Nsgmanual SPC 2018edition

This Manual of Nursing Procedures
is
dedicated to all
SPC Students of Nursing –
the past, the present and
the future…
ACKNOWLEDGEMENT
Through 2016 edition of the Manual of Nursing Procedures, the Department of

Nursing pays tribute to the nursing faculty members who over the years contributed to the
development of the manual. To the many unnamed nurses who, out of professionalism and a
sense of duty to the future generations of nurses contributed their time, wisdom and energies
to the further enrichment of the manual, to them go gratitude of the men and women of the
Alma Mater, San Pedro College, Inc.
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The review and editorial work for this edition was made possible with the support of:
Mrs. Jeannie H. Bibera, MSN, dean of nursing, for her encouragement and concern;
The untiring effort of the Working Committee: Erein Therese B. Acero, MN, Bevan
B. Balbuena, MN,Elizabeth S. Biol, MN, Jocelyn A. Cataraja, MN,Marilou T. Hernandez,
MN,Loyalda T. Lazarraga, MAN,Sheve S. Suam, MN and ; reader Elsie A. Tee, MAN PhD.
Ms. Azeneth Lou C. Daray and Ms. Maricris E. Ranez, our laboratory assistants, Ms.
Aileen A Samonte, our department secretary for their patience and diligent clerical work; and,
Dr. Desiderio Noveno Jr., Executive Vice-President and Dr. Ana Enero for their
administrative motivation and interest.
The Working Committee
FOREWORD
A manual of nursing procedures is one of the reference materials of the school.

Deemed indispensable because it simplifies instruction, in the manual are the lists of the step
by step procedures involved in the various aspects of nursing and patient care. The first
manual was put together by the pioneering instructors who saw to it that it was regularly
updated. This revision is the reason why for many years the manual stayed in loose-leaf form.
There was always a need to modify, add or discard practices because of new discoveries in
the field or because of the innovations in science and technology that brought about a
corresponding change on doing a procedure. In revising a procedure, the nursing laboratory
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played an important role. It was here where those new developments were tested and verified
before they were incorporated into the manual and passed on to the student nurses as part of
their training.
Mention must be made here of the pioneering instructors who started the manual to
recognize their trail-blazing work and the in valuable contributions to nursing education.
They are Mrs. Ma. Beauty H. Villanueva and Ms. Josefina Leonor. Their work kept growing
that as mentioned earlier, the manual stayed in loose-leaf form. Sometime in 1976 these
compilations were put together and consolidated. Now properly called The Manual of
Nursing Procedures, it was a selection of practices and procedures that had stood the test of
time and continued to be useful. This year also saw Mrs. Villanueva working with Mrs.
Antonia Alcantara and Mrs . Eleanor Pulido-Abear to tackle the more arduous task of
determining the principles behind the nursing procedures. Their work also included a section
which dealt with what nurses must commit to memory when preparing medications.
In the 1990s a new wave of interest to take a fresh look at the manual was led by Ms.
Corazon B. dela Peña, PhD., then College Dean, together with Mrs. Pacita Ulat-Veloso, then
head of the nursing department and Mrs. Merilyn Pangan-Moreno, the sitting clinical
coordinator. They were joined by some other clinical instructors in the persons of Mrs.
Yolanda Salvador-Cortezano, Mrs. Jocelyn Cabueñas and Mrs. Carmelita A. Cristal. This
new thrust included a library search to discover the latest techniques and developments in
procedural matters. As a result the team dropped certain practices from the manual which
were deemed obsolete. The glossary of medical terms and diagnostic procedures were
however, increased. One thing that remained constant and could not be replaced was the
human touch in caring for the sick and ailing. This was taught along side the new things
brought in by the advances in medical science and biotechnology.
The 20th century has been considered the technological century- an age when new
discoveries and inventions proliferated. Nursing refused to lag behind and nursing research
also grew by leaps and bounds. The end product of this new knowledge found its way into
our classrooms to benefit the students. The manual of year 2000 incorporated some changes
after consultations were made with the San Pedro Hospital Nursing Service staff. Recognition
must also be made of the graduates who enriched our library collections and demonstration
room to further add to the fund of instruction.
Before the manual went into print in 2003, Mrs. Elsie Antiporta-Tee, MAN, the Dean
of Nursing then, organized a team of faculty to review the manual. The team was composed
of Mrs. Ma. Clarissa Baylon, MN, Mrs. Jeannie Ho-Bibera, MSN, Mrs. Imelda Anne Violan-
Cuevo, BSN, Mrs. Ninfa Loberiza-. Galendez, MAN, Mrs. Surleyda Malubay- Garcia, BSN,
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Mrs. Elvira Foronda-Pabitay, BSN, Mrs. Dalisay R. Plasencia, MAT, and Pacita Ulat-Veloso,
MAEd, MAN. As a consequence of this review the presentation of the procedures as well as
their relevance to a specific group of learners was re-organized. First to be presented were the
general nursing procedures that were taught to students in level ll. The other procedures were
re-grouped according to body systems, which the students dealt with in levels III and IV. An
added feature incorporated into the manual was a section on flower arrangement which was in
keeping with the school’s long standing tradition of offering flowers to St. Therese on her
feast day. Also making an appearance for the first time was the section on table setting which
was intended to widen the horizons of the student nurses.
The 2007 edition is the 7th printing of the manual. Some procedures for Level ll have
been upgraded to keep abreast with current trends. The procedure on physical assessment is
given more emphasis with a detailed guide on how it will be performed. The editorial work
for this edition was a concerted efforts of Mrs. Eleanor P. Abear, MN, Mrs. Imelda Anne
Violan- Cuevo, MN, Nelly T. Decena, MAN, and Surleyda M. Garcia, MAN.
With the ever changing trends in the practice of nursing, the need to revise the earlier
edition is the felt need of the department. Thus the production of the 2011 revised edition
having some updated procedures for levels II and III.
Fundamentals of nursing which is now known as NCM 100 RLE is offered to students
in level I during the second semester. In an attempt to better upgrade the Manual of Nursing
Procedures, the present dean of the department, Mrs. Jeannie H. Bibera organized a team with
an emphasis to review, edit and enrich the existing manuscript.
THE SPC VISION AND MISSION STATEMENT
The San Pedro College is a Catholic Institution of learning dedicated to the Christian
education of the people of Davao and its neighboring regions. It is owned and managed by the
religious congregation known as the Dominican Sisters of the Trinity.
It believes in: individual and personal development through love and hard work; open
admission and religious freedom; meaningful education as manifested in sound professional
and technical training for community service and national development; and providing every
man an opportunity to education to enable him to develop his capacities and potentials as a
persons.
It respects diversity of culture and tradition and aims at unity and peace among men.
VISION
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San Pedro College, a Dominican learning community, living and spreading the love of the
compassionate Jesus, Healer and Teacher, upholds its core values serving the poor and
disadvantaged, the Filipinos and the world.
MISSION
To provide a nurturing environment beneficial in the total formation of persons:
 Strengthening spirituality and values formation

 Promoting global competitiveness through better outcomes – based education
 Sustaining the culture of academic excellence
 Upgrading student support services and programs
 Advancing programs through curriculum review and development
 Improving generation of knowledge through quality research and publication
 Creating an environment through better customer relations and satisfaction
 Strategizing human resource management and development
 Intensifying college-community engagement
 Building partnerships and linkages
 Working continuously toward institutional development both material or physical
and human infrastructure.
CORE VALUES
• Truth and wisdom
• Excellence and quality
• Respect the uniqueness of persons
• Social responsibility
• Family spirit and sense of caring
MISSION STATEMENT OF NURSING DEPARTMENT
We, the administrators, faculty and staff of the nursing Department commit ourselves to
continually:
1. provide quality Christian nursing education to the community through innovative

instructions, research and community extension services.
2. develop nursing graduates who are globally competitive equipped with knowledge,
skills, attitudes and values of truth and wisdom, excellence and quality, respect for
the uniqueness of persons, social responsibility and family spirit, and sense of caring.
SPC NURSE’S PIN
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The nurse’s pin was patterned from the first
school seal of San Pedro Hospital School of Nursing,
now San Pedro College.
This identifies the bearer as a nursing

alumnus of San Pedro College, Inc.
The pin carries two colors. The blue color signifies loyalty of the Gospel of Christ. The
gold color refers to the honor and glory of God. These colors as worn illuminate
characteristics of an SPCian nurse bearing witness as God’s servant in the spirit of services in
love.
These values were first implanted by the Dominican Sisters of the Trinity being the
founder-owner of San Pedro College. The pin’s symbols are:
The lamp represents Nightingale’s lamp which symbolizes dedication, commitment,

healing hand and the gentle art of caring for which nursing stands; the eternal flame
represents the desire for a life of service and learning the accurate knowledge and practice of
the nursing profession;
The nurse’s cap designates responsibility and accountability as the nurse moves along
on the highway of care;
The cross represents the redeeming love of Christ for the suffering humanity.
The motto “Love Serves”, written on top of the pin, reminds us of the spirituality of St.
Therese of the Child Jesus, whose love for God dominated every act big or little in her life.
NURSING – WHAT IT IS!
Nursing may be viewed as both an art and a science. It is an art because it is

concerned with skills that require proficiency and dexterity. It is a science because it requires
the systematic application of scientific knowledge.
Nursing today has certain characteristics:
 Nursing is caring.
 Nursing involves a close, personal contact with the recipient of care.
 Nursing is concerned with services that take humans into account as physiological,
psychological, sociological and spiritual organisms.
 Nursing is committed to personalized services for all persons without regard to color,
creed, social or economic status.
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 Nursing is committed to promoting individual, family, community and national health
goals in the best manner possible.
 Nursing is committed to the involvement in ethical, legal and political issues in the
delivery of health care.
 Nursing utilizes research to improve the quality of human life.
THE NURSE AS A PROVIDER OF HEALTH CARE
Roles of the Nurse:
There are varied major roles nurses assume today. These are the:
Therapeutic role
The nurse has a healing or curative role. Nurses utilize techniques that facilitate the
natural processes of healing whether it is physical, psychological and interpersonal.
Caring (comforting) role

The chief goal of the nurse in this role is to provide support. The nurse supports the
patient by attitudes and actions that show concern for patient welfare and acceptance
of the patient as a person, and not merely as a chart.
Nurses who comfort patients act to relieve anxiety, diminish pain and restore a sense
of well–being.
Caring activities also include those that preserve the dignity of the individual and
those often referred to as the “mothering behaviors” in nursing.
Communicating role
Communication is integral to all nursing roles. Actions related to communication
include collecting information, conveying information and influencing others. The
quality of a nurse’s communication is an important factor in nursing care. The nurse
must be able to communicate clearly and accurately in order to meet the client’s
health needs.
Teaching role
Nurses frequently act as teachers, imparting information and reinforcing changes in
behavior. For effective learning, a nurse must establish an environment in which
patients can learn, determine patient’s need to learn, assess his/her readiness to learn
and design teaching strategies for said learning.
Planning role
Planning by nurses occur during all phases of the nursing process, including
assessment, planning, intervention and evaluation. Nurses plan with patients, their
families and other health team members.
Coordination role
Coordination is needed to achieve high–quality care. With efficient communication
among team members, unnecessary duplications and gaps in services can be
minimized.
Protecting role
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This include nursing activities that ensure safety of patients from injury or
complications.
Rehabilitating role
Rehabilitating activities are those that maximize a patient’s capacities and minimize
limitations. These activities often help patients to change and to gain new skills.
Socializing role
For patients who are separated from their families and normal activities, socializing
offers a distraction and respite from the focus on illness. Patients do not always want a
therapeutic conversation, sometimes they just want news of another world and
conversation they can enjoy. This is particularly true of patients with long–term
illness.
Counselor role
The nurse helps the client to recognize and cope with stressful psychologic or social
problems, to develop improved interpersonal relationship , and to promote personal
growth. The nurse helps those she serves to become aware of their feelings and to deal
with them in a constructive manner.
Leadership role
Nursing have expanded and now nurses assume leadership in health maintenance and
disease–prevention and rehabilitative programs. Patients look up to nurses as
authorities on the care they receive, thus, nurses use this opportunity to help in the
delivery of health care to individuals, families and communities.
Administrative role
The nurse has an important role as the person who sees to it that nursing services are
organized, coordinated and dispensed to meet the patient’s particular needs for
nursing care.
Client advocate role
The may represent the client’s needs and wishes to other health professional by just
merely relaying it to them. Nurses assist clients in exercising their rights and help them speak
up for themselves.
POINTS TO REMEMBER ON BECOMING A STUDENT NURSE
KEY POINTS EXAMPLES & RELATED NOTES
1. Know that you are needed and The supervisory personnel, the head
wanted in this work, because you are. nurse, CI, and others know the
importance of your work and what you
contribute. They want you to have a
good working situation and good
working relationship.
2. When you desire to do your best, you Develop the sense of initiative and
will always have pride in your work. spend your duty time productively.
This in turn makes the dull moments
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less frequent.
3. Understand what your assignment is; Your assignment is made by the CI who
ask about it, if it is not clear. has the primary responsibility for your
supervision; or it may be made by a staff
nurse or headnurse who will give
instruction on the floor.
4. Make a work plan. Write down or This will save time and make your work
think very well what you have to do systematic and productive.
and how much time you have to do it.
Prioritize which patient to take care
and the task to be done first.
5. Be willing to accept changes in work Unexpected situations come up after

load and assignment when necessary. assignments are made. These make
Be ready to make adjustments and help changes in work necessary. Accepting
a fellow student, if needed. certain unavoidable changes help to
lessen frustrations and irritations.
Remember that the CI is interested in
you and wants to help you improve in
your work.
4. Report to the nurse or CI the Remember, proper and immediate

following: referral will prevent deteriorating
condition to occur
a. A patient’s request or complaint
which calls for a professional
nurse’s decision.
b. Changes in patient’s condition or
something which seems unusual
to you.
c. A problem or question about your
work.
5. As a nursing student, you are called
upon to be dependable. This means: When ill or otherwise unable to report
for work, notify the proper person as
a. Being on the job and being there
early as possible.
on time.
b. Doing an assigned task and

finishing it on time.
Never go off duty without first doing the
c. Keeping promises after telling
thing or going back and telling the
anyone, particularly a patient, that
patient why you are unable to do it.
you will do something.
6. As a nursing student, you are called

upon to be trustworthy. This means
that:
Remember everyone makes errors. If the
a. When accidents occur or errors
error is reported promptly, then
are made, you must report them at
something can be done to prevent
once.
complications.
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b. When personal experiences are Always ensure confidentiality.
shared to you, keep these in
confidence. It is an honor that the
person has trusted you especially
if the person is a patient. Do not
disappoint him.
c. When using supplies and Remember that hospital supplies are not
equipment, avoid careless waste common property and should be used
of materials and senseless abuse properly. Hospital property must not be
of equipment. taken out of the premises.
7. Try to be mindful of the feelings of The habit of being courteous will

others and try to show consideration remove almost every barrier to work in
by controlling your own emotions. harmony with others.
8. Nursing is an important job. It calls If you keep trying to improve your

for persons who want to grow in the work, success with pride and job
process of caring for others. satisfaction is certain to follow.
MAINTAINING GOOD PERSONAL HEALTH
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1. Accept your responsibility to your “Personal Health” means not only physical
self and others to keep as healthy as health but good mental health as well. The
possible. Staying in top physical WHO defines health as a state of complete
condition is necessary when working physical, mental and social well–being and not
with sick people. merely the absence of disease or infirmity.
2. Understand that keeping in good Eating well–balanced meals and obtaining

health requires daily attention to enough sleep and rest will help the body to
health needs. Obtain enough sleep resist infection and will lessen the effects of
and rest daily to feel at top illness, if it comes.
performance.
3. Remember what foods are essential Malnutrition which is commonly defined as

for good health. Start the day with a lack of necessary or appropriate food
substantial breakfast. substances may result.
4. Make a check on the amount of water Sufficient water (about 6–8 glasses daily) is
you drink daily. essential to health.
5. If you are overweight or underweight Excess body weight predisposes people to

take this problem to your health chronic health problems such as hypertension
service, if available, or to your family and diabetes mellitus. Inadequate nutrition is
doctor. associated with marked weight loss, altered
functional abilities, increased susceptibility to
infection, etc.
6. Bathe daily for health and social Close contact with patients make body
reasons. Use soap and water freshness a must. Nurses must not omit
generously to cleanse skin of feminine hygiene.
perspiration and bacteria. Then use a
good deodorant.
a. Shampoo the hair regularly and Oily hair may require daily shampoo. Dry hair
frequently enough to keep it in good and scalp may be shampooed less often,
condition and free from odor. using appropriate shampoo.
b. Give particular care to skin of the During the day the face is exposed to different
face. Cleanse often with mild soap substances from the atmosphere and to many
and skin cleanser. things (particularly your hands) which may
transfer bacteria to it. A skin kept from dirt
and oily deposit will not form blackheads and
unsightly blemishes.
7. Form a good habit of daily oral care. Regular visits to dentist, at least twice a year,
are essential to keep teeth and gums in good
a. Brush teeth after eating or at least condition. When unable to brush after eating,
thrice daily, including after wash mouth with water.
evening meal snack.
The use of mouthwash after eating onions or
b. Use a mouthwash (table salt is garlic is advisable; brushing has only a
good) after brushing regularly. temporary effect on odors.
8. Give special attention to the hands Do not allow hands to become chapped.
not only for reasons of personal Breaks in skin invite infection. Use a good
health and appearance, but to prevent lotion or cream to keep it smooth.
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the possible spread of disease–
producing organism.
a. Wash hands thoroughly (using Washing may be done:

special techniques) many times a. Before eating or handling any food.
throughout the day. b. After using the toilet.
c. After each contact with a patient and
after handling articles used in patient
care.
b. Keep fingernails clean and Long nails may injure the patient/and may
trimmed to moderate length. harbor dust and microorganisms.
9. Take excellent care of those feet. Rubbing with lotion or alcohol (has drying
They serve you well. effect on the skin) or foot powder, as desired,
will bring much relief to your feet.
a. When bathing, wash carefully and Damp areas, especially in interdigital spaces,
dry thoroughly. can invite fungus to thrive
b. Trim toe nails straight across. Careful trimming and care of toe nails can
prevent painful ingrown nails.
c. See to it that hose are large Too small hose can compress legs and so with
enough and longer than foot. underlying blood vessels.
d. Wear well–fitting rubber-soled This causes less jar to the body. Also they
shoes with proper support and reduce the irritation brought about by noise.
heels.
e. Alternate daily between two pairs Alternating pairs of shoes is good for the feet
of shoes, if possible. and makes the shoes last longer.
10. Check your posture and if help is Good posture is necessary for the body to
needed consult a health service to function at its best. Think of good posture as
work out a definite program to correct good body alignment and balance in all
your faulty habits. positions and activities.
11. Try to keep an even, keen, emotion. Emotional stress can produce negative and
Seek help for ways to better nonconstructive feeling about self.
understand yourself and others, if
necessary.
12. Become interested in some type of Activities or hobbies that take you outdoors
sports game, or hobby that gives real are especially good. Walking, swimming,
pleasure to you. Join with others in an dancing and cycling are excellent exercises
organization of choice. and all can be carried on into later life with
great benefit to both physical and social well
being.
13. Keep an open mind and use it to Keep self updated by reading, attending
keep up–to–date in a fast changing seminars and continuing education
world.
PRESENTING A GOOD APPEARANCE
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1. When you feel good about your In addition to being well–groomed the
appearance, your work, and your student nurse should have a pleasing
personal relationships, your whole appearance in keeping with the job of caring
day is likely to go better, because you for sick people.
think well of yourself.
2. If possible, give yourself the mirror
test before reporting for duty. Look at
yourself in a full-length mirror.
3. Start the day in a spotlessly clean, Uniform should be given good repair, with
well-fitting uniform. You are all buttons in place. The length of the slip
expected to wear a fresh uniform should be shorter than the length of the
each day. Wear an underclothing that uniform.
is washed daily and in good repair.
4. Be clean, look clean, and feel clean.

5. Check the way you stand and how Good posture gives an impression of poise
you walk. Set out to correct faulty and self–confidence which sparks a feeling
posture habits, if any. of well–being and success on the job.
6. Bathe daily and use an effective Being in close contact with the patients all
deodorant especially under the arms, day require special attention to clean and
to protect against being offensive to eliminating odors of any kind. Nurse should
patients and others. not omit feminine hygiene. This is very
important.
7. Give the face special skin care. It A skin kept from dirt and oily deposits will
should be impressively clean. not form blackheads and unsightly
blemishes.
8. Use cosmetics with restraint. Apply Highly scented toilet preparations are often
light lipstick and use only mild offensive to patients and should be avoided.
colognes. Perfumes should never be used on duty. Use
an effective lotion or cream to prevent
breaks in skin.
Heavy make up is never appropriate for
duty.
9. Keep hair in neat arrangement and in Well–kept hair does not obstruct vision and
keeping with good taste for work. prevents spread of microorganisms with
The nurse’s hair should be in keeping frequent touching.
with the practices of the particular
hospital or agency.
10. Take particular care of your hands,
for health reasons as well as
appearance.
a. Keep clean, wash thoroughly,
several times during the day as
necessary.
b. Keep hands chap–free and

smooth.
c. Keep nails clean. File or trim to Long nails are out of place in caring for sick
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moderate length. people. Sharp nails may injure the patient.
They also can harbor microorganisms.
11. Wear well–fitting shoes. Keep shoes Moccasins or flats without heels give a
clean, polished and in good repair. careless impression and do not give the feet
Pay attention to run down heels and proper support.
have them replaced as soon as
needed.
12. Wear clean hose or socks daily. Hose Avoid circular garters or rolled hoses for
should be free from unsightly runs. health reasons as well as for appearance’s
Be in good taste when in uniform. sake.
13. Earrings, rings, and other forms of Jewelry can harbor pathogenic
jewelry should not be worn while on microorganisms.
duty (except for wedding bands by
married individuals).
14. Gum chewing makes an unfavorable
impression with patients, watchers
and others.
15. Lounging in undignified positions Other people will respect the nurse better if
and talking in loud, boisterous voices she acts with proper decorum.
are damaging to the nurse’s poise and
composure.
APPROACHES TO PATIENT CARE

1. Think of the patient as an individual, When a patient enters a hospital, attention is
a person who needs help. If you can usually focused on physical ailments.
be sincerely courteous to all patients, However, one brings along feelings and
your approach is already good. emotions as well as physical complaints.
These feelings and emotions have a great
influence on physical recovery.
2. Keep in mind that most patients have Let the patient know what it is you are
fears and worries about their illness going to do. Explain what is going to
or injury. The patient may feel uneasy happen to him before starting each
about what is going to happen and procedure. Proper explanations can ease
may be anxious and concerned about patient’s fear and anxiety
his/her family or job affairs.
3. Allow the patient to maintain Avoid the habit of calling patients by their
individual identity by calling his/her injury, diseased organ or by bed number.
name. Learn the patient’s name.
Remember it and use it.
4. Allow the patient to maintain self– Be reminded of ways to allow the patient to
esteem, privacy and dignity. maintain self–respect and human dignity.
Avoid exposing the patient unnecessarily
when she or he is being examined and
treated. Avoid placing the patient in a
position which makes him or her feel that he
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is “on exhibit.”
5. Respect the patient’s right and Everyone has freedom of religion. We

privilege of continuing the practices should respect one’s belief and tradition
of his own religious faith without
derision or ridicule.
6. Respect the patient’s right to continue Be culture–sensitive
the customs and patterns of his
nationality (which may be different
from yours, without interference).
7. Allow the patient to continue in See that he is not “whittled down” about the
his/her ways, habits, rituals and little things of no consequences except to
“idiosyn- cracies” which are part of him/her.
his/her personality.
8. Think of the “whole patient”, not just Then, think of your care and service to the
in relation to his disease or injured patient as “complete care” that is to the
areas. To give care to the “whole” “whole person.”
patient means to:
a. Help the patient maintain or
improve physical fitness and body
functions.
b. Provide the atmosphere that helps Emotional feelings may help develop new
the patient feel mentally easy and physical complaint unless emotional
comfortable, inspite of any problem is resolved, or patient is reassured
physical discomforts. Encourage and encouraged.
patients and help them overcome
the feelings that they are disliked
or disapproved of.
c. Help in the prevention of injuries Avoid placing the patient in a position or
and accidents to patients. These situation which might lead to or cause an
are sometimes due to the neglect accident or injury. The nurse plays an
or carelessness and sometimes are important role in preventing the spread of
the results of improper care. infection among patients.
d. Help prevent patient from coming Frequent and conscientious handwashing is
in contact with or contracting a one of the surest ways of disease
“new” illness which has nothing prevention. (see pages for handwashing
to do with the condition for which procedure).
he/she is being treated.
BODY MECHANICS
Definition It is the coordinated use of the body parts to produce motion and maintain their
equilibrium in relation to the skeletal, muscular, and visceral systems and their
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neurological association. It is a term used to describe the efficient,
coordinated, and safe use of the body to move objects and carry out the
activities of daily living
Purposes
1. To maintain good body posture.

2. To promote good physiological functions of the body.
3. To use the body correctly and to maintain its effectiveness.
4. To prevent injury or limitation of movement of the musculoskeletal system.
Principles of Body Mechanics
1. The wider the base of support, the greater the stability of the nurse.
2. The lower the center of gravity, the greater the stability of the nurse.
3. The equilibrium of an object is maintained as long as the line of gravity passes
through its base of support.
4. Facing the direction of movement prevents abnormal twisting of the spine.
5. Dividing balanced activity between arms and legs reduces the risk of back injury.
6. Leverage, rolling, turning, or pivoting requires less work than lifting.
7. When friction is reduced between the object to be moved and the surface on which it
is moved, less force is required to move it.
8. Reducing the force of work reduces the risk of injury.
9. Maintaining good body mechanics reduces fatigue of the muscle groups.
10. Alternating periods of rest and activity helps to reduce fatigue
11. Pulling action requires less effort than pushing or lifting.
Note: Ask patient to help if he/she could, if not, get assistance from other nurses.
APPLICATION of BODY MECHANICS

A. STANDING
1. Stand erect with head upright, face forward, shoulders squared, back straight,
abdominal muscles tucked in, arms straight at sides with palms forward.
2. Keep feet 3 – 4 inches apart for a wide base of support. Place equal weight on both
legs to minimize strain on weight–bearing joints.
B. SITTING
1. Position the buttocks against the back of the chair. Hips and knees are flexed at right
angle to the trunk.
2. Keep trunk and head as in standing position.
3. Place feet flat on the floor at a 900 angle to the lower legs.
4. If the chair has arms, flex the elbows and place the forearms on the armrest to avoid
shoulder strain.
C. BODY MOVEMENT
KEY POINTS Rationale
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1. Start any body movement with Stretching creates unnecessary muscle
proper alignment and balance. fatigue and strain and places the lines of
gravity outside the base of support, resulting
in instability
2. Adjust the working area to waist This is to bring object being carried close to
level and keep your body close to the center of gravity
the area.
3. Face in the direction of the task. This avoids torsion of the spine as well as
increases your stability and balance.
4. When moving a heavy object, keep The closer the line of gravity to the center
your center of gravity as low as of base support, the greater the person’s
possible and centered over your stability
base of support.
5. Avoid working against gravity It takes less effort to slide, push or pull
whenever possible. objects than it does to lift or carry them.
6. Tighten the gluteal and abdominal Helps to support the abdomen and stabilizes
muscles before lifting any object. the pelvis to prepare them for action and
Often referred to as “putting on the prevent injury.
internal girdle.”
7. Carry object close to the body and Holding objects close to the body prevents
to the base of support. strain on the arm muscles. Body stability is
enhanced if the object is close to the base
support.
8. Use the palmar grip when grasping The hand muscles are larger and stronger
and lifting object. than the finger muscles.
9. When lifting heavy objects, squat Bending from the waist (stooping) to lift a
rather than stoop. heavy load is a major cause of back strain.
The squatting position uses the larger and
stronger ventral and femoral muscles of the
buttocks and thighs.
10. Use the body’s weight to pull or Body weight adds power to muscle action.
push objects.
11. Make your body movements Sudden, jerky movements expend more
smooth and rhythmic. energy and put more strain in the muscles
than controlled smooth motions.
D. MOVING UP THE CLIENT IN BED
The nurse will frequently encounter a semi–helpless or immobilized patient whose

position must be changed or who must be moved up in bed. Proper use of body mechanics
can enable her (and the helper) to move, lift, or transfer such a patient safely and at the same
time avoid musculoskeletal injury.
Procedure
Action Rationale
17
1. Check client’s record To assess client’s physical abilities (muscle
strength, presence of paralysis) and ability
to understand instructions.
2. Identify the client, introduce self and An explanation reduces apprehension and
explain the procedure to the patient. facilitates cooperation. It also promotes the
patient’s autonomy.
3. Perform hand hygiene and don gloves. Reduces transient and microorganism of
pathogens to others and self.
4. Provide for client’s privacy. To maintain client’s dignity.
5. Elevate bed to working height. Lessens strain on nurse’s back muscles by

bringing the height to center of gravity.
6. Lock the wheels of the bed and raise Prevent bed from dragging and client from
the rail on the side of the bed opposite injury.
you.
7. Adjust the head of the bed to flat Moving client upward against gravity
position as low as the client can requires more force and cause back pain.
tolerate
8. Remove all pillows and place one To protect the client’s head from injury
against the head of the bed. during upward movement.
9. Elicit client’s help by asking him to Lessens the workload of a nurse

a. flex the hips knees and position Flexing the hips and the knees keep the
the feet. entire lower legs off the bed surface thus
preventing friction. The large mucles of
client’s legs when pushing, increase force of
movement.
b. grasp the head of the bed and Client’s assistance provides additional
pull during the move power to overcome inertia and friction
or: raise the upper part of the during the move.
body on the elbows and push
with the hands and forearms
during the move.
or: grasp the overhead trapeze
with both hands and pull during
the move
10. Position yourself appropriately Prevents twisting the body when moving the
a. Face the direction of movement. client.
b. Place your feet apart. This increases your balance and wider base
of support.
c. Place your arm under the client’s This supports the heaviest part of the
thigh. client’s body (buttocks).
d. push down the mattress with the far Far arm acts as lever during the move.
arm
11. Instruct the client to move up in bed in Prepares the client for actual move thus
the count of three
18
reinforcing assistance
12. Move in coordination to transfer the
client up toward the head of the bed. Enables the nurse to improve balance as he
overcomes inertia.
13. Ensure client’s comfort and reassess
patient’s body alignment. Proper body alignment increases client’s
comfort, promotes rest and reduces hazards
of immobility.
14. Elevate side rails.
Ensures client’s safety
15. Remove gloves and wash hands.
Decreases transient microorganisms and the
transmission of pathogens to others and self.
16. Document the procedure that was done
Record in nurse’s notes patient’s new
position..
Variation A: For a client who has limited

strength of the upper extremities
Follow steps 1-8 ( moving up client in
bed)
9. Assist the client to flex the hips and
knees and position the feet. Place the This keeps them off the bed surface and
client’s arm across the chest. minimize friction during movement
10. Ask the client to flex the neck and
keep the head off the bed surface
during the move.
11. Position yourself as in step 10( a & b)
and place one arm under the clients This placement of the arms distributes the
back and shoulders and the other arm client’s weight and support the heaviest part
under the client’s thighs of the body.
patient’s body alignment.
14. Remove gloves and wash hands
15. Document the procedure that was done
Variation B: Two Nurses Using a Hand-

Forearm Interlock.
Two people are required to move clients
who are unable to assist because of their
condition or weight.
Using the technique described in Variation

A, with the second staff member on the
opposite side of the bed, both will
interlock their forearms under the client’s
thighs and shoulders and lift the client up
in bed.
Variation C. Two Nurses Using a Turn

Sheet.
Follow 1-10 in Variation A
19
11. Place a draw sheet or a full sheet
folded in half under the client, A turn sheet distributes the client’s weight
extending from the shoulder to the more evenly, decreases friction, and exerts
thighs a more even force on the client during the
move.
12. Each person rolls up or fanfold the
turn sheet close to the client’s body on This draws the weight closer to the nurse’s
either side and grasp the sheet close to center of gravity and increases their balance
the shoulders and buttocks of the and stability, permitting a smoother
client. movement
13. Assist the client to flex the hips and
knees and position the feet. Place the
client’s arm across the chest.
14. Ask the client to flex the neck and
keep the head off the bed surface The keeps them off the bed surface and
during the move. minimize friction during movement.
15. Move in coordination to transfer the
client up toward the head of the bed. Enables the nurse to improve balance as he
overcomes inertia.
patient’s body alignment. Proper body alignment increases client’s
comfort, promotes rest and reduces hazards
of immobility.
18. Remove gloves and wash hands. Ensures client’s safety.
19. Document the procedure that was
done. Record in nurse’s notes patient’s new
position.
Nurse Alert:
The nurse must avoid dragging the patient up in bed. Dragging against the bed linen
causes shearing force. With a shearing force the skin adheres to the surface of bed while the
layers of subcutaneous tissue and even the bones slide in the direction of body movement.
The underlying tissues and capillaries are compressed and may be severed by the pressure.
This can cause bedsores or pressure sores.
E. TURNING A CLIENT TO LATERAL OR PRONE POSITION IN BED

Purpose:
Movement to the lateral (side –lying) position may be necessary when placing the
bedpan beneath the client, when changing the client’s bed linen, or when repositioning the
client.
Procedure
Action Rationale
1. Review client’s record Determine the reason for logrolling the
patient and the patient’s diagnosis.
2. Identify the client, introduce self and An explanation reduces apprehension and
explain the procedure to the patient. facilitates cooperation. It also promotes the
patient’s autonomy.
3. Perform hand hygiene and don gloves Reduces transient and microorganism of
20
4. Provide for client’s privacy To maintain client’s dignity
5. Raise the bed to a comfortable Lessens strain on nurse’s back muscles by

working level. bringing the height to center of gravity.
you.
7. Move the client closer to the side of This will ensure that the client will be
the bed opposite the side the client will positioned safely in the center of the bed
face when turned with the use of a after turning.
pull sheet.
8. Place the client’s near arm across the Pulling the one arm forward facilitates the
chest, abduct the far shoulder slightly turning motion. pulling the other arm away
and externally rotate it. Place the from the body and externally rotating the
client’s near ankle and foot across the shoulder prevents that arm from being
far ankle and foot. caught beneath the client’s body during the
roll
9. Raise the side rails next to the client This ensures that client, who is close to the
before going to the other side of the edge of the mattress will not fall.
bed.
10. Position yourself on the side of the bed This facilitates the turning motion. making
toward which the client will turn, these preparations on the side of the bed
directly in line with client’s waistline closest to the client helps prevent
and as close to the bed as possible. unnecessary reaching.
Lean your trunk forward from the
hips. Flex hips, knees and ankles.
Assume a broad stance with one foot
forward and place weight on this foot
moved forward.
11. Pull or roll the client to lateral position This position of the hands supports the
by placing one hand on the client’s hip client at the two heaviest parts of the body,
and the other hand on the client’s far providing greater control of movement
shoulder during the roll.
12. Position the client on his side with Proper positioning of the arms and legs will
arms and legs positioned and prevent injury.
supported.
Variation: Turning the Client to a

Prone Position
Follow the pre-proceeding steps with two

exceptions:
 instead of abducting the far arm, Keeping the arm alongside the body
keep the client’s arm alongside the prevents it from being pinned under the
body for the client to roll over. client when the client is rolled
 roll the client completely onto the
abdomen
13. Assess the patient’s comfort and body Maximizes the patient’s comfort and
21
alignment. provides good body alignment.
14. Wash your hands and remove gloves Decreases transient microorganisms and the
transmission of pathogens to other and self.
15. Record the procedure, time, patient’s Communicates to the other members of the
response and other observations. health care team and contributes to the legal
record by documenting the care given to the
patient.
F. LOGROLLING THE PATIENT
Purpose:
Logrolling is a technique used to turn a patient whose body must at all times be kept
in straight alignment( like a log). An example is the client who has a spinal cord injury or a
spinal disorder, or who has had a spinal cord operation or a hip operation (with a prosthesis or
pin). Another nurse should assist you with this procedure.
Equipment:
1. Pillows
2. Drawsheet or full sheet folded in half
3. Wedge
4. Extra linen as needed
Procedure
Action Rationale
1. Review client’s record Determine the reason for logrolling the

patient and the patient’s diagnosis
2. Identify the client, introduce self and The reason for the procedure should be
explain the procedure to the patient. explained to the patient.
3. Perform hand hygiene and don gloves Reduces transient microorganism or

pathogens to transfer others and self.
5. Raise the bed to a comfortable Lessens strain on nurse’s back muscles by

working level. bringing the height to center of gravity.
you. Gently remove supportive device
around the patient (IF APPLICABLE).
7. The two nurses should position To have a balanced force when moving the
themselves on opposite sides of the patient.
bed
8. Place the client’s arm across the chest. To ensure that the hands will not be injured
or become trapped under the body during
the turn.
9. Place a pillow lengthwise between the Helps to maintain the correct alignment of
patient’s legs. the client’s lower extremities during the
22
turn.
10. One nurse should grasp the patient at Each staff member then has a major weight
the patient’s shoulders and waist, area of the client centered between the arms
supporting the neck. The other nurse
should grasp the patient at the patient’s
buttocks and knees, supporting the
legs. Roll the patient all in one motion
to a side-lying position.
11. One nurse counts: one, two, three, go Moving client in unison maintain the
then at the same time all staff client’s body alignment.
members pull the client to the side of
the bed.
12. Elevate the side rail on this side of the This prevents the client from falling while
bed. lying so close to the edge of the bed.
13. Place the patient in correct body The patient is aligned correctly to prevent
alignment and put the wedge against any contractures and damage to the spinal
his or her back. cord.
14. Flex the patient’s top leg at the knee Maximizes the patient’s comfort and
and place a pillow under the knee and provides good body alignment.
lower leg. A small pillow or folded
linen may be placed under the head
and shoulders.
Variation : Using a draw sheet/bedsheet

folded in half
a. The two nurses should position The nurses will grip the rolled drawsheet to
themselves on opposite sides of the roll the patient.
bed and roll the edges of the
drawsheet toward the patient.
b. With the drawsheet, slide the patient Allows ample room for positioning the
to the edge of the bed opposite the patient once he or she is rolled to the
direction to which the patient is to be opposite side.
turned.
c. Place a pillow lengthwise between the Helps maintain the correct alignment of the
patient’s legs . patient’s lower extremities as he or she is
turned.
d. Position the patient’s arms. To turn Proper positioning of the arms will prevent
the patient to the right, place his or injury.
her left arm to the side and the right
arm either flexed above the head or at
the side. Raise the bedrails to the
opposite side where you will turn the
patient. Both nurses should move to
the side of the bed to where patient
will be turned.
e. The first nurse go to the farthest side To ensure good alignment in the lateral
of the bed .reaching over the client, position.
grasp the far edge of the turn sheet,
and roll the client toward you. The
second nurse ( behind the client) helps
23
turn the client and provide pillow
supports .t
15. Remove gloves and wash your hands. Decreases transient microorganisms and the
transmission of pathogens to other and self.
16. Record the procedure, time, patient’s Communicates to the other members of the
response and other observations. health care team and contributes to the legal
record by documenting the care given to the
patient.
E. TRANSFERRING A PATIENT FROM BED TO CHAIR / WHEELCHAIR
Transferring a patient from bed to chair enables the nurse to change his surroundings
as well as his position. If the patient is able to tolerate transfer to a wheelchair, the nurse can
move him out of his room into other surroundings and increase his opportunities for
socialization. For patients who have been on bed rest, this is one of the first activities to be
resumed.
Procedure
Action Rationale
1. Review client’s record. Assess patient for ability to assist the

transfer and for presence of cognitive or
sensory deficits.
2. Verify Client’s identity, introduce Reduces patient anxiety and increases
yourself and inform patient of the cooperation.
purpose and destination.
3. Perform hand hygiene and don gloves Reduces transient microorganism and
prevents transmission of pathogens to self
and others.
5. Lower the height of the bed. Reduces distance patients has to step down,
thus decreasing risk of injury.
6. Allow patient to dangle feet for a few Allows time for assessing patient’s response
minutes. to sitting; reduces possibility of orthostatic
hypotension.
7. Bring wheelchair/ chair close to the Minimizes transfer distance. Provides
side of the bed, facing the foot of the stability
bed (If wheelchair, lock its brakes and
elevate foot pedals).
8. Assist patient to side of bed until feet Guides and helps patient maintain balance.
touch the floor.
9. Assist the patient to a standing Helps patient stand safely and gives time to
position and provide support. assess status.
10. Pivot patient so patients’ back is Moves patient into proper position to be
toward the wheelchair. seated.
11. Place patient’s hands on the arm Allows patient to gain balance and judge
supports of the wheel chair. distance to sit.
12. Bend at the knees, easing the patient Increases stability and minimizes strain on
into a sitting position. back.
24
13. Assist to maintain proper posture Broadest and therefore safest base of
resting on the chair’s back. support is with patient seated as far back on
the seat as possible.
14. Secure safety belts (if present), place Ensures safety and prepares patient for
patient’s feet on foot pedals and movement.
release brakes.
15. Remove gloves and wash your hands. Decreases transient microorganisms and the
transmission of pathogens to others and self.
16. Record in nurse’s note patient’s safe Documents the action taken.
transfer to chair.
Nurse Alert:
Transfer of a patient from bed to chair by one nurse requires assistance from the
patient and should not be attempted if the patient is unable to help or to understand the
nurse’s instructions.
F. TRANSFERRING A PATIENT FROM BED TO STRETCHER
Procedure
Action Rationale
1. Review client’s record. Assess patient for ability to assist the
transfer and for presence of cognitive or
sensory deficits.
2. Verify Client’s identity, introduce Reduces patient anxiety and increases
yourself and inform patient of the cooperation.
purpose and destination.
3. Perform hand hygiene and don gloves Reduces transient and microorganism of
4. Provide for client’s privacy To maintain client’s dignity.
5. Raise the height of the bed and lock It is easier for the client to move down a
brakes of bed. slant. Nurse must bend, thus preventing
back strain and prevents bed from moving.
6. Instruct/ assist patient to move to side Decreases risk of patient falling.

of bed near the stretcher. Lower side
rails of bed and stretcher.
7. Stand at outer side of stretcher and Diminishes gap between bed and stretcher;
push it toward bed. secures the stretcher position.
8. Instruct patient to move unto stretcher Promotes patient independence.

with assistance as needed (for able
patient).
Variation A (for disabled client)
a. Roll a pull sheet tightly against the This achieves better control over client
client. movement.
25
b. Place the arms across the chest. To prevent injury to these body part.
c. In unison with other staff Prevent stretcher from moving.
members, press the body tightly
against the stretcher.
d. Transfer the client to the stretcher.
Variation B: Using a Transfer

Board
Transfer board is a lacquered or

smooth polyethylene board which
may measure 45 to 55 by 182 cm.
with handholds along its edges. (It is
imperative to have enough people
assisting).
a. Turn the client to a lateral position
away from you
b. Position the board to the patient’s
back, and roll the client onto the
board
c. Pull the client and the board across
the bed to the stretcher safety
belts maybe place over the chest,
abdomen and legs.
9. Cover patient with sheet. Promotes comfort and protects privacy.
10. Elevate side rails on stretcher and Prevents falls.

secure safety belt (if available).
Release brakes of stretcher.
11. Stand at head of stretcher to guide it Pushing, not pulling ensures proper body
when pushing. mechanics.
12. Document relevant information Record in nurse’s notes the patient’s safe
transfer to stretcher.
SAN PEDRO COLLEGE

Davao City
26
PERFORMANCE CHECKLIST
MOVING UP the ABLE CLIENT in BED
Name: ________________________________ Grade: __________________

Year and Sec.: _________________ Date: _______________
Legend: 5 – Excellent; 4 – Very good; 3 – Good; 2 – Fair; 1 – Poor
Rating
5 4 3 2 1
1. Reviews client’s record
2.Identifies the client, introduces self and explains the
procedure to the patient.
3. Performs hand hygiene and don gloves.
4. Provides for client’s privacy.
5. Elevates bed to working height.
6.Locks the wheels of the bed and raises the rail on the side
of the bed opposite you.
7. Adjusts the head of the bed to flat position as low as the
client can tolerate.
8.Removes all pillows and place one against the head of the
bed.
9. Elicits client’s help by asking him to
a. flex the hips knees and position the feet.
b. grasp the head of the bed and pull during the move
or: raise the upper part of the body on the elbows and
push with the hands and forearms during the move.
or: grasp the overhead trapeze with both hands and pull
during the move
10. Positions self appropriately
a. Faces the direction of movement.
b. Places feet apart.
c. Places arm under the client’s thigh.
d. pushes down the mattress with the far arm
15. Instructs the client to move up in bed in the count of
three.
16. Moves in coordination to transfer the client up toward
the head of the bed.
13. Ensures client’s comfort and reassess patient’s body
alignment.
14. Elevates side rails.
15. Removes gloves and washes hands.
16. Documents the procedure that was done
Comments:
Criteria : I Knowledge (quiz) 30%

II Performance 70%
100%
27
________________________________ __________________________
Student’s Signature Over Printed Name Date
________________________________ __________________________
Instructor’s Signature Over Printed Name Date
SAN PEDRO COLLEGE

Davao City
28
TURNING a CLIENT to LATERAL POSITION
Name: ________________________________ Grade: __________________

Year and Sec.: _________________ Date: _______________
Rating
5 4 3 2 1
2. Identifies the client, introduces self and explains the
5. Elevates bed to working height.
6. Locks the wheels of the bed and raises the rail on the side
of the bed opposite you.
7. Moves the client closer to the side of the bed opposite the
side the client will face when turned with the use of a pull
sheet.
8. Places the client’s near arm across the chest, abduct the
far shoulder slightly and externally rotates it. Places the
client’s near ankle and foot across the far ankle and foot.
9. Raises the side rails next to the client before going to the
other side of the bed.
10. Positions self on the side of the bed toward which the
client will turn, directly in line with client’s waistline and as
close to the bed as possible. Leans trunk forward from the
hips. Flexes hips, knees and ankles .Assumes a broad stance
with one foot forward and weight placed on this forward
foot.
11. Pulls or rolls the client to lateral position by placing one
hand on the client’s hip and the other hand on the client’s
far shoulder
12. Positions the client on his side with arms and legs
positioned and supported
13. Ensures client’s comfort and reassesses patient’s body
alignment.
14. Elevates side rails.
16. Documents the procedure that was done
Comments:

II Performance 70%
100%
29
________________________________ __________________________
________________________________ __________________________
SAN PEDRO COLLEGE

Davao City
30
TRANSFERRING a PATIENT from BED to CHAIR / WHEELCHAIR
Name: ________________________________ Grade: __________________

Year and Sec. :_________________ Date: _______________
Rating
5 4 3 2 1
2. Identifies the client, introduces self and explains the
5. Lowers the height of the bed.
6. Allows patient to dangle feet for a few minutes.
7. Brings wheelchair/ chair close to the side of the bed,
facing the foot of the bed (If wheelchair, lock its brakes and
elevate foot pedals).
8. Assists patient to side of bed until feet touch the floor.
9. Assists the patient to a standing position and provide
support.
10. Pivots patient so patients’ back is toward the wheelchair.
11. Places patients’ hands on the arm supports of the wheel
chair.
12. Bends at the knees, easing the patient into a sitting
position.
13. Assists to maintain proper posture.
14. Secures safety belts (if present), places patient’s feet on
foot pedals and release brakes.
15. Removes gloves and washes your hands.
16. Record in nurse’s note patient’s safe transfer to chair.
Comments:

II Performance 70%
100%
31
________________________________ __________________________
________________________________ __________________________
HOUSEKEEPING
32
A. Definition
It is the provision of the patient with a safe, pleasant and suitable environment.
B. Responsibilities
All nurses should accept responsibility for the following:
1. Daily care of the patient’s room or unit.
2. The care of departmental facilities, such as nurse’s station, diet kitchen and utility
room.
3. Thorough cleaning of the room after discharge of a patient to make it ready for the
next patient.
4. Control of insects or pests.
C. Important Factors to Consider in Hospital Housekeeping
1. Immediate disposal of waste and garbage is essential for good sanitary practice.
2. Care of floor is necessary to promote cleanliness and provide attractive
surroundings.
3. Furniture should be kept clean and in good condition at all times.
4. Torn linen should be sent to the sewing room for mending, keeping in mind that
there should be enough linen to meet the needs of the patient.
5. All equipment used for the personal care of the patient should be cleaned and
ready for use at all times.
6. Greasy liquids should not be poured into the sink. Solid wastes, such as broken
blades, cotton balls, O.S., applicators, sanitary napkins and others of the same kind
should not be thrown into the toilet bowls, to prevent clogging of pipes.
7. Bits of food dropped on the floor or on any surface and other liquid or waste
should be immediately removed or mopped to prevent accident and to avoid
attracting flies and other insects.
D. Suggestions Relating to the Use and Care of Hospital Furniture ( metal or wood)
1. When the furniture in the room is of matching set, do not move any of it to another
room.
2. Do not force drawers or doors which are difficult to open or close. Investigate to
see if an article or linen has been crowded into the drawer or compartment. To
force closure in such an instance will damage the furniture.
3. Report immediately damaged furniture to the Carpentry Shop so it can be repaired
before it is damaged further.
4. Protect the dresser and bedside table by placing a suitable dish or container under
each flower vase or pot brought into the patient’s room.
5. If anything is spilled on the furniture, be sure that it is immediately cleansed.
6. Use mild soap solution to wash the furniture if necessary and dry it carefully after
it has been washed. Never use water in cleaning varnished furniture for they will
be injured by moisture.
7. When using the overbed table, raise it high enough to clear the foot of the bed so it
will not be damaged when moved.
8. When using the bed cranks, pull completely out when needed, to elevate or lower
the head or foot of the bed. If only partially in place, the crank may hit the bed,
scratching or marring it as each rotation is made.
9. Metal furniture may be adequately cared for by frequent washing with warm water
and soap and drying thoroughly. It should be handled carefully to prevent needless
denting of its surface.
10. In the daily cleaning of the room, care should be exercised in moving the furniture
so that it does not become marred or scratched.
E. Basic Cleaning Operations
33
Purpose: To maintain a safe, clean and healthful surrounding for the patients, visitors
and staff.
Cleaning Operations are:
I. Sweeping – is a cleaning operation to remove dirt from floor area. It precedes all
other daily cleaning operations.
Equipment:
1. Floor broom or brush
2. Dust pan
3. Garbage or trash can
Procedure:
1. Bring the equipment to the area to be swept.
2. Leave trash or garbage can out of traffic but near place of work.
3. Starting from the entrance, sweep with proper strokes towards the center of the
room. Accumulate dirt into a dust pan and deposit it into garbage or trash can.
4. When dust is heavy, tap brush or broom on the floor at the end of each stroke to
free dirt.
5. After sweeping, examine floor, see that all areas had been swept and dust streaks
are not present.
6. Straighten furniture and do other necessary cleaning operations.
7. Clean equipment used and return to proper place.
II. Mopping – is a cleansing operation to rub or wipe the floor with a mop using
soap and water.
Equipment:
1. Floor mop
2. Pail with soap solution
3. Pail with rinsing water
4. Mop wringer
Procedure:
1. Bring the equipment to the area to be mopped.
2. Dip the mop into the soap solution.
3. Place the mop on the wringer and wring.
4. Starting from the corner, mop the floor using firm and heavy strokes to loosen dirt.
5. Rinse and dry as necessary until whole area had been mopped.
6. Inspect work. Clean floor should not have streaks of dirt.
7. Clean all equipment used and return to the proper place.
III. Scrubbing – is a cleansing operation to remove dirt by rubbing hard with the use of
a brush with or without soap and water.
Equipment:
1. Coconut husk / electric polisher
2. Brush
3. Pail with soap solution
4. Pail with rinsing water
5. Mop
6. Dust cloth
Procedure:
34
1. Bring all equipment to the bedside.
2. Dip brush in soap solution; rub it against the surface to be cleansed.
3. Rinse using long strokes and following the grain of wood.
4. Wipe to dry using same strokes.
5. Inspect work and see that all dirt has been removed.
6. Return all equipment to proper places, clean and dry.
Note: After rinsing the floor, mop to dry then polish.
IV. Waxing – is the application of a protective coating to an area which may

be later polished by friction.
Equipment:
1. Appropriate wax
2. Several dust cloths
Procedure:
1. Rub the dust cloth to the wax and proceed waxing from the corner to the center of
the room, in case of floor; or from top to bottom, in case of furniture until all areas
have been covered.
2. This may be followed by rubbing, applying friction on the area with cloth to
achieve a smooth finish after waxing, depending on the instructions of the kind of
wax used. On floors, scrubbing with coconut husk or electric polishing may be
done to achieve a smooth and shiny finish.
3. Return all things used to proper places.
V. Washing – is a cleansing operation of removing dirt by the use of soap and water.
Procedure: Depending on the kind of article to be washed.
VI. Dusting – is a cleansing operation to remove dirt which may be washed.
CLASSIFICATION of DUSTING
A. According to materials used:
1. Dry dusting – use of dry cloth to remove dust, as in varnished furniture.
2. Damp dusting – use of damp cloth to remove dust on furniture not
destroyed by moisture.
B. According to Height
Low dusting – includes dusting of all places easily reached by standing on the
floor and is done daily.
High dusting – includes dusting of all places easily reached by standing on a chair,
and is done periodically.
LOW DUSTING
Purpose : For daily dusting
Equipment : A tray containing:
1. A basin or pail half- filled with water

2. Laundry soap or any detergent
3. Whisk broom or chicken feathers, or a stick with cloth wound at one end
4. Metal polish, if necessary
5. Pieces of dusting cloth
6. Newspaper for lining
Procedure:
35
1. Bring all the equipment to the place of work.
2. Line the chair or stool with newspaper and place the tray on it (never on
the floor).
3. Start dusting from the highest point to be cleansed towards the floor.
4. Dust in between bars and crevices with the use of a small brush, chicken
feather or a stick with cloth wound at one end.
5. In dusting bars, palm the cloth and grasp the bar as you wipe along the
surface.
6. If soap and water is to be used, rub the cloth moistened with soap to the
area rubbing it with friction until dirt has been loosened. Rinse and dry.
7. If necessary, clean and oil wheels of furniture and polish door knobs with
metal polish.
8. Inspect work if everything has been properly dusted. If properly cleaned, it
will appear bright and free of dust streaks.
9. Return all equipment to proper places, clean and dry.
HIGH DUSTING. Precedes general cleaning operations.

Purpose: To do general cleaning of a room from the ceiling to the floor
including all furniture and cabinets.
Equipment: Similar in preparation for daily dusting with the addition of broom or
brush with long handle and pieces of newspaper to cover the tops of
the cabinets that could not be moved.
Procedure:
1. Bring the equipment to the room and place the tray on a chair or stool lined
with paper.
2. Move all furniture that could be moved to one side of the room, otherwise
cover their top with newspaper to protect them from catching all dirt from
the ceiling.
3. Using the broom or brush with long handle start cleaning from the ceiling
to walls removing cobwebs and other dirt, paying attention to cracks and
crevices.
4. Brush window screens or dust window bars using dry dust cloth or one wet
with soap and water as needed. Rinse and dry. Sweep the floor and collect
all dust and deposit in a trash can.
5. Dust all furniture (procedure depending on the kind of furniture to be
cleaned and amount of dirt present).
6. Dust inside of cabinets and drawers beginning from top shelves removing
the articles inside one shelf at a time, changing the lining if necessary and
cleaning all articles before returning them to the shelf.
7. Move all furniture that have been cleaned to the clean area.
8. Repeat same procedure from Nos. 3 to 6.
9. When everything has been cleaned including floor, arrange the furniture
back to the place where they belong.
10. Inspect the room and see that everything has been cleaned.
11. Return all equipment used to proper places clean and dry.
CARE OF LINEN
Linen should be inspected, those which need mending, should be sent to the sewing
room. Those left should be sorted according to the kind and use and folded uniformly before
returning to the shelf.
CARE OF MEDICINE CONTAINERS AND CABINETS
36
Medicines should be removed from one shelf at a time, bottles should be wiped with
damp cloth without removing the cork or cap paying attention that the label will not be
discolored or destroyed. Arrange accordingly back to the shelf.
If there are medicines that have considerably discolored or have precipitated, report it
to the nurse in-charge for replacement, if necessary.
See that every article should be returned to the shelf intended for it.
For cabinets with glass, shelves or doors, the glass should be cleaned with damp
newspaper and wiped with a dry one or with smooth dust cloth that does not cause abrasions
or leave fibers on the area. Lock cabinets or drawers if necessary.
DAILY CARE OF THE UNIT
The patient unit has been defined as the area, furnishings and equipment necessary for
the care of a single patient. The unit may vary in size. It may be:
1. A suite including living room, bedroom and bath;

2. A single room containing furnishings, equipment and supplies used for the care
and comfort of just one patient, or;
3. The immediate surroundings of a patient in a ward where several patients are
placed.
Purpose: To provide clean, attractive and hygienic surrounding for the patient.
Equipment: Same as for daily dusting.
Procedure:
1. Maintain proper lighting and ventilation.
2. Clean articles and return them to their places clean and dry.
3. Dust all furniture, windows and walls.
4. Keep drawers clean, see that articles inside are clean and arranged in good order.
5. Keep mirrors clean and free from stains.
6. Provide clean drinking water.
7. Check if garbage can has been emptied.
8. Check if toilet and bathroom are clean. Toilet paper and soap may be provided per
hospital policy.
9. Take flowers to utility room (clean, arrange and return to bedside). May be
omitted for patients with allergy, or check hospital policy.
10. Check all equipment and articles in the room or bedside. Report those that are
missing or out of order.
11. Check if the calling device (buzzer) is functioning properly and within the reach of
the patient.
12. Lastly, see that the patient is comfortable and the general appearance of the room
suggests cleanliness, neatness and beauty.
Elimination of Unpleasant Odors

A clean room should not have any odor. Since reaction to odors vary so widely among
individuals, hospitals have attempted to keep the immediate environment of the patient free
from odors.
Good ventilation and cleanliness are essential factors in controlling odors. Very
undesirable odors are those of bad breath, body perspiration and other body discharges.
Precautions needed to prevent unpleasant odors in the patient’s unit:
37
1. Patient must be cleaned (daily bath with oral hygiene and external douche (for
females).
2. Bed linen must be changed daily or according to hospital policy.
3. All soiled linen, excrete and garbage must be disposed of properly.
4. Water in the flower vase must be changed daily.
5. All receptacles of patients excrete (bedpan, urinal, sputum cup, kidney basin) must
be cleaned properly after use.
6. Bathrooms and toilet must be cleaned daily.
7. Floors must be mopped with clean mop free from odor.
Cleaning of Toilet and Bathroom
Equipment: Same as in dusting and washing with the addition of toilet mop or brush.
Procedure:
1. Scrub tiled walls with soap and water. Rinse thoroughly.
2. Flush the toilet, and clean with soap and toilet mop or brush.
3. Flush to rinse the inside part.
4. If stain cannot be removed with soap, use cleanser, or small amount of caustic
soda, rubbing it with mop or brush being careful that the water does not splash to
your face (it burns).
5. Clean the outside of the bowl with soap and water and rinse thoroughly.
6. For metal accessories, use metal polish.
7. Scrub the floor with soap and water. Rinse.
8. Wipe the walls and outside of toilet bowl.
9. Replenish the supply of toilet paper and soap (if provided by the hospital).
For Lavatory and Sink
Wash thoroughly with soap and water using mop or brush as needed. If stains are hard
to remove, use cleanser. Rinse and dry with a damp cloth.
Care of Bed
Comfort, rest and sleep are all important in maintaining health and promoting
recovery from disease. Special attention, both in homes and in hospitals should be afforded
by providing healthful beds and bedding.
The sick person not only rests and sleeps in bed but may have his meals, recreations,
occupation and exercise in it. Therefore, cleanliness and comfort must be insured.
Note: General cleaning of the bed must be done from time to time as the need arises
after the patient’s discharge to make it ready for another patient.
Bed Cleaning
Purpose : To provide a clean bed for the patient.

Equipment: A tray containing the following:
1. Mattress brush
2. A basin or pail half–filled with water
3. Laundry soap or detergent
4. Several pieces of dusting cloth.
5. Chicken feathers or a stick with cloth wound at one end
6. Lubricant or oil for wheels, if needed
Procedure:
38
1. Straighten the mattress and inspect for stains or tears.
2. Brush the mattress from the head part using long firm strokes going towards the
foot part, at the same time inspecting for bed bugs.
3. Turn the mattress upside down.
4. Repeat same procedure as No.2.
5. Roll the mattress to the foot part.
6. Start cleaning the bed with soap and water, beginning from the head part, wash
bed frame, springs then raise the head rest if provided. Rinse and dry.
7. If completed, transfer the mattress to the clean side and do the same at the foot
part.
8. Oil wheels, if necessary.
9. Return all equipment used to proper place, clean and dry.
10. Mop the floor, if necessary.
11. Clean and arrange other furniture in the room or in the immediate vicinity of the
patient in the ward.
ADMITTING A PATIENT TO A HEALTH CARE AGENCY
39
Purposes:
1. To establish a positive, initial relationship with the client and significant others.
2. To orient the client and significant others to the immediate environment and the
services that are available.
3. To acquire database or information which generally includes a health history,
comprehensive subjective and objective data related to the current health, and a
physical assessment.
4. To enable the nurse to collaborate with the client and significant others to discuss
his/her needs and expectations for care.
Assessment:
1. Determine the name, sex, age, religion, civil status, admitting diagnosis or primary
symptoms of the patient and the name of the attending physician.
2. Estimate the expected time of arrival to the nursing unit or facility.
3. Anticipate special equipment that should be prepared such as oxygen, suction, IV
poles, bed boards and so on.
4. Determine the relative’s reliability as source of information, if applicable.
Possible Nursing Diagnoses:
Anyone who must leave the security of his previous pattern of living for care and
treatment in a health care agency is likely to be experiencing any of the following nursing
diagnoses:
1. Fear
2. Anxiety
3. Altered Family Process
4. Self–Care Deficit
5. Disturbance in Self–Concept
6. Social Isolation
Equipment:
1. Thermometer
2. Sphygmomanometer
3. Stethoscope
4. Scales for weight and height
5. Instruments used for physical assessment, e.g. penlight, tongue depressor, etc.
Procedure
Action Principle
1. Greet the client and the significant Welcoming the client and significant others
others. Introduce yourself. often help them feel at ease and less
frightened.
2. Let the client sit in a comfortable Data gathering is necessary in the plan of
position and take the data and care.
complaint.
3. Inform the client what will be
It is very stressful not knowing what to
happening and what to expect.
expect. Explanations tend to decrease
anxiety.
4. Take the client’s temperature, pulse, It is the nurse’s responsibility to obtain these
respiratory rate, blood pressure, vital signs and anthropometric measurements
weight and height and monitor as as a basic part of the client’s admission and
40
necessary. physical assessment.
5. Provide privacy. Providing privacy shows respect and helps

maintaining the patient’s dignity.
6. Change street clothes to hospital Facilitates organization and economy of time

gown. when preparing the client for certain
procedures.
7. Notify the physician in charge and This promotes friendship and inspires
introduce the client to the doctor. confidence.
8. Prepare the client for physical To alleviate immediate needs of the client.
examination, assist the physician and
carry out stat orders.
9. While waiting for the physician’s This enables the preparation of the room and
orders, notify the department about bed of the patient.
the patient to be admitted. Give
pertinent information to the nursing
staff.
10. Document on the client’s chart all All pertinent data should be documented.
necessary data. Client’s charts are also the source of
information
11. Bring the client to the department Promotes adjustment and sense of direction.
through wheelchair or stretcher at
the same time orienting the patient
and relatives on some hospital rules
like visiting hours, hospital places
like the pharmacy, accounting office
and nurse’s station as you pass them
on your way to the room.
12. Upon reaching the department, Promote friendship and inspires confidence.
introduce the client to the nurse-in-
charge.
13. Orient the client to his room as well Helps put the client at ease. Knowing how to
as the use of the equipment such as use equipment helps prevent accidents.
signal device (buzzer), adjustable
bed, side rails etc. Explain meal
times and visiting hours.
14. Endorse client’s condition and other The nursing history and assessment provide
pertinent data to the nurse-in-charge. information that is unique to the patient. It
forms the basis for identifying his/her
problems and care.
Sample Documentation
41
Date Time Nurse’s Notes
9/30/2016 3:30 PM Admitted per stretcher a 65-year-old

male conscious and coherent under the
service of Dr. Milana with chief
complaint of difficulty of breathing and
fever. Placed in a high Fowler’s
position.
3:45 Vital Signs taken: BP – 150/90,
temperature – 390 C, Pulse – 110 and
, Respiration – 28
Pallor and diaphoresis noted; with
labored breathing and circumoral
cyanosis.
3:50 Oxygen started at 2 liters per minute
per nasal cannula
4:00 Assessed by ROD Estigoy with STAT
medical orders made.
4:10 Nebulized with 1 nebule of Salbutamol.
4:15 Paracetamol 500 mg, 1 tablet, given
p.o. for fever.
Dr. J. Milana notified of admission.
4:20 Vital Signs rechecked: BP – 130/90,
Temperature – 38.10C, Respiration – 22
regular.
4:30 Transported to Room 401 per stretcher
with O2 @ 2L/ per nasal cannula.
Endorsed to nurse-in-charge
Loyalda Fuentes, St. N.
HOW TO ANSWER PATIENT’S CALL
42
KEY POINTS
1. Keep alert for client’s call or bell.

2. GO IMMEDIATELY to the patient’s bedside and ask what it is you can do for
him/ her. Use the patient’s name when you speak to him.
3. Do the thing that the patient asks if you are SURE it is all right and safe for this
particular patient.
4. Go at once to the CI or Headnurse if the request is something that you cannot do.
5. Place “signal cord” or call bell within easy reach of the patient.
6. Leave the patient comfortable and satisfied.
HOW TO ANSWER THE TELEPHONE
When receiving a call: State the hospital, ward, your name, your position and state “May I
help you?” For example, “San Pedro Hospital, St. Dominic, Miss Santos student nurse
speaking, may I help you?”
When someone is looking for somebody: Say “Who’s calling please?
Just a minute.”
Answering :When the person concerned is out : “Sorry he’s not in, would you like to
leave a message?”
When it is the doctor of the patient with an order, promptly call the head nurse or nurse-in-
charge to answer the call. Student nurses are not allowed to take telephone orders.
When terminating calls: Say thank you and goodbye.

Relay the message as soon as the person concerned arrives.
POINTS TO CONSIDER WHEN USING THE HOSPITAL TELEPHONE
1. Consider the length of call.

2. Do not use hospital telephone for personal use.
3. Answer the ward phone as promptly as possible.
4. Answer the telephone in a well modulated voice and in a courteous manner.
POINTS TO CONSIDER WHEN BRINGING A CELL PHONE
1. Turn off your mobile phone in order not to disturb patients or interfere with the
functioning of certain hospital equipment.
2. Do not send or create any text messages while on duty or in the classroom during ward
conferences.
3. Answer only emergency calls and never on the patient’s bedside. Limit the duration of
call to three minutes.
Hand Hygiene (DOH)
43
Hand washing is one of the simplest and most effective means of preventing the spread of flu
and other infectious diseases.
What you should do
 Wash your hands after: using the toilet, coughing or sneezing into hands, engaging in
any activity that may have contaminated hands.
 Wash your hands before: handling food, eating or drinking, smoking, brushing teeth,
engaging in any activity that involves hand-to-mouth contact.
 Wash your hands frequently throughout the day even if you think they don’t need to
be washed.
How you should do it
 Wet hands with warm water.
 Apply a generous amount of soap and lather hands well.
 Rub hands together for 20 seconds, paying special attention to the areas between
fingers and under nails.
 Rinse hands thoroughly with warm water.
 Dry hands with a disposable towel.
 Use the disposable towel to turn off the faucet and open the door.
MEDICAL HANDWASHING
Handwashing is, without a doubt, the most effective way to help prevent the spread of
organisms. It is the most important procedure in preventing nosocomial, or hospital-acquired
infections. Effective handwashing requires at least a 10–second vigorous washing with plain
soap or disinfectant and water. Hands that are visibly soiled need a longer wash or a repetition
of the procedure.
Equipment:
1. liquid or bar soap 4. sink with running H2O
2. towel (paper or cloth) 5. trash can
3. lotion (optional) 6. Tissue or paper towel
Procedure
Action Rationale
1. Stand in front of the sink. Do not The sink is considered contaminated.

allow your uniform to touch the sink Uniforms may carry organisms from place
during the washing procedure. to place.
2. Turn on water and adjust force. Water splashed from the contaminated
sink will contaminate your uniform.
3. Wet the hands from wrist area pointing Water should flow from the cleaner area
fingers toward the bottom of the sink. toward the more contaminated area.
Hands are more contaminated than
forearms.
4. Use bar soap or liquid soap lather Rinsing the soap removes the lather that
thoroughly with bar soap. Rinse the may contain microorganisms.
bar soap and return to soap dish.
44
5. Turns off the faucet and discard used This prevents the nurse from picking up
tissue. microorganisms from faucet handle.
6. Rub hands briskly starting palm to Rubbing motion and creating foam out of
palm. Ensure formation of lather soap help loosen dirt on the hands.
during the process.
7. Place right palm over left dorsum with Friction caused by firm rubbing and
interlaced fingers rubbing briskly, then rotational motion helps to loosen dirt and
left palm over right dorsum. organisms that can lodge between fingers,
in skin crevices of knuckles, on palms and
back of the hands, as well as the wrist and
forearms.
8. Palm to palm with fingers interlaced.
9. Back of fingers to opposing palm with
fingers interlocked.
10. Rotational rubbing of the left thumb
by clasping it in, the right palm and
vice versa.
11. Circular rubbing forward and
backward with clasped fingers
including thumb of right hand in left
palm and vice versa.
12. Rotational rubbing of forearm starting Contamination of hands extends until
above the wrist going up to the elbow forearms depending on the activities the
(NOTE: For initial handwashing upon person engages with. Length of
reporting for duty and at the end of the handwashing is determined by the degree
shift; otherwise, extends rubbing just of contamination
little below the wrist).Continue the
friction motion for 15 to 20 seconds.
13. Use brush or fingernails of the other Organisms can lodge and remain under
hand to clean under fingernails of the the nails where they can grow and be
other hand. spread to others.
14. Open faucet with tissue paper. This prevents the nurse from picking up
microorganisms from the faucet handle.
15. Rinse thoroughly with wrist pointed Running water rinses organisms and dirt
upward. Visually inspect for into the sink. hands are considered
remaining dirt or soap. cleaner.
16. Turn off the faucet with the use of This prevents the nurse from picking up
tissue or paper towel microorganisms from the faucet handle.
17. Dry hands and wrists with towel. Drying the skin well prevents chapping.
18. Use lotion on hands, if desired. Lotion helps to keep the skin soft.
19. Do after care after the procedure.
20. Wash hands after.
45
SAN PEDRO COLLEGE
Davao City
MEDICAL HANDWASHING
Name: ________________________________ Grade: __________________

Year and Sec.: _________________ Date: _______________
Rating
5 4 3 2 1
1. Checks for completeness of supply.
2. Stands in front of the sink with the uniform not touching
the sink.
3. Removes jewelry.
4. Turns on water and adjusts its force.
5. Wets the hands from wrist area with fingers pointing
toward the bottom of the sink.
6. With the bar or liquid soap, lathers hands thoroughly.
7. Rinses the bar soap and returns it to the soap dish.
8. Turns off the faucet by using tissue/paper towel.
9. Washes hands for 15 to 20 seconds with firm rubbing
and rotational motions following the correct sequence.
a. Palm to palm.
b. Right palm over left dorsum with interlaced
fingers and vice versa.
c. Palm to palm with fingers interlaced.
d. Back of fingers to opposing palms with fingers
interlocked.
e. Right thumb by clasping it in the left palm and
vice versa.
f. Clasps fingers including thumb of right hand in
left palm and vice versa.
g. Rotational rubbing of forearm starting above the
wrist going up to the elbow.
10. Uses brush or fingernails of the other hand to clean
under fingernails of the other hand.
11. Turns on the faucet by using tissue/paper towel.
12. Rinses thoroughly and inspects for remaining dirt or
soap.
13. Turns off the faucet with the use of paper towel.
14. Dries hands and wrists with paper or hand towel
starting from fingers then to wrist and forearm.
15. Applies lotion if desired.
16. Does after care after the procedure.
17. Washes and dries hands after
46
Comments:

II Performance 70%
100%
________________________________ __________________________
Student’s Signature over Printed Name Date
________________________________ __________________________
Instructor’s Signature over Printed Name Date
47
BEDMAKING
Definition: It is the proper adjustment of bed linens.
Types of Bed:
1. Standard Hospital Bed has a firm mattress on a metal frame that can be raised or
lowered horizontally. It is a bed that can be adjusted to a variety of positions. This
type of bed can be controlled manually or electrically.
2. Special Hospital Bed is a bed that is required for patients to maintain strict body
alignment. It rotates on an axis to turn the patient from supine to prone or vice –
versa. Two such beds are Stryker wedge frame and the CircOlectric bed.
a. Stryker wedge frame = is manually operated by the nurse, turns the patient
laterally through side-lying position. This bed is indicated for those with
spinal injuries or surgery requiring immobility.
b. CircOlectric bed = is operated electrically by the nurse using a push button
rotates the patient vertically through the standing position. This bed
permits frequent turning of the severely injured or immobilized patient
with minimal trauma and extraneous movement to prevent or treat
decubitus ulcer, as well as respiratory and circulatory complications.
Parts of the Bed:
The hospital bed is narrower than the usual bed so that the nurse can reach the client
from either side without undue stretching. It is 3 feet wide and 26 inches in height and
the length is usually 6 feet and 6 inches long.
1. siderails = protects the patients from accidental falls

2. wheel locks = prevents accidental movement of the bed.
3. patient’s signal = device to call for assistance from the health personnel
4. electronic or manual controls (cranks) = to change the position of the bed
Types of Bedmaking:
1. Unoccupied bed
a. open –bed
b. closed –bed
2. Obstetrical Bed
3. Post – operative Bed
4. Occupied Bed
General guidelines in Folding of Linen:
Bottom Sheet:
Fold lengthwise with the right side inside(RIBS) with the wider hem at the foot part of
the bed.
Fold again with the edge towards the centerfold of the linen.
Fold crosswise two times towards the foot part.
Top Sheet:
Fold lengthwise with the right side outside( ROTS ) and the wider hem at the head
part of the bed.
48
Rubber Sheet:
Roll both sides towards the center.
Cotton Draw Sheet:

Fold crosswise with the right side inside and fold again with the edge towards the
centerfold. Fold crosswise once.
Waterproof Under pad: (to be used instead of rubber and draw sheet i.e. blue chucks)
Same folding with the draw sheet.
Bath Blanket:
With two students facing one another holding both ends of the blanket with the right
side outside. Fold crosswise three times with the centerfold inside. Maintaining the hold of
the blanket, place the loose end with the wider hem, flip the rest of the folded sheets and
insert it back towards the hand that holds the blanket. Flip back the rest of the folds. Bring the
edges towards the center once.
Top Sheet: (Occupied Bed)

Fold the sheet crosswise. Follow the same sequence of folding with bath blanket.
INFECTION CONTROL IN BEDMAKING:
Apply these principles of basic infection control to all bedmaking procedures:
1. Microorganisms move through space on air current; therefore, handle linen

carefully. Avoid shaking it or tossing it into the laundry hamper (it should be
placed in the hamper).
2. Microorganisms are transferred from one surface to another whenever one
object touches another. Therefore, hold both soiled and clean linen away from
your uniform to prevent contamination of the clean linen by the uniform and
contamination of the uniform by soiled linen. In addition, avoid placing it on
the floor to prevent the spread of any bacteria present either on the linen or on
the floor.
3. Proper handwashing removes many microorganisms that would be transferred
by the hands from one item to another. Therefore, wash your hands before you
begin and after you finish bedmaking.
1. UNOCCUPIED BED is a bed that does not call for any special cases.
4. Open–Bed = The top covers are folded back to make it easier for a
patient to get in.
5. Closed-Bed = The top covers are drawn up to the headpart over the
pillows.
Purposes:
1. To provide comfort of the patient.
2. To reduce transmission of microorganism.
3. To stimulate and refresh the patient.
4. To maintain hygienic environment.
Equipment:
1 bottom sheet /Flat or fitted sheet 1or 2 pillow cases
1 top sheet additional pillow
1 bath blanket (optional)
49
Procedure:
Action Rationale
1. Wash your hands. It deters the spread of microorganism.
2. Assemble equipment and place on Organization promotes efficient time
bedside at the foot of the bed in their management.
order of use.
3. Grasp the mattress securely and shift Allows more foot room for the client and
it up to the head of the bed. moves the mattress against the head of the
bed.
FITTED BOTTOM SHEET
4. Follow steps 1 to 3. Position yourself Ensures good body mechanics and efficient
diagonally toward the head of the procedure.
bed
5. Start at the head with seamed side of Placement of seamed side toward mattress
the fitted sheet toward the mattress. prevents irritation to the client’s skin.
6. Lift the mattress corner with your Prevents straining of back muscles;
hand closest to the bed; with your decreases the chance that the sheet will pull
other hand, pull and tuck the fitted out from under the mattress.
sheet over the mattress corner; secure
at the head of the bed
7. Pull and tuck the fitted sheet over the Prevents straining of back muscles;
mattress corners at the foot of the decreases the chance that the sheet will pull
bed. out from under the mattress.
FLAT REGULAR SHEET
Follow steps 1 to 3
4. Place the bottom sheet with its center Proper positioning of linen ensures that
fold on the center of the mattress with adequate linen will be available to the cover
the bigger hem in line with the edge opposite side of the bed.
of the mattress at the footpart.
Open the sheet’s top layer towards
the center of the bed as you bring the
extra to the headpart.
5. Grasp the corner of the mattress near Lifting the mattress will prevent the linen
you with one hand and lift to tuck the from being caught by the spring of the bed.
excess.
6. Miter the sheet at the top corner by: Mitering will secure the bed linen while the
a. Picking up the edge of the sheet bed is occupied.
and holding straight up forming a (Fitted sheets do not require mitering).
double triangle.
b. Lay the upper part on the top of the
mattress.
c. Tuck the hanging part of the sheet.
7. Supporting your mitered corner, tuck
the sides of the bottom sheet under
the mattress on the side moving
towards the footpart.
8. Place the top sheet on the bed with Proper positioning of linen ensures that
the centerfold on the center and the adequate linen will be available to cover
50
wider hem even at the head of the opposite side of the bed.
mattress.
Open the sheet’s top layer towards the
center of the bed as you bring the extra
to the footpart. Follow the same
procedure with the top blanket or
spread it placing the upper edge
approximately 6” below the top of the
sheet.
9. Lifting the mattress, tuck the top sheet Untucking the side of the sheet will make it
under it. Miter the corner but do not tuck easier for the patient to slip in.
at the side.
10. Fold the upper 18” of the top sheet The cuff of sheet makes it easier for the
down to make a cuff. patient to pull to covers up.
Move to the other side of the bed and make Working on one side of the bed at a time
that side of the bed following the same saves energy.
procedure for securing the bed linen.
11. Grasp the center of the closed end of the This method makes it easy to slide pillow
pillow case. Gather the pillow case and case over the pillow. Poorly fitting case
turn it inside out over one hand. With the constricts fluffing and expansion of pillow.
same hand, grasp the middle of one end
of the pillow and pull the case over the
length of the pillow. Keep a firm hold on
the pillow.
12. Place the pillow at the head part of the Provides for a neater appearance.
bed with the open end facing away
from the entrance
13. For an open–bed , fanfold top sheet Having linen opened makes it more
to the footpart. convenient for the client to get into bed.
For closed bed, draw the top sheet
over the pillow.
14. Secure the signal device ( buzzer) on Having the signal device within client’s
the bed, according to hospital policy. reach makes it possible for him to call for
assistance as necessary.
15. Arrange the furniture.
16. Wash your hands.
Note: If blanket is used , follow the same procedure same as step # 8 , placing the upper
edge of the blanket approximately 6” below the top of the sheet .
B. OBSTETRICAL BED
Definition: It is a bed prepared for a patient who has given birth.
Purpose: To have a bed ready for patients who have just delivered.
Equipment:
1 bottom sheet any clean cotton sheet
1 waterproof underpad (SPH dry sheet) adult diaper (patient’s supply)
1 top sheet
51
Procedure:
Action Rationale
1. Perform 1-10 of the open–bed
2. Fanfold top sheet to the footpart.
3. Place the waterproof underpad where the To avoid frequent changing of linen.
buttocks lie and tuck if long.
If the pad is not available, fold any clean

cotton sheet and put it where the buttocks
will rest.
4. Slip the 2 pillows inside their cases (follow The pillow at the headboard protects the
step # 11 of open bed). Put 1 pillow against head from the injury, and the other to
the headboard (if with epidural anesthesia) provide comfort to relax the abdominal
and the other, where the back of the knees muscle, thus provide comfort.
will rest (with the open end facing away
from the entrance).
5. Secure the signal device (buzzer) on the

bed according to hospital policy.
6. Arrange the furniture.
7. Wash your hands.
C. POST-OPERATIVE BED :
Definition: It is a bed prepared for those who had undergone surgery.
Purposes:
1. To prepare warm, safe and comfortable bed in which the patient can be quickly
placed after surgery.
2. To protect the mattress from being wet and soiled and possibly stained.
General Consideration:
Ensure that all the needed equipment are assembled and ready for use before the
patient arrives from the Operating Room.
Equipment:
Same as the unoccupied bed with the addition of the following:
a. bed protector
b. bath towel
c. gown
d. blanket
e. I.V. stand
f. Suction apparatus
g. Suction catheter ( Fr. 12-14 for adults ; Fr. 8-10 for children)
h. Oxygen tank prepared with necessary connections
52
i. Goose neck lamp ( optional )
j. Waterproof underpad ( optional)
k. Hot Water Bag
On the bedside table are:

l. kidney basin lined with tissue paper
m. padded tongue depressor
n. tissue wipes/washcloth
Procedure:
Action Rationale
1. Proceed in the same manner as in

making an unoccupied bed ( Steps 1-7)
2. Place the bed protector across the head Protects the linen from getting soiled.
part of the bed, line it with the bath
towel and tuck (if long).
3. Place one pillow against the headboard Protect the head of the client from the
with open end away from the entrance headboard
4. Place the top sheet. Without tucking at To provide easy accessibility.

the footpart. Instead, fold back the
topsheet at the footpart in line with the
edge of the mattress. Fold back the
upper 18 inches of the topsheet as well.
5. Move to the other side of the bed and

do step 4.
6. Bring up the hanging side of the top For easy access when transferring client
sheet in line with the edge of the from stretcher to bed.
mattress. Fanfold to the side away from
the entrance.
7. If waterproof underpad is not available To protect the linen from being soiled
use the cotton draw sheet.
8. Hang the gown at the headboard.

9. Prepare the necessary equipment at the Facilitates access.
bedside before the patient arrives.
10. Once the patient is in from the Post The patient may feel cold.
Anesthesia Care Unit (PACU), place
him comfortably in bed and cover with
top sheet.
11. Loosely tuck the footpart of the top To allow free movement of the feet.
sheet.
12. Attach the necessary gadgets such as
oxygen, IVF, urine bag.
13. Wash your hands.
53
NOTE: If the weather is cold, use blanket and goose neck lamp for the patient’s comfort.
a. Spread the blanket over the top sheet 16 inches from the head part.
b. Fold back the top sheet in line with edge of the blanket on the head part and
fold back the blanket and top sheet together in line with the edge of the
mattress at the foot part.
c. Bring up one hanging sides of both blanket and top sheet in line with the edge
of the mattress at the side and fanfold to the side away from the entrance.
D. OCCUPIED BED
Definition: It is a bed prepared with the patient in it.
Purposes:
1. To provide comfort for the patient.
2. To maintain a hygienic environment.
3. To reduce transmission of microorganisms.
4. To refresh the patient.
5. To conserve the patient’s energy.
Equipment:
1 bottom sheet 2 pillow cases
1 waterproof underpad (optional) 1 blanket (optional)
1 top sheet 1 pair of working gloves
Procedure
Action Rationale
1. Check the chart for limitation on the To determine degree of help needed by the
patient’s physical activity. patient.
2. Identify and explain the procedure to Facilitates patient cooperation and determines
the patient. his level of activity.
3. Wash your hand. Handwashing deters the spread of
microorganisms.
4. Assemble equipment in order of use Organization facilitates the performance of
and place on bedside chair at the foot the task.
part of the bed.
5. Close the door and/or curtain. Provides provicy
6. Don working gloves Gloving protects the nurse from harm.
Provides privacy.
7. Lock the wheels and adjust the bed to Having the bed on high position reduces
high position. Lower the side rail strain on the nurse.
nearest you leaving the opposite side
rail up. Place the bed in the flat Having the mattress flat facilitates making a
position if the patient can tolerate it. wrinkle–free bed.
8. Check the bed linen for the patients’ It is costly and inconvenient when personal
personal items and hook the signal cord items are lost.
to the wall hanger.
9. Place the bath blanket, if available. Provides warmth and privacy.
Have the patient hold onto the bath
54
blanket while you reach under it and
remove top linen. Leave the top sheet
in place if the bath blanket is not
available but loosen the top sheet at
the foot part.
10. Grasp the mattress securely and shift it Allows more foot room for the patient and
up to the head of the bed with the positions the mattress against the head of the
assistance of another person. bed.
11. Assist the patient to turn toward the Allows the bed to be made on the vacant side.
opposite side of the bed, and
reposition the pillow under his head.
12. Loosen all bottom linens from the Facilitates removal of linens.
head and side of the bed.
13. Roll the soiled linen as close to the Facilitates removal of linen when the patient
patient as possible. turns to the other side.
14. Using clean linen, make the near side
of the bed following steps 4,5,6 & 7,
in “making an unoccupied bed.” Roll
clean linen as close to the patient as
possible.
15. Remove the pillow, change pillow
case and replace it on the clean side of
the bed with the open end facing away
from the entrance
16. Use the soiled pillowcase as laundry. Ensures patient safety and comfort.
17. Raise the side rail. Move to the other
side, and lower the side rail. Assist the
patient to turn toward the opposite side
of the bed and over the clean linen.
Reposition the clean pillow under the
head.
18. Roll soiled sheets one by one and Proper disposal of soiled linen prevents the
remove. Place in the laundry bag. Be spread of microorganisms.
sure to hold the soiled linen away from
the uniform.
19. Ease the clean linen from under the Remove wrinkles and creases in linen which
patient. Pull taut and secure bottom are uncomfortable to lie on.
sheet under the head of the mattress.
Miter the corner and tuck along the
sides of the mattress( steps 4-7).
20. Assist the patient to lie at the center of

the bed.
21. Place top sheet over patient with Allows bottom hem to be tucked securely
center of sheet in middle of bed under the mattress. Provides the privacy.
Have the patient hold onto the top
linen so that the bath blanket/top
55
sheet can be removed.
22. Secure the top sheet under the foot of Provides for neat appearance. Loosening linen
the mattress and miter the corners. over the patient’s feet gives more room for
Loosen the top sheet over the patient’s movement.
feet by grasping and pulling gently
towards the foot of the bed.
23. Raise the side rail. Lower the bed Provides for the patient safety.
height and adjust the head of the bed
to a comfortable position. Replace
the signal cord with in patient’s reach.
24. Return the furniture to their respective Keep the room clean and tidy
places.
25. Bring soiled linen to the utility room Prevents the spread of microorganism and for
or dispose according to the hospital proper disposal.
policy.
26. Remove gloves and dispose of Prevents the spread of microorganism.
properly. Wash and dry hands.
27. Document time, procedure done and Complete documentation of nursing care and
patient’s condition/ reaction. patient’s status.
STRIPPING
Purpose: To remove the bed linen preparatory to cleaning.
Procedure:
1. Place two chairs back to back at the foot part of the bed or near it.
2. Don working gloves.
3. Remove the soiled pillow case from a pillow and use it as a laundry bag.
Make a cuff at the open end of the slip and insert it at the back of one
chair. Remove the slip from the other pillows if there are and place these
in the laundry bag.
4. Place the pillows on the seat of the other chair.
5. Starting at the side near you, loosen all the bedlinens, by raising the
mattress with one hand and drawing out the linen with the other. Bring
the linen to the top of the mattress. After this, move to the other side of
the bed and do the same.
6. Roll the dirty linen one by one and place it inside the bag.
7. After all linen have been placed inside the laundry bag, turn the mattress
upside down and air. Airing of the mattress will depend on its type
8. Unfasten the bag from the chair. Bring bag to the Utility Room and place
it inside the hamper intended for the purpose.
9. Remove gloves and dispose properly.
10. Wash hands
56
SAN PEDRO COLLEGE
Davao City
BEDMAKING – Unoccupied Bed
Name: ______________________________ Grade: __________________

Year and Sec.: _________________ Date : __________________
Rating
5 4 3 2 1
1. Washes hands.
2. Assembles equipment according to order of use and
places on bedside chair.
3. Shifts mattress up to the head of the bed.
4. Places the bottom sheet on the mattress with the bigger
hem on the foot part and brings the excess to the head
part.
5. Tucks the head part of the bottom sheet.
6. Miters the bottom sheet.
7. Tucks the side of the bottom sheet.
8. Places the top sheet on the mattress with the bigger hem
on the head part and brings the excess to the foot part.
9. Tucks and miters the top sheet.
10. Makes a cuff at the head part of the top sheet.
11. Makes the other side of the bed.
12. Slips the pillow in its case and places it on the head part
with open end away from the entrance.
13. Places the pillow at the head part.
14. Draws the top sheet over the pillow to make a closed
bed.
15. Secures the signal device.
16. Arranges the furniture.
17. Washes hands.
18. Maintains body mechanics.
19. Performs the procedure neatly.
20. Is receptive to criticisms.
21. Shows calmness and confidence.
22. Uses correct English.
23. Manifests mastery of the procedure.
Comments:
57
II Performance 70%
100%
________________________________ __________________________
________________________________ __________________________
58
SAN PEDRO COLLEGE
Davao City
BEDMAKING – Obstetrical Bed
Name: _____________________________________ Grade: __________________

Year and Sec.: _________________ Date : ___________________
Rating
5 4 3 2 1
1. Washes hands.
2. Assembles equipment according to use and places on
bedside chair.
3. Shifts mattress up.
4. Places bottom sheet appropriately.
5. Tucks the headpart of the bottom sheet.
8. Places the top sheet on the mattress.
9. Makes the other side of the bed.
10. Fanfolds top sheet to footpart.
11. Places the waterproof underpad correctly or places the
clean cotton sheet correctly.
12. Slips the pillow in its case.
13. Places the pillow at the headpart with open end against
the entrance.
14. Places the other pillow where the back of the knees will
rest.
15. Secures the signal device.
17. Washes hands.
20. Is receptive to criticisms,
21. Shows calmness and confidence
Comments:
59
II Performance 70%
100%
________________________________ __________________________
________________________________ __________________________
60
SAN PEDRO COLLEGE
Davao City
BEDMAKING – Post-operative Bed
Name: _____________________________________ Grade: __________________

Year and Sec.: _________________ Date : __________________
Rating
5 4 3 2 1
1. Washes hands.
2. Assembles equipment and places on bedside chair.
3. Shifts mattress up to the head of the bed.
4. Places the bottom sheet on the mattress.
5. Tucks the headpart of the bottom sheet.
8. Places bed protector and bath towel at the head part
9. Places the top sheet on the mattress.
10. Folds back topsheet at the footpart.
11. Makes a cuff at the headpart of the mattress.
12. Does the same steps 5-10 at the other side of the bed.
13. Brings up the hanging side of the top sheet
14. Fanfolds top sheet to one side.
15. Places the pillow at the headpart.
16. Places the extra pillow where the knees rest.
17. Hangs the gown.
18. Prepares the necessary equipment at bedside.
19. Places the patient comfortably in bed.
20. Loosely tuck the footpart of the topsheet.
21. Attaches the necessary gadgets.
23. Washes hands.
26. Is receptive to criticisms.
27. Shows calmness and confidence.
Comments:
61
II Performance 70%
100%
________________________________ __________________________
________________________________ __________________________
62
SAN PEDRO COLLEGE
Davao City
BEDMAKING – Occupied Bed
Name: _________________________________ Grade: ________________________

Year and Sec.: _________________ Date : _________________________
Rating
5 4 3 2 1
1. Checks the patient’s chart.
2. Identifies the patient and explains the procedure.
3. Washes hands.
4. Assembles equipment according to use.
5. Places equipment at the bedside.
6. Dons working gloves.
7. Closes the door, windows, and curtains.
8. Locks the wheel of the bed and adjusts it.
9. Checks the bed linen for patient’s belongings.
10. Replaces top sheet with bath blanket.
11. Loosens the footpart of the bed.
12. Shifts mattress upward (with the help of another
person).
13. Positions patient comfortably at the opposite of the bed.
14. Loosens and rolls soiled linen.
15. Makes the near side of the bed. Places the bottom sheet
on the mattress with the bigger hem on the foot part and
brings the excess to the head part.
16. Tucks head part of the bottom sheet
19. Raises the side rail and moves to other side of the bed.
20. Lowers side rail and re-positions patient comfortably to
the other side of the bed
21. Removes pillow and changes its case.
22. Places pillow back under patient’s head.
23. Makes a laundry bag.
24. Rolls soiled sheets.
25. Holds soiled linen away from body and places in the
laundry bag.
26. Pulls clean linen gently on other side and does steps 15-
18.
27. Re-positions patient and his pillow at the center of the
bed.
28. Places the top sheet over the client with the center of the
sheet in the middle of the bed
29. Asks the client to hold onto the top linen to remove the
63
blanket.
30. Rolls the soiled bath blanket and places it inside the
laundry bag.
31. Tucks and miters the top sheet.
32. Grasps top sheet gently towards the foot of the bed.
33. Raises the side rail. Lower the bed height.
34. Adjust the head of the bed and attaches the signal cord.
35. Arranges furniture.
36. Disposes soiled linen according to hospital policy.
37. Removes and disposes gloves properly.
38. Washes and dries hands.
39. Documents procedure done including patient’s
responses and reactions.
40. Interacts with and observes patient during the entire
procedure.
43. Neatly performs the procedure.
44. Is receptive to criticism.
Comments:

II Performance 70%
100%
________________________________ __________________________
________________________________ __________________________
64
SAN PEDRO COLLEGE
Davao City
BEDSTRIPPING
Name: _____________________________________ Grade: __________________

Year and Sec.: _________________ Date : __________________
Rating
5 4 3 2 1
1. Places two chairs back to back at the foot or siade of the
bed
2. Dons working gloves
3. Removes the soiled pillow case from a pillow and make
it into a laundry bag
4. Removes the slip from the other pillows if there are and
places it inside the laundry bag
5. Places the pillows on the seat of the other chair
6. Loosens all linens starting at the near side by raising
the mattress with one hand and drawing out the linen
with the other hand
7. Brings the linen to the top of the mattress.
8. Moves to the other side of the bed and does the same.
9. Rolls the dirty linen one by one and place it inside the
bag.
10. Turns the mattress upside down and air
11. Unfastens the bag from the chair.
12. Brings bag to the utility room and places it inside the
hamper intended for the purpose.
13. Removes gloves
14. Washes hands
Comments:

II Performance 70%
100%
________________________________ __________________________
________________________________ __________________________
65
CHECKING THE VITAL SIGNS(VS)
Definition: Clinical measuremants specifically temperature pulse, respiration and blood

pressure that indicate the state ofth patient’s essential functions.Pain is
considered the “ fifth vital sign” in some organizations across the globe
I - TEMPERATURE
Definition: It is the difference between heat produced and heat lost by the body and is
measured through the use of a thermometer.
ROUTE ADVANTAGES DISADVANTAGES

 Cannot be used for clients who
Oral  Easy, fast, accurate
are unconscious, confused, prone
to seizures, recovering from oral
surgery, or under age 6.
 Need to wait 15–20 minutes after
eating.
Rectal  More reflective of core  Cannot be used for clients who
Temperature have rectal bleeding,
hemorrhoids, or diarrhea or who
are recovering from rectal
surgery.
 Contraindicated for cardiac
clients because it may stimulate
the vagus nerve and decrease
heart rate.
 Not recommended for newborns
because of risk of perforating the
anus.
Tympanic  Fast
 More reflective of core temperature
 Safe, good for children
Axillary  Safe, good for children and  Reports of accuracy are

newborns conflicting.
Forehead  Safe and easy  Measures skin surface, which can
be variable.
Temporal Normal: Close to rectal temperature,
arterial 10F or 0.50C higher than an oral  Measures skin surface
temperature, and temperature.
20F or 10C higher than an axillary  Least accurate method
temperature)
66
Normal Body Temperature:
1. Oral Temperature - 36.1 – 37.2 0 C or 97 – 99 0 C (Ave = 370 C)

2. Rectal Temperature - 36.7 – 37.8 0 C or 98 – 100 0 C (Ave = 37.50 C)
3. Axillary temperature - 35.6 – 36.7 0 C or 96 – 98 0 C (Ave = 36.70 C)
4. Tympanic - 37.5_ C or 99.5_F
Types of thermometers include:

 Electronic digital thermometer: Used for oral, rectal, or axillary temperature
measurements.
 Tympanic thermometer: For taking the temperature via the car
 Temporal artery thermometer: Measures arterial temperature through infrared
scanning of the temporal artery.
 Disposable paper strips with temperature sensitive dots: Used for skin/surface
temperature measurements.
A. Oral Method
Contraindications:
1. infants
2. unconscious and irrational patients
3. patients who breathe through their mouths
4. those with disease of the oral cavity or surgery of the nose or mouth
5. patients who have just taken cold or hot foods or fluids
Equipment:
1. Tray containing:
a. thermometer
b. jar of CB in water
c. jar with cut tissue paper
d. waste receptacle (must not be carton because waste fluid will contaminate the
surface on while it stands)
2. Watch with second hand
3. Jot down notebook and pen
Procedure
Action Rationale
1. Read the chart. To obtain necessary data.
2. Wash hands. To deter the spread of microorganism.

3. Determine any previous activity that Smoking or oral intake of foods/ fluids can
would interfere with accuracy of cause false temperature reading.
temperature measurement.
4. Bring the tray to the bedside and When the patient knows what is to be done,
explain the procedure to the patient. he will cooperate better.
5. Rinse the thermometer by using CB Chemical solutions may irritate mucus

with water in a firm twisting motion membrane and may have an objectionable
from the bulb to the stem and then odor or taste. CB or soft tissues will
67
dry using same motion using dry approximate the surface and twisting helps to
CB or clean soft tissues. come in contact with the thermometer’s entire
surface.
6. Place tip of thermometer under the When the bulb rests against the superficial
client’s tongue and along the blood vessels under the tongue and the mouth
gumline to the posterior sublingual is closed, a reliable measurement of body
pocket lateral to center of lower jaw temperature can be obtained.
and instruct him to close his lips
tightly.
7. An electronic thermometer will Allowing sufficient time for the oral tissues to
signal (beep) when a constant come in contact with the thermometer results
temperature registers.Wait 1-3 in a more nearly accurate measurement of
minutes for ordinary glass body temperature.
thermometer.
8. Remove the thermometer and wipe Cleansing from an area where there are few
it at once with dry CB or soft tissue organisms minimizes the spread of organisms
from stem down to the mercury bulb to cleaner area. Friction helps to loosen matter
using a firm twisting motion. from the surface.
9. Read measurement on display of

digital thermometer.
10. Inform client and/or watcher of Increases involvement and trust of the client.
temperature reading.
11. Cleanse the thermometer from the

stem to bulb using CB with water
twice, then dry with tissue wipe and
return to the container.
12. Dispose the used CB and tissue Confining contaminated articles help to
paper in the waste receptacle. reduce the spread of pathogens.
13. Record the temperature in the

jotdown notebook. Report to the CI
or headnurse any unusualities.
14. Wash hands.
15. Record the temperature on the TPR Accurate documentation allows for
masterlist sheet and graphic chart. comparison of data.
B. Axillary Method
Many hospitals in the Philippines obtain patient’s temperature by the axillary method.
If the axilla has just been washed, obtaining temperature should be delayed.
Equipment: Same as oral method except for the axillary thermometer.
1. Tray containing:
68
a. thermometer
b. jar of CB in water
c. jar with cut tissue paper
d. waste receptacle
2. Jot down notebook and pen

3. Client’s wash cloth or tissue wipes
Procedure
Action Rationale
6. Follow steps 1 to 5 of
oraltemperature taking.
7. Expose arm and shoulder by

removing one sleeve of client’s
gown. Avoid exposing chest.
8. Pat the patient’s axilla dry with a Moisture in the axilla may alter the result of
wash cloth or tissue. Place the the temperature. The deepest area of the axilla
probe of the thermometer into the provides the most accurate temperature
center of the axilla. Bring the measurement.
patient’s arm down close to his
body and place his forearm over his
chest.
9. Leave the thermometer in place Allowing sufficient time for the axillary tissue
until signal or beep is heard or 1-3 to come in contact with the thermometer bulb
minutes of ordinary thermometer. results in a reasonably accurate measurement
of body temperature.
10. Remove, dry with tissue paper and
read measurement on digital display
of the thermometer.
11. Inform client of temperature

reading.
12. Assist client in putting back the

sleeve of gown.
13. Follow subsequent steps of cleaning

like in oral method. (Steps 11 and
12)
14. Record reading in the jotdown

notebook. Report to the CI/HN for
unusualities.
15. Wash hands.
16. Document on the TPR master list

and graphic chart.
69
C. Rectal Method
Purposes:
a. To obtain the first temperature of newborn to check for rectal patency.
b. To check the core temperature of an adult.
Contraindications:
This method is contraindicated to the following patients:
1. With recent rectal surgery.

2. With diarrhea.
3. With disease of the rectum.
4. With cardiovascular alteration because the presence of the thermometer in the
rectum may stimulate the vagus nerve causing bradycardia or rhythm disorder.
5. With leukemia which may traumatize the rectal mucosa causing bleeding.
Equipment: Same as in oral method with the addition of:

1. lubricant 3. toilet paper (patient’s supply)
2. working gloves 4. thermometer (patient’s supply)
Procedure
Action Rationale
1. Read the chart. To obtain data.
2. Bring the preparation to the bedside Elicits the cooperation and understanding of
and explain the procedure. the significant other.
3. Place client in lateral position/ Sim’s Proper positioning ensures visualization of

position. anus. Flexing knee relaxes muscles for ease of
insertion.
4. Drape patient exposing only the Avoid embarrassment and provide privacy.
rectum.
5. Don working gloves. Gloves are used to avoid contact with bodily
secretions and to reduce transmission of
microorganisms.
6. Lubricate tip of rectal thermometer Lubrication reduces friction and facilitates the
or probe to approximately 1 inch insertion of the thermometer. This minimizes
above the bulb. irritation of the mucus membrane of the anal
canal.
7. With the dominant hand, hold the Aids in visualization of anus.

thermometer. With the non dominant
hand, separate buttocks to expose
anus.
8. Instruct client to take a deep Relaxes anal sphincter.

breath. Gently insert the thermometer
approximately 0.5 -1 inch. Release
buttocks to allow to fall in place.
70
9. Hold the thermometer in place until Allows sufficient time for thermometer to
the beep sound is heard. register a more accurate measurement of body
temperature.
10. Remove the thermometer and wipe Removes lubricant/ feces that may have
with dry tissue. Discard used tissue attached to the probe of the thermometer.
in the waste receptacle.
11. Read measurement on digital display

of the thermometer
12. Wipe anal area with tissue and make

client comfortable. Dispose soiled
tissue in the yellow bin.
13. Cleanse thermometer, as previously

learned.
14. Remove and dispose gloves in the

yellow bin.
15. Wash hands.
16. Record temperature in the jotdown

notebook.
17. Inform CI of any unusuality
18. Document in the graphic chart and

TPR master list.
D. Disposable (Chemical Strip) Thermometer
Procedure
Action Rationale
7. Follow steps 1 to 6 of oral
temperature-taking.
8. Apply tape to appropriate skin area,

usually forehead.
9. Observe tape for color changes.
10. Follow steps 16, 17, 18 of oral

temperature-taking.
Tympanic Temperature: Infrared Thermometer

It uses infrared sensors to sense the temperature of the tympanic membrane.
71
Procedure
Action Rationale
5. Follow steps 1, 2, &4 of oral
temperature taking.
6. Remove probe from container and

attach probe cover to tympanic
thermometer unit.
7. Turn client’s head to one side. For This technique straightens the ear canal to
an adult, pull pinna upward and facilitate insertion of the probe.
back; for a child, pull down and
back. Gently insert probe with firm
pressure into ear canal.
8. Remove probe from ear after the
reading is displayed on digital unit
(usually 2 seconds).
9. Remove probe cover and discard and
place the thermometer in storage
container.
10. Follow steps 16, 17, 18 of oral

temperature-taking.
II - PULSE
Definition: It is a rhythmical throbbing that results from a wave of blood passing
through an artery as the heart contracts.
Purpose: To obtain an estimate of the quality of the heart’s action per minute.
Possible sites for taking the pulse:

a. apical
b. radial artery f. popliteal artery
c. temporal artery g. carotid artery
d. dorsalis pedis h. brachial artery
e. femoral artery i. posterior tibialis
What to note while counting the pulse:

a. rate c. tension or compressibility
b. rhythm or regularity d. volume
Normal pulse rate per minute:
Children: Adult:
0 – 1 mo. - 120 – 160 (Ave: 140) Male - 70 – 80 beats/minute

11 – 12 mos. - 100 – 140 (Ave: 120) Female - 80 – 90 beats/minute
Toddler - 80 – 120 (Ave: 100)
Preschooler - 75 – 120 (Ave: 100)
Equipment: a. Watch with second hand. c. Alcohol swab

b. Jot down notebook and pen d. stethoscope
72
A. RADIAL PULSE
Procedure
Action Rationale
1. Explain the procedure to the patient. To gain cooperation and make client at ease.
2. Have the patient rest his arm along This position places the radial artery on the
side of his body with the wrist inner aspect of the patient’s wrist. The nurse’s
extended and the palm of the hand fingers rest conveniently on the artery with
downward, or place arm on top of thumb in a position to the outer aspect of the
the patient’s upper abdomen with patient’s wrist.
the palm downward position.
3. Place your first, second and third The fingertips which are sensitive to touch
fingers along the radial artery and will feel the pulsation of the patient’s radial
press gently against the radius; rest artery. If the thumb is used to palpate the
the thumb on the back of the patient’s pulse, the nurse may feel her own
patient’s wrist. pulse.
4. Apply enough pressure so that the Moderate pressure allows the nurse to feel the
patient’s pulsating artery can be felt superficial artery expand and contract with
distinctly. each heart beat.
5. Using a watch with a second hand, Sufficient time is necessary to detect

count the number of pulsation felt irregularities or other defects.
for one full minute.
6. If the pulse rate is abnormal in any When the pulse is abnormal, longer counting
way, repeat the counting to and palpation are necessary to identify most
determine accurately the rate, the accurately the unusual characteristics of the
quality and the volume. pulse.
7. Record pulse rate on the jot down

notebook.
8. Refer anything unusual to the
clinical Instructors and/ or head
nurse.
9. Record in client’s graphic chart and

VS master list.
B. CARDIAC RATE OR APICAL PULSE
If a peripheral pulse is irregular, weak, or extremely rapid, causing it to be difficult to

assess accurately, the apical rate may be assessed. The apical pulse is also used to assess
newborns, infants, and young children.
Procedure
Action Rationale
1. Explain the procedure to the patient Elicits cooperation from the client.
and/or significant others.
73
2. Assist the client on supine position.
3. Cleanse earpieces and diaphragm of Swabbing action removes dirt. ROH

stethoscope using alcohol swab. evaporates fast and render the parts dry easily
4. Raise the gown and properly drape Allows access to patient’s chest for proper
the client exposing the sternum and placement of stethoscope.
the left side of chest.
5. Warm the diaphragm of the Placing a cold diaphragm against the skin
stethoscope with your hand before may startle the patient and momentarily
applying it to the patient’s chest. increase the heart rate.
6. Place the diaphragm of the This gives the loudest and most distinctive
stethoscope over the apex of the sound of the heart.
heart, located at the fifth intercostal
space, left midclavicular line 5th
ICS, LMCL). Then, insert the
earpieces in your ears.
7. Move the diaphragm to the site of A full minute count is important for an
the loudest beats. Count the beats accurate assessment. A longer duration helps
for 60 seconds and note their determine pulse rhythm and quality.
rhythm and volume. Also evaluate In no instance, is the radial pulse count
the intensity (loudness) of heart greater than the apical pulse count.
sounds.
8. Remove the stethoscope and make
the client comfortable.
9. Record the apical pulse on the jot
down notebook.
10. Refer anything unusual to the CI or Referral of anything unusual in a patient
Head nurse. enables the professional nurse to respond
immediately to the needs or problem of the
11. Record the result on the chart and patient.
VS master list.
III - RESPIRATION
Definition: It is the exchange of oxygen and carbon dioxide between the atmosphere and
body cells and is initiated by the act of breathing.
Purpose: To obtain the respiratory rate per minute and an estimate of the
patient’s respiratory status.
Normal Rates:
Infants - 30 – 40/ minute
Children - 20 – 25/ minute
Adult - 16 – 20/ minute
Equipment: a. watch with second hand

b. jot down notebook and pen
74
Procedure
Action Rationale
1. While the fingertips are still in place Counting the respiration while presumably
after counting the radial pulse rate, still counting the pulse keeps the client from
observe the patient’s respiration. becoming conscious of his breathing which
can possibly alter his usual rate.
2. Note the rise and fall of the patient’s A complete cycle of inspiration and
chest with each inspiration and expiration constitutes one act of respiration.
expiration. This observation can be
made without disturbing the
patient’s bedclothes.
3. Using a watch with second hand, Sufficient time is necessary to observe rate,
count the number of respiration for depth and other characteristics.
one full minute.
4. If respirations are abnormal, repeat

to determine accurately the rate, the
characteristics of the breathing.
5. Record respiratory rate on the jot

down notebook including
abnormalities in rhythm and depth,
if any.
6. Refer to the CI and/or Headnurse

any abnormalities in rate and/or
rhythm.
7. Record the result in the client’s

graphic chart and the TPR master
list.
IV - BLOOD PRESSURE
Definition: Blood pressure is the lateral force exerted by the blood on the arterial
walls.
Purposes: 1. To aid in diagnosis
2. To observe changes in a patient’s condition.
Contraindications for Brachial Artery Blood Pressure Measurement

1. Surgery including the breasts, axilla, shoulder, arm or hands.
2. Venous Access Device such as AV shunt (in patients on hemodialysis) or IVF in
the arm.
3. Injury or disease to the shoulder, arm or hands such as trauma, burn or application
of cast or bandage.
Sites for BP taking:

1. either arm on the antecubital space
2. either leg on the popliteal space
3. dorsalis pedis
75
Equipment:
1. Stethoscope
2. Sphygmomanometer with appropriate size of cuff
3. Jotdown notebook and pen
4. Alcohol swab
Normal Ranges:
1. Infant - 50/40 – 80/50
2. Children - 87/48 – 117/64
3. Adult - 110/70 – 130/90
Procedure
Action Rationale
1. Explain the procedure to the patient. Nicotine causes vasoconstriction in peripheral
Make sure that client has not and coronary blood vessels which may cause
smoked cigarette or ingested increase in blood pressure. Caffeine is a
beverages that contains caffeine stimulant that increases blood pressure.
within 30 minutes
2. Place the patient in a comfortable This position exposes the brachial artery so
position with the forearm supported that a stethoscope can rest on it conveniently
and the palm upward. on the antecubital area
3. Position yourself so that the An accurate reading is obtained when the

calibration of the apparatus can be manometer column is in direct vision.
read at eye level and no more than 3
feet away.
4. Place the cuff so that the inflatable Pressure applied directly to the artery will
bag is centered and lies midway yield most accurate readings.
over the anterior surface of the
brachial artery, (the surface of the
brachial artery should be at the
center of the 2 tubings of the cuff)
so that the lower edge of cuff is 2.5
– 5 cm. above antecubital fossa.
5. Wrap the cuff smoothly and snugly A twisted cuff and wrapping could produce
around the arm with the end of the inaccurate reading.
cuff secure.
6. Use the fingertips to feel a strong Accurate blood pressure reading is possible
pulsation on the antecubital space. when the stethoscope is directly over the
artery.
7. Inflate the cuff to 30 mmHg where This will prevent you from missing the first
the pulsation disappears. Place the tap sound as a result of the auscultatory gap
diaphragm of the stethoscope (period where no sound is heard).
directly over the pulse.
8. Gradually deflate cuff all the way to First sound is the systolic BP and last sound is
zero taking note of the first and the diastolic BP.
last clear, loud sound.
9. Remove the cuff and make patient
comfortable.
76
10. Record the reading on the jot down
notebook.
11. Report any unusualities to the CI

and/or Headnurse.
12. Record BP on the VS sheet and VS

masterlist.
* Pulse pressure – the difference between systolic and diastolic pressures.

e.g. 120/ 80 BP
Pulse pressure is 40
– may be ordered in patients with Dengue Hemorrhagic Fever
77
SAN PEDRO COLLEGE
Davao City
VITAL SIGNS TAKING
Name: _________________________________ Grade: ______________________

Year and Sec.: _________________ Date : _____________________
Rating
5 4 3 2 1
1. Reads the chart.
2. Washes hands.
3. Prepares the equipment and brings to the bedside.
4. Identifies the patient and explains the procedure.
5. Wipes the thermometer from the bulb towards the stem
with alcohol swab.
6. Pats the axilla dry using washcloth or tissue paper.
7. Turns the thermometer on.
8. Places the thermometer in axilla directed upward
Positions patient’s arm across the chest.
9. Leaves thermometer in place for 2 to 60 seconds or until
a sound (beep) is heard.
10. Removes and wipes the thermometer dry using tissue
paper.
11. Reads temperature reading on the digital display.
12. Records result in the jotdown notebook. Inform client of
the result.
13. Disinfects the thermometer twice using CB with alcohol
from the stem to the bulb in a firm twisting motion.
14. Places fingers on the radial pulse with the arm across the
client’s chest with the palm positions downwrd.
15. With a watch with swift second hand, counts the pulse
rate for a full minute.
16. With fingers still in place after taking radial pulse, notes
the rise and fall of patient’s chest upon respiration.
17. Counts respiratory rate for one full minute.
18. Records PR and RR and notes for any unusual
characteristics in the jotdown notebook.
19. Applies the BP cuff on the arm without contraptions.
20. Feels for a strong pulsation on the brachial artery with
the use of 2-3 fingerpads.
21. Pumps the bulb until the pin of the manometer reaches
to approximately 30 mmHg above the point where the
systolic pressure is last heard or when the pulse
disappears.
78
22. Positions the diaphragm or bell of the stethoscope over
the pulse site with the earpiece into the ears.
23. Releases the air gradually with the use of the valve of
the bulb and takes note of the systolic blood pressure.
24. Continues to release air gradually and listen for the
diastolic blood pressure.
25. Removes the cuff and makes patient comfortable.
26. Records result on the jotdown notebook.
27. With the patient on supine position, locates the apical
pulse on the left side of the chest and drapes for privacy.
28. Warms the diaphragm of the stethoscope with the palm.
29. Places the diaphragm of the stethoscope over the PMI.
30. Counts the beat for one full minute.
31. Records result on the jotdown notebook.
32. Asks about patient’s stool and urine output within the
shift and record on the jotdown notebook.
33. Reports any unusualities in the VS.to the CI/HN.
34. Graphs/records results on the VS and TPR master list,
graphic sheet and patient’s chart.
35. Maintains body mechanics throughout the performance
of procedures.
36. Manifests neatness in the performed procedure.
37. Ensures safety and comfort.
38. Respects patient’s rights.
39. Receptive to criticisms.
40. Observes courtesy.
41. Shows calmness while performing the procedure.
42. Uses of correct English.
43. Shows mastery of the procedure.
Remarks:

II Performance 70%
100%
________________________________ __________________________
Student’s Printed Name and Signature Date
________________________________ __________________________
Instructor’s Printed Name and Signature Date
79
CLEANSING BED BATH
Definition : A bath given to weak and bedridden patients.

The nurse washes the entire body of a dependent client on bed.
Purposes :
1. To cleanse the body.
2. To refresh the patient.
3. To stimulate circulation.
4. To exercise muscles and joints.
5. To provide tactile stimulation.
6. To promote comfort and relaxation.
7. To improve self–concept.
8. To facilitate head–to–toe assessment.
General Instructions:
1. Ensure privacy. If in the ward, the bed should be screened; if in the PR the
windows/curtains should be adjusted.
2. Bed bath should be given one hour before meals or one hour after meals.
3. Always have everything ready before giving the bath.
4. If the patient is quite weak, all assistance should be given to free the patient from
exertion.
5. Children should never be left alone while bath is on going.
6. Unnecessary exposure or chilling must be avoided.
7. Special attention must be given to regions behind the ears, axillae, umbilicus, the pubis,
groins, spaces between fingers and toes or in areas where two skin surfaces come in
contact.
8. During the bath, the patient must be observed for objective signs such as rashes, swelling,
discoloration, pressure sores, discharges, abrasions, lice, burns, etc. The findings should
be recorded in the nurse’s notes and reported to the physician if they deemed important.
9. All treatments such as enema, douches or preparation for fields of operation should be
done before the bath so that the patient will remain clean and undisturbed afterwards.
10. The nurse should work quickly in a quiet soothing and unhurried fashion. Strokes should
be smooth and firm and ends of the wash cloth should not be allowed to dangle or drip.
Requisites:
1. Bath blanket or large towel
2. Bath towels (4),
3. Washcloths (3)
4. Patients clothing as called for
5. Linen as called for
6. Tray containing the following:
a. Wash basin half filled with warm water or water temperature as preferred
by patient)
b. Soap in a soap dish
c. Patient’s comb / hair brush
d. Talcum powder / lotion / oil
e. A pair of nail cutter if necessary
f. Two pitchers (one with cold and the other one with hot water)
g. Paper for lining
h. Bath thermometer
7. Pail for used water
8. Bedpan or urinal
80
9. Laundry bag
10. Working gloves (2 pairs)
Procedure
Action Rationale
1. Review chart for precautions It prevents injury to patient during bathing
concerning patient’s movement and activities, and determines level of assistance
positioning. required by patient.
2. Identify and discuss the procedure This promotes reassurance and provides
with the patient. Assess the patient’s knowledge about the procedure. Dialogue
ability to assist in bathing as well as also encourages patient participation and
with personal hygiene preferences. allows for individualized nursing care.
3. Wash hands and bring the necessary Bringing the needed equipment conserves
equipment to the bedside or overbed time and energy. Arranging items near the
table. patient makes for convenience, and helps
prevent stretching and twisting the nurse’s
nerves / muscles.
4. Close the curtains around the bed The first ensures the patient’s privacy while
and close the door if possible. Turn the second lessens the possibility of loss of
off the electric fan or airconditioner. body heat during the bath.
5. Wash your hands, dry, and don It deters the spread of microorganisms.
gloves.
6. Offer the bedpan or urinal and Voiding or defecating before a bath lessens
encourage the patient to urinate or the likelihood that the bath will be interrupted
allow to defecate. since the warm bath water may stimulate the
urge to void.
7. Change working gloves. It prevents the spread of microorganisms.
8. Raise the bed to working height. Having the bed in a high position prevents
strain on the nurse’s back.
9. Lower the side rail near you and Having the patient positioned near the nurse
assist the patient to the side of the and lowering the side rail help prevent
bed where you will work. Have the unnecessary stretching and twisting of
patient lie on his back. muscles on the part of the nurse.
10. Loosen top covers and place the bath The patient should not be exposed
blanket over the patient and roll the unnecessarily so that warmth may be
top sheet with contaminated side maintained. If a bath blanket is not available,
inside toward the footpart while the the top sheet may be used in its place.
patient holds the bath blanket in
place.
11. Assist the patient with oral hygiene. Oral hygiene helps maintain the teeth and
This may be done after the bath if gums in good condition. It also alleviates
the patient prefers it. unpleasant odor and taste.
81
12. Remove the patient’s gown keeping Removing the clothing provides access during
the bath blanket in place. the bath. Covering with a bath blanket
maintains the warmth of the patient.
Note:
If the patient has an intravenous line, IV fluids must be maintained at the prescribed
remove the gown from the free arm rate.
first. Lower the IV container and
pass the gown over the tubing and
container. Hang the IVF and check
the drip rate.
13. Raise the side rail. Fill the basin 2/3 Side rails maintain patient’s safety.
full with a warm H2O (43 – 460 C). Warm water is comfortable and relaxing for
Have the patient place fingers into the patient. It also stimulates circulation and
the basin to check water provides for more effective cleansing.
temperature. Lower the side rail
closer to you when you return to the
bedside to begin the bath.
Change the water as necessary
throughout the bath.
14. If allowed, remove the pillow and A towel prevents chilling and keeps the
raise the bed 30-400 angle. Put a blanket dry. Removal of pillow makes it
towel under patient’s head. easier to wash patient’s ears and neck.
15. Wash the face. Ask patient’s Having loose ends of a wash cloth drag across
preference whether or not to use the patient’s skin is uncomfortable. Loose
soap on the face. ends cool quickly and will feel cold to the
patient.
a. Wet and make a bath mitt wash
cloth.
b. Wipe the farther eye from the Rinsing or turning the cloth prevents spread
inner to the outer canthus. Turn of the organisms from one eye to the other.
the cloth before washing the other This direction prevents secretions from
eye. Do the same. entering the naso-lacrimal duct.
c. Rinse the wash cloth. Wash face Soap can be drying and maybe avoided as a
starting at the forehead, down to matter of personal preference.
the cheek, nose, chin and neck
ending at the ears.
16. Expose the patient’s far arm and The towel helps to keep the bed dry. Washing
place the towel lengthwise under it. the far side first eliminates contaminating a
Using firm long strokes, soap, rinse clean area once it is washed. Gentle friction
and dry the arm and axilla. stimulates circulation and helps remove dirt,
oil and organisms.
Strokes should be from distal to Firm strokes from distal to proximal areas
proximal areas. increase venous blood return.
17. Place a folded towel on the bed next Placing the hand in the basin of water is
to the patient’s hand and put the comfortable and relaxing for the patient. It
hand in the basin. Soap, rinse and allows for a thorough washing of the hand
82
dry the hand. and between the fingers, as well as facilitating
removal of debris from under the nails.
18. Do steps 18 & 19 to the nearer arm.
19. Spread the towel across the patient’s Spreading the towel across the patient’s chest
chest. Lower the bath blanket to the will avoid unnecessary exposure and chilling.
umbilical area. Soap, rinse and dry Dirt usually accumulates in between skin
the chest. Keep the chest covered folds.
with a towel between the washing
and rinsing. Pay special attention to
the skin folds under the female
patient’s breasts.
20. Lower the bath blanket to cover the Keeping the bath blanket in place avoids
perineal area. exposure and chilling.
21. Soap, rinse and dry the patient’s Skin fold areas may be sources of odor and
abdomen. Carefully inspect and skin breakdown if not cleaned and dried
cleanse the umbilical area and any properly.
abdominal folds or creases.
22. Return the bath blanket to the The towel protects the linen and prevents the
original position and expose the patient from feeling uncomfortable from a
patient’s far leg. Place the towel damp or wet bed.
under the far leg. Using firm long
strokes, soap, rinse and dry the leg
from the ankle to the knee and knee Dirt usually accumulates in these areas.
to thigh to groin.
Pay particular attention to the back
of the knee and the groin.
Do the same to the leg near you.
23. Spread the towel near the foot part Supporting the foot and leg helps reduce
and place the basin on the towel in strain and discomfort for the patient. Placing
between the feet. Bring the soap with the foot in a basin of water is comfortable and
soap dish and place on the towel. relaxing. It also allows for a thorough
Place the foot in the basin while cleaning of the foot, particularly in areas
supporting the ankle and heel with between the toes and under the toenails.
your hand and the leg with your arm.
Soap, rinse and dry each foot paying
particular attention to the areas
between the toes. Change the water.
Discard the wash cloth and towel. The washcloth, towel and water are
contaminated after washing the feet.
24. Wash gloved hands.
25. Lay a new towel under the buttocks.
26. Refill the basin with clean water. Changing to clean supplies decreases the
Use a new wash cloth spread of organisms.
27. Clean the perineal area. If patient Providing perineal self–care may decrease
prefers to do it by himself, make a the embarrassment of the patient. Effective
mitt on his hand. Remove the towel perineal care reduces odor and decreases the
under the buttocks with chance of infection through contamination.
contaminated side inside. Discard
the wash cloth and bath towel. Wash
83
gloved hands.
28. Assist the patient to a prone or The bath blanket maintains warmth and
lateral position. Lower the bath privacy. Clean, warm water prevents chilling
blanket exposing the buttocks. Lay and maintains the patient’s comfort.
towel along the side of the patient.
29. Soap, rinse and dry the patient’s Fecal material near the anus can be a source
back and the buttocks areas with a of microorganism. Prolonged pressure on the
new wash cloth. Using downward sacral area or other bony prominences may
strokes from nape to the upper compromise circulation and lead to the
buttocks going out to the farther development of decubitus ulcer.
side. Do the same with nearer side.
30. Using downward strokes, soap, rinse

and dry the farther buttocks starting
from the center towards the side,
paying attention on the gluteal folds
towards the anal area. Observe for
redness or other indications of skin
breakdown in the sacral area. Wash
gloved hands and wash cloth. Do the
same to the nearer buttocks and
clean the anus.
31. Remove the gloves and dispose A back rub improves circulation to the tissues
properly. If not contraindicated, give and aids in relaxation. The towel along the
the patient a back rub. side catches the excess powder or lotion to
protect the patient from skin irritation.
32. Assist the patient to lie on his back
comfortably.
33. Assist client with oral hygiene. (Oral A clean gown promotes the warmth and
care pp. 78) comfort of the patient.
34. Help the patient to a clean gown This facilitates ease in dressing.
before attending to his/her grooming
needs.
If with IVF, insert the arm with IVF
first and check the drip rate.
35. Groom the patient’s hair and remove Hair is lost during the process of combing.
the towel. The towel collects loose hair.
36. Assist the patient to clean and trim After a bath, nails are soft thus making it easy
fingernails or toenails if necessary. to trim or clean.
37. Change the bed linen. Providing clean linen promotes medical
asepsis and the comfort of the patient.
38. Lower bed to its original height, This makes the room / unit clean and tidy.
position the signal cord within easy
reach and arrange the furniture.
84
39. Remove all the equipment used Doing the after care of the equipment used is
including the soiled linen and bring the responsibility of a nurse or student nurse.
them to the Utility Room. Wash the
used equipment (if necessary) and
return to its proper place.
40. Wash your hands. Handwashing deters the spread of

microorganisms.
41. Record any significant observations. A careful record is important for planning and
Report to the CI/ Headnurse or individualizing the patient’s care.
attending physician (AP).
Note: For a right handed person, always stand at the ® side of the patient and for a left
handed person, his left.
85
SAN PEDRO COLLEGE
Davao City
CLEANSING BED BATH
Name: ________________________________ Grade: ______________________

Year and Sec.: _________________ Date : ______________________
Rating
5 4 3 2 1
1. Reviews patient’s chart.
2. Identifies, explains, and assesses the patient.
3. Washes hands and brings the necessary equipment.
4. Provides privacy.
5. Dons gloves.
6. Offers the bedpan or urinal.
7. Changes working gloves.
8. Raises the bed to a convenient working height.
9. Assists the client to the side of the bed near you.
10. Places the bath blanket over the patient.

11. Assists in oral hygiene (or may be performed after the
bath is through).
12. Removes the client’s gown.
13. Fills the basin with sufficient warm water (430 – 460C).
14. Checks water temperature.
15. Places the towels appropriately.
16. Makes a mitt and washes the farther eye from the inner
to the outer canthus.
17. Turns the mitt or uses the other corner of the mitt and
washes the other eye.
18. Asks the patient’s preferences whether to use soap on
the face.
19. Washes and dries the face, neck, and ears.
86
20. Exposes the patient’s far arm and places the towel
lengthwise under it.
21. Soaps, rinses and dries and covers the arm and axilla.
22. Soaps, rinses and dries the hand.
23. Changes the water as often as necessary.
24. Does the same to the nearer arm.

25. Spreads the towel across the patient’s chest while
lowering the blanket to the umbilical area.
26. Soaps, rinses and dries the chest.
27. Soaps, rinses and dries the patient’s abdomen and the
umbilical area.
28. Soaps, rinses, and dries the patient’s farther leg.
29. Does the same to the near leg.
30. Washes and dries the feet one at a time.
31. Changes washcloth and bath towel.

32. Refills the basin with clean water.
33. Assists or does the perineal care for the patient.
34. Discards washcloth and towel.
35. Assists the patient to his side or prone position.
36. Lays the towel correctly on bed.
37. Soaps, rinses and dries the back and buttocks.
38. Removes gloves correctly.
39. Does the back rub correctly.

40. Helps the patient put on a new gown.
41. Combs the hair properly.
42. Removes towel from under patient’s head.
43. Assists the patient in trimming or cleaning the finger
nails and toe nails if necessary using a folded towel from
the head to catch trimmed nails..
44. Changes the bed linen following the procedure of
making an occupied bed.
45. Does the after care of equipment.
46. Washes hands.
47. Documents all the observations on the nurses’ notes

48. Reports to the CI/ nurse-on-duty for any pertinent
observations.
87
51. Provides patient’s privacy throughout the procedure.
Remarks:

II Performance 70%
100%
________________________________ __________________________
________________________________ __________________________
88
SHAMPOO IN BED
Hair accumulates the same dirt and oil as the skin. It should be washed as often as
necessary to keep it clean. A weekly shampoo may be sufficient for some persons whereas
others may prefer to perform this aspect of personal hygiene daily. The nurse may need to
shampoo the hair of those patients who cannot get out of bed for bathing and showering or
who lack the strength or ability to independently care for their hair.
Definition: Washing of the hair with the use of shampoo or bath soap as often as
necessary to keep it clean.
Purposes:
1. To cleanse the hair and scalp.
2. To maintain or improve self–esteem.
3. To treat conditions of the scalp with topical applications of medications.
4. To remove substances, such as blood, body secretions, or electrode jelly (used
when an electroencephalogram or other such study is done.)
Assessment:
1. Examine the hair; note its distribution, cleanliness, texture and any indications of
parasitic infections, such as the nits of head lice on the hair shaft.
2. Inspect the scalp for lacerations, dry scaly patches, scratches, lesions, and swollen
areas.
3. Observe the patient for signs of any itchiness of the scalp, such as scratching the
head.
4. Note signs of dandruff on the shoulders and back of clothing.
5. Determine if the patient is receiving toxic chemotherapy or radiation treatments
that may cause loss of hair.
6. Read the client’s medical record to determine if the patient has any pathology,
such as hypothyroidism, or is receiving long–term steroid therapy that may alter
the texture and distribution of hair.
7. Identify if there are any sensory, cognitive, endurance, mobility, or motivational
deficits that interfere with the patient’s ability to perform hygienic practices.
8. Ask the client to describe the usual routine for shampooing including the
frequency and types of hair care products routinely used.
9. Inquire if the client experienced any itching, burning, or tenderness of the scalp.
10. Note the client’s history of hair or scalp problems and related treatments.
Pre-requisite: Check agency’s policy on hair shampoo.
Equipment:
1. Tray containing:
a. hair shampoo
b. 2 bath towels
c. pitcher with hot water
d. comb / hair brush
e. 2 dry CB
2. Two pails
a. pail containing 2/3 full of clean water
b. empty pail
3. Shampoo trough
4. Water proof pad
5. Paper linings
89
Procedure
Action Rationale
1. Assess need for shampoo and for Prevent injury to patient.
contraindications in performing hair
wash.
2. Explain the procedure to the patient. An explanation facilitates understanding and

cooperation.
3. Wash your hands. Handwashing reduces the transient

microorganism thus, deters the spread to
client and self
4. Assemble and bring the equipment to Organization is a form of appropriate time –

the patient’s bedside. management and prevents fatigue and
frustration of the patient.
5. Close the curtain or windows and Prevent chilling and provides privacy.
door.
6. Raise the bed to a height convenient Adjusting the bed helps to prevent muscle
for you and lower the nearer side strain or fatigue.
rail.
7. Position the patient near you. A supine position facilities drainage away
Reposition the pillow under the from the face, eyes and head. CB prevents
patient’s shoulders. entrance of water inside the ears.
8. Lay the waterproof pad under the

patient’s head covering the pillow.
Lay a towel on the waterproof pad.
9. Replace the top sheet with a bath
blanket
10. Place the shampoo through under the Using a trough provides a method for
patient’s head. Place empty pail to collecting and draining the water away from
collect drainage from the through. the patient and the bed.
11. Place a rolled bath towel under the Layered material absorbs water and prevents
patient’s nape with the ends of the the patient from feeling wet and chilled. It
towel placed on the patient’s chest also avoids saturating the bed linen.
part.
12. Comb or brush the patient’s hair. Removing tangles before washing will
prevent breaking strands of hair.
13. Place a damp wash cloth over the Dry CB will keep the water from collecting in
client’s eye. Place a dry CB in the air canal.
both external ears. Damp wash cloth will remain in place and
protect the eye from possible irritation
14. Wet the hair thoroughly with warm Wet hair dilutes the shampoo and helps to
water. Apply shampoo according to form suds.
patient’s preference.
90
15. Work the shampoo into a lather. Lathering helps distribute the shampoo
while massaging the scalp with the throughout the entire hair for uniform
pads of the fingertips. cleansing. Massaging the scalp stimulates
blood circulation
16. Rinse the hair with clean water. Rinsing prevents leaving shampoo in the hair,
which gives hair a dull appearance; if left on
the scalp, shampoo could cause irritation in
some people.
17. Remove shampoo trough.
18. Wrap the client’s head with towel Towel absorbs water.
from the patient’s neck.
19. Remove the damp wash cloth from

the eyes and CBs from the external
ears.
20. Remove the waterproof pad.
Reposition the pillow under the
head.
21. Change the towel wrapped around Fluffing thoroughly dries the hair.
the head with the dry towel from
the pillow. Fluff the hair with towel
and comb.
22. Remove the equipment used for Discarding the water and the equipment will
shampooing. prevent accidental spilling.
23. Raise the side rail and lower the bed Precautionary measures prevent falls and
before leaving the patient. injury to the patient.
24. Wash the equipment used and return

to their proper places
25. Wash your hands. Handwashing reduces the transient

client and self.
26. Report to CI or HN any pertinent

observations on the scalp.
27. Document care provided the client’s Careful recording is important for planning
ability to participate and his /her and individualizing the patient’s care.
response, including pertinent
observations on the scalp.
91
SAN PEDRO COLLEGE
Davao City
SHAMPOO IN BED
Name: _______________________________ Grade: __________________

Year and Sec.: _________________ Date :___________________
Rating
5 4 3 2 1
1. Assesses the need for shampoo and inspects the hair and
the scalp.
2. Explains the procedure to the client.
3. Washes hands and assembles equipment.
4. Provides privacy and dons gloves.
5. Raises the bed to an appropriate height. Lowers the
nearer side rail and instructs client to move towards the
nurse.
6. Repositions the pillow under the client’s shoulders.
Places the waterproof underpad over the pillow and lines
it with a towel.
7. Places shampoo trough and rolled towel under the neck
with the ends on the chest.
8. Combs/ brushes patient’s hair.
9. Inserts a dry CB to each external ears. Covers eyes with
damp wash cloth.
10. Places a pail / receptacle beneath the drain area of the
trough.
11. Wets the hair.
12. Lathers the shampoo well into the hair.
13. Massages the scalp with the fingertips.
14. Rinses the hair thoroughly.
15. Wipes any water and shampoo from the face.
16. Removes shampoo trough.
17. Removes ear plugs (CB) and damp wash cloth from the eyes.
18. Dries the hair with a towel and combs or brushes the
hair.
19. Raises the side rail.
92
20. Washes equipment and returns to their proper places.
21. Washes hands.
22. Documents the procedure done and the patient’s
responses.
of the procedure.

Remarks:

II Performance 70%
100%
________________________________ __________________________
________________________________ __________________________
93
ASSISTING THE CLIENT IN ORAL CARE
Definition: It is the brushing and flossing of the teeth including the inspection of the
mouth for dental carries, gum problems, soft plaque deposits, etc.
Purposes:
1. To cleanse the teeth of food residue and microorganisms.

2. To maintain moisture and integrity of the tissue.
3. To refresh the mouth.
4. To improve the pleasure of eating.
5. To prevent oral infection.
6. To relieve discomfort from inflamed lesions.
7. To prevent dental caries.
8. To maintain or improve self–concept.
Equipment:
1. Toothbrush
2. Toothpaste
3. Emesis basin
4. Glass of water
5. Towel
6. Mouthwash (optional)
7. Dental floss (optional)
8. Petroleum jelly (optional)
9. Working gloves
A. INDEPENDENT PATIENT
Procedure
Action Rationale
1. Identify the patient and explain the An explanation facilitates cooperation.

procedure.
2. Bring the equipment to the bedside. Organization facilitates the performance of

task.
3. Provide privacy for the client. The clientt may be embarrassed if cleansing
involves removal of dentures.
4. Wash your hands and don gloves. Handwashing deters the spread of
microorganisms.
5. Arrange equipment within client’s Facilitates self-care.

reach.
6. Assist the patient to a sitting A sitting or side–lying position prevents

position if permitted or help him aspiration of fluids into the lungs.
turn to one side.
94
7. Place the bath towel across the The towel protects the patient from dampness.
chest. Raise the bed to a Raising the bed promotes efficient body
comfortable working position. mechanics.
8. Encourage the patient to brush his The nurse should encourage the patient to
own teeth or assist if necessary. exercise as much independence as possible.
a. Moisten the toothbrush and Water softens the bristles.

apply toothpaste.
b. Place the brush at a 45 degree Brushing facilitates the removal of plaque and
angle to the gum line and brush tartar.
from the gum line to the crown Angling the brush permits cleansing of all
of each tooth. Brush the outer surfaces of the teeth.
and inner surfaces of the teeth.
Brush back and forth across the
biting surface of each tooth.
c. Brush the tongue gently with the This removes any coating that may be on the
toothbrush. tongue. Gentle motion does not stimulate the
gag reflex.
d. Have the patient rinse Vigorous swishing helps remove loosened

vigorously with water and spit debris.
into the emesis basin. Repeat
until clear.
e. Assist the patient to floss the Flossing aids in the removal of plaque and
teeth, if necessary. promotes healthy gum tissue.
f. Offer mouthwash if patient Flavored mouthwash leaves a pleasant

prefers. aftertaste.
9. If with denture, assist the patient Artificial dental devices can be more
with the removal (prior to brushing thoroughly cleaned when removed from the
of teeth) and cleansing of dentures if mouth.
necessary.
a. Apply gentle pressure with a 4 x A rocking motion breaks the suction between
4 gauze to grasp and remove the the denture and gum. Using a 4 x 4 gauze
upper denture plate. Place it prevents slippage and the spread of
immediately in a denture cup. microorganisms.
Lift the lower denture using a
slight rocking motion and place
in the denture cup.
b. If the patient prefers, add
denture cleanser to the cup with
water and follow the package
direction for cleaning, or brush
all areas thoroughly with a
toothbrush and toothpaste.
c. Rinse dentures thoroughly The basin with wash cloth will protect the
with water in a basin spread with dentures from breakage in case it is
a wash cloth. Return denture to accidentally dropped.
the patient after cleaning it. Water aids the removal of debris and the
cleansing agent.
95
10. Apply petroleum jelly to the lips, Petroleum jelly prevents cracking and drying
if needed. of the lips
11. Assist the patient to a safe and

comfortable position.
12. Do after care of the equipment.
13. Remove gloves and dispose Handwashing deters spread of

properly. Wash your hands. microorganisms.
14. Record the procedure done and the Charting provides accurate documentation of
patient’s responses. patient’s care.
B. DEPENDENT PATIENT
Equipment:
1. Toothbrush 8. Mouthwash solution

2. Toothpaste 9. Lubricating jelly
3. Kidney basin 10. Working gloves
4. A glass of water 11. Cleansing agent (hydrogen peroxide
5. Drinking straw at half strength)
6. Towel 12. Suction apparatus with catheter (optional)
7. Padded tongue depressor 13. Asepto syringe (optional)
Procedure
Action Rationale
1. Identify the patient and explain the An explanation facilitates cooperation.
procedure.
2. Bring the equipment to the bedside. Organization facilitates the performance of
task.
3. Provide privacy for the client. The client may be embarrassed if cleansing
involves removal of dentures.
4. Wash your hands and don gloves. Handwashing reduce the transient
client and self.
5. Adjust the height of the bed. Lower Helps prevent unnecessary stretching and
the side rail nearest you. twisting of muscles on the part of the nurse.
6. Position the patient on his side with A side lying position with the head turned
his head turned toward the nurse downward prevents aspiration of fluid into the
and tilted toward the mattress. lungs.
7. Place a bath towel across the chest A towel and kidney basin protects the client
and a kidney basin in a position from dampness.
under the client’s chin.
8. Open the mouth and gently insert a A padded tongue depressor keeps the mouth
padded tongue depressor between open for easier cleaning and prevents the
the back molars. patient from biting the nurse’s fingers.
96
9. If the client has his natural teeth, A toothbrush and padded depressor blade
clean them carefully with a padded provide friction necessary to clean areas
tongue blade moistened with where plaque and tartar accumulate.
mouthwash solution. Use a gauze or Hydrogen peroxide solution effectively cleans
padded tongue depressor moistened and removes encrustation from the oral
with hydrogen peroxide to gently cavity.
cleanse the gums, mucous
membranes and tongue. Remove
dentures if present and clean.
10. Rinse with small amount of water or Rinsing helps to clean debris from the mouth.
use a padded tongue depressor in
mouthwash solution to rinse the oral
cavity. Position head to the side to
allow return drainage of water or
use saliva ejector suction or asepto
syringe.
11. Wipe dry the patient’s mouth. Prevents skin irritation.
12. Apply lubricating jelly to client’s Lubrication prevents drying and cracking of
lips. the lips.
13. Place client to a comfortable Prevents pooling of secretions and

position. Leave patient in a lateral aspirations.
position with head turned toward
the side for 30 – 60 minutes after
oral hygiene. Remove the towel.
14. Do after care. Proper care of the soiled equipment maintains

medical asepsis.
15. Remove gloves and dispose Handwashing reduce the transient

properly. Wash your hands. microorganism thus, deters the spread to
client and self.
16. Document the procedure done and Written information documents the
any unusual observations including individualized care given to the patient.
bleeding, inflammation, tartar, etc.
97
SAN PEDRO COLLEGE
Davao City
PROVIDING ORAL CARE FOR DEPENDENT PATIENT
Name: _______________________________ Grade: ____________________

Year and Sec.: _________________ Date : _________________
Rating
5 4 3 2 1
1. Explains the procedure to the client.
2. Washes hands. Puts on gloves.
3. Checks the function of the suction apparatus.
4. Assembles the necessary equipment.
6. Positions the client on his side with his head turned
towards the nurse and chin tilted towards the mattress..
7. Protects the linen and the patient from wetness with a
towel across the chest and places the kidney basin under
the client’s chin..
8. Inserts a padded tongue depressor to open and separate
the upper and lower teeth.
9. Brushes the teeth or uses a padded tongue depressor
moistened with mouthwash solution. .
10. Instills rinsing solution or water at the same time
suctions the solution from the mouth or uses asepto
syringe..
11. Swabs the lips and mucous membrane with lubricant.
12. Places the client to a safe and comfortable position.
13. Does after care of equipment.
15. Documents pertinent information.
Remarks:

II Performance 70%
100%
________________________________ __________________________
________________________________ __________________________
98
FOOT AND TOENAIL CARE
Purposes:
1. To cleanse and promote the comfort of the feet.

2. To maintain the integrity of the integument.
3. To stimulate circulation to the lower extremities.
4. To prevent injury.
5. To treat local infections by soaking the feet in a medicated solution.
6. To prevent odors.
Equipment:
1. Warm water in a pitcher 9. Waterproof underpad

2. Wash basin 10. Working gloves
3. Soap in a soap dish 11. Nail brush
4. Hand towels, 2
5. Nail cutter or scissors
6. Nail file
7. Lotion (optional)
8. Powder (optional)
Procedure
Action Rationale
1. Identify client and assess the An appropriate plan for foot care cannot be
condition of the feet and toenails. individualized without pertinent data.
2. Explain the procedure, discuss any An explanation allays fear and aids in
identifiable foot and nail problems acquiring the patient’s cooperation.
with the patient.
The client should be informed of potential and
actual health problems.
microorganisms.
4. Assemble the equipment. Organization promotes efficient time

management.
5. Provide privacy. Providing privacy demonstrates respects for
the patient’s feelings.
6. Don your working gloves.

7. Place a pillow under the client’s This provides support and prevents muscle
knee fatigue
8. Lay the waterproof underpad at the A towel absorbs water and prevents wetting
footpart of the bed and line it with the linen.
towel beneath the client’s feet.
9. Soak each foot one at a time in warm Soaking softens the nails and helps to loosen
water for approximately 3–5 dry skin and debris. Warm water dilates blood
minutes. vessels which improves circulation and
promotes comfort.
99
10. Wash each foot with liberal amount Soap removes bodily oil, surface dirt and
of lathered soap paying attention to microorganisms.
interdigital spaces.
11. Brush the toenails. Dead cells and dirt trapped between the nail
and toe may require mechanical removal.
12. Change the water between the care The water should be clean and maintained at a
of each foot. temperature that promotes comfort.
13. Dry each foot thoroughly. Make sure Moisture supports the growth of fungi and can
to dry between each toe. also tend to lacerate skin if it cannot
evaporate.
14. If agency permits/ trim the nails Cutting straight across is less likely to result
straight across seeing to it that they in injury to adjacent tissue or to potential risk
are even with the tip of the toes. for ingrown nails.
Meanwhile, soak the other foot.
And follow the same procedure as
the first foot.
15. Apply lotion or powder to the legs or Lotion lubricates dry skin. Powder absorbs
feet if needed. Make client perspiration.
comfortable.
16. Dispose water and do after care of Caring for soiled articles supports the
equipment. principles of medical asepsis.
17. Remove gloves and dispose Handwashing reduce transient

properly. Wash your hands. microorganisms and deters its spread and to
client and self.
18. Document the care given, the Written information is a permanent record of
response of the patient, and the the care provided for the patient.
necessary observations you made.
100
SAN PEDRO COLLEGE
Davao City
FOOT AND TOENAIL CARE
Name: _______________________________ Grade: ____________________

Year and Sec.: _________________ Date : _________________
Rating
5 4 3 2 1
1. Identifies the client and assesses the condition of the feet
and toenails.
2. Explains the procedure.
3. Washes hands and assembles the equipment.
6. Places a pillow under the client’s knee.
7. Lays waterproof underpad and lines it with a towel
beneath the client’s feet.
8. Soaks each foot one at a time at least 3- 5 minutes with
warm water.
9. Washes each foot with well-lathered soap and brushes the
toenails if necessary. Changes water between each foot. .
10. Dries each foot thoroughly.
11. Trims toenails across.
12. Applies lotion or powder if needed.
13. Makes client comfortable.
14. Does after care of the equipment.
16. Documents the care given and reports pertinent
observations to the CI.
Remarks:

II Performance 70%
100%
________________________________ __________________________
________________________________ __________________________
101
BACK MASSAGE
Definition: Stimulation of the skin and underlying tissues with varying degrees of hand
pressure.
Purposes:
1. To provide an opportunity to assess the skin on the back.

2. To stimulate blood flow to the skin and underlying tissues.
3. To nonverbally communicate a concern for the patient’s comfort.
4. To relax tense muscle thereby relieving pain.
5. To promote rest or sleep.
Contraindications:
1. Red and tender areas since such signs may indicate presence of thrombus.
2. Rib fractures.
3. Surgical incisions in the chest and back.
4. Recent back trauma.
Strokes Used:
1. Effleurage – gliding and long rhythmic strokes with the use of
the whole hands.
- firm, even-pressured strokes are directed toward the heart to assist
blood return
- lighter pressure is used when moving away from the heart
2. Petrissage – pressing, squeezing, kneading, and rolling movement with the use of
both hands.
- deep circulation is enhanced
- C-shaped motions stimulate the muscle body
- promotes muscle relaxation
3. Friction - focused, deep, circular motions with the use of thumb pads,
heel of hand, or fingertips.
- penetrates deeper muscle layers
- done after effleurage and petrissage
4. Tapotement – brisk, vigorous, rhythmic, percussive hand movements palms,
fingertips, and knuckles are used to alternately tap, cup, slap, and
pummel muscle.
- alternately tap, cup, slap, and pummel muscles
- palms, fingertips, and knuckles are used
- invigorates and stimulates tired muscles
Equipment:
1. Massage lubricant or lotion as preferred by the patient.
2. Powder
3. Bath blanket
4. Towel
5. Stethoscope
6. Sphygmomanometer
Procedure
Action Rationale
1. Offer to give the client a back Offering rather than asking may make the
massage and explain the procedure. client feel less reluctant to accept this aspect
of care.
102
2. Remove jewelry. Wash your hands. Handwashing reduce the transient
Assemble necessary equipment. microorganism thus, deters the spread to
client and self.
3. Close the curtain or door. Raise the Privacy increases relaxation.

bed to working height and lower the Ensures proper body mechanics and prevents
side rail closest to you. strain on back muscles.
4. Assess client’s heart rate, respiratory Three-minute effleurage back rubs result in a
rate and blood pressure. decline in HR, RR and BP. Assessment
establishes baseline.
5. Assist the client to a prone or side- Either of these positions exposes an adequate
lying position with the back area for massage while maintaining privacy
exposed. Use a bath blanket to cover and warmth.
from the buttocks down to the lower
extremities. Lay the towel alongside
the patient’s back.
6. Warm the lubricant or lotion in the Cold lotion causes muscle tension.
palm of your hand or place the
container in warm water.
7. Using light strokes (effleurage) Effleurage relaxes the client and lessens
apply lotion/ powder starting from tension.
the sacral area towards the back and
shoulders.
8. Place your hands beside each other Continuous hand contact is soothing and
at the base of the client’s spine and stimulates circulation and muscle relaxation.
stroke upward to the shoulders and
back downward to the buttocks in
slow continuous strokes. Continue
for 3 to 5 minutes.
9. Massage the shoulders, the entire Firmer strokes with continued hand contact
back, areas over the iliac crests and promotes relaxation.
sacrum with circular stroking
motion. Keep your hands in contact
with the skin for 3 to 5 minutes
applying additional lotion/lubricant
as necessary.
NOTE: You may use the other strokes

(petrissage, friction or tapotement) as
the case maybe.
10. If other strokes are used, complete Long stroking motions are soothing and
the massage with additional long promote relaxation.
stroke movements.
11. During the massage, observe the Pressure may interfere with circulation and
skin for reddened or open areas. Pay lead to the development of decubitus ulcers.
particular attention to skin over bony A back massage stimulates circulation to
prominences. Avoid rubbing any these areas. Rubbing skin that remains
areas that remain red after pressure reddened can contribute to additional injury.
has been relieved.
103
12. Use a towel to pat dry and remove Removing excess lotion and applying powder
excess lotion. Apply powder if the provide additional comfort for the patient.
patient requests it.
13. Reposition the client and adjust bed

clothes and linen.

microorganisms.
15. Assess the client’s response and Accurate documentation provides a legal
record observations on the chart. record of the care provided and the condition
of the client.
104
SAN PEDRO COLLEGE
Davao City
GIVING A BACK MASSAGE
Name:__________________________________ Grade: _________________

Year and Sec.: _________________ Date : _________________
Rating
5 4 3 2 1
1. Explains the purpose of the procedure.
3. Assesses the patient for objective and subjective
data.
4. Raises the bed and lowers the near side rail.
5. Positions the patient.
6. Exposes the patient’s back up to the hip area.
7. Warms the lotion/ lubricant.
8. Applies the lotion to the back with light strokes.

9. Distributes the lotion across the surface of the back
with long strokes from the sacrum to the shoulders
and back again.
10. Administers firmer strokes over bony
prominences.
11. Kneads areas that are affected by the pressure of
body weight against the mattress.
12. Removes excess lotion /lubricant with a towel.
13. Repositions the patient and adjusts bed clothes and
linen.
14. Lowers the bed and raises the side rail.
15. Observes the response of the patient.
16. Charts nursing assessment and care.

17. Maintains body mechanics throughout the
performance of the procedures.
105
Remarks:

II Performance 70%
100%
________________________________ __________________________
________________________________ __________________________
106
EXTERNAL DOUCHE
Definition: It is the washing of genitals and anal area with water, soap and/or medicated
solution.
Purposes:
1. To cleanse the area of secretion and excretions.
2. To reduce unpleasant odors.
3. To prevent skin irritation and excoriation.
4. To control the potential for infection.
5. To promote comfort.
Equipment:
1. Bedpan with cover.
2. Waterproof underpad.
3. Bath blanket (optional)
4. A tray containing the following:
a. Sterile covered flushing can with sterile water or solution to be used.
b. Sterile pick up forceps in a disinfectant solution.
c. A jar of dry sterile CB (optional).
d. A jar of sterile CB soaked in soap sud solution.
e. A jar of sterile CB soaked in antiseptic solution.
f. Kidney basin lined with paper for waste.
g. Toilet paper. (client’s supply)
h. A piece of paper to wrap vaginal pads.
i. Working forceps in a sterile pack
j. Working gloves (2 pairs)
k. Sterile bowl or sterile kidney basin
5. Adult diaper or sanitary pad (client’s supply; optional)
6. Perineal cream or lotion if needed
Procedure
Action Rationale
1. Assess the need for external douche.
2. Identify the patient and explain the Exchanging information allays fears and
procedure. promotes cooperation.
3. Wash your hands. Handwashing reduce the transient

client and self.
4. Assemble and bring equipment to Organization promotes efficient time

the bedside. management.
5. Screen the client and close the door/ This ensures the patient’s privacy.
windows if possible.
6. Raise the bed to working height.
To protect the nurse from infection
7. Don gloves
8. Place waterproof pad, if available, as Cleansing may wet or soil an unprotected bed.
well as change the top sheet with
bath blanket if available.
107
9. Drape the client. This provides warmth and respect the privacy
of the client.
10. Remove adult diaper/sanitary pad.
Roll with the contaminated inside
and wrap with a piece of paper.
Place it on the paper lining under the
bed.
11. Place the client on a bedpan in a A bedpan will collect the water used during
dorsal recumbent position. perineal cleansing.
12. Change working gloves. Prepare

sterile pack. Open sterile bowl or
kidney basin. Place 7 or more CB
soaked in soap suds solution. Open
sterile working forceps and place it
on the sterile field with the handle at
the edge. Prepare tissue wipes at the
edge of the sterile field.
13. Lift the cover of the flushing can and To protect the inner side of the flushing can
fold with sterile side inside. Test the from contamination. Testing the temperature
water temperature (105°F or 41°C) of water prevents burns.
by pouring small amount of water
over the back of your hand and then
on the client’s thigh.
14. Flush the area with warm water or a Water dissolves or dilutes dried secretions.
soapy solution until the area is clean. Soap emulsifies fatty substances in the skin
and reduces the ability of microbes to grow
15. With one cotton ball soaked in SSS, and multiply.
wash the mons veneris in zigzag
motion going upward toward the
lower portion of the hypogastrium.
16. Use a second cotton ball in SSS to Thorough cleansing and care should be taken
wash the inner aspect of the farther to avoid introducing secretions and bacteria
thigh. Beginning in the crease of the into the opening through which urine is
groin and continuing outward toward release. Contamination of this area can lead to
the knee. These strokes are made a urinary tract infection.
with a back – and - forth motion and
are carried well underneath the
thigh.
17. A third cotton ball in SSS is used to
wash the inner aspect of the nearer
thigh using similar stroke.
18. A fourth cotton ball in SSS is used to
wash the farther labia majora in a
downward stroke towards the groin.
19. Do the same on the other labia.
20. A sixth cotton ball in SSS is used to
wash, with one downward stroke,
from the clitoris, meatus, vaginal
opening to perineum.
108
21. The above step is repeated with a 7th
cotton ball in SSS, and to include the
anus.
22. Rinse with sterile water and pat dry
using toilet paper from front to back.
23. Remove the client from the bedpan. Moisture supports the growth of
Loosen the drape from the legs. Turn microorganisms and contributes to
to side and dry the buttocks. discomfort.
24. Apply lotion on the buttocks as An emollient helps to soothe excoriated

needed (optional). tissue.
25. Put on diaper or sanitary pad and or
underwear. Remove the waterproof
pad and replace the bath blanket
with topsheet. Make the patient
comfortable.
24. Bring equipment back to the utility Controlling the spread of pathogens is a
room and do the after care. primary principle of asepsis.
25. Remove gloves and wash your Handwashing deters the spread of
hands. microorganisms.
26. Document the performance of the Written information documents the
procedure, the objective and individualized care of the patient.
subjective findings and the patient’s
response.
1
2 3
4 5
Legend:
1. mons 4. far labia
2. far leg 5. near labia
3. near leg 6. meatus to anus
Figure 2. Strokes Used in External Douche
109
SAMPLE DOCUMENTATION
4 – 28 – 2017 8:00 AM Perineal care provided. Moderate amount

of lochia rubra noted on perineal pad.
Episiotomy wound and perineum swollen. Bean-
sized external hemorrhoids noted. Verbalized
feeling of comfort after the procedure.
110
SAN PEDRO COLLEGE
Davao City
EXTERNAL DOUCHE
Name: __________________________________ Grade: ________________________

Year and Sec.: _________________ Date : ________________________
Rating
5 4 3 2 1
1. Washes hands thoroughly.
2. Prepares equipment and adjusts bed to a comfortable
working height.
3. Brings preparation to the bedside. Identifies patient and
explains procedure.
4. Provides privacy to the patient. Positions the patient
supine.
5. Changes topsheet with bath blanket.
6. Places bed protector.
7. Drapes patient with bath blanket and exposes the
perineal area.
8. Places patient on bedpan in a dorsal recumbent position.
9. Tests temperature of the water (410C or 1050F).
10. Flushes the area with warm water.
11. Applies soap using CB soaked with soap sud solution
using zigzag motion starting from the mons pubis. Uses
one cotton ball on each stroke.
12. Applies another cotton ball on the far groin going up
using zigzag stroke. Uses the same stroke on the near
groin.
13. Separates labia and applies another CB on each labia
using gentle downward stroke.
14. Applies the 6th CB soaked in soap sud solution using
downward stroke from the clitoris, meatus, vaginal
opening and perineum. The stroke is repeated with the
last CB, including the anus.
15. Rinses the area well.
16. Dries area from top down using toilet paper.
17. Removes bedpan and turns client to side immediately.
Dries the buttocks with toilet paper.
18. Applies lotion as needed.
19. Removes bed protector by rolling it to the center.
20. Replaces blanket with topsheet and makes client
comfortable.
111
21. Examines the content of the bedpan and throws it into
the toilet bowl.
22. Brings equipment back to the utility room and does the
after care.
24. Documents the procedure and other pertinent
observation.
of the procedures.
Remarks:

II Performance 70%
100%
________________________________ __________________________
________________________________ __________________________
112
APPLICATION OF HEAT AND COLD THERAPIES
Body temperature represents the difference between the heat produced in the body and
heat lost. Heat regulation takes place in the hypothalamus. Heat is lost from the skin by
radiation, conduction, convection and evaporation.
Many factors affect body temperature, including body rhythms, menstrual cycle,
muscle action, age, deficient sweat glands, environmental conditions, medications, etc.
Because many health decisions are based on body temperature readings, accuracy in
temperature–taking is essential.
Problems of hyperthermia and hypothermia require nursing assessment, planning,

implementation, and frequent evaluation. Applications of heat and cold therapies are part of
this treatment. Whether the application is cold or warm, temperature tolerance varies with the
individual and the part of the body to which it is applied, length of time of the application,
size of area under application, and whether it is moist or dry.
Heat and cold therapies are applied frequently in both the home and the hospital. In
the hospital setting, a doctor’s order is required before heat is applied.
I - APPLICATION OF ICE CAP

Purposes:
Uses of Cold Application
1. To provide topical anesthesia (for example, by placing an ice bag on the injection
site before giving the injection).
2. To prevent edema after bruises, spasms and sprains.
3. To lessen hemorrhage.
4. To reduce inflammation.
5. To decrease metabolism.
6. To lower body temperature.
Cold applications are either local or general, moist or dry.
Special Consideration:
Cold applications cause vasoconstriction with reduced blood flow to the skin,
therefore the skin becomes pale, mottled, cool to touch and numb. Whether the application is
cold or warm, temperature tolerance varies with the individual, the part of the body to which
it is applied, the area of application, and the length of time it is applied.
Equipment:
1. ice bag and cover 3. gel preparation
2. cracked ice 4. hand towel
Procedure
Action Rationale
1. Assess the need for application
2. Identify client and explain the An explanation facilitates cooperation of the

procedure. client.
113
3. Fill the ice bag with small pieces of
ice chips to approximately 2/3 full.
4. Press the air out of the bag and Air is a poor conductor of heat which will
tighten. Then test for leaks by interfere with the removal of heat from the
inverting the ice cap. body surface. Inverting the ice bag would
determine the tightness of the cover. Leakage
can cause discomfort to the patient.
5. Cover the bag or case with towel. A cover should be used to provide for
Bring to the bedside and apply to the absorption of the moisture which condenses
area. Refill when the ice melts. on the outside of the bag.
Observe the length of application as
ordered.
6. Do after care. Proper care of equipment ensures its

durability.
7. Wash hands. Handwashing deters the spread of

microorganisms.
8. Document the site, time, duration of Charting provides accurate documentation of

application and the client’s response. the implementation of treatment and the
client’s progress.
Note:
1. To be effective, the ice bag should be applied for ½ to 1 hour with an interval of
approximately 1 hour. In this way, the tissues are able to react to the effects of cold.
2. Placing the ice directly on the skin could cause burn.
After care of ice bag:
1. Empty ice bag.

2. Soap and rinse under running water.
3. Turn upside down to dry.
4. When dry, inflate with air to prevent damage of rubber lining. Screw cover in
place.
5. Return to proper place.
114
SAN PEDRO COLLEGE
Davao City
APPLICATION OF ICE CAP
Name:_________________________________ Grade: ________________
Year and Sec.: _________________ Date : ________________
Rating
5 4 3 2 1
1. Checks the physician’s order
2. Identifies client and explains the procedure.
3. Washes hands.
4. Assembles equipment.
5. Tests bag for leaks.
6. Fills ice bag with small pieces of ice about 2/3 full.
7. Expels air correctly.
8. Covers the bag.
9. Applies bag to the area.
10. Does after care.
11. Records procedure and client’s reaction.
performance of the procedure.
Remarks:

II Performance 70%
100%
________________________________ __________________________
________________________________ __________________________
115
TECHNIQUE FOR THE APPLICATION OF HOT WATER BAG
Purposes:
1. To relieve pain.
2. To reduce swelling, congestion and inflammation.
3. To relieve muscle spasm.
4. To provide comfort.
5. To decrease the blood supply in other areas of the body.
6. To raise the body temperature.
7. To increase the blood supply to the injured part thus promotes healing.
8. To stimulate metabolism.
Special Considerations
Prolonged exposure to heat can damage tissues from thermal burns. Special care is
required when heat is applied to the very young and very old who cannot tolerate heat well.
Special care is also given to persons who have circulatory disorders, debilitated, unconscious
and with impaired sensation, decreased or absent response to pain which may lead to the risk
of burns. Direct heat treatment is contraindicated if the patient has an open wound and a
sprained limb as vasodilation would increase pain and swelling.
Hot applications must be ORDERED by the PHYSICIAN.
Equipment:
1. Hot water bag and cover

2. Bath thermometer
3. A pitcher of hot water
4. A pitcher of cold water
5. Empty pitcher
6. Hand towel
Desired Temperature
Infants under 2 years - 105 – 1150F (40.50 - 460 C)

Children over 2 years and adult - 1150 – 1250F (460 - 510 C)
Procedure
Action Rationale
1. Check that there is a physician’s Reading the order clarifies the procedure.
order for heat application and obtain
the treatment (blue) ticket.
2. Identify client and assess for any Circulatory impairment may interfere with the
circulatory impairment to the area client’s ability to perceive heat and place him
where the compress is to be applied at risk for injury from the application of heat.
(numbness, tingling, impairment in
temperature, sensation or cyanosis).
3. Explain the procedure to the client. An explanation encourages the client’s

cooperation and reduces apprehension.
4. Gather the equipment. Organization promotes efficient time
management.
116
5. Pour an adequate amount of tap To determine the right temperature.
water into an empty pitcher and add
hot water to meet the desired water
temperature .
6. Test the temperature of water using
the bath thermometer. Right temperature of water prevents burning.
7. Pour the water from the pitcher into

the bag until it is about ½ - 2/3 full. More than this amount of water will make the
bag heavy.
8. Expel the air from the bag by resting
the bag on the table. Holding the The bag can easily be molded to the body
neck of the bag upright, flatten bag parts when applied. Absence of air makes it
against the table until the water less flat and less bulky.
reaches the neck portion. Or expel Expelling air would make the bag more
air by holding the bag up and flexible.
pressing the unfilled portion until
the water fills the neck of the bag.
9. Screw the stopper or fasten the top

tightly. To prevent leakage or accidental spill of hot
water which can result to burns.
10. Turn upside down and examine for
leakage. To ensure safe application.
11. Dry the bag using the hand towel.
12. Place the cloth cover of the bag and
fasten securely.
13. Place the prepared hot water bag
over one’s arm with the opening Provides opportunity to test the temperature
away from you. Bring to the of the hot water bag and protects the nurse
bedside. from burns.
14. Apply it on the affected area with
the neck of the bag away from the Prevents the risk of burn.
client’s body.
15. Stay with the client for the first 15
minutes to monitor the client’s Impaired circulation may affect the sensitivity
response to heat application. to heat and to ensure client’s safety.
16. Remove the hot water bag. Carefully

evaluate the skin’s condition and Maximum therapeutic effects of heat occur
effectiveness of the heat application. within 20–30 minutes. Extended use of heat
(beyond 45 minutes) results in tissue
congestion and vasoconstriction. This
rebound phenomenon results in increased risk
of burns from the application of heat.
17. Do the after care of equipment.
Wash your hands. These techniques support the principle of
asepsis.
18. Record the treatment and the client’s
response. Written records provide documentation of the
procedure.
117
SAN PEDRO COLLEGE
Davao City
APPLICATION OF HOT WATER BAG
Name: _________________________________ Grade: __________________

Year and Sec.: _________________ Date : __________________
Rating
5 4 3 2 1
1. Confirms the written physician’s order.
3. Assesses the area for any circulatory impairment
4. Washes hands.
5. Assembles the equipment.
6. Tests the temperature of the water.
7. Pours water from the pitcher into the bag until it is about
one – half full.
8. Expels the air correctly.
9. Screws in the stopper securely.
10. Wipes the bag.
11. Examines very well for leaks.
12. Covers bag with cloth.
13. Applies to affected area with the neck away from the
client’s body.
14. Assesses the response of the client to the heat.
15. Removes the hot water bag after 30 minutes or
according to the time prescribed by the physician.
16. Replaces wet linen.
17. Assists the client to a safe and comfortable position.
18. Does the after care of equipment appropriately.
19. Washes hands.
20. Charts the procedure and other significant observations.
Remarks:
118
II Performance 70%
100%
________________________________ __________________________
________________________________ __________________________
119
GIVING A SITZ BATH
Definition: Sitz bath is a local hot water bath which consists of the immersion of the
pelvic region of the client who is in a sitting position.
Giving a Sitz Bath:
To give a Sitz bath, a client is placed in a shallow tub or basin containing enough
warm water so that only the pelvic area is submerged.
The nurse should implement the plans for the care of assigned clients so as to allow
approximately 15 to 30 minutes for the sitz bath. Although intended to cause vasodilation,
prolonged heat may cause the reverse effect if the warm temperature is sustained. By
coordinating the preparation of the equipment with the client’s readiness, the maximum
effects of the procedure are likely to be achieved.
Purposes:
1. To increase local circulation.

2. To reduce swelling.
3. To promote healing.
4. To help relax local muscles.
5. To relieve pain.
Assessment:
1. Ensure that there is a physician’s written order.
2. Consult the agency’s policy for the amount of time and temperature recommended
for Sitz bath (if not ordered).
3. Read the client’s record to determine the reason for the Sitz bath, such as
promoting healing of perineal incision.
4. Assess the client’s mental status and any evidence of sensory or cardiovascular
disease.
5. Inspect the perineal area for color, swelling, discharge, integrity, evidence of
external hemorrhoids, drains, packing or dressing material.
6. Observe the client’s ability to sit directly on the buttocks; note signs of discomfort.
7. Take the client’s vital signs and compare them with the recommended range for
the client’s age; determine the pattern of the vital sign recordings.
8. Ask the client to describe the sensations he experiences in the perineum and
rectum especially with sitting, walking and when eliminating urine or stool.
Equipment:
1. Sitz bath chair
2. Bath thermometer
3. Bath towels and clean gown
4. Bath blanket
5. Sterile dressings and T – binder (optional)
6. Pitcher of hot water
7. Pail ¾ filled with tap water
8. 2 Safety pins (large)
120
Procedure
Action Rationale
1. Check the physician’s order. It is a way of insuring that the procedure is
implemented according to the physician’s
directions.
2. Identify the client and explain An explanation relieves apprehension and
the procedure. promotes of cooperation.
3. Assess the client’s condition. Serves as a baseline data.

Take patient’s vital signs.
4. Wash your hands and assemble Handwashing reduce the transient
equipment. microorganism thus, deters the spread to
client and self.
5. Pour some amount of hot water Using the thermometer is the most reliable
into the pail and test the method for determining the actual
temperature of the water with a temperature.
bath thermometer and maintain
at 43-46 ‘C or 110-115 ‘F.
6. Fill the Sitz basin 1/3 to ½ full. When the client’s hips are submerged, the
water will be displaced and the level of the
water will increase.
7. Close the door and window in To provide privacy.
the private room or by drawing
the curtains in the ward.
8. Have the patient void. Prevents interruption of the procedure as

warm water stimulates voiding.
9. Remove clothing from below the Leaving the upper part of the body covered
waist. Wrap the towel around the maintains modesty and warmth. Towel
waist with opening at the back prevents undue exposure of the lower part of
portion. the body.
10. Assist the client to sit in the Direct pressure may heighten discomfort.
basin without pressure on the Changes in the distribution of blood and
perineum and with the feet flat external heat can increase the potential for
on the floor. Provide a foot stool adverse effects.
if necessary A footstool can prevent pressure at the back
of the thigh.
11. Cover the client’s back, This maintains body warmth and prevents
shoulders, and lower legs with a chilling.
cotton bath blanket.
12. Stay with client and observe The nurse should not leave the client alone
closely for signs of weakness, unless absolutely certain that it safe to do so.
vertigo, pallor, tachycardia and
nausea. If noted, stop the
procedure and assist the client to
sit. Take the vital signs and
inform CI/NOD.
121
13. Help the client out of the chair Being clean and dry promotes a refreshed
upon completion of the feeling.
procedure and assist to dry and
change with clean clothes/gown.
14. Help the client return to bed. The client may feel dizzy with changes in
Recheck the pulse and instruct to posture and the redistribution of blood
stay in bed for 30 minutes. volume to the pelvic region.
15. Notify the doctor for presence of Removal of rectal / vaginal plugs might
vaginal/rectal plugs. (Do not induce bleeding.
attempt to remove.)
16. Empty the Sitz basin, clean and Water left on the floor can lead to accidental
dry before returning to the utility falls and injury.
room. Wipe away water that may
have dripped on the floor.
17. Wash your hands. Washing reduce the transient microorganism

thus, deters the spread to client and self.
18. Document pertinent Accurate written report provides a permanent

observations. record of the individuals care.
Sample Documentation
DATE TIME NURSES NOTES
4 / 25 /2017 10 AM Minimal amount of bloody drainage noted

on peri-pad from the area of
hemorrhoidectomy. Verbalized that the
area is tender and that sitting is difficult.
Has not felt the urge to defecate since
surgery (4-23-17).
10:15 AM Hot sitz bath provided at 43-46’C for 20
minutes as ordered. Verbalized “Maghulat
gyud ko ani kay maayo akong pamati
pagkahuman.”
10:30 Rectal plug removed by Dr. Arce. Dry and
sterile dressing applied.
Angel Locsin, St.N.
122
SAN PEDRO COLLEGE
Davao City
HOT SITZ BATH
Name: __________________________________ Grade:_____________________
Year and Sec.: _________________ Date : _____________________
Rating
5 4 3 2 1
1. Checks the physician’s order.
2. Identifies client and explains procedure.
3. Checks client’s vital signs and general condition.
4. Washes hands.
5. Assembles equipment.
6. Tests the temperature of the water with a bath
thermometer (43-460C or 110-1150F).
7. Fills the Sitz basin 1/3 to ½ full.
9. Asks client to void.
10. Removes client’s clothing and wraps towel around the
waist with the opening at the back .
11. Assists the client into the sitz basin.
12. Covers the client’s back, shoulders and lower legs with a
blanket.
13. Observes the response of the client frequently.
14. Helps the client out of the sitz bath chair and assists to
dry and put on clean bed clothes/ gown.
15. Assists client to return to bed.
16. Rechecks the client’s VS and instructs to stay in bed for
30 minutes.
17. Empties the Sitz basin, cleans and dries it before
returning to the utility room.
18. Washes hands.
19. Documents pertinent observations.
Remarks:

II Performance 70%
100%
________________________________ __________________________
________________________________ __________________________
123
TEPID SPONGE BATH
Definition: A bath using tepid water and wash cloth or sponge to reduce fever.
Purpose/s:
Equipment:
Basin
Pitcher filled with hot water.
Pitcher with cold water.
Waterproof underpad or rubbersheet
Bath blanket
Wash clothes (about 6 pieces)
Bath towel
Thermometer in a thermometer tray
Working gloves
Bath thermometer
Procedure
Action Rationale
1. Identify the client and take vital Provides the baseline data to be used when
signs. Assess patient’s condition. evaluating the client’s response to the
treatment.
2. Explain the procedure to client or Informing the client elicits cooperation.
watcher.
3. Wash hands and assemble all Removes transient microorganism and

equipment and bring to bedside. reduces the risk of cross-contamination to
client and self.
4. Close doors and windows in To provide privacy, and protect from draft.
private rooms or draw curtains in
the ward. Put off air conditioner
or electric fan.
5. Adjust the bed to the working Protects your back from strain.
height.
6. Don gloves. Lay the waterproof Prevents the linens from getting wet.
underpad.
7. Change the topsheet with a bath Avoids exposure to draft.
blanket. Remove client’s gown.
Starting from the farther arm.
NOTE: If with IVF, refer to
cleansing bed bath for the
removal of gown.
8. Pour/ mix water in a basin with This is the normal range of water temperature
the temperature of 27-370C (80- in a tepid bath.
980F). Immerse 6 washcloths
into the basin. Pour cold water
and mix with hot water until the
temperature reaches 27-37 oC
(80-90OF).
124
9. Wring, roll and apply washcloth These areas contain large superficial blood
to the forehead. vessels that help the transfer of heat.
Note: Check regularly the
temperature of the washcloths.
10. Gently pat the 6 wash cloths on Promotes a decrease in temperature within a
the client’s face, neck safe time frame and avoid the chance of
extremities, back and buttocks. chilling.
The whole procedure should last A bath given less than 30 minutes tend to
for 30 minutes. increase body heat production by causing
shivering.
Abdomen and chest are not Blood vessels are located deeper and TSB is
usually sponged. not very effective to reduce temperature.
11. After sponging each body part, The friction caused by rubbing may raise the
pat dry with bath towel and body temperature and covering prevents
cover it with the bath blanket. exposure to draft.
12. Monitor the client’s reaction to When client’s temperature is slightly above
treatment, and recheck TPR after normal, procedure can be discontinued to
15 minutes and after completing prevent rebound effect.
the bath. Temperature will go down naturally.
Discontinue procedure if 1-20F
above desired level is obtained.
13. Remove washcloths from Light clothing maintains the body
forehead, axillae, groins and pat temperature. Excessive clothing and covering
dry these areas. Change the can result to a temperature elevation.
client’s gown and replace the
bath blanket with the topsheet.
14. Lower the bed to its previous Promotes client’s safety and convenience.
height.
15. Do the aftercare of equipment
used.
16. Document the treatment Provides information to the health care team
performed, client’s vital signs, regarding the client’s response to the
response and any complications. treatment; a legal record of the care giver.
DOCUMENTATION:
DATE TIME NURSES NOTES

5- 22 -17 8 AM Vital signs checked.
Temperature 39‘C. Tepid
sponge bath done
continuously for 20
minutes.
8:15 AM Temperature rechecked
38’C. Encouraged to
increase oral fluid intake.
8:30 AM Temperature decreased to
37.5‘C . Kept comfortable
in bed
Sandra Park, St.N.
125
BASIC GUIDELINES FOR MAINTAINING SURGICAL ASEPSIS
All practitioners involved in the intraoperative phase have a responsibility to provide

and maintain a safe environment. Adherence to aseptic practice is part of this responsibility.
The 8 basic principles of aseptic technique are as follows:
1. All materials in contact with the surgical wound and used within the sterile field must
be sterile. Sterile surfaces or articles may touch other sterile surfaces or articles and
remain sterile; contact with unsterile objects at any point renders a sterile area
contaminated.
2. Gowns of the surgical team are considered sterile from the front the chest to the level
of the sterile field. The sleeves are also considered sterile from 2 inches above the
elbow to the stockinette cuff.
3. Sterile drapes are used to create a sterile field. Only the top surface of a draped table is
considered sterile. During draping of a table or patient, the sterile drape is held well
above the surface to be covered and is positioned from front to back.
4. Items should be dispensed to a sterile field by methods that preserve the sterility of the
items and the integrity of the sterile field. After a sterile package is opened, the edges
are considered unsterile. The sterile supplies, including solutions, are delivered to a
sterile field or handed to a scrubbed person in such a way that the sterility of the
object or fluid remains intact.
5. The movements of the surgical team are from sterile to sterile areas and from unsterile
to unsterile areas. Scrubbed persons and sterile items contact only sterile areas;
circulating nurses and unsterile items contact only unsterile areas.
6. Movement around a sterile field must not cause contamination of the field. Sterile
areas must be kept in view during movement around the area. At least a 1-foot
distance from the sterile field must be maintained to prevent inadvertent
contamination.
7. Whenever a sterile barrier is breached, the area must be considered contaminated. A

tear or puncture of the drape permitting access to an unsterile surface underneath
renders the area unsterile. Such a drape must be replaced.
8. Every sterile field should be constantly monitored and maintained. Items of doubtful
sterility are considered unsterile. Sterile fields should be prepared as close as possible
to the time of use.
126
SURGICAL HAND SCRUB
Definition: It is a vigorous and lengthy cleaning of the skin of the hands and forearms with
water, antiseptic agent and scrub / sponge to create friction. It is called counted
– stroke scrub.
Equipment:
1. surgical cap
2. surgical mask
3. antimicrobial soap
4. plain scrub brush
5. sink with foot, knee or elbow control and high faucet
6. sterile towels (optional)
Purposes:
1. To remove dirt and skin oil from the hands and lower arms.
2. To reduce the count of microorganisms count to as near zero as possible.
Elements:
1. water 3. scrub or sponge
2. antiseptic agent 4. friction
Anatomical Timed Scrub Method
Area Time
1. Nails - 30 sec. ĉ brush

2. Fingers - 1 min. ĉ sponge
3. Palmar surface 15 sec. ĉ brush
4. Dorsal surface - 15 sec. ĉ sponge
5. Forearm , divided in half to 2 - 1 min. ĉ sponge
inches above elbow. - (30 sec. each half.)
6. Repeat process for each other hand
Counted Brush Stroke Method
Area Time
1. Nails - 20 strokes ĉ brush

2. Fingers , each side & web space. - 10 strokes ĉ sponge
3. Palmar surface. - 10 strokes ĉ brush
4. Dorsal surface - 10 strokes ĉ sponge
5. Forearm , divided in half to 2” above - 40 strokes each half ĉ sponge
elbow.
6. Repeat process for other hand.
Procedure
Action Rationale
1. Check for completeness of supply. Prevents having to stop to obtain those

materials needed.
127
2. Remove all pieces of jewelry, Jewelry harbors microorganism.
including the wedding ring.
3. Trim nails if needed. No nail polish Microorganisms collect in chipped nail polish
or artificial nails should be worn. and under artificial or long fingernails.
4. Wear a surgical cap and a disposable Provides a barrier to reduce the spread of
mask. microorganisms from the hair or respiratory
tract.
5. Stand before the sink keeping the The sink is considered to be contaminated.
body away from it.
6. Turn on the faucet and adjust the Frees hands from touching anything this time.
pressure using the foot, knee or The water should remain running.
elbow control.
Water splashed from the contaminated sink
may come in contact with your uniform, thus,
contaminating it.
7. Holding your hands above your Since the hands will be the cleanest area once
elbow, wet the skin from the the scrub is completed it follows the principle
fingertips down to the elbow. of allowing water to flow from the cleanest to
the most contaminated area.
8. Wet and apply approximately 1 tsp Soap emulsifies skin oils and contaminants
of antimicrobial soap on the palm and facilitates their removal.
using foot, knee or elbow control
and work up a lather.
9. When using a pre-packaged scrub Once the scrub has begun, the brush is never
brush-sponge pad, open the package, put down until the scrub is complete as it
remove the nail cleaner and clean would then be contaminated.
the nails and discard.
Remove the brush and discard the
wrapper. Do not put down the brush
once the scrub has begun.
If the brush or sponge is not
impregnated with the cleaning
agent, moisten the brush or sponge
and dispense the soap into it.
10. Using the brush, make 20 circular The scrubbing action loosens resident bacteria
strokes on the nails (starting with the and contaminants, thus facilitating their
less dominant hand). removal.
Circular motion mechanically removes
microorganisms.
11. Scrub all skin surfaces using circular The scrubbing action loosens resident bacteria
strokes: and contaminants, thus facilitating their
a. each finger removal.
b. palm Circular motion mechanically removes
c. back of the hand microorganisms.
d. forearms (divide into 2 then 10
128
strokes on each of the 4 parts of the first
half of the forearm then another 10
strokes on each 4 parts of the second
half of the forearm paying extra
attention on the elbow)
12. After scrubbing the less dominant The brush contains lather that may contain
hand, rinse the brush and transfer it microorganisms. Rinsing will remove the
to the other hand. lather from the brush.
13. Continue the procedure on the

dominant hand following steps 8 to
10.
14. When the scrub is finished on the

dominant hand, drop the brush on
the sink.
15. With the use of foot, knee or elbow To avoid contamination of your hands.
control, turn on the faucet and rinse
the arms starting from the fingertips Water should flow from the area of least
to the elbow. contamination to the area of most
contamination.
16. Turn off the water using the foot, To avoid contamination of your hands.
knee or elbow control.
17. Dry each hand and arm with Drying prevents irritation of the skin. Dry
opposite ends of the sterile towel, from the cleanest area to the more
working from the fingertips towards contaminated area.
the elbow.
18. Discard towel properly.
19. Position the hands and elbow above After surgical hand scrubbing, the hands are
the waist without touching any part considered to be surgically clean. Keeping it
of the scrub uniform. in your line of vision will prevent
contamination.
20. Enter the operating room using the Using this manner when entering the
back or the buttocks. Operating room will prevent contamination of
the scrubbed hands.
129
SAN PEDRO COLLEGE
Davao City
SURGICAL HANDSCRUBBING
Name: _______________________________________ Grade: ___________

Year and Section: ______________________________ Date: ____________
Legend: 5 – Excellent 4 - Very Good 3 - Good 2 – Fair 1 – Poor

Rating 5 4 3 2 1
2. Removes all pieces of jewelry, including the wedding
ring.
3. Trims nails if needed. Removes nail polish or artificial
nails.
4. Wears surgical cap and disposable mask.
5. Stands before the sink keeping the body away from it.
6. Turns on the faucet and adjusts the pressure using the foot,
knee or elbow control.
7. Holds hands above elbow, wets the skin from the
fingertips down to the elbow.
8. Wets and applies approximately 1 tsp of antimicrobial
soap on the palm using foot, knee or elbow control and
works up a lather.
9. Using a pre-packaged scrub brush-sponge pad, opens the
package, removes the nail cleaner and cleans the nails and
discard.
10. Removes the brush and discards the wrapper without
putting down the brush.
11. Moistens the brush or sponge and dispense the soap into
it.
12. Using the brush, makes 20 circular strokes on the nails
(starting with the less dominant hand).
13. Scrubs all skin surfaces using circular strokes:
a. each finger
b. palm
c. back of the hand
d. forearms (divide into 2 then 10 strokes on each

of the 4 parts of the first half of the forearm then
another 10 strokes on each 4 parts of the second
half of the forearm paying extra attention on the
elbow)
14. After scrubbing the less dominant hand, rinses the brush
and transfers it to the other hand.
15. Continues the procedure on the dominant hand following
steps 11 to 13.
130
16. When the scrub is finished on the dominant hand, drops
the brush on the sink.
17. With the use of foot, knee or elbow control, turns on the
faucet and rinses the arms starting from the fingertips to
the elbow.
18. Turns off the water using the foot, knee or elbow control.
19. Positions the hands and elbow above the waist without
touching any part of the scrub uniform.
20. Enters the operating room using the back or the buttocks.
21. Maintains body mechanics throughout the performance of
the procedure.

Comments:
_________________________________ _________________
Student’ Signature Over Printed Name Date
_________________________________ __________________
131
FEMALE CATHETERIZATION
Definition:
It is the introduction of a catheter through the urethra into the bladder for instilling or
removing fluids.
Purposes:
1. To control urinary incontinence.
2. To relieve urinary retention.
3. To obtain a sterile urine specimen.
4. To measure the residual urine remaining in the bladder after voiding.
5. To maintain an empty bladder during surgery.
6. To provide access for instilling medication into the bladder.
7. To monitor hourly urine production in seriously ill patient.
General Instructions:
1. Keep the drainage bag below the level of the condom to prevent urinary reflux
which may cause urinary tract infection.
2. Avoid loops and kinks in the tubing to allow continuous drainage of the urine.
3. Never attempt to remove catheter without physician’s order. Inform NOD for any
discomfort or inconvenience felt by the patient.
4. Never allow the urine bag to touch the floor as this may cause ascending infection.
5. Change the condom catheter daily and provide skin care to prevent undue
complication.
Equipment:
1. External douche tray
2. Bedpan with cover
3. Waterproof underpad
4. Bath blanket
a. Pick–up forceps in disinfectant solution
b. Working forceps in a sterile pack
c. Lubricant – Ky Jelly
d. Gloves of your size
e. Betadine solution
f. Sterile dry CB – one pack
g. Catheter – Fr. 12 – 14 for adults; Fr. 8 – 10 for children
h. Sterile catheterization pack containing:
a. drape – fenestrated drape or eye sheet
b. OS
c. Kidney basin
d. Specimen bottle -
i. Equipment for indwelling Catheter
a. foley catheter
b. sterile 5cc syringe (to be filled with 5cc triple distilled water)
c. vial of triple distilled water, sterile
d. plaster
e. urine bag
6. Gooseneck lamp (optional)
132
Procedure
Action Rationale
1. Check for doctor’s order. Verifying the medical order ensures that the
correct intervention is administered to the
right patient.
2. Assess whether patient is allergic to There is possibility of exposure to allergens in

iodine or plaster. antiseptic, tape, latex and lubricant. Allergy to
povidone is common.
3. Perform hand hygiene. Assemble Hand hygiene deters the spread of
equipment. microorganisms. Organization promotes
efficient time management.
4. Identify and explain the procedure to Ensures it is the right patient. An explanation
the patient. reduces apprehension and encourages
cooperation.
5. Provide a good light. Good lighting is necessary to see the meatus
clearly (may be different in multiparous
women).
6. Provide for privacy by screening and
closing the door/ windows. Privacy reduces embarrassment and aids in
relaxation during the procedure.
7. Raise bed to appropriate working Having the bed at the proper height prevents
height. Stand on the patient’s right back and muscle strain. Positioning allows for
side if you are right-handed, on the ease of use of dominant hand for catheter
patient’s left side if you are left- insertion.
handed.
8. Replace top sheet with bath blanket.
Place waterproof underpad under the Prevents soiling of bed linen.
patient.
9. Place patient on a dorsal recumbent
position (supine with knees flexed Good visualization of the meatus is important.
and feet apart) and drape him/her. Avoids unnecessary exposure of body parts
and maintains patient’s comfort.
10. Do perineal flushing. Cleansing the area with soap decreases the
possibility of introducing organisms into the
bladder.
11. Prepare the urine receptacle and The tubing facilitates connecting the catheter
tubing if an indwelling catheter is to to the drainage system.
be inserted.
12. Open the sterile pack and bring it Placement of the equipment near the work site
near the perineal area. Observe increases efficiency. Sterile technique protects
aseptic technique. Squeeze a small the patient and prevents the spread of
amount of lubricant over the sterile microorganisms.
OS placed in the sterile field.
13. Get 2 CBs with betadine from the jar Organization promotes efficient time
and place on the sterile field on top management.
of the several OS. Uncover the
specimen bottles.
14. Put on sterile gloves. Grasp the A drape provides a sterile field where the
133
upper corners of the fenestrated or equipment and hands will be placed.
eye drape and unfold it. Apply drape
over perineum, exposing labia. Be
sure not to touch contaminated
surface,
15. Lubricate 1 – 2 inches of the catheter Lubrication facilitates the insertion of the
tip. Avoid clogging the lumen. catheter and reduces urethral trauma and
discomfort when inserting it.
16. With the thumb and forefinger of Separating the labia helps expose the meatus
your non – dominant hand, spread so its location is visible.
the labia and identify the urinary
meatus. Maintain the hold until the
catheter has been inserted.
17. Use your dominant hand or pick up Moving from an area where there is likely to
forceps to pick up a cotton ball with be less contamination to an area where there
betadine. Clean one labial fold, top is more contamination helps prevent the
to bottom then discard the cotton spread of microorganisms. Cleaning the
ball. Using a new cotton ball for meatus last helps reduce the possibility of
each stroke, continue to clean the introducing microorganisms into the bladder.
other labial fold then directly over
the meatus.
18. Pick up catheter with gloved Prevents soiling of patient and bed with
dominant hand 3-4 inches from draining urine.
catheter tip. Hold end of catheter
loosely coiled in palm of dominant
hand. Place distal end of catheter in
urine receptacle if straight
catheterization is ordered.
The female urethra is about 3.5 cm to 6.2 cm (
19. Insert the tip of the catheter into the 1 ½ - 2 ½ inches) long. Applying force on the
dimple-like structures below the catheter is likely to injure mucous
clitoris which is the meatus about 2 – membranes. The sphincter relaxes and the
3 inches or until urine flows. Do not catheter can enter the bladder easily when the
force the catheter through the patient relaxes. Advancing an indwelling
urethra. Ask the patient to breathe catheter an additional ½ inch to 1 inch ensures
deeply and rotate the catheter gently placement within the bladder and facilitates
if slight resistance is met. inflation of the balloon (if Foley catheter)
without damaging the urethra.
20. Hold the catheter securely with your Movement, however slight, increases the risk
non-dominant hand while the of introducing organisms within the urethra.
bladder empties. Collect a specimen, In general, no more than 750ml -1,000 ml. of
about 20-30 ml if required. Continue urine should be removed at one time. Pelvic
drainage according to hospital floor blood vessels may become engorged
policy. from the sudden release of pressure leading to
a possible hypotensive episode.
21. Remove the catheter smoothly and The catheter is only needed to drain urine
slowly (if straight catheter is used). present in the bladder and is not intended for
continuous use.
134
22. If a Foley catheter is used, introduce Creates a balloon to ensure catheter retention.
5 cc (or follow manufacturer’s Maximizes continuous bladder drainage
instruction) of distilled water/ air to Proper attachment prevents trauma to the
secure the catheter. Gently pull the urethra and meatus from tension on the
catheter until the retention balloon is tubing. Ensures that catheter tip is anchored.
snuggled against the bladder neck.
(Resistance will be met). Remove
the fenestrated drape.
23. Attach catheter to urine bag below Ensures proper drainage by gravity. Prevents
the level of the bladder. Tape urinary reflux which may cause UTI.
catheter to the inner thigh.
24. Remove and clean the equipment Urine kept at room temperature may cause
and make patient comfortable. Label organisms, if present, to grow and distort
the urine specimen and send to the laboratory findings.
laboratory promptly.
25. Remove gloves and wash your Handwashing deters the spread of
hands. microorganisms.
26. Record the time of the A careful record is important for documenting
catheterization, the amount of the data after the patient’s care.
urine removed, a description of the
urine and the patient’s reaction to the
procedure.
135
SAN PEDRO COLLEGE
Davao City
FEMALE CATHETERIZATION
Name: _________________________________ Grade:____________________

Year and Sec.: _________________ Date :___________________
Legend: 5 – Excellent; 4 – Very good; 3 – Good; 2 – Fair; 1– Poor
Rating
5 4 3 2 1
2. Assesses whether patient is allergic to iodine or plaster.
3. Washes hands. Assembles equipment.
4. Identifies and explains the procedure to the patient.
5. Provides good light.
6. Provides privacy
7. Replaces top sheet with a bath blanket. Places waterproof

underpad.
8. Positions the client on a dorsal recumbent with knees flexed
and feet apart and drapes the client.
9. Does perineal flushing.
10. Prepares the urine receptacle and tubing if an indwelling
catheter is to be inserted.
11. With aseptic technique, opens the pack between the clients
thigh and brings it near the perineal area.
12. Squeezes a small amount of lubricant over the sterile OS .
13. Gets 2 CBs with betadine from the jar and places it on the
sterile field.
14. Puts on sterile gloves. Places fenestrated drape over the
vulvar area exposing the labia.
15. Lubricates 1-2 inches of the catheter tip.
16. With the thumb and forefinger of your non-dominant hand
spread the labia. With the dominant hand, disinfects the
meatus twice using CB with betadine.
17. Maintains hold until after catheter has been inserted.
18. Inserts the tip of the catheter into the dimple- like structure
just below the clitoris about 2-3 inches or until urine flows.
Asks the patient to breathe deeply as catheter is inserted.
19. Holds the catheter securely with the non-dominant hand
while bladder is emptied. Collects a specimen if required.
20. Removes the catheter smoothly and slowly (if straight
catheter is used)
21. If a Foley Catheter is used, introduces 5 cc of sterile
distilled H2O to secure the catheter; gently pulls the catheter
until retention balloon is snuggled against the neck of the
bladder. Tapes the catheter to the inner thigh.
22. Attaches catheter to the urinary drainage bag below the level
of the bladder.
136
23. Removes and cleans the equipment. Makes the patient
comfortable. Labels the urine specimen and sends to the
laboratory promptly.
25. Records the time of the catheterization, the amount of the
urine removed, a description of the urine and the patients
reaction to the procedure.
Remarks:

II Performance 70%
100%
________________________________ __________________________
________________________________ __________________________
137
MALE CATHETERIZATION
Equipment:
1. Foley cath of the appropriate size.
2. Bath blanket.
3. Waterproof underpad.
4. Plaster.
5. Gooseneck lamp ( optional)
1. Lubricant 6. A jar with CB in sterile H2O

2. Sterile forceps in a pack 7. Packed sterile dry CB
3. Working and sterile gloves of your size 8. Catheterization Pack
4. Beta dine solution 9. Sterile 5cc syringe filled ĉ sterile H2O
5. Jar with CB in SSS 10. Vial of sterile distilled H2O
Procedure:
Action Rationale
1. Follow steps 1-7 (female cath)
8. Raise the siderails at the opposite side of Ensures patient’s safety and provide
the bed. Assist the patient to move away adequate space for opening of the sterile
from you. pack.
9. With the patient supine and knees slightly Draping keeps the patient warm and
apart, drape by fanfolding the bedcovers reduces embarrassment.
down to the midthigh exposing the
perineal area. Use a bath blanket to cover
the trunk. Place the waterproof underpad
under the buttocks.
10. Place sterile pack on the bed at the level Placement of the equipment near the
of the hips. Open the pack observing the work site increase efficiency. Sterile
proper sterile technique. Bring the sterile technique protects the patient.
kidney basin near the working area
11. Don working gloves. Do perineal care; Cleansing the area with soap decreases
remove and discard gloves properly. the possibility of introducing organisms
Perform hand hygiene again. into the bladder. Hand hygiene deters
the spread of microorganisms.
12. Open the sterile catheterization pack and Placement of equipment near the
place it on the bed at the level of the hips worksite increases efficiency. Sterile
using sterile technique. Bring the sterile technique protects the patient and
kidney basin near the working area prevents the spread of microorganisms.
13. Squeeze a small amount of lubricant over Organization promotes efficient time
the sterile OS placed in the sterile field. management.
Get 2 CBs with betadine from the jar and
place on the sterile field on top of the
several OS. Open the covers of the
specimen bottles.
138
14. Don sterile gloves. To protect nurse from infection.
15. Place the opening of the fenestrated drape Maintain sterility of work surface.
over the penis and onto the perineum
without touching the upper top surface.
16. Lubricate around 3 -4 inches of the

catheter. Avoid clogging the lumen.
17. With the non- dominant hand, lift penis Prevents undue trauma when inserting
to position perpendicular to patient’s the catheter into the urethra.
body and cleanse in a circular motion
moving outward from the meatus down Straighten urethral canal to ease cath
to the base of glans with the use of CB insertion.
with betadine. Discard and cleanse again Disinfects the area and prevents the
with 2 more CBs in betadine if necessary. spread of microorganisms.
18. Maintaining the hold of the shaft, pick up Relaxation of external sphincter aids in
the catheter with the dominant hand. insertion of catheter.
Hold end of the catheter loosely coiled in
palm of dominant hand. Pull the penis
slightly upward and ask the patient to
beardown as if to void. Slowly insert the
catheter into the meatus about 7-9” using
a rotating motion until urine flows. If
resistance is felt, withdraw the catheter a Forcing the entry of the catheter through
little and ask the patient to take a slow urethra may cause damage to the
deep breath again while you insert the mucosa.
catheter slowly. If resistance persists and
the catheter will not advance, remove it
and notify the physician.
19. Gently push the catheter in 1-2 inches Further advancement of catheter ensures
more after urine starts to flow. Allow proper placement.
30cc or more urine to flow and collect the
specimen as ordered. Instruct patient
to breathe deeply and remove the catheter
gently (if straight catheter is used).
20. If Foley catheter is used, inject the Creates a balloon to ensure catheter
contents of the pre - filled syringe (or retention.
follow manufacturers order) to secure the
catheter. Gently pull the catheter until the Maximizes continuous bladder drainage.
retention balloon is snuggled against the
bladder neck. (Resistance will be met). Proper attachment prevents trauma to
Remove the fenestrated drape. Tape the urethra and meatus tension on the
catheter on the anterior thigh or lower tubing.
abdomen.
21. Attach the catheter to the urinary bag Proper placement of the urinary bag
below the level of the bladder. Coil facilitates drainage and prevents urinary
excess tubing on the mattress and secure reflux that may cause UTI.
it on the bed frame.
139
22. Remove and clean the equipment and Urine kept at room temperature may
make patient comfortable. Label the urine cause organisms, if present, to grow and
specimen and send to the laboratory distort laboratory findings.
promptly.
23. Remove gloves and wash your hands. Handwashing deters the spread of
microorganisms.
24. Record the time of the catheterization, A careful record is important for
the amount of the urine removed, a documenting data after the patient’s
description of the urine and the patient’s care.
reaction on the procedure.
140
SAN PEDRO COLLEGE
Davao City
MALE CATHETERIZATION
Name: __________________________________ Grade:___________________

Year and Sec.: _________________ Date : ___________________
Rating
5 4 3 2 1
1. Checks the physicians order.
3. Washes hands. Assembles equipment.
6. Positions the patient on supine with knees slightly apart.
Drapes by fanfolding the bedcover down to the midthigh
exposing the perineal area. Uses a bath blanket to cover the
trunk. Places the waterproof underpad under the buttocks.
7. Dons working gloves. Does perineal care. Removes and
discards gloves properly. Washes hands.
8. Opens the pack aseptically and places it on the bed at the
level of the hips. Brings the sterile kidney basin near the
working area.
9. Squeezes a small amount of lubricant over the sterile OS.
10. Gets 2 CBs from the pack and places them on the sterile
field. Pours betadine over them.
11. Dons sterile gloves.
12. Places the opening of the sterile drape over the penis and
onto the perineum without touching the upper top surface.
13. Lubricates around 3-4 inches of the catheter.
14. With the non- dominant hand, lifts the penis and cleanses in
a circular motion moving outward from the meatus down to
the base of glans with the use of CB with betadine. Discards
and cleanses again with 2 more CBs in betadine.
15. With the hand still holding the shaft of the penis, picks up
the catheter with the dominant hand 3-4 inches below the
tip. Pulls the penis slightly upward and asks the patient to
bear down as if to void.
16. Slowly inserts the catheter in the meatus about 7-9 inches
using a rotating motion until urine flows.
17. If resistance is felt, withdraws a little the catheter and asks
the patient to take a deep breath again if resistance persists,
removes it and notifies the physician.
18. Gently pushes the catheter in 1-2 inches more after urine
141
starts to flow. As the bladder empties collects the specimen
if required.
19. Removes the catheter smoothly and slowly if straight
catheter is used.
20. If Foley catheter is used, injects content of the pre-filled
syringe to secure the catheter. Gently pulls the catheter until
the retention balloon is snuggled against the bladder neck.
21. Removes the fenestrated drape and tapes the catheter to
lower abdomen or anterior thigh.
22. Attaches the catheter to the urinary bag below the level of
the bladder. Coils the excess tubing on the mattress and
secures on the bed frame.
23. Removes and cleans the equipment. Makes the patient
comfortable. Labels the urine specimen and sends to the
laboratory promptly
25. Records the time of the catheterization, the amount of the
urine removed, a description of the urine, and the patient’s
reaction to the procedure.
Remarks

II Performance 70%
100%
________________________________ __________________________
________________________________ __________________________
142
REMOVING AN INDWELLING CATHETER
Requisite:
When the physician writes the order to discontinue the indwelling catheter, the
catheter is removed. The catheter and bag should be disposed of in the dirty utility
room, not left in the patients room trash can.
Equipment:
- Treatment Ticket - needle ( if needed) - 2 CBs with Water
- 5 or 10 cc syringe - working gloves - tissue paper/ absorbent towel
Procedure:
Action Rationale
1. Check the order on the patient’s Prevents removing a catheter from the
chart. wrong patient.
2. Obtain a 5 to 10 ml syringe The water in the balloon must be
(depending on the size of the withdrawn prior to removing the catheter.
balloon of the catheter) and an
absorbent towel.
3. Wash your hands. Prevents the spread of microorganisms.
4. Check the patient’s identification Correctly identifies the right patient;
band and explain the procedure. reduces fear of the unknown.
Warn the patient that there may
be a slight discomfort as the
catheter is removed.
5. Don gloves. To prevent the possible transmission of
microorganisms when there is a chance of
coming into contact with any body fluid.
6. Place the absorbent towel on the Protects the mattress. If a portion of the
mattress under the catheter and water/solution remains in the balloon, the
attach the syringe to the balloon inflated balloon will injure the urethral
port. Withdraw all the water or canal.
solutions from the balloon.
7. Hold the absorbent towel in your Prevents soiling by spilled urine.

non –dominant hand in front of The upward position of the catheter will
the perineum. Pinch the catheter allow urine in the tubing to flow faster into
near the meatus with your the urine bag.
dominant hand and pull it steadily
out onto the absorbent towel until
the end is retrieved. Hold the
catheter at an upward angle to the
drainage tubing so that any urine
in it will drain into the drainage
bag.
8. Inspect the catheter to make Ensures that a piece of catheter is not left
certain it is intact. If it is not, in the bladder.
notify the physician immediately.
9. Measure the output in the Reduces transfer of microorganisms.
drainage bag. Record the output To make an accurate record of I & O.
143
on the I & O sheet. Empty the
urine into the toilet bowl and
dispose the urine by into the
yellow bin.
10. Remove gloves, wash hands and Remove transient microorganisms and risk
make the patient comfortable. of transmission to others. Extra fluid helps
Instruct the patient to drink extra to flush the bladder.
fluid and warn that there may be Irritation of the mucosa in the urethra may
mild burning with the first few cause burning sensation with voiding.
voidings.
11. Document the time of removal Sets guideline by which all nurses will
and time by which patient should know when to check to see if the patient
have next voiding time. has voided.
Note:
Make sure the patient voids within 4-6 hrs. after the removal of catheter. If unable,
refer to the CI or nurse on duty.
144
SAN PEDRO COLLEGE
Davao City
REMOVING AN INDWELLING CATHETER
Name:__________________________________ Grade: ___________________
Year and Sec.: _________________ Date : ___________________

Rating
5 4 3 2 1
1. Checks the order on the patient’s chart.
2. Obtains the medicine ticket, 5 to 10 ml syringe and an
absorbent towel.
3. Washes hands.
4. Checks the patient’s identification and explains the
procedure
5. Dons gloves.
6. Places the absorbent towel on the mattress under the
catheter.
7. Attaches the syringe to the balloon part, withdraws the
water from the balloon until resistance is met.
8. With the non-dominant hand, holds the absorbent towel in
front of the perineum.
9. Pinches of the catheter near the meatus and pulls it steadily
out onto the absorbent towel until the end is retrieved.
10. Holds the catheter at an upward angle to the drainage tubing
so that the urine drains to the drainage bag.
11. Inspects the catheter to make certain it is intact. If it is not,
notifies the physician immediately.
12. Measures the output in the drainage bag.
13. Empties the urine into the toilet and disposes the drainage
unit in the yellow garbage bin and cleans the measuring
equipment.
14. Removes gloves, washes hands and makes patient
comfortable. Instructs the patient to drink extra fluid and
warns that there may be mild burning with the first few
voiding.
15. Documents the time of removal, amount of urine collected
into the I and O flow sheet and the time the patient should
have void.
Remarks:

II Performance 70%
100%
________________________________ __________________________
________________________________ __________________________
145
APPLYING A CONDOM CATHETER
Definition:
Condom Catheter is a device that resembles a condom with a large caliber connection at
its distal end. This is connected to drainage bag, to contain the urine. The device adheres to
the penile skin without producing irritation and has sufficient elasticity to maintain its
watertight seal whether the penis is in erect or flaccid state.
Equipment:
-Urinary drainage bag with tubing - washcloth towel
- condom catheter - plaster
- bath blanket - working gloves
Procedure:
Action Rationale
1. Follow steps 1-11 (male

catheterization)
2. Grasp the penis firmly with your This space prevents irritation of the tip of
nondominant hand. Roll the the penis and provides for full drainage of
condom smoothly over the penis the urine.
with your dominant hand leaving
about 1 to 2 inches of space
between the end of the penis and
the rubber or plastic connecting
tube.
3. Secure the condom catheter firmly Prevents impending the blood circulation
but not too tightly to the penis by of the penis.
wrapping a strip of elastic tape
around the base of the penis over
the condom catheter.
4. Securely attach the urinary drainage Allows drainage of urine into the
system into the condom collecting bag. Kinked tubing encourages
catheter.Avoid kinking or twisting backflow of urine.
the drainage bag.
5. Remove gloves.
6. Anchor the tube to the anterior Proper attachment prevents tension on the
thigh or lower abdomen of the condom sheath and potential inadvertent
client. removal.
7. Hang the urine drainage bag below This facilitates drainage of urine and
the level of the bladder to the bed prevents the backflow of urine.
frame away from the entrance.
8. Wash your hands. Do after care. Proper disposal of equipment prevents

transmission of microorgansisms.
9. Document the application of the To ensure that procedure was done
condom, time and pertinent correctly.
observations.
10. Inspect the penis 30 minutes after
the procedure and check urine flow.
146
SAN PEDRO COLLEGE
Davao City
CONDOM CATHETERIZATION
Name: __________________________________ Grade: __________________

Year and Sec.: _________________ Date: ___________________
Rating
5 4 3 2 1
1. Checks the physician’s order.
3. Washes hands . Assembles equipment.
6. Positions the patient on supine and knees slightly apart.
Drapes by fanfolding the bedcover down to the midthigh
exposing the perineal area. Uses a bath blanket to cover the
trunk. Places the waterproof underpad under the buttocks.
7. Dons working gloves and does perineal care.
8. Rolls the condom smoothly over the penis leaving about 1
inch between the end of the penis and the rubber or plastic
connecting tube.
9. Secures the condom catheter firmly by wrapping a strip of
elastic tape around the base of the penis over the condom
catheter.
10. Attaches the urinary drainage system severely into the
condom catheter.
11. Removes gloves and disposes in yellow garbage bin.
12. Plasters the tube to the thigh or abdomen of the patient.
13. Hangs the urine drainage bag to the bed frame away from
the rooms entrance.
14. Washes hands. Do after care.
15. Teaches the patient about the drainage system :
a. To keep the drainage bag below the level of the
condom.
b. To avoid loops and kinks in the tubing.
147
16. Documents the application of the condom time and pertinent
observations.
17. Inspects the penis 30 minutes after the procedure and checks
urine flow.
18. Changes the condom catheter daily and provide skin care.
Remarks:

II Performance 70%
100%
________________________________ __________________________
________________________________ __________________________
Instructor’s Over Signature Printed Name Date
148
DONNING and REMOVING STERILE GLOVES
(Open Glove Technique)
The sterile gloves provide a barrier between the nurse’s hands and the objects she
contacts. She is able to freely touch objects in a sterile field without fear of contamination.
When wearing sterile gloves, she should always remain conscious of which objects are sterile
and which are not.
Equipment:
A pair of sterile prepowdered gloves
Procedure
Action Rationale
To don gloves:
1. Perform thorough hand hygiene / Reduces number of microorganisms residing

scrub hands thoroughly. on surfaces of hands.
2. Remove carefully the outer package Prevents inner glove package from
wrapper by separately peeling apart accidentally opening and touching
the sides. contaminated objects.
3. Grasp inner package and lay it on a Sterile objects held below your waist is
clean flat surface just above waist considered contaminated. Inner surface of
level. Open the package keeping the your glove package is considered sterile.
gloves on the wrappers inside
surface.
4. Identify right and left gloves. Each Proper identification of gloves prevents
glove has a cuff approximately 5 contamination by improper fit. Gloving of
cms. (2 inches) wide. Glove your dominant hand first improves your dexterity.
dominant hand first.
5. With thumb and first two fingers of Inner edge of cuff will lie against your skin
your non–dominant hand, grasp and that is not considered sterile.
edge of cuff of glove for dominant
hand. Touch only inside surface of
glove.
6. Carefully pull glove over your If glove’s outer surface touches your hand or
dominant hand, leaving a cuff and wrist, it is contaminated.
being sure that cuff does not roll up
to your wrist. Be sure that thumb
and fingers are in proper spaces.
7. With your gloved dominant hand, Cuff protects your gloved fingers. Sterile
slip your four fingers underneath touching sterile prevents glove contamination.
second glove’s cuff with the thumb
abducted.
8. Carefully pull second glove over Contact of gloved hand with exposed hand
your non–dominant hand. Do not results in contamination.
allow fingers and thumb of gloved
149
dominant hand to touch any part of
your exposed non dominant hand.
To remove gloves:
9. Use dominant hand to grasp the Contaminated area does not come in contact
opposite glove near cuff end on the with hands or waist.
outside exposed area. Remove it by
pulling it off, inserting it as it is
pulled, keeping the contaminated
area on the inside. Hold the
removed glove on the remaining
glove hand.
10. Slide fingers of ungloved hand

between the remaining glove and
wrist, remove it by pulling it off,
inverting as it is pulled keeping the
contaminated area on the inside and
securing the first glove inside the
second.
11. Discard gloves inside the wrapper Proper disposal reduces risk for infection,
into the appropriate container and transmission and contamination of othe items.
wash hands. Handwashing reduces the spread of
microorganism.
150
SAN PEDRO COLLEGE
Davao City
DONNING AND REMOVING STERILE GLOVES
Name:__________________________________ Grade: ___________________
Year and Sec.: _________________ Date : ___________________
Rating
5 4 3 2 1
1. Washes hands.
2. Selects appropriate size of gloves.
3. Prepares adequate work area at waist height.
4. Opens wrapper correctly.
5. Places gloves with cuff end toward the body.
6. Grasps first glove touching inside only.
7. Turns to side of sterile field and pulls glove.
8. Lifts second glove by slipping gloved fingers under cuff.
9. Turns to side of sterile field and pulls glove on.
10. Unrolls cuff touching only outside of glove.
11. After use, removes gloves by turning them inside out
without touching outside surface with bare hands.
12. Drops used gloves onto wrapper.
13. Rolls gloves in wrapper and disposes them properly.
Remarks:

II Performance 70%
100%
________________________________ __________________________
________________________________ __________________________
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ASSISTING IN THE INSERTION OF NASOGASTRIC/NASOINTESTINAL TUBE
FOR SUCTION AND ENTERAL FEEDINGS
Introduction: The insertion of NGT is done by a doctor, nurse or other competent health
worker. A student is encouraged to assist the doctor or nurse who will perform
the procedure.
Equipment:
-Working gloves - Ice chips in an emesis basin
- Cup of ice or water and straw - Water-soluble lubricant
-Towel and tissues - Tongue blade
- Flashlight or penlight -Appropriate French tube for feeding
- Hypoallergenic tape, rubber band, - Suction machine
safety pin - Disposable irrigation set (optional)
- 20-ml syringe or asepto syringe, 30 ml - Stethoscope
or larger with small bore tube
Procedure:
Action Rationale
1. Review client’s medical record. Confirms physician’s prescription for

inserting a nasogastric tube; history of
nasal or sinus problems
2. Gather equipment. Wash hands/hand Promotes efficiency. Removes transient
hygiene. microorganisms and deters its spread to
others.
3. Check client’s ID band; explain Verifies correct client; reduces anxiety
procedure, showing items and increases client cooperation .
4. Place client in Fowler’s position, at least Facilitates passage of the tube into the
a 45° angle or higher, with a pillow esophagus and swallowing.
behind client’s shoulders; provide for
privacy. Place comatose clients in
semi-Fowler’s position.
5. Place towel over chest, with tissue wipes Prevents soiling of gown and bedding.
within reach. Don gloves Protects nurse from contamination with
body fluids; lacrimation can occur during
insertion through nasal passages.
Determines the most patent nostril to
6. Examine nostrils assess as client
Facilitate insertion.
breathes through each nostril.
Approximates length of tube needed to
7. Measure length of tubing needed by
reach stomach.
using tube as a tape measure:
- Measure from bridge of client’s nose
to earlobe to xiphoid process of
sternum.
- If tube is to go below stomach
(nasoduodenal or nasojejunal):
Place a small piece of tape on tube to
mark length .
Clears nasal passage without pushing
152
8. Have client blow nose, and encourage Microorganisms into inner ear;
swallowing of water if level of facilitates passage of tube.
consciousness and treatment plan
permit.
9. Assist doctor or nurse to:
Facilitate passage into the nares.
a. Lubricate first 4 inches of tube with
water-soluble lubricant.
b. Insert tube as follows: Hyperextension of the neck reduces
b1. Instruct the patient to hyperextend the curvature of the nasopharengeal
the neck and gently advance the junction.
tube towards the nasopharynx .
Ensures tip’s placement.
b2. When client feels tube in back of
throat, use flashlight or penlight
to locate tip of tube. • Opens esophagus and assists in tube
insertion after tube has passed through
b3. Instruct client to flex head toward nasopharynx and reduces risk of tube
the chest. entering trachea.
• Assists in pushing tube past oropharynx.
Swallowing facilitates closure of
b4. Instruct client to swallow, offer epiglottis.
ice chips or water, and advance
tube as client swallow.
b5. If resistance is met or with • The tube should never be forced against
changes in respiratory status resistance because of the danger of
,withdraw the tube and re injury.
lubricate it and insert in the other
nostril.Repeat procedure 9b1 to
9b4
• Assists with tube insertion.
10. Advance tube, giving client sips of
water, until taped mark is reached.
• Ensures proper placement in the
11. Check placement of tube: stomach.
• Attached syringe to free end tube,
and aspirate sample of gastric
contents. • Prevents leakage of gastric contents.
• Leave syringe attached to free end of
tube. • Confirm correct placement; if
• If prescribed, obtain X-ray; keep nasoduodenal or nasojejunal feeding
client on right side until X-ray is are required, passage through pylorus
taken. may require several days.
Note: Evidence of aspiration of stomach
contents into the respiratory tract
(immediate response) are as follows:
coughing, dyspnea, cyanosis,
auscultation of crackles or wheezes.
Interventions:
a. position client on side
b. suction nasotracheally and oral
tracheally
c. consult physician stat to order
chest X-ray • Prevents tube from becoming dislodged.
153
12. Secure tube with tape, or use a
commercially prepared tube holder. • Prevents trauma to nasal mucosa by
• Split a 4-inches piece of tape to a reducing pressure on nares.
length of 2-inches and secure tube
with tape by placing the intact end of
the tape over the bridge of the nose.
Wrap split ends around the tube as
exist the nose. • Allows client movement without causing
• Place a rubber band, using a slip friction on nares; metal devices are
knot, around the exposed tube (12-18 removed for X-rays to prevent artifacts.
inches from nose toward chest); after
X-ray, pin rubber band to client’s
gown. • Reduces anxiety and teaches client how
13. Instruct client about movements that to prevent tugging on tube with head
can dislodge the tube. movement.
• Provides for decompression as
14. Gastric decompression: prescribed by physician; intermittent or
• Remove syringe from free end of tube, continuous suctioning is determined by
and connect tube to suction tubing; type of tube inserted.
set machine on type of suction and
pressure as prescribed.
• Levine tubes are connected to
intermittent low pressure.
• Salem sump or Anderson’s tube is
connected to continuous low suction.
• Provides information about patency of
• Observe nature and amount of gastric tube and gastric contents.
tube drainage.
• Indicates effectiveness of intervention.
• Assess client for nausea, vomiting, and
abdominal distention.
• Promotes comfort.
15. Provides oral hygiene and cleanse nares
with a tissue.
• Prevents the spread of microorganisms;
16. Removes gloves, dispose of protects other workers from coming into
contaminated materials in proper contact with objects contaminated with
container, and wash hands/hand body fluids.
hygiene.
• Promotes comfort and safety.
17. Position client for comfort and place
call light within easy reach.
• Promotes continuity of care and shows
18. Document: implementation of intervention.
• The reason for the tube insertion.
• The type of tube inserted.
• The type (intermittent or continuous)
of suctioning and pressure setting.
• The nature and amount of aspirate and
drainage.
• The client’s tolerance of the
procedure.
• The effectiveness of the intervention,
such as nausea relieved.
154
INSERTION OF A SMALL-BORE
FEEDING TUBE
19. Repeat actions 1 through 8, as stated • See actions 1 through 8
earlier.
20. Open adapter cap on tube, snap off end • Activates Keolube lubricant in tube’s
of water vial, and inject water into lumen.
feeding tube adapter.
21. Close adapter cap. • Ensures a tight fit so water does not
leak from adapter site.
Check that stylet does not protrude • Prevents mucosa trauma.

through holes in feeding tube; adjust as
necessary.
22. Repeat actions 9 through 12, as stated • See action 9 to 12.
earlier.
23.Check placement of tube: • Ensures that correct placement has been
• Aspirate gastric contents with Luer- achieved; provides measurement of pH of
Lok syringe secretions, as explained in action 13.
• Measure pH of aspirate with Note: May not be able to aspirate
chemstrip pH. contents from small-bore tubes.
24. Leave stylet in place until X-ray • Provide a safety measure. See the
confirms that placement in case tube Nursing Alert on small-bore feeding tubes
needs to be advanced into the duodenum (in the Enteral Tube Feeding section).
or jejunum.
25. Obtain X-ray. Remove stylet from • Confirms placement of tube prior to
feeding tube after X-ray, and plug the instilling formula; prevents gastric juices
open end of tube until feeding from seeping out of the tube.
26. Repeat actions 17 through 20.
27. Replace small-bore tube every 3 to 4 • Prevents obstruction and sepsis of
weeks. small-bore tubes
28. Wash hands/hand hygiene. • Prevents the spread of microorganisms.
155
ADMINISTRATION OF THERAPEUTIC AGENTS
Introduction:
The administration of medicine is a grave responsibility entrusted to the nurse. The doctor
by written order will indicate the drug name, amount of the drug per dose, the drug form
(tablets, capsules, etc.), the route by which to administer the drug and the frequency or
number of times a day the drug is to be taken. However, the nurse is expected to carry out
these orders intelligently, promptly and with extreme accuracy.
Definition: Medication is the administration of a substance for the diagnosis, cure,

treatment, relief or prevention of diseases.
The nurse is expected to take into consideration the following:
1. The general principles related to drug administration.

2. The various types of drugs and their uses.
3. The minimum and maximum dosage of drugs.
4. The most effective means of administration and its expected effect.
5. Signs and symptoms which would indicate patient’s idiosyncrasy or allergy.
6. Various factors such as weight, health status, age, surgery, diagnostic procedure,
chemotherapy which must be considered in determining the method and time of
administration of drugs.
7. Those factors such as genetics, environmental, drug interaction, weight, etc. which
may modify the drug action.
8. The nurse should also know the new drugs which are continually appearing in the
market.
GENERAL INFORMATION ABOUT DRUG ADMINISTRATION:

1. Doctors should order in writing the name of the drug, amount, time and frequency of
giving as well as the method of administration.
2. Verbal orders should be accepted only in extreme emergencies. A written order must be
obtained as soon as the emergency has been controlled.
3. If a physician orders a drug over the telephone, a registered nurse must take down the
information. On the next visit, the physician signs the written record of the verbal order.
4. The nurse should inform the doctor of any known patient’s allergies.
5. The nurse should recognize commonly used abbreviations and symbols utilized in
medication administration.
6. The nurse should bear in mind that accuracy in the measurement of drugs is vital
especially in pediatric doses where a relatively small error become magnified.
7. The nurse should know the usual therapeutic as well as side effects of each drug.
8. The physician must be notified immediately in case of error.
9. The nurse should question an order which in her judgment is erroneous. She
should tactfully clarify the order with the physician who made it.
10. The nurse should be knowledgeable of the patient’s diagnosis or tentative
diagnosis.
11. Each type of drug preparation usually requires a specific method of administration.
12. The route of administration of the drug affects the optimal dosage of the drug. (Optimal
(Optimal dosage of drugs administered by injection may be different from those
administered orally.)
13. The safe administration of medication requires a knowledge of anatomy and physiology
as well as knowledge of the drug and the reason it has been prescribed.
14. The method of administration of drug is partially determined by the age of the patient,
level of consciousness and the disease process. Any difficulties encountered when
administering medicines should be reported.
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15. Appropriate precautionary measures should be considered to avoid errors and accidents
in the preparation and the administration of therapeutic agents.
16. Physiologic activities of the body can be maintained, improved or in some instances
restored by the administration of therapeutic agents.
17. Persons vary in the way they metabolize injected or ingested agents or the way they
react to agents applied externally.
18. Each patient has his own needs for explanations and support with respect to the
administration of medicines. Some people want to know about their medicines, others
prefer not to. The amount of knowledge that a person requires is dependent upon
individual circumstances.
ROUTES OF ADMINISTRATION OF THERAPEUTIC AGENTS:
How therapeutic agent is administered Term Used to Describe the Route

(Route)
1. Having patient swallow Oral Administration
2. Placing therapeutic agent under the tongue. Sublingual administration
3. Having patient inhale the therapeutic agent. Inhalation
4. Inserting therapeutic agent into:
1. Vaginal administration
1. vagina
2. Rectal administration
2. rectum
5. Placing the therapeutic agent on the skin. Topical Application
6. Dropping therapeutic agent into the mucous Instillation
membrane.
7. Flushing mucous membrane with large Irrigation
amounts of the therapeutic agent.
8. Injecting therapeutic agent into the: Parenteral Administration
a. Corium a. Intracutaneous or intradermal injection

b. Subcutaneous tissue b. Hypodermic/subcutaneous injection
c. Muscle tissue c. Intramuscular injection
d. Vein d. Intravenous injection
e. Subarachnoid space of spinal canal e. Intrathecal or Intraspinal
f. Peritoneal cavity f. Intraperitoneal
g. Heart g. Intracardiac
h. Cavity of a joint h. Intra–articular
GENERAL RULES IN THE ADMINISTRATION OF MEDICINES
1. Observe the “ten rights” (Joyce Kee) in giving each medication:

1.1 the right patient 1.6 the right dose
1.2 the right drug 1.7 the right time
1.3 the right route 1.8 the patient’s right to education
1.4 the right assessment 1.9 the right evaluation
1.5 the right documentation 1.10 the patient’s right to refuse
2. Consult the clinical instructor or the head nurse if a written order is not clear as to
meaning, not legible or not signed by the doctor.
3. Wash hands thoroughly before measuring and preparing medication.
4. Make certain that all equipment are clean.
5. When giving pills or tablets, place in proper container directly from the bottle. Do not
touch them with your hands.
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6. Determine if medication is to be delayed or omitted for a specific length of time, as for x –
ray examination or basal metabolic test, blood chem, and/or in cases where the drug/s can
adversely affect the patient’s vital signs or condition.
7. Never leave the medicine cabinet unlocked. Never leave your cart or medicine tray out of
your sight.
8. Do not return to stock any excess medicine or medicine refused by a patient.
9. Do not use a drug which is discolored, has precipitated, is contaminated or outdated.
10. Provide drinking straws for irritating drugs and for those likely to stain the teeth e.g.
iodine and iron preparation.
11. Do not pour a drug from one bottle to another.
12. Never give two or more drugs at one time, unless ordered.
13. Do not permit a patient to carry medicine to another patient.
14. Know the minimum and maximum doses for the medication being given.
15. Report immediately to the CI or nurse- in- charge any error in medication.
16. Always provide a glass of fresh water to the patient immediately after giving an oral
medication, unless water is contraindicated.
17. The nurse who prepares a medicine should also give it and do the necessary recording.
18. Recap needles using the fish-hook technique, (Infection Control) if necessary.
19. Enteric coated drugs should never be powdered or crushed before administration.
20. Buccal and sublingual medication should be allowed to dissolved completely before the
patient drinks or eats.
21. Suspension and emulsion should be immediately administered after shaking and pouring
in the bottle.
22. Cough syrups are never diluted and followed up with water.
23. Sedatives are given with warm milk to increase or hasten desired effect of drug when not
contraindicated.
24. Never use milk or any juice to mark the taste of the medicine to a child for she/he may
develop unpleasant association and refuse them in the future.
Rules in Measuring Medication
1. Measure the exact amount of drug ordered with a calibrated equipment.

2. Do not converse with anyone while preparing a medication.
3. Ensure adequate lighting.
4. Make sure that the medicine glass is dry before pouring or measuring a medication.
5. Cleanse the mouth of every bottle after use and before replacing the cap..
6. Hold the medicine glass at eye level and place thumb nail of the hand holding the glass at
the level of the scale of the desired fluid volume
7. Measure accurately liquid medication. Check that the scale is even with the fluid level at
its surface or base of meniscus
8. Use of dropper: The size of the drops varies according to the size of the dose in the
medicine dropper , the angle at which the dropper is held and the viscosity of the liquid.
Use of syringe: Draw up small volumes (less than 10 ml) with syringe without needle,
unless drug has its own specific measuring device.
Rules Regarding Labels
1. Give medication only from clearly labeled containers.

2. For each dose of medicine prepared, read the label three times: before/after locating the
bottle from the medicine box, before preparing the desired amount of drug and before
returning the bottle to the medicine box.
A. Oral
1. Liquids – after locating the bottles from the medicine box, before preparing the
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desired amount of drug and before returning the bottle to the medicine
box.
2. Tablet, Pills and Capsules – after locating the tablet/pills/capsules from the medicine
box; before placing in the medicine glass and before opening the unit pack.
B. Parenteral – after locating in the vial/ampule; before withdrawing the medicine

from vial/ampule and after withdrawing the medicine from vial/ampule.
3. Never give a drug with an effaced label and from an unmarked bottle or box.
4. Pour medicine from the bottle on the side opposite the label.
5. Labels on medicine containers should be changed only by the pharmacist.
6. If a drug has two commonly used names, both names should appear in the label.
7. Take note of the expiry date marked on the label.
Rules for Giving Medications
1. Give the medication within 30 minutes before or after the schedule for which it is ordered.
2. Always identify the patient before giving the medication.
3. If the medication is refused or cannot be administered, notify the CI /head nurse, and
record accordingly on the patient’s chart.
4. Remain at the bedside until the patient has taken the medicine.
5. Administer only those medicines which you have prepared.
6. Never give two drugs together, unless specifically ordered to do so. Different drugs taken
at the same time may form a chemical compound that can be injurious to the patient or
will render the drug inactive or less effective.
7. When a patient goes to the Operating Room, all orders for medication are automatically
discontinued. New orders for post – operative medications will be written by the doctor.
8. When special tests are being done, medications due at the particular time are omitted.
They are resumed when next dose is due. (This is true of BID, TID, QID orders, etc.).
Medications given once a day are also administered.
9. Nurses should listen carefully to the patient who questions the addition or deletion of a
medication. If a patient questions the drug or dose you prepared to administer, recheck the
order.
10. Medicine ticket for Stat order should be torn halfway after the drug is administered.
Inform NOD.
Rules for Recording Drugs Administered
1. Record if an ordered medication is refused and if it cannot be administered for whatever

reason.
2. Record each dose of medicine soon after it is administered.
3. Use standard abbreviations in recording medications.
4. Never record medication before it has been administered.
5. Record only those medicines which you have administered.
6. Record time, kind, dose and route of drug given.
7. Record effect (beneficial or untoward) of medication.
8. Affix your initials on the appropriate space of the medication sheet for those medications
you actually have administered. If delayed or first dose of drug is to be given, indicate the
time above your initial
TEN COMMANDMENTS:
1. Thou shalt know thy drug.
2. Thou shalt read the label three times.
3. Thou shalt clarify thy doubts.
4. Thou shalt measure the drug accurately.
5. Thou shalt only think of what thou art doing.
159
6. Thou shalt use the medication ticket always.
7. Thou shalt give the drug promptly.
8. Thou shalt give the drug to the right patient.
9. Thou shalt report errors promptly.
10. Thou shalt chart only what thou hath given.
ORAL MEDICATION
Oral administration of drugs is generally the safest, most convenient, and the least
expensive. Drugs for oral administration are available in many different forms: tablets, enteric
coated tablets, capsules, syrups, emulsion, elixirs, oils, suspensions, powders, and granules.
Oral drugs are sometimes prescribed in higher dosage than their parenteral equivalents
because after absorption through the gastrointestinal system, they are immediately broken
down by the liver before they reach the systemic circulation. Nausea, vomiting, inability to
swallow and unconsciousness may contraindicate oral administration.
Purpose: To prepare and administer oral medication safely and accurately so that
patient may receive maximum therapeutic effectiveness from them.
Equipment: OPTIONAL:
1. Medicine/s 10. Spoons as required
2. Medicine ticket/s 11. Mortar and pestle
3. Medicine tray 12. Stirring rod if powder is used
4. Medicine glasses 13. Tongue depressor
5. Medicine dropper/s 14. Drinking straws
6. Syringe/s
7. Glass of water
8. Paper wipes
9. Waste receptacle
Procedure
Action Principles
1. Locate the corresponding medication The source of the order is more reliable than
ticket due for the shift and compare the medication tickets which are only a
it with the doctor’s order. devices for convenience.
2. Check for history of allergies. Fill up This ensures that no patient is given a
the medication booklet. medication containing an ingredient to which
the patient is allergic.
3. Arrange the ticket/s automatically Organization and planning result in economy
either by the location of the patients of time and effort and minimize confusion.
or by some other factors.
4. Wash your hands. Prevent spread of microorganisms.
5. Bring requisites to preparation area. Broken rim of the medicine glass can injure
Check the medicine glass to ensure or damage the mucous membrane of the
that the rim is not broken. patient’s mouth or lips.
6. Take one medicine ticket at a time, For organization of work, avoidance of

locate medicine in the box, read and confusion, and ensures safety of patient.
compare label against the medicine
160
ticket. Note also the expiration date.
Remove the medicine from the box.
7. Before pouring or getting the Proper checking ensures correct drug is
prescribed dose; compare name of prepared.
drug on the label with name of drug
on medicine ticket.
8. Pour or prepare prescribed dosage of
medicine in glass as follows:
LIQUIDS
a. Shake bottle if necessary To mix the drug well and obtain the right
(suspensions, granules). dose.
b. Remove cap and place it upside Avoid contamination.
down on the counter.
c. Hold medicine glass with the For accurate measurement.
non-dominant, with the
thumbnail, marking the level of
the prescribed amount. Read at
eye level using the lower
meniscus.
d. Hold bottle with the dominant To ensure that label is intact and could be
hand with label facing up. Pour read.
the exact prescribed amount.
e. Wipe rim of bottle with paper Ants and other insects may feast on the liquid
towel. Replace the cap. that is left.
TABLETS, PILLS, CAPSULES
a. Using the index finger of the
dominant hand, gently tap the
bottle to allow the prescribed
number of medicine into the
bottle cover.
If in a box, tap the prescribed
number into a dry medicine
glass.
b. Place packaged dose or unit-dose The wrapper keeps the medication clean and
capsules or tablets directly into facilitates identification. When not used, it
the medicine cup. Do not could be returned to the medication box.
remove the medication from the
wrapper until at the bedside.
POWDERS
a. Shake powder from its base.
b. Add required amount of water to

powder in its container and
shake until thoroughly
dissolved.
161
DROPS
a. Before inserting the medicine
dropper into the bottle, press the
rubber and draw up the
prescribed amount at eye level.
b. Place the dropper (with
medicine) inside the medicine
glass.
EFFERVESCENT TABLET
a. Read the instructions for
preparation on the label.
b. Pour in a glass the amount of
water required and drop the
effervescent tablet
c. Allow tablet to dissolve completely.
9. When through with medicine Frequent checking ensures the proper
preparation, place ticket and observance of the safeguards in drug
medicine on the tray according to the administration.
hospital protocol.
10. Read again the label on medicine If drugs are spilled or refused, positive
and check against medicine ticket identification as to name and amount can be
before returning the drug/ container made.
to the medicine box.
11. Complete the preparation until all Keeping drugs identified ensures proper
medicines and tickets are on the tray. administration of the correct drug to the
See to it that each medication is in a correct patient.
separate container.
12. Keep medication ticket and drug Ensures accuracy of the prepared medication.
together at all times.
13. Have the CI or nurse check the

prepared medicines. Also, present
the filled up medication booklet for
her signature.
14. While transporting medication to the Careful handling and close observation
patient’s bedside, carefully hold the prevent accidental or deliberate
tray in front and at waist level. disarrangement of medications.
15. At each patient’s bedside:
a. Identify patient before giving Ensures proper identification of patient
medicine. Check the medication consider that illness and strange surroundings
ticket, ask the patient to state his often cause patient to be confused.
name. If the patient is a child,
ask the parents to tell you the
name of the child.
b. Perform any assessment Provides data if the medication should be
necessary prior to giving certain given.
162
medication (e.g get BP before
giving Nifedipine, Methergin or
get heart rate (HR) before giving
Digoxin . Record result in the
jotdown notebook.
c. Assist patient to sitting or high Prevents aspiration and promotes swallowing
Fowler’s position if necessary. of medication.
d. Give the prepared medicine. If Consider patient’s right to be beard and thus,
the patient expresses doubt about prevent error medication.
the medication, always recheck
the order, drug label, and dosage
stated in the container.
e. Pour drinking water and hand to Cough syrup is intended to have a soothing
the patient (if not effect in the mucous membrane of the throat.
contraindicated. Cough syrup is
not followed by water).
f. Stay at bedside until patient has The presence of the nurse will encourage the
taken the medicine. patient to swallow the medicine. Unless the
nurse has seen that the medicine has been
taken, it cannot be recorded that the drug was
administered .
g. Offer additional fluids as Fluids facilitate swallowing it helps dissolve
necessary. and dilute solid drugs.
h. Turn medicine ticket after each Ensures that medicine has been given
medication .
16. Repeat all steps until all medicines

in tray are given.
17. Return medicine tickets to the place Careful management of medication tickets
provided for them. reduce the possibility of error and losses.
18. Wash all equipment used, dry and To deter the spread of microorganism
return to their proper place. Wash
hands.
19. Immediately record the medications Immediate recording prevents the possibility
given. of accidentally repeating administration of the
a. Affix initial on medication sheet drug.
the patient’s chart.
b. Document on the nurse’s notes.
Include also special factors related
to oral administration (eg. NGT
clamped following administration)
in addition to the usual factors
charted.
163
SAN PEDRO COLLEGE
Davao City
ADMINISTRATION OF MEDICINE BY MOUTH
Name: ________________________________ Grade: ____________________

Year and Sec. _________________ Date : ____________________
Legend: 5 – Excellent; 4 – Very good 3 – Good; 2 – Fair; 1 – Poor
Rating
5 4 3 2 1
1. Checks physician’s orders and finds the corresponding
medication tickets.
2. Arranges the tickets in order in the medication tray.
3. Washes hands.
4. Brings requisites to preparation area.
5. Takes one medicine ticket at a time.

6. Reads first the ticket, locates medicine in the box, reads
label and notes also the expiration date. Removes
medicine from the box.
7. Compares name of drug on label with name of drug on
medicine ticket.
8. Pours or prepares prescribed dosage of medicine in glass
as follows:
Liquids / Suspension:
a. Shakes bottle if necessary
b. Removes cap and places it upside down on the
counter.
c. Holds medicine glass at eye level.

d. Places thumb on prescribed level and reads it at
the lower meniscus.
e. Pours the exact amount of medicine prescribed
into the medicine glass.
f. Wipes rim of bottle with tissue paper and replaces
cap.
Tablets, Pills, Capsules:
a. If in a bottle, gently shakes the prescribed number
into the bottle cover.
b. If in a box, shakes prescribed number into the
medicine glass.
164
9. Rechecks label of medicine and dosage with the
medicine ticket before returning to its medicine box.
10. Places ticket with corresponding medicine on tray.
11. Takes each remaining ticket in turn until all medicines
and tickets are on the tray.
12. Places each medicine in a separate container.
13. Keeps medication ticket and drug together at all times.

14. Presents prepared medicines and medication booklet to
CI for checking.
15. Transports medications to the patient’s bedside carefully
and keeps the medication tray in sight at all times.
16. At each patient’s bedside:
a. Identifies patient by asking patient to state his
name or by checking the wrist band against the
medication ticket.
b. Assists patient to sit or be in comfortable

position.
c. Hands medicine to patient.
d. Hands drinking water to patient (if not
contraindicated).
e. Stays at bedside until patient takes the
medicine. Makes patient comfortable.
f. Turns medicine ticket to show that medicine has
been given.
17. Returns medicine tickets to the place provided for them.
18. After care of equipment: Soaps, rinses, and dries
equipment used and returns to proper places.
19. A. Initials the medication sheet to the corresponding
drug, time, and date.
B. On the nurse’s notes, documents the:
b. 1 drug, dose, time, route given
b. 2 significant symptoms in relation to drug/s.

b. 3 drug/s that have not been given and reason for
omission.
b. 4 Signature
of the procedure.

165
Remarks:

II Performance 70%
100%
________________________________ __________________________
________________________________ __________________________
166
ADMINISTRATION VIA THE NASOGASTRIC TUBE (NGT)
Definition: Administration of medications/feeding via the NGT or OGT for patients who
are unconscious, too weak or unable to take medicines/ feeding orally.
Purposes:
1. To improve or maintain the nutritional status of the patient
2. To administer prescribed medication.
Principles:
1. Elevate the head of the bed 30 -90 degrees before feeding and leave it up for 30-60
minutes after the feeding.
2. Keep the head of the bed elevated at least 30 degrees at all times if the pt. is
receiving continuous feeding.
3. Assess bowel sounds at least once every 8 hours.
4. Assess abdomen for distention.
5. Check the tube position with in the GI tract before each feeding is started or at
least once each shift.
6. Check for gastric residual by aspirating via the gastric tube before each
intermittent feeding or at least every 4 hours if the patient is receiving continuous
feeding. If the gastric residual is greater than one- half the volume given in the last
feeding or greater than 150cc, re-instill the residual and delay the next feeding for
1-2 hours.
Equipment:
1. medicine and medicine ticket 5. medicine glass
2. asepto syringe for adults; 6. drinking water
2 cc or 5 cc syringe for children 7. sterile tongue depressor
3. stethoscope for stirring
4. mortar and pestle 8. prescribed feeding
Procedure
Action Rationale
1. Check the physician’s order for Ensures that correct medications/feeding will
medication/ feeding. be administered.
2. Wash your hands then assemble Hand washing deters the spread of
equipment. microorganisms.
3. Identify and explain the procedure to Proper identification of patient prevents
the patient. medication error.
4. Assess S/S that would suggest lack of
tolerance in the previous feeding (e.g.
abdominal distention, etc.)
5. Raise the bed to a working height.
6. Elevate the patient’s head 30 degree or This position enhances the gravitation flow of
as near normal position for eating as the solution and prevents the possibility of
possible. aspiration into the lungs.
7. Pinch off the tube and remove the plug, Pinching or clamping NGT prevents excess
cap or clamp and attach the asepto air from entering the tubing and causing
syringe or syringe. distention.
8. Check the placement of the NGT using
167
either of the following techniques:
8.1 Aspirate a small amount of (5-10 Obtaining gastric or intestinal contents is the
ml) of gastric contents into a best evidence of proper tube placement.
syringe. Return the residual contents to the stomach to
prevent fluid and electrolyte imbalance.
NOTE: If the gastric aspirate exceeds 50 cc,
withhold the next feeding, refer or
follow agency protocol.
8.2 Place the diaphragm of the A whooshing, gurgling or bubbling sound is
stethoscope just below the xiphoid heard while auscultating the epigastrium or
process. Using a syringe slowly left upper abdominal quadrant.
introduce 5-20 ml. of air into the
tube while listening with the
stethoscope for the entry of air into
the stomach.
9. Administer the drug through a syringe This gives the stomach time to accommodate
barrel or asepto syringe connected to the fluid and decreases GI distress.
the tubing. Hold the barrel of the
syringe approximately 6 inches higher
than the patient’s nose and allow the
medication to flow into the stomach by
gravity. Only in cases when there is
difficulty of the medication flowing
through should the plunger or bulb of
the syringe be used.
If the medication does not flow
properly, do not force it. It may be too
thick. If so, dilute with water.
10. Follow medication with small amount Irrigation clears drug from the sides of the
of liquid: tube reducing the risk of clogging.
2 – 5 ml. for newborns
20 – 25 ml. for children
30 – 50 ml. for adults
11. Close the tube. Maintain patient’s To facilitate the down–flow of medication
position for 20 – 30 minutes. into the stomach and prevent reflux into the
esophagus.
NOTE: Feed the patient first before giving To prevent leakage and gastric reflux into the
his/her medication. esophagus and enhance the normal digestive
This procedure will be discussed in process in case of gastrostomy,
level three. duodenostomy and jejunostomy feeding.
12. Do the aftercare of equipment and wash
hands.
13. Document the procedure done Proper documentation prevents medication
including pertinent observations. error.
SAMPLE DOCUMENT:
5/19/11
11:40 AM Checked for residual prior to feeding. 25 cc gastric
content aspirated and reinstilled. Abdomen soft, bowel
sounds present in all quadrants 200 cc of Isocal feeding
given via NGT. Tolerated feeding without evidence of
discomfort. Head of bed maintained at 30 degree angle
Joshua Kabalu, St. N.
168
OPTHALMIC MEDICATION
Introduction: An error with an eye medication can cause significant damage. It is imperative
to check each medication very carefully before instilling it. Eye medications
must be kept sterile.
Definition: Ophthalmic (eye) medication is the administration of a medicine to the eyes. It
may be in the form of drops or ointment.
Purposes:
1. To treat infections.
2. To relieve inflammations.
3. To hasten the healing process of the eye after surgery.
4. To diagnose foreign bodies and corneal abrasions.
5. To dilate the pupils to facilitate refraction.
6. To lubricate the socket for insertion of artificial eye.
7. To protect the neonate from eye infection (Crede’s prophylaxis).
8. To anesthetize the eye.
Equipment: A tray containing:

1. Prescribed eye medication 5. Sterile NSS
2. Tissue paper 6. Plaster (optional)
3. Gauze pads / eye dressing (optional) 7. Working gloves
4. Sterile CB
Nursing Consideration: Sterile gloves must be worn for post–op cases and where drainage is
present.
Procedure Rationale
1. Verify the correctness of the Different medications or doses may be

physician’s order. Make sure which ordered for each eye.
eye is to be medicated.
2. Wash your hands. Careful hand washing removes transient
microorganisms and its spread.
3. Prepare the necessary materials and Organization saves time.
bring to the bedside.
4. Identify and explain the procedure to Ensures the correct patient and to gain
the patient. cooperation.
5. Don gloves. Assess the eyes for May be an adverse effect of medication.
inflammation discharges and change
in vision.
6. Place patient in supine or in sitting Excess solution can flow away from the tear
position with neck hyperextended duct preventing systemic absorption through
and turned slightly toward the the nasal mucosa. This also prevents flow to
affected eye. the uninfected eye.
7. Cleanse the affected eye/s from inner To prevent contamination of the other eye and
to outer canthus with the use of CB the lacrimal duct.
moistened with NSS.
8. Uncap the medication container. Stabilizes the eye area. The lower
Place the non–dominant thumb or conjunctival sac is exposed as the lower lid is
169
two fingers near the margin of the pulled down. This also allows easier view of
lower eyelid immediately below the the eye and easy retraction of the eyelid.
eyelashes and apply gentle pressure
downward over the bony
prominence.
9. Instruct patient to look up while Looking upward inhibits the desire to blink.
focusing on something on the ceiling.
Instilling Eye Drops

10. Hold the dropper close to the eye, ½ Prevents eye injury and dropper
- ¾ inch above the conjunctival sac, contamination. Blinking discharges some of
but avoid touching the eyelid or the medication from the eye.
eyelashes, which may startle the
patient and cause blinking.
11. Approach the eye from the side and The patient is less likely to blink if a side
instill the prescribed number of approached is used. When instilled into the
drops to fall in the lower conjunctival sac, drops will not harm the
conjunctival sac. cornea.
12. Release the lower lid after the eye
drop is instilled.
Squeezing the eye expels the medication.
13. Ask the patient to gently close the
eyes.
This minimizes the risk of systemic effects
14. Apply gentle pressure over the naso- from the medication.
lacrimal duct for at least 30 seconds.
Administering Eye Ointment

Follow steps 1-9 in instilling eye drops.
10. Apply a thin line of eye ointment
from the inner canthus to the outer
canthus along the lower eyelid inside
the conjunctival sac.
11. Ask patient to gently close his eye Aids in melting and spreading ointment under
and move the eyeball around in the the lids and over the surface of the eyeball.
socket.
12. Gently wipe from the inner to the Provides for the patient’s comfort; the
outer canthus any excess direction of the wipe reduces the risk of
medication. Use separate tissue infection.
paper for each eye.
13. Apply eye patch if indicated. Maintains eye closure and prevents cross
infection.
14. Dispose soiled supplies into a proper Decreases the spread of microorganisms.
receptacle.
15. Remove gloves and wash hands. Prevents spread of microorganisms.
16. Document the procedure noting the Communicates to the members of the health
time, dose, route of medication, care team and contributes to the legal record
appearance of the patient’s eye, by documenting the care given to the patient.
response to the drug and any other
related information.
17. Monitor patient to assess the effects The nurse is responsible for monitoring the
of the medication. desired effects, potential side effects and
allergic reactions to the medications.
170
OTIC MEDICATION
Definition: Otic medication is the administration of a drug through the ears.

Purposes:
1. To treat infection.
2. To relieve pain.
3. To soften and remove impacted cerumen.
4. To produce local anesthetic effect.
5. To facilitate removal of a foreign body.
Contraindications:
1. Perforated ear drum.
2. Hydrocortisone is contraindicated in viral (herpes) and fungal infections.
Equipment:
A tray containing:
1. Prescribed medication 3. Dry CB
2. Cotton tipped applicator 4. Penlight
5. Working gloves (optional)
Procedure
Action Rationale
1. Verify the physician’s order. The source of the order is more reliable than
the medication ticket which is only a device
for convenience
2. Check for allergies. Allergy is a contraindication.
3. Wash your hands. Removes transient microorganism and
reduces deters it transfer to client.
4. Prepare the necessary materials and
bring to the bedside.
5. Identify and explain the procedure to Ensures the correct patient and gain
the patient. cooperation from him/her.
6. Position the patient to lie on the side Facilitates flow of the medication down the
opposite the affected area. ear canal by gravity.
7. Assess the affected ear. Use the
penlight if necessary.
Don nonsterile gloves.
8. Clean pinna and meatus of the ear Decreases contact with fluid.
canal.
9. Straighten the auditory canal by pulling This permits the solution to reach all areas of
the pinna down and back for children the canal easily.
below 5 years. It is up and back for
patients over 5 years.
10. Hold the medicine dropper ½ inch The tip of the dropper should remain sterile.
above the ear and rest your hand on the
patient’s head until the prescribed
number of drops fall against the sides To avoid patient’s discomfort.
of the ear canal.
171
11. Instruct the patient to remain in this Facilitates the flow of the ear drops down the
position for 2–3 minutes. ear canal. This position prevents the escape of
drug from the ear.
12. Apply gentle pressure on the tragus of Pressing on the tragus assist the flow of the
the ear with your finger. medication into the ear canal.
13. Apply a portion of dry CB on the The CB helps retain the medication when the
external ear canal. Remove after 10–30 patient is up. If pressed tightly into the canal
minutes. the cotton will interfere with the action of the
drug and the outward movement of the
normal secretions.
Removes transient microorganism and
14. Wash hands. reduces the risk of cross-contamination to
client and self.
15. Document the drug, number of drops, Documentation of the actions of the nurse is a
time administered and the ear proof that treatment was administered.
medicated affix the initial in the
medication sheet.
16. Evaluate the condition of the Determine possible skin reaction.

surrounding skin.
APPLICATION OF NASAL MEDICATION
Definition:
Nasal instillation is the administration of a medication into the nasal cavity.
Purposes:
1. To shrink swollen mucous membranes.

2. To loosen secretion and facilitate drainage.
3. To treat infections of the nasal cavity and or sinuses.
Equipment:
1. prescribed medication
2. medicine ticket
Procedure:
Action Rationale
1. Check the doctor’s order. Reading the order ensures that the nurse
follows the doctor’s directions.
2. Wash hands and assemble the Removes transient microorganism and

equipment. reduces the risk of cross-contamination to
client and self.
3. Identify the patient. Explain the

procedure.
172
4. Instruct the patient to blow the nose, if Clears the nasal passage.
indicated.
5. Let the patient assume a supine

position with a pillow under the
shoulders allowing the head to fall over
the edge of the pillow.
6. Elevate the nares slightly by pressing the Facilitates instillation of the medication.
thumb against the tip of client’s nose.
7. Hold the dropper just above the client’s If the drops are directed towards the base of
nostril and direct the drops toward the the nasal cavity, they will run down the
midline of the superior concha of the eustachian tube.
ethmoid bone as the client breathes
through the mouth.
Avoid touching the mucous Avoids injury to the tissue and
membranes of the nostrils. contamination of the dropper.
1. Ask the patient to: Allows the solution to come in contact with
a. inhale slowly and deeply through all of the nasal surface.
the nose.
b. hold his/her breath for several
seconds and then to exhale slowly
and
c. remain in the supine position for
one minute.
2. Discard any medication that remains in

the dropper. Return the dropper back
into the bottle.
3. Make the patient comfortable.
4. Return the equipment. Wash hands.
5. Document all relevant information. Records help to communicate to the

members of the health team. Document
response to the medicine and any unusual
reaction.
VAGINAL MEDICATION
Definition: It is the introduction of medications into the vagina in the form of suppository,
tablets, or creams which melts at body temperature.
Purposes:
1. To remove offensive or irritating discharge.
2. To relieve vaginal discomfort such as pain or itchiness.
3. To reduce inflammation.
4. To hasten the progress of labor.
5. To promote family planning method.
Equipment:
173
a. Vaginal medication as ordered
b. Sterile gloves
c. Tissue paper
d. Perineal pad (optional)
e. Water-soluble lubricant
2. External douche tray (to include waste receptacle)
3. Bedpan
Procedure
Action Rationale
1. Check the doctor’s order and for Prevents occurrence of adverse reactions.
history of allergies.
2. Wash your hands. Handwashing reduces the number of

microorganisms and risk of cross
contamination among client and self.
3. Prepare equipment and bring to the Organization promotes efficient time

bedside. management.
4. Identify the patient and explain the An explanation of the procedure reduces the
procedure to her. patient’s anxiety.
5. If patient is able, ask her to void and do A full bladder may cause discomfort and
perineal care. injury to vaginal lining when suppository is
inserted.
6. Provide privacy.
7. Have the patient lie in the dorsal This position provides easy access to and
recumbent position and drape good exposure of the vaginal canal, easy
appropriately. insertion of suppository and allows
suppository to dissolve without being
dislodged.
8. Assess area, note odor or discharge Assessment data provide a baseline for
inquire about itching or discomfort. monitoring the effectiveness of medication.
9. If the patient is unable to do perineal A bedpan will collect the water used during
care by herself, place the patient on a perineal cleansing.
bedpan.
Follow procedure in doing external Cleansing the area with soap and water
douche. Dry buttocks with tissue paper decreases the possibility of introducing
or towel. microorganisms.
10. Put on gloves. The use of gloves prevents transmission of

infection between nurse and patient.
11. If the medication is a suppository, This allows easier insertion.

remove the suppository from the foil
174
wrapper. Lubricate the rounded end of
the suppository.
12. With the non-dominant gloved hand This exposes the vaginal orifice.
gently retract the labial folds.
13. Insert the rounded end of the Proper placement of the suppository ensures
suppository about 3-4 inches or length equal distribution of medication along the
of the index finger along the posterior walls of the vaginal cavity.
wall of the vagina or as far as it will go.
14. Withdraw the finger and wipe away This provides for patient comfort.
with tissue paper any remaining
lubricant around the orifice and labia.
15. Instruct the patient to remain on her This position allows medication to melt and
back for at least 15 minutes. The hips to flow into the vaginal fornix.
may also be elevated on a pillow.
16. Offer perineal pad or panty liner before This avoids staining of clothing.
the patient resumes ambulation. Place
patient in a comfortable position.
17. Remove the gloves by pulling them Removing gloves in this manner prevents
inside out and placing them in an spread of microorganisms.
appropriate receptacle (yellow garbage
bin).
18. Wash hands.
19. Record your observations, and the A written summary provides an accurate
response of the patient. documentation of the care given and response
of the patient to treatment.
20. Check with the patient in 15 minutes to Decreases patient’s anxiety.

ensure that the suppository did not slip
out and to allow patient to verbalize
any concerns or problems.
21. Observe for effectiveness of the

medicine. Inspect the condition of the
vaginal canal and external genitalia
between applications.
Sample Documentation:
5/2/2011 11:30 AM White cheesy patches noted

around the labia. Perineal care done.
Mycostatin suppository inserted to
vagina. Perineal pad applied.
Janice Reyes, St. N.
RECTAL MEDICATION
175
Definition: It is the insertion of a rectal medication in the form of a suppository which
melts at body temperature.
Purposes:
1. To produce a general or systemic effect such as reducing temperature and nausea.
Example: paracetamol
2. To stimulate defecation through mechanical pressure or chemical irritation of the
nerve endings of the rectum.
Example: bisacodyl
3. To destroy a number of microorganisms in the GIT pre and post GI surgery.
Example: metronidazole
Equipment: A tray containing the following:

1. Rectal suppository – straight from the refrigerator
2. Clean disposable gloves
3. Tissue paper
4. H2O soluble lubricant
Procedure
Action Rationale
1. Follow steps 1-4 (vaginal suppository)
5. Ask the patient to assume a side lying This position exposes the anus and helps the
(Sims) position with upper leg flexed. patient relax the external anal sphincter.
6. Cover patient with topsheet exposing Draping the patient maintains his privacy and
only the anal area. facilitates relaxation.
7. Don gloves.
8. Remove suppository from its wrapper,

and lubricate the pointed end or see
manufacturer’s instruction.
Note: Suppositories like Dulcolax must

be hardened first in the refregeratoror
through use of cracked ice to ensure it
stays intact during insertion.
9. Ask the patient to take slow, deep Forcing a suppository through a constricted
breaths through his mouth to relax the sphincter causes pain.
anal sphincter.
10. Retract the patient’s buttocks with The suppository must be placed against the
your non-dominant hand. With your rectal mucosa for eventual absorption and
gloved index finger, insert the therapeutic action.
suppository gently through the anus,
with a slight twisting motion past the
176
internal sphincter, and against the rectal
wall: 10 cm (4 inches) in adults, 5 cm
(2 inches) in children and infants.
11. Withdraw your finger and wipe off the This provides patient comfort. Urge to expel
patient’s anal area with toilet paper. it will pass in a minute or so.
Hold both buttocks tightly together for
a few seconds while patient breathes
deeply.
12. Discard the gloves by turning them Disposing of the gloves in this manner may
inside out and dispose of them in reduce transfer of microorganisms.
appropriate receptacle (yellow garbage
bin).
13. Ask the patient to remain flat or on this This prevents the expulsion of the
side for 5 minutes. If suppository is for suppository.
laxative purposes, it must remain in Stimulate the lower bowel within this time
position for 25 – 45 minutes or until frame.
patient has the urge to defecate
14. Wash your hands. Handwashing removes transient
microorganisms and reduces the risk of cross-
contamination to client and self.
15. If the suppository contains a laxative or Being able to call for assistance provides the
fecal softener, place the call bell within patient with a sense of control over
the patient’s reach so he can obtain elimination.
assistance to reach a bedpan or toilet.
16. Record objective and subjective Written information documents the procedure
findings, time of insertion and the given.
patient’s response.
PARENTERAL MEDICATION
177
Introduction:
Developing manual dexterity in the administration of parenteral medication before
approaching a patient with a needle and syringe greatly decreases nervousness. Giving an
injection means the possibility of causing pain. Focusing on the beneficial effect that the
medication brings to the patient will help ease apprehension.
The nurse must have the knowledge of parenteral medication, its action and effects. In
the nursing skills laboratory, the student can have a considerable time to learn and practice
the correct technique in the administration of an invasive procedure. The observance of the
standard precautions like aseptic technique and computation of dosages as well as mastery of
the procedure, will contribute to ensure that the medication reaches the proper location.
Definition:
Parenteral medication is the administration of medication into the body tissues other
than the alimentary tract.
General Instruction:
1. Use only sterile needles and syringes.
2. Select the appropriate length of needle to deposit the medication in the proper
tissue layer.
3. Select the injection site carefully to avoid major nerves, blood vessels and
underlying organs.
4. Select an injection site that is relatively free of hair, lesions, inflammation, rashes,
moles, freckles and the like.
5. Rotate injection sites for patients receiving repeated injections (e.q. insulin) by
establishing a predetermined plan.
6. Obtain, assistance as needed in giving an injection when the patient is a frightened
child or an uncooperative adult.
7. Aspirate by pulling back the plunger to avoid injecting subcutaneous and
intramuscular medications into a blood vessel (exception: heparin).
8. Check for drug allergies before administration of injection.
9. Know the medication you will administer and observe for side effects and
therapeutic action.
Common Routes:
1. Intradermal – ID
2. Subcutaneous – SQ, subcut, SC
3. Intramuscular – IM
4. Intravenous – IV
INTRADERMAL or INTRACUTANEOUS INJECTION
Definition: It is the introduction of a solution by means of a syringe and needle into the
superficial layer of the skin or just below the epidermis of the skin.
Purposes:
1. To identify allergens to which the patient may be hypersensitive (skin test).

2. To diagnose individuals who have developed antibodies against specific
pathogens, such as tubercle bacillus.
3. To vaccinate, e.g. BCG.
Sites of Injection:
178
1. Inner surface of the forearm
2. Upper chest if not hairy
3. Upper back beneath the
Equipment:
A. Injection tray lined with sterile towel containing:
1. Medicine ticket
2. Solution prescribed
3. Disposable sterile tuberculin syringe
4. Disposable sterile 2 cc syringe
5. Disposable sterile needle G25 – 26, 5/8”
6. Disposable sterile aspirating needle
7. A jar of CB soaked in 70% ROH (more than two CBs) / alcohol swab
8. Waste receptacle
Procedure
Action Rationale
1. Check the physician’s order and To ensure that the patient receives the right
assemble all equipment. medication at the right time by the proper
route.
2. Assess the patient’s history of allergies Certain substances have similar compositions,
and note the substances the patient is the nurse should not administer substance if
allergic to and normal allergic the patient is known to be allergic to prevent
reactions. its occurrence.
microorganisms.
4. Follow the basic 5 rights (1st 5 rights). Promotes patient’s safety by preventing
medication error.
5. Pick up syringe and attach aspirating This prevents contamination of the needle and
needle. syringe.
6. Proceed as in the procedure of Pharmaceutical products for parenteral
preparing/withdrawing a drug from an administration are supplied in various
ampule or vial. containers.
NOTE: To prepare for skin testing,

withdraw 0.9 cc of the diluent and
0.1 cc of the prescribed medicine.
7. Change aspirating needle with G – 25

or 26 needle. Maintain sterility by
retaining the cap of the needle. Place on
top of hypotowel.
8. Present preparation to C.I. or head This guards against error in medication.

nurse for checking together with the
empty ampule or vial of the drug
prepared and medication booklet for
signing.
9. Carry tray to patient’s room. Identify This prevents errors in medication. An
179
the patient and explain the procedure. explanation encourages patient cooperation
and reduces apprehension.
10. Select an area on the inner aspect of the The forearm is a convenient and easy location
forearm (or other appropriate sites). for introducing an agent intradermally.
11. Cleanse the area with CB soaked in Pathogens on the skin can be forced into the
70% alcohol wiping with a firm, tissues by the needle. Drying the skin will
circular motion and moving outward prevent introducing alcohol into the tissues
from the injection site. Discard used during injection as alcohol is irritating to the
CB. Allow the skin to dry. tissues and this makes patient uncomfortable.
12. Pick up syringe and remove the cap. Taut skin provides an easy entrance into
Use your non-dominant hand to grasp intradermal tissue.
the dorsal forearm and gently pull the
skin taut.
13. Place the needle 5-15 degree angle Intradermal tissue will be entered when the
against the patient’s skin. With bevel needle is held as near parallel to the skin as
side up, insert the needle beneath the possible and is inserted about 1/8 inch.
skin so that the point of the needle can
be seen through the skin. Insert the
needle only about 1/8 inch or almost
flat against the patient skin.
14. Slowly inject the agent while watching If a small wheal or bleb appears, the agent is
for a small wheal or bleb to appear. If in intradermal tissue.
none appears, withdraw the needle
slightly.
15. Withdraw the needle quickly at the Withdrawing the needle quickly and at the
same angle that it was inserted. angle at which it entered the skin minimizes
tissue damage and discomfort for the patient.
16. Do not massage the area after removing Massaging the area may interfere with test
the needle. Pat dry. Encircle the wheal results by spreading medication to underlying
with a blue or black pen. subcutaneous tissue. A red pen may influence
the reading.
17. Use the fish-hook technique to recap Most accidental puncture wounds occur when
the used needle and place it on top of recapping the needles. Using this method
the hypodermic towel. protects the nurse from accidental injury with
the needle.
18. Write the time injected, due time and The nurse considers the well–being of the
site at the back of the medicine ticket. patient.
19. Instruct the patient and/or watcher not The physician will interpret the result of the
to disturb the wheal nor erase the mark. procedure.
Inform the patient / watcher that you
will be back with the physician after 30
minutes.
20. Inform the CI or NOD of the procedure Awareness of the procedure done and to give
done, patient’s name, due time and site. time to contact the physician for
180
Endorse the medicine ticket to the interpretation.
NOD.
21. Leave the medicine ticket and the used If the result is doubtful, there may be a need
hypodermic syringe on the sterile. to re-skin test as ordered.
towel for possible re-skin testing. Wash Handwashing removes transient
your hands. microorganisms and deters cross-
contamination to clients and self.
22. Observe the area for signs of a reaction A circle easily identifies the site of
within 30 minutes. Accompany the intradermal injection and allows for careful
attending physician or ROD who will observation of the exact area.
interpret the result.
23. Write the positive (+) or negative (-)

sign on the appropriate space of the
medicine ticket, medication sheet and
on your medication booklet, as the case
may be.
24. Document in the chart the Accurate documentation is necessary to

administration of the medication. prevent a medication error.
a. time
b. name of drug
c. dosage
d. site of injection
e. result
f. name of physician who interpreted
the result.
Sample Documentation: Nurse’s Notes
Date Time
0.1 cc of Ampicillin 250 mg injected ID.
4/25/2017 9:00 a.m. Read as negative by Dr. N. Arce after 30
minutes.
Angel Cruz, St.N.
SAN PEDRO COLLEGE

Davao City
181
ADMINISTRATION of INTRADERMAL or INTRACUTANEOUS INJECTION
Name:_________________________________ Grade: ___________________

Year and Sec.: _________________ Date : ___________________
Rating
5 4 3 2 1
1. Verifies facts in the medication ticket by checking it
against the doctor’s order.
2. Obtains equipment and assembles syringe and needle to
be used on the injection tray.
3. Gets the drug from the patient’s medication box and
checks it with the medication ticket.
4. Washes hands.
5. Withdraws the drug with the prescribed amount/ dosage
from the ampule/ vial.
6. Changes aspirating needle with G.25 or 26 needle and
places it on the injection tray.
7. Presents preparation to CI/ Headnurse for checking.
8. Carries tray to patient’s bedside.
9. Confirms patient’s identity by asking for name or by
checking the wristband.
10. Explains the procedure to the patient.
11. Selects an appropriate injection site.
12. Exposes and cleanses area with cotton balls with
alcohol, from center moving outward in circular motion.
13. Picks up syringe between the thumb and 3 fingers with
the bevel of the needle pointing up.
14. Stretches skin by pulling skin to the back of the arm
with the non-dominant hand.
15. Places plunger almost parallel (at 5 to 15 degrees) to the
patient’s hand with the bevel up.
16. Injects solution slowly about 0.1 cc forming a bleb/
wheal.
17. Withdraws needle slowly and pats the area with dry
cotton ball.
18. Encircles the wheal with black or blue pen and instructs
patient and /or watcher accordingly.
19. Notes time of administration, due time and site at the
back of the medicine ticket.
20. Assists patient to a comfortable position.
21. Turns ticket upside down. Inform staff nurse or CI, skin
testing is over with complete data given.
182
22. Requests and accompanies the physician to read result
after 30 minutes.
23. Disposes materials used properly.
24. Washes hands.
25. Records/ documents medication on patient’s chart.
Notes time of administration, site, time due, physician
who read the result and puts the mark (-) negative or
positive (+) on the medicine ticket and medication sheet,
as the care may be.
26. Informs NOD/ HN of the result.
of the procedures.
Remarks:

II Performance 70%
100%
________________________________ __________________________
________________________________ __________________________
SUBCUTANEOUS or HYPODERMIC INJECTION
Definition:
183
It is the introduction of a small amount of solution by means of a syringe and needle
into the adipose tissue beneath the skin.
Purposes:
1. To deliver medication more rapidly to the bloodstream than oral administration.

2. To allow slower and sustained drug administration than intramuscular injection.
3. To prevent destruction of the drug by the action of digestive secretions.
4. To minimize tissue trauma and avoid the risk of hitting large blood vessels and
nerves.
Special Considerations:
1. If 2’’ (5 cm) of tissue can be grasped, insert the needle at a 90-degree angle; if
only 1” of tissue can be grasped, use a 45-degree angle for the injection.
2. Injection sites should be rotated from one side of the body to the other.
3. Heparin or insulin injections are given in the abdomen on both sides of and below
the umbilicus outside of a 2” radius around the umbilicus from the costal margins
to the iliac crests. May refer to hospital protocol for other sites. Do not aspirate
before injecting the heparin or insulin.
4. The needle angle used depends on the length of the needle and the amount of
subcutaneous tissue at the site.
5. A record should be kept of where each insulin injection is given. Insulin is
absorbed more quickly and uniformly when injected into the abdominal sites.
Precaution:
1. Subcutaneous injection sites should be rotated.
2. When giving medication other than insulin and heparin, aspirate after inserting the
needle into the site and before injecting the medication.
3. For heparin, injection sites should be rotated within the abdominal area only
alternating from one side to another.
4. For insulin, sites should be rotated in any available appropriate site.
Sites:
1. Lateral and anterior aspects of upper arm
2. thigh
3. lower abdomen
4. upper back
5. upper ventrogluteal and dorsogluteal areas.
Equipment:
1. Medicine
2. Medication tray
3. Injection tray – Hypo tray
4. Syringe
5. Disposable sterile aspirating needle
6. Disposable sterile injection needle g.25 5/8" or g.26 1"
7. Jar of CB with 70% ROH
8. Waste receptacle
9. Sharps container
10. Jar of dry CB
Procedure
Action Rationale
184
1. Get the medicine ticket and compare it The source of the order is more reliable than
with the doctor’s order. the medication ticket which is only a device
for convenience
2. Wash hands and assemble syringe and Deter the spread of microorganisms
needle to be used in the injection tray.
3. Withdraw the drug from ampule/vial Prolonged exposure to the air and or contact
into the syringe and replace the with moist surface will contaminate the
aspirating needle with the injecting needle.
needle.
4. Present the medication to your C.I. or The C.I’s signature signifies that the checking
Headnurse for checking and signing of process actually took place.
the medication booklet.
5. Carry tray to the patient’s bedside. Cooperation is easily gained when the patient
Identify the patient carefully and knows what is to be performed.
explain what you are going to do.
6. Select the site for injection (review Selecting a site where skin appears to be
sites). Rotate sites according to healthy and free of irritation and
schedule. inflammation reduces the discomfort of the
injection.
7. Cleanse with an alcohol swab (or CB Friction aids in cleaning the skin. A clean area
saturated with 70% ROH) the area to be is contaminated when a soiled object is
injected. Apply a firm, circular motion, rubbed over its surface. ROH 70% is an
starting at the center and going to the antiseptic solution for the skin.
outer portion of the area.
8. Grasp the area surrounding the site of Cushioning the subcutaneous tissue helps to
injection and hold in a cushion fashion. ensure having the needle enter into the
subcutaneous connective tissue.
9. Inject the needle quickly at an angle of Pain is minimized by inserting the needle
30 degrees to 60 degrees, depending on without hesitation. Subcutaneous tissue is
the amount of the tissue. abundant in well–nourished, hydrated persons
and scarce in emaciated dehydrated ones.
10. Once the needle is in position, release Injecting the solution into compressed tissue
the grasp on the tissue, and hold the results in pressure against nerve fibers and
hub of the needle. creates discomfort.
11. Pull back gently the plunger of syringe Substance injected directly into the blood
to determine whether needle is in the stream are absorbed immediately.
blood vessel or not.( Not done when
injecting HEPARIN or INSULIN)
12. If no blood appears, inject the solution Rapid injection may cause discomfort.
slowly. If blood appears, remove the
needle and replace it with a sterile one
before continuing with the procedure.
6. Rub the area gently with CB with Rubbing aids in the distribution and
ROH. Make patient comfortable. (Do absorption of the solution and relieves
not rub if contraindicated, like discomfort.
185
HEPARIN and INSULIN).
7. Turn the medicine ticket upside down Indicates the medicine has been administered.
on the hypo tray.
8. Do after care. Discard the used syringe Proper disposal of sharps prevents accidental
and needle into the container for sharps. pricks.
9. Wash your hands and return medicine Prevents transmission of microorganisms.

ticket to its box promptly. Careful management of tickets reduces error
and losses.
10. Record the drug given, amount given, Prompt recording prevents chances of errors
site and reactions, if any. in medication.
SAN PEDRO COLLEGE

Davao City
186
ADMINISTRATION of SUBCUTANEOUS INJECTION
Name: __________________________________Grade: ___________________

Year and Sec.: _________________ Date : ___________________
Rating
5 4 3 2 1
1. Verifies the order on the patient’s medication ticket/s by
checking it against the doctor’s order.
be used in the injection tray.
3. Gets the drug from the patient’s medicine box and
checks it with medication ticket.
4. Washes hands.
5. Withdraws the drug with the prescribed amount.
Changes the aspirating needle with the injection needle
and places it on the injection tray.
6. Presents the medication to the CI or Headnurse for
checking
7. Carries tray to the patient’s bedside
8. Checks patient’s identity by asking to state name and /
or by checking on his wristband.
9. Selects an appropriate injection site. Rotates sites
according to planned schedule.
10. Cleanses the area or injection site with CB with ROH
from center moving outward in circular motion.
11. Grasps the area around the injection site and holds in a
cushion fashion.
12. Injects the needle quickly at 300 – 600 angle depending
upon the amount of subcutaneous tissue present at the
site and the needle length.
13. Pulls back the plunger of the syringe gently to determine
whether the needle is in the blood vessel or not. (NA for
Heparin and Insulin)
14. Injects the drug slowly.
15. Removes the needle quickly and applies gentle pressure
at the site using CB with ROH.
16. Makes patient comfortable. Turns ticket upside down in
hypo tray.
17. Records the time and the date of injection, amount, site
and route and patient’s reaction to the medication.
18. Puts back the medication ticket to the box promptly.
19. Does after care. Disposes equipment properly.
20. Washes hands.
187
of the procedures.
Remarks:

II Performance 70%
100%
________________________________ __________________________
________________________________ __________________________
INTRAMUSCULAR INJECTION
Definition:
188
It is the introduction of medication deep into the muscle tissue where a large network
of blood vessels can absorb it readily and quickly.
Purposes:
1. To allow less painful administration of irritating drugs.

2. To allow more rapid absorption of the drug compared to subcutaneous injection.
3. To administer large doses (up to 5 ml in appropriate sites) of the medication.
4. To give drugs to patients who can not take medications orally and for drugs that
are degraded by the digestive juices.
Sites:
1. deltoid
2. vastus lateralis
3. rectus femoris
4. dorsogluteal
5. ventrogluteal
Equipment:
1. Hypodermic tray lined with sterile towel.
2. Prescribed medication
3. Medication ticket
4. Sterile needles for aspirating and for injecting G.20 – 22 1 ½”
5. Sterile syringes
6. Jar CB soaked in 70% ROH
7. Waste receptacle
8. Sharps container
9. Jar of dry CB
Procedure
Action Rationale
1. Follow steps # 1-7 of subcutaneous

injection.
8. Select the sites for injection:
i. VENTROGLUTEAL
Place palm of left hand on ®
greater trochanter so that index
finger points toward anterosuperior
iliac spine. Spread first and middle
fingers to form a V. The injection
site is the middle of the V.
ii. DORSOGLUTEAL
Place hand on iliac crest and Toes pointing inward will relax the muscles
locate the posterosuperior iliac of the buttocks. Injection into tense muscle
spine. Draw an imaginary line causes pain. Good visualization of the buttock
between the trochanter and the iliac aids in correct location of the site.
spine. The injection site is the outer
quadrant.
C. DELTOID:
Locate the lower end of the acromial This is the densest site containing no major
process and measure 2 – 3 fingers blood vessels and nerves.
189
breadths. Inject just below that area.
D. VASTUS LATERALIS/RECTUS
FEMORIS
Locate middle outer third of the thigh This area contains big muscles.
by dividing the thigh into 3 parts and
drawing a longitudinal line from the
greater trochanter of the femur down
to the knee. Select the middle third
lateral aspect as injection site.
9. Gently tap the selected site of injection Stimulation of the peripheral nerve helps to
with fingers several times. minimize the initial reaction when the needle
is inserted.
10. Clean the area thoroughly using CB Pathogens present in the skin can be forced
with ROH from the proposed site of into the tissue by the needle.
injection going outside in a circular
motion. Have an extra alcohol swab
ready for use after injection.
11. Grasp the area surrounding the site of Cushioning the subcutaneous tissue helps to
injection and hold it in a cushion ensure having the needle enter into the areolar
fashion. connective tissue.
12. Once the needle is in position, release Injecting the solution into compressed tissue
the grasp on the tissue, and hold the results in pressure against nerve fibers and
hub of the needle. creates discomfort.
13. Inject the needle quickly at 900 angle. Pain is minimized by inserting the needle
without hesitation (see book for 900 L).
14. Pull back gently the plunger of syringe Substance injected directly into the blood
to determine whether needle is in the stream are absorbed immediately.
blood vessel or not.
15. If no blood appears, inject the solution Rapid injection may cause discomfort.
slowly. If blood appears, remove the Beginning again prevents the medication from
needle, discard the set and begin the being injected intravenously and the
procedure. Prepare another dose of reinjection of aspirated blood.
medication.
16. Rub the area gently with CB with Rubbing aids in the distribution and
ROH. Make patient comfortable. Do absorption of the solution and relieves
not rub if contraindicated. discomfort.
17. Turn the medicine ticket upside down Indicates the medicine has been administered.
on the injection tray.
19. Wash your hands and return medicine Prevents transmission of microorganisms.
ticket to its box promptly. Careful management of tickets reduces error
and losses.
190
Z – Technique of Intramuscular Injection
Z – technique intramuscular injection is the introduction of oily or viscous medication

deep into the muscle tissue. The technique seals the medication in the chosen muscle site.
Indication:
It is used for certain drugs that irritate and discolor the subcutaneous tissues (eg. Iron).
It provides less discomfort and decrease the occurrence of lesions at the injection site.
Procedure
Action Rationale
1. Follow steps # 1-7 of subcutaneous
injection.
8. Using the thumb and forefinger make a Z–track method prevents leakage and tracking
movement forming Z on the muscles. of medication through subcutaneous tissue
9. Hold steadily the syringe and aspirate with needle removal after injection.
for blood.
9a. If with blood, withdraw the needle Presence of blood indicates the needle is
and dispose of the syringe and placed in a blood vessel where it is
needle. Draw up the medication contraindicated to inject the medication.
with a new syringe.
9b. If without blood, slowly inject the Injecting medication slowly allows the tissue
medication. Wait for 10 seconds to absorb the medication and prevents
before withdrawing the needle. untoward bruising. Waiting for 10 seconds
allows time for the medication to disperse into
Inject the needle slowly into the
the tissue, helping prevent it from traveling
muscles at 900 angle.
back up the needle track.
10. Withdraw the needle while releasing Letting go of the tissue while withdrawing the
the tissue. Gently wipe the injection site needle disrupts the path of the needle track,
with ROH swab. DO NOT MASSAGE preventing the medication from traveling to
the SITE. Use alternate sites for the skin surface. Massage might force the
subsequent injections. medication out into the SQ tissue.
11. Make patient comfortable.
12. Turn back the medicine ticket on the Indicates the medicine has been administered.
injection tray.
14. Wash your hands and return medicine Careful management of tickets reduces error
ticket to its box promptly. and losses.
191
SAN PEDRO COLLEGE
Davao City
ADMINISTRATION of INTRAMUSCULAR INJECTION
Name: ________________________________ Grade: ________________________

Year and Sec.: _________________ Date : ________________________
Rating
5 4 3 2 1
1. Verifies the facts on the medication ticket by checking it
against the doctor’s order.

be used in the injection tray.
3. Gets the drug from the patient’s medicine box and
checks it with medication ticket.
4. Washes hands.
5. Withdraws the prescribed amount of drug. Replaces the
aspirating needle with the injection needle and places it
on the injection tray.
6. Presents the medication to CI or headnurse for checking.
7. Confirms patient’s identity by asking to state his/her

name or by checking on wristband.
8. Selects an appropriate injection site. Locates the site
correctly.
9. Cleanses the injection site with CB with ROH from the
center outward in circular motion.
10. Grasps the area around the injection site and holds in a
cushion fashion.
11. Injects the needle quickly at an angle of 900.

12. Pulls back gently the plunger of the syringe to determine
whether the needle is in the vein or not.
13. Injects the drug slowly.
14. Removes the needle quickly and applies gentle pressure
at the site with CB with ROH.
15. Makes patient comfortable. Tears / turns back
medication ticket.( for STAT order only)
16. Records time and date of injection, amount, site and
route of administrations as well as patient’s reaction to
the combined Doctors’ and Nurses’ notes.
192
17. Puts back the medication ticket to the patient’s medicine
box or Kardex promptly.
18. Does after care. Disposes equipment properly.

of the procedures.
Remarks:
II Performance 70%
100%
________________________________ __________________________
________________________________ __________________________
193
ASPIRATING DRUGS from AMPULES and VIALS
Action Rationale
AMPULES
1. Before preparing to open the ampule The drug tends to be trapped in the stem and
make certain that all of the drug is in it may be necessary to tap the stem several
the ampule proper and not in the stem. times to help bring the drug down.
2. Wipe neck of the ampule with cotton Wiping the ampule with an antiseptic solution
ball soaked in 70% alcohol. is necessary to remove the dust that might
have lodged in it.
3. Use sterile piece of gauze or dry cotton Sterile material is necessary because it will be
ball to hold ampule while breaking to in direct contact with the opening of the
protect the fingers. ampule when the stem is removed.
4. Discard cotton or gauze and the stem

and put the ampule down.
5. To remove drug, insert the needle into The fluid in the ampule is immediately
the ampule and withdraw the solution displaced by air, therefore there is no
being careful not to touch the mouth of resistance to its withdrawal.
the ampule with the needle in order to
minimize all chances of contamination.
VIALS
1. Remove metal cap by means of a file. This exposes the rubber part which is the
means of entrance into the vial.
2. Cleanse rubber cap with cotton ball This increases the pressure within the vial and
soaked in 70% alcohol. Inject air of the the drug can be withdrawn easily since fluids
same amount as the solution to be move from an area of greater pressure to an
withdrawn. area of lesser pressure.
3. Hold the plunger firmly when

withdrawing drugs from vial especially
when solution is in large amount.
STARTING an INTRAVENOUS INFUSION
Definition: Intravenous therapy is the aseptic instillation of fluid, electrolytes, nutrients or

medications through a needle into a vein.
Purposes:
1. To administer fluids and chemical substances when circumstances prevent the

patient from consuming a normal diet and oral liquids.
194
2. To replace fluids and chemical substances when the patient has experienced their
loss through vomiting, diarrhea, bleeding, etc.
3. To provide access to the circulatory system if it becomes necessary to administer
emergency medications.
4. To maintain an access to the circulatory system for the intermittent administration
of scheduled medications.
Nursing Considerations:
1. The solution will infuse safely at the prescribed rate.
2. The venipuncture site will remain nontender and not infected throughout the
infusion.
Factors Affecting Flow Rate:

1. Age 5. Patency of the needle
2. Condition of patient 6. Position of the site
3. Solution used 7. Height of the IV pole
4. Manufacturer’s drop factor 8. Kinking of the tube
Equipment:
A. An IV tray containing the following:
1. IV solution as ordered
2. IV tubing
3. Needle (butterfly or vasocan as the case may be)
4. Tourniquet
5. Antiseptic swabs or CB soaked in ROH
6. Plaster and masking tape for the label
7. Armboard, if needed
8. Scissors
9. Medicine ticket
10. IVF label
B:
1. IV stand
Procedure
Action Rationale
1. Check the IV solution and medication Checking ensures that the patient receives the
additives with the physician’s order. correct IV solution and medication as ordered
(compare medicine ticket with what is by the physician.
written on the medical order sheet.)
2. Wash your hands. This prevents the spread of microorganisms.
3. Gather all equipment and prepare the Having all equipment available saves time.
IV solution and tubing.
a. Maintain aseptic technique when Prevents the contamination of IV solution and
opening sterile packages and IV set which can infect rapidly the patient.
solution.
b. Clamp tubing, uncap the spike and This punctures the seal in the IV bag or bottle.
insert it into the entry site on the
195
bag or bottle as the manufacturer
directs. If an additive is ordered,
incorporate it before inserting the
spike into the entry site.
c. Suspend the IV solution on a hook Suction effect causes fluids to move into the
in the preparation area and press drip chamber and also prevents air from
the drip chamber and allow it to fill moving down the tubing.
at least halfway.
d. Remove the cap at the end of the This removes air from the tubing which can in
tubing, release the clamp and allow larger amounts, act as an air embolus.
the fluid to move through the
tubing. (This is termed as priming
the tubing). Allow fluid to flow
until all air bubbles have
disappeared. Close the clamp and
recap the end of the tubing,
maintaining sterility of the set–up.
4. Notify the physician or nurse who will Facilitates accomplishment of the task.
insert the IV. When he/she arrives,
bring preparation to the bedside.
5. Identify the patient and explain the Explanation allays the patient’s anxiety.
procedure.
6. Have the patient in a supine or low The supine position permits either arm to be
Fowler’s position in bed. used and allows for good body alignment.
The low Fowler’s position is usually the most
comfortable for the patient.
7. Suspend the bag or bottle of solution on The fluid height should be 18 – 24 inches
the IV stand. above level of the vein. This height is
sufficient to overcome the venous pressure.
8. Hand the tourniquet to the doctor / Anticipating the needs of the doctor is one
nurse, followed by a CB with alcohol good characteristics of a nurse.
and the needle or vasocan. Observe
while the doctor / nurse is inserting.
9. Release the tourniquet when he/she The tourniquet causes increased venous
indicates or when a return flow of pressure resulting in automatic backflow, an
blood to the adapter is observed indication that the needle is inserted into the
(optional - can be done by doctor.) vein.
10. Connect the tubing to the needle.
11. Start the flow of solution promptly by Blood will clot readily if IV flow is not
releasing the clamp on the tubing. maintained. If the needle accidentally slips
Examine the site for signs of out of the vein, solution will accumulate and
infiltration. infiltrate into surrounding tissue.
12. Support the needle with a small piece The pressure of the wall of the vein against
of gauze or tissue paper under the hub, the bevel of the needle will interrupt the rate
196
if necessary, to keep the needle in of flow of the solution. The wall of the vein
place. can be easily punctured by the needle.
13. Loop the tubing near the site of entry The smooth structure of the vein does not
and anchor it with plaster to prevent offer resistance to the movement of the
pulling of the needle. needle. The weight of the tubing is sufficient
to pull the needle out of the vein if it is not
well anchored.
14. Anchor the arm to an armboard for An armboard protects against change in the
support, if necessary. position of the vein and acts as a reminder to
the patient to minimize arm movements.
15. Adjust the rate of flow according to the The physician prescribes the rate of flow in
doctor’s order accordance to the patient’s condition.
16. Complete the label and tape to the IVF

bag/ bottle.
17. Do the after care of equipment and Deters the spread of microorganisms.
wash your hands.
18. Document the procedure and the This provides accurate documentation and
patient’s response. Chart the time, site, ensures continuity of care.
device used, solution and rate of flow
and the physician / nurse who inserted
the needle.
19. Monitor periodically (at least every 30 This documents the patient’s response to the
minutes) to check flow rate and observe infusion.
for infiltration and other untoward
symptoms .
NURSING ALERT:
If infusion is not flowing well, lower the bottle/bag to check if the line is still patent.
NEVER FLUSH or PINCH IV tubings of infusion.
4/28/2017 3:30 PM D5LR 1L with 1 ampule Benutrex C
inserted as venoclysis by Dr. Flores to the
left dorsal metacarpal vein and regulated
at 30 gtt/min. No untoward symptoms
noted.
Leny Rodrigo, St. N.
197
SAN PEDRO COLLEGE
Davao City
STARTING an INTRAVENOUS INFUSION
Name: _________________________________ Grade: _____________________

Year and Sec.: _________________ Date : ____________________
Rating
5 4 3 2 1
1. Checks the written medical order.
2. Washes hands.
3. Assembles needed equipment.
4. Closes the roller clamp in the tubing.
5. Removes the protective covering of the IV bag / bottle
and tubing without contamination.
6. Incorporates additives aseptically as needed
7. Connects the tubing to the IV bag/bottle.
8. Partially fills the drip chamber.
9. Opens the clamp and flushes air from the tubing (primes
the tubing).
10. Calls the doctor/nurse and brings preparation to bedside.
11. Identifies the patient. Explain the prcedure to the client
12. Hangs the fluid container on the IV stand.
13. Assists the patient to a low Fowler’s position.
14. Assists the physician / nurse in the insertion of IV fluid.
15. Releases the tourniquet.
16. Opens the roller clamp to allow slow but gradual
infusion of solution.
17. Notes that solution continues to drip and site does not
become swollen.
18. Secures tubing with strips of plaster.
19. Adjusts the flow rate as prescribed.
20. Restrains the arm with an armboard as necessary.
21. Positions patient comfortably.
22. Attaches the completed IVF label.
198
23. Does after care of equipment.
24. Washes hands.
25. Records the appropriate information on patient’s chart.
Remarks:

II Performance 70%
100%
________________________________ __________________________
________________________________ __________________________
199
PERIPHERAL VEINS USED IN INTRAVENOUS THERAPY
200
REGULATING INTRAVENOUS FLOW RATE
To prevent circulatory overload or underload, the nurse must administer IVF

medication at the prescribed flow rate – the amount of fluid given at a specified time. The
nurse should mathematically convert the rate of infusion prescribed by the physician into
comparable drops per minute. Use the standard formula hereunder to calculate the correct
flowrate:
a. Standard Formula:
Rate = Volume (cc) x gtt factor (cc)
Duration (hrs) x 60 min/hr (constant)
Duration = Volume (cc) x gtt factor (cc) .

Rate (gtt/min) x 60 min/hr (constant)
Drop Factor:
Blood – wgtts/cc
Macroset – 15 or 20 gtts/cc (check manufacturer’s direction)
Microset – 60 mgtts/cc
Example:
1. How many hours would 500 cc D5IMB last if the rate is 30 mgtts/min.
Duration = 500 cc x 60 mgtts/cc .

30 mgtts/min x 60 min/hr
= 16.7 hours
2. How many cc/hr will you consume?
= 500
16.7
= 30 cc/hr.
Purposes:
1. To comply with prescribed rate ordered by the physician.

2. To assist in reassessing the progress of the fluid infusion.
3. To prevent circulatory overload or insufficient correction of hypovolemia.
Nursing Consideration:
1. Read the current written medical order for the volume and number of hours of
infusion.
2. Determine the manufacturer’s drop factor and the ratio of drops per milliliter.
Equipment:
1. Jotdown notebook and ballpen.

2. Wrist watch with a swift second hand.
3. Strip of plaster or masking tape as marker or to be used as time strip if necessary.
201
Procedure
Action Rationale
1. Check the physician’s order. This ensures that the correct solution is being
given with the correct medication and
determines the exact time/period for
administration of the IV solution.
2. Check the patency of the IV line and Any interference with the patency of the IV
needle. line will influence the IV flow rate.
3. Assess the IVF site, drip rate, volume The drop factor of the equipment varies
infused and correct operation of the according to the manufacturer and will be
device at least every hour for adults displayed on the outer package. Equipment
and more frequently for children. labeled as micro drop or minidrop is standard
and delivers 60 mgtt/ml but macrodrop
delivery systems vary. Some of the more
common types of equipment according to
manufacturer are Travenol Macrodrop, 10
gtt/ml, Abbott Macrodrop, 15 gtt/ml, and
McGaw Macrodrop, 15gtt/ml.
4. Count the drops per minute in the drip Holding the watch next to the drip chamber
chamber. Hold the watch beside the allows the eyes to focus on drops and the
chamber. second hand on the watch to provide an
accurate count.
5. Adjust the IV clamp as needed and This regulates the flow rate into the drip
recount the drops per minute. chamber.
6. Monitor the IV flow rate at frequent This provides for observation of the IV
intervals and the patient’s response to infusion and the patient’s response.
the infusion.
7. Document the ff:
a.) type of IV infusion
b.) amount
c.) flow rate
d.) patient’s response
4/28/2017 4:45 PM D5IMB 500 cc with ½ amp. Benutrex C

regulated at 30 mgtts/ min. Armboard applied to
limit movement of extremity. IVF continues to
infuse at above rate. No tenderness or swelling at
site. No dyspnea or shortness of breath noted.
Voided once, soaking wet his diaper.
Leny Rodrigo, St. N.
202
SAN PEDRO COLLEGE
Davao City
REGULATING INTRAVENOUS FLUIDS
Name: __________________________________ Grade: ___________________

Year and Sec.: ____________________________ Date : ___________________
Rating
5 4 3 2 1
1. Checks the written medical order.
2. Identifies the drop factor on the IV tubing package.
3. Calculates correctly the rate of drops per minute.
4. Checks the patency of the IV line and needle.
5. Counts the number of drops flowing into the drip
chamber for 1 full minute.
6. Tightens or releases the roller clamp until the calculated
rate is infusing.
7. Monitors the IV flow rate at frequent intervals.
8. Documents the type of infusion, amount, flowrate and
patient’s response to the prescribed infusion rate.
Remarks:
203
II Performance 70%
100%
________________________________ __________________________
________________________________ __________________________
204
DISCONTINUING an INTRAVENOUS INFUSION
When the patient no longer needs IV fluids, IV medications or access for emergency
drugs, the cannula is removed. Standard precautions must be followed when removing an IV
cannula because there is almost always a slight amount of bleeding that occurs.
Indications:
1. The patient’s oral fluid intake and hydration status are satisfactory so that no
further IV solutions are ordered.
2. There is a problem with the infusion that cannot be fixed.
3. The medications administered by IV route are no longer required.
Equipment:
An IV tray containing the following:
1. Dry CB
2. Plaster to cover the site temporarily / Band aid.
3. CB soaked in 70% ROH
4. Working gloves
5. Empty box for receptacle
6. IVF ticket
Procedure
Action Rationale
1. Check the physician’s order for Prevents inadvertently discontinuing the IV
discontinuing IVF. and having to restart it.
2. Wash hands and assemble equipment.
3. Identify the patient and explain the

procedure.
4. Release anchorage of arm, tubing and Movement of the needle can injure the vein
needle. Loosen the tape at the and cause discomfort to the patient.
venipuncture site while holding the Countertraction prevents pulling the skin that
needle firmly and applying causes discomfort.
countertraction to the skin.
5. Don gloves and clamp the infusion Clamping the tubing will prevent the fluid
tubing. from flowing out of the needle on the patient
or bed.
6. Hold a swab above the venipuncture Pulling out in line with the vein prevents
site, withdraw the needle quickly by injury at the vein.
pulling it out along the line of the vein.
7. Immediately apply firm pressure to the Pressure helps stop the bleeding and prevents
site, using the swab for 2 – 3 minutes. hematoma formation.
8. Hold the patient’s arm or leg above the Raising the limb decreases blood flow to the
body if any bleeding persists. area.
9. Check the needle or catheter to make If a piece of needle or tubing remains in the
patient’s vein it could move centrally (toward
205
sure it is intact. Report a broken needle the heart or lungs) and cause serious
or catheter to the nurse in-charge problems. Application of a tourniquet
immediately. If the broken piece can be decreases the possibility of the piece moving
palpated, apply a tourniquet above the until a physician is notified.
insertion site.
10. Apply the dry CB / Band aid to cover The dressing continues the pressure and
the IV site. covers the open area in the skin, preventing
infection.
11. Discard used supplies appropriately. This prevents the spread of microorganisms.
Remove gloves and wash hands.
12. Record the amount of fluid infused on This ensures accurate documentation of the
the I and O record sheet and on the patient’s response.
chart if necessary. Include the type of
solution used, time and reason for
discontinuing the infusion and the
patient’s response.
206
BLOOD TRANSFUSION
Definition: A blood transfusion is the introduction of whole blood or components of blood,

such as plasma, serum, erythrocytes, or platelets, into the venous circulation.
Purposes:
1. To restore/ increase circulating blood volume after surgery, trauma, child birth.
2. To restore or increase the red blood cell level after severe and chronic anemias and
to maintain blood hemoglobin levels such as in leukemia
3. To provide selected cellular components as replacement therapy such as clotting
factors, platelets and albumin.
Types of blood and blood products and indications for use:
Type Indications
1. Whole blood (type A,B,AB or O, To expand blood volume, to restore circulation

and Rh(+) or Rh(-) and renal blood flow when plasma volume is
decreased but the red cell mass is adequate, as
in acute hemorrhage, acute dehydration or
burns; to replace deficient coagulation factors
in bleeding disorders.
2. Packed red cells (high Used when blood volume is adequate but the
Hematocrit, since approximately red cell mass is inadequate, as in chronic
80% of the plasma is removed) anemia.
3. Platelets For patients with severe thrombocytopenia

(reduced platelets;) Replaces platelets, for
example in Dengue Hemorrhagic Fever.
4. Albumin To expand the blood volume rapidly when

blood volume is reduced in shock or burns;
also to increase level of albumin in patients
with hypoalbuminemia.
5. Prothrombin complex (for Used for bleeding associated with deficiencies

example, konyne, Proplex) of those factors.
contains factors VII, IX, and XI
and prothrombin
6. Factors VIII fraction or For hemophiliacs

(cryoprecipitate) Caution: May transmit infection, transfuse
with a filter.
7. Fibrinogen preparations Used particularly for bleeding associated with

congenital hypofibrinogenemia (a deficiency
of fibrinogen, a necessary factor for blood
coagulation)
207
PRECAUTION: There is no margin for error when administering blood products
because adverse reactions can be considerable and life-threatening.
1. Blood transfusion must be matched to the patient’s blood type (A,B,O,AB), Rh

group and other factors.
2. A blood product infusion should begin within 30 minutes of leaving the blood
bank.
3. A blood warmer may be used if the patient is in critical condition or it patient is
feeling chilly before infusion.
4. Blood transfusion should be checked every 15-30 minutes to ensure that it is
running on time.
5. Blood components that are still hanging after 4O without refrigeration must be
discontinued.
6. In the post infusion period, the patient’s urine is observed for signs of hematuria,
indicating a transfusion reaction.
7. If a transfusion reaction occurs, stop the blood, start the saline, stay with the
patient and immediately notify the physician. If shortness of breath occurs, start
low flow oxygen (1-2 L/min.) per agency protocol. Return the blood component
bag to the blood bank or laboratory with the transfusion reaction form.
Acute Transfusion Reactions:
CLINICAL
REACTION CAUSE
MANIFESTATIONS
ACUTE HEMOLYTIC Infusion of ABO incompatible Chills, fever, low back pain,
whole blood, RBCs or flushing, tachycardia, tachypnea,
components containing 10 ml or hypotension, vascular collapse,
more of RBCs. hemoglobinuria,
Antibodies in the patient’s plasma hemoglobinemia, bleeding, acute
attach to antigens on transfused renal failure, shock, cardiac arrest,
RBCs causing RBC destruction. death.
FEBRILE, NON- Sensitization to donor white Sudden chills and fever (rise in
HEMOLYTIC (most blood cells; platelet or plasma temperature of greater than 1 Oc),
common) proteins. headache, flushing, anxiety,
muscle pain.
MILD ALLERGIC Sensitivity to foreign plasma Flushing, itching, urticaria
proteins. (hives)
ANAPHYLACTIC Infusion of IgA proteins to IgA- Anxiety, urticaria, wheezing,
deficient recipient who has progressing to cyanosis, shock,
developed IgA antibody. possible cardiac arrest.
CIRCULATORY Fluid administered faster than the Cough, dyspnea, pulmonary

OVERLOAD circulation can accommodate congestion (rales), headache,
hypertension, tachycardia,
distended neck veins.
208
SEPSIS Transfusion of contaminated Rapid onset of chills, high fever,
blood components vomiting, diarrhea and marked
hypotension and shock.
Equipment:
1. Blood transfusion set (g. 19-22 needle) 5. Ordered 0.9% (NSS) 1L

2. Sterile dry CB (2 pcs.) 6. Plaster
3. Cross matching result 7. Working gloves
4. Ordered blood component 8. Sterile OS(1pc.)
Procedure
Action Rationale
1. Check the doctor’s order and Verifies doctor’s prescription for blood
Ensure that the consent form (if transfusion and patient’s consent.
required) is signed.
2. See that the patient has a patent A needle smaller than g. 19 may break up red
g. 18-19 cannula in place. cells.
3. Obtain the blood product from the Prevent bacterial growth and destruction of
laboratory and initiate transfusion RBC
within 30 minutes.
In the Laboratory check the following:

a. type of blood product
b. Client’s name, ward and room
number
c. Cross-matching compatibility
d. Donors blood group
e. Expiration date and time on
blood bag
f. presence of blood clot
4. Wash hands and assemble Deters spread of microorganisms and saves

equipment with another nurse. time.
5. Verify and record the blood product For safety 2 nurses must verify the order and
and identify the client with another match the numbers on the blood component
nurse with those of the crossmatching slip.
a. Compare the donor numbers, the Provides for a double-check, to decrease the
ABO group and the correct blood risk of error. The blood component must not
Type on the crossmatching slip be transfused after the expiration date. If the
with the label and numbers on the unit contains clots, it should be returned to the
blood component bag. One nurse blood bank or laboratory.
should read the numbers from the
crossmatching slip while the
other checks the numbers on the
blood component bag. Verify the
expiration date on the blood
component bag;check the bag for
clots.
209
b. client name, room and hospital
number, blood group and RH
type.
6. Don working gloves. Reduces risk of contact with blood borne

pathogens.
7. Close the clamp of the tube and Priming the filter and tubing, removes air and
insert the spike in the port of the eases the blood flow. Care is taken to close
blood bag. Invert the blood bag, clamp so that none of the blood products is
press the filter chamber, open the accidentally lost.
clamp and prime. Close the clamp.
8. Identify the patient and explain the Ensures the right patient to be infused. A
procedure.Instruct client to empty fresh urine specimen will be needed if
his/her urinary bladder transfusion reaction occurs (presence of
hematuria)
9. Check patient’s VS and known Provides baseline data.
allergies. If VS are above normal,
consult the physician
10. If the above mainline is not a saline Combining a small amount of saline with
solution, change it 1st with an blood decreases the viscosity and helps the
ordered NSS. Run it KVO rate. blood infuse more easily.
Keep the bottle /bag of the mainline
sterile.
11. Disinfect the injection port of the Y Prevents spread of contamination.
tube with CB in betadine solution.
12. Insert the g.19 needle to the port.
Wrap it with the sterile OS and
secure with the plaster. Close the
regulator of NSS.
13. Close the regulator of NSS. Regulate To observe for immediate as well as delayed
the blood flow at 20 gtts/minute for transfusion reactions. Most transfusion
the first 15 minutes. Remain with the reaction occurs within the first 15 minutes to
patient and monitor for at least 30 minutes. On going assessment is needed to
every 5 minutes for 15 minutes. detect delayed reaction.
Reassess patient’s vital signs at the
end of the 15 minutes. If no adverse
reaction occurs, adjust the flow rate
as ordered. Take vital signs at the
end of 30 minutes and then every 30
minutes or as directed by agency
policy, until the transfusion is
completed. Blood must be transfused
within 4 hours of release from the
blood bank or laboratory.
NOTE: Flow rate will depend on

the blood product to be infused.
a. RBC – 1 unit over 2-3 hours
(< 4 hours)
210
b. Platelets- 30-60 minutes or more
slowly (< 4 hours)
c. Fresh frozen plasma- 200 ml/hour
or more slowly.
14. Remind the patient to call a nurse Appropriate medical and nursing
immediately if any unusual interventions can be instituted.
symptoms are felt during the
transfusion.
15. If Any untoward reactions, occur,
STOP TRANSFUSION and report
to the NOD immediately.
16. After the transfusion, close the
regulators of both lines change NSS
to the previous solution and regulate
to the prescribed rate. Remove the
blood bag and discard appropriately.
17. Remove gloves and wash your
hands.
18. Document the following: Documentation is a proof that treatment has
1. Start and completion time of been carried out and shows what nursing care
transfusion. has been done.
2. Amount of blood given.
3. Blood type and serial number
4. Vital signs and assessment data
gathered during transfusion
5. Transfusion reactions if any and
its nursing interventions
SAMPLE DOCUMENTATION:
5/15/17 3:00 pm Initial VS taken: BP 110/90, P - 80, RR – 18.

3:15 pm Present IVF changed to plain NSS 1L. Regulated
to keep vein open. One unit of packed RBC type
O with SN01234567 started as sidedrip and
regulated at 20gtts/min. for the first 15 minutes.
Rate increased to 30 gtts/min. as ordered. No
unusual signs and symptoms noted. Coherent . No
complaints of any change in feelings. Pulse is
3:30 pm strong and regular. No fever nor chills noted. BP
120/90. Transfusion flow rate maintained at 30
gtts./min. Packed RBC flowing well as regulated.
BP stable at 120/90. Afebrile and conversant.
3:45 pm Pulse strong. No complaints of itchiness or nausea.
RBC transfusing well, BP and pulse strong and
4:30 pm stable. Breathing regularly. No change in temp.
6:00 pm Transfusion consumed and terminated. Mainline
IVF of plain NSS changed to previous fluid of D5
LR1L at 500 cc level. IVF regulated at 30gtt/m.
6:30 pm Fair condition. Dinner served. Ate well.
Piolo Pascal, St. N.
211
DISCHARGING CLIENT FROM THE HEALTH CARE AGENCY
Purposes:
1. To facilitate the person to return to a state of independence.
2. To determine the patient and family’s preparedness for discharge
3. To promote continued care outside the institution through linkages to community
resources.
4. To avoid legal and moral impediments for the health care practitioners, patients,
and family members after discharge.
Procedure
Action Rationale
1. Verify doctor’s order for discharge It is physician’s responsibility to
discharge a client
2. Administer discharge instructions on the following:

a. Medication- discuss the indication, adverse
reactions, route, dosage, frequency, and
duration
b. Exercise – explain the type of exercise needed
(active or passive)
c. Treatment – inform available resources in the
community for continuous treatment
d. Outpatient – inform the patient when to go back
to doctor’s clinic for follow-up check up including
the address and telephone numbers of the doctor’s
clinic
e. Diet – explain to the patient and significant others
the type of foods therapeutic to client. Facilitate
referral to the dietician if ordered.
3. Determine the availability of community resources

necessary for client’s continuous care such as
Health clinics, rehabilitation centers
4. Verify availability of therapeutic equipment/

assistive devices necessary for home care such as
walker/cratches, wheelchairs, oxygen set, suction
machine, respirator, nebulizer, and the like.
5. Carry out medical orders of termination of

therapeutics before discharge ( i.e. discon-
tinuation of IVF, catheters, etc.)
6. Facilitate billing procedures. Instruct patient/

Significant others about the proceedings. Refer
Patient to the social work services for financial
Assistance when necessary.
212
7. Instruct the patient to present the discharge
slip to the nurse on duty when obtained.
8. Assist the client to change hospital

gown to street clothes and pack up belongings.
9. Wheeled the patient to hospital exit according

to institutional discharge protocol.
10. Present the discharge slip to the security guard

11. Ensure that transportation is available and safe
for the client.
12. Go back to the unit and strip patient’s bed sheets

following standard precautionary measures.
facilitate general cleaning of patient’s room
by the housekeeping personnel.
13. Wash your hands

14. Document the procedures
SAMPLE DOCUMENTATION
April 10, 2017 8:15 AM Seen and examined by Dr. Cruz with discharge order.
Surgical Resident on Duty, Dr. Go gave discharge plans
8:25 AM Discharge health teachings rendered to patient and significant
others to wit:
a. Take home medications including right dosage, route,
frequency, and duration of treatment
b. Perform active range of motion exercises on unaffected
limb
c. Elevate affected limb with 2 pillows
d. Use crutches as demonstrated when ambulating
e. Perform daily dressing of wounds as demonstrated using
aseptic technique
f. Remind to go back to Dr. Cruz’s clinic on April 17, 2017 at
1:00pm.
g. Encourage high fiber diet such as leafy vegetables, fruits.
h. Include high protein food such as meat and fish
11 AM IVF discontinued as ordered.
11:10 AM Billing form forwarded
11:55 AM Discharged per wheelchair, with accounting clearance
Gina Lopez, RN, MAN

PRC#120910
213
San Pedro College
Davao City
DISCHARGING PATIENT from the HEALTH CARE AGENCY
Name:_________________________________ Rating:____________________
Year/Section:____________________ Date:_____________________
PROCEDURE 5 4 3 2 1
1. Checks patient’s chart for doctor’s order
2. Carries out discharge order
3. Renders discharge health teachings utilizing METHOD process
4. Determines availability of therapeutic/assistive device to be used
at home (if applicable)
5. Informs patient/significant others of available health care
facilities in the community
6. Follows up clinical summary if needed
7. Facilitates billing process making sure that the physician has
written the complete patient’s diagnosis
8. Informs patient/significant others of their schedule to follow up
billing form at the billing section and cashier.
9. Secures the discharge slip from the patient/significant others
when available
10. Instructs patient to change hospital gown to street clothes
11. Ensures that patient has packed up all belongings
12. Wheels the patient to hospital exit
13. Presents the discharge slip to the security guard
14. Ensures that patient boarded to transport service safely
15. Returns to the unit, strip the bed
16. Informs housekeeping personnel to clean the room
17. Washes hands
18. Documents the procedure
Remarks:
________________________________ ___________________
Students’ Signature Over Printed Name Date
________________________________ ___________________
Insructors’ Signature Over Printed Name Date
214
POST MORTEM CARE
Definition: It is the care given to the body after death.

Purposes:
1. To prepare the body in a manner that will reduce the family’s distress when
viewing the body.
2. To prevent distortions in the body’s appearance.
Equipment:
1. A basin half–filled with water.
2. Towel and wash cloth
3. Cotton balls
4. Identification tags (2)
5. Safety pins
6. Forceps
7. Mortuary gown
8. Plastic bag for soiled equipment
9. Working gloves
10. Plaster if not using shroud kit.
Procedure
Action Rationale
1. Let the doctor pronounce the patient’s This is a necessary legal procedure.
death. Note the exact time of death.
2. Screen the bed in the ward or close the Other patients may be upset with the sight of
door in the private room. the roommate’s death. The family will
appreciate privacy with the body.
3. Wash hands.
4. Assemble the equipment for the The body is prepared in a clean condition
cleaning, wrapping and identifying the before it is transferred to the mortuary.
body.
5. Put on working gloves
6. Place the body supine with the arms A normal anatomical position prevents
extended at the side or folded over the discoloration of the skin from pooling blood
abdomen. in the area visible in a casket.
7. Close the eyelids by applying gentle Creates a natural sleeping appearance.The

pressure. If lids do not close, saturate eyes may not be easily closed if the time
cotton with water and place it over the between the death and preparation of the body
eyes (remove after). is prolonged.
8. Replace or retain dentures within the Dentures maintain the natural contour of the
mouth. face. They may be difficult to insert several
hours after death.
215
9. Place a small towel under the chin to If the mouth is allowed to remain open, it may
close an open mouth. resist closing later.
10. Remove soiled dressings, venipuncture Live pathogens continue to be present even
devices, indwelling catheter, etc. and though the patient is dead. A container acts as
dispose all contaminated and soiled transmission barrier to control the spread of
items to appropriate containers. microorganisms.
11. Pack all body orifices with cotton using Stool or urine may be released after death
forceps. If to be embalmed when the sphincters relax.
immediately, packing is not necessary.
12. Cleanse any obviously soiled areas of Because the body is washed by the mortician,
the body. Provide grooming and a complete bath is not required. Cleansing and
hygiene to the person’s face and hair grooming the body provides support to the
by: family.
a. Washing any secretions from the
face.
b. Combing the hair in a neat style.
c. Removing any hair clips and pins
13. Remove and make inventory of the All personal valuables must be accounted for.
valuables still attached to the body.
14. Endorse valuables to the family. Valuables must be returned to the immediate
family.
15. Dress the deceased with the mortuary Tagging facilitates determination of the
gown, if any. Attach identification tag identity of one body from another.
to the right great toe or right ankle.
16. Cover the body with a clean mortuary Covering the body promotes respect and
sheet and zip it. Attach the second prevents its observation by curious on-
identification tag at the top of the sheet. lookers.
17. Remove gloves and dispose of Handwashing deters the spread of
properly. Wash hands. microorganisms.
The permanent records should note where and
18. Complete charting. to whom the body was endorsed.
19. Prepare the room for terminal The unit must be cleaned and disinfected for
disinfection. subsequent use.
Date Time Nurse’s Note
5/31/2017 9:00 AM Last rites administered by Fr. Cruz.
9:30 AM BP not audible. Pulse not appreciated.
10:00 AM Examined by Dr. Flores. Pupils are fixed and
dilated.
10:05 AM Pronounced dead by Dr. Flores in the presence
of family members
10:10 AM Jewelries given to the wife.
10:15 AM Post mortem care performed.
10:30 AM Brought to morgue per stretcher.
Sunshine Lacruz St. N.
216
PHYSICAL ASSESSMENT
Definition: It is a systematic, comprehensive, continuous collection, validation and

communication of client’s data using a variety of methods.
Purpose:
1. To obtain baseline data and expand the data base from which subsequent phases of
the nursing process can evolve
2. To identify a variety of patient problems (actual and potential)
3. To identify factors placing the patient at risk and determine the areas of preventive
nursing.
4. To evaluate the outcome of treatment and therapy.
5. To enhance the nurse-patient relationship
6. To make clinical judgments
Equipment:
Stethoscope Safety pins and cotton swabs

Ophthalmoscope / otoscope Pen light
Tuning fork Sphygmomanometer
Percussion hammer Watch with second hand
Snellen’s Chart Tape measure
Tongue depressor Special marking pen
Techniques:
A systematic approach to physical assessment is important to prevent omissions. The

usual sequence of assessment activities are (1) look (inspect), (2) feel (palpate), (3) tap or
thump (percuss), and (4) listen (auscultate).
1. Inspection – it is an assessment technique in which the examiner observes the body

surface. The nurse notes the general body contour, posture, color of skin,
presence of rashes, scars and any external visible pathology.
2. Palpation – is an assessment technique in which the examiner feels with his or her
fingers and one or both hands. The degree of pressure applied during palpation
varies, depending on, for example, the tenderness of the area and the depth of
palpation required. Some organs are always palpable and changes in size,
shape and location may be felt. Others are palpable only when enlarged or
displaced.
3. Percussion – is an assessment technique in which the examiner “thumps” or “taps” a body
surface with a percussion hammer or the hand or fingers. Percussion assesses
density of a cavity or organ.
4. Auscultation- is an assessment technique in which the examiner listens to and
assesses the sound produced by various body organs and tissues such as heart,
lung or bowel with the use of a stethoscope.
Essential Conditions for a Good Physical Examination

1. Good lighting and ventilation
2. Full exposure of the area to be examined
3. Patient in a relaxed state.
4. Grounded with ethical considerations ( consent, privacy, confidentiality, veracity
and voluntarism)
217
General Procedure
1. Explain the procedure to the client to avoid unnecessary anxiety as well as

facilitate patient’s cooperation.
2. Obtain patient’s consent (written or verbal) to ensure that patient’s right is
respected.
3. Gather all equipment to save time and energy.
4. Wash hands to deter spread of microorganisms.
5. Don gloves when necessary to protect from infectious microorganisms.
6. Close the curtains and doors to provide privacy.
7. During interview, ask questions tactfully in a non-judgmental way to avoid
patient’s intimidation.
8. Use open-ended questions oftentimes to explore patient’s data and history.
9. Expose only the area/s being assessed to avoid unnecessary exposure.
10. Perform physical assessment appropriately and efficiently.
11. Communicate to the patient the result of your assessment.
12. Show gratitude and appreciation to patient after the procedure.
13. Do aftercare.
14. Document the procedure with your assessment findings.
15. Notify the physician for any abnormalities noted to promote collaborative
management.
CONTENTS OF A PHYSICAL EXAMINATION
I. General Survey
Observe for: - race, sex

- general physical development
- nutritional state
- mental state (oriented, disoriented, confused, responsive,
unresponsive, incoherent, somnolent, unconscious)
- evidence of pain, restlessness
- body position, stature, gait
- clothes, age, hygiene, grooming
- emotional status, including attitudes or mood
- apparent state of health, in acute distress or chronically ill.
II. Vital Signs and Clinical Measurement

Include actual body weight, height, temperature, blood pressure (BP), pulse rate (PR),
respiratory rate (RR), and heart rate (HR).
III. Skin
1. Color – cyanosis, pallor, jaundice, flushing, pigmentation.
2. Lesions – macule, papule, etc. (distribution, type, configuration, size).
3. Vascularity – evidence of bruising, bleeding, edema, vascular and purpuric lesions
(angioma, purpuras, petechiae)
4. Moisture – dryness, sweating, oiliness
5. Texture – rough, smooth, scaly
6. Temperature – warm, hot, cold
218
7. Mobility and turgor – firm, loose, wrinkled, edematous, turgid, skin rapidly
resumes its original shape; loss of turgor is indicated by persistence of the skin
fold for a time after pinching.
8. Hair and nails.
NOTE: The skin is normally warm, slightly moist and smooth and returns quickly to
its original shape when picked up between two fingers and released.
IV. Head - normally, the skull and face are symmetrical, with distribution of hair varying
from person to person.
1. Hair – quantity and distribution
texture – dry, brittle; luster, color
2. Scalp – lice, dandruff, lesions, lacerations, tenderness or swelling.
3. Skull – size, contour, configuration, depression
4. Face – portrays emotions, pain intelligence and understanding

a. observe for expression – flat, expressionless, wide eyed, confused or
quizzical expression, angry, excited.
b. Symmetry
c. Edema
d. Masses or lesions
e. Involuntary movements- tics, spasmodic contractions
f. Shape – round, oval, triangular
g. Skin – color and pigmentation
5. Forehead – smooth, furrowed with wrinkles

6. Eyes – general expression, use of corrective aid such as contact lens, eyeglasses.
a. eyebrows – quality of hair, presence of flakes, scars, lesions, etc.
b. eyelids – lid margins are normally clear, the lacrimal duct opening (puncta)
are evident at the nasal side of the upper and lower lids.
Observe for:
- height of palpebral fissures (longitudinal openings between the eyelids
which appear equal in size when the eyes are open)
- blinking reflex
- presence of edema, hemorrhage, hematoma
- color – redness, cyanosis, pallor
- direction of lashes (outward, inward)
- lid eversion or inversion
c. Bulbar and palpebral conjunctiva – color (pale, pink, red)
- growths or lesions
d. Sclerae – clear, color and pigments
e. Cornea and lens – check transparency, opacities, ulcerations, scratches
f. Iris – color
g. Pupil - normally constrict with light and when looking at near objects and
dilate in the dark and when looking at far objects. They are round and can
change in size from very small (pinpoint) to large (occupying the entire
space of the iris)
h. Eyeballs
- position and alignment
219
- prominence of eyeballs – sunken, bulging
- eye movement
1. extra ocular movement – movement of the eyes in conjugate
fashion
2. nystagmus – rapid, lateral horizontal or rotary movement of the
eye; may be normal as result of fatigue
3. strabismus – deviation of one eye so that the visual axis is no
longer parallel to that of the other eye.
4. convergence – ability of the eye to turn in and focus on a very close
object.
i. Visual Acuity (use Snellen’s Chart)
- normal vision is 20/20
- myopia – near sightedness
- hyperopia – far sightedness
7. Ears – symmetry
a. pinna – observe for size, shape, color, lesions, masses, swelling.
- discharge – whether serous, purulent, sanguinous; observe
odor
- tenderness; consistency of the cartilage
b. external canal – normally clear with perhaps minimal cerumen
- examine for discharges; impacted cerumen; inflammation; masses,
foreign bodies, etc.
c. tympanic membrane – examine for color, luster, shape, position,
transparency, integrity, and scarring
d. auditory acuity – distance within which one can hear spoken words or a
watch tick (occlude one ear at a time when testing). A person with
normal hearing can hear whispered word from approximately 30-60
cms. and a watch tick from 13 cm.
e. response to mechanical tests
- Weber’s test – test for lateralization of vibration
- Rhine’s Test - compares air and bone conduction
8. Nose – inspect the external surface of the nose for symmetry color, shape
and size.
9. Mouth
a. lips – color; moisture; masses; ulceration; fissures; lesions; edema;
congenital defect.
b. teeth –number (32 in adult); arrangement; general condition; caries;
discoloration; fillings; absence of one tooth or more; abnormal
dental shape and use of artificial teeth.
c. gum – color; texture; discharge; swelling; retraction, bleeding;
lesions.
d. buccal mucosa – normally the mucosa should be pink, smooth and
fine lesions
e. tongue – is normally midline and covered with papillae which vary in size
from the tip to the back. Observe for the size; color;
thickness; lesions; moisture; symmetry; deviation from midline.
f. hard palate and soft palate; uvula – observe for ulcerations congenital
defects and symmetry when the patient says “ah”.
g. tonsils – size; ulcerations; exudates; inflammation
h. ability to masticate and swallow
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i. odor of breath – use of tobacco or alcohol, poor dental hygiene;
gingivitis, acetone breath – for diabetic coma, musty odor for severe
liver disease; urinary odor – for uremic status.
10. Pharynx – for inflammation; exudates and masses.
11. Larynx – voice (hoarseness) and disorder of speech.
V. Neck
a. Inspect all the areas of the neck anteriorly and posteriorly for muscular symmetry,
masses, unusual swelling or pulsations and range of motion - which includes right
and left lateral, right and left rotation, flexion, extension, and hyperextension. The
neck should move easily without any discomfort.
b. Thyroid – inspect enlargement; is not visible, especially in extremely thin persons.
If palpable, it is not normally smooth, without nodules, masses or irregularities, or
bruits (gushing sound) produced by blood moving through a narrow vessel.
c. Trachea – palpate for deviation
d. Lymph nodes and salivary glands – cervical nodes – not normally palpable unless
the patient is very thin.
- observe location, size, shape, consistenc
e. Carotid arteries – patient is or at semi-Fowler’s position (30-40 degrees); neck
should not be flexed.
f. Observe for any limitation (e.g. torticollis)
VI. Breast
a. nipples and areolae – position, pigmentation, inversion, discharge, crusting
and masses
b. breast tissue – size, shape, color, symmetry, surface, contour, skin
characteristics, level of breast; note for any retraction or dimpling
c. axillae – rashes, infection, lymph nodes
VII. Chest and Lungs

A. Inspection
Observe for Normal findings
- Symmetry of the posterior chest - Thorax is symmetrical, it moves easily
and the posture and mobility of and without impairment upon
the thorax upon respiration, respiration. There are no bulges nor
retraction of intercostal spaces retraction of the intercostal spaces.
- Note the anteroposterior - The AP diameter of the thorax in relation
diameter in relation to the to the lateral diameter is approximately
lateral diameter of the chest 1:2
Examine for skin lesions, masses, cyanosis.
- Respiratory rate and rhythm –
regular, irregular, noisy, deep,
fast, slow
- Presence of:
10. dyspnea – exertional, paroxysmal, nocturnal, orthopnea
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11. cough – single or paroxysmal
5. unproductive cough – short, sharp, no production of sputum.
6. productive cough – sputum is raised with rattle and distinctive sound – brassy
when it is unproductive and has strident quality
- whooping – characterized by long strident, inspiratory, noise (whoop
preceding the cough)
12. hemoptysis – spitting or coughing up of blood
13. describe sputum – color, amount, odor, time of day
14. hiccup or hiccough – sudden involuntary diaphragmatic contraction
producing an inspiration interrupted by glottial closure with a characteristic
sound
15. rib cage shape - funnel, barrel, pigeon
16. chest condition:
- presence of tubes and drainage
17. spinal deformities:
7. scoliosis – abnormal lateral curvature of the spine
8. lordosis – the normal anterior lumbar curvature is exaggerated
9. kyphosis – exaggeration of the normal thoracic convexity
B. Palpation
1. Palpate the ribs and costal margins for symmetry mobility and tenderness and the
spine for tenderness and vertebral position.
2. Areas of tenderness, masses, inflammation.
3. Fremitus – sensation felt by the hand when place on the part.
- ask patient to say ‘99’ posteriorly, it is generally equal throughout the
lung fields. It may be decreased or absent anteriorly, when posture is not
erect, or when excessive tissue or underlying structures are present.
4. Crepitation – fine crackling feeling due to air in the soft tissue, as in
subcutaneous emphysema.
5. Pleural friction rub – a leathery or grating feeling resulting from rubbing one
pleural surface against another and is due to the presence of
inflammation or absence of adequate lubricating fluid.
C. Percussion
- detect changes from normal density of the organ
- resonance: dull, flat, tympanitic
D. Auscultation
- quality of breath sounds: clear, coarse, diminished, absent
- rales – sound in the lung from the movement of fluid or exudates in the airway or
passage of air through constricted tube
a. coarse rales or rhonchi or gurgling rales – occur in the larger bronchi
b. moist, medium, crepitantrales – arise from relatively thin fluid moving in
bronchi or bronchioles
c. dryrales – produced by movements of thick exudate or the vibration of
inflamed or edematous membrane.
VIII. Heart
A. Inspection
- Inspect for bulging, heavy or thrusting in the precordium
- Note for pulsation
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- Precordial bulge – protrusion of bony thorax once right ventricle hypertrophies
due to enlargement from CHF
B. Palpation
- location of apical beat – note also rate, rhythm, duration
- presence of:
a. thrills- palpable murmur – fine buzzing sensation similar to that
felt while holding a purring cat
b. note size and force of PMI (point of maximal impulse)
C. Percussion
- define cardiac borders or area of cardiac dullness
D. Auscultation
- count cardiac rate, note cardiac rhythm – regular, irregular, rapid, slow
(tachycardia, bradycardia)
- abnormal beats – bigeminal, trigeminal, premature
- palpitations – pounding, fluttering, missing, stopping
- murmurs – turbulent blood flow, note pitch, quality, grade loudness, radiation
IX. Abdomen
A. Inspection
- be sure patient has an empty bladder, lying comfortably with abdomen
fully exposed.
1. Observe the general contour of the abdomen – flat, protuberant,
scaphoid, concave, local bulges, symmetry, visible peristalsis
aortic pulsations.
2. Umbilicus – contour , hernia, color, discharge, odor, signs of
inflammation
3. Skin – scars, rashes, lesions, pigmentation, etc.
B. Auscultation - abdomen have the familiar “growling” sound, it has 5 – 35 bowel

sounds per minute. There should be no rubs or bruits.
1. bowel sound – pitch, duration, absence, increased, gurgling
2. bruit – aorta and renal arteries – abnormal blood flow
C. Percussion
- note tympany and dullness (tympany normally predominates)
- masses; fluid levels
D. Palpation (light)
- determine muscle tension and resistance, tenderness and superficial masses or
organ enlargement
- skin fold test for dehydration
E. Palpation (deep)
- masses – size, shape, consistency, mobility, location
- abnormal distention – 6 f’s – fluids, fat, flatus, fetus, feces, food
- area of tenderness, deep and rebound tenderness
- palpable organs: liver, kidney, cecum and abdominal aorta
- lymph nodes – inguinal and femoral areas
X. Genito – Urinary
- observe distribution of pubic hair, size, shape, color lesion , edema nodules
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- external genitalia – size, location and placement of urethral meatus, discharge,
lesions.
- scrotum - size, contour, skin color, lesions, symmetry, shape, tenderness
- inspectmons pubis, labia majora, perineum, distribution of pubic hair,
inflammation, swelling, lesions, growths.
- separate labia and inspect vestibule – note inflammation, swelling, lesions,
discharges, atrophy, abnormal odor, clitoris, urethral opening, vaginal introitus
- groin – note any scars, lesions, enlarge lymph nodes, hernia, bulging
- rectum – perineal region – any discoloration, inflammation, skin lesions, scars,
tissues, fistula, hemorrhoids
XI. Extremities
Upper limb
6. Shoulder and Arms – inspect for swelling, deformity, atrophy, symmetry palpate
sternoclavicular joint at sternum, grooves and head of humerus for
tenderness, nodules, fluid (note: range of motion).
7. Elbows – note for swellings, nodules, deformities, observe range of motion.
8. Forearms – flex, extended, supinate, pronate – note range of motion; pain
9. Hands and Wrist – inspect missing, deformed fingers, contractures , swelling
redness, pallor, bone enlargements, nodules, atrophy, tremors.
- condition of hand – callused, strained, scarred, soft, well manicured.
- palpate all bones of the wrist, hands, fingers for tenderness or nodules
10. Nails – color, shape, deformities, lesions
Lower limb
11. Hip joint and thighs – range of motion, pain tenderness; if one leg is longer than
the other, any deformities, scars, amputation.
12. Leg and knees – range of motion, deformities, edema, inflammation
13. Foot – deformities (clubfoot, flatfoot), alignment, tenderness, range of motion of
ankle joint
14. Nails – color, deformities, lesions, shape.
TOPOGRAPHIC DIVISIONS OF THE ABDOMEN
RIGHT UPPER LEFT UPPER

QUADRANT QUADRANT
UMBILICUS
RIGHT LOWER
QUADRANT LEFT LOWER
QUADRANT
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Figure 8: The Abdominal Quadrants
Content of each quadrant:
1. Right Upper Quadrant – Liver, gallbladder, pylorus, duodenum, head of the pancreas,
right adrenal gland, portion of the right kidney, hepatic flexure of the colon, portions of
the ascending colon and transverse colon.
2. Left Upper Quadrant – Left lobes of the liver, spleen, stomach, body of the pancreas, left
adrenal gland, portion of the left kidney, portions of the transverse and descending colon,
splenic flexure of the colon.
3. Right Lower Quadrant – Lower pole of the right kidney, cecum, appendix, portions of the
ascending colon, bladder if distended, right ovary, right salpinx, uterus if pregnant, right
spermatic cord, right ureter.
4. Left lower Quadrant – Lower pole of the left kidney, sigmoid, colon, portion of the
descending colon, bladder if distended, left ovary and left salpinx, uterus is pregnant, left
spermatic cord, left ureter.
RIGHT LEFT
HYPOCHONDRIAC EPIGASTRIC HYPOCHONDRIAC
REGION
RIGHT UMBILICAL LEFT

LUMBAR REGION LUMBAR
HYPOGASTRIC
REGION
RIGHT INGUINAL LEFT INGUINAL
OR ILIAC OR ILIAC
Figure 9: The Nine Divisions of the Abdomen
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Content of the Divisions:
1. Right Hypochondriac – right lobe of the liver, gall bladder, part of the duodenum, flexure
of the colon, part of the right kidney, right adrenal gland.
2. Epigastric – pyloric end of the stomach, duodenum, pancreas, abdominal aorta portion of
the liver.
3. Left hypochondriac – stomach, spleen, tail of the pancreas, splenic flexure of the colon,
upper pole of the left kidney, left adrenal gland.
4. Right lumbar ascending colon, lower half of the right kidney, part of the duodenum and
jejunum.
5. Umbilical – omentum, mesentery, transverse colon, lower part of the jejunum and ileum.
6. Left lumbar – descending colon, lower half of the kidney, part of the jejunum and ileum.
7. Right Inguinal – cecum, appendix, lower end of the ileum, right ureter, right spermatic
cord, right ovary in females.
8. Hypogastric – ileum, bladder, pregnant uterus in females.
9. Left Inguinal – sigmoid, left ureter, left spermatic cord, left ovary.
POST PARTUM ASSESSMENT

Definition:
Post partum assessment is a process of thorough examination and evaluation of
the woman’s physical, psychological, and physiological functioning during a certain
period after giving birth; normal, caesarian section, or by instrumentation.
Purposes:
a. To examine the physical, psychological, and physiological status of post partum
patient.
b. To determine the involution process of post partum,
c. To evaluate the normal postpartum adaptation level,
d. To assess for possible postpartum complications.
Equipment:
a. Additional top sheet
b. Sterile and working gloves
c. BP apparatus
d. Thermometer
e. Tape measure
General Procedure:
1. Gather all equipment to save time and energy.
2. Wash your hands to deter spread of infection.
3. Explain the procedure to the patient, the nature of the procedure and purposes.
4. Upon entering the room, while communicating the patient, observe for patient’s
general appearance including how she communicate the newborn.
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5. Close doors, windows, and curtains to provide privacy.
6. Instruct the patient to void to prevent interruption of the procedure. Some
assessment technique may stimulate the patient to urinate.
7. Have the patient lie on bed to promote preferable and comfortable position for
both the patient and the examiner.
8. Instruct the patient to breath normally promote relaxation.
9. Do assessment correctly and efficiently using the AVBUBBLEHER technique:
9.1 A – APPEARANCE
a. Observe for patient’s general appearance, body built, activities, hygiene,
mood, color, and communication.
9.2 VITAL SIGNS
a. Take Blood pressure, cardiac rate, respiratory rate, pulse rate, and axillary
temperature. To determine patient’s physiologic status.
9.3 B – BREASTS-
a. Ask the patient if she is lactating and breastfeeding.
b. If the patient is wearing bra, instruct her to remove it.
c. Inspect the size, shape, color, and discharges.
d. Assess the nipples
e. Using the base of your four fingers, palpate the breast gently in a rotating
motion, one after the other. Make sure to expose only the breast being
examined.
f. Take note for localized tenderness and masses.
9.4 U – UTERUS
a. Instruct the patient to expose her abdomen. If the patient is wearing adult
diaper, open the diaper by pulling only the anterior part without removing
the diaper. This is to better visualize the area being examined.
b. If patient has delivered via caesarian section, gently pull the gauze or
dressing to visualize the incision site. Inspect the incision site. Replace the
gauze/dressing without contaminating it.
c. Check the relationship of the fundus to the umbilicus by measuring its
distance using finger-breadths. This will determine the involution of the
uterus.
d. Inspect the location of the fundus in the quadrant of the abdomen.
Displacement of the uterus may indicate full bladder and/or postpartum
problems.
e. Gently palpate the hypogastric area to determine uterine contraction.
Patient may complain of mild to moderate pain upon palpation, assure
patient that it is normal. If patient had caesarian delivery, palpate the
fundus with extreme care because the abdominal incision is exquisitely
tender.
9.5 B – BOWEL
a. Ask the patient when was the last time she defecated. Ask the consistency
and color of the stool. Constipation is common among postpartum patients.
If the patient has delivered via caesarian section or has underwent painless
delivery, bowel elimination might be delayed due to the effect of the
anesthetic agents.
b. Ask the patient if she has the urge to defecate. Patient may sometimes
withhold the urge to defecate due to pain in the perineal area.
c. Auscultate and listen for the bowel sounds.
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9.6 B – BLADDER
a. Ask the patient her last voiding time. Ask for the color, amount, and
presence of tenderness while voiding.
b. Inspect for bladder distention. Patient may hold urine due to pain during
urination. Full bladder will impede uterine contraction.
c. If patient is on indwelling catheter, take note of the patency of the tubings,
amount and color of urine.
9.7 L –LOCHIA
a. Assist the patient on dorsal recumbent position.
b. Inspect the diaper for discharges. Take note of the color, consistency,
amount, and odor.
c. With your gloved hands, you may hold the clots to determine if it is blood
clots or retained tissues.
d. If the diaper is soiled, instruct the patient to replace it with new one after
perineal washing.
e. Instruct patient to let the health care provider observe the diaper content
before discarding it.
9.8 E – EPISIOTOMY/EPISIORRHAPHY
a. Still on a dorsal recumbent position, inspect the perineum. Note the
presence of episiorrhaphy or repair of lacerations, its characteristics, color,
and discharges.
9.9 H – HOMAN’S SIGN

a. Assess the lower legs of the patient for any discoloration, distention, and
tenderness.
b. With the knees flexed, dorsiflex the foot of the patient. Instruct the patient
to report pain on the calf while doing the procedure. Pain on the calf during
dorsiflexion indicates positive Homan’s sign.
9.10 E - EMOTION
a. Observe patient’s behavior and responses during the whole interaction. To
evaluate patient’s emotional status.
b. Observe how the patient interacts with the newborn. To evaluate patient’s
postpartum emotional phase. At the same time, it will also evaluate
patient’s readiness for parenting role.
9.11 R - RHOGAM
a. Determine the blood rhesus factor of the patient, the husband, and the
newborn. To determine incompatibility or rhesus factor.
b. Note for signs of Rh incompatibility.
c. Ensure that the patient has received second dose of Rhogam within 72 hours
postpartum if Rh incompatibility is diagnosed or suspected as ordered by
the physician.
10. Inform the patient of the result of the assessment. Patient has the right to know
her condition.
228
11. Acknowledge patient’s cooperation during the procedure and express gratitude. To
strengthen nurse-patient therapeutic relationship.
12. Do aftercare.
13. Document the procedure and significant findings.
14. Refer to the physician if necessary so appropriate actions will be taken.
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SanPedroCollege
DavaoCity
PHYSICAL ASSESSMENT
Name:___________________________ Grade_________
Year & section____________________ Date__________
PHYSICAL HEALTH ASSESSMENT 1
1. Assessing Appearance and Mental Status
Equipment: RATING
Tape measure 5 4 3 2 1
1. Explain procedure to the patient. (what you are going
to do, why it is necessary, and how he can cooperate)
2. Do handwashing
3. Provide privacy
Assessment
4. Observe body built, height and weight in relation to
the client’s age, lifestyle and health.
5. Observe the client’s posture and gait, standing, sitting
and walking
6. Observe the client’s overall hygiene and grooming.
Relate these to the person’s activities prior to the
assessment.
7. Note body and breath odor.
8. Observe for signs of distress in posture or facial
expression.
9. Note obvious signs of health and illness
10 Assess the client’s attitude
11. Note the client’s affect/mood and the appropriateness
of responses
12. Listen for quality, quantity and organization of
speech.
13. Listen for relevance and organization of thoughts.
14. Document pertinent findings in the chart.
2. Assessing the Skin
Preparation
1. Assemble equipment and supplies: millimeter ruler,
examination gloves and magnifying glass.
2. Do handwashing.
Procedure
3. Provide Privacy.
Assessment
5. Inspect uniformity of skin color.
6. Assess edema if present.
7. Inspect, palpate and describe skin lesions. Apply
gloves if lesions are open or draining.
8. Observe and palpate skin moisture.
230
9. Palpate skin temperature. Compare two feet and the
two hands using the backs of fingers.
10. Note skin turgor.
Location of skin lesions on body surface diagram.

(drawing)
3. Assessing the Hair
1. Inspect the evenness of growth over the scalp.

2. Inspect hair texture and oiliness.
3. Note presence of infections or infestations by parting
the hair in several areas and checking behind the ears
and along the hairline at the neck.
4. Inspect amount of body hair.
4. Assessing the Nails
Equipment: Acetone
Cotton ball
1. Inspect the fingernail plate shape to determine its
curvature and angle.
2. Inspect fingernail and toenail textures.
3. Inspect fingernail and toenail color, lesions and
obvious deformities.
4. Inspect tissues surrounding nails.
5. Perform blanch test or capillary refill test (CRT).
6. Document findings in the chart.
5. Assessing the Skull and Face
1. Inspect the skull for shape and symmetry

2. Inspect the facial features.
3. Inspect the eyes for edema and hollowness.
4. Note symmetry of facial movements. Ask the client
to elevate the eyebrows, frowns or lower the
eyebrows, close the eyes tightly, puff the cheeks and
smile then show the teeth.
5. Palpate the skull for nodules or masses and
depressions. (include the fontanels for pediatric
patients) .
6. Assessing the Eye Structures and Visual Acuity
1. Assemble equipment and supplies:

• Cotton tip applicator
• Examination gloves
• Millimeter ruler
• Penlight
• Snellen’s chart or E chart
• Opaque card
6.a External Eye Structures
2. Inspect the eyebrows for hair distribution and

alignment and for skin quality and movement
3. Inspect the eyelashes for evenness of distribution and
direction of curl.
231
4. Inspect the eyelids for surface characteristics,
position in relation to cornea, ability to blink, and
frequency of blinking. Inspect the lower eyelids
while the client’s eyes are closed.
5. Inspect the bulbar conjunctiva and palpebral
conjunctiva (by everting the lids) for color, texture
and presence of lesions.
6. Inspect and palpate the lacrimal duct.
7. Inspect the cornea for clarity and texture. ( Ask the
client to look straight ahead. Hold a penlight at an
oblique angle to the eye, and move the light slowly
across the corneal surface).
8. Assess each pupil’s direct and consensual reaction to
light.
6b. Visual Fields
9. Assess peripheral visual fields
6c. Extraocular Muscle Tests
10. Assess the six ocular movements to determine the
eye alignment and coordination.
6d. Visual Acuity
11. Assess near vision
12. Assess distant vision
13. Perform functional vision tests if the client is unable
to see the top line (20/200) of the Snellen’s chart.
a. counting fingers
b. hand movement
c. light perception
7. Assessing the Ears and Hearing
1. Assemble equipment and supplies

• otoscope with several sizes or ear specula
7a. Auricles
2. Inspect the auricles for color, symmetry of size and
position.
3. Palpate the auricles for texture, elasticity and areas of
tenderness.
7b. External Ear Canal and Tympanic Membrane
4. Using an otoscope, inspect the external ear canal for
cerumen, skin lesions, pus and blood.
5. Inspect the tympanis membrane got color and gloss.
7c. Gross Hearing Acuity Tests
6. Assess client’s response to normal voice tones. If
client has difficulty hearing the normal voice,
proceed with the following tests.
7. Have the client occlude one ear, out of the client’s
sight, place a ticking watch 2-3 cm (1-2 in) from the
unoccluded ear. (watch tick tast)
8. Ask what the client can hear. Repaet with the other
ear.
7d. Tuning Fork Test
232
9. Perform Weber test.
10. Perform Rinne test.
11. Document pertinent findings.
8. Assessing the Nose and Sinuses
1. Assemble the equipment and supplies.

8.a. Nose
2. Inspect the external nose for any deviations in shape,
size or color and flaring or discharge from the nares.
3. Lightly palpate the external nose to determine any
areas to tenderness, masses and displacements of
bone and cartilage.
4. Determine patency of both nasal cavities. (Ask the
client to close the mouth, exert pressure on one naris
and breathe through the opposite naris. Repeat the
procedure to assess patency of the opposite naris.
5. Inspect the nasal cavities using flashlight.
6. Observe for the presence of redness, swelling, growth
and discharge.
7. Inspect the nasal septum between the nasal chambers.
8. Palpate the maxillary and frontal sinuses for
tenderness.
9. Document findings in the client record.
9. Assessing the Mouth and Oropharynx
1. Assemble the equipment and supplies:

• examination gloves
• tongue depressor
• 2 x 2 gauze pads
• flashlights or penlight
9.a. Lips and Buccal Mucosa
1. Inspect the outer lips for symmetry of contour, color
and texture. (Ask client to purse lips as it to whistle)
2. Inspect and palpate the inner lips and buccal mucosa
for color, moisture, texture and presence of lesions.
3. Palpate the tongue and floor of the mouth for any
nodules. Lumps or excoriated areas. (Use a piece of
gauze to grasp the tip of the tongue and with the
index finger of other hand, palpate the back of the
tongue, its border and its base.
9.b. Teeth and Gums
1. Inspect the teeth and gums while examining the inner
lips and buccal mucosa.
2. Inspect the dentures and gums underneath.
3. Ask the client to remove complete or partial dentures.
Inspect their condition, nothing in particular broken
or worn areas.
4. Inspect the surface of the tongue for position, color
and texture. Note for any deviation. (Ask the client to
protrude the tongue)
5. Inspect the tongue movement. (Ask the client to roll

the tongue upward and move it from side to side.)
233
6. Inspect the base the base of the tongue, the mouth
floor and the frenulum. (Ask the client to place the tip
of his tongue against the roof of the mouth.)
7. Inspect salivary duct openings for any swelling or
redness.
8. Don gloves
9.c. Salivary Glands
9.d. Palates and Uvula
1. Inspect the hard and soft palate for color, shape,
texture and the presence of bony prominence. (Ask
the client to open his mouth wide and tilt his head
backward. Then, depress tongue blade as necessary,
and use penlight for appropriate visualization.)
2. Inspect the uvula for position and mobility while
examining the palates. (To observe the uvula, ask the
client to say “ah” so that the soft palate rises.)
9.e. Oropharynx and Tonsils

1. Inspect the oropharynx for color and texture
2. Inspect one side at a time to avoid eliciting the gag
reflex. to expose one side of oropharynx, press a
tongue blade against the tongue on the same side
about halfway back and while the client tilts his head
back and opens the mouth wide. Use penlight for
illumination, if needed.
3. Inspect the tonsils for color, discharge and size.
4. Elicit the gag reflex by pressing the posterior tongue
with a tongue depressor.
5. Document findings in chart.
10. Assessing the Neck
10.a. Neck Muscle

1. Inspect the neck muscle (sternocleidomastoid and
trapezius for normal swelling or masses). Ask the
client to hold her neck erect.
2. Observe head movement. Ask the client to:
a.) Move her chin to the chest (determines function of
thew sternocleidomastoid muscle).
b.) Move her head back so that the chin points
upward.
c.) Move her head so that the ear is moved toward the
shoulder on each side (determines function of the
sternocleidomastoid muscle).
d.) turn her head to the right and to the left
(determines function of the sternocleidomastoid
muscle).
3. Assess muscle strength. Ask the client to :
a.) Turn her head to one side against the resistance of
your hand. Repeat with the other side.
b.) Shrug her shoulders against the resistance of your
hands.
10.b. Lymph Nodes
4. Palpate the entire neck for enlarge lymph nodes.
234
10.c. Trachea
5. Palpate the trachea for lateral deviation. Place your
fingertip or thumb on the trachea in the suprasternal
notch and then move your finger laterally to the left
and the right in spaces bordered by the clavicle, the
anterior aspect of the sternocleidomastoid muscle and
the trachea.
10.d. Thyroid Gland
6. Inspect the thyroid gland
a. Observe the lower half of the neck overlying the
thyroid gland for symmetry and visible masses.
b. Ask the client to hyperextend her neck and
swallow. If necessary, offer a glass of water for the
client to swallow.
7. Palpate the thyroid gland for smoothness. Note any
areas of enlargement, masses or nodules.
8. If enlargement of the gland is suspected:
Auscultate over the thyroid area for a bruit.
9. Document pertinent findings in the chart.
Comments
_________________________________ _____________
________________________________ ____________
Clinical Instructor’s Signature Date
235
A. Anterior View B. Posterior View
Figure 10 – Anatomical Position
236
SanPedroCollege
DavaoCity
PHYSICAL ASSESSMENT
Name:___________________________ Grade_________
Year & section____________________ Date__________
PHYSICAL HEALTH ASSESSMENT 2
1. Assessing the Thorax and Lungs

RATING
1. Assemble equipment and supplies: 5 4 3 2 1
*stethoscope
*Skin marker/pencil
*centimeter ruler
Assessment
2. Inspect the shape and symmetry of the thorax from
the posterior and lateral views.
3. Inspect spinal alignment for deformities.
Have the client to stand from a lateral position.
Observe the standing client from the rear. Have the
client bend forward at the waist and observe from
behind.
4. Palpate the posterior thorax.
For clients who have no respiratory complaints,
rapidly assess the temperature and integrity of all
chest skin.
For clients who do have respiratory complaints,
palpate all chest areas for bulges, tenderness or
abnormal movements. Avoid deep palpation for
painful areas especially if fractured rib is suspected.
5. Palpate the posterior chest for respiratory excursion.
Place the palms of both hands over the lower thorax,
with your thumbs adjacent to the spine and your
fingers stretched laterally. Ask the client to take deep
breath while you observe the movement of your
hands and any lag in movement.
6. Palpate the chest for vocal (tactile) fremitus, instruct
to say 1, 2, 3. Place the palmar surfaces of your
fingertips of the ulnar aspect of your hand or closed
fist on the posterior chest starting near the apex of the
lungs.
7. Ask the client to repeat such words as “blue moon”
or “one, two, three.”
8 Repeat the two steps moving your hands sequentially
to the base of the lungs.
9. Compare the fremitus on both lungs and between the
apex and the base of each lung either: 1) using one
hand and moving it from one side of the client to the
corresponding area on the other side 2) using two
hands that are placed simultaneously on the
237
corresponding areas of each side of the chest.
10. Percuss the thorax.
11. Percuss for diaphragmatic excursion.
12. Auscultate the chest using the flat disc diaphragm of
the stethoscope. Warm the diaphragm slow deep
breath.
13. Uses the systematic zigzag procedure used in
percussion.
14. Ask the client to take slow, deep breaths through the
mouth. Listen at each point to the breath sounds
during a complete inspiration and expiration.
15. Compare findings at each point with the
corresponding point on the opposite side of the chest.
Anterior Thorax
16. Inspect breathing patterns.
17. Inspect the costal angle and the angle at which the
ribs enter the spine.
18. Palpate the anterior chest.
19. Palpate the anterior chest for respiratory excursion.
Place the palms of both palms of your hand on the
lower thorax with your fingers laterally along the
lower rib cage and your thumbs along the costal
margins.
Ask the client to take a deep breath while you
observe the movement of your hands.
20. Palpate tactile fremitus in the same manner as for the
posterior chest.
If the breasts are large and cannot be retracted
adequately for palpation this part of the examination
is usually omitted.
21. Percuss the anterior chest systematically.
Begin above the clavicles in the supraclavicular space
and proceed downward to the diaphragm.
22. Compare one side of the lung to the other.
23. Displace female breasts for proper examination.
24. Auscultate the trachea.
25. Auscultate the anterior chest.
Use the sequence used in percussion beginning over
the bronchi between the sternum and the clavicles.
26. Document the findings in the client’s record.
2. Assessing the Heart and the Central Vessels
Posterior Thorax
1. Simultaneously inspect and palpate the precordium
for the presence of abnormal pulsations, lifts, or
heaves.
Inspect and palpate the aortic and pulmonic areas,
observing them at an angle and to the side, to note for
238
the presence and absence of pulsations.
Inspect and palpate the tricuspid area for pulsations
and heaves or lifts
Inspect and palpate the apical area for pulsation.
Nothing its specified location (it may be displaced
laterally or lower) and diameter. If displaced laterally,
record the distance between the apex and the MCL in
centimeters.
Inspect and palpate the epigastric area at the base of
the sternum for abdominal aortic pulsations
2. Auscultate the heart in all four anatomic sites: aortic,
pulmonic, tricuspid, and apical (mitral).
Carotid Arteries
3. Palpate the carotid artery.
Use extreme caution
4. Auscultate the carotid artery.
Jugular Veins
5. Inspect the jugular veins distention.
The client is placed in a semi-Fowler’s position, with
the head supported on a small pillow.
6. The jugular distention is present, assess the jugular
venous pressure (JVP).
Assemble equipment and supplies: millimeter ruler,
7. Locate the highest visible point of distention of the
internal jugular vein.
8. Document pertinent findings in the patient’s chart.
13. Assessing the Peripheral Vascular System

Peripheral Pulses
1. Palpate the peripheral pulses (except the carotid pulse)
on both sides of the client’s body individually,
simultaneously, and systematically to determine the
symmetry of pulse volume.
Peripheral Veins
2. Inspect the peripheral veins in the arms and legs for
the presence and/or appearance of superficial veins
when limbs are dependent and when limbs are
elevated.
3. Assess the peripheral leg veins for signs of phlebitis.
Peripheral Perfusion
4. Inspect the skin of the hands and feet for color,
temperature, edema and skin changes.
5. Assess the adequacy of arterial flow if arterial
insufficiency is suspected.
6. Document findings in the client’s record.
14. Assessing the Breast and Axillae
1. Assemble equipment.
 Centimeter ruler
Assessment
239
3. Palpate the carotid artery.
Use extreme caution
4. Auscultate the carotid artery.
Jugular Veins
5. Inspect the jugular veins distention.
The client is placed in a semi-Fowler’s position, with
the head supported on a small pillow.
6. The jugular distention is present, assess the jugular
venous pressure (JVP).
Assemble equipment and supplies: millimeter ruler,
7. Locate the highest visible point of distention of the
internal jugular vein.
8. Document pertinent findings in the patient’s chart.
13. Assessing the Peripheral Vascular System
Peripheral Pulses
1. Palpate the peripheral pulses (except the carotid pulse)
on both sides of the client’s body individually,
simultaneously, and systematically to determine the
symmetry of pulse volume.
Peripheral Veins
2. Inspect the peripheral veins in the arms and legs for
the presence and/or appearance of superficial veins
when limbs are dependent and when limbs are
elevated.
3. Assess the peripheral leg veins for signs of phlebitis.
Peripheral Perfusion
4. Inspect the skin of the hands and feet for color,
temperature, edema and skin changes.
5. Assess the adequacy of arterial flow if arterial
insufficiency is suspected.
13. Assessing the Breast and Axillae
1. Assemble equipment.
 Centimeter ruler
Assessment
2. Inspect the breast for size, symmetry, and contour or
shape while the client is in a sitting position.
3. Inspect the skin of the breast for localized
discolorations or hyperpigmentation, retraction or
dimpling, localized hypervascular areas, swelling or
edema.
4. Emphasize any retraction by having the client:
 Raise the arms above the head
 Push the hands together, with elbows flexed
 Press the hands down on the hips
5. Inspect the areola area for size, shape, symmetry,
color, surface characteristics, and any masses or
lesions.
6. Inspect the nipples for size, shape, symmetry, color,
240
surface characteristics, and any masses or lesions.
7. Palpate the axillary, subclavicular, and supraclavicular
lymphnodes.
9. 8
The client is seated with the arms abducted and
.
supported on the nurse’s forearm
Use the flat surfaces of all fingertips to palpate the
four areas of the axilla:
 The edge of the greater pectoral muscle along the
anterior axillary line.
Palpate the breast for masses, tenderness and any
discharge from the nipples.
Palpate the areola and the nipples for masses.

11. Compress each nipple to determine the presence of
any discharge. If discharge is present, milk the breast
along its radius to identify the discharge-producing
lobe.
12. Assess any discharge for amount , color, consistency
and odor.
13. Note any tenderness on palpation.
14. Document pertinent findings in the client’s record.
2. Assessing the Abdomen
Equipment:
* Examine light
* Tape measure (metal/unstretchable cloth)
* Water – soluble skin marking pencil
* Stethoscope
2. Ask client to urinate, empty bladder makes assessment
more comfortable.
3. Assist the client to a supine position with the arms
placed comfortably at the sides.
4. Place small pillows beneath the knees and the head to
reduce tension in the abdominal muscles. Expose only
the client’s abdomen from chest line to the pubic area
to avoid chilling and shivering, which can tense the
abdominal muscles.
Assessment
5. Inspect the abdomen for skin integrity
6. Inspect the abdomen for contour and symmetry.
7. Observe the abdominal contour while standing at the
client’s side when the client is supine.
8. Ask the client to take a deep breath and to hold it.
9. Assess the symmetry of contour while standing at the
foot of the bed.
10. If distention is present, measure the abdominal girth
by placing a tape around the abdomen at the level of
the umbilicus.
11. Observe abdominal movements associated with
respiration, peristalsis or aortic pulsations.
241
12. Observe the vascular pattern.
Auscultation of the abdomen

13. Auscultate the abdomen for bowel sounds, vascular
sounds and peritoneal friction rubs.
Percussion of the liver
14. Percuss the liver to determine its size.
Palpation of the Abdomen
15. Perform light palpation first to deter areas of
tenderness and/or muscle guarding.
16. Systematically explore all four quadrants.
17. Perform deep palpation over all four quadrants.
Palpation of the Liver
18. Palpate the liver to detect enlargement and
tenderness, blow R coastal margin.
Palpation of the Bladder
19. Palpate the area above the pubic symphysis if the
client’s history indicates possible urinary retention.
Assessing the Female Genitals and Inguinal Area
*examination gloves
*Drape
*supplemental lightning
Assessment
2. Inspect the distribution, amount, and characteristics
of pubic hair.
3. Inspect the skin of the pubic area for parasites,
inflammation, swelling and lesions. To assess pubic
skin adequately, separate the labia majora and labia
minora.
4. Inspect the clitoris, urethral orifice, and vaginal
orifice when separating the labia majora.
5. Palpate the inguinal lymphnodes.
19. Assessing the Male Genitals and Inguinal Area
• Examination gloves
Pubic Hair
2. Inspect the distribution, amount, and characteristics
of pubic hair.
Penis
3. Inspect the penile shaft and glans penis for lesions,
nodules, swellings and inflammation.
4. Inspect the urethral meatus for swelling,
inflammation, and discharge.
Compress or ask the client to compress the glans

slightly to open the urethral meatus to inspect it for
242
discharge. If the client has reported a discharge,
instruct the client to strip the penis from the base to
the urethra.
5. Palpate the penis for tenderness, thickening, and
nodules. Use your thumb and first two fingers.
Scrotum
6. Inspect the scrotum for appearance, general size, and
symmetry.
To facilitate inspection of the scrotum during a
physical examination, ask the client to hold the penis
out of the way.
Inspect all skin surfaces by spreading the rugaeted
surface of the skin and lifting the scrotum as needed to
observe posterior surfaces.
7. Palpate the scrotum to assess status of underlying
testes, epididymis, and spermatic cord. Palpate both
testes simultaneously for comparative purposes.
Inguinal Area
8. Inspect both inguinal areas for bulges while the client
is standing, if possible.
The client remains at rest.
Next, have the client hold his breath and strain or bear
down, as though having a bowel movement.
9. Palpate hernias.
10. Document findings in the client record.
20. Assessing the Rectum and Anus
1. Position the client.
In adults, a left lateral or Sims position with the
upper leg accurately flexed is required for the
examination.
For females: a dorsal recumbent position with hips
externally rotated and knees flexed or lithotomy
position may be used.
For males: A standing position while the client bends
over the examining table may also be used.
Assessment
2. Inspect the anus and surrounding tissue for color,
integrity, and skin lesions.
Then ask the client to bear down as though defecating.
Describe the location of all abnormal findings in terms
of a clock, with the 12 o’clock position toward the
pubic symphysis.
3. Palpate the rectum for anal sphincter tonicity, nodules,
masses, and tenderness.
4. On withdrawing the finger from the rectum and anus,
observe it for feces.
5. Document findings in the client.
243
Comments:
______________________________________ ________________
Student’s signature over Printed Name Date
______________________________________ ________________
Clinical Instructor’s signature Date
244
San Pedro College
DavaoCity
PHYSICAL ASSESSMENT
Name:_______________________________ Grade_________
Year & section________________________ Date__________
PHYSICAL ASSESSMENT 3
RATING
5 4 3 2 1
Assessing the Musculoskeletal System
1. Inspect the muscle for size. Measure the muscle with
a tape
2. Compare each muscle on one side of the body to the
same muscle on the other side for any apparent
discrepancies.
3. Inspect the muscle and tendons for contractures and
fasciculation.
4. Inspect any tremors of the hands and arms by having
the client hold the arms out in front of the body.
5. Palpate muscles at rest to determine muscle tonicity.
6. Palpate muscle while client is doing active range of
motion. Check flaccidity, spasticity, and smoothness
of movement. (Flexion and extension movement)
7. Palpate muscle while the client is doing passive range
of motion.
8. Test muscle strength. Compare the right side with left
side.
Grade Description
0 No muscular contraction detected
1 A barely detectable trace of
contraction
2 Active movement with gravity
eliminated
3 Active movement against gravity
4 Active movement against gravity and
245
some resistance
5 Active movement against full
resistance
Bones
1. Inspect the skeleton for normal structure and
deformities.
2. Palpate the bone to locate any areas of edema or
tenderness.
Joints
1. Inspect the joint for swelling.
2. Palpate each joint for tenderness, swelling,
crepitation, and presence of nodules.
3. Assess joint for range of motion, smoothness of
movement.
Neurologic Assessment
1. Determine the client’s orientation to time, place and
person by tactful questioning.
2. Determine client’s Level of Consciousness
(RLS/GCS). Make use of the Neuro Assessment
Graphic Sheet.
3. Assess the Cranial Nerves
a. Cranial Nerve I- Olfactory
Ask the client to close eyes and identify different
mild aromas, such as coffee, alcohol, vanilla, alcohol.
b. Cranial Nerve II – Optic
Ask client to read Snellen’s chart and check
visual fields by confrontation .
c. Cranial Nerve III- Oculomotor
Assess six ocular movements and pupil reaction.
d. Cranial Nerve IV- Trochlear; 6-Abducens
Assess six ocular movements. CN 6 assess ability to
gaze laterally.
e. Cranial Nerve V – Trigeminal
While the client looks upward, lightly touch
lateral sclera of eye to elicit BLINK reflex. To
test light sensation, have client close eyes, and
wipe a wisp of cotton over the client’s forehead
and paranasal sinuses. Use blunt and sharp ends
of safety pin for deep sensation over the same
area.
f. Cranial Nerve VII- Facial
Ask client to smile, raise the eyebrows, frown, puff
out his cheeks, close his eyes tightly (against attempt
to open them).
g. Cranial Nerve VIII- Acoustic (Vestibulocochlear)
Assess client’s ability to hear spoken words, and
vibrations from tuning fork (Apply Weber and Rinne
Test.).
h. Cranial Nerve IX – Glossopharyngeal
Depress the tongue with a tongue blade, and note
pharyngeal movement as the person says “ahhh” or
yawns. Touch the posterior pharyngeal wall with
tongue blade and note the gag reflex. Apply tastes on
246
posterior tongue for identification.
i. Cranial Nerve X- Vagus
Assess with CN IX; assess client’s speech for
hoarseness.
j. Cranial Nerve- XI - Spinal Accessory
Ask the client to shrug shoulders against resistance
from your hands and turn his head to side against
resistance from your hand. Repeat for the other side.
k. Cranial Nerve X- Hypoglossal
Ask client to protrude his tongue at midline, then
move it side to side.
Reflexes
1. Biceps Reflex – test the spinal cord level C5-C6
Partially flex the client’s arm at the elbow, and rest
the forearm over the thighs, placing the palm of the
hand down. Place the thumb of your nondominant
hand horizontally over the biceps tendon.
Deliver a blow (slight downward thrust) with the
percussion hammer to your thumb. Observe the
normal slight flexion of the elbow, and feel the
biceps’s contraction through your thumb.
2. Triceps Reflex – test the spinal cord level C7, C8
Flex the client’s arm at the elbow level, and support it
in the palm of your nondominant hand. Palpate the
triceps tendon about 2-5 cm (1-2 in) above the elbow.
Deliver a blow with the percussion hammer directly
to the tendon. Observe for the normal slight extension
of the elbow.
3. Brachioradialis Reflex – tests the spinal cord level
C3, C6
Rest the client’s arm in a relaxed position on your
forearm or on the client’s own leg.
on the radius 2-5 cm (1-2 in) above the bony
prominence on the thumb side of the wrist. Observe
the normal flexion and supination of the forearm. The
fingers of the hand may also extend slightly.
4. Patellar Reflex – test the spinal cord level L2,L3,L4
Ask the client to sit on the edge of examining table so
that his legs hang freely.
Locate the patellar tendon directly below the patella.
to the tendon. Observe the normal extension or
kicking out of leg as the quadriceps muscle contracts
5. Achilles Reflex – tests the spinal cord level S1;S2.
With the client in the same position as for the patellar
reflex, slightly dorsiflex the client’s ankle by
supporting the foot lightly in the hand.
to the Achilles tendon just above the heel. Observe
and feel the normal plantar flexion (downward jerk)
of the foot.
6. Plantar (Babinski’s) Reflex –
Use modearately sharp object, such as the handle of
247
percussion hammer.
Stroke the lateral border of the sole of the client’s
foot, starting at the heel, continuing to the ball of the
foot, and then proceeding across the ball of the foot
toward the big toe. Observe for the response.
Normally, in adult all five toes bend downward.
Motor Function
1. Gross Motor and Balance Test
a. Walking Gait
Ask the client to walk across the room and back,
and assess the client’s gait.
b. Romberg’s test
Ask the client to stand with feet together and arms
resting at the sides, first with eyes open , then closed
or 20 to 30 seconds without support.
c. Standing with one foot with eyes closed
Ask the client to close his eyes and stand on one foot,
then the other. Stand close to the client during the
test.
d. Heel-Toe Walking
Ask the client to walk a straight line, placing the heel
of one foot directly in front of the toes and then on
the heels.
e. Toe or heel Walking
Ask the client to walk several steps on the toes and
then on the heels.
2. Fine motor Test for Upper Extremities
a. Finger to Nose Test
Ask the client to abduct and extend the arms at
shoulder height and rapidly touch the nose alternately
with one index finger and then the other. Have the
client repeat the test with the eyes closed if the test is
performed easily.
b. Alternating Supination and pronation of hands

and Knees
Ask the client to pat both knees with the palms of
both hands and then with the backs of the hands
alternately at an ever-increasing rate.
c. Finger to Nose and to the Nurse’s finger
Ask the client to touch the nose and then your index
finger held at a distance at about 45cm (18 in) at a
rapid and increasing rate.
d. Fingers to Fingers
Ask the client to spread the arms broadly at shoulder
height and then bring the fingers together at the
midline, first with the eyes open and then closed, first
slowly and then rapidly.
e. Fingers to thumb
Ask the client to touch each finger of one hand to the
thumb of the same hand as rapidly as possible.
3. Fine Motor test for the lower extremities
248
Ask the client to lie supine and to perform these test:
a. Heel Down opposite Shin
Ask the client to place the heel of one foot just below
the opposite knee and run the heel down the shin to
the foot. Repeat with the other foot. The client may
also use a sitting position for this test.
b. Toe or Ball of Foot to the Nurse’s finger
Ask the client to touch your finger with the large toe
of each foot.
4. Light-touch Sensation
a. Compare the light touch sensation of symmetric
areas of the body.
b. Ask the client to close the eyes and to respond by
saying “yes” or “now” whenever the client feels the
cotton wisp touches his skin.
c. With a wisp of cotton, lightly touch specific spot
and then the same spot on the other side of the body.
d. Test areas on the forehead, cheek, hand, lower
arm, abdomen, foot, and lower leg. Check a specific
area of the limb first.
e. Ask the client to point to the spot where the touch
was felt.
e. If areas of sensory dysfunction are found,
determine the boundaries of sensation by testing
responses about every 2.5cm (1 in) in the area.
Make a sketch of the sensory loss area for
recording purposes.
5. Pain Sensation
Equipment: Broken tongue depressor
a. Assess pain sensation as follows:
b. Ask the client to close his eyes and to say “sharp”,
“dull”, “don’t know” when the sharp or dull end of
the broken tongue depressor is felt.
Alternately, use the sharp and dull end of the sterile
pin or needle to lightly prick designated anatomic
areas at random. The face is not tested in this manner.
Allow at least 2 seconds between each test.
6. Temperature Sensation
Touch skin areas with test tubes filled with hot or
cold water.
Have the client respond saying “hot”, “cold” or
“don’t know”.
7. Position or Kinesthetic Sensation
249
Commonly, the middle fingers and the large toes are
tested for the kinesthetic sensation.
To test the fingers, support the client’s arm with one
hand and hold the client’s palm in the other. To test
the toes, place the client’s heels on the examining
table.
Ask the client to close his eyes.
Grasp a middle finger or a big toe firmly between
your thumb and index finger and exert the same
pressure on both sides of the finger or toe while
moving it.
Use a series of brisk up-and-down movements before
bringing the finger or toe suddenly to rest in one of
the three positions.
Moving the finger of toe until it is up, down, or
straight out, and ask the client to identify the position.
8. Tactile Sensation
For the entire test, the client’s eyes need to be closed.
a. One-and-Two point Discrimination
Alternatively stimulate the skin with two pins
simultaneously and then with one pin. Ask
whether the client feels one or two pinpricks.
b. Stereognosis
Place familiar objects- such as key, paper clip, or
coin- in the client’s hand, and ask the client to
identify them.
If the client has a motor impairment of the hand
and is unable to manipulate an object, write a
number or letter on the client’s palm, using a
blunt instrument, and ask the client to identify it.
c. Extinction Phenomenon
Simultaneously stimulate two symmetric areas of
the body, such as the thighs, the cheeks, or the
hands.
9. Document findings in the client’s chart.
Comments
_______________________________ _____________
Student’s signature over Printed Name Date
_______________________________ _____________
Clinical Instructor’s signature Date
250
ESSENTIAL INTRAPARTUM CARE
Definition: It is the care given to patients during the intrapartum stage of labor
Purposes: a. To prevent intrapartum and post partum complications

b. To establish breastfeeding and early latching on.
c. To prevent neonatal complications
d. To promote maternal and child bonding
e. To promote involution
Legal basis:
DOH Unang Yakap campaign
R.A. 10028 or the Expanded Breastfeeding Act
MDG 5
Equipment:
Sterile OB pack containing: basin
2 big drapes (layette)
3 small drapes (hypotowels)
1 pair of leggings
Sterile Instrument set containing: blade holder tissue forceps

mayo scissors, placental currette
bandage scissors, 2 ovum forceps
3 clamps
Needle holder
Sterile cord clamp
Sterile bonnet
Surgical blade
Disposable syringe 5cc
Suture – chromic 2-0 double armed
Sterile flushing bowl/kidney basin with cottonballs soaked in betadine solution
OS
Local anesthesia
Oxytocic drugs
Sterile gloves
Procedure:
PROCEDURE RATIONALE
1. Determine when to open the OB pack To limit the exposure of the sterile
equipment.
2. Do medical hand washing To deter the spread of microorganism
3. Obtain the pack and check its sterility To ensure sterility
and expiration
4. Open the OB pack aseptically To prevent contamination
251
5. Open the instrument set and cautiously
drop the contents on the sterile field
6. Place all sterile supplies on the sterile To ensure completeness of equiment
field:
Flushing bowl cotton balls
Suture disposable syringe
Surgical blade OS
Cord clamp Bonnet
3 pairs of surgical gloves
7. Using pick up forceps, arrange all For easy accessibility of the equipment
equipment according to its use
(see illustration….)
8. Perform surgical hand scrubbing To ensure aseptic technique
9. Don sterile gloves
10. With assistance, aspirate 5 cc of local To be used during episiotomy and
anesthesia episiorrhaphy
11. Prepare the suture; cut the suture 1/3 Cutting needle is used to suture the skin,
for the cutting, 2/3 for the round needle while the round needle is for the soft
tissues
12. Mount the round needle to the needle Round needle is used first.
holder and secure the cutting needle.
13. Mount the surgical blade into the blade This is used for the episiotomy
holder
14. Drape the client’s legs aseptically To maintain sterility
15. Place 1 hypotowel under patient’s
buttocks
16. Coach the patient the proper breathing To promote effective pushing technique
and pushing technique
17. Do Ritgen’smaneuver during crowning To prevent perineal laceration
18. Assist the baby’s head in external To align the baby’s head and its shoulder
rotation
19. Anchor the baby’s neck, pull the head To deliver the anterior shoulder first
downwards and upward then the posterior shoulder
20. Slide your hands on baby’s back and To deliver the entire body of the baby
grasp both legs
21. Immediately place the baby on the To promote maternal and child bonding
mother’s abdomen for essential
newborn care
22. After cutting the cord, do Brandt To easily pull the placenta
Andrew’s maneuver
23. Place 1 hypotowel on the hypogastric To maintain sterility
area of the mother
24. Massage the uterus To promote uterine contraction causing
the separation of placenta from the
endometrium
25. Observe for the signs of placental To prevent premature pulling of the
separation placenta
26. Perform Crede’smaneuver (counter To prevent uterine prolapse or uterine
traction) while applying traction of the inversion
cord to pull out the placenta
27. Replace another hypotowel under the To maintain sterility during suturing
buttocks
252
28. Assist in the episiorrhapy or repair of To promote easy and time healing of
laceration episiotomy or laceration
29. Do perineal cleaning To prevent infection
30. Remove all drapes from the patient
31. Apply contoured brief/adult diaper For the presence of vaginal secretions
and lochia
32. Straighten the legs of the patient Promote comfort
33. Change patient’s gown and make patient
comfortable
34. Dispose the placenta appropriately Promote proper waste disposal
35. Remove all sharps and dispose properly
36. Wash the instrument according to
hospital protocol
37. Place all soiled linens into the hamper
38. Clean the area
39. Remove gloves
40. Document the procedure
SAN PEDRO COLLEGE
253
12 C de Guzman St., Davao City
NURSING 101
PREPARING AND ASSISTING BIRTHING PROCESS
Name___________________________________ Date:___________
Rating:________
Year/Section_____________________________
Legend:
5 – Excellent; 4 – Very Good; 3 – Good; 2 – Fair; 1 – Poor
PERFORMANCE POINTS
I. PREPARATION 5 4 3 2 1
1. Washes hands
2. Gather all necessary
equipment
3. Open the sterile pack
aseptically
4. Open the instrument set
aseptically and drop it
cautiously on the sterile
table
5. Add all necessary supplies
aseptically on the sterile
table.
6. Arrange all instruments
according to its use using
sterile pick up forceps
7. Performs surgical
handwashing
8. Perform open gloving
technique
9. Withdraws local anesthesia
10. Prepares the suture
correctly
11. Mount the surgical blade
into the blade holder
12. Drapes the patient’s legs,
buttocks, and hypogastric
area aseptically
II. ASSISTING DELIVERY
254
13. Perform ritgen’s maneuver
during crowning
14. Assist fetal external rotation
when the baby’s head is
out.
15. Delivers the baby’s body
correctly
16. Identifies baby’s gender
and time of delivery
17. Let the mother look at the

newborn
18. Places the newborn on
mother’s abdomen
III. DELIVERY OF THE
PLACENTA
19. Perform Brandt Andrew’s

maneuver
20. Places sterile hypotowel on
the hypogastric area
21. Performs Crede’s
maneuver
22. Apply traction of the
placenta
23. Catch the placenta with
sterile basin
24. Observe the time and type
of placental delivery
IV. ASSISTING
EPISIORRHAPY OR
REPAIR
25. Replace the hypotowel

under the buttocks
26. Offer the local anesthesia
27. Offer the suture and tissue
forceps to the physician
28. Assist the physician in
episiorrhaphy correctly.
V. AFTERCARE
29. Remove all drapes from the
patient
30. Do perineal cleaning using
cotton balls with betadine
31. Apply adult diaper
32. Straighten patient’s legs
simultaneously
33. Change patient’s gown and
make patient comfortable
34. Discard the sharps,used
supply, and other wastes
according to infectious
255
control and waste
segregation protocol.
35. Wash and disinfect the
instruments according to
hospital protocol
36. Mop the floor
37. Remove gloves correctly
38. Wash hands
39. Document properly.
COMMENTS:
Supervised by:
______________________________
Clinical Instructor
Conformed by:
______________________________
Student’s Printed Name and signature
ESSENTIAL NEWBORN CARE
Definition: It is the care rendered to the immediate newborn
Purposes:
a. To evaluate newborn’s ability to adapt extrauterine life
256
b. To prevent hypothermia
c. To prevent newborn infection
d. To prevent bleeding from the unbilical cord
e. To establish maternal-child bonding
f. To establish breastfeeding
g. To prevent newborn complications
Legal basis:
DOH Unang Yakap Campaign
EO 51 – Milk code of the Philippines
RA 10028 – Expanded Breastfeeding Act
MDG 4
Equipment:
Sterile gloves
Cord care set : 1 forceps, 1 scissors, 1 cord clamp
2 warm baby’s drape (layette)
Bonnet
Terramycin eye ointment
Vitamin K
Hepatitis B
2 disposable tuberculin syringe
1 disposable needle G23 (as aspirating needle)
Alcohol swab
Waste disposable
Medication tray
Tape measure
Rectal thermometer
Stethoscope
Working gloves
Procedure:
PROCEDURE RATIONALE
1. Wash hands using medical handwashing To deters the spread of microorganism

2. Prepare all needed equipment To save time and energy
3. Do double gloving To maintain aseptic technique
4. Call out time of birth after the delivery To determine the exact time of delivery
5. On mother’s abdomen, immediately dry To prevent hypothermia. Wiping the face
the newborn using the first baby’s drape. clears the secretions on nose and mouth.
Wipe first the face.
6. Wipe dry the baby for at least 30 This will also stimulate the baby to cry
seconds
7. Do not wipe off vernixcaseosa It provide natural protection of baby’s
skin
257
8. Do not wash the baby for the first 6 Bathing causes hypothermia and
hours infection
9. Carry out rapid newborn assessment To ensure wellbeing
10. Remove wet drape/layette To ensure that newborn is dry
11. Initiate skin to skin contact by placing Promote warm for the baby, maternal
the baby prone on mother’s abdomen or and newborn bonding, and stimulate
between the breasts uterine contraction thus preventing
postpartum bleeding.
12. Place the bonnet on newborn’s head To keep the newborn warm
13. Use the second drape/layette to cover To avoid unnecessary exposure thus
the baby’s back preventing colds
14. Remove the first glove It is already considered unsterile
15. Palpate the cord for pulsation, when Pulsation delivers more blood from the
pulsation stops, apply the cord clamp 2 placenta to the newborn thus preventing
cms from the base anemia and prevent
intraventricularhemorrhage
16. From the cord clamp, milk the cord once Prevent spurt of blood upon cutting
5cms towards the perenial area
17. Apply forceps/clamp 4 cms from the first Provide space for cutting
clamp
18. Cut the cord in between clamps
19. Encourage the mother to nudge her It allows maternal-newborn bond and
newborn into her breast stimulate the release of oxytocin thus
promoting uterine contraction
20. Take the initial vital signs of the Determine fetal coping extrauterine.
newborn; cardiac rate, respiratory rate, Rectal temperature also checks anal
and rectal temperature. Repeat every 30 patency
minutes using axillary thermometer for
the succeeding monitoring.
21. AdministersTerramycin eye ointment on Prevent ophthalmianeonatorum
both eye
22. Administer Vitamin K 1mg Promotes coagulation thus prevents
intramuscularly at left thigh bleeding
23. Administer Hepatitis B vaccine 0.5cc Promotes antibodies against Hepatits B
intramuscularly at right thigh virus
24. Measure the anthropometrics of the
newborn; head circumference, chest
circumference, abdominal
circumference, length, and weight.
25. Let the newborn stay at mother’s Maximizes maternal child bonding
abdomen for at least 90 minutes
26. Initiate breastfeeding Provides nourishment for newborn and
maternal involution.
San Pedro College
Davao City
ESSENTIAL NEWBORN CARE
258
Name______________________________________________
Rating_________________________
Year/Section:________________________________________
Date__________________________
Legend:
5 – Excellent; 4 – Very Good; 3 – Good; 2 – Fair; 1 – Poor
5 4 3 2 1
PERFORMANCE POINT
1. Do medical handwashing
2. Gather all needed equipment
3. Withdraw 0.1 cc of Vitamin K into
the tuberculin syringe
4. Aspirate 0.5cc of Hepa B vaccine
into the tuberculin syringe
5. Place the medications on the hypo
tray with the cotton swab, tape
measure, rectal thermometer
6. Perform double sterile gloving
aseptically
7. Announce the exact time of baby
out
8. Get 1 big layette and dry the
newborn thoroughly, wiping the
face then the body for at least 30
seconds
9. Monitor APGAR scoring after the
first minute of life then after
minutes.
10. Perform skin to skin contact by
positioning the baby prone on
mother’s abdomen
11. Get the second drape to cover the
baby
12. Remove the first glove
13. Palpate the cord for pulsation
14. Apply cord clamp 2 cms from the
base once pulsation stop
15. Milk the cord 5 cms from the cord
clamp towards the perineal area
16. Apply forceps 4 cms from the cord
clamp
17. Cut the cord in between the
clamps
18. Initiate latching on
19. Take initial vital signs of the
newborn using rectal
thermometer for the temperature
20. Administer eye ointment on the
lower conjunctiva of both eyes
starting on the inner to outer
259
canthus
21. Administer Vitamin K
intramuscularly at left thigh
22. Administer Hepatitis B vaccine at
right thigh
23. Perform the complete
anthropometric measurements
24. Encourage the mother to do
breastfeeding
25. Do aftercare
26. Document the procedure
REMARKS:
_______________________________________
________________________________
CLINICAL INSTRUCTOR Student’s Name & signature
COMMUNITY HEALTH NURSING
NURSING HOME VISIT
Definition
A home visit is a professional face to face contact made by a nurse to the client or the
family to provide necessary health care activities and to further attain an objective of the
agency.
Principles in Preparing for a Home Visit
260
1. A home visit should have a purpose or objective
2. Planning for a home visit should make use of all available information about the client
and his family through family health records, knowledge of the health center
personnel, including those from other agencies that may have rendered services to the
client or family.
3. Planning should revolve around the essential needs of the individual and his family
but priority should be given to those needs recognized by the family itself.
4. Planning of a continuing care should involve the individual and his family.
5. Planning should be flexible and practical.
Factors to be Considered in Determining the Frequency of Home Visit
There is no definite rule as to the frequency of a home visit. Since the population in a
given community is much more than what the nurse can handle, prioritization of needs for a
home visit is necessary.
1. The physical, psychological, and educational needs of the individual and family.
2. The acceptance of the family for the services offered; their willingness and interest to
cooperate.
3. Other health agencies and the number of health personnel already involved in the care
of the family.
4. The policy of a given agency and the emphasis placed in a given health program.
5. A careful evaluation of past services given to a family and how this family made use
of such nursing services.
6. The ability of the client and his family to recognize their own needs, their knowledge
of available resources and their ability to use these resources on their own accord.
Making a Home Visit
1. Before leaving the clinic, it is important to have the correct name and address of the
clients to be visited.
2. The record of these cases have been reviewed as regards to previous visits.
3. Bring watch with second hand, pen, memorandum book or notebook, and umbrella.
4. Upon arrival, observe the rules of courtesy by ringing the bell or knocking at the
door.
5. After being admitted, introduce yourself professionally if it is a first visit. Explain the
purpose of the visit.
6. The nurse should sit down and talk with the client in order to obtain needed
information.
7. Select the most responsible member of the family to assist during the visit and to give
care or treatment in the period between visits.
8. Look for a place to put down the bag, on a table or chair six feet away from the
bedside. Line the table with newspaper before putting down the bag.
9. If nursing care will be given, proceed to get articles needed from the bag, observing
bag technique.
10. Make an appointment for the next visit.
BAG TECHNIQUE
CHN Bag
 is an essential and indispensable equipment of the Community Health Nurse
which she has to carry along with her when she goes out home visiting.
261
Contents of the Bag:
1. Soap in a soap dish 12. Kidney basin Bottles containing:
2. Plastic & paper 13. Medicine glass a. Alcohol 70%
wrappers 14. Thermometer b. Sterile water
3. Tissue paper 15. Tongue depressor c. Soap suds solution
4. Waste receptacle 16. Plaster d. Hydrogen peroxide
5. Apron 17. OS e. Spirit of ammonia
6. Towel lining 18. Reagent strips f. Benedict’s solution*
7. Match 19. Disposable syringe g. Acetic acid*
8. Test tubes (2 pcs) (5ml, 2ml) h. Denature alcohol*
9. Test tube holder 20. Disposable needles (*Optional)
10. Droppers (2 pcs) (G. 22,23,24)
11. Sterile cotton balls
Principles to Consider in the Use of the Bag
1. The bag should contain all necessary articles, supplies and equipment which may be
used to answer emergency needs.
2. The bag and its contents should be cleaned as often as possible, supplies replaced and
ready for use at any time.
3. The bag and its contents should be well protected from contact with any article in the
home of the clients. Consider the bag and its contents clean while any article
belonging to the client as dirty or contaminated.
4. The arrangement of the bag’s contents should be the one most convenient to the user
to facilitate efficiency and avoid confusion.
5. Perform handwashing as frequently as the situation calls for to help minimize or avoid
contamination of the bag and its contents.
6. The bag, when used for a communicable case, should be thoroughly cleaned and
disinfected before keeping and re-using.
BAG TECHNIQUE
 is a tool which the nurse, during her home visit, can perform a nursing procedure
with ease and deftness, saving time and effort with view of effective nursing care.
Principles of Bag Technique
1. The use of the bag technique should minimize, if not totally prevent, the spread of
infection from individual to families to the community.
2. Bag technique should save time and effort on the part of the nurse in the performance
of the nursing procedures.
3. Bag technique should not overshadow the nurse’s concern for the client, but rather
show her effectiveness in providing total care to an individual or family.
4. Bag technique can be performed in a variety of ways depending upon agency policies,
actual home situations, etc. as long as principles of avoiding transfer of infection is
carried out.
Procedure
Action Rationale
262
1. Place the bag on a flat surface Paper lining serves as protection for
(table/ chair/ floor) lined with a the bag and its content.
paper lining
2. Ask for water to wash your hands or Handwashing prevents the spread of
ask where you can do it. microorganisms.
3. Open the bag and take out the

double wrapped soap dish
containing soap (wrapped in plastic
bag) and tissue paper or hand towel.
Close the bag.
4. Wash hands with soap and water

(under running water or using
pouring method) and wipe them dry.
Place used hand towel between the
double wrappers.
5. Spread the towel lining (it should All equipment are placed on the towel
not exceed the paper lining). Put out lining to prevent contamination.
the things needed for the specific
nursing procedure to be performed.
Arrange them on the towel lining.
Close the bag.
6. Put on the apron, then place the The apron serves as protection for the
waste receptacle outside the paper nurse who will perform the procedure.
lining.
7. Proceed on the specific nursing care

or treatment.
8. Clean the things used. Place dry Maintaining cleanliness is needed at

equipment on top of the first layer all times.
wrapper. Wash hands with soap and
water, then dry.
9. Re-wrap the soap dish. Disinfect all

equipment used with 70% alcohol.
10. Open the bag and return all

equipment used in their proper
order. Fold the apron and towel
lining with exposed side inside.
Close the bag.
11. Sit down and have a talk with the

mother or the person in-charge of
the client. Record your
observations, the temperature,
treatment done, results of test
performed and specific instructions
given. Make an appointment for the
263
next visit.
12. Dispose the waste receptacle with Proper disposal is necessary to prevent
its contents properly before leaving contamination.
the home. (Note: Use this
opportunity to check sanitation of
immediate environment or waste
and garbage disposal, drainage, etc.)
13. Pick up the paper lining by its center

fold and discard.
URINE TEST FOR ALBUMIN AND SUGAR
Purpose: To test the presence of albumin and sugar in the urine.

(Urine can be tested for glucose at home or in the laboratory by stick method
or by Benedict’s test.)
Dipstick Test
There is a chemical at the end of the strip which changes in color when it comes in
contact with urine albumin or glucose. One can read and compare the color on the strip with
the guide/chart displayed on the bottle/ container.
Preparation
1. Urine specimen
2. Reagent strip
Procedure
Action Rationale
1. Collect a fresh midstream urine sample First morning samples contain the
in a clean, dry container, preferably highest concentration of target markers.
glass.
2. Remove one reagent strip from the Prolonged exposure to light and air will
bottle and immediately replace the cause a reaction and may give false
container cap, minimizing the exposure reading.
of the remaining strips to light and air.
3. Completely immerse the reagent pads Removing immediately after the

of the strip in the urine sample for 30 recommended time frame prevents
seconds to one minute and then remove dissolving out the reagent pads.
immediately.
4. While removing the reagent strip, run This is to remove excess urine.
the edge of the strip against the rim of
the specimen container. Hold strip in a
horizontal position to prevent possible
cross contamination of chemicals
located in adjacent reagent pads.
264
5. Compare the color change of reagent
pads to the corresponding color chart on
the bottle label. Read results according
to the chart’s time frame for each panel
tested.
6. Record the results of your readings for

discussion and/or evaluation with your
physician or health care provider.
Discard the used reagent strip properly.
Interpretation for Albumin
Traces
Yellow Green - +1
Dark yellow green - +2
Bluish green - +3
Blue - +4
A positive test for albumin implies the presence of pregnancy-induced hypertension

(PIH). Refer the client to the physician or nearest health center.
Interpretation for Sugar
Blue - Negative
Dark blue - +1
Yellow green - +2
Brown - +3
Orange - +4
The presence of sugar in the urine may indicate diabetes mellitus. Refer the client to
the physician or nearest health center.
SAN PEDRO COLLEGE

Davao City
BAG TECHNIQUE
Name: ________________________________________ Grade:

___________
Year and Section: _______________________________ Date:
____________
Legend: 5 – Excellent 4 – Very Good 3 – Good 2 – Fair 1 - Poor
I – BAG TECHNIQUE Rating

5 4 3 2 1
265
1. Places the bag on a flat surface lined with a
paper lining
2. Asks for water to wash your hands or ask
where you can do it.
3. Opens the bag and takes out the double
wrapped soap dish containing soap and
hand towel. Closes the bag.
5. Spreads the towel lining and puts out the
things needed for the specific nursing
procedure to be performed. Arrange them
on the towel lining. Closes the bag.
6. Puts on the apron, then places the waste
receptacle outside the paper lining.
7. Proceeds on the specific nursing care or
treatment.
SUB-TOTAL
II - URINE TEST FOR ALBUMIN AND SUGAR 5 4 3 2 1

8. Removes one reagent strip from the bottle
and immediately replace the container cap.
10. Completely immerse the reagent pads of the
strip in the urine sample for 30 seconds to
one minute.
11. While removing the reagent strip, runs the
edge of the strip against the rim of the
specimen container.
12. Compares the color change of reagent pads
to the corresponding color chart on the
bottle label.
13. Documents the results of the test.
14. Informs the client of the results and renders
appropriate health teachings.
15. Discard the used reagent strip properly.
16. Refers the client to physician or nearest
health center if test is positive for albumin
or sugar.
SUB-TOTAL
III - AFTERCARE 5 4 3 2 1
17. Washes used equipment.
18. Dries equipment and places them on top of
the first layer wrapper.
20. Re-wraps the soap dish.
21. Disinfects all equipment used with 70%
alcohol.
22. Returns all equipment in the bag in their
proper order.
266
23. Folds the towel lining correctly.
24. Folds the apron correctly.
25. Closes the bag.
26. Interacts with the client all throughout the
procedure.
27. Record pertinent observations.
28. Discards the waste receptacle and paper
lining properly.
29. Makes an appointment for the next visit.
31. Manifests neatness in the performance of
the procedure.
34. Shows calmness while performing the
procedure.
SUB-TOTAL
TOTAL
Remarks:
Criteria I Knowledge (quiz) 30%

II Performance 70%
100%
_______________________________ ___________________
_______________________________ ___________________
267
APPLICATION OF RESTRAINTS
Definition:
Restraints are protective devices used to limit the physical activity of a client or to
immobilize an extremity or the client himself/herself.
Types:
1. Physical Restraints: devices applied to reduce the client’s movement.
2. Chemical Restraints: are medications used to control the client’s behavior.
Indication:
To limit activities of clients who are:
a. confused
b. combative
268
c. high risk for falling when left unattended
Special Precaution:
The Omnibus Budget Reconciliation Act (OBRA) of 1987 defines client’s rights and
choices regarding the use of restraints. Under these guidelines, the reasons for the use of
PHYSICAL RESTRAINTS are to be clearly stated:
a. The use of restraints must be part of the client’s medical treatment;

b. All other restrictive interventions must be tried first.
c. Supporting documentation must be provided.
Key Elements Of Restraint Documentation
 Reason for the restraint

 Method of restraint
 Application: Date, Time, and client’s response
 Duration
 Frequency of observation and client’s response
 Safety: Release from restraint with periodic, routine exercise and
assessment for circulation and skin integrity
 Assessment of the continued need for restraint
 Client outcome
Equipment:
1. Restraints
2. Pads
Procedure:
269
Action Rationale
1. Explain the rationale for application Explanation facilitates cooperation.

of restraints. Repeatedly reinforce
rationale.
2. Prepare the restraints. Organization promotes efficient time

management.
3. Assess the skin for irritation. Provides baseline assessment.
4. Apply restraints to client assuring Maintains adequate circulation and

some movement of body parts. mobility. Prevents skin breakdown.
One to two fingers should slide Restraint should be easy to release.
between restraints and client’s
skin. Tie the straps securely with
clove hitch.
To make a clove hitch: clove hitch is a knot for fastening a

a. Make a figure of eight; rope about a spar, pole or another
b. pick up the loops; rope.
c. put the limb through the loops
d. and secure.
Pad bony prominences.
5. Secure restraints to bed frame. Prevents accidental injury to client

Do not tie the straps to the side from moving side rails and
rails. decreases client’s ability to untie
restraints.
6. Assess restraints and skin integrity Permits muscle exercises.

every thirty minutes. Release Promotes circulation. every two hours.
restraints at least for 10 minutes every
2 hours.
7. Document the procedure noting the Communicates to the members of the

time of application and condition of health team and contributes to the
the client. legal record by documenting the need
for restraints.
8. Continually assess the need for Assist in evaluating client’s

restraints. ( at least every 8 hours) response to restraints.
270
D.
Figure 11: Making a Clove Hitch Knot
Technique:
A. Make a figure – eight
B. Pick up the loops
C. Securing the knot
D. The clove hitch knot
271
A. Jacket D. Elbow
B. Belt E. Limb or Extremity
C. Mitten or hand F. Mummy
Figure 12: Types of Physical Restraints

OPERATING ROOM
272
SKIN PREPARATION (Shaving)
Introduction:
Hair may be removed from the site of the surgical incision because it harbors bacteria
that might cause a wound infection. The skin around the operative site is prepared to reduce
the number of organisms present and to inhibit rebound growth.
Working gloves Cotton–tipped

applicator (optional)
Wash cloth Kidney basin
Razor with new blade Pick up forceps
Bed protector Basin with warm water
Jar with CB soaked in SSS or antiseptic soap
Procedure
Action Rationale
1. Check with CI the site to be shaved. Avoid wrong site to be shaved.
2. Identify and explain the procedure to Facilitates cooperation and provides

the patient. reassurance.
3. Assemble equipment. Expose the area Having equipment ready saves time.
to be shaved and drape the patient Draping patient provides privacy.
appropriately.
4. Wash hands and put on gloves. Handwashing deters the spread of

microorganisms. Gloves are worn as part
of universal precaution.
5. Place bed protector pad under the area Protector pad protects bed linen.
to be shaved.
6. Apply soap solution to small areas of Soap emulsifies normal fatty substances
the skin and work up a lather. on the skin and loosens dirt so that water
can penetrate and soften the hair.
7. Shave with one hand while gently Stretching eliminates wrinkles so that the
stretching the skin taut with the other. nurse can accomplish a close shave.
Hold the razor between a 30 – 450 angle Shaving in the direction of the hair growth
and make long gentle strokes in the minimizes skin irritation. Gentle long
direction of hair growth. Rinse hair and strokes at the specified angles help to
soap from razor as necessary. prevent nicking and cutting the skin.
8. Continue moving drape until entire area This provides patient’s privacy. Sharp
is shaved. Replace razor if it becomes razor reduces risk of injury.
dull.
9. Use wash cloth and warm water to This minimizes irritation of the skin.
remove any excess soap and remaining
hair. Dry carefully.
10. Check at the level of the shaven area This checks whether all hair has been
for isolated hairs that may have been removed.
273
missed by the razor.
11. Report any cuts in skin to CI, Nurse on Cuts in skin may be a potential source of
Duty or physician. infection.
12. Discard equipment according to agency

policy. Do after care.
13. Wash hands after removing gloves. Deters the spread of microorganisms.
14. Record the procedure done. Provides documentation of the procedure.
SAN PEDRO COLLEGE

Davao City
274
SKIN PREPARATION (SHAVING)
Name: _________________________________ Grade:____________________

Year and Sec. _________________ Date :___________________
Legend: 5 – Excellent; 4 – Very good; 3 – Good; 2 – Fair; 1– Poor
Rating
5 4 3 2 1
1. Check with CI the site to be shaved.
2. Identify and explain the procedure.
3. Assemble needed equipment and drape patient
appropriately.
4. Wash hands and put on gloves.
5. Place bed protector pad under the area to be shaved.
6. Apply soap and work up a lather.
7. Shave while gently stretching the skin taut. Make long
gentle strokes in the direction of hair growth.
8.. Continue moving drape until entire area is shaved.
9. Use wash cloth and warm water and remove any excess
soap and remaining hair then dry carefully.
10. Check for isolated hairs at the level of the shaven area.
11. Report any cuts in skin to CI, NOD or physician.
12. Discard equipment and do after care.
13. Remove gloves and wash hands
14. Document the procedure.
Remarks

II Performance 70%
100%
________________________________
__________________________
________________________________
__________________________
DONNING A STERILE GOWN AND CLOSE GLOVING
The nurse must wear a sterile gown in the Operating Room, so sterile objects can be
comfortably handled with less risk of contamination. A nurse assisting physician with
275
invasive procedure in a treatment room may also wear a sterile gown. A gown is applied after
surgical handwashing and after the nurse has donned a mask and surgical cap. He/She either
picks a gown from a sterile field or has a gown assistant hand him/her one.
The entire surface of the gown is not considered sterile. Only the area form the
anterior waist to the collar including anterior sleeves is sterile.
Equipment:
1. sterile gloves 3. surgical cap
2. disposable mask 4. sterile gown
Procedure:
Action Rationale
1. Wear cap and surgical mask. Cap and mask reduce chances of
transmitting
organism to gown by direct contact or
airborne
transmission.
2. Perform the surgical hand scrubbing. Scrubbing eliminates microorganisms

from
surface of hands.
After surgical hand scrubbing, the

hands are
rendered to be surgically clean.
Therefore, it
3. Enter the swing door of the OR using the should not touch any part of the OR
back or the butt. door.
4. Stand on the side of the table where the Contact of outer surface of gown with
sterile gowns are positioned. Grasp one a dirty or
sterile gown with the dominant hand and clean surface would result in
stand in an area where the gown may be contamination of
opened without risk of contamination. the gown.
If a sterile OR towel is not available,

the bottom
part of the gown can be used in wiping
5. Hold the sterile gown away from the the
body. Hold the bottom part of the gown with hands, making sure that it will not
the other hand to be used in wiping the swing or
dominant hand. Bend a little while wiping come in contact with a portion of your
the hand, wrist, forearm to the elbow body,
extending about 2 inches. thus, causing it to be contaminated.
6. Do the same procedure on the non-

dominant hand, this time the dominant hand
holds the bottom part of the gown to wipe the
non- dominant hand, to the forearm, running
through the elbow and 2 inches beyond that.
7. Raise up the gown a little higher to locate Racing the gown a little higher
276
the armholes. The non- dominant hand grasps facilitates easier
the armholes by inserting the fingers securely location of the armholes and prevents
while bringing it up and lowering the bottom the risk of
part of the gown. touching the floor.
8. Slip the hands inside the armholes while Extension of arms straight ahead
the gown is held away from the body. Keep keeps sterile
the hands at shoulder level and allows it to outer surface of the gown in view and
unfold with the inside of the gown toward the reduces
wearer. risk of contamination.
Since closed gloving technique will be

used,
keeping the hands at the proximal
edge of the
9. Push the hands and forearms into the
cuff will prevent contamination to the
sleeves of the gown. Advance the hands only
sterile
to the proximal edge of the cuff.
gloves during donning.
Call for the circulating nurse to pull the Working from behind the scrub nurse
gown over the shoulder touching only the prevents
inner aspect of the gown and tie the strings of contamination by the circulating
the gown. nurse.
Cuff of glove facilitates easier

handling of
10. Lift the first glove and grasp it through glove.
the fabric or sleeve. Place the glove palm
down along the forearm of the matching Only sterile items come in contact
hand, with thumb fingers pointing toward with each
elbow. Glove cuff lies over gown wristlet. other.
11. Hold glove cuff securely by hand on Prevents the hands from
which it is placed. Sleeve to cover gown contaminating the
wristlet entirely. sterile gloves.
12. As cuff is drawn back onto wrist, fingers Provides a closed sterile method of
are directed into their cots in glove, and donning
glove is adjusted to hand. gloves.
13. Use the gloved hand to position Provides a closed sterile method of
remaining glove on the opposite sleeve in donning
the same fashion. Place glove cuff around gloves.
gown cuff. Draw second glove onto hand,
and pulls cuff into place and adjusts fingers
of gloves.
Gloved hands are held above the waist

14. After donning of the sterile gown and or at the
gloves, position or place the gloved hands at level of the sterile table to prevent it
the chest or on the sterile top of the back from
table. becoming unsterile.
277
PERFORMANCE CHECKLIST FOR GOWNING AND CLOSED GLOVING
Name: ____________________________ Yr./Section: __________ Date: _________ Grade: ________
Legend:
278
5 - Excelent 4 - Very Good 3 - Good 2 - Fair 1 - Poor
RATING 5 4 3 2 1
1. Wears cap and surgical mask.
2. Performs the surgical hand scrubbing.
3. Enters the swing door of the OR using his/her back or with the
butt.
4. Stands on the side of the table where the sterile gowns are
positioned. Grasps one sterile gown with the dominant hand and
stands in an area where the gown may be opened without risk
of contamination.
5. Holds the sterile gown away from the body. Holds the bottom
part
of the gown with the other hand to be used in wiping the dominant
hand. Bends a little while wiping the hand, wrist, forearm to the
elbow extending about 2 inches.
6. Does the same procedure on the nondominant hand, this time the
dominant hand holds the bottom part of the gown to wipe the non-
dominant hand, to the forearm, running through the elbow and 2
inches beyond that.
7. Raises up the gown a little higher to locate the armholes. The
non-
dominant hand grasps the armholes by inserting the fingers
securely
while bringing it up and lowering the bottom part of the gown.
8. Slips the hands inside the armholes while the gown is held away
from the body. Keeps the hands at shoulder level and allows it to
unfold with the inside of the gown toward the wearer.
9. Pushes the hands and forearms into the sleeves of the gown.
Advances the hands only to the proximal edge of the cuff.
Calls the circulating nurse to pull the gown over the shoulder touching only
the inner
shoulder and side seams. Ties or clasps the neckline and ties the inner waist strings of
the
gown touching only the inner aspect of the gown.
10. Lifts the first glove. Grasps it through the fabric or sleeve. Cuff of
glove facilitates easier handling of glove. Places the glove palm
down along the forearm of the matching hand, with thumb fingers
pointing toward elbow. Glove cuff lies over gown wristlet.
11. Holds glove cuff securely by hand on which it is placed. Sleeves
to cover gown wristlet entirely.
12. As cuff is drawn back onto wrist, fingers are directed into their
cots in glove, and glove is adjusted to hand.
13. Uses the gloved hand to position remaining glove on the
opposite
sleeve in the same fashion. Place glove cuff around gown cuff.
Draws second glove onto hand, and pulls cuff into place and
adjusts fingers of gloves.
14. After the student have donned the sterile gown and closed
gloving,
the gloved hands are held together at the chest or rest in the
sterile
279
top of the back table.
_________________________________ _____________
Student's Printed Name and Signature Date
_________________________________
_____________
Instructor's Printed Name and Signature Date
SERVING SURGEON’S GOWN AND GLOVES
Equipment: sterile gown and gloves
Procedure Rationale
280
1. The scrub person lifts up the folded sterile This portion of the gown will be used to dry the
gown and unfolds it, hands to the surgeon the hands of the surgeon and later, this will
lower portion of the gown (making sure that be considered as unsterile since it is below
the hand is at a distance, about halfway through waist level.
the unfolded gown).
If a towel is available, the scrub person serves

the towel by unfolding it, holding top portion
while the surgeon grabs the other end.
2. The sterile gloved hand is inserted at the To prevent contamination.

anterior shoulder portion of the gown exposing
the open armholes towards the surgeon.
3. The gown is held until the surgeon’s hands

and forearms are in the sleeves of the gown. (
The circulating nurse then assists the gowned
individual by pulling the gown onto the
shoulders, adjusts the back and ties the cords).
4. The scrub nurse grasps the glove under the Checking for holes will ensure that the gloves
everted cuff. Checks for holes by inflating the to be used by the surgeon is sterile. Inflating
gloves. will also facilitate easier insertion.
5. Serves the dominant glove with the palm and

thumb facing towards the surgeon’s hand.
6. Stretches the cuff of the glove with the four Stretching the gloves will allow the surgeon to
fingers and thumbs abducted. insert his/her hand without touching the scrub
person's gloves.
The scrub person protects own gloved fingers
by holding them beneath the cuff of the glove,
and their thumbs by holding them away from
the partly-gloved hand.
7. Exerts a slight upward pressure on the cuff

while the surgeon inserts his/her hand into the
glove using firm downward thrust.
8. Pulls the cuff over the wristlet of the gown

while the surgeon slips his/her hand well into
the glove.
9. The procedure is repeated to don the other

glove.
SAN PEDRO COLLEGE
PERFORMANCE CHECKLIST FOR SERVING SURGEON’S GOWN AND GLOVES
Name: _________________________________________ Grade: _________

Year and Section: ________________________________ Date: __________
281
Legend: 5 – Excellent 4- Very Good 3- Good 2- Fair 1- Poor
RATING 5 4 3 2 1
1. The scrub person lifts up the folded sterile gown and unfolds it, hands to
the surgeon the lower portion of the gown (making sure that the hand is at a
distance, about halfway through the unfolded gown).
If a towel is available, the scrub person serves the towel by unfolding it,
holding top portion while the surgeon grabs the other end.
2. The sterile gloved hand is inserted at the anterior shoulder portion of the
gown exposing the open armholes towards the surgeon.
3. The gown is held until the surgeon’s hands and forearms are in the
sleeves of the gown. ( The circulating nurse then assists the gowned
individual by pulling the gown onto the shoulders, adjusts the back and ties
the cords).
4. The scrub nurse grasps the glove under the everted cuff. Checks for holes
by inflating the gloves.
5. Serves the dominant glove with the palm and thumb facing towards the
surgeon’s hand.
6. Stretches the cuff of the glove with the four fingers and thumbs abducted.
7. Exerts a slight upward pressure on the cuff while the surgeon inserts
his/her hand into the glove using firm downward thrust.
8. Pulls the cuff over the wristlet of the gown while the surgeon slips his/her
hand well into the glove.
9. The procedure is repeated to don the other glove.
10. Maintains body mechanics throughout the performance of the
procedure.
Comments:
Criteria: I. Knowledge (Quiz) 30%

II. Performance 70%
100%
_________________________________ _________________
_________________________________ __________________
282
OPENING OF THE PACK AND INSTRUMENTS

Introduction
A sterile field is a work surface area prepared to hold sterile equipment during a sterile technique
procedure. It provides an area in which sterility is continually maintained.
283
Equipment:
Packed sterile gowns and drapes
Packed sterile pick-up forceps
Packed abdominal set
Packed suture basin (small and big round basin)
Packed cutting insruments
Packets of different sponges (MS, AP, OS, CB, PB, cottonoids)
Packed sterile suture book
Packs of accessory instruments ( suction tubings and tip, cautery pencil and tip)
Procedure Rationale
1. Do medical handwashing. To deter the spread of microorganism.
To ensure placement of the gowns and drapes after opening

2. Place the sterile pack on the back table the pack. The gowns are usually positioned near the scrub
with the cuff towards the scrub room. room to avoid overeaching.
3. Open the pack gradually following the The folded cuff serves as a line of demarcation between
direction of the folded cuff. sterile and unsterile portion of the pack.
4. Open and remove the sterile pick-up The sterile pick-up forceps will be used to manipulate
forceps from its wrapper. anything that is within the sterile field.
5. With the use of the sterile pick-up

forceps, position the drapes and gowns on Allows enough space at the the center of the table where all
opposite upper corners of the table. necessary instruments will be placed.
6. Unwrap the following using the banana To enable to open the pack easily for aseptic removal of
peel technique and place it on the instruments and sponges.
back table without causing contamination:
a. Big and heavy individually packed
instruments
b. Abdominal set
c. Cutting instruments
d. Accessory instruments
e. Suture basin ( Big and small round
basin)
f. Suture book
7. Open the pack of MS (medium sponge)

and place it one by one in the big round Counting each sponge as you place it in the round basin
basin using the sterile pick up forceps. ensures completeness before the start of the surgery.
8. Open and drop the surgical blades in the Provides protection from accidental injury during the
small round basin. preparation of the instruments.
9. Open the outer wrapping of the sterile

gloves and discard. Hold then fold the inner
wrapping inside out. Ensures sterility of the gloves.
10. Using the sterile pick up forceps, Promotes organization.
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remove the gloves and place it beside the
gowns.
11. Keep close watch on the open sterile

items at all times. Ensures sterility of all the items.
SETTING-UP THE INSTRUMENTS IN THE MAYO

Procedure Rationale
1. Pick up the sterile mayo cover and inserts To prevent contamination of the sterile gloved
the gloved hand in the cuff of the drape while hand from the unsterile mayo table.
holding the edges of the bottom of the mayo
cover.
2. Slip the mayo cover over the frame of the To create a sterile area for the instruments.
mayo stand. (A wide margin is maintained
between the cover and the lower portion of the
scrub person’s gown).
3. Unfold the cover to extend over upright Sterile drapes should be placed on the patient,
support of the stand. furniture, and equipment to be included in the
sterile field to prevent transfer of
microorganism.
4. Get one towel and cover the top of the mayo To establish an aseptic barrier that minimizes
table. the passage of microorganisms.
5. Get the instrument set and place it on the
mayo table top. Unwrap the set slowly; roll the
wrapper under the instruments. Make sure that
the loose instruments are held securely while
removing the wrapper.
6. Roll the wrapper neatly and secure each end Provides organization of the instruments in the
with a rubber band. Place the rolled wrapper on mayo table.
the left side the mayo table and position the
instruments’ handles over the roll.
7. Arrange the loose instruments like knife
handles, retractors and tissue forceps in its
proper place.
8. Unlock the towel clip and pulls out the
ovum forceps from the handles of the
instruments.
9. Place the ovum forceps at the back table
while the towel clip is positioned with the rest
of the instruments on the rolled towel.
10.Mount the blades on the knife handles with
the use of the needle holder.
11. The scrub nurse informs the circulating To reduce the incidence of retained sponges
nurse that he/she is ready to count. (Initial and instruments during surgery.
counting).
12. Picks up one of the tissue forceps and uses
the tip of the handle in counting the
instruments. Start the counting by stating the
name of the instrument and its quantity.
a. Towel clips (7)
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b. Fine curves (12)
c. Straight clamps (6)
d. Big curves (6)
f. Allis forceps (3)
g. Babcocks (3)
h. Needle holders (2)
i. Army Navy retractors (2)
j. Long thumb forceps (1)
k.Tissue forceps without teeth (Thumb
Forceps) (2)
l. Tissue forceps with teeth
(Tissue Forceps) (2)
m.Adson forceps ( with and without
teeth) (2)
n. Scalpels (2)
o. Metzenbaum scissors (1)
p. Mayo scissors (1)
q. Suture scissors (1)
13. Separate 4 towel clips and position it
diagonally on one side or opposite side of the
scalpels.
14. Place the 3 towels at the back table. Attach To facilitate organization throughout the
the suction tip to the tubing as well as the tip of draping of the patient.
the cautery to the cautery pencil. Then roll
tubings properly and place it on the mayo
table.
15. Bring the drapes to the mayo table and
place it over the instruments and accessory
items.
16. Take the remaining 4 towels and unfold
each towel with folded portion facing up.
Arrange the towels in a cascading manner.
17. Wait for the surgeon to signal the start of
the procedure by draping the patient.
GASTRO-INTESTINAL SYSTEM
ADMINISTERING A CLEANSING ENEMA
Definition: An enema is the introduction of a solution into the large intestine via the
rectum. The instilled solution distends the lower bowel, may irritate
intestinal mucosa, and thus increase peristalsis.
Classification:
A. Cleansing Enemas - are given to remove feces from the colon, commonly to:
 Relieve constipation or fecal impaction
 Prevent involuntary escape of fecal material during surgical procedures
 Promote visualization of the intestinal tract by radiographic or instrument
examination
 Help establish regular bowel function during a bowel training program
B. Retention Enemas - are retained in the bowel for a prolonged period for different reasons:
 Oil retention enemas: Lubricate the stool and intestinal mucosa, making
defecation easier.
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 Carminative enemas: help to expel flatus from the rectum and provide relief
from gaseous distention.
 Medicated enemas: provide medications that are absorbed through the rectal
mucosa.
 Anthelmintic enemas: destroy intestinal parasites.
Recommended volume
1. Non–retention enema
Infant - 50 – 250 ml
Toddler/ Preschooler - 250 – 350 ml
School age - 300 – 500 ml
Adolescent - 500 – 750 ml
Adult – 750 – 1,000 ml
2. Retention enema - 250 ml or less
Equipment:
a. rectal catheter
Infant - Fr. 10-12
Toddler/ Preschooler - Fr. 14-16
School age - Fr. 16-18
Adolescent - Fr. 20-30
b. enema can with tubing

c. lubricant
d. pitcher with hot and cold water
e. solution as ordered by the physician – SSS, NSS, tap water
f. toilet paper (patient’s supply)
g. kidney basin
h. working gloves
i. apron or gown to protect the uniform
2. Bedpan with cover
4. Irrigation stand or IV stand
Procedure
Action Rationale
1. Review the written medical order. Verifying the medical order is crucial to
ensuring that the proper enema is
administered to the right patient.
2. Assess patient’s condition. Determines factors indicating need for

enema and conditions that contraindicate
use of enema.
3. Identify and explain the procedure. Plan The patient is better able to relax and
with patient where he/she will defecate cooperate if he is familiar with the
(bedpan, commode or nearby bathroom procedure and is provided everything in
ready for his use.) readiness when he feels the urge to defecate.
Defecation usually occurs within 5 – 10
minutes.
287
microorganisms.
5. Assemble the necessary equipment in the Organization promotes efficient time

utility room. Connect the rubber tubing to management.
the irrigating can and close the stop cock.
6. Prepare needed solution. Warm premixed The nurse is held accountable for any injury
soap sud solution by soaking the such as burning.
container in a basin with hot water.
Check the temperature with the back of
your hand. Pour mixture in the irrigating
can.
7. Connect the tip of the rectal tube and Although permitting air to enter the
expel the air directly to the kidney basin. intestine is not harmful, it may further
Replace catheter in its wrapper. distend the intestine.
8. Cover the tray and bring it to the bedside.
9. Provide patient’s privacy. Ensuring the patient’s privacy and warmth

aids in relaxation. The position of the
reclining person has not been found to alter
the results of the enema significantly.
10. Raise bed to appropriate working height
& raise side rail on patient’s left. Promotes good body mechanics & patient
safety.
11. Put on working gloves.
Gloves protect the nurse from contact with
microorganisms in the feces.
12. Hang the irrigating can to the IV stand.
Raise height of enema container Height at which solution is hung determines
accordingly: its force. Excessive pressure can force
High Enema – 30-45 cm (12-18 inches) colonic bacteria into the small intestine or
Regular Enema – 30 cm (12 inches) may rupture the colon.
Low Enema – 7.5 cm (3 inches)
13. Generously lubricate the end of the rectal
tube 2 to 3 inches.
Lubrication facilitates the insertion of the

14. Place a waterproof underpad under the rectal tube through the anal sphincter and
buttocks of the patient. prevents injury to the mucosa.
15. Position and drape the patient in left A bath blanket and bed protector protects
Sim’s position with the anus exposed. the bed linen from becoming wet.
16. Lift the patient’s buttocks to expose the Facilitates the flow of the solution by
anus. Slowly and gently insert the rectal gravity into the descending colon.
tube directing it at an angle pointing
toward the umbilicus. Ask the patient to Good visualization of the anus helps prevent
take several deep breaths. injury to tissues. The anal canal is
approximately 2.5 cm to 5 cm (1 – 2 inches)
Adults – 7.5- 10 cm (3-4 inches)
in length. The tube should be inserted past
Children – 5 – 7.5 cm (2–3 inches)
the internal anal sphincter. Further insertion
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Infants – 2.5 – 3.8 cm (1–1.5 inches) may damage intestinal mucosa. The
suggested angle follows the normal
intestinal contour. Slow insertion of the tube
minimize spasms of the intestinal wall and
17. If there is resistance in the insertion, sphincter. Deep breathing helps relax the
allow a small amount of solution to enter. anal sphincters.
Withdraw tube slightly then continue to
insert. Do not force entry of the tube. Ask Resistance may be due to spasms of the
the patient to take several deep breaths intestine or failure of the internal sphincter
through the mouth. to open. The solution may help to reduce
spasms and relax the sphincter, thus making
continued insertion of the tube safe. Forcing
a tube may cause injury to the intestinal
18. Open the stop cock and introduce the wall. Taking deep breaths help relax the
solution slowly over a period of 5 to 10 anal sphincter and abdominal muscle.
minutes. Hold the tube in place.
Introducing the solution slowly helps
19. Close the stop cock if the patient prevent rapid distention of the intestine and
complains of increased pain or cramping a desire to defecate.
or if fluid escapes around the rectal tubes.
The patient may be instructed to take Discomfort may cause poor retention of
small fast breaths or to pant. fluid. Various technique can be used to help
the patient relax muscles and prevent the
20. After the solution has been given, close expulsion of the solution prematurely.
the stop cock and place layers of toilet
tissue around tube at anus and gently
withdraw rectal tube. Withdraw tube This amount of time usually allows
gently but quickly. Have the patient muscular contraction to become sufficient
retain the solution until the urge to to produce good results.
defecate becomes strong, usually in about
5 – 15 minutes.
21. Repeat steps 13 – 17 until return flow is
clear.
22. Remove the gloves turning them inside
out and place in the kidney basin.
The gloves are removed in a manner which

23. When the patient has the strong urge to prevents to avoid contact with any
defecate, place him in a sitting position microorganisms that may be present on the
on a bedpan or assist him to the comfort outside of the gloves.
room. The sitting position is most natural and
24. Observe the character of the stool (color, facilitates the act of defecation.
consistency, approximate amount,
presence of blood, mucus, etc.) and the
patient’s reaction to the enema. Remind The nurse needs to evaluate and record the
the patient not to flush the toilet before patient’s response to treatment.
the nurse inspects the results of the
enema. If patient has hemorrhoids,
instruct to bear down gently during tube
insertion. This causes the anus to open
and facilitates insertion. Observe for
syncope, decreased heart rate and cardiac
dysrhythmias. Vagal stimulation can
289
occur from distention of the bowel.
25. Assist the patient if necessary with
cleansing the anal area. Offer soap and
water to wash his hands and tissue to dry
them. Cleansing deters the spread of
microorganisms.
26. Assess condition of abdomen; cramping,
rigidity or distention can indicate a
serious problem.
27. Leave the patient clean and comfortable.
Do the aftercare for equipment properly.
28. Perform hand hygiene. After care of equipment prevents the spread
of bacteria.
29. Record the procedure, type of solution,
length of time solution was retained, Deters the spread of microorganisms.
amount, color, consistency of return and
relief of flatus and abdominal distention. A written summary documents the care
provided and the patient’s response.
NOTE:
Repeated enema produces irritation of bowel mucosa and perineal area, as well as
electrolyte loss and exhaustion on the patient.
5/11/2011 8:00 AM No bowel movements in the last three

days. Encouraged to increase oral fluids.
8:30 AM Visited by Dr. Vilma Recto and gave an
10:00 AM order for cleansing enema. Soap sud solution of
500 ml introduced as enema. Moderate amount
of hard pebble-like shaped stools expelled. More
soap sud solution introduced in fractional doses
of 250-ml. Moderate amount of hard brownish
stools noted. Clear return flow obtained after the
final dose. Kept clean
10:45 AM and comfortable.
Nina Santos, St. N.
290
SAN PEDRO COLLEGE
Davao City
ENEMA
Name:__________________________________ Grade: ______________________

Year and Sec. _________________ Date : ______________________
Rating
5 4 3 2 1
1. Checks the medical order.
2. Assesses patient’s condition.
3. Identifies and explains procedure to the patient.
4. Washes hands.
5. Prepares equipment.
6. Connects the rectal tube and expels the air.
7. Brings the preparation to the bedside.
8. Provides privacy and dons gloves.
9. Hangs the irrigating can about 18 inches above the anus.
10. Places waterproof underpad under the patient.
11. Positions and drapes the patient in left Sim’s position
with the anus exposed.
12. Lubricates tube 2 – 3 inches.
13. Slowly and gently inserts the rectal tube directing it to
the umbilicus.
14. Opens the stop–cock and introduces the solution slowly
over a period of 5 – 10 minutes while holding tube in
place.
15. After the solution has been given, closes the stop–cock
and withdraws the tube gently but quickly.
16. Repeats procedure until return flow is clear.
17. Wraps tip of the rectal tube with toilet paper and places
it in a kidney basin.
18. Removes gloves.
19. Assists patient to the bedpan, commode or of comfort
room.
20. Assists the patient while cleansing the anal area.
21. Leaves the patient clean and comfortable.
291
22. Does the after care of equipment.
23. Washes hands.
24. Records the procedure and the results of the enema.
of the procedure.
Remarks:

II Performance 70%
100%
________________________________ __________________________
________________________________ __________________________
ADMINISTERING PRE–PACKAGED ENEMA
Purposes:
1. To relieve constipation.
2. To relieve intestinal flatus.
292
3. To prepare the lower colon for treatment exam.
4. To prevent newborn infection from maternal feces.
Equipment:
1. Pre–packaged enema
3. Bedpan, commode or toilet
4. Toilet paper (patient’s supply)
5. Lubricant
6. Working gloves
Procedure
Action Rationale
1. Review the physician’s order for the You may not legally complete the treatment
type of enema to be given. without the order.
2. Check the patient’s medical diagnosis Alerts you to potential problems that could
and other health problems. occur as a result of the enema administration.
3. Check VS. To obtain baseline data prior to the procedure.
4. Screen the patient by closing door and Provides privacy.

curtains around the bed.
5. Raise the bed to a comfortable height. Reduces the strain placed on the back.
6. Place in left Sim’s position with the Facilitates the flow of enema solution by
right leg acutely flexed as possible. gravity in the natural direction of the colon.
Provides adequate exposure of anus.
7. Put on gloves. When there is a chance of coming into contact

with feces, gloves should be worn to prevent
possible transmission of microorganisms.
8. Place the waterproof underpad. Prevents soiling of linen.
9. Remove the cap on the enema tip and Prelubricated tips may dry with the passage of
check the tip for adequacy of time.
lubrication (or follow manufacturer’s
direction). Additional lubrication may
be needed.
10. Separate patient’s buttocks and insert This decreases the chance of scraping the
the enema tip 1 – 2 inches toward the patient’s rectal wall.
umbilicus.
11. Squeeze and roll the enema container, Rolling the container dispenses the solution
toward the patient’s rectum until all of into the intestines.
the solution is administered.
12. Remove the container and ask the Promotes peristalsis and more complete
293
patient to remain in Sim’s position for evacuation. This position also prevents
5 – 10 minutes. premature leakage of the solution.
13. Hold together the buttocks of an infant Facilitates retention of the enema solution.
and or other patient to retain the
solution.
14. Place the patient in a sitting position in An upright sitting position facilitates
a bedpan or assist in getting to the defecation by gravity.
bathroom.
15. Stay with the patient and observe for

response including untoward signs and
symptoms.
16. Instruct patient not to flush the toilet Observation of the feces is necessary for
and note the character of the stools. accurate charting.
17. Cleanse the rectal area with toilet paper Fecal material is caustic to the skin.
and water.
18. Dispose of and clean equipment.
19. Remove gloves.
20. Do handwashing. Prevents spread of microorganisms.
21. Return patient’s bed to original height.
22. Record the procedure and other

pertinent observations.
ADMINISTERING ENTERAL TUBE FEEDINGS
Definition: Administration of liquid feedings given via the G.I. tract.
Equipment
• Asepto syringe or 20- to 50-ml syringe • Formula

• Emesis basin • Infusion pump
for feeding tube
• Clean towel • Water to follow feeding
• Disposable gavage bag and tubing • Nonsterile gloves
Procedure
294
Action Rationale
1. Identify client and review medical Verifies health care provider’s

record for formula, amount, and time. prescription for appropriate formula
and amount.
2. Wash hands/hand hygiene. Handwashing deters the spread of

microorganisms
3. Identify the patient Identifying the patient ensures that the

right patient receives the intervention
and helps prevent errors.
4. Explain procedure to client. Reduces anxiety and increases client

cooperation.
5. Assemble equipment within reach. Ensures efficiency when initiating

Add color to formula per institutional feeding. Color will distinguish formula
policy. If using a bag, fill with aspirate.
prescribed amount of formula.
6. Position the client with the head of Reduces risk of pulmonary aspirations
the bed elevated at least 30 to 45 in the event that the client vomits or
degrees or as near normal position for regurgitates formula.
eating as possible.
7. Put on nonsterile gloves. Gloves prevent contact with blood and

body fluids.
8. Provide privacy. Puts the client at ease.
9. Observe for abdominal distention; Assesses for delayed gastric emptying

auscultate for bowel sound. indicates presence of peristalsis and
ability of GI tract to digest nutrients.
Verification of tube placement by X- Radiologic examination confirms the
ray is done on doctor’s order before correct placement of enteral tube, thus
client receives the first feeding. prevent the aspiration of liquid food or
stomach contents into the respiratory
tract.
10. Verify tube placement. Attach
syringe into adapter port, aspirate Indicates whether gastric emptying is
stomach contents, and determine delayed. Reduces risk of regurgitation
amount of gastric residue. If residue and pulmonary aspiration related to
is greater than 50 to 100 ml (or in gastric distention. Prevents electrolyte
according with agency protocol), hold imbalance.
feeding until residue diminishes.
Instill aspirated contents back into
feeding tube.
11. Visualize aspirated contents,

checking for color and consistency. Gastric fluid can be green with particles,
off-white or brown if old blood is
present.
12. Administer tube feeding.
295
Provides nutrient as prescribed.
Intermittent Bolus
13. Pinch proximal end of feeding tube.

Prevents excessive air from entering
patient’s stomach/intestine or leaking of
contents.
14. Remove plunger from syringe and
attach barrel of syringe to end of Provides system to deliver feeding.
tube.
15. Fill syringe with measured

amount formula. Allows gravity to control flow rate,
reducing risk of diarrhea from bolus
feeding.
16. Allow formula to infuse slowly;
continue adding formula to syringe Prevents air from entering stomach.
until prescribed amount has been Decreases risk of diarrhea.
administered.
17. Flush tubing with 30 to 60 ml or

prescribed amount of water for Ensures that remaining formula in
irrigation to the syringe. tubing is administered and maintains
patency of tube; prevents air from
entering the stomach.
18. When the syringe has emptied, hold
the syringe high and disconnect it Holding the syringe high, will not allow
from tube. Clamp the tube and cover backflow of formula out of tube and
the end with the cap. onto the patient.. Clamping the tube
prevents air from entering the stomach.
Capping the end of tube deters entry of
microorganisms. Covering the end
protects the patient and linens from fluid
Intermittent Gavage Feeding leakage from the tube.
19. Hang bag on IV pole so that it is 18

inches above the client’s head. Allows gravity to promote infusion of
formula.
20. Remove air from bag’s tubing.
Prevents air from entering stomach.
Decreases risk of diarrhea.
21. Attach distal end of tubing to
feeding tube adapter, and adjust drip Allows gravity to control flow rate,
to infuse over prescribed time. reducing risk of diarrhea from bolus
feeding.
22. When bag empties of formula, add
30 to 60 ml or prescribed amount of Prevents air from entering stomach and
water and clamp the tubing reduces risk for gas accumulation.
immediately after water has been Maintains patency of feeding tube.
instilled.
23. Change bags every 24 hours.

Decreases risk of multiplication of
Continuous Gavage microorganisms in bag and tubing.
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24. Check tube placement and gastric
residual every 4 to 6 hours. Checking placement verifies that the
tube has not moved out of the stomach.
Checking gastric residual monitors
absorption of the feeding and prevents
distention, which could lead to
aspiration.
25. If residual is above 100 ml, stop
feeding. Reduces risk of regurgitation and
pulmonary
26. Add prescribed amount of formula to
bag for a 4-hour period; dilute with Provides client with prescribed nutrients
water if prescribed. and prevents bacterial growth (formula
is easily contaminated).
27. Hang gavage bag on IV pole. Prime
tubing. Removes air from tubing.
28. Thread tubing through feeding pump

and attach distal end of tubing to Provides for controlled flow rate;
feeding tube adapter; keep tubing prevents loops in tubing.
straight between bag and pump.
29. Adjust drip rate.

Infuses formula over prescribed time.
30. Monitor infusion rate and sign of
respiratory distress or diarrhea. Prevents complications associated with
continuous gavage.
31. Flush tube with water every 4 hours
as prescribed or following Maintains patency of tube.
administration of medications.
32. Replace disposable feeding bag at

least every 24 hours, in accordance Prevents the spread of microorganisms.
with institution’s protocol.
33. Elevate head of bed at least 30

degrees at all times, and turn client Prevents aspiration and promotes
every 2 hours. digestion and reduces skin breakdown.
34. Provide oral hygiene every 2-4

hours. Provides comfort and maintains the
integrity of buccal cavity.
35. Administer water as prescribed, with
and between feedings. Ensures adequate hydration.
36. Remove gloves and wash

hands/hand hygiene. Prevents the spread of microorganism.
37. Record total amount of formula and

water administered on intake and Documents administration of feeding
output (I & O) form and client’s and achievement of expected outcome,
response to feeding. for example, client tolerates feeding and
weight is maintained or increased.
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STOOL SPECIMEN COLLECTION
Definition: Collection of stool specimen for presence of parasites.
Rationale:
Many parasitic infections are “silent” or produce only mild symptoms. Half of human
parasitic infections, can be diagnosed through a stool examination because their causative
agents inhabit the GI tract.
Purpose of the test:

Stool exam test is used to make a differential diagnosis of the cause of protracted
diarrhea with the aforementioned characteristic.
Significant Findings:
iii. Normal: No oval parasites found
iv. Abnormal:
1. Trophozoites of Entamoeba histolytica
2. Cysts of Giardia lamblia
3. Presence of helminth larvae, ova or proglottids.
4. Tangle number of Cryptosporidiosis and Blastocysts hominis if other organisms
have been ruled out.
5. Other parasites.
Equipment:
1. Working gloves
2. Sterile collection container with cover
3. A completed label for the container
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4. Duly accomplished stool exam request slip
Sample Collection:
1. Fresh, warm, nonformed stools are usually required for protozoan screening.
2. Examination for helminths can be done with formed stool.
3. The first stool in the morning is usually preferred.
4. Stool must be delivered to the laboratory in 30 minutes or less after defecation.
5. Collection cups should be filled in an upright position.
6. To prevent the spread of infection, wear gloves when filling the collection cup or
whenever in contact with the stool and wash hands at least in beginning and with
patient contact.
7. For maximum detection of parasites, three non–formed stools should be collected over
a 5–day period, every other day (stool series).
8. Label the sample container with the patient’s name, type of test, form number,
physician’s name and the date and time.
Patient Preparation:
Pretest assessment: Check whether the patient has received mineral oil, a waxy
suppository, or a barium X–ray within 4 days before this test. If so, notify the laboratory and
physician because the test will probably have to be delayed.
Patient Teaching:
1. Stress the importance of handwashing before and after defecation/ collection.
2. Explain what day(s) the sample will be collected and the preferred time for stool
collection, based on the presumed type of infection and laboratory scheduling. Stress
the importance of samples being sent to the laboratory immediately.
3. Do not contaminate the specimen with urine or any other discharges. Let the patient
void before the specimen collection.
4. If a dependent:
a. Explain that anything which is contaminated with stool is best handled with
gloves, both by the patient and health care worker.
b. Explain the mechanisms for spread of infection and / or reinfection and ways to
prevent it.
5. If ambulatory and capable of self–care and / or not hospitalized:
a. Provide with or tell where toilet collection containers are available and explain
how to use it in the toilet for collecting the stool specimen.
b. Inform the person that the collection cup should be filled one fourth full (more
than one sample maybe requested) and that it is important to keep the lid clean of
any feces.
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RESPIRATORY SYSTEM
ADMINISTERING OXYGEN
Definition: Administration of oxygen at concentration greater than that in ambient air with
the intention of treating or preventing the symptoms and manifestation of
hypoxia (Dougherty 2015)
Purposes:
300
1. To correct hypoxemia.
2. To decrease myocardial work
3. To decrease the work of breathing.
Equipment:
1. Flowmeter attached to oxygen tank or piped in oxygen
2. Humidifier with sterile distilled water
3. Equipment for administering oxygen ( As ordered by the physician)
a. nasal catheter (Adult: Fr. 12–14; Children: Fr. 8-10)
b. nasal cannula
c. mask
4. Adhesive tape if nasal catheter is used.
5. Gauze pad for potential areas of pressure (optional)
Procedure
I - NASAL CATHETER
Action Rationale
1. Determine the need for oxygen To provide baseline observations and to
treatment by performing respiratory ensure the most appropriate device is selected
assessment verifying the order for to meet the parient’s need prior to
treatment. commencing oxygen therapy

microorganisms.
3. Identify and explain the procedure to An explanation relieves apprehension and

the client and review safety precautions promotes cooperation. The nurse promotes
necessary when oxygen is in use. the safety of the client and others by
providing pertinent information.
4. Assist the client to a semi-Fowler’s Allows free movement of the diaphragm and
position if possible. expansion of the chest wall.
5. Open the oxygen valve and check that To ensure proper functioning.
the oxygen is flowing freely through
the tubing and feel the oxygen at the tip
of the cath.
6. Regulate the liter gauge as prescribed. To ensure the appropriate amount of oxygen
is selected to meet the patient’s need.
7. Measure from the tip of the nose to the An insertion of the correct length of catheter
lobe of the ear and insert gently. facilitates oxygen administration and comfort
for the client.
8. Fasten to bridge of nose and forehead Correct placement of fastener facilitates

or cheek with adhesive tape. oxygen administration and comfort for the
client.
9. Encourage the client to breathe through Keeping the mouth closed provides optimal
his nose with his mouth closed. delivery of oxygen to the client’s lungs.
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10. Record the time therapy was started, The client’s respiration, color, oxygen
rate of oxygen flow per minute, and saturation will indicate the effectiveness of
client’s response to therapy. the oxygen therapy.
11. If oxygen therapy is to be discontinued, Liter gauge will have more pressure to
close oxygen valve then oxygen liter contend with and ruin the equipment.
gauge. Withdraw catheter very gently. When performing these tasks the nurse
Cleanse client’s nostril after. demonstrates a conscientious concern for the
client’s comfort.
12. Do after care of equipment.
II - NASAL CANNULA
Action Rationale
1. Follow steps 1- 4 of nasal catheter
oxygen administration.
2. Connect the nasal cannula to the oxygen Oxygen forced through a water reservoir is
set–up with humidifier. If using a wall humidified before it is delivered to the client,
outlet as oxygen source plug flowmeter thus preventing dehydration of the mucous
into outlet by pushing until it snaps into membranes.
place. If a lock release button is present,
depress it as you place the flowmeter.
3. Apply the curve of the prongs pointing Correct placement of prongs and fastener
down to the client’s nostrils. facilitates oxygen administration and comfort
a. Adjust the loops behind the ears of the client.
and then down the chin
b. Move the cinch adjustment to keep
the prongs in the nose
4. Open the oxygen valve To facilitate delivery of the oxygen
5. Use gauze pads at the ear beneath the Pads reduce the irritation and pressure thus
tubing as necessary. protect the skin.
6. Encourage the client to breathe through Keeping the mouth closed provides optimum
the nose with mouth closed. delivery of oxygen to the lungs.

microorganisms.
8. Assess and chart the client’s response to To determine the effectiveness of the oxygen
therapy. therapy.
Check the liter flow, humidifier and safety
9. Inspect the equipment on a regular basis. precautions.
10. Remove and clean the cannula and The continued presence of the cannula causes
nares at least every 8 to 12 hours or irritation and dryness of the mucous
according to agency recommendation. membranes.
Check the nares for evidence of irritation or
bleeding.
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III – MASK
1. Follow steps 1 – 4 of nasal catheter [
oxygen administration
2. Attach the face mask to the oxygen set–
up with humidification. Start the flow Oxygen forced through a water reservoir is
of oxygen at the specified rate. humidified before it is delivered to the client,
thus preventing drying and dehydration of the
mucous membranes.
3. Apply the face mask to the bridge of
A loose or poorly fitting mask will result in
the nose first then position over the
oxygen loss and decreased therapeutic value.
chin, adjusting strap snugly around the
Masks if applied too tightly may may cause a
head.
feeling of suffocation.
4. Use gauze pads to reduce irritation on Pads reduce irritation and pressure thus
the client’s ears and scalp. protect the skin.
Handwashing deters the spread of
5. Wash your hands. microorganisms.
The tight–fitting mask and the moisture from
6. Remove the mask and dry the skin
condensation can irritate the skin on the face.
every 2 to 3 hours if the oxygen is
There is danger of inhaling powder if it is
running continuously. Do not use
placed on the mask.
powder around the mask.
7. Assess the client’s vital signs, color, To ensure that the client is not over or under
response to therapy and monitor the oxygenated and that the equipment is working
equipment on a frequent basis. properly
A written summary provides an accurate

8. Record the type of therapy and the documentation of the care and response of the
client’s response. client to treatment.
5/27/2017 1:50 PM Restless during sleep, R – 32, P – 118,

BP – 148/90. Slightly cyanotic. Placed in high
Fowler’s position. O2 via nasal cannula
administered at 4 L/min., as ordered. VS
rechecked. RR-25, P-100, BP 130/80.
Verbalized “mas okay na akong ginhawa”
Janice Tan, St. N
SAN PEDRO COLLEGE

Davao City
ADMINISTERING OXYGEN
Name: _________________________________ Grade: _________________

Year and Sec. _________________ Date __________________
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Rating
PROCEDURE 5 4 3 2 1
1. Washes hands before contact with the client.
2. Makes pertinent assessment.

3. Checks the medical orders for direction on the use of
oxygen.
4. Places the client in a semi – or high-Fowler’s position.
5. Explains the purpose of the procedure.
6. Posts signs indicating oxygen use and precautions.
7. Connects the flowmeter to the source of oxygen.
8. Attaches and fills the humidifier, with sterile water.

9. Measures the nasal cannula from the tip of the nose to
the ear
10. Connects the tubing / cannula to the oxygen source.

11. Adjusts the flow to an amount appropriate for the
client’s condition or amount prescribed.
12. Adjusts the fit of the cannula or mask for comfort and to
avoid leaking.
13. Observes the client’s immediate response.
14.Provides the client with a signal device.
15. Washes hands.
16. Charts significant information.
17. Returns to obtain reassessment data.

18. Refills humidifier, as needed.
19.Maintains body mechanics throughout the
304
24.Uses correct English.
25.Shows mastery of the procedure.
Remarks:

II Performance 70%
100%
____________________________________ __________________________
____________________________________ __________________________
SUCTIONING THE NASOPHARYNGEAL AND OROPHARYNGEAL AREAS
The oropharynx extends behind the mouth from the soft palate above the level of the
hyoid bone and contains the tonsils. The nasopharynx is located behind the nose and extends
to the level of the soft palate. Oropharyngeal or nasopharyngeal suctioning is used when the
client is able to cough effectively but is unable to clear secretions by expectorating or
swallowing.
Purposes:
305
1. To remove excess saliva or emesis from the oral cavity.
2. To clear the upper airway of mucoid secretions.
3. To obtain sputum culture.
4. To relieve respiratory distress.
Indications for Suctioning:

1. When the client is unable to mobilize his/her secretions from the oropharynx
and/or trachea to maintain a patent airway.
Equipment:
1. Suction apparatus
2. Sterile suction catheter (with suction control port)
3. Sterile water or saline
4. Sterile container
5. Sterile gloves
6. Clean towel
7. 5 cc. syringe (for tracheostomy suctioning)
8. Personal Protective Equipments (PPE)
a. Mask, goggles or face shield
b. gown or disposable apron (optional)
Size of suction catheter Duration of Suctioning Intervals

Newborn : Fr. 6 3 – 5 seconds
Infant : Fr. 6 – 8 5 – 8 seconds 30 seconds to 1 minute
Child : Fr. 8 – 10 8 – 10 seconds
Adult : Fr. 12 – 16 10 – 15 seconds
Procedure
Action Rationale
1. Ascertain if there is a need for . Suctioning also stimulates coughing which

suctioning by performing a respiratory can be painful for patients with surgical
assessment. incisions and other conditions. Suctioning can
be traumatic to the airway mucosa
2. Prepare equipment at the bedside. Bringing everything to the bedside conserves

time and energy. Arranging things nearby is
convenient, saves time and avoids
unnecessary stretching, and twisting of
muscles on the part of the nurse.
3. Wash your hands. Put on PPE. Hand hygiene and PPE prevent spread of
microorganism. PPE is required based on
transmission precautions
4. Identify the patient and explain to the Identifying the patient ensures the right
client how the procedure will help to patient receives the intervention and helps
clear the airway and relieve breathing prevent errors.
problems. Explain that coughing,
306
sneezing or gagging is normal. An explanation of the procedure relieves the
client’s anxiety about procedure.
5. Close the curtains around the bed or This ensures privacy.

close the door and properly position the
client. Positioning of the head to one side or
hyperextending the neck promotes smooth
For conscious client:
insertion of the catheter into the oropharynx
a. Semi–Fowler’s position with head or nasopharynx, respectively.
turned to one side for oral
suctioning.
b. Semi–Fowler’s position with neck

hyperextended for nasal suctioning.
For unconscious client:

c. Lateral position facing the nurse. The lateral position prevents the client’s
tongue from obstructing the client’s airway,
promotes drainage of pulmonary secretions,
and prevents aspiration of gastrointestinal
contents.
6. Place a towel or waterproof pad across This protects the bed linen or the client’s
the patient’s chest. clothes or gown from secretions. Secretions
on the towel can be discarded, thus reducing
spread of bacteria.
7. Turn the suction on to the appropriate Proper suction pressure provides safe negative
pressure if applicable. pressure according to the client’s age. High
Wall Unit pressures can cause excessive
Adults : 100-150 mmhg trauma,hypoxemia and atelectasis
Neonates : 60-80 mmhg
Infants & children 80-125 mmhg
Adolescent: 80 – 150 mmhg
Portable Unit
Adults : 10-15 cmhg
Neonates : 6-8 mmhg
Infants & children 8-10 mmhg
Adolescent: 8 – 15 mmhg
Water or NSS lubricates the lubricates the
8. Pour sterile water or NSS into sterile inside of the catheter and helps move
container. secretions in the catheter .
It helps check if the suction equipment is
working properly ; also it is use to clear the
catheter between suction attempts.
Suctioning removes air from the patient’s

9. Increase the patient’s supplemental airway and can cause hypoxemia.
oxygen or apply supplemental oxygen Hyperoxygenation can prevent suction
per facility policy or primary care induced hypoxemia
provider orders
CAUTION : For COPD patients
oxygen must not be over 2 L/min
307
10. Peel back the wrapper of the catheter To facilitate easy removal of the catheter from
until the adapter is exposed. the wrapper.
11. Apply a sterile glove to your dominant The sterile gloves maintains asepsis as
hand. Remove wrapper around the catheter is passed into the client’s mouth or
catheter with the non-dominant nose.
unsterile hand. Coil the catheter around
your dominant hand using fingers as To prevent contamination.
your remove it from the wrapper.
12. Holding the sterile suction catheter with

the gloved hand, connect it to the
suction tubing that is held with the This distance ensures that the suction catheter
unsterile hand remains in the pharyngeal region. Insertion of
the catheter past this point places the catheter
13. Approximate the distance between the into the trachea.
client’s ear lobe and tip of the nose and
place the thumb and forefinger of Moistening the catheter tip reduces friction
gloved hand at that point (6 – 8 inches). and eases insertion of catheter. Applying
suction while the catheter is in the sterile
14. Moisten the catheter tip with sterile solution ensures that suction equipment is
solution. Apply suction with catheter functioning before catheter is inserted.
tip in the solution and remove the
oxygen delivery device, if appropriate.
Correct distance for insertion ensures proper

15. Insert the suction catheter: placement of catheter. The general guideline
for determining the distance for nasopharynx
a. For nasopharyngeal suctioning, suctioning is to estimate the distance from the
gently insert catheter through the patient’s earlobe to the nose.
naris along the floor of the nostril
towards the trachea. Roll the
catheter between your fingers to
help advance it. Advance the
catheter approximately 5 - 6 inches Stimulation of the gag reflex is reduced.
to reach the pharynx
Do not apply suction during
insertion.
b. For oropharyngeal suctioning,

gently insert the catheter into one
side of the mouth toward the
trachea. Advance the catheter 3-4
inches to reach the pharynx .
Turning the catheter as it is withdrawn
minimizes trauma to the mucosa.
16. Apply suction intermittently by
occluding the control port with the thumb Suctioning longer than 10-15 seconds robs the
of the nondominat hand , gently rotating respiratory tract of oxygen supply which may
the catheter as it is being withdrawn. Do result to hypoxemia.
not suction for more than 10-15 seconds at Suctioning too quickly maybe ineffective of
atime. removing secretions
308
This will prevent hypoxemia because
suctioning removes air from the patient’s
17. Replace the oxygen delivery device airway
using your nondominant hand
Flushing the catheter with sterile solution
removes secretions from the catheter and
18. Flush the catheter with sterile solution lubricates the catheter for the next suctioning.
by placing it in the solution and applying
suction. If the client is able to cough productively,
further suctioning may not be needed if his
airway is clear upon auscultation.
If suctioning is needed, repeat steps 14-17. The interval reoxygenation and reventilation
of airways. Excessive suction passes
The interval between suctioning should be contribute to complication.
at least 30 seconds to one minute. No more
than three suction passes should be made Mouth is suctioned last to prevent
during suction episode. transmission of contaminants because more
microorganism are usually found in the
mouth.
NOTE: Suction the oropharynx after
the nasopharynx If suctioning is to be
done constantly, use a separate suction
cath for each orifice. Properly label
them and maintain sterility. This technique reduces transmission of
microorganism. Proper positioning with
19. When procedure is completed, remove raised side rails and proper bed height provide
gloves from your dominant hand over the patient comfort and safety.
coiled catheter , pulling them off inside out.
Remove the glove from your nondominant
hand and sispose gloves, catheter and
container with solution in the appropriate
receptacle. Assist the patient in a
comfortable position.
Secretions retained and accumulated in the
mouth is irritating to the mucous membranes
20. Offer oral hygiene. and unpleasant for the patient.
This assesses the effectiveness of suctioning

and the presence of complications
21. Reassess the patient’s respiratory status
including respiratory rate, effort, oxygen
saturation and lung sounds. Removing PPE properly reduces the risk of
infection transmission and contamination of
22.Remove additional PPE, if used. other items. Hand hygiene prevents the spread
Perform hand hygiene of microorganism.
Recording this information documents that

the procedure was completed and the client’s
23. Record the time of suctioning, amount, status during and after the procedure.
309
consistency, color and odor of secretions
and the client’s response to the procedure.
Empty suction bottle at the end of every
shift.
Note: Store the catheter according to the agency’s or doctor’s preference.
5/3/2017 8:30 AM Gargling respirations audible. Nasal flaring

noted. R–30, P–100 and regular, BP–140/ 90.
Encouraged to breathe deeply and to cough. Unable to
cough out secretions effectively.
8:35 AM Oropharyngeal hygiene done. Suctioned a moderate
amount of yellowish, sticky secretions. Encouraged to
do deep breathing . RR – 24. Abnormal respiratory
sounds not noted. Mouth wash done. Encourage to take
more fluids p. o.
Kathy Daniel, St. N.
SUCTIONING THE TRACHEOSTOMY
Definition:
Tracheostomy suctioning is the removal of secretions from the trachea or bronchi by
means of a suction catheter inserted into the tracheostomy tube. Tracheal suction is essential
component of managing secretions, maintaining respiratory function and a patent airway
A. Indications of Tracheostomy Suctioning
1. Presence of prominent audible secretions
2. Visible secretions
3. Decrease oxygenation
4. Diminished breath sounds
Equipment:
1. Suction source ( wall or portable) 7. Sterile 2-10 ml. syringe ( optional)
2. Sterile aspirating catheter 8. Mask
Infants : Fr. 6 to 8
Children : Fr. 8 to 10
Adults : Fr. 12 to 16
3. Sterile container
4. Sterile gloves
5. Sterile NSS or sterile water
6. Clean towel or waterproof pad
310
Procedure
Action Rationale
1. Obtainbaseline vital signs An immediate baseline data serves as an
index for needing suctioning as well as a
bases for evaluating its effectiveness.
2. Prepare equipment at the bedside.
Preparation of equipment allows smooth
performance of the procedure without
interruption.
3. Explain the procedure to the client.
An explanation relieves apprehension and
facilitates cooperation.
4. Wash hands with bactericidal soap and
water or apply bactericidal alcohol To minimize the risk of cross infection
hand rub, put on disposable plastic
apron, disposable gloves and eye
protection
5. Assist the client to a semi–Fowler’s

position if conscious. An unconscious A sitting position helps the client to cough
client should be placed in the lateral and breathe more easily. This position also
position facing you. uses gravity to aid in the insertion of the
catheter. A lateral position prevents the
airway from becoming obstructed and
promotes drainage of secretions.
6. Place a towel or warterproof pad
across the client’s chest.
Absorbent material protects the client and bed
linen.
7. Turn the suction on to the appropriate
pressure: Proper suction pressure provide safe negative
a. Wall unit: pressure according to the client’s age.
Adult : 110 – 150 mmHg Excessive negative pressure can precipitate a
Child : 95 – 110 mmHg pneumothorax.
Infant: 50 – 95 mmHg
b. Portable unit:
Adult : 10 – 15 mmHg
Child : 5 – 10 mmHg
Infant : 2 – 5 mmHg
8. Open the sterile container and place it

on the bedside table or overbed table The chambers within the container maintain
without contaminating the inner the sterility of items that will be in direct
surface. contact with the client’s airway.
9. Pour sterile saline or water into the

container. Sterile solution is needed to lubricate the
catheter to decrease friction and promote
smooth passage of the catheter.
10. Hyperoxygenate the client for 1 to 3
minutes by using the manual To prevent acute hypoxia during suctioning.
311
resuscitating bag
11. Apply a sterile glove to your dominant The sterile glove reduces the risk of infection.
hand. Remove wrapper around the
catheter with the non–dominant
unsterile hand and discard.
Sterile technique prevents introducing
12. Holding the sterile suction catheter with organisms into the respiratory tract.
the gloved hand, connect it to the
suction tubing that is held with the
unsterile hand.
Lubricating the inside of the catheter with
13. Moisten the catheter by dipping it into saline helps move secretions through the
the container of sterile saline. Occlude catheter. Occluding the suction control port
the suction control port to check while the catheter is in the sterile solution
suction. ensures that suction equipment is functioning
well before insertion.
Removing the oxygen allows access to the

14. Remove the oxygen administration tracheostomy tube.
equipment with the unsterile hand.
Hyperoxygenation and hyperventilation aid in
15. Using your nondominant hand and a preventing hypoxemia during suctioning.
manual resuscitation bag, hyperventilate
the patient, delivering 3 to 6 breaths .
Using the suction while inserting the catheter
16. Using the sterile hand, gently but can cause trauma to the tracheal mucosa and
quickly insert the catheter into the trachea respiratory infection.
about one third of its length or
approximately 10 -15 cm or until the client Catheter should not go further than the carina
coughs if resistance is felt , withdraw the to prevent trauma
catheter about 1 cm before applying suction
by placing the thumb over the port control Catheter inserted with suction off can reduce
and slowly withdraw the remainder of the trauma
catheter.
Occlusion of suction control port activates
17. Apply suction by occluding the suction suction pressure. Rotation removes secretions
control port with the thumb of the unsterile from all surfaces of the airway and prevents
hand. Gently rotate the catheter with the trauma from suction pressure on one area of
thumb and index finger of the gloved hand the airway.
as you withdraw it. Limit suctioning to 10
seconds duration only for adults; newborn Prolong suctioning may result in acute
5-8 sec., children 5-10 sec. at 30 seconds – hypoxia, cardiac arrhythmia (Day et al 2002),
1 minute interval. mucosal trauma, infection and the patient
experiencing a feeling of choking
18. Encourage the client to cough during Coughing helps loosen and move secretions
suctioning. to the area of the catheter.
19. Using your nondominant hand and a Hyperoxygenation and hyperventilation aid in
manual resuscitation bag, hyperventilate preventing hypoxemia during suctioning
the patient, delivering 3 to 6 breaths .
312
20. Attach the oxygen administration This prevents hypoxemia
equipment with the unsterile hand.
21. Flush the catheter with saline and Flushing cleanses the catheter and lubricates
assess the need to repeat suctioning. Allow it for the next insertion. Allowing a time
the client to rest at least 3 – 5 minutes interval and replacing the oxygen help
between suctioning. Readminister oxygen compensate for hypoxia induced by the
between suctioning efforts and when previous suctioning.
suctioning is completed.
22. When the procedure is completed, turn Keeping contaminated articles confined to
off the suction and disconnect the catheter certain areas limits the transmission of
from the suction tubing. Remove the sterile microorganisms. Handwashing deters the
glove inside out and dispose the glove, spreads of microorganisms by direct contact.
catheter and container in a waste
receptacle. Wash hands.
23. Offer oral hygiene after suctioning Respiratory secretions that accumulate in the
mouth are irritatingto the mucuous
. membranes and unpleasant for the patient.
Reassessment helps evaluate the effect of
suctioning. Breathing should be relatively
effortless and quiet.
24. Reassess the patient’s respiratory This assess the effectiveness of suctioning
status, including respiratory rate, effort, and presence of of complications.
oxygen saturation and lung sounds.
25. Record the time of the suctioning and A written summary provides accurate
the nature and amount of secretions. Also documentation of comprehensive care.
note the character of the client’s
respirations before and after suctioning.

5/3/2017 10:15 AM Shallow, noisy respiration noted at 32 per
minute. Lips slightly cyanotic. Looks anxious,
P–108 and regular. Hyperoxygenated with 100%
oxygen for 2 minutes. Tracheostomy suctioned.
Small amount of thick yellowish secretions
removed. Reoxygenated at 100% oxygen for 1
minute. R–28, P–100 within 10 minutes after
suctioning.
10:25 AM No abnormal breath sounds noted at this
time.
Erich Reyes, St., N.

COLLECTING A SPUTUM SPECIMEN
Definition: Sputum is the mucous secretion from the lungs, bronchi and trachea.
313
Purposes:
1. For culture and sensitivity test.

2. To identify cancer in the lung and its specific cell type.
3. To identify the presence of acid–fast bacilli.
4. To assess the effectiveness of drug therapy.
Equipment:
1. A sterile container with a cover

2. Disinfectant and CB to cleanse the outside of the container and tissue paper to dry
it
3. A completed label for the container, with identifying information about the client.
4. A completed requisition to accompany the specimen to the laboratory.
5. Mouth wash (optional)
6. Working gloves
7. Mask
Procedure
Action Rationale
1. Explain the procedure to the client. An explanation provides reassurance and

promotes cooperation.
2. Make sure the client can expectorate Prevents the spread of microorganisms.
the sputum directly into the sputum
cup. Leave the container with the client
if assistance is not required. If the client Protects the nurse from acquiring infection.
needs assistance, wear the gloves and
mask.
3. Ask the client to sit and to breathe

deeply thrice and then cough up 1–2
tbsp. (15–30 ml.) of sputum depending
on the specified amount.
4. Ask the client to hold the sputum cup Containing the sputum within the cup restricts
(or hold it) and expectorate into it, the spread of microorganisms to others.
making sure that the sputum does not
come in contact with the outside of the
container.
5. Cover the container immediately after Covering the container prevents the
the collection. inadvertent spread of microorganisms.
6. Determine the respiration rate and any

abnormalities or difficulty in breathing.
7. Assess the color of the client’s skin, This indicates impaired blood oxygenation.
especially any cyanosis.
8. Wipe the outside of the container with a Prevents the spread of microorganisms.
314
disinfectant if the sputum has contacted
the outside surface.
9. Place the completed label on the Labeling ensures proper identification of the
container, (name, room number, specimen.
purpose, specimen series number).
10. Provide the client with water to rinse This removes any unpleasant taste.
the mouth.
11. Together with the laboratory requisition Overgrowth of other organisms can interfere
slip, send the specimen to the with the test results if the specimen remains at
laboratory within 20 minutes. room temperature for an extended period of
time.
12. Document collection of the sputum A written summary provides accurate

specimen on the client’s chart. Include documentation of the procedure.
the color, consistency, amount and odor
of the sputum. Chart any discomfort
experienced by the client.
Note: Collect the sputum specimen (not saliva) early in the morning before breakfast
to obtain an overnight accumulation of secretions. The mouth may be rinsed with
water but no mouth wash should be used prior to collection of specimen.
SAN PEDRO COLLEGE

Davao City
315
COLLECTING SPUTUM SPECIMEN
Name: __________________________________ Grade: __________________

Year and Sec. _________________ Date: ___________________
Rating
PROCEDURE
5 4 3 2 1
1. Washes hands.
3. Provides client with privacy.
4. Positions client correctly.
5. Holds the sputum cup for the client if he is unable to.
6. Assists client to breathe deeply three times and then

cough up 1-2 tbsp. (15 – 30 ml) of sputum.
7. Collects expectorated specimen correctly.
8. Covers the container immediately after collection.
9. Cleanses outside of the container with a disinfectant if

the sputum has contacted the outside surface.
10. Provides the client with water to rinse the mouth.
11. Labels specimen correctly and completely.
12. Sends the specimen to the laboratory within 20 minutes

of collection together with the laboratory requisition
slip.
13. Documents collection of the sputum specimen on the

client’s chart including color, consistency and amount.

of the procedure.
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Remarks:

II Performance 70%
100%
________________________________ __________________________
________________________________ __________________________
URINARY SYSTEM
COLLECTION OF URINE SPECIMEN
Purposes:
1. For routine urine analysis
2. For urine culture and sensitivity (C & S )
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3. For timed-urine specimens
TYPES:
A. CLEAN CATCH MIDSTREAM URINE
Equipment:
1. Sterile collection container with cover
2. Label (client’s name, room # and type of specimen)
3. Duly accomplished urine exam request slip.
4. External douche tray
5. Bedpan or urinal
Procedure
FEMALE
ACTION RATIONALE
1. Identify the Patient Ensures correct patient
2. Explain the procedure Allays anxiety, promotes cooperation
3. Perform hand hygiene decreases likelihood of microorganism

transfer
4. Provide Privacy Allows the patient to be relax and

Produce specimen more quickly
5. Spread the labia with thumb and forefinger of Provide access to urethral meatus
non - dominant hand
NOTE: Put on sterile gloves when assisting

dependent patient
6. Assist or allow patient to clean the perineum Cleaning from least contaminated area
independently by cleaning the area with cotton to the greatest contaminated area will
ball or gauze , moving from front to back motion decrease bacterial levels.
Repeat three times using a fresh swab each time,
Begin with the left side, then right side ,then
Center
7, Rinse area with sterile water and dry with Prevents contamination of specimen
cotton ball or gauze with antiseptic solution
( If indicated in the hospital policy)
8. While continuing holding the labia apart, Initial stream flushes out microorganism
Instruct the client to initiate stream. After that accumulate at the urethral meatus
the patient starts urine stream, pass container prevents transfer into specimen
into stream and collect 30-60 ml
.
9. Replace cap on specimen container Retains sterility and prevents spillage of
clean any urine spillage in the exterior of the urine sample
318
surface of container and label
10. Transport the specimen to the laboratory Bacteria grow quickly in urine
Within 15 – 30 minutes or refrigerate
(Do not refrigerate more than 2 hours)
MALE
1. Hold penis with one hand and in circular Clean least contaminated area to area of
motion using an antiseptic swab, clean end of greatest contamination to reduce
penis, moving from center to outside. If bacteria levels
uncircumcised, retract foreskin before
cleaning.
2. Rinse area withy sterile water and dry with Prevents contamination of specimen
Cotton ball or gauze with antiseptic solution
( If indicated in the hospital policy)
3. Still holding the penis, instruct Initial stream flushes out microorganism
the client to initiate stream. After that accumulate at the urethral meatus
the patient starts urine stream, pass container prevents transfer into specimen
into stream and collect 30-60 ml.
4. Replace cap on specimen container Retains sterility and prevents spillage

clean any urine spillage in the exterior
surface of container and label it
5. Transport the specimen to the laboratory Bacteria grow quickly in urine

within 15 – 30 minutes or refrigerate
(Do not refrigerate more than 2 hours)
SPECIAL CONSIDERATIONS:
1. The first voided morning specimen contains the greatest concentration of solute.
2. If the client is being evaluated for renal colic, strain the specimen to catch stones
or stone fragments. Place an unfolded “4 x 4” gauze pad or a fine–mesh sieve over
the specimen container, and carefully pour the urine through the gauze or sieve.
Send the specimen to the laboratory immediately, or refrigerate it if analysis will
be delayed longer than 1 hour.
3. Inform the client that restriction of food or fluid is not required.
4. Check for recent use of medication that may affect test result.
5. If menstruating, record this in the laboratory requisition slip.
B. CLOSE DRAINAGE SYSTEM
Equipment:
1. Plaster or catheter clamp
2. Working gloves
3. Sterile specimen container and label
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Procedure
Action Rationale
1. Gather equipment. Promotes efficiency.
2. Explain procedure to client. Allays anxiety, increases participation.
3. Wash hands and don gloves. Decreases transmission of microorganisms
4. Provide privacy. Decreases embarrassment.
5. If no urine is visible in the tubing, apply This allows fresh urine to collect in the
a non-traumatic clamp/gate clip a few catheter.
centimetres distal to the sampling port
3. Once sufficient urine has collected in . Decreases transmission of microorganisms

the tube, wipe the sampling port with Allowing the alcohol to dry prevents
an alcohol-impregnated swab. Allow contamination of specimen with alcohol
to dry.
4. Stabilising the tube below the sampling

port, insert the needle into the port at an This facilitates collection of the urine sample
angle of 45
In a needle-free system, insert the

syringe into the sampling port
according to the manufacturer’s
recommendations
5. Aspirate the required amount of urine.

Inject urine into sterile specimen Ensure accurate identification of the urine
container and label sample collected.
6. Wipe the sampling port with an alcohol

swab, allow to dry To disinfect the sampling port
7. Unclamp the catheter tubing

For urine to drain freely into the urobag
5. Remove gloves and dispose
gloves and syringe needle properly. To prevent transmission of microorganism
Wash your hands.
6. Record collection of specimen and any

pertinent observations and send Bacteria grow quickly in urine
specimen to the laboratory within 15-30
minutes.
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A. NORMAL FINDINGS IN ROUTINE URINALYSIS.
Physical characteristics:
color straw
appearance clear
reaction – pH 4.5 to 8.0
specific gravity 1.005 to 1.020
Chemical Characteristics:
Albumin none
Sugar none
Microscopic Findings:
Squamous Epithelial cells few

Pus cells 0 – 4/ high – power field (hpf)
RBC 0 – 3/ / high – power field
Casts none, except occasional hyaline cast
Crystals present
Parasites none
Yeast cells none
Implications of results:
Variations in urinalysis finding may result from diet, non–pathologic conditions,
specimen collection time and other factors. The following benign variations are commonly
non–pathologic:
Specific gravity:
Urine becomes darker and its color becomes stronger as the specific gravity
increases. Specific gravity is highest in the first – voided morning specimen.
Urine pH:
Greatly affected by diet and medications, urine pH influences the appearance
of urine and the composition of crystals. An alkaline pH (above 7.0) characteristic of a
diet high in vegetables, citrus fruit, and dairy products but low in meat cause turbidity
and the formation of phosphate, carbonate and amorphous crystals. An acid pH
(below 7.0) typical of a high–protein diet produces turbidity and formation of oxalate,
cystine, amorphous urate, and uric acid crystals.
Protein:
Normally absent from the urine, protein can appear in urine in a benign
condition known as orthostatic (postural) proteinuria. Transient benign proteinuria can
also occur with fever, exposure to cold, emotional stress, or strenuous exercise.
Sugars:
Usually absent from the urine. Transient, non–pathologic glycosuria may
result from emotional stress or pregnancy and may follow ingestion of a high–
carbohydrate meal.
321
Red cells:
Hematuria may occasionally following strenuous exercise.
B. ABNORMAL FINDINGS
1. Color:
Changes in color can result from diet, drugs and may be from metabolic,
inflammatory, or infectious disease.
2. Odor:
In diabetes mellitus, starvation and dehydration, a fruity odor accompanies
formation of ketone bodies. In urinary tract infection, a fetid odor is common.
3. Turbidity:
Turbid urine may contain blood cells, bacteria, fat or chyle, suggesting renal
infection.
4. Specific gravity:
Low specific gravity (less than 1.005) is characteristic of diabetes insipidus,
nephrogenic diabetes insipidus, acute tubular necrosis and pyelonephritis. Fixed
specific gravity, in which values remain 1.010 regardless of fluid intake, occurs in
chronic glomerulonephritis with severe renal damage. High specific gravity
(greater than 1.020) occurs in nephrotic syndrome, dehydration, acute
glomerulonepthritis , congestive heart failure, liver failure and shock.
5. pH:
Alkaline urine pH may result from Fanconi’s syndrome, urinary tract
infection, and metabolic or respiratory alkalosis. Acid urine pH is associated with
renal tuberculosis, pyrexia, phenylketonuria and alkaptonuria, and all forms of
acidosis.
6. Protein:
Proteinuria suggests renal diseases, such as nephrosis, glomerulosclerosis,
glomerulonephritis, nephrolithiasis, polycystic kidney disease and renal failure. It
can also result from multiple myeloma.
7. Sugars:
Glycosuria usually indicates diabetes mellitus but also may result from
pheochromocytoma, Cushing’s syndrome, and increased intracranial pressure.
Fructosuria, galactosuria and pentosuria, generally suggest rare inherited
metabolic disorders.
8. Ketones:
Ketonuria occurs in diabetes mellitus when cellular energy needs exceeds
available cellular glucose. Ketonuria may also occur in starvation states and in
conditions of acutely increased metabolic demand associated with decreased food
intake, such as diarrhea or vomiting.
9. Cells:
Hematuria indicates bleeding within the genitourinary tract and may result
from infection, obstruction, inflammation, trauma, tumors, glomerulonephritis,
renal hypertension, lupus nephritis, renal tuberculosis, renal vein thrombosis,
hydronephrosis, pyelonephritis, scurvy, malaria, parasitic infection of the bladder,
322
subacute bacterial endocarditis, polyarteritis nodosa and hemorrhagic disorders.
Numerous white cells in urine usually imply urinary tract inflammation, especially
cystitis or pyelonephritis. An excessive number of epithelial cells suggest tubular
degeneration.
10. Cast:
Excessive number of casts indicate renal disease. Hyaline casts are associated
with renal parenchymal disease inflammation, and trauma to the glomerular
capillary membrane; epithelial casts, with renal tubular damage, nephrosis,
eclampsia, amyloidosis, and heavy metal poisoning; fatty and waxy casts, with
renal parenclymal disease, renal infarction , subacute bacterial endocarditis,
vascular disorders, sickle cell anemia, scurvy, blood dyscrasias, malignant
hypertension and acute inflammation; and white blood cell casts, with acute
pyelonephritis and glomerulonephritis, nephrotic syndrome, pyogenic infection,
and lupus nephritis.
11. Crystals:
Some crystals normally appear in urine, but numerous calcium oxalate crystals
suggest hypercalcemia. Cystine crystals (cystinuria) reflect an inborn error of
metabolism.
12. Other components:

Yeast cells and parasites in urinary sediment reflect genitourinary tract
infection, as well as contamination of external genitalia.
C. URINE CULTURE AND SENSITIVITY RESULT
1. NORMAL FINDINGS
Culture result of sterile urine are normally reported as “no growth”. This
finding indicates the absence of UTI.
2. ABNORMAL FINDINGS
Bacterial counts of 100,000 or more organisms /cc (100 x 10 6/L) of a single
microbe species indicate probable UTI. Counts under 100,000/cc (100x 10 6/L) may be
significant, depending on the client’s age, sex, history and other individual factors.
CONTINUOUS BLADDER IRRIGATION
Definition:
This procedure helps prevent urinary tract obstruction by flushing out small blood
clots that form after prostate or bladder surgery. Continuous flow of irrigating solution creates
a mild tamponade that may prevent venous hemorrhaging.
Equipment:
1. Containers of irrigating solution (NSS)
2. Y – type IV tubing
3. IV stand
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4. Medicine ticket
1. Always have a second container of irrigating solution available.
2. Make sure the solution is running freely.
3. Measure outflow volume accurately - volume should be equal or greater than
inflow.
4. Assess for changes in appearance and blood clots in the outflow .
If: Outflow is BRIGHT RED – infuse rapidly
Outflow is CLEAR - 40 – 60 gtts/min
Complications:
1. Interruptions in continuous irrigation system predispose to infection.
2. Obstruction in catheter’s outflow will result to bladder distention and possibly
bleeding.
Procedure
Action Rationale
1. Confirm the order for catheter
irrigation, including infusion Verifying the medical order ensures that the
parameters. If irrigation is to be correct intervention is administered to the
implemented via gravity infusion, right patient. The solution which is
calculate the drip rate administered via gravity, at the appropriate
rate will prevent urinary tract obstruction
from blood clots.
2. Check the diagnosis or the medical Alerts you to the observations you will need
condition and the purpose of the to make. For example, if the irrigation is hung
irrigation. for a client who had urinary tract surgery, you
would expect to possibly see urine that is
pinkish in color and contains clots.
3. Identify and explain the procedure to Ensures the right patient receives the
the client. intervention and helps prevent errors.
Discussion promotes reassurance and
provides knowledge about the procedure.
4. Screen the client by closing the door and This ensures patient’s privacy and
the curtains around the bed cooperation
5. Wash your hands and put on gloves.

Aseptic technique prevent the spread of
microorganism.
4. Using sterile technique, close the clamp
on the tubing and insert the irrigation The irrigation tubing connects the irrigation
tubing spike into the port on the bag of solution to the catheter.
irrigation fluid.
5. Open the clamp on the tubing and allow
the fluid to flow to the end of the Replaces the air in the tubing with irrigation
324
tubing. fluid.
6. Close the clamp.
Prevents spilling of irrigation fluid.
7. Hang the bag of irrigating solution on
an IV stand 3 feet above the level of the The fluid flows by gravity into the bladder.
client’s bladder.
8. Squeeze the drip chamber to one-half to
one-third full. If the drip chamber is overfilled, you will not
be able to see and satisfactorily count the flow
rate.
9. Using sterile technique, wipe off the
inflow port of the catheter and connect The solution flows from the bag through the
the irrigation tubing to the inflow port inflow port and into the bladder.
of the catheter.
10. Empty the catheter drainage bag and
measure the urine, noting its amount It allows accurate assessment of the drainage
and characteristics of the urine. after the irrigation solution is instilled. The
assessment of the urine also serves as a
baseline for future comparison.
11. Open the irrigation tubing clamp and
adjust the flow rate according to the
This allows continual gentle irrigation.without
prescribed flow rate. If the irrigation is
causing discomfort to the patient.
to be done with medicated solution, use
An electronic infusion device regulates the
an electronic infusion device to regulate
flow of the medication accurately.
the flow.
12. Remove gloves and wash your hands. Hand hygiene prevents the spread of
microorganism.
13. After approximately 15 minutes:
a. Assess the color of the drainage in The drainage in the outflow system should be
the outflow system. If the drainage pink, dark pink, or clear. Bright red drainage
is bright red, check the client’s vital could indicate fresh bleeding or hemorrhage.
signs and notify the physician.
If there is an obstruction to urinary outflow,
b. Assess the client’s bladder for the bladder becomes distended or it is filled
distention. with irrigating solution.
The non-dominant hand is used to stabilize
c. Assess for clots in the outflow the outflow tubing and keep it from being
tubing. If clots are present, milk or pulled out of the client. The squeezing and
strip the tubing. To milk, place your pulling motion by the dominant hand moves
non-dominant hand on the outflow the clot toward the drainage bag.
tubing proximal to the client. With
the use of your dominant hand, Communicates the findings to the other
make a squeezing and gently members of the health care team and
pulling motion on the tubing in a contributes to the legal record by
direction away from the client documenting the care given to the client.
toward the drainage bag.
14. Record the procedure in the client’s

chart. Note the volume of the solution
hung, the flow rate, the type of
solution, and the observations regarding
drainage and bladder distention.
325
INTAKE AND OUTPUT MONITORING
Introduction:
Intake and output (I & O) is measured and recorded whenever a client has a potential
or an actual fluid balance problem. The physician orders the I & O monitoring usually for
client’s receiving IV therapy, has a nasogastric tube, a foley catheter or other drainage tube.
Purposes:
1. To monitor the client’s fluid status over a 24-hour period.

2. To evaluate the effectiveness of the diuretic or rehydration therapy.
Equipment:
1. I and O sheet
2. Calibrated cup or glass
3. Graduated container for output
4. Bedpan or urinal
5. Working gloves
6. Pen
Procedures :
Action Rationale
1. Wash hands. Deters spread of microorganisms.
2. Explain the procedure to the client. Elicits client’s cooperation.

Make sure the equipment to be used are
available in the unit. Take note of the
following information:
a. All fluids taken orally must be

recorded (water, juice, softdrink,
soup, including tube feeding).
b. I & O form for recording must be

used.
c. Voiding into the bedpan or urinal,

and not into toilet is a must.
3. Place I and O sign over the client’s bed.
INTAKE:
4. Measure all oral fluids using a Provides for accuracy of measurement.

calibrated graduated glass or instruct
client /watcher to do so.
5. Measure parenteral fluid intake

including infusions like IVF, IV
medications and blood transfusions.
326
Documents fluid intake.
6. Record time and amount of all fluid
intake in the I & O sheet.
OUTPUT:
Prevents spread of microorganisms.
1. Put on working gloves.
Provides accurate measurement.
2. Measure all fluid output using a
graduated container or instruct client
/watcher to do so.
Empty urine, diarrhea,vomitus, gastric
suction, drainage from post surgical
wounds or other drainage collection device
into the graduated container. Take note of
the reading. Prevents cross–contamination.
2. Empty or discard the output

appropriately.
3. Remove gloves and wash hands.

Provides information to the health care team
4. Record time and amount of output, regarding the client’s response to the
color, odor, clarity and abnormal treatment and legal record of care given.
constituents, on the output side of the I
and O sheet.
HEMATOLOGY SCREENING
Hematology is the study of blood. Hematologists are concerned with all aspects of
blood such as blood volume, blood flow and test done on the blood for the diagnosis of
disease in other organs.
Complete Blood Count and Differential
The complete blood count includes the following tests:
327
1. red blood corpuscle (cell) count
2. hemoglobin determination
3. hematocrit
4. white cell count
5. white cell differential
A: Hemoglobin (Hgb), Total
Purpose:
1. To measure the severity of anemia or polycythemia and monitor response
to therapy.
2. To supply figures for calculating mean corpuscular hemoglobin
concentration.
Client preparation:
Explain that this test helps determine if the client has anemia or polycythemia
or assesses response to treatment. Inform the client or parents that the test requires a
blood sample.
Normal Findings:
Age Hemoglobin levels

a. Less than 7 days 17 to 22 g/dl
b. 1 week 15 to 20 g/dl
c. 1 month 11 to 15 g/dl
d. children 11 to 13 g/dl
e. adult males 14 to 18 g/dl
f. elderly males 12.4 to 14.9 g/dl
g. adult females 12 to 16 g/dl
h. elderly females 11.7 to 13.8 g/dl
Low hemoglobin concentration may indicate anemia, recent hemorrhage, or
fluid retention causing hemodilution; an elevated hemoglobin may also suggest
hemoconcentration from polycythemia or dehydration.
B. Erythrocyte Count
This test reports the number of red blood cells (RBCs) found in a microliter (cubic
millimeters of whole blood, and is included in the complete blood count.
Values:
Age Hemoglobin levels
Full – term infants ---- 4.4 to 5.8 million/u liter (4.4 to 5.8 x 1012/L
Two months old ---- 3 to 3.8 million/ u liter (3.0 to 3.8 x 1012/L)
Children ---- 4.6 to 4.8 million/u liter
Adult males ---- 4.5 to 6.2 million/u liter (4.5 to 6.2 x 1012 / L)
328
Adult females ---- 4.2 to 5.4 million/u liter (4.2 to 5.4 x 1012/ L)
An elevated RBC count may indicate primary or secondary polycythemia, or
dehydration; a depressed count may indicate anemia, fluid overload, or recent
hemorrhage.
C. White Blood Cell (WBC) Count
Part of the CBC, the WBC count reports the number of white cells found in a
microliter (cubic millimeter) of whole blood by using a hemocytometer or an
electronic device, such as the Coulter counter.
Purposes:
1. To detect infection or inflammation
2. To determine the need for further tests, such as the WBC differential or bone
marrow biopsy.
3. To monitor response to chemotherapy or radiation therapy.
Normal Values:
The WBC count ranges from 4,100 to 10,900/ u liter (4.1 to 10.9 x 109/L).
An elevated WBC count (leukocytosis) usually signals infection such as an
abscess, meningitis, appendicitis or tonsillitis, etc. A high count may also result from
leukemia and tissue necrosis caused by burns, myocardial infarction or gangrene.
A low WBC count (leukopenia) indicates bone marrow depression that may
result from viral infection or from toxic reactions, such as those following treatment
with antineoplastics, ingestion of mercury or other heavy metals, or exposure to
benzene or arsenicals. Leukopenia characteristically accompanies influenza, typhoid
fever, measles, infectious hepatitis, mononucleosis, and rubella.
A. White Blood Cell (WBC) Differential
It evaluates the distribution and morphology of white cells; it also provides more
specific information about a client’s immune function than the WBC count.
Purposes:
1. To evaluate the body’s capacity to resist and overcome infection.
2. To detect and identify various types of leukemia infection.

3. To detect allergic reactions.
4. To assess the severity of allergic reactions (eosinophil count).
5. To detect parasitic infections.
Table 2: Differential Count of White Blood Cells

Reference Values for Adults
Cells Relative Value Relative Value
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Neutrophils 47.6% to 76.8% 1,950 to 8,400/u liter
Lymphocytes 16.2% to 43% 660 to 4,600/u liter
Monocytes 0.6% to 9.6% 24 to 960/ u liter
Eosinophils 0.3% to 7% 12 to 760/u liter
Basophils 0.3% to 2% 12 to 200/u liter
Table 3: Differential Count of White Blood Cells

Reference Values for Children
Cells Relative Value (Boys) Absolute Value (Girls)

Neutrophils 38.5% to 71.5% 41.9% to 76.5%
Lymphocytes 19.4% to 51.4% 16.3% to 46.7%
Monocytes 1.1% to 11.6% 0.9% to 9.9%
Eosinophils 1% to 8.1% 0.8% to 8.3%
Basophils 0.25% to 1.3% 0.3% to 1.4%
General changes in the white cells indicate the presence of disease. A rise in the WBC
is usually caused by conditions that stimulate the bone marrow to produce white blood cells
to fight off invading organisms.
A fall in the WBC usually indicates that bone marrow depression is occurring.
Neutrophils:
An increase in the number of neutrophils indicates the presence of a bacterial or

parasitic infections process. If the infection is prolonged and severe, the bone marrow may
release immature blood cells. Chemotherapeutic drugs and disorders of cell production such
as leukemia may also cause the release of immature neutrophils.
Eosinophils:
An increase count may be caused by a hyperimmune or allergic reaction where there

is antigen–antibody response. Some cancers such as Hodgkin’s disease, myelogenous
leukemia, and lung and bone cancer, also cause a rise in eosinophils.
A disease may be associated with congestive heart failure infection monunucleosis,
Cushing’s syndrome and aplastic and pernicious anemias.
Basophils:
Basophils are not as well understood as other white cells. They appear to play a role in
allergic and anaphylactic reactions, since their number decrease when these conditions are
present.
Lymphocytes:
Viral infections are the primary causes of an increase in the lymphocyte count.
Bacterial infections and hormonal disorders such as hypothyroidism and hypoadrenalism, as
well as lymphocytic leukemia and lymphosarcoma are also causes.
Decrease in lymphocytes are associated with Hodgkin’s disease, lupus
erythematosus, burns, trauma and the administration of cortiscoteroids.
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Monocytes:
Since monocytes act as scavenger cells to dispose of non–infectious foreign

substance, they are not as diagnostically significant as other white cells. They may be
increased in viral, bacterial, and parasitic infections, collagen diseases, and some malignant
hematological disorders.
Decreases have no significance in relation to disease.
Nursing Implications of Abnormal Findings:
The WBC, and the differential, if it is done, must be monitored by the nurse and
assessed along with other data collected. When WBC is elevated, signs and symptoms of both
local and systematic infections must be explored.
B. Hematocrit (Hct.)
Hematocrit measures the percentage by volume of packed red blood cells (RBCs) in a
whole blood sample.
Purposes:
1. To aid diagnosis of abnormal states of hydration, polycythemia and anemia.
2. To aid in calculating red cell indices.
3. To monitor fluid imbalance.
4. To monitor blood loss and evaluate blood replacement.
5. To conduct routine screening as part of the CBC.
Values: Hct. values vary, depending on the client’s sex and age; type of sample. Preference
value range.
men : 0.40 to 0.54 %
women : 0.37 to 0.47 %
Implications of results: Low hematocrit may indicate anemia or hemodilution; high
hematocrit suggests polycythemia or hemoconcentration caused by blood loss.
TESTING BLOOD FOR GLUCOSE OR HEMOGLUCOTEST
Definition: It is the immediate measurement of blood for glucose using blood sample from
a fingerstick or heelstick otherwise known as hemoglucotest or capillary blood
glucose.
Normal Values:
Adult = 80 – 120 mg /dl
10. Hypoglycemia in newborns is defined as blood sugar below 30 mgs.dl ; in
children and adults if below 50 mgs /dl.
Equipment:
1. cotton ball with ROH 4. matching strip
2. dry cotton ball 5. working gloves
331
3. Glucometer set
Procedure
Action Rationale
To ensure that the correct procedure is
1. Check the doctor’s order.
adminitered
2. Wash hands. Deters spread of mucriorganisms.
3. Assemble all equipment and check the As any device fails under the right condition
monitor and testing strips before
bringing to the bedside. Reduces risk of errors.
4. Identify the client. Ensures right patient receive the right

intervention and reduce risks of errors.
5. Explain the procedure to the client / Elicits cooperation.

watcher.
6. Put on the gloves. To minimize the risk of cross infection and
contamination
7. Select the puncture site (fingers, toes, The side of the finger is less painful and
heels) If finger is use, pierce the side of easier to obtain a droplet of blood. Sites are
the finger. Ensure that the site of rotated to avoid infections from multiple
piercing is rotated. stabbings and becoming toughened and to
reduce pain.
The fingertip may need milking from Milking the finger can cause tissue fluid
palm of hand toward finger to gain a contamination and a false low reading,
large enough droplet of blood but avoid hemolysis and impeded blood flow.
milking the finger alone.
Decreases risk of infection.
8. Disinfect the site with CB with ROH.
Allow to dry or let the patient wash
his/her hands with soap and water and
dry.
9. Activate the blood glucose monitoring Ensures accuracy of result.
device and set the the appropriate code
if applicable. Insert the strip.
10. Using the lancet or activate safety- The side of the finger is less painful and it is
engineered medical device , prick the easier to obtain blood from the site.
finger at the side , ensure correct depth Correct depth setting ensures patient’s
setting is used comfort.
11. Wipe away the first drop of blood if so First drop may contain large portion of serous
directed by the manufacturer. fluid that dilutes the specimen causing false
results.
12. Let blood drop on the appropriate To ensure accurate result.

portion of the testing strip or fill from
the side if strip is dose-filled type.
Ensure that that the window of the test
strip is entirely covered with blood.
332
13. Apply pressure on the punctured site
with a gauze or dry cotton ball , To ensure patient safety and to stop bleeding.
monitor for excess bleeding.
14. Take note of the reading; and confirm it
with the clinical instructor or nurse on Double checking decreases risk of errors.
duty.
*Make sure the CI or NOD is notified of Provides information to health care team
the result for appropriate action regarding the client’s response to the
treatment; and legal record of care given
15. Remove gloves and discard lancet,
testing strip, used gauze or cotton ball To prevent health - care related infections and
and strip to the appropriate container. spread of microorganism.
16. Record time, result and client’s
response/s to the procedure.
.
ARTERIAL BLOOD GAS (ABG) ANALYSIS
Arterial Blood Gas (ABG) analysis evaluates gas exchange in the lungs by measuring
the partial pressures of oxygen (PaO2) and carbon dioxide (PaCO2), and the pH of an arterial
sample. PaO2 indicates how much oxygen the lungs are delivering to the blood. PaCO 2
indicates how efficiently the lungs eliminate carbon dioxide. The pH indicates the acid–base
level of the blood, or the hydrogen ion (H+) concentration. A blood sample for ABG analysis
may be drawn by percutaneous arterial puncture or from an arterial line.
333
Purposes: 1. To evaluate the efficiency of pulmonary gas exchange.
2. To assess integrity of the ventilatory control system.
3. To determine the acid–base level of the blood.
4. To monitor respiratory therapy.
Client preparation: As appropriate, explain that this test evaluates oxygen delivery to the
blood and elimination of carbon dioxide. Inform the client that the test requires a blood
sample. Instruct the client to breathe normally during the test, and warn that a brief cramping
or throbbing pain may occur at the puncture site.
Procedure: Perform an arterial puncture. Before sending the sample to the laboratory,
include the following information on the requisition slip:
1.Indicate whether the client was breathing room air or receiving oxygen therapy
when the sample was drawn. If he was receiving oxygen therapy, give the flow rate.
2. If the client is receiving mechanical ventilation, note the F1O2 and tidal volume.
3. Record the client s’ temperature and respiratory rate.
Precautions: If the client is receiving oxygen therapy, discontinue oxygen therapy from 15 to
20 minutes before drawing the sample to measure ABGs on room air.
Values: Normal ABG values fall within the following ranges:
PaO2 : 80 to 100 mm Hg.

PaCO2 : 35 to 45 mm Hg.
pH : 7:35 to 7:45
O2CT : 15% to 23%
O2 Sat. : 94% to 100%
HCO3 : 22 to 26 meq./liter
Implications of results: Low PaO2, O2CT and O2 saturation levels, in combination with a
high PaCO2 value, may be due to conditions that impair respiratory function, such as
respiratory muscle weakness or paralysis (in Guillain-Barre Syndrome or myasthenia gravis)
respiratory center inhibition (from head injury, brain tumor, or drug abuse, for example), and
airway obstruction, similarly low readings may result from bronchiole obstruction caused by
asthma or emphysema, from an abnormal ventilation–perfusion ratio caused by partially
blocked alveoli or pulmonary capillaries, or from alveoli that are damaged or filled with fluid
because of disease, hemorrhage or near–drowning.
When inspired air contains insufficient oxygen, PaO 2, O2CT and O2 Sat. also
decrease, but PaCO2 may be normal. Such findings are common in pneumothorax, impaired
diffusion between alveoli and blood or in an arteriovenous shunt that permits blood to bypass
the lungs.
Post – test care:

11. After applying pressure to the puncture site, tape a gauze pad firmly over it.
12. Monitor vital signs, and observe signs of circulatory impairment, such as swelling,
discoloration, pain, numbness or tingling in the bandaged arm or leg.
13. Watch for bleeding from the puncture site.
334
CAPILLARY FRAGILITY
TOURNIQUET TEST, RUMPEL – LEEDE CAPILLARY FRAGILITY TEST
A nonspecific method for evaluating bleeding tendencies, the capillary fragility test
(positive–pressure test) measures capillaries’ ability to remain intact under increased
intracapillary pressure. In this test, a blood pressure cuff is placed around the client’s upper
arm and the pressure raised to a point midway between the systolic and diastolic blood
pressure but no higher than 100 mm Hg. At this pressure, blood can enter the arm and hand
but can not easily return to circulation. Pressure is maintained for 5 minutes. This temporary
increase in pressure may cause bleeding of the capillaries and formation of petechiae in the
arm, wrist or hand. The number of petechiae within a given circular space is recorded as the
test result.
335
Purposes:
1. To assess the fragility of capillary walls.
2. To identify platelet deficiency (thrombocytopenia).
Client Preparation: Explain that this test helps identify abnormal bleeding tendencies.
Inform the client that restriction of food or fluids is not required and that he may feel
discomfort from the pressure of the blood pressure cuff.
Procedure: To perform this test, select and mark a “2” (5 cm.) space on the client’s forearm.
Select a site that’s free from petechiae, otherwise, record the number of petechiae present on
the site before starting the test. The client’s skin temperature and the room temperature should
be normal to ensure accurate results.
Fasten the cuff around the arm, and raise the pressure to a point midway between the
systolic and diastolic blood pressures. Maintain this pressure for 5 minutes; then release the
cuff. Count the number of petechiae that appear in the “2” space. Record test results.
Precautions: Do not repeat this test on the same arm within 1 week.
This test is contraindicated in client s with disseminated intravascular
coagulation (DIC) or other bleeding disorders, and in those with significant
petechiae.
Values : A few petechiae may normally be present before the test. Fewer than 10
petechiae in the fore arm 5 minutes after the test is considered normal, or
negative; more than 10 petechiae is considered as positive result.
The following scale may also be used to report test results:
Number of petechiae Score
0 to 10 1+
11 to 20 2+
21 to 50 3+
51 or more 4+
Implications of results: A positive finding (more than 10 petechiae present, or a score of 2+
to 4+) indicates weakness of the capillary walls (vascular purpura) or a platelet defect, and
occurs in conditions such as thrombocytopenia, purpura senilis, Vit. K deficiency,
dysproteinemia, polycythemia vera and in severe deficiencies of factor VII, fibrinogen, or
prothrombin.
Post–test Care: Encourage the client to open and close his hand a few times to hasten return
of blood to the forearm.
Table 4: List of Symbols and its Definition
Abbreviation Definition
Symbols
♂ male
♀ female
↓ decrease
↑ increase
336
> greater than or equal to
< less than or equal to
≈ approximately
C with
(+) positive
(-) negative
/ per
@ at
Table 5: A – Abbreviation of Medical Terms
a.c. before meals
A.M. or a.m. before noon
A/G albumin globulin ratio
ACLS Advanced Cardiac Life Support
ACTH Adrenocorticotrophic hormone
ad lib as much as needed; desired
ADH antidiuretic hormone
ADL activities of daily living
AFB Acid Fast Bacillus
Ag antigen
AGA average gestational age
AIDS Acquired Immune Deficiency Syndrome
AKA Above Knee Amputation
AMA Against Medical Advice
amt. amount
ANA antinuclear antibodies
anes. anesthesia
Anti – HA antibody to hepatitis A
Anti – HB antibody to hepatitis B
Anti – HBc antibody to hepatitis B core antigen
Anti – HBe antibody to hepatitis B “e” antigen
Anti – HBs antibody to hepatitis B “surface” antigen
AP & Lat. anteroposterior and lateral
ARC AIDS Related Complex
ARDS Adult Respiratory Distress Syndrome
ARF Acute Renal Failure
ASAP as soon as possible
ASHD Arteriosclerotic Heart Disease
ASO Antistreptolysin – O
B
b.i.d. twice a day
B.R.P. bathroom privilege
Abbreviation List
Ba barium
BAO branch artery occlusion
BBB bundle branch block
BCG Bacillus Calmette Guerin vaccine
BKA Below Knee Amputation
BM bowel movement
BP blood pressure
337
BPH benign prostatic hypertrophy
BUN Blood Urea Nitrogen
C
C&S Culture & Sensitivity
C. centigrade /celsius
C.P.D. Cephalopelvic Disproportion
C.S.F. Cerebrospinal Fluid
C/S cesarean section
CA carcinoma
Ca. calcium
CAD Coronary Artery Disease
cap. capsule
CAPD Continuous Ambulatory Peritoneal Dialysis
CAT Scan Computerized Axial Tomography
Cath. catheter
CBC complete blood count
CBD common bile duct
CBI continuous bladder irrigation
CC chief complaint
cc cubic centimeter
CCU Coronary Care Unit
CHD Coronary Heart Disease
CHF Congestive Heart Failure
CHO carbohydrate
Chol. cholesterol
Cl chlorides
CT clotting time
cm. centimeter
CNS central nervous system
CO carbon monoxide
CO2 carbon dioxide
COPD Chronic Obstructive Pulmonary Disease
CPK creatine phosphokinase
CPR cardio – pulmonary resuscitation
CRF chronic renal failure
cu. mm. cubic millimeter
CVA Cerebrovascular Accident
CVP Central Venous Pressure
CXR chest x – ray
D
D&C Dilatation and Curettage
D/C discontinue
D5NS 5% Dextrose in Normal Saline
D5LR 5% Dextrose in Lactated Ringers
D5W 5% Dextrose in Water
Abbreviation List
DOA dead on arrival

DOE dyspnea on exertion
DR Delivery Room
DTR deep tendon reflex
DUB Dysfunctional Uterine Bleeding
338
Dx diagnosis
E
E.N.T. Ear, Nose & Throat
ECCE extracapsular cataract extraction
ECT electro – convulsive therapy
EEG electroencephalogram
EKG electocardiogram
elix. elixir
EMB ethambutol
EMG electromyography
EOM extra ocular movement
ESR Erythrocyte Sedimentation Rate
ESRD End-Stage Renal Disease
ET endotracheal
ETA endotracheal tube aspirate
ETOH ethanol
F
F.C. Foley Catheter
F.R. fluid restriction
FBS fasting blood sugar
Fe iron
FHR fetal heart rate
FO2 Fraction of inspired O2
FSH Follicle Stimulating Hormone
FT ♀ full term female
FT♂ full term male
Fx. fracture
G
G.T.T. Glucose Tolerance Test
G.U. genitourinary
GC gonococcus (gonorrhea)
GCS Glascow Coma Score
GDM Gestational Diabetic
gm. gram
gtt. /gtts drop / drops
GYN/ gyne gynecology
GSCS gram staining, culture and sensitivity
H
h.s. hour of sleep
H2O water
HAV hepatitis A virus
HBcAg hepatitis B core antigen
HBeAg hepatitis B “e” antigen
HBV hepatitis B virus
Hct hematocrit
HDL High Density Lipoprotein
HEENT head, eyes, ears, nose and throat
Abbreviation List
Hgb. hemoglobin
HIV human immunodeficiency virus
HPV human papilloma virus
339
I
I&D incision & drainage
I&O intake & output
I.U. international units
I.U.G.R. intrauterine growth retardation
IBW ideal body weight
ICCE intracapsular cataract extraction
ICP Intracranial Pressure
ICU Intensive care unit
IgA immunoglobulin A
IgD immunoglobulin D
IgE immunoglobulin E
IgG immunoglobulin G
IgM immunoglobulin M
IM intramuscular
Inf. Hep. infectious hepatitis
INH isoniazid
IOL intraocular lens
IOP intraocular pressure
IPPB Intermittent Positive Pressure Breathing
IV intravenous
IVF intravenous fluid
IVP intravenous pyelogram
IVPB intravenous piggyback
K
K potassium
kg. kilogram
KUB kidney, ureter, bladder (x – ray plain film of abdomen)
KVO keep vein open
L
L liter
Lab. laboratory
Lap laparatomy
Lb pound
LBBB left bundle branch block
LDH lactic dehydrogenase
LE lupus erythematosus
LH luteinizing hormone
liq. liquid
LLQ left lower quadrant
LMP last menstrual period
LOA left occipitoanterior
LOC level of consciousness
LOP left occipitoposterior
LOT left occipitotransverse
LP lumbar puncture
LSA left sacroanterior
LSP left sacroposterior
Abbreviation List
LST left sacrotransverse

LUQ left upper quadrant (abdomen)
LV left ventricle
340
LVH left ventricular hypertrophy
M
mcg. microgram
MCH Maternal and Child Health
Meq. milliequivalents (per liter)
Mg magnesium
mg. milligram
MI myocardial infarction
ml. milliliter or cc
mm. millimeter
MRI Magnetic Resonance Imaging
N
N nitrogen
N.S. (n.s.) normal saline
N/A not applicable
n/v nausea and vomiting
Na sodium
NaCl sodium chloride
NB newborn
NGT nasogastric tube
NHM No Heroic Measure (SPH)
NPH Neutral Protamine Hagedorn = insulin with prolonged effect
NPO nothing by mouth
nsg nursing
NSVD normal spontaneous vaginal delivery
O
o.d. right eye
o.s. left eye
O.T. occupational therapy
o.u. both eyes
O2 oxygen
OBS organic brain syndrome
O.D. once a day
oint. ointment
OOB out of bed
OPD out patient department
ophth. ophthalmology
OR operating room
ORIF open reduction, internal fixation
ortho. orthopedic
oz. ounce
P
P pulse
p after
p.c. after meals
P.M.I. point of maximum impulse
p.o. by mouth
P.P. post partum
Abbreviation List
P.P.D. Purified Protein Derivative (tuberculin)

p.r.n. whenever necessary
P.R.O.M. premature rupture of membranes
341
P.T.A. prior to admission
P.Z.I. protamine zinc insulin
PE physical exam
PAC premature atrial contractions
Pap Papanicolaou
PAP Prostate Acid Phosphatase
Pb lead
PBI protein bound iodine
PCP Pneumocystis carinii pneumonia
PD peritoneal dialysis
PDA Patent Ductus Arteriosus
PEEP positive end expiratory pressure
PERRLA pupils equal, round, react to light & accommodation
pH. hydrogen ion concentration
PID pelvic inflammatory disease
PKU phenylketonuria
PO2 partial oxygen tension
PO4 phosphate
psych. psychiatry
pt. patient
PTH parathyroid hormone
PTT partial thromboplastin time
PUD Peptic Ulcer Disease
PVC premature ventricular contraction
PZA pyrazinamide
Q
q every
q.d. every day
q.h. every hour
q.i.d. four times a day
q.o.d. every other day
q.o.h. every other hour
q2h, q3h, q4h, etc. every two, three, four, etc. hours
qt. quart
R
R.N. Registered Nurse
R.T. respiratory therapy
R/O rule out
RA Rheumatoid Arthritis
RAIU radioactive iodine uptake
RBBB right bundle branch block
RBC red blood cells or count
Rehab. rehabilitation
RF rheumatoid factor for arthritis
Rh rhesus blood factor
RHD rheumatic heart disease
RMT right mentotransverse
ROA right occiput anterior
ROM range of motion
Abbreviation List
ROP right occiput posterior
342
ROT right occiput transverse
RR recovery room
RSA right sacrum anterior
RSR regular sinus rhythm
RST right sacrum transverse
Rt. right
RUE right upper extremity
RUQ right upper quadrant
Rx treatment
S
s without
s.l. Sub–lingual
S/P Status post
S/S Signs and symptoms
SA Sino–atrial
SA Block Sino–atrial block
sc subcutaneous
sed. rate sedimentation rate
SGA small for gestational age
SGOT serum glutamic oxalacetic transaminase
SLE systematic lupus erythematosus
SOB shortness of breath
SLE systematic lupus erythematosus
SOB shortness of breath
Sod. Bicarb (NaHCO3) sodium bicarbonate
Sp. Gr. specific gravity
ss half
ST sinus tachycardia
Staph staphlococci (us)
stat. at once
Strep streptococcus
SVC superior vena cava
T
TOF Tetralogy of Fallot
T&A tonsillectomy & adenoidectomy
TAHBSO total abdominal hysterectomy with bilateral salpingo-orphorectomy
t.i.d. three times a day
T.O. telephone orders
T3 triiodothyronine
T4 thyroxine
tab. tablet
TB tuberculosis
Tbsp. tablespoon
temp. temperature
TENS transcutaneous electrical nerve stimulation
TIA transient ischemic attack
TPN Total Parenteral Nutrition
TPR temperature, pulse, respiration
trach. tracheotomy
TSH thyroid stimulating hormone
Abbreviation List
343
tsp. teaspoon
TUR transurethral resection
TURP transurethral resection of the prostate
U
u unit
U.G.I.B. Upper Gastrointestinal Bleed
USD ultrasound
U.S.P. United States Pharmacopeia
U/A urinalysis
UGI Upper Gastrointestinal
UGIS Upper Gastrointestinal Series
URI upper respiratory infection
UTI urinary tract infection
V
V.D. venereal disease
V.D.R.L. Venereal Disease Research Lab (serology)
VS vital signs
VSD ventricular septal defect
VA visual acuity
VBAC vaginal birth after cesarean section
VPB ventricular premature beat
VR ventricular rate
VT tidal volume
W
WBC white blood cells or count
wt. weight
Z
Zn zinc
Table 6: NORMAL VALUES in HEMATOLOGY
Examination Normal Value Clinical significance
Bleeding time Duke method: 1-3 min. Prolonged in purpura

IVY method : 1 – 6 min. hemorrhagica where platelets
are reduced, and in
344
chloroform and phosphorus
poisoning.
Clotting time 5 – 15 min. Prolonged in hemorrhagic

disease and in various
coagulation factor
deficiencies.
`
Factor V assay 5 – 10 % concentration Pro – accelerin factor
Factor VIII assay 30 – 35% concentration Deficient in classical

hemophilia.
(Antihemophilia factor)
30% Deficient in Christmas
Factor IX assay (plasma
disease (pseudohemophilia)
thromboplastin component)
Fibrinogen 200 – 400 mg/dl Increased in pregnancy,
pneumonia, infections
accompanied by leuko-
cytosis, and nephrosis.
Decreased in acute yellow
atrophy of liver, cirrhosis,
typhoid fever, chloroform
poisoning, abruptio placenta.
Factor X 7 – 10% concentration
(Stuart Factor)
75 – 125%
Increased activity associated
Fibrinolysis (whole blood clot
with massive hemorrhage,
lysis time)
extensive surgery, and
No lysis in 24 hours.
transfusion reactions.
Partial thromboplastin 60 – 70 sec. Prolonged in Factor VIII, IX
and X deficiency.
345
NORMAL VALUES in HEMATOLOGY
Prothrombin time 70 – 100% of control or 11 – Prolonged in factor X

15 sec. deficiency and other
hemorrhaging disease, and in
cirrhosis, hepatitis, and acute
toxic necrosis of the liver.
Erythrocyte count M = 4.2 – 5.4 m/mm3 Increased in severe diarrhea
W = 3.6 – 5.0 m/mm3 and dehydration,
polycythemia rubra vera,
secondary polycythemia,
acute poisoning, pulmonary
fibrosis and Averan disease.
Decreased in all anemias,
leukemia and after
hemorrhage, when blood
volume has been depleted.
Erythrocyte sedimentation < 50 y.o. M = 0 – 15 mm/hr Increased in tissue

rate F = 0 – 20 mm/hr destruction whether
> 50 y.o. M = 0 – 20 mm/hr inflammatory or degene-
F = 0 – 30 mm/hr rative, and during
menstruation, pregnancy and
in acute febrile disease.
Hematocrit Male = 40 – 54% Decreased in severe anemia,

Female = 36 – 46% or pregnancy, acute massive
blood loss. Increased in
erythrocytosis of any cause
and in dehydration or
hemoconcentration
associated with shock.
Hemoglobin Male = 13.5 – 18 g/dl Decreased in various

Female = 12 – 16 g/dl anemias, pregnancy, severe
or prolonged hemorrhage,
and with excessive fluid
intake. Increased in
polycythemia, chronic
obstructive pulmonary
disease, failure of
oxygenation because of
congestive heart failure and
normally, in people living at
high altitudes.
346
NORMAL VALUES in HEMATOLOGY

Leukocyte count Total: Elevated in acute infectious
5,000 – 10,000 mm3 or disease, and In the
5 – 10 x 103 / ml or lymphocytic and monocytic
5 – 10 x 109 /L (SI units) fractions in viral disease,
allergy, intestinal parasitosis.
Elevated in acute leukemia,
following menstruation, and
following surgery or trauma,
agranulocytosis, and by toxic
agents such as chemothe-
rapeutic agents used in
treating malignancy.
Monocyte Erythrocyte Indices Adult 4 – 6% of total WBC or
Decreased (<4%):
Child (200 – 600 mm3)
lymphocytic, leukemia,
aplastic anemia
Elevated (>6%) viral
diseases, cancer, collagen
diseases, anemias.
Mean corpuscular volume 80 – 98 cu

Increased in macrocytic
(MCV)
anemias. Decreased in
microcytic anemia.
Mean corpuscular hemoglobin 27 – 31 uug/cell

Increased in macrocytic
(MCH)
anemias. Decreased in
microcytic anemia.
Mean corpuscular hemoglobin 32 – 36% or .32 - .36 g/dl
Decreased in severe
concentration (MCHC)
hypochronic anemia
Reticulocytes Adult: 0.5–1.5% of total red
Increased with any condition
cells
stimulating increase bone
marrow activity, i.e.
infection, blood loss (acute
and chronic), following from
iron therapy in iron
deficiency anemia,
polycythemia rubra vera.
Decreased with any
condition depressing bone
morrow activity, acute
leukemia. Late stage of
severe anemia.
347
Table 7: NORMAL BLOOD VALUES
Examination Normal Adult Values CLINICAL SIGNIFICANCE

* Increased * Decreased
Bilirubin Total: 0.3 – 1.4 mg/dl
Hemolytic anemia
Direct: .1 - .4 mg/dl
(indirect)
Indirect: .2 – 1.0 mg/dl
Biliary obstruction
Hepatocellular damage
pernicious anemia
Hemolytic disease of
newborn
Calcium 1.5 – 10.5 mg/dl or Tumor or hyperplasia Hypoparathy-

1.6 4.3 – 5.3 mEq/L Hyperparathroidism roidism Celiac
hypervitaminosis D disease
Multiple myeloma
Nephritis with uremia Rickets
Osteomalacia
Malnutrition
Nephrosis
After
parathyroidec-
tomy
CO2 content Adults: 22 – 30 mEq/L Tetany Acidosis

22 – 30 mmol/L
(SI unit)
Infants: 20 – 28 mEq/L Respiratory disease Nephritis
Intestinal Obstruction Eclampsia
vomiting
Diarrhea
Anesthesia
Copper Males: 70 – 140 mg/dl Cirrhosis of liver.

Females: 80 – 155 mg/dl Pregnancy
Creatinine Male : 3 – 35 mg/ml or Myocardial infarction

phosphokinase 15 – 20 IU / L
Female: 5 – 25 mg/ml or Skeletal muscle disease
10 – 80 IU/L
Creatinine 3–7 mg/100 ml. Biliary obstruction
Pregnancy
Nephritis
Renal Destruction
Trauma to muscle
Pseudohyperthrophic
muscular dystrophy
348
NORMAL BLOOD VALUES

Creatinine 1 – 2 mg/100 ml Nephritis
Chronic renal disease
Fatty acids Total: 250 – 390 mg/ml. Diabetes Hyperthyroidism

Anemia
Nephrosis
Hypothryroidism
Nephritis
Fibrinogen 200 – 400 mg/dl Pneumonia Cirrhosis

Acute infections Acute toxic
Pregnancy necrosis of liver
Anemia
Nephrosis Typhoid fever
Carcinoma Chloroform or
phosphorus
poisoning
Abrupt placentae
Glucose (FBS) 70 – 110 mg/dl (serum) Diabetes Hyperinsulinism
60 – 110 mg/dl (plasma) Nephritis Hypothyroidism
Hyperthyroidism Late hyperpitui-
tarism
Plasma Early hyperpituitarism Pericious

Cerbral lesions vomiting
Infections Addison’s disease
Pregnancy Extensive
Uremia hepatic
Damage
Iceterus index 1 – 6 units Biliary obstruction Secondary
Hemolytic anemias anemias
Iodine protein bound 4.0 – 8.0 ug/100ml Hyperthyroidism Hypothyroidism

(PBI)
Iron 65 – 150 ug./100ml Pernicious anemia Iron deficiency

Aplastic anemia anemia
Hemolytic anemia
Hepatitis
Hemochromatosis
Total lipids 400 – 800 mg/dl Hypothyroidism Hyperthyroidism
Diabetes
Nephrosis
Glomerulonephritis
Phospholipids 150 – 380 mg/dl Diabetes
Nephritis
349
NORMAL BLOOD VALUES

Magnesium 1.8 – 3 mg/dl Ingestion of epsom Chronic
salts alcoholism
Parathyroidectomy Toxemia of
pregnancy
Severe renal
disease
Nonprotein Acute nephritis
25 – 40 mg/dl
Nitrogen Polycystic kidneys
Obstructive uropathy
Whole blood
Peritonitis
Congestive heart
failure
Pregnancy
Osmolality 275 – 300 mOsm/kg Inappropriate
secretion of
anti-diuretic
hormone
Oxygen saturation, 95 – 98% Polycythemia Anemia

arterial Anhydremia Cardiac
decompen-
sation
Chronic
obstructive
Pulmonary
disease
pCO2 35 – 45 mm Hg Respiratory acidosis Respiratory

Metabolic alkalosis alkalosis
Metabolic
acidosis
pH Arterial : 7.35 – 7.45 Vomiting Uremia
Venous : 7.36 – 7.41 Hyperpnea Diabetic acidosis
Fever Hemorrhage
Intestinal obstruction Nephritis
pO2 75 – 100 mm. Directly related
Hg. to oxygen saturation
350
NORMAL BLOOD VALUES

Pepsinogen 200 – 425 units / ml. Condition which
decrease gastric
acidity
Pernicious
anemia
Achlorhydria
Phenylalanine 0 – 2 mg/100 ml Phenylketonuria

Oasthouse urine
disease
Phosphatase, acid 0 – 2 units / ml. Garcinoma of prostate

Advanced Paget’s
(Shinowara – Jones – Disease
Reinhart units) Hyperparathyroidism
Phosphatase, alkaline 4 – 13 (King – Conditions reflecting

Armstrong ) increase osteoblastic
units / ml. activity of bone
Rickets
Hyperparathyroidism
disease
Liver
Phosphorus, inorganic 2.5 – 4.5 mg/dl Chronic nephritis Hyperparathy –

Hyperrarathyroidism roidism
Potassium 3.5 – 5.0 mEq/L Addison’s disease Diabetic acidosis

Oligura Diarrhea
Anuria Vomiting
Tissue breakdown or
hemolysis
Protein, Total 6.0 – 8.0 g/dl Hemoconcentration Malnutrition

shock Hemorrhage
Albumin 3.5 – 5.5 gm/dl Multiple myeloma Loss of plasma

(globulin fraction) from burns
Proteinuria
Whole Blood 1.5 – 3.5 gm/100 ml Chronic infectious
Globulin (globulin)
Paper electrophoresis % of total proteins Liver disease

(globulin)
351
NORMAL BLOOD VALUES

Sodium 1.35 – 1.48 mEq/L Hemoconcentration Alkali deficit
Nephritis Addison’s
Pyloric Obstruction disease
Myxedema
Transaminase (SGOT) 8 – 40 u/ml Myocardial infarction
or AST Skeletal muscle
disease
Liver disease
Transaminase (SGPT) or 5 – 25 units/ml Same conditions as

ALT SGOT, but increased
and more marked in
liver disease than
SGOT
Urea nitrogen 6 – 20 mg/dl Acute glomeru- Severe hepatic

lonephritis failure
Obstructive uropathy Pregnancy
Mercury poisoning
Nephrotic syndrome
Uric Acid Male : 2.1 – 7.5 mg/dl Gouty arthritis

Female: 2.0 – 6.6 mg/dl Acute leukemia
Lymphomas treated
Bychemotheraphy
Toxemia of pregnancy
Vitamin A 0.5 – 2.0 units/ml Hypervitaminosis Vitamin A defi-
ciency
Table 8: NORMAL VALUES in URINE CHEMISTRY
CLINICAL SIGNIFICANCE
Examination Normal Adult Values
Acetone and Zero Uncontrolled diabetes
Acetoacetate Mellitus
Starvation
Ammonia 20 – 70 mEq/L Diabetes mellitus

0.6 mg/L Pernicious vomiting
Cirrhosis and other
destructive
disease of the liver
Calcium Less than 150 mg/24 Hyperparathyroidism

hrs.
352
NORMAL VALUES in URINE CHEMISTRY
Chorionic Zero Pregnancy
Gonadotropin (HCG) Chorioepithelioma
Hydatidiform mole
Copper 0 – 100 ug./ 24 hrs. Wilson’s disease

Cirrhosis of liver
Creatine Less than 100 mg / 24 Muscular dystrophy

Fever
hrs. Carcinoma of liver
Pregnancy
Creatinine Male: 20 – 26 mg / kg / Measures glome-

240 rular filtration
Female: 14 – 22 rate
mg/kg/240 Renal disease
Chlorides 9 gm/L (as NaCl) Advanced melanoma

Bile melanin Zero Ochronosis
Hemoglobin and Zero Extensive burns

myoglobin Transfusion of
incompatible blood
Myoglobin increased
in severe crushing
injuries to muscle
Lead < 100 ug / 24 hrs. Lead poisoning
Glucose Random: Zero Diabetes mellitus

24 hrs: 130 mg / 24 hrs. Pituitary disorders
Intracranial pressure
Lesion in floor of 4th
ventricle
Urea clearance Maximum clearance: Renal disease

64 – 99 ml. / min.
Standard clearance:
41 – 65 ml./min
Urobilinogen 0.05 – 2.5 mg / 24 hrs. Liver and biliary tract Complete or

.3 - .8 gms / 24 hrs. disease nearly biliary
Hemolytic anemias obstruction
Diarrhea
Renal
insufficiency
353
NORMAL VALUES in URINE CHEMISTRY
Urea 25 – 35 gm/ 24 hrs. Excessive protein Impaired kidney
catabolism function
Uric acid .3 - .8 gm/240 Gout (see blood uric Nephritis (see

acid) blood
uric acid)
Table 9: CEREBROSPINAL FLUID in NORMAL VALUES
Examination Normal adult values CLINICAL SIGNIFICANCE

Cell count 0 – 5 mononuclear Bacterial meningitis
cells / cu. mm. or Neurosyphilis
0 – 10 WBC/m/ 160% - Anterior poliomyelitis
100% lymphocytes Encephalitis
lethargica
Chloride 113 – 133 mEq/L Uremia Acute

generalized
meningitis
Tubercular
meningitis
Colloidal gold curve 0001111000 Acute meningitis

Neurosyphilis
Glucose 40 – 80 mg/dl Diabetes mellitus Acute meningitis

50 – 80% of blood Diabetic coma Tuberculous
glucose Epidemic encephalitis meningitis
Uremia Insulin shock
Protein
Lumbar 15 – 45 mg/100 ml Acute meningitis
Cisternal 15 – 25 mg/100 ml Tubercular meningitis
Ventricular 5 – 15 mg/100 ml Neurosyphilis
Poliomyelitis
Guillain–Barre
syndrome
354
OTHER DIAGNOSTIC MODALITIES
Sequencing of Imaging Examination:
In order to prevent interference in other testing due to the use of contrast agents in
many tests, thereby causing delays in subsequent studies, the following sequence is
recommended:
1. All non–contrast studies should be done before any type of contrast study.
2. All ultrasound (US) studies should be done before barium studies.
3. All nuclear medicine studies should be done before barium studies.
4. All computerized tomography (CT) Scan requiring oral or rectal contrast should
be done before barium studies (unless time allows for repreparing of the client).
5. All iodine contrast examinations should precede all barium studies.
6. All gastrointestinal (GI) tract studies should be done before any upper GI tract
procedures.
7. Oral cholecystograms must precede GI, small – bowel or large – bowel studies.
8. Intravenous pyelogram (IUP) and bladder studies should be done before barium
studies.
Commonly Used X – ray Studies:
A:
1. Chest Film
2. Synonym: Chest X – ray
3. Explanation of the Test: A chest film is the most commonly used X – ray study. It
can be done in radiology department or, as a “portable” X – ray taken to the client
in a hospital room or in a community setting, in a van.
Presently it is used to determine lung ventilatory; heart position and size;
vascular patterns in chronic respiratory disease; and the presence of atelectasis,
hydrothorax, pneumothorax, infection, tuberculosis, lung tumors and infiltrate. A
comparison with previous chest films for change often provides the most valuable
information.
Implication for Nursing:
1. No permit is needed.
2. No physical preparation of the client is necessary.
3. Client education: It is important to stand up straight and “tall” as possible; a front
and side view (called an anterior / posterior (A & P) and lateral) are usually the
minimum number of views. Clothing must be removed to the waist. No jewelry
such as necklaces may be worn, nor should cardiac monitor patches be left in
place. The client will be required to take two deep breaths and hold the second one
for approximately 15 seconds.
4. Length of time needed. Usually only a few minutes.
B:
1. Plain film of the Abdomen
2. Synonyms: Scout film, KUB (kidney, ureter, bladder), flat plate of abdomen.
3. Explanation of the test: A plain film of the abdomen is usually done as first step in
diagnosis of abdominal / discomfort, trauma, enlargement of the abdomen, or
with any examination of the GI system. The presence of excessive gas in the
bowel (bowel distention), ascites, or the position of the liver, and kidneys can be
determined, as can the location of abdominal at times, depending on their
355
composition, and a viscus perforation can be detected by the presence of air under
the diaphragm, which will elevate it.
Implication for Nursing: Plain Film of the Abdomen:
a. No permit is needed.
b. Physical preparation: Bowel preparation is sometimes required, but most often the
abdominal plain film is done without preparation because of insufficient
knowledge as to the cause of the abdominal problems. Check with the physician.
In the absence of specific instructions, no preparation should be done. Unless
otherwise specified, the bladder should be emptied before the test.
c. Client education: The person will need to know that there should be little or no
discomfort associated with the test other than lying briefly on a hard surface. If it
is possible, one view at least will be taken with the individual standing (or sitting).
If that is not possible, a view will be taken with the client on his or her left side.
d. Length of time needed: Usually only a few minutes.
C.
1. Barium Enema
2. Synonyms: Double–contrast study of the colon, air contrast study of the colon,
lower GI study.
3. Explanation: Barium Enema is a study of the large bowel by using barium as a
contrast medium; barium is introduced through the rectum of a tube retrograde
flow and retained as the radiologist observes the bowel filling under fluoroscopy
X–ray are taken as well during the filling process and again after the client has
eliminated as much barium as is possible.
A double–contrast, or air contrast study is the introduction of a thicker
barium solution that is expelled and air introduced to “push” the barium against
the colon walls, thereby outlining them.
Barium enemas are indicated in any suspected lower intestinal disease or
problem such as tumor, polyps, diverticulum, occult bleeding, the presence of
mucus or pus in the stool, complaints of lower abdominal pain, changes in bowel
habits or stool formation, positional anomalies, or any form of obstruction.
It is contraindicated when a perforated viscus is suspected (severe
abdominal pain/cramping).
4. Implications for nursing:
a. Permits are not usually required.
b. Physical preparation: Notify the physician if the client has severe
abdominal cramping or pain before the test.
c. Low residue dinner (lugaw only) at 7 PM
d. For elderly – drink 30 cc of castor oil at 8:00 PM (one hour after dinner)
Middle age and young adult – drink 60 cc castor oil at 8:00 PM (one hour
after dinner)
e. Drink one glass of water every 30 minutes until bed time.
f. Nothing per mouth (NPO) starting 12 midnight until after the procedure is
completed the following morning.
g. Dulcolax 2 suppositories per rectum at 6:00 AM.
h. Post – test care
1. The client will also need to know the importance of removing all
the barium after the test. She or he can recognize the presence of
the barium in the stool of the unusually light colon of the stool only
streaks of white in the stool
i. Length of time needed: Approximately one hour.
356
D:
1. Oral Cholecystograms
2. Synonyms: OCG, gall bladder series, GB series, oral cholecystography, gall
bladder radiography, chole–GI series.
3. Explanation of the test: It is an X–ray test, rarely done with the advent of
ultrasound using an oral contrast medium in capsule form to visualize the internal
anatomy of the gall bladder in order to evaluate its function and the patency of the
cystic duct, as well as to determine the presence of nonradiopaque gallstones.
4. This test is contraindicated in:
a.) Any liver dysfunction (e.g serum bilirubin level greater than 3 to 4 mg/dl)
b.) Client allergic to contrast medium.
c.) Early pregnancy (first trimester). The contrast medium may have
teratogenic effects on the fetus at this time and X–ray itself is a hazard.
5. Implication for Nursing:
a.) No permit is needed.
Note: Plain film should be taken first (inform radiotechnologist in
duty).
b.) Preparation for Chole – GI series in SPH.
1. Low residue, non–fatty dinner (lugaw only) at 7:00 PM
2. Take one tablet of BILOPTIN at 8 PM observe for 30 minutes for
untoward reaction from the tablet. If none, proceed to # 3.
3. Take one tablet of BILOPTIN every 5 minutes for a total of
_____ six (6) tablets if the client is 140 lbs. or less

_____ eight (8) tablets of BILOPTIN if client is 141 – 180 lbs.
_____ ten (10) tablets if client is more than 180 lbs.
15. The first dose of BILOPTIN should be given at least 10 hours

before the scheduled procedure. No cathartics should be given at
any time.
4. Nothing per mouth (NPO) starting 12 midnight until after the

procedure is completed the following morning.
E:
1. Intravenous Pyelogram
2. Synonym: IUP, excretory urogram.
3. Explanation of the test: An IUP is a frequently used X–ray study of the kidney that
delineates the calyx, pelvis, and lower part of the urinary tract through the use of
an intravenous, iodinated contrast medium that is excreted by the urinary system.
4. An IUP is contraindicated:
a.) If the blood urea nitrogen (BUN) concentration is greater than 50 mg/dl.
b.) With a history of sensitivity to the contrast medium.
c.) In states of severe dehydration or oliguria.
d.) In client being medicated for chronic respiratory conditions such as
emphysema, asthma or bronchitis.
5. Implications for Nursing:
a.) Consent is needed.
b.) Assess for any history of allergic response to shellfish or previous contrast
material. Skin testing may be done.
c.) Preparations:
c.1 Low residue dinner (lugaw only) at 7:00 PM
c.2 For elderly – drink 30 cc castor oil at 8:00 PM (one hour after
dinner). Middle age and young adult – drink 60 cc castor at 8
357
PM (one hour after dinner).
c.3 Drink one glass of water every 30 minutes until bed time.
c.4 Nothing per mouth (NPO) starting 12 midnight until after the
c.5 Dulcolax suppositories per rectum at 6:00 PM
c.6 client education
a.) Explain the steps of the preparation and procedures with
rationale for each
1.) Generally the contrast medium is given of intravenous
drip, but it may be given by a bolus injection.
2.) There will be several position changes.
3.) Client will be asked to empty. Their bladders and then
have another film taken.
4.) Stress the importance of letting the radiologist or
technician know any sensation such as itching, shortness
of breath, or any other discomfort.
d.) Length of time needed: Approximately 45 minutes to one hour.
F:
1. Upper Gastrointestinal Series
2. Synonyms: Barium swallow, esophagogram, UGT – series and small – bowel
series, enteroclysis study, hypotonic duodenography.
3. Explanation of the test: These tests make up what is generally referred to as the GI
series and can be used to study one or all parts of the upper GI tract. Because of
this, the series is with varying titles to indicate the focus or scope of the
examination to be done. Visualization of the esophagus – position, patency, and
contour – is called an esophagogram and is often done to diagnosed a hiatal
hernia; examination of the function of the esophagus (peristalsis) is usually called
a barium swallow. If the total upper GI tract is to be observed, the test is referred
to as an upper GI series; a small–bowel series implies that the focus is on or
include examination of the jejunum and ileum.
4. Implication for nursing:
a.) Permit is not required.
b.) Physical preparation:
1. Low residue dinner (lugaw only)
2. Increase oral fluid intake.
3. Nothing per mouth (NPO) starting 12 midnight until after the
4. Fasting period should be at least 4 – 6 hours prior to the procedure.
c.) Post–test care:
1. Return to the usual diet unless other test are scheduled.
2. Increase fluid intake to assist in softening the stool to help in
eliminating the barium or other contrast medium.
3. The stool will be light or streaked with white if barium was used
and a laxative or enema may be ordered to help prevent
constipation.
d.) Length of time needed:
a.) Barium swallow: 15 to 20 minutes
b.) UGI: one hour
c.) UGI – with small–bowel series: 1 to 3 hours, or longer (can be up
to 5 hours), depending on how rapidly the barium moves.
A. Ultrasound of the Urinary Bladder, Pelvis, Prostate and Pregnancies Less than 3
months:
358
1. Preparation: a full bladder is required to carry out these procedures.
2. If, the client does not have the feeling to void, encourage at least 5 glasses of
water to facilitate bladder filling.
3. Do not let client void until after procedure.
R E F E R E N C E S
Altmon, G. (2010). Fundamentals and advanced nursing skills. Singapore: Delmar

Learning.
359
Anderson K. (2002). Mosby’s medical nursing and allied health dictionary. (4 th Edition). St
Louis: Mosby, Inc.
Berman, A., Snyder, S., Kozier, B. & Erb, G. (2008). Fundamentals of nursing, concepts,
process and practice. (8th ed.). Singapore: Pearson Education South Asia Pte Ltd.
Chin, P. (2001). Fundamentals of nursing. Texas: Skidmore Roth Publishing, Inc.
Daniels, R. (2004.) Nursing fundamentals. Singapore: Delmar Learning.
Daniels, R., Grendell, R. and Wilkins, F. (2010). Nursing fundamentals caring and clinical
decision making (2nd ed.). USA: Delmar Cengage Learning.
DeLaune, S. C. & Ladner, P. K. (2011). Fundamentals of nursing. (3rd ed.) Australia:

Delmar Thomson Learning,
De Wit, S. C. (2001). Fundamental concepts and skills for nursing. Philadelphia: W.B.
Saunders Co.
National League of Government Nurses, Inc. (2000). Community Health Nursing Services in
the Philippine Department of Health, Manila, (9 th ed.).
Phillips, N.(2008) Operating Room Technique(11th ed). Singapore. Elsevier (Singapore) Pte,
Ltd.
Potter, P. A. & Perry, A. G. (2017). Fundamentals of nursing. (6 th ed.). Singapore: Elsevier

(Singapore) Pte, Ltd.
Smeltzer, S. & Bare, B. (2010 ). Medical-Surgical Nursing. (10th Edition). Philadelphia:

Lippincott Williams & Wilkins,
Resource manual for health care I & II.(1998).
Department of Health Manual
San Pedro College Manual of Nursing Procedure., (2000 Edition).
360
APPENDICES
APPENDIX A
TABLE SETTINGS
Setting the Table
361
Dust the table first before laying the silence cloth or board smoothly on it. If
necessary, fasten it to stay in position. Lay the tablecloth carefully at the middle,
lengthwise crease up, and centered. Smooth out any wrinkle in the cloth. The tablecloth
should extend over the table an equal distance at each end, preferably 25 to 40
centimeters. When place mats and table runners are used, no silence cloth is needed. Place
the decoration, if there is one, at the center of the table. Allow 50 to 80 cm. for each cover
in order to provide sufficient space for each person.
If plates are placed at this time, they should occupy the center of the cover, at least 2
cm from the edge of the table. Place the flat silver beside the plate, about 2 cm from the
edge of the table and perpendicular to it. Lay the silver close to the plate but do not
crowd.
Place the knife, sharp edge in, to the right of the plate; the fork, tines up, to the left of
the plate; the spoon, bowl up, to the right of the knife. Place additional forks to the left of
the first fork, except for the cocktail fork, which is placed to the right or on the service
plate. Additional spoons are placed to the right of the first spoon. Forks and spoons may
be arranged in the order of their use in the meal, beginning from the outside. Some prefer
to place the main fork next to the plate, arranging the other in the order in which they are
used. Or if desired, the silver may be arranged in order of size.
If butter spreaders are used and the knife is not needed, it may not be necessary to
include the knife in the setting. The forks are then placed. A salad fork is not necessarily
used in the informal meal where the salad is usually not served as a separate course. The
silver for dessert and after-dinner coffee is placed just before dessert is served.
Put all serving silver at a convenient place adjacent to the dish with which each is to
be used, following the general line of the other silver on the table, that is, always parallel
or perpendicular to the edge of the table. Provide service silver for all serving dishes. Do
not put the individual silver into the serving dishes.
At the left of the fork and in line with the silver, place the napkin, neatly folded, with
the loose corner at lower right toward the plate. At a family meal, a ring or some other
device may hold it. In formal meals in which a service plate is placed at the cover until
exchanged for the heated plate of the first course, the napkin is placed on the service plate.
Place the water glass at the tip of the knife and slightly to the right of it. Place coffee
cups or teacups at the right of the spoons with the handles parallel to the edge of the table
and on line that passes slightly below the center of the plate. If milk is served, place it at
the right of the water glass.
Place salt and pepper shakers in convenient places, spacing them uniformly. One set
for every two or three persons is desirable. If individual salt and peppershakers are used,
these should be placed directly in front of the cover. Place the sugar bowl and cream
pitcher directly in front of the host/ hostess, the sugar to the right and the cream to the left,
with handles of both following the same line, preferably parallel to the edge of the table.
Place bread and butter plates, when used, at the tip of the fork slightly to the left.
Serving silver to be used by the host/ hostess should be placed by the serving dish if
the dish is set in front of the host’s/ hostess’s cover, but it should be with the host’s/
hostess’s silver if the dish is at the side of the host’s/ hostess’s cover.
362
A serving table or teacart is often used to save steps and facilitate the service of a
meal. It should be placed near the dining table and where it can be conveniently moved to
the kitchen and back. On the serving table may be placed such articles as water and milk
pitcher, coffee or tea service, extra pieces of silver, and some food for another course,
such as salad.
In setting the table for informal service, make sure that you provide warm dishes for
hot food and chilled dishes for cold food. Serve hot food hot, cold food cool. Put ice in the
water glasses, if desired, and fill them three-fourths full cold water just before the meal
begins. Refill the pitcher and place it conveniently near the member of the family who can
take charge of refilling the glasses as needed.
If bread is served, cut the loaf in half slices lengthwise or in smaller slices if the loaf is
large, then arrange them carefully on a plate. Place bread, butter, jelly, and other cold food
on the table shortly before the meal is served.
Immediately before serving, place hot food conveniently near the person who will
pass or serve them. If beverage goes with the main dish, it must be served along with the
other hot food. It may be served from the kitchen or at the table. Beverage cups should be
filled three-fourths full. If the beverage is served at the table, its container should be
placed near the one who will serve it with the handle of the pot parallel to the edge of the
table at a distance convenient for grasping. Arrange the food uniformly on the plates.
Make sure that everything is assembled before announcing the meal. If the food will
be passed at the table a uniform plan should be followed.
Forms and Styles of Table Service
The forms of table service are generally classified as informal or formal.
Informal service includes those forms in which the host and other members of the
group, as well as the waiter, may participate. It is friendly, gracious, and simple.
Formal service is that form in which the host/ hostess has no part other than
overseeing to ensure that the proceedings go on smoothly. It is dignified, elegant, and
elaborate.
What differentiates each type of entertaining is primarily a matter of degree:
The type of menu and number of courses served. A formal dinner would have more
courses and wines and a more elaborate menu than a semi-formal one.
363
The kind of service used. A butler and more waiters per person would be needed in
formal than for a less formal affair.
The lavishness of the décor / place settings. A formal event would require the finest
linen, sterling silver, crystal, and the best porcelain available.
The dress code. Formal attire means white or black tie for men and long gowns for
the ladies.
The wording and form of the invitations, the forms of address used, and the replies
expected.
The strict adherence to the rules of protocol, especially those concerning the Order
of Precedence in the seating arrangement.
APPENDIX B
FLOWER ARRANGEMENT
Flower arrangements need to harmonize with the décor: a mass arrangement would suit a
Victorian drawing-room and a simple or free-form design would complement a modern
apartment.
364
Equipment:
1. Flower Vase 4. Scissors
2. Flower 5. Water
3. Flower Holder
CONSTRUCTING A TRADITIONAL
(TRIANGULAR) ARRANGEMENT
Many traditional designs are constructed in 6. Determine the width by placing a

low bowls or containers with a stem, such as stem on each side of the block of
an urn. The following instructions are for an foam flowing downward slightly; the
arrangement using florist’s foam. three points of the triangle are now
established. The remaining stem
1. Secure a foam holder in the base of the shall now radiate from the center
container. outwards. Keeping within the
imaginary triangle formed by the
2. Cut a square block of foam which will fit first three stems (Fig. 3. b.).
into the container leaving space for water
at the sides; the foam should project about
1 ½ inches (4 cm) above the rim of the
container.
3. Soak the foam and place it in the

container; a large design will require a cap
of 2 inch (5 cm.).
4. Since any arrangement must incorporate

height, width and depth, begin the design
with an outline of fine, pointed material.
Define the height with a straight stem
about one to one and a half times the
height of the container.This first stem
should be inserted in the foam about two-
thirds of the distance from the front 7. Create depth by placing some stems
to the front and near of the design.
8. The next stage is to create the most

eye-catching part of the
arrangement. Place the most
dominant flower at a point just
above the base of the main stem with
three or five larger leaves radiating
out from it to give extra strength to
5. Push the stem well into the foam. the centre.
9. Place staggered lines of plant material

radiating out from the centre and decreasing
in size towards the outer edges. Remember
to place material to the back of the design to
create depth and to give an even balance to
365
the arrangement so that it does not fall over.
10. Fill in with transitional material-material

which is half-way in size and color
intensity between outline and central
material (above).
Note: When you are using a selection of

different colors, try to group them in a
harmonious manner; for instance,
dominant colors such as red or white can
give a spotted effect if scattered
indiscriminately throughout the design.
11. Finally check your arrangement from all

angles, ensuring that the foam or wire is
not visible and that there is sufficient
space between the flowers to show each
one to advantage.
12. Carefully fill up the container with

water using a long-spouted watering-
can, then sit back and enjoy your
creation.
SIMPLE, MODERN or FREE-FORM
Modern designs differ from traditional ones The emphasis is on strong line, and in
in the restrained use of plant material and some designs there may be more than
the creation of a striking and dramatic one centre of interest. For instance,
design. The emphasis is on bold and cane or vines can be formed into
interesting plant material shown to great loops, and the “enclosed” space
effect by the use of space within the design. created will then balance a more solid-
The shape is usually free-form without a looking flower or leaf. Very often the
geometric silhouette, and the plant material container is an important part of the
is selected for its form, texture and interest, design.
often rising above the rim of the container,
which forms an important part of the design Simple designs also use few flowers
and leaves, but have a less clear form
of outline.
366
1. Begin with a wide, shallow bowl into 3. Insert sparse, twiggy branches
which a pinholder is fixed slightly off flowing out nearly horizontally on
centre (Fig. 3.e). one side of the irises. Weight can be
provided at the base of the design
2. Insert three irises on to the pinholder in with two or three large leaves
gradated steps, each one facing a slightly placed to one side and a few stones
different direct (Fig. 3.f). in the water on the other side
(Fig. 3.g).
367

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This Manual of Nursing Procedures

Through 2016 edition of the Manual of Nursing Procedures, the Department of

The Working Committee

A manual of nursing procedures is one of the reference materials of the school.

THE SPC VISION AND MISSION STATEMENT

To provide a nurturing environment beneficial in the total formation of persons:

 Strengthening spirituality and values formation

MISSION STATEMENT OF NURSING DEPARTMENT

1. provide quality Christian nursing education to the community through innovative

SPC NURSE’S PIN

This identifies the bearer as a nursing

The lamp represents Nightingale’s lamp which symbolizes dedication, commitment,

NURSING – WHAT IT IS!

Nursing may be viewed as both an art and a science. It is an art because it is

Nursing today has certain characteristics:

THE NURSE AS A PROVIDER OF HEALTH CARE

Roles of the Nurse:

Caring (comforting) role

POINTS TO REMEMBER ON BECOMING A STUDENT NURSE

KEY POINTS EXAMPLES & RELATED NOTES

5. Be willing to accept changes in work Unexpected situations come up after

4. Report to the nurse or CI the Remember, proper and immediate

b. Doing an assigned task and

6. As a nursing student, you are called

7. Try to be mindful of the feelings of The habit of being courteous will

8. Nursing is an important job. It calls If you keep trying to improve your

MAINTAINING GOOD PERSONAL HEALTH

KEY POINTS EXAMPLES & RELATED NOTES

2. Understand that keeping in good Eating well–balanced meals and obtaining

3. Remember what foods are essential Malnutrition which is commonly defined as

5. If you are overweight or underweight Excess body weight predisposes people to

a. Wash hands thoroughly (using Washing may be done:

KEY POINTS EXAMPLES & RELATED NOTES

4. Be clean, look clean, and feel clean.

b. Keep hands chap–free and

APPROACHES TO PATIENT CARE

KEY POINTS EXAMPLES & RELATED NOTES

5. Respect the patient’s right and Everyone has freedom of religion. We

1. To maintain good body posture.

Principles of Body Mechanics

APPLICATION of BODY MECHANICS

KEY POINTS Rationale

D. MOVING UP THE CLIENT IN BED

The nurse will frequently encounter a semi–helpless or immobilized patient whose

5. Elevate bed to working height. Lessens strain on nurse’s back muscles by

9. Elicit client’s help by asking him to Lessens the workload of a nurse

Variation A: For a client who has limited

Variation B: Two Nurses Using a Hand-

Using the technique described in Variation

Variation C. Two Nurses Using a Turn

E. TURNING A CLIENT TO LATERAL OR PRONE POSITION IN BED

5. Raise the bed to a comfortable Lessens strain on nurse’s back muscles by

Variation: Turning the Client to a

Follow the pre-proceeding steps with two

1. Review client’s record Determine the reason for logrolling the

3. Perform hand hygiene and don gloves Reduces transient microorganism or

4. Provide for client’s privacy To maintain client’s dignity

5. Raise the bed to a comfortable Lessens strain on nurse’s back muscles by

Variation : Using a draw sheet/bedsheet

1. Review client’s record. Assess patient for ability to assist the

F. TRANSFERRING A PATIENT FROM BED TO STRETCHER

4. Provide for client’s privacy To maintain client’s dignity.

6. Instruct/ assist patient to move to side Decreases risk of patient falling.

Name: ______________ Grade:

Name: ______________ Grade:

Name: ______________ Grade:

Name: ______________ Grade:

Name: ____________ Grade: