SKILLS LABORATORY NO.

___
MONITORING FLUID INTAKE AND OUTPUT

NAME: ______________________________________ Score: ______________

DEFINITION:
• The measurement and recording of all fluid intake and output during the 24 hour
period.

PURPOSE:
1.
2.

EQUIPMENT:
• Calibrated cup or glass
• Calibrated water pitcher
• Bedpan/ urinal
• Calibrated container for urine
• Intake and output record
• 24 hour record in chart

PROCEDURE RATIONALE
1. Check doctor’s order for measuring
intake and output.
2. Assess the client’s knowledge and
ability to participate.
3. Wash hands.
4. Organize equipment needed.
INTAKE
5. Place calibrated cups in the room
and instruct client and relatives to
measure all fluids consumed by
the client on the cup provided.
6. Measure all oral intakes of water,
juice, beverage, soup with
calibrated cup.
7. Measure all intravenous intake and
gastric tube feeding, if any.
8. Record time and amount of all fluid
intake and bedside I&O form.
9. Transfer 8-hour total fluid intake
from bedside I&O record to 24-
hour I&O record on client’s chart.
10. Compute 24-hour intake record by
adding all 8-hour total intake.
OUTPUT
11. Wear non-sterile gloves.
12. Measure the amount of urine
output accurately:
a) Empty urine bedpan into
calibrated container.
b) If the client is with
indwelling catheter,
measure the contents of the
urine bag and discard its

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 contents after each
measurement.
13. If any, diarrheic stools and
vomitous should be measured and
added to output tally.
14. Remove and discard gloves. Wash
hands.
15. Record the time and amount of
output on bedside I&O record.
16. Transfer 8-hour output total to 24-
hour I&O record on client’s chart.
17. Compute 24-hour output record by
totaling all 8-hour total output.

Remarks:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

_________________________ _________________________
Clinical Instructor Student’s Signature

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COLLEGE OF NURSING
 SKILLS LABORATORY NO. ___
NASOGASTRIC TUBE FEEDING

NAME: ______________________________________ Score: ______________

DEFINITION:
• It is the administration of gastrointestinal (enteral) feeding via nose directly into
the stomach with the use of gastric tube.

PURPOSE:
1.
2.
3.
4.

EQUIPMENT:
• Prescribed amount of enteral feeding
• Stethoscope
• Asepto syringe
• Gloves
• 30 cc of distilled water for flushing

PROCEDURE RATIONALE
1. Check physician’s order for
formula, rate, route and frequency
of feeding.
2. Assess bowel sounds before
feeding.
3. Assess client regarding discomfort
from tube and determine need for
adjustment.
4. Observe tube insertion site for
signs of irritation or pressure.
5. Explain the procedure to the client.
6. Wash hands.
7. Prepare tube feeding at room
temperature and other equipment
to be used.
8. Assist the client to high fowlers
position or elevate head of bed 30
degree.
9. Check the tube placement and
patency by X-ray or any of the
following:
a) Introduce 5-20 ml of air
into NGT and auscultate at
the epigastric area, gurgling
sound is heard.
b) Aspirate a gastric content
which is yellowish or
greenish in color.
c) Immerse the tip of the tube
in the glass of water; no
bubbles should be
produced.

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 10. Infuse feeding:
a) Pinch proximal end of the
feeding tube.
b) Attach syringe to
nasogastric tube and
aspirate small number of
contents to fill tube and
lower portion of the tube.
c) Fill syringe with measured
amount of formula. Release
tube and hold syringe at 12
inches above the tube point
of insertion into the client;
refill; repeat until the
prescribed amount has
been delivered to the client.
11. Flush 30 ml of water into the NGT
after the feeding.
12. Clamp the NGT before all of the
water is infused.
13. Reposition the client to low or
semi-fowler’s position for at least
30 minutes after the feeding.
14. Do after care of equipment.
15. Wash hands
16. Document the procedure done.

Remarks:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

_________________________ _________________________
Clinical Instructor Student’s Signature

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COLLEGE OF NURSING
 SKILLS LABORATORY NO. ___
CATHETERIZATION

NAME: ______________________________________ Score: ______________

DEFINITION:
• It is the insertion of a catheter through the urethra into the bladder to drain urine
or to instill medication or fluid.

PURPOSE:
1.
2.
3.
4.
5.

EQUIPMENT:
• Catherization tray with sterile • Drainage tube
catheter • Collection bag
• Sterile gloves • Tape
• Cleansing solution • Sterile drapes
• Syringe w/ sterile H2O • Sterile cleansing swabs
• Lubricant • Thumb forceps
• Safety pin

PROCEDURE RATIONALE
1. Gather the equipment needed.
2. Identify the client and explain the
procedure.
3. Wash hands.
4. Assist the client to an appropriate
position and drape all areas except
the perineum.
a) Female-Dorsal Recumbent
(supine with knees flexed)
b) Male-Supine with legs
slightly abducted.
5. Establish adequate lighting.
6. Open the catheterization set and
arranges the sterile field.
7. Set up receptacle for soiled
cleaning swabs
8. If drainage bag is in separate bag,
open attach it to bed.
9. Put on sterile gloves.
10. For an indwelling catheter, attach
syringe and test balloon by
instilling sterile water and deflating
balloon by withdrawing the water.
11. If drainage bag is in set, connect
distal end of catheter to drainage
tubing.
12. Clean urinary meatus with
antiseptic solution using a
downward stroke.

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 13. Lubricate the distal portion of the
catheter and place it on a nearby
sterile field.
14. Insert the catheter gently, in
rotating motion. Instruct the client
to take a slow deep breath upon
insertion. For male patient, hold
the penis at 45-degree angle until
urine flows.
a) Length of catheter insertion
Male: 6-9 inches
Female: 2-3 inches
15. Inflate the retention balloon with
sterile water.
16. Tape the catheter to the thigh of a
female patient and to the lower
abdomen for a male patient.
17. Secure the drainage tubing and
place drainage bag below the level
of the bladder.
18. Assist the client to a comfortable
position.
19. Gather and discard disposable
equipment.
20. Wash hands.
21. Document the procedure.

Remarks:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

_________________________ _________________________
Clinical Instructor Student’s Signature

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 SKILLS LABORATORY NO. ___
REMOVAL OF INDWELLING CATHETER

NAME: ______________________________________ Score: ______________

PURPOSE:
1.
2.

EQUIPMENT:
• Syringe without needle • Protective pad
• Clean gloves • Bed pan/ urinal

PROCEDURE RATIONALE
1. Check the physician’s written
order.
2. Wash hands.
3. Assemble the equipment.
4. Identify the client the procedure.
5. Remove covers and drape to
expose catheter perineal area.
6. Wear clean gloves.
7. Place protective pad under the
patient’s thigh.
8. Empty urine tubing into the
catheter bag.
9. Remove any tape that may be
holding the catheter to the leg.
10. Insert syringe end into balloon
port and pull the plunger to
remove all the air or fluid from the
balloon.
11. Ask the client to take a deep
breath if able and gently pull out
the catheter. Stop if resistance is
felt, and recheck the balloon port.
12. Clean the client’s perineal area.
13. Dispose material used and
removed gloves.
14. Wash hands.
15. Document the pertinent data.

Remarks:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

_________________________ _________________________
Clinical Instructor Student’s Signature

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COLLEGE OF NURSING
 SKILLS LABORATORY NO. ___
COLOSTOMY CARE

NAME: ______________________________________ Score: ______________

DEFINITION:
• Colostomy in an artificial anus created surgically in the colon designed for
patients unable to expel feces through the rectum.

PURPOSE:
1.
2.

EQUIPMENT:
• Clean gloves • Water, tissue paper
• Linen saver • Bed pan
• Asepto syringe

PROCEDURE RATIONALE
1. Assess the appearance of the
stoma and the condition of the
bag.
2. Wash hands.
3. Assemble the equipment needed.
4. Identify the client. Explain the
procedure to the client.
5. Provide privacy.
6. If using toilet, seta client on toilet,
with pouch over toilet; if using bed
pan, place the pouch/ bag over the
bed pan.
7. Put on clean gloves.
8. Place linen saver on abdomen
around and below the pouch/ bag.
9. Remove clamp on the bottom of
bag and place within easy reach.
10. Slowly unfold end of pouch and
allow feces to drain into bedpan or
toilet.
11. Press sides of lower end of pouch
together.
12. Squirt asepto syringe with full tap
water into the bottom of bag.
13. Roll up the bag and re-clamp the
bag.
14. Wipe outside pouch with clean, wet
washcloth.
15. Remove gloves and discard all
equipment appropriately.
16. Spray room freshener, if needed.
17. Wash hands.
18. Record the procedure, and any
unusual observations.

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Remarks:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

_________________________ _________________________
Clinical Instructor Student’s Signature

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COLLEGE OF NURSING
 SKILLS LABORATORY NO. ___
CHANGING THE COLOSTOMY BAG

NAME: ______________________________________ Score: ______________

EQUIPMENT:
• Clean washcloth or 4x4 gauze pads
• Warm tap water
• Clean gloves
• Lubricant or skin cream (optional)
• Scissors
• Plastic waste bag
• Ostomy Wafer (Skin Barrier)
• Ostomy Drainage bag
• Disposable Bed Protector

PROCEDURE RATIONALE
1. Assess the appearance of the
stoma and the condition of the bag
and the characteristics of the fecal
waste.
2. Wash hands.
3. Gather equipment.
4. Identify the client and explain the
procedure.
5. Provide privacy.
6. Place the disposable bed protector
under the client’s hips.
7. Wear clean gloves.
8. Remove the soiled plastic stoma
bag from the skin carefully.
9. Discard soiled stoma bag in plastic
waste bag.
10. Remove gloves and wash hands.
11. Apply clean gloves.
12. Clean the stoma and skin with
warm tap water. Pat dry.
13. Apply a small amount of lubricant
or protective cream around the
area of the ostomy.
14. Place gauze over orifice of stoma
while preparing the wafer and
pouch application.
15. Trace pattern onto paper back of
wafer and cut as traced.
16. Attach clean stoma bag or pouch
to wafer.
17. Remove gauze pad from the orifice
of stoma.
18. Remove paper backing from wafer
and place on skin over the stoma.
19. Tape wafer edges down with
hypoallergenic tape.
20. Remove disposable bed protector
and discard all used equipment.

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 21. Wash hands.
22. Record pertinent data.

Remarks:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

_________________________ _________________________
Clinical Instructor Student’s Signature

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COLLEGE OF NURSING