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NAME: __________________________________________ DATE: ______________
POSTURAL DRAINAGE
DEFINITION
_____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________
PURPOSE
_____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________
EQUIPMENT
PROCEDURE RATIONALE 5 4 3 2 1
1. Wash hands.
2. Organize equipment.
3. Explain procedure to patient and family.
4. Administer bronchodilators,
expectorants, or warm liquids if ordered.
5. Encourage patient to void.
6. Loosen any tight clothing and
auscultate breath sounds.
7. Position patient to drain upper lung
segments/lobes:
● Sitting upright in bed or chair—targets
right and left chest.
● Leaning forward in sitting position—
targets back.
● Lying flat on back—targets right and
left chest.
Lying on abdomen, tilted to right or left
side—targets right or left back.
(correct position to drain right posterior

segment)
1
8. Position patient to drain middle lobe:
● Lying on back, tilted to left side in
Trendelenburg’s position—targets right
chest.
(correct position to drain right middle lobe)
● Lying on abdomen, tilted to left side

with hips elevated—targets right back.
9. Position patient to drain basal/lower
lobes:
● Lying in Trendelenburg’s position on
back—targets right and left chest.
● Lying in Trendelenburg’s position on
abdomen—targets right and left back
(correct position to drain lower right and left

lobes)
● On right or left side in

Trendelenburg’s position—targets back.
● Lying on abdomen—targets right and
left back
(correct position to drain right and left back)

10. Maintain patient in position until chest
percussion and vibration are completed
(approximately 5 minutes).
11. Assist patient into position for coughing
or for suctioning of trachea.
2
12. Auscultate chest areas for breath
sounds.
13. Continue until identified target areas
have been drained.
14. Auscultate breath sounds, and assist
patient with mouth care.
15. Position patient in bed with head of bed
elevated 45 degrees or
more.
16. Turn patient to side with pillow at back.
17. Raise side rails, and place call light
within reach.
18. Wash hands.
Ability to answer questions
TOTAL SCORE
Performance: _______
Ability to Answer: _______
Total Score: _______
3
NAME: __________________________________________ DATE: ______________
TEACHING TO USE AN INCENTIVE SPIROMETER

DEFINITION
_____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________
PURPOSE
_____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________
EQUIPMENT
1. Explain the procedure to the patient.
2. Place the patient in a comfortable sitting
or semi-fowler’s position.
3. For post-op patient, try to avoid
discomfort, coordinate exercise with
administration of pain relievers. Instruct
and assist patient with splinting of
incision.
4. Let the patient hold the device with one
hand, and the mouthpiece with the
other hand.
5. Instruct to exhale normally and place
lips securely around the mouthpiece.
6. Instruct to inhale slowly and as deeply
as possible through the mouthpiece
without nose breathing.
7. Tell patient to hold breath at the count
of 3.
8. Instruct to remove lips from the
mouthpiece and exhale normally.
9. Let the patient take several normal
breaths before attempting another one
with the incentive spirometer.
10. After the exercise, encourage to cough
after a deep breath.
11. Encourage to do incentive Spirometry
5-10 times every 1-2 hours during
daytime.
4
12. Chart procedure done, number of
repetitions, and average volume.
TOTAL SCORE
5
NAME: __________________________________________ DATE: ______________
SUCTIONING
DEFINITION
_____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________
PURPOSE
_____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________
EQUIPMENT
1. Determine the need for suctioning.
3. Prepare the necessary equipment.
4. Wash hands.
5. Place the patient in a semi-fowler’s
position.
6. Place a towel over the patient’s chest.
7. Put on clean gloves. Designate one
hand as “clean” and the other hand as
“contaminated”.
8. Using the clean hand pick-up suction
catheter, and with contaminated hand
attach the suction catheter to the
connector.
9. Turn on suction machine and test
patency with the saline solution or
sterile water.
A. ORAL AND NASOPHARYNGEAL SUCTIONING
10. Gently insert suction catheter either
through the nose or mouth with the
suction off by keeping the port open.
11. Once the correct position is
ascertained, suction for 5-10 seconds
by gently rotating catheter by rolling it
between the thumb and forefinger while
slowly withdrawing the catheter.
6
12. Release suction and withdraw catheter
completely.
13. Flush catheter with saline solution or
sterile water.
14. Repeat suctioning as needed and
according to patient’s tolerance.
B. TRACHEOSTOMY AND ENDOTRACHEAL TUBE SUCTIONING
15. Hyperventilate patient’s lungs with
resuscitation bag before suctioning.
16. Gently insert catheter either through the
endotracheal or tracheostomy tube with
the suction off by keeping the port open.
17. Insert the catheter about 6 inches for
adults, less for pedia, or until the patient
coughs or there’s resistance.
18. Suction for 5-10 seconds, gently
rotating catheter by rolling it between
the thumb and forefinger while slowly
withdrawing the catheter.
19. Release suction and withdraw catheter
completely.
20. Hyperventilate the patient.
21. Flush catheter with saline solution or
sterile water.
22. Repeat suctioning as needed or
according to patient’s tolerance. Allow
2-3 minutes rest in between suctions
23. When suctioning is completed, turn off
suction machine. Detach catheter from
suction tube, remove gloves, and
dispose safely and properly.
24. Place patient in a comfortable position,
assess effectiveness of suctioning by
auscultating and observing breathing
patterns.
25. Chart the time, characteristics of
secretions, and patient’s reaction.
TOTAL SCORE
Performance: _______ Ability to Answer: _______ Total Score: _______
7
NAME: __________________________________________ DATE: ______________
TRACHEOSTOMY CARE
DEFINITION
_____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________
PURPOSE
_____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________
EQUIPMENT
1. Check the condition tracheostomy and
the need for cleaning.
4. Wash hands thoroughly.
5. Place patient in a semi-fowler’s position.
Provide privacy.
6. Place a clean towel on the patient’s
chest under the tracheostomy site.
7. Don on clean gloves and suction
trachea and pharynx thoroughly.
8. Remove oxygen source then remove
the inner cannula by turning it about 90°
counterclockwise to unlock it. Replace
with the non-permanent inner cannula,
lock it, and then attach oxygen source.
9. Drop and soak inner cannula into a
bowl of hydrogen peroxide for a few
minutes.
10. Change gloves and proceed cleaning
the inner cannula.
11. Clean the inner cannula inside out
thoroughly, using pipe cleaners, brush,
or swabs moistened with sterile saline.
12. Rinse well with sterile water or saline
and dry it thoroughly with sterile gauze.
8
13. Remove oxygen source replace non-
permanent inner cannula with the clean
inner cannula, secure it, and then attach
back to oxygen source.
14. Clean the other inner cannula the same
way and then store properly.
15. Clean the flange of the outer cannula.
Use clean cotton-tipped swabs soaked
with hydrogen peroxide for cleaning.
Rinse with cotton-tipped swabs soaked
with saline solution.
A. CHANGING THE TRACHEOSTOMY DRESSING
16. Remove the soiled dressings gently and
dispose properly.
17. Clean around the incision site with
cotton tipped swabs or sterile gauze
soaked with sterile saline solution. If
encrustations are difficult to remove
may use hydrogen peroxide.
18. Wipe only once with each swab or
gauze then discard it.
19. Use sterile applicator stick to apply
antibiotic ointment around incision site if
ordered.
20. Carefully slip sterile dressing over the
incision site.
B. CHANGING THE TRACHEOSTOMY TIES
21. Untie or cut soiled ties while holding
tracheostomy tube securely with
another hand.
22. Remove soiled ties carefully.
23. Grasp one end of the sterile tie and pull
it through the slit or opening on the side
of the tracheostomy tube. Then tie it
securely.
24. Pull the other end of the sterile tie under
the patient’s neck, pass it through the
slit or opening then secure it in place.
25. The ties should be tight enough to keep
the tube secure, but loose enough to
permit two fingers to fit between the ties
and the neck.
26. Place the patient in a comfortable
position and assess respiratory status.
9
27. Do aftercare. Wrap the non-permanent
inner cannula with sterile gauze and
store it in a dry place.
28. Chart procedure done, and any
observations.
TOTAL SCORE
10
NAME: __________________________________________ DATE: ______________
CARE OF CLIENTS WITH CHEST TUBE

DEFINITION
_____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________
PURPOSE
_____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________
EQUIPMENT
1. Assess for respiratory distress and
chest pain. Auscultate breath sounds.
2. Observe chest tube dressing.
3. Check tubing and connections
periodically. Coil and fasten tubing so
as not to form loops or kinks.
4. Place the drainage system upright and
below chest level of the patient at all
times.
5. Make sure end of the long tube in the
water sealed bottle is submerged
approximately in 2cm of water.
6. Mark the original fluid level with tape on
the outside of the drainage bottle.
7. Check fluctuation or tidaling of water or
drainage in the tubing.
8. Report continuous bubbling in the
water-sealed bottle.
9. Encourage patient to change position
frequently. Maintain good body
alignment.
10. Encourage coughing and deep
breathing exercises every hour.
11. Always keep two large clamps or
hemostats for each chest tube at the
bedside.
11
12. Strip or milk the tubing in the direction
of the drainage bottle only if indicated.
13. Chart amount, character, and rate of
accumulation of drainage as ordered or
at least every eight hours.
TOTAL SCORE
12
NAME: __________________________________________ DATE: ______________
OBTAINING AN ECG
DEFINITION
_____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________
PURPOSE
_____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________
EQUIPMENT
1. Check the doctor’s orders.
3. Place the ECG machine at the bedside
and plug the power cord.
4. Do hand washing.
5. Place the patient in a supine position
with arms on the side. Provide privacy.
6. Ask the patient to undress, exposing
chest, wrist, and ankles. Drape
appropriately.
7. If area is excessively hairy, clip the hair.
Clean excess oil or other substances
from the skin.
8. Apply electrode paste or gel to patient’s
wrist and ankles.
9. Place the limb leads, then attach to the
appropriate limb lead wires.
10. Put a small amount of electrode gel or
paste at each electrode position site.
11. Position chest electrodes as follows:
V1 – 4th ICS at right sternal border
V2 – 4th ICS at left sternal border
V3 – halfway between V2 & V4
V4 – 5th ICS at midclavicular line
V5 – 5th ICS at anterior axillary line
V6 – 5th ICS at midaxillary line, level with V4
13
12. Tell patient to relax and breathe
normally. Instruct to lie still, avoid
movement, coughing or talking while
ECG is recording.
13. Press AUTO and observe the tracing
quality.
14. When the machine is finishes recording,
remove the electrodes and wipe clean
the patient’s skin.
15. Dress client and place in a comfortable
position.
16. After disconnecting the lead wires from
the electrodes, clean the electrodes as
indicated, and store properly the wires
and machine.
17. Label ECG recording with the patient’s
name, age, sex, date and time.
TOTAL SCORE
14
NAME: __________________________________________ DATE: ______________
APPLYING A CARDIAC MONITOR

DEFINITION
_____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________
PURPOSE
_____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________
EQUIPMENT
3. Do hand washing.
4. Place the client flat on bed. Provide
privacy.
5. Expose the chest and abdominal area,
determine electrode positions. If
necessary, clip the hair 10 cm in
diameter around each electrode side.
6. Clean the area with alcohol and dry
completely.
7. Remove the backing from the pre-gelled
electrode and apply electrode to the
site, and press firmly.
8. Repeat with the other electrodes to
complete either 3-lead or 5-lead system
3-LEAD SYSTEM
• WHITE lead on the right pectoral area
• BLACK lead on the left pectoral area
• RED lead on the left lower abdominal area
5 LEAD SYSTEM
• The 3-lead system plus
• DARK RED lead on the right sternal area
• GREEN lead on the right lower abdominal
area
9. When all the electrodes are in place,
check waveform for clarity, position and
size.
15
position and drape.
11. Do aftercare.
12. Record the time and date monitoring
begins.
TOTAL SCORE
16
NAME: __________________________________________ DATE: ______________
INSERTING A STRAIGHT OR INDWELLING CATHETER (MALE AND FEMALE)
DEFINITION
_____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________
PURPOSE
_____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________
EQUIPMENT
1. Review prescriber’s order; identify
patient; explain purpose, procedure,
and how patient can assist, depending
upon patient’s mental status.
2. Gather all equipment and place on
bedside table.
3. Wash hands, and don clean gloves.
4. Adjust bed to a workable height, and
lower side rail.
5. Assist/place patient to a supine position
with knees flexed. (Use assistance from
other personnel as necessary.)
6. Drape patient with blanket or sheet
covering abdomen and lower legs.
For male: Cover patient’s upper body
with a blanket, and fold bed sheets
down to expose penis.
For female: Cover patient’s body with a
blanket or sheet. Cover each leg with
separate sheet crisscrossing sheets
over the patient’s abdomen. When it is
time to examine the female genitalia,
only the perineum is exposed affording
the patient the privacy necessary for the
exam.
17
7. Cleanse perineal area with appropriate
antibacterial solution, rinse well, and
dry.
8. Remove clean gloves, discard, and
wash hands.
9. Open sterile package, and place plastic
package container at the foot of the
bed.
10. Place catheter tray on the bed between
the patient’s legs.
11. Fold back blanket/sheet to expose
perineum.
12. Open white outer wrapping away from
sterile package with last turn toward
patient.
13. Remove sterile absorbent pad and
place under patient’s buttocks.
If he or she is able, have patient lift
buttocks.
14. Don sterile gloves, remove sterile
equipment from catheter tray, and
arrange for use.
15. Pour antiseptic or Betadine solution
over cotton balls (use a different
solution if patient is allergic to
Betadine).
16. Uncap syringe filled with lubricant, or
tear open package; lubricate catheter
tip generously. Leave catheter tip in
sterile lubricant on sterile field until
used.
17. If specimen is ordered, uncap sterile
container and place nearby on the
sterile field.
18. If a straight/in-and-out catheterization is
being done, place the urine collection
container close to the patient.
19. If an indwelling catheterization is being
done, place drainage bag on sterile
field.
20. For Male: Place the fenestrated drape
(with the hole in the middle) over the
penis, exposing the urinary meatus.
For Female: Place the fenestrated

drape (with the hole in the middle) over
the perineum exposing the urinary
meatus.
18
21. For Male: Hold the penis upright with
your non-dominant hand.
If uncircumcised, retract foreskin.
Hold glans of penis to prevent closing of
urethra.
To cleanse urinary meatus and insert
catheter:
● With dominant, sterile, gloved hand,
use forceps to pick up a cotton ball
saturated with antiseptic or Betadine
solution.
● Move in a circular motion from the
meatus down to base of glans.
● Discard each cotton ball after use.

● Repeat cleaning at least 2 to 3 more
times.
● Discard forceps, and with dominant,
sterile, gloved hand, pick up lubricated
catheter about 3 to 4 inches from the
tip.
● Lift penis to a 90-degree angle
(perpendicular to body) and exert slight
traction by pulling upward.
● Insert catheter into urinary meatus
about 7 to 9 inches in an adult (less in
an infant or child) or until urine begins to
flow. When urine appears, advance the
catheter another1–2 inches. Hold in
place.
19
22. For Female: Carefully retract labia to
fully expose urinary meatus with non-
dominant hand.
To cleanse urinary meatus and insert
catheter:
● With dominant, sterile, gloved hand,
use forceps to pick up a cotton ball
saturated with antiseptic or Betadine
solution and cleanse the urinary meatus
with one downward stroke each time,
one on each side and then down the
middle.
● Discard each cotton ball after use.

● Repeat cleaning at least 2 to 3 times.
● With dominant hand, continue to hold
labia apart.
● Discard forceps and with dominant,
sterile, gloved hand, pick up lubricated
catheter about 3 to 4 inches from tip.
● Insert the catheter into the urinary
meatus about 2 to 3 inches (less with
infants and children) or until urine
begins to flow. Hold in place.
20
23. If a straight/in-and-out catheterization is
being done, and a urine specimen is
needed, collect about 30 mL of urine in
the sterile specimen container by
placing the container under the
drainage end of the catheter.
24. If an indwelling catheter is being
inserted, follow steps for insertion; then,
with the dominant hand, fill the 10-mL
balloon with approximately 8 mL of
water. Gently pull back the catheter to
make sure it is in place.
25. For an indwelling catheter, after the
balloon is filled with water and catheter
is intact in the bladder, secure catheter
to patient’s upper leg with tape or a
Catheter Secure Device, unless
contraindicated by facility policy. Secure
bag to bed rail.
26. Remove drapes, used catheter
equipment, and dry perineum.
27. Position patient for comfort, side rails
up, and in low position, depending on
patient’s activity status.
28. Measure and record urine as indicated/
ordered.
29. Discard gloves and used equipment in
the proper waste disposal and wash
hands.
TOTAL SCORE
21
NAME: __________________________________________ DATE: ______________
PERFORMING CATHETER CARE

DEFINITION
_____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________
PURPOSE
_____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________
EQUIPMENT
1. Identify patient; explain purpose,
procedure, and how patient can assist.
2. Wash hands.
3. Provide privacy.
4. Raise bed and lower side rail on
working side.
5. Place patient in supine position, and
expose perineal area.
6. Don clean gloves and wash the urinary
meatus and the proximal catheter with
soap and water; rinse, and gently dry
with towel.
7. After removing contaminated gloves
and washing hands, open catheter care
kit or assemble equipment on over-bed
table and remove tape if used to secure
catheter to patient’s upper thigh.
8. Don clean gloves and cleanse urinary
meatus using a circular motion moving
from middle toward outside with
antiseptic-soaked cotton ball or swab.
Dispose of cotton ball/swab in trash
bag.
9. Gently pull catheter taut and cleanse
with a new cotton ball/swab from
catheter insertion site down catheter
tubing about 4 to 5 inches toward
drainage bag. Dispose of used cotton
ball/swab.
10. Dispose of all cleaning materials in
proper waste container.
22
11. Remove gloves and re-tape catheter
(as per facility policy).
12. Position patient for comfort, lower bed,
and raise side rail.
13. Wash hands
TOTAL SCORE
23
NAME: __________________________________________ DATE: ______________
MONITORING BLOOD GLUCOSE LEVEL

DEFINITION
_____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________
PURPOSE
_____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________
EQUIPMENT
1. Check doctor’s orders.
2. Explain the procedure to the client.
3. Gather the necessary equipment.
4. Do hand washing and don on clean
gloves.
5. Remove test strip from the vial or
unwrap from individual pack.
6. Turn on glucometer and check if the
code number matches the code number
of the strip.
7. For adult, massage the side of the
finger towards the puncture site.
8. Cleanse site with a cotton ball with
alcohol.
9. Hold lancet perpendicular to the skin,
and prick the site.
10. Slightly squeeze or milk puncture site
until a hanging drop of blood has
formed.
11. Gently touch the drop of blood to the
pad of test strip without smearing the
blood.
12. Insert strip into the glucometer
according to manufacturer’s directions.
24
13. Apply pressure to the puncture site with
a dry cotton ball.
14. Read blood glucose result and
document. Inform patient of the result.
15. Turn off glucometer and do aftercare.
16. Remove gloves and do hand washing.
17. Record blood glucose result. Report
abnormal result to the physician
immediately.
TOTAL SCORE
25
NAME: __________________________________________ DATE: ______________
NASOGASTRIC TUBE FEEDING

DEFINITION
_____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________
PURPOSE
_____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________
EQUIPMENT
1. Remove the osteorized feeding or
formula from the refrigerator. Warm
feeding or allow coming to room temp.
3. Do hand washing.
4. Bring OF and equipment to the bedside.
5. Place the patient in a fowler’s position
and provide privacy.
6. Check tube placement. Attach asepto
syringe to the end of the NGT. Place a
stethoscope over the left upper
quadrant of the abdomen just below the
coastal margin. Inject 10-20 cc of air.
7. Assess for residual feeding contents.
8. Kink the tubing, remove the bulb, fill the
asepto syringe with the feeding, and
then unkink the tube.
9. Allow the feeding to flow in by gravity.
Give feeding slowly keeping the asepto
syringe filled at all times.
10. Always keep the asepto syringe at least
1 foot above the edge of bed.
11. After feeding, flush tubing with at least
30 cc of water.
12. Kink the tube. Remove asepto syringe
and clamp the tube tightly and securely.
26
13. Maintain semi-fowler’s position for 30-
60 minutes after feeding is completed.
14. Wash equipment with soap and water,
dry, and store properly.
15. Chart type and amount of feeding,
including water, and patient’s tolerance.
TOTAL SCORE
27
NAME: __________________________________________ DATE: ______________
REMOVING A NASOGASTRIC TUBE

DEFINITION
_____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________
PURPOSE
_____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________
EQUIPMENT
3. Wash hands and don on clean gloves.
4. Place the patient in a semi-fowler’s
position. Provide privacy.
5. Place a towel across the patient’s chest.
6. Wet adhesive tapes attached to the
NGT, and carefully remove the tapes
away from the face.
7. Instruct the patient to take a deep
breath and hold it.
8. Kink NGT then quickly and carefully
remove tube while patient’s holding his
breath.
9. Dispose NGT as per agency’s policy.
10. Offer oral care to the client then place in
a comfortable position.
12. Document procedure done.
TOTAL SCORE

28
NAME: __________________________________________ DATE: ______________
GASTRIC LAVAGE
DEFINITION
_____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________
PURPOSE
_____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________
EQUIPMENT
4. Place patient in a semi-Fowler’s
5. Do hand washing then don on clean
gloves.
6. Check NGT placement.
7. Aspirate stomach contents with syringe
attached to the NGT before instilling
water or antidote. Save specimen for
analysis.
8. Remove the syringe. Attach funnel or
50 mL syringe to the NGT.
9. Elevate the funnel above the patient’s
head and pour about 150-200 mL of
solution into the funnel.
10. Lower the funnel and siphon gastric
contents into the bucket. Save samples
of the first two washings.
11. Repeat lavage procedure until the
returns are relatively clear and no
particulate matters are seen.
29
12. At the completion of lavage:
• Stomach may be left empty
• An absorbent may be instilled and
allowed to remain in the stomach
• A saline cathartic may be instilled in
the NGT.
13. Kink NGT, remove syringe or funnel,
and then clamp tubing.
position.
16. Do aftercare.
17. Chart procedure, solution instilled,
characteristics of return flow, and
patient’s response.
TOTAL SCORE
30
NAME: __________________________________________ DATE: ______________
CARING FOR A GASTROSTOMY TUBE

DEFINITION
_____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________
PURPOSE
_____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________
EQUIPMENT
gloves.
4. If the gastrostomy tube is new, dip a
cotton-tipped swab into a sterile solution
and gently clean around the insertion
site.
5. If the gastro-tube insertion site has
healed and has no more sutures, wet a
washcloth and apply a small amount of
soap. Gently cleanse the insertion site
and then rinse.
6. Pat the skin around the insertion site
dry.
7. If there are no more sutures, rotate the
guard or external bumper 90° at least
once a day.
9. Place patient in a comfortably in bed.
10. Do aftercare.
11. Record procedure; include appearance
of site, any discharges, and patient’s
response.
TOTAL SCORE

31
NAME: __________________________________________ DATE: ______________
COLOSTOMY CARE
DEFINITION
_____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________
PURPOSE
_____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________
EQUIPMENT
2. Wash hands.
5. Don on clean gloves.
6. Identify the type and location of ostomy.
Check skin integrity around the stoma.
7. Empty the contents of the pouch
through the bottom opening into a
bedpan.
8. Peel the colostomy bag slowly while
holding the client’s skin taut. If the bag
is disposable, place disposable
colostomy bag in a plastic bag and
discard properly.
9. Use toilet paper to remove excess feces
from the stoma and skin, if needed.
10. Using warm water and soap, cleanse
the skin around the stoma.
11. Rinse and dry skin thoroughly after
cleansing.
12. Center the pouch over the stoma and
press adhesive surface gently around
the stoma.
32
13. Smooth out any wrinkles, working from
the stoma then outwards.
14. Fasten closure clip on the bottom of the
pouch.
position.
16. Do aftercare and wash hands
thoroughly.
17. Document the procedure; and the
consistency, color and amount of stool.
TOTAL SCORE
33
NAME: __________________________________________ DATE: ______________
ADMINISTERING AN ENEMA
DEFINITION
_____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________
PURPOSE
_____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________
EQUIPMENT
1. Check the doctor’s orders.
gloves.
5. Place the client in a left lateral position.
Provide privacy
6. Place a Kelly pad under the buttocks
and drape the patient.
7. Lubricate about 2 inches of the rectal
tube.
8. Open the clamp and run some solution
through the connecting tubing and the
rectal tube to expel air in the tubing.
9. Insert the tube smoothly and slowly into
the rectum, directing it toward the
umbilicus.
10. Insert the tube 3-4 inches (ADULT), 2-3
inches (CHILD), and 1-1.5 inches
(INFANT).
11. If there’s resistance ask the client to
take a deep breath, and then run a
small amount of solution through the
tube to relax the internal anal sphincter.
12. A. Raise the solution container and
open clamp to allow fluid flow
(CLEANSING ENEMA)
34
13. B. Compress the pliable container by
hand (FLEET ENEMA)
14. For low enemas hold the solution
container no higher than 12 inches
above the rectum.
For high enemas hold the solution
container no higher than 18 inches
above the rectum.
15. Administer the fluid slowly. If client
complains of fullness or pain, clamp to
stop the flow for 30 seconds, and then
continue at a slower rate.
16. If using a plastic container, roll up
container as the fluid is instilled.
17. After all the solution has been instilled,
or when the client has the urge or wants
to defecate; close the clamp, and
remove the rectal tube.
18. Place the rectal tube in a disposable
towel as you withdraw it.
19. Ask the client to remain lying down.
Ensure that the client retains the
solution for the appropriate amount of
time. 5-10 mins (CLEANSING ENEMA)
at least 30 mins (RETENTION ENEMA)
20. Assist the client to defecate.
21. Ask the client not to flush the feces.
22. If stool specimen is required, ask the
client to use the bedpan or the bedside
commode.
23. Place the patient back comfortable on
bed, and drape.
24. Do aftercare.
25.r Remove gloves and do hand washing.
26. Chart procedure, type of solution used,
time retained, stool characteristics, and
relief of flatus and abdominal distention.
TOTAL SCORE

35
NAME: __________________________________________ DATE: ______________
COLLECTING STOOL SPECIMEN FOR CULTURE

DEFINITION
_____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________
PURPOSE
_____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________
EQUIPMENT
1. Gather necessary equipment.
2. Identify the patient.
3. Place disposable collection container
(hat) in toilet or bedside commode to
catch stool without urine.
4. Instruct patient to void first and not to
discard toilet paper with stool.
5. Tell patient to call you as soon as bowel
movement is completed.
6. Perform hand hygiene and put on
gloves
7. After patient has passed a stool, use
the tongue blades to obtain a sample,
free of blood or urine, and place it in a
dry, clean container.
8. Collect as much of the stool as possible
to send to the laboratory.
9. Place lid on container. Remove gloves
and perform hand hygiene.
10. Check specimen label with patient
identification bracelet. Label should
include patient’s name and identification
number, time specimen was collected,
route of collection, identification for
person obtaining sample, and any other
information required by agency policy.
11. Place label on the container per facility
policy. Place container in plastic
sealable biohazard bag.
36
12. Transport specimen to laboratory while
stool is still warm.
13. If immediate transport is impossible,
check with laboratory personnel or
policy manual as to whether
refrigeration is contraindicated.
12. Insert culture swab into nasal passage
to inflamed area, being careful
not to touch other nasal structures.
13. Gently and rapidly rotate swab at site
and move from nasal passage
without touching sides of nasal
passage.
14. Offer patient tissues to blow nose.
15. Securely place top on culture tube and
discard tongue depressor
into trash.
16. Position patient comfortably.
17. Wash hands.
18. Attach completed identification label
and lab requisition to culture tube. Send
to lab immediately.
TOTAL SCORE
37
NAME: __________________________________________ DATE: ______________
IRRIGATING A COLOSTOMY
DEFINITION
_____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________
PURPOSE
_____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________
EQUIPMENT
2. Select a consistent time for irrigation.
3. Have the patient sit on a chair in front of
a commode, or by the side of the toilet;
or sit on the commode or toilet itself.
Provide privacy.
5. Wash hands and don on clean gloves.
6. Hang irrigating reservoir with the
prescribed solution. The bottom of the
reservoir is approximately at the level of
the patient’s shoulder and above the
stoma.
7. Remove the pouch or covering from
stoma. Wash around the stoma with
soap and warm water, then dry well.
8. Apply irrigation sleeve, directing the
open tail into the commode.
9. Open tubing clamp of the irrigating
reservoir to release a small amount of
solution into the commode.
10. Lubricate the tip of the cone/catheter,
and gently insert into the stoma. Insert
the catheter no more than 3 inches.
11. Hold the cone/shield gently and firmly
against the stoma.
38
12. If the catheter does not advance easily,
allow water to flow slowly while
advancing the catheter. Never force the
catheter.
13. Start irrigation. Allow water to enter the
colon slowly for 5-10 minutes. If
cramping occurs, slow the flow rate or
clamp the tubing.
14. Hold cone/shield in place for 10
seconds after water is instilled, then
gently remove cone/catheter from the
stoma.
15. As feces and water flow down the
irrigating sleeve, periodically rinse
sleeve with water.
16. Allow 10-15 minutes for most of the
returns, then dry sleeve tail and apply
tail closure.
17. Leave sleeve in place for about 20
minutes and let patient ambulate.
18. After solution has stopped flowing from
the stoma, remove irrigating sleeve and
cleanse skin around stoma opening with
mild soap and water.
19. Attach new appliance to stoma if
needed.
position.
21. Clean equipment with soap and water.
Dry and store in a well-ventilated area.
22. Chart procedure, amount of irrigating
solution used, stool characteristics, and
patient’s reaction.
TOTAL SCORE
39
BIBLIOGRAPHY
Ellis, Janice and et.al. Modules for Basic Nursing Skills 6th ed. Lippincott Williams &
Wilkins. Philippines.
Evans-Smith, Pamela. Taylor’s Clinical Nursing Skills: A Nursing Process Approach.

Lippincott Williams & Wilkins. USA. 2005.
Kozier, Barbara and et.al. Fundamentals of Nursing: Concepts, Process, and Practice
8th ed. Pearson Education Asia Pte. Ltd. Singapore.
Lippincott Manual of Nursing Practice 8th ed. Lippincott Williams & Wilkins. Philippines.
2006.
Myers, Ehren. RNotes: Nurse’s Clinical Pocket Guide. F.A. Davis Co. Thailand.
Rhaoads, Jacqueline and Bonnie Juvie Meeker (2008). Davis Guide to Clinical Nursing
Skills. F.A. Davis Company. Philadelphia.
Timby, Barbara. Fundamental Nursing Skills and Concepts 8th ed. Lippincott Williams &
Wilkins. USA. 2005.
40

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NAME: __________________________________________ DATE: ______________

(correct position to drain right posterior

(correct position to drain right middle lobe)

● Lying on abdomen, tilted to left side

(correct position to drain lower right and left

● On right or left side in

(correct position to drain right and left back)

Ability to answer questions

TEACHING TO USE AN INCENTIVE SPIROMETER

Ability to answer questions

Ability to answer questions

Ability to answer questions

CARE OF CLIENTS WITH CHEST TUBE

Ability to answer questions

Ability to answer questions

APPLYING A CARDIAC MONITOR

Ability to answer questions

INSERTING A STRAIGHT OR INDWELLING CATHETER (MALE AND FEMALE)

For Female: Place the fenestrated

● Discard each cotton ball after use.

● Discard each cotton ball after use.

Ability to answer questions

PERFORMING CATHETER CARE

Ability to answer questions

MONITORING BLOOD GLUCOSE LEVEL

Ability to answer questions

NASOGASTRIC TUBE FEEDING

Ability to answer questions

REMOVING A NASOGASTRIC TUBE

Ability to answer questions

Performance: _______ Ability to Answer: _______ Total Score: _______

Ability to answer questions

CARING FOR A GASTROSTOMY TUBE

Performance: _______ Ability to Answer: _______ Total Score: _______

Ability to answer questions

Ability to answer questions

Performance: _______ Ability to Answer: _______ Total Score: _______

COLLECTING STOOL SPECIMEN FOR CULTURE

Ability to answer questions

Ability to answer questions

Evans-Smith, Pamela. Taylor’s Clinical Nursing Skills: A Nursing Process Approach.

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NAME: ____________________________ DATE:

Performance: ___ Ability to Answer: _ Total Score: _____

Performance: ___ Ability to Answer: _ Total Score: _____

Performance: ___ Ability to Answer: _ Total Score: _____