Inspect size, shape, equality

B. Test for direct reaction and consensual reaction

b.1 room is dimly lit

25
 b.2 let client look straight ahead

b.3 shine light from side of face (do not let client look at the
light)

b.4 observe for constriction of pupil on the examined eye

(direct reaction)

b.5 observe for constriction of pupil of the opposite eye

(consensual reaction)

b.6 repeat procedure with the other eye.

5. Accommodation/Convergence

A. Let client gaze at a distant object (e.g. the far wall)

B. Observe size of pupil and position of eyes

C. Let client transfer gaze to a near object ( about 10 cm. or 4

Inches away from bridge of client’s nose)

c.1 observe for constriction of pupils as gaze is transferred.

c.2 observe for convergence of eyes as gaze is transferred.

6. Extraocular Movements

A. Let client sit or stand 2 feet away from examiner at eye

level.

B. Instruct client to keep head steady and follow movements of

Finger or object with eyes only.

C. Move object in 6 directions of gaze.

D. Observe for parallel eye movement and presence of abnormal eye

movement.

7. Eyelids

A. Inspect position, edema, color

B. Ask client to open and close eyes (adequacy of closure)

C. Palpate for masses

26
 PA CHARTING
U S U

S
EARS
A. Inspect for deformities, size, alignment

B. Palpate for nodules.

C. Grasp auricle upward and backward for adults. For pediatrics

Grasp auricle downward and backward.

D. Use penlight to check auditory canal

E. Check auditory canal for color, discharges

F. Check for auditory acuity (whisphered voice or ticking of

watch)

f.1 instruct client to occlude one ear with his/her finger

f.2 examiner stays 1-2 feet away

f.3 examiner covers mouth or stays behind client

f.4 whisper words to the unoccluded ear. Words should

have equally accented syllabus (e.g. nine-four-ten)

f.5 let client repeat words

f.6 repeat steps f.1.1 to f.1.5 with other ear

NOSE
A. Inspect external structures for
a.1 symmetry
a.2 deformity

a.3 shape

a.4 size

B. Palpate
b.1 tenderness

b.2 nodules

C. Examine internal structure

c.1 tilt client’s head

27
 c.2 put thumb at tip of nose

c.3 uses penlight to check the following:

c.3.1 nasal mucosa – color, swelling, exudates, bleeding

c.3.2 nasal septum – deviation, bleeding, perforation

c.3.3 inferior and middle turbinates – color, swelling,

exudates, polyp

SINUSES:
A. Instruct client to look down

With the use of thumb, palpate both frontal sinuses. Note for \Tenderness

B. Using thumb, palpate maxillary sinuses at side of nose. Note for

tenderness

MOUTH
A. Put on gloves

B. Lips
b.1 inspect for color, cracking, ulcers

b.2 palpate for lumps

C. Gums/Buccal Mucosa
c.1 uses tongue depressor to gently push out cheek on one
side
c.2 uses penlight to inspect for bleeding, discoloration,
growth

c.3 repeats step c.1 – c.2 on other side

PA CHARTING
U S U

S
D. Teeth
d.1 uses tongue depressor

d.2 let client open mouth

d.3 inspect for missing teeth, loose teeth, extraction, caries,

abnormal shape and position

E. Roof of Mouth (Hard Palate)

e.1 Inspect for color, architecture, deformities

F. Tongue
f.1 Inspect dorsum – color, papillae, texture

f.2 Instruct client to stick tongue out and move tongue from
side to side

28
 f.3 Inspect for size, symmetry

f.4 Instruct for client to raise tongue. Inspect floor of mouth

PHARYNX
A. Place tongue depressor on middle third of tongue

B. Instruct client to say “Ah” and inspect for rise of soft palate

C. Inspect for the following:

a. color

b. symmetry

c. discharge

d. ulcerations

e. enlargement of tonsils

f. alignment and characteristics of uvula

NECK
A. Symmetry

B. Scars

C. Growths

D. Enlargement of parotid glands

E. Palpate for lymph nodes using pads of fingers

e.1 occipital

e.2 post-auricular

e.3 pre-auricular

e.4 tonsilar

e.5 submandibular

e.6 submentum

29
 e.7 cervical (deep, superficial)

e.8 supraclavicular

TRACHEA
- Inspect for the following
A. alignment
B. deviation

THYROID GLAND
Posterior Approach
A. Stand behind client
B. Ask client to tilt head slightly forward

C. Ask client to move head to one side (e.g. right side)

C. With client’s head tilted to the right, use left hand to move
Thyroid cartilage to the right

D. Palpate thyroid gland with right hand

E. Ask client to swallow and check for thyroid enlargement

F. Repeat procedures on other side and reverse position of hands

NOTE: Anterior approach may also be used

PA CHARTING
U S U

S
POSTERIOR CHEST
1. Draping: Expose posterior chest

2. Position: Arms across chest

3. Inspect/observe:
a. rate of respiration

b. rhythm of respiration

c. depth of respiration

d. effort/use of accessory muscles

e. shape of chest

f. Symmetry

30
 4. Palpate for:
a. Masses

b. Tenderness

5. Respiratory Excursion
a. Place both thumbs along spinal processes at the level of
T10 on both sides. Thumbs should be 2 inches apart
b. Palms of both hands should be lightly contacting the
posterolateral surfaces on either side

c. A small skinfold should appear between the thumbs

d. Instruct client to take deep breaths

e. Note symmetrical movements of thumbs

6. Tactile Fremitus – May use one hand of both hands

a. Place ball or lower palm of hands over symmetric
intercostal spaces starting at apex of lung going down to
the base
b. Let client say “one-one-one” or “ninety-nine”

c. Note the degree of vibration at different parts of chest

7. Percussion
a. Use correct percussion technique

b. Percuss using the correct sequence

c. Identify the percussion notes/ tones

8. Auscultation
a. Let client take deep breaths while auscultating lung

b. Auscultate lung using correct sequence

c. Identify the breath sound heard

ANTERIOR CHEST
1. Draping: Expose anterior chest

2. Position: Hands at side

3. Inspect/observe the following:

a. rate of respiration

b. rhythm of respiration

c. depth of respiration

31
 d. effort/use of accessory muscles

e. symmetry

f. shape of chest

4. Palpate for:
a. tenderness

b. masses

5. Tactile Fremitus – may use one hand or both hands

a. Place ball or lower palm of hands over symmetric
intercostals space starting at apex of lungs going down to
the base

PA CHARTING
U S U

S
b. Let client say “one-one-one” or “ninety-nine”

c. Note the degree of vibration at different parts of chest

6. Percussion
a. Use correct percussion technique

b. Percuss chest using correct sequence

c. Identify percussion notes/tones

7. Auscultation
a. Let client take deep breaths while auscultating lungs

b. Auscultate using correct sequence.

c. Identify the breath sound heard.

8. Heart Sounds (S1 S2)

a. Locate area where S1 is louder than S2 at 5th ICS LMCL

b. Auscultate the 1st heard sounds (S1)

c. Locate the 2nd ICS right sternal border.

d. Locate the 2nd ICS left sternal border.

e. Auscultate heart sound on areas c and d where S2 is

louder than S1.

32
BREAST
1. Draping: Expose anterior chest

2. Position: Standing/Sitting
3. Inspect both breast for:
a. size
b. symmetry

c. color

d. dimpling/retractions

e. contour

f. rashes/lesions

4. Inspect both nipples for:

a. color

b. size

c. lesions/cracks

d. direction in which they point

e. discharges

5. Hands at waist
a Inspect as in 2a and 2b

6. Hands over head or behind neck

a. Inspect as in 2a and 2b

7. Palpation
a. Let client lie on supine position

b. Instruct client to put hands behind neck on the side to be

examined. Place rolled towel under shoulder as necessary.

c. Palpate breast using appropriate technique

d. Palpate the tail of spence

e. Palpate for infraclavicular nodes

f. Repeat steps a-e on the other breast

AXILLA
- Inspect for:
a. rashes

33
b. growth

c. odor

- Palpate for:
a. nodules
NOTE: repeat steps in inspection and palpation on the other
Axilla

PA CHARTING
U S U

S
ABDOMEN
1. Draping: Expose from xiphoid process until below symphysis
Pubis
2. Identify the quadrants

U U S

S
3. Identify the nine regions

4. Position: Client on supine position with knees flexed or with

Pillow under knees

5. Inspect for the following:

A. scars

B. striae

C. rashes/lesions

D. contour

E. symmetry

F. at eye level inspect for:

f.1 pulsation

f.2 visible peristalsis

6. Auscultation
A. Warm stethoscope with palm of hand

B. Auscultate for bowel sounds

b.1 in all quadrants

34
 b.2 count bowel sounds for one minute at RLQ

b.3 auscultate for bruit near umbilical area as necessary

7. Percussion
A. Use correct percussion technique

B. Percuss abdomen by quadrants

C. Identify percussion notes/tones

D. Percussion of liver
d.1 Start at 2 fingerbreadths below right 5th ICS MCL

d.2 Percuss going down using correct percussion

technique

d.3 Marks with a pen the point when percussion sound

changes form resonance to dullness

d.4 Below: start 3 fingerbreadths, below umbilicus at

right MCL

d.5 Marks with a pen the point when percussion sound

changes from tympany to dullness

d.6 Measures the length between the 2 points with a

centimeter ruler
NOTE: Percussion of the liver can start from down going up.
8. Palpation
A. Light palpation
a.1 depress abdomen by ½ inch or 1 cm
a.2 lightly palpate abdomen by quadrants

B. Deep palpation. May use one or 2 hands

b.1 depress abdomen by 2-4 inches

b.2 do deep palpation by quadrants

C. Palpation of Liver: Stay at client’s right side

c.1 Place left hand posteriorly at the 11th or 12th rib and
apply upward pressure

c.2 Place right hand at anterior abdomen with fingertips

lower level of liver dullness.

c.3 Ask clients to inhale deeply while pressing right

fingers upward feeling for the liver’s lower edge

35
 PA CHARTING
U S U

S
EXTREMITIES
1. Inspect extremities for the following:
A. Size
B. Symmetry

C. Rashes/lesions

D. Edema

2. Locate and palpate the following pulses:

A. Popliteal

B. Dorsalis pedis

C. Posterior tibialis

3. Reflexes
A. Use reflex hammer to elicit knee reflex

4. Range of Motion:
A. Neck
a.1 flexion
a.2 extension

a.3 hyperextension

a.4 lateral flexion

a.5 rotation

B. Shoulder
b.1 flexion

b.2 extension

b.3 hyperextension

b.4 abduction

b.5 adduction

b.6 internal rotation

36
 b.7 external rotation

b.8 circumduction

C. Elbow
c.1 flexion

c.2 extension

D. Forearm
d.1 supination

d.2 pronation

E. Wrist
e.1 flexion

e.2 extension

e.3 hyperextension

e.4 abduction (radial flexion)

e.5 adduction (ulnar flexion)

F. Fingers
f.1 flexion

f.2 extension

f.3 hyperextension

f.4 abduction

f.5 adduction

G. Thumb

g.1 flexion

g.2 extension

g.3 opposition

37
 PA CHARTING
U S U

S
H. Hip
h.1 flexion

h.2 extension

h.3 hyperextension

h.4 abduction

h.5 adduction

h.6 internal rotation

h.7 external rotation

h.8 circumduction

I. Knee
i.1 flexion

i.2 extension

J. Feet
j.1 inversion

j.2 eversion

K. Toes

k.1 flexion

k.2 extension

k.3 abduction

k.4 adduction

38
REMARKS:

Name of Student:

Clinical Instructor’s Signature:

Date:

Revised by:
Prof. Ramonita M. Nakao
Asst. Prof. Kathleah S. Caluscusan
1stsem 2018

39
 COLLEGE OF NURSING
SillimanUniversity
DumagueteCity

BAG TECHNIQUE
Definition:
Bag Technique: A tool that makes use of a PH bag through which the health worker,
during a home visit, can perform procedure(s) in the home with ease and deftness,
saving time and effort, with the end view of rendering effective health care.
PH Bag: Is an essential and indispensable equipment of the health worker which
has to be carried along as one goes out on home visits.
Rationale: To render effective care to clients and/or members of the family during home visit.

Principles:
1. The use of the bag technique should minimize, if not totally prevent, the spread of infection
from individuals to the family and the community.
2. Bag Technique should save time and effort of the health worker in performing procedures.
3. Bag Technique should not overshadow the concern for the client. Rather it should demonstrate
the effectiveness of total care given to an individual or family.
4. Bag technique can be performed in a variety of ways depending upon agency policies actual
situations, etc., as long as principles of avoiding transfer of infection is carried out.

Special Considerations in the use of the bag:

1. The bag should contain all the necessary articles, supplies and equipment, which may be used to answer
emergency needs.
2. The bag and its contents should be washed and cleaned as soon as possible; its supplies being replenished,
and ready for use at any time.
3. The bag and its contents should be well protected from contact with any article in the home of the patients.
Consider the bag and its contents clean and/or sterile, while any article belonging to the patient as
contaminated.
4. The arrangements of the bag contents should be in accordance to its sequence of use and convenience of
the user so as to facilitate efficiency and avoid confusion.
5. Handwashing is done as frequently as the situation necessitates and it should minimize contamination of
the bag and its contents.
6. If the bag was used for a communicable case; the bag or its contents should be appropriately cleaned,
disinfected and air-dried.
7. The bag technique is done as soon as you get into the home of your client.
8. Carry your PH bag in a manner that its state of cleanliness is maintained. Do notswing them, nor place
them on the floor. Use the paper lining (with technique) if you have to lay open your PH bag in a place
where it might be contaminated.
9. Periodically wash the cloth lining and good morning towel(s); air-dry the rest of the bag contents.

Expected contents of the bag:

Oral thermometer Hand towel (Good Morning)
Penlight (functional) Cloth lining, white 1 foot by 2 ft.
Littman brand stethoscope Apron, knee length, white
Aneroid sphygmomanometer Soap in soap dish, hotel size
Tape measure 3 sterile 4x4 sponges
1 Pean or Round nose forceps, curve Pack of cotton applicators
Bandage scissors, 2 inch blade to centimeter ruler Adhesive plaster, small
Tongue depressors Kidney basin, small
Betadine solution, 1 oz. 2 Paper lining
Spirit of Ammonia Paper waste receptacle
Alcohol 70% Isopropyl Pairs of gloves
Cotton balls in a small plastic container Plastic bag, small
The Procedure:
STEPS RATIONALE
1. Place the PH bag in the table lined with a It protects the PH bag from contamination. The paper

40
clean paper.
2. Open the bag, tuck handles under it and lay
out the cloth lining over the paper lining.
3. Take out the wash cloth and soap container.
Place them in one corner of the cloth lining.
Close the bag.
4. Wash hands (abbreviated) with soap and water
either in the clients kitchen or a nearby water
source. Dry hands well.
5. Open bag. Bring out and put on apron with the
seam toughing the uniform of the health
worker.
6. Put out all the necessary articles needed for
care. Put out the plastic bag too as needed for
the after care.
7. Transfer all necessary articles into a paper
lined bedside table or chain. Place them on the
cloth lining. Place the paper waste receptacle
outside paper lining.
8. Proceed with the needed care.
9. After attending to the client’s needs or
treatment, rinse test tube well or wash test
tubes if they are still to be used for another
client.
Wash hands with soap and water. Wipe to dry
after washing the test tube.
10. Place all wet articles inside a plastic bag
container. This will have to be properly
cleaned in dorm or in the LR laboratory or at
home.
11. Open the bag and return all articles into their
proper places. Those with special containers
should be properly returned into their case(s)
before returning them into the bag.
12. Continue with your health teachings. Arrange
for the time of the next visit.
13. When you are ready to leave the home,
perform you final handwashing.
14. Remove ones apron folding inside the soiled
side (left to right), then refolding them to a
convenient size. Secure it inside the bag.
15. Return into the bag the handwashing
equipments then the cloth lining.
41
should be wide enough and free from tears or holes.
Give enough uncluttered space for equipment and
supplies.
Frequent handwashing reduces the possibility of
transfer of infectious agents.
Attain comfort and security; maintain hygiene.
To remove gross contamination and indirectly teach
the family the value of handwashing before
undertaking any procedure.
It also prevents possible infection from the care
provider to the patient.
The wrong side (side with the seam) is the clean side
and the right side which gets in contact with the
client is the contaminated side.
To protect the caregiver.
This will save time in performing every procedure
uninterrupted. It will also prevent contamination of
the PH bag contents.
For convenience.
Undertaking this step prevents undue spillage and
contamination of the bag contents.
It prevents the spread of infection.
Moist contents encourage growth of microorganisms,
which can spread in all the contents of the bag.
Organizing the placement of the things inside the bag
saves time, effort and anxiety.
The health worker should consider the workload and
schedule of ones client. However, one should not
also be misinterpreted of “hurrying to leave” for
whatever reasons.
The PH bag is kept clean both inside and outside.
Correct handling of equipment ensures such state of
cleanliness.
The first content to come out once the bag is used,
shall be the last thing to be places back into the bag
when the care of the client is over.
 STEPS RATIONALE
16. Lift the PH bag and do either of the following: 1)
Crumple the paper lining starting from the middle
section of the paper then throw out in the garbage Use appropriate technique to avoid contamination of
can or 2) Pick up with technique so it can be reuse. your clean hands.

Pick up the waste receptacle with technique and

throw it into the garbage container.

If you wish to re-use the paper lining, fold it with

the contaminated side folded in together.
17. Do the necessary recording as the case maybe.
18. Do the appropriate care to the equipment upon
reaching home.

Reference: Reyala, J etal. (2000). Community Health Nursing Services in the Philippine
Department of Health. 9th ed. Manila:NLGN Inc.

Revised by: Prof. Ramonita M. Nakao RN MA

Date: Summer 2002

42
 BAG TECHNIQUE
Performance Checklist
SATIS- UNSATIS-
FACTORY FACTORY
CRITERIA REMARK
S
1. Place bag on table lines with paper
2. Spread cloth lining.
3. Wash hands.
4. Put on apron.
5. Put out the necessary article needed for care.
6. Transfer all necessary materials to bedside, in a
lined chair or table.
7. After ones care of the client, cleanse all
materials used and place over cloth lining or
inside the plastic bag if wet.
8. Open bag and return all articles used.
9. Converse with client as needed.
When ready to leave…
10. Wash hands and dry.
11. Remove apron folding L to R and refolding to
desired size which fits into the bag.
12. Return handwashing equipment, cloth lining.
13. Lift bag and do aftercare of paper lining and
waster receptacle.
14. Discard.

Student:

Signature of Clinical Instructor

Date:

Comments:

43
 COLLEGE OF NURSING
SillimanUniversity
DumagueteCity

EXAMINATION OF URINE FOR GLUCOSE & ALBUMIN

A. Definition: This is an inexpensive chemical examination done on a urine specimen to screen a
client for probable urinary tract infection and/or diabetes mellitus.

B. Purposes:
1. To identify client who are positive for glucose in the urine specimen.
2. To recognize those clients who may be positive/negative for protein in their urine.

B. Preparation:
1. Before the articles are assembled explain the procedures to the patient. Ask patient to void (clean catch)
and place urine in a clean bottle. Set aside urine specimen.
2. Spread paper lining on table, on chair, or floor.
3. Open bag and follow procedure in bag technique, washing hands and putting on apron.
4. Remove from bag the following articles:
Test tube 2 (10 cc) Cotton balls
Medicine droppers (3) Tin can cover (at least 3 inches in diameter)
Test tube holder Match sticks
Alcohol denatured Extra paper lining for second set-up
Acetic acid 10 cc Plastic bag
Benedict’s solution 30 cc Powdered soap
Long cotton applicator
Steps:
1. Fill test tube two -thirds full of urine. Set aside.
2. Place the tin can cover outside paper lining. Saturate cotton ball with denatured alcohol and place in tin can
cover.
3. Light cotton balls previously wet with alcohol in tin cover.
4. Heat at the level of the urine and bring to boiling point.
5. Hold test tube against light and examine for a cloudy ring.
6. If there is a ring, add 3 to 5 drops of acetic acid and heat again.
If cloudiness disappears, there is no albumin. If top liquid is opaque, it is read as “trace”, if frankly cloudy “+ to
++ albumin”, if ring is white resembling the white of and egg, it is +++ albumin. (Ifthere is none, set aside.)
7. Place 2 cc of Benedict’s solution in the test tube and heat over flame.
8. Add 3-5 drops of urine, shaking it simultaneously and heat until it boils.
9. Check the result.
No change in color - negative for sugar
Blue green - traces of sugar
Yellow green - + to ++
Orange yellow - +++ to ++++
10. Pour solution into the ground or toilet. Rinse test tube and medicine dropper with clean water.
11. Return to set up and continue with health teachings.
12. Do final hand washing.
13. Return equipment to bag.
14. Record results.
15. Upon reaching SUCN/Home/Dormitory, soak used equipment in a soapy solution for at least 10-30 minutes.
Rewash all used equipment using test tube brush. Dry them thoroughly (inside of test tubes as well as outside)
using the long cotton applicators. Air dry the CHN bag overnight to reduce the smell of the chemicals.

44
 BAG TECHNIQUE AND URINALYSIS

Performance Checklist

SATIS- UNSATIS-
FACTORY FACTORY REMARKS

45
BAG TECHNIQUE
1. Place bag on table lined with clean paper.
2. Lay the cloth lining over paper lining.
3. Wash hands and wipe to dry.
4. Bring out apron with technique.
5. Put all necessary articles needed for care.
6. Transfer all necessary articles on the beside
set-up and bring to bedside of patient, prn.
7. After ones care, clean the articles used and
place them inside the plastic bag.
8. Open bag and return articles to their proper
places.
9. Remove apron with technique.
10. Return folded cloth lining into the bag and
close bag.
11. Record observations prn.
12. Gather used papers, cotton balls etc. and
place them inside the paper bag.
13. Lift the bag. Fold newspaper lining.
URINALYSIS
1. Explain procedures as well as the process of
urine collection to the client.
2. Perform nos. 1-5 of bag technique.
3. Saturate cotton balls with alcohol and pace
them in the tin cover.
A. Test of Albumin
a. Fill test tube 2/3 full of urine.
b. Heat upper part of tube and bring to
boiling point.
c. Hold test tube against light and examine
for a cloudy ring.
d. If there is a ring, add 3-5 drops of acetic
acid and heat again. (If there is none, set
aside.)
e. Observe result.
B. Test of Urine Sugar
a. Place 2 cc of Benedict’s solution in the
test tube and heat over flame.
b. Add 3-5 drops of urine, shaking it
simultaneously and heat until it boils.
c. Note change in color.
4. Pour solution on the ground or toilet. Rinse
test tube and droppers.
5. Rinse test tube well/wash if test tube are
still to be used for another client. Dry with
cotton ball.
6. Return equipment to bag.
7. Record results prn.

____________________________
Student’s Signature C.I’s Signature

BASIC BODY MECHANICS

46
 The following principles of body mechanics have been selected because of their applicability to commonly
encountered nursing situations. Examples of how they can be applied are included to facilitate your understanding.

1. Weight is balanced best when the center of gravity is directly above the base provided by the feet. In this
position, you can maintain balance and stability with the least amount of effort. When this posture is not
maintained, the potential for strain, fatigue and poor stability is increased.
2. Enlarging the base of support increases the stability of the body, (changes in position should not cause the
center of gravity to fall beyond the edge of the base). Therefore, when you assist a patient to move, you will
be more stable if your feet are apart than if they are close together.
3. A person or an object is more stable if the center of gravity is close to the base of support. Apply this
principle by bending at the knees and keeping your back straight (thus keeping the center of gravity directly
above and close to the base of support), rather than by bending forward at the waist.
4. Enlarging the base of support in the direction of the force to be applied increases the amount of force that
can be applied. Place one foot forward when you push a heavy object (such as a bed with a patient in it), or
place one foot back when moving a patient toward the side of the bed near you.
5. Tightening of the abdominal muscles upward and the gluteal muscles downward before undertaking any
activity decreases the chance of strain for injury. (We call this putting on the “internal girdle”). If you
practice this continuously, you will eventually do it automatically when you prepare for any activity.
6. Facing in the direction of the task to be performed and turning the entire body in one place (rather than
twisting) lessens the susceptibility of the back to injury. Also, the spine functions less effectively when it is
twisted.
7. Lifting is better undertaken by bending the legs and using leg muscles rather than by using the back
muscles. Because large muscles tire less quickly than small muscles, you should use the large gluteal and
femoral muscles rather than the smaller muscles of the back.
8. It is easier to move an object on a level surface than to move it against the force of gravity, for example, on
a slanted surface. Therefore, you will need less effort to move a patient up in bed if you first lower the head
of the bed.
9. Less energy is required to move an object when friction between the object and the surface on which it rests
is minimized. Because friction opposes motion, you can make the task of moving a patient in bed easier by
working on a smooth surface.
10. It takes less energy to hold an object close to the body than at a distance from the body; it is also easer to
move an object that is close. This is because the muscles are strongest when contracted and weakest when
stretched. Therefore, hold heavy objects close to your body and move the patient near to your side of the
bed (for bathing, for example) to conserve energy.
11. The weight of the body can be used to assist in lifting or moving. When you help a patient to stand, you can
use the weight of your body by rocking back, counterbalancing the patient’s weight. You can use the
patient’s weight by placing his or her legs in a knee up position before moving from back to side.
12. Smooth, rhythmical movements at moderate speed require less energy. Smooth, continuous motions also
are more accurate, safe and better controlled than sudden, jerky movements.
13. When a soft object is pushed, it absorbs part of force being exerted, leaving only a part available to do the
moving. When a soft object is pulled, all of the force exerted is available for the task of moving. Think of
patients to be moved as soft objects, and try to use a pulling motion whenever possible.
14. Dividing activity between arms and legs reduce the risk of back injury/strain.
- the health worker can increase overall muscle strength by synchronized use of as many muscle
groups as possible
15. Reducing the force of work reduces the risk of injury.
16. Maintaining good body mechanics reduces fatigue of muscle groups.
17. Alternating periods of rest and activity help reduce fatigue.
18. Leverage, rolling, turning, pivoting, pushing/pulling requires less work than lifting.
COLLEGE OF NURSING
SillimanUniversity
DumagueteCity

BEDMAKING

ASEPSIS IN BEDMAKING

The following are the principles of asepsis applied to all bedmaking procedures:
1. Wash hands before you begin bedmaking.

47
 2. Handle linen carefully, avoid shaking it, tossing it into the laundry hamper (it should be placed in the
hamper) or throwing it to the floor.
3. Hold both dirty and clean linen away from your uniform.
4. Wash your hands after you finish bedmaking.
5. Do not touch your face in between the procedures.

BODY MECHANICS IN BEDMAKING

The principles of body mechanics are applied to all bed making procedures:

Raise the bed (if possible) to an appropriate height before you begin. Lock the wheels.
When you must, bend your knees, not your back
Point your hand and face in the direction that you are moving. Avoid twisting movements.
Conserve steps by making a few trips around the bed as possible.

TYPES OF BED:

UNOCCUPIED BED
1. CLOSED BED
2. OPEN BED

OCCUPIED BED

A. UNOCCUPIED BED

An unoccupied bed can either be closed or open bed.

I. MAKING A CLOSED BED

Definition:
Preparation of the closed bed is done in readiness for the use of upcoming patients.

Purposes:
1. To conserve the client’s energy and maintain currently health status.
2. To promote the client’s comfort
3. To provide a clean, neat environment for the client
4. To provide a smooth, wrinkle-free bed foundation thus minimize a source of skin irritation

Equipment:
 Two flat sheets or one fitted and one flat sheet
 Cloth drawsheet
 One blanket (optional)
 One bedspread (for making a closed bed)
 Waterproof pads or rubber sheets
 Pillowcase(s) for the head pillow(s)
 Plastic laundry bag or portable linen hamper, if available

Procedures:
PRINCIPLES, RATIONALE, KEY POINTS

STEPS
1. Determine what linens to be used.  To avoid unnecessary extra linens or lack of
it.

2. Wash hands thoroughly.  To prevent spread of infection.

3. Place the fresh linen on the client’s chair or  To facilitate orderly placement of linens.

48
overbed table in the patient’s unit.
The following is the order of placement:
a. 1 bottom sheet (fitted sheets)
b. Cotton drawsheet
c. 1 rubber sheet (may be optional)
d. 1 top sheet
e. 1 blanket (optional)
f. 1 pillowcase for each pillow on bed
g. bedspread
4. Grasp the mattress securely and turn or move
the mattress up to the head of the bed.
5. Apply the bottom sheet at the foot part on the bed
with the centerfold to approximate the center of
the mattress.
 Make sure hem side is down.
 Spread the sheer going to the head part, then
to the farther side.
 Allow sufficient amount of sheet at the top
to tuck under the mattress.
 Miter the corners (for fitted bottom sheets),
working from the head part to the foot.
6. If a rubber sheet is used, place it over the middle
part of the bed, centerfold at the center. The top
and bottom edges extend from the middle part of
the client’s back to the area of the mid-thigh or
knee.
 Lay the cloth draw sheet over the rubber
sheet in the same manner.
7. Place the top sheet at the head part on the bed with
hem side up, unfold them, tuck them in and miter
the foot part. Create a cuff… Fold back the flap
before moving to the other side.
PRINCIPLES, RATIONALE, KEY POINTS
STEPS
8. Move to the other side, and tuck the linens starting
from the foot part. Pull each sheet firmly and
make them wrinkle-free.
Optional: Make a vertical or a horizontal toe pleat in
the top sheet.
a. Vertical toe pleat: Make a fold in the sheet 5-
10 cm (2-4 inches) perpendicular to the foot
49
 Arrangement of the linens in the chair
follows the principle:
The last to apply will be at the bottom
and the first one to apply will be at the top.
 Proper placement of the mattress ensures
appropriate fitting of linens.
 The larger hem should be at the head part.
Allocate more linens to tuck in.
 The top sheet needs to be well tucked to keep
the linens securely in place.
 Fanfold the uppermost half of the folded
draw sheet at the center or far edge of the
bed and tuck in the near edge.
 The rubber sheet is used to protect the bed
for post-op, incontinent and other patients
with wound drainage.
 Cloth draw sheets are used to prevent direct
contact of rubber sheet to the patient’s skin.
 Completing one entire side of the bed at a
time saves time and energy.
 Wrinkles can cause discomfort fro client and
irritates the skin.
 To provide additional room for the client’s
feet.
 Loosening the top covers around the feet
after the client is in bed is another way to
 of the bed. provide additional space.
b. Horizontal toe pleat: Make a fold in the sheet
5-10 cm (2-4 inches) across the bed near the
foot.

 Fold back and create a cuff of the top sheet.  To minimize dust from adhering to exposed
Optional: linens.
 Fold back the side flaps of the top sheet
before applying the bedspread.  Minimize dust adhering to the hanging flaps
 Tuck in the top sheet, blanket and spread at of the topsheet.
the foot of the bed and miter at the foot part  Ensure that each side of the top sheet and
using all three linen. bedspread are of the same length.
 Tuck in the top sheet, blanket and spread at
the foot of the bed, and miter at the front
part, using all three linen.
.

9. Put clean pillowcases on the pillows as required.  To complete the making of the unoccupied
bed.
 Grasp the pillowcase at the center of the
closed end of the case with one hand.  For even distribution of the case when
applied to the pillow.
 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 pillowcase to fit the pillow.
 A smooth fitting pillowcase is more
comfortable than a wrinkled one.
 Place the pillow (s) appropriately at the head
of the bed with the folded side towards the  For patient’s comfort in using the bed. To
neck part of the patient when lying down in minimize the loosening of the pillowcase
bed. whenever the patient moves ones head.

10. Attach the call light within the patient’s reach  To provide client comfort and safety.
and leave the bed in high or low position,
depending on patient’s condition of or facility
policy.

II. MAKING AN OPEN BED

Definition: A type of unoccupied bed which is done when a patient is out of bed for brief period or
out of the unit for laboratory or diagnostic procedures.

Procedures:

PRINCIPLES, RATIONALE, KEY POINTS

STEPS
1. Assess the patient’s health status.  To determine if the person can safely get out
of bed.

2. Explain the client what you are going to do,  To ensure cooperation.

50
 why is it necessary and how he or she can
cooperate.

3. Inspect the bed linens to determine what can  To avoid unnecessary extra linens.
be re used.

4. Wash hands thoroughly.  To prevent spread of infection.

5. Assemble equipment and supplies needed.  Having everything ready ensures ease and
systematic performance.

6. Place the fresh linen on the client’s chair or  To facilitate orderly placement of linens and
over bed table in the patient’s unit. also to prevent cross contamination by
 1 bottomsheet (fitted sheet) making sure new linens will not come in
 1 rubber sheet (may be optional) contact with soiled linens.
 1 Cotton drawsheet
 1 blanket (optional)
 1 pillowcase for each pillow on bed

7. Assist the client out of bed.  Make sure that patient’s condition allows
him or her to be out of bed.
 Assist the client to a comfortable chair.

8. Strip the bed.  For safe performance of the procedure.

 Check the bed linens for any items belonging
to the client. Remove attached equipment
(call bell, waste bag, drainage tubes) from
the bed linen.

9. Remove pillowcase(s) from pillows and place  Pillowcase can be used as an improvised
it on a chair or bedside table. hamper if laundry bag is not available.

10. Loosen all sides of beddings systematically.  Moving systematically around the working
 Start at the head part of the bed. area prevents stretching and reaching and
possible muscle strain.

PRINCIPLES, RATIONALE, KEY POINTS

STEPS
11. Fold reusable linens such as bedspread and  Folding linens saves time and energy when
top sheet. The sequence is as follows: applying the linens on the bed.
 First, fold the linen in half from left to right
then grasp it at the center of the middle fold
bringing the top edges together.

12. Remove the rubber sheet and discard if  Rubber sheet can be reused if not soiled.
soiled.

51
13. Roll all soiled linen inside the bottom sheet.  These actions are essential to prevent the
Hold it away from your uniform, place this transmission of microorganisms.
inside the laundry bag or directly in the linen
hamper.

14. Grasp the mattress securely and turn or move  Proper placement of the mattress ensures
the mattress up to the head of the bed. appropriate fitting of linens.

15. Apply the bottom sheet on the bed with the  The larger hem should be at the head part.
centerfold to approximate the center of the Allocate more linens to tuck in.
mattress. Make sure them side is down.
 Spread the sheet going to the head part, then  The top sheet needs to be well tucked to keep
to the farther side. Allow sufficient amount the linens securely in place.
of sheet at the top to tuck under the mattress.
 Miter the corners (except for fitted bottom
sheets), working from the head part to the
foot.

16. If a rubber sheet is used, place it over the
middle part of the bed, centerfold at the
center. The top and bottom edges extend from
the middle part of the client’s back to the area
of the mid-thigh or knee.
 Fanfold the uppermost half of the folded
draw sheet at the center or far edge of the
bed and tuck in the near edge.
 The rubber sheet is used to protect the bed
for post-op, incontinent and other patients
with wound drainage.

 Lay the cloth draw sheet over the rubber
sheet in the same manner.
 Place the top sheet at the head part of the bed
with hem side up, unfold them, tuck in the
foot part and miter.
 Cloth draw sheets are used to prevent direct
contact of rubber sheet to the patient’s skin.
 Completing one entire side of the bed at a
time saves time and energy.

17. Move to the other side and spread the linens  To provide additional room for the client’s
and tuck the linens starting from the bottom feet.
sheet. Pull each sheet firmly and make them
wrinkle-free.

Optional: Make a vertical or a horizontal toe

 Loosening the top covers around the feet
pleat in the top sheet.
after the client is in bed is another way to
a. Vertical toe pleat: Make a fold in the sheet provide additional space.
5-10 cm (2-4 inches) perpendicular to the
foot of the bed.

PRINCIPLES, RATIONALE, KEY POINTS

STEPS
b. Horizontal toe pleat: Make a fold in the
sheet 5-10 cm (2-4 inches) across the bed
near the foot.

18. Put clean pillowcases on the pillows as  To complete the making of the unoccupied
required. bed.
 Grasp the pillowcase at the center of the  For even distribution of the case when
closed end of the case with one hand.

52
  Gather up the sides of the pillowcase and applied to the pillow.
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 pillowcase to fit the pillow.

 Place the pillow (s) appropriately at the head

of the bed with the folded side towards the
neck part of the patient when lying down in
bed.
 A smooth fitting pillowcase is more
comfortable than a wrinkled one.
 For patient’s comfort in using the bed. Also,
to minimize the loosening of the pillowcase
whenever the patient moves ones head.

19. Fanfold the top sheet at the side facing the  This makes it easier for the client to get into
door of the room. the bed.

20. Attach the call light within the patient’s  To provide client comfort and safety.
reach and leave the bed in high or low
position, depending on patient’s condition of
or facility policy.

III. CHANGING OCCUPIED BED

Definition: The making of a bed while the client is occupying or lying on the bed. This is done when clients may be
too weak to get out of the bed because their illness done not allow them to sit out of the bed or they may be
restricted to stay in bed because traction and other therapies.

GUIDELINES ON HOW TO CONSERVE CLIENT’S ENERGY IN

MAKING AN OCCUPIED BED:

 Maintain the client in proper body alignment. Do not move or position a client which is contraindicated by
the client’s health condition.
 Solicit assistance from “bantay” when necessary to ensure safety.
 Move the client in a gentle and smooth manner following the principles of body mechanics.
 Explain in the client’s level of understanding what you intend to do throughout the procedure before
continuing.
 Utilize bed making and bed bath time to assess and gratify client’s needs.

Equipment:
 The same materials needed in doing an open bed.

STEPS PRINCIPLES, RATIONALE, KEY POINTS

1. Assess patient’s condition before moving and
positioning client.
 Determine signs of incontinence and
condition of linens
 Inspect client’s skin condition
To be informed of the patient’s health condition.
 To indicate the need for protective
waterproof pads.
 To identify the need for special mattress (e.g.
crate), footboard or heel protectors.

53
2. Explain the procedure.  To ensure cooperation.

3. Assemble equipment and supplies needed  Having everything ready ensures ease and
folding them according to its usage. systematic performance of procedure.

4. Wash hands thoroughly.  To prevent spread of infection.

5. Provide for client privacy.  To deter anxiety and embarrassment.

6. Remove top bedding.

 Remove any equipment attached the bed
linen, such as call bell or signal light.
 Loosen all top linen at the foot of the bed and
replace topsheet with bath blanket.
 Spread the bath blanket over the top sheet.
 Leave the topsheet over the client. If
necessary, replace it with a bath blanket as  The top sheet need to be replaces if it will be
follows: changed and if it will provide sufficient
a. Request the client to hold the top edge warmth.
of the blanket.
b. Reaching under the blanket, grasp the
top edge of the sheet and draw it down
to the foot of the bed, fanfolding in the
process.
c. Remove the sheet from the bed and
place it in the soiled linen hamper
otherwise fold it according to use.

 To prevent cross contamination.

7. Raise the siderail nearest the client.  Protects the client from falling.
 If there is no siderail, have another nurse/
“bantay” to support the client.

8. Change the bottomsheet and draw sheet.  To facilitate easy placement of linens on the
 Assist the client to turn on the other side. mattress.
 Loosen the bottomsheet of the side you are
working on.

54
 PRINCIPLES, RATIONALE, KEY POINTS
STEPS

 Fanfold the drawsheet and bottomsheet at the
center of the bed as close to the client as
possible.
 Place the new bottomsheet on the bed with
enough linens at the head part to tuck in, and
vertically fan fold the half to be used on the
far side of the bed.
 Reapply the rubber sheet.
 Place the clean drawsheet on the bed with the
centerfold at the corner of the bed.
 Assist the client to roll over toward you into
the clean side of the bed.
 Move the pillow to the clean side.
 Raise the siderail before leaving the client
side of the bed.
 Move to the other side of the bed and lower
the siderail.
 Remove the used linen and place it in the
portable hamper.
 Unfold the fanfoldedbottomsheet from the
center of the bed.
 Facing the side of the bed, use both hands to
straighten and pull the bottomsheet.
 Tuck in the linen.
 Unfold the bottomsheet and
drawsheetfanfolded pull it tightly with both
hands and tuck in as needed.
 Doing this leaves the near half of the bed
free to be changed.
 Tuck the sheet under the near half of the bed.
Miter at the head part.
 This would depend on the necessity based on
patient’s condition.
 Client rolls over the fanfolded linens.
 To continue making the other half of the bed.
 To secure the client’s safety.
 To continue making the other half of the bed.
 Minimize contact with the used linens.
Making the linens wrinkle free prevents irritation
of the skin.
 Pull the sheet in 3 sections:
Face the side of the bed to pull the middle
section.
Face the far top corner to pull the bottom
section.
Face the far bottom corner to pull the top
section.

9. Reposition the client at the center of the bed.
 Reposition the pillows at the center of the
bed.
 Assist the client to the center of the bed.
 To promote client’s comfort.
 Determine what position the client requires
or prefers and assist him or her to that
position.

10. Apply or complete the top bedding.
 Spread the topsheet over the client and either
ask the client to hold the top edge of the
sheet or tuck it under the shoulders.
 Miter the foot part and create a toe pleat.
 The sheet should remain over the client when
the bath blanket or used sheet is removed.
 Tucking in more linens at the foot part
prevents them from coming off.

PRINCIPLES, RATIONALE, KEY POINTS

STEPS
11. Raise the side rails as necessary. Place the

55
 bed in the low position before leaving the
bedside.
 Attach the signal cord to the bed linen within
the client’s reach.
 Put personal items within easy reach.

12. Bedmaking is not normally recorded.

ACCESSORIES FOR THE BED

Among the devices often added to the bed are the bedboard, the foot-board, and the cradle or Anderson
frame. These devices may be ordered by a physician. But in many facilities they are added at the nurse’s discretion.

BEDBOARDS

A bedboard is used when the patient needs an especially firm bed, it is placed directly under the mattress.
Bedboards are often used for orthopedic patients or for those who have a history of back problems. Some patients
are simply more comfortable sleeping on a firm surface.

FOOTBOARDS

A footboard may be placed at the foot of the bed for a variety of reasons, most commonly to keep the
patient from shifting to the foot of the bed and/or to give him firm surface to exercise against. Some physicians
routinely order a footboard for their patients. Linen is tucked in around the footboard and is held up off the patient’s
feet; through this is not the primary function of the device.

All the footboards are not alike. Some are merely boards that fit at the foot of the mattress. Some require
that a boey or “block” be added, so that the feet of a shorter patient can reach the board. Other footboards fit under
the mattress and the slide up to the appropriate point on the bed. Footboards that allow the patient’s feet to rest flat
against them help to prevent footdrop.

CRADLES

A cradle, or Anderson frame, is a device designed specifically to keep linens up off the feet and lower legs
of patients when necessary, as in cases of edema, leg ulcers and burns. Arrange the top linen over the device and
pin it in place. Some facilities do not allow pining because it can tear the linen. In these situations, linen must
simply be tucked as securely as possible around the frame.

There are several varieties of cradles, including a simple rod that arches over the bed, which is help in place
by the mattress and a lattice-work, which is also arch-shaped and which sometimes includes a socket for light
treatments. If your facility has no cradle, you can make one by simply cutting one side of a strong cardboard box.

Reference:
Kozier, B. et al. Fundamentals of Nursing, 7th Ed. Pearson Education, Inc. (2004)

Revised by:
Prof. Ramonita Nakao and
Miss Khristine Gail C. Vendiola, RN
( June 2006)

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 SILLIMANUNIVERSITYCOLLEGE OF NURSING
DumagueteCity

BEDMAKING
Performance Checklist

I. CLOSED BED
SATIS- UNSATIS- REMARKS
FACTORY FACTORY
1. Wash hands.
2. Assemble needed linens.
3. Place linens in the order to be used.
4. Raise the bed to appropriate height.
5. Grasp the mattress securely.
6. Apply the bottom sheet at the foot part of
the bed, centerfold on the middle of the
mattress; hem side down. Provide extra linen to
tuck in well.
7. Miter corners of the bottom sheet, working
from the head of the bed to the foot part.
8. Place the rubber sheet, centerfold at the
center of the mattress.
9. Lay the cloth draw sheet over the rubber
sheet in the same manner.
10. Place the top sheet on the bed, starting at the
head part hem side up. Top edge is even with
the top edge of the mattress.
11. Fold back the sides of the top sheet.
12. Move to the other side, spread and secure
all linens.
13. Put clean pillowcases.
14. Place the bedspread ensuring that the
centerfold is in the center of the mattress.
15. Attach call light and other items attach to
bed.
16. Wash hands.

II. OPEN BED

SATIS- UNSATIS- REMARKS

FACTORY FACTORY
1. Assess the client’s health status.
2. Determine linens that can be reused.
3. Wash hands before beginning the bedmaking
activity.
4. Assemble needed equipment and needed
linens.
 Hold linen away from uniform.
5. Raise the bed to appropriate height.
6. Loosen all beddings systematically.

57
 SATIS- UNSATIS- REMARKS
FACTORY FACTORY
7. Stripping the bed.
 Check for any items belonging to the client.
 Remove attached equipment (if applicable)
 Separate soiled linen, folding appropriately
those that can be reused.
 Move mattress to the head of the bed.

8. Apply the bottomsheet, centerfold on the

middle of the bed; hem side down.
 Ensure more linen is allocated to the head
part.
9. Miter top corners of the bottomsheet from
the head of the bed to the foot part.
10. Place rubbersheet over the middle part,
centerfold at the center of the mattress.
11. Lay the cloth drawsheet over the
rubbersheet in the same way.
12. Place the top linen on bed, at the head
portion of the bed using centerfold as guide,
allocating more linen at the foot part.
 Make a toepleat if appropriate to facility.
 Tuck in the linens at the foot part and miter
at the lower corners of top linen.
13. Move to the other side of the bed. Spread
and tuck in all linen.
14. Put on pillowcase, taking care to keep
pillow end and the case away from the
uniform.
15. Fan fold or fold back the top cover at one
side or bring them down to the center of the
bed.
16. Replace call light and other items attach to
bed.
17. Arrange personal belongings of client in
easy reach.
18. Dispose soiled linens appropriately.
19. Wash hands.

III. OCCUPIED BED

SATIS- UNSATIS- REMARKS

FACTORY FACTORY
1. Assess the client’s condition.
2. Explain to the client what is to be done.
3. Determine what linen can be re- used.
4. Provide privacy.
5. Wash hands.
6. Assemble equipment and supplies needed,
folding them according to use.

SATIS- UNSATIS- REMARKS

FACTORY FACTORY
7. Raise the bed to convenient working level.
8. Remove top bedding.
 Remove any attached equipment.
 Loosen all sides of the top linen.

58
  Leave the top sheet over the client if this
will be changed otherwise remove the top
sheet (if to be re used) and replaced with
bath blanket.
9. Raise side rail on the opposite side.
10. Turn the patient to the opposite direction.
11. Loosen the bottom sheet, rubber sheet (if
used) and draw sheet of the side you are
working in.
12. Fanfold the three linens at the center of the
bed.
13. Put new bottom sheet, at the foot portion
rubber sheet and draw sheet, straighten and
tuck. Miter the bottom sheet at the top
corner.
14. Assist the client to roll over toward you
onto the clean side of the bed.
15. Raise the side rail before moving to the
other side.
16. Move to the other side of the bed and lower
thesiderail.
17. Loosen and remove used linen and place in
a portable hamper.
18. Unfold the fan folded bottom, rubber and
draw sheets at the center of the bed.
19. Tuck in linens layer by layer with miter
bottom sheet at the head part.
20. Place the top sheet with centerfold at the
middle of mattress. Replace bath blanket
with technique.
21. Reposition the pillows at the center of the
bed.
22. Change pillowcase and reposition pillow at
the center of the bed.
23. Apply top linen, removing used top sheet or
bath blanket and mitering lower portion of
fresh top linen.
24. Ensure continued safety of the client:
 Raise the side rail if indicated.
 Place the bed in the low position.
 Attach signal cord and arrange unit.
25. Dispose soiled linens appropriately.
26. Wash hands.
Revised by:
PROF. RAMONITA M. NAKAO and
MISS KHRISTINE GAIL C. VENDIOLA

June 2006
Date: Summer 2006

COLLEGE OF NURSING
SillimanUniversity
DumagueteCity

SHAMPOO IN BED
Definition: Washing the hair and scalp of a bed patient.
Purpose: 1. To cleanse the hair and scalp

59
 2. To stimulate circulation
3. To prevent infection
Equipment:
bath blanket pail or big basin
* 2 bath towels 2 pitchers of water – 1 tap water & 1 warm water
* face towel (when water is mixed, test heat by pouring over wrist)
big rubber sheet/Kelly pad old newspaper
cotton balls (4 pcs.) places inside * comb container
bedpan * soap or shampoo
waste receptacle * patient’s own
Procedure:
Important Steps Rationale
1. Ask permission from physician. To make sure that shampoo in bed is not
contraindicated to patient’s condition.
2. Explain procedure. To reduce anxiety since patient maybe
apprehensive about positioning or risk of water
entering his/her eyes.
Reduces transfer of microorganism.
3. Wash hands.

4. Prepare soap or shampoo solution.

(Optional for clients without shampoo)

5. Fill pitchers with water. One pitcher with

tap water and one pitcher with warm water.
Water temperature for shampoo in bed
should be at 110°F or 43.44°C.

6. Bring equipment to bedside and arrange

them conveniently on table.
7. Close window and screen bed. To prevent draft and provide privacy.

8. Put on gloves and offer bedpan. To protect health worker; prevent interruption
while procedure is going on.
9. Move bedside table away from head of bed,
prn.

10. Place bath towel on top of pillow and set

aside.

11. Have patient lie diagonally across bed with

head near edge of bed.

12. Place a folded blanket under patient’s

neck. See to it that patient is kept in a
comfortable position.
NOTE: If Kelly pad is available, there is no
need for a folded blanket.

13. Place bath towel under patient’s head and

upper shoulders.
Important Steps Rationale

60
14. Make rubber sheet into an improvised
Kelly pad and place it under patient’s head
on top of bath towel.
15. Place pail on chair or floor lined with
paper and adjust trough in place.

16. Comb patient’s hair. Place hair combings in Removing tangles results in more thorough
waste receptacle. cleaning.
17. Protect ears with cotton balls. Protect eyes Prevents soapsuds or water from entering eyes
using face towel. and ears.
18. Slowly pour warm water over patient’s hair Water aids in distribution of shampoo suds
until it is completely wet. Apply a small
over hair. Warm water opens the pores of the
amount of shampoo.
scalp.
19. Work up a lather with both hands. Start at
the client’s hairline and work toward the
back of neck. Lift head slowly with one Massage increases scalp circulation.
hand to wash back of head. Massage back The pads of the fingers are used so that the
by applying pressure with your fingertips. fingernails will not scratch the scalp.

20. Rinse with warm water and repeat as often

as necessary. Washing with shampoo and
water may be repeated as necessary. Soap should be well rinsed out of the hair to
keep it from being sticky. Shampoo remaining
in the hair may dry and irritate the scalp.
21. Do the final rinsing with tap water, fore Change ear plug PRN.
warning patient.
Rinsing with cold water causes constriction of
22. Squeeze out excess water from hair and pores of scalp, prevents chilling and leaves
remove ear plug. patient with a refreshed feeling.

23. Roll rubber sheet, fold carefully and place

it inside the pail.

24. Rub head with towel until hair is partly dry.

25. Replace pillow protected with dry towel.

26. Comb hair. Leave bath towel until hair is

thoroughly dry.

27. Assist patient to a comfortable position.

28. Tidy unit and do after care of equipment.

a. Bring equipment to utility room, clean
and return to proper places.
b. Wash and rinse patient’s comb and
Accurate documentation should be timely and
return to bedside.
descriptive of patient’s response and should
include pertinent observations.
29. Record in nurse’s notes procedure
accomplished and report any observations
(e.g. lesions, dry flaky scalp, localized
areas of inflammation).

61
 SILLIMANUNIVERSITYCOLLEGE OF NURSING
DumagueteCity

SHAMPOO IN BED
Performance Checklist

SATIS- UNSATIS- REMARKS

FACTORY FACTORY
1. Assess need of patient to have a shampoo in
bed.
2. Ask permission from physician.
3. Explain procedure to patient.
4. Wash her/his hands.
5. Assemble equipment.
6. Bring equipment to bedside.
7. Close windows and screen bed.
8. Put on gloves and offer a bedpan or encourage
patient to use the toilet (if ambulatory or with
bathroom privileges).
9. Move bedside table away from head of bed.
10. Place bath towel on top of pillow and set
aside.
11. Assist patient in lying diagonally across the
bed.
12. Place a small pillow or rolled blanket under
patient’s neck.
13. Place a bath towel under patient’s head.
14. Fashion rubber sheet into an improvised Kelly
pad and places it under patient’s head.
15. Place pail on chair or floor lined with paper and
adjusts trough in place.
16. Comb patient’s hair and place hair combings in
waste receptacle.
17. Get two cotton balls and place them into each
ear.
18. Protect eyes using face towel.
19. Wet hair and lather hair and scalp using soap or
shampoo.
20. Massage scalp.
21. Rinse head with warm water repeating this as
needed.
22. Repeat washing hair with soap and water as
needed.
23. Forewarn patient and gives the final rinsing with
cold water.
24. Squeeze out excess water from hair and removes
ear plug.
25. Roll rubber sheet, fold it carefully and place
inside pail.
26. Rub head with a towel until hair is partly dry.
27. Replace pillow protected with a dry towel.
28. Comb hair and leaves bath towel until hair is dry.
29. Does aftercare of the
a. Patient:
- straighten beddings
- makes patient comfortable
- tidies the unit

51
62
 SATIS- UNSATIS- REMARKS
FACTORY FACTORY
b. Equipment:
- returns them to utility room
- cleans them
- returns them to their proper places
- washes and rinses patient’s comb and returns
it to patient’s unit.
30. Charts the following:
- Date and time shampoo was given
- Name of shampoo/soap used
- Observations /Reaction of patient

REMARKS:

___________________________________
Student’s Name

Clinical Instructor’s Signature

Date

63