Professional Documents
Culture Documents
U P
Determine:
The location of running water and soap or soap substitutes
Assemble the equipment:
Soap
Warm, running water
Disposable or sanitized towels
Wet the hands thoroughly by holding them under the running water, and apply
soap to the hands.
Hold the hands lower than the elbows, so that the water flows from the
arms to the fingertips.
If the soap is liquid, apply 2-4 ml (1 tsp). if it is bar soap, granules, or
sheets, rub them firmly between the hands
Thoroughly wash and rinse the hands.
Use firm, rubbing and circular movements to wash the palm, back and wrist of
each hand. Interlace the fingers and thumbs, and move the hands back and forth.
Continue this motion for 10 seconds.
1
CHIRANJEEV NURSING INSTITUTE NAKA , AY0DHYA .U P
Apply the soap and wash as described earlier in Step 6, maintaining the hands
uppermost.
After washing and rinsing, use a towel to dry one hand thoroughly in a rotating
motion, from the fingers to the elbows. Use a new towel to dry the other hand and
arm.
For the next items, evaluate the students in general according to the criteria. (5 as the highest
score)
5 4 3 2 1
Mastery
Orderliness
Proper attitude in assessing the client followed.
Ability to answer questions
Proper reporting observed.
Student’s signature: __________________
Evaluator’s Signature: __________________
Comments:________________________________________________________________________
___________________________________________________________________________
2
CHIRANJEEV NURSING INSTITUTE NAKA , AY0DHYA .U P
Comments:________________________________________________________________________
___________________________________________________________________________
3
CHIRANJEEV NURSING INSTITUTE NAKA , AY0DHYA .U P
For the next items, evaluate the students in general according to the criteria. (5 as the highest
score)
5 4 3 2 1
Mastery
Orderliness
Proper attitude in assessing the client followed.
Ability to answer questions
Proper reporting observed.
Student’s signature: __________________
Evaluator’s Signature: __________________
Comments:________________________________________________________________________
___________________________________________________________________________
4
CHIRANJEEV NURSING INSTITUTE NAKA , AY0DHYA .U P
Comments:________________________________________________________________________
___________________________________________________________________________
5
CHIRANJEEV NURSING INSTITUTE NAKA , AY0DHYA .U P
For the next items, evaluate the students in general according to the criteria. (5 as the highest
score)
5 4 3 2 1
Mastery
Orderliness
Proper attitude in assessing the client followed.
Ability to answer questions
Proper reporting observed.
Student’s signature: __________________
Evaluator’s Signature: __________________
Comments:________________________________________________________________________
___________________________________________________________________________
6
CHIRANJEEV NURSING INSTITUTE NAKA , AY0DHYA .U P
Comments:________________________________________________________________________
___________________________________________________________________________
7
CHIRANJEEV NURSING INSTITUTE NAKA , AY0DHYA .U P
8
CHIRANJEEV NURSING INSTITUTE NAKA , AY0DHYA .U P
9
CHIRANJEEV NURSING INSTITUTE NAKA , AY0DHYA .U P
Place the head in a comfortable position to one side without excessive pressure
to sensitive areas.
Place pillows under trunk, as needed, to relieve pressure and increase comfort.
Place arms comfortably at client’s side and uncross legs with feet approximately
a foot apart.
Maintaining Prone Position
14. To maintain prone:
Use a shallow pillow or folded towel to support client’s heat comfortably.
Place pillow under abdomen to support back.
Place an additional pillow under lower leg to reduce pressure of toes and
forefoot against bed.
Moving from Prone to Supine Position
15. Repeat Actions 1-8.
16. To move from prone to supine:
Remove positioning towers or pillows.
Slide your hands underneath client.
Move client segmentally to one side of the bed to accommodate the new
position.
Position inside arm next to client’s body with client’s palm next to hip.
Roll client to supine position by logrolling the client toward you using the
client’s outside shoulder and hip for leverage.
Position client away from direction of roll to prevent undue pressure.
When client reaches supine, uncross, the arms and legs and place into anatomic
positions.
10
CHIRANJEEV NURSING INSTITUTE NAKA , AY0DHYA .U P
11
CHIRANJEEV NURSING INSTITUTE NAKA , AY0DHYA .U P
For the next items, evaluate the students in general according to the criteria. (5 as the highest
score)
5 4 3 2 1
Mastery
Orderliness
Proper attitude in assessing the client followed.
Ability to answer questions
Proper reporting observed.
Student’s signature: __________________
Evaluator’s Signature: __________________
Comments:________________________________________________________________________
___________________________________________________________________________
12
CHIRANJEEV NURSING INSTITUTE NAKA , AY0DHYA .U P
Comments:________________________________________________________________________
___________________________________________________________________________
13
CHIRANJEEV NURSING INSTITUTE NAKA , AY0DHYA .U P
Comments:________________________________________________________________________
___________________________________________________________________________
14
CHIRANJEEV NURSING INSTITUTE NAKA , AY0DHYA .U P
15
CHIRANJEEV NURSING INSTITUTE NAKA , AY0DHYA .U P
sheet. Pull the remainder of the sheet firmly so that there are no wrinkles.
Complete this same process for the drawsheet(s).
9.Apply or complete the top sheet, blanket, and spread. Place the top sheet, hem-
side up, on the bed so that its center fold is at the center of the bed and the top
edge is even with the top edge of the mattress.
Unfold the sheet over the bed. Optional: Make a fold in the sheet to
provide additional room forthe clients feet.
vertical toe pleat: make a fold in the sheet 5-10 cm (2-4in) perpendicular
to the foot of the bed.
Horizontal toe pleat: Make a fold in the sheet 5-10 cm (2-4 in) across the
bed near the foot.
Follow the same procedure for blanket and the spread, but place the top
edges about 15 cm (6in) from the head of the bed to allow a cuff of sheet
to be folded over them. Tuck in the sheet, blanket, and spread at the foot of the
bed, and miter the corner using all three layers of linen. Leave the sides of the
top sheet, blanket, and spread hanging freely, unless toe pleats were provided.
Fold the top of the top sheet down over the spread, providing a cuff.
Move to the other side of the bed, and secure the top bedding in the same manner.
10.Put clean pillowcases On the pillows as required. Grasp the closed end of the
pillowcase at the center with one hand. Gather up the sides of the Pillowcase and
place them over the hand grasping the case. Then grasp the center of one short
side of the pillow through the pillowcase. With the free hand, pull the pillowcase
over the pillow. Adjust the pillowcase so that the pillow fits into the corners of
the case and the seams are straight. Place the pillows appropriately at the head of
the bed.
11.Provide for client comfort and safety. Attach the signal cord so that the client
can conveniently use it. If the bed is currently being used by a client, either fold
back the top covers at one side or fanfold them down to the center of the bed.
Place the bedside table and the overbed table so that they are available to
the patient. Leave the bed in the high Position if the client is returning by
stretcher, or place in the low Position if the client is returning to bed after
being up.
12. Document and report pertinent data.
Variation : Surgical Bed
Strip the bed.
Place and leave the pillows on the bedside chair.
Apply the bottom linens as for an unoccupied bed. Place a bath blanket on the
foundation of the bed, if this is agency practice.
Place the top covers on the bed as you would for an unoccupied bed. Do not tuck
them in, miters the corners, or make a toe pleat.
Make a cuff at the top of the bed as you would for an unoccupied bed. Fold the
top linens up from the bottom.
On the side of the bed where the client will be transferred, fold up the two outer
corners of the top linens so they meet in the middle of the bed forming a triangle.
Pick up the apex of the triangle, and fanfold the top linens lengthwise to the other
side of the bed.
Leave the bed in high position with the side rails down.
Lock the wheels of the bed if the bed is not to be moved.
For the next items, evaluate the students in general according to the criteria. (5 as the highest
score)
5 4 3 2 1
Mastery
Orderliness
Proper attitude in assessing the client followed.
Ability to answer questions
Proper reporting observed.
Student’s signature: __________________
Evaluator’s Signature: __________________
Comments:________________________________________________________________________
___________________________________________________________________________
16
CHIRANJEEV NURSING INSTITUTE NAKA , AY0DHYA .U P
17
CHIRANJEEV NURSING INSTITUTE NAKA , AY0DHYA .U P
Unfold and fanfold bottom sheet from the center of the bed.
Facing the side of the bed, use both hands to pull the bottom sheet so that it
is smooth, and tuck excess under the side of the mattress.
Unfold the drawsheet fanfolded at the center of the bed and pull it tightly
with both hands. Pull the sheet in three sections:
Face the side of the bed to pull the middle section.
Face the far top corner to pull the bottom section.
Face the far bottom corner to pull the top section.
Tuck the excess drawsheet under the side of the mattress.
6. Reposition the client in the center of the bed.
Reposition the pillows at the center of the bed.
Assist the client to the center of the bed. Determine what position the client
requires or prefers, and assist the client to that position.
7. Apply or complete the top bedding.
Spread the top sheet over the client, and either ask the client to hold the top
edge of the sheet or tuck it under the shoulders, the sheet should remain
over the client when the bath blanket or used sheet is removed.
Complete the top of the bed.
8. Ensure the continued safety of the client.
Raise the side rails. Place the bed in the low position before leaving the
bedside.
Attach the signal cord to the bed linen within the client’s reach.
Put items used by the client within easy reach.
Bed making is not normally recorded.
For the next items, evaluate the students in general according to the criteria. (5 as the highest
score)
5 4 3 2 1
Mastery
Orderliness
Proper attitude in assessing the client followed.
Ability to answer questions
Proper reporting observed.
Student’s signature: __________________
Evaluator’s Signature: __________________
Comments:________________________________________________________________________
___________________________________________________________________________
18
CHIRANJEEV NURSING INSTITUTE NAKA , AY0DHYA .U P
19
CHIRANJEEV NURSING INSTITUTE NAKA , AY0DHYA .U P
Comments:________________________________________________________________________
___________________________________________________________________________
20
CHIRANJEEV NURSING INSTITUTE NAKA , AY0DHYA .U P
21
CHIRANJEEV NURSING INSTITUTE NAKA , AY0DHYA .U P
Comments:________________________________________________________________________
___________________________________________________________________________
22
CHIRANJEEV NURSING INSTITUTE NAKA , AY0DHYA .U P
Procedure
Explain to the client what you are going to do, why it is necessary, and how she
can cooperate.
Wash hands and observe other appropriate infection control procedures.
Provide for client privacy.
Prepare the client and the environment.
Fold the top bed linen to the foot of the bed and fold the gown up to exposed
genital area.
Place a bath towel under the client’s hips.
Position and drape the client and clean the upper and inner thighs
For females
Position in a back lying position with the knees flexed and spread well apart.
Cover her body and legs with a bath blanket. Drape the legs by tucking the
bottom corners of the bath blanket under the inner sides of the legs. Bring the
middle portion of the base of the blanket up over the pubic area.
Put on gloves, and wash and dry the upper inner thighs.
23
CHIRANJEEV NURSING INSTITUTE NAKA , AY0DHYA .U P
For males
Position the male client in a supine position with knees slightly flexed and hips
slightly externally rotated.
Put on gloves, and wash and dry the upper inner thighs
Inspect the perineal area
Note particular areas of inflammation, excoriation, or swelling, especially
between the labia in females or the scrotal folds in males.
Also note excessive discharge or secretion from the orifices, and the presence of
odors.
Wash and dry the perennial genital area.
For females
Clean the labia majora. Then spread the labia to wash the folds between the labia
majora and minora.
Use separate quarters of the wash cloths for each stroke, and wipe from the pubis
to the rectum. For menstruating women and clients with clients with indwelling
catheters, use clean wipes, cotton balls, or gauze. Take a clean ball for each
stroke.
Rinse the area well.
Dry the perineum thoroughly.
For males
Wash and dry the penis, using firm strokes.
If the client is uncircumcised, retract the prepuce to expose the glans penis for
cleaning. Replace the fore skin after cleaning the glans penis.
Wash and dry the scrotum. The posterior folds of the scrotum may need to be
clean in step 9 with the buttocks.
Inspect the perineal orifices intactness
Inspect particularly around the urethra in clients with indwelling catheter.
Clean between the buttocks.
Assist the client to turn on to the side facing away from you.
Pay particular attention to the anal area and posterior folds in the scrotum in
males. Clean the anus with toilet tissue before washing it, if necessary.
Dry the area well.
For post delivery or menstruating females, apply a perineal pad as needed, from
front to back.
Document:
Any unusual findings such as redness excoriation, skin break down,
discharge, or drainage.
Any localized area of tenderness.
For the next items, evaluate the students in general according to the criteria. (5 as the highest
score)
5 4 3 2 1
Mastery
Orderliness
Proper attitude in assessing the client followed.
Ability to answer questions
Proper reporting observed.
Student’s signature: __________________
Evaluator’s Signature: __________________
Comments:________________________________________________________________________
___________________________________________________________________________
24
CHIRANJEEV NURSING INSTITUTE NAKA , AY0DHYA .U P
Note: If the bed linen is to be reused, place it over the bedside chair. If it is to be
changed, place it in the linen hamper.
Make a bath mitt with the washcloth.
25
CHIRANJEEV NURSING INSTITUTE NAKA , AY0DHYA .U P
Wash the client’s eyes with water only, and dry them well. Use a separate
corner of the washcloth for each eye. Wipe from the inner to the outer canthus.
Ask whether the client wants soap used on her face.
Wash, rinse, and dry the client’s face, ears and neck.
Remove the towel from under the client’s head.
Wash the arms and hands.
Place a towel lengthwise under the arm away from you.
Wash, rinse and dry the arm by elevating the clients arm and supporting the
client’s wrist and elbow.
Apply deodorant or powder if desired.
Optional: place a towel on the bed and put a washbasin on it. Place the client’s
hands in the basin. Assist the client as needed to wash, rinse and dry her hands,
paying particular attention to the spaces between her fingers.
Repeat for hand and arm nearest you.
Wash the chest and the abdomen.
Place bath towel lengthwise over chest. Fold bath blanket down to the client’s
pubic area.
Lift the bath towel off her chest, and bathe her chest and abdomen with your
mitted hand, using long, firm strokes. Rinse and dry well.
Replace the bath blanket when the areas have been dried.
Wash the legs and feet.
Expose the leg farthest from you by folding the bath blanket towards the other
leg, being careful to keep the perineum covered.
Lift leg and place the bath towel lengthwise under the leg. Wash, rinse and dry
the leg, using long, smooth, firm strokes from the ankle to the knee to the thigh.
Reverse the coverings and repeat for the other leg.
Wash the feet by placing them in the basin of water.
Dry each foot.
Obtain fresh, warm, bathwater now or when necessary.
Wash the back and then the perineum.
Assist the client into a prone or side-lying position facing away from you. Place
the bath towel lengthwise alongside the back and buttocks while keeping the
client covered with the bath blanket as much as possible.
Wash and dry the client’s back, moving from the shoulders to the buttocks, and
upper thighs, paying attention to the gluteal folds.
Perform a back massage now or after completion of bath.
Assist the client to the supine position and determine whether the client can
wash the perineal area independently. If she can not do so, drape the client and
wash the area.
Assist the client with grooming aids such as powder, lotion or deodorant.
Use powder sparingly. Release as little as possible into the atmosphere.
Help the client put on a clean gown or pajamas.
Assist the client to care for hair, mouth and nails.
For the next items, evaluate the students in general according to the criteria. (5 as the highest
score)
5 4 3 2 1
Mastery
Orderliness
Proper attitude in assessing the client followed.
Ability to answer questions
Proper reporting observed.
Student’s signature: __________________
Evaluator’s Signature: __________________
Comments:________________________________________________________________________
___________________________________________________________________________
26
CHIRANJEEV NURSING INSTITUTE NAKA , AY0DHYA .U P
27
CHIRANJEEV NURSING INSTITUTE NAKA , AY0DHYA .U P
Aid, if indicated.
Do not massage the area.
Dispose of the syringe and needle safely.
Remove gloves.
Circle the injection site with ink to observe for redness or induration per agency
policy.
Document all relevant information.
Record the testing material given, the time, dosage, route, site and nursing
assessments.
For the next items, evaluate the students in general according to the criteria. (5 as the highest
score)
5 4 3 2 1
Mastery
Orderliness
Proper attitude in assessing the client followed.
Ability to answer questions
Proper reporting observed.
Student’s signature: __________________
Evaluator’s Signature: __________________
Comments:________________________________________________________________________
___________________________________________________________________________
28
CHIRANJEEV NURSING INSTITUTE NAKA , AY0DHYA .U P
29
CHIRANJEEV NURSING INSTITUTE NAKA , AY0DHYA .U P
Comments:________________________________________________________________________
___________________________________________________________________________
30
CHIRANJEEV NURSING INSTITUTE NAKA , AY0DHYA .U P
31
CHIRANJEEV NURSING INSTITUTE NAKA , AY0DHYA .U P
Clean the site with an antiseptic swab. Using a circular motion, start at the center
and move outward about 5 cm (2in).
Transfer and hold the swab between the third and fourth fingers of your
nondominant hand in readiness for needle withdrawal, or position the swab on the
Client’s skin above the intended site. Allow skin to dry prior to injecting
medication.
Prepare the syringe for injection
Remove the needle cover without contaminating the needle.
If using a prefilled unit–dose medication, take caution to avoid dripping medication
on the needle prior to injection. If this does occur, wipe the medication off the
needle with sterile gauze.
Inject the medication using a Z–track technique.
Use the ulnar side of the nondominant hand to pull the skin approximately 2.5 cm
(1inch) to the side.
Holding the syringe between the thumb and forefinger, pierce the skin quickly and
smoothly at a 90–degree angle, and insert the needle into the muscle.
Hold the barrel of the syringe steady with your nondominant hand, and aspirate by
pulling back on the plunger with your dominant hand. Aspirate for 5 to 10 seconds.
If blood appears in the syringe, withdraw the needle, discard the syringe, and
prepare a new injection.
If blood does not appear, inject the medication steadily an slowly (approximately
10 seconds per milliliter) while holding the syringe steady.
After injection, wait 10 seconds.
Withdraw the needle.
Withdraw the needle smoothly at the same angle of insertion.
Apply gentle pressure at the site with a dry sponge. Do not massage the site.
If bleeding occurs, apply pressure with dry sterile gauze until it stops.
Discard the uncapped needle and attached syringe into the proper receptacle.
Remove gloves. Wash hands.
Document all relevant information
Include the time of administration, drug name, dose, route, and the client’s
reactions.
Assess effectiveness of the medication at the time it is expected to act.
For the next items, evaluate the students in general according to the criteria. (5 as the highest
score)
5 4 3 2 1
Mastery
Orderliness
Proper attitude in assessing the client followed.
Ability to answer questions
Proper reporting observed.
Student’s signature: __________________
Evaluator’s Signature: __________________
Comments:________________________________________________________________________
___________________________________________________________________________
32
CHIRANJEEV NURSING INSTITUTE NAKA , AY0DHYA .U P
33
CHIRANJEEV NURSING INSTITUTE NAKA , AY0DHYA .U P
34
CHIRANJEEV NURSING INSTITUTE NAKA , AY0DHYA .U P
Comments:________________________________________________________________________
___________________________________________________________________________
35
CHIRANJEEV NURSING INSTITUTE NAKA , AY0DHYA .U P
36
CHIRANJEEV NURSING INSTITUTE NAKA , AY0DHYA .U P
For the next items, evaluate the students in general according to the criteria. (5 as the highest
score)
5 4 3 2 1
Mastery
Orderliness
Proper attitude in assessing the client followed.
Ability to answer questions
Proper reporting observed.
Student’s signature: __________________
Evaluator’s Signature: __________________
Comments:________________________________________________________________________
___________________________________________________________________________
37
CHIRANJEEV NURSING INSTITUTE NAKA , AY0DHYA .U P
Comments:________________________________________________________________________
___________________________________________________________________________
38
CHIRANJEEV NURSING INSTITUTE NAKA , AY0DHYA .U P
Comments:________________________________________________________________________
___________________________________________________________________________
39
CHIRANJEEV NURSING INSTITUTE NAKA , AY0DHYA .U P
Comments:________________________________________________________________________
___________________________________________________________________________
40
CHIRANJEEV NURSING INSTITUTE NAKA , AY0DHYA .U P
Comments:________________________________________________________________________
___________________________________________________________________________
41
CHIRANJEEV NURSING INSTITUTE NAKA , AY0DHYA .U P
Preparation
Be guided with the purpose and principles of home visit.
Check the completeness of the public health bag including its
arrangements.
Procedure
1.Upon arrival, place the bag on the table lined with a clean paper. The clean side
must be out and the folded part, touching the table.
2. Ask for a basin of water or a glass of a drinking water if tap water is not
available.
3. Open the bag and take out the towel and soap
4. Wash hands using soap and water. Wipe to dry.
5. Take out the apron from the bag and put it on with the right side out.
6. Put out all the necessary articles needed for the specific care.
7. Close the bag and put it in one corner of the working area.
8. Proceed in performing the necessary nursing care and treatment.
9. After giving the treatment, clean all things that were used and perform hand
washing.
10. Open the bag and return all things that were used in their proper places after
cleaning them.
11. Remove apron, folding it away from the person, the soiled side in and the
clean side out. Place it in the bag.
12. Fold the lining, place it inside the bag and close the bag.
13. Take the record and have a talk with the mother. Write down all the necessary
data that were gathered, observations, nursing care and treatment rendered. Give
instructions for care of patients in the absence of the nurse.
14. Make appointment for the next visit (either home or clinic) taking note of the
date and time
42
CHIRANJEEV NURSING INSTITUTE NAKA , AY0DHYA .U P
For the next items, evaluate the students in general according to the criteria.
(5 as the highest score)
5 4 3 2 1
Mastery
Orderliness
Proper attitude in assessing the client followed.
Ability to answer questions
Proper reporting observed.
43
CHIRANJEEV NURSING INSTITUTE NAKA , AY0DHYA .U P
For the next items, evaluate the students in general according to the criteria.
(5 as the highest score)
5 4 3 2 1
Mastery
Orderliness
Proper attitude in assessing the client followed.
Ability to answer questions
Proper reporting observed.
44
CHIRANJEEV NURSING INSTITUTE NAKA , AY0DHYA .U P
For the next items, evaluate the students in general according to the criteria.
(5 as the highest score)
5 4 3 2 1
Mastery
Orderliness
Proper attitude in assessing the client followed.
Ability to answer questions
Proper reporting observed.
45
CHIRANJEEV NURSING INSTITUTE NAKA , AY0DHYA .U P
PROCEDURES 3 2 1 0
1. Prepare the client
a. Identify the patient and introduce self.
b. Does the history taking and measures the fundic height.
c. Explain the procedure.
d. Instruct the patient to empty her bladder.
e. Position the woman supine with knees slightly flexed. Place a pillow or
rolled towel under the right side.
f. Wash your hands using warm water.
g. Observe the woman’s abdomen for longest diameter and where fetal
movement is apparent.
2. Perform the first maneuver
a. Stand at the foot of the patient , facing her, and place both hands flat on
her abdomen.
b. Palpate the superior surface of the fundus. Determine consistency, shape
and mobility.
3. Perform the second maneuver.
a. Face the client and place the palms of each hand on either side of the
abdomen.
b. Palpate the sides of the uterus while the right hand palpates the opposite
side of the uterus from top to bottom. Then hold the right hand steady, and
repeat palpation using the left hand on the left side.
c. Determine where to assess the fetal heart rate.
4. Perform the third maneuver.
a. Gently grasp the lower portion of the abdomen just above the symphysis
pubis between the thumb and index finger and try to press the thumb and
finger together. Determine any movement and whether the part is firm or
soft.
5. Perform the fourth maneuver.
a. Place fingers on both sides of the uterus approximately 2 inches above
the inguinal ligaments, pressing downward and inward in the direction of
the birth canal. Allow fingers to be carried downward.
6. Explains the result of the procedure to the patient.
7. Documentation and after care.
For the next items, evaluate the students in general according to the criteria. (5 as the highest
score)
5 4 3 2 1
Mastery
Orderliness
Proper attitude in assessing the client followed.
Ability to answer questions
Proper reporting observed.
Student’s signature: __________________
Evaluator’s Signature: __________________
Comments:________________________________________________________________________
___________________________________________________________________________
46
CHIRANJEEV NURSING INSTITUTE NAKA , AY0DHYA .U P
Monitoring of Labor
CHECKLIST
Legend:
3-Very Satisfactory 0- Did not perform the procedure
2- Satisfactory 1- Needs Improvement
PROCEDURES 3 2 1 0
1. Prepare the client
a. Identify the patient and introduce self.
b. Does the history taking and measures the fundic height.
c. Explain the procedure.
d. Instruct the patient to empty her bladder.
e. Position the woman supine with knees slightly flexed. Place a
pillow or rolled towel under the right side.
f. Wash your hands using warm water.
g. Observe the woman’s abdomen for longest diameter and where fetal
movement is apparent.
PROCEDURE
1. Locate and assess for the fetal heart rate.
2. Locate the fundus of the uterus and determine the ff:
a. duration of contraction
b. interval
c. frequency
d. strength
3. Document the result and monitor as appropriate depending on the
stage of labor.
4. Put on sterile gloves.
5. Inform the patient to breath though the mouth as you do the internal
examination of the vagina.
6.Insert laterally your middle and index fingers of your dominant
hand.
7. Assess for cervical dilatation, effacement and fetal station.
8. Once the examination is done, inform the patient to relax and do the
aftercare.
9. Explain the result of the procedure to the patient.
10. Properly document the result of the monitoring to the appropriate
sheet.
For the next items, evaluate the students in general according to the criteria.
(5 as the highest score)
5 4 3 2 1
Mastery
Orderliness
Proper attitude in assessing the client followed.
Ability to answer questions
Proper reporting observed.
Student’s signature: __________________
Evaluator’s Signature: __________________
Comments:
_________________________________________________________________________
_________________________________________________________________________________
__
47
CHIRANJEEV NURSING INSTITUTE NAKA , AY0DHYA .U P
For the next items, evaluate the students in general according to the criteria.
(5 as the highest score)
5 4 3 2 1
Mastery
Orderliness
Proper attitude in assessing the client followed.
Ability to answer questions
Proper reporting observed.
48
CHIRANJEEV NURSING INSTITUTE NAKA , AY0DHYA .U P
For the next items, evaluate the students in general according to the criteria.
(5 as the highest score)
5 4 3 2 1
Mastery
Orderliness
Proper attitude in assessing the client followed.
Ability to answer questions
Proper reporting observed.
Student’s signature: __________________
Evaluator’s Signature: __________________
Comments:
_________________________________________________________________________
_________________________________________________________________________________
__
49
CHIRANJEEV NURSING INSTITUTE NAKA , AY0DHYA .U P
50
CHIRANJEEV NURSING INSTITUTE NAKA , AY0DHYA .U P
51
CHIRANJEEV NURSING INSTITUTE NAKA , AY0DHYA .U P
Comments:________________________________________________________________________
___________________________________________________________________________
52
CHIRANJEEV NURSING INSTITUTE NAKA , AY0DHYA .U P
REFERENCES:
53