Wah Institute of Nursing

Wah Medical College

Wah Cantt

Fundamental of Nursing Skills Manual Page 1

 MAKING AN UNOCCUPIED BED
1. PURPOSES
o To conserve patient’s energy and maintain current health status.
o To provide client comfort.
o To provide a clean, neat environment for the client.
o To provide a smooth, wrinkle free bed foundation , thus minimizing sources of skin
irritation

2. EQUIPMENT:
o Two large sheets.
o Draw sheet.
o Blanket (Optional)
o Mackintosh(optional)
o Pillow cases
o Hamper bag
o Chair

3. PROCEDURES

S# STEPS RATIONALE S U
1 Identify the patient To give care to the right patient
2 Check from RN/patient’s chart/ Ensure patient’s safety as well as
Kardex for orders or specific use of proper body mechanics for
precautions for movement and nurse and patient.
positioning.
3 Collect equipment and supplies Save time and energy
4 Place the fresh linen on the patient’s Organizing linen in order of use
chair in order of use, at the foot end of saves time and energy
bed.
5 Place hamper bag in a convenient Facilitates disposal of soiled linen
place
6 Explain procedure to the patient Minimizes anxiety and promotes
cooperation
7 Wash hands Prevents transmission of micro
organisms
8 Draw room curtains around the bed or Maintaining privacy, thus
close the door promoting emotional and physical
comfort.
9 Remove call bell/light Provides easy access to bed and
linen
10 Adjust bed in working position and Minimizes strain on nurses back.
lock the bed. Ensures safety
11 Loosen all linen starting from head Makes work easy.
end of the bed from the working side.
12 Fan folds soiled linen. Provides maximum space for clean
linen.

Fundamental of Nursing Skills Manual Page 2

13 Fan folds half of the clean bottom S U
sheet vertically. Tuck and mitre the
corner at the head end and tuck in the
working side
14 Place the mackintosh and the draw Draw sheet eliminates irritating
sheet vertically at the center of the bed wrinkles and folds.
and tuck them firmly.
15 Move on to the other side and lower Provides easy access
the side rail.
16 Remove the used linen and place them Reduces transmission of micro
in the hamper bag organisms
17 Pull the bottom sheet, mackintosh and Provides comfort
the draw sheet firmly.
18 Mitre the head end corner of the
bottom sheet and tuck it in.
19 Tuck mackintosh and draw sheet
firmly
20 Change the pillow case and reposition Maintains patient’s comfort
it at the center of the bed, turning the
opening away from the door/main
entrance.
21 Assist the patient to a comfortable
position.
22 Spread the top sheet over the patient
(You may ask patient to hold it while
removing the used sheet). A blanket
may be used if required
23 Ask the patient to slightly flex the Helps in making the pleat easily.
knees
24 Make a vertical toe pleat Provides additional space for the
patient’s feet
25 Tuck the foot end of top sheet and
mitre the corners
26 Fold 6 inches of the top sheet to make Makes it easier for the patient to
a cuff pull the sheet up
27 Adjust call bell and return bed to a Ensures patients safety and
comfortable position comfort
28 Place over bed table and chair in Promotes sense of well being and
proper place, arranging personal items minimizes exertion on the patient
with in easy reach on bedside dooly.
29 Replace all equipment Ensures readiness for next use.
30 Wash hands Prevents transmission of micro
organisms

Fundamental of Nursing Skills Manual Page 3

 MAKING AN OCCUPIED BED

1. PURPOSES
o To conserve patient’s energy and maintain current health status.
o To provide client comfort.
o To provide a clean, neat environment for the client.
o To provide a smooth, wrinkle free bed foundation , thus minimizing sources of skin
irritation

2. EQUIPMENT
o Two large sheets.
o Draw sheet.
o Blanket (Optional)
o Mackintosh(optional)
o Pillow cases
o Hamper bag
o Chair

3. PROCEDURES

S# STEPS
1 Identify the patient
2 Check from RN/patient’s chart/
Kardex for orders or specific precautions
for movement and positioning.
3 Collect equipment and supplies
4 Place the fresh linen on the patient’s chair
in order of use, at the foot end of bed.
5 Place hamper bag in a convenient place
6 Explain procedure to the patient
7 Wash hands
8 Draw room curtains around the bed or
close the door
9 Remove call bell/light
10 Adjust bed in working position and lock
the bed.
11 Assist the patient to turn on far side of the
bed. Raise the side rails of that side.
Adjust the pillow.
12 Loosen all linen starting from head end of
the bed from the working side.
13 Fan folds soiled linen near the patient
14 Fan folds half of the clean bottom sheet
vertically as close to the patient as
RATIONALE S U
To give care to the right patient
Ensure patient’s safety as well as use of
proper body mechanics for nurse and
patient.
Save time and energy
Organizing linen in order of use saves
time and energy
Facilitates disposal of soiled linen
Minimizes anxiety and promotes
cooperation
Prevents transmission of micro organisms
Maintaining privacy, thus promoting
emotional and physical comfort.
Provides easy access to bed and linen
Minimizes strain on nurses back. Ensures
safety
Protects accidental fall
Makes work easy.
Provides maximum space for clean linen.
S U

Fundamental of Nursing Skills Manual Page 4

 possible. Tuck and mitre the corner at the
head end and tuck in the working side.
15 Place the mackintosh and the draw sheet Draw sheet eliminates irritating wrinkles
vertically at the center of the bed and tuck and folds.
them firmly.
16 Assist the patient to roll over towards you, Prevents accidental fall.
adjust the pillow and raise the side rail.
17 Move on to the other side and lower the Provides easy access
side rail.
18 Remove the used linen and place them in Reduces transmission of micro organisms
the hamper bag
19 Pull the bottom sheet, mackintosh and the Provides comfort
draw sheet firmly.
20 Mitre the head end corner of the bottom
sheet and tuck it in.
21 Tuck mackintosh and draw sheet firmly
22 Change the pillow case and reposition it at Maintains patient’s comfort
the center of the bed, turning the opening
away from the door/main entrance.
23 Assist the patient to a comfortable
position.
24 Spread the top sheet over the patient (You
may ask patient to hold it while removing
the used sheet). A blanket may be used if
required
25 Ask the patient to slightly flex the knees Helps in making the pleat easily.
26 Make a vertical toe pleat Provides additional space for patient’s feet
27 Tuck the foot end of top sheet and mitre
the corners
28 Fold 6 inches of the top sheet to make a Makes it easier for patient to pull sheet up
cuff
29 Adjust call bell and return bed to a Ensures patients safety and comfort
comfortable position
Place over bed table and chair in proper Promotes sense of well being and
30 place, arranging personal items with in minimizes exertion on the patient
easy reach on bedside dooly.
31 Replace all equipment Ensures readiness for next use.
32 Wash hands Prevents transmission of micro organisms

Fundamental of Nursing Skills Manual Page 5

 HYGIENE CARE: COMPLETE OR PARTIAL BED BATH

BED BATH

1. PURPOSES:

 To remove transient microorganisms, body secretions and excretions, and dead skin
cells.
 To stimulate peripheral circulation.
 To improve patient's self esteem.
 To promote relaxation and comfort.
 To prevent or eliminate unpleasant body odors.

2. EQUIPMENT:

 Bath Basin (one)

 Bath towel (two)
 Soap with soap dish.
 Mittens/wash cloth.
 Bed linen.
 Gown and pajama.
 Linen, hamper bag.
 Comb or brush.
 Lotion.
 Gloves (disposable).
 Bath Thermometer (optional)

3. PROCEDURE:

S. # STEPS RATIONALE S U

1. Identify the patient To give care to the correct patient

2. Explain procedure to patient Promotes patient's cooperation and

participation

3. Assess patient's level of independence Participation improves patient's self

and involvement in procedure esteem

4. Arrange equipment in convenient place Easy access and order of equipment

prevents waste of time and energy
and prevents interruption during
procedure

5. Close the doors or draw curtains and put Air current increases the loss of
off fans body heat by convection. Maintains

Fundamental of Nursing Skills Manual Page 6


6. Keep side rails up while away from the
patient's bedside
7. Adjust bed to working position
8. Wash hands.
9. Offer bedpan/ urinal (if required)
(Follow respective checklist).
10. Assist with oral hygiene as necessary
(Refer to "mouth care" procedure)
11. Position patient comfortably. Move
patient towards the side close to nurse.
12. Fill basin 2/3 with warm water. Check
water temperature with your inner
aspect or wrist. (41°C and 43°C or
105°F to 109°F. Allow patient to check
water temperature.
13. Remove gown and pajama (Remove
clothing according to patient's
convenience). If patient has intravenous
lines ask for help.
14. Drape patient with sheet.
15. Spread towel across patient's chest on
top of sheet.
16. Wash patient's eye with water only and
dry them well. Use separate corner for
each eye.
17. Wipe the eyes from the inner to the
Fundamental of Nursing Skills Manual
privacy and avoids chilling
Raising, side rails maintains client's
safety as nurse leaves beside
Ensures proper body mechanics and S U
prevents strain on nurse's back.
Prevents risk of cross infection.
Prevents interruption and promotes
comfort.
Facilitates access and prevents strain on
back muscles
Promotes comfort, relaxes muscles, and
prevents accidental burning of patient’s
skin.
Provides full exposure of body parts
bathing.
Maintain privacy.
Prevents linen from getting soiled or
wet.
Prevents transmitting of
microorganisms.
Prevents secretions from entering the
Page 7
 outer canthus.
18. Wash patient's Face, Ears, and Neck
with soap.
19. Rinse each part of the face, ears and
neck with the other wash cloth. Dry
them well.
20. Expose the far arm of the patient. Place
bath towel length wise under arm.
21. Wash arm using long, firm strokes from
distal to proximal areas (fingers to
axilla)
22. Rinse and dry arm and axilla
thoroughly.
23. Repeat steps 19 to 21 for the other arm.
24. Place towel directly on bed and put the
basin on it. Immerse patient's hands in
water. Allow hands to soak for 3 to 5
minutes.
25. Assist patient to wash, rinse, and dry
hands paying particular attention to
interdigital spaces.
26. Change the water and check
Temperature of water with inner aspect
of wrist. Change water more frequently
if it becomes dirty or cool
27. Cover patient's chest with bath towel
and fold top sheet down to umbilicus.
With one hand, lift edge of towel away
from chest. With mitten hand, bath
chest using circular strokes. Take
special care to wash skin folds under
Fundamental of Nursing Skills Manual
nasolacrimal ducts.
Soap lowers surface tension thus
facilitates removal of debris and
bacteria.
Removes soap and microorganisms.
Moisture promotes bacterial growth.
Eliminates contamination of the area
once it is washed. Protects the bed linen
from becoming wet.
Soap lowers surface tension thus
facilitates removal of debris and
bacteria. Long, (inn strokes from distal
to proximal area increases venous
return.
Removes soap and microorganisms.
Drying prevents bacterial growth.
S U
Secretions and dust present between
fingers may damage the skin.
Maintains patient's comfort and prevents
accidental burning.
Present's unnecessary exposure. Towel
maintains warmth and privacy.
Secretions and dirt collect easily in areas
of skin folds and may damage the skin.
Page 8
 female's breasts. Keep patient's chest
covered between washing and rinsing.
Dry well.

28. Keep towel over chest. Fold top sheet Prevents chilling and unnecessary
down to the pubic region. exposure.

29. Bath abdomen with mitten hand, giving
special attention to umbilicus and
abdominal folds. Use circular strokes.
Rinse and dry well. Keep abdomen
Covered between washing and rinsing.
Soap lowers surface tension thus
facilitates removal of debris and
bacteria.

30. Pull top sheet back to neck and remove Maintains privacy, comfort and
bath towel. warn1th.

31. Expose far leg of patient and place bath Eliminates contamination of the area
towel length wise under the leg. Flex once it is clean. Protects bed linen from
patient’s leg slightly at knee Joint. becoming wet.

32. Wash legs using long, firm strokes from Soap lowers surface tension thus
ankle to thigh. Rinse and dry well facilitates removal of debris and
bacteria. Long, firm strokes from distal
to proximal area increases venous
return.

33. Repeat steps 30 to 31 for the other leg

34. Place basin on bed and allow feet to Soaking softens nails, loosens debris
soak for 3 - 5 minutes. beneath nails and enhances feeling of
cleanliness.

35. Wash feet paying particular attention to Secretions and dust present between
interdigital spaces. Rinse and dry well toes may damage skin.

36. Change water and check its temperature Maintains patient's comfort and prevents
with inner aspect of wrist. (41 ° - 43°C accidental burning.
or 105F° -109°F).

37. Assist patient to turn on to other side. Expose back and buttocks for bathing.
Place towel length wise along with
patient's back.

Fundamental of Nursing Skills Manual Page 9

38. Wash back using circular strokes from
shoulder to buttocks. Rinse and dry
thoroughly. Pay special attention to
clean gluteal folds. Observe for any
redness or skin breakdown.
Promotes relaxation and prevents skin S U
breakdown. (Prolong pressure on bony
prominence may impair circulation and
lead to development of decubitus ulcer).

39. Provide back care. (Refer "Back care"

procedure).

40. Change water and check water Maintains patient's comfort and prevents
temperature with the inner aspect of accidental burning.
wrist. (41 ° - 46° C or 105° - 109°P).

41. Assist patient to turn in supine position. Prevents unnecessary exposure. Patients
Cover chest and upper extremities with may prefer to wash their own genitalia.
towel and lower extremities with top
sheet. Expose only genitalia. Wash,
rinse and dry perineum. If patient can
wash, assist patient. Give special
attention to skin folds. (Refer to
"perineal care" procedure).

42. Change bed linen, (refer "occupied bad Prevents infection and promotes
making" procedure) comfort.

43. Assist patient to put on clean clothing. Maintains warmth, comfort and
Comb/ brush hair and make him/ her promotes self- esteem.
Comfortable.

44. Perform hand and foot care. ("Refer

hand and foot care" procedure).

45. Adjust bed according to patient's Ensures safety.

comfort and raise side rails.

46. Clean and replace equipment. Ensures readiness for next use and
maintains medical asepsis

47. Keep patient's area neat and tidy. Promotes environmental safety.

48. Wash hands Prevents risk of cross infection

49. Document in nursing notes Date/ time, Communicates care given and patient's
type of hygiene care given any pertinent condition. Protects nurses legally.
observation and patient's response.

Fundamental of Nursing Skills Manual Page 10

 ASSISTING PATIENT IN SHOWER BATH

1. PURPOSES:

 To remove transient microorganisms, body secretions and excretions, and dead skin
cells.
 To stimulate peripheral circulation.
 To improve patient's self esteem.
 To produce a sense of well being.
 To promote relaxation and comfort.
 To prevent or eliminate unpleasant body odors.

2. EQUIPMENT:
 Bath towel
 Shampoo/ soap
 Bed Linen
 Gown and pajama
 Lotion
 Bath slippers (Patient's own)
 Plastic apron (For nurse)
 Plastic chair
 Hamper bag

3. PROCEDURE

S. # STEPS RATIONALE S U

1. Identify the patient. Gives care to correct patient.

2. Assess patient's level of independence and Improves patient's self esteem.

involvement in procedure.

3. Discuss time for bath with patient Gives patient feeling of autonomy.

4. Check shower for cleanliness and proper Saves time and prevents
functioning. transmission of microorganisms
and delays.

5. Collect equipment and arrange it at Prevents possible falls when patient

convenient place. reaches for equipment.

Fundamental of Nursing Skills Manual Page 11

6. Assist patient to bathroom, use wheelchair
if necessary.
7. SHOWER BATH
a. Without Assistance:
Demonstrate patient how to use call bell for
assistance. Instruct him/her to call
immediately if feeling faint or weak.
Demonstrate patient how to adjust the knob
of the shower to regulate water temperature.
b. With Assistance:
Place a chair in the shower room.
Have patient wear slippers. Put on plastic
apron. Regulate water temperature
according to patient's tolerance.
Assist patient to remove gown and pyjama.
Place a towel across the patient's lap when
removing the gown. Assist patient in
shower.
8. Assist patient out of the shower and back to
his room. Provide assistance if needed.
9. Provide back care (if required).
10. Clean and replace equipment.
11. Dispose off soiled linen in hamper bag and
take hamper bag to soiled utility room.
12. Wash hands.
Fundamental of Nursing Skills Manual Page 12
Prevents accidental falls.
Prevents accidents.
S U
Protects from burn and cold.
Conserves energy and prevents
accidents.
Prevents the risk of cross infection
(ringworm or other fungal
infection).
Protects clothes.
Prevents accidental burns and
promotes patient comfort.
Prevents unnecessary exposure
Ensures safety.
Maintains integrity of skin.
Ensures readiness for next use and
maintains medical asepsis.
Prevents transmission of
microorganisms.
Prevents cross infection
 13. Document in nurses notes: Communicates care given and
patient’s condition. Protects legally.
Date/ time, procedure performed and patient
response.

Back care

1. PURPOSES:

 To assess skin condition.

 To promote relaxation and comfort.
 To stimulate circulation.
 To relieve muscle tension.
 To decrease risk of skin breakdown.

2. EQUIPMENT

 Lotion
 Bath towel
 Soap if
 Basin with warm water necessary
 Mittens
 Gloves (Optional)

3. PROCEDURE

S# STEPS RATIONALE S U
1. Identify the patient. Gives care to the correct patient
2. Assess the need for back care. Determines patient’s potential for benefit
from a back rub, signs of fatigue, movement
reflecting muscle stiffness.
3. Explain procedure and desired position Minimizes anxiety and gains cooperation
to the patient.
4. Collect equipment and arrange it in Saves time energy and prevents interruption
convenient place. during procedure.
5. Draw curtain or close door and put off Maintains privacy and decreases the loss of
fans body heat by convection and avoids chilling.
6. Adjust bed to working position Ensures proper body mechanics and prevents
strain on nurses back.
7. Wash hands. Prevents risk of cross infection.
8. Turn patient to lateral or prone position Provides easy access and exposure.
with back facing towards nurse.
9. Expose patient's back from shoulder to Prevents unnecessary exposure of body parts.
buttocks. Cover remaining part of the Privacy promotes relaxation.

Fundamental of Nursing Skills Manual Page 13

 body
10. Clean back if required (refer "bed bath"
procedure).
11 Observe for any discoloration and skin Facilities early detection and timely
break down paying special attention to interventions.
the bony prominence.
12. Pour small amount of lotion into hands Prevents friction and promotes comfort. S U
and rub hands together to warm the
lotion.
13. Massage the sacral area in circular Gentle, firm strokes promote relaxation.
motion. Move up along the massage, Continues contact with skin is soothing and
spine the scapulae with circular firm stimulates circulation to tissues.
strokes. Do not allow hands to leave
patient's skin. Continue Massage,
moving down the sacral area and repeat
for 3 minutes Pay special attention to
bony prominence.
14. Need first up the vertebral column and Increases circulation to muscles and releases
then over the entire back. tension.
15. End massage with long stroking Long stroking is most soothing of massage
movements. Lessen the pressure with movements.
each massage stroke and tell patient you
are ending the massage.
16. If patient is lying on side, ask patient to To cover the whole surface area.
turn to opposite side, and massage the
other side.
17. Wipe excess lotion with bath towel. Excess lotion 'can be an irritant.
Assist the patient to tie the gown or Prevents unnecessary exposure.
pajamas
18. Remove gloves (if worn)
19. Make patient comfortable.
20. Ensures readiness for next use and maintains
Clean and replace equipment
medical asepsis.
21. Wash hands. Prevent the risk of cross infection.
22. Document in nurses notes: Communicates care given and patient’s
Date/ time, procedure performed any condition. Protects legally.
pertinent observation and patient
response.
23 Assist patient to comfortable position Restores comfort.
after drops are absorbed.
24 Timely documentation prevents future
Document in nursing notes.
Administration errors.
25 Assist patient to comfortable position. Provides for patient's sense of well being
26 Wash hands Prevents the transmission of microorganism.

Fundamental of Nursing Skills Manual Page 14

 BLOOD PRESSURE
1. PURPOSES:

 To maintain a base line measure of arterial pressure.

 To monitor response of the circulatory system to various disease conditions and
therapies.

2. EQUIPMENT:

 Sphygmomanometer (B.P apparatus).

 B.P cuff (Appropriate size).
 Stethoscope
 Spirit swabs.
 Flow sheet.
 Black pen

3. PROCEDURE:

S.# STEPS RATIONALE S U

1. Identify the patient. To give care to the Correct patient.

2. Explain procedure to patient. Reduces anxiety and gains cooperation.

3. Collect & check equipment. Ensures proper functioning of apparatus.

4. Have patient in sitting or supine Promotes comfort and relaxes patient.

position. Provides accurate reading.

5. Wash hands. Prevents cross infection.

6. Clean ear piece of stethoscope with Prevents transmission of microorganisms.

spirit swab.

7. Be sure that the manometer is Ensures accurate reading of mercury

positioned vertically at eye level. level.

8. Support patient's fore-arm at heart level, Blood pressure increases when the arm is
with palm turned up. below heart level and decreases when the
arm is above heart level.

Fundamental of Nursing Skills Manual Page 15

9. Expose patient's left upper arm by
removing constructing clothing.
10 Wrap the deflated cuff evenly around
the upper arm by placing the lower edge
of the cuff2.5 cm (1-2 inches) above the
antecubital space. Ensure the center of
the bladder is applied directly over the
medial aspect of the upper arm.
11. Place the stethoscope in your ears and
check the diaphragm by tapping.
12. Make sure to unlock the mercury
column before inflating.
13. Palpate brachial or radial pulse with one Indicates approximate systolic pressure
hand. Close the valve of the bulb.
Inflate the cuff noting the level of
mercury where pulse disappears.
14. Deflate cuff quickly and wait for 30
sees; tighten the valve.
15. Relocate brachial artery and place the
diaphragm of stethoscope over the
brachial pulse and hold it in place
(Do not let the diaphragm touch the cuff
or patient's clothing).
16. Inflate the cuff to 30 mmHg above
where the pulse disappeared.
17. Slowly release the valve and allow
mercury to fall at the rate of 2-3 mmHg
per sec.
18. Note point on manometer when first
clear sound is heard.
19. Continue to deflate cuff gradually
noting point at which sounds disappear.
Fundamental of Nursing Skills Manual
Ensures proper cuff application. Tight
sleeves interfere with the ability to hear
pulsations and may cause inaccurate
readings.
Even wrapping produces equal pressure.
Too loose/ tight cuff will give inaccurate
reading. The bladder directly over the
brachial artery gives accurate reading.
Tapping is done to check whether the
sound is audible.
(Done if it is the initial examination)
Prevents venous congestion and false
high reading.
Proper stethoscope placement ensures
optimal sound reception. Improper
position of diagram causes muffled
sounds and often results in false low
systolic and false high diastolic readings
Ensures accurate measurement of systolic
pressure.
Too rapid or too slow decline of mercury
level can cause inaccurate readings.
First sound indicates the systolic pressure.
This is noted as the diastolic pressure.
Page 16
20. Deflate cuff rapidly and completely. Prevents arterial occlusion resulting in
Remove cuff from patient's arm. Lock numbness and tingling of patient's arm.
mercury column unless measurement
must be repeated).

21. Assist patient to a comfortable position. Ensures patient's comfort.

Cover the upper arm.

22. Inform B.P reading (depends on Promotes participation in care and

patient’s conditions) understanding of health status.

23. Clean stethoscope with spirit swab and Prevents spread of microorganism and
return equipment to appropriate place safety of equipment.

24. Wash hands. Prevents transmission of microorganisms.

25. Record accurately in the flow sheet Timely documentation ensures accurate
according to hospital policy. therapeutic intervention, if needed.

ASSESSING PULSE

1. PURPOSES:

 To obtain a base line of heart rate and rhythm.

 To identify whether pulse rate is within normal range.
 To determine whether the pulse rhythm is regular and pulse volume is appropriate.
 Assess client’s cardiovascular status.
 To monitor patient at risk for pulse alterations.
 To evaluate effects of medication on heart function.
 To assess effects of exercise/activity on heart function.

2. EQUIPMENT:

 Watch with second hand.

 Paper or flow sheet
 Pen (red ink).

3. PROCEDURE:

S. STEPS RATIONALE S U
#

1. Identify the patient. To give care to the correct patient.

Fundamental of Nursing Skills Manual Page 17

2. Wash hands. Prevents the risk of cross infection

3. Collect equipment. Easy access to equipment prevents

delay, saves time and energy and
prevents interruption during
procedure.

4. Explain procedure to patient. Gains cooperation, reduced patient's

anxiety

5. Place patient in a comfortable position. Relaxed position of lower arm and

extension of wrist permits full
Rest patient's arm alongside his body with exposure of artery for palpation.
the wrist extended and the palm of the
hand downward or inward.

Patient can sit with his forearm at a 90°

angle to the body resting on a support and
with the wrist extended and the palm of
the hand downward.

6. Place tips of first two or middle three Fingertips are most sensitive parts of S U
fingers of dominant hand over groove hand to palpate arterial pulsation.
along radial or thumb side of patient's Thumb has pulsation that may
inner wrist. interfere with accuracy

7. Lightly compress against radius; press Pulse is more accurately assessed

pulse initially, and then relax pressure so with moderate pressure. Too much
pulse becomes easily palpable. pressure occludes pulse and impairs
blood flow.

8. Using a watch with a second hand, count Sufficient time is necessary to assess
the number of pulsations felt for 1 minute. the rate, rhythm and amplitude of
the pulse.

9. Assess the pulse, rhythm, and amplitude Irregularity in heart rate may disrupt
while counting rate. the cardiac output. Amplitude of
pulse indicates the quality of the
heart's contraction.

10. Wash hands. Prevents risk of cross infection

11. Record pulse on flow sheet with red pen Promotes continuity of care.
and rhythm and amplitude in nurse's notes
(if abnormal).

Fundamental of Nursing Skills Manual Page 18

Assess the following peripheral pulses

 Temporal
 Carotid
 Brachial
 Radial
 Femoral
 Popliteal
 Posterior tibial
 Dorsalis pedis

TEMPERATURE

1. PURPOSE:

 To obtain a baseline data for subsequent evaluation.

 To determine changes in body temperature in response to specific therapies. .
 To monitor patient at risk for elevated temperature.

2. EQUIPMENTS: (ORAL)

 Rectangular tray containing with

a. Thermometer (oral).
b. Gallipots (4).
c. Tissue / cotton balls.
d. Small kidney tray.
e. Jar of antiseptic solution. (Dettol 1 %, savlon 2% or alcohol 70%) or Jar of
soapy solution
f. Jar of clean water.

 Black pen.
 Watch with second hand.
 Piece of blank paper / flow sheet.

Additional equipment for Axillary temperature:

Fundamental of Nursing Skills Manual Page 19

 1. Towel/tissue for drying the axila.

Additional equipment for rectal temperature:

1. Thermometer (rectal).
2. Lubricant (KY jelly).
3. Disposable gloves.
4. Tissue paper.

S. # STEPS RATIONALE S U

1. Identify the patient. To give care to the correct patient.

2. Assess the site for temperature. Helps in identifying the most

appropriate site for reading
temperature..

3. Wash hands. Reduces risk of cross infection.

4. Collect equipment. Saves time and energy.

5. Check thermometer for damaged bulb. Mercury may leak through cracks and
broken glass and may cause injury.

6. Explain the procedure to the patient Relieves patient’s fears and anxiety
and anxiety cooperation.

7. If thermometer is in the case.

Take out thermometer from the case.
Wash the thermometer with soap and
water from bulb end to finger end in
firm twisting motion
Rinse it with cold water.
Cleans the thermometer and decreases
the chance of infection.
Cleans the thermometer from least
contaminated to most contaminated
area.

Dry with cotton swab/ tissue from bulb

end towards finger end using finger
twisted motion

If thermometer is in bottle.

Take out the thermometer from

antiseptic solution and put in clean Cleans the thermometer and decreases
the chance of infection.

Fundamental of Nursing Skills Manual Page 20

 water.

Wipe with dry cotton swab from bulb Clean the thermometer from least
end to finger end using firm twisted contaminated to most contaminated
motion. area.

8. Read thermometer at eye level.

9. Lower the level of mercury below 35°C Mercury should be below 35°c.
by gently shaking it with firm grip. Thermometer reading must be below
client's actual temperature before use.
Gentle shake lowers mercury level in
glass tube.

Ensures correct reading.

ORAL METHOD
Ensure patient has not taken hot/cold
fluids and not smoked for at least 10-15 The thermometer needs to reflect the
minutes (or according to the policy). core temperature of the blood in larger
Place thermometer under the tongue at a blood vessels of the posterior pocket.
45°angle in a position that allows the
bulb to rest against the tongue tissue.

Instruct the patient to, close his/ her

mouth carefully with lips held firmly
together

Avoid biting down the thermometer

Refrain from speaking.

To ensure accurate results and prevent
Leave the thermometer in place for 2-3 thermometer from falling out or
minutes. breaking.

Grasp the stem of the thermometer, asks To ensure correct reading.

the patient to open his/ her mouth,
remove the thermometer.
Less likely to chip on the patients
Wipe off any secretion from teeth or break the thermometer
thermometer with cotton swab/ tissue.
Wipe in rotating fashion from finger to
bulb end.

Read the thermometer at eye level (by

Wiping allows clear reading of
slowly rotating).
thermometer. Wiping is done from

Fundamental of Nursing Skills Manual Page 21

 area of least contamination to area of
greater contamination.
Ensure accurate reading.

AXILLARY METHOD

Put the curtains around patients' bed or Provides privacy and comfort.
close door (as required).
Ensure that axilla is dry.
Moisture conducts heat, and may give
Move clothing or gown away from an in accurate reading
patient's shoulder and arm.
Provides optimal exposure of axilla.
Place the thermometer in center of
axilla, lower the patient's arm over the
thermometer, and place the forearm
across the chest. Maintains proper position of
thermometer against blood vessels.
Gently hold the arm in place (if
required).
Movement can displace thermometer
can give false reading and
Leave the thermometer in place for a thermometer can fall and break.
minimum of 3-5 minutes.

Remove the thermometer, raise it to eye Ensure accurate reading

level, and note the reading

Ensure accurate reading

10. Wash thermometer with soap and warm Avoid contact of microorganisms with
water using firm twisted motion. nurse’s hand.

11. Rinse with cold water.

12. Dry it with cotton swab/ tissue using

firm twisted motion.

13. Inform client of temperature reading Promotes participation in care and

understanding of health status.

14. Replace thermometer in the provided Storage container prevents breakage.

case antiseptic solution

Fundamental of Nursing Skills Manual Page 22

15. Wash hands.

16. Document accurately on flow sheet. Reduce transmission of

microorganism

ASSESSING RESPIRATION
1. PURPOSES:

 To acquire base line data for subsequent evaluation.

 To monitor abnormal respiratory status and identify changes.
 To monitor patients at risk for respiratory alterations
 To evaluate effects of medication and activity on respiratory status.
2. EQUIPMENT:

 Watch with second hand.

 Flow sheet
 Pen (black)
3. PROCEDURE:

S. # STEPS RATIONALE S U

1. Identify the patient. To give required care to the right

patient.

2. Wash hands. Prevents the risk of cross infection

3. Collect equipment Easy access to equipment prevents

delay, saves time and energy and
prevents interruption during
procedure.

4. Be sure client's chest is visible. Remove

bed linen or gown.

5. Assess patient's activity prior to A patient who has been exercising

checking respiration. will need to rest for few minutes to
permit the accelerated respiratory
rate return to normal.

6. Place patient in a comfortable position.

Fundamental of Nursing Skills Manual Page 23

7. a. Place hand against patient's chest to Awareness of respiratory rate
feel his chest movement or
assessment would cause the patient
b. Place patient's arm across the chest
voluntarily to alter the respiratory
and observe the chest movement while
pattern.
Supposedly taking the radial pulse.

8 Check the respiratory rate, rhythm and

Accuracy of reading
depth for 1 minute.

9 Wash hands. Prevents the risk of cross infection.

10 Document in flow sheet and (if

Promotes continuity of care.
required) nurse's notes.

MOUTH CARE OF AN UNCOUNSIOUS

PURPOSES:

 To maintain an intact and well-hydrated lips, tongue and mucus membranes of the
mouth.
 To remove secretions from oral cavity.
 To prevent fowl breathing, dental carries and infection.
 To enhance the client's feelings of well being.

EQUIPMENT:

 Kidney basin (Emesis basin)

 Face towel.
 Tissue roll.
 Disposable/ latex gloves.
 Tongue blade.
 Tongue depressor (Padded)
 Mouth applicator/ Artery forceps.
 Mouth gag (padded)
 Gauze swabs (pack)
 Gallipots.
 Paper bag/ thrash bin.
 Large tray.
 Petroleum jelly.
 Glass with water.
 Pair of scissors.
 Cotton balls.
 Pyodine mouth washes.
 Torch.
 Suction tube

Fundamental of Nursing Skills Manual Page 24

 STEPS RATIONALE S U
1. Identify the patient. Give care to right patient.

2. Explain the procedure to patient and Reduces anxiety and to provide meaningful
family member (if present). stimulation to unconscious patient.
Unconscious patient may retain ability to
hear. To gain cooperation of family
members.
3. Collect equipment and check for working Saves time and energy.
condition.
4. Adjust the bed to working position; lower Avoids back strain.
the side rails of working side.
5. Wash hands. Minimizes cross infection.
6. Place patient in side lying position with Prevents aspiration of saliva.
head of the bed lowered.
7. Draw curtains or close the door. Maintains privacy.
8. Place towel under patient's face and kidney Receives secretions and to prevent soiling of
dish under patient's chin. bed linen.
9. Wear gloves. Minimizes cross infection.
10. Inform the patient and retract patient's Avoids biting down by unconscious patient
upper and lower teeth with padded tongue and to provide access to oral cavity.
blade between back molars.
11. Assess the oral cavity for dry mucosa,
Provides baseline data.
blisters, sores or inflammation.
12. Insert mouth gag to open patients mouth
(2nd Nurse holds it).
NOTE: (Never put your fingers in an
unconscious patient's mouth).
13. Perform the following steps: Mechanical action removes food particles
a. Dip the tongue blade (padded) or mouth between the teeth and chewing surfaces.
applicator in pyodine solution, squeezes it
and clean. Swabbing helps to remove secretions and
 Chewing and inner surfaces first. crust from mucosa and moistens it.
 Outer tooth surfaces.
 Swab roof of mouth and inside
cheeks.
 Gently swab the tongue.
14. Moisten the tongue blade/ applicator in Proper cleaning. It helps to remove pyodine
clean water to rinse several time. that can be irritating to mucosa
15. Remove the mouth gag, gently
supporting lower Jaw and informing the
patient that procedure is finished.
16. Remove the towel and kidney dish.
17. Apply thin layer of petroleum jelly to Avoids lip cracking.
lips.
18. Remove gloves and wash hands. Minimizes cross infection.
19. Adjust bed to original place and make

Fundamental of Nursing Skills Manual Page 25

 patient comfortable.
20. Raise the side rails Ensure patients safety
21. Return equipment to designated placeKeep patients environment neat and reduces
transmission of infection.
22. Document in nurses notes about oral Communicates care given and patient’s
assessment and the care given. condition. Protects legally.

Height and weight

1. PURPOSES

 To provide a general measure of health.

 To provide a base line comparison in nutritional status.
 To provide a measurement of patient's fluid status.
 To calculate drug dose.

2. EQUIPMENT

 Weighing scale/ Measuring tape

 Flow sheet
 Initial assessment form
 Black pen

3. PROCEDURE

S# STEPS RATIONALE S U
1. Identify the patient Gives care to right patient.
2. Ensure that patient has: Voided and removed (shoes, Ensures accurate reading
heavy jewelry and extra clothing).
3. Set the scale at zero Calibrated scale ensures accurate
measurements.
4. Instruct patient to: Patient's movement causes
Stand on the center of platform facing scale and balance beam to oscillate and may
remain still. result in inaccurate reading.
Note the Weight
5. Measures height: Height is measured by Placing
Have patient remain standing on scale platfom, smooth, flat surface against crown
facing away from scale. or vertex of head. Patient position
Instruct patient to: encourages keeping head erect.
Stand erect, with heels together. Erect posture ensures accurate

Fundamental of Nursing Skills Manual Page 26

 Buttocks should touch to scale stick. reading.
Look straight ahead.
Raise metal rod on weighing scale, until it rests on
top of the patient's head.
6. Read height in inches/cm as recorded on height scale.
7. Record Weight in flow sheet and height in Serves as a record and
assessment form. communicates continuity of care

Fundamental of Nursing Skills Manual Page 27