Performance Manual On Nursing Procedures

PERFORMANCE
MANULA ON
NURSING
PROCEDURES
CHAPTER 1
ASEPSIS
HANDWASHING
DONNING A CAP AND A MASK
SURGICAL SCRUB
GLOVING
CLOSE GOWNING AND GLOVING
HANDWASHING
PERFORMANCE POINTS
1. Assess hands for cuts and breaks contaminated in the skin and areas that are heavily.
2. Remove jewelries and wristwatch,
3. Do not touch any part of the skin.
4. Open the faucet and adjust the flow of water.
5. Wet hands and lower forearm under running water. Keep hands downward in position.
6. Get the soap and lather thoroughly.
7. While holding the soap with one hand, use your other hand in rubbing all areas of your
hand. Do the same with other hand.
8. Rinse the soap and return it on the soap dish without touching any part of the skin.
9. With hands in downward position, rinse starting from the water to fingers.
10. Get paper towel/towel and dry your hands starting from the fingers to forearms.
11. Close the faucet using the paper towel.
12. Discard the paper towel.
DONNING A CAP AND A MASK
PERFORMANCE POINTS
1. Identify specific isolation precaution needed for the client’s condition.

2. Wash hands.
3. Place cap to head, be sure to tuck hair under cap.
4. Secure mask around mouth and nose.
5. Secure eyeglasses if any.
6. Enter client’s room or area and explain the rationale for wearing a cap and mask.
7. After performing the necessary procedures, remove cap and mask before leaving the
room.
SURGICAL SCRUB
PERFORMACE POINTS
1. Gather material to be used.

2. Inspect skin integrity.
3. Remove jewelries chipped nail polish.
4. Wear appropriate attire (complete OR attire).
5. Open sterile package containing the gown and create a sterile field.
6. Open sterile gloves on the sterile field.
7. At the surgical sink, wet arms, hands and elbows.
8. Maintain hands in upright position.
9. Apply soap and rub hands and arms up to 2 inches above elbows.
10. Rinse both hands and arms.
11. Get/ask for a brush. Rinse brush and apply soap.
12. Following hospital protocol, brush non-dominant hand by your dominant hand
starting from the finger tips and nails and to all areas of the hand and arm.
13. Rinse brush thoroughly and reapply soap.
14. Brush your dominant hand by you non-dominant. Follow steps of No. 12.
15. Rinse brush, hands and arms, be careful not to touch any part of the sink and
faucet.
16. Repeat steps 12 to 15.
17. Drop the brush into the sink.
18. Keep arms flexed and proceed to the area with sterile field.
GLOVING
PERFORAMANCE POINTS
1. Be sure that fingernails are short. Remove jewelries.

2. Wash and dry hands.
3. Maintain the sterility of the gloves during the entire procedure.
4. Remove the package from the outer wrapper. Place the package on a clean dry
surface.
5. Open the package by pulling the corners of the wrapper.
6. Identify the right and left gloves. Glove dominant hand first.
7. Get the first glove by grasping the folded cuff with the thumb and first two fingers
of non-dominant hand, touching only the cuff.
8. Slip in your dominant hand on the glove. Hold hand above waist level.
9. Using the gloved dominant hand, slip your fingers under the cuff of other glove.
10. Slip the glove onto non-dominant hand.
11. Interlock the fingers of your gloved hands to fit gloves into each other.
12. If gloves are solid, remove as follows: using the fingers of your dominant hand,
grasp the outer part of the glove at the wrist.
13. Pull the glove down to the fingers (glove to glove).
14. Slip the ungloved fingers of your non-dominant hand under the glove of your
dominant hand (skin to skin).
15. Pull and remove the glove.
16. Disposed soiled gloves and wash hands.
CLOSED GOWNING AND GLOVING
PERFORMANCE POINTS
1. Maintain sterility of gown and gloves during the entire procedure.

2. Grasp the gown and step backward.
3. Allow the bottom part of the gown to fall.
4. Dry hands and arm using the bottom part of the gown.
5. Open the gown and slip both arms in the gown simultaneously.
6. Keep your hands inside the sleeves of the gown. The circulating nurse will secure the
ties of the gown.
7. With hands still inside the sleeves, open the wrapper of the sterile gloves already place
on the sterile field.
8. With your dominant sleeved hand, place the palm of the non-dominant hand glove
against the sleeved palm of the non-dominating hand.
9. Grasp the cuff of the glove with your non-dominant hand. With your dominant hand, turn
the cuff over the end of the non-dominant hand and gown’s cuff.
10. Slowly extend the fingers into the glove while holding the glove and the gown cuffs.
11. With gloved non-dominant hand repeat steps 8-10.
12. Interlock your gloved hands to fit the gloves.
CHAPTER II
HEALTH ASSESSMENT
TAKING BODY TEMPERATURE, PULSE RATE AND

RESPIRATION
ADMINISTERING PULSE OXIMETRY
TAKING BLOOD PRESSSURE
PHYSICAL ASSESSMENT
TAKING BODY TEMPERATURE, PULSE RATE AND RESPIRATION
PERFORMANCE POINTS
1. Prepare equipment’s such as oral glasses thermometer, cotton balls (with and without
alcohol), and wristwatch with secondhand.
2. Wash hands before starting the procedures.
3. Identify the patient and explain the procedure.
4. Provide privacy.
5. Place client in appropriate position.
6. Obtain oral thermometer form the container.
7. Wipe the thermometer with cotton ball with alcohol from the bulb to the stem. Dry it with
dry cotton ball in the same manner.
8. Check level of mercury and shake down 35.5 C (96 F).
9. Using snapping wrist action, instruct patient to open his mouth and raise the tongue.
10. Place in thermometer client’s mouth under the tongue and along the gum line with the tip
end exposed. Instruct client to hold lips closed.
11. Leave the thermometer in place for 5-10 minutes. (While waiting the nurse may count
the client’s radial pulse and respiration).
ASSESSING RADIAL PULSE
12. While taking the client’s temperature. Begin to assess his radial rate.
13. Position client’s arm comfortably by resting on either his lap, table, in bed.
14. Support client’s wrist by grasping outer aspect with thumb. Place index and middle finger
over the client’s artery and palpate pulse.
15. Count pulse to one full minute using wristwatch with second hand.
16. Assess rhythm, volume of pulse.
ASSESSING RESPIRATION
17. After taking the pulse rate, do not remove fingers from the wrist. Observe the chest
movement while supposedly taking the radial pulse.
18. Count the respiratory rate for one full minute. An inhalation and exhalation in count as
one respiration. This is observed with the rise and fall of the chest wall.
19. Observe the depth, rhythm, and character of respirations.
20. Remove thermometer from the client’s mouth. Wipe it dry cotton ball from the stem to
bulb.
21. Read at eye level rotating slowly until mercury level in visualized.
22. Shale thermometer down to 35.5 C (95 F).
23. Wash thermometer with soap and water. Return thermometer to proper container.
24. Wash hands.
25. Document reading of body temperature, pulse and respiration. Record pertinent data.
ADMINISTERING PULSE OXIMETRY
PERFORMAMCE POINTS
1. Assess baseline data: vital signs, nail bed, and skin color and tissue perfusion.
2. Check oximeter equipment if functioning properly.
3. Identify the client and explain the procedure.
4. Choose sensor appropriate for client’s weight, size desired location.
5. Wash hands.
6. Select an appropriate site for the sensor.
7. Clean the site with an alcohol wipe or soap and water.
8. Apply the sensor.
9. Connect the sensor to the oximeter with sensor cable. Turn on the machine.
10. Set and turn on the machine.
11. Inspect and/or move or change the location of an adhesive toe or finger sensor every 4
hours and a spring tension sensor every 2 hours to provide client’s safety.
12. Immobilize the client’s monitoring site to ensure accuracy of measurement.
13. Document and notify physician of abnormal.
TAKING BLOOD PRESSURE
PERFORMANCE POINTS
1. Assess for factors that affect blood pressure.

2. Determine client’s baseline blood pressure.
3. Wash hands.
4. Determine which extremity is most appropriate for reading.
5. Prepare materials (BP apparatus and sphygmometer). Select a cuff size that
completely encircles client’s upper arms without overlapping bladder ends.
6. Inform client and explain the procedure.
7. Position clients appropriately.
8. Move client’s clothing away from upper aspect of arm.
9. Positon client’s arm at hear level, extending elbow with palm turned upward. Have
client relax arm and not overly tighten elbow.
10. Wrap deflated cuff evenly around the upper arm. For an adult place, place the lower
border of cuff approximately 2.5 cm (1 inch) above the antecubital space.
11. Apply cuff snugly and smoothly over upper arm.
12. Palpate the brachial artery in the antecubital space using the index and middle
finger.
13. Insert earpiece of stethoscope into ears with a forward tilt.
14. Relocate the brachial pulse and place bell or diaphragm directly over brachial pulse.
Hold the diaphragm with the thumb and index finger.
15. Close the valve on the pump by turning the knob clockwise.
16. Inflate cuff to 30 mmHg above the normal systolic reading of the client.
17. Release the valve of the cuff carefully so that the pressure decreases at the rate of
2-3 mmHg per second. As the pressure falls, identify the manometer reading by
listening for the korotkoff’s sounds.
18. Mark the first audible sound as the systolic pressure reading the last audible sound
as the diastolic pressure reading.
19. After the final sound has disappeared, deflate the cuff rapidly and completely.
20. Remove cuff or wait 2 minutes before taking a second reading.
21. Inform client of reading.
22. Position client comfortably in bed.
23. Put all equipment in proper place.
24. Wash hands.
25. Document and report pertinent data.
PHYSICAL ASSESSMENT 1: ASSESSING THE APPEARANCE AND MENTAL STATUS
PERFORMANCE POINTS
1. Greet and identify the client. Explain the procedure.

2. Wash hands and observe appropriate infection control procedures.
3. Provide for client privacy.
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 client’s overall hygiene and grooming. Relate these to the person’s activity prior
to the assessment.
7. Note body and breathe odor in relation to activity level.
8. Observer for signs of distress in posture or facial expression.
9. Note obvious signs of health or illness.
10. Assess the client’s attitude.
11. Note the client’s affect/mood. Assess the appropriateness of the client’s response.
12. Listen for quantity of speech (amount and pace) quality ( loudness, clarity, inflection) and
organization (coherence of thought and vagueness).
13. Listen for relevance and organization of thoughts
14. Document findings.
PHYSICAL ASSESSMENT 2: ASSESSING THE SKIN
PERFORMANCE POINTS
1. Greet and identify the patient. Explain the procedure.

2. Wash hands.
4. Position client appropriately and comfortably.
5. Inquire if the client has any history of skin allergies and skin problems.
6. Inspect for skin color and uniformity of skin color.
7. Assess edema if present. Note location, color, temperature, shape and the degree to
which the skin remains indented or pitted then pressed by a finger.
8. Inspect, palpitate and describe skin lesions. Don gloves if lesions to determine shape
and texture. Describe lesions to shape and texture. Describe lesions according to
location, color, configuration, size, shape, type and structure.
9. Observe and palpate skin moisture.
10. Palpate skin temperature. Compare the two feet and the two hands using the back of the
fingers.
11. Note skin turgor (fullness or elasticity) by lifting and pinching the skin on extremity.
12. Position client comfortably after the assessment.
13. Inform client findings as necessary.
14. Wash hands.
15. Document findings and report significant deviation from normal to the physician.
PHYSICAL ASSESSMENT 3: ASSESSING THE HEAD, SKULL AND FACE
PERFORMANCE POINTS
1. Wash hands
2. Greet an identify client. Explain the procedure.
3. Provide privacy.
4. Position client appropriately
5. Palpate
a. Skull. Inspect for size, shape and symmetry.
b. Scalp. Inspect for dandruff, lesions, and masses.
c. Hair. Inspect color, distribution and nits or pediculosis.
d. Face. Note symmetry of facial movements. Assess function of the facial nerve. Ask
the client to smile, frown, elevate, and lower eyebrows, close eyes tightly, puff the
cheeks and show the teeth.
6. Palpation.
a. Skull. Palpate for nodule or masses and depression.
b. Hair. Notice the texture.
c. Face. Palpate the temporomandibular joint for pain and tenderness.
8. Inform client of finding as necessary.
9. Wash hands.
PHYSICAL ASSESSMENT 4: ASSESING THE EYES, NOSE, MOUTH AND THROAT
PERFORMANCE POINTS
1. Preparer equipments:
a. Eyes. Penlight, opthalmoscope, Snellen chart.
b. Ears, otoscope, tuning fork.
c. Nose. Nasal speculum.
d. Mouth. Tongue depressor.
e. Others,
2. Greet and identify the patient. Explain the procedure.
3. Wash hands and wear gloves.
4. Provide privacy and position client appropriately and comfortably.
EYES
5. Inquire client’s history of eye disease, injury or surgery; family history of diabetes;
current symptoms of eye problems; and use of eyeglasses, contact lenses or
medication.
6. Inspection.
a. Palpebral fissures. Assess symmetry and width.
b. Lid margins. Observe for scaling, secretions, erythema and position of
eyelashes.
c. Conjunctivae. Inspect for congestion and color.
d. Sclerae and irises. Observe color.
e. Pupils, observe the size, shape symmetry, and reaction to light and
accommodation.
f. Muscles and nerves. Assess the six ocular movements.
g. Inner eye. Perform fundoscopic examination with the use of an opthalmoscope
and locate the red reflex. Check the transparency of the anterior and posterior
chambers, cornea and lens. Examine the retina optic disc, macula and blood
vessels.
7. Palpation.
a. Upper lids. Evaluate strength by attempting to open the client’s closed lid against
her resistance.
b. Eyeballs. Assess tenderness and tension.
8. Vision testing.
a. Test visual acuity with Snellen chart. Test a client wearing corrective lenses with
and without lenses.
b. Test visual peripheral fields using the cover and uncover test and note
nystagmus or convergence.
c. Perform functional vision test using light perception hand movement (HM) and
counting finger (CF)
EARS
9. Inquire client’s family history of hearing problems of loss; presence of any ear
problems; medication history and signs and symptoms of ear problems.
10. Inspection.
a. Auricles. Inspect, color, symmetry of size and position.
b. External ear canal. Inspect for discharges, impact cerumen and inflammation
using an otoscope.
c. Tympanic membrane. Inspect for color and gloss.
11. Palpation. Examine the pinna for tenderness, consistency of cartilage, swelling and
pain.
12. Assess gross hearing acuity test.
a. Assess client’s response to normal voice tones.
b. Perform the watch tick test.
c. Perform weber’s test to assess bone conduction.
d. Conduct the rinne test to compare air conduction to bone conduction.
NOSE AND SINUSES
13. Inquire client’s history of allergies and difficulty breathing through the nose, sinus
infections, injuries to nose or face, nose bleeds; any medication taken; any changes
in sense of smell.
14. Palpation.
a. External nose. Inspect for any deviations in shape, size or color and flaring or
discharges from the nares.
b. Nasal passageway. Assess interior structure using nasal speculum. Note nasal
septum for position. Bleeding or perforation; mucous membranes for hydration
and color and nasal turbinates for color and swelling.
15. Palpation.
a. External nose. Determine any areas of tenderness, masses and displacement of
bone and cartilage.
b. Sinuses. Palpate the maxillary and frontal sinuses and tenderness.
MOUTH AND OROPARYNX
16. Inquire of client’s history of mouth, gums and dental problems.
17. Inspection.
a. Lips. Observe color, moisture and pigmentation, masses, ulceration and fissures.
b. Teeth. Note the number, arrangement and general condition.
c. Gingivae. Asses for color, vesicles, ulcerations and masses.
d. Buccal mucosa. Assess for color, ulcerations, masses and vesicles.
e. Pharynx. Note inflammation, exudates and masses.
f. Tongue.
 Assess postion, color and
 Assess function of the glossopharyngeal nerve.
 Assess function of the hypoglossal nerve.
g. Salivary glands, inspect the hard and soft palate for color, shape, texture and the
presence of bony prominences,
h. Palates. Inspect the hard and soft palate for color, shape, texture and the
presence of bony prominences.
i. Uvula. Inspect for position and mobility while examining the palate. Ask the client
say “ah” so that the soft palate rises.
j. Oropharynx. Inspect for color and texture using a tongue depressor. Use a
penlight for illumination.
k. Tonsils. Inspect for color, discharge and size.
18. Palpation.
a. Cervical nodes and salivary glands. Palpate for enlargement ad tenderness.
b. Trachea. Note deviation for midline.
c. Thyroid. Palpate for nodules, masses or irregularities.
d. Carotid arteries. Note amplitude and asymmetry of pulsations.
19. Auscultations. Listen for bruits over carotid arteries.
NECK
20. Inquire client’s history of any problems with neck lumps, neck pain or stiffness, any
previous diagnosis of thyroid problems and any other treatment provided.
21. Inspection.
a. Neck muscles (sternocleidomastoid and trapezius). Inspect for abnormal
swellings or masses. Assess muscle symmetry. Assess range of motion and
strength.
b. Thyroid glands. Inspect for symmetry and visible masses. Ask client hyperextend
the head and swallow. Observe movement of the thyroid and cricoid cartilage as
client swallow and note if swallowing causes as bulging of the gland.
c. Jugular veins. Note distention.
22. Palpation.
a. Lymph nodes. Palpate for tenderness and swelling
b. Trachea palpate for lateral deviation.
c. Thyroid gland. Palpate for smoothness, enlargement, masses or nodules.
24. Inform client of finding as necessary.
25. Wash hands.
26. Document findings and report significant deviations from normal to the physician.
PHYSICAL ASSESSMENT 5: ASSESSING THR ABDOMEN
PERFORMANCE POINTS
1. Prepare equipment, examine light, tape measure, water-soluble skin-marking pencil and
stethoscope.
2. Wash hands.
3. Greet and identify patient. Explain the procedure.
4. Provide for client procedure.
5. Inquire client’s history of bowel habits, change in appetite, specific abdominal signs and
symptoms, hematemesis, previous and current problems and treatment.
6. Position client in supine position with the arms placed comfortably at the sides. Place
small pillows beneath the knees and the head to reduce tension in the abdomen from
chest line to the public area.
7. Inspection.
a. Observe for contour and symmetry, if distention is present, measure the abdominal
girth with a tape measure.
b. Observe abdominal movements associated with respiration, peristalsis or aortic
pulsation.
c. Observe for scars, striae, rashes and lesions
8. Auscultation. Auscultate the abdomen before percussing and palpating to avoid
stimulating intestinal activity and altering bowel sounds.
a. In all quadrants, listen for active bowel sounds irregular gurgling noises occurring
about every 5-20 seconds. Note frequency, pitch and duration of sounds.
b. Auscultate for bruits over the abdominal aorta and the renal, iliac, and femoral
arteries.
9. Percussion.
a. Percuss all quadrants. Notes of areas tympany or dullness. Use a symmetric pattern.
Begin in the lower left quadrants, proceed to the lower right quadrant, the upper right
quadrant and upper left quadrant.
b. Percuss liver size starting in the right midclavicular line below the level of the
umbilicus and moving upward and downward to locate the liver border.
c. Strike at the costovertebral angles, noting tenderness or pain.
10. Palpation.
a. Abdomen. Palpate in all quadrant and follow with deep palpation. Assess organ
location and abdominal muscle tone. Note unusual masses, pulsations, tenderness
or pain.
b. Kidney. Palpate kidney bimanually slightly below umbilicus. Note size, shape and
tenderness.
c. Abdominal aorta. Palpate contour and pulsations.
d. Lymph nodes. Palpate inguinal and femoral areas bilaterally. Note enlargement.
11. Position client comfortably in bed after assessment.
13. Wash hands.
14. Document findings and report significant deviations from normal to the physicians.
PHYSICAL ASSESSMENT 6: ASSESSING THE MUSCULOSKELETAL MUSCLE
PERFORMANCE POINTS
1. Wash hands.
2. Greet and identify client. Explain procedures.
4. Position client appropriately.
5. Inquire client’s history of presence of muscle pain and associated signs and symptoms,
limitations to movement, loss of funetion, or previous and current problems involving
musculoskeletal system.
6. Inspection.
a. Observe the client’s able to perform functional task of daily living. (e.g. performing
personal hygiene, rising from sitting and standing, walking up and down stairs,
walking on a level surface). Note an pain the client experiences while performing
functions are being examined.
b. Extremities. Examine arms and legs. Note the size symmetry, muscle mass and
deformities.
c. Spine. Assess for range of motion (i.e. flexion, extension, lateral flexion and rotation)
and lateral or anteroposterior curvature.
d. Joints. Assess all major points, noting any limitations to active range motion, sweliing
or redness.
 Neck. Assess flexion, lateral extension and lateral rotation.
 Shoulders. Assess flexion, extension and rotation.
 Elbows. Assess flexion, extension, supination, and pronation.
 Wrists. Assess flexion, extension ulnar and radial deviation.
 Fingers. Assess flexion, extension abduction and adduction.
 Hips. Assess flexion, extension and rotation.
 Knees. Assess flexion, extension.
 Ankles. Assess dorsiflexion, plantar flexion, inversion and eversion.
 Toes. Assess flexion, extension, abduction and adduction.
7. Palpation,
a. Joints of the neck and upper and lower extremities. Palpating while noting
tenderness, swelling, temperature, limitations to passive range of motion and
crepitation.
b. Muscle. Palpate to assess size, tone and any tenderness.
c. Spine. Palpate noting any deformities and crepitation.
8. Percussion.
Directly percuss the spine from the cervical to lumber region, using the ulnar surface of
the list. Note any pain or tenderness.
11. Wash hands.
PHYSICAL ASSESSMENT 7: ASSESS THE NEUROLOGICAL SYSTEM
PERFORMANCE POINTS
1. Prepare equipment: percussion hammer, tongue depressor, wisps of cotton, test tubes
of hot and cold water.
2. Wash hands.
3. Greet and identify client. Explain procedure.
5. Position client appropriately.
6. Note the components of the neurological examination.
a. Mental status.
b. Cranial nerve function
c. Cerebellar function
d. Motor function
e. Sensory function
f. Reflexes
7. Assess mental status. During history taking, determine the following:
a. State consciousness. Note whether the client is alert, somnolent, stuporous or
comatose.
b. Orientation to person, place and time.
c. Memory, including immediate, recent and remote.
d. Cognition, including calculations, current events and response to proverbs.
e. Judgement and problem solving ability.
f. Emotion, including mood, affect and congruence response.
8. Assess cranial nerve (CN) functions.
a. Olfactory nerve (CNI). With the client’s eye close, present various odors, occluding
one nostril at a time. Note client’s ability to identify odor.
b. Optic nerve (CNII). Test visual acuity and visual fields. Examine the optic disc with
an opthalmoscope.
c. Oculomotor (CNIII), trochlear (CNIV) and abducens (CNVI) nerves. Assess
extraoculomotor motion.
 Evaluate the six cardinal positions of gaze. Look for parallelism and note
nystagmus (involuntary movement).
 Perform the cover/uncover test note movement of eye when uncovered or
opposed eye when contralateral eye covered.
 Assess corneal light reflex. Note symmetry of reflection to light of the pupil.
Check size and shape of pupils and papillary reaction to light and
accommodation.
d. Trigeminal eye (CNV)
 Motor. Assess the client’s ability to chew and strength to bite.
 Sensory. Assess the client’s ability to distinguish light touch and pain. Lightly
stroke client’s face with a cotton wisp, and gently prick the skin with a sterile
pin or toothpick on forehead (to assess ophthalmic branch), check (to assess
the maxillary branch), and chin (to assess the mandibular branch).
e. Facial nerve (CNVII)
 Motor. Assess symmetry of facial movement as the client smiles, frown,
grimaces, clenches his teeth and so forth.
 Sensory. Ask the client to identify various distinct flavors placed on the
anterior two thirds of the tongue.
f. Acoustic nerve (CN VII)
 Vestibular branch. Perform the Romberg test to evaluate equilibrium. Have
the client to stand with feet together and eyes closed for 20-30seconds
without support. Note excessive swaying.
 Cochlear branch. Assess client’s ability to hear spoken words and vibration of
tuning fork.
g. Glossopharyngeal nerve (CNIX)
 Motor. Ask the client to move tongue from side to side and up and down. Test
for the gag reflex by gently touching the posterior pharyngeal wall with a
tongue blade.
 Sensory. Apply taste on posterior tongue for identification.
h. Vagus nerve (CNX). Ask client to swallow and note swallowing and vocal cord
movement. Ask client’s speech for hoarseness.
i. Accessory nerve (CNXI). Assess strength of sternocleidomastoid and upper
trapezius muscles by asking the client to move the head against resistance of your
hand. Observe and palpate the contraction of the sternocleidomastoid muscle on the
opposite resistance of your hands.
j. Hypoglossal nerve (CNXII). Test strength and articulation of the tongue by having the
client push the tongue to the side of the mouth against resistance applied to the
check. Ask the client to stick out of the tongue and the returns it to the mouth while
you observe for deviation, asymmetry, tremors and fascicultations.
9. Cerebellar function.
a. Assess posture, gait and balance. Have the client walk forward and backward in
straight line.
b. Assess coordination in the upper extremities by having the client perform the finger
to nose test.
c. Assess coordination in the lower extremities by having the client tap the toes and
slide the heel down the contralateral skin.
10. Motor function.
a. Muscle mass. Assess symmetry and distribution distally and proximally, and
circumference of extremities.
b. Tone. Evaluate resistance of muscle in response to passive motion during flexion
and extension of extremities.
c. Strength. Assess hands and squeeze muscle strength in each extremity against
resistance during flexion and extension (abduction and adduction) comparing
bilaterally. Rate on a 5-point scale. (0-absence, 1-trace,2-poor, 3-fair/good, 5-
normal).
d. Observe for involuntary movements (tremors, tics, twitching, fasciculations), and
abnormal postures (fetal, decorticate or decerebrate).
11. Sensory function.
a. Light touch. With client’s eyes closed, have the client indicate response to cotton
wisp lightly stroked on the skin (back of hands, forearms and upper arms, torso,
thigh, tibia, and dorsal portion of foot). Compare bilaterally and distal proximal.
b. Pain. Repeat the pattern of light touch assessment, using a sterile safety pin to elicit
sharp sensation. Alternate with the pin’s rounded end for contrast.
c. Stereognosis. Ask the client to identify small objects placed in his hands, one at a
time.
d. Graphesthesia. Ask the client to identify a number that is trace in his palm with your
finger tip.
12. Deep tendon reflexes. Striking with the reflex hammer, compare reflex amplitude
bilaterally, grading on a 4-point (4+=hyperactive, 2+ or 3+= average, 1+= diminished,
0=no response).
a. Brachioradialis (C5, C6). Strike the radius tendon about 1-2 inches above the wrist.
Observe the flexion and supination of the forearm.
b. Biceps (C5, C6). Place your thumb or forefinger at the base of the base of the tendon
and strike it. Observe for flexion of the arm at the elbow.
c. Triceps (C7, C8). Strike the triceps tendon just above the elbow. Observe for slight
elbow extension.
d. Patellar quadriceps (L2, L3, L4). Sharply strike the patellar tendon. Observe the
extension of knee.
e. Achilles ankle jerk (S1, S2). Support the client’s foot in the dorsiflexed position, tap
the Achilles tendon and observe for plantar flexion.
13. Superfacial cutaneous reflexes.
a. Abdominal. Stroke the abdomen above (T8, T9, T10) and below (T10, T11, T12) the
umbilicus bilaterally. Observe for contraction of abdominal muscles and deviation of
the umbilicus toward the stimulus.
b. Cremasteric (L1, L2). In a male patient, stroke the inner surface of the thigh. Observe
for prompt elevations of the testes on the ipsilateral side.
c. Plantar/Babinski (L4, L5, S1, S2). Extend the client’s leg with the feet relaxed. Stroke
the lateral aspect of the soloed rom the heel to the ball of the foot, curving medially
across the ball. Observe for flexion of toes.
14. Pathological reflexes.
a. Brudzinski’s sign. Flex patient’s neck forward while in recumbent position. Observe
involuntary flexion of the knee and pain.
b. Kernig’s sign. Flex patient’s leg at hip and knee. Observe neck flexion and pain.
c. Ankle clonus. Support client’s knee in partly flexed position while other hands sharply
dorsiflexes the foot and maintains it in dorsiflexion.
15. Position client comfortably.
17. Wash hands.
PHYSICAL ASSESSMENT8: ASSESSING FEMALE AND MALE GENITALS AND INGUINAL
AREA
PERFORMANCE POINTS
1. Prepare equipment:
Female: gloves, drape, supplement lighting.
2. Wash hands.
4. Provide client privacy.
5. Position and drape client appropriately.
6. Don gloves.
FEMALE GENITALIA.
7. Inquire client’s history of menstruation, last menstrual period (LMP), regularity of cycle,
sexually transmitted disease, previous and current problems on reproduction and urinary
system.
8. Inspection and palpation. These examinations are performed almost simultaneously.
Place the client in lithotomy position and drape her properly.
a. External genitalia. Assess pubic hair distribution. Note any nits and lice. Inspect the
labia majora, mons pubis, and perineum. Note skin color integrity.
b. Internal genitalia. Separate the labia majora, and inspect clitoris, urethral meatus,
and vaginal opening. Note abnormal color, ulcerations, edema, nodules or discharge.
c. Inguinal lymph nodes. Use the pads of the finger in rotary motion, noting any
enlargement or tenderness.
MALE GENITALIA
9. Inquire client history of voiding patterns and any changes, bladder control, urinary
incontinence, frequency urgency, abdominal pain, any symptoms of sexually transmitted
disease, any swelling that could indicate presence of hernia, family history of nephritis,
malignancy of the prostate or kidney.
10. Inspection.
a. Pubic hair. Assess distribution, and not any lice or nits.
b. Penis. Retract the foreskin, if present. Note any ulcerations, masses, or scaring on
the glans of penis. Inspect the urethral meatus for locations and discharge.
c. Scrotum. Inspect posterior and anterior aspects, assessing size, contour, and
symmetry. Note ulcerations, masses, redness or swelling.
d. Inguinal area. Look for bulges with or without the client bearing down or when raising
his head of the bed.
11. Palpation.
a. Penis. Palpate the shaft for lesions, nodules or masses, if present, note tenderness,
contour, size and degree of induration.
b. Scrotum. Palpate each testes and epididymis, assessing shape, and consistency.
Note any masses or unusual tenderness. Look for any nodules or tenderness of
spermatic, cord and vas deferens.
c. Inguinal and femoral areas. Assess for hernias.
RECTUM
12. Inspection. Examine the anus and perineal and sacral regions with the client lying in the
left Sims positon and properly draped, if necessary, use an alternative position for the
examination. Male clients may stand and bend over the table: female clients may
assume the lithotomy position.
a. Spread the buttocks, and note any inflammation, nodule or scars, lesions,
ulcerations, rashes, bleeding, fissures or hemorrhoids.
b. Check for bulges when the client bears down.
13. Palpation.
a. Sphincter. Ask the client to bear down. Slowly insert your lubricant index finger of the
gloved hand through the anal sphincter. Assess sphincter tone.
b. Rectum and rectal walls. Gently rotate your index finger to palpate the rectum and
rectal walls anteriorly and posteriorly. Note any nodules, masses or tenderness.
Palpate for fecal impaction.
c. Prostate. In the male client, anteriorly palpate the two lateral lobes of the prostate
gland for irregularities, nodule, edema or tenderness.
d. Fecal material. Withdraw your finger gently. Test any fecal material on the glove for
occult blood.
14. Remove gloves.
17. Wash hands.
PHYSICAL ASSESSMENT 9: ASSESSING PERIPHERAL VSCULAR SYSTEM
PERFORMANCE POINTS
1. Wash hands.
4. Position client appropriately and comfortably.
5. Inquire client history of heart disorders, varicosities, arterial diseases and
hypertension; lifestyle habits such as exercise pattern, activity patterns and
tolerance, smoking and use of alcohol.
6. Inspection.
a. Peripheral views. Inspect peripheral views in the arm and the legs for the
presence of superficial veins when limbs are dependent and when limbs are
elevated.
b. Peripheral perfusion. Inspect the skin of the hands and feet for color, edema,
texture and skin changes.
7. Palpation.
a. Peripheral pulses. Palpate peripheral pulses on both sides of the client’s body
individual, simultaneously and systematically to determine the symmetry of pulse
volume and pulsations.
b. Peripheral veins. Assess peripheral leg veins for sign for phlebitis. Note
tenderness on palpation and pain on calf muscles with forceful dorsiflexion of
both foot. ( (+) homan’s sign) and warmth to touch.
c. Peripheral perfusion. Assess for adequacy of arterial blood flow.
 Buerger’s test (arterial adequacy test). Ask the client to raise one leg or
one arm at about 30cm. (1feet) above heart level move the foot or hand
briskly up and down for about 1 minute and then sit up and dangle the leg
or arm. Original color returns in 10 seconds; veins in feet and hands fill in
about 115 seconds.
 Capillary feet refill test. Squeeze client’s fingernail and toenail between
your fingers sufficiently to cause blanching. Note immediate return of
color.
8. Positon client comfortably after the assessment.
10. Wash hands.
PHYSICAL ASSESSMENT 10: ASSESSING THORAX, HEART, BREAST AND AXILLAE
PERFORMANCE POINTS
1. Prepare equipment: stethoscope.

2. Wash hands.
3. Greet and identify client. Explain procedure.
5. Position client comfortably. Drape the anterior chest when it is not being examined.
POSTERIOR THORAX
6. Inquire client history of heart and lung disease; allergies, lifestyle habits any medication
being taken or current problems.
7. Palpation.
a. Inspect the spinal alignment for deformities.
b. Inspect symmetry of the thorax form posterior and lateral views. Compare the
anteroposterior diameter to the transverse diameter.
8. Palpation.
a. Assess the temperature and integrity of all chest pain.
b. Palpate all chest areas for bulges, tenderness or abnormal movements.
c. Assess respiratory excursion notices the distance that your thumbs part.
d. Palpate for tactile fremitus using the ulnar surface of the hand. Ask the client to say
“ninety nine” or “tres-tres”.
9. Percussion. Percuss for diaphragmatic excursion on complete exhalation and inhalation,
marking points where resonance changes to dullness. Detect, compare and localize
abnormal percussion sounds.
10. Auscultation with a stethoscope. Listen over the same areas and in the same patterns
for percussion comparing from side to side and moving from apices to lung bases.
ANTERIOR THORAX
11. Inspection.
a. Inspect for structural deformities.
b. Assess the width of the costal angle/
c. Notice the rate and the rhythm of breathing. Observe for respiratory abnormalities
(e.g. bulging or retraction of intercostals space and use of accessory muscles) and
asymmetry.
12. Palpation. Palpate for respiratory excursion and tactile fremitus in the same manner as
for the posterior chest.
13. Percussion. Percuss the anterior chest systematically. Begin above the clavicles in the
supraclavicular space and proceed downward to the diaphragm. Compare one side of
the lungs to other. Displace female breast for proper examination.
14. Auscultation. Auscultate the anterior chest over the same areas and in the same manner
as for percussion. Notice the distribution of vesicular and bronchovesicular sound.
HEART
15. Inspection.
a. Precordium. Look for lifts, heaves, thrust or pulsations.
b. Apical impulses. Observe for visible pulsations.
16. Palpations.
a. Auscultatory areas. Using the palms, palpate all aucultatory areas , note vibrations
and thrills
b. Apical impulses. Locate and access the rate and strength of pulsations.
17. Percussion. Percuss the heart’s borders in the 5th LICS, noting areas of cardiac dullness.
18. Auscultation.
a. In each auscultatory area, listen with the stethoscope’s diaphragm (best for high
pitched sounds) and bell (best for low pitched sounds).
 The aortic area is in the 2nd ICS to the right of the sternum.
 The pulmonic area is on the 2nd ICS at the left of sternum.
 The tricuspid area is in the 4th ICS along the left side of the sternum.
 The apical/mitral area or point of maximal impulse (PMI) is on the 5th ICS at
the left midclavicular line, 2-3 inches from the tricuspid area.
b. Identify S1 and S2 (lub-dub sound). S1 is the loudest in the themitral area and S2 is
loudest in the aortic and mitral area.
c. Determine the heart rate and rhythm. Note any adventitious sound.
BREAST AND AXILLAE
19. Inquire client’s history of breast cancer, any medication being taken, menstrual cycle
(woman) previous or current breast problems such as nipple discharges, masses,
tenderness or pain.
20. Inspection.
a. Breast. With client sitting, inspect for size, symmetry and contour or shape.
b. Breast skin. Inspect for discoloration or hyperpigmentation, retraction or dimpling and
swelling or edema.
c. Areola. Inspect for size, shape, symmetry, color, surface characteristics any masses
or lesions.
d. Nipple. Inspect for size, shape, positon, color, discharge and lesion.
21. Palpation.
a. Palpation. With client sitting, palpate for masses and tenderness using concentric
circle pattern. Start at one point and move systematically to the end point to ensure
that all breast surfaces are assessed. Pay particular attention to the upper outer
quadrant area and the tail of Spence.
b. Areola and nipple. Palpate for masses. Compare each nipple to determine presence
of discharges. Note discharges for amount, color, consistency and odor.
c. Axillary, subclavicular and supraclavicular lymph nodes. With client sitting and arms
are abducted and supported on the nurse’s forearm, palpate clavicular lymph nodes,
and use the flat surfaces of all fingertips to palpate the four areas of the axilla.\
 Muscular pectoralis major along the anterior axillary line.
 Thoracic wall in the midaxillary area
 Upper part of the humerus.
 Anterior edge of the latissimus dorsi muscle along the posterior axillary line.
23. Inform client of findings as necessary.
24. Wash hands.
CHAPTER III
ADMINSTRATION OF MEDICATION
ADMINISTERING ORAL, SUBLINGUAL, AND BUCAL

MEDICATIONS
WITHDRAWING MEDICATION FROM AN AMPULE
WITHDRAWING MEDICATION FROM A VIAL
ADMINISTERING AN INTRADERMAL INJECTION
ADMINISTERIN AN SUBCUTANEOUS INJECTION
ADMINISTERING AN INTRAMUSCULAR INJECTION
ADMINITERING MEDICATION VIA PIGGYBACK
ADMINISTERING EYE AND EAR MEDICATION
TEACHING SELF-ADMINISTRATION WITH A METRED DOSE
INHALER
ADMINISTERING RECTAL MEDICATIONS
ADMINITERING VAGINAL MEDICATIONS
ADMINISTERING ORALM SUBLINGUAL, AND BUCCAL MEDICATIONS
PERFORMANCE POINTS
1. Check for doctor’s orders for the drugs to be given.

2. Determine the accuracy of the drugs to be administered.
3. Arrange the medication tray and cups.
4. Identify the patient and explain the effects and actions of the drug entertain any question
the client may have.
5. Assess the client’s ability to swallow food and liquid.
6. Assess for any contradictions for the drug as well as the client’s record for allergies.
7. Perform handwashing and put on clean gloves when necessary.
8. Following the rights in giving the medication, prepare the tablet or capsule by pouring the
medication cup without touching.
9. To prepare the liquid medication, remove cup and place cup upside down. Pour
medication at eye level until desire dose is reached.
10. Administer the drug in this manner assist the client in a sitting or lateral position and let
the client hold the tablet or medication cup. Offer a glass of liquid and straw if needed.
11. For buccal medications, instruct the client to dissolve the medication in the mouth
against the cheek while for sublingual drugs, instruct the client to dissolve the medication
under the tongue.
12. Dispose properly soiled supplies and reposition patient comfortably.
13. Record full detail about the procedure done.
14. Restore and clean unit restock when needed.
WITHDRAWING MEDICATIONS FROM AN AMPULE
PERFORMANCE POINTS
1. Determine the contents of the vial for the correct medication and dosage.
2. Assess for the integrity of the vial and its content.
3. Perform handwashing technique.
4. Verify doctor’s orders and check against the vial prepared.
5. Check for medication route and select the needle and syringe size appropriate for
the technique.
6. Withdraw the plunger to the desire volume of medication.
7. Clear the rubber top of the vial with an alcohol pad or cotton ball.
8. Remove needle cap. Maintain sterility of the needle.
9. Lay the needle cap on a clear surface or on the hypotray.
10. Place the needle in the center of the vial and inject the air slowly.
11. Invert vial and withdraw the desired volume of medication.
12. One again check for the appropriate dose of the drug to be administered.
13. Slowly draw the needle form the vial.
14. Recap needle and replace it with a new needle for injection.
15. Label the syringe with the drug, dose, date, and time.
16. Store medication properly until it is ready to be administered to the client.
WITHDRAWING MEDICATIONS FROM VIAL
PERFORMANCE POINTS
1. Determine the contents of the vial for the correct medication and dosage.
2. Assess for the integrity of the vial and its content.
3. Perform handwashing technique.
4. Verify doctor’s orders and check against the vial prepared.
5. Check for medication route and select the needle and syringe size appropriate for
the technique.
6. Withdraw the plunger to the desire volume of medication.
7. Clear the rubber top of the vial with an alcohol pad or cotton ball.
8. Remove needle cap. Maintain sterility of the needle.
9. Lay the needle cap on a clear surface or on the hypotray.
10. Place the needle in the center of the vial and inject the air slowly.
11. Invert vial and withdraw the desired volume of medication.
12. One again check for the appropriate dose of the drug to be administered.
13. Slowly draw the needle form the vial.
14. Recap needle and replace it with a new needle for injection.
15. Label the syringe with the drug, dose, date, and time.
16. Store medication properly until it is ready to be administered to the client.
ADMISITERING AN INTRADERMAL INJECTION
PERFORMANCE POINTS
1. Verify doctor’s order for the medication and prepare materials and solution for injection
and applies and sterile technique during in the entire procedure.
2. Identifies the patient and explain the procedure, read the medicine card.
3. Allay any tears/anxiety client may have.
4. Place the patient in comfortable and right position.
5. Identifies the anatomical landmarks by palpation and inspection and identifies injections
site correctly.
6. Cleans the injection site with cotton ball with alcohol using circular motion working from
the site of injection outward.
7. Uses free hand of stretch skin.
8. Insert needle, level up 10-15 degree angle just under the skin.
9. Releases the skin, anchors the barrel and injects the medication slowly until wheal is
formed.
10. At the same angle, withdraws the needle.
11. Wipes with dry cotton ball excess medication from skin without pressing the wheal.
12. Encircles the site of the wheal with blue or black ball pen and mark the due date and
time.
13. Does not recap the needle and make the patient comfortable.
14. Explains the patient the possible outcomes.
15. Dispose the needle and syringe properly.
16. Performs proper and correct documentation of the procedure (verbalize the written
documentation.
ADMINISTERING A SUBCUTANEOUS INJECTION
PERFORMACE POINTS
1. Verify doctor’s order for the drug to be administered.

2. Adhere to all the rights of drug administration throughout the entire procedure.
3. Prepare the materials and solution for injection and applies sterile technique during the
entire procedure.
4. Identifies the patient and explain the procedure and reads the medication card.
5. Place the patient in comfortable and right position.
6. Identifies the anatomical landmarks by palpation and inspection and identifies injection
site correctly.
7. Cleans the injection site with alcohol using circular motion working from the site of
injection outward.
8. Place the cotton ball with alcohol in between fingers, removes cap of needle and
maintains sterility of the needle.
9. Grasp the skin firmly between the thumb and the forefinger to elevate the subcutaneous
tissue (cushion the skin).
10. While supporting the injection site, thrust the needle in to the tissue at 45 angle.
11. Release the pt’s tissue and checks for the presence of blood by pulling the plunger
backward, verbalized what to do in case blood is aspirated and cushion the skin again.
12. If no blood is aspirated, injects the solution.
13. Remove the needle smoothly and quickly at 45 angle.
14. Applies gently pressure on the injection site with a cotton swab.
15. Does not recap the needle and position the pt comfortably.
16. Dispose the needle and syringe properly.
17. Performs and proper correct documentation of procedure done.
ADMINISTERING AN INTRAMUSCULAR INJECTION (DELTOID)
PERFORMANCE POINTS
3. Place pt in a comfortable position.
site correctly.
injection outward.
7. While maintaining sterility of the needle, taut skin if injection site and thrust the needle
into the muscle at 90 angles.
8. Checks for presence of blood by pulling the plunger backward and verbalizes what to do
in case of blood is aspirated.
9. If blood is not present, inject the solution.
10. Removes the needle smoothly and quickly 90 angles.
11. Applies the gentle pressure against injection site using a swab.
12. Does not recap the needle and position the pt comfortably. Dispose the needle and
syringe properly.
13. Position the pt properly.
14. Performs proper correct documentation of the procedure done.
ADMINISTERING AN INTRAMASCULAR INJECTION (DORSO-GLUTEAL)
PERFORMANCE POINTS
3. Place pt in a comfortable position.
site correctly.
injection outward.
7. While maintaining sterility of the needle, taut skin if injection site and thrust the needle
into the muscle at 90 angles.
8. Checks for presence of blood by pulling the plunger backward and verbalizes what to do
in case of blood is aspirated.
9. If blood is not present, inject the solution.
10. Removes the needle smoothly and quickly 90 angles.
11. Applies the gentle pressure against injection site using a swab.
12. Does not recap the needle and position the pt comfortably. Dispose the needle and
syringe properly.
13. Position the pt properly.
14. Performs proper correct documentation of the procedure done.
ADMINISTERING MEDICATIONS VIA PIGGYBACK
PERFOMACE POINTS
1. Check for the order of the medication against physician’s order.

2. Review information regarding the drug.
3. Wash hands and put no gloves when needed.
4. Prepare materials to be used for the procedure.
5. Identify the pt correctly and check his/her identification bracelet.
6. Explain the procedure to the client and give the reason why the drug is to be given.
7. Close the clump on tubing on secondary infusion set. Spike the medication with the
secondary infusion tubing.
8. Open the clamps and allow tubing to fill with solution.
9. Assess the placement of the IV catheter in the vein and skin condition at the IV site.
10. Hang the piggyback medication bag above the level of primary IV bag.
11. Connect piggyback tubing to primary at y-pot. Clean the port with antiseptic swab and
insert needle into center of the port.
12. Secure the tubing with adhesive tape.
13. Administer the medication. Check for prescribed length of time for the infusion. Regulate
of the flow of piggyback.
14. Check the primary infusion line when medication is finished.
15. Dispose contaminated materials properly.
16. Document procedure done.
ADMINISTERING EYE AND EAR MEDICATIONS
PERFORMANCE POINTS
1. Assess and verify accuracy of medication to be given against doctor’s orders.

2. Verify drugs contradictions, action and effects.
3. Gather the necessary equipment and supplies.
4. Adhere to all the rights of drug administration throughout the procedure.
5. Identify the pt correctly and check his/her identification bracelet.
6. Explain the procedure and assist the client as needed.
7. Assess the conditions of the client’s eye and ears.
8. Wash your hands and apply non-sterile gloves if needed.
9. Position the client in a supine with head slightly hyperextended
INSTILLING EYEDROPS
10. Remove cap form bottle and place cap on its side.
11. Squeeze the prescribed dose of medication into the eye dropper.
12. Place a tissue below the lower lid.
13. Hold the eye droppers above the eyeball.
14. Pill down on the client’s cheeks to expose the lower conjunctival sac.
15. Instruct the client to look up and drop prescribed dose into the center of the conjunctival
sac.
16. Place fingers on either side of the client’s nose and instruct client to close her /his eyes
and move eyes.
EYE OINMENT APPLICATION-LOWER LID
17. Separate client eyelids and grasp lower lid/ exert down ward pressure over the cheek.
18. Apply eye ointment along inside edge of the lower eyelid from inner to outer canthus.
19. Instruct the client to look down and grasp lashes near center upper lid. Draw lid up and
away from the eyeball.
20. Squeeze ointment along upper lid starting at inner canthus.
MEDICATION DISK
21. Open sterile package and press sterile gloved finger against the disk.
22. Instruct the client to look up.
23. Pull the client’s lower eyelid down and place the disk horizontally in the conjunctival. Pill
the lower eyelid out, up and lower disk. Instruct the client to blink several times.
24. Instruct the client to press the fingers against the closed lids.
REMOVING AN EYE MEDICATION DISK
25. Inver the lower eyelids and identify the disk. If in the upper eye, stroke the client’s closed
eyelids to move the disk to the corner of the eye.
26. Slide the disk on to the lower eyelids end out of the client’s eye.
EAR MEDICATION
27. Positon the client in a side lying with the affected ear facing up
28. Straighten the ear canal by pulling the pinna.
29. Instill the drops into ear canal/
30. Instruct the client to maintain the position of 2 to3 minutes.
31. Place a cotton ball on the outermost part of the canal.
32. Remove gloves and restore unite properly
33. Positon the client comfortably and reassess his/her condition.
34. Document the procedure done.
ADMINISTERING NASAL MEDICATIONS
PERFORMANCE POINTS
1. Perform handwashing and prepare equipment to be used.

3. Identify the client and explain the purpose of the procedure.
4. Assess the client’s congestion, discharge and condition of the nasal mucosa.
5. If nasal inhaler is used, explain how this works.
6. Instruct the client to blow his/her nose and assist client to assume desired head position.
7. Squeeze nose drips into dropper and have client exhale and close are nostril.
8. Instruct the client to inhale while the medication is sprayed into the first nostril. If drops
are used, insert dropper and instill the described dose.
9. Have the client blot excess drainage and instruct not to low nose.
10. Repeat the procedure on the on other nostril.
11. Help client to resume to a comfortable position.
12. Dispose of soiled articles and restore unit.
13. Evaluate the effect of the medication in 15-20 minutes.
TEACHING SELF-ADMINISTRATION WITH A METERED INHALER (MDI)
PERFORMANCE POINTS
1. Assess and verify accuracy of medication to be given against doctor’s orders.

2. Perform handwashing and prepare equipment to be used.
3. Strictly adhere to all the rights of medication administration.
4. Assess client’s respiratory status.
5. Evaluate the history of the episode of the client’s distress.
6. Let the client manipulate canister demonstrate how canister fits into the inhaler and allow
the client to return demonstrate.
7. Explain the purpose of metered dose inhaler including dose and frequency.
8. Instruct the client to shake the inhaler before each puff.
9. Place the canister into the applicator.
10. Have the client to place the mouthpiece in mouth.
11. Have the client down to dispenser and inhale simultaneously once.
12. Let the client remove the mouthpiece and hole breath for 10 seconds then slowly exhale.
13. Instruct the client to repeat dose as required, waiting one full minute between
inhalations.
14. Have the client to wait 5 to 10 minutes before taking other prescribed medications via
metered dose inhales.
15. Record the medication administration and your own observations.
ADMINISTERING RECTAL MEDICATIONS
PERFORMANCE POINTS
1. Assess the client‘s need for the drug.

2. Verify physician’s order.
3. Check for the accuracy of the drug to be administered.
4. Identify the client and explain the procedures to done.
5. Review for the client’s history for surgeries, bleeding and drug allergies.
6. Gather all equipment needed.
7. Provide for privacy throughout the procedure and asses the client’s readiness.
8. Wash hands and apply disposable gloves.
9. Assist client into sim’s position.
10. Check for client comfort and asses any difficulty.
11. Visually assess the client’s external anus.
12. Remove suppository from the wrapper and lubricate tip.
13. Explain to the client that she/he will experience a cool sensation and pressure.
14. Retract the buttocks, visualize the anus and gently insert the suppository through anus.
15. Remove finger and clean client’s area.
16. Discard gloves used.
17. Have client remain in bed or on side for 10 minutes.
18. Place client light within client’s reach alert the nurse for any problems.
19. Record procedure done.
ADMINISTERING VAGINAL MEDICATIONS
PERFORMANCE POINTS
1. Verify doctor’s order for the drug to be administered.

2. Identify the client and explain the purpose of the procedure.
3. Assess the client’s level of comfort and symptoms.
4. Instruct the client to void and perform handwashing.
5. Prepare and arrange equipment to be used at patient’s bedside.
6. Provide privacy throughout the procedure.
7. Assis the client in a dorsal recumbent or sim’s positon.
8. Drape the client appropriately.
9. To clearly visualize vaginal orifice positions lighting to illuminate.
10. Assess the perennial area.
11. Remove the suppository from the package and apply water soluble lubricant.
12. If applicator is used, fill the applicator with medication.
13. For suppository, retract the client’s labia.
14. Insert applicator 2 to 3 into the vagina. Push the plunger to administer the
medication.
15. Withdraw the applicator and place the towel.
16. When administering a double or irrigation, position the client on a bed pan and hang
the solution container approximately 2 feet above the vagina area.
17. Apply lubricant to the irrigation nozzle and insert into the vagina open clamp and
allow amount of solution to flow. Rotate nozzle around the entire vaginal area.
18. Wipe and clean client’s perineal area.
19. Apply a perineal pad.
20. Remove gloves, wash hands and store applicator.
21. Instruct client lay flat for at least 30 minutes.
22. Raise side rails and place call light within child’s reach.
23. Document/record procedure done.
CHAPTER IV
PROMOTION SAFETY HYGIENE
APPLYING RETRAINTS
BATHING A CLIENT IN BED
SHAMPOING A CLEINT IN BED
MAKING UNOCCUPIED BED
MAKING AN OCCUPIED BED
PROVIDING PERINEAL AND GENITAL CARE
BACK RUB
APPLYING RESTRAINTS
PERFORMNACE POINTS
1. Assess the need for restraints. Verify doctor’s orders.

2. Greet and identify client.
3. Explain to client and family the procedure and its purpose.
4. Allow the client enough time to express feelings and concerns.
5. Wash hands.
6. Provide client privacy as indicated.
7. Apply the selected restraint snugly. Observe safety precautions.
JACKET RESTRAINT
8. Provide jacket over the client’s clothing or hospital gown with the opening form or back
depending on the type
9. Put the tie at the end of the vest, flap across the chest and place it through the slit in the
opposite side of the chest. Do the same on the other side.
10. Inform the client that ties will be attached to bed or chair for his safety.
11. Position client appropriately to enable maximum chest expansion for breathing.
WRIST OR/AND ANKLE RESTRAINTS
12. Pad bony prominences on the wrist or/ and ankle if needed to prevent skin breakdown.
13. Apply the padded portion of the restraint around the ankle or wrist.
14. Pull the tie of the restraint through the slit in the wrist portion or through the buckle.
15. Using a half bow know (quick release knot/square knot), attach the other end of the
restraint to bedframe or chair.
16. Slip two fingers under the restraint to check for tightness.
17. Wash hands.
18. Document procedure and note client’s restrained as needed.
19. Check on the client every half an hour while restrained and as needed.
20. Assess circulatory status of restrained extremities every 2 hours and as needed.
Release one restraints from each extremity for at least every 2 hours and record.
BATHING A CLIENT IN BED
PERFORMANCE POINTS
1. Assess the patient and verify the order.

2. Gather the necessary equipment ( basin for water, soap, linen,. In the other of use: bath
blanket, towel, wash, cloths as need, clean gowns or pajamas, supplements to patient’s
personal toilet articles clean gloves 2 pairs.)
3. Identify client and explain procedure.
4. Provide privacy.
5. Remove the top linen, placing a bath blanket over the patient before removing the top
sheet.
6. Obtain water from the bath.
7. Position patient in supine if tolerated. Move client to your side of the bed. Bath the
patient in the following order.
8. Spread a towel across the patient’s chest. Tucking it under the chin.
9. Make a mitt out of a wash cloth.
10. Wash face with or without soap as client wishes.
11. Remove patient’s gown.
12. Place the towel lengthwise under the far arm.
13. Do the far arm first. Using long, frim strokes toward the center of the body wash the
hand, arm, and axilla in the order.
14. Wash hands thoroughly, dry well between fingers. Use an orange wood stick clean
under the nails if needed.
15. Place towel under the near arm and wash the near hand, arm, and axilla in the same
way.
16. Fold the bath blanket down to the waist. Place the towel over bath blanket.
17. Wash chest, being certain to wash, rinse and dry thoroughly under the breast of a
female client.
18. Leave the chest covered with the towel while rinsing the mitt. Rinse and dry the chest.
19. Fold the both blanket down to pubic bone, leaving towel over the chest.
20. Wash, rinse and dry the lower abdomen especially umbilicus. Remove the towel and
replace bath blanket over the chest and arms.
21. Remove the bath blanket from the far leg only, tucking it under the leg and up around the
hip to avoid exposure drafts. Place towel lengthwise under the far leg.
22. Bending the leg at the knee, slide the basin onto the bed and place the fool in tit
carefully.
23. Wash leg using, form strokes toward the center of the body. Rinse and dry.
24. Wash and rinse the foot, being be careful to do each separately. Remove the basin from
bed.
25. Dry the foot, giving special attention to areas between the toes.
26. Wash the near leg and foot in same way.
27. Put on glove.
28. Wash the genital area. Change water as necessary.
29. Take off and dispose gloves.
30. Turn patient on the side, facing away from you. Drape properly.
31. Wash, rinse and dry the back using long firm strokes. Include the back of the neck.
32. Put on gloves. Wash, rinse and dry buttocks.
33. Remove gloves. Help patient put on clean gown or pajama.
34. Do back rub.
35. Comb hair.
36. File or cut fingernails and toenails short.
37. Make the occupied bed.
38. Allow client to rest
39. Restore the unit.
40. Document procedure.
SHAMPOING A CLIENT IN BED
PERFORMANCE POINTS

2. Wash hands.
3. Gather the necessary supplies and equipment (comb and brush, a basin safety pin,
soap, shampoo, cotton balls, small pitcher, 2 large pitcher, 2 large pitchers of water one
for hot and one for cold), Kelly pad, small rubber sheet, pail, bath towel, Face towel,
newspaper, bed screen, if necessary etc.)
6. Assess any scalp problems.
7. Assess client’s activity tolerance.
8. Loosens the gown.
9. Fold top sheet down to the middle and replace with bath blanket and cover the chest
with bath towel.
10. Remove pillow and bring patient’s head close to the edge of the bed by placing him
diagonally across the bed.
11. Support shoulders with pillow unless contraindicated. Place rubber sheet under patient’s
head and shoulders.
12. Place towel around patient’s shoulders and neck. Hold towel in place by safety pins.
13. Arrange kelly pad under patient’s shoulders and neck. Hold towel in place by safety pins.
14. Cover eyes with folded face towel.
15. Plug ears with cotton balls.
16. Wet hair thoroughly.
17. Shampoo hair and scalp. Make a good lather while massaging the scalp with the pads
for our fingertips.
18. Rinse the hair thoroughly.
19. Squeeze as much water as possible out of the hair with your hands.
20. Remove Kelly pad and drop to the pail.
21. Cover hair with face towel lying across the patient’s chest.
22. Remove face towel over eyes, cotton balls form ears and pillows under shoulders.
23. Dry hair, ears and neck.
24. Bring back patient at the center of the bed. The rubber protecting the pillows placed
under the head while hair is drying.
25. Assist patient to comb and arrange hair.
26. Remove and wash equipment.
27. Replace top linen and remove bath blanket.
28. Allow patient to rest.
29. Wash hands.
30. Document the procedure and note client’s response.
MAKING AN UNOCCUPIED BED
PERFORMANCE POINTS
1. Wash hands before starting the procedure.

2. Collect correct linens.
3. Stack linen in order to use
4. Arrange work area properly
5. Remove pillow cases.
6. Loosen top and bottom sheets, rubber sheet and draw sheet.
7. Remove items to be reused, fold and place across back of chair.
8. Remove and dispose of remaining sheets without contaminating uniform.
9. Move mattress to head pf bed, if necessary.
10. Place bottom sheet and spreads in correct positon, with seams faced correctly.
11. Miter corners of bottom sheet.
12. Tuck remainder of the sheet under.
13. Place rubber sheet on bed, using center fold as guide. Tuck near edge.
14. Place cloth draw sheet over rubber sheet. Tuck near edge.
15. Place top sheet on bed, using centerfold as guide.
16. Miter corner of top linen at foot of the bed. Allows upper position to hang freely.
17. Make one complete side of the bed at a time.
18. Put on clean pillow case away from uniform.
19. Face open end of pillow away from the door.
20. Restore unit.
21. Use a good body mechanics throughout the procedure.
22. Complete procedure in five minute or less.
23. Wash hands at the end of the procedure.
24. Document the procedure.
MAKIING AN OCCUPIED BED
PERFORMANCE POINTS
1. Wash hands before starting the procedure.

2. Collect correct linens.
3. Stack linen in order to use
4. Arrange work area properly.
5. Explain procedure to patient and provide privacy.
6. Loosen all linen near side.
7. Place bath blanket over top sheet and pull sheet out from under it.
8. Move patient to far side of bed. Provide side rails as necessary.
9. Fanfold each piece toward center of bed and tuck under patient’s back and buttocks.
10. Position clean bottom sheet correctly.
11. Tuck sheet under at top bottom, miters corners, and tucks alongside of mattress.
12. Fanfold other half of sheet toward center of bed, tucking it under the bed the soiled
bottom sheet.
13. If rubber sheet in use, unfolds and pulls over the folded bottom sheet. Tuck it in.
14. Place draw sheet. Tucks near side under mattress and fanfolds other half toward center
of bed, tucking it under back and buttocks.
15. Help patient roll over, folded linens and onto clean linens, adjust pillow and put up side
rail if necessary.
16. Move to the other side of the bed.
17. Loosen linens, removes and disposes off soiled linens correctly.
18. Pull, straighten and tuck bottom sheet, rubber sheet and draw sheet. Miter bottom sheet.
19. Move patient to center of bed.
20. Place top sheet on bed and remove bath blanket from beneath it.
21. Remove pillow, put on clean pillow case and replace pillow under patient’s head.
Observe principles of medical asepsis.
22. Dispose of all linens in accordance with agency policy.
23. Restore unit.
24. Use a good body mechanics throughout the procedure.
25. Complete procedure in ten minute or less.
26. Wash hands at the end of the procedure.
27. Document the procedure. Note client response.
PROVIDING PERINEAL AND GENITAL CARE (FEMALE)
PERFORMANCE POINTS
1. Assess client’ self-care abilities.

2. Wash hands.
3. Prepare and gather the materials to use.
4. Identify ad greet the patient. Explain the procedure.
6. Place the water proof pad.
7. Place the client on back-lying position with the knee flexed and spread well apart.
8. Fold the top bed linen to the foot of the bed.
9. Cover the body and the legs with bath blanket.
10. Drape the legs by tucking the bottom of corners of both blanket under the inner sides of
the legs.
11. Bring the middle portion of the base of the blanket up over the pubic area.
12. Place client on a bed pad.
13. Don the clean gloves.
14. Lean the perineal area. First, the meatus down, then labia minor, and labia majora using
the figure of seven strokes. Suing new cotton ball/gauze every strokes.
15. Rinse the area well. Dry the perineum thoroughly, paying particular attention the folds
between the labia.
16. Note if there’s any signs of inflammation, swelling especially between the labia folds.
Also, note for excessive secretions from the orifices and the presence of odors.
17. Assist the client to turn side facing away from you. Clean between the buttocks and dry
the area well.
18. Dispose of linens and garbage appropriately.
19. Remove gloves and wash hands.
20. Document the procedure. Note any unusual findings.
PROVIDING CLIENT’S SELF-CARE-ABILITIES
PERFORMANCE POINTS
1. Assess client’ self-care abilities.

2. Wash hands.
3. Prepare and gather the materials to use.
4. Identify ad greet the patient. Explain the procedure.
6. Place the water proof pad.
7. Place the client on back-lying position with the knee flexed and spread well apart.
8. Fold the top bed linen to the foot of the bed.
9. Cover the body and the legs with bath blanket.
10. Drape the legs by tucking the bottom of corners of both blanket under the inner sides of
the legs.
11. Bring the middle portion of the base of the blanket up over the pubic area.
12. Put on clean gloves.
13. Wash and dry the penis using firm strokes. If the patient is uncircumcised, retract the
prepuce to expose the glans penis for cleaning. Replace the foreskin after cleaning the
glans penis.
14. Note any signs for inflammation, excoriation or selling especially in the scrotal folds.
15. Clean and dry upper inner thighs.
16. Assist the client to onto side facing away from you.
17. Clean and dry between buttocks paying particular attention to the anal area and
posterior folds of the scrotum.
18. Dispose of linens and garbage appropriately.
20. Document the procedure. Note any unusual findings.
BACK RUB
PERFORMANCE POINTS
1. Prepare the things needed. (lotin, etc.)

2. Wash hands.
4. Move patient close to your side of the bed.
5. Position client on the abdomen if possible.
6. Pull top covers down below buttocks.
7. Poor small amount of lotion into your hands and rub palm together.
8. With feet apart (outside one ahead of the inside one) place hands at the sacral area, one
on either side of the spinal column.
9. Rub toward the neckline, using long, firm, smooth strokes.
10. Pause at the neckline and using thumbs, rub up into the hairline while using the fingers
to massage the sides of the neck.
11. With kneading motion, rub out along the shoulders. Continue the kneading motion and
move up the opposite side towards the shoulder.
12. Placing hands side by side with palms, rub in figure 8 pattern over buttocks and sacral
area.
13. Move the figure 8 back and forth to include entire buttocks area.
14. Again, using kneading positon, move up the opposite side toward the shoulder.
15. Complete back rub using kneading position, move up the opposite side toward the
shoulder.
16. Replace top covers, reposition patient.
17. Return the lotion.
18. Was hands.
BED BATH
PERFORMANCE POINTS

2. Gather the necessary equipment (basin for water, soap, linen,. In the other of use: bath
blanket, towel, wash, cloths as need, clean gowns or pajamas, supplements to patient’s
personal toilet articles clean gloves 2 pairs.)
4. Provide privacy.
5. Fold top sheet down and replace it with bath blanket.
6. Obtain water from the bath.
7. Prepare the bed and position client in supine position if tolerated. Move client ear the
side of the bed.
8. Spread a towel across the patient’s chest. Tucking it under the chin.
9. Make a mitt out of a wash cloth.
10. Wash face with or without soap as client wishes.
11. Remove patient’s gown.
12. Place the towel lengthwise under the far arm.
13. Do the far arm first. Using long, frim strokes toward the center of the body wash the
hand, arm, and axilla in the order.
14. Wash hands thoroughly, dry well between fingers. Use an orange wood stick clean
under the nails if needed.
15. Place towel under the near arm and wash the near hand, arm, and axilla in the same
way. Change water as needed.
16. Fold the bath blanket down to the waist. Place the towel over bath blanket.
17. Wash chest, being certain to wash, rinse and dry thoroughly under the breast of a
female client.
18. Leave the chest covered with the towel while rinsing the mitt. Rinse and dry the chest.
Change water as needed.
19. Fold the both blanket down to pubic bone, leaving towel over the chest.
20. Wash, rinse and dry the lower abdomen especially umbilicus. Remove the towel and
replace bath blanket over the chest and arms. Change the water as needed.
21. Remove the bath blanket from the far leg only, tucking it under the leg and up around the
hip to avoid exposure drafts. Place towel lengthwise under the far leg.
22. Bending the leg at the knee, slide the basin onto the bed and place the fool in tit
carefully.
23. Wash leg using, form strokes toward the center of the body. Rinse and dry.
24. Wash and rinse the foot, being be careful to do each separately. Remove the basin from
bed. Change the water as needed.
25. Dry the foot, giving special attention to areas between the toes.
26. Wash the near leg and foot in same way.
27. Put on glove.
28. Wash the genital area. Change water as necessary.
29. Take off and dispose gloves.
30. Turn patient on the side, facing away from you. Drape properly.
31. Wash, rinse and dry the back using long firm strokes. Include the back of the neck.
32. Put on gloves. Wash, rinse and dry buttocks.
33. Remove gloves. Help patient put on clean gown or pajama.
34. Do back rub.
35. Comb hair.
36. File or cut fingernails and toenails short.
37. Make the occupied bed.
38. Allow client to rest
39. Restore the unit.
CHAPTER V
PROMOTING FLUID, ELECTROLYTE AND ACID-BASE

BALANCE
MEASURING INTAKE AND OUTPUT

PREPARING AN INTRAVENOUS INFUSION
MONITORING AND INTRAVENOUS INFUSION
ADDING MEDICATIONS TO AN IV SOLUTION
ADMINISTERING BLOOD TRANSFUSION
MEASURING INTAKE AND OUTPUT
PERFORMANCE POINTS
1. Assess the client’s risk factors for fluid overload.

2. Assess if client is receiving fluids or medications that would predispose her to fluid
overload.
3. Asses the client’s risk factor for fluid loss.
4. Determine if the client’s urine output is in excess of her fluid intake.
5. Assess the client’s ability to understand and cooperate with intake output measurement.
6. Wash hands.
7. Greet and identify patient.
8. Explain the rules of intake and output (I&O) record.
9. Measure all oral fluids in accord with agency policy. Record all IV fluids as they are
infused.
10. Apply non sterile gloves.
11. Empty urinal, bedpan, or foley drainage bag into graduated container. Other output also
may be recorded, including nasogastric suction, suction bulb (eg. Jackson-pratt or
hemovac), or chest tubes. Refer to agency policy.
13. Record time and amount output on bedside I&O record.
14. Transfer 8 hour total fluid intake from bedside I&O to graphic sheet or 24 hour I&O
record on client’s chart.
15. Record all forms of intake, except blood and blood products, in the appropriate column.
16. Completer 24 hour intake record by adding all 8 hour totals.
17. Wash hands.
PREPARING AN INTRAVENOUS INFUSION
PERFORMANCE POINTS
1. Verify the order indicating the type of solution, the amount to be given, rate of flow of the
infusion and any client allergies (e.g. to tape).
2. Prepare equipment (infusion set, IVF, IV pole, adhesive tape, etc.)
4. Wash hands.
5. Open and prepare the infusion set.
6. Remove the tubing from the container, and straighten it out.
7. Slide the tubing clamp along the tubing untie it is just below the drip chamber to facilitate
its access.
8. Close the clamp.
9. Leave the ends of tubing covered with plastic caps until the infusion started.
10. Spike the solution container.
11. Remove the protective cover from the entry site of the bag.
12. Remove the cap from the spike, and insert the spike into the insertion site of the bag or
bottle.
13. Hang the solution container on the pole.
14. Adjust the pole so that the container is suspended about 1m (3ft) above client’s head.
15. Partially fill the drip chamber with solution.
16. Squeeze the chamber gently until it is half full of solution.
17. Prime the tubing.
18. Remove the protective cap, and hold the tubing over a container. Maintain the sterility of
the end of the tubing and cap.
19. Release the protective cap, and hold the tubing over a container. Maintain the sterility of
the end of the tubing and cap.
20. Release the clamp, and let the fluid run through the tubing until all bubbles are removed.
Tap the tubing if necessary with your fingers to help the bubbles move.
21. Wash hands.
MONITORING AN INTRAVENOUS INFUSION
PERFORMANCE POINTS
1. Gather the pertinent data.

 From the physician’s order, determine the type and sequence of solutions to be
infused.
 Determine the rate of flow and infusion schedule.
2. Ensure that the correct solution is being infused.
 If the solution is incorrect, slow the rate of flow to a minimum to maintain the
patency of the catheter.
 Report the error to the nurse in charge, and change the solution to the correct
one. Note that agencies have different poilices about how and to whom to report
the incident.
3. Observe the rate of flow every hour.
 Compare the rate of flow regularly, for example, every hour, against the infusion.
 If the rate is too fast, slow it so that the infusion will be completed at the planned
time.
4. Inspect the patency of IV tubing and needle.
5. Inspect the tubing for pinches or kinds or obstructions of flow. Arrange the tubing o that if
is lightly coiled and under no pressure. Sometimes the tubing becomes caught under the
client’s arm and the weight of the arm blocks the flow.
6. Observe the position of the tubing. If it is dangling below the venipuncture, coil it
carefully on the surface of the bed.
7. Open the drip regulator, and observe for rapid flow of fluid form the solution container
into the drip chamber. Then partially close the drip chamber to reestablish the prescribed
rate flow.
8. Lower the solution container below the level of the infusion site, and observe for a return
flow of blood from vein.
9. Observe the position of the solution container. If it less than 1 m (3ft) above the IV site,
readjust it to correct height of the pole.
10. Observe the drip chamber. If it less than half full squeeze the chamber to allow the
correct amount of fluid to flow in.
11. Inspect the insertion site for fluid infiltration.
12. If infiltration is not evident but infusion is not flowing, determine whether the needle is
dislodged from the vein.
13. Gently pinch the IV tubing adjacent to the needle site.
14. Use a sterile syringe of saline to withdraw fluid form the rubber at the end of the tubing
near the venipuncture site. If blood does not return, discontinue the intravenous solution.
15. Inspect the insertion site for phlebitis.
16. Inspect and palpate the site every 8 hour. Phlebitis can occur as a result of injury to the
vain, for example, because of mechanical trauma or chemical irritation. Chemical
irritation. Chemical injury to a vein can occur from intravenous electrolytes and
medications. The clinical signs are redness, warmth, and swelling at the intravenous site
and burning pain along the course of the vein.
17. If phlebitis is detected, discontinue the infusion, and apply warm compress to
venipuncture site. Do not use this injured vein for further infusion.
18. Inspect the intravenous site for bleeding.
 Oozing or bleeding into the surrounding tissue can occur while the infusion is
freely flowing but is more likely to occur after the needle has been removed from
the vein.
19. Teach the client ways to maintain infusion system, for example:
 Call for assistance if the solution stops dripping or the venipuncture site becomes
swollen.
 Avoid sudden twisting or turning movements of the arm with the needle or
catheter.
 Avoid stretching or placing tension on the tubing.
 Try to keep the tubing from dangling below the level of the needles.
 Notify the nurse if:
a. There is sudden change in the flow rate or if the solution stops dripping.
b. The solution container is nearly empty.
c. There is blood in the IV tubing.
d. Discomfort or swelling is experienced at the IV site.
20. Document all relevant information.
ADDING MEDICATIONS TO AN IV SOLUTION
PERFORMANCE POINTS
1. Check the order for the medication, dosage, time and route of administration.
2. Review information regarding the drug.
3. Determine the additives in the solution of an existing IV line.
4. Assess the patency of the IV.
5. Assess the skin of the IV site.
6. Assess the client’s drug allergy history.
7. Assess the client’s understanding of the purpose of the medication.
8. Check order for the IV solution additives ordered.
9. Determine the whether the ordered additives are compatible with the IV solution and with
each other.
10. Wash hands; apply gloves, if needed.
11. Using appropriate technique, draw up ordered additives.
ADDING MEDICATION TO A NEW SOLUTION.
12. Remove protective cover form new bag or bottle.
13. Inspect the bag or bottle. Inspect the fluid. Check expiration date.
14. Add medication to IV solution.
 For plastic IV bag, locate port with rubber topper.
 For IV bottle, locate the x, circle, or triangle over ht IV injection site.
 Wipe off port or site antiseptic swab.
 Insert needle into center of port or site.
 Inject medication into bag.
 Remove needle from bag.
15. Mix medication into IV solution.
16. Label the bag.
 Write the name and dose of medication, date, time, and your initials.
 Apply to bag outside down.
ADDING MEDICATION TO AN EXISTING SOLUTION
17. Identify client by using armband and calling name.
18. Explain the purpose and route of the medication.
19. Clamp the IV tubing and remove bag from IV pole.
20. Add medication to IV solution.
 For plastic IV bag, locate port with rubber stopper.
 For IV bottle, locate the x, circle or triangle over the IV injection site.
 Wipe off port or site with antiseptic swab.
 Insert the needle into center of port or site.
 Inject medication into bag.
 Remove needle from bag.
21. Mix medication into IV solution.
22. Apply new label.
 Write the name and dose of medication, date, time, and your initials.
 Apply to bag upside down.
23. Unclamp the tubing and regulate the flow.
24. Remove gloves and dispose of all used materials.
25. Wash hands.
26. Document the preparation of the IV solution.
ADMINISTERING BLOOD TRANSFUSION
PERFORMANCE POINTS
1. Verify the written order for the transfusion.

3. Explain the procedure to the client.
4. Start IV if necessary.
5. Have the client sign consent forms.
6. Obtain baseline vital signs.
7. Obtain the blood product from the blood bank within 30 minutes of initiation.
8. Verify the blood product and the client with another nurse.
 Client’s name, blood group, RH type.
 Cross match compatibility.
 Donor blood group and RH type.
 Unit and hospital number.
 Expiration date and time on blood bag.
 Type of blood product compared with written order.
 Presence of clots in blood.
9. Wash hands and put on gloves.
10. Open blood administration kit and close roller clamps.
11. For Y-tubing set:
 Spike the normal saline bag and prime the tubing between the saline bag and the
filter.
 Squeeze sides of drip chamber and allow filter to partially fill.
 Open lower roller clamp and prime tubing to the hub.
 Close lower clamp.
 Invert blood bag once or twice. Spike blood bag, open clamps, and fill tubing
completely, covering the filter with blood.
 Close lower clamp.
12. For single-tubing set:
 Spike blood unit using filer tubing.
 Squeeze drip chamber and allow the filter to fill with blood.
 Open roller clamp and allow tubing to fill with blood.
 Piggyback a saline line into the blood administration tubing.
 Secure all connections with tape.
13. Attach tubing to venous catheter aseptically and open clamps on blood tubing.
14. Infuse the blood product at the ordered rate.
15. Remain with client for the first 15-30 minutes, monitoring vital signs, frequently according
to institutionally policy.
16. After blood has infused, flush the tubing with normal saline.
17. Dispose of bag, tubing, and gloves appropriately. Wash hands.
CHAPTER VI
NUTRITION
INSERTING A NASOGASTRIC TUBE

TUBE FEEDING
REMOVING A NASOGASTRIC TUBE
GASTROSTOMY OR JEJUNOSTOMY FEEDING
GASTRIC LAVAGE
INSERTING A NASOGASTRIC TUBE
PERFORMANCE POINTS
1. Verify the order for insertion of the nasogastric tube.

2. Prepare the material needed (NG tube of appropriate size plastic or rubber. Glove, non-
allergic adhesive tape, asepto syringe, KY jelly, stethoscope, facial tissue, safety pin)
3. Greet and identify the patient.
4. Explain the procedure.
5. Assist client to a high fowler’s positon if health permits and support head on a pillow.
6. Place towel across the chest.
7. Assess the client’s nares.
 Ask the client to hyperextend the head, and using a flashlight, observe the
intactness of the tissue of the nostrils, including any irritations or abrasions.
 Examine the nares for any obstructions or deformities by asking the client to
breathe through one nostril while occluding other.
 Select the nostril that has the greater airflow.
 For infant, obstruct one of the nares, and feel for air passage from the other.
8. Prepare the tube. If a rubber tube is being used, placed it on warm water.
9. Determine how far to insert the tube.
 Use the tube to mark off the distance from the tip of the client’s nose to the tip of
the earlobe to the tip of the sternum.
 For infant and young children, measure form the nose to the tip of the earlobe
and then to the point midway between the umbilicus and the xiphoid process.
 Mark this length with adhesive tape if the tube does not have markings.
10. Insert the tube.
 Don gloves.
 Lubricate ht tip of the tube well with water soluble lubricant or water to ease
insertion.
 Insert the tube, with its natural curve toward the client, into the selected nostril.
Ask the client to hyperextend the neck, and gently advance the tube toward the
nasopharynx.
 Do not hyperextend or hyperflex the infant’s neck.
 Direct the tube along the floor of the nostril and toward the ear on the side.
 Slight pressure is sometimes required to pass the tube into nasopharynx. And
some client’s eye may water at this point. Tears are natural body response.
Provide the client with tissue if needed.
 If the tube meets resistance, withdraw it, relubricate it, and insert it other nostril.
 Once the tube reaches the oropharynx (throat) the client will feel the tube in the
throat and may gag and retch. Ask the client to tilt the head forward, and
encourage the client to drink and swallow.
 If the client gag’s, stop the tube momentarily. Have the client rest, take sips of
water to calm the gag reflex.
 In cooperation with the client, pass the tube 5 to 10 cm (2 to 4 inches) with each
swallow, until the indicated length is inserted.
 If the client continues gag and tube does not advance in each swallow, withdraw
it slightly, and inspect the throat by looking through the mouth. If so, withdraw it
until it is straight, and try to insert it.
11. Ascertain correct placement of the tube.
 Aspirate stomach contents, and check their acidity
 Introduce air and listen for gurgling sound.
 If the sign does not indicate the placement in the stomach, advance the tube 5cm
(2 inches), and repeat the test.
 For tubes that are to be placed into the duodenum or jejunum, advance the tube
5 to 7.5 cm (2 to 3 inch) per hour until x-ray study confirms its placement.
12. Secure the tube by taping it to the bridge of the client’s nose.
 If the client has oily skin, wipe the nose first with alcohol.
 Cut 7.5 cm (3 inches) of tape, and split it lengthwise at one end, leaving a 2.5 cm
tab at the end.
 Place the tape over the bridge of the client’s nose, bring the split ends under the
tubing and back up over nose. For infants or small children, tape the tube to the
area between the end of nares and the upper lip as well is the cheek.
13. Attach the tube to a suction source or feeding apparatus as ordered, or clamp the end of
the tubing. The tube, if inserted preoperatively, is usually clamped; or it may be covered
with gauze square or plastic specimen bad and an elastic band.
14. Secure the tube to the client’s gown.
 Loop the elastic band around the end of the tubing, and attach the elastic band of
the gown with a safety pin. Or attach a piece of adhesive tape to the tube, and
pin the tape to the gown.
 For infants and young children, restraints may be necessary dying tube insertion
and throughout therapy.
TUBE FEEDING
PERFORMANCE POINTS
1. Check the physician’s order.

2. Wash hands.
3. Prepare the equipment needed (asepto syringe with bulb, stethoscope, formula, water
for flushing, calibrated glass, pulverized medications if any.
4. Identify patient and explain the procedure.
5. Provide privacy if the client desires.
6. Place patient in semi-fowlers position.
7. Test the placement of the tube.
8. Assess residual formula, reinstill gastric contents according to ageny/doctor’s order.
9. Administer residual amount of water to ensure that the tube is patent, then any
medications ordered and the formula.
10. Fill and refill the asepto syringe. Do not allow the formula and water to fall below the
neck of the tube to prevent entrance of air.
11. Follow the remainder of the water to rinse formula out of the tubing.
12. Clap and cover the feeding tube before all the water is instilled.
13. Pin the tubing to the client’s gown.
14. Maintain on semi fowlers position for at least 30 minutes.
15. Wash the equipment thoroughly with soup and water so that it is ready for reuse.
16. Wash hands.
REMOVING NASOGASTRIC TUBE
PERFORMANCE POINTS
1. Confirm the doctor’s order to remove the tube.

2. Prepare equipment needed (tissue, clean disposable gloves, 50 ml syringe optional,
plastic disposable bag)
4. Explain the procedure will cause no discomfort.
5. Assist the client to a sitting position if health permits.
6. Place the disposable pad across the client’s chest to collect any spillage of mucuos and
gastric secretions from the tube.
7. Provide tissue to the client to wipe the nose and mouth after tube removal.
8. Detach the tube.
 Disconnect the nasogastric tube from the suction apparatus, if present.
 Unpin the tube from the client’s gown.
 Remove the adhesive tape securing the tube to the nose.
9. Remove the tube.
 Put on the disposable gloves.
 Ask to client to take deep breath and to hold it.
 Pinch the tube with the gloved hand.
 Quickly and smoothly withdraw the tube.
 Place the tube in the plastic bag.
 Observe intactness of the tube.
10. Ensure client comfort.
11. Dispose the equipment appropriately.
12. Assess the nasogastric drainage if suction was used.
 Measure the amount of gastric drainage, and record it on the client’s fluid output
record.
 Inspect the drainage for appearance and consistency.
GASTRONOMY OR JEJUNOSTOMY FEEDING
PERFORMANCE POINTS
1. Confirm the doctor’s order to remove the tube.

2. Prepare the equipments needed (feeding solution, asepto syringe with bulb, water 4.4
gauze squares).
4. Explain the procedure to the patient.
5. Check the patency of the tube that is sutured in place.
 Determine the placement of the tube.
 Pour 15 to 30 ml of water to the syringe, remove the tube clamp, and allow the
water to flow into the tube.
 If the water does not flow freely, notify the nurse in charge and/ or physician.
6. Check for residual formula.
 Attach the bulb to the syringe, and compress the bulb.
 Attach the syringe to the end of the feeding tube, and withdraw and measure the
stomach or jejuna contents.
 Follow agency practice if there is no more than 50 ml of undigested formula. Hold
feeding if there is more than 150 ml and recheck in 3 to 4 hours. Notify the
physician if a large residual still remains.
 For continuous feedings, check the residual every 4-6 hours, and hold the
feeding if there is a 2 hour volume. Then recheck in 2 hours and restart unless
the residual remains large; the physician should be notified if a large residual
persist.
7. Administer the feeding.
 Hold the asepto syringe 7 t o15 cm (3 to 6 inch) above the ostomy opening.
 Slowly pour the solution into the asepto syringe, and allow it to flow through the
ube by gravity.
 Just before all the formula has run through and the syringe is empty, add 30 ml of
water.
 If the tube is sutured is in place, hold it right, remove the syringe and then clamp
the tube to prevent leakage.
8. Ensure client comfort and safety.
9. After feeding ask the client to remain in the sitting position or a slightly elevated right
lateral positon for at least 30 minutes.
10. Assess status of peristomal skin.
11. Check orders about cleaning the peristomal skin, applying a protectant, and applying
appropriate dressings.
12. Observe for a common complications of enteral feedings; aspiration, hyperglycemia,
abdominal distention, diarrhea, and fecal impaction. Report findings to the physician.
13. When appropriate, teach the client how to administer feedings and when to notify the
physician or nurse practitioner concerning problems.
14. Document all assessments and interventions.
GASTRIC LAVAGE
PERFORMANCE POINTS
1. Verify the order.

2. Prepare the materials needed (asepto syringe, irrigating solution, kidney basin,
stethoscope).
5. Place disposable towel under the end of gastrointestinal tube.
6. Turn off suction.
7. Don gloves.
8. Disconnected gastrointestinal tube for the connector.
9. Determine the tube is in the stomach.
10. Irrigate the tube.
 Draw up the ordered volume of irrigating solution in the asepto syringe; 30 ml of
solution per instillation is usual, but up to 60 ml may be given per instillation if
ordered.
 Attach the asepto syringe to the nasogastric tube and slowly inject the solution.
 Gently aspirate the solution.
 If you encounter difficulty in withdrawing the solution, inject 20 ml of ari and
aspirate again, and/or reposition the client or nasogstric tube. If aspirating
difficulty continues, reattach the tube in intermittent low suction, and notify the
nurse in charge or physician.
 Repeat the above steps until ordered amount of solution is used.
11. Reestablish suction.
 Reconnect the nasogastric tube to suction.
 Observe the system for several minutes to make sure it is functioning.
CHAPTER VII
PROMOTING SLIN INTEGRITY AND PERFORMING

WOUND CARE
OBTAINING A WOUND DRAINAGE SPECIMEN FOR

CULTURING
IRRIGATING A WOUND
APPLYING A DRY DRESSING
APPLYING A WET TO DAMP DRESSING (WET TO DRY TO
MOST DRESSING)
OBTAINING A WOUND DRAINAGE SPECIMEN FOR CULTURING
PERFORMANCE POINTS
1. Assess the wound and the surrounding tissues.

2. Assess the client’s overall status.
5. Wash hands and apply gloves.
6. Remove old dressing.
7. Dispose dressing and gloves appropriately.
8. Wash hands again.
9. Open the dressing supplies aseptically and apply gloves.
10. Assess the wound’s appearance.
11. Irrigate the wound with normal saline prior to collecting the culture.
12. Bot excess saline with as sterile gauze pad.
13. Remove the culture swab from the tube and roll the swab over the granulation tissue.
14. Remove swab in culture tube. Don’t touch swab to any surface outside collection tube.
15. Recap the tube.
16. Crush the medium located in the bottom or cap of the tube.
17. Remove the gloves. Wash hands, and apply sterile gloves. Dress the wound.
18. Label and transport the specimen to the laboratory.
19. Remove the gloves and wash the hands.
20. Document all assessment findings and actions taken.
IRRIGATING WOUND
PERFORMANCE POINTS
1. Confirm written order for wound irrigation.

2. Prepare the equipments needed.
5. Assess the client’s pain level and medicate if needed.
6. Assist the client onto a waterproof pad in position that will allow the irrigant to flow from
the clean to dirty areas of the wound.
7. Wash hands and apply gloves. Remove and discard the old dressing.
8. Assess the wound’s appearance.
9. Remove and discard gloves and wash hands.
10. Prepare the sterile irrigation tray and dressing supplies.
11. Apply sterile gloves and goggles if needed.\
12. Pour sterile, room temperature irrigation solution into sterile container.
13. Position the sterile basin so the irrigant will flow into the basin.
14. Fill the syringe with irrigant and gently flush the wound. Repeat until clear or the ordered
amount of fluid has been used.
15. Dry edges of the wound with sterile gauze.
16. Assess the wound’s appearance and drainage.
17. Apply a sterile dressing. Remove gloves and dispose of properly. Wash hands.
18. Document all assessment findings and taken,
APPLYING A DRY DRESSING
PERFORMANCE POINTS
1. Gather supplies.
2. Provide privacy.
4. Explain procedure to client.
5. Wash hands.
6. Apply clean exam gloves.
7. Remove dressing and place in appropriate receptacle.
8. Observe the undressed wound.
9. Cleanse around the incision with warm, wet washcloth.
●Cleanse the suture line with prescribe solution.
●Used application should not be reintroduce into the sterile solution.
10. Remove used exam gloves.
11. Wash hands.
12. Set up supplies.
13. Apply a new pair of clean exam gloves.
14. Grasping just the edge, apply a new gauze dressing. Tape lightly.
16. Conduct client/family education about the dressing.
APPLYING A WET TO DAMP DRESSING (WET TO DRY TO MOIST DRESSING)
PERFORMANCE POINTS
1. Explain procedure to patient.

2. Wash hands.
3. Apply clean gloves and other needed protective clothing.
4. Assess client need for pain medication.
5. Inform client that the dressing is going to be removed.
6. Remove wet to damp dressing and dispose of appropriately. Note the makeup of the old
dressing.
7. Observe the undressed wound.
8. Cleanse the skin around the incision, if necessary.
9. Remove used exam gloves.
10. Wash hands.
11. Set up supplies in a sterile field.
12. Apply sterile gloves.
13. Place packing material in the bowl with the ordered solution.
●Wring gauze or packing until damp.
●Gently place wet gauze over the area.
14. Apply dry external dressing. Secure dressing with tape.
16. Conduct client/family education about the dressing.
CHAPTER VIII
PROMOTING URINARY AND BOWEL ELIMINATION
OFFERING AND REMOVING BEDPAN

OFFERING AND REMOVING URINAL
APPLYING A CONDOM CATHETER
FEMALE CATHETERAZATION
MALE CATHETERAZATION
CLOSED BLADDER IRRIGATION
ADMINISTIRING ENEMA
CHANGING A BOWEL DIVERSION OSTOMY APPLIANCE
POUCHING A STOMA
OFFERING AND REMOVING BEDPAN
PERFORMANCE POINTS
1. Gather materials needed.

2. Assess how much the client can participate with the procedure.
3. Inform the patient about the procedure.
4. Provide privacy.
5. Wear gloves.
6. Lower head of bed.
7. Assist client to side lying position.
8. Place bedpan under the buttocks.
9. Help the client to roll on to her back. (Other technique: Place patient on dorsal
recumbent position and help the patient raise her hips and slide the pan in place).
10. Check placement of bedpan. If indicate, elevate head of bed at 45 degree angle.
11. When patient is done, place patient in supine position.
12. Support the bed pan and assist the patient to roll to side and remove the bedpan.
13. Assist the patient with cleaning or wiping.
14. Measure urine output. Empty, clean and store bedpan in proper place.
15. Remove soiled gloves and wash your hands.
16. Document the urine output, color and turbidity.
OFFERING AND REMOVING URINAL
PERFOMANCE POINTS

2. Inform patient about the procedure.
3. Provide privacy.
4. Wear gloves.
5. Lift the covers and allow patient to place urinal or palace it yourself.
6. After patient is done remove urinal.
7. Assist client in cleaning or wiping.
8. Measure urine output.
9. Empty and rinse urinal and place it in proper place.
10. Remove soiled gloves and wash your hands.
11. Document urine output color and turbidity.
APPLYING CONDOM AND CATHETER
PERFORMANCE POINTS

2. Inform patient about the procedure.
3. Assess the patient for ability to participate.
4. Provide privacy.
5. Place patient on semi-fowler’s position.
6. Wear gloves.
7. Fold patient’s gown across his abdomen and pull the sheet over the patient’s legs.
8. Assess patient’s genitalia.
9. Shave any excess hair at the base of the penis.
10. Retract patient’s foreskin and clean the penis with betadine 7.5%.
11. Rinse and dry the area.
12. Position the rolled condom at the distal portion of the penis and unroll it.
13. Secure the base of the condom catheter with the belt.
14. Attach the drainage bag tubing to the catheter tubing. Secure the urine bag.
15. Check that condom and tubing are not twisted.
16. Cover the client.
17. Dispose used materials and wash hands.
18. Reposition the client comfortable.
19. Empty the bag and measure and record urine output every four hours.
20. Remove the condom catheter once a day to clean the area and skin assessment.
FEMALE CATHETERIZATION
PERFROMANCE POINTS
a. Assess the patient’s need for catheterization and refer patient to the doctor.
b. Verify doctor’s order for catheterization.
c. Prepare the necessary materials.
d. Perform hand washing.
1. Identifies patient and explains the procedure.
2. Positions the patient properly and ensures patient’s privacy.
3. Applies aseptic technique in the entire procedure.
4. Open catheterization kit.
5. Adds and prepares materials that will be used.
6. Dons first glove and fills the syringe with distilled water.
7. Dons the second glove and applies sterile drapes to the patient.
8. With non-dominant hand, separates the labia minor what the thumb and index finger.
Never removes the finger until catheter is inserted.
9. With the dominant hand, uses sterile forcep to pick swabs. Clean first from the meatus
downward and then on either side using a new swab for each stroke.
10. Picks up the catheter in the urine receptacle using the uncontaminated hand.
11. Lubricates the insertion end or tip of the catheter.
12. Gently insert the catheter in the direction of the urethra until urine flows.
13. Connects to the catheter to the urine bag and ensures that the emptying base of the bag
is closed.
14. Inflates the balloon by inject 5-10cc of distilled water and checks the anchor.
15. Tapes the catheter with non-allergic tape at the thigh of the patient.
16. Remove drapes and makes the patient comfortable.
17. Disposes soiled materials properly.
18. Accurately records the procedure done.
MALE CATHETERIZATION
PERFORMANCE POINTS
a. Assess the patient’s need for catheterization and refer patient to the doctor.
b. Verify doctor’s order for catheterization.
c. Prepare the necessary materials.
d. Perform hand washing.
1. Identifies patient and explains the procedure.
2. Positions the patient properly and ensures patient’s privacy.
3. Applies aseptic technique in the entire procedure.
4. Open catheterization kit.
5. Adds and prepares materials that will be used.
6. Dons first glove and fills the syringe with distilled water.
7. Dons the second glove and applies sterile drapes to the patient.
8. Grabs the penis firmly behind the glans with the non-dominant hand and retracts the
foreskin of the uncircumcised male
9. With the dominant hand, uses sterile forcep to pick swabs. Clean first from the meatus
downward and then on either side using a new swab for each stroke.
10. Picks up the catheter in the urine receptacle using the uncontaminated hand.
11. Lubricates the insertion end or tip of the catheter.
12. Lifts the penis to a position at 90 degree angle and inserts the catheter until urine flows.
13. Inflates the balloon by inject 5-10cc of distilled water and checks the anchor.
14. Connects to the catheter to the urine bag and ensures that the emptying base of the
bag is closed.
15. Tapes the catheter with non-allergic tape at the thigh of the patient.
16. Remove drapes and makes the patient comfortable.
17. Disposes soiled materials properly.
18. Accurately records the procedure done.
CLOSED BLADDER IRRIGATION
PERFORMANCE POINTS
1. Verify the written order for the irrigation.

2. Assess patient’s condition.
4. Administer pre-procedure medication as ordered by the doctor.
6. Place the patient on dorsal recumbent position.
7. Wash hands and provide privacy to the patient.
8. Measure and record the urine output and empty the urine bag.
9. Expose the indwelling catheter and place a water-resistant drape under it.
10. Hang the prescribed irrigation solution within an irrigation tubing from an IV stand.
11. Wear sterile gloves.
12. Clamp the urinary catheter.
13. Remove the cap from the irrigation port of the 3 way catheter.
14. Cleanse irrigation port with antiseptic solution.
15. Remove the clamp from the catheter and observe the urine drainage.
16. As ordered, infuse the prescribed amount.
17. Clamp the irrigation tubing accordingly to the prescribed amount of irrigant.
18. Remove the clamp and monitor the drainage.
19. Place the patient in comfortable position.
20. Dispose soiled materials and wash your hands.
ADMINISTERING ENEMA
PERFORMANCE POINTS
a. Verifies the presence of doctor’s order of administering enema to the client.

b. Prepare the needed materials and solutions.
c. Performs handwashing before and after the procedure.
1. Identifies the patient and explains the procedure.
2. Provide privacy to the client throughout the procedure.
3. Places the water proof pad under the client’s buttocks
4. Positions the client in lest sim’s position.
5. Prepares the irrigation can, tubing and solutions and hangs the enema can on the IV
stand about 18-24 inches above the level of the patient’s rectum.
6. Lubricates the rectal tube and allows a small amount of solution to flow through the
tubing into bedpan.
7. Dons glove and lift the upper buttock of the patient.
8. Insert the tube slowly and smoothly around 3-4 inches into the patient’s anus.
9. Administer the solution slowly. If the patient complains of fullness or pain, use the clamp
to stop the flow for 30 seconds, and then restart the flow at a slower rate.
10. Closes the clamp after all the solutions has been administered or when the client cannot
hold anymore and wants to defecate.
11. Removes the rectal tube and place it in a disposable towel.
12. Encourages the patient to retain the enema solution.
13. Assist the patient to defecate.
14. Assist the patient with all necessary cleaning.
15. Makes the patient comfortable.
16. After care of the unit and materials used.
17. Document the procedure done. Record the kind and amount of stool and solution used
and the character of the return flow.
CHANGING A BWOEL DIVERSION OSTOMY APPLIANCE: POUCHING A STOMA
PERFORMANCE POINTS
1. Assess the stoma for color and texture.

2. Assess the condition of the skin surrounding the stoma.
3. Gather materials needed and wash hands.
5. Positon the patient comfortable.
6. Wear gloves.
7. Remove current ostomy appliance after emptying the pouch.
8. Dispose the appliance appropriately.
9. Wash hands.
10. Wear gloves.
11. Cleanse the stoma and skin with a warm tap water and pat dry.
12. Measure stoma at base.
13. Place the gauze pad over the stoma and prepare the new wafer and pouch.
14. Trace the pattern on paper backing of wafer.
15. Cut water as traced.
16. Attach clean pouch to wafer. Be sure that the port is closed.
17. Gently remove the gauze from orifice of the stoma.
18. Gently remove the paper backing from wafer and place it on skin with stoma centered in
cutout opening of water.
19. Using hypo allergenic tape, secure the edges of the wafer.
20. Dispose the soiled materials properly and wash hands.
CHAPTER VIX
MOBILITY
MOVING A CLIENT UP IN BED

ASSISSTING A CLIENT TO A SITTING POSITION IN BED
MOVING A CLIENT TO A SITTING POSITION O NTHE EDGE OF THE BED
SIMPLE TRANSFER TO WHEELCHAIR
HEMPLEGIC TRANSFER TO WHEELCHAIR
LIFT SHEET TRANSFER TO STRETCHER
ADMINISTERING PASSIVE RANGE OF MOTOION (ROM) EXERCISES
LOF ROLLING A CLIENT
CARING FOR A WET CAST
ASSESSING A CASTED EXTREMITY
APPLICATION AND REMOVAL (SET UP) OF SKELETAL TRACTION
MONITORING SKELETAL TRACTION
MONITORING SKIN TACTIN
PLACING A JEWETT-TAYLOR BACK BRCE
ASSESSTING WITH AMBULATION
TEACHING PATIENT TO WALK WITH CRUTCHES
TEACHING A PATIENT TO WALK WIT HCANE
ASSISTING CLIENT TO WALK WITH WALKER
CARE OF PATIENT WITH AMPUTATED LIMBS
POSITIONING AND EXERCISING
MOVING A CLIENT UP IN BED
PERFORMANCE POINTS

2. Inform the client that you would be moving him up in bed.
3. Adjust the bed and the client’s position.
a. Adjust the head of the bed to flat positon or as low as the client can tolerate.
b. Raise the bed to the height of your center of gravity.
c. Lock the wheels on the bed and raise the rail on the side of the bed opposite you.
d. Remove all the pillows, place one against the head of the bed.
4. Elicit the client’s help in lessening your workload.
a. Ask the client to flex the hips and knees and position the feet so that they can be
used effectively for pushing.
b. Ask the client to:
 Grasp the head of the bed with both hands and pull during the move OR
 Raise the upper part of the body on the elbows and push with the arms.
 Grasp the overhead trapeze with both hands and list and pull during the
move.
5. Position yourself appropriately, move the client.
a. Face the direction of the movement and then assume a brad stance, with the foot
nearest the bed behind the forward foot and weight on the forward foot. Incline your
trunk forward from the hips.
b. Flex hips, knees, and ankles.
c. Place your near arm under the client’s thigh. Push down on the mattress with the far
arm.
d. Tighten your gluteal, abdominal, leg, and arm muscles, and rock form the back leg
front leg and back again.
e. Shift the weight to the front of the leg as the client pushes with the heels and pulls
with the arms, moving the client toward the head of the bed.
6. Endure client comfort.
7. Elevate the head of the bed and provide appropriate support devices for the client’s new
position.
ASSISTING A CLIENT OF A SITTING POSTION IN BED
PERFORMANCE POINTS

2. Inform the client that you would be assisting her to sitting position in bed.
3. Position yourself and the client appropriately before performing the move.
4. Ask the client to place the arm at sides with the palm on the hands against the surface
of the bed to provide additional power to lift.
5. Face the head of the bed, and stand at the side of the bed beside the client’s buttocks.
6. Assume a broad stance with the foot farthest from the bed forward and body weight on
this foot.
7. Place the hand nearest the client over the client’s far shoulder to rest between the
shoulder blades.
8. Place the hand on your free arm on the edge of the surface of the bed near the client’s
shoulder, and use it to push during the lift.
9. Coordinate the client and lift with the arm and hand ever the client’s shoulder with other
hand, and shifting your weight form the forward to the back foot in a rocking motion.
10. Let the client simultaneously push with the hands and arms.
MOVING CLIENT TO SITTING POSITION ON THE EDGE OF THE BED
PERFORMANCE POINTS

2. Inform the client that you would be assisting her to sitting position on the edge of the
bed.
3. Position yourself and the client appropriately before performing the move.
4. Ask the client to lateral position facing you.
5. Raise the head of the bed slowly as high as it well.
6. Position the client’s feet and lower legs at the edge of the bed.
7. Stand beside the client’s hips and face the far corner pf the bottom of the bed.
8. Assume broad stance, placing the foot nearest the client forward. Incline your trunk
forward from your hips. Flex your hips, knees, and ankles.
9. Place on arm around the client’s shoulders and the other arm beneath both of the
client’s thighs near the knees.
10. Tighten your gluteal, abdominal, leg, and arm muscles.
11. Left the client’s thighs slightly.
12. Pivot the balls of your feet in the desire direction facing the foot of the bed while pulling
the client’s feet and leg off the bed.
13. Keep supporting the client until the client is well balanced and comfortable.
14. Assess vital signs (pulse, respirations and blood pressure) as indicated by client’s heath
status.
SIMPLE TRANFER TO WHEELCHAIR
PERFORMANCE POINTS
1. Wash hands.
3. Lowers bed to level of wheelchair seat.
4. Position wheelchair next to bed.
5. Make sure wheelchair and be wheels are locked.
6. Raise footrest pedals and leg supports.
7. Assist patient to sitting positon in bed.
8. Assists patient with robe and slippers.
9. Assist patient into chair.
10. Places patient’s feet and legs on support.
11. Uses good body mechanics throughout.
12. Washes hands.
HIMPLEGIC TRANSFER TO WHEELCHAIR
PERFORMANCE POINTS
1. Wash hands.
3. Lowers bed to level of wheelchair and makes sure that bed wheels are locked.
4. Positions and prepares wheelchair. Place chair on the patient’s unaffected side, with
wheels locked, and food and leg supports raised.
5. Assists patient to side of bed.
6. Assist patient to sitting positon.
7. Helps patient with robe and slippers.
8. Block’s patient affected leg with own knee.
9. Raise patient to feet.
10. Pivots patient on affected side.
11. Lowers patient into chair.
13. Aligns patient and makes him comfortable.
14. Washes hands.
15. Documents the procedure.
LIFT SHEET TRANSFER TO WHEELCHAIR
PEROFRMANCE POINTS
1. Wash hands.
3. Folds lift sheet and positons it properly.
4. Positions bed and stretcher correctly, with all wheels locked.
5. Coordinates own and assistant’s movements to move patient to edge of bed..
6. Coordinates own and assistant’s movements to move patient onto stretcher.
8. Covers patient.
9. Raise and rinse or fastens safety belt.
10. Washes hands.
ADMIINISTERING PASSIVE RANGE OF MOTION (ROM) EXERCISES
PERFORMANCE POINTS
1. Be aware of the client’s medical diagnosis.

2. Assess client consciousness and cognitive function.
3. Wash hands and wear gloves.
4. Explain procedure to patient.
5. Provide privacy, exposing only the extremity to be exercised.
6. Assist bed to comfortable height for performing ROM.
7. Lower bed rail only the side of the body.
8. Describe the passive ROM exercise you are performing.
9. Start at clients head am ROM exercise down each side of the body.
10. Repeat each ROM exercise as the client tolerates as maximmog five times.
HEAD
11. With the clients in a sitting position if possible.
 Rotation. Turn the head from side to side.
 Flexion and extension. Tilt the head towards the chest and then slightly upward.
 Lateral flexion. Tilt the head on each side as to almost touch the ear tot the
shoulder.
NECK
12. With the client in sitting position, is possible.
 Rotation. Rotate in semi-circle while supporting the head.
TRUNK
13. With the client in sitting position if possible.
 Flexion and extension, bed the trunk forward, straighten, and then extend slightly
backward.
 Rotation. Turn the shoulders forward and return to normal position.
 Lateral flexion. Tip trunk to the left side, straighten, and tip to the right side.
14. ARM
 Flexion and extension. Extend a straight arm upward toward the head, the downward
along the side.
 Adduction and abduction. Extend a straight arm toward the midline away from the
midline.
SHOULDER
15. Internal and external rotation. Ben the elbow at a 90 angle with upper arm parallel to the
shoulder. Move the lower arm upward and downward.
16. ELBOW
 Flexion and extension. Supporting the arm, flex and extend the elbow.
 Pronationand supination. Flex elbow, move the hand in a palm up and palm
down position.
17. WRIST
 Flexion and extension: supporting the wrist, flex and extend the wrist.
 Adduction and abduction: supporting the lower arm, turn wrist right to left, left to
right, then rotate the wrist in a circulation motion.
18. HAND
 Flexion and extension. Support the wrist, flex and extend the fingers.
 Adduction and abduction. Support wrist, spread fingers apart and then bring
them close together.
 Opposition: supporting the wrist, touch each finger with the tip of the thumb.
 Thumb rotation: support the wrist, rotate the thumb in a circular motion.
HIP AND LEG
19. With client in supine position, if possible.
 Flexion and extension: support the lower leg. Flex leg toward the chest and
extend the leg.
 Internal and external rotation. Support the lower leg, angle the foot inward and
outward.
 Adduction and abduction. Slide the leg away from the client’s midline and then
back to the midline.
20. KNEE
 Flexion and extension: support the lower leg, flex and extend the knee.
21. ANKLE
 Flexion and extension: support the lower leg, flex and extend the ankle.
22. FOOT
 Adduction and abduction: support the ankle, spread the toes apart then bring
them close together.
 Flexion and extension. Support the ankle, extend the toes upward and then flex
the toes downward.
23. Observe client for signs of exertion, pain or fatigue.
24. Replace covers and position client in proper body alignment.
25. Place side rails in original position.
26. Wash hands.
LOG ROLLING A CLIENT
PERFORMANCE POINTS
1. Assess the client’ ability to assist in log rolling.

2. Assess the client’ overall condition.
3. Wash hands.
4. Identify patient and inform the client of the reason and need for turning.
5. Elevate the bed to working height.
6. Using one or more assistants, place a turn sheet under the client.
7. The lead nurse provides direction for the client and other nurses.
8. With one stuff member on each side of the bed.
 The lead nurse gives the signal for the move.
 The staff member on the side of the bed holds the turn/draw sheet to guide the
direction of the move.
 The second staff member applies gentle pressure at the client’s back in the
direction of the move, using draw sheet.
 The client assists with the turning as much as possible.
9. Positions pillows at the client’s back and abdomen.
10. Assess for client’s comfort and proper alignment.
11. Elevate side rails and lower bed height.
12. This proper procedure is repeated for turning the client to the supine position.
CARING FOR A WET CAST
PERFORAMNCE POINTS
1. Greets and identifies the patient.

2. Explains the patient that the cast will feel warm as the plaster dries.
3. Uses only palms of the hands on the cast when turning and positioning for the first 24
hours.
4. Support the cast with pillows if necessary.
a. Keep the casted extremity above the level of heart.
b. Maintain angles built into the cast.
c. Prevent cracking from under pressure.
d. Prevent flat spots in the cast caused by pressure on the bed. For example when the
client has long leg cast, place pillow under knees to maintain the angles of the cast
and under lower leg to prevent pressure and flattering of the heel area.
5. Keep the cast uncovered.
6. If the cast is near at the patient’s groin, protect this area with plastic to avoid soiling the
edges of the cast.
7. If edges are rough and crumbling, pull stockinet over the cast and tape down.
8. “Petal” edge of cast with tape if stockinet is used.
a. Cut tape into 4 inch strips.
b. Place half the tape on the inside of the cast.
c. Anchor remaining tape to outside of cast
ASSESSING FOR A CASTED EXTREMITY
PERFORMANCE POINTS

2. Introduce self.
3. Explains the rationale for the procedure.
4. Encourage the patient to verbalize if he feels any unusual sensations in the casted
extremity.
5. Check the patient’s fingers or toes to make sure that they are pink in color.
6. Feels the finer or toes to make sure they are warm.
7. Ask what the patient feels when you touch his toes. The patient should have normal
sensation and be able to identify which digit you’re touching.
8. Assess for capillary refill by applying pressure to one of the toenails or fingernails.
9. Ask the patient to move the fingers or toes that are affected by the cast.
10. Ask the patient to identify the exact location of any pain. Assess for adequate blood
supply or nerve paralysis.
11. Checks for any drainage form a wound under the cast. Note the color and amount of
drainage. Mark the circumference of the stain on the cast as a gauge pf any increases in
the amount of drainage.
12. Informs client about the findings.
13. Report any unusual odor increase in drainage.
14. Document the findings.
APPLICATION AND REMOVAL (SET UP) OF SKELETAL TRACTION
PERFORMANCE POINTS
1. Preparatory phase
a. Define traction
b. Enumerate
1. Indication for traction
2. Principle for traction
3. [arts of the orthopedic bed
c. Check for doctor’s order.
2. Psychological preparation
a. Speaks clearly on a pleasant tone of voice
b. Facial expression indicates interests and understanding.
 Guide conversation so that the patient is allowed to express his wishes and inner
feelings.
 Explain and discusses procedures with patients or relatives.
3. Actual application
a. Attach pearson attachment in Thomas splint observing the proper alignment (screw
of Pearson attachment should be in line with the knee of the patient)
b. Tie one end of the thigh rope at the medical junction of the Thomas splint; the mount
rest splint to Thomas splint and Pearson attachment.
c. Applying slings observing the principles:
1. Apply from medical to lateral upright of Thomas splint and Pearson attachment.
2. Smooth surface should get contact with the skin of the patient.
3. Apply snugly, not too tight nor too loose.
4. Provide space 1-1 ½ inch between slings.
5. Popliteal area and ankle should be free form slings.
6. If the slings is too long, fanfold it.
d. Transfer affected leg to prepare Thomas splint ad Pearson attachment.
1. Inform patient to hold on the overhead trapeze. Flex the unaffected leg and at the
count of three lift the buttocks.
2. Nurse A should apply manual traction
3. Nurse B should support the affected led and do alignment of the deformity by:
 Placing the 1st pulley, in line with groin of the patient.
 Placing the 2nd pulley, in line with the knee of the patient.
 Placing the 3rd pulley, in line with 2nd and 3rd pulley.
4. Nurse B will lift the affected leg.
5. Nurse C should apply the prepared Thomas splint and Pearson attachment.
6. Nurse D should remove the Braun boiler splint.
e. Apply traction weight by trying one end of the traction rope to the Steinman holder
pass one end of the traction rope to third puller and pass to the traction bag making
a square knot.
f. Tie the other end of the thigh rope to attach the suspension rope at the middle of the
thigh rope and pass the other end to the first pulley; then pass the suspension bag
(hang suspension bag temporarily in the clamp); tie at the Thomas splint and
Pearson attachment making clove-hitch knot.
g. Places the foot board making a ribbon knot.
h. Hang the suspension bag; check the alignment of the traction, then remove the rest,
splint and check the efficiency of traction with the patient coordination.
i. Give at least 5 nursing care related with skeletal balance traction.
4. Removal of the set up (balance skeletal muscle) from orthopedic bed.
a. Re-application of rest splint; hang the suspension bag.
b. Removal of suspension rope.
c. Application of manual traction.
d. Removal of traction tape from the 3rd pulley and finish with a clove hitch knot in
the rest splint; Thomas splint and end in the Pearson attachment.
5. Able to finish at reasonable time.
6. Skills, systematic and well-coordinated movements in moving the whole procedure.
MONITORING SKELETAL MUSCLE
PERORMANCE POINTS

2. Explains the procedure.
3. Check the pin and the wound area surrounding the pin.
a. Pin should be immobile.
b. Wound should be clean and dry.
4. Assess for infection at the pin site. Note any local pain, redness, heat or drainage.
5. Provide for pin site care if ordered.
a. Clean the area with normal saline or hydrogen peroxide soaked cotton tipped
applicators.
b. Rinse with sterile water or normal saline.
c. Apply antibacterial ointment to site as ordered.
6. Examine all body prominences for pressure areas or abrasions.
7. Assess distal extremity for pulses, temperature, color and edema.
8. Check for normal range of motion and sensation in the affected extremity.
9. Check the ropes and weights to make sure the pull goes directly through the long axis of
the fracture bone.
10. Check the traction mechanism.
a. Weigh should be hang freely, off the floor and bed.
b. Knots should be away from the pulleys.
MONITORING SKIN TRACTION
PERFORMANCE POINTS
1. Washes hands.
2. Greet and identifies patient.
4. Examines the material (tape, foam rubber, or plastic) that attaches the weights the
extremity.
a. Material should be held in place, not slipping
b. Material should be fit comfortably, neither too loose or too tight.
5. Examine all body prominences for pressure areas or abrasions.
a. Traction should be removed ever y4 hrs.
b. Washes, dries thoroughly and powders skin before applying traction.
6. Examine the extremity distal to the traction.
a. Note any presence of edema.
b. Takes and records peripheral pulses.
c. Checks temperature and color to see if both are normal.
7. Observe for possible for neurological impediment form traction sling encouraging on
popliteal space or axilla.
8. Asks the patient to move the extremity that is distal to traction.
a. Note if full range of motion is present.
b. Ask patient if he has any decreased or unusual sensations.
9. Examine the ropes and weights to see that the pull directly through the long axis of the
fracture bone.
10. Checks the traction mechanism.
a. Weigh should be hang freely, off the floor and bed.
b. Knots should be away from the pulleys.
c. Ropes should be move freely through pulleys.
d. Pulleys should not be constrained by knots.
11. Make sure that the patient is positioned correctly in bed.
12. Places sheepskin or alternative material under the affected area.
13. Provides footboard to prevent foot drop.
WPLACING A JEWETT-TAYLOR BACK BRACE
PERFORMANCE POINTS
1. Washes hands.
2. Explains procedure to patient.
3. Provide privacy.
4. Puts T-shirt on patient.
5. Place the bed in flat position. Keeps side rails in UP position on side of the bed from you.
6. Log rolls or ask patient to turn side to farthest away from you.
7. Position brace on the back so that struts fit on either side of the spinal cord and fits
natural lumbar curve of the back.
8. Log rolls to the patient to a supine position.
9. Places the front section of the brace positioning the iliac wings (made of plastic material)
over the iliac crest. Adjust the triangular sternum piece; the metal struts will fell into
place.
10. Secures the brave with Velcro straps.
11. Observe under the brace for pressure areas.
12. If pressure areas are present, pas the area under the brace with ABD pads until brace
can be adjusted.
ASSISTING WITH AMBUALTION
PERFORMANCE POINTS
1. Washes hands before and after.

2. Prepares patient and explains procedure.
3. Prepare the environment. Clears floor area; if necessary, locks bed wheel; raises head
of bed; lowers bed level.
4. Place patient’s robe and shoes within convenient reach
5. Position the patient at the edge of the bed, using proper body mechanics.
6. Helps patient put on robe and shoes, allows patient to dangle legs.
7. Assess patient’s condition before standing.
8. Assist’s patient to stand, using good body mechanics.\
9. Reassesses patient’s condition before waling.
10. Walks in step with patient and support patient by grasping belt and robe at the middle of
the neck.
11. Encourages patient to avoid looking at feet.
12. Assist’s patient to sit down on bed, using good body mechanics.
13. Pivots patient back into positon on bed.
14. Makes patient comfortable; charts activity.
TEACHING A PATIENT TO WALK WTH CRUTCHES
PERFORMANCE POINTS

2. Inform client you will be teaching crutch ambulation.
3. Assess client for strength, mobility, range of motion, visual acuity, perception difficulties
and balance.
4. Adjust crutches to fit the client.
 The crutches pad should fit 1.5 to 2 inches below the axilla.
 The hand grip should keep the elbow bent at 30 flexion.
5. Lower the height of the bed.
6. Dangle the client. Assess for vertigo.
7. Instruct client to position crutches lateral to and forward of feet. Demonstrate correct
positioning.
8. Assist the client to a standing position with crutches.
9. Four-point gait.
 Position crutches to the side and in front of each foot.
 Move the right crutch forward 4 to 6 inches.
 Move the left foot forward, even with the left crutch.
 Move the left crutch forward 4 to 6 inches.
 Move the right foot forward, even with right crutch.
 Repeat the four point gait.
10. Three. Point gait.
 Advance both crutches and the weaker leg forward together.
 Move the stronger leg forward, even with the crutches.
 Repeat the three-point gait.
11. Two-point gait.
 Move the left crutch and right leg forward 4 to 6 inches.
 Move the right crutch and left leg forward 4 to 6 inches.
 Repeat the two-point gait.
12. Swing-through gait.
 Move both crutches forward together 4 to 6 inches.
 Move both legs forward even with the left crutches.
 Repeat the swing through gait.
13. Walking up stairs
 Instruct client to position the crutches as if walking.
 Place the strong leg on the first step.
 Pull the leg up and move the crutches up to the first step.
 Repeat the all steps.
14. Walking downstairs.
 Position the crutches as if walking.
 Place the strong leg on the first step.
 Move the crutches down to the next lower step.
 Place partial weight on hands and crutches.
 Put on total weight on hands and crutches.
 Move strong leg to same step as weak leg and crutches.
 Repeat all steps.
15. Wash hands.
16. Document the procedures.
TEACHING A PATIENT TO WALK WITH CANE
PEROFRMANCE POINTS

2. Inform client you will be teaching cane ambulation.
3. Lower the height of bed.
and balance.
6. Apply gait belt around client’s waist, if needed.
7. Have the client hold the cane in the hand opposite in the affected area.
8. Have the client push up form sitting while pushing down on the bed with the arms.
9. Let the client stand at bedside for a few moments.
10. Assess the height of the cane.
11. Walk to side and slightly behind client.
12. The cane gait.
 Move the cane and the weaker the leg forward at the same time for the same
distance.
 Place on the weight on the weaker leg and cane.
 Move strong leg forward.
 Place weight on the strong leg.
 Client grasp the arm of the chair with the free hand and lowers into the chair
 Place cane out of the way but within reach.
13. Wash hands.
ASSISTING CLIENT WITH WALKER
PERFORMANCE POINTS

2. Inform client you will be teaching walker ambulation.
3. Lower the height of bed.
5. Provide a robe and shoes with form, non-slip shoes.
and balance.
7. Apply gait belt around client’s waist, if needed.
8. Place walker in front of the client.
9. Have the client push form sitting while pushing down on the bed with the arms.
10. Have the client transfer hands to the walker one at a time.
11. The handgrips should be just below waist level.
12. Walk to the side and slightly behind the client.
13. The walker gait.
 Move walker and weaker leg forward simultaneously.
 Place as much weight as allowed weaker leg.
 Move the strong leg forward.
14. Sitting with a weaker.
 Have client turn around and back up the chair.
 Have the client place hands on the armrests, one hand at a time.
 Using the armrests for support, client lowers into the chair.
15. Wash hands.
CARE OF PATIENTS WITH AMPUTE LIMBS (POSITIONING AND EXERCISING)
PERFORMANCE POINTS
1. Greet and identifies patient

2. Introduce self.
3. Explains the rationale for the intervention of the patient.
4. Places bed board under mattress, preferably at the time of surgery.
5. For the first 24hrs, elevates foot of bed.
6. Place patient in prone position every shift for at least one hour.
7. Explain the importance of the exercises to the patient. Tells the patient what that
because the flexor muscles are stronger than extensors, the stump will be permanently
flexed and abduct unless the patient practices the range of motion exercises.
8. If ordered, assist the patient with quadriceps setting exercises with below knee
amputation.
a. Extend leg and try to push the popliteal area of the knee into the bed, try to move
patella proximally.
b. Contract quadriceps and hold the contraction for 10 seconds.
c. Repeat the procedure four or five times.
d. Repeat this exercise at least 4x day.
9. Teach stump exercises.
a. Lie on a prone position with foot hanging over the end of the bed.
b. Keep stump next intact leg to extend. Stump and to contact gluteal muscles.
c. Hold contraction for 10 seconds.
d. Repeat this exercise at least 4x day.
10. Teach abduction exercise:
a. Place a pillow between the patient’s thighs.
b. Squeeze the pillow about 10 seconds and then relax for 10 seconds.
c. Repeat this exercise at least 4x day
11. Have the patient keep track of time spent with the stump flexed and then
Spend an equal amount of time with the stump extended.
CHAPTER X
PROMOTING OXYGENATION
MAINTAINING AND CLEANING TRACHOSTOMY TUBE

OROPHARYNGEAL AND NASOPHARYNGEAL SUCTIONING
ADMINISTERING OXYGEM THERAPY
PEROFORMING HEIMLIC MANUEVER
ADMINISTERING CARDIO PULMONARY RESUCITATION
MAINTAINING AND CLEANING TRACHEOSTOMY TUBE
PERFORMANCE POINTS
1. Assess the need to clean the tracheostomy tube.

2. Assess rate, rhythm and depth of respiration.
3. Assess passage wat of air through tracheostomy tube.
4. Explain procedure to the pt allay and fear/anxiety the pt might be feeling.
5. Prepare materials to be used. Wash hands and apply gloves.
6. Remove soiled dressing and discard.
7. Cleans neck plate with applicators and hydrogen peroxide.
8. Rinse neck plate with applicators and hydrogen peroxide.
9. With hydrogen peroxide and cotton application, cleanse thoroughly the skin under the
neck plate.
10. Rinse skin under the neck plate with application and sterile and saline.
11. Using a dry cotton applicator, pat dry the skin.
12. Prepare the clean tracheostomy tres. Art will tape to fit around the client’s neck plus 6
inches. Cut the end of the tape on the diagonal. Pen Vecrotreson continuous neck band.
13. With the old tie in place, insert one 3 end of the new tie through the neck plate from the
back to front. Pull the tie ends until it is even then bring the both ends around the back pf
the neck to other side.
14. Insert the end of the tape through the second opening of the neck plate from back to
front.
15. Tie the both ends of the new tape through the second opening of the neck. Be sure that
the tie is secured.
16. Cut and remove the old tracheostomy tapes and discard.
17. Place one finger under the tracheostomy ties to test security. Insert gauge under neck
plate of tube.
18. Discard all soiled dressing and the according to institutional policy.
19. Position the pt properly to promote comfort.
20. Document change and leaning done to the tracheostomy tube.
OROPHARYNGEAL AND NASOPHARYNGEAL SUCTIONING
PERFOMANCE POINTS
1. Determine pt’s need for suctioning.

2. Explain to the pt the procedure and the need or suctioning allay any fears or anxiety
client may have.
3. Prepare equipment and materials needed and place pt in appropriate position.
4. Sets the pressure on the suction gauge.
5. Opens the sterile package and uses the appropriate size of the suction tube.
6. Opens the sterile water and gauze pack don sterile gloves.
7. With sterile gloved hand, pick up the catheter and connect it to the suction machine.
8. Measure the length of catheter to be inserted.
9. Lubricate end introduce the catheter correctly without applying suction.
10. Performs suctioning by applying pressure on the suction control past and gently rotates
the catheter.
11. Apply intermittent suction for 5-10 seconds, rotates the catheter, then removes finger
from the suction control past and removes the catheter.
12. Cleanse the catheter by wiping off thick secretions or by flushing it with sterile water.
13. Encourage the pt to perform deep breathing and coughing between suctions.
14. Promotes client comfort and hygiene.
15. Dispose soiled materials and ensure availability of materials for the next suction.
16. Assess the effectiveness of suctioning.
17. Documents procedure done and relevant data observed.
ADMINISTERING OXYGEN THERAPY BY NASAL CANULA
PERFORMANCE POINTS
1. Assess the client the need for oxygen therapy and verify the doctor’s order for the
therapy.
2. Prepare equipment such as oxygen tank with flow mete, humidifier with sterile or distilled
water, nasal cannula of appropriate size and padding or the elastic band.
3. Wash hands before staring the procedure.
4. Identify pt and explain procedure alleviate any fear as anxiety pt may be feeling.
5. Place pt on ssemi fowler’s positon.
6. Set-up the oxygen equipment and the humidifier.
7. Attach nasal cannula and tubing to the humidifier.
8. Open the value of the oxygen tank and check the content of the tank.
9. Turn on the regulator at the prescribed rate and ensure proper functioning.
10. Check that the oxygen is flowing freely through the tubing.
11. Put the cannula over the client’s face with the outlet prong setting into the nares and
elastic band to left and right ears and adjust strap under the chin.
12. Assess the client regularly, assess vital signs, color, breathing pattern and chest
movements.
13. Inspect the equipment on a regular basis.
14. Make sure that safety precautions are being followed.
15. Record procedure done and all nursing assessment.
ADMINISTERING OXYGEN THERAPY BY FACE MASK.
PERFORMANCE POINTS
1. Determine the need for O2 therapy and verify the order for therapy
2. Prepare equipment such as O2 tank with flow meter, humidifier with sterile or distilled
water, face mask, of appropriate size and padding for the elastic band.
3. Wash hands before staring the procedure.
4. Identify pt and explain procedure. Entertain any questions the client may have.
5. Place pt on semi-fowlers position.
6. Set-up the oxygen equipment and the humidifier.
7. Turn on the O2 at prescribed rate and ensure proper functioning.
8. Check if O2 is properly flowing through the tube mask.
9. Guide the mask toward the client’s face and apply form the nose down to the chin.
10. Fit the mask to the contours of the client’s face.
11. Secure the elastic band around the client’s head so that the mask is comfortable but
snug.
12. Pad the band behind the ears and over the bony prominences.
13. Assess client regularly assess vital signs, color, breathing pattern and chest movements.
14. Inspect the facial skin frequency for dampness dry as necessary.
15. Inspect the equipment on a regular basis.
16. Make sure that safety precautions are being followed.
17. Record procedure done and all nursing assessment.
PERFORMING HEIMLICH MANEUVER
PERFORMANCE POINTS
1. Assess air exchange.

2. Establish the cause of air obstruction.
3. Determine airway obstruction as to compete or partial blockage.
4. Activate emergency response assistance. Consciousness adult client. Sitting or
standing.
5. Stand behind the client and wrap your arms around the client’s waist.
6. Make a fist with one hand and with your other hand, grasp it. Place the thumb side of pt
fist against the client’s abdomen.
7. Perform a quick upward into 3 the client’s abdomen.
8. Repeats the thrust until client either expels the foreign body or loses consciousness.
9. Establish cause of obstruction and determine whether completer or partial.
10. As the client remains supine, kneel astride the client’s abdomen.
11. Locate for hypoid process and place the heel of one hand below it. Place the second
hand on the first hand.
12. Perform a quick upward thrust into the diaphragm. Repeat as necessary.
13. Perform finger sweep.
14. Open client’s airway and attempt ventilation conscious adult sitting or standing chest
thrust.
15. Assess airway for complete or partial blockage and initiate emergency response
assistance.
16. Stand behind the client and encircle the client wit harms under the maxilla.
17. Make a fist place the thumbs side of the fist on the mid sternum and group the fist with
the second hand.
18. Perform backward thrusts until the foreign body is removed. Unconscious adult-chest
thrust.
19. Assess airway for complete or partial blockage and initiate emergency response
assistance.
20. As the client remains in supine, kneel at the client’s side.
21. Locate for the lower half of the sternum and place the heel of one hand at this site.
22. Perform each thrust in a slow, separate distinct manner.
23. Continue sequence of Heimlick maneuver, finger sweep and rescue breathing as long as
necessary.
ADMINISTERING CARDIO PULMONARY RESUCITATION
PERFORMANCE POINTS
1. Determine whether the area is safe to initiate CPR.

CPR-one rescue-adult.
2. Assess client’s responsiveness and level of consciousness.

3. Call for help and assess abilities of available of assistance.
4. Activate emergency response assistance.
5. Place client in supine position on a hard flat surface.
6. Kneel beside the client and position self properly.
7. Open airway before performing head tilt chin lift maneuver.
8. Assess for respirations through LLF (look, listen, and feel).
9. If respiration is absent, check for obstruction by giving and full breaths.
10. If no obstructions, activate artificial respiration through mouth to mouth.
11. Assess for the rise and fall of the chest.
12. Palpate for the carotid pulse. If present continue AR but if absent, activate CPR.
13. Maintain a position on knees parallel to sternum. Position the hands for compression by
interlocking the fingers.
14. Wit harms straight end the elbows locked, deliver the compression at the appropriate
rate and depth.
15. Maintain the appropriate ratio for compression with ventilation (15:2).
16. Reassess condition of client after four cycles.
CPR-TWO RESCUERS-ADULT
17. Rescuers are position opposite side of the client.
18. Rescuer 1, who performs the cardiac compression maintain the verbal account and
rescuer 2, positioned at the head monitors respiration, pulse and performs rescue
breathing.
19. Both rescuers maintains the appropriate ratio for compression and ventilations (5:1)
20. When switching is done, rescuers completes their portion of the cycle. Client status is
reassessed after each change.
21. Repeat sequence as long as necessary or until medical help answer.
CHAPTER XI
MATERIAL AND CHILD NURISNG PROCEDURES
LEOPOLD’S MANEUVER
FUNDIC HEIGHT MEASUREMENT
AUSCULTATING FETAL HEART TONE
IMMEDIATE CARE OF THE NEWBORN
BATHING A NEWBORN
ADMINISTRATION OF VITAMIN K
ADMINISTRATION OF CREDE’S PROPHYLAXIS
NEWBORN CARE
LEOPOLD’S MANUEVER
PERDORMANCE POINTS
1. Assess the client.

2. Gather the equipment to be use.
3. Do hand washing.
5. Provide privacy in the entire procedure.
6. Allow the client of void before doing the procedure.
7. Place the client in supine/dorsal recumbent position.
8. Do the first maneuver (upper goal)
a. Examiner must face the client’s head
b. Palpate uterine fundus
c. Determine what fetal part is at the uterine fundus
9. Do the second maneuver ( sides of maternal abdomen)
a. Examiner must face the client’s head
b. Palpate with one hand on each side if the abdomen.
c. Palpate fetus with two hands.
d. Assess which side is spine and which side is the extremities.
10. Do the third maneuver ( lower pole)
a. Examiner faces the client’s head.
b. Palpate just above the symphysis pubis.
c. Palpate for the fetal presenting part between two hands
d. Assess for fetal descent
11. Fourth maneuver (presenting part evaluation)
a. Examiner faces the client’s head
b. Apply downward pressure on uterine fundus.
c. Hold the presenting part between index finger and thumb.
d. Assess for the fetal presentation.
12. Note all the assessment
13. Place the patient in a comfort position.
14. Place the patient in a comfortable position.
15. Do hand handwashing.
16. Document the procedure done including findings.
FUNDIC HEIGHT MEAUREMENT
PERFORMANCE POINTS
1. Assess gestational age.

3. Do hand washing.
5. Provide privacy in the entire procedure
6. Place the client in supine position.
7. Instruct the client to relax.
8. Get the tape measure.
9. Place the zero line of the tape measure on the superior edge of the symphysis pubis.
10. Bring the tape over abdominal curve to the top if the fundus.
11. Measure the fundic height using the centimeter side of the tape measure.
12. Note the measurement.
13. Place the patient in a comfort position.
14. Place the patient in a comfortable position.
15. Do hand handwashing.
AUSCULTATE FETAL HEART RATE
PERFORMANCE POINTS
1. Do hand washing.
4. Instruct the patient to void first before the procedure.
5. Provide privacy in the entire procedure
6. Place the client in supine position.
7. Locate for the fetal back
8. Locate for the fetal presentation.
9. Lubricate the Doppler of Fetoscope.
10. Place the fetoscope at the fetal back.
11. Listen for the fetal heart tone.
12. Count the feta heart rate.
13. Remove excess lubricant and place the patient in a comfortable postion.
14. Do hand handwashing
15. Record the data gathered.
IMMEDIATE CARE OF THE NEWBORN.
PERFOMANCE POINTS
1. Do hand washing.
2. Checks identification (name of mother, baby’s sex and room number) upon receiving for
the DR nurse.
3. Hold a warm sterile blanket, grasp the infant through the blanket by placing one hand
under the back and the other around the leg.
4. Rub infant dry so that so that no body heat is lost by evaporation
5. Swaddle the infant loosely with blanket so that respiratory efforts are compromised.
6. Lay the infant in the bassinet.
7. Place a drop light to maintain body temperature.
8. Place the infant in a trendelenberg position. Head down and to the side, allowing
mucuos and fluid drain from the mouth.
9. Sucti0on the infant first and then the nose to clear airway (5-10 seconds)
10. Assess for the consistency, color and for presence of blood.
11. Record the first cry of infant.
12. Assess for the APGAR score.
a. Auscultate for the heart rate.
b. Asses for the respiratory effort.
c. Assess for the muscle tone. Infant should resist any effort to extend their extremities.
d. Tet for reflex irritability.
e. Assess for the color.
13. Obtain body temperature using rectal thermometer.
14. Clean the thermometer form the bulb to the stem.
15. Do hand washing.
BATHING NEWBORN
PERFORMANCE POINTS
1. Prepare all materials needed.

2. Take the temperature of the infant.
3. Infant must be partially wrapped to prevent chilling.
4. Clean the eyes first using cotton balls moistened with water. From inner canthus out.
One cotton ball is used for each stroke.
5. Clean the face with cotton balls deep in clear water.
6. Clean the opening of the nose.
7. Clean the external ear.
8. Pick up the baby using the football hold. Support his head and shoulder securely.
9. Make a good lather on one hand and gently shampoo the head do not allow the soap to
get into the eyes.
10. After shampooing, rinse the head well. Pat dry.
11. Undress the baby.
12. Using the cotton ball/gauze/wash cloth, clean the body in this order: neck, arm, chest,
abdomen, back, genitalia, and legs and between the legs, buttocks.
13. Remove or spread the vernix caseosa according to institutional policy.
14. Rinse well.
15. Place the cotton blanket over the baby quickly
16. Be sure to dry creases and skin folds.
17. Do handwashing. Apply antiseptic solution using as applicator to the cord end and the
inner rim of the skin cuff surrounding the base of the cord.
18. Inspect the genitalia.
19. Place the baby’s clothing.
20. Place the baby in bassinet with proper identification.
21. Dispose the soiled materials.
22. Do proper documentation for the procedure.
ADMINISTRATION OF VITAMIN K
PERFORMANCE POINTS
1. Do handwashing
2. Prepare all materials needed.
3. Get the vitamin k.
4. Check for the expiration date if it is clearly labeled.
5. Tap liquid in top chamber of the ampule into the bottom part.
6. Alcohol wipe the neck of the ampule.
7. Snap top off away from your body.
8. Using tuberculin syringe, withdrew medication by inverting the ampule or by holding it an
insert the needle. Then pull the plunger.
9. Withdraw 0.1 cc of vitamin k.
10. Remove the syringe form the ampule and remove bubbles from syringe.
11. Check the dosage of medication in the syringe
12. Place the infant in supine position.
13. Locate for the vastus lateralis.
14. Clean the injection site using cotton ball with alcohol. Do it in a circular motion, form
inner to outer.
15. Hold the thigh of the infant firmly.
16. Inject the needle in a 90 degree angle then aspirate.
17. If no blood, introduce the medication slowly.
18. Remove the needle and apply pressure on site.
19. Discard the syringe after use.
21. Document procedure done
ADMINISTRATION OF CRED’S PROPHYLAXIS
PERFORMANCE POINTS
1. Verify the type of prophylaxis to be used.

2. Do handwashing
3. Gather the supplies. Check for the aspiration date.
4. Ensure that the medication is clearly labeled.
5. Observe aseptic technique in the entire procedure.
6. Place the infant in supine position.
7. Clean the eyes.
8. Stabilize the head with one hand and pull down the conjunctival sac.
9. With one hand, instill the silver nitrate. One drop at a time.
10. Do the same procedure to other hand.
11. Do not instill the solution directly on the cornea.
12. Be careful not drop any medication on the infant’s cheek.
13. If eye ointment will be sued, open the eyelids.
14. Apply ointment from the inner to outer canthus.
15. Make sure that the tip of the ointment tube will not touch the eyelids of the infant.
16. Avoid the infant’s hand to get contact with his eyes.
18. Document procedure done
NEWBORN CARE
PERFORMANCE POINTS
1. Gather the materials needed. Do handwashing.

2. Observe aseptic technique in the entire procedure
3. Wear sterile glove.
4. With clean blanket, receive the infant from the DR.
5. Checks identification (name of mother, baby’s sex and room number)
6. Place the infant in the bassinet.
7. Place a drop light to maintain body temperature.
8. Keep the baby arm by placing a blanket.
9. Place the infant in a trendelenberg position, to promote drainage of secretions.
10. Gently suction the mouth first before the nose.
11. Perform the APGAR scoring.
12. Remove gloves.
OIL BATH
13. Perform oil bath/warm
 Get a cotton ball with baby oil.
 Remover or spread the vernix caseosa.
WARM BATH
 Fill the basin 2/3 full of warm water.

 Hold the infant using football hold.
 Check for the water temperature by placing the elbow in water.
14. Clean the eyes of the infant first from inner to outer canthus. One cotton ball each
stroke.
15. Clean the nose;
16. Clean the ears.
17. Clean the boy (neck, arm, chest, abdomen, back, genitalia, and legs and between the
legs, buttocks).
18. Pat dry.
19. Get ht antropometric measurements in cm using tape measure.
a. Head circumference
b. Chest circumference
c. Abdominal circumference
d. Length of the infant.
20. Apply crede’s prophylaxis 1%
21. Wash hands and don sterile gloves.
22. Do cord care.
23. Administer 0.1 c of vit. K, IM vastus lateralis
24. Get the footprint of the infant and thumb mark of the mother.
25. Put on the identification bracelet.
26. Wrapped the infant using a clean blanket.
27. Place the infant in the bassinet with drop light to keep warm.
28. Wash hands
29. Do proper and correct documentation after the procedure.
CHAPTER XII
ADDTITIONAL NURSING PROCEDURES
BAG TECHNIQUE
PERFORMING BENEDICT’S TEST
APPLICATION OF ICE BAG
APPLICATION OF HOT WATER BAG
BAG TECHNIQUE
PERFORMANCE POINTS
1. Assess the needs of client.

2. Establish rapport to family members to promote cooperation.
3. Identify the client and explain the procedure to be done.
4. Take client’s history.
5. Lay paper on flat surface of either table, chest or box, if none, use the floor.
6. Place the bag on the left side of the paper lining.
7. Open the bag and take out the towel and soap.
8. Wash hands using pouring method instead of running water.
9. Remove apron from the bag and put it on.
10. Observe proper technique.
11. Remove from the bag all the materials needed for the care.
12. Close the bag.
13. After performing the care, wash all the materials used.
14. Dispose soiled materials.
15. Do handwashing.
16. Return the materials in their proper in the bag.
17. Take off the apron and fold properly.
18. Put it back again in the bag.
19. Close the bag.
20. Get the bag.
21. Get the paper lining. Fold it and dispose.
22. Record the visit accurately.
PERFORMING BENEDICT’S TEST
PERFORMANCE POINTS
1. Assess the patient’s need for glucose.

3. Do handwashing.
4. Prepare the materials to be used (benedict’s solution, test tube, alcohol lamp, test tube
holder).
5. Place a 5 cc of benedict’s solution over the flame.
6. Heat the test tube with benedict’s solution over the flame.
7. Do allow the solution to boil.
8. Add 3-5 drops of urine and heat gradually until it boils.
9. While heating, shake the test tube simultaneously.
10. Note the result:
a. (-) blue in color
b. (+) - (+2) yellow green in color.
c. (+3) – (+4) orange yellow in color.
11. Clean the materials used.
APPLICATION OF ICE BAG
PERFORMANCE POINTS
1. Gather the materials.

2. Place the bag into the ice bag. If crushed ice is used, place crushed ice under running
water.
3. Fill the bag at least 2/3.
4. Cover and secure the top.
5. Invert the bag and check for leakage.
7. Place the ice bag directly on the site of treatment.
8. Check the site every now and then.
9. Remove the bag and make the patient comfortable.
APPLICATION OF HOT WATER BAG
PERFORMANCE POINT
1. Gather the materials.

2. Check the temperature of water.
3. Fill the bag about 2/3 full expel the air.
4. Expel the air.
5. Secure the cover.
6. Dry the bag and check for leakage
7. Wrap the bag with dry towel and secure it.
9. Place the hot bag directly on the site of treatment.
10. Check the site every now and then.
11. Remove the bag and make the patient comfortable.

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PERFORMANCE

1. Identify specific isolation precaution needed for the client’s condition.

1. Gather material to be used.

1. Be sure that fingernails are short. Remove jewelries.

1. Maintain sterility of gown and gloves during the entire procedure.

TAKING BODY TEMPERATURE, PULSE RATE AND

1. Assess for factors that affect blood pressure.

1. Greet and identify the client. Explain the procedure.

1. Greet and identify the patient. Explain the procedure.

1. Prepare equipment: stethoscope.

ADMINISTERING ORAL, SUBLINGUAL, AND BUCAL

1. Check for doctor’s orders for the drugs to be given.

1. Verify doctor’s order for the drug to be administered.

1. Check for the order of the medication against physician’s order.

1. Assess and verify accuracy of medication to be given against doctor’s orders.

1. Perform handwashing and prepare equipment to be used.

1. Assess and verify accuracy of medication to be given against doctor’s orders.

1. Assess the client‘s need for the drug.

1. Verify doctor’s order for the drug to be administered.

1. Assess the need for restraints. Verify doctor’s orders.

1. Assess the patient and verify the order.

1. Assess the patient and verify the order.

1. Wash hands before starting the procedure.

1. Wash hands before starting the procedure.

1. Assess client’ self-care abilities.

1. Assess client’ self-care abilities.

1. Prepare the things needed. (lotin, etc.)

1. Assess the patient and verify the order.

PROMOTING FLUID, ELECTROLYTE AND ACID-BASE

MEASURING INTAKE AND OUTPUT

1. Assess the client’s risk factors for fluid overload.

1. Gather the pertinent data.

1. Verify the written order for the transfusion.

INSERTING A NASOGASTRIC TUBE

1. Verify the order for insertion of the nasogastric tube.

1. Check the physician’s order.

1. Confirm the doctor’s order to remove the tube.

1. Confirm the doctor’s order to remove the tube.

1. Verify the order.

PROMOTING SLIN INTEGRITY AND PERFORMING

OBTAINING A WOUND DRAINAGE SPECIMEN FOR

1. Assess the wound and the surrounding tissues.

1. Confirm written order for wound irrigation.

1. Explain procedure to patient.

OFFERING AND REMOVING BEDPAN

1. Gather materials needed.

1. Gather materials needed.

1. Gather materials needed.

1. Verify the written order for the irrigation.

a. Verifies the presence of doctor’s order of administering enema to the client.

1. Assess the stoma for color and texture.

MOVING A CLIENT UP IN BED

1. Greet and identify patient.

1. Greet and identify patient.

1. Greet and identify patient.

1. Be aware of the client’s medical diagnosis.

1. Assess the client’ ability to assist in log rolling.

1. Greets and identifies the patient.

1. Greets and identifies the patient.

1. Greets and identifies the patient.

1. Washes hands before and after.

1. Greet and identifies patient.

1. Greet and identifies patient.