OSCE REVIEWER
- indwelling catheter has a small balloon inflated on
Catheterization
Urinary Catheterization:
- the introduction of a catheter through the urethra
into the bladder for the purpose of withdrawing urine.
PURPOSES:
• To relieve urinary retention
• To obtain a sterile urine specimen from a
woman
• To measure the amount of residual urine in the
bladder
• To empty bladder before and during surgery
and before certain diagnostic examinations.
SIZES URETHRAL CATHETER:
CHILDREN: 8 – 10 Fr
FEMALE ADULT: 12 – 16 Fr
MALE ADULT: 16 – 20 Fr
URINARY CATHETERS:
- a tube placed in the body to drain collect urine from
the bladder.
• Urinary Incontinence: leaking urine or being
unable to control when you urinate.
• Urinary Retention: being unable to empty
your bladder when you need to.
• Surgery on the prostate or genitals
• Other medical conditions such as multiple
sclerosis, spinal cord injury, dementia, or
other operations.
TYPES OF CATHETERS:
- FOLEY CATHETER: common type of indwelling
catheter. It has soft, plastic or rubber tube that is
inserted into the bladder to drain the urine.
1. INDWELLING CATHETERS:
- one that is left in the bladder.
- can be used for short or a long time.
- collects urine by attaching to a drainage bag.
(the bag has valve that can be opened to allow to urine
to flow out.:
- may be inserted into the bladder in 2 ways:
• Catheter is inserted through the urethra. This
is the tube that carries urine from the bladder
to the outside of the body.
• Insert a catheter into your bladder through a
small hole in your lower belly.
the end of it. This prevents the catheter from sliding
out of your body. When the catheter needs to be
removed, the balloon is deflated.
2. CONDOM CATHETER:
- can be used by men with incontinence.
- there is no tube placed inside the penis.
- instead, a condom-like device is placed over the
penis.
- a tube leads from this device to a drainage bag.
- condom catheter must be changed everyday.
3. INTERMITTENT CATHETERS:
- you would only use an intermittent catheter when
you only need to use a catheter to drain the bladder
and then remove it.
- this can be done only once or several times a day.
- the frequency will depend on the reason you need to
use this method or how much urine needs to be
drained from the bladder.
DRAINAGE BAGS:
- catheter most often attached to a drainage bag.
- keep the drainage bag lower than your bladder so
that urine does not flow back up into your bladder.
- empty the drainage device when it is about one half
full and a t bedtime.
- Always wash your hands with soap and water before
emptying the bag.
PREPARATION OF THE PATIENT:
1. ADEQUATE EXPLORATION: on some
instances, catheterization is the last resort, use
other techniques first for drawing out the
urine before proceeding to catheterization.
2. POSITION: dorsal recumbent for the female
and supine for the male using a form mattress
or treatment table, Sim’s or Lateral position
can be an alternate for the female patient.
3. PROVISION OF PRIVACY
RETENTION OR INDWELLING CATHETER (FOLEY)
- A catheter to remain in place for the following
purposes:
a. The gradual decompression of an over distended
bladder
 OSCE REVIEWER

b. for intermittent bladder drainage 8. Teach the patient the importance of personal
hygiene, especially the importance of careful
c. for continuous bladder drainage
cleaning after bowel movement and thorough
- an indwelling catheter has a balloon which is inflated washing of hands frequently.
after the catheter is inserted into the bladder. Because
the inflated balloon is larger than the opening to the
urethra, the catheter is retained in the bladder. REMOVING THE INDWELLING CATHETER AND
AFTERCARE OF THE PATIENT:
PROCEDURE OF INSERTION:
1. Be sure the balloon is deflated before
1. Inflate the balloon with the prefilled syringe
attempting to remove the catheter. This may
before inserting the catheter to check for
be done by inserting a syringe into the balloon
balloon patency. Aspirate the fluid back into
valve or by cutting the balloon valve.
the syringe when it is determined that the
2. Have the patient take several deep breaths to
balloon is patent.
help him relax while gently removing the
2. Hold the catheter with one hand and inflate the
catheter. Wrap the catheter in a towel or
balloon according to the manufacturer’s
disposable, waterproof drape.
instructions, as soon as the catheter is in the
3. Clean the area at the meatus thoroughly with
bladder and urine has begun to drain from
antiseptic swabs after the catheter is removed.
bladder. Usually 5 ml to 10 ml of sterile water
4. See to it that the patient’s fluid intake is
is used.
generous and record the patient’s intake and
3. If the patient complains of pain after the
output. Instruct the patient to void into the
balloon is inflated, allow it to empty and
bedpan or urinal
replace the catheter with another one. The
5. Observe the urine carefully for any signs of
balloon is probably located in the urethra and
abnormality
is causing discomfort owing to distention
6. Record and report any usual signs such as
4. Exert slight tension on the catheter after the
discomfort, a burning sensation when voiding,
balloon is inflated to assure its proper
bleeding, and changes in vital signs, especially
placement in the bladder.
the patient’s temperature. Be alert to any signs
5. Connect the catheter to the drainage tubing
of infection and report them promptly.
and drainage bag if not already connected.
6. Tape the catheter along the anterior aspect of
the thigh for a female patient. Be sure there is
LUBRICATE:
no tension on the catheter when it is taped to
the patient. Male: 5 -7 inches
7. Hang the drainage bag on the frame of the bed
below the level of the bladder. Female: 1 – 2 inches

NGT Insertion & Gavage Feeding DEFINITION:

CARING FOR THE PATIENT WITH AN INDWELLING - Administration of feed directly into the stomach
CATHETER: through the nose (nasogastric) or mouth (orogastric).
1. Be sure to wash hands before and after caring PURPOSES:
for a patient with an indwelling catheter.
2. Clean the perineal area thoroughly, especially - to provide adequate nourishment to the patients who
around the meatus, twice a day and after each cannot feed themselves (ex. Surgery in oral cavity,
bowel movement. This helps prevent unconscious or comatose state.)
organisms for entering the bladder.
- to administer medications.
3. Use soap or detergent and water to clean the
perineal area and rinse the area well. INDICATIONS:
4. Make sure that the patient maintains a
1. Head and Neck injury
generous fluid intake. This helps prevent
2. Coma
infection and irrigates the catheter by
3. Obstruction of esophagus or oropharynx
increasing urinary output.
4. Severe anorexia nervosa
5. Encourage the patient to be up and about as
ordered. 5. Recurrent episodes of aspiration
6. Increased metabolic needs – burns, cancer,
6. Record the patient’s intake and output
etc.,
7. Note the volume and character of urine and
7. Poor oral intake
record observations carefully
 OSCE REVIEWER

EQUIPMENT: - DIARRHEA:
1. Formula feed • Type of feed
2. Graduated container • Gut injection
3. Large syringe (30 – 60 ml)
4. Water in a container - CONSTIPATION:
5. Stethoscope • Inadequate fluid intake
6. Kidney tray • Immobility
7. Towel and mackintosh • Use of opiates
8. Clean gloves
- BLOCKED TUBE:

TYPES OF NGT: • Inadequate or no flushing of tube

• Administering meds via tube
1. FINE-BORE FEEDING TUBE: - DERANGED ELECTROLYTES
- Short term enteral feeding (4 – 6 weeks) - FLUID OVERLOAD

• Malnutrition - INTESTINAL OBSTRUCTION

• Head and neck surgery
- DISLODGED TUBE
• Inadequate intake
• Oral cavity fistulae - WEIGHT / LOSS GAIN
- to prolong and sustain life - EXCORIATION OF SKIN AROUND TUBE
2. RYLE’S TUBE: Risks associated with NGT
- to drain gastric contents
- pneumothorax
• Abdominal distention
- coiling of the tube in the throat
• Unconscious patient
• Major surgery - sinusitis
• Intestinal obstruction
- acid reflux
- to stop vomiting and prevent aspiration
- aspiration pneumonitis
- severe sepsis
CONTRAINDICATIONS:
- head injury
MEASURE LENGTH OF FEEDING TUBE:
- rhinorrhea
- from bridge of nose to ear to the bottom of xiphoid
- obstructing esophageal process.

- epistaxis POSITIONING OF PATIENT DURING INSERTION:

- feeding above an obstruction - Semi fowlers position (45 degree)

- recent gastro esophageal anastomosis

- history of nasal or sinus surgery

Procedures:
- occlusions

Complications of NGT feeding: Before:

- ASPIRATION:
1. Identify patient and explain procedure to
• Due to feed regurgitation patient and that feeding will take around 10 to
• Or incorrect tube placement 20 minutes to complete. Also explain that
patient will experience a feeding of fullness
- NAUSEA AND VOMITING: after feeding. Proper explanation allays
anxiety and ensures cooperation.
• Due to rapid feeding
Explanations to be given to patients who are
• Poor gastric emptying
 OSCE REVIEWER
comatose or unconscious as they may hear and
perceive the instructions.
2. Assess for food allergies, time of last feed,
bowel sounds, and laboratory values. Proper
Assessment will prevent risk of complications.
3. Place container with feed in warm water.
Warms the fluid to be fed.
4. Assist patient to fowler’s position (35 to 45
degree). Fowler’s position enhances
gravitational flow of feed through tube and
prevents risk of aspiration.
During:
5. Wash hands. Reduces risk of transmission of
microorganisms.
6. Spread towel and mackintosh over the
patient’s chest. Reduces risk of transmission of
microorganisms.
7. Don gloves and attach syringe to nasogastric
tube. Pinch tube while attaching the syringe to
the tube. Pinching of the tube prevents air
from entering the tube.
8. Aspirate stomach contents. If there is doubt
about tube placement inform physician and
obtain an order for X-ray. If residual gastric
contents exceed 100ml for intermittent tube
feedings or greater than 1.5 times the hourly
rate for continuous feeding, withhold feed and
notify physician.
9. Also assess the aspirant for visual aspirates:
- Visual characteristics of feeding tube
aspirates:
• GASTRIC: may be grassy green with
sediment, brown (if blood is present
and has been acted upon by gastric
acid). May also appear clear and
colorless (often with shreds of off-
white to tan mucus or sediment).
• INTESTINAL: generally, more
transparent than gastric aspirants and
may appear bile-stained tanging in
color from light to dark golden yellow
or brownish green.
• RESPIRATORY: tracheobronchial
secretions may consist of off-white to
tan sediment.
- Assessing aspirants for visual characters
provides information about placement of
tube.
10. If residual contents are within limits and
placement of tube is confirmed, return gastric
contents to stomach through syringe using
gravity to regulate flow. Returning gastric
contents to stomach prevents fluid and
electrolyte imbalance.
11. If tube placement is confirmed in stomach,
pinch the feeding tube prevents air from
entering the stomach and causing distention.
12. Fill syringe barrel with water and allow fluid
to flow by gravity, raising the barrel above the
level of the patient’s head. Water clears the
tube and the rate of flow is regulated by raising
or lowering the syringe.
13. Pour feed into syringe barrel and allow it to
flow by gravity. Keep on pouring feed /
formula to barrel when it is three quarters
empty. Pinch tube whenever necessary to stop
when pouring. Prevents air from entering
tube.
14. After feeding the patient flush the tube with at
least 30cc of water. Prevents clogging of tube.
15. After tube is clear close end of the feeding tube
while pinching the tube. Prevents leakage.
Pinching prevents air entry.
16. Rinse equipment with warm water and dry.
Prevents bacterial growth.
17. Keep head of bed elevated for 30 to 60 minutes
after feeding. Prevents aspiration.
After:
18. Wash hands. Reduces the risk of transmission
of microorganisms
19. Document type and amount of feeding,
amount of water given, and tolerance of feed.
20. Monitor breath sounds, bowel sounds, gastric
distention, diarrhea, constipation, and intake
and output. Evaluates for aspiration effects on
gastrointestinal system and therapeutic
effects of feeding.
21. Instruct the patient to notify nurse if he
experiences a sensation of fullness, nausea,
and vomiting. Indicates intolerance of feed.
SPECIAL CONSIDERATIONS:
1. Intermittent/continuous feeding of solution
from an intravenous (IV) pole and adjusting
the rate of administration by flow regulators
are done in some situations.
2. Siphon method can be used to administer clear
fluid. This is done immersing the tip of the tube
in the feed, taking care to avoid air entering
into it and then raising the container 12 inches
above tube according to institution policy.
3. Change the nasogastric tube according to
institution policy.
4. Change the articles, every 24 hours or
according to institution policy.
Gastric Lavage
- commonly called STOMACH WASH or GASTRIC
SUCTION, the process of cleaning out the contents of
the stomach.
 OSCE REVIEWER

- it has been used for eliminating poisons from the 2. LARYNGOSPASM: uncontrolled and
stomach. involuntary muscle contraction (spasm) of the
larynx cord.
PURPOSE:
- For urgent removal of ingested substance to decrease 3. HYPOXIA and HYPERCAPNIA: lack of oxygen
systemic absorption. in the body tissues.

- to empty the stomach before endoscopic procedure.
- to diagnose gastric hemorrhage and to arrest
hemorrhage.
INDICATION:
- With patient has ingested poison
- collecting stomach acid for tests
4. BRADYCARDIA: pulse slow and lower than
normal.
5. SHORTNESS OF BREATH: patient might
experience dyspnea due to a tube inserted
through the oropharynx that can obstruct the
patient airway, which cause low oxygen
supply.

- cleaning the stomach before and upper endoscopy in

6. MECHANICAL INJURY: to the throat,
someone who has been vomiting blood.
esophagus, and stomach.
- relieving pressure in someone with blockage in the
intestines
CONTRAINDICATIONS:
IV Fluids and Drug Computation
- Loss of airway protective reflexes, such as in a patient A. HYPERTONIC SOLUTIONS:
with a depressed state of consciousness.
- Hypertonic Sodium Chloride
- Ingestion of a corrosive substance such as a strong
- 3 % NaCl
acid or alkali.
- 5 % NaCl
- Ingestion of a hydrocarbon with high aspiration
potential. USES:
- Patients who are at risk of hemorrhage or - used in the acute treatment of severe hyponatremia
gastrointestinal perforation. and should only be used in critical situations to treat
hyponatremia.
TECHNIQUE:
- used in patients with cerebral edema
1. Gastric lavage involves the passage of a tube
via the mouth or nose down into the stomach, - some patients may need diuretic therapy to assist in
followed by sequential administration and fluid excretion.
removal of small volumes of liquid.
2. The placement of the tube in the stomach must CAUTION:
be confirmed either by air insufflation while - should be infused at a very low rate to avoid risk of
listening to the stomach, by pH testing a small pulmonary edema
amount of aspirated stomach contents, or x-
ray. This is to ensure the tube is not in the - if administered in large quantities and rapidly, they
lungs. may cause ECF excess and circulatory overload.
3. Lavage is repeated until the returning fluid
- Dextrose 10 % (D10W)
shows no further gastric contents.
4. If the patient is unconscious or cannot protect - Dextrose 10 % in water
their airway then the patient should be
USES:
intubated before performing lavage.
- used in treatment of ketosis of starvation and
COMPLICATION:
provides calories and free water.
1. ASPIRATION PNEUMONIA: while taking the
CAUTION:
unwanted poison or drugs out of the stomach
(lavage), the substances might accidentally - Should be administered using a central line if
enter the respiratory canal, into the lungs and possible.
cause aspiration pneumonia.
- Dextrose 20 % (D20W)
- Dextrose 20 % in water
 OSCE REVIEWER

cause hyperglycemia. Use with caution for

patients with diabetes mellitus.
USES:
9. CHECK INTEGRITY OF IV SOLUTION:
- Used as an osmotic diuretic that causes fluid shifts solution should be clear with the container
between various fluid compartments to promote and seals intact. IV solutions are covered in
diuresis. overwrap, do not remove until ready for use.
Check for minute leaks by squeezing the
- Dextrose 50 % (D50W) container firmly, if leaks are found, discard
- Dextrose 50 % in Water solution may be compressed.

- 5 % Dextrose in 0.9 % Saline:

USES: • Fluid and electrolyte replenishment

- used to treat severe hypoglycemia - 5 %Dextrose in 0.45 % Saline:

- administered rapidly via IV bolus • Maintenance fluid

- 5 % Dextrose in Lactated Ringer’s

NURSING CONSIDERATIONS FOR HYPERTONIC • Fluid and electrolyte replenishment and

SOLUTIONS: caloric supply

1. DOCUMENT FOR BASELINE DATA: before

B. HYPOTONIC SOLUTIONS:
infusion, assess the patient’s vital signs, edema
status, lung sounds, and heart sounds, glucose
levels. Continue monitoring during and after - 0.45 % Sodium Chloride Solution (0.45 % NaCl)
the infusion.
2. WACTH FOR SIGNS OF HYPERVOLEMIA: • Half-strength normal saline
since hypertonic solutions move fluid from the • ½ NS
ICF to the ECF, they increase the extracellular
fluid volume and increase the risk for USES:
hypervolemia. Look for signs of swelling in - Used for replacing water in patients who have
arms, legs, face, shortness of breath, high hypovolemia with hypernatremia
blood pressure, and discomfort in the body.
3. MONITOR AND OBSERVE THE PATIENT CAUTION:
DURING ADMINISTRATION: hypertonic - Excessive use may lead to hyponatremia due to the
solutions should be administered only in high dilution of sodium.
acuity areas with constant nursing
surveillance for potential complications.
4. VERIFY ORDER: prescriptions for hypertonic
- 0.33 % Sodium Chloride Solution (0.33 % NaCl)
solutions should state the specific hypertonic
fluid to be infused, the total volume to be • 5 % Dextrose in 0.33 Sodium Chloride
infused, the infusion rate and the length of • 1/3 strength normal saline
time to continue the infusion.
5. ASSESS HEALTH HISTORY: patients with
kidney or heart disease and those who are USES:
dehydrated should not receive hypertonic IV - Used to allow kidneys to retain needed amounts of
fluids. These solutions can affect renal water. Free water helps kidneys eliminate solutes.
filtration mechanisms and can easily cause
hypervolemia to patients with renal or heart - typically administered for patients with dextrose to
problems. increase tonicity.
6. PREVENT FLUID OVERLOAD: ensure that
CAUTION:
administration of hypertonic fluids does not
precipitate fluid volume excess or overload. - Used in caution for patients with heart failure and
7. DO NOT ADMINISTER PERIPHERALLY: renal insufficiency.
hypertonic solutions can cause irritation and
damage to the blood vessel and should be
administered through a central vascular - 0.225 % Sodium Chloride (0.255% NaCl)
access device inserted into a central vein.
8. MONITOR BLOOD GLUCOSE CLOSELY: rapid • 5 % Dextrose in 0.225 Sodium Chloride
infusion of hypertonic dextrose solutions can
 OSCE REVIEWER
USES:
- Used as maintenance fluid for pediatric as it is most
hypotonic fluid available.
- typically administered with dextrose to increase
tonicity
- 2.5 % Dextrose in Water (D2.5W)
USES:
- used to treat dehydration and decrease the levels of
sodium and potassium
CAUTION:
- Should not be administered with blood products as it
can cause hemolysis of red blood cells.
NURSING CONSIDERATIONS FOR HYPOTONIC
SOLUTIONS:
1. DOCUMENT BASELINE DATA
2. DO NOT ADMINISTER IN
CONTRAINDICATED CONDITIONS:
Hypotonic solutions may exacerbate existing
hypovolemia and hypotension causing
cardiovascular collapse. Avoid use in patients
with liver disease, trauma, or burns.
3. RISK FOR INCREASED INTRACRANIAL
PRESSURE (IICP)
4. MONITOR FOR MANIFESTATIONS OR FLUID
VOLUME DEFICIT.
5. DO NOT ADMINISTER ALONG WITH BLOOD
PRODUCTS.
6. CHECK INTEGRITY OF IV SOLUTION
- 0.45 % Saline:
• Fluid replacement among patients with
hypovolemia
• Avoid in patients with trauma, risk for
increased ICP or burns.
HYPOTONIC FLUIIDS:
- have lower concentration of solutes than blood
plasma. This causes an intracellular shift of fluid,
leading to cellular swelling.
- HALF NORMAL SALINE: (0.45% NS) the classic
hypotonic fluid
• Useful for maintenance fluids
- D5W: 5% Dextrose in Water (D5W) is technically
considered isotonic, but it acts as a hypotonic fluid.
This is because the glucose is metabolized quickly,
leaving free water which is hypotonic.
• Useful for mixed with meds hypernatremia
C. ISOTONIC SOLUTIONS:
- Normal Saline Solution (NSS) (0.9 % NaCl)
• Isotonic solution of choice for expanding ECF
Volume
• Infused to correct extracellular fluid volume
deficit
• Used alongside administration of blood
products
• Used to replace large sodium losses with heart
failure, pulmonary edema, and renal
impairment
CAUTION:
- Should not be used for patients with heart failure,
pulmonary edema, and renal impairment.
- Dextrose 5% in Water D5W)
• Initially isotonic and provides free water when
dextrose is metabolized (making it hypotonic)
• Expands the ECF and ICF, helpful in
rehydrating and excretory purposes.
CAUTIONS:
- should not be used for fluid resuscitation because
hyperglycemia can result. Should be avoided in clients
at risk increased intracranial pressure.
- Lactated Ringer’s Solution in 5% Dextrose:
• D5LR
• LR
• Ringer’s Lactate
• Hartmann Solution
USES:
- uses to correct dehydration, sodium depletion, and
replace GI tract fluid losses
- also used in fluid losses caused by burns, fistula
drainage, and trauma.
- often administered for patients with metabolic
acidosis because it is an alkalizing solution.
CAUTION:
- should not be given to patients who cannot
metabolize lactate. Used in caution for patients with
heart failure and renal failure.
- Ringer’s Solution
• Similar indications for Lactated Ringer’s
solution but without the contraindications
related to lactate.
 OSCE REVIEWER

NURSING CONSIDERATIONS FOR ISOTONIC

SOLUTIONS: INSTRUMENT IDENTIFICATION
1. DOCUMENT BASELINE DATA
2. OBSERVE FOR SIGNS OF FLUID OVERLOAD
3. MONITOR MANIFESTATIONS OF - CURETTE: a surgical
CONTINUED HYPOVOLEMIA instrument designed for
4. PREVENT HYPERVOLEMIA scraping or debriding
5. ELEVATE THE HEAD OF THE BED AT 35 TO biological tissue or debris in a
45 DEGREES biopsy, excision or cleaning
6. EDUCATE PATIENTS AND FAMILIES procedure.
7. CLOSE MONITORING FOR PATIENTS WITH
HEART FAILURE - DeBakey TISSUE FORCEP:
8. CHECK INTEGRITY OF IV SOLUTION type of atraumatic tissue
used in vascular procedure
to avoid tissue damage
during manipulation.
IV FLUIDS:
1. HYPERTONIC: enter the vessel from the cells.
Therefore, the cell will SHRINK. - Hegar’s Uterine Dilators:
2. ISOTONIC: stays where it put, stay the same
used to measure the level of
(ISO MEANS EQUAL)
3. HYPOTONIC: go out of the vessel + into the dilation of a woman’s uterus or
cell. Therefore, the cell will SWELL. to induce further dilation.

IV FLUIDD CALCULATION:
- POZZI FORCEPS
1. FLOW RATE: (ml/hr) TENACULUM: specialized
OB/Gyne device used for
e.g. D5 ¼ NS 500 cc to run for 24 hours holding multiple structures,
500 ml / 24 hours such as the cervix, uterus,
blood vessels and the
Ans: 21 ml/hr fallopian tubes in order to
perform multiple
2. DRIP RATE: Volume x drop factor gynecological procedures.
Time x 60 (mins)

e.g. Normal Saline 500 cc to run for 6 hours (drop

- COLLIN VAGINAL SPECULUM:
factor: 20 drops / ml)
a gynecological instrument used
500 x 20 for performing pelvic
6 hours x 60 mins examinations; pap smears or
examining the cervix.
ANSWER: 28 gtts/min.

3. BASIC DRUG CALCULATION:

Desired Dose x Volume / Amount of Diluent
Stock Dose
e.g.: Order: Ampicillin 350 mg
- UTERINE SOUND: used for
probing and dilating the uterus
through the cervix to measure the
length of the cervical canal and
the uterus.

Stock: Ampicillin 500 mg in a 5 ml vial - CHERON DRESSING FORCEPS:

device used for grasping, holding,
350 mg x 5ml and mobilizing dressing materials
500 mg of different sizes with purpose of
absorbing blood and fluids.
Answer: 3 ml
 OSCE REVIEWER

- 100 ml GALLIPOT: a small jar of glazed - ALLIS TISSUE FORCEPS: used

earthenware, used for holding medicine. to hold or grasp heavy tissue

- STAINLESS STEEL INSTRUMENT

BASKET: sturdy and corrosion
resistant metal used for medical
instruments. - LITTLEWOOD TISSUE
FORCEPS: used for grasping
slippery tissue.

CAESARIAN SECTION INSTRUMENTS:

- BACKHAUS TOWEL CLAMPS: used to fasten drapes
- DOYEN RETRACTORS: used
of towels to patient during medical procedures in
order to stay on. for retracting the bladder away
from the incision site on the
uterus and guarding potential
- OUTLET FORCEPS: used
when injury when suturing.

• Fetal scalp is visible

without separating
the labia - LANGENBECK RETRACTORS:
• The fetal skull has used to retract skin during
reached the pelvic closure of the rectus sheath. Can
floor be used in pairs.
• The sagittal suture is in the anteroposterior
diameter or right or left occiput anterior or
posterior position (rotation does not exceed
45)
- MORRIS RETRACTORS AND
- ARTERY FORCEPS: for BALFOUR RETRACTORS:
controlling bleeding and for the commonly used retractors.
retraction of tissues, skin, etc.
Other name is hemostatic
forceps.

- GREEN ARMYTAGE - BALFOUR RETRACTORS:

FORCEPS: used to hold the self-retaining and not be held
once it is inserted.
incised uterine edges prior
to closing the hysterectomy
incision. Fur forceps are
commonly used.
- MAYO SCISSORS: classified
ads dissecting or suture scissors
- SPONGE HOLDING FORCEPS: used to cut tough scar tissue.
used to hold sponges and swabs.
 OSCE REVIEWER
- SPENCER LIGATURE
SCISSORS: used for cutting
stitches or suture.
Perioperative Nursing
- Period of time constitutes the surgical experience, it
includes the pre-operative, intraoperative, and post -
operative phase of nursing care.
- PREOPERATIVE PHASE: period of time when the
decision for surgical intervention is made to when the
patient is transferred to the operating room table.
- INTRAOPERATIVE PHASE: period of time that begins
with transfer of the patient to the operating room area
and continues until the patient is admitted to the Post
Anesthesia Care Unit.
- POSTOPERATIVE PHASE: period of time that begins
with the admission of the patient to the postoperative
anesthesia care unit and ends after follow up
evaluation in the clinical setting or home.
PREOPERATIVE PHASE
PRE-ADMISSION TESTING:
1. Initiates initial pre-operative assessment
2. Initiates education appropriate to patients
needs
3. Involves family in interview
4. Verifies completion of pre-operative
diagnostic testing.
5. Verifies understanding of surgeon specific
pre-operative orders (bowel preparation, pre-
operative shower)
6. Discusses and reviews advance directive
document
7. Begins discharge planning including need for
transportation and care.
ADMISSION TO SURGICAL CENTER:
1. Completes pre-operative assessment
2. Assesses for risks of postoperative
complications
3. Reports unexpected findings or any deviations
from normal.
4. Verifies that operative consent has been
signed.
5. Coordinates patient education and plan of care
with nursing staff and other health team
members.
6. Reinforces previous education.
7. Explain phases in perioperative period and
expectations
8. Answers patients and family’s questions.
IN THE HOLDING AREA:
1. Identifies patient
2. Assesses patient’s status, baseline pain and
nutritional status.
3. Reviews medical record
4. Verifies surgical site and that it has been
marked per institutional policy
5. Establishes IV line
6. Administers medications if prescribed
7. Takes measures to ensure patients comfort
8. Provides psychological support
9. Communicates patient’s emotional status to
other appropriate members of the health care
team
INTRAOPERATIVE PHASE
MAINTENANCE OF SAFETY:
1. Maintains specific, controlled environment
2. Effectively manages human resources,
equipment, and supplies for individual patient
care
3. Transfers patient care to operating room bed
or table
4. Positions patient based on functional
alignment and exposure of surgical site
5. Applies grounding device to patient
6. Ensures that the sponge, needles, and
instrument counts and correct
7. Completes intraoperative documentation
PHYSIOLOGIC MONITORTING:
1. Calculates effects on patient of excessive fluid
loss or gain
2. Distinguishes normal from abnormal cardio
pulmonary data
3. Reports changes in patients’ vital signs
4. Institutes measures to promotes
normothermia, intravenous
PSYCHOLOGICAL SUPPORT: (before induction and
when patient is conscious)
1. Provides emotional support to patient
2. Stands near touches patient during
procedures and induction
3. Continues to assess patient’s emotional status
POST OPERATIVE PHASE
TRANSFER OF PATIENT TO POST ANESTHESIA
CARE UNIT:
1. COMMUNICATES INTRAOPERATIVE
INFORMATION:
• Identifies patient by name
• States type of surgery performed
• Identifies type and number of
anesthetics and analgesic agents used.
• Reports patient’s vital signs and
response to surgical procedure and
anesthesia
• Describes intraoperative factors
insertion of drains or catheters,
administration of blood, medications
 OSCE REVIEWER
during surgery and or occurrence of
unexpected events
• Describes physical limitation
• Reports patient’s pre-operative level
of consciousness
• Communicates necessary equipment
needs
• Communicates presence of family or
significant others
POST OPERATIVE ASSESSMENT RECOVERY AREA:
1. Determines patient’s immediate response to
surgical intervention
2. Monitor patient’s vital signs and physiologic
status
3. Administers medication, fluid and blood
components therapy if prescribed
4. Provides oral fluids if prescribed for
ambulatory surgery patients
5. Assesses patient’s readiness for transfer in
hospital unit or for discharge home based on
institutional policy
SURGICAL NURSING UNIT:
1. Continues close monitoring of patients
physical and psychological response to
surgical intervention
2. Assesses patient’s pain level and administers
appropriate pain relief measures
3. Provides education to patient during
immediate recovery period
4. Assists patients in recovery and preparation
for discharge home
5. Determines patient’s psychological status
6. Assists with discharge planning
CATEGORIES OF SURGERY BASED ON URGENCY
- EMERGENT: patient requires immediate attention;
disorder maybe life threatening
INDICATION FOR SURGERY: without delay
Ex. Severe bleeding, bladder or intestinal
obstruction, fractured skull, gunshot or stab
wounds, excessive burns.
- URGENT: patient required prompt attention
INDICATION OF SURGERY: within 24 to 30
hours.
Ex. Acute gallbladder infection, kidney or
urinary stones.
- REQUIRED: patient needs to have surgery
INDICATOIN FOR SURGERY: plan within a few
weeks or months
Ex. Prostatic hyperplasia without
bladder obstruction, thyroid disorder,
cataracts.
- ELECTIVE: Patient should have surgery
INDICATION FOR SURGERY: failure to have
surgery not catastrophic
Ex. Repair of scars, simple hernia, vaginal
repair
- OPTIONAL: decision rests with patient
INDICATION FOR SURGERY: personal
preference
Ex. Cosmetic surgery
EINC Steps
“ESSENTIAL INTRAPARTUM NEWBORN CARE”
PRIOR TO WOMAN’S TRANSFER TO THE DR
- Ensure that mother is in her position of choice while
in labor
- Asked mother if she wishes to eat/drink or void
- Communicated with the mother: informed her of
progress of labor, gave reassurance and
encouragement.
WOMAN ALREADY IN THE DR
- Checked temperature in DR area to be 25 – 28 C;
eliminated air draft
-Asked woman if she is comfortable in the semi0-
upright position (the default position of delivery
table)
- Ensured the woman’s privacy
- Removed all jewelry then washed hands thoroughly
observing the WHO 1-2-3-4-5 procedure
- Prepared a clear, clean newborn resuscitation area
on a firm and flat surface. Checked the equipment if
clean, functional and within easy reach.
- Arranged materials/supplies in a linear sequence;
a. Gloves, dry linen, bonnet, oxytocin injection, plastic
clamp, instrument clamp, scissors, 2 kidney basins
b. In a separate sequence, for after the 1st breastfeed;
Eye ointment, (stethoscope to symbolize PE), vitamin
K, hepatitis B and BCG vaccines (plus cotton balls, etc.)
- Cleaned the perineum with antiseptic solution.
- Washed hands and put on 2 pairs of sterile gloves
aseptically. (If same worker handles perineum and
cord).
AT THE TIME OF DELIVERY:
- Encouraged woman to push as desired
- Draped the clean, dry linen over the mother’s
abdomen or arms in preparation for drying the baby.
 OSCE REVIEWER
- Applied perineal support and did controlled delivery
of the head
- Called out time of birth and sex of baby
- Informed the mother of outcome
FIRST 30 SECONDS:
- thoroughly dried baby for at least 30 seconds,
starting from the face and head, going down to the
trunk and extremities while performing a quick check
for breathing.
1-3 MINUTES:
- Removed the wet cloth
- Placed baby in skin-to-skin contact on the mother’s
abdomen or chest
- Excluded a 2nd baby by palpating the abdomen in
preparation for giving oxytocin
- Gave IM oxytocin within one minute of baby’s birth
after wiping the soiled gloves with the wet cloth.
- Removed 1st set of gloves after positioning the baby
for cord clamping. Decontaminated the gloves
properly (0.5 % chlorine solution at least 10 minutes)
- Palpated umbilical cord to check for pulsations
- Placed the instrument clamp for 5 cm from the base
- Cut near plastic clamp (not midway)
- Performed the remaining steps of the AMTSL:
- waited for strong uterine contractions then
applied controlled contraction and counter
traction on the uterus, continuing until
placenta was delivered.
- massaged the uterus until it is firm.
- Inspected the lower vagina and perineum for
lacerations/tears and repaired lacerations/tears, as
necessary.
- Examined the placenta for completeness and
abnormalities.
- Cleaned the mother; flushed perineum and applied
perineal pad/napkin/cloth.
- Checked baby’s color and breathing; checked that
mother was comfortable, uterus contracted.
- Disposed of the placenta in a leak-proof container or
plastic bag.
- Decontaminated (soaked in 0.5 % chlorine solution)
instruments before cleaning; decontaminated 2nd pair
of gloves before disposal, stating that decomposition
lasts for at least 10 minutes.
- Advised mother to maintain skin-to-skin contact.
Baby should be prone on mother’s chest in between
the breasts with head turned to one side.
15 – 90 MINUTES:
- Advised mother to observe for feeding cues and cited
examples of feeding cues.
- Supported mother, instructed her on positioning and
attachment
- Walled for FULL BREASTFEED to be completed
- After a complete breastfeed, administered eye
ointment (first), did through physical examination,
then did Vitamin K, hepatitis B and BCG injections
(simultaneously explained purpose of each
intervention).
- Advised OPTIONAL/DELAYED bathing of baby (and
was able to explain the rationale).
- Advised breastfeeding per demand
- In the first hour; check baby’s breathing and color;
and check mother’s vital signs and massaged uterus
every 15 minutes.
- In the second hour; check mother-baby dyad every
30 minutes to 1 hour.
- Completed all RECORDS.
Wound Care
DRESSING:
- A dressing is a sterile pad or compress applied to
wound to promote healing and protect the wound
from further harm.
- It is used to have direct contact with a wound but
bandage is used to hold a dressing in place.
GENERAL INSTRUCTION:
1. Practice strict aseptic technique to prevent
cross infection to the wound and from the
wound.
2. All articles should be disinfected thoroughly to
make sure that they are free from pathogens
3. Wash hands thoroughly before and after the
procedure.
4. Instruments used for one dressing cannot be
used for another until they have been
sterilized.
5. Use masks, sterile gloves and gowns for large
dressings to minimize the wound
contamination.
6. Dressings are not changed for at least 15
minutes after the room has been swept or
cleaned.
7. Use individually wrapped sterile dressings
and equipment for the greatest safety of the
wound.
8. Create a sterile field around the wound by
spreading sterile towels.
9. Avoid talking, coughing, and sneezing when
the wound is opened.
10. During the procedure, the nurse works
carefully to avoid contaminating the patient’s
skin, clothing and bed linen with soiled
instruments and dressings
 OSCE REVIEWER
11. Cleaning the wound should be done from the
cleanest area to the less clean area. Consider
the wound area cleaner than the skin area
even if the wound is infected. Therefore, clean
the wound from its center to the periphery.
12. If the dressings are adherent to the wound due
to drying of the secretions or blood, wet it with
physiologic saline before it is removed from
the wound.
13. When dressing the wound, keep the wound
edges are near as possible to promote healing.
14. When drains are in place, anticipate drainage
and re-enforce the dressings accordingly. The
dressings over the drains should not be
combined with the dressings on the wound
line.
15. The amount of discharge from the wound
should be accurately measured by recording
the number and size of the dressings changed.
Note the color, odor, amount and consistency
of the drainage.
16. When the wound drainage is diminished, the
drains are to be shortened. This should be
done in consultation with the doctor. Usually
the doctor gives a written order.
17. Before doing the dressing, inspect the wound
for any complications such as dehiscence and
evisceration. If present, report it immediately
to the surgeon and immediate steps are to be
taken
18. Avoid meal timings
19. Give an analgesic prior to be painful dressings
PRELIMINARY ASSESSMENT
- Check the diagnosis and the general condition of the
patient
- Check the purpose for which the dressing is to be
done
- Check the condition of the wound – the type of the
wound, the types of suturing applied, the type of
dressings to be applied, etc.
- Check the physician’s orders for the type of dressing
to be applied and the specific instructions, if any,
regarding the cleaning solutions, removal of sutures,
drains and the application of medications, etc.
- Check the patient’s name, bed number and other
identifications
- Check the nurse’s records to find out the general
condition of wound
- Check the abilities and limitations of the patient
- Check the consciousness of the patient and the ability
to follow instructions
- Check the articles available in the unit.
PREPARATION OF THE ARTICLES
ARTICLES:
A sterile tray containing:
- 1 Artery Forceps: To clean the wound
- 2 Dissecting Forceps: To clean/to hold the gauze
piece / to scratch dead tissue
- 1 Scissors: for the debridement of the wound, if
necessary or to cut the gauze pieces fit around the
drainage tubes, etc.
- 1 Sinus Forceps: to open the sinus tract or to pack the
sinus tract, if necessary
- 1 Probe: to open the sinus tract or to pack the sinus
tract, if necessary
- 1 Small Bowl: to take the cleaning solutions
- 1 Safety Pin: to fix the drain, in case the drains are cut
short
- Gloves, masks and gowns: to use when large wounds
are dressed
- Cotton balls, gauze pieces pads, etc., as necessary: to
clean and dress the wound
- Slit or dressing towels: to create a sterile field around
the wound
An unsterile tray containing:
- Cleaning solutions as necessary: to clean the wound
and the surrounding area
- Ointment and powders as ordered: to apply on the
wound
- Vaseline gauze in sterile containers: to prevent the
dressing adhering to the wound
- Ribbon gauze in sterile containers: to pack a sinus
tract or penetrating wound
- Swab sticks in sterile container: to apply medications
if necessary.
- Transfer forceps in a sterile container: to handle the
sterile supplies
- Bandages, binders, pins, adhesive plaster, and
scissors: to fix the dressing in place
- A large bowel with disinfectant solution: to discard
the used instruments
- Kidney tray and paper bag: to collect the wastes
- Mackintosh and towel: to protect the bed with linen
and patient clothes
PREPARATION OF THE PATIENT AND THE
ENVIRONMENT
1. Identify the patient and explain the procedure
to win the confidence and cooperation. Explain
the sequence of the procedure and tell the
patient how he can cooperate in the procedure
2. Provide privacy with curtains and drapes
3. Apply restraints, in case of children
4. AS far as possible, avoid meal timings; the
dressings may be done either one hour before
the meals or after meals
 OSCE REVIEWER
5. Offer bedpan or urinal prior to the dressings
6. See that the cleaning of the room is done at
least one hour before the expected time of the
dressings.
7. Shave the area if necessary to remove the
hairs. Removal of the adhesive is more painful
if the hair is present. So, the shaving should be
done before the first dressing is applied
8. Place patient in a comfortable and relaxed
position depending on the area to be dressed
9. Give proper support to the body parts if the
patient has to raise and hold it position for a
considerable time
10. See that the patient’s room is in order with no
unnecessary articles. Clear the bedside table
or the overbed table, so that there is sufficient
space to set up a sterile field and to arrange
needed supplies and equipment.
11. Close the doors and windows to prevent
drafts. Put off fan
12. Adjust the height of the bed for the
comfortable working of the doctor or nurse so
that they have neither to stop nor overreach to
do the dressing. Bring the patient to the edge
of the bed.
13. Call for assistance if necessary e.g., to do the
unsterile procedure, to transfer sterile
supplies, etc.
14. Protect the bed with a mackintosh and towel
15. Fold back the upper bedding towards the foot
end of the bed leaving a bath blanket or sheet
over the patient. Expose the part as necessary
16. Untie the bandage or adhesive and remove the.
Make use that the dressing is not removed
from its place until the nurse is ready to do
dressing (after washing her hands)
17. Turn the head of the patient to one side, so that
the patient may not see the wound and get
worried about it
PROCEDURE
STEPS OF PROCEDURES:
1. Tie the mask: to prevent wound contamination
with droplets
2. Wash hands thoroughly: to prevent cross
contamination
3. Put on gown, gloves etc., as necessary: to
ensure asepsis
4. Open the sterile tray. Spread the sterile towel
around the wound: pour physiologic saline
and wet it before removal
5. Pick up dissecting forceps and remove the
dressings and put it in the paper bag. Discard
the dissecting forceps in the bowl of lotion
6. Note the type and the amount of drainage
present
7. Ask the assistant to pour small amount of
cleansing solution into the bowl
8. Clean wound from the center to periphery,
discarding the used swabs after each stroke
9. After thoroughly cleaning of the wound, dry
the wound with dry swabs using the same
precautions. Discard the forceps in the bowl of
lotion
10. Apply medications if ordered
11. Apply the sterile dressings. Apply the gauze
pieces first and then the cotton pads. Reinforce
the dressings on the dependent parts where
the drainage may collect
12. Remove the gloves and discard it into bowl
with lotion
13. Secure the dressings with bandage or adhesive
tapes
AFTER CARE OF THE PATIENT AND THE ARTICLES
1. Help in the patient to dress up and to take a
comfortable position in the bed
2. Replace the bed linen
3. Remove the mackintosh and towel
4. Take all articles to the utility room. Discard
soiled dressings into a covered container and
send for incineration. Remove the instruments
and other articles from the disinfectant
solution and clean them thoroughly. Dry them.
Re-set the tray and send for autoclaving.
5. Wash hands
6. Return to the bedside to assess the comfort of
the patient
DOCUMENTATION
1. Record the procedure on the nurse’s record
with date and time
2. Record the condition of the wound, the type
and amount of drainage, condition of the
sutures, etc.
3. On the nurse record date, time, type of wound
and sign
4. Report to the surgeon any abnormalities found
Oxygen Therapy
Purpose
1. Deliver low to moderate levels of oxygen to relieve
hypoxia.
Assessment/Preparation
• Assess respiratory status (i.e., breath sounds, respiratory
rate and depth, presence of sputum, arterial blood gases
if available).
• Assess past medical history, noting chronic obstructive
pulmonary disease (COPD). For clients with COPD,
hypoxemia is often the stimulus to breathe because they
chronically have high blood levels of carbon dioxide. If
additional oxygen is needed, a low-flow system is
essential to maintain slight hypoxemia so breathing is
stimulated.
• Assess for clinical signs and symptoms of hypoxia:
anxiety, decreased level of consciousness, inability to
concentrate, fatigue, dizziness, cardiac dysrhythmias,
pallor or cyanosis, dyspnea.
Equipment
• Oxygen source
• Flowmeter
• "No smoking" sign
• Humidifier and distilled water (for high-flow O2 therapy)
Procedure
1. Review chart for physician's order for oxygen to ensure
that it includes method of delivery, flow rate, titration
orders; identify client.
 OSCE REVIEWER
Rationale: Prevents potential errors.
2. Wash your hands.
Rationale: Handwashing reduces transmission of
Vital Signs
microorganisms.
3. Identify client and proceed with 5 rights of medication PULSE RATE.
administration. Explain procedure to client. Explain that
oxygen will ease dyspnea or discomfort, and inform - the beating of the heart
client concerning safety precautions associated with
oxygen use. Encourage him or her to breathe through the RESPIRATORY RATE.
nose.
Rationale: Oxygen is a drug and administering using the 5 - the act of breathing
rights avoids potential errors. Teaching helps ensure
compliance with therapy. TEMPERATURE
4. Assist client to semi- or high Fowler's position, if
tolerated. - to determine the degree of internal heat of a patient’s
Rationale: These positions facilitate optimal lung expansion. body.
5. Insert flowmeter into wall outlet. Attach oxygen tubing
to nozzle on flowmeter. If using a high O2 flow, attach FACTORS:
humidifier. Attach oxygen tubing to humidifier
Rationale: Oxygen in high concentrations can be drying to the 1. Time of the day
mucosa.
6. Turn on the oxygen at the prescribed rate (Fig. 5). Check 2. Age
that oxygen is flowing through tubing (Fig. 6). 3. Gender
Rationale: Oxygen must be administered as prescribed. 4. physical exercise
7. Hold nasal cannula in proper position with prongs
curving downward
5. emotions
8. Place cannula prongs into nares 6. pregnancy
9. Wrap tubing over and behind ears 7. environment changes
10. Adjust plastic slide under chin until cannula fits snugly
8. infection
11. Place gauze at ear beneath tubing as necessary
Rationale: Proper placement in nares ensures accurate 9. drugs
administration. Note: The cannula permits some freedom of 10. food
movement and does not interfere with the client's ability to
eat or talk. DIFFERENT ROUTE/SITES IN TAKING PR;
12. If prongs dislodge from nares, replace promptly.
Rationale: To ensure correct oxygen delivery and prevent 1. apical
hypoxemia. 2. carotid
13. Assess for proper functioning of equipment and observe
client's initial response to therapy. 3. radial
Rationale: Assessment of vital signs, oxygen saturation, color, 4. brachial
breathing pattern, and orientation helps the nurse evaluate 5. temporal
effectiveness of therapy and detect clinical evidence of
hypoxia.
6. femoral
14. Monitor continuous therapy by assessing for pressure 7. popliteal
areas on the skin and nares every 2 hours and rechecking 8. dorsalis pedis
flow rate every 4 to 8 hours.
Rationale: Permit early detection of skin breakdown or NORMAL RANGE;
inadequate flow rate.
Pulse Rate:

- Newborn: 120-160 bpm

- Adult: 60-100 bpm

Respiratory Rate:

- Newborn: 30-50 per minute

- Adult: 12-20 per minute

PULSE RATE:

- SKILLS/ABILITY

1. Washes hands.

2. Explain procedure to the patient.

3. Have the patient rest his arm along the side of his
body with the wrist extended and the palm of the hand
downward.
 OSCE REVIEWER

4. Place the 2nd and 3rd fingers along the radial artery 12. Dispose of tissue in a receptacle for contaminated
and press it gently against the radius. items.

5. Apply only enough pressure so that you can feel the 14. Wash thermometer in soapy water. Rinse and dry
patient’s pulsating artery distinctly. and replace the thermometer in its container.

6. Using a watch with a second hand, count the number BLOOD PRESSURE MONITORING
of pulsations felt on the patient’s artery for one full
- NORMAL RANGE: 120/60
minute.
FACTORS:
7. Document the result
1. time of the day
RESPIRATORY RATE:
2. age
1. Washes hands 3. gender
4. physical exercise
2. Explain the procedure to the patient
5. emotions
3. While the fingertips are still in place after counting 6. pregnancy
the PR, observe the patient’s respiration 7. environment changes
8. infection
4. Note the rise and fall of the patient’s chest with each
9. drugs
inspiration.
10. food
5. Using a watch with a second hand, count the number
1. Identify the patient.
of respirations for one full minute.
2. Explain the procedure to the patient
6. Document the result
3. Washes hands
TEMPERATURE:
4. Place the patient in a comfortable position with the
1. Identify patient
arm supported and palms upward
2. Explain the procedure to the patient
5. Roll the patient’s sleeves above the elbow
3. Make sure the thermometer is in operating
6. Place the cuff so that the inflatable bag is centered
condition
over the brachial artery. The lower edge of the cuff is
4. Perform hand hygiene and don gloves if appropriate 1 inch above the antecubital fossa.
or indicated.
7. Wrap the cuff smoothly around the arm and tuck the
5. Select the appropriate site end of the cuff securely under the preceding wrapper.
If using an aneroid gauge, check if the needle gauge is
6. If stored in a chemical solution, wipe the within the zero mark. If using the mercurial
thermometer dry with soft tissue, using a firm twisting sphygmomanometer, place yourself in a way that the
motion. Wipe from bulb toward fingers. meniscus of the mercury can be read at eye level.
7. Grasp the thermometer firmly with the thumb and 8. Use fingertips to feel for the strong pulsation of the
forefinger. Pressed and on the digital thermometer. brachial artery
8. Leave the thermometer in place until 9. Tighten the screw valve on the air pump.
signals/sounds are heard. (1 full minute)
10. Inflate the cuff while continuing to palpate the
9. Place thermometer’s bulb within the back of the artery. Note the point on the gauge where the pulse
right or left pocket under patient’s tongue and tell the disappears.
patient to close lips around thermometer (oral), in the
rectum as described when using a digital thermometer 11. Deflate the cuff and wait 15 seconds.
(rectal), or in the center of the axilla with arm against
12. Place the stethoscope earpieces in the ears. Direct
chest wall (axillary).
the era tips forward into the canal and not against the
11. Remove thermometer. Using a firm twisting ear itself.
motion, wipe it once from fingers down to the bulb.
13. Place the stethoscope bell or diaphragm firmly but
11. Read the thermometer by holding it horizontally at with as little as possible over the brachial artery. Do
eye level. not allow stethoscope to touch clothing or cuff.
 OSCE REVIEWER

14. Pump the pressure 30 mm Hg above the point at

which the systolic pressure was palpated and
estimated. Open manometer valve and allow air to
escape slowly (allowing the gauge to drop 2 to 3 mm
per heartbeat).

15. Note the point on the gauge at which the first faint,
but clear, the sound appears and slowly increases in
intensity. Note this number as the systolic pressure.

16. Note the pressure at which the sound first becomes

muffled. Also, observe the point at which sound
completely disappears. These may occur separately or
at the same point.

17. Allow remaining air to escape quickly. Repeat any

suspicious reading but wait for 30 to 60 seconds
between readings to allow normal circulation to
return to the limb. Be sure to deflate the cuff
completely between attempts to check blood pressure.

18. Remove the cuff and clean the equipment

19. Perform hand hygiene. If gloves are worn, discard

them in the proper receptacle.

20. Document the result