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MODULE #1 Student Activity Sheet
Lesson title: SURGICAL HANDWASHING Materials:

Learning Targets:
At the end of the module, students will be able to: Book, pen and notebook
1. Report and document up-to-date client care accurately and
comprehensively. References:
2. Work effectively in collaboration with inter-, intra-, and
multidisciplinary and multi-cultural teams. Smeltzer, S. Bare, B,. Hinkie J., Cheever, K.,
3. Practice beginning management and leadership skills in the (2010). Brunner and Suddarth’s Textbook of
delivery of care. Medical-Surgical Nursing (12th ed.).
4. Conduct research with an experienced researcher. Philadelphia, Pennsylvania: Lipincott Williams
& Wilkins
Elis, J. R Bentz, P. M.,(2008). Basic Nursing

Skills (5th ed.). Lipincott Williams & Wilkins
Potter, Perry, Stockert, & Hall; Fundamentals

of Nursing Ninth Edition
A. LESSON PREVIEW/REVIEW
This course deals with the application of concepts, principles, theories and methods of
developing nursing leaders and managers in the hospital and community-based settings. It
also includes ethico-moral/legal aspects of health care and nursing practice and the nurses’
responsibilities for personal and professional growth.
B.MAIN LESSON
SURGICAL HANDWASHING
Surgical hand washing requires the removal and killing of transient microorganisms and substantial
reduction and suppuration of the resident flora of the surgical team for the duration of the operation, in
case a surgical glove is punctured/torn. Ensure that fingernails are kept short and clean.
This document is the property of PHINMA EDUCATION

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PURPOSES OF SURGICAL SCRUB
1. To remove dirt, oils and bacteria from the hands and forearms of operating personnel.
2. It kill transient bacteria and have a prolonged depressant effect on the resident bacteria and
should not irritate skin or be time consuming.
3. Brushes and nail cleaners are commonly used with an antiseptic. Brushes should be soft
enough to not damage skin, but still achieve the expected result. It is important that specific
attention is paid to the fingernails as this area has the highest bacterial load.
SURGICAL SCRUB TECHNIQUES
Preparation for scrubbing
1.All staff should be in suitable surgical attire,with sleeves above the elbow (rolled if necessary) and
tops tucked into trousers.
2.All hair should be contained within a surgical hat.
3.Fingernails should be short and free from polish or artificial nails
4.Nails may be cleaned if necessary by using a disposable pick under running water.
5.All jewellery should be removed.
6.Hands and arms should be washed with plain microbial solution and running water immediately before
beginning the surgical scrub.
7.Hands and arms should be wet before applying scrub solution.
8.The first wash should encompass the hands and arms to the elbows, utilizing a systematic method to
cover all areas
SURGICAL HAND SCRUB
2 METHODS OF SCRUB PROCEDURES
● NUMBERED STROKE PROCEDURE- a certain number of brush strokes are designated for each
fingers, palm, back of the hands and arm.
● TIMED SCRUB METHOD – each scrub should last from three to five minutes, depending on facility
protocol

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SCRUBBING
EQUIPMENT
ANTIBACTERIAL LIQUID SOAP
Family Germ Protection Soap. Leaves Your Skin

Refreshed After Every Wash. Get Long-Lasting
Protection Against Germs That Causes Infection &
Common Diseases. Gentle on Skin. For the Whole
Family. Moisture Lock Formula.
SCRUB BRUSH WITH NAIL CLEANER
The E-Z Scrub 205 is a single-use Povidone-Iodine

Surgical Scrub Brush/Sponge with nail cleaner
designed for preoperative cleaning of healthcare
personnel arms and hands. It significantly reduces
the number of micro-organisms on care-givers'
hands and arms, consequently reducing the
patient's risk of infection.

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Scrub sinks, also referred to as surgical sinks or medical

sinks, are vital to keeping Operating Rooms up and
running, and are imperative to the health and safety of
patients. They serve as the scrub station for surgeons
and other OR staff to scrub their hands and arms before
a surgical or invasive procedure. .
Its absorbent, 100 percent cotton towels are fully

disposable and sterile to make cleanup quick and
easy while also helping to reduce the risk of cross
infection

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A. SURGICAL HANDWASHING
EQUIPMENT
• Deep sink with foot or knee controls for dispensing water and soap (faucets should be high
enough for hands and forearms to fit comfortably)
• Antimicrobial agent approved by the health care facility
• Surgical scrub sponge with plastic nail pick (optional)
• Paper face mask, cap or hood, surgical shoe covers
• Sterile towel
PROCEDURE SCRIPT
1. Remove any watches and rings from your Good morning, I am Nurse Jasper, and I'm
hands. Ensure that your sleeves end at least two going to perform Surgical hand washing. ,
to three inches above your elbows. Roll your this is done to remove transient micro-
sleeves up if necessary organisms from the nails, hands and
forearms.
Before the procedure I will remove any

watches and rings from my hand
Rationale:
Jewelries harbors microorganisms and prevent
the patient from receiving a “possible” burn from
the current from electrocautery
2. Before beginning the scrubbing process We use aseptic technique in opening the

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open your gown and gloves using aseptic gown and gloves to prevent contaminating
technique and ensure they remain sterile our hands after surgical scrub
Rationale:
Not to contaminate hands after surgical scrub
(packages of gloves and gowns are considered
unsterile )
3. Wash your hands with regular soap to Wash your hands with regular soap to
remove any gross debris. Rinse your hands by remove any gross debris and keep your
keeping them elevated and let the water run down hands elevated while rinsing in a running
to your elbows. water
Rationale:
To remove bacteria and oils on hand
4. Remove scrub brush from the package The use of the nail cleaner is to remove
and use nail cleaner to clean the fingernails debris and transient microorganism from
the nails, hands and forearm
Rationale:
To remove debris and transient microorganisms
from the nails, hands and forearm.

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5.Squeeze scrub brush under water to release

soap from sponge
6.With scrub brush perpendicular to fingers, begin We need to scrub each sides of our fingers,
to scrub all four sides of each finger with back-in- hands, and wrist to inhibit the rapid
forth motion. rebound growth of microorganism
Rationale:
To reduce the resident microbial count to a
minimum , and inhibit rapid rebound growth of
microorganisms
7.Scrub dorsal and palm surfaces of hand and

wrist with a circular motion
8.Starting at the wrist, scrub all four sides at the
arm to the elbow.
9.Transfer scrub brush to the other hand and
repeat steps 6 to 8
10. Discard scrub brush and rinse hands and
arms, starting with the fingertips and working
toward the elbows.
Rationale:
To prevent from dripping from fingertips
11. Allow contaminated water to drip off the Keep our hands above our wrist to allow
elbows by keeping hands above the wrist. the contaminated water to drain
Rationale:
To drain/ flush the bacteria and keep fingers
elevated to maintain sterility of hands after
scrubbing
12. Dry with the sterile towel. Using care not to Sterile towel is a 100 percent cotton that
let the towel touch anything, take the top of the are fully disposable and can be used in
towel and pat one hand the forearm dry. Carefully drying our hands and forearm after hand
take the bottom of the towel and pat dry your scrubbing.
other hand and forearm

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Rationale:
Drying prevents facilitates donning/putting on
gloves
PERFORMANCE EVALUATION CHECKLIST
Name of Student:
______________________________________________________
Level & Block: School Year & Term:

______________________ ________________
Area of assignment: Inclusive Dates: Overall Rating

_____________________ ____________________
SURGICAL HANDWASHING
PERFORMED PERFORME UNABLE
INDEPENDENTL D WITH TO
Procedure/Skill Y ASSISTANC PERFOR Remarks

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E M
4-5 2-3 0-1
1.Remove any watches and rings from

your hands. Ensure that your sleeves
end at least two to three inches above
your elbows. Roll your sleeves up if
necessary
2.Before beginning the scrubbing

process open your gown and gloves
using aseptic technique and ensure they
remai
3.Wash your hands with regular soap to

remove any gross debris. Rinse your
hands by keeping them elevated and let
the water run down to your elbows.
4.Remove scrub brush from the package

and use nail cleaner to clean the
fingernails
5.Squeeze scrub brush under water to
release soap from sponge
6.With scrub brush perpendicular to

fingers, begin to scrub all four sides of
each finger with back-in-forth motion.
7.Scrub dorsal and palm surfaces of
hand and wrist with a circular motion
8.Starting at the wrist, scrub all four

sides at the arm to the elbow.
9.Transfer scrub brush to the other hand

and repeat steps 6 to 8
10. Discard scrub brush and rinse

hands and arms, starting with the
fingertips and working toward the

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elbows.
11.
12. Allow contaminated water to drip

off the elbows by keeping hands above
the wrist.
13.
12.Dry with the sterile towel. Using care
not to let the towel touch anything, take
the top of the towel and pat one hand the
forearm dry. Carefully take the bottom of
the towel and pat dry your other hand
and forearm
Remarks:________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
______________
_____________________________________________ _____________________________________________
Conformed : Student’s Signature Clinical Instructor
C. LESSON WRAP-UP
AL STRATEGY: CAT: Student Response Cards
1. For each student, the instructor will create a set of student response cards. Index cards, colorful bits of
paper, and cardstocks can all be used to make cards.
2. The instructor will write the response choices on each card, such as A, B, C, D, or color-code them, such as
green for Yes and red for No, and place them in an envelope or punch holes in them and attach red strings.
3. The teacher will ask the class a question about the information you just learned in class.
4. The teacher will ask you to hold up your card with the correct answer to the question.
5. The teacher will quickly scan the entire classroom for each student's response. This will provide the
instructor an idea of who understands and who does not understand the questions and material presented.

NUR 106: MS RLE
Lesson title: GOWNING AND CLOSED GLOVING Materials:

Learning Targets:
4. Conduct research with an experienced researcher. Philadelphia, Pennsylvania: Lipincott Williams
& Wilkins


This course deals with the application of concepts, principles, theories and methods of developing
nursing leaders and managers in the hospital and community-based settings. It also includes ethico-
moral/legal aspects of health care and nursing practice and the nurses’ responsibilities for personal
and professional growth.
B.MAIN LESSON
GOWNING and CLOSED GLOVING

Surgical Gown is a robe or smock worn in operating rooms and other parts of hospitals as a guard against
contamination. Surgical hand antisepsis is defined as ‘an extension of handwashing and ‘the antiseptic surgical
scrub or antiseptic hand rubs performed before donning sterile attire preoperatively.
Closed Gloving is placing of gloves on the hands. During physical examination and invasive procedures,
such as phlebotomy or surgery, this is done to protect both caregiver and patient from transmissible diseases.

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PURPOSE OF SURGICAL GOWNING

1. To prevent contamination to the surgical wound
2. Help control infection via aseptic principles.
3. Help ensure the control of infection and microbial contamination by skin flora.
4. provide a barrier protection to prevent blood strikethrough and fluid contamination.
PURPOSE OF SURGICAL GLOVING

1. To act as a protective barrier to prevent the possible transmission of diseases between healthcare
professionals and patients during surgical procedures.
2. Are required for any invasive procedure and when contact with any sterile site, tissue, or body
cavity is expected.
3. Sterile gloves help prevent surgical site infections
4. Reduce the risk of exposure to blood and body fluid pathogens for the health care worker.
EQUIPMENT NEEDED:
SURGICAL GOWN SURGICAL GLOVES

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BONNET AND FACEMASK MAYO TABLE
GOWNING
1. With one hand, pick up the entire folded gown from the wrapper by grasping the gown
through all layers, being careful to touch only the inside top layer which is exposed.
2. Once your hands are securely pinching the gown in these slots, step back from the shelf
and allow the gown to drop.
3. Make sure the gown does not touch any surrounding unsterile objects.
Pick up gown pack Open the gown

4. Grasp the inside shoulder seams and open the gown with the armholes facing you.
5. Carefully insert your arms part way into the gown one at a time, keeping hands at
shoulder level away from the body.

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6. Slide the arms further into the gown sleeves and when the fingertips are level with the
proximal edge of the cuff, grasp the inside seam at the cuff hem
using thumb and index finger. Be careful that no part of the hand protrudes from the sleeve
cuff.
Put your hands into the sleeves Slide your arms further down the gown sleeves
7. A theatre assistant will fasten the gown behind you, positioning it over the shoulders by
grasping the inside surface of the gown at the shoulder seam. The theatre assistant’s hands
should only ever be in contact with the inside surface of the gown.
8. The theatre assistant then prepares

to secure the gown at
the neck and upper back. Gowns differ in
how they are secured, but most with have
either ties, buttons or velcro tabs.
An assistant should fasten the gown

behind you
As mentioned above, before the final tie is fastened, you need to don sterile gloves. This guide skips
over the step to give you a focused overview of the various stages of gowning.
1. There is a cardboard slip holding two ties together across the front of the gown.

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2. Detach the cardboard slip from the short tie, ensuring you keep hold of the short tie in your left hand.
3. Now pass the cardboard slip to the theater assistant, ensuring not to make direct contact with their
hand.
4. They will pass the tie around your back – now take the tie, and let them pull the cardboard off the tie
so that you can tie a bow at your waist.
Detach cardboard slip Detach the tie from the

Turn whilst the assistant holds
from shirt tie and pass to cardboard and tie a knot
the cardboard
assistant

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GLOVING (CLOSED TECHNIQUE)
1. Grip the sterile inside pack through your gown cuffs keeping the fingers inside the gown
cuff, open and display the gloves upside down
2. Place your right thumb inside the top cuff edge of the right glove (thumb-to-thumb), pick
up and lay flat on your right hand.
3. Place left thumb under the cuff exposed on right glove, and stretch glove over right
hand
4. Keeping your right fingers straight, pull down the glove with your left hand, using a
combination of glove and sleeve pulling
5. Ensure the white cuff remains inside the glove
6. Repeat procedure with left glove
Once you have completed the scrub, hold both hands higher than elbows and away
from surgical attire prior to gowning.
B.GOWNING and CLOSED GLOVING

EQUIPMENT
• Package of proper-size sterile gloves (latex free if nurse or patient has
sensitivity or allergy)
• Sterile pack containing sterile gown
• Clean, flat, dry surface

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• Paper face masks, cap or hood, surgical shoe covers
PROCEDURE SCRIPT
APPLYING STERILE GOWN
1. Before entering the operating room or treatment area, Good morning, I am Nurse Jasper,
apply cap, face mask, eyewear, and foot covers (paper and I'm going to perform Gowning
or cloth covers fit over work shoes). and Closed gloving.
Rationale: We do gowning to help control

To helps prevent the spread of germs infection via aseptic principles, and
we also perform closed gloving to
reduce the risk of exposure to blood
and body fluid for the health care
workers
Before entering the operating room

or treatment area, make it sure to
wear cap, face mask, eye wear and
foot covers to helps prevent the
spread of germs
2.Perform thorough surgical hand wash

Now let’s perform surgical hand
Rationale: washing, this is done to remove dirt,
To remove dirt, oils and bacteria from the hands and oils and bacteria from the hands and
forearms of operating personnel. forearms of operating personnel.
3. Circulating nurse assists by opening a sterile pack The circulating nurse is

containing a sterile gown (folded inside out). responsible for managing
all nursing care within the operating
room, observing the surgical team
4. Circulating nurse prepares a glove package by from a broad perspective, and
peeling the outer wrapper open while keeping the inner assisting the team to create and
contents sterile. Place the inner glove package on sterile maintain a safe, comfortable
field created by sterile outer wrapper. environment for the patient's
surgery.
5. Reach down to the sterile gown package; lift folded

gown directly upward and step back away from table.
6. Holding folded gown, locate neckband. With both

hands grasp the inside front of gown just below

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neckband.
7. Allow the gown to unfold, keeping the inside of the

gown toward the body. Do not touch the outside of the
gown with bare hands.
Rationale:
Outside of the gown considered sterile
8.With hands at shoulder level, slip both arms into (Scrub Nurse to Circulating Nurse)
armholes simultaneously (see illustration). Ask the
circulating nurse to bring gown over your shoulders by Once my arms are placed inside the
reaching inside to arm seams and pulling gown on, armholes of the gown, bring the
leaving sleeves covering hands. gown over my shoulders so I could
completely pull the gown on.
Place arms in sleeves
9. Have circulating nurses securely tie the back of the

gown at neck and waist (see illustration). (If the gown is
wraparound style, do not touch the sterile flap to cover it
until you are gloved.)

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Circulating nurse ties scrub gown
PERFORMING CLOSED GLOVING
10. Closed gloving
a. With hands covered by gown sleeves, open inner In closed gloving technique, the
sterile glove package scrub person’s hands remains inside
the sleeves and should not touch the
cuffs
Grip the sterile inside pack through

your gown cuffs keeping the fingers
inside the gown cuff, open and
display the gloves upside down.
Scrub nurse opens glove package
b. With the dominant hand inside the gown cuff, pick up Using my dominant hand, I will pick
the glove for the non-dominant hand by grasping the up the glove for my non-dominant
folded cuff. hand.
c. Extend the non-dominant forearm with palm up and I will extend my non-dominant
place the palm of the glove against the palm of the non- forearm with palm facing upward
dominant hand. Glove fingers point toward the elbow. and place the palm of glove against
palm of non-dominant hand

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d. Grasp back of glove cuff with covered dominant hand Grasp back of glove cuff with
and turn glove cuff over end of non-dominant hand and covered dominant hand and turn
gown cuff glove cuff over end of non-dominant
hand and gown cuff
Gloves are applied to the left hand as the right hand

remains inside the cuff.
e. Grasp top of glove and underlying gown sleeve with Grasp top of glove and underlying
covered dominant hand. Carefully extend fingers into the gown sleeve with covered dominant
glove, being sure that the glove cuff covers the gown hand
cuff.
f.Glove dominant hand in same manner, reversing Use a gloved non-dominant hand to
hands (see illustration). Use a gloved nondominant hand pull on the glove. Keep hand inside
to pull on the glove. Keep hand inside sleeve (see sleeve
illustration)
Second glove is applied
g. Be sure that fingers are fully extended into both Be sure that fingers are fully
gloves. extended into both gloves
11. For wraparound sterile gowns: take gloved hand and
10

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release fastener or ties in front of gown.
10. Hand paper tab connected to sterile tie to

circulating nurse, who is non-sterile (see illustration).
Circulating nurse stands still as you turn completely
around to the left, allowing for margin of safety as gown
wraps around and covers your back. Take back sterile
ties from circulating nurses and secure ties to gown.
Hand tie to sterile team member
11

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Name of Student:
______________________________________________________

______________________ ________________

_____________________ ____________________

E M
4-5 2-3 0-1
1. Before entering the operating room or

treatment area, apply cap, face mask,
eyewear, and foot covers (paper or cloth
covers fit over work shoes).
2. Perform thorough surgical hand wash
3. Circulating nurse assists by opening a

sterile pack containing sterile gown
(folded inside out).
12

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4. Circulating nurse prepares a glove

package by peeling the outer wrapper
open while keeping inner contents
sterile. Places inner glove package on
sterile field created by sterile outer
wrapper.
5. Reach down to sterile gown package;

lift folded gown directly upward and step
back away from table.
6. Holding folded gown, locate

neckband. With both hands grasp inside
front of gown just below neckband.
7. Allow gown to unfold, keeping inside
of gown toward body. Do not touch
outside of gown with bare hands.
8.With hands at shoulder level, slip both

arms into armholes simultaneously (see
illustration). Ask circulating nurse to bring
gown over your shoulders by reaching
inside to arm seams and pulling gown
on, leaving sleeves covering hands.
9. Have circulating nurse securely tie

back of gown at neck and waist (see
illustration). (If gown is wraparound style,
do not touch sterile flap to cover it until
you are gloved.)
10. Closed gloving
A.With hands covered by gown sleeves,

open inner sterile glove package
13

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b. With dominant hand inside gown cuff,

pick up glove for non-dominant hand by
grasping folded cuff.
c. Extend non-dominant forearm with
palm up and place palm of glove against
palm of non-dominant hand. Glove
fingers point toward elbow.
d. Grasp back of glove cuff with covered

dominant hand and turn glove cuff over
end of non-dominant hand and gown cuff
e. Grasp top of glove and underlying

gown sleeve with covered dominant
hand. Carefully extend fingers into glove,
being sure that glove cuff covers gown
cuff
f.Glove dominant hand in same manner,

reversing hands (see illustration). Use
gloved nondominant hand to pull on
glove. Keep hand inside sleeve (see
illustration)
g. Be sure that fingers are fully extended

into both gloves.
11 For wraparound sterile gowns: take

gloved hand and release fastener or ties
in front of gown.
12.Hand paper tab connected to sterile

tie to circulating nurse, who is non-sterile
(see illustration). Circulating nurse
stands still as you turn completely
around to left, allowing for margin of
safety as gown wraps around and covers
14

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your back. Take back sterile tie from

circulating nurse and secure tie to gown.
Remarks:________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
______________
_____________________________________________ _____________________________________________
Conformed: Student’s Signature Clinical Instructor
C. LESSON WRAP-UP
AL STRATEGY: CAT: Summary Paragraph
The students will be required to write “What was learned today”. Instruct the students that they should
limit their answer/idea in one paragraph only.
15

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Lesson title: OPERATING ROOM INSTRUMENTS Materials:

Learning Targets:
Philadelphia, Pennsylvania: Lipincott Williams
4. Conduct research with an experienced researcher.
& Wilkins


developing nursing leaders and managers in the hospital and community-based
settings. It also includes ethico-moral/legal aspects of health care and nursing practice
and the nurses’ responsibilities for personal and professional growth.
B. MAIN LESSON
1. Finger rings are on the proximal end;

this is the handle area of the
instrument.
2. Shanks define the length of the
instrument, which is determined by
the depth of the wound.
3. Ratchets that allow for the jaws to be
closed and locked on tissues.
4. Between the shanks and the jaw is
the joint, which is where the two
halves of the instrument are joined
to permit for opening and closing.
These joints are either a box lock or
a screw joint.
5. Jaws are the working portion of the
instrument.
Mayo scissors and Kocher forceps

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2
Student Nurse’s Copy
2
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6.
1. Tissue forceps have a spring action joint at

the distal end that holds the instrument open
until compressed.
2. The handle grip is where the surgeon’s
fingers are placed.
3. The shanks determine the length of the
forceps.
4. The jaws and the tips are the working end
of the forceps; these are determined by the
type of tissue that is being
5. grasped
Tissue forcep
Retractors are used to hold a surgical wound open

to expose the site that is being worked on. A
handheld retractor will be designed with a handle, a
shank, a blade or blades, and tips.
Richardson-Eastman double-ended retractor
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Instrument classification:
Instruments are categorized according to its function. Retracting and exposing - These instruments are
designed to hold back or pull aside wound edges, organs,
Accessory – These instruments that does not fall into any vessels, nerves, and other tissues to gain access to the
of the other categories but has a specific function and is operative site. They are generally referred to as retractors
an integral part of the surgical procedure. and are either manual (handheld) or self-retaining (stay
open on their own). Retractors have one or more blades.
Clamping and occluding - Used to compress vessels These blades are used for holding back tissues without
and other tubular structures to impede or obstruct the flow causing trauma and should not be confused with a cutting
of blood and other fluids. These clamps are atraumatic blade. Retractor blades are usually curved or angled and
ratcheted instruments that are straight, curved, or angled may be blunt or have sharp or dull prongs. The blades will
and have a variety of inner jaw patterns. These clamps vary in size according to the depth of the wound and the
may totally occlude or partially occlude the tissues area of placement. Handheld retractors consist of a blade
between the jaws. attached to some type of handle, which is pulled back or
held in place by the user.
A total occlusion clamp has the ability to completely
compress or close the jaws at the initial engagement of Manual retractors are often used in pairs, one on each
the ratchet device. The partial occlusion clamp is side of the wound. Some are double-ended, with a blade
capable of varying levels of compression. on each end and a slight variation in size or shape.
Examples of handheld retractors are Parker, Joseph Skin
Cutting and dissecting - Used to incise, dissect, and Hook, Senn, Ragnell, and Richardson.
excise tissues. Cutting instruments have single or double
razor sharp edges or blades, such as a scalpel, scissors, Self-retaining retractors are holding devices with two or
or osteotome. Dissecting instruments may have a cutting more blades that spread the wound apart or hold tissues
edge and come in a variety of designs. Examples include back. A self-retaining retractor has a ratchet, crank,
curettes, cone tip dissectors, and biopsy forceps. spring, or locking device that holds it open. Examples of
self-retaining retractors are the Balfour, Omni-Tract,
Bookwalter, Burford, Finochietto, Weitlaner, and Gelpi.
Grasping and holding – Designed to grip and manipulate
body tissues. They are often used to stabilize tissue that is
to be excised, dissected, repaired, or sutured. Tissue Suctioning and aspirating – Used to remove blood, fluid,
forceps are the non-ratcheted style and are often referred and debris from operative sites. These suction tips may be
to as pickups or thumbs. The tips may be smooth or disposable or nondisposable and come in a variety of
serrated and may have interlocking teeth. They vary in shapes and sizes according to use. Some examples of
size and shape according to use. these hollow tips include the Yankauer, Frazier, Poole,
and Baron.
Probing and dilating - Used to explore a structure,
opening, or tract. These are often blunt, malleable, and
wire-like instruments. Dilating instruments are used to
gradually enlarge an orifice or tubular structure, to open a
stricture, or to introduce another instrument. They come in
sets numbered from the smallest to the largest. A few
examples of dilators are Hanks, Van Buren, Bakes, and
Mahoney.
Suturing and stapling – Used to ligate, repair, and Viewing – These instruments allow visualization of a
approximate tissues during a surgical procedure. This structure or cavity. Various examples include the nasal
mainly includes needle holders, which are used to hold speculum, ridged and flexible endoscopes, and
curved suture needles, but also includes other items such endoscopic camera.
as a knot pusher, endo stitch, and endo loops. Stapling
devices are used to ligate, anastomose, or approximate Instrument sets - Instruments are generally placed into
tissues. Stainless steel, titanium, and INSORB absorbable sets according to the type of procedures that are
material are used for stapling. Staples are designed to be performed at the facility. Typically, instruments from each
noncrushing when inserted into the tissues to promote category will be selected for the assembly of a set. These
healing. sets are then assembled, labeled, sterilized, and stored for
Page 4 of 18
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later use. Instrument sets are often labeled according to

A nondisposable stapler uses disposable stapling the procedure,degree of the procedure (i.e., major or
cartridges that have to be assembled during setup. minor) or the specialty area. For instance, a hysterectomy
Disposable staplers are assembled, packaged, and set would be used to perform a hysterectomy, and an
sterilized by the manufacturer. Some examples of stapling orthopedic basic set can be used for a number of
devices are skin staplers, kigating clips, linear cutters, and orthopedic procedures.
intraluminal staplers.
Proper handling of instruments
Surgical instruments are very costly and are a huge financial expense of medical institutions, thus, properly preparing,
using, and processing instruments does not only assure prolonged life of the instrument and decreased repair and
repairmen cost, but also ensures patient safety. Surgical instruments are designed for a specific use and utilizing them
for any other than its intended purpose will damage or dull the instrument (e.g., using tissue scissors to cut drapes or
dressings or using a hemostat to open a medication vial). Misuse of instruments can also endanger patients.
Simple steps can keep instruments in proper working order.

● Instruments should be handled individually or in small groups to prevent damage that might occur if they
become entangled or are piled on top of one another.
● They should not be jostled around in the tray when setting up or looking for a certain item.
● Before, during, and after surgery, instruments should be placed onto the designated area.
● They should not be tossed or dropped.
● Heavy items and instruments should never be placed on top of another instrument. These types of
mishandlings cause misalignment and dull blades and can damage instrument tips.
● To ensure patient safety, instruments should be inspected and tested before each surgical procedure.
● Instruments should be clean and free of debris, properly aligned, damage free, and in good working order.
● During surgery, instruments should be wiped or rinsed with sterile water as they become soiled with blood and
tissue. This ensures removal from the box lock, serrations, jaws, and any crevice. Blood and tissue that is
allowed to dry and harden can cause an instrument to become stiff and not work properly. This can also make
the cleaning process difficult and interfere with the sterilization process.
● Nondisposable suction tips should be periodically irrigated with a syringe and sterile water to remove trapped
blood and debris.
● Saline should not be used to wipe, rinse, or soak instruments. Exposure to saline will cause corrosion and
pitting.
● After the surgical procedure, all disposable sharps and blades should be removed and discarded in a sharps
container.
● Instruments should be opened, disassembled, and submerged in water or enzymatic solution. The instruments
should be placed in the solution so that they do not become entangled or damaged.
● Heavy instruments should be placed first, and lighter, more delicate ones should be placed on top.
● Sharp edges or tips should be placed so that they do not endanger the personnel who will be cleaning them.
● Delicate instruments, rigid endoscopes, cameras, and fiberoptic light cords should be separated to prevent
damage.
● All cords should be loosely coiled.
● Power saws and drills should never be immersed in solutions.
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CUTTING INSTRUMENTS
KNIFE/SCALPEL HOLDER SUTURE /STITCH SCISSORS MAYO BANDAGE SCISSORS METZENBAUM
Use for anatomical dissection Designed for easy removal of Used for cutting sutures To size bandages and dressings. Use for cutting delicate tissues
sutures To cut through medical gauze. To
cut through bandages already in
place.
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TISSUE FORCEPS
FORCEPS WITHOUT TEETH: TISSUE FORCEPS WITH TEETH: RUSSIAN TISSUE FORCEP DeBakey TISSUE FORCEP ADSON TISSUE FORCEP
LONG AND RETISSUE GULAR LONG AND REGUL
Non-toothed forceps used for fine Used for grasping moderate to heavy Use to grasp dense tissue to grasp tissue in vascular hold and manipulate tissues
handling of tissue and traction tissue and used during wound closure.
procedures (grasp)
during dissection.
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GRASPING INSTRUMENTS
BABCOCK ALLIS KOCHER (OCHSNER) FOERSTER (OVUM)
Use to grasp delicate tissue Use to hold or grasp heavy tissue Used for grasping tough, fibrous, Used for creating a sponge stick, for
slippery tissues such as muscle and grasping tissues such as the lungs,
fascia. or for removing uterine contents
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RANDALL STONE FORCEPS TENACULUM
Use for grasping and removing kidney stone, Used to hold or pick up small pieces of tissue such
gallstone and polyps as the ends of arteries.
CLAMPING INSTRUMENTS
KELLY CLAMP
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Allow easier placement of ligatures around the To hold delicate tissue and use in most surgical Used to occlude bleeding before ligation (stops
forceps and also use in surgery for temporary procedure bleeding before closing off a blood vessel
occlusion of a vessel
CRILE FORCEPS MIXTER/RIGHT-ANGLED FORCEPS PEAN

Use for clamping blood vessels or tissue before Use for clamping, dissection or grasping tissue Use for clamping large tissue and vessels
cauterization or ligation
RETRACTORS
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SENN VOLKMANN ARMY NAVY DEAVER
Used for exposing superficial wound. Retractor commonly used in small Use to retract incisions that are Used for deep wound retraction
bone and joint procedures small or shallow or layers of skin
MALLEABLE RICHARDSON WEITLANER VEIN RETRACTOR
Used for deep wound retraction. Use for holding back multiple layers Self-retaining; sharp or dull; used popular retractor used during
of deep tissue for exposing superficial wound neurosurgery or as rib spreaders.
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RETRACTORS
GREEN GOITER /a.k.a.goiter balfour with self retaining

SKIN HOOKS
retractor; loop retractor. retractor
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Used to retract the soft tissues Used for retracting soft tissue. are surgical instruments that are used
to hold an incision or wound open
during surgical procedures. used in
abdominal surgery to hold open the
abdominal
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NO. 3 KNIFE HANDLE NO. 7 KNIFE HANDLE NO. 4 KNIFE HANDLE NO. 10 BLADE
Knife handles are used to hold Used when precision cutting is Has a larger tip to accommodate Used for making skin incisions.
various blades to create a scalpel. needed in a confined space or a the larger blades.
deep wound
NO. 11 BLADE NO. 12 BLADE NO. 15 BLADE NO. 20 BLADE

Used for puncturing the skin or to A no. 12 blade is sometimes used Used for creating small precise Used with the no. 4 handle to
initiate the opening of an artery. during tonsillectomies, parotid incisions. create a larger and/or deeper
surgeries, septoplasties, and cleft incision and on heavy tissues and
palate procedures. bone.
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Precautions and Techniques in Instruments by Black and Hocksan

Passing and Care of Passing and Handling of Suture
Instruments Materials
The scrub nurse should know the various steps The scrub nurse should know the suture
of the different operations so that she may keep preferences of each surgeon.
one step in advance of the surgeon at all times.
The sutures are prepared and kept between
She must be thoroughly familiar with the the folds or compartments of the towel on
characteristics of each surgeon’s technique. The the Mayo table with the ends far extended
scrub nurse may pass the instrument to the for easy extraction.
surgeon with her right hand, or the same nearest
operative field.
The scrub nurse should prepare sutures
suitable to the nature of the operation and to
When passing the instrument, It should be held
the surgeon’s suture.
at the shank between the cushions of the thumb
and first two fingers with the tip visible and the
handle is free for the surgeon’s palm. If the scrub nurse is not sure of the surgeon’s
suture preferences, she may ask him what
The curve of the instrument goes with the curves will he require will arrange her work
of the surgeon’s hands. accordingly.
By a slight turn of the wrist, the rings of the The scrub nurse should always prepare three
instruments handle are gently turned over the working needles in advance.
surgeon’s finger.
Needle holder are received from the surgeon
Tissue and thumb forceps are held with the tip before another suture is passed.
down.
Needle should be kept in a suture towel if not
Slightly soiled instruments should be wiped off threaded on needle holders.
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with wet sponge to remove all free fatty

substances and blood, they should then be All needles must be accounted for the scrub
returned to proper position. nurse.
Instrument tables should never be in disorderly The suture ligature is passed in functional
state during an operation so that the scrub nurse position.
can work smoothly and with speed.
The suture material does not get entangled or
Impaired instruments should never be passed to
coiled.
the surgeon.
The scrub nurse should not allow sutures to
Any instrument or supplies that have come into
hand over the edge of the Tables which are
contact with contaminated areas must be
discarded. They should be lifted from the field not considered sterile.
with transfer forceps or received by the kidney
basin and should never be touched with the
gloved hands. The scrub nurse should be familiar
with the surgical hand signals.
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C. LESSON WRAP-UP
AL STRATEGY: CAT: 3-2-1

You will be asked by your instructor to write your answers to the following:
3 Three things I learned

2 Two things that I’d like to learn more about
1 One question I still have
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Lesson title: POST ANESTHESIA CARE UNIT Materials:

Learning Targets:
& Wilkins



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B. MAIN LESSON:
Post Anesthesia Care Unit
Determining Readiness for Discharge From the PACU
A patient remains in the PACU until fully recovered from the anesthetic
agent. Indicators of recovery include stable
blood pressure, adequate respiratory function, and adequate oxygen

saturation level compared with baseline. Many hospitals use a scoring
system (eg, Aldrete score) to determine the patient’s general condition
and readiness for transfer from the PACU. Throughout the recovery
period, the patient’s physical signs are observed and evaluated by
means of a scoring system based on a set of objective criteria. This
evaluation guide allows an objective assessment of the patient’s
condition in the PACU. The patient is assessed at regular intervals, and
a total score is calculated and recorded on the assessment record. The
patient is discharged from the phase I PACU by the anesthesiologist or
anesthetist to the critical care unit, the medical-surgical unit, the phase
II PACU, or home with a responsible family member. In some hospitals
and ambulatory care centers, patients are discharged to a phase III
PACU, where they are prepared for discharge
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POSTOPERATIVE NURSING CARE
Name of Student:
______________________________________________________

______________________ ________________

_____________________ ____________________
PERFORMED PERFORMED UNABLE

INDEPENDENTLY WITH TO
Procedure/Skill ASSISTANCE PERFORM Remarks
4-5 2-3 0-1
1. Record time patient’s return to

unit and asses:
 Airway
 Breathing
 Circulation
2. Obtain baseline vital signs

including oxygen saturation.
3. Assess neurologic status,
including level of consciousness
and movement of extremities.
4. Assess level of pain by checking:
 Last dose and type of pain
control medications
 Current pain intensity
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5. Assess wound dressing and

drainage tubes by checking:
 Type and amount of
drainage
 Tubing connection to the
gravity or suction drainage
if applicable
6. Assess color and appearance of
the skin.
7. Asses urinary status in terms of:
 Time of voiding
 Presence of catheter,
patency and total output
 Bladder distension or
urge to void.
8. Position of airway maintenance,
comfort, and safety.
9. Check IV infusion in terms of:
 Type of solution
 Amount of fluid remaining
 Patency and flow rate
 Condition of IV site and
size of catheter
10. Position call light within reach and
orient patient to use the call light.
11. Ensure the emesis basin and
tissues are available
12. Determine the emotional
condition and support needed by
patient.
13. Check and carry out doctors
orders.
14. Plan for discharge and follow-up

care.
Remarks:____________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
__________________________________________________
_____________________________________________ _____________________________________________
Conforme : Student’s Signature Clinical Instructor
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C. LESSON WRAP-UP

1. For each student, the instructor will create a set of student response cards. Index
cards, colorful bits of paper, and cardstocks can all be used to make cards.
2. The instructor will write the response choices on each card, such as A, B, C, D, or
color-code them, such as green for Yes and red for No, and place them in an envelope
or punch holes in them and attach red strings.
3. The teacher will ask the class a question about the information you just learned in
class.
5. The teacher will quickly scan the entire classroom for each student's response. This
will provide the instructor an idea of who understands and who does not understand the
questions and material presented.
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Lesson title: POST ANESTHESIA CARE UNIT DRUG Materials:

STUDY
Learning Targets: Book, pen and notebook
At the end of the module, students will be able to:
1. Report and document up-to-date client care accurately and References:
comprehensively.
2. Work effectively in collaboration with inter-, intra-, and Smeltzer, S. Bare, B,. Hinkie J., Cheever, K.,
(2010). Brunner and Suddarth’s Textbook of
multidisciplinary and multi-cultural teams.
Medical-Surgical Nursing (12th ed.).
3. Practice beginning management and leadership skills in the Philadelphia, Pennsylvania: Lipincott Williams
delivery of care. & Wilkins


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DRUG STUDY - POST OPERATIVE

MEDICATION THERAPEUTIC INDICATIONS CONTRAINDICATIONS SIDE NURSING
ACTIONS EFFECTS RESPONSIBILITIES/PRECAUTI
ONS
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DRUG STUDY CHECKLIST
Name of Student:
______________________________________________________

______________________ ________________

_____________________ ____________________
MEDICATION (10%)
THERAPEUTIC ACTION (15%)
INDICATION (15%)
CONTRAINDICATION (15%)
SIDE EFFECTS (15%)
NURSING RESPPONSIBILITIES (30%)
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C. LESSON WRAP-UP

In this lesson, describe "what was learned today." Keep your responses and ideas to no
more than one paragraph.
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Lesson title: WOUND DRESSING Materials:

Learning Targets:
1. Utilize the nursing process in caring for clients across
the lifespan with problems in oxygenation, fluid and electrolyte References:
balance, metabolism and endocrine functioning, inflammatory
and immunologic reactions, cellular aberration and acute & Smeltzer, S. Bare, B,. Hinkie J., Cheever, K.,
chronic case; (2010). Brunner and Suddarth’s Textbook of
2. Apply the research process in addressing Medical-Surgical Nursing (12th ed.).
nursing/health problems to improve quality of care;
& Wilkins
3. Integrate the role of culture and history in the plan of
care;

This module aims that the student nurse will be able to obtain the principles and
techniques of nursing care management of sick clients across lifespan with
emphasis on the adult and the older person, population group in any setting with
alterations/problems in oxygenation, fluid and electrolyte balance, nutrition and
metabolism, infection, inflammatory and immunologic response, cellular
aberration and acute & chronic conditions.
B. MAIN LESSON:
WOUND DRESSING
A wound dressing is anything that is used in direct contact with a wound to help it heal and
prevent further issues or complications. Different wound dressings are used based on the type of the
wound, but they all aim to help reduce infection.
Wound dressings also help with the following:
1. Stop bleeding and start clotting
2. Absorb excess blood, plasma, or other fluid
3. Wound debridement
PURPOSES:
● To promote wound healing by primary intention.
● To prevent infection

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● To assess the healing process.

● To protect the wound from mechanical trauma.
● To absorb drainage.
● To prevent contamination from bodily discharge.
Types of Wounds
INCISION CONTUSION
● caused by sharp instrument. ● blow from a blunt object. Closed wound
skin appears ecchymotic.
Ex. knife or scalpel
ABRASION
PUNCTURE
● surface scrape, either unintentional or ● penetration of the skin and often, the
intentional. It is an open wound involving underlying tissues from a sharp instrument.
the skin, painful.
LACERATION PENETRATING WOUND
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● tissues torn apart, often from accidents. ● caused by objects that penetrate the body
Ex. Pierce the skin and lacerate, disrupt,

destroy or contuse adjacent tissue.
TYPES OF WOUND DRESSINGS
FOAM TRANSPARENT
CLOTH
extremely soft and absorbent, most commonly used when a doctor
this type of wound dressing is
the most commonly used. depending on the brand. wants to closely monitor healing of a
helps to protect the wound while specific wound.
versatile and is used to protect
open wounds from a number of it’s healing and maintains a Since transparent dressings are
minor injuries whether it’s a
healthy moisture balance. made using a clear film, it’s much
scraped knee, an
uncomfortable cut or an injury good for wounds that may exhibit easier to monitor wounds using this
in a sensitive area foul smelling odors.
type of dressing in compared to a
cloth or foam bandage.
often used on larger, more
complicated wounds.
HYDROCOLLOID
● non-breathable, self-adhesive dressing.
● works by creating moist conditions to help speed up healing time and are made out of a flexible
material for increased comfort.
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● The surface of hydrocolloid dressings is coated with a substance containing polysaccharides and
other polymers that work to absorb water and form a gel.
This gel is in direct contact with your wound and helps it heal faster.
HYDROGEL ALGINATE COLLAGEN

It acts in a way that adds extremely absorbent and are most commonly used for chronic
moisture to your wound so it used on wounds that have wounds with a slow or stalled
healing time.
heals faster and breaks down excessive drainage.
dry, dead tissue. used on pressure sores,
transplant sites, surgical wounds,
The absorbency is up to 20x its
ulcers, burns or injuries that
weight, making them perfect for
cover a large area of your body.
extreme or deep wounds.
WOUND DRESSING PROCEDURE
EQUIPMENT
● Sterile loves
● Variety of gauze dressings and pads
● Irrigation kit
● Cleaning solution
● Sterile solution: water, normal saline, sodium hypochlorite (Dakin’s solution)
● Clean, disposable gloves
● Tape, ties, bandage as needed
● Waterproof pad and bag
● Extra gauze dressings
● Montgomery ties; elastic net
● Mask, goggles, or gown for risk of splashing
ASSESSMENT: SCRIPT
1. Identify patient using two identifiers Nurse: “Good morning, I am Jenna your nurse
(e.g., name and birthday or name and this shift from 8am-4pm. I am going to change
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medical record number) your wound dressing. But before we proceed, I

would like to know some details. What is your
Rationale: complete name?
Ensures correct patient
Patient: My full name is Maria Dela Cruz.
2. Review medical record for information about Nurse: Thank you Maria, upon checking your
size and location of wound medical record your wound is located at the right
side of your leg. Can you show me your right leg?
Rationale:
Provides baseline to compare your findings. Patient: (showing her right leg)
Helps to plan for proper type and number of
supplies needed. Alerts you when help is
needed to hold dressings in place
3. Assess the patient's level of comfort using a Nurse: Can you tell me how much pain you feel
scale of 0-10. right now? From the scale of zero as the lowest
pain scale and 10 is the highest.
Rationale:
Removal of dry dressing is painful: some Patient: 6 out of 10
patients require pain medication.
4. Review orders for dressing change procedure Nurse: I see, let me check the chart to verify the
doctor’s order and start changing you wound
Rationale: dressing. Do you have any allergies to certain
Indicates type of dressing or applications use. agents or tape?
5. Assess patient for allergies to wound Patient: I don’t have any allergies to any agent or
cleansing agents or tape tape.
Rationale:
Prevents adverse reactions.
6. Assess patient’s and family’s knowledge of Nurse: What are the ways you do whenever
purpose and steps of dressing change you’re in pain?
Rationale: Patient: I usually elevate my leg and position in a

Determine specific areas for patient and way that I feel comfortable.
family teaching.
7. Assess for risk of delayed or poor wound Nurse: Okay, that’s better. Within this week, did
healing notice any bleeding or discharge?
Rationale: Patient: I don’t notice any bleeding or discharge. I

Physiological changes and effects of disease have a feeling that it is recovering.
and treatment conditions can affect wound
healing.
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PLANNING SCRIPT
8. Explain procedure to patient and instruct him Nurse: The goal of wound irrigation is to remove
or her not to touch wound area or sterile foreign material, decrease bacterial contamination
supplies of the wound, and in addition, may I advise you to
avoid touching your wound site or any other
Rationale: sterile supplies.
Decreases anxiety
9. Position patient comfortably and drape with Nurse: I will placed you Mam/Sir on your
blanket to expose only wound site. comfortable position with a drape blanket
exposing only the wound site.
Rationale:
Provides access to wound yet minimizes
unnecessary exposure
10. Plan dressing changes 30-60 minutes Nurse: I will change your dressing every 30 - 60
following administration of analgesia. minutes following the administration of analgesia.
Rationale:
Allows for peak action of medication so patient
so patient has optimal level of comfort during
dressing change. Patients tolerate dressing
changes when their pain is controlled.
IMPLEMENTATION SCRIPT/RATIONALE
11. Close room door or pull bedside curtains. Provides privacy and reduces transmission of
Perform hand hygiene and apply gloves microorganism
12. Position patient comfortably and drape only Nurse: I am going to placed you Mam on your
to expose wound site. comfortable position exposing only your wound
area.
Rationale:
Draping provides access to wound while
minimizing unnecessary exposure.
13. Place disposable bag within reach of work Ensures easy disposable of soiled dressings.
area. Prevents soiling of outer surface of bag.
14. Remove tape: gently push skin away from Nurse: Mam I will remove the tape on your wound
tape while pulling adhesive from skin. gently, tell me if you feel any pain.
Rationale:
Push- pull technique releases tape from skin,
reducing chance of skin damage.
15. With gloved hand carefully remove gauze Nurse: I am going to moisten the gauze using
dressings one layer at a time, taking care not saline solution,and I will remove the gauze
to dislodge drains or tubes. carefully ans slowly, then take a deep breathe,
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a. If dressing sticks on dry dressing, inhale and exhale.

moisten with saline and the remove
Rationale
Removal of one layer at a time reduces chance of
accidental removal of underlying drains.
Prevents damage to wound tissue.
16. Observe for wound for color, edema, drains Provides estimate of drainage amount and
and exudates and amount of drainage on assessment of condition of wound.
dressing
17. Fold dressings with drainage contained inside Reduces transmissions of microorganism.
and remove gloves inside out. With small Prevents contact of hands with material on
dressings remove gloves inside out over gloves.
dressing. Dispose of gloves and soiled
dressings in disposable bag. Perform hand
hygiene
18. Open sterile dressing tray or individually Sterile dressings remain sterile while on or within
wrapped sterile supplies. Place on bedside sterile surface. Preparation of supplies prevents
table and apply clean gloves break in technique during dressing change.
19. Clean wound with solution. Using gauze or Nurse: Mam, using an antiseptic swab or septic
antiseptic swab, clean from least- solution we will clean your wound, this is to
contaminated area, which is the incision and prevent contamination and the spread of infection
surrounding skin. Dry area. Remove and at your incision site.
dispose of gloves and perform hand hygiene.
Rationale:
Prevents contamination of previously cleaned
area. Reduces transmission of infection.
20. Apply dressing

a. Dry dressing Allows handling of sterile supplies without
1. Apply clean or sterile gloves. contamination.
2. Inspect wound for appearance, Once the wound is clean you are able to better
drains, drainage and integrity. inspect the wound condition. Indicates status of
3. Apply sterile, loose woven gauze wound healing.
(4x4, 2x2) dry dressing, covering Protects wounds from external environments.
wound. Apply additional gauze as
needed.
21. Secure dressing

a. Tape: apply tape 2.5-5 cm (1-2 inches) Goal for securing dressing is to keep dressing in
beyond dressing, use non allergic tape to place and intact without causing damage to
secure dressing in place. underlying and surrounding skin.
Secure dressing. Reduces sensitivity reaction to
tape.
b. Montgomery ties Ties allow for repeated dressing changes without

1. Open by exposing adhesive surface the need for tape removal and subsequent skin
tape on the end of each tie. and tissue damage.
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2. Place ties on opposite sides of the Solid skin barrier protects intact skin from stench
dressing. and tension of adhesive tape.
3. Place adhesive directly on skin or
apply a solid skin barrier to skin and
secure end of tape on skin barrier.
4. Secure dressing by lacing ties across
it
c. For dressings on extremity, secure Prevents slipping of dressing.
dressing with rolled gauze or elastic
net.
22. Remove gloves and dispose of them in bag. Reduces transmission of infection.
Remove any mask, eyewear or gown
23. Write date and time dressing applied in ink on Provides guide for when to perform next dressing
tape securing dressing change.
24. Help patient to comfortable position. Improves patient comfort.
25. Dispose of supplies and perform hand Reduces transmission of infection.

hygiene
EVALUATION SCRIPT
26. Inspect condition of wound and any drainage. Nurse: “We are almost done. Let me now check
and evaluate your wound dressing for any
Rationale: leakage or drainage.”
Determines rate of healing
27. Ask patient to rate level of pain during and Nurse: “Can you tell me how much pain do you
after the procedure. feel right now? From the scale of zero as the
lowest pain scale and 10 is the highest.
Rationale:
Pain is early indicator of wound complications Patient: “5 out 10”
or result of dressing material pulling
underlying tissue.
28. Inspect condition of dressing and note any Nurse: “I see, I will take note and document
observable drainage every shift. including the current condition. Besides, I will
come here to visit and recheck your wound every
Rationale: 3-4 hours to check on you and your wound.
Determines status of wound drainage. Thank you, Maria. See you later.
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WOUND DRESSING
Name of Student:
______________________________________________________

______________________ ________________
Area of assignment: Inclusive Dates: Overall

_____________________ ____________________ Rating

Procedure Remark
Y ASSISTANC PERFOR
s
E M
4-5 2-3 0-1
ASSESSMENT:
1. Identify patient using two

identifiers (e.g. name and
birthday or name and
medical record number)
2. Review medical record for
information about size and
location of wound
3. Assess patient’s level of
comfort using a scale of 0-
10.
4. Review orders for dressing
change procedure
5. Assess patient for allergies
to wound cleansing agents
or tape
6. Assess patient’s and
family’s knowledge of
purpose and steps of
dressing change.
7. Assess for risk of delayed
or poor wound healing
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PLANNING
8. Explain procedure to
patient and instruct him or
her not to touch wound
area or sterile supplies
9. Position patient
comfortably and drape with
blanket to expose only
wound site.
10. Plan dressing change 30-
60 minutes following
administration of
analgesia.
IMPLEMENTATION
11. Close room door or pull

bedside curtains. Perform
hand hygiene and apply
gloves
12. Position patient
comfortably and drape only
to expose wound site.
13. Place disposable bag
within reach of work area.
14. Remove tape: gently push
skin away from tape while
pulling adhesive from skin.
15. With gloved hand carefully
remove gauze dressings
one layer at a time, taking
care not to dislodge drains
or tubes.
A. If dressing sticks on
dry dressing ,
moisten with saline
and the remove
16. Observe for wound for
color, edema, drains and
exudates and amount of
drainage on dressing
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17. Fold dressings with

drainage contained inside
and remove gloves inside
out. With small dressings
remove gloves inside out
over dressing. Dispose of
gloves and soiled
dressings in disposable
bag. Perform hand hygiene
18. Open sterile dressing tray
or individually wrapped
sterile supplies. Place on
bedside table and apply
clean gloves
19. Clean wound with solution.
Using gauze or antiseptic
swab, clean from least-
contaminated area, which
is the incision and
surrounding skin. Dry area.
Remove and dispose of
gloves and perform hand
hygiene.
20. Apply dressing
a. Dry dressing
b. Apply clean or
sterile gloves.
c. Inspect wound for

appearance,
drains, drainage
and integrity.
d. Apply sterile, loose
woven gauze (4x4,
2x2) dry dressing,
covering wound.
Apply additional
gauze as needed
21. Secure dressing
A. Tape: apply tape
2.5-5 cm (1-2
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inches) beyond
dressing, use non
allergic tape to
secure dressing in
place.
B. Montgomery ties
1. Open by
exposing
adhesive
surface tape on
end of each tie
2. Place ties on
opposite sides
of dressing.
3. Place adhesive
directly on skin
or apply a solid
skin barrier to
skin and secure
end of tape on
skin barrier.
4. Secure
dressing by
lacing ties
across it.
.
C. For dressings on
extremity, secure
dressing with rolled
gauze or elastic
net.
22. Remove gloves and
dispose of them in bag.
Remove any mask,
eyewear or gown
23. Write date and time
dressing applied in ink on
tape securing dressing
24. Help patient to comfortable
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position.
25. Dispose of supplies and
perform hand hygiene
EVALUATION
26. Inspect condition of wound

and any drainage.
27. Ask patient to rate level of
pain during and after the
procedure.
28. Inspect condition of
dressing and note any
observable drainage every
shift.
Remarks:____________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
_______________________________________________________________________
_____________________________________________ _____________________________________________
Conforme: Student’s Signature Clinical Instructor
Page 13 of 14
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C. LESSON WRAP-UP

class.
Page 14 of 14
NUR 106: MS RLE
Lesson title: WOUND IRRIGATION Materials:

Learning Targets:
& Wilkins
care;

B. MAIN LESSON:
WOUND IRRIGATION
฀ The act of flushing a wound with a gentle stream of liquid in order to remove dead or
necrotic tissue and other debris.
฀ Used to help clean a wound and keep it hydrated. Keeping a wound clean and hydrated
ultimately helps the wound heal quickly.
There are a couple of different types of fluids that a wound can be irrigated with:
a. Water –is very accessible and therefore, very easy to use for wound irrigation.
b. Normal Saline –the most common fluid used in wound irrigation since it does not
alter the normal healing of the wound. Normal saline is an isotonic solution,
meaning it has the same osmotic pressure as bodily fluids.

NUR 106: MS RLE
c. Hydrogen peroxide – hydrogen peroxide helps to kill germs and bacteria while
flushing the wound. However, it’s use is controversial because there is some
evidence that overusing this solution may slow wound healing
PURPOSES OF WOUND IRRIGATION

● Assist with the maintenance of a moist wound environment
● Maintenance of a moist wound environment
● Facilitate debridement
● Boost wound healing
CONTRAINDICATIONS
Irrigation may not be necessary for certain highly vascular areas such as the scalp.
Wounds with fistulas or sinuses with unknown depth should undergo careful evaluation before
irrigation is performed to avoid forcing bacteria and debris containing fluids further into the
wound or other body spaces.
WOUND IRRIGATION PROCEDURE

Equipment:
● Irrigant/cleaning solution (volume 1.2 to 2 times the estimated wound volume)
● Irrigation delivery system, depending on amount of pressure desired
● Sterile irrigation 35-ml syringe with sterile soft 19-gauge Angio catheter
● Clean gloves and sterile gloves
● Waterproof under pad, if needed
● Gauze dressing supplies
● Disposable waterproof bag
● Gown, goggles, or mask if risk of spray.
WOUND IRRIGATION PROCEDURE

ASSESSMENT: SCRIPT
1. Identify patient using two identifiers (e.g., Good morning/afternoon Ma’am/Sir! My name is
name and birthday or name and medical Jasper, and I will be your nurse for today. But
record number) according to agency policy. before we proceed, I would like to know some
details. What is your complete name?
Rationale:
Ensures correct patient.
2. Assess patient’s level of pain. How do you feel right now? Do you feel any
pain? From the scale of zero as the lowest pain
Rationale: scale and 10 is the highest.
Provides baseline to measure patient’s
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response to therapy. Discomfort is related

directly to wound or indirectly to muscle
tension or immobility.
3. Review medical record for health care I will check your medical records for the irrigating
provider’s prescription for irrigation of open prescription solution
wound and type of solution
Rationale:
Open wound irrigation requires medical
order, including type of solution to use.
4. Review medical record for signs and Do you feel any untoward signs and symptoms
symptoms related to patient’s open wound. concerning your wounds?
Rationale: I will assess your wound site and please tell me

Data provide baseline to indicate change in if you feel any pain during the assessment
condition of wound.
a. Extent of impairment of skin integrity,

including size of wound. (Measure
length, width, and depth in centimeters in
the ff. order: length, width, and depth.)
Rationale:
Assess volume of irrigation solution
needed. Data also used as baseline to
indicate change in condition of wound.
b. Verify the number and types of drains

present.
Rationale:
Awareness of drain placement facilities safe
dressing removal and identifies type and
quantity of new dressings needed. Expect
amount to decrease as healing takes place.
c. Drainage from wound (amount and color)
(Amount can be measured by part of
dressing saturated on in terms of quantity
e.g., scant, moderate, copious
Rationale:
Serious drainage is clear like plasma:
sanguineous or bright red drainage indicates
fresh bleeding; serosanguineous drainage is
pink. Purulent drainage is thick and yellow,
pale, green or white
d. Odor (must state whether or not there is

odor)
Rationale:
Strong odor indicates infection process.
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e. Wound tissue color
Rationale:
Color represents balance between necrotic
tissue and new scar tissue.
f. Consistency of drainage
Rationale:
Type of color of drainage depend on
moisture of wound and type of organism
present.
g. Culture reports
Rationale:
Chronic wounds heal by secondary intention,
and they are often colonized with bacteria.
h. Condition of dressing: dry and clean;

evidence of bleeding, profuse drainage.
Rationale:
Provides initial assessment of present wound
drainage.
PLANNING: SCRIPT
1. Explain procedure of wound irrigation and Wound irrigation is a non-invasive procedure in

cleaning how you will prepare the patient. which a steady flow of a solution is used to
achieve wound hydration; remove debris, dead
Rationale: cells, pathogens, and excess blood or other
Reduces patient’s anxiety. exudates such as pus in an open wound; and
assist with a better visual examination
2. Administer prescribed analgesic 30-60 30 minutes to 1 hour before we start irrigating the
minutes before starting the wound irrigation wound, administering prescribed analgesic would
procedure. help to control the pain level and could help you
Rationale: move easily
Promotes pain control and permits patient to
move more easily and be positioned to
facilitate wound irrigation.
3. Position patient to access wounds for easy I will placed you Mam/Sir on your comfortable
irrigation. position during irrigation
a. Position comfortably so wound is vertical
to the collection basin, which permits
gravitational flow of irrigating solution
through the wound and into the collection
receptacle.
Rationale:
Directing solution from top to bottom of
wound and from clean to contaminated
area reduces spread of infection.
Position patient, keep in mind bed
surfaces needed for later preparation
Page 4 of 12
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equipment.
b. Place a container of irrigant/cleaning

solution in a basin of hot water to warm
solution to body temperature.
Rationale:
Warmed solution increases comfort and
reduces vascular constriction response in
tissues.
c. Place padding or extra towel in bed

Rationale:
Protects bedding.
IMPLEMENTATION:
1. Perform hand hygiene. Reduces transmission of microorganisms.
2. Form a cuff on a waterproof bag and place it Cuffing helps to maintain a large opening,
near bed. thereby permitting placement of contaminated
dressing without touching the refuse bag itself.
3. Close the room door or bed curtains. Maintains privacy
4. Apply gown, mask, goggles if needed. Protects nurse from splashes or sprays of blood
and body fluids
5. Apply clean gloves and remove soiled Reduce transmission of microorganism

dressing and discard waterproof bag. Discard
gloves and perform hang hygiene.
6. Prepare equipment: open sterile supplies

7. Put on clean or sterile gloves Reduce transmission of microorganism
8. To irrigate wound with wide opening:

a. Fill 35-ml syringe with irrigating solution. Flushing wound helps remove debris and
facilitates healing by secondary intention.
b. Attach soft 19-gauge Angio catheter.
Provides ideal pressure for cleaning and
c. Hold syringe tip 2.5 cm (1 inch) above removing debris.
upper end of wound and over area being
cleaned. Prevents syringe contamination.
d. Using continuous pressure, flush wound:

repeat Steps 8a, b, and c until solution
draining into basin is clear. Clear solutions indicates that you have removed
all debris.
9. To irrigate deep wound with very small

opening:
a. Attach soft 19-gauge Angio catheter to Catheter permits direct flow of irrigant into
filled irrigating syringe. wound. Expect wound to take longer to empty
when opening is small.
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b. Gently insert tip of catheter into wound Removes tip from fragile inner wall of wound
and pull out about 1 cm (1/2 inch).
c. Using slow, continuous pressure, flush Cleans all wall surfaces.

wounds. Caution: splashing sometimes
occur during this step.
d. Pinch off catheter just below syringe Avoids contamination of sterile solution.
while keeping catheter in place.
e. Remove and refill syringe. Reconnect to Indicates wound clear of debris.

catheter and repeat until solution draining
into basin is clear.
10. Obtain cultures, if ordered, after cleaning with Types of wound culture obtained depends on
nonbacteriostatic saline. resources availability in facility. The three most
common types of wound specimens are tissue
biopsy, needle aspiration wound fluid, and swab
technique.
11. Assess type of tissue in wound bed and Identifies wound healing progress and
periwound skin. determines if wound has increased in size.
12. Dry wound edges with gauze. Prevents maceration of surrounding tissue
caused by excess moisture.
13. Apply appropriate dressing. Maintains protective barrier and healing

environment for wound.
14. Remove gloves and, if worn, mask, goggles Prevents transfer of microorganism.
and gown.
15. Dispose of equipment and soiled supplies. Reduce transmission of microorganism

Perform hand hygiene.
16. Help patient to comfortable position.

EVALUATION: SCRIPT
1. Inspect dressing periodically. Do you feel any untoward signs and symptoms
Rationale: concerning your wounds?
Determines patient’s response to wound
irrigation and need to modify plan of care. I will assess your wound site so please tell me if
you feel pain during the assessment
2. Determine patient’s level of pain How do you feel right now? Do you feel any
Rationale: pain? From the scale of zero as the lowest pain
Patient’s pain should not increase as result of scale and 10 is the highest.
wound irrigation
3. Observe for presence of retained irrigant.

Rationale:
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Retained irrigant is medium for bacterial

growth and subsequent infection.

WOUND IRRIGATION
Name of Student:
______________________________________________________

______________________ ________________
Overall
Rating

Procedure Remark
ASSISTANCE PERFORM
s
4-5 2-3 0-1
ASSESSMENT:
5. Identify patient using

two identifiers (e.g.,
name and birthday or
name and medical
record number)
according to agency
policy.
6. Assess patient’s level
of pain.
7. Review medical record
for health care
provider’s prescription
for irrigation of open
wound and type of
solution.
8. Review medical record
for signs and symptoms
related to patient’s
open wound.
A. Extent of
impairment of skin
Page 7 of 12
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integrity, including
size of wound.
(Measure length,
width, and depth in
centimeters in the
ff. order: length,
width, and depth.)
B. Verify number and

types of drains
present.
C. Drainage from
wound (amount and
color) (Amount can
be measured by
part of dressing
saturated on in
terms of quantity
e.g., scant,
moderate, copious)
D. Odor (must state
whether or not there
is odor)
E. Wound tissue color
F. Consistency of
drainage
G. Culture reports
H. Condition of
dressing: dry and
clean; evidence of
bleeding, profuse
drainage.
PLANNING:
4. Explain procedure of
wound irrigation and
cleaning how you will
prepare patient.
5. Administer prescribed
analgesic 30-60
minutes before starting
wound irrigation
Page 8 of 12
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procedure.
6. Position patient to
access wound for easy
irrigation.
A. Position
comfortably so
wound is vertical to
collection basin,
which permits
gravitational flow of
irrigating solution
through wound and
into collection
receptacle.
B. Place container of
irrigant/cleaning
solution in basin of
hot water to warm
solution to body
temperature.
C. Place padding or
extra towel in bed
IMPLEMENTATION:
17. Perform hand hygiene.
18. Form cuff on

waterproof bag and
place it near bed.
19. Close room door or bed
curtains.
20. Apply gown, mask,
goggles if needed.
21. Apply clean gloves and
remove soiled dressing
and discard waterproof
bag. Discard gloves
and perform hang
hygiene.
22. Prepare equipment:
open sterile supplies
23. Put on clean or sterile
gloves
Page 9 of 12
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24. To irrigate wound with

wide opening:
A. Fill 35-ml syringe
with irrigating
solution.
B. Attach soft 19-
gauge Angio
catheter.
C. Hold syringe tip 2.5
cm (1 inch) above
upper end of wound
and over area being
cleaned.
D. Using continuous
pressure, flush
wound: repeat
Steps 8a, b, and c
until solution
draining into basin
is clear.
25. To irrigate deep wound with very small opening:
A. Attach soft 19-

gauge Angio
catheter to filled
irrigating syringe.
B. Gently insert tip of
catheter into wound
and pull out about 1
cm (1/2 inch).
C. Using slow,
continuous
pressure, flush
wounds. Caution:
splashing
sometimes occur
during this step.
D. Pinch off catheter

just below syringe
while keeping
catheter in place.
E. Remove and refill

syringe. Reconnect
Page 10 of 12
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to catheter and
repeat until solution
draining into basin
is clear.
F. Obtain cultures, if
ordered, after
cleaning with non-
bacteriostatic
saline.
G. Assess type of
tissue in wound bed
and periwound skin.
H. Dry wound edges
with gauze.
I. Apply appropriate
dressing.
J. Remove gloves
and, if worn, mask,
goggles and gown.
K. Dispose of
equipment and
soiled supplies.
Perform hand
hygiene.
L. Help patient to
comfortable
position.
EVALUATION:
4. Inspect dressing
periodically.
5. Determine patient’s
level of pain
6. Observe for presence
of retained irrigant.
Remarks:____________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
_______________________________________________________________________
Page 11 of 12
NUR 106: MS RLE
_____________________________________________ _____________________________________________
C. LESSON WRAP-UP

class.
Page 12 of 12
NUR 106: MS RLE
Lesson title: BANDAGING Materials:

Learning Targets:
& Wilkins
care;

B. MAIN LESSON:
BANDAGING
Bandage- a strip of material used mainly to support and immobilize a part of the body.
USES:
✔ To support – fractured bone
✔ To immobilize – dislocated shoulder/jaw
✔ To apply pressure – stop bleeding and improve venous blood flow
✔ To secure a dressing in place.
✔ To retain splints in place

NUR 106: MS RLE
Types of Bandages
TYPES OF BANDAGES
CRAPE BANDAGE ADHENSIVE BANDAGE

TRIANGULAR GAUZE / COTTON
BANDAGE use to retain dressing and
triangular bandages type of wooden gauze
which has the quality of also used where application
could be used on many lightly woven, cotton
stretching. of pressure to the area is
parts of the body. material. Frequently
needed.
used to retain dressings
on wounds of fingers,
hands, toes, feet, ears,
eyes, head.
METHODS OF APPLYING BANDAGES
CIRCULAR BANDAGING SPIRAL
used to hold dressings on body parts such as arms, legs, a roller bandage applied spirally around a limb. tailed
chest or abdomen or for starting others bandaging bandage a square piece of cloth cut or torn into strips
techniques. For circular bandage we used strips of cloth from the ends toward the center, with as large a center
or gauze roller bandage or triangular bandage folded left as necessary. The bandage is centered over a
down to form strip of bandage (cravat). compress on the wound and the ends are then tied
separately.
Page 2 of 4
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REVERSE SPIRAL
spiral bandage where the bandage is folded back on itself by 180° after each turn. This V-shaped fold allows the
bandage to fit to the tapered shape of the body part all the way along. This type of bandaging is required when
using non-elasticated bandages.
FIGURE OF EIGHT
A bandage in which the turns cross each other like the figure eight, used to retain dressings, to exert pressure
for joints (or to leave the joint uncovered), to fix splints for the foot or hand, for the great toe, and for sprains or
hemorrhage.
Page 3 of 4
NUR 106: MS RLE
C. LESSON WRAP-UP

class.
Page 4 of 4
NUR 106: MS RLE
Lesson title: DRUG STUDY Materials:

Learning Targets:
& Wilkins
care;


NUR 106: MS RLE
B. DRUG STUDY
ACTIONS EFFECTS RESPONSIBILITIES/PRECAUTIONS
Page 2 of 4
NUR 106: MS RLE
C. DRUG STUDY CHECKLIST
Name of Student:
______________________________________________________

______________________ ________________

_____________________ ____________________
D.
MEDICATION (10%)
INDICATION (15%)
SIDE EFFECTS (15%)
Page 3 of 4
NUR 106: MS RLE
C. LESSON WRAP-UP

In this lesson, describe "what was learned today." Keep your responses and ideas to no more
than one paragraph.
Page 4 of 4
NUR 106: MS RLE
Lesson title: DONNING AND DOFFING OF PPE Materials:

1. Utilize the nursing process in caring for clients across References:
the lifespan with problems in oxygenation, fluid and electrolyte
balance, metabolism and endocrine functioning, inflammatory Smeltzer, S. Bare, B,. Hinkie J., Cheever, K.,
and immunologic reactions, cellular aberration and acute & (2010). Brunner and Suddarth’s Textbook of
chronic case;
2. Apply the research process in addressing & Wilkins
3. Integrate the role of culture and history in the plan of Elis, J. R Bentz, P. M.,(2008). Basic Nursing
care Skills (5th ed.). Lipincott Williams & Wilkins

techniques of nursing care management of sick clients across lifespan with emphasis
on the adult and the older person, population group in any setting with
metabolism, infection, inflammatory and immunologic response, cellular aberration and
acute & chronic conditions.
B. MAIN LESSON
Who needs PPE?

● Patients with confirmed or possible SARS-CoV-2 infection should wear a facemask
when being evaluated medically.
● Healthcare personnel should adhere to Standard and Transmission-based Precautions
when caring for patients with SARS-CoV-2 infection.

NUR 106: MS RLE
Page 2 of 9
NUR 106: MS RLE
How to Put on (Don) PPE Gear?

PROCEDURE SCRIPT
1. Identify and gather the proper PPE to Nurse: Good morning, I am Nurse Jasper,
don. and I will demonstrate the proper way of
Rationale: donning PPE. This is very important because
Ensure choice of gown size is correct (based it helps reducing contamination of healthcare
on training. workers caring for patients with transmissible
infectious diseases
2. Perform hand hygiene using hand Nurse: Hand hygiene is therefore the
sanitizer. most important measure to avoid the
Rationale: transmission of harmful germs and prevent
First line protection and making the hands health care-associated infections.
sanitize.
3. Put on the isolation gown. Nurse: Let's put on an isolation gown, and tie
● Tie all of the ties on the gown. all the ties needed to secure the gown.
Assistance may be needed by
other healthcare personnel.
Rationale:
Ensure proper donning of the PPE.
4. Put on NIOSH-approved N95 filtering Nurse: Lets wear N95, face shield, or
facepiece respirator or higher (use a goggles, and gloves for our own safety and
facemask if a respirator is not protection.
available)
● If the respirator has a nosepiece,
it should be fitted to the nose with
both hands, not bent or tented.
Do not pinch the nosepiece with
one hand. Respirator/facemask
should be extended under chin.
Both your mouth and nose
should be protected. Do not wear
respirator/facemask under your
chin or store in scrubs pocket
between patients.
Rationale:
Ensure hindrance of any airborne or droplet
transmission.
5. Put on face shield or googles.

● When wearing an N95 respirator
or half facepiece elastomeric
Page 3 of 9
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respirator, select the proper eye

protection to ensure that the
respirator does not interfere with
the correct positioning of the eye
protection, and the eye protection
does not affect the fit or seal of
the respirator.
Rationale:
Face shields provide full face coverage.
Goggles also provide excellent protection for
eyes, but fogging is common.
6. Put on gloves
● Gloves should cover the cuff
(wrist) of the gown.
Rationale:
Ensure hindrance of any airborne or droplet
transmission.
7. Healthcare personnel may now enter Nurse: Once we are done donning PPE, we
the patient room. can now finally enter the patient room.
How to Take Off (Doff) PPE Gear

PROCEDURE RATIONALE
1.Remove gloves Ensure glove removal does not cause

additional contamination of hands. Gloves
can be removed using more than one
technique (e.g., glove-in-glove or bird beak).
2.Remove gown
Untie all ties (or unsnap all buttons).
Some gown ties can be broken rather than
untied. Do so in gentle manner, avoiding a
forceful movement. Reach up to the
shoulders and carefully pull gown down and
away from the body. Rolling the gown down
is an acceptable approach. Dispose in trash
receptacle.
3.Healthcare personnel may now exit

patient room.
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4.Perform hand hygiene Ensure sanitizing the hands before touching

or holding objects that may cause
transmission of microorganism such as
bacteria, viruses and other organism causing
disease.
5.Remove face shield or goggles.

Carefully remove face shield or goggles by
grabbing the strap and pulling upwards and Only the face shield or goggles’ strap is
away from head. Do not touch the front of considered clean or sterile from
face shield or goggles. microorganism while the front of the face
shield or goggles’ front may have potential
microorganisms that could cause infections.
6.Remove and discard respirator (or

facemask if used instead of respirator). Do
not touch the front of the respirator or
facemask.
Respirator: Remove the bottom strap by

touching only the strap and bring it carefully
over the head. Grasp the top strap and bring Only the respirator and face shield’s strap are
it carefully over the head, and then pull the considered clean or sterile from
respirator away from the face without microorganism while the front of the
touching the front of the respirator. respirator and face shield may have potential
Facemask: Carefully untie (or unhook from microorganisms that could cause infections.
the ears) and pull away from face without
touching the front.
7.Perform hand hygiene after removing Ensure sanitizing or washing hands before
the respirator/facemask and before touching or holding objects could avoid or
putting it on again if your workplace is lessen the potential transmission disease.
practicing reuse.
Page 5 of 9
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DOFFING AND DONNING
Name of Student:
______________________________________________________
Level & School Year &Term:
Block_____________________ ________________
_______________ ___________________ Rating
PROCEDURE/SKILL PERFORMED PERFORMED UNABLE REMARKS

DONNING PPE ASSISTANCE PERFORM
0-1 2-3 4-5
1. Identify and gather the proper PPE

to don.
2. Perform hand hygiene using hand

sanitizer.
3. Put on an isolation gown.
4. Put on NIOSH-approved N95

filtering facepiece respirator or
higher (use a facemask if a
respirator is not available)
Page 6 of 9
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5. Put on a face shield or goggles.
6. Put on gloves
7. Healthcare personnel may now

enter the patient room.
PROCEDURE/ SKILL PERFORMED PERFORMED UNABLE REMARKS

DOFFING PPE ASSISTANCE PERFORM
0-1 2-3 4-5
1. Remove gloves
2. Remove gown
3. Healthcare personnel may now

exit the patient room.
5. Remove face shields or goggles.
6. Remove and discard respirator (or

facemask if used instead of
respirator).
7. Perform hand hygiene after

removing the respirator/face mask
and before putting it on again if
your workplace is practicing reuse.
Remarks:____________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Page 7 of 9
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____________________________________________________________________________
____________________________________________________________________________
________________________________________
_________________________________ _______________________________________
Page 8 of 9
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C. LESSON WRAP-UP

Page 9 of 9
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Lesson title: INTRAVENOUS THERAPY Materials:

chronic case;

B. MAIN LESSON
INTRAVENOUS THERAPY
Intravenous therapy (IV) is therapy that delivers fluids directly into a vein.
The intravenous route of administration can be used both for injections, using a syringe at
higher pressures; as well as for infusions, typically using only the pressure applied by
gravity. IV fluid therapy is used to maintain homeostasis when enteral intake is insufficient
(e.g., when a patient is “nil by mouth” or has reduced absorption), and to replace any
additional losses.
The nurse should decrease the IV drip rate, place the patient in high Fowler position,
keep the patient warm, monitor vital signs frequently, and administer oxygen if necessary.

NUR 106: MS RLE
The most common way to categorize IV fluids is based on their tonicity:
1. Isotonic. Isotonic IV solutions that have the same concentration of solutes as blood
plasma.
2. Hypotonic. Hypotonic solutions have lesser concentration of solutes than plasma.
3. Hypertonic. Hypertonic solutions have greater concentration of solutes than plasma.
COLOR CODING
FOR IV
SOLUTIONS
PNSS -
GREEN
PLAIN LRS -
BLUE
D5LRS -
PINK
D5WATER -
PINK/RED
D5 NM -
ORANGE
D10WATER -
BLUE
GREEN / RED
D5 0.9NaCL -
SKY
BLUE
Page 2 of 15
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PNSS PLAIN LRS D5 LRS D5 WATER
D10 WATER D5 NM D50 WATER D5 0.9NaCL D5 0.3 NaCL
Principles: Priming:
฀ Prime IV Tubing to expel air ● Compress drip chamber, fill 1/3 to 1/2
฀ Regulate every 15-20min ● Remove cap on end of tubing, KEEP and maintain
฀ Use distal veins sterility
฀ 15-30 degrees angle ● Slowing open roller clamp and prime tubing with fluid,
฀ check for backflow return roller clam to off position.
● Inspect for air bubbles, tap tubing where bubbles are
visible, and invert ports and tap to fill and remove air
● Replace cap from end of tubing.
Page 3 of 15
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Parts of IV Tubing
Purposes of Intravenous (IV) Therapy
● To supply fluid when clients are unable to take in an adequate volume of fluids by mouth
● To provide salts and other electrolytes needed to maintain electrolyte imbalance
● To provide glucose (dextrose), the main fuel for metabolism
● To provide water-soluble vitamins and medications
● To establish a lifeline for rapidly needed medications.
INTRAVENOUS THERAPY
PROCEDURE SCRIPT
1. Gather all equipment and bring to bedside. Nurse: Good morning! I am your nurse
Check intravenous (IV) solution and medication Jasper for this shift from 8am-4pm.
additives with physicians’ order. Your doctor has ordered IV fluids and
IV medication. I will be your nurse to
Rationale: insert your Intravenous fluid so we can
Having equipment available saves time and start infusing and administering your
facilitates accomplishment of task. Checking the medication. But before we start, May I
order ensures that the patient receives the ordered know your full name?
IV solution and medication.
Patient: Hello Jasper, I am Maria Dela
Cruz.
2. Explain need for IV solution and procedure to Nurse: The insertion of the IV Fluid is
patient. a bit painful, so expect a little
discomfort. I suggest to have a deep
Rationale: breathing while inserting the catheter
Explanation allays anxiety. to decrease your anxiety.
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Patient: Oh, thanks for the info, I heard

of that. I will take your advice, nurse
Jasper.
3. Perform hand hygiene. If using an anesthetic Nurse: (After hand hygiene) “I have
(numbing) cream, apply cream to a couple of here a numbing cream to ease pain.
potential insertion sites.
Patient: Oh, that’s better! Thank you
Rationale: nurse Jasper.
Hand hygiene deters the spread of
microorganisms. Anesthetic (numbing) cream
decreases the amount of pain felt at the insertion
site. Some of the numbing cream take up to an
hour to become effective.
IMPLEMENTATION RATIONALE
4. Prepare IV solution and tubing. a.
a. Maintain aseptic technique when opening a. Asepsis is essential for
sterile packages and IV solution. preventing the spread of
b. Clamp tubing, uncap spike, and insert into microorganisms.
entry site on bag as manufacturer directs. b. This punctures the seal in the
IV bag.
● Suction causes fluid to move into drip

chamber and prevents air from moving down
the tubing
c. Squeeze drip chamber and allow it to fill at
c. This removes air from tubing; in
least half way.
larger amounts, air can act as
an embolus.
d. Remove cap at end of tubing, release clamp

and allow fluid to move through tubing. d. This ensures correct flow rate
Allow fluid to flow and recap the end of and proper use of equipment.
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tubing, maintaining sterility of setup.
e. If an electronic device is used, follow

manufacturer's instructions for inserting
tubing and setting infusion rate. e. This provides for administration
of correct solution with
f. Apply a label if medication was added to the prescribed medication or
container. (Pharmacy may have added additive.
medication and applied labels.) Label tubing
with date and time tubing is hung. f. This permits immediate
evaluation of IV according to
g. Place time-tape on container and hand IV schedule.
on pole.
g. This will inform the upcoming
shift on duty about the due time
of the IV fluid.
5. Place patient in low Fowler's position in bed. ● The supine position permits either arm
Place protective towel or pad under patient's arm. to be used and allows for good body
alignment.
●
●
6. Select appropriate site and palpate accessible The use of an appropriate site
veins. decrease discomfort for the patient and
reduces the risk for damage to body
tissues.
●
●
7. If the site is hairy and agency policy permits, clip Hair can harbor microorganisms.
a 2-inch area around the intended entry site.
8. Apply tourniquet 5-6 inches above venipuncture ● Interrupting the blood flow to the heart
site to obstruct venous blood flow and distend vein. causes the vein to distend. Interrupting
Direct tourniquet ends away from the entry site. the arterial flow impedes venous filling.
Check to be sure the radial pulse is still present. Distended veins are easy to see,
palpate, and enter. The end of the
tourniquet could contaminate the area
of injection if directed toward the site of
entry.
●
9. Ask patient to open and close his or her fist. Contracting the muscles of the forearm
Observe and palpate for a suitable vein. Try the forces blood into the veins, thereby
following techniques if vein cannot be felt. distending them further.
a. Release tourniquet and have the patient a. Lowering the arm below heart
lower his or her arm below the level of the level, tapping the vein, and
heart to fill the veins. Reapply tourniquet applying warmth help distend
and gently tap over the intended vein to help veins by filling them with blood.
distend it
b. Remove tourniquet and place warm moist b. Warm moist compresses help
compresses over indented vein for 10-15 dilate veins.
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minutes.
10. Don clean gloves. ● Gloves protect against transmission of

HIV and other blood-borne infections.
●
11. If using intradermal lidocaine: The lidocaine numbs the skin and
makes the insertion less painful.
●
● ●
Cleanse small area of possible insertion site Cleansing that begins at the site of
with alcohol using a circular motion. entry and moves outward in a circular
● Inject a small amount (0.2 to 0.3 ml) of motion carries organisms away from
cream: Wipe cream off insertion site. the site of entry. Organisms on the skin
● Cleanse the entry site with an antiseptic can be introduced into the tissues or
solution (alcohol swab) followed by the bloodstream with the needle.
antimicrobial solution (povidone iodine)
according to agency policy.
- Use a circular motion to move from
the center outward for several
inches.
12. Use the nondominant hand, placed about 1 to ● 2 Pressure on the vein and surrounding
inches below entry site, to hold skin taut against tissues helps prevent movement of the
vein. Avoid touching prepared site. vein as needle or catheter is being
inserted. The needle entry site and
catheter must remain free of
contamination from unsterile hands.
13. Enter skin gently with catheter help by the hub
in the dominant hand, bevel side up, at a 10-to-30-●
degree angle. ●
● Catheter may be inserted either directly over● This allows needle or catheter to enter
the vein or from the side of the vein. While the vein with minimal trauma and
following the course of the vein, advance deters passage of the needle through
needle or catheter into vein. A sensation of the vein.
"give" can be felt when a needle enters vein.
14. When blood returns through the lumen of the

needle of the flashback chamber of the catheter, ●
●
advance either device 1/8 to 1/4 inches farther into
vein. ● The tourniquet causes increase
● A catheter needs to be advance until the venous pressure, resulting in automatic
hub is at the venipuncture site, but the exact backflow. Placing the catheter well into
technique depends on the type of device the vein helps to prevent dislodgement.
used.
15. Release tourniquet.

● Quickly remove protective cap from IV ●
Bleeding is minimized and the patency
tubing and attach tubing to catheter orof the vein is maintained if the
needle. Stabilize catheter or needle with
connection is made smoothly between
nondominant hands. the catheter and tubing.
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16. Start solution flow promptly by releasing the● Blood clots form readily if IV flow is not
clamp on the tubing. Examine the tissue around the maintained. If the catheter accidentally
entry site form signs of infiltration. slips out of the vein, solution will
accumulate and infiltrate into
surrounding tissue.
●
17. Secure the catheter with narrow non allergenic● The smooth structure of the vein does
tape (1/2 inch) placed sticky side up under hub and not offer resistance to the movement of
crossed over the top of the hub. the catheter. The weight of the tubing
is sufficient to pull it out of the vein if it
is not well anchored. Non Allergenic
tape is less likely to tear fragile skin
●
●
18. Place sterile dressing over the venipuncture Transparent dressing allows easy
site. visualization of site but may place
● Agency policy may direct nurses to use patients at increased risk for infection.
gauze dressing or transparent dressing. Gauze dressing absorbs drainage and
Apply tape to dressing if necessary. Loop may have a decreased infection rate.
tubing near the entry site and anchor to Discussion continues about the
dressing. effectiveness of various types of
dressings.
●
●
19. Mark date, time, site and type and size of Other personnel working with the
catheter used for infusion on the tape. Anchor infusion will know what type of device
tubing. is being used, the site, and when it was
inserted.
20. Remove all equipment and dispose of in proper
manner. ●
● Remove gloves and perform hand hygiene.● Hand hygiene deters the spread of
microorganisms.
21. Anchor arm to and arm board for support, ● if An arm board or site protector helps to
necessary, or apply site protector or tube-shaped prevent the position of the catheter in
mesh netting over insertion site. the rate of flow.
●
22. Adjust rate of solution flow according to amount The physician prescribes the rate of
prescribed or follow manufacturer's directions for flow.
adjusting the flow rate on the infusion pump.
23. Document the procedure and the patient's ● This provides accurate documentation
response. Chart time, site device, used, and and ensures continuity of care.
solution.
24. Return to check flow rate and observe for ● This documents patient's response to
infiltration 30 minutes after starting infusion. infusion.
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IV ADMINISTRATION
Name of Student:
______________________________________________________
Level & School Year &Term:
Block_____________________ ________________
_______________ ___________________ Rating

Procedure/Skill INDEPENDENTL D WITH TO Remark
Y ASSISTANC PERFOR s
E M
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0-1 2-3 4-5

1. Gather all equipment and
bring it to the bedside. Check
intravenous (IV) solution and
medication additives with
physician’s order.
2. Explain the need for IV
solution and procedure to
patient.
3. Perform hand hygiene. If
using an anesthetic (numbing)
cream, apply cream to a
couple of potential insertion
sites.
4. Prepare IV solution and
tubing.
a. Maintain aseptic technique
when opening sterile
packages and IV solution.
b. Clamp tubing, uncap spike,

and insert into entry site on
bag as manufacturer directs.
c. Squeeze the drip chamber

and allow it to fill at least half
way.
d. Remove cap at end of

tubing, release clamp and
allow fluid to move through
tubing. Allow fluid to flow and
recap the end of tubing,
maintaining sterility of setup.
e. If an electronic device is
used, follow manufacturer's
instructions for inserting
tubing and setting infusion
rate.
f. Apply a label if medication

was added to the container.
(Pharmacy may have added
medication and applied label.)
Label tubing with date and
time tubing is hung.
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g. Place time-tape on
container and hand IV on
pole.
5. Place the patient in low
Fowler's position in bed.
Place a protective towel or
pad under the patient's arm.
6. Select appropriate site and
palpate accessible veins.
7. If the site is hairy and
agency policy permits, clip a
2-inch area around the
intended entry site.
8. Apply tourniquet 5-6 inches
above venipuncture site to
obstruct venous blood flow
and distend vein. Direct
tourniquet ends away from
the entry site. Check to be
sure the radial pulse is still
present.
9. Ask the patient to open and
close his or her fist. Observe
and palpate for a suitable
vein. Try the following
techniques if the vein cannot
be felt.
a. Release tourniquet and

have the patient lower his or
her arm below the level of the
heart to fill the veins. Reapply
tourniquet and gently tap over
the intended vein to help
distend it
b. Remove tourniquet and

place warm moist
compresses over indented
vein for 10-15 minutes.
10. Don clean gloves.
11. If using intradermal
lidocaine: Cleanse small area
of possible insertion site with
alcohol using a circular
motion. Inject a small amount
(0.2 to 0.3 ml) of cream: Wipe
cream off insertion site.
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Cleanse the entry site with an

antiseptic solution (alcohol
swab) followed by
antimicrobial solution
(povidone iodine) according to
agency policy. Use a circular
motion to move from the
center outward for several
inches.
12. Use the nondominant
hand, placed about 1 to 2
inches below the entry site, to
hold skin taut against the
vein. Avoid touching prepared
site.
13. Enter skin gently with
catheter help by the hub in
the dominant hand, bevel side
up, at a 10-to-30-degree
angle. Catheter may be
inserted either directly over
the vein or from the side of
the vein. While following the
course of the vein, advance
needle or catheter into vein. A
sensation of "give" can be felt
when needle enters vein.
14. When blood returns
through the lumen of the
needle of the flashback
chamber of the catheter,
advance either device 1/8 to
1/4 inches farther into the
vein. A catheter needs to be
advanced until the hub is at
the venipuncture site, but the
exact technique depends on
the type of device used.
15. Release tourniquet.
Quickly remove protective cap
from IV tubing and attach
tubing to catheter or needle.
Stabilize catheter or needle
with nondominant hands.
16. Start solution flow
promptly by releasing the
clamp on the tubing. Examine
the tissue around the entry
Page 12 of 15
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site form signs of infiltration.

17. Secure the catheter with
narrow non allergenic tape
(1/2 inch) placed sticky side
up under hub and crossed
over the top of the hub.
18. Place sterile dressing over
the venipuncture site. Agency
policy may direct nurse to use
gauge dressing or transparent
dressing. Apply tape to
dressing if necessary. Loop
tubing near the entry site and
anchor to dressing.
19. Mark date, time, site and
type and size of catheter used
for infusion on the tape.
Anchor tubing.
20. Remove all equipment
and dispose of it in the proper
manner. Remove gloves and
perform hand hygiene.
21. Anchor arm to and arm
board for support, if
necessary, or apply site
protector or tube-shaped
mesh netting over insertion
site.
22. Adjust rate of solution flow
according to amount
prescribed or follow
manufacturer's directions for
adjusting the flow rate on the
infusion pump.
23. Document the procedure
and the patient's response.
Chart time, site device, used,
and solution.
24.Return to check flow rate
and observe for infiltration 30
minutes after starting infusion.
Remarks:____________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Page 13 of 15
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____________________________________________________________________________
________________________________________
__________________________________ ______________________________________
C. LESSON WRAP-UP

1. For each student, the instructor will create a set of student response cards. Index cards,
colorful bits of paper, and cardstocks can all be used to make cards.
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2. The instructor will write the response choices on each card, such as A, B, C, D, or color-code
them, such as green for Yes and red for No, and place them in an envelope or punch holes in
them and attach red strings.
5. The teacher will quickly scan the entire classroom for each student's response. This will
provide the instructor an idea of who understands and who does not understand the questions
and material presented.
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Lesson title: BLOOD TRANSFUSION Materials:

chronic case;

B. MAIN LESSON
BLOOD TRANSFUSION

NUR 106: MS RLE
● A blood transfusion is a routine medical procedure in which donated blood is
provided to you through a narrow tube placed within a vein in your arm.
Administration of blood and blood components requires knowledge of correct
administration techniques and possible complications.
● This potentially life-saving procedure can help replace blood lost due to surgery or
injury. A blood transfusion also can help if an illness prevents your body from
making blood or some of your blood’s components correctly.
● Blood transfusion usually occurs without complications. When complications do
occur, they’re typically mild.
● Most blood transfusions are performed in the acute care setting and sometimes
must be done emergently. Patients with chronic transfusion requirements often
can receive transfusion in other settings.
● People receive blood transfusions for many reasons – such as surgery, injury,
disease and bleeding disorders.
● Blood has several components, including:
o Red cells carry oxygen and help remove waste products
o White cells help your body fight infections
o Plasma is the liquid part of your body
o Platelets help your blood clot properly
- A transfusion provides part or parts of body you need, with red blood cells being
the most commonly transfused. You can also receive whole blood, which contains
all the parts, but whole blood transfusions aren’t common.
- Researchers are working on developing artificial blood. So far, no good
replacement for human blood is available.
PURPOSES
● Restore blood volume NURSING RESPONSIBILITIES
● Replace Clotting factors 1. Confirm that there is a physician’s
● Improve oxygen carrying capacity
order and a signed consent from the
● Restore Blood elements that are
depleted client.
● Prevent Complications 2. Have two nurses confirm that the
client name and ID number, blood
type, RH type, and product unit
PRETRANSFUSION ASSESSMENT numbers are correct. Check also the
expiration date.
Patient History – to determine the history of 3. Make sure the transfusion is started
previous transfusions as well as previous within 30 minutes of arrival at the
reactions to transfusions. bedside.
4. Maintain asepsis. If possible wear
Physical Assessment – systematic physical gloves before performing
assessment and measurement of baseline venipuncture, transfusion blood, and
vital signs and fluid status are important when terminating blood and disposing
before transfusion. of equipment
5. Use the appropriate blood
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administration set.
6. Mix the blood cells with plasma gently
COMPLICATIONS
to maintain their integrity.
Febrile Nonhemolytic Reaction – is caused 7. Assess the client closely for
by antibodies to donor leukocytes that remain transfusion reaction.
in the unit of blood or blood component; it is 8. If any reaction occurs
the most common type of transfusion a. Stop infusion immediately
reaction. b. Notify the physician
c. Maintain patency of the IV with
Acute Hemolytic Reaction – the most normal saline
dangerous and potentially life threatening, d. Send the blood to the laboratory
type of transfusion reaction occurs when the e. Monitor vital signs frequently
donor blood is incompatible with that of the f. Send a urine specimen to the
recipient laboratory if haemolytic reaction is
suspected.
Allergic Reaction – some patients develop
urticaria (hives) or generalized itching during
a transfusion; the cause is thought to be
sensitivity reaction to a plasma protein within
the blood component being transfused.
Bacterial Contamination - contamination

can occur at any point during procurement or
processing but often results from organism
on the donor’s skin.
Transfusion – Related Acute Lung Injury

(TRALI) – is a potentially fatal, idiosyncratic
reaction that is defined as the development of
acute lung injury occurring within 6 hours
after blood transfusion.
Delayed Hemolytic Reaction – usually

occurs withing 14 days after transfusion,
when the level of antibody has been
increased to the extent that a reaction can
occur.
Disease Acquisition – certain diseases can

still be transmitted by transfusion of blood
components despite advances in donor
screening and blood testing.
Complications of Long-term Transfusion

Therapy - patients with long term transfusion
Page 3 of 18
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requirements are at greater risk for infection
transmission and for becoming more
sensitized to donor antigens , simply because
they are exposed to more units of blood and,
consequently, more donors.
BLOOD TRANSFUSION PROCEDURE

EQUIPMENT:
IV TRAY COMPATIBLE BT SET IV CATHETER NEEDLE G.18
PLASTER TOURNIQUET BLOOD PRODUCT
Page 4 of 18
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IV STAND PLAIN NSS GLOVES
BLOOD TRANSFUSION
PROCEDURE SCRIPT
1. Introduce self to patient. Identify patient Nurse: Good morning Ma’am/Sir! I am

using two patient-identifiers Nurse Jasper, I’am the nurse in-charged
for your Blood transfusion today. Please
Rationale:
state your complete name and birthday,
To ensure patient safety and reliability of the Ma’am/Sir. Thank you!
patient’s identification process.
2. Verifies that informed consent has been

obtained.
Rationale:
Provides sufficient information to patient and
ensures understanding of the procedure.
3. Verifies the physician’s order, noting the

indication, rate of infusion, and any
premedication orders.
Rationale:
Complies with The Joint Commission standards
and improves patient safety - ensures correct
patient and doctor’s order.
4. Administers any pre-transfusion Nurse: As prescribed by your physician, I

medications as prescribed. will give you pre-blood transfusion
medication to prevent any adverse
Rationale: reactions.
To prevent adverse reactions
5. Obtains IV fluid containing normal saline
Page 5 of 18
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solution and a blood administration set.
Rationale:
To facilitate intervention
6. Obtains the blood product from the blood

bank according to agency policy.
Rationale:
Ensures proper blood typing cross-matching for
patient safety
7. Wears procedure gloves whenever

handling blood products.
Rationale:
Reduce spread of microorganisms
8. Rechecks the physician’s order.
Rationale:
To avoid mistakes
9 With another qualified staff member (as

deemed by the institution) verifies the patient and
blood product identification, as follows:
Rationale:
To prevent any problem in relation to tranfusion
a. Has the patient state his full name and

date of birth (if he is able) and compares it to the
name and date of birth located on the blood bank
form.
b. Compares the patient name and hospital

identification number on the patient’s
identification bracelet with the patient name and
hospital identification number on the blood bank
form attached to the blood product
c. Compares the unit identification number
located on the blood bank form with the
identification number printed on the blood
product container.
d. Compares the patient’s blood type

listed on the
blood bank form with the blood type listed
Page 6 of 18
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on the blood product container.
e. If all verifications are in agreement,

both staff members sign the blood bank
form attached to the blood product
container. Contacts the blood bank
immediately if any discrepancies occur
during the identification process; and does
not administer the blood product.
f. Documents on the blood bank form the
date and time that the transfusion was
begun.
g. Make sure that the blood bank form

remains attached to the blood product
container until administration is complete.
10.Removes the blood administration set from

the package and labels the tubing with the date
and time.
Rationale:
Determines proper equipment is used
11.Closes the clamps on the administration set.
Rationale:
Prevents the flow of blood while checking for
patency
12.Removes the protective covers from the

normal saline solution container port and one of
the spikes located on the “Y” of the blood product
administration set. Place the spike into the port of
the solution container and opens the roller clamp
closest to that spike.
13.Hangs the normal saline solution container on

the IV pole.
Rationale:
Gravity allows the normal saline to flow
14.Compresses the drip chamber of the

administration set and allows it to fill up halfway
Rationale:
This checks for patency of the line
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15.Primes the administration set with normal
saline.
Rationale:
This checks for patency of the line
16.Attaches the blood filter to the second “Y” port
on the administration set and primes it with
normal saline solution by inverting it.
17.Inspects the tubing for air. If air bubbles
remain in the tubing, flicks the tubing with a
fingernail to mobilize the bubbles.
Rationale:
Prevents the air to enter into the vein of patient
18.Gently inverts the blood product container

several times.
Rationale:
For proper distribution of blood product and avoid
clotting of blood products
19.Removes the protective covers from the
administration set and the blood product port.
Carefully spikes the blood product container
through the port.
Rationale:
Maintains aseptic technique at all times and
prevents contamination
20.Hangs the blood product container on the IV
pole.
Rationale:
Hanging blood product above the patient allows it
to flow thoroughly and prevents it from clotting
21.Slowly opens the roller clamp closest to the
blood product.
22.Obtains and records the patient’s vital signs, Nurse: I will take your Vital signs, please
including temperature, before beginning the inform me if you feel any untoward signs
transfusion. and symptoms such as difficulty of
breathing.
Rationale:
This will serve as baseline data record for
comparison later
23.Using aseptic technique, attaches the distal
end of the administration set to the IV catheter.
Page 8 of 18
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Rationale:
This reduces spread of microorganisms
24.Using the roller clamp, adjusts the drip rate,

as prescribed. (Keep in mind that blood
administration sets have a drip factor of 10
drops/mL.).
Rationale:
This is to avoid fluid overload of the patient and
its the standard drop for blood transfusion.
25.Remains with the patient during the first 5 Nurse: I will monitor you for 5 minutes to
minutes and then obtains vital signs. watch out for any untoward reaction
Rationale:
For proper assessment and to monitor any
allergic reactions and attend any patient needs
26.Makes sure that the patient’s call bell or light Nurse: You may use this emergency bell
is readily available and tells him alert the nurse or light if you feel uncomfortable during the
immediately of any signs or symptoms of a transfusion.
transfusion reaction, such as back pain, chills,
itching, or shortness of breath.
27.Obtains vital signs in 15 minutes, then again Nurse:I just would like to inform you that I
in 30 minutes, and then hourly while the am going to check your vital signs (BP,
transfusion infuses. Temperature, Heart rate and Respiratory
rate) with a given interval
Rationale:
Changes in vital signs can indicate problems in
blood transfusion
28.After the unit has infused, closes the roller

clamp closest to the blood product container and
opens the roller clamp closest to the normal
saline solution to flush the administration set with
normal saline solution.
Rationale:
To allow flow of the remaining blood in the line
29.Closes the roller clamp and then disconnects

the blood administration set from the IV catheter.
Rationale:
To avoid contamination
30.If another unit of blood is required, the second

unit can be hung with the same administration
Page 9 of 18
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set.
31.Discards the empty blood container and

administration set in the proper receptacle
according to agency policy
Rationale:
For infection control
Variation: Transfusion Reaction

32.Stops the transfusion immediately if signs or
symptoms of a transfusion reaction occur.
Rationale:
To avoid any further problem or allergic reaction
33.Does not flush the tubing with the normal

saline solution attached to the blood
administration set.
Rationale:
To prevent contamination
34.Disconnects the administration set from the IV

Catheter.
35. Obtains vital signs and auscultates heart and

breath sounds.
Rationale:
For proper monitoring of patients health status
and check any problem
36.Maintains a patent IV catheter by hanging a

new infusion of normal saline solution, using new
tubing.
37. Notifies physician as soon as the blood has

been stopped and patient has been assessed.
Rationale:
For immediate action and monitoring of patient
38.Places the administration set and blood

product container with the blood bank form
attached inside a biohazard bag and sends into
the blood bank immediately.
Rationale:
For laboratory exam
Page 10 of 18
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39.Obtains blood (in the extremity opposite the
transfusion site) and urine specimens according
to agency policy.
Rationale:
For test any further problem
40..Continues to monitor vital signs frequently.

Rationale:
To check patient’s status
41.Administers medications as prescribed.
Page 11 of 18
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Name of Student:
______________________________________________________

______________________ ________________

_____________________ ____________________
BLOOD TRANSFUSION

E M
4-5 2-3 0-1
1.Introduce self to patient. Identify

patient using two patient-identifiers.
2.Verifies that informed consent has

been obtained.
3.Verifies the physician’s order, noting

the indication, rate of infusion, and any
premedication orders.
4.Administers any pre-transfusion

medications as prescribed.
5.Obtains IV fluid containing normal

saline solution and a blood
administration set.
Page 12 of 18
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6.Obtains the blood product from the
blood bank according to agency
policy.
7.Wears procedure gloves whenever

handling blood products.
8.Rechecks the physician’s order.
9.With another qualified staff member

(as deemed by the institution) verifies
the patient and blood product
identification, as follows:
a. Has the patient state his full

name and date of birth (if he is able)
and compares it to the name and date
of birth located on the blood bank
form.
b.Compares the patient name

and hospital identification
number on the patient’s
identification bracelet with the
patient name and hospital
identification number on the
blood bank form attached to
the blood product
c.Compares the unit
identification number located
on the blood bank form with the
identification number printed on
the blood product container.
d.Compares the patient’s blood
type listed on the
blood bank form with the blood
type listed on the blood product
container.
e. If all verifications are in
agreement, both staff members
sign the blood bank form
attached to the blood product
container. Contacts the blood
bank
immediately if any
discrepancies occur during the
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identification process; and
does not administer the blood
product.
f. Documents on the blood
bank form the date and time
that the transfusion was begun.
g. Make sure that the blood

bank form remains attached to
the blood product container
until administration is complete.
10.Removes the blood administration

set from the
package and labels the tubing with the
date and time.
11.Closes the clamps on the

administration set.
12.Removes the protective covers

from the normal saline solution
container port and one of the spikes
located on the “Y” of the blood product
administration set. Places the spike
into the port of the solution container
and open the roller clamp closest to
that spike.
13.Hangs the normal saline solution

container on the IV pole.
14.Compresses the drip chamber of

the administration set and allows it to
fill up halfway
15.Primes the administration set with
normal saline.
16.Attaches the blood filter to the

second “Y” port on the administration
set and primes it with normal saline
solution by inverting it.
17.Inspects the tubing for air. If air

bubbles remain in the tubing, flicks the
tubing with a fingernail to mobilize the
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bubbles.
18.Gently inverts the blood product

container several times.
19.Removes the protective covers

from the administration set and the
blood product port. Carefully spikes
the blood product container through
the port.
20. Hang the blood product container

on the IV pole.
21.Slowly opens the roller clamp

closest to the blood product.
22.Obtains and records the patient’s

vital signs, including temperature,
before beginning the transfusion.
23.Using aseptic technique, attaches

the distal end of the administration set
to the IV catheter.
24.Using the roller clamp, adjusts the
drip rate, as prescribed. (Keep in mind
that blood administration sets have a
drip factor of 10 drops/mL.).
25.Remains with the patient during the
first 5 minutes and then obtains vital
signs.
26.Makes sure that the patient’s call
bell or light is readily available and
tells him to alert the nurse immediately
of any signs or symptoms of a
transfusion reaction, such as back
pain, chills, itching, or shortness of
breath.
27.Obtains vital signs in 15 minutes,

then again in 30 minutes, and then
hourly while the transfusion infuses.
28.After the unit has infused, closes

the roller clamp closest to the blood
product container and opens the roller
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clamp closest to the normal saline
solution to flush the administration set
with normal saline solution.
29.Closes the roller clamp and then

disconnects the blood administration
set from the IV catheter.
1. If another unit of blood is

required, the second unit can be hung
with the same administration set.
31.Discards the empty blood container

and administration set in the proper
receptacle according to agency policy
Variation: Transfusion Reaction
32.Stops the transfusion immediately

if signs or symptoms of a transfusion
reaction occur.
33.Does not flush the tubing with the

normal saline solution attached to the
blood administration set.
34..Disconnects the administration set

from the IV Catheter.
35. Obtains vital signs and auscultates

heart and breath sounds.
35. Maintains a patent IV catheter
by hanging a new infusion of normal
saline solution, using new tubing.
37. Notifies the physician as soon as

the blood has been stopped and
patient has been assessed.
38.Places the administration set and

blood product container with the
blood bank form attached inside a
biohazard bag and sends it into the
blood bank immediately.
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39.Obtains blood (in the extremity
opposite the transfusion site) and
urine specimens according to agency
policy.
40.Continues to monitor vital signs

frequently.
41.Administers medications as
prescribed.
Remarks:____________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
__________________________________________________
_____________________________________________ __________________________________________
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C. LESSON WRAP-UP

than one paragraph.
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Lesson title: OXYGENATION Materials:

chronic case;

B. MAIN LESSON
OXYGENATION

NUR 106: MS RLE
● Oxygenation is a basic human need.

● Breathing is synonymous with life.
● The respiratory system replenishes the body’s oxygen supply and eliminates wastes
from the blood in the form of carbon dioxide.
MEASURES THAT PROMOTE ADEQUATE RESPIRATORY FUNCTION
1. Adequate oxygen supply from the environment. Man requires 21% of oxygen from
the environment in order to survive.
“The higher the attitude, the lower the oxygen concentration”.
2. Deep breathing and coughing exercises. To promote lung expansion and to loosen
mucus secretions. Inhale deeply through the nose, then exhale passively through the
mouth.
3. Positioning. SEMI-FOWLER’S or HIGH FOWLER’S position promotes maximum

lung expansion. By gravity, the diaphragm moves down, abdominal organs do not
compress the diaphragm.
4. Patent airway. To promote gaseous exchange between the person and the
environment.
CAUSES of AIRWAY OBSTRUCTION
● Tongue (among unconscious clients, the tongue tends to fall back).
● Mucous secretions
● Edema of the airways (rhinitis, laryngitis, bronchitis)
● Spasms of airways (laryngospasm, bronchospasms)
● Foreign bodies (aspirated foods, fluids, or coins)
Airway obstruction is characterized by noisy breathing.
5. Adequate hydration. To maintain moisture of the mucous membrane lining and

respiratory tract. This is necessary to prevent irritation and infection. Fluids also
liquefy mucus secretions. Fluid intake should ideally be 6 – 8 glasses of fluid,
preferably water everyday.
6. Avoid environmental pollutants, alcohol and smoking. These factors inhibit
mucociliary functions.
7. Chest physiotherapy (CPT)
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● Percussion (clapping) – forceful striking of the skin with a cupped hands. It

can mechanically dislodge tenacious secretions from the bronchial walls.
● Vibrations – is a series of vigorous quivering produced by hands that are
placed flat against the client’s chest wall. It is done to loosen mucous
secretions.
● Postural drainage – is expulsion of secretions from various lung segments by
gravity. This involves placing the client in different positions so that the area of
the lung congestion will be in a vertical position with the bronchus. This
facilitates drainage by gravity.
o Each position during the postural drainage will be assumed by the

client for 10 – 15 minutes.
o The entire treatment should last only for 30 minutes.
o Gradual change of position should be observed to prevent
exhaustion and postural hypotension.
o Before postural drainage, bronchodilators medication or nebulization
therapy is given to loosen mucus secretions, as ordered.
o The best time to do the postural drainage treatment is before meals, in
the morning upon awakening and at bedtime.
o Do not perform postural drainage immediately after meals
because it may cause vomiting, thereby aspiration
o Provide good oral hygiene after the procedure. To remove
unpalatable taste of the mucus secretions from the mouth.
8. Bronchial Hygiene Measures.

a. Steam Inhalation
b. Aerosol inhalation
c. Medimist Inhalation
The purposes of the steam inhalation are as follows:

- done among pediatric clients to administer bronchodilators or mucolytics
● To liquefy mucous secretions expectorants
● To warm and humidify inspired air. To relieve edema of the airways.- done
among adult clients to administer bronchodilators or mucolytics
● To soothe irritated airways. Expectorants.
● To administer medications
9. Suctioning
Oropharyngeal and Nasopharyngeal
● To clear airways from mucus secretions.
10. Incentive Spirometry (IS)

● Done to enhance deep inspiration
11. Intermittent Positive Pressure Breathing (IPPB)

● Done to administer oxygen at pressures higher than the atmospheric pressure.
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12. Administration of supplemental oxygen

● Indication: Hypoxemia
● s/ sx of Hypoxemia
o restless (initial sign)
o increased pulse rate
o rapid, shallow respiration and dyspnea
o light – headedness
o flaring of nares
o substernal or intercostal retraction
o cyanosis
C. LESSON WRAP-UP

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Lesson title: SUCTIONING TECHNIQUE Materials:

chronic case;

B. MAIN LESSON
SUCTIONING TECHNIQUES

NUR 106: MS RLE
Suctioning is necessary when patients are unable to clear respiratory secretions from
the airways by coughing or other less invasive procedures. Suctioning techniques include
oropharyngeal and nasopharyngeal suctioning, orotracheal and nasotracheal suctioning, and
suctioning an artificial airway.
In most cases use sterile technique for suctioning because the oropharynx and trachea are
considered sterile. The mouth is considered clean; therefore, you suction oral secretions after
suctioning the oropharynx and trachea. In the home setting, use a “clean” versus “sterile”
technique because the patient is not exposed to pathogens common to health care settings.
Teach patients appropriate measures for disinfecting equipment Each type of suctioning
requires the use of a round-tipped, flexible catheter with holes on the
sides and end of the catheter.
When suctioning, you apply negative pressures (100-150 mm Hg for adults) during withdrawal
of the catheter, never on insertion. Patient assessment determines the frequency of suctioning.
It is indicated when rhonchi, gurgling breath sounds, and diminished breath sounds are audible
on auscultation or visible secretions are present after other methods to remove airway
secretions have failed.
You may also use suctioning to obtain a sputum specimen for culture or cytology if the patient is
not able to cough productively. Too-frequent suctioning puts patients at risk for development of
hypoxemia, hypotension, arrhythmias, and possible trauma to the mucosa of the lungs
Oropharyngeal and Nasopharyngeal Suctioning.

Oropharyngeal or nasopharyngeal suctioning is used when a patient can cough effectively but
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unable to clear secretions by expectorating.

Apply suction after a patient has coughed. Once the pulmonary secretions decrease and a
patient is less fatigued, he or she is then able to expectorate or swallow the mucus, and
suctioning is no longer necessary.
A. OROPHARYNGEAL AND NASOPHARYNGEAL SUCTIONING
PROCEDURE SCRIPT
1. Inform the client and explain the purpose of Nurse: Good morning Ma’am/Sir! I am Nurse
the procedure. Jasper, I’m the nurse in-charged for you today.
Please state your complete name and
Rationale: birthday, Ma’am/Sir. Thank you!
To allay anxiety.
2. Assess indications for suctioning:
Audible secretions for suctioning

Adventitious breath sounds (auscultated)
3. Position the client
Conscious: Semi – Fowler’s position

Unconscious: Lateral Position
4. Adjusting to appropriate pressure of suction

equipment
WALL UNIT PORTABLE

UNIT
ADULT 100-120 10-15 mm Hg

mm Hg
CHILD 95-110 mm 5-10 mm Hg

Hg
INFANT 50-95 mm 2-5 mm Hg

Hg
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Rationale:
To prevent trauma to mucous membrane of
airways.
5. Use the appropriate size of sterile suction

catheter
Adult: Fr. 18 – 12
Child: Fr. 10 – 8
Infant: Fr. 8 – 5
Rationale:
To prevent trauma to mucous membrane of
the airway
6. Don sterile gloves
Rationale:
Sterile technique prevents introduction of
microorganisms into the respiratory tract.
7. Length of the catheter
Measure from the tip of the client’s nose to the

earlobe or about 13 cm / 5 in for an adult
8. Lubricate catheter
 Nasopharyngeal suction tip – use

water soluble lubricant
 Oropharyngeal suction tip – sterile
water / NSS
Rationale:
To reduce friction.
9. Apply suction DURING WIRTHDRAWAL of Nurse: Mam/Sir, may I advise you to relax
the suction catheter during the insertion of suction catheter.
NEVER apply suctioning DURING
INSERTION!
Rationale:
To prevent trauma to the mucous membrane
10. Apply suction for 5 – 10 seconds
(maximum 15 seconds)
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Rationale:
Over suctioning causes HYPOXIA and VAGAL
STIMULATION.
11. Hyperventilate client with 100% oxygen
before and after suctioning
Rationale:
To prevent hypoxia.
12. Allow 20 – 30 seconds interval between Nurse: How do you feel right now?
each suctioning
Rationale:
To bring up mucous secretions into the upper
airways, and to prevent hypoxia.
13. Provide oral and nasal hygiene.
Rationale:
To prevent proliferation of bacteria and other
infection
14. Dispose contaminated equipment / articles

safely.
 Use ONE sterile suction catheter for
each episode of suctioning.
Rationale:
To prevent contamination of the environment.
15. Assess the effectiveness of suctioning.

 Auscultate chest for clear breath
sounds.
16. Document relevant data.
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NUR 106: MS RLE
OROPHARYNGEAL AND NASOPHARYNGEAL SUCTIONING
Name of Student:
______________________________________________________

______________________ ________________

_____________________ ____________________

4-5 2-3 0-1
1.Inform the client and explain the

purpose of the procedure.
2.Assess indications for suctioning:
Audible secretions for suctioning

Adventitious breath sounds
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(auscultated)
3.Position the client
Conscious: Semi – Fowler’s position

Unconscious: Lateral Position
4.Adjusting to appropriate pressure of

suction equipment
5.Use the appropriate size of sterile
suction catheter
Adult: Fr. 18 – 12
Child: Fr. 10 – 8
Infant: Fr. 8 – 5
6.Don sterile gloves
7.Length of the catheter
Measure from the tip of the client’s

nose to the earlobe or about 13 cm / 5
in for an adult
8.Lubricate catheter
 Nasopharyngeal suction tip –
use water soluble lubricant
 Oropharyngeal suction tip –
sterile water / NSS
9.Apply suction DURING
WIRTHDRAWAL of the suction
catheter
NEVER apply suctioning DURING

INSERTION!
10.Apply suction for 5 – 10 seconds
(maximum 15 seconds)
11.Hyperventilate client with 100%
oxygen before and after suctioning
12.Allow 20 – 30 seconds interval
between each suctioning
13.Provide oral and nasal hygiene.
14.Dispose contaminated equipment /

articles safely.
 Use ONE sterile suction
catheter for each episode of
suctioning.
15.Assess the effectiveness of
suctioning.
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 Auscultate chest for clear

breath sounds.
16.Document relevant data.
Remarks:____________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
__________________________________________________
_____________________________________________ _____________________________________________
C. LESSON WRAP-UP

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Lesson title: STEAM INHALATION Materials:

chronic case;

B. MAIN LESSON
STEAM INHALATION
PROCEDURE SCRIPT
1.Inform the client and explain the purpose of Nurse: Good morning Ma’am/Sir! I am Nurse
the procedure. Jasper, I’m the nurse in-charged for you today.
Please state your complete name and
Rationale: birthday, Ma’am/Sir. Thank you!
To allay anxiety.
1. Place the client in semi – fowler position. Nurse: I will place you on a semi fowler
position
Rationale:
For maximum inhalation of steam.

NUR 106: MS RLE
2. Cover the client’s eyes with wash cloth
Rationale:
to prevent irritation.
3. Check the electrical devise before use.
Rationale:
To prevent injury.
4. Place the steam inhalator in a flat, stable

surface
Rationale:
To prevent scalding from hot water.
6.Place the spout 12 – 18 inches away from

the client’s nose or adjust the distance of the
hot water.
Rationale:
CAUTION: Avoid burns. Cover the chest

with towel to prevent burns due to
dripping of condensate from the steam.
Assess for redness on the side of the face
which indicates first degree burns.
7.To be effective, render steam inhalation

therapy for 15 – 20 minutes.
1. Instruct the client to perform deep Nurse: Mam/Sir after the procedure
breathing exercises (DBE) and coughing please do deep breathing and coughing
exercise after the procedure exercises to help expectorate your
Rationale: secretions
To facilitate expectoration of mucous
secretions.
10..Provide good oral hygiene after the

procedure
Do after – care of equipment.

Make relevant documentation.
Rationale:
To remove unpalatable taste of sputum from
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the mouth.
STEAM INHALATION
Name of Student:
______________________________________________________

______________________ ________________

_____________________ ____________________

4-5 2-3 0-1
1.Inform the client and explain the

purpose of the procedure.
2.Place the client in semi – fowler
position.
3.Cover the client’s eyes with wash
cloth
4.Check the electrical devise before

use.
5.Place the steam inhalator in a flat,
stable surface
6.Place the spout 12 – 18 inches away
from the client’s nose or adjust the
distance of the hot water.
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7.To be effective, render steam

inhalation therapy for 15 – 20 minutes.
8.Instruct the client to perform deep

breathing exercises (DBE) and
coughing exercise after the procedure
9.Provide good oral hygiene after the

procedure
Do after – care of equipment.

Make relevant documentation.
Remarks:____________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
__________________________________________________
_____________________________________________ _____________________________________________
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C. LESSON WRAP-UP

Page 5 of 5
NUR 106: MS RLE
Lesson title: APPLYING NASAL CANNULA AND OXYGEN Materials:

MASK
Book, pen and notebook
Learning Targets:
At the end of the module, students will be able to: References:
the lifespan with problems in oxygenation, fluid and electrolyte Smeltzer, S. Bare, B,. Hinkie J., Cheever, K.,
and immunologic reactions, cellular aberration and acute & Philadelphia, Pennsylvania: Lipincott Williams
chronic case; & Wilkins
2. Apply the research process in addressing
nursing/health problems to improve quality of care; Elis, J. R Bentz, P. M.,(2008). Basic Nursing
3. Integrate the role of culture and history in the plan of Skills (5th ed.). Lipincott Williams & Wilkins
care
B. MAIN LESSON
NOTE:
Oxygen is colourless, odourless, tasteless and dry gas that supports combustion.
NURSING IMPLICATIONS:
1. Since oxygen is colourless, odourless, tasteless gas, leakage cannot be detected.
2. Since oxygen is dry gas, it can irritate mucous membrane of the airways.
3. Since oxygen supports combustion, it can cause fire.

NUR 106: MS RLE
OXYGEN SYSTEMS
LOW FLOW ADMINISTRATION DEVICES
Nasal cannula (24 – 45% at 2 – 6 Simple face mask Partial Rebreathing Mask
LPM)
(40 -60% at 5 – 8 LPM) (60 – 90% at 6 – 10 LPM)
May be used in clients with
COPD at 2 – 3 LPM if venture
mask is not available.
Non – rebreathing mask Croupette (“Cru-Pet”) Oxygen tent

(95 – 100% at 6 – 15 LPM)
PARTIAL REBREATHING MASK NON – REBREATHING MASK
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NUR 106: MS RLE
HIGH FLOW ADMINISTRATION DEVICES
VENTURI MASK FACE MASK

Low – concentration venturi – type mask is preferred
for clients with COPD because it provides accurate
amount of oxygen. They require 2 – 3 LPM or 28%
oxygen.
Page 3 of 16
NUR 106: MS RLE
OXYGEN HOOD INCUBATOR / ISOLLETE
Can be placed used for low and high flow Can be used for low and high flow concentration.
concentration
ALTERATIONS IN THE RESPIRATORY FUNCTION

1. Hypoxia
● Insufficient oxygenation of tissues.
● Clinical signs of hypoxia
EARLY SIGNS OF HYPOXIA LATE SIGNS OF HYPOXIA

Tachycardia Bradycardia
Increased RATE and Depth of Dyspnea
respiration Decreased systolic BP
Slight increase in systolic BP Cough, Hemoptysis
Other clinical signs of acute Other clinical signs of acute
hypoxia hypoxia
Nausea and vomiting Fatigue, lethargy
Oliguria, anuria Pulmonary ventilation increases
Headache, dizziness, irritability RBC count and Haemoglobin
Apathy, Memory loss concentration increases
Clubbing of fingers
2. Altered breathing patterns

a. RATE
● Tachypnea – rapid respiratory rate
● Bradypnea – slow respiratory rate
● Apnea – cessation of breathing
b. VOLUME
● Hyperventilation
o Excessive amount of air in the lungs
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o It results from deep rapid respirations.

● Hypoventilation
o Decreased rate and depth of respiration
o It causes retention of carbon dioxide.
c. RHYTHM
● Cheyne – stokes - marked rhythmic waxing and waning of respirations
from very deep to very shallow breathing and temporary apnea.
● Kussmaul’s (hyperventilation) – increased rate and depth of respiration,
seen in metabolic acidosis and renal failure.
● Apneustic – prolonged gasping inspiration followed by a very short,
usually inefficient expiration.
● Biot’s – shallow breaths interrupted by apnea.
d. EASE OF EFFORT
● Dyspnea – difficult or laboured breathing
● Orthopnea – inability to breath except in upright or sitting position.
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APPLYING A NASAL CANNULA OR OXYGEN MASK

NOTE: When device is used in the home, the home care equipment vendor provides the equipment. Oxygen-
delivery device as ordered by patient's health care provider. Oxygen tubing (consider extension tubing),
humidifier if indicated, sterile water for humidifier, oxygen source, oxygen flowmeter, stethoscope, pulse
oximeter, appropriate room signs
PROCEDURE SCRIPT
1. Identify patient using two identifiers Nurse:Good morning Ma’am/Sir! I am Nurse
(e.g., name and birth date or name and medical Jasper, I’m the nurse in-charged for you
record number) according to agency policy. today. Please state your complete name and
Compare identifiers with information on birthday, Ma’am/Sir. Thank you!
patient's MAR or medical record.
Rationale:
To ensure patient safety and reliability of the
patient’s identification process.
2. Assess patient's respiratory status, including

symmetry of chest wall expansion, chest wall
abnormalities (e.g., kyphosis), temporary
conditions (e.g., pregnancy, trauma) affecting
ventilation, respiratory rate and depth, sputum
production, and lung sounds.
Rationale:
Respiratory assessment helps to determine the
adequacy of respiration and enables the
identification of changes to respiratory function.
3. Observe for patent airway and remove Nurse: Ma’am/Sir do you experience
secretions by having patient cough and difficulty breathing?
expectorate mucus or by suctioning.
CLINICAL DECISION: Patients with sudden

changes in their vital signs, level of
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NUR 106: MS RLE
consciousness, or behavior are often

experiencing profound hypoxia. Patients who
demonstrate subtle changes over time have
worsening of a chronic or existing condition or a
new medical condition.
Rationale:
To prevent aspiration
4. Obtain a patient's most recent SpO2 or

arterial blood gas (ABG) values if available.
Review patient's medical record for medical
order for oxygen, noting delivery method, flow
rate, and duration of oxygen therapy.
Rationale:
The purpose of pulse oximetry is to check how
well your heart is pumping oxygen through your
body.
It may be used to monitor the health of
individuals with any type of condition that can
affect blood oxygen levels, especially while
they're in the hospital
The use of ABG Lab result is to find out how

well your lungs are able to move oxygen into
the blood and remove carbon dioxide from the
blood.
5.Explain to the patient and family what Nurse: Ma’am/Sir this procedure delivers
happens during the procedure and the purpose oxygen into your body and will help you to
of oxygen therapy. breathe.
You can receive oxygen therapy from tubes
resting in your nose, a face mask, or a tube
.
placed in your trachea, or windpipe.
This treatment increases the amount
Page 7 of 16
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of oxygen your lungs receive and deliver to

your blood
Rationale:
Reduces transmission of microorganisms and
eliminating uncontrollable sources of infection
7. Attach oxygen-delivery device (e.g., nasal

cannula or mask) to oxygen tubing and attach
to humidified oxygen source adjusted to
prescribed flow rate
8. Position tips of the nasal cannula properly in

the patient's nares and adjust elastic headband
or plastic slide on cannula so it is snug and
comfortable.
If using an oxygen face mask, adjust elastic

band over ears until mask fits comfortably over
patient's face and mouth.
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Applying nasal cannula and adjusting fit to

patient comfort.
Rationale:
To secure the nasal cannula
9. Maintain sufficient slack on oxygen tubing

and secure the patient's clothes.
10. Observe proper functioning of oxygen-

delivery devices.
a. Nasal cannula: Cannula is positioned

properly in nares with humidification
functioning.
b. Reservoir nasal cannula Oxymizer: Fit

as for nasal cannula. Reservoir is positioned
under patient's nose or worn as a pendant
c. Nonrebreathing mask: Apply mask over
Page 9 of 16
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patient's mouth and nose to form tight seal.

Valves on mask close so exhaled air does not
enter reservoir bag
d. Partial rebreathing mask: Apply mask

over patient's mouth and nose to form tight
seal. Ensure that bag remains partially inflated
.
e. Venturi mask: Apply mask over patient's
mouth and nose to form a tight seal. Select
appropriate flow rate
f. Face tent: Apply tent under patient's chin and

over mouth and nose. It will be loose, and a
mist is always present
11. Verify setting on flowmeter and oxygen

source for proper setup and prescribed flow
rate.
Rationle:
To monitor the amount of oxygen we are giving
to patient
12. Check cannula/mask every 8 hours. Keep

humidification container filled at all times.
Rationale:
A humidifier releases moisture, some

fractions of the molecules of oxygen in the
air would be displaced by water molecules,
compromising the natural oxygen and
nitrogen mixture that we breathe in.
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13.Monitor patient's response to changes in

oxygen flow rate with pulse oximetry.
NOTE: Monitor ABGs when ordered; however,

obtaining ABG measurement is an invasive
procedure, and ABGs are not measured
frequently.
14. Observe for decreased anxiety, improved Nurse: How do you feel right now?
level of consciousness and cognitive abilities,
decreased fatigue, absence of dizziness,
decreased respiratory rate, improved color,
improved oxygen saturation, and return to
patient's baseline vital signs.
Rationale:
To evaluate the effectiveness of the oxygen
15. Check adequacy of oxygen flow each shift.
16. Observe the patient's external ears, bridge

of nose, nares, and nasal mucous membranes
for evidence of skin breakdown.
17.Make relevant documentation.
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APPLYING A NASAL CANNULA OR OXYGEN MASK

Name of Student:
______________________________________________________

______________________ ________________

_____________________ ____________________

E M
4-5 2-3 0-1
1.Identify patient using two identifiers

(e.g., name and birth date or name
and medical record number)
according to agency policy. Compare
identifiers with information on a
patient's MAR or medical record.
2. Assess the patient's respiratory

status, including symmetry of chest
wall expansion, chest wall
abnormalities (e.g., kyphosis),
temporary conditions (e.g., pregnancy,
Page 12 of 16
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trauma) affecting ventilation,

respiratory rate and depth, sputum
production, and lung sounds.
3. Observe the patent airway and

remove secretions by having patient
cough and expectorate mucus or by
suctioning.
4. Obtain a patient's most recent

SpO2 or arterial blood gas (ABG)
values if available. Review patient's
medical record for medical order for
oxygen, noting delivery method, flow
rate, and duration of oxygen therapy.
5.Explain to the patient and family
what happens during the procedure
and the purpose of oxygen therapy.
7. Attach oxygen-delivery device (e.g.,

nasal cannula or mask) to oxygen
tubing and attach to humidified oxygen
source adjusted to prescribed flow
rate
8. Position tips of nasal cannula

properly in patient's nares and adjust
elastic headband or plastic slide on
cannula so it is snug and comfortable.
If using an oxygen face mask, adjust

elastic band over ears until mask fits
comfortably over patient's face and
mouth.
Applying nasal cannula and
adjusting fit to patient comfort.
9. Maintain sufficient slack on oxygen

tubing and secure the patient's
Page 13 of 16
NUR 106: MS RLE
clothes.
10. Observe for proper functioning of

oxygen-delivery devices.
e. Nasal cannula: Cannula is
positioned properly in nares with
humidification functioning.
f. Reservoir nasal cannula
Oxymizer: Fit as for nasal cannula.
Reservoir is positioned under
patient's nose or worn as a pendant
g. Nonrebreathing mask: Apply
mask over patient's mouth and nose to
form tight seal. Valves on mask close
so exhaled air does not enter reservoir
bag
h. Partial rebreathing mask:
Apply mask over patient's mouth and
nose to form tight seal. Ensure that
bag remains partially inflated
e. Venturi mask: Apply mask over
patient's mouth and nose to form a
tight seal. Select appropriate flow rate
f. Face tent: Apply tent under patient's
chin and over mouth and nose. It will
be loose, and a mist is always present
11. Verify setting on flowmeter and

oxygen source for proper setup and
prescribed flow rate.
12. Check cannula/mask every 8

hours. Keep the humidification
container filled at all times.
13.Monitor patient's response to

changes in oxygen flow rate with pulse
oximetry.
Page 14 of 16
NUR 106: MS RLE
14. Observe for decreased anxiety,

improved level of consciousness and
cognitive abilities, decreased fatigue,
absence of dizziness,
decreased respiratory rate, improved
color, improved oxygen saturation,
and return to the patient's baseline
vital signs.
15. Check adequacy of oxygen flow

each shift.
16. Observe the patient's external

ears, bridge of nose, nares, and nasal
mucous membranes for evidence of
skin breakdown.
17.Make relevant documentation.
Remarks:____________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
__________________________________________________
_____________________________________________ __________________________________________
Page 15 of 16
NUR 106: MS RLE
C. LESSON WRAP-UP

Page 16 of 16
NUR 106: MS RLE
Lesson title: DRUG STUDY Materials:

chronic case;


NUR 106: MS RLE
DRUG STUDY

ACTIONS EFFECTS RESPONSIBILITIES/PRECAUTI
ONS

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DRUG STUDY CHECKLIST
Name of Student:
______________________________________________________

______________________ ________________

_____________________ ____________________
MEDICATION (10%)
INDICATION (15%)
SIDE EFFECTS (15%)

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NUR 106: MS RLE
C. LESSON WRAP-UP

than one paragraph.
Page 4 of 4
NUR 106: MS RLE
Lesson title: COMPUTED TOMOGRAPHY SCAN (CT Materials:

SCAN)
Book, pen and notebook
Learning Targets:
At the end of the module, students will be able to: References:
1.Utilize the nursing process in caring for clients across the
Smeltzer, S. Bare, B,. Hinkie J., Cheever, K.,
lifespan with problems in oxygenation, fluid and electrolyte
balance, metabolism and endocrine functioning, inflammatory Medical-Surgical Nursing (12th ed.).
and immunologic reactions, cellular aberration and acute & Philadelphia, Pennsylvania: Lipincott Williams
chronic case; & Wilkins
2.Apply the research process in addressing nursing/health Elis, J. R Bentz, P. M.,(2008). Basic Nursing
problems to improve quality of care; Skills (5th ed.). Lipincott Williams & Wilkins

3.Integrate the role of culture and history in the plan of care of Nursing Ninth Edition
B. MAIN LESSON
● A cardiac scoring CT is a series of tomograms, translated by a computer and displayed on

an oscilloscope screen, usually using a contrast medium.
● This provides layers of cross-sectional images of the heart and reconstructs cross-sectional,
horizontal, sagittal, and coronal plane images.
● This test is used to diagnose coronary artery calcium content, and screens for coronary artery
calcium content in high-risk patients and patients with chest pain of unknown origin.

NUR 106: MS RLE
COMPUTED TOMOGRAPHY of the Heart and Calcium Scoring
Normal results: Abnormal results:

100 or less 101 – 400
Indicates risk of significant coronary artery Indicates an increased risk of myocardial
disease (CAD) is minimal, and it’s unlikely that infarction in the future and further testing is
the patient has a narrowing of the arteries. suggested.
Greater than 400
Signifies extensive calcification and that the

patient may have a critical narrowing of the
arteries due to plaque. Further assessment is
required immediately.
Patient preparations:
1. Check consent if it has been signed prior to the procedure.
2. No food or fluid restriction.

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NUR 106: MS RLE
3. Assess allergy to shellfish.

4. Instruct the patient to remain still despite minimal discomfort, because movement can limit
accuracy of the test.
5. Caution the patient about noisy, clicking sounds during the procedure.
6. The patient is placed in supine position on an x-ray table and table slides into the circular
opening of the CT scanner, and the scanner revolves around the patient.
7. After the test, have the patient resume his usual diet and medications unless otherwise ordered.
Contraindications
Pregnancy = it has potential risk for the fetus. Patients with coronary stents = may alter the
quality of the picture.
C. LESSON WRAP-UP

class.

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NUR 106: MS RLE
Lesson title: MRI OF THE CARDIOVASCULAR SYSTEM Materials:

1.Utilize the nursing process in caring for clients across the References:
and immunologic reactions, cellular aberration and acute & Medical-Surgical Nursing (12th ed.).
chronic case; Philadelphia, Pennsylvania: Lipincott Williams
& Wilkins
2.Apply the research process in addressing nursing/health
problems to improve quality of care; Elis, J. R Bentz, P. M.,(2008). Basic Nursing
3.Integrate the role of culture and history in the plan of care
techniques of nursing care management of sick clients across lifespan with emphasis on
the adult and the older person, population group in any setting with alterations/problems
in oxygenation, fluid and electrolyte balance, nutrition and metabolism, infection,
inflammatory and immunologic response, cellular aberration and acute & chronic
conditions.
B. MAIN LESSON
A. MAGNETIC RESONANCE IMAGING of the Cardiovascular

System

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NUR 106: MS RLE
A noninvasive procedure that uses radiofrequency magnetic field that generates images on a
monitor.It provides cross-sectional images of the anatomy in multiple planes and can delineate fluid-
filled soft tissue in great detail.
Purpose:
● It can detect congenital heart disease, valvular heart disease, and vascular anomalies such as
thoracic aneurysm.
● It also helps detect cardiac tumors and structural anomalies.
Normal Findings: Abnormal Findings:

No anatomic or structural dysfunctions are Cardiomyopathy, pericardial disease, or
present in cardiovascular tissue. congenital diseases (atrial or ventricular septal
defects), pericardial or intracardiac masses and
vascular diseases.
Patient Preparation:
1. Explain the procedure to the patient and make sure that an informed consent was obtained.
2. The patient is placed in a supine position on a padded, nonmetallic bed which slides to the
desired position inside the scanner.
3. Radiofrequency energy is directed at the patient's chest. The resulting images appear on a
monitor and are recorded on film or magnetic tape.
4. Instruct the patient to remain still during the procedure.
5. Monitor the sedated patient’s hemodynamic, cardiac, respiratory, and mental status until the
sedative effects have worn off.
6. If the patient is unstable, monitor the patient’s oxygen saturation, cardiac rhythm, and respiratory
status during the test.
Contraindication
Patients with metal implants that cannot or shouldn’t be removed, e.g. artificial pacemakers, and
intracranial aneurysm clip.

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NUR 106: MS RLE
C. LESSON WRAP-UP

color-code them, such as green for Yes and red for No, and place them in an
envelope or punch holes in them and attach red strings.
class.
4. The teacher will ask you to hold up your card with the correct answer to the
question.
5. The teacher will quickly scan the entire classroom for each student's response.
This will provide the instructor an idea of who understands and who does not
understand the questions and material presented.

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NUR 106: MS RLE
A. Lesson title: CARDIAC CATHETERIZATION Materials:

& Wilkins
This module aims that the student nurse will be able to obtain the principles and techniques of
nursing care management of sick clients across lifespan with emphasis on the adult and the
older person, population group in any setting with alterations/problems in oxygenation, fluid and
electrolyte balance, nutrition and metabolism, infection, inflammatory and immunologic
response, cellular aberration and acute & chronic conditions.

NUR 106: MS RLE
B. MAIN LESSON
CARDIAC CATHETERIZATION
Is the passing of a catheter into the right or left side or both sides of the heart.
A B

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NUR 106: MS RLE
Cardiac Catheterization
Determines blood pressure and blood flow in the
chambers of the heart, permits blood sample
collection, and records films of the heart’s
ventricles (contrast ventriculography) or arteries
(coronary arteriography or angiography).
Normal findings:
The test reveals no abnormalities of heart
chamber size or configuration, wall motion or
thickness, or direction of blood flow or valve
motion.
Coronary arteries should have a smooth and
regular outline.
Normal results:
Right atrium = 6 mmHg
Right ventricle = 30/6
Pulmonary artery = 30/12
Left atrium = 12
Left ventricle = 140/12
Ascending aorta = 140/90
Pulmonary artery wedge = + or - 1-2 mmHg of the left atrium pressure
1. Explain the procedure to the patient

2. NPO for at least 6 hours before the test.

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NUR 106: MS RLE
3. Test takes 1 – 2 hours.

4. Tell the patient that he may receive a mild sedative but will remain conscious during the
procedure.
5. Ask allergies to shellfish, iodine, or contrast media.
6. Advise to discontinue anticoagulant therapy.
During the procedure:

1. Place the patient in supine position. ECG leads are applied and IV line is inserted.
2. Local anesthetic is injected at the catheterization site and the catheter is passed through the
sheath into the vessel. The catheter is guided to the cardiac chambers or coronary arteries using
FLUOROSCOPY.
3. When the catheter is in place, the contrast medium is injected through it to visualize the cardiac
vessels and structures.
4. Vitals signs are monitored frequently.
After the procedure:

1. Pressure is applied to the catheter insertion site for 30 mins, dressing is applied when hemostasis
occurs.
2. Monitor v/s q 15min for 2 hours, q 30 min for the next 2 hours, and then q 1 for 2 hours. If no
hematoma or other problems arise, check q 4 hours. If signs are unstable, check q 5 min and notify
the doctor.
3. Observe the insertion site for a hematoma or blood loss, reinforce the pressure dressing, as
needed.
4. Check the patient’s color, skin, temperature, and peripheral pulse below the puncture site. The
brachial approach carries a higher incidence of vasospasm (characterized by cool fingers and hand
and weak pulses on the affected side; this usually resolves within 24 hours.
5. Enforce bed rest for 8 hours.
6. If femoral route was used, keep the patient’s leg extended for 6 – 8 hours.
7. If antecubital fossa was used, keep the arm extended for at least 3 hours.
8. Resume medications withheld before the test as ordered. Administer analgesics as ordered.
9. Obtain for a posttest ECG to check for possible myocardial damage.

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NUR 106: MS RLE
Cardiac catheterization
interference:
Patient anxiety increases the heart
rate and cardiac chamber pressure
C. LESSON WRAP-UP

class.
question.

5
NUR 106: MS RLE
Lesson title: PULMONARY CATHETERIZATION Materials:

& Wilkins
the adult and the older person, population group in any setting with alterations/problems in
oxygenation, fluid and electrolyte balance, nutrition and metabolism, infection,
conditions.
B. MAIN LESSON
Pulmonary Artery Catheterization

Also known as Swan-Ganz catheterization
Uses a balloon-tipped, flow-directed catheter to provide intermittent occlusion of the pulmonary
artery.
This procedure permits measurement of both pulmonary artery pressure (PAP), and pulmonary
artery wedge pressure (PAWP).

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NUR 106: MS RLE

Pulmonary artery wedge pressure reading accurately reflects left atrial pressure and left-ventricular
end-diastolic pressure.
Purpose:
● It helps to assess right- and left-sided heart failure.
● It also helps monitor fluid status in patients who have suffered serious burns or who have renal
disease, noncardiogenic pulmonary edema, or acute respiratory distress syndrome.
Normal pressures:
Right atrial pressure = 1 -6 mmHg
Systolic right ventricular pressure = 20 – 30 mmHg
End-diastolic right ventricular pressure = less than 5 mmHg
Systolic PAP = 20 – 30 mmHg
Diastolic PAP = 10 – 15mmHg
Mean PAP = less than 20 mmHg

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PAWP = 6 – 12 mmHg
Left atrial pressure = about 10 mmHg
Abnormal results:
Increased right atrial pressure = indicate pulmonary disease, right-sided heart failure, fluid
overload, cardiac tamponade, tricuspid stenosis and insufficiency, or pulmonary hypertension.
Elevated right ventricular pressure = results from pulmonary hypertension, pulmonary valvular
stenosis, right-sided heart failure, pericardial effusion, constrictive pericarditis, chronic heart
failure, or ventricular septal defects.
Increased PAP = characteristic of increased pulmonary blood flow, as in a left-to-right shunt

secondary to atrial or ventricular septal defect; increased pulmonary arteriolar resistance, as in
pulmonary hypertension or mitral stenosis; COPD; pulmonary edema or embolus; and left-sided
heart failure from any cause.
Elevated PAWP = results from left-sided heart failure, mitral stenosis and insufficiency, cardiac
tamponade, or cardiac insufficiency
Depressed PAWP = results from hypovolemia
1. Explain the procedure to the patient.

2. Place the patient in supine position or semi-Fowler’s position if the patient can’t tolerate
supine.
3. Monitor all pressures of the patient in the same position.
4. The catheter balloon is checked for defects using sterile technique, and all ports are
flushed to ensure patency.
5.Positioning for antecubital and subclavian insertion

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NUR 106: MS RLE
6.The catheter is introduced into the vein percutaneously and directed to the right atrium. The
catheter balloon is inflated so that venous flow carries the catheter tip through the right atrium
and tricuspid valve into the right ventricle and into the pulmonary artery.
7.To record PAWP, the catheter balloon is inflated with the specified amount of air (no more than
1.5cc).
8.The balloon shouldn’t be overinflated further if a PAWP waveform occurs with less than the
recommended inflation volume.
9.Overinflation could distend the pulmonary artery, causing vessel rupture.
10. When the catheter’s correct positioning and function have been established, the catheter is
sutured to the skin and antimicrobial ointment and an airtight dressing are applied
Obtain a chest x-ray to confirm

catheter placement.
PA catheterization interference:
Mechanical ventilators with
positive pressure caused increased
intrathoracic pressure, raising
catheter pressure.
C. LESSON WRAP-UP


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NUR 106: MS RLE
class.
question.

5
NUR 106: MS RLE
Lesson title: ELECTROCARDIOGRAPHY (PART 1) Materials:

& Wilkins
conditions.
B. MAIN LESSON
ELECTROCARDIOGRAPHY
The most commonly used test for evaluating
cardiac status, graphically records the electric
current (electrical potential) generated by the
heart.
The standard resting ECG uses 12 different
leads:
Standard limb leads (leads I, II, and III)
The augmented limb leads (aVR, aVL, and aVF)
Precordial or chest leads (V1, V2, V3, V4, V5,
and V6)

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ECG tracings consist of three identifiable waveforms:

P wave = depicts atrial depolarization
QRS complex = depicts ventricular depolarization

T wave = depicts ventricular repolarization
12-lead Electrocardiography
Computerized ECG machines use small electrode tabs that peel off a sheet and adhere to the patient’s
skin.
Electrode tabs can remain on the patient’s chest, arms, and legs to provide continuous lead placement
for serial ECG studies.
Purpose:
To identify primary conduction abnormalities, cardiac arrhythmias, cardiac hypertrophy, pericarditis,
electrolyte imbalance, myocardial ischemia, infarction site and extent.
It also helps evaluate the effectiveness of cardiac drugs.
The lead II waveform, known as the rhythm strip, depicts the heart’s rhythm more clearly than
any other waveform.
Lead II

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Normal results:
P vawe = doesn’t exceed 2.5 mm in height or last longer than 0.12 sec (1 mm = I small box =
0.04 sec)
PR interval = includes the P wave and PR segment, persists for 0.12 to 0.20 sec for cardiac
rates over 60 beats/minute.
QT interval = lasts 0.40 – 0.52 sec
R wave voltage = in V1 through V6 leads doesn’t exceed 27 mm.

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QRS interval = lasts 0.06 to 0.1 sec
12 - lead Electrocardiography
Negative deflections = indicate that the current is moving away from the positive electrode (Leads
aVR, V1, V2, V3, and V4)
Positive deflections = indicate that the current is moving away from the negative electrode (Leads I,
II, III, aVF, aVL, V5, and V6).
1. Explain the procedure to the patient and ask that the patient remain still and not to talk during the
test because his voice may distort the ECG tracing.
2. Place the patient in supine or semi-Fowler’s position. Expose his chest, both ankles, and both
wrists for electrode placement. If the patient is female, provide a chest drape.

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Proper placement of electrodes:

V1 = 4th ICS, right sternal border
V2 = 4th ICS, left sternal border
V3 = midway between V2 and V4
V4 = 5th ICS, midclavicular, left
V5 = midway between V4 and V6,
anterior axillary
V6 = 5th ICS, midaxillary line, left
3. If the patient has a pacemaker, indicate on the request and the patient’s record that a pacemaker is
present and whether a magnet is used.
After the procedure:
Remove the electrodes and reposition the patient’s gown and bed covers.
C. LESSON WRAP-UP


5
NUR 106: MS RLE
Lesson title: ELECTROCARDIOGRAPHY PART 2 Materials:

& Wilkins
conditions.
B. MAIN LESSON
ELECTROCARDIOGRAPHY
Purpose
To perform electrocardiography according to the standard of care.
Assessment
Assess the client's medical record for information regarding the needs for an ECG.

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NUR 106: MS RLE
Assess the client's heart rate, heart sounds, and blood pressure.
Assess the client's chest for areas of irritation, skin breakdown, or excessive hair growth that may
interfere with the electrode placement.
Equipment
● ECG machine
● Recording paper
● Disposable pre-gelled electrodes
● 4" × 4" gauze pads or washcloth
● Optional: clippers, marking pen
PROCEDURE SCRIPT
1. Verify the order for the ECG in the client's

chart
Rationale:
Verification of order prevents potential errors.
2. Confirm the client's ID by checking two Nurse: “Good morning, How are you? I am Jasper
client identifiers according to your facility's policy. your nurse this shift from 8am-4pm. But before we
proceed, I would like to know some details. What is
your complete name?”
Rationale:
Checking identification ensures client
safety through concept of correct
procedure for correct client.
3. Provide privacy and explain the procedure Nurse: “I need to record an ECG which is an
to the client. Explain that the test records the electrical trace of the heart. The procedure will
heart's electrical activity and that it may be involve placing some sticky pads onto your chest
repeated at certain intervals. Emphasize that no and limbs. I will then connect these sticky pads to
electrical current will enter the body. Tell the client the ECG machine’s leads to record the tracing.
that the test typically takes about 5 minutes. Do you have any clarification?”
Rationale:
Explanation of procedure protects
client's rights and encourages
participation in care.
4.Wash your hands.
Rationale:
Handwashing reduces transfer of
microorganisms

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NUR 106: MS RLE
5.Place the ECG machine close to the client's bed

and plug the cord into the wall outlet or, battery-
operated, ensure that it is functioning. Turn on the
machine and input required client information. If the
client is already connected to a cardiac monitor,
move the electrodes to accommodate the
precordial leads.
Rationale:
Moving electrodes and keeping client away from
electrical fixtures and power cords will minimize
electrical interference on ECG tracing.
6.Have the client lie supine in the center of the bed Nurse: “You may lie flat on the center of your bed
with arms at his sides. You may raise the head of with arms at your sides. Your arms and legs
the bed to promote comfort. Expose the arms and should be relaxed to minimize muscle trembling
legs and cover the client appropriately. The arms which can cause electrical interference”
and legs should be relaxed to minimize muscle
trembling, which can cause electrical interference.
Rationale:
This position increases client comfort.
Relaxing arms and legs reduces
trembling and creates a better tracing.
7.If the bed is too narrow, place the client's hands

under his buttocks to prevent muscle tension. Also
use this technique if the client is shivering or
trembling. Make sure the feet are not touching the
bed board.
8.Select flat, fleshy areas to place the limb lead

electrodes. Avoid muscular and bony areas. If the
client has an amputated limb, choose a site on the
stump.
Rationale:
Tissue conducts current more
effectively than bone, which produces
a better tracing.
9.If an area is excessively hairy, clip it. Clean Nurse: “I am going to wipe the excess oil and dirt
excess oil or other substances from the skin with on your skin using soap and water, are you
soap and water to enhance electrode contact. comfortable with that?”
Rationale:
Do not shave hair; shaving causes
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NUR 106: MS RLE
microabrasion on skin.
1. Apply disposable electrodes to the client's Nurse: “Now I am going to place the electrodes
wrists and to the medial aspects of the ankles. at your wrists and medial aspects of your knees”
(See Positioning Chest Electrodes.) Apply the

pre-gelled electrode directly to the prepared site,
as recommended by the manufacturer's
instructions. To guarantee the best connection to
the lead wire, position disposable electrodes on the
legs with the lead connection pointing superiorly
Rationale:
Positioning lead connections superiorly guarantees
best connection to lead wire
11.Expose the client's chest. Put a pre-gelled Nurse: “I am going to place these electrodes on
electrode at each electrode position. If your client is your chest (for female patient)
a woman, be sure to place the chest electrodes below your breast tissue, stay relax and calm, this
below the breast tissue. In a large-breasted will be painless and easy.”
woman, you may need to displace the breast tissue
laterally.
Rationale:
Proper lead placement ensures
accurate test results.
12.Connect the lead wires to the electrodes. The

tip of each lead wire is lettered and color-coded for
easy identification. The white or RA lead wire goes
to the right arm; the green or RL lead wire, to the
right leg; the red or LL lead wire, to the left leg; the
black or LA lead wire, to the left arm; and the
brown or V1 to V6 lead wires, to the chest
electrodes.
Rationale:
Proper setup ensures proper
functioning.
13.Check to see that the paper speed selector is

set to the standard 25 mm/second and that the
machine is set to full voltage. The machine will
record a normal standardization mark—a square

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NUR 106: MS RLE
that is the height of two large squares or 10 small

squares on the recording paper.
14.Ask the client to relax and breathe normally. Tell Nurse: “Lie still and don’t talk during the
the client to lie still and not to talk when you record recording , relax and take a breathe, I assure you
the ECG. this will be quick and easy”
Rationale:
Having clients relax and remain still
will produce a better tracing.
15.Press the AUTO button. Observe the tracing

quality. The machine will record all 12 leads
automatically, recording three consecutive leads
simultaneously. Some machines have a display
screen so that you can preview waveforms before
the machine records them on paper. If any part of
the waveform height extends beyond the paper
when you record the ECG, adjust the normal
standardization to half standardization. Note this
adjustment on the ECG strip because this change
will need to be considered in interpreting the
results.
Rationale:
Note any adjustments made during
tracing to ensure accurate
interpretation of results.
16.When the machine finishes recording the 12- Nurse: “Now we are done, How do you feel right
lead ECG, remove the electrodes and clean the now? I am going to remove the electrodes and
client's skin. clean your skin”
17.After disconnecting the lead wires from the

electrodes, dispose of the electrodes.
Rationale:
Proper disposal reduces the spread of
microorganisms.
18.Assist the client to a comfortable position.

Ensure the bed is in a low position.
Rationale:

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NUR 106: MS RLE
Repositioning of bed promotes client

safety.
19.Remove any remaining equipment and wash

your hands.
Rationale:
Handwashing reduces transfer of microorganisms
20.Document in your notes the test's date and time Sample Documentation
and significant responses by the client. Verify the
date, time, client's name, and assigned ID number
on the ECG itself. Note any appropriate clinical Client complained of substernal chest pain 9/10.
information on the ECG. Sublingual NTG administered as ordered. EKG
obtained. Vital signs as per flow sheet. Dr. Smith
at the bedside to assess client and review ECG.
At 1705, client rated chest pain 0/10.
Jasper Lemuel V. Caragay,RN

6
NUR 106: MS RLE
ELECTROCARDIOGRAPHY
Name of Student:
______________________________________________________

______________________ ________________
Area of assignment: Inclusive Dates: Overall Ratin

_____________________ ____________________

E M
4-5 2-3 0-1
1.Verify the order for the ECG in the

client's chart
Rationale:
Verification of order prevents potential
errors.
2.Confirm the client's ID by checking two
client identifiers according to your
facility's policy.
Rationale:
Checking identification
ensures client safety
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NUR 106: MS RLE
through concept of correct

procedure for correct client.
3.Provide privacy and explain the

procedure to the client. Explain that the
test records the heart's electrical activity
and that it may be repeated at certain
intervals. Emphasize that no electrical
current will enter the body. Tell the client
that the test typically takes about 5
minutes.
Rationale:
Explanation of procedure
protects client's rights and
encourages participation in
care.
4.Wash your hands.
Rationale:
Handwashing reduces
transfer of microorganisms
5.Place the ECG machine close to the

client's bed and plug the cord into the
wall outlet or, battery-operated, ensure
that it is functioning. Turn on the
machine and input required client
information. If the client is already
connected to a cardiac monitor, move
the electrodes to accommodate the
precordial leads.
Rationale:
Moving electrodes and keeping client
away from electrical fixtures and power
cords will minimize electrical
interference on ECG tracing.
6.Have the client lie supine in the center

of the bed with arms at his sides. You
may raise the head of the bed to
promote comfort. Expose the arms and
legs and cover the client appropriately.
The arms and legs should be relaxed to
minimize muscle trembling, which can

8
NUR 106: MS RLE
cause electrical interference.
Rationale:
This position increases
client comfort. Relaxing
arms and legs reduces
trembling and creates a
better tracing.
7.If the bed is too narrow, place the

client's hands under his buttocks to
prevent muscle tension. Also use this
technique if the client is shivering or
trembling. Make sure the feet are not
touching the bed board.
8.Select flat, fleshy areas to place the

limb lead electrodes. Avoid muscular
and bony areas. If the client has an
amputated limb, choose a site on the
stump.
Rationale:
Tissue conducts current
more effectively than bone,
which produces a better
tracing.
9.If an area is excessively hairy, clip it.

Clean excess oil or other substances
from the skin with soap and water to
enhance electrode contact.
Rationale:
Do not shave hair;
shaving causes
microabrasion on skin.
2. Apply disposable electrodes to

the client's wrists and to the medial
aspects of the ankles.
(See Positioning Chest Electrodes.)

Apply the pre-gelled electrode directly to
the prepared site, as recommended by

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NUR 106: MS RLE
the manufacturer's instructions. To

guarantee the best connection to the
lead wire, position disposable electrodes
on the legs with the lead connection
pointing superiorly
Rationale:
Positioning lead connections superiorly
guarantees best connection to lead wire
11.Expose the client's chest. Put a pre-

gelled electrode at each electrode
position. If your client is a woman, be
sure to place the chest electrodes below
the breast tissue. In a large-breasted
woman, you may need to displace the
breast tissue laterally.
Rationale:
Proper lead placement
ensures accurate test
results.
12.Connect the lead wires to the

electrodes. The tip of each lead wire is
lettered and color-coded for easy
identification. The white or RA lead wire
goes to the right arm; the green or RL
lead wire, to the right leg; the red or LL
lead wire, to the left leg; the black or LA
lead wire, to the left arm; and the brown
or V1 to V6 lead wires, to the chest
electrodes.
Rationale:
Proper setup ensures
proper functioning.
13.Check to see that the paper speed

selector is set to the standard 25
mm/second and that the machine is set
to full voltage. The machine will record a
normal standardization mark—a square
that is the height of two large squares or
10 small squares on the recording
10
NUR 106: MS RLE
paper.
14.Ask the client to relax and breathe

normally. Tell the client to lie still and not
to talk when you record the ECG.
Rationale:
Having client relax and
remain still will produce a
better tracing.
15.Press the AUTO button. Observe the

tracing quality. The machine will record
all 12 leads automatically, recording
three consecutive leads simultaneously.
Some machines have a display screen
so that you can preview waveforms
before the machine records them on
paper. If any part of the waveform height
extends beyond the paper when you
record the ECG, adjust the normal
standardization to half standardization.
Note this adjustment on the ECG strip
because this change will need to be
considered in interpreting the results.
Rationale:
Note any adjustments
made during tracing to
ensure accurate
interpretation of results.
16.When the machine finishes recording

the 12-lead ECG, remove the electrodes
and clean the client's skin.
17.After disconnecting the lead wires

from the electrodes, dispose of the
electrodes.
Rationale:
Proper disposal reduces spread of
microorganisms.

11
NUR 106: MS RLE
18.Assist the client to a comfortable

position. Ensure the bed is in a low
position.
Rationale:
Repositioning of bed
promotes client safety.
19.Remove any remaining equipment

and wash your hands.
Rationale:
Handwashing reduces transfer of
microorganisms
20.Document in your notes the test's

date and time and significant responses
by the client. Verify the date, time,
client's name, and assigned ID number
on the ECG itself. Note any appropriate
clinical information on the ECG.
C. LESSON WRAP-UP
than one paragraph.

12

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NUR 106: MS RLE

MODULE #1 Student Activity Sheet

Lesson title: SURGICAL HANDWASHING Materials:

Elis, J. R Bentz, P. M.,(2008). Basic Nursing

Potter, Perry, Stockert, & Hall; Fundamentals

This document is the property of PHINMA EDUCATION

PURPOSES OF SURGICAL SCRUB

SURGICAL SCRUB TECHNIQUES

Preparation for scrubbing

2.All hair should be contained within a surgical hat.

3.Fingernails should be short and free from polish or artificial nails

7.Hands and arms should be wet before applying scrub solution.

SURGICAL HAND SCRUB

2 METHODS OF SCRUB PROCEDURES

This document is the property of PHINMA EDUCATION

This document is the property of PHINMA EDUCATION

ANTIBACTERIAL LIQUID SOAP

Family Germ Protection Soap. Leaves Your Skin

SCRUB BRUSH WITH NAIL CLEANER

The E-Z Scrub 205 is a single-use Povidone-Iodine

This document is the property of PHINMA EDUCATION

Scrub sinks, also referred to as surgical sinks or medical

Its absorbent, 100 percent cotton towels are fully

This document is the property of PHINMA EDUCATION

Before the procedure I will remove any

This document is the property of PHINMA EDUCATION

This document is the property of PHINMA EDUCATION

5.Squeeze scrub brush under water to release

7.Scrub dorsal and palm surfaces of hand and

This document is the property of PHINMA EDUCATION

PERFORMANCE EVALUATION CHECKLIST

Level & Block: School Year & Term:

Area of assignment: Inclusive Dates: Overall Rating

This document is the property of PHINMA EDUCATION

4-5 2-3 0-1

1.Remove any watches and rings from

2.Before beginning the scrubbing

3.Wash your hands with regular soap to

4.Remove scrub brush from the package

6.With scrub brush perpendicular to

8.Starting at the wrist, scrub all four

9.Transfer scrub brush to the other hand

10. Discard scrub brush and rinse

This document is the property of PHINMA EDUCATION

12. Allow contaminated water to drip

Conformed : Student’s Signature Clinical Instructor

AL STRATEGY: CAT: Student Response Cards

This document is the property of PHINMA EDUCATION

Lesson title: GOWNING AND CLOSED GLOVING Materials:

Elis, J. R Bentz, P. M.,(2008). Basic Nursing

Potter, Perry, Stockert, & Hall; Fundamentals

GOWNING and CLOSED GLOVING

This document is the property of PHINMA EDUCATION

PURPOSE OF SURGICAL GOWNING

PURPOSE OF SURGICAL GLOVING

SURGICAL GOWN SURGICAL GLOVES

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BONNET AND FACEMASK MAYO TABLE

Pick up gown pack Open the gown

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8. The theatre assistant then prepares

An assistant should fasten the gown

This document is the property of PHINMA EDUCATION