FATHER SATURNINO URIOS UNIVERSITY

San Francisco St. Butuan City 8600, Region XIII Caraga, Philippines
Tel. Number 085-3421830 local 4853
Nursing Program

NCM 122 RLE

Fundamentals of Nursing Practice
Compilation of Procedures

Name: _____________________________ Section: ______

NURSING PROCEDURES LECTURE RETURN GRADE
DEMONSTRATION DEMONSTRATION
DATE CI’s SIGNATURE DATE CI’s SIGNATURE

Handwashing
Moving, Lifting and
Transporting/ Transferring
Client Technique

Bedmaking

Vital Signs Taking

Cleansing Bed Bath, Hair
Shampoo, Occupied Bed
Making

Post-Mortem Care
Name: _________________________________________________ Section____________________________
Clinical Instructor (Lecture Demo): __________________________ Date of Lecture Demo________________

Handwashing

Basic Concept: Handwashing is a method of decontaminating hands and is considered as the most effective
infection control measure.
Objectives:
1. To reduce the number of microorganisms on the hands.
2. To reduce the risk of transmission of microorganisms in clients.
3. To reduce the risk of cross contamination among clients.
4. To reduce the risk of transmission of infectious organisms to oneself (Berman & Snyder, 2012).
Equipment:
Soap
Warm running water
Paper towels
Preparation:
1. Determine the location of the running water and soap or soap solution.
2. Assess the hands. Nails should be kept short and remove jewelry.
3. Check hands for break in the skin.
4. Fold back the sleeves of the uniform or laboratory gown if it hinders the procedure.

PROCEDURE RATIONALE
1. Open faucet and regulate flow of water.
2. Hold hands lower than elbows and wet hands
under running water.
3. Apply enough soap to cover all hand surfaces.
4. Rub hands palm to palm.
5. Then, right palm over left dorsum in an
interlaced fingers and vice versa.
6. Palm to palm with fingers interlaced.
7. Back of fingers to opposing palms with fingers
interlocked.
8. Rotational rubbing of left thumb clasped by the
right palm and vice versa.
9. Rotational rubbing, backwards and forwards
with clasped fingers of right hand to left palm and
vice versa.
10. Then, the wrists. Left hand to right wrists and
vice versa.
11. Rinse hands with water.
12. Use paper towel to turn off faucet. Discard paper
towel to appropriate bin.
13. Dry hands thoroughly in a patting motion with a
single use paper towel.
14. Discard paper towels to appropriate bin.
Name: _________________________________________________ Section____________________________
Clinical Instructor (Return Demo): __________________________ Date of Return Demo________________

PERFORMANCE CHECKLIST

Handwashing

Criteria for evaluation or rating the student’s performance:

1 - Performs the step or procedure independently, correctly and appropriately. Shows excellent attitude and gives
the correct rationale of the step/ procedure to be performed. Answers the question/s correctly and analyzes the
situation on or before performing the procedure.
2 – Performs more independently with increasing dependability but occasionally needing assistance. Shows very
satisfactory attitude and gives the correct rationale of the step/ procedure to be performed but occasionally needing
follow-up instructions and explanations.
3 – Performs expected step/ procedure but needs supervision, follow-up instructions and explanations. Has
knowledge about the topic, step or procedure but needs reinforcement.
4 – Performs with close supervision. The student needs repeated, specific, detailed guidance and direction to be
able to perform the step/ procedure correctly and appropriately. There is a need to improve performance.
5 – Performs with very close supervision. The student shows poor or no interest in the step/ procedure to be
performed; cannot answer the question raised by the supervising clinical instructor based on the step or procedure
to be performed; unable to grasp understanding of the topic or procedure; unable to perform the required step and
state the rationale after being instructed, guided or directed. Student’s behavior is inappropriate and potentially
harmful to the client.

1 2 3 4 5
ASSESSMENT
1. Determine the location of the running water and soap or soap solution.
2. Assess the hands. Nails should be kept short and remove jewelry.
3. Check hands for break in the skin.
PLANNING
1. Ensures that materials/ equipment is available; handwashing facility (hand-
control or knee lever faucet is functioning.
2. If wearing long-sleeved uniform or laboratory gown, folds the sleeves.
IMPLEMENTATION
1. Opens faucet and regulates flow of water.
2. Holds hands lower than elbows and wets hands under running water.
3. Applies enough soap to cover all hand surfaces.
4. Rubs hands palm to palm.
5. Then, right palm over left dorsum in an interlaced fingers and vice versa.
6. Palm to palm with fingers interlaced.
7. Back of fingers to opposing palms with fingers interlocked.
8. Rotational rubbing of left thumb clasped by the right palm and vice versa.
9. Rotational rubbing, backwards and forwards with clasped fingers of right hand to
left palm and vice versa.
10. Then, the wrists. Left hand to right wrists and vice versa.
11. Rinses hands with water.
12. Uses paper towel to turn off faucet.
13. Dries hands thoroughly in a patting motion with a single use paper towel.
14. Discard paper towel to appropriate bin.
 EVALUATION
1. Applies concepts or principles learned in the performance of the procedure.
2. Has kept clothes free from splashes of water or of becoming wet.
3. Observes infection control measures.
4. Performs procedure with ease and deftness.
5. Displays a positive behavior when performing the procedure.

Comments:

Rating: ______

________________________________________
Signature Over Printed Name of CI
Name: _________________________________________________ Section____________________________
Clinical Instructor (Lecture Demo): __________________________ Date of Lecture Demo________________

MOVING AND LIFTING CLIENT IN BED

Basic Concept : Moving and lifting means to shift or lift the patient from one position to another
with assistance when the patient is not able to move or lift own self.

Objectives:

1. To perform the task efficiently.

2. To avoid the patient from unnecessary effort.
3. To prevent nurses from strain and back injuries

Materials :
Pillows Handrolls
Lifting sheet

Preparation:
1. Before moving , assess the following:
- Client’s weight, age, level of consciousness, disease process
- Degree of exertion permitted
- Physical abilities to assist with positioning
- Ability to assist with the move
- Ability to understand instructions
- Degree of comfort or discomfort when moving
- Presence of orthostatic hypotension
2. Plan around encumbrances to movement e.g. tubes, IV, cast or incision sites.
3. Review client’s record and nursing plan of care for patient activity.
4. Provide for client privacy

A. Moving a Client up in Bed (One Nurse)

PROCEDURE RATIONALE

1. Wash hands
2. Explain the rationale of procedure to the client.
3. Lower the head of the client so that it is flat or as the
client tolerate.
4. Raise the bed to a comfortable working heights.
5. Remove the pillow and place it at the head of the bed.
6. Lock the wheels on the bed, and raise the rail on the
side of the bed opposite you to ensure client’s safety
7. Place one arm under the clients shoulder and the other
arm under the clients thighs.
8. Instruct the client to grasp the headboard and with her
knees flexed on bed Ask her to help push toward the
head of the bed.
9. At the count nurses count lift and pull the client
upward as the client help push with her arms & feet.
10. Position client comfortably, replace pillow and
arrange linen as necessary.
 B. MOVING a Client Up in Bed with Assistance
PROCEDURE RATIONALE

1.Two Nurses
1. Follow step # 1-5 (procedure for one nurse)
1.1 Position one nurse on each side of the
client.
1.2 Each should have one arm under the client’s
shoulder and one arm under the client’s thigh.
1.3 Together the two nurses lift as the team
leader counts.
1.4 Position client comfortably, replace pillow and
arrange linens.
2.Two Nurses (Alternate Position)
2. Follow step # 1 to 5 (one nurse)
2.1 Position one nurse at the client’s upper
body. Nurse arm nearest to the headboard
should be under the client’s head and the other
Name: _________________________________________________ Section____________________________
Clinical Instructor (Return Demo): __________________________ Date of Return Demo_________________

PERFORMANCE CHECKLIST

Moving and Lifting Client in Bed

Criteria for evaluation or rating the student’s performance:

1 - Performs the step or procedure independently, correctly and appropriately. Shows excellent attitude and gives
the correct rationale of the step/ procedure to be performed. Answers the question/s correctly and analyzes the
situation on or before performing the procedure.
2 – Performs more independently with increasing dependability but occasionally needing assistance. Shows very
satisfactory attitude and gives the correct rationale of the step/ procedure to be performed but occasionally needing
follow-up instructions and explanations.
3 – Performs expected step/ procedure but needs supervision, follow-up instructions and explanations. Has
knowledge about the topic, step or procedure but needs reinforcement.
4 – Performs with close supervision. The student needs repeated, specific, detailed guidance and direction to be
able to perform the step/ procedure correctly and appropriately. There is a need to improve performance.
5 – Performs with very close supervision. The student shows poor or no interest in the step/ procedure to be
performed; cannot answer the question raised by the supervising clinical instructor based on the step or procedure
to be performed; unable to grasp understanding of the topic or procedure; unable to perform the required step and
state the rationale after being instructed, guided or directed. Student’s behavior is inappropriate and potentially
harmful to the client.

1 2 3 4 5
Assessment
1. Assess the following
a. The degree of exertion permitted
b. Physical abilities to assist with positioning
c. Ability to assist with the move
d. Ability to understand instructions
e. Degree of comfort or discomfort when moving
f. Weight, age, and disease process
g. Presence of hypostatic hypotension
2. Assess the presence of encumbrances to movement like tubes, contraption, IV, cast,
incision sites, etc.
3. Review’s client’s record and nursing plan of care
Planning
1. Plans on:
a. How to move client
b. The need to get help
c. For any modification
2. Provides privacy
3. Ensures safety and security before moving the client like locking the wheels of the
bed, floor free from materials or objects, etc.
Implementation
One Nurse
1. Washes hands
2. Explains the rationale of the procedure to the client
3. Lowers the head of the client
4. Raise the bed to a comfortable working height
5. Locks the wheels of the head
6. Places one arm under the client’s shoulder and the other arm under client’s thighs
 7. Ask the client to flex knees and place hand on the nurse’s shoulder
8. Instructs client to move toward the head of the bed
9. Lifts and pulls the client as he/she pulls with arms and pushes with feet
10. Positions the client comfortable, replacing the pillow and arranging bed linens as
necessary
Multiple Nurses
1. Washes hands
2. Explains the rationale of the procedure to the client
3. Lowers the head of the client
4. Raise the bed to a comfortable working height
5. Locks the wheels of the bed
Two Nurses
a. Positions one nurse on the other side of client
b. Each nurse has one arm under the client’s shoulders and one arm under the client’s
thighs
Two Nurses (Alternate Position)
a. Positions one nurse at a client’s upper body. The nurse arm is at the nearest head of
the bed or under the client’s head and the other at the shoulder (client’s nearest arm)

b. Positions the other nurse’s hands at the client’s torso and lower back
Three Nurses
a. Positions one nurse at the client’s upper body. The nurse arm is at the nearest head of
the bed or under the client’s head and the other at the shoulder (client’s nearest arm)
b. Positions the third nurse at the client’s lower torso
Four Nurses
a. Positions two nurses on both sides of the client, each supporting the shoulders

b. Positions the other two nurses on both sides of the client’s hips or thighs
6. Coordinates movement of all nurses and patient pushes at 3 counts
7. Position client comfortably
8. Supports position with pillows to maintain proper body alignment
Using Sheet or Linen to Move Client up in Bed
1. Explains the procedure to the client
2. Places pillow at the head of the bed
3. Places regular sheet folded in half lengthwise in the same manner as in making a bed
extending from the neck to thighs
4. Puts client flat on bed
5. Each worker stands close to the side of the bed
6. Grasps the sheet as in occupied bed making
Evaluation
1. Recalls and applies related principles and concepts
2. Has kept the client safe and free from injury
3. Performs the procedure with ease and efficiency
4. Gives simple and clear instruction to client
5. Has good command to instruction or order to other nurses
6. Shows a positive and caring attitude
7. Accepts criticism, suggestion and comment from the instructor positively

Comments:

Rating: ______

________________________________________
Signature Over Printed Name of CI
Name: _________________________________________________ Section____________________________
Clinical Instructor (Lecture Demo): __________________________ Date of Lecture Demo________________

Bed Making
CLOSED BED

Definition: Closed bed is an unoccupied bed made with top sheet, blanket and bedspread drawn up to the head
of the mattress in preparation for a newly admitted client.
Objective: To provide comfort and rest to a client who may occupy it.
Assessment:
1. Condition of the bed
2. Availability and cleanliness of linens
3. Condition of immediate environment
Planning:
1. Equipment and supplies
Bed linens in order of use:
a. bottom sheet
b. rubber sheet
c. cotton draw sheet
d. top sheet
e. blanket
f. bed cover or bed spread
g. pillow case
h. pillow
Bedside chair or bedside over bed table
2. Environmental considerations
3. Recall relevant principles

OPEN BED

Definition: Open bed is an occupied bed with top covers folded back so that client can easily get into the bed.
Objectives:
1. To prepare bed for occupancy of a particular client
2. To freshen the bed and make patient comfortable
Assessment:
1. Potential client who is incontinent or having excess drainage
2. Client’s activity orders or physical mobility
3. Pulse and respiration rate before getting out of bed
4. Linens to be changed
Planning:
1. Explain the proposed activity
2. Ask client if he/she feels able to sit on chair
3. Prepare needed equipment/ supplies (same as in closed bed, protective pads/ bath towels if necessary)
ANESTHETIC BED

Definition: Anesthetic bed is also known as ether bed or surgical bed. It is prepared to receive an immediate post-
operative patient.
Objectives:
1. To provide warmth and comfort for post-operative patient
2. To facilitate transfer of patient on to the bed
Assessment:
1. General condition of the patient (LOC, V/S)
2. Type of surgery
3. Environmental consideration
4. Equipment and supplies
a. the same linens used for bed making
b. rubber and cotton draw sheet
c. 1 blanket
d. 2 hot water bags with cover
e. materials on bedside table:
- emesis basin/ kidney basin
- tissue paper wipes
- tongue depressor (tongue blade wrapped in gauze)
- BP Apparatus (stethoscope and sphygmomanometer)
- special record forms
f. materials at bedside
- oxygen set-up
- intravenous stand
- drainage bottle
- suction apparatus
- shock blocks
Planning:
1. Recall related principles
2. Need for modification
3. Prepare all the equipment
IMPLEMENTATION
STEPS KEY POINTS
CLOSED BED
Wash hands
Assemble linens, bring to bedside and place on chair or
table
Slip on mattress cover and adjust it smoothly
Place bottom sheet on the bed with centerfold on center
of the mattress, with lower edge aligned with the edge
of the mattress at foot part. Sheet should be right side
up. Open lengthwise and fanfold upper layer to the
center of the bed, working towards the head of the bed.
Lift corner of the mattress from underneath and tuck in
the excess part of the sheet over the head of the
mattress. Miter the corner
Finish side near you by tucking sheet snugly from head
part downwards. Pull sheet tightly by holding it with
palms downward and tucking it with palms upward
Lay rubber sheet on bed, folded in half with centerfold
at the center of the mattress and top edge at 18 inches
from the head end. Fanfold top layer to center of bed.
Lay the draw sheet over the rubber sheet in the same
manner, with top edge 16 inches from the head and of
the bed
Tuck together the draw sheet and the rubber sheet
firmly under the mattress
Go to the other side of the bed. Tuck in bottom sheet
from head part of the bed, working towards the foot
part then miter corner
Pull down to straighten rubber sheet and then draw
sheet. Tuck in together starting at the center, then at top
and then at bottom
Return to the first side of bed. Lay top sheet on bed
with vertical centerfold on center of bed, being sure
that top edge of sheet is seam up (wrong side up) and
even with top edge of mattress. Carry the narrow
hemmed end of the sheet to the foot part. Unfold it
towards the far side of the bed.
Place the blanket on the bed following centerfold, with
top edge about 6 inches from the head edge of mattress.
Spread mattress evenly over the bed
Placed bed spread on the bed with top edge extending 1
inch above the blanket’s edge. Spread evenly over the
bed
Make toe pleat (optional) A horizontal toe pleat is made
by folding 2-4 inches pleat across the sheet about 6-8
inches from the foot of the bed.
Miter the corner at the foot of the bed
Moving to the other side of the bed, straighten and tuck
top sheet, blanket and bed spread at the foot of the bed.
Miter the corner
Slip the pillow case and place at head part of the bed
with opening facing away from the door.
Place bedside table at the head part of the bed and the
chair at the side of the foot part of the bed
Tidy the unit
Wash hands
OPEN BED
Wash hands
Assemble equipment. Carry to bedside
Assist patient to a comfortable chair
Gather patient’s belonging left on bed and place on
bedside table
Strip bed. Discard soiled linens. Fold reusable linens
into eight parts and place at back of chair
Make bed following procedure for closed bed.
Grasp folded top sheet, blanket and bed spread by
either making a diagonal or pie fan folding or
horizontal fan folding
Place pillow in pillow case and position at head part of
the bed
Assist patient back to bed
Observe patient’s reaction. Tidy unit
Bring dirty linens to laundry room
Wash hands
ANESTHETIC BED
Wash hands
Assemble all equipments and bring to bedside table
Make the bed as in closed bed
Place another rubber sheet at the top part of mattress
where the patient’s head will lie. Tuck in at sides
On the foot part, fold back the extra length of the top
sheet, blanket, bed spread. Spread smoothly along the
edge of the blanket to form a cuff
Go to the head of the bed, fold edge of the t form top
linens to form a cuff
On the side towards the door, fold together the top
linens about 8 inches wide. Fan fold the rest up to about
¼ width exposing ¾ of the made bed
Place pillow in pillow case and with closed side
towards the door. Stand it against the head board

Place two hot water bags with cover between fan folded
sheet
Leave the bed in high position

Place additional items needed on bedside table

Position needed equipments at bedside depending on
the type of surgery done and on condition of the patient
Wash hands
Name: _________________________________________________ Section____________________________
Clinical Instructor (Return Demo): __________________________ Date of Return Demo________________

PERFORMANCE CHECKLIST
BED MAKING

1 2 3 4 5
CLOSE BED
Assessment:
1. Checked condition of the bed
2. Availability and cleanliness of the linens
3. Assessed condition of the immediate environment
Planning:
1. Complete equipment and supplies
2. Environmental Considerations
3. Recall relevant principles
Implementation:
1. Wash hands
2. Assemble all equipment to the bedside
3. Bottom sheet properly aligned at the foot part with right side up

4. Rubber sheet placed 18 inches from the head of the bed

5. Draw sheet laid over the rubber sheet, 16 inches from the head of the bed

6. Mitered bottom sheet and tucked rubber and cotton draw sheet neatly and
properly on the working side before transferring to the other side.

7. Top sheet’s edge aligned on the head of the bed with wrong side up

8. Laid blanket 6 inches from the head of the bed with right side up

9. Placed Bed spread extending 1 inch above the blanket’s edge

10. Toe pleat made 2-4 inches across the sheet 6-8 inches from the foot of
the bed
11. Mitered the corner at the foot of the bed
12. Doing first the side near the worker then the other side
13. Slipped pillow into the pillow case and placed on the head part of the
bed
14. Positioned pillow case with open end away from the door
OPEN BED
Assessment:
1. Identified potential client who is incontinent or having excess drainage

2. Determined client’s activity orders and physical mobility

3. Checked Pulse and respiration rate before getting out of bed
4. Determined linens to be changed
Planning:
1. Explained the proposed activity
2. Asked if the patient is able to sit on a chair
3. Prepared needed equipment or supplies
Implementation:
1. diagonal or pie fan folding
2. horizontal fan folding

ANESTHETIC BED
Assessment:
 1. General condition of the patient

2. Type of surgery
3. Environmental consideration
4. Equipments and supplies
Planning:
1. Recall related principles
2. Need for modification
3. Prepare all the equipments
Implementation:
1. Placed another rubber sheet and cotton draw sheet at the top part of the
mattress
2. On the foot part, folded back the extra length of the top sheet, blanket,
bed spread along the edge of the mattress and formed a cuff.

3. On the head of the bed, folded the top sheet, blanket and bed spread to
form a cuff.
4. On the side towards the door, fold together twice, top sheet, blanket and
bed spread.
5. Exposed ¾ of the bed
6. Placed pillow in the pillow case with side towards the door and placed it
against the headboard.
7. Placed two hot water bags with covers between fan folded sheet

8. placed additional equipments on bedside table

9. Positioned needed equipments at bedside.
Evaluation:
1. Foundation of bed smooth and taut
2. Top linens neatly folded
3. relevant principles applied
4. Attitude

Comments:

Rating: ______

________________________________________
Signature Over Printed Name of CI
Name: _________________________________________________ Section____________________________
Clinical Instructor (Lecture Demo): __________________________ Date of Lecture Demo________________

BED STRIPPING

Definition: Bed stripping is removing or stripping of linens from the bed

Objectives:
1. To prepare the bed for cleansing after a patient has been discharged
2. To freshen bed and to turn mattress when the patient is out of bed
3. To check the functioning of the bed for necessary repairs
Assessment:
1. To identify linens to be replaced or re-used
2. Ascertain condition of the bed
Planning:
1. Prepare equipments needed: hamper
2. Recall related principles

IMPLEMENTATION
STEPS KEY POINTS
Adjust height of the bed to a comfortable position
Move bed away from wall. Place hamper at bed
side and chair at the side of the bed nearest the
worker
Check for patient’s belongings such as rosaries,
medals and etc. left on the bed and place on bedside
table. Gather used tissues and the like, place into
paper bag and discard
Raise the mattress with one hand and loosen all
linens with the other hand. Working all around the
bed, starting at the head of bed to foot part on one
side and foot part to head on the other side
Remove pillowcase by grasping pillow at open end
case with one hand and pulling case over the pillow
with another hand
- pillow case may be used in lieu of hamper by
folding back about 5 inches at the open end to form
a cuff which can be used to anchor the pillowcase
at the back of the chair
Fold corners of bed spread towards center of bed
and fold into a ball. Put in hamper
- for linens to be re-used, fold sheet by grasping top
edge with one and at center other hand at edge
nearest you. Fold top edge down even with the
bottom edge again. Pick up spread at center and
fold so that the farthest side comes even with
nearest side. Place folded linen at the back of chair
Do the same with blanket, top sheet and cotton
draw sheet
Fold rubber sheet into quarters and place over back
of chair. If to be washed, place alongside soiled
linens.
Fold bottom sheet in the same manner as other
sheets and place over top sheet. Put this bundle into
hamper.
Move mattress up to the head of bed
 Raise the back rest and foot rest. Air for 15-20
minutes
Bring hamper to laundry room
Wash hands
Report needed repairs

Name: _________________________________________________ Section____________________________

Clinical Instructor (Return Demo): __________________________ Date of Return Demo________________

PERFORMANCE CHECKLIST
BED STRIPPING
1 2 3 4 5
Assessment
Thoroughly assess functioning condition of the bed
Separate soiled linens from usable ones
Planning
Needed equipment complete
Relevant principles recalled
Implementation
Avoid raising dust while loosening bed linens
Fold soiled linens towards the center of bed into balls
Fold re-usable linens for easy re-use
Wrap small pieces of linens with bigger ones
Discard soiled linens properly
Air mattress with foot and back rest raised
Evaluation
Reported needed repairs
Relevant principles applied
Attitude

Comments:

Rating: ______

________________________________________
Signature Over Printed Name of CI
Name: _________________________________________________ Section____________________________
Clinical Instructor (Lecture Demo): __________________________ Date of Lecture Demo________________

VITAL SIGNS
Basic Concept: Vital signs are physiologic measurements of the neurologic, metabolic, respiratory, hormonal
and cardiovascular status of the body. They include the body temperature, pulse rate, respiratory rate, blood
pressure and oxygen saturation. These measurements are of utmost importance because they are the basis for
identifying physiologic disturbances or even life threating health conditions. Thus, vital signs are monitored
periodically.

Blood Temperature- The balance between heat produced and heat loss from the body. Body heat is primarily
produced by metabolism. The heat regulating center is found in the hypothalamus.

Pulse Rate- It is the wave of blood created by contraction of the left ventricles of the heart. It is regulated by
Autonomic Nervous System (ANS).

Respiratory Rate- The act of breathing, transport of oxygen from the atmosphere to the body cells and transport
of carbon dioxide from the cell to the atmosphere.

Blood Pressure- Refers to the force of blood against the arterial walls. Maximum blood pressure exerted on the
walls of arteries when the left ventricle of the heart pushes blood through the aortic valve into the aorta during
systole.

I. Objectives: Vital Signs are measured for the following purpose

1. To monitor the client’s physiologic health status.
2. To provide baseline data for future comparisons
3. To identify health alterations
4. To identify contraindications prior to administration of medications
5. To identify contraindications prior to any diagnostic or invasive procedures.
II. Materials
Thermometer
BP apparatus
Cleansing Alcohol balls in a container
Picking Forceps soak in antiseptic solutions, if using cotton balls soaked in alcohol
Clean Gloves
Waste Receptacles or Kidney Basin
Face towel of patient
Wrist watch with second hand
III. Preparation
1. Prepare all necessary materials
2. Determine frequency of measuring vital signs
3. Determine appropriate site and device for patient
4. Obtain previous baseline data or measurement or previous patient’s record
5. Assess the following
a. Signs and symptoms of vital signs alterations
b. Risk factor of vital signs
c. Factors affecting or influencing vital signs
d. Determine previous activity that interferes in assessing or measuring vital signs.
e. Determine degree of assistance
f. Assess the immediate environment of the client
g. Perform hand hygiene or hand washing.
h. Check the client’s chart for name, birthdate, age and gender
PROCEDURE RATIONALE
ASSESSING THE TEMPERATURE
1. Greet the client, introduce yourself and verify the
client’s identity.
2. Ensure that the client is calm and quiet. Ask what the
client did for the past 12 minutes. If patient was
engaged in a strenuous activity, allow 10-15 minutes
to rest.
3. Expose the patient axilla by securely folding the
client’s shirt sleeve or gown up to the deltoid region.
4. If axilla, is moist, dry it with the patient’s towel using
patting motion.
5. Remove thermometer from the container.
6. With a cotton ball, wipe the thermometer in a rotating
motion from the temperature sensor to the neck.
7. Place the thermometer in the center of the patient’s
axilla.
8. Assist the patient to place the arm tightly across the
abdomen to keep thermometer in place.
9. Wait until the thermometer will buzz
10. Note the result of the temperature
Note: Remain holding the thermometer in place if the
client is irrational or is very young.

ASSESSING PERIPHERAL PULSE

11. Assist the client to a comfortable supine position or
to a sitting position on a chair or at the edge of the
bed.
12. Select the pulse site point. Normally the radial pulse
is taken.
13. Place the two or three fingertips (index, middle and
ring) lightly and squarely over the pulse point. Never
use the thumb in assessing pulse.
14. Rest the arm in a 90 degrees angle across the
abdomen with palm facing downward.
15. Observe the first minute the regulatory of the pulse,
count for one full minute.
16. Note the pulse rhythm and volume.
ASSESSING THE RESPIRATORY
17. Feel the rise and fall of the diaphragm while
supposedly taking the radial pulse.
18. Count the RR in 60 seconds. One inhalation and one
exhalation are counted as one cycle.
19. When abnormal breathing pattern is noted use the
next 60 seconds to carefully observe the
characteristics of the client’s respirations.
20. Note the rate, depth, rhythm and character of
respiration
21. Refer any abnormal findings or any complaints of the
clients (Ex. Difficulty of breathing).
ASSESSING BLOOD PRESSURE
22. Position the client appropriately and allow 10-15
minutes rest, if the patient is engaged in a strenuous
activity before BP assessment.
a. In a lying positing with arms at the side, palm
facing up
 b. In a sitting position with arm slightly flexed, the
forearm supported at the heart level and facing up.
23. Fold the patient’s shirt sleeves or gown up to the
shoulder, making it sure it is secured and will not fall
to the brachial area.
24. Ask the client not to speak when BP is being
measured.
25. Smoothly and evenly apply the cuff with its lower
border located at about 2.5cm above the antecubital
space.
26. Ensure the tube is place in line with the brachial
artery
27. Measure if the cuff is snugly fitted by inserting your
2 fingers into the BP Cuff.
28. Position oneself, so that the manometer is vertically
at the eye level. Observation should not be father than
1m (Approximately 1 yard) away.
29. Insert the earpieces of the stethoscope in your ears so
that they tilt slightly forward. Be sure sounds are clear
not muffled.
30. Ensure that the stethoscope hangs freely and is not
contact with any object.
31. Warm the diaphragm of the stethoscope
32. Locate the brachial artery and place the diaphragm of
the stethoscope over the brachial pulse. Secure the
chest piece by placing over the palm of the non-
dominant hand over it.
33. Close the valve of the pressure bulb clockwise until it
is tight.
34. Quickly inflate cuff until the last sound then add 30
mmhg.
35. Slowly release/ open the pressure valve and allow the
manometr gauge to fall at a rate of 2-3 mmhg/per
scond.
36. Note the point on manometer where the first clear
sound is heard. The sound will slowly increase in
intensity
37. Continue to deflate the cuff, noting the point at which
sound disappears. Listen for 10-20mmh after the last
sound, then allow remaining air to escape quickly.
38. Remove the cuff from the client’s arm and assist
patient to assume a comfortable position. Cover the
upper arm if it was previously clothed
39. Discuss the findings to the client and do health
teachings as needed
40. Wash Hands
41. Documentation.
A. Chart in TPRBP sheet according to hospital policy.
B. Report abnormal findings of vital signs
C. Report any alterations/observable signs and
symptoms of the patient
D. Patient’s Reactions
Reference
Berman, Aubrey, Synder, Shirlee, Frandsen, Geralyn (2016). Kozier and Erb’s Fundamentals of Nursing
concepts, Process and practice 10th ed.
Name: _________________________________________________ Section____________________________
Clinical Instructor (Return Demo): __________________________ Date of Return Demo________________

PERFORMACE CHECKLIST
Assessing Vital Signs

Criteria for evaluation or rating the student’s performance:

1 - Performs the step or procedure independently, correctly and appropriately. Shows excellent attitude and gives
the correct rationale of the step/ procedure to be performed. Answers the question/s correctly and analyzes the
situation on or before performing the procedure.
2 – Performs more independently with increasing dependability but occasionally needing assistance. Shows very
satisfactory attitude and gives the correct rationale of the step/ procedure to be performed but occasionally needing
follow-up instructions and explanations.
3 – Performs expected step/ procedure but needs supervision, follow-up instructions and explanations. Has
knowledge about the topic, step or procedure but needs reinforcement.
4 – Performs with close supervision. The student needs repeated, specific, detailed guidance and direction to be
able to perform the step/ procedure correctly and appropriately. There is a need to improve performance.
5 – Performs with very close supervision. The student shows poor or no interest in the step/ procedure to be
performed; cannot answer the question raised by the supervising clinical instructor based on the step or procedure
to be performed; unable to grasp understanding of the topic or procedure; unable to perform the required step and
state the rationale after being instructed, guided or directed. Student’s behavior is inappropriate and potentially
harmful to the client.

1 2 3 4 5
ASSESSMENT
1. Determine frequency of measurement of vital signs
2. Obtain previous baseline data or measurement.
3. Assess the following
a. Signs and Symptoms of vital signs alterations
b. Risk factors of vital signs alterations
c. Factors affecting or influencing vital signs.
4. Determine client’s previous activity that interferes in assessing or measuring
vital signs.
5. Assess the immediate environment of the client.
6. Check the client’s chart for name, birthdate, age and gender.
PLANNING
1. Prepare all necessary materials
2. Determine degree of assistance needed
IMPLEMENTATION
1. Greet the client, introduce self and verifies the client identity.
2. Ensure that the client is calm and quiet. Ask what the client did for the
past 15 minutes
3. If patient engages in a strenuous activity, allow 10-15 min, rest
4. Expose the client’s axilla by securely folding the client’s shirt sleeve or
gown up to the deltoid region.
5. Dries the client’s axilla if wet or sweating
6. Remove thermometer from its container
7. With a cotton ball, wipes the thermometer in a rotating motion from
temperature sensor to the neck.
8. Places the thermometer in the center of patient’s axilla
9. Assist the patient to place the arm tightly across the abdomen to keep the
thermometer in place
10. Wait until the thermometer buzzes and note the result of the temperature.
11. If the client is irrational, hold the thermometer
12. Assesses the client to a comfortable supine position or to a sitting position
on a chair or at the edge of the bed.
13. Select the pulse point. Normally the radial pulse is taken.
14. Places two or three fingertips (index, middle and ring)lightly and squarely
over the pulse point.
15. Rest the rms 90 degrees angle across the abdomen with plm, facing
downward
16. Observes for the first minute the regulatory of pulse , count for one full
minute.
17. Notes the pulse rhythm and volume
18. Feel the rise and fall of the diaphragm while supposedly taking the radial
pulse.
19. Count the RR for 60 seconds. One inhalation and one exhalation are
counted as one respiratory cycle
20. When abnormal breathing pattern is noted, uses the next 60 seconds to
carefully observe the characteristics of the clients respirations.
21. Note the rate, depth, rhythm and character of respiration.
22. Refer any abnormal findings or any complaints of the clients (Difficulty of
Breathing).
23. Position the client appropriately (allow 10-15 mins if the patient is
engaged in a strenuous activity before BP assessment).
a. In a lying position with arms at the side, palm facing up
b. In a sitting position with arms slightly flexed, the forearm supported at the
heart level and palm facing up.
24. Fold the patient’s shirt sleeves or gown up to the shoulder, making sure it
is secured and will not fall to the brachial artery
25. Ask the client not to speak when BP is being measured.
26. Smoothly and evenly applies the cuff with its lower border located at
about 2.5 cm above the antecubital space
27. Ensure that the tube is in place in line with the brachial artery
28. Measure if the cuff is snugly fitted by inserting your 2 fingers into BP
cuff.
29. Position oneself, so that manometer is vertically at the eye level.
Observation should not be farther than 1m (approximately 1 yard) away
30. Insert the earpiece of the stethoscope in your ears so that they tilt slightly
forward. Be sure sounds are clear not muffled
31. Ensure that the stethoscope hang freely and is not in contact with any
object.
32. Warm the diaphragm of the stethoscope.
33. Locates the brachial artery
34. Places the diaphragm of the stethoscope over the brachial artery
35. Secure the piece by placing the palm of non dominant hand over it

36. Close the valve of pressure bulb clockwise until it is tight.

37. Quickly inflates cuff until the last sound add 30 mmhg
38. Slowly release/opens the pressure valve and allows the mercury
manometer gauge to fail at a rate of 2-3mmh per second
39. Note the point on manometer where the first sound is heard
40. Continue to deflate the cuff, noting point at which sound disappears.
41. Listen for 10-20mmhg after the last sound, and then allows remaining air
to escape quickly.
 42. Removes the cuff from the client’s arm and assist client to assume
comfortable position. Cover the upper arm if it was previously clothed.
43. Discusses finding with the client and do health teachings as needed.

44. Washes hand

45. Document the following:
46. A. Chart in the TPRBP sheet according to hospital policy
B. Report any abnormal findings of vital signs
C. Report any alterations/observable signs and symptoms of vital signs

D.Patient’s Reaction
EVALUATION
1. Performs the procedure with ease and deftness
2. Recall and applies related principles and procedures
3. Obtain accurate data on measurement
4. Has kept patient comfortable.
5. Display a positive and caring attitude in the performance of the procedure.

Comments:

Rating: ______

________________________________________
Signature Over Printed Name of CI
Name: _________________________________________________ Section____________________________
Clinical Instructor (Lecture Demo): __________________________ Date of Lecture Demo________________

THE CLEANSING BED BATH

DEFINITION: The act of washing the body with soap and water while the patient is in bed.
OBJECTIVES:
1. To cleanse the skin as bathing removes perspiration, some bacteria, sebum and dead skin cells.
2. To stimulate circulation.
3. To promote a positive self image
4. To reduce body odors.
5. To promote range of motion (ROM).
ASSESSMENT:
1. Vital signs
2. degree of assistance needed
3. patient’s preference for bathing procedure
4. availability of bathing supplies and equipment
5. need as to what bed linen is to be changed
6. patient’s activity order
7. environmental and procedural modification needed
PLANNING:
1. Recall relevant principles to be threaded through.
2. complete materials and equipments to be used:
a. wash cloth
b. face towel (optional)
c. bath towel
d. bath blanket
e. soap in a soap dish
f. comb (patient’s own)
g. talcum powder (patient’s own)
h. deodorant (patient’s own)
i. nail cutter
j. newspaper
k. clean linen (as needed)
l. clean gown
m. bath basin ½ full of warm water ( approximately 43-46 C or 110-115 F) tested by pouring on
wrist)
n. screen as needed
o. bedpan or urinal (at bedside)
p. pail, basin (2), pitcher(2)
3. Conserve steps in doing the procedure
4. plan for modification if indicated
PROCEDURE:
STEPS KEY POINTS
1. Before beginning the bath, determine:
a. vital signs
b. other care the patient is receiving as
roentgenography, physiotherapy
c. aspects of the patient’s health status that affects
the bathing process.
2. explain the procedure to the patient
3. Inspect linens and determine which linen, needs to
be changed.
4. Clear bedside table. Table cover should be removed
after clearing table. Line the table top with newspaper
before placing bath basin on it.
5. Close the windows and door to make sure the room
is free from drafts.
6. Screen patient especially if he is in a semi-private
room or ward.
7. Offer the patient a bedpan or urinal or ask whether
he or she wishes to use the toilet or commode.
8. Wash hands
9. Prepare and bring all the necessary articles to the
bedside.
10. Arrange linen in order of use on a chair
11. Adjust bed to appropriate height
12. Loosen top bedding at foot bed. Place bath blanket
over the top sheet is being removed. Fold top sheet and
place on chair.
13. Assist patient to move to side of bed nearest you
14. Remove clothing keeping patient covered with
bath blanket. Avoid exposing the patient
unnecessarily. If patient’s arm or shoulder is injured,
begin removal of clothing from uninjured side.
15. place bath towel under head and face towel under
chin
16. make a bath mitt with the wash cloth
a. Triangular method
- lay your hand over one corner of the wash cloth
- fold the top corner over your hand
- fold the side corners over the hand
- tuck the second corner under the cloth on the
palmar side to secure the mitt
b. Rectangular method:
- lay your hand over the wash cloth, and fold one
side over your hand;
- fold the second side over your hand
- fold the top of the cloth down, and tuck it under
the folded side against your palm to secure the mitt.
17. Wash region around the eyes with clear water.
Wipe from inner canthus outward and use a separate
position of the wash cloth for each eye.
18. Wash face, neck and ears thoroughly with soap and
water. Rinse well then dry.
a. consult patient first as to his preference before
applying soap to the area.
 b. use firm, gentle motion on face using upward
strokes. Clean ears well.
c. rinse off soap thoroughly and dry area well
19. Remove face towel and place over rack
20. Remove bath towel under head
21. Uncover farther arm and place bath towel
lengthwise under it. Wash the arm with soap and water
using firm long strokes from distal to proximal areas.
22. Soap are paying particular attention to the axilla.
Rinse well and dry.
23. Do the same procedure for the nearer arm.
24. Place a towel directly on the bed and put basin on
it. Place patient’s hands in the basin. Assist him/her to
wash, rinse and dry them paying particular attention to
spaces between the fingers.
25. Change the water
26. Cover chest and abdomen with bath towel and fold
bath blanket down to the pubic area
27. Soap chest and abdomen working under towel.
Rinse well and dry. Cover area with bath blanket. Pay
particular attention to the navel and to area under
breasts of female patients.
28. Turn patient on his side. Have patient’s back
towards the nurse with body slightly diagonal to bed.
29. Place bath towel lengthwise on bed alongside back
and soap area (including back of neck) rinse
thoroughly and dry.
Do back rub after.
a. rub in circular motion over sacral area
b. move your hands up the center of the back and
then over both scapulae
c. massage in circular motion over the scapulae
d. move hands down the sides of the back
e. massage areas over right and left iliac crests
f. repeat steps as needed
g. massage pressure areas gently and only if there is
no evidence of underlying tissue damage
h. pat dry any excess solution with a towel
30. Put on patient’s gown or pajama top if any
31. Change water
32. Bathe thighs and legs in the same manner and
order as the arms paying particular attention to the
inguinal areas. Drape bath blanket around groin.
33. Flex patient’s knees and wrap blanket around legs.
Have edge of blanket come just below knees and be
sure patient is unnecessarily exposed.
34. Place bath towel under feet
35. Place basin on towel
36. Put feet flat into basin (feet may be placed in basin
one at a time) Avoid pressure on patient’s calves and
ankles.
37. Wash feet thoroughly with soap and water using
washcloth. Particular attention should be given to areas
between toes and heels
38. Remove feet from basin by placing one hand under
patient’s legs while the other hand draws basin out.
When washing one foot at a time, place cleaned foot
on bath towel before proceeding with other foot.
Lotion may be applied to rough and calloused areas.
39. Dry feet paying close attention to areas between
toes.
40. Bring basin and washcloth to utility room
41. Clean washcloth and basin well with soap and
water. Refill basin with water.
42. Bring wash cloth and basin back to patient’s unit
43. Place needed articles within reach of patient and
instructs him or her to finish bath or crotch care.
a. “finishing the bath” is the term used to wash the
genital area. This is done by the patient
b. the nurse may leave the unit placing a call bell
within easy reach while patient is finishing the bath
unless his/her condition requires the nurse’s presence.

c. If the patient is unable to finish the bath, the

female nurse does this for female patients while a male
nurse or orderly may do it for male patients. Careful
cleansing of the hands must be done by nurse or
orderly afterwards.
44. Have patient wash his hands (while patient is
finishing his bath, the nurse brings in a small pitcher of
water to wash patient’s hands with)
45. Put on rest of clothing, if any
46. Make patient’s bed (occupied bed)
47. Do hair and nail care
48. make patient comfortable in bed
49. Do after care of unit
50. Clean equipment used and return to their proper
places
51. Wash hands
52. Chart the following:
a. time bed bath was given
b. signs and symptoms observed
c. complains made
d. condition of the patient
Name: _________________________________________________ Section____________________________
Clinical Instructor (Lecture Demo): __________________________ Date of Lecture Demo________________

HAIR SHAMPOO

CONCEPT: Cleansing the hair to keep it free from dirt and make the patient feel fresh and comfortable.
OBJECTIVES:
1. To cleanse the patient’s hair and head
2. to promote the physical and mental comfort
3. to complete a treatment for pediculi
ASSESSMENT:
1. Assess the condition of hair and scalp
2. degree of assistance and modification needed
3. availability of supplies and equipment
PLANNING:
1. Check doctor’s needed
2. confer with the patient as to the best time of the day for the shampoo
3. provide privacy
4. Prepare all equipment needed
a. Hair brush and comb
b. Shampoo of patient’s choice
c. Jar of cotton balls
d. Pitcher of water with desired temperature 43-44 C (110 F)
e. Pail
f. Kelly pad (inflated) or rubber sheet
g. Bath towel
h. Plastic sheet
i. Wash cloth or pad
j. Hair dryer (optional)
5. Recall relevant principles
6. plan for modification, if indicated
PROCEDURE:
STEPS KEY POINTS
1. Wash hands
2. Offer bedpan or encourage patient to use toilet
(if ambulatory or with bathroom privileges)
3. Position the patient diagonally in bed with the head near the
side of the bed in which you will work
4. Remove pins and ribbons from the hair; brush and comb it.
5. Place the plastic sheet or pad on the bed under the head over
the pillow
6. Remove pillow from under the client’s head, and place it
under the client’s head, and place it under the shoulders
7. Tuck a bath towel around the patient’s shoulders
8. Line the floor with newspaper
9. Place inflated Kelly pad under the head, with the tail into the
pail. Place a folded washcloth or pad where the patient neck
rests on the edge of the Kelly pad
10. Place a damp washcloth over the patient’s eyes
11. Stuff the patient’s ears with dry cotton balls
12. Wet hair thoroughly with water of the desired temperature
13. Apply shampoo to the scalp. Make a good lather with the
shampoo while massaging the scalp using the pads of the finger
tips. Massage all areas of the scalp systematically e.g. starting at
the front and working to the back f the head.
14. Rinse well. Apply shampoo again. Make a good lather and
massage scalp as before.
15. Repeat step 14 until hair is sufficiently clean
16. Rinse hair thoroughly to remove all the shampoo
17. Squeeze as much water as possible out of the hair with your
hands. Do not pull hair
18. Remove wash cloth and dry face
19. Remove cotton balls and drop into coil
20. Remove Kelly pad under the head and drop into the pail
21. Wrap the patient’s hair with towel.
22. dry hair and assist the patient in combing
23. Tidy the bed and make the patient comfortable
24. Do after care of the unit and equipment used
25. wash hands
26. Chart:
a. assessment finding of hair and scalp
b. date and time shampoo was given
c. name of shampoo used
d. reaction of the patient
Name: _________________________________________________ Section____________________________
Clinical Instructor (Lecture Demo): __________________________ Date of Lecture Demo________________

OCCUPIED BED MAKING

CONCEPT: Making a bed safely for a bedridden patient

OBJECTIVES:
1. To change the linens of the bed without unnecessarily exposing the patient's body
2. To free the bed from wrinkles by having a good foundation of the bed thus preventing skin irritation to the
patient
3. To provide patient's comfort and safety
ASSESSMENT:
1. Assess the linens to be changed
2. Check the general condition of the patient including the vital signs
3. Determine positions that maybe contraindicated to the patient
4. Degree of assistance needed
5. Type of linen/s needed
6. Availability of linens
7. Safety and special precautions to be observed in moving the patient
- locking the wheels of the bed
- adjusting the height of the bed to its working level
- side rails
- facing the direction of movement
PLANNING:
1. Greeting, introduction, asking, explain
2. Prepare needed supplies and equipment
- linens arranged in order of use
- linen hamper
- chair
- bath blanket
- screen if necessary
PROCEDURE:
STEPS KEY POINTS
1. Wash hands. Gather all equipment and bring to bedside.
place linens on chair and hamper at bedside.
2. Provide privacy by putting up the screen of closing the
door
3. Adjust the bed to a comfortable working height. Put up
side rails at the opposite the worker.
4. Remove any equipment attached to bed and any
patient's belonging on the bed
5. Loosen all top linens at the foot of the bed
6. Remove bed spread and blanket carefully. If to be re-
used fold each in a manner that readily reapplied to bed
later and place on the back of the chair. If soiled , discard
into the hamper.
7. Leave top sheet over the patient if it is to be changed it
replaced with bath blanket as follows:
a.spread the bath towel over the top sheet
b. ask the client to hold the top edge of the towel
c. holding the bottom edge of the towel over the top sheet
to the head part. Grasp together bottom edge of bath towel
and top edge of top sheet and pull down until patient is
adequately covered by bath towel
d. remove the sheet from the bed, fold and place at the
back of the chair
e. reaching under the blanket from the side, grasp the top
edge of the sheet and draw it down to the feet of the bed,
leaving the blanket in place
8. Loosen drawsheet, rubber sheet and bottom sheet
9. Move patient nearer to the worker
10. Assist patient to assume the Sim's lateral position
facing away from the worker. Move the pillow with the
patient
11. Roll the draw sheet, rubber sheet and bottom sheet
piece by piece, towards the back of the patient and tuck
under patient's back and buttocks
12. proceed to the basic bed making, fan folding vertically
the clean bottom sheet at the center of the bed. Tuck in at
top, miter corner and finish tucking the side
13. Apply rubber sheet and cotton draw sheet and tuck in
well under the mattress
14. Help the patient to roll over the folded linen and on to
the clean linen and let lie in supine position. Adjust the
pillow under patient's head
15. Raise the side rail, if necessary, before leaving the side
of the bed
16. Move to the other side of the bed and lower the side
rail
17. Assist the patient to Sim's lateral position away from
the worker
18. loosen the side foundation linens from the bed
19. Unfold each piece of clean linen towards you and
proceed to the basic bed making until bottom sheet, rubber
sheet and draw sheet are well tucked under the mattress
20. Reposition pillow at the center of the bed and assist
patient to the center of the bed in a position preferred or
requires
21. Return to first side and lower side rail
22. Place top sheet over the patient so that centerfold is in
the center of the bed and the top edge is at the client
shoulder
23. Ask the patient to hold the top edge of the sheet as you
pull the bath blanket from top to bottom
24. Fold the bath blanket if to be reused
25. Add the blanket and the bed spread and proceed by
tucking the top sheet, blanket and bed spread at the foot
part and make a modified miter at both corners
26. Instead of a toe pleat, you may have the patient point
his or her toes up, which allows room for the toes after the
bed has been made
27. Change pillowcase and slip under the patient's head
28. re-attach signal cord and other equipment removed
earlier
29. Tidy the unit or remove screen
30. Return hamper with soiled linens to laundry room
31. wash hands
Name: _________________________________________________ Section____________________________
Clinical Instructor (Return Demo): __________________________ Date of Return Demo________________

PERFORMANCE CHECKLIST
CBB, Hair Shampoo, Occupied Bed Making

1 2 3 4 5
Cleansing Bed Bath
ASSESSMENT:
Vital signs
degree of assistance needed
patient’s preference for bathing procedure
availability of bathing supplies and equipment
need as to what bed linen is to be changed
patient’s activity order
environmental and procedural modification needed
PLANNING
Recalled relevant principles to be threaded through.
Materials and equipment to be used is complete
Conserved steps in doing the procedure
Planned for modification if indicated
PROCEDURE
Introduced self and verified client’s identity
Before beginning the bath, determined:
a. vital signs
b. other care the patient is receiving as roentgenography,
physiotherapy
c. aspects of the patient’s health status that affects the bathing
process.
Explained the procedure to the patient
Inspected linens and determined which linen, needs to be changed.
Lined the table and floor with newspaper
Closed the windows and door to make sure the room is free from
drafts.
Screened patient especially if he is in a semi-private room or ward.
Offered the patient a bedpan or urinal or ask whether he or she wishes
to use the toilet
Washed hands
Prepared and bring all the necessary articles to the bedside.
Arranged linen in order of use on a chair
Adjusted bed to appropriate height
Loosened top bedding at foot bed. Place bath blanket over the top
sheet is being removed. Fold top sheet and place on chair.
Assisted patient to move to side of bed nearest you
Removed clothing keeping patient covered with bath blanket. Avoid
exposing the patient unnecessarily. If patient’s arm or shoulder is
injured, begin removal of clothing from uninjured side.
Placed bath towel under head and face towel under chin

Made a bath mitt with the wash cloth: Triangular or Rectangular

Washed region around the eyes with clear water. Wipe from inner
canthus outward and use a separate position of the wash cloth for each
eye.
Washed face, neck and ears thoroughly with soap and water. Rinse
well then dry.
Removed face towel and place over rack
Removed bath towel under head
Uncovered farther arm and place bath towel lengthwise under it. Wash
the arm with soap and water using firm long strokes from distal to
proximal areas.
Soap paying particular attention to the axilla. Rinse well and dry.
Did the same procedure for the nearer arm.
Placed a towel directly on the bed and put basin on it. Place patient’s
hands in the basin. Assist him/her to wash, rinse and dry them paying
particular attention to spaces between the fingers.
Changed the water
Covered chest and abdomen with bath towel and fold bath blanket
down to the pubic area
Applied soap on chest and abdomen working under towel. Rinse well
and dry. Cover area with bath blanket. Pay particular attention to the
navel and to area under breasts of female patients.
Turned patient on his side. Have patient’s back towards the nurse with
body slightly diagonal to bed.
Placed bath towel lengthwise on bed alongside back and soap area
(including back of neck) rinse thoroughly and dry.
Done with back rub
Put on patient’s gown or pajama top if any
Changed water
Bathed thighs and legs in the same manner and order as the arms
paying particular attention to the inguinal areas. Drape bath blanket
around groin.
Flexed patient’s knees and wrap blanket around legs. Have edge of
blanket come just below knees and be sure patient is unnecessarily
exposed.
Placed bath towel under feet
Placed basin on towel
Placed feet flat into basin. Avoid pressure on patient’s calves and
ankles.
Washed feet thoroughly with soap and water using washcloth.
Particular attention should be given to areas between toes and heels
Removed feet from basin by placing one hand under patient’s legs
while the other hand draws basin out. When washing one foot at a
time, place cleaned foot on bath towel before proceeding with other
foot. Lotion may be applied to rough and calloused areas.
Dried feet paying close attention to areas between toes.
Brought basin and washcloth to utility room
Cleansed washcloth and basin well with soap and water. Refill basin
with water.
Brought wash cloth and basin back to patient’s unit
Placed needed articles within reach of patient and instructs him or her
to finish bath or crotch care.
Have patient wash his hands
Put on rest of clothing, if any
Do hair and nail care
Hair Shampoo
ASSESSMENT
Assessed the condition of hair and scalp
Assessed degree of assistance and modification needed
Availability of supplies and equipment
PLANNING:
Checked doctor’s order as needed
Conferred with the patient as to the best time of the day for the
shampoo
Provided privacy
Prepared all equipment needed
Recalled relevant principles
Planned for modification, if indicated
PROCEDURE
Position the patient diagonally in bed with the head near the side of
the bed in which you will work
Removed pins and ribbons from the hair; brush and comb it.
Placed the plastic sheet or pad on the bed under the head over the
pillow
Removed pillow from under the client’s head, and place it under the
client’s head, and place it under the shoulders
Tucked a bath towel around the patient’s shoulders
Placed inflated Kelly pad under the head, with the tail into the pail.
Place a folded washcloth or pad where the patient neck rests on the
edge of the Kelly pad
Placed a damp washcloth over the patient’s eyes
Stuffed the patient’s ears with dry cotton balls
Wet hair thoroughly with water of the desired temperature
Applied shampoo to the scalp. Make a good lather with the shampoo
while massaging the scalp using the pads of the finger tips. Massage
all areas of the scalp systematically e.g. starting at the front and
working to the back f the head.
Rinsed well. Apply shampoo again. Make a good lather and massage
scalp as before.
Squeezed as much water as possible out of the hair with your hands.
Do not pull hair
Removed wash cloth and dry face
Removed cotton balls and drop into coil
Removed Kelly pad under the head and drop into the pail
Wrapped the patient’s hair with towel.
Dried hair and assist the patient in combing
Occupied Bed Making
ASSESSMENT:
Assessed the linens to be changed
Checked the general condition of the patient including the vital signs
Determined positions that maybe contraindicated to the patient
Degree of assistance needed
Type of linen/s needed
Availability of linens
Safety and special precautions to be observed in moving the patient
PLANNING:
Prepare needed supplies and equipment
PROCEDURE:
Loosened drawsheet, rubber sheet and bottom sheet
Moved patient nearer to the worker
Assisted patient to assume the Sim's lateral position facing away from
the worker. Move the pillow with the patient
Rolled the draw sheet, rubber sheet and bottom sheet piece by piece,
towards the back of the patient and tuck under patient's back and
buttocks
Proceed to the basic bed making, fan folding vertically the clean
bottom sheet at the center of the bed. Tuck in at top, miter corner and
finish tucking the side
 Applied rubber sheet and cotton draw sheet and tuck in well under the
mattress
Helped the patient to roll over the folded linen and on to the clean
linen and let lie in supine position. Adjust the pillow under patient's
head
Raised the side rail, if necessary, before leaving the side of the bed
Moved to the other side of the bed and lower the side rail
Assisted the patient to Sim's lateral position away from the worker
Loosened the side foundation linens from the bed
Unfolded each piece of clean linen towards you and proceed to the
basic bed making until bottom sheet, rubber sheet and draw sheet are
well tucked under the mattress
Repositioned pillow at the center of the bed and assist patient to the
center of the bed in a position preferred or requires
Returned to first side and lower side rail
Placed top sheet over the patient so that centerfold is in the center of
the bed and the top edge is at the client shoulder
Asked the patient to hold the top edge of the sheet as you pull the bath
blanket from top to bottom
Folded the bath blanket if to be reused
Added the blanket and the bed spread and proceed by tucking the top
sheet, blanket and bed spread at the foot part and make a modified
miter at both corners
Instead of a toe pleat, you may have the patient point his or her toes
up, which allows room for the toes after the bed has been made
Change pillowcase and slip under the patient's head
Tidy the bed and make the patient comfortable
Do after care of the unit and equipment used
Washed hands
Chart the following:
Date and time bed bath and hair shampoo was given
Assessment findings of the patient’s skin, hair and scalp
Name of Soap, lotion/oil, shampoo/conditioner used

Comments:

Rating: ______

________________________________________
Signature Over Printed Name of CI
Name: _________________________________________________ Section____________________________
Clinical Instructor (Lecture Demo): __________________________ Date of Lecture Demo________________

Postmortem Care (Care of Body after Death)

Basic Concept: Post-mortem care is an independent nursing procedure done to the body after death. It is a
continuation of quality of care to a patient.

Objectives:
1. To clean the patient’s body
2. To prepare the body from the morgue.
3. To make the body appear natural and comfortable as possible for the deceased.

Materials/ Equipment:
Tray lined with drape
3 Basins with water
2% Lysol solution
Soap in a soap dish
Pair of scissors and dressing tray (OS, plaster)
Kidney basin
Mortuary box with three tags
3 tags: hospital no., name of client, date and time of death, physician
4 safety pins
Cotton balls
Gauze or 3 soft strings
Incontinent pad
Clean gloves
3 wash cloths
Towel
Bath blanket
Linens
- White linen (folded diagonally) Cadaver bag
- Any linen/ sheet to cover the body while waiting for the messenger

Preparation:
1. Assess that death has been pronounced by the physician.
2. Determine the cause of death.
3. Determine client’s religion, culture and beliefs.
4. Prepare materials needed.
5. Provide privacy.
6. Wear gloves.
7. Change linen/ blanket to bath blanket.
 STEPS RATIONALE
1. Straighten the body, placed dentures if the patient has
any, keep the mouth close and eyes before rigor mortis
sets in.
2. Remove all appliances, jewelry and endorse properly.
3. Remove extra bed linen, pillows, and leave one pillow
under the head.
4. Move the body near your working area.
5. Bath body aseptically with soap and water then rinse
with Lysol. Start from the face and include the neck.
6. Then the upper extremities.
7. Chest and abdomen
8. Back, start bathing from upper back or shoulder
towards the buttocks/ lower back
9. Lower extremities
10. Perineum (optional)
11. Change soiled dressings.
12. Inset cotton balls to the nose, vagina and anus.
13. Fold the hands to the chest or abdomen.
14. Place a tag.
15. Tie the ankles together. Then, place a tag.
16. Turn the body away from you.
17. Lay sheet diagonally and spread the portion of the
sheet towards you.
18. Place incontinent pad at the back and buttocks.
19. Turn the body again towards you.
20. Raise the side rail. Then, go back to your working area
(other side of the bed) and lower the side rail.
21. Spread the rolled portion of the sheet. Then, the
incontinent pad.
22. Raise the side rail. Then, go back to your working area
(other side of the bed) and lower the side rail.
23. Fold the sheet, covering the entire body part.
a. While covering, slowly remove the bath blanket.
b. Cover starting from the foot, then body, and head.
24. Pin on the head, center, and on the foot. Place a tag.
25. Cover another sheet while waiting for the messenger.
26. Do after care and wash hands.
27. Document
Time or cessation of vital signs
Person notified and time of notification
List and document valuable and personal effects
Time body removed from unit, destination and
removed by whom
Other relevant information
28. Bring the cadaver to the morgue.
Name: _________________________________________________ Section____________________________
Clinical Instructor (Return Demo): __________________________ Date of Return Demo________________

PERFORMANCE CHECKLIST

Postmortem Care (Care of Body after Death)

Criteria for evaluation or rating the student’s performance:

1 - Performs the step or procedure independently, correctly, and appropriately. Shows excellent attitude and gives
the correct rationale of the step/ procedure to be performed. Answers the question/s correctly and analyzes the
situation on or before performing the procedure.
2 – Performs more independently with increasing dependability but occasionally needing assistance. Shows very
satisfactory attitude and gives the correct rationale of the step/ procedure to be performed but occasionally needing
follow-up instructions and explanations.
3 – Performs expected step/ procedure but needs supervision, follow-up instructions and explanations. Has
knowledge about the topic, step or procedure but needs reinforcement.
4 – Performs with close supervision. The student needs repeated, specific, detailed guidance and direction to be
able to perform the step/ procedure correctly and appropriately. There is a need to improve performance.
5 – Performs with very close supervision. The student shows poor or no interest in the step/ procedure to be
performed; cannot answer the question raised by the supervising clinical instructor based on the step or procedure
to be performed; unable to grasp understanding of the topic or procedure; unable to perform the required step and
state the rationale after being instructed, guided, or directed. Student’s behavior is inappropriate and potentially
harmful to the client.

1 2 3 4 5
ASSESSMENT
1. Assess that death has been pronounced by the physician.
2. Determines the cause of death.
3. Determine client’s religion, culture, and beliefs.
PLANNING
1. Prepares the needed materials and arranges it according to use.
2. Provide privacy.
IMPLEMENTATION
1. Wears glove.
2. Changes linen to bath blanket.
3. Straighten the body, placed dentures if the patient has any, keep the mouth close
and eyes before rigor mortis sets in.
4. Remove all appliances, jewelry and endorse properly.
5. Remove extra bed linen, pillows, and leave one pillow under the head.
6. Bathes body aseptically with soap and water then rinse with Lysol. Start from the
face and include the neck.
a. then, the upper extremities
b. Chest and abdomen
c. Back, starts bathing from the upper back.
d. Lower extremities
e. Perineum (optional)
7. Changes soiled linens
8. Inset cotton balls to the nose, vagina, and anus.
9. Folds the hands to the chest or abdomen.
10. Place tag.
11. Tie the ankles together. Then, place a tag.
12. Turn the body away.
13. Lay sheet diagonally and spread the portion of the sheet towards you.
14. Place incontinent pad at the back and buttocks.
15. Turn the body again (towards the nurse)
 16. Raise the side rail and moves to the other side of the bed.
17. Spread the rolled portion of the sheet. Then, the incontinent pad.
18. Raise the side rail. Then, goes back to the working area.
19. Folds the sheet, covering the entire body part.
a. While covering, slowly remove the bath blanket.
b. Cover starting from the foot, then body, and head.
20. Pins on the head, center, and on the foot.
21. Places a tag.
22. Covers another sheet while waiting for the messenger.
23. Do after care and wash hands.
24. Document
Time or cessation of vital signs
Person notified and time of notification
List and document valuable and personal effects
Time body removed from unit, destination and removed by whom
Other relevant information
25. Bring the cadaver to the morgue.
EVALUATION
1. Performs the procedure with ease and deftness.
2. Applies related and relevant principles.
3. Observes appropriate infection control measures throughout the performance of the
procedure.
4. Makes the body appear natural and comfortable as possible.
5. Cleans the deceased body well.
6. Wraps the body neatly and snugly.
7. Shows positive and caring attitude as a student nurse.

Comments:

Rating: ______

________________________________________
Signature Over Printed Name of CI