B. NSG 120.2 Checklist

MINDANAO STATE UNIVESITY – MARAWI CITY
College of Health Sciences
PROCEDURE CHECKLIST
NSG 120.2
Fundamentals of Nursing Practice
Skills Laboratory
Compiled by:
Naima D. Mala, RN, MN, MAN, PhD.
Donnabelle L. Abdullah, RN, MAN

Shiennah O. Jamesula, RN, MAN
Jonaid M. Sadang, RN, RM, MAN, LPT
Namera T. Datumanong, RN, MAN
Jamal Tango P. Alawiya, LPT, RN
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NAME OF STUDENT
2
TABLE OF CONTENTS
Page No.
Module 1
BASIC INFECTION CONTROL
Medical Handwashing 4
Donning and Removing Personal Protective Equipment 6
Module 2
HYGIENE AND COMFORT
Administering a Tepid Sponge Bath (TSB) 10
Performing Bed Bath 13
Shampooing Hair 16
Performing Oral Care 18
Providing Special Oral Care 20
Changing a Hospital Gown for a Patient with an Intravenous Fluid 22
Changing an Unoccupied Bed 24
Changing an Occupied Bed 29
Post Mortem Care 33
Module 3
MOBILITY AND SAFETY
Using the Principles of Body Mechanics 38
Transferring/ Transporting Clients 41
Positioning 47
Module 4
ASSISTING WITH ELIMINATION AND PERINEAL CARE
Performing Perineal Care 50
Providing Catheter Care 53
Offering and Removing a Bedpan and Urinal 55
Collecting a Urine Specimen 57
Module 5
OXYGENATION
Administering Oxygen 60
Teaching Deep breathing Exercise 63
Module 6
FLUID AND ELECTROLYTES
Starting an Intravenous Infusion 66
Monitoring an Intravenous Fluid 68
Changing an Intravenous Container and Tubing 70
Discontinuing an Intravenous Infusion 72
Skills Competency Record 74
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I. BASIC INFECTION CONTROL
PROCEDURES:
➢ Medical Handwashing
➢ Donning And Removing Personal Protective Equipment
GENERAL OBJECTIVE:
➢ To apply principles of basic infection control when practicing all aspects of nursing with particular
emphasis on medical handwashing and using of personal protective equipment
LEARNING OUTCOMES
The student will be able to:
➢ Describe the requirements for Standard Precautions as identified by the Centers for Disease Control
and Prevention (CDC).
➢ Assess the healthcare environment in order to identify possible sources of transmission of
microorganisms
➢ Identify situations in which handwashing is essential
➢ Accurately determine and identify situations which require specific personal protective equipment
(PPE).
➢ Implement actions to prevent transmission of microorganisms
➢ Perform medical handwashing correctly
➢ Put on and remove PPE correctly so as to avoid contaminating own body or clothing
➢ Maintain personal hygiene appropriately for the clinical setting
➢ Evaluate own performance in relation to maintaining Standard Precautions and protecting both the
patient and self from the transmission of microorganisms.
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NAME: ______________________________________________ DATE: _________________________

MEDICAL HANDWASHING
DEFINITION:
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PURPOSE:
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EQUIPMENT:
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CONSIDERATIONS BEFORE, DURING and AFTER THE PROCEDURE:

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THINGS TO DOCUMENT AFTER THE PROCEDURE:

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PROCEDURE RATIONALE C X N R
1. File or cut nails short. Check hands for Poor personal hygiene and an open area of
breaks in the skin and cuticles. the skin provide areas in which
microorganism grow and should receive
extra attention during cleaning.
2. Remove watch and all other hand and Microorganisms collect in jewelry and watch
wrist jewelry. Roll sleeves above the bands.
elbows. Removing jewelry makes it easier to wash all
areas of hands and wrists.
3. Stand in front of the sink, turn on the Water that is too hot can chap the skin. Too
water and adjust the flow and much force can cause splashing and spread
temperature. of microorganisms to other areas especially
your uniform.
4. Wet elbow to hands under a running Hands are the most contaminated part of the
water while always keeping hands arm.
lower than the elbows. Water should flow from the elbow which is
the least contaminated area over the hands
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and down the drain.

5. Get about 1 teaspoon of liquid soap Soap lather emulsifies fats and aids in
and lather thoroughly. cleansing.
6. With firm rubbing and circular motions, Friction helps loosen dirt and
wash palms, back of the hands, each microorganisms.
finger, areas between the fingers,
knuckles, wrists and forearms.
Continue friction motion for at least 15
seconds.
7. Use fingernails of opposite hand or an Orange stick helps remove dirt and reduces
orange stick to clean under the chance of microorganisms to under the nails.
fingernails.
8. Rinse hands thoroughly with water Water should run from cleaner area (elbow)
flowing toward the fingertips. over the hands and then down the drain.
9. Pat hands dry with a paper towel Prevents chapping of the skin. The cleanest
starting from the fingers then towards areas are now the fingers and hands so
the forearms and discard properly. drying should progress from clean to less
clean.
10. Turn off the water with a dry paper Keep clean hands from touching
towel, if faucet is hand operated. contaminated faucet.
12. Inspect hands and nails for Ensures cleanliness of hands and nails.
cleanliness.
COMPLETED Yes No DATE OF COMPLETION SIGNED
REMARKS:
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NAME: _________________________________________________ DATE: _________________________
DONNING AND REMOVING PERSONAL PROTECTIVE EQUIPMENT

(GLOVES, GOWN, MASK, EYEWEAR)
DEFINITION:
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PURPOSE:
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EQUIPMENT:
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PERFORMANCE INDICATORS:
C –The step was correctly performed
X- The step was not performed
N- The execution of the step needs improvement
R- The step was correctly performed after remediation
1. Prepare necessary equipment and supplies.
2. Wash your hands.
3. Don a clean gown.
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• Pick up a clean gown and allow it to unfold in front of you.

• Slide the arms and the hands through the sleeves.
• Fasten the ties at the neck to keep the gown in place.
• Overlap the gown at the back as much as possible, and
fasten the waist ties or belt.
Don the face mask
• Locate the top edge of the mask.
• Hold the mask by the top two strings or loops.
• Place the upper edge of the mask over the bridge of the
nose, and tie the upper ties at the back of the head or
secure the loops around the ears.
4. • Secure the lower edge of the mask under the chin, and
tie the lower ties at the nape of the neck.
• If the mask has a metal strip, adjust this firmly over the
bridge of the nose.
• Wear the mask only once, and do not wear any mask
longer that the manufacturer recommends or once it
becomes wet.
• Do not leave a used face mask hanging around the neck.
Putting an eyewear or face shield
5. • Wear protective eyewear by snugly fitting it to cover both
eyes.
• Wear face shield making sure to cover entire face
Don clean disposable gloves
• Pick up a clean glove using the left hand and properly
6. insert on the right hand.
• Glove the left hand.
• Pull the gloves up to cover the cuffs of the gown.
To remove soiled personal protective equipment, remove the

gloves first because they are the most soiled.
• If wearing a gown that is tied at the waist in front, undo
the ties before removing gloves.
• Remove the first glove by grasping it on its palmar
surface just below the cuff, taking care to touch only
glove to glove.
• Pull the first glove completely off by inverting or rolling the
7. glove inside out.
• Continue to hold the inverted removed glove by the
fingers of the remaining gloved hand. Place the first two
fingers of the bare hand inside the cuff of the second
glove.
• Pull the second glove off the fingers by turning it inside
out. This pulls the first glove inside the second glove.
• Using the bare hand, continue to remove the gloves,
which are now inside out, and dispose of them in the
waste container.
8. Wash your hands.
Remove protective eyewear or face shield and dispose of
9.
properly or place in the appropriate receptacle for cleaning.
Remove the mask
10. • If using a mask with strings, first untie the lower strings
and then untie the top string. Hold ties securely. Remove
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the mask from the face.

• If using a mask with ear loops, hold the ear loops of both
ears securely and remove mask from the face.
• Discard the disposable mask in the waste container.
• Wash the hands again if they have become contaminated
by accidentally touching the soiled part of the mask.
Remove the gown when preparing to leave the room.
• Avoid touching soiled parts on the outside of the gown, if
possible.
11. • Grasp the gown along the inside of the neck and pull
down over the shoulders.
• Roll up the gown with the soiled part inside, and discard it
in the appropriate container.
REMARKS:
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II. PROMOTING HYGIENE AND COMFORT
PROCEDURES:
➢ Administering A Tepid Sponge Bath (TSB)
➢ Performing Bed Bath
➢ Shampooing Hair
➢ Performing Oral Care
➢ Providing Special Oral Care
➢ Changing A Hospital Gown For A Patient With An Intravenous Fluid
➢ Changing An Unoccupied Bed
➢ Changing An Occupied Bed
➢ Post Mortem Care
GENERAL OBJECTIVE:
➢ To provide each patient with hygiene according to individual needs, conditions, and preferences.
➢ To promote comfort and stimulate circulation.
➢ To prevent or eliminate body odors through hygiene
➢ To make beds that are both safe and comfortable for patients in healthcare setting.
➢ To care for the patient’s body after death in a skilled and respectful manner
LEARNING OUTCOMES
➢ Assess the patient effectively to determine the appropriate method for hygiene, considering culture,
developmental level, financial status, health status and personal preferences.
➢ Analyze assessment data to determine special problems or concerns regarding hygiene that must be
addressed to successfully complete hygiene practices.
➢ Plan the individual hygienic procedures for a specific patient according to the cultural preferences,
developmental level, financial status, health status and personal preferences.
➢ Implement and complete the hygiene procedures carried out and the patient’s comfort level.
➢ Document the hygiene practices completed, any special preferences, and abnormal findings while
performing hygiene for the patient.
➢ Assess the patient and type of bed to determine the appropriate bed making procedure.
➢ Complete the appropriate bed making technique, utilizing appropriate body mechanics and safety for
the nurse and the patient.
➢ Evaluate the effectiveness of the bed making procedure.
➢ Assess the patient to verify that vital functions have ceased.
➢ Analyze assessment data to determine special concerns that must be addressed in order to care for the
patient and family after the patient’s death.
➢ Plan post-mortem care based on patient and family wishes as well as standard hospital policies.
➢ Provide postmortem care with sensitivity and respect.
➢ Evaluate the effectiveness and document the postmortem care done.
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NAME: ______________________________________________ DATE: _________________________
ADMINISTERING A TEPID SPONGE BATH (TSB)

DEFINITION:
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PURPOSE:
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EQUIPMENT:
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Reduces anxiety; promotes
1. Explain procedure to patient.
compliance.
Provide privacy by closing windows Eliminates drafts, thus preventing
2.
and doors. chilling; provides privacy.
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Perform hand washing. Organize Reduces microorganism transfer;

3.
equipment, and apply gloves. promotes efficiency.
Lower side rails and position patient
4. Promotes comfort.
on his back.
Undress the patient while covering
5. the body with a bath blanket. Roll top Prevents chilling and protects privacy.
sheet to the bottom of the bed.
6. Place plastic pads under patient. Prevents linen soilage.
Fill basin with tepid water and place
7. washcloths and one towel in basin of Cools cloths and towel.
water.
Wring washcloths and place one in
each of the following areas:
Promotes rapid cooling due to
8. • Over forehead increased vascularity of these regions.
• Under armpits
• Over groin
Rewet and replace washcloths as
9. Maintains coolness of cloths.
they become warm.
Wring the wet towel and place around
10. Cools extremity.
one of patient’s arm.
Wring a washcloth and sponge the
other arm for 3 to 4 minutes. Repeat
11. Gradually cools extremity.
steps 10 and 11 with the opposite
arm.
Remove towel from arm and place in
basin, dry both arms thoroughly using Prepares towel for future use; prevents
12.
a dry towel, and replace light blanket chilling.
over body.
Continue by sponging and drying the
following areas for 3 to 5 minutes
each (you may use steps 9 to 11
when sponging legs):
• Chest
• Left leg
13. • Back To continue cooling patient’s body.
• Abdomen
• Right leg
• Buttocks
Note: Stop every 10 minutes to
reassess temperature and pulse in
order to assess the effectiveness of
treatment and prevent overcooling.
Observe for shivering, discomfort, or Can cause increase in core
14. agitation. If present, terminate
temperature.
procedure and notify the physician.
Check patient’s temperature and
15. Prevents complications related to
pulse.
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• If temperature is above 37.7 overcooling.

degrees Celsius (100 F), proceed
with bath (continue step 14).
• If temperature is 37.7 degrees
Celsius (100 F) or below,
terminate the procedure.
• If pulse rate is significantly
increased, terminate the
procedure for 5 minutes and
recheck; if it remains significantly
elevated, terminate procedure
and notify physician.
Remove all cloths and towels and dry Terminates treatment; promotes
16.
patient thoroughly. comfort.
17. Replace gown. Restores privacy.
Reposition patient for comfort and
18. Promotes comfort and safety.
raise side rails.
Properly discard all washcloths,
towels, plastic pads, and wet linens.
19. Maintains cleanliness of environment.
(If necessary, obtain dry linens and
remake bed.)
Remove and discard gloves and
20. Reduces microorganism transfer.
perform hand washing.
Document the procedure done, and
21. For continuous patient’s care.
changes in patient’s vital signs.
REMARKS:
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NAME: _____________________________________________ DATE: _________________________
PERFORMING BED BATH

DEFINITION:
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PURPOSE:
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EQUIPMENT:
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1. Some institution needs
doctor’s order for a procedure
Confirm doctor’s order. to be done.
Check patient identification and condition.
To determine if patient could
tolerate the procedure.
2. Gather the necessary equipment and then To promote efficiency of the
bring to the bedside. health procedure to be done.
3. Explain the purpose and procedure to the To promote patient’s
patient. cooperation and participation.
4. Perform hand washing. Don on gloves if To reduce spread of
necessary. microorganisms.
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5. Assess patient’s temperature, pulse, and

respiratory rate. Assess also other signs of To provide baseline data.
fever.
6. Provide privacy. Close all windows and doors. To allay fear and anxiety.
7. To transfer the heat through
Prepare warm water (60°C).
conduction.
8. Remove the patient’s cloth. Cover the patient’s
Blanket provides warmth and
body with a top sheet or blanket.
privacy.
9. Fill two basins about two-thirds full with warm Warm water promotes comfort
water (43-46 °C or 110-115 °F). and relaxation of muscles.
10. Pull side rails up and then assist the patient to
move toward the side of the bed where you To maintain patient safety.
will be working.
11.
To prevent shivering and
Face, neck, ears:
provide privacy.
a. Put mackintosh and big towel under the
patient’s body from the head to shoulders.
Place face towel under the chin. To protect the patient’s skin
b. Make a mitt with the sponge towel and from the nails of the health
moisten with plain water. care provider. Mitt retains
c. Wash the patient’s eyes. Cleanse from
water and heat than a loosely
inner to outer corner. Use a different
section of the mitt to wash each eye. held cloth.
d. Wash the patient’s face, neck, and ears.
e. Use soap on these areas only if the patient
Soap tends to dry the face
prefers.
f. Rinse and dry carefully. which is exposed to air more
than any other parts of the
body.
12. Upper extremities:
a. Move the mackintosh and big towel under
the patient’s far arm.
b. Uncover the far arm.
c. Fold the sponge cloth and moisten.
d. Wash the far arm with soap and rinse. Use To clean the upper
long strokes: wrist to elbow→ elbow to extremities.
shoulder→ axilla→ hand
e. Dry the area by face towel
f. Move the mackintosh and big towel under
the near arm and uncover it
Wash, rinse, and dry.
13. Chest and abdomen:
a. Move the mackintosh and bath towel
under the upper trunk.
b. Put another bath towel over the chest
To clean the chest and
c. Fold the sponge towel and moisten
abdomen.
d. Wash breasts with soap and rinse. Dry by
the big towel covering.
e. Move the bath towel covering the chest to
abdomen.
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f. Fold the sponge cloth and moisten.

g. Wash abdomen with soap, rinse and dry
h. Cover the trunk with top sheet and remove
the bath towel from the abdomen.
14. To use new and clean tap
Change the warm water.
water.
15. Lower extremities:
a. Move the mackintosh and bath towel
under the far leg. Put pillow or cushion
under the bending knee.
b. Cover the near leg with bath towel
c. Fold the sponge cloth and moisten.
d. Wash with soap, rinse and dry. To clean the lower extremities.
e. Direction to wash: from foot joint to knee→
from knee to hip joint
f. Repeat the same procedure on the near
side.
Cover the lower extremities with top sheet
Remove the cushion, mackintosh and big
towel
16. Back and buttocks:
a. Turn the patient on left lateral position with
back towards you.
b. Move the mackintosh and big towel under
the trunk.
c. Cover the back with big towel
To clean the back area and
d. Fold the towel and moisten. Uncover the
the buttocks.
back.
e. Wash with soap and rinse. Dry with big
towel
f. Back rub if needed ✽See our nursing
manual “Back Care”
g. Remove the mackintosh and big towel
17. Return the patient to supine position. To make the patient
comfortable
18. Do perineal care:
To clean the perineal area.
✽See our nursing manual for “Perineal care”
19. Assist the patient to wear clean cloth. To allow patient to have a
fresh and clean clothing.
20. After bed bath:
a. Make the bed tidy and keep the patient in To make the patient
comfortable position. comfortable.
Check the IV flow and maintain it with the To administer the prescribed
IV solution.
speed prescribed if the patient is given IV.
21. Document procedure and report any abnormal For legal purposes and for
findings. future references.
COMPLETED Yes No DATE OF SIGNED

COMPLETION
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NAME: _____________________________________________ DATE: _________________________
SHAMPOOING HAIR
DEFINITION:
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PURPOSE:
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EQUIPMENT:
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Assess the hair and scalp prior to initiating To obtain baseline and data and to
1
the procedure. plan for appropriate care
Prepare the equipment needed and bring to
2 Promotes efficiency.
bedside.
Explain the procedure to the patient. Promotes understanding and
3
cooperation.
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Remove pillow. Have the patient lie on his

4 back. Position patient with head and Facilitates the procedure.
shoulders near edge of bed.
Place a linen protector or rubber draw sheet To protect the bed from becoming wet
5 under the Patient’s head. and to facilitate draining off of water
and shampoo.
Put the inflated Kelly pad on top of the
Provides a place to shampoo the hair
rubber draw sheet with one end extending
6 without getting the bed wet as well as
to the receptacle for water. Position
means of removing the water.
patient’s head comfortably over the pad.
Place a towel around the patient’s shoulder
7 To keep the shoulders and chest dry.
and neck.
Fanfold the top bedding down the waist and
8 cover the upper part of the patient with bath To provide warmth for the patient.
blanket.
9 Offer a towel to patient to cover eyes. Shampoo may irritate the eyes.
Place dry cotton balls in both ears. Prevents the water from entering the
10
ears.
11 Wet hair thoroughly with warm water.
Apply small amount of shampoo to the
scalp. Make a good lather while massaging
Massaging the scalp promotes
12 the scalp with the pads of your fingertips
circulation to the scalp.
starting at the front toward the back of the
head.
Rinse hair thoroughly and apply conditioner Rinsing well removes all shampoo that
13 if desired. may cause drying and irritation if left in
the hair.
Dry the patient’s hair, ears and neck with a Thorough drying promotes warmth and
14
towel. comfort.
Remove the damp towel, cotton balls and
15
Kelly pad.
Comb the hair and allow the patient to
16 For patient’s comfort.
assist if able.
Position the patient comfortably. Place
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pillow under the head.
Remove the bath blanket and pull the top
18 Provides warmth and comfort.
sheet over the patient’s chest.
Clean all the equipment used before
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returning it to their proper places.
Wash hands and document assessment
20
findings.
REMARKS:
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NAME: _____________________________________________ DATE: _________________________
PERFORMING ORAL CARE

DEFINITION:
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PURPOSE:
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EQUIPMENT:
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Assemble articles for brushing and
1 Promotes efficiency.
flossing.
2 Provide privacy. Prevents embarrassment.
Place patient in a sitting or high-Fowler’s
3 position. If patient cannot sit, place him in Decreases risk of aspiration.
side lying position.
4 Arrange articles within patient’s reach. Facilitates self-care.
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Place towel across the patient’s chest. If

the patient is in lying position, place a towel Prevents spillage and promotes
5
and a rubber draw sheet under the comfort.
patient’s head.
Wash hands and don gloves. Reduces microorganism transfer and
6
exposure to body fluids.
Inspect the integrity of the lips, teeth, To obtain baseline data and plan for
7
buccal mucosa, gums, palate and tongue. appropriate care.
Assist patient with brushing as necessary. Brushing decreases microorganism
8 Position mirror and kidney basin near the growth in mouth. Use of mirror permits
patient for use during activity. cleaning back and sides of teeth.
Brush patient’s teeth if he/she is unable to
perform self-care.
a. Hold the brush against the teeth with the
bristles at a 45-degree angle.
b. Move the bristles back and forth and in
9 To maintain oral hygiene.
circular motion until all the outer and inner
surfaces of the teeth and gums are
cleaned.
c. If the tongue is coated, brush it gently
with the toothbrush.
Assist patient in rinsing mouth. Give water. Removes toothpaste and oral
10
Allow patient to spit in the kidney basin secretions.
Remove the kidney basin and help the
11 Promotes comfort.
patient in wiping his/her mouth.
Remove gloves. Return equipment to Prevents the transmission of
12
proper place and wash hands. microorganisms.
Document assessment of teeth, tongue,
gums and oral mucosa, including any Proper documentation of findings for
13
problems such as sores or inflammation appropriate plan of care.
and swelling of the gums.
REMARKS:
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NAME: ______________________________________________ DATE: _________________________
PROVIDING SPECIAL ORAL CARE

DEFINITION:
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PURPOSE:
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EQUIPMENT:
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Assemble equipment after washing Prevents contamination and
1
hands. promotes efficiency.
2 Explain the procedure to the client. Demonstrates respect for the client
Position the unconscious patient in a
side-lying position with head of the bed
3 Prevents aspiration.
lowered. If the head of the patient
cannot be lowered, turn it to side.
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To prevent soiling of patient’s

4 Place a towel under the patient’s chin.
gown.
5 Don gloves For infection control
To obtain baseline data and plan
6 Inspect mouth and teeth.
for appropriate care.
Place the kidney basin against the
7 patient’s chin and lower cheek to
receive the fluid from the mouth.
Brush teeth, tongue and mouth Decrease microorganism growth in
8
surfaces. mouth.
Rinse the mouth by drawing about 30
ml (1oz of water) into a syringe and
inject it gently into each side of the Promotes removal of toothpaste
9
mouth. Allow the water to drain into the and water to prevent aspiration.
kidney basin by gravity or use a rubber-
tipped syringe or suction to aspirate it.
Inspect the mouth. If tissues appear dry
or unclean, clean them with cotton
10 Facilitate thorough oral cleaning.
tipped-applicators or gauze and
cleansing solution.
Using separate applicators, clean all
mouth tissues—the cheeks, roof of the
11 To clean the entire mouth.
mouth and tongue. Rinse as
necessary.
12 Remove kidney basin and towel.
Wipe the patient’s mouth and lubricate Prevent dryness of lips and
13
the lips with petroleum jelly. promote comfort.
Remove gloves and discard. Wash
14 hands and return equipment to proper For infection control.
place.
Document all assessment findings and
15 For legal purposes.
procedure done.
COMPLETION
REMARKS:
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NAME: _____________________________________________ DATE: _________________________
CHANGING A HOSPITAL GOWN FOR A PATIENT WITH AN INTRAVENOUS FLUID
DEFINITION:
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PURPOSE:
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EQUIPMENT:
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This saves time and effort,
1. Gather all necessary equipment at bedside.
and for an orderly procedure.
To prevent spread of
2. Do hand washing and don on clean gloves.
microorganism.
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3. Place the patient in supine position. To facilitate the procedure.

To identify unusual changes
4. Inspect the intravenous site and the arm. thus prevents possible
complications.
5. Count the flow rate of the infusion. This serves as baseline data.
6. Cover the patient with a blanket or top sheet. To maintain privacy.
Ask the patient to turn to side and untie the
strings of the patient’s gown at the back. Assist
To facilitate removing of the
7. patient to lie on his back and slip the soiled
gown.
gown off the patient’s shoulder and arm on the
side without the IVF.
Carefully slide the other sleeve off the shoulder,
over the arm, IV catheter and IV tubing. Remove
To prevent injury and to
the container of fluid from the IV stand and slide
8. facilitate removing of the
the gown over the fluid container, keeping the
gown.
container higher than the infusion site at all
times.
Remove the patient’s gown carefully under the
To maintain clean
9. top sheet and place the soiled gown in the
environment.
appropriate receptacle.
Gown the patient by placing the sleeve of the
clean gown over the IV fluid container. Rehang
the fluid container and slide the gown over the To facilitate changing of new
10.
tubing and arm with the intravenous catheter in gown to the patient.
place. Position the gown over the patient’s
shoulder appropriately.
Place the clean gown over the opposite arm and To facilitate changing of new
11.
shoulder. gown to the patient.
Assist the patient to turn to side and tie the
12. To secure the gown.
gown appropriately at the back.
Place patient in lying position and assist in To promote comfort to the
13.
adjusting the gown under the covers. patient.
To make sure that it is within
the prescribed flow, thus
14. Count the rate of flow of the infusion.
prevents possible
complications.
REMARKS:
________________________________________________________________________________________
________________________________________________________________________________________
24
NAME: ______________________________________________ DATE: _________________________
CHANGING AN UNOCCUPIED BED

DEFINITION:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
PURPOSE:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
EQUIPMENT:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
This prevents the spread of
1. Perform hand washing.
microorganism.
Gather all the necessary equipment.
To save time and effort; for an
2. Arrange on a chair by the bedside in the
orderly procedure.
order in which items will be used.
Raise the bed to an appropriate working For proper body mechanics;
3. height. Don on gloves if handling soiled prevents cross-contamination via
linens. soiled linen.
Place a chair at the foot of the bed and Securing the bed is important to
4.
lock the bed. Remove pillowcases, and avoid injury.
25
place pillows on a chair or at the bedside

table.
Loosen all bedding systematically, starting Moving around the bed
at the head of the bed on the far side and systematically prevents stretching
5.
moving around the bed up to the head of and reaching and possible muscle
the bed on the near side. strain.
Folding linens saves time and
Fold reusable linens, such as the
6. energy when reapplying the linens
bedspread and top sheet on the bed.
on the bed and keeps them clean.
This prevents cross-
Remove the waterproof pad and discard it
7. contamination via soiled
if soiled.
pad/linen.
Roll all soiled linen inside the bottom These actions are essential to
sheet, hold it away from your uniform. prevent the transmission of
8.
Place it directly on the hamper and not on microorganisms to the nurse and
the floor. others.
9.I Remove gloves and do handwashing.
microorganism.
Place the folded bottom sheet with its
center fold on the center of the bed.
Spread the sheet out over the mattress, The top of the sheet needs to be
and allow a sufficient amount of sheet at well tucked under to remain
10.
the top to tuck under the mattress. Place securely in place, especially when
the sheet along the edge of the mattress at the head of the bed is elevated.
the foot of the bed and do not tuck it in
(unless contour or fitted sheet).
Miter the sheet at the top corner on the
near side and tuck the sheet under the
mattress, working from the head of the bed
to the foot. To miter the corner:
a. Pick up the selvage edge with your
hand nearest the head of the bed.
b. Lay a triangle over the side of the bed
c. Tuck the hanging part of the sheet
11. This secures sheet to the bed.
under the mattress.
d. Drop the triangle over the side of the
bed.
e. Tuck the sheet under the entire side of
bed.
If waterproof draw sheet is used, place it If the patient soils the bed, the
over the bottom sheet so that the draw sheet and pad can be
12.
centerfold is at the centerline of the bed changed without the bottom and
and the top and bottom edges extend from top linens on the bed. Having all
26
the middle of the patient’s back to the area bottom linens in place before
of the mid-thigh or knee. Fanfold the tucking them under the mattress
uppermost half of the folded draw sheet at avoids unnecessary moving about
the center or far edge of the bed and tuck the bed. A draw sheet can aid
in the near edge. moving the patient in bed.
Lay the cloth draw sheet over the A draw sheet can aid in moving
13.
waterproof sheet in the same manner. the patient in bed.
Optional: Before moving to the other side
Completing one entire side of the
of the bed, place the top linens on the bed
14. bed at a time saves time and
hem side up, unfold them, tuck them in,
energy.
and miter the bottom corners.
Move to the other side and tuck in the
bottom sheet under the head of the This secures sheet to the bed;
mattress, pull the sheet firmly, and miter wrinkles can cause discomfort for
15.
the corner of the sheet. Pull the remainder the patient and breakdown of
of the sheet firmly so that there are no skin. Tuck the sheet in at the side.
wrinkles.
Complete this process for the draw
16. For an orderly procedure.
sheet/s.
Place the top sheet, hem side up, on the
bed so that its center-fold is at the center
This ensures appropriate
17. of the bed and the top edge is even with
coverage.
the top edge of the mattress. Unfold the
sheet over the bed.
Optional: Make a vertical or a horizontal
toe pleat in the sheet.
a. Vertical toe pleat: Make a fold in the
sheet 5 to 10 cm (2 to 4 inches) This provides additional room for
18.
perpendicular to the foot of the bed. the patient’s feet.
b. Horizontal toe pleat: Make a fold in the
sheet 5 to 10 cm (2 to 4 inches) across
the bed near the foot.
Follow the same procedure for the blanket
and the bed spread, but place the top
19. edges about 15 cm (6 inches) from the
For an orderly procedure.
head of the bed to allow a cuff of sheet to
be folded over them.
Tuck in the sheet, blanket, and bed spread
at the foot of the bed, and miter the corner,
This ensures appropriate
using all three layers of linen. Leave sides
20. coverage; secures sheets to the
of the top sheet, blanket, and bed spread
bed.
hanging freely unless toe pleats were
provided.
The cuff of sheet makes it easier
Fold the top of the top sheet down over the
21. for the patient to pull the covers
spread, providing a cuff.
up.
27
Move to the other side of the bed and

22. secure the top bedding in the same For an orderly procedure.
manner.
Grasp the closed end of the pillowcase at
the center with one hand. Gather up the
sides of the pillowcase and place them
over hand grasping the case. Then grasp
the center of one short side of the pillow
through the pillowcase.
23. This completes bed preparation.
With the free hand, pull the pillowcase over

A smoothly fitting pillowcase is
the pillow. Adjust the pillowcase so that the
24. more comfortable than a wrinkled
pillow fits into the corners of the case and
one.
the seams are straight.
Place the pillows appropriately at the top of
25.
the bed.
For a Closed Bed: Place pillow on bed Preserves bed when patient is out
26. with open end facing the wall or place of room for extended period or
pillow on the bedside table. when new patient is expected.
For Open Bed: Pull top of sheet (and
Prepares bed for patient when
27. blanket) to head of bed and fanfold both
return is expected momentarily.
back neatly to bottom third of the bed.
Facilitates moving patient from
For Post-operative Bed: Make an open
stretcher to bed without prolonged
bed but do not tuck top sheet and blanket,
exposure of draft; prevents
leaving top sheet and blanket fan-folded to
28. interference of patient transfer to
the side of bed opposite door. After patient
bed by bed linens and makes
is transferred to bed, pull covers across
covering the patient easy. This
bed and tuck and miter at bottom.
secures the linen on bed.
Dispose of soiled linens according to
29. microorganism and cross-
hospital policy.
contamination.
To prevent the spread of
30. Do hand washing.
microorganism.

REMARKS:
________________________________________________________________________________________
________________________________________________________________________________________
28
________________________________________________________________________________________
A. Closed Bed
B. Open Bed
C. Post-operative Bed
29
NAME: _____________________________________________ DATE: _________________________
CHANGING AN OCCUPIED BED

DEFINITION:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
PURPOSE:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
EQUIPMENT:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
This promotes reassurance, thus
1. Explain procedure to the client. gains trust and cooperation of the
patient.
30

Perform hand washing and put on
2. microorganism, and cross-
disposable gloves if linen is soiled.
contamination via linens.
Privacy is a fundamental right of
every patient. This promotes trust
3. Provide privacy.
and gains patient’s cooperation
throughout the procedure.
Remove any equipment attached to the Disconnecting tubes from linens
4. bed linen, such as a signal light or any prevents discomfort and accidental
tubes/drain. dislodging of tubes.
Loosen all the top linen at the foot of the
5. bed, and remove the bed spread and This facilitates the removal of linens.
the blanket.
Leave the top sheet over the patient or
replace it with a bath blanket as follows:
a. Spread the bath blanket over the
top sheet, and then ask the patient
to hold the top edge of the blanket. The top sheet can remain over the
b. Reaching under the blanket from
6. patient if it is being changed and if it
the side, grasp the top edge of the
sheet and draw it down to the foot will provide surface warmth.
of the bed, leaving the blanket in
place.
c. Remove the sheet from the bed
and place it in the soiled linen
hamper.
7. Raise the side rail nearest the patient. If
there is no side rail, have another nurse
This protects the patient from falling.
support the patient at the edge of the
bed.
8. Assist the patient to turn on the side
This facilitates easy and proper way
facing away from the side where the
of changing the old linens.
clean linen is.
9. Loosen the foundation of the linen on
the side of the bed near the linen
supply. Fanfold the draw sheet and the Doing this leaves the near half of the
bottom sheet at the center of the bed, bed free to be changed.
as close to and under the patient as
possible.
10. Place the new bottom sheet on the bed,
and vertically fanfold the half to be used
on the far side of the bed as close to the Centering the sheet ensures
patient as possible. Tuck the sheet sufficient coverage for both sides of
under the near half of the bed and miter the mattress.
the corner if a contour sheet is not being
used.
31
11. Place clean draw sheet on the bed with

If the patient soils the bed, the draw
the centerfold at the center of the bed.
sheet and pad can be changed
Fanfold the uppermost half vertically at
without the bottom and top linens on
the center of the bed and tuck the near
the bed. A draw sheet can aid
side edge under the side of the
moving the patient in bed.
mattress.
12. Assist the patient to roll over toward you
This ensures safety; the movement
onto the clean side of the bed. The
allows the bed to be made on the
patient rolls over the fanfold linen at the
other side.
center of the bed.
13. Move the pillows to the clean side for
This promotes comfort; protects
the patient’s use. Raise the side rails
patient from falling.
before leaving the side of the bed.
14. Move to the other side of the bed and To facilitates easy and orderly
lower the side rail. changing of linens.
15. Remove the used linen and place it in This prevents cross-contamination
the portable hamper. via soiled linens.
16. Unfold the fan-folded bottom sheet from
the center of the bed. Facing the side of
This removes wrinkles and creases
the bed, use both hands to pull the
in the linens, which are
bottom sheet so that it is smooth and
uncomfortable to lie on.
tuck the excess under the side of the
mattress.
17. Unfold the draw sheet fan-folded at the
center of the bed and pull tightly with
both hands. Pull the sheet in three
This facilitates easy and orderly
sections:
changing of linens; this removes
a. Face the side of the bed to pull the
wrinkles and creases in the linens,
middle section.
b. Face the far top corner to pull the which are uncomfortable to lie on.
bottom section, and
c. Face the far bottom corner to pull
the top section.
18. Tuck the excess draw sheet under the
This secures sheets to the bed.
side of the mattress.
19. Reposition the pillow in the center of the
bed, and then assist the patient to the
This ensures safety; and promotes
center of the bed. Determine what
patients comfort.
position the patient requires or prefers
and assist the patient to that position.
20. Spread the top sheet over the patient
This allows bottom hems to be
and either ask the patient to hold the top
tucked securely under the mattress
edge of the sheet or tuck it under the
and provides for privacy.
shoulders. The sheet should remain
32
over the patient when the bath blanket

or used sheet is removed.
21. Secure top linens under the foot of the
mattress and miter corners. Loosen top
This provides for a neat appearance.
linens over the patient’s feet by grasping
Loosening linens over the patient’s
them in the area of the feet and pulling
feet gives more room for movement.
gently toward the foot of the bed.
22. Raise side rails. Place the bed in the
low position before leaving the bedside This provides for the patient’s safety.
unless contraindicated.
23. Attach the signal cord to the bed linen
This provides for the patient’s safety.
within the patient’s reach.
24. Put items used by the patient within
This prevents patient from falling.
easy reach.
25. Dispose the soiled linens according to This prevents cross-contamination
hospital policy. via soiled linens.
26. This prevents the spread of
Perform hand washing.
microorganisms.
REMARKS:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
33
NAME: ______________________________________________ DATE: _________________________
POST MORTEM CARE

DEFINITION:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
PURPOSE:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
EQUIPMENT:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Check vital functions and if permitted to A registered medical practitioner who
1. so, pronounce patient’s death. Notify has attended deceased person
physician and record time of death and during the last illness is required to
34
time pronounce dead. give a medical certificate of the

cause of death. The certificate
requires the doctor to state the last
date on which he or she saw the
deceased alive and whether or not
he/she has seen the body after
death.
Only registered medical practitioner
Notify the following: nursing supervisor, can certify death. Nurses who have
admitting or census department, adjusted their scope of practice and
2. appropriate agency for organ been assessed as competent to do
procedures, medical examiner, and so may confirm/verily death in
designated mortician. accordance with agreed trust
procedure.
Inform the patient’s relatives or next of
kin of the patient’s death if not present.
Prepare them sensitively for changes
3. Ensure that this kin is handled in a
to the body.
sensitive and appropriate manner with
as much as privacy as possible.
Ask if the relatives wish to contact an
appropriate religious leader or other
This promotes respect for patient’s
4. appropriate person to the person’s faith
religious/cultural practices.
or ethnic origins that need to be
attended to immediately.
To prevent interruptions of the
5. Gather all necessary equipment.
procedure once commenced.
This prevents the transmission of
Perform hand washing and put on microorganism; wearing protective
6.
disposable gloves and gown. clothing reduces the risk of
contamination with body fluids.
To maintain the patient’s dignity and
Lay the patient on his/her back with one
for future management of the body
7. pillow in place. Straighten body and
as rigor mortis occurs 2 – 6 hours
limbs in supine position with bed flat.
after death.
To maintain patient’s dignity and for
Gently close patient’s eyes if open by
aesthetic purposes. Closure of eyes
applying light pressure for 30 seconds.
will provide tissues protection in case
8. In case of corneal or eye donation,
of corneal donation. Moistened
close the eye with gauze moistened with
gauze prevents the eyes from drying
normal saline. Do not apply tape.
out.
Remove watch, jewelry and all
9. possessions. Give it to the nearest
relative.
35
Removing such attachment from the

Remove IV line and other tubes unless
10. patient if a death is suspicious could
autopsy is to take place.
destroy evidence.
Place disposable pads to the perianal
area to absorb any stool or urine
The body can continue to excrete
11. released as the sphincter muscle
fluids after death.
relaxes. Drain the bladder by gently
pressing on the lower abdomen.
The dressing will absorb any leakage
from the wounds and provide
Exuding wounds should be covered with
protection from any staff coming into
12. absorbent gauze and secured with an
contact with the body. If post mortem
occlusive dressing.
is required existing dressings should
be left in place and covered.
Wash the patient if necessary, unless
For hygienic and aesthetic reasons.
requested not to do so for
13. Washing of a patient if a death is
religious/cultural reasons or patient has
suspicious could destroy evidence.
died in suspicious circumstances.
Clean the patient’s teeth and gums
using a moistened, soft toothbrush or This provides comfort and patient’s
14.
suction to remove any debris and dignity after death.
secretions.
Clean any dentures and replace them in
For hygienic and aesthetic reasons.
the mouth. Keep the jaw closed and
If dentures cannot be replaced send
15. teeth in place by placing a small pillow
them with the body in a clearly
or rolled up towel under the patient’s
identified receptacle.
chin.
Tidy the hair as soon as possible after
This guides funeral directors for final
16. death and arrange into the preferred
presentation.
style (if known).
Shaving a deceased person when
Patients should not be shaved; usually a
they are still warm can cause
17. funeral director will do this. Some faiths
bruising and marking, which only
prohibit shaving.
appear days later.
Leave the wrist identification band in
place. If the deceased person has a
18. known infectious disease (CATEGORY Infection control policy.
3), you must inform anyone else who
comes in contact with this patient.
Attach a second identification tag to the This provides patient’s proper
19.
ankle or great toe. identification.
20. If the body is to be viewed, replace top This promotes patient’s privacy and
36
linens and tidy the unit. dignity as a patient.

Wrap the body and attach identification This provides patient’s proper
21.
tag on outside, if facility policy indicates. identification.
Transport body to facility morgue or wait This facilitates proper endorsement
22.
for the arrival of the mortician. and transfer of patient after death.
Put away or dispose equipment and
23. supplies used according to the hospital Infection control policy.
policy.
Remove gloves and apron. Dispose
24. according to hospital policy and perform
microorganism.
hand washing.
Document Post Mortem activities
including:
• Time of cessation of Vital Signs.
• Persons notified and time of
notification. For legal purposes and proper
25. • List and documentation of valuable documentation of care.
and personal effects.
• Time body removed from unit,
destination and by whom removed.
• Other information required by
facility.
REMARKS:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
37
III. MOBILITY AND SAFETY
PROCEDURES:
➢ Using Principles Of Body Mechanics
➢ Transferring/Transporting Clients
➢ Positioning
GENERAL OBJECTIVE:
➢ To apply principles of body mechanics to conserve energy, decrease potential for strain, injury and
fatigue and promote safety.
➢ To transfer a patient from a bed to a chair, wheelchair, commode or stretcher with maximum comfort
and safety for the patient and nurse.
➢ To move and position a patient in bed using good body mechanics
LEARNING OUTCOMES
➢ Examine each physical task encountered to determine the most appropriate way to accomplish it for the
safety of the nurse and that of the patient.
➢ Apply principles of body mechanics appropriately.
➢ Teach use of body mechanics to patients, family members, and assistive personnel to ensure correct
body movement and to prevent musculoskeletal injury.
➢ Analyze the use of body mechanics during activity.
➢ Evaluate own or patient body movement in specific situations.
➢ Assess a patient’s ability to move, bear weight and maintain balance.
➢ Plan an effective transfer technique for the patient.
➢ Position the patient in anatomically correct and effective position as well as comfortable or required for
examination and therapy.
➢ Carry out a variety of different transfer techniques safely.
➢ Use appropriate selected lift devices to assist in the transfer of the patient.
➢ Evaluate the effectiveness of the transfer technique and document the procedure transfer technique
and positioning in the patient’s plan
38
NAME: ______________________________________________ DATE: _________________________
USING PRINCIPLES OF BODY MECHANICS

DEFINITION:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
PURPOSE:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
EQUIPMENT:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
A. PRINCIPLES WHEN HANDLING EQUIPMENT, AND WHEN MOVING, LIFTING, TURNING,
AND POSITIONING CLIENT.
1. Stand with back, neck, shoulders,
Maintains proper body alignment.
pelvis, and feet in as straight a line as
39
possible; knees should be slightly

flexed and toes pointed forward.
2. Keep feet apart to establish broad
Provides greater stability.
support base; keep feet flat on floor.
3. Flex knees and hips to lower center of
Establishes more stable position;
gravity (heaviest area of body) close to
prevents pulling on spine.
object to be moved.
4. Move close to object to be moved or Promotes use of large muscles of
adjusted; do not lean or bend at waist. extremities rather than of spine.
5. Use smooth, rhythmic motions when
Prevents improper alignment and
using bed cranks or any equipment
inefficient muscle use.
requiring a pumping motion.
6. Use arm muscles for cranking or
Avoids use of spine and back
pumping and arm and leg muscles for
muscles.
lifting.
7. Secure tubes, drains, traction, and
other equipment by whatever means
Prevents dislodgement of tubes and
are needed for proper functioning
reflux of contaminants into body.
during moving, lifting, turning, and
positioning.
8. Move client close to edge of bed in one
unit or move client to side of bed at any
time during procedure, moving one unit
of the body at a time from top to bottom
Maintains correct alignment;
or vice versa (i.e., head and shoulders
facilitates comfort; prevents physical
first, trunks and hips second, and legs
injury.
last). Coordinate move so everyone
exerts greatest effort on count of three;
the person carrying the heaviest load
should direct the count.
B. PRINCIPLES WHEN MOVING A HEAVY OBJECT OR CLIENT.
9. Review each move again before move
Reinforces original plan.
is made.
10. Allows full use of arm and leg
Face client or object to be moved.
muscles.
11. Place hands or arms fully under client
or object; lock hands with assistant on Provide extra leverage.
opposite side, if necessary.
12. Prepare for move by taking in a deep Facilitates use of large muscle
breath, tightening abdominal and groups; prevents injury to arms
gluteal muscles, and tucking chin during move and centers client’s
toward chest. (If client cannot provide weight.
40
assistance, instruct client to cross arms

on chest).
13. Prevents fatigue and subsequent
Allow adequate rest periods, if needed.
physical injury.
14. When performing a move, keep
heaviest part of the body within base of Promotes stability.
support.
15. Perform pulling motions by leaning
backward and pushing motions by
leaning forward, maintaining wide base
support with feet, keeping knees flexed Prevents injury to vertebrae and
and one foot behind the other; push back muscles.
and pull (instead of lifting, whenever
possible) using muscles of the arms,
legs, not back.
16. Always lower head of bed as much as
Avoids pulling against gravity.
permissible.
17. When moving from a bending to a
standing position, stop momentarily
once in standing position before
Allows time to straighten spine and
completing next move. When getting
re-establish stability.
client into a chair, stop to allow client
and self to stand to establish stability
before pivoting into chair.
18. Move in as straight and direct a path as
Avoids vertebral and back injury
possible, avoiding twisting and turning
related to rotating and twisting spine.
of spine.
19. When turning is unavoidable, use a
pivoting turn; when positioning client in Avoids twisting of spine and possible
chair or carrying client to a stretcher, muscle strain.
pivot toward chair or stretcher together.
REMARKS:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
41
NAME: _______________________________________ DATE: ________________________________
TRANSFERRING/TRANSPORTING CLIENTS
DEFINITION:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
PURPOSE:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
EQUIPMENT:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
1. Client identification validates the
Identify the client and explain the
correct patient and correct
procedure.
procedure. Discussion and
42
explanation help allay anxiety and

prepare the client for what to
expect.
2. Hand hygiene and gloving
Perform hand washing and put on gloves, if
prevent the spread of
necessary.
microorganisms.
3. This provides clients privacy
Close the door or curtains.
during the procedure.
A. ASSITING CLIENT TO A SITTING POSITION IN BED
4. Proper bed height helps reduce
Adjust the bed at an appropriate and
back strain while you are
comfortable working height.
performing the procedure.
5. Place client flat on bed or as low as the Flat position helps to decrease
client can tolerate with arms on the side, the gravitational pull of the upper
and palms facing downwards. body.
6. Removing pillows from under the
client facilitates movement;
Place a pillow at the head of the bed and
placing pillow at the head of the
remove all other pillows.
bed prevents accidental head
injury against the top of the bed.
7. Client can use major muscle
groups to push. Even if the client
Ask the client (if able) to bend his or legs
is too weak to push on the bed,
and put his or her feet flat on the bed to
placing the legs in this fashion will
assist the movement.
assist with movement and prevent
shearing of the skin on the heels.
8. Doing such positions opposite the
Position yourself at the client’s midsection
center of the body mass, lowers
with your feet spread, shoulder width apart
the center of gravity, and reduces
and one foot slightly in front of other.
the risk for injury.
9. Place your arm that is nearest to the
client’s shoulders over the client’s This facilitates easy, safe and
shoulders resting between the shoulder orderly steps in assisting client to
blades. Place the other hand near the edge a sitting position.
of the bed by the client’s shoulder.
10. Push the hand that is by the edge of the This facilitates easy, safe and
bed and pull the client towards you. Assist orderly steps in assisting client to
lifting the client in a sitting position. a sitting position.
11. Assist the client to a comfortable position
Readjusting the bed with supports
and readjust the pillows and supports as
and side rails ensures client
needed. Raise the side rails. Place the bed
safety and comfort.
in the lowest position.
B. ASSISTING A CLIENT TO A SITTING POSITION ON THE EDGE OF THE BED
43
12. Proper bed height and positioning

Place the bed in the lowest position. Raise
facilitate an easy and safe
the head of the bed slowly, and as high as
changing of position into a sitting
the client can tolerate.
position.
13. Encourage the client to make use of a
stand-assisting aid attached to the side of
the bed, if available, to move to the side of Encourages independence,
the bed and to a side-lying position, facing reduces strain for the nurse, and
the side of the bed the client will sit on. decreases risk for client injury.
Turn the client facing you. Place the client’s
lower legs and feet at the edge of the bed.
14. Stand near the client’s hips. Stand with The nurse center of gravity is
your legs and shoulder width apart with one placed near the client’s greatest
foot near the head of the bed, slightly in weight to safely assist the client to
front of the other foot. a sitting position.
15. Place one arm around the client’s This facilitates easy, safe and
shoulders and the other arm under the orderly steps in assisting client to
client’s thigh near the knees. a sitting position.
16. Encourage the client to make use of the
Gravity lowers the client’s legs
stand-assisting device. Assist the client to
over the bed. The nurse transfers
sit up on the side of the bed by lifting the
weight in the direction of motion
client’s thighs and gently turning the client
and protects his or her back from
on the edge of the bed. Keep your back
injury.
straight and avoid twisting.
17. Let the client dangle his legs on the edge of This allows the circulatory system
the bed. to adjust to a change in position.
C. TRANSFERRING CLIENT FROM BED TO WHEELCHAIR
18. Make sure the bed brakes are locked. Put
the wheelchair next to the bed, facing the Locking brakes or bracing the
foot of the bed. If available, lock the brakes chair prevents movement during
of the chair. If the chair does not have transfer and increases stability
brakes, brace the chair against a secure and the client safety.
object.
19. Place the bed in the lowest position. Raise
the head of the bed to a sitting position, or Proper bed height and positioning
as high as the client can tolerate. Lower facilitate the transfer.
side rails.
20. Assist the client in a side-lying position, Encourages independence,
facing the side of the bed where the chair reduces strain for the nurse, and
is. decreases risk for client injury.
21. The nurse center of gravity is
Stand with legs apart with one foot forward
placed near the client’s greatest
near the head of the bed.
weight to safely assist the client to
44
a sitting position.
22. Assist the client in sitting at the edge of the
bed. Let legs dangle for a few minutes.
The sitting position facilitates

transfer to the chair and allows
the circulatory system to adjust to
a change in position.
23. This position provides stability

Stand facing the client. Spread your feet
and allows for smooth movement
about shoulder width apart and flex your
using the legs’ large muscle
hips and knees.
groups.
24. Position yourself as close as possible to
Doing so provides balance and
the client, with your foot positioned on the
support.
outside of the client’s foot.
25. Place your hands around the client’s waist.
Place the client’s one hand on your
shoulder, and the other hand on your waist.
Holding at the gait belt prevents

injury to the client.
26. Ask the client to slide his buttocks to the This action facilitates easy and
edge of the bed until the feet touch the safe transfer of client from bed to
floor. wheelchair.
27. On the count of three, use your legs (not
your back) to help raise the client to a
standing position; turn the client with his This action facilitates easy and
back to the chair. safe transfer of client from bed to
wheelchair. If indicated brace your
front knee against the client’s
weak extremity as he or she
stands to prevent from buckling
and falling.
28. Ask the client to walk backwards until he This ensures proper positioning
feels the chair with the back of his legs. before sitting.
29. Tell the client to grasp the arms of the chair Flexing hips and knees uses
and gently lower the client into the chair. major muscle groups to aid in
45
Flex your hips and knees when helping the movement and reduce strain on
client sit in the chair. the nurse’s back.
30. This ensures safety and comfort
Place feet on the foot rest of the
for the client while on the chair.
wheelchair. Make client comfortable and
Blanket provides warmth and
drape if necessary.
privacy.
D. TRANSFERRING CLIENT FROM BED TO STRETCHER
31. Adjust the head of the bed to a flat position Proper positioning facilitates the
or as slow as the client can tolerate. transfer.
32. Proper bed height and lowering
Raise the bed to a height ½ inch higher
the side rails makes transfer
than the transport stretcher. Lower the side
easier and decreases the risk for
rails, if in place.
injury.
33. A draw sheet supports the client’s
weight, reduces friction during the
Loosen the draw sheet or place a lifter lift, and provides for a secure
under the client. Roll the sheet close to the hold. A lifter board makes it easier
client’s body. to move the client and minimizes
the risk for injury to the client and
nurses.
34. Positioning equipment makes the
Position the stretcher next to and parallel to transfer easier and decreases the
the bed. Lock the wheels on the stretcher risk for injury. Locking the wheels
and the bed. keeps the bed and stretcher from
moving.
35. This position facilitates safe
Have the client fold arms against chest and
transfer of the client from bed to
move chin to chest.
stretcher.
36. Let the assistant stand across the middle of
Doing so supports head, upper,
the stretcher and grasp the other rolled end
and lower parts of the client’s
of the sheet by the client’s head part and
body.
lower hip area.
37. Climb onto the mattress beside hips and
buttocks of the client. Grasp the rolled
sheet by the shoulder part and hip area of
the client.
This facilitates easy, safe and

comfortable transfer of client from
bed to stretcher.
38. On the count of three, let the nurse Working in unison distributes the
46
standing on the stretcher side of the bed work of moving the client and
pull the sheet, while the nurse kneeling on facilitates the transfer.
the bed should lift the draw sheet,
transferring the client’s weight toward the
transfer board, and pushing the client from
bed to stretcher.
39. Remove the transfer board (if used), then
then raise the side rails of the stretcher.
This ensures client safety.
Transfer any IVFs to the IV pole of the
stretcher.
40. Place client comfortably on the stretcher, Blanket promotes comfort,
and drape properly. warmth and privacy.
41. This prevents the spread of
Remove gloves and perform hand washing.
microorganisms.
REMARKS:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
47
NAME: _____________________________________________ DATE: _________________________
POSITIONING
DEFINITION:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
PURPOSE:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
EQUIPMENT:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
1. Supine For physical examination, resting in bed,
Lying on the back with arms at undergoing anesthesia.
sides.
2. Prone To improve oxygenation in patients with

Lying on stomach with head turned acute respiratory distress.
48
to the side. To relieve pressure on the back, coccyx,

and hips.
3. Dorsal recumbent For physical examination of abdomen and
Lying on the back with arms at genitalia, perineal care and examination
sides, legs apart, knees bent, and during labor.
feet flat on the bed.
4. Trendelenburg During some abdominal surgeries to shift
Lying on back with arms at sides, abdominal contents upward.
bed positioned so foot part of the
bed is higher than the head part.
5. Reverse Trendelenburg After certain angiography procedures,
Lying on back with arms at sides, allows head of bed to be elevated without
bed positioned so that head part of causing pressure on the femoral artery.
the bed is higher than foot part, but During certain abdominal surgeries to shift
no flexion at waist. abdominal contents downward.
6. Lateral For patient comfort and to promote lung

Lying in the left or right side, and cardiac function. To relieve Pressure
supported behind back and on bony prominences of the coccyx and
between knees and ankles with sacrum.
pillows, in good body alignment
7. Sims' For rectal examinations and administering
Lying on the left side in semi-prone enemas.
position with right leg flexed and
drawn up toward the chest; the left
arm is positioned along the patient's
back.
8. Low Fowler's To prevent aspiration during tube feeding.
Head of the bed elevated 30
degrees
9. Semi-Fowler's To comfortably watch television or
Head of the bed elevated 45 converse with visitors. After abdominal
degrees surgeries to relieve tension on incision. To
assist patients who have difficulty
breathing.
10. High Fowlers To eat and drink without risk of choking.
Head of bed elevated 90 degrees To assist patients who have difficulty
breathing
11. Lithotomy For vagina and gynecological surgery and
Lying on back with knees flexed examination, delivery of neonate, pelvic
above the hips and legs supported and gynecological surgery and
in stirrups. procedures.
REMARKS:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
49
IV. ASSISTING WITH ELIMINATION AND PERINEAL CARE

PROCEDURES:
➢ Providing Catheter Care
➢ Offering And Removing A Bedpan And Urinal
➢ Performing Perineal Care
➢ Collecting A Urine Specimen (Clean Catch, Midstream)
GENERAL OBJECTIVE:
➢ To assist with the use of bedpans, urinals or commodes in a hygienic manner considering
psychological factors.
➢ To promote hygiene and comfort
➢ To cleanse and remove excessive secretions by providing appropriate perineal care
➢ To provide appropriate catheter care
➢ To correctly obtain a urine specimen using proper technique
LEARNING OUTCOMES
➢ Assess the patient effectively to determine the need for assistance with elimination
➢ Analyze data to determine special needs, concerns, and self-care abilities in completing elimination and
perineal care.
➢ Determine the assistance needed to complete the procedure.
➢ Demonstrate the proper techniques for assisting with elimination and perineal care.
➢ Evaluate the effectiveness of the elimination and perineal care techniques.
➢ Assess the condition of the patient’s catheter and status of urination.
➢ Implement appropriate catheter care.
➢ Properly obtain a urine specimen and handle properly the specimen collected.
50
NAME: ______________________________________ DATE: _________________________________
PERFORMING PERINEAL CARE

DEFINITION:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
PURPOSE:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
EQUIPMENT:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
1. Wash hands and don on clean gloves.
2. Explain procedure to the client.
3. Prepare necessary equipment and supplies.
51
4. Pull curtain around client’s bed, or close room door,

then place a bath blanket over the client’s abdomen
and thighs.
5. Place the Kelly pad under the client’s buttocks.
6. Place a pail just below the Kelly pad.
7. FOR FEMALES:
Assist client to dorsal recumbent position.
8. Lower side rail and help client flex knees and
spread legs.
9. Fold lower corner of bath blanket up between
client’s legs onto abdomen.
10. Assess the genitalia for signs of inflammation, skin
breakdown, or infection.
11. Wash external genitalia and upper thighs by
pouring sterile water 6 inches away from the area.
12. Wash labia majora. Use non-dominant hand to
gently retract the labia majora. With dominant
hand, wash carefully in between skinfolds. Wipe in
direction from perineum to rectum (front to back).
13. Repeat on opposite side using separate section of
washcloth. Cleanse and dry are thoroughly.
14. Separate labia with non-dominant hand to expose
urethral meatus and vaginal orifice. With dominant
hand, wash downward from pubic area toward
rectum in one smooth stroke. Use separate section
of cloth for each stroke. Cleanse thoroughly around
labia minora, clitoris, and vaginal orifice.
15. Pour warm water over perineal area.
16. Dry perineal area thoroughly, using front-to-back
method.
17. FOR MALES:
Position the patient in a supine position with knees
flexed and hips slightly externally rotated.
18. Fold top half of the bath blanket down below the
penis. Wash and dry the patient’s upper thighs.
19. Put on gloves. Gently and firmly raise the penis. If
patient is uncircumscribed, retract foreskin
(prepuce) to expose the glans penis for cleaning.
20. Wash tip of penis at urethral meatus first. Using
52
circular motion, cleanse from meatus outward.

Discard washcloth, and repeat with clean cloth until
penis is clean. Rinse and gently dry.
21. Return foreskin to its natural position.
22. Wash shaft of penis with gentle but firm downward
strokes. Rinse and dry thoroughly.
23. Gently cleanse scrotum. Lift carefully and wash
underlying skinfolds. Rinse and dry.
24. Fold lower corner of bath blanket back between
client’s leg and over perineum. Ask client to lower
legs and assume comfortable position.
25. Remove Kelly pad. Take off gloves and dispose in
proper receptacle. Perform hand hygiene.
26. Place client in a comfortable position and cover with
a sheet or blanket.
27. Document the procedure and any assessment
findings like vaginal discharges and lochia.
REMARKS:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
53
NAME: _____________________________________________ DATE: _________________________
PROVIDING CATHETER CARE

DEFINITION:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
PURPOSE:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
EQUIPMENT:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
ACTION RATIONALE C X N R
1 Identify the patient.
2 Explain the procedure.
3 Provide privacy.
4 Wash hands and don on gloves.
5 Place patient in dorsal recumbent position.
54
6 Cover the patient with a bath blanket and

expose perineal area only.
7 Place a waterproof pad under the patient’s
buttocks
8 Provide routine perineal care, making sure all
perineal folds are cleansed thoroughly.
9 Hold catheter securely near the meatus with
the gloved non-dominant hand. Using clean
washcloth, soaps and water, take the non-
dominant hand and wipe in a circular motion
along the length of the catheter for about 10
cm (4 inches). Avoid placing tension on or
pulling on the exposed catheter tubing.
10 Replace as necessary the anchor device used
to secure the catheter tubing to the patient’s
leg or abdomen.
11 Check tubing if draining and urine bag if intact
or full.
12 Empty collection bag as necessary or at least
every 8 hours.
COMPLETION
REMARKS:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
55
NAME: _____________________________________________ DATE: _________________________
OFFERING AND REMOVING A BEDPAN & URINAL
DEFINITION:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
PURPOSE:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
EQUIPMENT:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
1. Bring the bedpan and other necessary Arranging things conserves time,
equipment to bedside. energy, and avoid unnecessary
stretching and twisting of the muscles
of the nurse.
2. Perform hand hygiene and put on gloves. To prevent the spread of
microorganisms.
3. Identify the patient. To ensure the right patient receives the
intervention and helps prevent errors.
4. Close curtains or door of the room. To ensure patient’s privacy.
5. Explain the procedure to the patient and To promote reassurance and provide
assess the patient’s ability to assist with knowledge about the procedure. To
the procedure. encourage participation.
56
6. Adjust height of bed to comfortable To prevent back and muscle strain.

working height.
7. Place patient in a supine position with To facilitate correct placement of
head of the bed elevated about 30o or patient on bedpan.
assist patient to a side-lying position.
8. Place waterproof pad under patient’s To prevent soiling the bed.
buttocks.
9. Ask the patient to bend the knees then lift
his hips upward. Assist patient by placing To lessen the energy needed to lift the
your hand under the patient’s lower back patient.
and assist with lifting. Slip the bedpan into
place with other hand.
10. If in a side-lying position, slip the bedpan
under the patient’s buttocks. With one Ensures proper placement of the
hand, roll the patient onto her back. bedpan.
11. Ensure proper position of bedpan. The To prevent spills onto the bed, ensure
patient’s buttocks must be resting on the patient comfort, and prevent injury.
rounded shelf of the regular bedpan.
12. Raise the head of bed to sitting position asTo facilitate elimination and provide
tolerated. Cover the patient with linens. privacy.
13. Raise side rails. Leave the patient if Promotes self-esteem and respect for
necessary. privacy. Side rails may assist the
patient in repositioning.
REMOVING OF THE BEDPAN
14. Perform hand hygiene and don on clean
gloves.
15. Lower head of bed and ask the patient to This facilitates easy removal of
bend knees. bedpan.
16. Remove bedpan in the same manner it
was offered. Ask the patient to lift the To lessen energy needed by nurse in
buttocks up from the bedpan. Assist the lifting.
patient by placing your nearest hand to the
patient’s lower back.
17. Offer tissue paper and then discard in To allow patient to clean perineal area.
proper receptacle.
18. Raise side rail. Lower bed height and
adjust head of bed to a comfortable To promote patient safety.
position.
19. Empty and clean the bedpan, measuring Cleaning reusable equipment helps
urine in graduated container, if necessary. prevent the spread of microorganisms.
Store in proper place.
20. Remove gloves and perform hand hygiene. To prevent the spread of
microorganisms.
REMARKS:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
57
NAME: _____________________________________________ DATE: __________________________
COLLECTING A URINE SPECIMEN (CLEAN CATCH, MIDSTREAM)
DEFINITION:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
PURPOSE:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
EQUIPMENT:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
1. Bring necessary equipment to bedside This conserves time and energy.
2. Perform hand hygiene and put on PPE. This prevents the transmission of
microorganisms.
3. Explain the procedure to the client. If the
patient can perform the task without Explanation provides reassurance and
assistance, leave the container at bedside promotes cooperation.
58
and let the patient collect specimen.

4. FEMALE. Separate the labia and clean the
urethral meatus from front to back using a
new wipe for each stroke. This prevents cross contamination of the
MALE. Clean the tip of the penis, wiping in a different areas.
circular motion away from the urethra.
5. Bacteria in the distal urethra and at the
Instruct the client to start voiding. urinary meatus are cleared by the first few
milliliters of urine expelled.
6. Place the specimen container into the To avoid contaminating the interior of the
midstream of urine and collect the specimen, specimen container and the specimen
taking care not to touch the container to the itself.
perineum or penis.
7. Collect urine in the container and cap the To prevent contamination or spilling of the
container tightly, touching only the outside of specimen.
the container and cap.
8. Remove and discard gloves. To prevent spread of microorganisms.
9. Perform hand hygiene. To prevent spread of microorganisms.
10. Attach the specimen label to the cup, not the To prevent errors in diagnosis or therapy.
lid, and transport it to the laboratory with the
laboratory requisition form.
11. Send specimen to the laboratory immediately. Bacterial cultures must be started
immediately before any contaminating
organisms can grow, multiply and produce
false results.
12. Document relevant data.
REMARKS:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
59
V. PROMOTING OXYGENATION
PROCEDURES:
➢ Administering Oxygen By Cannula, Face Mask, And Face Tent
➢ Teaching Deep-Breathing Exercises
GENERAL OBJECTIVE:
➢ To administer oxygen to patients, using equipment appropriately in a safe and effective manner
➢ To assist patients effectively with deep breathing as necessary
LEARNING OUTCOMES
➢ Identify general conditions that necessitate oxygen administration.
➢ Assess the patient for indicators of oxygen need including dyspnea, feelings of breathlessness, dusky
nail beds or mucus membranes, oxygen saturation level, anxiety or cognitive changes and other factors
affecting oxygenation.
➢ Identify the benefits and hazards of Oxygen administration.
➢ Implement oxygen therapy effectively.
➢ Document oxygen administration, method and amount of oxygen administered and patient’s response
to oxygenation.
➢ Assess the patient effectively to determine the need for a respiratory care procedure. Educate the
patient regarding the importance of deep breathing exercise.
➢ Teach the patient appropriate deep breathing and assess the patient ability to perform the exercise
➢ Evaluate the effectiveness of deep breathing exercise and document the procedure and patient’s
response appropriately.
60
NAME: _____________________________________________ DATE: _________________________
ADMINISTERING OXYGEN BY CANNULA AND FACE MASK
DEFINITION:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
PURPOSE:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
EQUIPMENT:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
1. Verify written order for oxygen therapy, including
methods of delivery and flow rate.
2. Introduce self and verify the client’s identity.
3. Explain to the client the purpose of procedure.
61
4. Perform hand hygiene and put on PPE, if

indicated.
5. Provide client privacy, if appropriate.
A. SETTING UP THE OXYGEN EQUIPMENT AND THE HUMIDIFIER
6. Attach the flow meter to the wall outlet or tank.
The flow meter should be in the off position.
7. Fill the humidifier bottle with water. Attach the
humidifier bottle to the base of the flow meter.
8. Attach the prescribed oxygen tubing and delivery
device (cannula & mask) to the humidifier.
9. Turn on oxygen flow at the prescribed rate by
turning the thumbscrew (wall outlet) or knob
(tank).
10. Check the tubing for kinks. Feel for the flow of air
at the outlets of the cannula, mask, or tent.
11. Check for presence of bubbles in the humidifier as
the oxygen flows through.
12. Apply the appropriate oxygen delivery device.
B. USING CANNULA
13. Put the cannula over the client’s face, with the
outlet prongs fitting into the nares and the tubing
hooked around the ears. Adjust the fit of the
tubing by sliding the adjuster upward to hold the
cannula in place. (see Figure 1)
Figure 1. NASAL CANNULA

14. Gently position nasal prongs into client’s nares,
with curves of prongs pointing toward the floor of
the nostrils.
15. If the cannula will not stay in place, tape it at the
sides of the face.
16. Pad the tubing and band over the ears and
cheekbones as needed.
17. Assess the nares, face, and ears every 4 hours
for signs of skin irritation and breakdown.
18.
Inspect nasal prongs for presence of nasal
secretions or crusts. Wipe the prongs with gauze
pad as needed.
62
C. USING FACE MASK

19.
Guide the
mask
toward the
client’s
face, and
apply it
from the
nose
Figure 2. Face Mask
downward.
20. Fit the mask to the contours of the client’s face.
Adjust the elastic strap around the client’s head so
that the mask fits snugly but comfortably on the
face.
21. Inspect the facial skin frequently for dampness,
and dry and treat it as needed.
22. Assess the client’s vital signs, level of anxiety,
color, and ease of respirations.
23. Assess the client in 15 to 30 minutes, depending
on the client’s condition, and regularly thereafter
for clinical signs of hypoxia, tachycardia,
confusion, dyspnea, restlessness, and cyanosis.
Review oxygen saturation and arterial blood gas
results if available.
24. Inspect the equipment on a regular basis. Check
liter flow and level of water in the humidifier.
25. Document findings in the client record.
REMARKS:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
63
NAME: ____________________________________________ DATE: _________________________
TEACHING DEEP-BREATHING EXERCISES
DEFINITION:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
PURPOSE:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
EQUIPMENT:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
1. Introduce self to client and verify client’s To ensure that the proper procedure is
identity. administered to the right patient.
2. Perform hand hygiene. To prevent transmission of microorganisms.
3. Demonstrate deep-breathing exercises by To show the client the appropriate
placing your hands palms down on the procedure.
border of your rib cage, and inhale slowly
64
and evenly through the nose until the

greatest chest expansion is achieved.
4. Hold your breath for 2-3 seconds. Then To allow full oxygen exchange. This helps
exhale slowly through the mouth. Continue move oxygen into the lungs and carbon
exhalation until maximum chest contraction dioxide out of your lungs.
has been achieved.
5. Help the client perform the deep breathing These exercises will help client’s breathing,
exercises. clear the lungs, and lower the risk of
pneumonia (for post-op clients).
6. Ask the client to assume a sitting position. To maximize lung expansion.
7. Place the palms of your hands on the This is to assess respiratory depth.
border of the client’s rib cage.
8. Ask the patient to perform deep breathing. To ensure proper execution of the skill.
9. Encourage the client to carry out the This is to improve lung capacity and faster
exercise at least every 2 hours, taking a recovery.
minimum of five breaths in each session.
10. Document the teaching and all relevant To have a legal record. This also serves as
assessments. a communication among the members of
the healthcare team.
REMARKS:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
65
VI. FLUIDS & ELECTROLYTES
PROCEDURES:
➢ Starting An Intravenous Infusion
➢ Monitoring An Intravenous Infusion
➢ Changing An Intravenous Container And Tubing
➢ Discontinuing An Intravenous Infusion
GENERAL OBJECTIVE:
➢ To prepare and maintain intravenous infusions accurately, with comfort and safety for patients.
LEARNING OUTCOMES
➢ Assess the patient to prepare and maintain appropriate intravenous (IV) therapy
➢ Review assessment data to determine special needs or concerns that must be addressed to
provide safe IV infusion therapy for individual patient.
➢ Determine appropriate patient outcomes of the IV infusion therapy and recognize the potential
adverse effects.
➢ Correctly start, monitor, change and discontinue (as ordered) the IV infusion therapy, utilizing
appropriate supplies and equipment in a safe, effective manner.
➢ Evaluate the effectiveness and safety of the IV infusion therapy.
➢ Document the infusion therapy and nursing care provided in the patient’s plan of care and in
the patient’s record.
66
NAME: ______________________________________________ DATE: _________________________
STARTING AN INTRAVENOUS INFUSION
DEFINITION:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
PURPOSE:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
EQUIPMENT:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
1. Arranging things conserves time, energy,
Gather the equipment at bedside. and avoid unnecessary stretching and
twisting of the muscles of the nurse.
2. Attach an IV fluid label. Place it on the The label is applied upside down so it can
container (readable when bottle is turned be read easily when the container is
67
upside down). hanging up.
3. Remove the tubing from the package and

To facilitate access to the device.
straighten it out.
4. Slide the tubing clamp along the tubing until
it is just below the drip chamber. Close the To facilitate its access.
clamp.
5. Leave the ends of the tubing covered with This will maintain the sterility of the ends of
the plastic caps until the infusion is started. the tubing.
6. Expose the insertion site of the bag or bottle
by removing the protective cover. Remove This will connect the tubing set to the
the cap from the spike and insert the spike intravenous bottle or bag.
at the insertion site of the bag or bottle.
7. Adjust the IV pole so that the container is This height is needed to enable gravity to
suspended about 1 meter above the client’s overcome venous pressure and facilitate
head. flow of the solution into the vein.
8. The drip chamber is partially filled with
Squeeze the drip chamber gently until it is
solution to prevent air from moving down
half full of solution.
the tubing.
9. Prime the tubing.
Remove the protective cap and hold the To prevent contamination of the
tubing over a container. Maintain the equipment.
sterility of the end of the tubing and the cap.
10. Release the clamp and let the fluid run
through the tubing until all bubbles are The tubing is primed to prevent the
removed. Tap the tubing if necessary with introduction of air into the client.
your fingers to help the bubbles move.
11. Re-clamp the tubing and replace the tubing To prevent contamination of the
cap, maintaining sterile techniques. equipment.
12. Perform hand hygiene. To prevent the spread of microorganism.
REMARKS:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
68
NAME: ____________________________________________ DATE: __________________________
MONITORING AN INTRAVENOUS INFUSION
DEFINITION:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
PURPOSE:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
EQUIPMENT:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
1. Perform hand hygiene. To prevent the spread of microorganism.
2. Position the client appropriately and expose
To gain access to the IV site.
IV site.
3. Compare the label on the container to the To ensure that the correct solution is being
physician’s order. infused.
4. Observe the rate of flow every hour or Infusions that are too fast or too slow can be
minute by comparing the rate of flow harmful to the client.
69
regularly.
5. Read the volume in an IV bag by pulling the
Stretching the bag allows the fluid meniscus
edges of the bag apart at the level of the
to fall to the proper level.
fluid and read the remaining volume.
6. If the container is too low, the solution may
Observe the position of the solution
not flow into the vein because there is
container. If it is less than 3 ft. above the IV
insufficient gravitational pressure to
site, readjust it to the correct height of the
overcome the pressure of the blood within
pole.
the vein.
7. If too much fluid has infused in the time
interval, you may need to notify the Solution administered too quickly may
physician. In some agencies, you may slow cause a significant increase in circulating
the infusion to less than the ordered rate so blood volume.
that it will be completed at the planned time.
8. Inspect the insertion site for fluid infiltration
or extravasation such as swelling. If
To prevent further injury to tissues.
present, stop the infusion immediately and
remove the catheter.
REMARKS:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
70
NAME: _____________________________________________ DATE: __________________________
CHANGING AN INTRAVENOUS CONTAINER AND TUBING
DEFINITION:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
PURPOSE:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
EQUIPMENT:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
ACTION RATIONALE 5 4 3 2
1. Obtain the correct solution container. Read the
To prevent introducing wrong
label of the new container and compare to
infusion to the client.
physician’s order.
2. To prevent the spread of
Perform hand hygiene.
microorganism.
3. Set up the IV equipment with the new container To save time and effort.
71
and label.
4. Closing the clamps prevents the
fluid in the drip chamber from
Close the roller clamp on the administration set.
emptying and air from entering the
tubing during the procedure.
5. Carefully remove the cap on the entry site of the
Touching the opened entry site on
new IV solution container and expose the entry
the IV container results in
site, taking care not to touch the exposed entry
contamination.
site.
6. Touching the spike on the
Lift empty container off the IV pole and invert it.
administration set results in
Quickly remove the spike from the old IV
contamination and the tubing would
container, being careful not to contaminate it.
have to be discarded.
7. Using a twisting and pushing motion, insert the
administration set spike into the entry site of the To allow access to the IV contents.
IV container. Hang the container on the IV pole.
8. Alternately, the new IV fluid container can be
This allows for an alternative method
hanged on the IV pole and insertion of the
of connecting the administration set
administration set is done as it hangs on the IV
to the IV fluid container.
pole.
9. Opening the clamp regulates the
Slowly open the roller clamp on the flow rate into the drip chamber.
administration set, and count the drops. Adjust Verifying the rate ensures patient
until the correct drop rate is achieved. receives the correct volume of
solution.
10. Prevents transmission of
Remove gloves and perform hand hygiene.
microorganisms.
REMARKS:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
72
NAME: ____________________________________________ DATE: __________________________
DISCONTINUING AN INTRAVENOUS INFUSION
DEFINITION:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
PURPOSE:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
EQUIPMENT:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
1. To avoid anxiety and gain cooperation.
Introduce self and verify client’s identity.
Validation of client’s identity ensures that
Explain the procedure to the client.
the right patient receives the intervention.
2. To prevent transmission of
Perform hand hygiene.
microorganisms.
73
3. Expose the IV site. Place water absorbent

To prevent soiling the bed linens.
linen under the extremity with the IV site.
4. Clamping the tubing prevents the fluid
Clamp the infusion tubing. from flowing out of the needle onto the
client or bed.
5. To prevent transmission of
Apply clean gloves. microorganisms and to protect yourself
from fluid contact.
6. Remove the dressing and tape at the Movement of the catheter can injure the
venipuncture site while holding the needle vein and cause discomfort to the client.
firmly and applying counter traction to the Counter traction prevents pulling the skin
skin. and causing discomfort.
7. To assess for complications (infection or
Assess the venipuncture site.
phlebitis).
8. Apply the sterile gauze above the This is to maintain sterility of the gauze
venipuncture site by touching only the upper and provide pressure on the venipuncture
portion of the gauze. site.
9. Withdraw the catheter from the vein by
pulling it out along the line of the vein. Do Pulling it out in line with the vein avoids
not press down on the sterile gauze pad injury to the vein.
while removing the catheter.
10. Immediately apply firm pressure to the site, Pressure helps stop the bleeding and
using sterile gauze, for 2 to 3 minutes. prevents hematoma formation.
11. Hold the client’s arm above heart level if any Raising the limb decreases blood flow to
bleeding persists. the area.
12. The dressing continues the pressure and
Apply new sterile dressing to the site with
covers the open area in the skin and
tape.
prevents infection.
13. Discard used supplies and remove and
To prevent spread of microorganisms.
discard gloves appropriately.
14. Perform hand hygiene. To prevent spread of microorganism.
15. Document all relevant information. To ensure continuity of care.
REMARKS:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
74
Republic of the Philippines

Mindanao State University
COLLEGE OF HEALTH SCIENCES
Marawi City
SKILLS COMPETENCY RECORD
Name_________________________________ Date: ____________________________
The following is a list of nursing skills covered in this semester. You are to be evaluated and graded
following the performance indicators based on rubric by your lab instructor. It is necessary for you to
get Satisfactory Ratings or better (75% and above) for you not to undergo remediation. Failure after
remediation of only one nursing skill will make you not qualified to advance to higher level courses.
Instruction: Please indicate the score you have obtained from each of the skill procedures listed
below. If you have obtained a mark less than 75%, you need to undergo remediation.
NURSING SKILLS SCORE REMARKS

(Passed, Failed or Not Performed)
1. Medical Handwashing
2. Donning and Removing Personal
Protective Equipment
3. Administering A Tepid Sponge Bath (TSB)
4. Performing Bed Bath
5. Shampooing Hair
6. Performing Oral Care
7. Providing Special Oral Care
8. Changing A Hospital Gown For A Patient
With An Intravenous Fluid
9. Changing An Unoccupied Bed
10. Changing An Occupied Bed
11. Post Mortem Care
12. Using Principles of Body Mechanics
13. Transferring/Transporting Clients
14. Positioning
15. Performing Perineal Care
16. Providing Catheter Care
17. Offering and Removing a Bedpan and
Urinal
18. Collecting A Urine Specimen
19. Administering Oxygen
75
20. Teaching Deep Breathing Exercises

21. Starting an Intravenous Infusion
22. Monitoring an Intravenous Infusion Fluid
23. Changing an Intravenous Container and
Tubing
24. Discontinuing an Intravenous Infusion
(To be filled by the Instructor)

__________ Qualified to advance
__________ Not qualified to advance
Remarks/Comments:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
_________________________
(Signature over Printed Name)
Laboratory Instructor
76
REFERENCES
Ellis, Janice and et.al. Modules for Basic Nursing Skills 6th ed. Lippincott Williams &Wilkins.
Philippines.
Evans-Smith, Pamela. Taylor’s Clinical Nursing Skills: A Nursing Process Approach.

Lippincott Williams & Wilkins. USA. 2005.
Kozier, Barbara and et.al. Fundamentals of Nursing: Concepts, Process, and Practice 8th
ed. Pearson Education Asia Pte. Ltd. Singapore.
Lippincott Manual of Nursing Practice 8th ed. Lippincott Williams & Wilkins. Philippines.
2006.Myers, Ehren. RNotes: Nurse’s Clinical Pocket Guide.F.A. Davis Co. Thailand.
Rhaoads, Jacqueline and Bonnie Juvie Meeker (2008).Davis Guide to Clinical Nursing
Skills. F.A. Davis Company. Philadelphia.
Timby, Barbara. Fundamental Nursing Skills and Concepts 8th ed. Lippincott Williams
&Wilkins. USA. 2005.
Temple, J. & Johnson, J. (2005). Nurses’ Guide to Clinical Procedures 5th edition.
Lippincott Williams & Wilkins.

B. NSG 120.2 Checklist

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MINDANAO STATE UNIVESITY – MARAWI CITY

College of Health Sciences

Donnabelle L. Abdullah, RN, MAN

Namera T. Datumanong, RN, MAN

Jamal Tango P. Alawiya, LPT, RN

I. BASIC INFECTION CONTROL

NAME: ______________________________________________ DATE: _________________________

CONSIDERATIONS BEFORE, DURING and AFTER THE PROCEDURE:

THINGS TO DOCUMENT AFTER THE PROCEDURE:

and down the drain.

NAME: _________________________________________________ DATE: _________________________

DONNING AND REMOVING PERSONAL PROTECTIVE EQUIPMENT

CONSIDERATIONS BEFORE, DURING and AFTER THE PROCEDURE:

THINGS TO DOCUMENT AFTER THE PROCEDURE:

X- The step was not performed

N- The execution of the step needs improvement

R- The step was correctly performed after remediation

• Pick up a clean gown and allow it to unfold in front of you.

To remove soiled personal protective equipment, remove the

the mask from the face.

II. PROMOTING HYGIENE AND COMFORT

NAME: ______________________________________________ DATE: _________________________

ADMINISTERING A TEPID SPONGE BATH (TSB)

CONSIDERATIONS BEFORE, DURING and AFTER THE PROCEDURE:

THINGS TO DOCUMENT AFTER THE PROCEDURE:

X- The step was not performed

N- The execution of the step needs improvement

R- The step was correctly performed after remediation

Perform hand washing. Organize Reduces microorganism transfer;

• If temperature is above 37.7 overcooling.

NAME: _____________________________________________ DATE: _________________________

PERFORMING BED BATH

X- The step was not performed

N- The execution of the step needs improvement

R- The step was correctly performed after remediation

5. Assess patient’s temperature, pulse, and

f. Fold the sponge cloth and moisten.

COMPLETED Yes No DATE OF SIGNED

NAME: _____________________________________________ DATE: _________________________

CONSIDERATIONS BEFORE, DURING and AFTER THE PROCEDURE:

THINGS TO DOCUMENT AFTER THE PROCEDURE:

X- The step was not performed

N- The execution of the step needs improvement

R- The step was correctly performed after remediation

Remove pillow. Have the patient lie on his

NAME: _____________________________________________ DATE: _________________________

PERFORMING ORAL CARE

CONSIDERATIONS BEFORE, DURING and AFTER THE PROCEDURE:

THINGS TO DOCUMENT AFTER THE PROCEDURE:

X- The step was not performed

N- The execution of the step needs improvement

R- The step was correctly performed after remediation

Place towel across the patient’s chest. If

NAME: ______________________________________________ DATE: _________________________

PROVIDING SPECIAL ORAL CARE

CONSIDERATIONS BEFORE, DURING and AFTER THE PROCEDURE:

THINGS TO DOCUMENT AFTER THE PROCEDURE:

X- The step was not performed

N- The execution of the step needs improvement

R- The step was correctly performed after remediation

To prevent soiling of patient’s

NAME: _____________________________________________ DATE: _________________________

CHANGING A HOSPITAL GOWN FOR A PATIENT WITH AN INTRAVENOUS FLUID

NAME: ______________________ DATE: _

NAME: _________________________ DATE: _

NAME: ______________________ DATE: _

NAME: _____________________ DATE: _

NAME: _____________________ DATE: _

NAME: _____________________ DATE: _

NAME: ______________________ DATE: _

NAME: _____________________ DATE: _

NAME: ______________________ DATE: _

NAME: _____________________ DATE: _

NAME: ______________________ DATE: _

NAME: ______________________ DATE: _

NAME: _______ DATE:

NAME: _____________________ DATE: _