NCM 101 HEALTH ASSESSMENT RLE

SANTOS, KIMBERLY WYNE C. Date: 2/8/23

BSN LEVEL I - N22A

MR. RALPH MARCO ALONZO

ASSISTING PATIENT ON POSITIONING DURING PHYSICAL EXAMINATION

Introducing ourselves to the patient and explaining to the patient what position you will assist them in and how
it will be done. Patient safety is of top priority. Always perform a hygiene, wearing gloves is essential also you
might past an bacteria or some you may get from patients. Some patients are sensitive to touching them, when
opening the conversation, it’s important to ask for permission, so it is better to ask them before changing their
position and explain the procedure you will do for them. Ensure you use positive, motivational, and patient-first
language always. Provide patients comfort and safety. Maintaining patient dignity and privacy minimizes
exposure of the patient, who often feels vulnerable perioperatively. You need to be gentle when touching the
patient.

There are 8 purposes in assisting patients on positioning during physical assessment. To promote comfort to
the patient, to relieve pressure on various parts, To stimulate circulation, To provide proper body alignment, To
carry out nursing intervention, To perform surgical and medical interventions, To prevent complications caused
by immobility, To promote normal physiological functions. There are also devices or apparatus that can be
used to help position the patient properly like bed boards, pillows.
 NCM 101 HEALTH ASSESSMENT RLE

SANTOS, KIMBERLY WYNE C. Date: 2/1/23

BSN LEVEL I - N22A

MR. RALPH MARCO ALONZO

HEALTH HISTORY TAKING

In Taking a history from a patient you need to identify your patient first, ask the patients permissions that you
will speak with them about their health history. The goal of obtaining a medical history from the patient is to
understand the state of health of the patient. To begin, we need to put the patient at ease and comfort.
Generally, it helps to be warm and welcoming so as to put the patient at ease. Failure to obtain a complete
health history result in a lack of information that can negatively impact the patient. Interviewing skills develop
through experience and practice. A relationship built on trust and respect for the patient’s privacy is necessary
to develop a good rapport. It is important to understand how to assist the patient in relaying important details
and to ensure that what the patient has expressed is understood. It is important to understand how to assist
the patient in relaying important details and to ensure that what the patient has expressed is understood.

Ask their present complaint and gain as much information as you can about the specific complaint. Use
PQRST to assess each symptom. All the questions pertaining to patients' symptoms and chief complaint were
being asked, including history of presenting illness, history of past medical and surgical history as well as
medication, dietary history, family history and social history. During the process, I realized that we had to be
careful in phrasing our questions, give good verbal and non-verbal cues, differentiate closed and open ended
questions and ask relevant questions systemically. This is to ensure that the patient wouldn't feel disturbed or
angry and more pleased to give information. Interviewing skills develop through experience and practice.
Active listening along with careful questioning are essential to obtain a thorough, accurate history. The greatest
part of the medical history is obtained during the interview.
 NCM 103 FUNDAMENTALS OF NURSING PRACTICE

SKILLS LAB

SANTOS, KIMBERLY WYNE C. Date: 2/7/23

BSN LEVEL I - N22A

MRS. RUBY D. VARGAS

ESTABLISHING & MAINTAINING A STERILE FIELD

Establishing & Maintaining a Sterile Field is an important component of infection prevention.

It is important to arrange the furniture before opening supplies when MAINTANING a sterile field. Before
opening any supplies, all packages must be checked to ensure the integrity of the packaging materials.do not
allow sterile items to touch any part of the outer packaging once it is opened. There should not be any holes or
tears in the outside wrappers. Be aware of areas of sterile fields that are considered contaminated.

Any part of the field below waist level or above shoulder level. Any supplies or field that you have not directly
monitored and turned away from the sterile field. Example a Gauze can be opened by firmly grasping each
side of the sealed edge with the thumb side of each hand parallel to the seal and pulling carefully apart. Drop
items from six inches away from the sterile field.
 NCM 103 FUNDAMENTALS OF NURSING PRACTICE

SKILLS LAB

SANTOS, KIMBERLY WYNE C. Date: 2/7/23

BSN LEVEL I - N22A

MRS. RUBY D. VARGAS

OPEN GLOVING

Open Gloving Remove sterile gloves from the outer packaging, Open the inside sterile glove wrapper. Open
the inside sterile glove wrapper without touching the area of the packaging the gloves contact, pick up the first
glove by the sleeve with the opposite hand only touching the inner surface, Do not touch the inside of the
package or the sterile part of the gloves with your bare hands during the process. Maintain sterility throughout
the procedure of donning sterile gloves. Finish gloving the remaining hand when proper sterile gloving is you
can now perform sterile procedure.

In removing a sterile glove Grasp the outside of one cuff with the other gloved hand. Avoid touching your skin.
Pull the glove off, turning it inside out and gather it in the palm of the gloved hand and dispose of contaminated
wastes appropriately. Perform Hand Hygiene after.
 NCM 103 FUNDAMENTALS OF NURSING PRACTICE

SKILLS LAB

SANTOS, KIMBERLY WYNE C. Date: 2/7/23

BSN LEVEL I - N22A

MRS. RUBY D. VARGAS

SURGICAL HANDWASHING

Surgical Handwashing has an important role in preventing and reducing the transfer of health-related
infections. This will be performed by using disposable scrub brush, remove debris from underneath fingernails
using a nail cleaner, preferably under running water. Surgical hand antisepsis should be performed using a
suitable antimicrobial soap. Scrub each side of each finger, between the fingers, and the back and front of the
hand always keeping the hand higher than the arm. This prevents bacteria-laden soap and water from
contaminating the hand. Rinse hands and arms by passing them through the water in one direction only, from
fingertips to elbow. Do not move your arm back and forth through the water.
 NCM 103 FUNDAMENTALS OF NURSING PRACTICE

SKILLS LAB

SANTOS, KIMBERLY WYNE C. Date: 1/31/23

BSN LEVEL I - N22A

MRS. RUBY D. VARGAS

MEDICAL HANDWASHING

Medical Handwashing is a simple yet effective way to prevent infections, ways to avoid getting sick and
prevent spreading germs to others. Handwashing with soap prevents many common and life-threatening
infections. Many illnesses start when hands become contaminated with disease-causing bacteria and viruses.
If we don't wash our hands properly before having contact with others, we can infect our patients.

In doing medical handwashing we need to make sure, or you should Ensure jewelry has been removed
Jewelry may “hide” bacteria and viruses from the action of washing/scrubbing. DO NOT use a single damp
cloth to wash and dry hands. Disposable cloths or paper towels are preferred for hand drying after you've
washed your hands.
 NCM 103 FUNDAMENTALS OF NURSING PRACTICE

SKILLS LAB

SANTOS, KIMBERLY WYNE C. Date: 1/24/23

BSN LEVEL I - N22A

MRS. RUBY D. VARGAS

(VITAL SIGNS)

ASSESSING BODY TEMPERATURE

Checking the Body Temperature of the patient. Before going to the patient, you need to make sure the
equipment you will use isa working well. Assessing body temperature is a nursing procedure that provide a
baseline data. There are also four sites where you check the temperature of the patient this Rectal, Oral -The
thermometer is placed in the mouth under the tongue. Axillary-The thermometer is placed in the armpit.
Tympanic. The thermometer is placed in the ear. Temporal artery-The thermometer scans the surface of the
forehead.

Before taking a temperature as a nurse, you always want to perform hand hygiene, clean the thermometer. By
placing the thermometer in the center of the armpit, placing it in the wrong way may give you an inaccurate
result. Digital thermometers may take longer than 30 seconds before beeping. The normal temperature is 36.5
to 37.5. After using the thermometer make sure you clean the thermometer again. Don’t forget to tell the
patient’s temperature.
 NCM 103 FUNDAMENTALS OF NURSING PRACTICE

SKILLS LAB

SANTOS, KIMBERLY WYNE C. Date: 1/24/23

BSN LEVEL I - N22A

MRS. RUBY D. VARGAS

(VITAL SIGNS)

ASSESSING PERIPHERAL PULSE

A pulse is a wave of blood created by contraction of the left ventricle of the heart. The pulse rate normally
increases with activity, so it is important to ask your patient what they have done before going to the hospital or
to the clinic if they run, dance, or exercise. Did they get scared?

Pulses indicate numerous patient characteristics including the degree of relaxation, regularity of cardiac
contractions and sufficiency of cardiac output. Pulse, normal pulse can range between 60 to 100 bpm in adults,
for children 70-100 bpm, Newborn 100 above. An individual’s pulse rate can fluctuate considerably due to
fitness level, illness, injury, emotional state.

There is a specific pulse site the Radial, Temporal, Carotid, Apical, Brachial, Femoral, Popliteal, Posterior,
Dorsalis but in my return demo we get pulse in the brachial site. Always perform proper hygiene to prevent
spread the infection specially in taking pulse because you are touching the patient directly Use first and second
fingertips (never the thumb) to press firmly but gently on the wrist. Never use the thumb because you will feel
the use inaccurately. Making sure the patient body is rest arms are position correctly. Begin counting the beats
of the pulse. Count pulse for 60 seconds until the second-hand returns of your watch.

NCM 103 FUNDAMENTALS OF NURSING PRACTICE

 SKILLS LAB

SANTOS, KIMBERLY WYNE C. Date: 1/24/23

BSN LEVEL I - N22A

MRS. RUBY D. VARGAS

(VITAL SIGNS)

ASSESSING RESPIRATIONS

The respiration rate is the number of breaths a person takes per minute. The rate is usually measured when a
person is at rest and simply involves counting the number of breaths for one minute by counting how many
times the chest rises.

When a person inhales, oxygen enters their lungs and travels to the organs. When they exhale, carbon dioxide
leaves the body. A normal respiratory rate plays a critical role in keeping the balance of oxygen and carbon
dioxide even in the body.

As you take the pulse of the patient can take the respiration rate also by holding them gently in the top of their
shoulder continue to hold the extremity as a distraction for the patient and count the respirations for one
minute, best to take your respiratory rate while sitting up in a chair The normal respiration rate for an adult at
rest is 12 to 20 breaths per minute. A respiration rate under 12 or over 25 breaths per minute while resting is
considered abnormal. When counting breaths, it is best to be as unobtrusive as possible because many
patients tend to breathe faster when they know that attention is being directed to their breathing. It is essential
to measure a person’s respiratory rate at rest to determine whether it is normal. Exercise or even walking
across a room can affect it.

NCM 103 FUNDAMENTALS OF NURSING PRACTICE

 SKILLS LAB

SANTOS, KIMBERLY WYNE C. Date: 1/24/23

BSN LEVEL I - N22A

MRS. RUBY D. VARGAS

(VITAL SIGNS)

ASSESSING BLOOD PRESSURE

Blood pressure is the pressure of blood pushing against the walls of your arteries. Arteries carry blood from
your heart to other parts of your body. Blood pressure 120/80 mm Hg are considered within the normal range.
Systolic blood pressure (the first number) – indicates how much pressure your blood is exerting against your
artery walls when the heart beats.Diastolic blood pressure (the second number) – indicates how much
pressure your blood is exerting against your artery walls while the heart is resting between beats.

Hypertension Stage is when blood pressure consistently ranges at 140/90 mm Hg or higher. f your blood
pressure is higher than 180/120 mm Hg and you are experiencing signs of possible organ damage such as
chest pain, shortness of breath, back pain, numbness/weakness.

When taking blood pressure make sure your patient is not talking of moving this can you a wrong result of their
blood pressure. Like in taking pulse also making sure the patient is sitting properly and arms are rest. Locate
your pulse by lightly pressing your index and middle fingers slightly to the inside center of the bend of your
elbow. Slide the cuff onto your arm, making sure that the stethoscope head is over the artery. f you released
the pressure too quickly or could not hear your pulse, DO NOT inflate the cuff again right away.  Hold the
pressure gauge in your left hand and the bulb in your right. Close the airflow valve on the bulb by turning the
screw clockwise. Inflate the cuff until you feel the pulse when it stop You should remember so you will add 30
in the first number or the systolic pressure. Listen carefully for the first pulse beat. As soon as you hear it, note
the reading on the gauge. This reading is your systolic pressure. Continue to slowly deflate the cuff. Listen
carefully until the sound disappears.