BASIC ASSESSMENT AND

BASIC CARE PROCEDURES

 NOTRE DAME OF TACURONG COLLEGE
COLLEGE OF NURSING
Lapu-Lapu Street, Tacurong City, Sultan Kudarat, Philippines
Telephone No.: (064) 200-3631 Fax No.: (064) – 200-4131

A. HANDWASHING

1. HANDWASHING – MEDICAL TECHNIQUE

DEFINITION
 A vigorous short rubbing together of all the surfaces of soap lathered hands followed by
rinsing under stream of running water.
 Considered as single most important and basic preventive technique for interrupting
possible infectious process.

PURPOSE
 To prevent possible transfer of microorganisms,
 To reduce the risk of cross contamination among clients.

EQUIPMENT
 Liquid soap/soap bar with soap dish
 Hand towel
 Tissue paper
 Orange stick

PROCEDURE RATIONALE
1. Inspect hands, observing for visible soiling, breaks  Poor personal hygiene and an
or cuts in the skin and cuticles. open area of the skin provide areas
in which microorganism grow and
should receive extra attention
during cleaning.
2. Remove jewellery and watch and push long sleeves  Microorganisms collect in jewellery
above the elbows. Don’t allow the uniform to touch and watch bands.
the sink.  Removing jewellery makes it easier
to wash all areas of hands and
wrists.
3. Adjust the water to appropriate temperature and  Water that is too hot can chap skin.
flow. Too much force can cause
splashing and spread of
microorganisms to other areas
especially your uniform.
4. Wet elbows to hand under the running water always  Hands are the most contaminated
keeping hands lower than elbow. part of the arm.
 Water should flow form the elbow
which is the least contaminated
area over the hands and down the
drain.
5. Lather hands with liquid soap or if bar soap is used  Soap lather emulsifies fats and
wash soap and lather hand. aids in cleansing.
If bar soap is accidentally dropped, repeat the  Sink is contaminated and dropping
procedure. bar soap causes contamination.

6. Return bar soap on the soap dish without touching  Soap dish is contaminated.
the dish.
7. Wash hands thoroughly using firm circular motion  Friction helps loosen dirt and
and friction on back of the hands, palms and wrists. microorganisms
Wash each finger individually paying special  Relathering ensures more thorough
attention to areas between fingers and knuckles by
 interlacing fingers and thumbs moving hands back
and forth. Re-lather if necessary
8. Rinse elbow down to hands completely, keeping
hands lower than elbows
9. Clean fingernails carefully under running water using
orange stick.
10. Turn off faucets with a hand towel or tissue paper.
11. Dry hands thoroughly with towel starting from the
fingertips, hands and then wrists and forearm.
12. Use hand lotion if desired.
13. Inspect hands and nails for cleanliness.
cleansing.
 Water should run from cleaner area
(elbow) over the hands and then
down the drain.
 Orange stick helps remove dirt and
reduces chance of microorganisms
to remain under nails.
 Keeps clean hands from touching
contaminated faucet.
 Prevents chapping of the skin. The
cleanest areas are now the fingers
and hands so drying should
progress from clean to less clean.
 Keep skin soft and lubricated.
 Ensures cleanliness of hands and
nails.
 NOTRE DAME OF TACURONG COLLEGE
COLLEGE OF NURSING
Lapu-Lapu Street, Tacurong City, Sultan Kudarat, Philippines
Telephone No.: (064) 200-3631 Fax No.: (064) – 200-4131

A. HANDWASHING

1. CHECKLIST ON HANDWASHING – MEDICAL TECHNIQUE

Student Name: _____________________________________ Year Level: _________________

Inclusive Date: _____________________

Direction: In using the checklist, please use the following rating scale in evaluating the performance
of the student.

5 Excellent
Student performs the procedure correctly, and perfectly.
Student states the rationale correctly and completely.
Student is able to answer questions accurately.
4 Very Satisfactory
Student performs the procedure correctly.
Student states the rationale correctly but incompletely.
Student is able to answer questions.
3 Satisfactory
Student performs the procedure correctly but failed to states the rationale.
Student is able to answer questions when cued.
2 Fair
Student performs the procedure when cued.
Student fail to states the rationale.
Student is able to answer questions when cued.
1 Poor
Student fails to perform the procedure correctly even when cued.
Student does not know the rationale.
 PROCEDURE 1 2 3 4 5
Assessment
1. Assess the hands for visible soiling, breaks or cuts in the skin 1 2 3 4 5
and cuticles
Planning
2. Assemble the equipment. 1 2 3 4 5
Implementation
3. Remove jewellery and watch and push long sleeves above the
elbows. Don’t allow the uniform to touch the sink. 1 2 3 4 5
4. Adjust the water to appropriate temperature and flow. 1 2 3 4 5
5. Wet elbows to hand under the running water always keeping
hands lower than elbow. 1 2 3 4 5
6. Lather hands with liquid soap or if bar soap is used wash soap
and lather hand. 1 2 3 4 5
If bar soap is accidentally dropped, repeat the procedure.
7. Return bar soap on the soap dish without touching the dish. 1 2 3 4 5
8. Wash hands thoroughly using firm circular motion and friction
on back of the hands, palms and wrists. Wash each finger 1 2 3 4 5
individually paying special attention to areas between fingers
and knuckles by interlacing fingers and thumbs moving hands
back and forth. Re-lather if necessary
9. Rinse elbow down to hands completely, keeping hands lower
1 2 3 4 5
than elbows
10. Clean fingernails carefully under running water using orange
stick. 1 2 3 4 5
11. Turn off faucets with a hand towel or tissue paper. 1 2 3 4 5
12. Dry hands thoroughly with towel starting from the fingertips,
hands and then wrists and forearm. 1 2 3 4 5
13. Use hand lotion if desired. 1 2 3 4 5
Evaluation
14. Inspect hands and nails for cleanliness. 1 2 3 4 5
Documentation
15. Record time when handwashing is done 1 2 3 4 5

Total Points: ______________

Average: ______________
RD Grade: _____________

________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
_______________

________________________________
Signature over Printed Name
(FACULTY)
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
_______________

________________________________
Signature over Printed Name
(Student)
 NOTRE DAME OF TACURONG COLLEGE
COLLEGE OF NURSING
Lapu-Lapu Street, Tacurong City, Sultan Kudarat, Philippines
Telephone No.: (064) 200-3631 Fax No.: (064) – 200-4131
2. HANDWASHING – SURGICAL TECHNIQUE
DEFINITION
 Type of handwashing used in the operating room.
PURPOSE
 To remove soil and most transient microorganisms from the skin.
EQUIPMENT
 Brush
 Sink with faucet and running water
 Liquid soap
 Sterile towel
 Nail cutter
PROCEDURE
1. Inspect hands for cuts in the skin and cuticles.
Do not scrub if there are open lesions or breaks
in the skin.
2. Remove rings, chipped nail polish, and watch
and push long sleeves above the elbow.
3. Put on cap or hood, shoes cover and a mask.
4. Use a deep sink with side foot pedal.
5. Turn on water using foot or knee control and
adjust temperature to be comfortably warm.
6. Wet hands starting from the tips of fingers to
forearms keeping hands higher than elbows.
7. Apply soap to a scrub brush or open a pre-
packed scrub brush if available.
8. With brush on your dominant hand, using a
circular motion, scrub nails and all skin areas of
non-dominant hand and arm ( ten stroke to each
of the areas)
9. Take second scrub brush and repeat actions in
no. 8 on your dominant hand and arm.
10. Keep the hands and arms above elbow level,
place the fingertips under running water and
thoroughly rinse the fingers, hands and the
arms.
11. Keep arms flexed and proceed to operating or
procedure room.
RATIONALE
 Breaks in skin facilitate
development of infection.
 To decrease resident and transient
microorganisms.
 To prevent introduction of
contaminants into environment.
 To prevent hands and forearm form
touching a soiled surface.
 Warm water removes less of the
protective oil of the skin than hot
water.
 Water will drain off your elbow,
flowing from cleanest area to less
clean area.
 To remove resident bacteria from
the skin surfaces.
 The circular motion mechanically
removes microorganisms,
scrubbing the non-dominant hands
first sets a routine you can
remember to prevent
contamination.
 Same as above.
 Allows flow of water from the area
of least (hand) contamination to the
area of most contamination (elbow)
 Prevents water from flowing from
least clean area (elbows) to most
 (hands) clean area.
12. Secure a sterile towel by grasping it on one  Maintain sterility of the towel.
edge, opening it at full length making sure it
does not touch your uniform/
13. Dry each hand and arm separately, extend one  Prevents contamination by drying
side of the towel around finger and hands and from cleanest to least clean area.
dry in a rotating motion up to the elbow.
14. Reverse towel and repeat same action on the  To prevent contamination of gown.
other hand and arm, thoroughly drying the skin.
Discard towel into linen hamper.
 NOTRE DAME OF TACURONG COLLEGE
COLLEGE OF NURSING
Lapu-Lapu Street, Tacurong City, Sultan Kudarat, Philippines
Telephone No.: (064) 200-3631 Fax No.: (064) – 200-4131

2. CHECKLIST ON HANDWASHING – SURGICAL TECHNIQUE

Student Name: _____________________________________ Year Level: _________________

Inclusive Date: _____________________

Direction: In using the checklist, please use the following rating scale in evaluating the performance
of the student.

5 Excellent
Student performs the procedure correctly, and perfectly.
Student states the rationale correctly and completely.
Student is able to answer questions accurately.
5 Very Satisfactory
Student performs the procedure correctly.
Student states the rationale correctly but incompletely.
Student is able to answer questions.
4 Satisfactory
Student performs the procedure correctly but failed to states the rationale.
Student is able to answer questions when cued.
3 Fair
Student performs the procedure when cued.
Student fail to states the rationale.
Student is able to answer questions when cued.
2 Poor
Student fails to perform the procedure correctly even when cued.
Student does not know the rationale.
 PROCEDURE 1 2 3 4 5
Assessment
1. Assess the hands for visible soiling, breaks or cuts in the skin 1 2 3 4 5
and cuticles
Planning
2. Assemble the equipment. 1 2 3 4 5
Implementation
3. Remove rings, chipped nail polish and watch and push long
sleeves above the elbow. 1 2 3 4 5
4. Put on cap or hood, shoes cover and a mask.
1 2 3 4 5
5. Use a deep sink with side foot pedal. 1 2 3 4 5
6. Turn on water using foot or knee control. 1 2 3 4 5
7. Wet hands starting from the tips of fingers to forearms keeping
hands higher than elbows. 1 2 3 4 5
8. Apply soap to a soap brush or open a pre-packed scrub. 1 2 3 4 5
9. With brush on dominant hand, scrub nails and all skin areas of
non-dominant hand and arm using circular motion ( ten stroke
to each of the areas) 1 2 3 4 5
10. Repeat actions in no. 9 on dominant hand. 1 2 3 4 5
11. Place the fingertips under running water and thoroughly rinse
the fingers, hands and the arms and keeping hands and arms
above elbow level. 1 2 3 4 5
12. Keep arms flexed and proceed to operating room. 1 2 3 4 5
13. Secure a towel by grasping it on one edge, and open it at full
length. 1 2 3 4 5
14. Extend one side of the towel around finger and hands and dry
in a rotating motion up to the elbow. 1 2 3 4 5
15. Reverse towel and repeat same procedure on the other hand. 1 2 3 4 5
16. Discard towel into linen hamper. 1 2 3 4 5
Evaluation
17. Inspect hands and nails for cleanliness. 1 2 3 4 5
Documentation
18. Record time when handwashing was done. 1 2 3 4 5
Total Points: ______________
Average: ______________
RD Grade: _____________

________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
_______________

________________________________
Signature over Printed Name
(FACULTY)
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
_______________

________________________________
Signature over Printed Name
 (Student)

NOTRE DAME OF TACURONG COLLEGE

COLLEGE OF NURSING
Lapu-Lapu Street, Tacurong City, Sultan Kudarat, Philippines
Telephone No.: (064) 200-3631 Fax No.: (064) – 200-4131

B. HEALTH ASSESSMENT AND PHYSCIAL EXAMINATION

DEFINITION
 Health assessment is the collection of data about an individual’s health. Physical
examination is a head to toe review of each body system that offers objective information
about the client and allows the health care provider to make clinical judgment.

PURPOSE
 Health Assessment.
1. To make a clinical judgment or diagnosis about the individual’s health state or
condition.
2. To obtain baseline data about the client’s functional abilities

 Physical Examination
1. For routine screening to determine the client’s eligibility for health insurance.
2. For acquiring a new job
3. For client’s admission to the hospital.

EQUIPMENT
 BP apparatus  Otoscope
 Thermometer  Stethoscope
 Penlight  Percussion hammer
 Drape  Vaginal speculum
 Screen  Gloves
 Tongue depressor  Gowns
 Nose speculum

PROCEDURE RATIONALE
1. Assess the client’s physical and psychological  Allows health care provider to
aspect before and during examination gather complete data bout the
client’s health status.
2. Review the body areas to be examined.  Helps examiner (health care
provider) identify which part of the
body is to be examined
systematically.
3. Make a physical and environmental preparation  Proper preparation of the
before examination: environment, client and equipment
1. Environment ensures smooth physical
a. Infection control – wear gloves during examination with few interruptions.
palpation to reduce contact with
microorganisms.
b. Environmental – client requires privacy. A
well-equipped examination room is
preferable and adequate lighting is needed.
c. Equipment – hand washing is done before
examination. Equipment should be clear
and ready for use.
 2. Physical preparation involve:
a. Ensuring that client is dressed and properly
draped. If examination is limited to a
certain part of the body it is unnecessary to
undress the client completely.
b. Positioning – health care provider assumes
proper positioning to that body parts are
accessible and client feels comfortable.
c. Psychological preparation – explaining the
procedure to be done reduces anxiety. The
health care provider should convey an
open, receptive and a professional
approach.
4. Gather and take the health history of the client.  To have a comparison with
1. Personal history previous illness/es and present
2. Family history health condition.
3. History of present illness
4. History of past illness/es
5. Conduct physical examination from head to toe  To assess, determine and identify
(Cephalocaudal) using the four skills in assessment abnormal findings in the body
1. Inspection – the process of observation (sense system.
of sight)
2. Palpation – assessment through the sense of
touch. Through palpation of the hands can
make sensitive physical signs which include
roughness, texture and mobility.
3. Percussion – involve tapping the body with the
fingertips to evaluate the size, borders and
consistency of the body organs and to discover
body fluid and body cavities.
6. Auscultation – is listening to the sounds produced
by the body with the aid of stethoscope.
Note the general appearance, level of
consciousness, skin color, nutritional status,
posture, mobility, facial expression, speech,
hearing and personal hygiene.

PROCEDURE Methods Used RATIONALE

A. Assessing the skin

1. Skin color Inspection  Varies from light to deep brown.
2. Uniformity of skin color  Generally uniform except in the
areas of lighter pigmentation (palm,
lips, nails and beds) in dark skinned
people.
3. Skin lesions  Freckles, some birthmarks, some
fat and raised nevi (moles),
abrasions or other lesions
4. Skin moisture Palpation  Moisture in skin folds and axillae
(varies with environmental
temperature and activity).
5. Skin turgor  When pinched, skin springs back to
previous state.

B. Assessing the nails

1. Nail Texture Inspection  Smooth texture
2. Nail plate shape  Convex curvature; angle between

3. Nail bed color
C. Assessing the head
1. Hair – evenness of
growth over the scalp.
a. Evenness
b. Texture and oiliness
c. Thickness/thinness
d. Infection and
infestation (lice)
2. Assessing the skull and
face.
a. Skull for size, shape
and symmetry
b. Skull of nodules or
masses and
depressions
c. Symmetry of facial
movement.
3. Assessing the eye,
structure and visual
acuity
a. Inspect the eyebrows
for hair distribution.
b. Eyelids – ability of
blinking.
c. Conjunction (lining the
eyelids by reverting
the lids).
d. Cornea – clarity and
texture
e. Pupil for color and
symmetry of size
f. Pupil reaction to light.
g. Reaction to
accommodation.
4. Assessing the ears.
a. Auricles – color
symmetry
b. Auricles for elasticity
and areas for
tenderness
c. Hearing acuity:
- Client’s response
to normal voice
nail and nail bed.
 Highly vascular and pink in light
skinned clients. Dark skinned client
may have brown or black
pigmentation.
Inspection  Evenly distributed.
 Silky, resilient hair.
 Thick hair.
 No infection of infestation.
Inspection/  Rounded (normocephalic and
Palpation symmetric with frontal, parietal and
occipital prominences) smooth
contour.
Palpation  Smooth, uniform consistency;
absence of nodules or masses.
 Symmetrical facial movement.
Inspection  Hair evenly distributed, skin, intact,
symmetrically aligned, equal
movement.
 Skin intact; no discharge; no
discoloration.
 Lids close symmetrical.
 Shiny, smooth, pink or red.
 Transparent, shiny, smooth, details
or iris are visible.
 Black in color, equal in size;
normally 3-7 mm in diameter,
round smooth border, it is flat and
round.
 Illuminated pupil constricts
(directed response). Non-
illuminated pupil constricts.
 Pupils constrict when looking at
near object; pupils dilate when
looking at far object; pupils
converge when near objects is
moved toward nose.
Inspection  Color same as facial skin.
Palpation  Mobile firm and not tender; pinna
recoils after it is folded.
 Normal voice tones audible.
 tones.
- Client’s response  Able to repeat non-consecutive
to whispered number.
voice-
nonconsecutive
numbers.
5. Assessing the nose
a. External nose for any Inspection  Symmetric and straight.
deviation in shape,  No discharge of flaring.
size or in color and  Uniform color.
flaring or discharge
from the nares
b. External nose to Palpation  Not tender, no lesions.
determine any areas of
tenderness, masses
and displacement of
bone and cartilage.
c. Patency of both nasal  Air movement is restricted in one
cavities or both nares.
6. Assessing the mouth
and oropharynx
a. Lip and buccal mucosa Inspection  Uniform pink color (darker in bluish
hue in Mediterranean groups and
dark-skinned clients.
b. Teeth and gums  Pinkish gum, smooth white, shiny
tooth enamel.
c. Tongue/floor of the  Central position
mouth
d. Tongue movement  Moves freely; no tenderness.
e. Oropharynx and  Pink and smooth posterior wall.
tonsils – inspect the
oropharynx for color
and texture.
D. Assessing the neck.
1. Inspect the neck muscles. Inspection  Muscles equal in size, head
centered.
2. Observe head movement  Coordinated, smooth movement
with no discomfort.
3. Palpate the thyroid glands Palpation  Lobes may not be palpated.
for smoothness
E. Assessing the thorax and
lungs
1. Shape symmetry of the Inspection  Symmetrical chest
thorax form posterior and
lateral views.
2. Palpate the posterior Palpation  Skin intact; uniform temperature
thorax
3. Palpate the posterior chest  Full and symmetric chest
for respiratory excursion expansion. When the clients take a
deep breath, your thumb should
move apart an equal distance and
the separate 3-5 cm during deep
inspiration
4. Anterior thorax. Inspect the Inspection  Regular rhythm rate 16-20/min.
breathing pattern.
5. Breath sounds Auscultation  Normal breath sounds-vesicular,
broncho vesicular and bronchial
F. Assessing the abdomen
1. Inspect the abdomen for Inspection  Unblemished skin; uniform color
skin integrity
2. Inspect the abdomen for  Flat, rounded (convex or scaphoid)
contour and symmetry. concave.
3. Auscultate the abdomen Auscultation  Audible bowel sounds.
for vowel sounds.
4. Palpate the liver Palpation  May not be palpable.
G. Musculoskeletal
1. Inspect the muscle for Inspection  Equal in size both sides of the
size. body.
2. Inspect joints for swelling. Inspection  No swelling.
3. Palpate each joints for Palpation  No swelling/tenderness/no nodules
tenderness, smoothness of
movement, swelling,
crepitation and presence
of nodules.
4. Palpate the bones to Palpation  No swelling/tenderness.
locate any areas of edema
or tenderness.
H. Neurological
1. Bicep reflex – the partners Percussion  The contraction of the biceps can
elbow is slightly bent and be seen and felt.
the palm faces downward.
2. Triceps reflex - the Percussion  The contraction of the triceps can
partners elbow is sharply be seen as the elbow extends.
bent; forearm is placed
across the chest wall with
the palm turned toward the
body. The triceps muscle
is struck with the
percussion hammer just
above the elbow.
3. Knee- the patient is in the Percussion  The contraction of the quadriceps
sitting position. The patella causes the knee to extend.
is struck with the
percussion hammer. If
patient is lying down, the
reflex is tested while the
examiners hands are
placed under the knees to
bend them.
4. Ankle - the leg is bent at Percussion  The foot jerks and moves
the knee and the foot is downward.
supported in a waling
position. The Achilles
tendon is stuck with the
percussion hammer
5. Plantar – the lateral aspect Percussion  The toes bend or curl.
of the sole of the foot is
stroked with an object.
 NOTRE DAME OF TACURONG COLLEGE
COLLEGE OF NURSING
Lapu-Lapu Street, Tacurong City, Sultan Kudarat, Philippines
Telephone No.: (064) 200-3631 Fax No.: (064) – 200-4131

B. CHECKLIST ON HEALTH ASSESSMENT AND PHYSICAL EXAMINATION

Student Name: _____________________________________ Year Level: _________________

Inclusive Date: _____________________

Direction: In using the checklist, please use the following rating scale in evaluating the performance
of the student.
 5 Excellent
Student performs the procedure correctly, and perfectly.
Student states the rationale correctly and completely.
Student is able to answer questions accurately.
6 Very Satisfactory
Student performs the procedure correctly.
Student states the rationale correctly but incompletely.
Student is able to answer questions.
5 Satisfactory
Student performs the procedure correctly but failed to states the rationale.
Student is able to answer questions when cued.
4 Fair
Student performs the procedure when cued.
Student fail to states the rationale.
Student is able to answer questions when cued.
3 Poor
Student fails to perform the procedure correctly even when cued.
Student does not know the rationale.

PROCEDURE 1 2 3 4 5
Assessment
1. Assess the client’s physical and psychological aspect before 1 2 3 4 5
and during examination
2. Review body areas to be examined. 1 2 3 4 5
Planning
3. Make a physical and environmental preparation before
examination 1 2 3 4 5
4. Determine and prepare materials/equipment needed. 1 2 3 4 5
Implementation
5. Identify the client. 1 2 3 4 5
6. Explain the procedure to the client. 1 2 3 4 5
7. Properly position the client. 1 2 3 4 5
8. Take the health history of the client. 1 2 3 4 5
9. Conduct physical examination using the four skills in physical
assessment. 1 2 3 4 5
a. Skin 1 2 3 4 5
b. Nails 1 2 3 4 5
c. Head 1 2 3 4 5
 d. Eyes 1 2 3 4 5
e. Ears 1 2 3 4 5
f. Nose 1 2 3 4 5
g. Mouth and Throat 1 2 3 4 5
h. Neck 1 2 3 4 5
i. Chest Anterior 1 2 3 4 5
j. Chest Posterior 1 2 3 4 5
k. Breast 1 2 3 4 5
l. Abdomen 1 2 3 4 5
m. Musculoskeletal 1 2 3 4 5
n. Neurologic 1 2 3 4 5
10. Reposition the client 1 2 3 4 5
Evaluation
11. Make findings of health assessment and physical examination
done on the client. 1 2 3 4 5
Documentation
12. Record/document and report any pertinent findings found
during assessment to appropriate personnel. 1 2 3 4 5
Total Points: ______________
Average: ______________
RD Grade: _____________

________________________________________________________________________________
________________________________________________________________________________
_________________

________________________________
Signature over Printed Name
(FACULTY)
________________________________________________________________________________
_____________________________________________________________________

________________________________
Signature over Printed Name
(Student)

NOTRE DAME OF TACURONG COLLEGE

COLLEGE OF NURSING
Lapu-Lapu Street, Tacurong City, Sultan Kudarat, Philippines
Telephone No.: (064) 200-3631 Fax No.: (064) – 200-4131

C. TAKING VITAL SIGNS OR CARDINAL SIGNS

DEFINITION
 The measurement of physiologic functioning, specially body temperature, blood pressure,
pulse and respiration.

PURPOSE
 Serves as guide in meeting the needs of the client.
 Aids in the planning of care for the client.
 Establish baseline values of the client’s cardio respiratory integrity.

1. TEMPERATURE TAKING

DEFINITION
 Balance between heat production and heat loss by the body.
PURPOSE
 To determine alterations in thermo regulating systems of the body.
 To establish baseline data for subsequent evaluation.
1.1 ORAL METHOD
EQUIPMENT
 Thermometer – oral, axillary and rectal
 Alcohol, cotton balls
 Watch with second hand
 Paper and pen
PROCEDURE
1. Identify the client and explain the procedure.
2. Assess the client’s mouth.
3. Assemble the equipment needed.
4. Wash hands.
5. Ask the client if he/she has taken hot or cold liquids
of if he/she smoked.
6. Rinse and dry thermometer before use with a cotton
ball or soft tissue from bulb to the stem with a firm
twisting motion
7. Hold the thermometer firmly at the stem with thumb
and forefinger and with a strong wrist motion shake
it until the mercury is down to lowest calibration.
8. Read the thermometer horizontally at eye level and
rotating it until mercury line can be seen clearly.
9. Ask the client to lift up his/her tongue and place he
bulb end of the thermometer under the tongue
directed towards the side and instruct him/her to
close lips tightly.
10. Leave the thermometer in place for 3-8 minutes for
more accurate reading
11. Remove the thermometer and wipe it from stem
down to the bulb using a twisting motion.
12. Read the thermometer at eye level.
13. Wash thermometer with soap and water, dry and
shake the thermometer and return it to the container
14. Dispose wipe and used contaminated items in a
receptacle.
15. Wash hands.
16. Record result in graphing sheet for documentation.
RATIONALE
 To ensure doing the procedure to
the right client and lessen the
apprehension on the procedure.
 To determine if there is an oral
lesion.
 To promote efficiency of the health
care provider
 To prevent the spread of
microorganism
 To make sure that the temperature
reading is accurate
 Rinsing the thermometer removes
dirt/chemical solutions and the
cotton ball with the aid or friction
helps in drying the thermometer.
 Shaking will bring down mercury. A
construction in the mercury line
near the bulb of the thermometer
prevents the mercury from
dropping to low.
 Holding thermometer at eye level
facilitates reading in and rotating
the thermometer will aid in placing
the mercury line in position where it
can be read best
 Superficial blood vessel, which are
sensitive to hat, are present under
the tongue.
 To provide sufficient/adequate time
for recording of the temperature.
 Cleaning from a cleaner to a dirtier
area minimizes the spread of
microorganism as friction aids to
loosen matter from a surface.
 For accurate reading.
 Washing removes organisms and
prevent contamination.
 Confining contaminated articles
helps to reduce the spread of
microorganisms.
 Reduces transmission of
microorganisms.
 To serve as baseline date for
 health care providers.

NOTRE DAME OF TACURONG COLLEGE

COLLEGE OF NURSING
Lapu-Lapu Street, Tacurong City, Sultan Kudarat, Philippines
Telephone No.: (064) 200-3631 Fax No.: (064) – 200-4131

C. VITAL SIGNS/CARDINAL SIGNS

1. TEMPERATURE TAKING

1.1 CHECKLIST ON TEMPERATURE TAKING ORAL METHIOD

Student Name: _____________________________________ Year Level: _________________

Inclusive Date: _____________________

Direction: In using the checklist, please use the following rating scale in evaluating the performance
of the student.

5 Excellent
Student performs the procedure correctly, and perfectly.
Student states the rationale correctly and completely.
Student is able to answer questions accurately.
7 Very Satisfactory
Student performs the procedure correctly.
 Student states the rationale correctly but incompletely.
Student is able to answer questions.
6 Satisfactory
Student performs the procedure correctly but failed to states the rationale.
Student is able to answer questions when cued.
5 Fair
Student performs the procedure when cued.
Student fail to states the rationale.
Student is able to answer questions when cued.
4 Poor
Student fails to perform the procedure correctly even when cued.
Student does not know the rationale.

PROCEDURE 1 2 3 4 5
Assessment
1. Assess the client’s skin if warm to touch. 1 2 3 4 5
2. Assess client mouth for oral lesions and sores. 1 2 3 4 5
Planning
3. Wash hands 1 2 3 4 5
4. Gather the equipment needed. 1 2 3 4 5
5. Identify the client and explain the procedure. 1 2 3 4 5
6. Rinse and dry thermometer from the bulb to the stem with a
firm twisting motion 1 2 3 4 5
7. Shake the thermometer with strong wrist motion until the
mercury is down to lowest calibration. 1 2 3 4 5
8. Read the thermometer horizontally at eye level and rotating it
until mercury line can be seen clearly. 1 2 3 4 5
9. Place the bulb end of the thermometer under the tongue
(directed towards the side) 1 2 3 4 5
10. Leave the thermometer in place for 3-8 minutes. 1 2 3 4 5
11. Remove the thermometer and wipe it from stem down to the
bulb in a twisting motion. 1 2 3 4 5
12. Read the thermometer at eye level. 1 2 3 4 5
13. Wash thermometer with soap and water, dry and shake and
return to container 1 2 3 4 5
14. Discard the soiled articles used. 1 2 3 4 5
15. Wash hands. 1 2 3 4 5
Evaluation
16. Evaluate the temperature taken. 1 2 3 4 5
Documentation
17. Record result in a graphing sheet. 1 2 3 4 5
 Total Points: ______________
Average: ______________
RD Grade: _____________

________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
_______________

________________________________
Signature over Printed Name
(FACULTY)
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
_______________

________________________________
Signature over Printed Name
(Student)

1.2 AXILLARY METHOD

EQUIPMENT
 Axillary thermometer
 Cotton balls and alcohol
 Watch with a second hand
 Paper and pen

PROCEDURE
1. Identify and explain procedure to patient.
2. Wash hands.
3. Gather equipment needed.
4. Draw curtain around bed and/or close door.
5. Assist client in supine or sitting position.
6. Move clothing or gown away from shoulder and arm
7. Wipe thermometer form bulb to stem with firm
rotating motion using soft tissue or cotton balls.
8. Grasp thermometer firmly with thumb and forefinger
and sharply flick wrist downward, continue shaking
until mercury line reaches lowest markings.
9. Raise client’s arm away from torso, insert bulb into
center of axilla, lower arm over bulb and place arm
across client’s chess.
10. Leave thermometer in place for 5-10 minutes for
RATIONALE
 To ensure correct procedure to
right patient.
 Explaining procedure reduces
anxiety and fear thus promoting
cooperation from the client.
 Reduces transmission of
microorganisms.
 To facilitate systematic assessment
and measurement.
 To maintain client privacy and
promote comfort.
 To provides easy access to axilla.
 To expose axilla for correct
thermometer placement.
 To remove chemical solutions, dust
or dirt that may irritate mucous
membrane and to prevent spread
of microorganism.
 To ensure accurate reading.
 To maintain proper position of
thermometer bulb against blood
vessel in axilla.
 To provide sufficient time for
 more accurate reading recording of the temperature.
11. Remove thermometer and wipe off any remaining  To prevent cross contamination.
secretions with clean tissue. Wipe with rotating  Wipe from are with least
motion form stem toward the bulb. contamination to area most
contaminated.
12. Read thermometer at eye level.  To ensure accurate reading.
13. Inform client of thermometer reading.  To promote participation in care
and understanding of the status.
14. Store thermometer in appropriate protective storage  Protective storage container
prevents breakage.
15. Assist client in replacing clothing of gown.  Restores sense of well-being.
16. Wash hands.  To reduce transmission of
microorganism.
17. Record result.  Serves as baseline data for health
care providers.

NOTRE DAME OF TACURONG COLLEGE

COLLEGE OF NURSING
Lapu-Lapu Street, Tacurong City, Sultan Kudarat, Philippines
Telephone No.: (064) 200-3631 Fax No.: (064) – 200-4131

1.2 CHECKLIST ON TEMPERATURE TAKING AXILLA METHOD

Student Name: _____________________________________ Year Level: _________________

Inclusive Date: _____________________

Direction: In using the checklist, please use the following rating scale in evaluating the performance
of the student.

5 Excellent
Student performs the procedure correctly, and perfectly.
Student states the rationale correctly and completely.
Student is able to answer questions accurately.
8 Very Satisfactory
Student performs the procedure correctly.
Student states the rationale correctly but incompletely.
Student is able to answer questions.
7 Satisfactory
Student performs the procedure correctly but failed to states the rationale.
Student is able to answer questions when cued.
6 Fair
Student performs the procedure when cued.
Student fail to states the rationale.
Student is able to answer questions when cued.
 5 Poor
Student fails to perform the procedure correctly even when cued.
Student does not know the rationale.

PROCEDURE 1 2 3 4 5
Assessment
1. Assess the client’s skin of warm to touch. 1 2 3 4 5
2. Assess for most appropriate site to check the temperature. 1 2 3 4 5
Planning 1 2 3 4 5
3. Wash hands.
4. Gather the equipment needed. 1 2 3 4 5
Implementation
5. Identify the client and explain the procedure. 1 2 3 4 5
6. Wipe thermometer form bulb to stem with firm twisting motion. 1 2 3 4 5
7. Shake the thermometer firmly with strong wrist motion until
mercury is down to lowest marking. 1 2 3 4 5
8. Assist the client in a supine of sitting position. 1 2 3 4 5
9. Raise client’s arm away from torso, insert bulb into center of
axilla, lower arm over bulb and place across client’s chest. 1 2 3 4 5
10. Leave thermometer in place for 5-10 minutes. 1 2 3 4 5
11. Remove thermometer and wipe off any remaining secretions
from stem toward the bulb with a rotating motion. 1 2 3 4 5
12. Read thermometer at eye level. 1 2 3 4 5
13. Wash the thermometer with soap and water, dry and shake
and return to container. 1 2 3 4 5
14. Assist client in replacing clothing of gown. 1 2 3 4 5
15. Wash hands. 1 2 3 4 5
Evaluation
16. Evaluate the temperature taken. 1 2 3 4 5
Documentation
17. Record result in a graphing sheet. 1 2 3 4 5
Total Points: ______________
Average: ______________
RD Grade: _____________

________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
_______________

________________________________
Signature over Printed Name
(FACULTY)
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
_______________
________________________________
1.3 RECTAL METHOD
EQUIPMENT
 Rectal thermometer
 Cotton balls and alcohol
 Watch with second hand
 Paper and pen
PROCEDURE
1. Identify and explain procedure to patient.
2. Wash hands.
3. Gather equipment needed.
4. Draw curtain around bed and/or close door.
5. Wipe thermometer form bulb to stem with rotating
motion using soft tissue or cotton balls.
6. Put on disposable gloves.
7. Grasp thermometer firmly with thumb and forefinger
and sharply flick wrist downward. Continue shaking
until mercury line reaches lowest markings.
8. Assist client to Sims position/side lying with upper
leg flexed. Move side bed linen to expose only anal
area.
9. Lubricate mercury bulb around 2.5 cm (inch).
10. With non-dominant hand, separate client’s buttocks
to expose anus. Ask client to breathe slowly and
relax.
11. Gently insert thermometer into anus towards
Signature over Printed Name
(Student)
RATIONALE
 To ensure correct procedure to
right patient.
 Explaining procedure reduces
anxiety and fear thus promoting
cooperation from the client.
 Reduces transmission of
microorganisms.
 To facilitate systematic assessment
and measurement.
 To maintain client privacy and
promote comfort.
 To remove chemical solution dust
or dirt that may irritate mucous
membrane and prevent transfer of
microorganisms.
 To maintain standard precautions
when exposed to items soiled with
body fluids.
 To provide accurate reading.
 To minimize embarrassment.
 Sims position/side lying exposes
anal area for correct thermometer
placement.
 To reduce friction and facilitate
insertion without irritating the
mucous membrane,
 Fully exposed anus for
thermometer insertion.
 Breathing slowly relaxes anal
sphincter for easier thermometer
insertion.
 To avoid injury to anal sphincter.
 direction of umbilicus 3.8 cm (1.5inch). do not force
thermometer.

12. Leave thermometer for 1-3 minutes for more  To provide sufficient/adequate time
accurate reading. for recording of the temperature.
13. Carefully remove thermometer and wipe off any  To prevent cross contamination.
remaining secretion with clean tissue. Wipe with  Wipe from area with least
rotating motion from stem toward bulb. contamination to area most
contaminated.
14. Read thermometer at eye level. Gently rotate until  To ensure correct reading.
scale appears.
15. Wipe client’s anal area with soft tissue to remove  To provide comfort and hygiene.
excess lubricant or feces and discard tissue. Assist
client in assuming a comfortable position.
16. Clean thermometer with alcohol before storing in  Protective storage container
appropriate protective storage. prevents breakage.
17. Remove and dispense gloves in appropriate  To reduce transfer of
receptacle. Wash hands. microorganism.
18. Record result.  It serves as baseline data for
health care providers.
 NOTRE DAME OF TACURONG COLLEGE
COLLEGE OF NURSING
Lapu-Lapu Street, Tacurong City, Sultan Kudarat, Philippines
Telephone No.: (064) 200-3631 Fax No.: (064) – 200-4131

1.3 CHECKLIST ON TEMPERATURE TAKING RECTAL METHOD

Student Name: _____________________________________ Year Level: _________________

Inclusive Date: _____________________

Direction: In using the checklist, please use the following rating scale in evaluating the performance
of the student.

5 Excellent
Student performs the procedure correctly, and perfectly.
Student states the rationale correctly and completely.
Student is able to answer questions accurately.
9 Very Satisfactory
Student performs the procedure correctly.
Student states the rationale correctly but incompletely.
Student is able to answer questions.
8 Satisfactory
Student performs the procedure correctly but failed to states the rationale.
Student is able to answer questions when cued.
7 Fair
Student performs the procedure when cued.
Student fail to states the rationale.
Student is able to answer questions when cued.
6 Poor
Student fails to perform the procedure correctly even when cued.
Student does not know the rationale.
 PROCEDURE 1 2 3 4 5
Assessment
1. Assess the client’s skin of warm to touch. 1 2 3 4 5
2. Assess for most appropriate site to check the temperature. 1 2 3 4 5
3. Assess for any presence of lesions, sores in the anal region. 1 2 3 4 5
Planning 1 2 3 4 5
4. Wash hands.
5. Gather the equipment needed. 1 2 3 4 5
Implementation 1 2 3 4 5
6. Identify the client and explain the procedure.
7. Wear gloves. 1 2 3 4 5
8. Wipe the thermometer from bulb to stem with a firm rotating 1 2 3 4 5
motion.
9. Shake the thermometer with strong wrist motion until the 1 2 3 4 5
mercury reaches the lowest marking.
10. Position the client to Sims/Side lying position with the upper 1 2 3 4 5
leg slightly flexed.
11. Drape the client by exposing the anal area only. 1 2 3 4 5
12. Lubricate mercury bulb around 2.5 cm (1inch). 1 2 3 4 5
13. With non-dominant hand separate client’s buttocks to expose 1 2 3 4 5
anus.
14. Gently insert the bulb into anus around 3.8 cm (1.5inch). 1 2 3 4 5
15. Leave thermometer in place for 1-3 minutes. 1 2 3 4 5
16. Remove thermometer and wipe off any secretion from stem 1 2 3 4 5
toward bulb with a rotating motion.
17. Read thermometer at eye level. 1 2 3 4 5
18. Wipe client’s anal area with soft tissue. 1 2 3 4 5
19. Wash the thermometer with soap and water. Dry shake and 1 2 3 4 5
return to container.
20. Discard soiled articles used. 1 2 3 4 5
21. Wash hands. 1 2 3 4 5
Evaluation 1 2 3 4 5
22. Evaluate the temperature taken.
Documentation 1 2 3 4 5
23. Record result in a graphing sheet.
Total Points: ______________
Average: ______________
RD Grade: _____________

________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
_______________

________________________________
Signature over Printed Name
(FACULTY)
________________________________________________________________________________
________________________________________________________________________________
___________________________________________________________________

________________________________
Signature over Printed Name
(Student)

NOTRE DAME OF TACURONG COLLEGE

 COLLEGE OF NURSING
Lapu-Lapu Street, Tacurong City, Sultan Kudarat, Philippines
Telephone No.: (064) 200-3631 Fax No.: (064) – 200-4131

2. PULSE TAKING

DEFINITION
 Expansion of the arterial walls occurring with each ventricular contraction.

PURPOSE
 To provide clinical data regarding the heart’s pumping action and the adequacy of
peripheral artery blood flow.

EQUIPMENT
 Watch with second hand.

PROCEDURE RATIONALE
1. Wash hands.  To reduce transfer of
microorganisms.
2. Identify the client and explain procedure.  To ensure right procedure to right
patient.
 To alleviate fear and anxiety, thus
promoting cooperation.
3. Have the patient rest his arm alongside of his body  This position places the radial
with the wrist extended and the palm of the hand artery on the inner aspect of the
downward. patient’s wrist.
4. Place the tips of your middle three fingers on the  Finger tips are sensitive to touch
palm side of the patient’s wrist. Rest thumb on the and will feel the pulsation of the
back of the patient wrist. patient’s artery.
 Thumb should not be used
because it has pulse to avoid
confusion.
5. Apply enough pressure so that you can feel the  Pressing too hard may stop flow of
pulse (not too hard not too light) the blood and you will not be able
to feel the pulse.
 Too little pressure will be
imperceptible.
6. Using a watch with second hand count hand the  Sufficient time is necessary to
number of pulsation felt on the patient for one full detect irregularities and
minute. abnormalities.
7. If the pulse rate is abnormal, repeat the counting in  Repeating the count is necessary
order to determine accurately its rate, quality and for accuracy.
rhythm
8. Wash hands.  For infection control measures.
9. Record the pulse rate, rhythm and force immediately  To serve as baseline data for
in the graphing sheet. health care provider.

NOTRE DAME OF TACURONG COLLEGE

COLLEGE OF NURSING
Lapu-Lapu Street, Tacurong City, Sultan Kudarat, Philippines
Telephone No.: (064) 200-3631 Fax No.: (064) – 200-4131
 2. CHECKLIST ON PULSE TAKING

Student Name: _____________________________________ Year Level: _________________

Inclusive Date: _____________________

Direction: In using the checklist, please use the following rating scale in evaluating the performance
of the student.

5 Excellent
Student performs the procedure correctly, and perfectly.
Student states the rationale correctly and completely.
Student is able to answer questions accurately.
4 Very Satisfactory
Student performs the procedure correctly.
Student states the rationale correctly but incompletely.
Student is able to answer questions.
3 Satisfactory
Student performs the procedure correctly but failed to states the rationale.
Student is able to answer questions when cued.
2 Fair
Student performs the procedure when cued.
Student fail to states the rationale.
Student is able to answer questions when cued.
1 Poor
Student fails to perform the procedure correctly even when cued.
Student does not know the rationale.

PROCEDURE 1 2 3 4 5
Assessment
1. Assess client’s condition. 1 2 3 4 5
2. Check nature of pulse.
Planning 1 2 3 4 5
3. Wash hands.
4. Assemble the equipment. 1 2 3 4 5
Implementation 1 2 3 4 5
 5. Identify the client and explain the procedure.
6. Have the patient rest his arm alongside of his body with the 1 2 3 4 5
wrist extended and the palm of the hands downward.
7. Place the tips of your middle three fingers on the palm side of 1 2 3 4 5
the patient’s wrist. Rest thumb on the back of the patient wrist
8. Apply enough pressure so that you can feel the pulse (not too 1 2 3 4 5
hard not too light)
9. Using a watch with second hand count hand the number of 1 2 3 4 5
pulsation felt on the patient for one full minute.
10. If the pulse rate is abnormal, repeat the counting in order to 1 2 3 4 5
determine accurately its rate, quality and rhythm
11. Wash hands. 1 2 3 4 5
Evaluation 1 2 3 4 5
12. Evaluate nature of pulse.

Documentation 1 2 3 4 5
13. Record the pulse rate, rhythm and force immediately in the
graphing sheet.
Total Points: ______________
Average: ______________
RD Grade: _____________

________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
_______________

________________________________
Signature over Printed Name
(FACULTY)
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
_______________

________________________________
Signature over Printed Name
(Student)

NOTRE DAME OF TACURONG COLLEGE

COLLEGE OF NURSING
Lapu-Lapu Street, Tacurong City, Sultan Kudarat, Philippines
Telephone No.: (064) 200-3631 Fax No.: (064) – 200-4131

3. RESPIRATION TAKING

DEFINITION
 The act of breathing which includes intake of oxygen and the output of carbon dioxide.
PURPOSE
 To provide valuable information about a client’s physical and emotional health.

EQUIPMENT
 Watch with second hand.

PROCEDURE RATIONALE
1. Wash hands.  To reduce transfer of
microorganisms.
2. Identify and explain procedure to the client.  To ensure right procedure to right
patient.
 To alleviate fear and anxiety, thus
promoting cooperation.
3. Hold the client’s wrists just as if you were taking  This way client is not conscious
his/her pulse. breathing is being watched.
 Awareness of respiratory rate
assessment will cause the client
voluntarily to alter the respiratory
pattern.
4. Note the rise and fall of the client’s chest with each  Complete cycle of inspiration and
respiration. expiration constitutes one act of
respiration.
5. Using a watch with a second hand, count the  Sufficient time to observe depth
number of respiration for one full minute. and the other characteristics is
necessary.
6. Record the number of respiration.  Serves as a baseline data.

NOTRE DAME OF TACURONG COLLEGE

COLLEGE OF NURSING
Lapu-Lapu Street, Tacurong City, Sultan Kudarat, Philippines
Telephone No.: (064) 200-3631 Fax No.: (064) – 200-4131

3. CHECKLIST ON RESPIRATION TAKING

Student Name: _____________________________________ Year Level: _________________

Inclusive Date: _____________________

Direction: In using the checklist, please use the following rating scale in evaluating the performance
of the student.
 5 Excellent
Student performs the procedure correctly, and perfectly.
Student states the rationale correctly and completely.
Student is able to answer questions accurately.
4 Very Satisfactory
Student performs the procedure correctly.
Student states the rationale correctly but incompletely.
Student is able to answer questions.
3 Satisfactory
Student performs the procedure correctly but failed to states the rationale.
Student is able to answer questions when cued.
2 Fair
Student performs the procedure when cued.
Student fail to states the rationale.
Student is able to answer questions when cued.
1 Poor
Student fails to perform the procedure correctly even when cued.
Student does not know the rationale.

PROCEDURE 1 2 3 4 5
Assessment
1. Assess client’s condition. 1 2 3 4 5
2. Check nature of respiration. 1 2 3 4 5
Planning 1 2 3 4 5
3. Wash hands.
4. Identify client and explain procedure. 1 2 3 4 5
Implementation 1 2 3 4 5
5. Hold the client’s wrists just as if you were taking his/her pulse.
6. Note the rise and fall of the client’s chest. 1 2 3 4 5
7. Using a watch with a second hand, count the number of 1 2 3 4 5
respiration for one full minute.
8. Wash hands. 1 2 3 4 5
Evaluation 1 2 3 4 5
9. Evaluate the character of respiration.
Documentation 1 2 3 4 5
10. Record the character and the depth the respiration.
Total Points: ______________
Average: ______________
 RD Grade: _____________

________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
_______________

________________________________
Signature over Printed Name
(FACULTY)
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
_______________

________________________________
Signature over Printed Name
(Student)

NOTRE DAME OF TACURONG COLLEGE

COLLEGE OF NURSING
Lapu-Lapu Street, Tacurong City, Sultan Kudarat, Philippines
Telephone No.: (064) 200-3631 Fax No.: (064) – 200-4131

4. BLOOD PRESSURE TAKING

DEFINITION
 Pressure exerted on the wall of the arteries when the left ventricle of the heart pushes
blood into the aorta.

PURPOSE
 To determine vascular resistance to blood flow.
 To determine the effectiveness of cardiac muscle in pumping bllod to overcome the
vascular resistance.

EQUIPMENT
 Blood Pressure Apparatus
 Sphygmomanometer
 Stethoscope
 Paper and pen
 PROCEDURE
1. Identify and explain procedure to the client.
2. Assess the client’s physical status.
3. Assemble the equipment
4. Wash hands.
5. Place client in a comfortable position (lying or sitting)
and position the arm at the level of the heart with the
palm of the hand facing up (preferably use Left arm
because it is nearer the heart)
6. Place the cuff so that the inflatable bag is centred
over the brachial artery, approximately midway on
the arm so that lower edge of the cuff is about 2.5
cm (1 to 2 inches) above the inner aspect of the
elbow. The tubing should leave the edge on the cuff
nearer the client’s elbow.
7. Warp cuff around arm smoothly and snugly (not to
lose, not too tight.
8. Feel the pulse beat over the brachial artery at the
inner aspect of the elbow with the use of fingertips
and don’t allow diaphragm or bell of the stethoscope
to touch clothing cuff.
9. Place stethoscope earpiece in your ears and close
screw valve on the air pump.
10. Palpate brachial artery, turn valve clockwise to close
and compress bulb to inflate cuff to 30mm Hg above
points where palpated pulse disappears, then slowly
release valve (deflating cuff). Noting reading when
pulse is felt again.
11. Release the air in the cuff slowly so that the
pressure goes down at the rate of 2 – 3 mm
Hg/second and listen for the sound (first distinctly
loud muffling sounds is systolic pressure)
12. Continue to release the air evenly and slowly (last
soft muffling sound is diastolic pressure)
13. After the final sound has disappeared deflate cuff
RATIONALE
 To ensure right procedure is done
to client and gain the client’s
cooperation.
 To ensure that the clients is rested
and to identify the affected side of
the client.
 To promote the efficiency of the
health care provider.
 To decrease the transfer of
microorganisms.
 This position places the brachial
artery on the inner aspect of the
elbow that a stethoscope disc can
rest on it conveniently. having the
arm above the level of the heart
causes a decrease in BP.
 Pressure in the cuff applied directly
to the artery will give the most
accurate readings. If the cuff get in
the way of the stethoscope disc on
the anterior elbow, readings are
likely to be inaccurate. A cuff
placed upside down with the tubing
toward the patients head will give a
false reading.
 A smooth cuff and wrapping
procedure equal pressure and give
accurate reading. A cuff too loosely
wrapped will give inaccurate
reading.
 Having the stethoscope disc
directly over the artery makes more
accurate reading, and having the
stethoscope disc firmly placed on
the skin away from clothing and the
cuff prevents missing sounds.
 Sounds are heard more clearly
when the earpiece follow the
direction of the ear canal.
 Lack of blood in patient’s arm may
cause a temporary tingling and
numbing sensation.
 If the air released too slowly from
the cuff, there will be congestion in
the extremity causing false reading
and if it is released too rapidly
sounds may not be heard at
accurate levels.
 Diastolic is when the blood flows
easily in the brachial artery and it is
approximately equivalent to the
amount of pressure normally
present on the walls of arteries
when the heart is at rest.
 To release the remaining air from
 rapidly and completely. the cuff and prevent congestion in
extremity.
14. Roll the cuff and place it in the case. Wipe the  This method of removing dirt
earpieces of the stethoscope with antiseptic swab prevents possible cross infection of
and out back in its proper place. the ears.
15. Wash hands.  To prevent the transmission of
microorganisms.
16. Record result.  To serve as baseline data for
health care provider.

NOTRE DAME OF TACURONG COLLEGE

COLLEGE OF NURSING
Lapu-Lapu Street, Tacurong City, Sultan Kudarat, Philippines
Telephone No.: (064) 200-3631 Fax No.: (064) – 200-4131

3. CHECKLIST ON RESPIRATION TAKING

Student Name: _____________________________________ Year Level: _________________

Inclusive Date: _____________________

Direction: In using the checklist, please use the following rating scale in evaluating the performance
of the student.

5 Excellent
Student performs the procedure correctly, and perfectly.
Student states the rationale correctly and completely.
Student is able to answer questions accurately.
4 Very Satisfactory
Student performs the procedure correctly.
Student states the rationale correctly but incompletely.
Student is able to answer questions.
3 Satisfactory
Student performs the procedure correctly but failed to states the rationale.
 Student is able to answer questions when cued.
2 Fair
Student performs the procedure when cued.
Student fail to states the rationale.
Student is able to answer questions when cued.
1 Poor
Student fails to perform the procedure correctly even when cued.
Student does not know the rationale.

PROCEDURE 1 2 3 4 5
Assessment
1. Assess the client’s physical condition. 1 2 3 4 5
2. Assess for factors that affect blood pressure.
3. Determine the client’s baseline blood pressure. 1 2 3 4 5
Planning 1 2 3 4 5
4. Wash hands.
5. Gather the equipment needed. 1 2 3 4 5
Implementation 1 2 3 4 5
6. Identify the client and explain the procedure.
7. Place client in a comfortable position (lying or sitting) and 1 2 3 4 5
position the arm at the level of the heart.
8. Place the cuff at the center observing at least 1 to 2 inches 1 2 3 4 5
above the inner aspect of the brachial artery.
9. Warp cuff around arm smoothly and snugly. 1 2 3 4 5
10. Feel the pulse beat over the inner aspect of the elbow with the 1 2 3 4 5
use of fingertips.
11. Place the stethoscope earpiece and close screw valve on the 1 2 3 4 5
air pump.
12. Palpate brachial artery, close valve clockwise compress bulb 1 2 3 4 5
to inflate cuff to 30mm Hg.
13. Release the valve (deflating) on the cuff slowly so that the 1 2 3 4 5
pressure goes down at the rate 2-3 mmhg/sec. Listen to the
sound (first distinct loud muffling sound is systolic)
14. Continue to release the air evenly and slowly (last soft muffling 1 2 3 4 5
sound is diastolic pressure)
15. Deflate cuff rapidly and completely after the final sound has 1 2 3 4 5
disappeared.
16. Clean and store the equipment. 1 2 3 4 5
17. Wash hands. 1 2 3 4 5
Evaluation 1 2 3 4 5
18. Evaluate the nature of the blood pressure.
19. Evaluate the client condition. 1 2 3 4 5
Documentation 1 2 3 4 5
 20. Record the result taken.
Total Points: ______________
Average: ______________
RD Grade: _____________

________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
_______________

________________________________
Signature over Printed Name
(FACULTY)
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
_______________

________________________________
Signature over Printed Name
(Student)
NOTRE DAME OF TACURONG COLLEGE
COLLEGE OF NURSING
Lapu-Lapu Street, Tacurong City, Sultan Kudarat, Philippines
Telephone No.: (064) 200-3631 Fax No.: (064) – 200-4131

D. PREPARATION OF STERILE FIELD

DEFINITION
 Sterile Filed is a microorganism-free area that can receive sterile supplies.

PURPOSE
 To create a non-contaminated area prior to sterile or invasive procedure.

EQUIPMENT
 Package containing a sterile drape
 Sterile equipment as needed
 Wrapped sterile gauze
 Antiseptic solution

PROCEDURE RATIONALE
1. Confirm the sterility of the package  To ensure that the package is
clean and dry. Moist indicates
contamination and package must
be discarded.
2. Select clean work surface above waist level.  Below waist level is considered
contaminated.
3. Wash hands.  To prevent the transmission of
microorganism.
4. Assemble the supplies in the work area.  To promote efficiency.
To open a wrapped package on a surface
5. Place the package at the center of the work area so  To prevent subsequent reaching
that the top flap of the wrapper opens away from over the exposed sterile contents,
you. this could contaminate them.
6. Pinch the wrappers top flap between your thumb  Touching only the outside of the
and index finger. wrapper maintains the sterility of
the inside of the wrapper.
7. Repeat for side flaps, opening the top one first. Use
the right hand for the right flap, and the left hand for
the left flap.
8. Pull the fourth flap or the innermost flap toward you,
allowing it to fall flat on the surface. Make sure that
the flap does not touch your uniform.
To add sterile item on sterile field
9. Open the sterile item while holding outside wrapper
in non-dominant hand.
10. Carefully peel wrapper onto dominant hand.
11. Place items well within the sterile filed. Small items
such as gauze dressing may be dropped 6-8 inches
above the sterile files. Large items should be put
down carefully.
12. Dispose outer wrapper.
To add liquid solution to a sterile field
13. Read the solution label and strength three times
14. Remove the lid and place sterile side up onto a
clean surface.
15. Holding the bottle, pour the liquid from 6-8 inches
above the sterile container in the sterile field.
16. Pour slowly to prevent splashing
17. Keep ypur arm as far as possible from the sterile
field. Avoid reaching over the sterile field.
 By using both hands, you avoid
reaching over the sterile field.
 If the inner surface touches any
unsterile article like the uniform, it
is considered contaminated.
 To free dominant hand for
unwrapping the outer package.
 Items remain sterile, inner surface
of the wrapper covers hands,
making it sterile.
 To prevent accidental
contamination of sterile field.
 To prevent contamination of the
sterile field.
 To ensure giving the right
medication.
 To prevent contamination of the lid.
 To avoid the possibility of the two
container touching each other.
 If liquid is spilled in sterile field, the
spot is considered contaminated.
 To prevent contamination of the
sterile area.
 NOTRE DAME OF TACURONG COLLEGE
COLLEGE OF NURSING
Lapu-Lapu Street, Tacurong City, Sultan Kudarat, Philippines
Telephone No.: (064) 200-3631 Fax No.: (064) – 200-4131

D. CHECKLIST ON PREPARATION OF STERILE FIELD

Student Name: _____________________________________ Year Level: _________________

Inclusive Date: _____________________

Direction: In using the checklist, please use the following rating scale in evaluating the performance
of the student.

5 Excellent
Student performs the procedure correctly, and perfectly.
Student states the rationale correctly and completely.
Student is able to answer questions accurately.
4 Very Satisfactory
Student performs the procedure correctly.
Student states the rationale correctly but incompletely.
Student is able to answer questions.
3 Satisfactory
Student performs the procedure correctly but failed to states the rationale.
Student is able to answer questions when cued.
2 Fair
Student performs the procedure when cued.
Student fail to states the rationale.
Student is able to answer questions when cued.
1 Poor
Student fails to perform the procedure correctly even when cued.
Student does not know the rationale.
 PROCEDURE 1 2 3 4 5
1. Select clean work surface above the waist level 1 2 3 4 5
2. Wash hands 1 2 3 4 5
3. Assemble the supplies. 1 2 3 4 5
To open wrapped package on a surface 1 2 3 4 5
4. Place the package on the center of the work area.
5. Pull the top flap wrapper between thumb and index finger away 1 2 3 4 5
from you.
6. Open side flaps opening the tip flap first. Right hand for the right 1 2 3 4 5
for the right flap and left for the left flap.
7. Pull the innermost flap toward you. 1 2 3 4 5
To add sterile item on sterile field 1 2 3 4 5
8. Open sterile item while holding outside wrapper.
9. Peel the wrapper onto dominant hand. 1 2 3 4 5
10. Place the item 6-8 inches above the sterile field. 1 2 3 4 5
11. Dispose outer wrapper. 1 2 3 4 5
To add liquid solution to a sterile field. 1 2 3 4 5
12. Read the label solution and strength three times.
13. Remove the lid and sterile side up on clean surface. 1 2 3 4 5
14. Pour liquid from 6-8 inches above into the sterile container in the 1 2 3 4 5
sterile field.
15. Pour slowly 1 2 3 4 5
16. Avoid reaching over the sterile field. 1 2 3 4 5
Total Points: ______________
Average: ______________
RD Grade: _____________

________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
_______________

________________________________
Signature over Printed Name
(FACULTY)
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
_______________

________________________________
Signature over Printed Name
(Student)
 NOTRE DAME OF TACURONG COLLEGE
COLLEGE OF NURSING
Lapu-Lapu Street, Tacurong City, Sultan Kudarat, Philippines
Telephone No.: (064) 200-3631 Fax No.: (064) – 200-4131

E. GLOVING TECHNIQUE

DEFINITION
 It is a method where sterile gloves are worn aseptically.

PURPOSE
 To prevent any accidental contact of a substance that could carry a blood-borne
pathogen with small breaks in the skin.

EQUIPMENT
 Sterile gloves (appropriate size for individual)
PROCEDURE RATIONALE
1. Remove jewelry particularly rings  Rings may tear the gloves and can
harbor organism.
2. Wash hands  To minimize the transfer of
organism
3. Remove outer wrapper carefully by separating and  To prevent inner glove package
peeling apart sides and lay it on clean, flat surface. from accidentally opening and
touching the contaminated objects.
4. Open inner wrapper and touching only the outside,  The outer portion of the inner
secure both flaps in open position. wrapper is contaminated. Inner
portion of the wrapper is sterile.
5. Identify right and left glove. Each glove has cuff  Proper identification of gloves
approximately 5 cm and 2 inches wide. Glove contamination by improper fit.
dominant hand. Gloving dominant hand first
promotes efficiency.
6. With thumb and first two fingers of non –dominant  The inner of the first glove is now
hand, grasp the inner fold of the cuff. Lift the glove,
holding away from the body. Slip dominant hand
touching only the inner surface of the glove.
7. With gloved dominant hand, slip four fingers  Contact of gloved hand with
underneath second glove cuff. Lift the glove away exposed hand result in
from the body. Slide the second hand into the contamination.
second glove, touching only the inner part of the
glove.
8. Adjust fingers of both gloves using gloved hand.  If a sterile object (first gloved hand)
 touches a second sterile object
(second gloved hand) both remains
sterile.
9. Raise gloved hand above waist level.  Below waist level is considered
contaminated,
GLOVE DISPOSAL
10. Grasp outside of one cuff with other gloved hand,  Minimizes contamination of
avoid touching the wrists. underlying skin.
11. Pull glove off, turning it inside out. Discard in  Outside of glove should not touch
receptacle. skin.
12. Take fingers of care hand and tuck inside remaining  This method neatly encloses the
glove cuff. Pull glove of, inside out. Discard in used object in the glove, making
receptacle. disposal more sanitary.
NOTRE DAME OF TACURONG COLLEGE
COLLEGE OF NURSING
Lapu-Lapu Street, Tacurong City, Sultan Kudarat, Philippines
Telephone No.: (064) 200-3631 Fax No.: (064) – 200-4131

E. CHECKLIST ON GLOVING TECHNIQUE

Student Name: _____________________________________ Year Level: _________________

Inclusive Date: _____________________

Direction: In using the checklist, please use the following rating scale in evaluating the performance
of the student.

5 Excellent
Student performs the procedure correctly, and perfectly.
Student states the rationale correctly and completely.
Student is able to answer questions accurately.
4 Very Satisfactory
Student performs the procedure correctly.
Student states the rationale correctly but incompletely.
Student is able to answer questions.
3 Satisfactory
Student performs the procedure correctly but failed to states the rationale.
Student is able to answer questions when cued.
2 Fair
Student performs the procedure when cued.
Student fail to states the rationale.
Student is able to answer questions when cued.
1 Poor
Student fails to perform the procedure correctly even when cued.
Student does not know the rationale.
 PROCEDURE 1 2 3 4 5
1. Remove jewelry, particulary rings. 1 2 3 4 5
2. Wash hands 1 2 3 4 5
3. Remove outer wrapper, peeling apart sides and lay it on clean, flat 1 2 3 4 5
surface.
4. Open inner wrapper and touching only the outside. 1 2 3 4 5
5. Secure both flaps open. Identify right and left glove. 1 2 3 4 5
6. grasp the inner fold with thumb and first two fingers of non- 1 2 3 4 5
dominant hand and slip the hand touching only the inner surface.
7. With gloved dominant hand, slip four fingers underneath second 1 2 3 4 5
glove cuff. Lift the glove away from the body. Slide the second
hand into the second glove, touching only the inner part of the
glove.
8. Adjust fingers of both gloves using gloved hand. 1 2 3 4 5
9. Raise gloved hand above waist level. 1 2 3 4 5
GLOVE DISPOSAL 1 2 3 4 5
10. Grasp outside of one cuff with other gloved hand, avoid touching 1 2 3 4 5
the wrists.
11. Pull glove off, turning it inside out. Discard in receptacle. 1 2 3 4 5
12. Take fingers of care hand and tuck inside remaining glove cuff. 1 2 3 4 5
Pull glove of, inside out. Discard in receptacle.
Total Points: ______________
Average: ______________
RD Grade: _____________

________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
_______________

________________________________
Signature over Printed Name
(FACULTY)
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
_______________

________________________________
Signature over Printed Name
(Student)
 NOTRE DAME OF TACURONG COLLEGE
COLLEGE OF NURSING
Lapu-Lapu Street, Tacurong City, Sultan Kudarat, Philippines
Telephone No.: (064) 200-3631 Fax No.: (064) – 200-4131

F. GOWNING TECHNIQUE

DEFINITION
 It is one of the method of wearing sterile gown when surgical asepsis is necessary.

PURPOSE
 To prevent the spread of the microorganisms.
 To avoid the risk of infection before undergoing invasive procedures.

EQUIPMENT
 Sterile gown
 Sterile cap
 Surgical mask
 Foot cover (optional)

PROCEDURE RATIONALE
1. Wash hands  To prevent and limit the transfer of
microorganisms
2. If required, put on:  To prevent the mask from failing to
a. Protective cap. the front of the uniform.
b. Face mask.
b.1. Find the top edge of mask (usually has then
metal strap along edge).
b.2. Hold the mask by top two strings. Tie two
upper strings at the back of head with ties
above the ear.
b.3. Tie lower strings snugly around with mask
well under chin.
c. Foot covers.

3. Perform thorough surgical wash.  To remove resident bacteria from

hands and forearm.
4. Open sterile pack containing gown. Holding folded  Clean hands may touch inside of
gown, locate the neckband with both hand, grasp gown without contaminating the
the inside front of the gown with both hands just outer surface. Neckband of the
below neckband. gown is considered sterile.
5. Allow gown to unfold, keeping inside of the gown  Outer portion of gown is
toward the body. Do not touch outer portion of the considered sterile.
gown with bare hands.
6. With hand at shoulder level, slip both arms into arm  The inside part of the gown is
holes simultaneously. A second person or circulating considered unsterile and this
nurse who is not sterile bring of pull gown over the maybe touched by second person.
shoulders, touching only the inside surface of the
gown. Pull the gown into place and tie the neckties.
7. The gowned nurse then bends forward to make the  Waist ties are sterile until touched
 waist ties (locate waist level on the side gown.
These are then tied by second person.
8. If the gown is contaminated at any point, it is
discarded and steps 3 through 7 should be
repeated.
by second person. Care must be
taken not to touch the front of the
gown.
 To prevent cross-conatmination.
 NOTRE DAME OF TACURONG COLLEGE
COLLEGE OF NURSING
Lapu-Lapu Street, Tacurong City, Sultan Kudarat, Philippines
Telephone No.: (064) 200-3631 Fax No.: (064) – 200-4131

F. CHECKLIST ON G GOWNING TECHNIQUE

Student Name: _____________________________________ Year Level: _________________

Inclusive Date: _____________________

Direction: In using the checklist, please use the following rating scale in evaluating the performance
of the student.

5 Excellent
Student performs the procedure correctly, and perfectly.
Student states the rationale correctly and completely.
Student is able to answer questions accurately.
4 Very Satisfactory
Student performs the procedure correctly.
Student states the rationale correctly but incompletely.
Student is able to answer questions.
3 Satisfactory
Student performs the procedure correctly but failed to states the rationale.
Student is able to answer questions when cued.
2 Fair
Student performs the procedure when cued.
Student fail to states the rationale.
Student is able to answer questions when cued.
1 Poor
Student fails to perform the procedure correctly even when cued.
Student does not know the rationale.

PROCEDURE 1 2 3 4 5
1. Wash hands 1 2 3 4 5
2. Put on:
 a. Protective cap
b. Surgical mask
c. Foot covers
3. Tie two upper strings at the back of head.
4. Tile lower strings snugly around with mask well under the chin
5. Perform handwashing.
6. Open sterile pack containing gown. Grasp inside front of gown
with both hands just below the neckband.
7. Allow gown to unfold, keeping inside of gown towards body. Do
not touch outside of gown with bare hands.
8. Slip both arms into arm holes simultaneously
9. Ask another person, bring or pull gown over shoulders an tie the
neck ties.
10. The gowned nurse then bends forward to make the waist ties.
These are then tied by second person.
11. If the gown is contaminated repeat steps 3 through 7.

Total Points: ______________

Average: ______________
RD Grade: _____________

________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
_______________

________________________________
Signature over Printed Name
(FACULTY)
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
_______________

________________________________
Signature over Printed Name
(Student)