NCM 100 H.A Procedure DPPERR

Basic Cleaning Procedure
Definition:
- This procedure provides a simple but effective way to clean a room and maintain a
reliable operation.
Purposes:
1. To reduce dust that lives on the room.

2. To provide a clean environment for the patient.
3. To reduce the number of microorganisms in the room.
Principles:
1. Clean from the ceiling to the floor.

2. Remove all furniture.
3. Have sufficient cleaning equipment and supplies before beginning work.
Equipment:
1. Mop 4. Coconut husk 7. Gloves

2. Dusting Cloth 5. Basin for washing 8. Antiseptic solution
3. Floorwax 6. Laundry Soap
Rationales:
Dusting:
1. To save time and energy and prevents spread of microorganisms.

2. To facilitate easy cleaning of the room and ceiling is considered the cleanest area of the
room.
3. To avoid spreading of dust.
4. To facilitate easy removal of the dust from the walls.
5. To remove the microorganisms and damp cloth is common in cleaning.
6. To avoid the spreading and returning of dusts that contains microorganisms to the clean
furniture.
7. To facilitate easy removal of dirt.
8. To facilitate easy removal of dirt in the small areas that is very difficult to reach.
9. To remove dust in the bed can make it comfortable to lie on.
10. To see if your work is well-organized.
11. To have an organized work and to prepare for the next use.
Sweeping:
1. To save time and effort.

2. To avoid dust into the furniture.
3. To eliminate dirt and dust.
4. To avoid spreading of dust.
5. To facilitate easy removal of dust.
6. To see if your work is well-organized.
7. To eliminate dust that lives in the room.
9. To avoid the spreading of dust that contains microorganism.
10. To prevent the spread of microorganism.
Washing:

2. To avoid spillage of water on the floor.
3. To avoid dirt and dust.
4. To eliminate number of microorganisms and to have an easy squeezing of the cloth.
5. To eliminate microorganism.
6. To eliminate dirt.
7. To entirely remove dirt and dust.
8. Because used water is contaminated already.
9. To facilitate easy removal of dirt thus preventing it from returning.
10. To protect yourself from infectious illness.
11. To have an organized work.
Mopping:
1. To remove dust on the floor.

3. To eliminate dirt and donning gloves on hands prevents the chance of acquiring
infectious disease.
4. Because the rear part is the most contaminated area.
5. To avoid spreading of microorganisms.
6. To avoid cross-contamination.
7. To dry the specific area.
Scrubbing:
1. To facilitate easy removal of dirt on the floor.

2. To clean the area.
Waxing:
1. To facilitate easy removal of dirt on the floor.

2. To prevent the floor from damaging.
Procedure in cleaning a room:
1. To avoid the dust from reaching the furniture.

2. Ceiling is the cleanest part of the room.
3. To eliminate dust.
Reference:
www.hud-gov/offices/lead/lbp/hudguidelines/ch14.pdf
Medical Handwashing
Definition:
- It is considered one of the most effective infection control measures.
Purposes:
1. To reduce the number of microorganisms on hands.

2. To reduce the risk of transmission of microorganisms to clients.
3. To reduce the risk of cross-contamination among clients.
4. To reduce the risk of transmission of infectious organisms to client and within self.
Principles:
1. Clean from least contaminated to most contaminated.

2. Do not touch the outside and inside portion of the sink.
3. Keep the hands and forearms lower than the elbow.
Equipment:
1. Soap 3. Disposable or 4. Tissue paper

2. Warm running water sanitized towels. 5. Orange stick
Rationales:

2. Microorganisms can lodge into the settings of jewelry.
3. Sleeves in the uniform may carry microorganisms.
4. To prevent the spread of microorganisms.
5. Warm water removes less of the protective oil of the skin than hot water.
6. To loosen dirt and microorganisms that can lodge on the palms and hands.
7. Adding soap maintains the lather which suspends organisms.
8. The circular action creates friction that helps remove microorganisms mechanically.
Interlacing the fingers and thumbs cleans the interdigital space.
9. To contact all surfaces effectively.
10. Drying the skin will prevent chapping. Dry hands first as they are considered the
cleanest areas than the others.
11. This prevents us from picking up microorganisms from the faucet handles.
12. To secure the equipment.
Reference:
Kozier, Barbara et al. Fundamentals of Nursing: Concepts, Process, and Practice, Eighth
Edition, Volume 1, Pearson Education South Asia Pte Ltd., 23-25 First Lok Yang Road, Jurong,
Singapore 629733, Pages 684 - 685
Open Gloving
Definition:
- Basic skill of wearing gloves for routine of sterile procedure.
Purposes:
1. To enable the nurse/us to handle or touch sterile objects freely without contaminating
them.
2. To prevent transmission of potentially infectious microorganisms from the nurse’s hands
to clients at high risk of infection.
Principles:
1. Sterile to sterile.
2. Do not put your hands with sterile gloves below the waist.
Equipment:
1. Sterile gloves (disposable)
Rationales:
1. To ensure the sterility of the gloves.

3. Any moisture on the surface could contaminate the gloves.
4. The inner surfaces which are next to the sterile gloves remain sterile.
5. So that we could insert our fingers easily.
6. If the thumb is kept against the palm, it is likely to contaminate the outside of the gloves.
7. To avoid contamination.
8. To maintain the sterility of the gloves.
9. Helps prevent accidental contamination of the gloves by the back of the hand.
11. Prevent accidental contamination of the gloves from touching the skin in the wrist.
13. The soiled part of the gloves is folded to the inside to reduce the chance of transferring
any microorganisms.
Reference:
Open Bed
Definition:
- This type of bed is where the top covers are generally folded back so that a client can
easily get into the bed.
Purposes:
1. To promote the client’s comfort.

2. To provide a clean environment for the client.
3. To provide a smooth, wrinkle-free bed foundation thus minimizing sources of skin
irritation.
Principles:
1. The opening part of the pillow should not face the door.
2. Wash hands thoroughly before beginning the procedure.
3. Observe body mechanics.
Equipment:
1. Mattress 4. Cotton Draw Sheet 7. Pillow

2. Bottom Sheet 5. Top Sheet
3. Rubber Sheet 6. Pillow Case
Rationales:
1. To prevent spreading of microorganisms.

3. To prevent cross-contamination.
4. To provide comfort.
5. Opening the linens on the bed reduces strain on the nurse’s arm and diminished the
spread of microorganisms.
6. To see if the linens are correctly done.
7. To arrange easily the other half after the first half of the bed.
8. To have that neat appearance and to secure the linens.
9. To protect the mattress from urine excretion.
10. To make the patient comfortable.
11. To save time; thick linens provide warmth and comfort.
12. So that you will be able to see if the linens are done correctly.
13. Just to make sure if the sheets are stable.
14. For preparation of the arrival of the patient.
15. Working on one side saves time and energy.
16. To have that wrinkle-free bed.
17. To provide neat appearance and comfort.
18. To ensure comfort of the patient.
19. To welcome the patient; a sign of patient to where to get in.
References:
Closed Bed
Definition:
- A bed prepared for a new patient. It is termed closed because the top cover was
arranged and that all linen beneath the bedspread is all protected from dirt and dust.
Purposes:
1. To provide client’s comfort.

2. To provide neat and clean environment for the client.
3. To provide a wrinkle-free bed thus minimized irritation.
Principles:
1. Wash hands thoroughly before starting the procedure.

2. Have everything ready to save time and effort.
3. Work first to the side where you are standing.
4. Always maintain body mechanics.
Equipment:
1. Mattress 4. Cotton Draw Sheet 7. Pillow

2. Bottom Sheet 5. Top Sheet 8. Bedspread
3. Rubber Sheet 6. Pillow Case
Rationales:
1. To prevent spreading of microorganisms.

2. To save time and effort and to make work well-organized.
3. To save time, effort, and energy.
5. To save time.
6. Opening linens on bed reduces strain on arms and diminished the spread of
microorganisms.
8. To reduce discomfort of the upcoming patient.
9. This protects the bed from soiling.
10. To provide comfort and prevents skin irritation.
11. It provides warmth and comfort.
12. To save time.
13. To reduce discomfort.
14. To welcome the patient with a presentable bed.
15. To save time.
16. Bedspread protects the linens from microorganisms.
17. To save time and energy.
18. To save time.
19. Working at the other side at a time saves time.
20. To be more efficient.
21. To make it wrinkle-free and provides comfort.
22. To protect the linens and is more presentable.
23. To protect the pillow from microorganisms.
24. To ensure comfort and wrinkle-free bed.
Reference:
Occupied Bed
Definition:
- This is a bed made with a patient occupying it.
Purposes:
1. To conserve the clients energy and maintain healthy status.

2. To promote client’s comfort.
3. To provide a neat and clean environment for the client/patient.
4. To provide a wrinkle-free bed; minimize skin irritation.
Principles:

2. Maintain client in a good hygiene.
3. Wash hands thoroughly after handling patient’s bed/linen.
4. Hold soiled linen away from the uniform.
5. Soiled linen should never shorten to avoid the spread of microorganisms.
Equipment:
1. Mattress 5. Top Sheet 9. Dust Cloth

2. Bottom Sheet 6. Pillow Case 10. Gloves
3. Rubber Sheet 7. Pillow
4. Cotton Draw Sheet 8. Bed Bath
Rationales:
1. To avoid the spread of microorganisms.

3. To inform the client and to attain his/her cooperation.
5. To facilitate easy removal of the top sheet, lowering only the side rail close to the nurse
reduces client’s risk of falling.
6. To give privacy to the client and to avoid the client from risk of falling.
7. To prevent the spread of microorganisms and to ensure patient’s comfort.
8. To maintain soiled linens together and promote client’s comfort if he/she rolls to the
other side.
9. To cover the bed with clean sheets.
10. To maintain the comfort of the patient.
11. To avoid the mattress from getting soiled.
12. To ensure safety of the patient.
13. To ensure safety of the patient.
14. Working at one side at the time saves time and energy.
15. To have that neat appearance and wrinkle-free bed.
16. To promote comfort.
18. To ensure comfort of the patient and to have a presentable bed.
20. To ensure client’s healthy status.
Reference:
Hot Water Bag Application
Definition:
- Hot water bag application is applied to the affected part of the body for local and
systematic effects. It helps increase blood flow to the affected area bringing oxygen,
nutrients, and leukocytes.
Purposes:
1. To promote vasodilation.
2. To reduce edema.
3. To relieve muscle pain.
Principles:
1. Measure the temperature of the water using a bath thermometer.

2. Assess the circulatory status.
3. Handle the patient with care.
4. Always explain the procedure to the patient.
Equipment:
1. Hot water bag 3. Hot water 5. Pitcher

2. Bath thermometer 4. Cotton flannel
Rationales:
1. To remove transient microorganisms.

3. To avoid possible accidents during application of the hot water bag.
4. Leakage can cause burns to the patient’s skin.
5. To determine the right temperature of the hot water.
6. To avoid overflowing of the hot water during application of the hot water bag.
7. Air can easily change the temperature of the hot water.
8. To avoid wetting and to ensure safety of the patient.
9. To avoid direct contact into the patient’s skin.
10. To prepare for the hot water bag application.
11. To gain patient’s cooperation and trust.
12. To prevent the patient from getting burnt if the bag will accidentally burst.
13. To avoid skin irritation and prevent from burning the patient’s skin.
15. To promote patient’s well-being and for documentation purposes.
16. Serve as medium of transfer of microorganisms.
17. To be ready for the next use.
Reference:
Ice Cap/ Ice Bag Application
Definition:
- Ice cap/ ice bag application is a procedure done to provide cold anesthetic effect on
inflamed or edematous part of the patient’s body.
Purposes:
1. To relieve pain.
2. To control bleeding.
3. To reduce cell metabolism.
Principles:
1. Always explain the procedure to the patient.

2. Check ice cap for leakage.
3. Wash hands before and after the procedure.
Equipment:
1. Ice bag 3. Cotton flannel 5. Wash cloth

2. Ice cap 4. Pitcher with water 6. Basin
Rationales:

3. Leakage can cause skin irritation.
4. Helps the ice bag to be light in weight.
5. Air could easily melt the ice.
6. To avoid direct contact to the patient’s skin.
7. To gain patient’s cooperation.
8. To prevent patient from chilling and to avoid rebound phenomenon.
9. Records for proper documentation.
10. To promote patient’s well-being.
11. To lessen moisture and to prepare for the next use.
References:
Taking Vital Signs
Definition:
- Measurement of Physiologic functioning specifically temperature, pulse, respiration, and

blood pressure and the 5th vital sign, pain.
Purposes:
1. To create a baseline data.

2. To determine the cause of illness which serves as a guide in meeting the need of the
patient.
3. To observe the general condition of the patient.
4. To aid the physician in making his diagnosis and planning patient’s care.
Principles:
1. Before taking the vital signs, be sure that the patient has rested.
2. In taking the PR, it will always depend on the condition of the patient.
Equipment:
1. Pencil or Pen 4. Sphygmomanometer 8. Cotton Balls

2. Paper 5. Stethoscope 9. Alcohol
3. Watch with second 6. Waste Receptacle
hand 7. Tissue Paper
Rationales:
1. To save time and energy

2. To prevent the spread of microorganism
3. To gain patient’s cooperation
4. For the patient to be comfortable and to make vital signs accurate
5. To know the background/recent activity of the patient.
6. To prevent contamination
7. To avoid the spread of microorganism
8. To have an accurate result
9. It will allow sufficient time for the mercury to expand and ensure accurate result
10. To check for client’s respiration
11. To check for client’s pulse
12. To palpate client’s radial pulse
13. To check if pulse is weak or strong
14. To accurately check respiratory rate
15. To check for respiration
16. To check respiratory rate
17. To provide accurate documentation in client’s state
18. To position client properly that pop apparatus is placed at the level of the heart
19. Pressure applied directly to the artery vein mostly accurate reading
20. To ensure that the brachial artery is palpable and position the stethoscope
21. Pressure in the inflated cuff must be greater than the systolic pressure to accurate the
flow of the blood through the brachial artery
22. Using a slow of flatting allows you to determine the point of gauze
24. To avoid transfer of microorganism
25. To obtain accurate result
26. To have fast recovery of the patient
27. Record purposes
28. To avoid cross contamination
29. To prevent from microorganism
30. To have organized work
References:
Assessment of Apical Pulse
Definition:
- The central pulse located at the apex of the heart. It is indicated for clients/patients
whose peripheral pulse is irregular as well as for clients with known cardiovascular,
pulmonary and renal disease.
Purposes:
1. To establish baseline data for subsequent evaluation.

2. To determine whether the cardiac rate is within normal range and rhythm is regular.
3. To monitor the client with cardiac disease and those receiving medications to improve
heart action.
Principles:
1. Observe professional ethics and cleanliness.

2. Count in one full minute.
Equipment:
1. Watch with second 3. Antiseptic solution 6. Paper

hand 4. Cotton balls
2. Stethoscope 5. Pencil
Rationales:

4. To decrease anxiety of the patient.
5. Prevent contamination and spreading of microorganism.
6. To get accurate result.
7. The metal is cold and can startle the client when place immediately on chest.
8. To have accurate result.
9. The heartbeat is normally loudest over the apex of the heart.
10. For documentation.
11. To make patient comfortable.
12. For the patient to be relax.
13. To prevent contamination.
To prevent the spread of microorganism.
Reference:
Offering and Removing a Bedpan and Urinal
Definition:
- This procedure covers and offers an aspect of elimination by providing a barrier to

prevent slopping and irritation and to maintain comfort, modesty, and privacy to the
patient.
Purposes:
1. Provides facilities for elimination if the patient is unable to use the bathroom or bedside
commode.
2. Provides privacy and comfort to the patient.
3. Maintains modesty to the patient.
Principles:
1. Observe infection control measure throughout for your protection as well as the patient.
2. Maintain straightforward attitude and respect the patient’s privacy, keeping exposure to
the minimum.
3. If bedpan is metal, warm it by rinsing it with warm water.
Equipment:
1. Bedpan/Urinal 3. Towel 5. Tissue paper

2. Gloves 4. Waste receptacle 6. Bell
Rationales:

3. To secure patient’s privacy and to avoid the spread of microorganisms.
4. To avoid the spread of microorganisms because floor is considered contaminated.
5. To prevent muscle strains and promote body mechanics.
6. To avoid the patient from risk of falling.
7. Soiled bedpan makes patient tense thus hinder elimination. Powder prevents sticking of
bedpan to patient’s buttocks.
8. To facilitate easy insertion of bedpan.
9. To support the client.
10. To avoid back pain.
11. To prevent spillage of fluids.
12. To provide privacy.
13. Prevents transferring of microorganisms into the urinary meatus.
14. Washing prevents skin abrasion and excessive accumulation of microorganisms.
15. Soiled draw sheet can make patient prone to skin irritation.
17. Don gloving can prevent direct contact with microorganisms.
19. To avoid spillage of the fluids.
20. To leave an accurate documentation.
Reference:
Singapore 629733, Page 1338
Morning Care
Definition:
- A care provided as patient awaken in the morning. It is often provided after client’s
breakfast although it may be before breakfast.
Purposes:
1. To clean the patient before the physician will visit him/her.

2. To promote comfort and hygiene.
3. To help improve self-image.
4. To give the nurse an opportunity to strengthen the nurse-patient relationship.
Principles:
1. Medical handwashing should be done before and after the procedure.

2. Comfort and safety of the client should be considered.
3. Observe proper body mechanics.
Equipment:
1. Linens 6. Basin 11. Mouthwash

2. Bedpan/Urinal 7. Face towel 12. Razor (optional)
3. Towel 8. Kidney basin 13. Comb
4. Waste receptacle 9. Toothbrush 14. Bath towel
5. Tissue paper 10. Toothpaste 15. Bell
Rationales:

4. To avoid contamination and to avoid the patient from falling.
5. Rolled towel prevents the patient from acquiring back pain.
7. Prevents offensive cold and skin irritation.
8. Prevents bed from getting wet.
9. Prevents cross-contamination from any microorganisms.
10. Facilitates tooth brushing.
11. Helps determine type of hygiene that the client needs.
12. To assist in tooth brushing.
13. It facilitates removal of plaques and tartar and cleanses the surface area of the teeth.
14. Helps remove debris from patient’s mouth.
15. Helps provide cleanliness and neat appearance.
16. This can be done with patient’s consent.
17. Prevents bed from getting wet.
18. Prevents secretion from entering and irritating the nasolacrimal ducts.
19. Soap has drying effect and irritation maybe avoided as a matter of personal preferences.
Firm upward strokes prevent the skin from sagging.
20. Prevents the spread of microorganisms.
21. Provides warmth and comfort.
22. Provide privacy in eating.
23. To prepare for the next use.
Reference:
Singapore 629733, Page 742
Cleansing Bed Bath
Definition:
- This kind of bath is to cleanse and refresh the patient. It also aids to stimulate circulation
for an increase of elimination through the skin.
Purposes:
1. To remove transient microorganism, body secretions and excretions, and dead skin
cells.
2. To stimulate circulation of the skin.
3. To promote a sense of well-being.
4. To produce relaxation and comfort.
5. To prevent and eliminate unpleasant body odors.
Principles:
1. Before bathing a client, determine first the type of bath, self-care ability, any movement
or positioning precautions, and etc.
2. Perform hand hygiene.
3. Provide for client’s privacy.
Equipment:
1. Basin 5. Patient’s gown 9. Gloves (if

2. Mitten 6. Soap appropriate,
3. Paper lining 7. Soap dish necessary)
4. Bath blanket 8. Bath towels
Rationales:

2. To gain the patient’s cooperation.
3. To provide privacy to the patient.
4. Air currents increase loss of heat from the body by convection.
5. To save time and effort and to prevent the excess water from the basin to spill at the
working area.
6. To facilitate easy placement of the bath blanket.
7. The bath blanket provides comfort, warmth, and privacy.
8. Warm water and activity can help circulation of the skin.
9. To prevent the bed from getting wet and also to prevent cross-contamination.
10. A bath mitt retains water and heat better than a cloth loosely held and prevents ends of
washcloth from dragging across the skin.
11. This prevents secretion from entering the nasolacrimal ducts.
12. To eliminate dirt. Rinsing will prevent the skin from dying and irritation.
13. Spreading the towel lengthwise protects the bed from becoming wet.
14. This will promote circulation by increasing venous blood return.
15. This will keep the client warm while preventing unnecessary exposure of the chest.
16. Firm strokes from distal to proximal areas promote circulation by increasing venous
blood return.
17. This will avoid irritation of the respiratory tract by powder inhalation. Excessive powder,
however, can cause caking, which leads to skin irritation.
18. Also to promote circulation by stimulating venous blood return.
19. Flexing will promote relaxation. Bath towel will prevent the bed from getting wet.
20. To remove dirt from the foot (feet). Soaking loosens dirt.
21. To help eliminate growing bacteria from the perineum. Using clean water will ensure the
safety of the patient.
22. To provide comfort to the patient.
23. To make patient comfortable, preventing the risk of irritation on skin.
24. To promote clean hygiene on patient’s nails.
25. To help patient rest and feel relax.
26. To provide a clean environment to the patient.
References:
Tepid Sponge Bath
Definition:
- This type of cleansing bath is given to clients who are at risk of fever or having a high
temperature.
Purposes:
1. To lower down body temperature.

2. To give warmth and comfort.
3. To stimulate circulation of the blood.
Principles:
1. Provide for patient’s privacy.

2. Assist client’s vital signs.
3. Obtain physician’s order if client has certain problems.
Equipment:
1. Washcloth for mitten 4. Bath blanket 7. Bath towel

2. Hot water bag 5. Basin with water 8. Bedpan and Urinal (if
3. Ice bag 6. Soap necessary)
Rationales:
1. To make sure if the client is not contraindicated with the procedure.

6. The client will be more comfortable after voiding.
7. Bath blanket provides warmth, comfort, and privacy.
8. To help lower down body temperature.
9. To promote homoeostasis.
10. Sponging promote circulation by increasing venous blood return; also to help lower down
body temperature.
11. To prevent the skin from acquiring skin irritation and to help reduce chilling.
12. To slowly finish the procedure.
13. To have that neat appearance and promoting client’s self-image and comfort.
14. To promote flow of fresh air.
15. To help excess sweat comes out from the body to lower down body temperature.
16. To let the patient relax after the procedure.
17. To prevent cross-contamination.
18. To recheck if there is any changes in the patient’s vital signs after doing the procedure.
19. For documentation purposes.
Reference:
Special Mouth Care
Definition:
- This type of hygiene care is provided for clients who are debilitated or unconscious or
who has excessive dryness, sores, or irritations on the mouth.
Purposes:
1. To maintain the intactness and health of the lips, tongue, and mucous membranes of the
mouth.
2. To prevent oral infections.
3. To clean and moisten the membranes of the mouth and lips.
Principles:
1. Inspect lips, gums, oral mucosa, and tongue for deviations from normal.
2. Assess the client’s usual mouth care practices.
3. Check if the client has bridgework or wears dentures.
Equipment:
1. Towel 4. Mouthwash 7. 2% Lysol solution

2. Kidney basin 5. Lubricants
3. Toothbrush or tongue 6. Suction machine (if
depressor necessary)
Rationales:

2. To identify mouth problems of the patient.
4. To prevent the patient from getting wet.
5. Brushing removes bacteria and freshens breath.
6. To help dissolve mucus and reduce the saliva’s acidity which helps decrease bacteria.
7. Rinsing removes cleaning agent and food particles. Use suction because fluid remaining
in the mouth may be aspirated in the lungs.
8. To prevent liquid from draining down and wetting the patient and the bed.
9. To remove excess debris from the mouth and also to promote comfort and sense of well-
being.
10. Lubrication prevents cracking and subsequent infection.
11. To make the patient relax and feel the sense of well-being.
13. To prepare the kidney basin for cleaning.
14. To eliminate microorganisms and infection that might left in the kidney basin.
Reference:
Shampoo on Bed
Definition:
- A type of procedure that washes the patient’s hair while on bed because they cannot get
out of the bed due to certain illness.
Purposes:
1. To stimulate blood circulation to the scalp.

2. To distribute hair oils and provide a healthy sheen.
3. To increase the client’s comfort.
4. To assess or monitor hair scalps problems.
Principles:
1. Determine routinely used shampoo products.

2. Provide privacy when doing the procedure.
3. Conduct on-going assessments such as any scalp problems or intolerance to the
procedure.
4. Report any problems noted to the nurse in-charge.
Equipment:
1. Diluted shampoo 3. Bath blanket 5. Pitcher with water

2. Washcloth 4. Basins/Pails 6. Kelly’s pad
Rationales:

3. To prevent the pillow from getting wet and to avoid hyperextend of the neck.
4. To keep the bed dry.
5. Bath towel collects any removed hair, dirt, and scally material.
6. Kelly’s pad keeps the bed dry.
7. To make the patient comfortable and to prevent undue strain.
8. To avoid water from entering the ears.
9. To make the patient relax and washcloth will protect the eyes from soapy water.
10. Massaging stimulates the blood circulation of the scalp. The pads of the fingers are used
so that the fingernails will not scratch the scalp.
11. Shampoo remaining in the hair may dry and irritate the hair and scalp.
12. To provide warmth and comfort.
13. To have that good appearance on the patient.
References:
Post Mortem Care
Definition:
- Post mortem care is a care given to patients who are pronounced dead by the attending
physician. This is to provide them clean hygiene even if they are now dead.
Purposes:
1. To provide a clean hygiene to the dead patient.

2. To make dead patient presentable when doing the embalming.
3. To respect and give dignity to the dead patients.
Principles:
1. Inform supervisors and the relatives if patient has pronounced dead by the attending
physician.
2. Respect the beliefs of the relatives/kin of the patient.
3. Even if patient is dead, still provide them privacy in doing the procedure.
Equipment:
1. Mask 5. Sterile forceps 9. Nail cutter

2. Gown 6. CBB Equipment 10. Identification cards
3. Sterile gloves 7. Comb
4. Cotton balls 8. 2% Lysol solution
Rationales:
1. This is to inform the supervisor that the patient is now pronounced dead.
4. This is to talk and give emotional advices to the relatives of the dead.
6. To provide privacy to the dead patient.
8. This is to do the procedure easily.
9. To be ready for the procedure and to avoid the threat of rigor mortis.
10. This is to keep the dead body presentable.
11. To make sure that the dead body is in the normal image.
12. To ensure that dead patient’s eyes are normally closed without the presence of rigor
mortis.
13. To avoid the infectious microorganisms to enter the ears and the nose.
14. To avoid the infectious microorganisms to enter the rectum.
15. To avoid the infectious microorganisms to enter the vagina.
17. To readily clean the dead body.
18. To provide hygiene care of the dead patient’s nails.
19. To prevent over pressure and to avoid the stiffness of the muscles when rigor mortis
occurred.
20. To prepare the dead patient.
21. To have that presentable hair of the dead patient.
22. To identify the dead patient.
23. To secure the dead patient and to be ready for the embalming.
24. To securely identify the patient.
25. Because male attendant are capable of carrying heavy things such as the dead body of
a dead patient.
26. To separate soiled dressings with CD and non-CD cases can avoid the spread of
infection.
27. To avoid cross-infection.
28. To sterilize the forceps used in the procedure.
29. To decontaminate the area.
Reference:
Per Orem Medication
Definition:
- A type of medication that is given to a patient by mouth as order by the physician.
Purposes:
1. To provide medication that has systematic effects or local effects on gastrointestinal tract
or both.
2. To cure client’s certain disease.
3. To make patient have his/her fast recovery.
Principles:
1. Check the drug label three times.

2. Secure the appropriate amount of drug as per order by physician.
3. Use always the medicine ticket to make sure that you are giving the right medicine to the
right patient.
Equipment:
1. Medicine Ticket 4. Medicines/drugs 8. Lysol solution

2. Disposable 5. Tissue paper 9. Soap
medication cup 6. Glass of water
3. Trays 7. Towels
Rationales:
1. To prepare for the procedure.

5. To avoid errors in giving the medicine.
6. Organization of supplies saves time and reduces the chance of errors.
For Liquid Medication:
1. To make sure you are giving the right medicine to the right patient.
2. To avoid unnecessary errors.
3. To make sure that you are giving the exact amount of medicine to be taken by the
patient.
4. This is to prepare for the giving of the medicine.
5. This prevents the cap from sticking.
6. To avoid unnecessary errors.
For tablets, capsules, caplets, and spansules medicine:
1. To make sure you are giving the right medicine to the patient.
2. Certain medications have a specified time frame at which they expire and need to be
reordered by the primary care provider.
3. This third safety check reduces the chance of errors.
Continuation of Liquid Medication:
7. To make sure that you are giving the right medicine to the right patient.
9. To know the right patient for the certain medicine and information can facilitate
acceptance of and compliance with therapy.
10. To avoid aspirating the medicine to the lungs.
11. To avoid spillage of medicine to the patient’s clothing.
12. To provide comfort and to remove debris of medicines from the mouth.
13. To know if the medicines were already administered.
14. For the patient to be relax.
After Care:
15. To reduce the number of microorganisms.

16. To sterilized the medicine glass.
References:
Administering Intradermal and Intramuscular Injection
Definition:
Intradermal Injection
- Intradermal injection are injections given to a patient in which the goal is to empty the
contents of the syringe between the layers of the skin.
Intramuscular Injection
- An intramuscular injection is a technique used to deliver a medication deep into the

muscles. This allows the medication to be absorbed into the bloodstream quickly.
Purposes:
1. To determine if client is allergic.

2. To create a baseline data.
3. To conduct skin allergy test.
1. To provide medication that a client needs.

2. To cure client’s disease.
3. To have fast recovery of the patient.
Principles:
1. Wash hands before doing the procedure.

2. Sterile syringe and a needle should be prepared and placed on a sterile tray.
1. Check the medication administration record.

2. Expel the air from the syringe.
3. Check the label of medication carefully.
Equipment:
1. Vial or ampule 5. Distilled water 9. Medicine tray

2. Sterile syringe 6. Withdrawing needle 10. Black or blue ballpen
3. Alcohol swabs 7. Injecting needle
4. Cotton balls 8. Medicine ticket
Rationales:
1. To reduce the possibility of drug errors.

2. To check if we are assessing the right patient.
3. To reduce the transfer of microorganisms.
4. To avoid the chance of drug errors and to prevent the spread of microorganisms.
5. To maintain the sterility of the equipment.
Ampules

3. To protect your fingers from pricking into the needle.
4. To prepare for the administration of the medicine.
5. This is to prepare for the administration of medicine.
6. To be ready for the administration of injection.
Vial Liquid Form
1. To sterilized the file and to prevent the spread of microorganisms.

3. This is to make sure you are following the right physician’s order. Also to save time and
energy.
4. To be ready for the administration of the drug.
Vial Powdered Form
1. To maintain the sterility of the syringe.

3. It is because the withdrawing needle is only use for withdrawing the liquid.
4. Distilled water should mix to the medication given.
Intradermal Preparation
1. To be ready with the injection.

3. The withdrawing needle is not capable for injection.
4. To be ready with the injection.
6. To prepare for the procedure.
7. To verify if you are administering the right patient.
8. If air is injected, it may gain entry to the blood stream and block a blood vessel which will
cause, may be death of the patient.
9. Taut skin allows for easier entry of the needle.
10. Facilitates needle placement just below the epidermis.
11. Blab formation confirms proper drug administration.
12. Prevents tissue trauma.
13. Aids in re-assessment of the injected site.
14. To get an accurate result.
Intramuscular Preparation
1. To eliminate microorganisms on the site and if air is accidentally injected, it will gain
entry to the bloodstream and block a blood vessel that will cause harm to the patient.
2. To facilitate easy insertion of the needle and to avoid accidental injecting of the blood
vessel.
3. This will help reduce the discomfort of the patient.
4. To prepare for the administration of the intramuscular drug.
5. Using a quick motion of withdrawing the needle will lessen the client’s discomfort.
8. To check for the patient’s reaction.
Z Tract Technique
1. To facilitate easy insertion of the needle to the patient’s muscle.

2. This is to make sure that the medicine is correctly administered to the muscle.
3. This is to reduce patient’s discomfort.
Reference:
Positioning and Draping the Patient
Definition:
Positioning – is the proper way of placing the patient for certain procedures and/or examinations.
Draping – is the covering of the patient.
Purposes:
Positioning
1. To prevent muscle discomfort to the patient.

2. To provide safety and comfort.
Draping

2. To decrease anxiety of the patient.
Principles:

2. Keep client comfortable.
3. Always provide privacy to the patient.
Equipment:
1. Pillow 4. Rolled Towels 7. Foot board

2. Hospital Gowns 5. Eyesheet
3. Blanket 6. Sand bags
DORSAL RECUMBENT POSITION
Definition:
- Back-lying position with knees flexed and hip externally rotated; small pillow under the head.
Rationales:
1. To gain patient’s cooperation and reduce anxiety.

2. To have easy access to the body areas to be examined.
3. To expose the area to be examined.
4. To support the neck of the patient and to avoid strain.
5. Minimum exposure lessens embarrassment.
6. To prevent unnecessary exposure.
LITHOTOMY POSITION
Definition:
- Back-lying position with feet supported by stirrups; hips should be in line with the table.
Rationales:
1. To prepare patient for examination.

2. To have an easy access to the body to the body area to be examined.
3. To prevent the linens from getting soiled.
4. To expose only the body parts to be examined.
SIM’S POSITION
Definition:
- Side-lying position with lower most arm behind the body and upper most leg flexed.
Rationales:
1. To facilitate exposure to the body parts to be examined.

2. Provide comfort to the patient.
3. To facilitate exposure to the parts to be examined.
4. To expose the part to be examined.
ERECT POSTION
Definition:
- The patient stands erect with feet forward, arms hanging to the sides.
Rationale:
1. To assess gait, gesture, and balance.
PRONE POSITION
Definition:
- Patient lies on his abdomen; face-lying position with or without small pillow.
Rationale:
1. To prepare patient for examination.
DORSAL OR SUPINE POSITION
Definition:
- Back-lying position with or without pillow.
Rationales:
1. To prepare for examination.

3. To prevent body strain.
FOWLER’S POSTION
Definition:
- Head and trunk are raised 45° to 60° relative to the heels and knees may not be reflexed.
Rationales:

SEMI-FOWLER’S POSITION
Definition:
- Head and trunk are raised to 15° to 45°. Sometimes called low fowler’s and typically means 30 of
elevation.
Rationale:
HIGH FOWLER’S POSITION
Definition:
- Head and trunk are raised to 60° to 90°.
Purposes:
1. Position of choice for people who have difficulty in breathing.

2. Some with heart problems.
Rationale:
KNEE-CHEST OR GENITOPECTORAL POSTION
Definition:
- Kneeling position with torso at 90° angle to hips; area to be examined is rectum.
Rationales:

2. To facilitate breathing and provide comfort.
3. To prevent arm strain and provide comfort.
4. Expose the part to be examined.
HYPEREXTENSION POSITION
Definition:
- The patient’s cervical spine is hyperextended when looking over the ceiling.
Rationale:
1. To be ready for the examination.
TRENDELENBURG POSITION
Definition:
- Patient lies flat on his back with the legs together with the foot.
Rationale:
1. To promote venous circulation.
REVERSE TRENDELENBURG POSITION
Definition:
- Head of bed raised and foot lowered.
Rationale:
1. To promote stomach emptying and to prevent esophageal reflux..
SHOCK POSITION
Definition:
- Head is supported with pillow.

Rationale:
1. Preparation for examination.
ORTHOPNEIC POSITION
Definition:
- Client sits either in bed or side of the bed.
Rationale:
1. To facilitate respiration.
SITTING POSITION
Definition:
- A seated position; areas to be examined are head, neck, posterior and anterior thorax.
Rationale:
Reference:
Kozier, Barbara et al. Fundamentals of Nursing: Concepts, Process, and Practice, Eighth Edition, Volume
2, Pearson Education South Asia Pte Ltd., 23-25 First Lok Yang Road, Jurong, Singapore 629733, Pages
1130 - 1141
Basic Perineal Care
Definition:
- It is a procedure done in cleaning the perineum including the external genital of the
patient.
Purposes:
1. To remove normal perineal secretion and odor.

2. To prevent infection.
3. To promote client comfort.
Principles:
1. Always wash the hands before and after the procedure.

2. Explain the procedure to the patient.
3. Provide privacy.
4. Keep the equipment within reach.
Equipment:
1. Bath towel 7. Cotton balls wet with 11. Gloves (for male
2. Bedpan prescribed solution patients)
3. Waste receptacle 8. Pitcher with warm
4. Picking forceps water (43°C to 46°C
5. Dressing forceps or 110°F to 115°F)
6. Sterile dry cotton 9. Rubber sheet
balls 10. Cotton draw sheet
Rationales:
For Female Client
1. To gain cooperation and reduces anxiety.

3. For easy access of the equipment.
4. To provide privacy. Hygiene is a personal matter.
5. To prevent the beddings from getting wet. Towel will dry the buttocks.
6. Minimum exposure lessens embarrassment and provides warmth.
7. Warm water and activity can stimulate the need to void.
8. To facilitate easy disposal of waste material.
9. To wash out the dirt from the vulva. The pitcher should not touch the vulva to prevent
contamination.
10. Using separate cotton balls for each stroke prevents the transmission of microorganisms
from one area to another. Start cleaning from distal to proximal area.
11. Moisture supports the growth of microorganisms.
12. To keep the client dry and comfortable.
13. Wrinkle-free beddings will prevent skin irritation.
14. To prevent contamination and be ready for the next use.
For Male Client
1. To make patient comfortable and to avoid body strains.

3. To expose the glans penis (top of the penis). Retracting the foreskin is necessary to
remove the smegma (thick, cheesy secretion) that collects under the foreskin that will
facilitate the bacterial growth.
4. This will ensure thorough cleaning of the area.
5. This will ensure thorough cleaning of the area.
6. The scrotum tends to be more soiled than the penis because of its proximity to the
rectum, thus it is usually clean after the penis.
7. To thoroughly clean the area.
8. To avoid skin irritation.
9. Moisture supports the growth of microorganisms.
10. Replacing the foreskin prevents constriction of the penis, which may cause edema.
11. To clean the area.
12. Wrinkle-free beddings will prevent skin irritation.
13. To prevent contamination and be ready for the next use.
Reference:
Physical Assessment
Definition:
- Physical Assessment is an evaluation of the body and its function using IPPA
(Inspection, Palpation, Percussion, and Auscultation) and involves the detailed
examination of the body from head to toe.
Purposes:
1. To obtain baseline data about the client’s functional abilities.

2. To supplement, confirm, and refute data obtained in the nursing history.
3. To obtain data that will help establish nursing diagnosis and plans of care.
4. To evaluate the physiologic outcomes of health care and thus the progress of a client’s
health problems.
5. To make clinical judgments about a client’s health status.
6. To identify areas for health promotion and disease prevention.
Principles:
1. In performing Physical Assessment, always provide client’s privacy.

2. Always explain the procedure/assessment to the client.
3. Wash your hands before and after the procedure.
Equipment:
1. Height Chart 8. Nasal speculum 14. Cotton applicators

2. Weighing Scale 9. Opthalmoscope 15. Gloves
3. Sphygmomanometer 10. Otoscope 16. Lubricants
4. Stethoscope 11. Percussion (reflex) 17. Tongue blades
5. Digital Thermometer hammer (depressors)
6. Skinfold’s caliper 12. Tuning fork 18. Snellen’s chart
7. Flashlight or penlight 13. Vaginal Speculum
Rationales:
1. To promote organization and prevents the nurse from leaving the client to search for a
piece of equipment.
4. To gain patient’s cooperation and to reduce anxiety.
Normal and Abnormal Findings
GENERAL SURVEY
NORMAL FINDINGS ABNORMAL FINDINGS

1. Proportionate, varies with lifestyle. Excessively thin or obese.
2. Relaxed, erect posture; coordinated Tense, slouched, bent posture, uncoordinated
movement. movements; tremors.
3. Clean, neat Dirty, unkempt
4. No body odor or minor body odor relative to Foul body odor, ammonia odor, acetone
work or exercise; no breath odor. breath odor,; foul breath.
5. No distress noted. Bending over because of abdominal pain,
wincing, frowning, or labored breath.
6. Healthy appearance. Pallor; weakness; lesions
7. Cooperative, able to follow instructions. Negative, hostile, withdrawn.
8. Appropriate to situation. Inappropriate to situation.
9. Healthy appearance Pallor; weakness; lesions
10. Cooperative, able to follow instructions. Negative, hostile, withdrawn.
11. Appropriate to situation. Inappropriate to situation.

12. Understandable, moderate pace; clear Rapid or slow pace; overly loud or soft; uses
tone and inflection; exhibits thought generalizations; lacks association.
association.
13. Logical sequence; make sense; has sense Illogical sequence; flight of ideas; confusion;
of reality. vague.
14. Can follow and elaborate Cannot follow and cannot elaborate.
15. This is to prepare for the examination ---------------------------------------------------------
SKIN

1. Varies from light to deep brown; from ruddy Pallor, cyanosis, jaundice, erythema.
pink to light pink; from yellow overtones to
olive.
2. Generally uniform except in areas exposed Areas of either hyperpigmentation or
to the sun; areas of lighter pigmentation hypopigmentation.
(palms, lips, nail beds) in dark-skin people.
3. No edema Has edema (See the scale for describing
edema)
4. Freckles, some birthmarks, some flat and Various interruptions in skin integrity; irregular,
raised nevi; no abrasions or other lesions. multicolored, or raised nevi.
5. Moisture in skin folds and the axillae (varies Excessive moisture (e.g. in hyperthermia),
with environmental temperature and humidity, excessive dryness (e.g. in dehydration)
body temperature, and activity.)
6. Uniform; with normal range. Generalized hyperthermia (e.g. in fever);
generalized hypothermia (e.g. in shock);
localized hyperthermia (e.g. in infection);
localized hypothermia (e.g. in arteriosclerosis).
7. When pinch, skin springs back to previous Skin stays pinched or tented or moves back
state; may be slower in elders. slowly (e.g. in dehydration)
SCALP AND HAIR

1. Evenly distributed hair. Patches of hair loss (i.e., alopecia).
2. Silky, resilient hair. Brittle hair (e.g., hypothyroidism); excessively
oily or dry hair.
3. No infection or infestation. Flaking, sores, lice, nits (louse eggs), and
ringworm.
4. Variable. Hirsutism (abnormal hairiness) in women;
naturally absent or sparse leg hair (poor
circulation).
NAILS

1. Convex curvature; angle of nail plate about Spoon nail; clubbing (180° or greater).
160°.
2. Smooth texture. Excessive thickness or thinness or presence
of grooves or furrows; Beau’s lines;
discoloured or detached nail - often due to
fungus.
3. Highly vascular and pink in light-skinned Bluish or purplish pint (may reflect cyanosis);
clients; dark-skinned clients may have brown pallor (may reflect poor arterial circulation).
or black pigmentation in longitudinal streaks.
4. Intact epidermis. Hang nails; paronychia (inflammation).
5. Prompt return of pink or usual color Delayed return of pink or usual color (may
(generally less than 4 seconds). indicate circulatory impairment).
HEAD AND FACE

1. Rounded (normocephalic and symmetric, Lack of symmetry; increased skull size with
with frontal, parietal, and occipital more prominent nose and forehead; longer
prominences); smooth skull contour. mandible (may indicate excessive growth
hormone or increased bone thickness).
2. Smooth, uniform consistency; absence of Sebaceous cyst; local deformities from
nodules or masses. trauma; masses, nodules.
3. Symmetric or slightly asymmetric facial Increased facial hair; thinning of eyebrows;
features; palpebral facial fissures equal in size; asymmetric features; exophthalmos;
symmetric nasolabial folds. myxedema faces; moon face.
4. Symmetric facial movements. Asymmetric facial movements (e.g. eye on
affected side cannot close completely);
drooping of eyelid and mouth; involuntary
facial movements (i.e. tics or tremors).
5. Symmetric sensations Asymmetric sensations of forehead, cheeks,
and chin
6. Elastic and tender Non-elastic and non-tender
7. Not tender, no swelling, and crepitation Tender, swelling, and with crepitation
EYES AND VISION
1. Hair evenly distributed; skin intact. Loss of hair; scaling and flakiness of skin.
Eyebrows symmetrically aligned; equal Unequal alignment and movement of
movement. eyebrows.
2. Equally distributed; curled slightly outward Turned inward
3. Skin intact; no discharge; no discoloration. Redness, swelling, flaking, crusting, plaques,

Lids close symmetrically. Approximately 15 to discharge, nodules, lesions. Lids close
20 involuntary blinks per minute; bilateral asymmetrically, incompletely, or painfully.
blinking. Rapid, monocular, absent, or infrequent
blinking. Ptosis, or entropion; rim of sclera
visible between lid and iris.
4. Transparent; capillaries sometimes evident; Jaundiced sclera (e.g., in liver disease);

sclera appears white (darker or yellowish and excessively pale sclera (e.g., in anemia);
with small brown macules in dark-skinned reddened sclera; lesions or nodules (may
clients) indicate damage by mechanical, chemical,
allergenic, or bacterial agents).
5. Shiny, smooth, and pink or red Extremely pale (possible anemia); extremely
red (inflammation); nodules or other lesions
RATIONALE
6.a. Closing the eyelids contracts the orbicular muscle, which prevents lid eversion.
6.b. Upward or outward pulling on the eyelashes causes muscle contraction
6.c. These actions evert the lid, that is, flip the lower part of the lid over on top of itself
6.d. This is to detect sensitivity of the eyelids
6.e. Pinkish conjunctiva, moist in texture, no Reddish conjunctiva (may indicate

lesions and no foreign bodies. inflammation); dry in texture, with lesions and
foreign bodies
7. No edema or tenderness over lacrimal Swelling or tenderness over lacrimal gland

gland
8. No edema or tearing Evidence of increased tearing; regurgitation of

fluid on palpation of lacrimal sac
9. Transparent, shiny and smooth; details of Opaque; surface not smooth (may be the result
the iris are visible. In older people, a thin, of trauma or abrasion). Arcus senilis in clients
grayish white ring around the margin, called under age 40.
arcus senilis, may be evident.
10. Client blinks when the cornea is touched, One or both eyelids fail to respond.
indicating that the trigeminal nerve is intact.
11. Transparent. No shadows of light on iris. Cloudy. Crescent-shaped shadows on far side
Depth of about 3 mm. of iris. Shallow chamber (possible glaucoma)
12. Black in color; equal in size; normally 3 to Cloudiness, mydriasis, miosis, anisocoria;
7 mm in diameter; round smooth border, iris bulging of iris toward cornea
flat and round.
13. Illuminated pupil constricts (direct Neither pupil constricts. Unequal responses.
response). Non-illuminated pupils constricts Absent responses.
(consensual response).
14. Pupils constrict when looking at near One or both pupils fail to constrict, dilate, or
objects; pupils dilate when looking at far converge.
objects; pupils converged when near object
is moved toward nose.
15. When looking straight ahead, client can Visual field smaller than normal (possible
see objects in the periphery glaucoma); one-half vision in one or both eyes
(possible nerve damage).
16. Both eyes coordinated, move in unison, Eye movements not coordinated or parallel; one
with parallel alignment or both eyes fail to follow a penlight in specific
directions, e.g., strabismus (cross-eyes)
Nystagmus (rapid involuntary rhythmic eye

movement) other than at end point may indicate
neurologic impairment
17. Light falls symmetrically on both pupils Light falls off center on one eye (indicates
(e.g., at “6 o’clock” on both pupils) misalignment)
18. Uncovered eyes do not move If misalignment is present, when dominant eyes
is covered, the uncovered eye will move to focus
on object.
19. Able to read newsprint Difficulty reading newsprint unless due to aging
process
20. 20/20 vision on Snellen-type chart Denominator of 40 or more on Snellen-type

chart with corrective lens
21. Normal Signs of glaucoma, heart disease, etc.
EARS AND HEARING
1. Color same as facial skin. Bluish color of earlobe (e.g., cyanosis); pallor
(e.g., frostbite); excessive redness
(inflammation or fever)
2. Mobile, firm, and not tender; pinna recoils Lesions (e.g., cysts); flaky, scaly skin (e.g.,
after it is folded. soborrhea); tenderness when moved or
pressed (may indicate inflammation or
infection of external ear)
3. Distal third contains hair follicles and glands Redness and discharge
4. Pearly gray color, semitransparent Pink to red, some opacity.
Yellow-amber
White
Blue or deep red
Dull surface
5. Normal voice tones audible Normal voice tones not audible (e.g., request
nurse to repeat words or statements, leans
toward the speaker, turns the head, cups the
ears, or speaks in loud tone of voice)
A.
Unable to hear ticking in one or both ears
 Able to hear ticking in both ears
B.
Sound is heard better in impaired ear,
 Sound is heard in both ears or is localized
indicating a bone-conductive hearing loss; or
at the center of the head
sound is heard better in ear without a problem,
indicating a sensorineural disturbance (Weber
positive)
Bone conduction time is equal to or longer
than the air condition time i.e., BC > AC or BC
 Air-conducted (AC) hearing is greater than = AC (negative Rinne; indicates a conductive
bone-conducted (BC) hearing, i.e., AC > hearing loss)
BC (positive Rinne)
NOSE AND SINUSES
1. Symmetric and straight Asymmetric
No discharge or flaring Discharge from nares
Uniform color Localized areas of redness or presence of skin

lesions
2. Not tender; no lesions Tenderness on palpation, presence of lesions
3. Air moves freely as the client breathes Air movement is restricted in one or both nares
through the nares
4.Patent, presence of clear watery discharge Not patent
5. Mucosa pink Mucosa red, edematous
Clear, watery discharge Abnormal discharge (e.g., pus)
No lesions Presence of lesions (e.g., polyps)
6. Nasal septum intact and in midline Septum deviated to the right or to the left
7. Not tender Tenderness in one or more sinuses
8. Not tender Tenderness occur
9. There is no presence of inflammed sinus or Presence of inflammed sinus or sinuses

sinuses
MOUTH AND OROPHARYNX
1. Uniform pink color (darker, e.g., bluish hue, Pallor; cyanosis

in Mediterranean groupa and dark skinned
clients) Blisters; generalized or localized sweeling;
fissures, crusts, or scales (may result from
Soft, moist, smooth texture excessive moisture, nutritional deficiency or
fluid deficit)
Symmetry of contour
Inability to pursed lips
Ability to pursed lips
2. Uniform pink color (freckled brown Pallor, leukoplakia (white patches), red,
pigmentation in dark-skinned clients) bleeding)
Moist, smooth, soft, glistering, and elastic Excessive dryness

texture (drier oral mucosa in elderly due to
decreased salivation) Mucosal cysts; irritation from dentures;
abrasions; ulcerations; nodules
3. 32 adult teeth Missing teeth; ill-fitting dentures
Smooth, white, shiny tooth enamel Brown or black discoloration of the enamel
(may indicate staining or the presence of
Pink gums (bluish or brown patches in dark caries)
skinned-clients)
Excessively red gums
Moist, firm texture to gums
Spongy texture; bleeding; tenderness (may
No retraction of gums (pulling away from the indicate periodontal disease)
teeth)
Receding, atrophied gums; swelling that
partially covers the teeth)
4. Smooth, intact dentures Ill-fitting dentures; irritated and excoriated area

under dentures
5. Central position Deviated from center (may indicate damage to

hypoglossal [twelfth cranial] nerve); excessive
Pink color (some brown pigmentation on trembling
tongue borders in dark-skinned clients); moist,
slightly rough; thin whitish coating Smooth red tongue (may indicate iron, vitamin
B12, or vitamin B3 deficiency)
Smooth, lateral margins; no lesions
Dry, furry tongue (associated with fluid deficit
Raised papillae (taste buds) (white coating (may be oral yeast infection)
Nodes, ulcerations, discoloration (white or red

areas); areas of tenderness
6. Moves freely; no tenderness Restricted mobility
7. Smooth tongue base with prominent veins Swelling, ulceration
8. Smooth with no palpable nodules Swelling, nodules
9. Same as color of buccal mucosa and floor Inflammation (redness and swelling)
of mouth
10. Light pink, smooth, soft palate Discoloration (e.g., jaundice or pallor)
Lighter pink hard palate, more irregular texture Palates the same color
Irritations
Exostoses (bony growths) growing from the

hard palate
11. Gag reflex present Absent gag reflex - may indicate problems with
glossopharyngeal (ninth cranial) or vagus
(tenth cranial) nerve
12. Positioned in midline of soft palate Deviation to one side from tumor or trauma;
immobility (may indicate damage to trigeminal
[fifth cranial] nerve or vagus [tenth cranial]
nerve)
13. Pink and smooth posterior wall Redenned or edematous; presence of lesion,
plaques, or discharge
14. Pink and smooth Inflamed
No discharge Presence of discharge
Of normal size or not visible Swollen
 Grade 1 (normal): The tonsils are behind  Grade 2: The tonsils are between the
the tonsillar pillars (the soft structures pillars and the uvula
supporting the soft palate
 Grade 3: The tonsils touch the uvula
 Grade 4: One or both tonsils extend to the

midline of the oropharynx
15. Gag reflex present Absent gag reflex - may indicate problems with
glossopharyngeal (ninth cranial) or vagus
(tenth cranial) nerve
16. Can distinguish taste Cannot distinguish taste
NECK
1. Muscles equal in size; head centered Unilateral neck swellings; head tilted to one
side (indicates presence of masses, injury,
muscle weakness, shortening of
sternocleidomastoid muscle, scars)
2. Coordinated, smooth movements with no Muscle tremor, spasms, or stiffness

discomfort
a.Limited range of motion; painful movements;
a) Head flexes 45° involuntary movements (e.g., up-and-down
nodding movements associated with
b) Head hyperextends 60° Parkinson’s disease
c) Head laterally flexes 40° b.Head hyperextends less than 50°
d) Head laterally rotates 70° c.Head laterally flexes less than 40°
d.Head laterally rotates less than 70°
3.
a) Equal strength a. Unequal strength
b) Equal strength b. Unequal strength
4. Not palpable Enlarged, palpable, possibly tender

(associated with infection and tumors)
5. Central placement in midline of neck; Deviation to one side, indicating possible neck
spaces are equal on both sides tumor; thyroid enlargement; enlarged lymph
nodes
6. Not visible on inspection Visible diffuseness or local enlargement
Glands ascends during swallowing but is not Gland is not fully movable when swallowing
visible
7. Lobes may not be palpated Solitary nodules
If palpated, lobes are small, smooth, centrally

located, painless, and rise freely with
swallowing
8. Absent of bruit Presence of bruit
POSTERIOR AND LATERAL THORAX
1. Anteroposterior to transverse diameter in Barrel chest; increased anteroposterior to

ration of 1:2 transverse diameter
Chest symmetric Chest asymmetric
2. Spine vertically aligned Exagerrated spinal curvatures (kyphosis,

lordosis)
Spinal column is straight, right and left
shoulders and hips are at same height Spinal column deviated from one side, often
accentuated when bending over. Shoulders or
hips not even.
3.
a. Skin intact; uniform temperature a. Skin lesions; areas of hyperthermia
b. Chest wall intact; no tenderness; no masses b. Lumps, bulges; depressions; areas of

tenderness; movable structures (e.g., rib)
4. Full and symmetric chest expansion (i.e., Asymmetric and/or decreased chest
when a client takes a deep breath, your expansion
thumbs should move apart an equal distance
and at the same time; normally the thumbs
separate 3 to 5 cm [1 1/2 to 2 inches] during
deep inspiration)
5. Bilateral symmetry of vocal fremitus Decreased or absent fremitus (associated with

pneumothorax)
Fremitus is heard most clearly at the apex of
the lungs Increased fremitus (associated with
consolidated lung tissue, as in pneumonia)
 Low-pitched voices of males are more
readily palpated than higher pitched
voices of females
6. Percussion notes resonate, except over Asymmetry in percussion

scapula
Areas of dullness or flatness over lung tissue
Lowest point of resonance is at the diaphragm (associated with consolidation of lung tissue or
(i.e., at the level of the eighth to tenth rib a mass)
posteriorly
Note: Percussion on rib normally elicits

dullness
7. Excursion is 3 to 5 cm (11/2 to 2 inches) Restricted excursion (associated with lung

bilaterally in women and 5 to 6 cm (2 to 3 disorder)
inches) in men
Diaphragm is usually slightly higher on the

right side
8. Vesicular and bronchovesicular breath Adventitious breath sounds (e.g., crackles,

sounds gurgles, wheeze, friction rub)
Absence of breath sounds
ANTERIOR THORAX
9. Quiet, rhythmic, and effortless respirations Altered breathing patterns
10. Costal angle is less than 90°, and the ribs Costal angle is widened (associated with
insert into the spine at approximately a 45° chronic obstructive pulmonary disease)
angle
11.
c. Skin intact; uniform temperature c. Skin lesions; areas of hyperthermia
d. Chest wall intact; no tenderness; no masses d. Lumps, bulges; depressions; areas of

tenderness; movable structures (e.g., rib)
12. Full symmetric excursion; thumbs normally Asymmetric and/or decreased respiratory
separate 3 to 5 cm (11/2 to 2 inches) excursion
13. Same as posterior vocal fremitus; fremitus Same as posterior fremitus

is normally decreased over heart and breast
tissue
14. Percussion notes resonate down to the Asymmetry in percussion notes

sixth rib at the level of the diaphragm but are
flat over areas of heavy muscle and bone, dull Areas of dullness or flatness over lung tissue
on areas over the heart and the liver, and
tympanic over the underlying stomach
15. Bronchial and tubular breath sounds Adventitious breath sounds
16. Bronchovesicular and vesicular breath Adventitious breath sounds

sounds
HEART AND CENTRAL VESSELS
1. No pulsations Pulsations
 No pulsations  Pulsations
 No lift or heave  Diffuse lift or heave, indicating enlarged or

overactive right ventricle
 Pulsations visible in 50% of adults and
palpable in most PMI in fifth LICS at or  PMI displaced laterally or lower (indicates
medial to MCL enlarged heart)
 Diameter of 1 to 2 cm (1/3 to 1/2 cm)  Diameter over 2 cm (indicates enlarged

heart or aneurysm)
 No lift or heave
 Diffuse lift or heave lateral to apex
 Aortic pulsations (indicates enlargement or overactivity of
left ventricle)
 Bounding abdominal pulsations (e.g.,

aortic aneurysm)
2. S1: Usually heard at all times Increased or decreased intensity
Usually louder at apical pulse Varying intensity with different beats
S2: Usually heard at all times Increased intensity at aortic area
Usually louder at base of heart Increased intensity at pulmonic area
Systole: silent interval; slightly shorter duration Sharp-sounding ejection clicks

than diastole at normal heart rate (60 to 90
beats/min.) S3: in older adults
Diastole: silent interval; slightly longer duration S4: may be a sign of hypertension
than systole at normal heart rates
S3: in children and young adults
S4: in many older adults
3. Symmetric pulse volume Asymmetric volumes (possible stenosis or

thrombosis
Full pulsations, thrusting quality
Decreased pulsations (may indicate impaired
Quality remains same when client breathes, left cardiac output)
turns head, and changes from sitting to supine
position Increased pulsations
Elastic arterial wall Thickening, hard, rigid, beaded, inelastic walls

(indicate arteriosclerosis)
4. No sound heard on auscultation Presence of bruit in one or both arteries

(suggests occlusive artery disease)
5. Veins not visible (indicating right side of Veins visibly distended (indicating advanced
heart is functioning normally) cardiopulmonary disease)
Bilateral measurements above 3 to 4 cm are

considered elevated (may indicate right-sided
failure)
Unilateral distention (may be caused by local

obstruction)
6. Veins not visible (indicating right side of Veins visibly distended (indicating advanced
heart is functioning normally) cardiopulmonary disease)
Bilateral measurements above 3 to 4 cm are

considered elevated (may indicate right-sided
failure)
Unilateral distention (may be caused by local

obstruction)
PERIPHERAL VASCULAR SYSTEM
1. Symmetric pulse volumes Asymmetric volumes (indicate impaired

circulation)
Full pulsations
Absence of pulsation (indicates arterial
spasms or occlusion)
Decreased, weak, thready pulsations (indicate

impaired cardiac output)
Increased pulse volume (may indicate

hypertension, high cardiac output, or
circulatory overload)
2. In dependent positions, presence of Distended veins in the thigh and/or lower leg
distention and nodular bulges at calves or on posterolateral part of calf from knee to
ankle
When limbs elevated, veins collapse (veins
may appear tortuos or distended in older
people)
3. Limbs not tender Tenderness on palpation
Symmetric in size Pain in calf muscles with forceful dorsiflexion

of the foot (positive Homan’s test)
Warmth and redness over vein
Swelling of one calf or leg
BREAST AND AXILLA
1. Females: Rounded shape; slightly unequal Recent change in breast size; swellings;
in size; generally symmetric marked asymmetry
Males: Breasts even with the chest wall; if

obese, may be similar in shape to female
breasts
2. Skin uniform in color (same in appearance Localized discolorations or hyperpigmentation

as skin of abdomen or back)
Retraction or dimpling (result of scar tissue or
Skin smooth and intact an invasive tumor)
Diffuse symmetric horizontal or vertical Unilateral, localized hypervascular areas

vascular pattern in light-skinned people (associated with increased blood flow
Striae (stretch marks); moles and nevi Swelling or edema appearing as pig skin or
orange peel due to exaggeration of the pores
3. No lesions Presence of lesions
4. Round or oval and bilaterally the same Any asymmetry, mass, or lesions
Color varies widely, from light pink to dark

brown
Irregular placement of sebaceous glands on

the surface of the areola (Montgomery’s
tubercles)
5. Round, everted, and equal in size; similar in Asymmetrical size and color
color; soft and smooth; both nipples point in
the same direction (out in young women and Presence of discharge, crust, or cracks
men, downward in older women)
Recent inversion of one or both nipples
No discharge, except for pregnant or breast-
feeding females
Inversion of one or both nipples that is present

from puberty
6. No tenderness, masses, or nodules Tenderness, masses, nodules
7. No tenderness, masses, nodules, or nipple Tenderness, masses, nodules, or nipple

discharge discharge
8. No tenderness, masses, nodules, or nipple Tenderness, masses, nodules, or nipple

discharge discharge
9. This examination will help detect any abnormalities in the breast
ABDOMEN
1. Unblemished skin Presence of rash or other lesions
Uniform color Tense, glistening skin (may indicate ascites,

edema)
Silver-white striae (stretch marks) or surgical
scars Purple striae (associated with Cushing’s
disease or rapid weight gain and loss)
2.
a) Flat, rounded (convex), or scaphoid a) Distended

(concave)
b) Evidence of enlargement of liver or spleen
b) No evidence of enlargement of liver or
spleen c) Asymmetric contour, e.g., localized
protrusions around umbilicus, inguinal
c) Symmetric contour ligaments, or scars (possible hernia or tumor)
3. Symmetric movements caused by Limited movement due to pain or disease

respirations process
Visible peristalsis in very lean people Visible peristalsis in non-lean clients (possible
bowel obstruction)
Aortic pulsations in thin persons at epigastric
area Marked aortic pulsations
4. No visible vascular pattern Visible venous patterns (dilated veins) is
associated with liver disease, ascites, and
venocaval obstruction
5. Audible bowel sounds Hypoactive, i.e., extremely soft and infrequent

(e.g., one per minute). Hypoactive sounds
Absence of arterial bruits indicate decreased motility and are usually
associated with manipulation of the bowel
Absence of friction rub during surgery, inflammation, paralytic ileus, or
late bowel obstruction
Hyperactive sounds indicate increased

intestinal motility and are usually associated
with diarrhea, an early bowel obstruction, or
the use of laxatives
True absence of sounds (none heard in 3 to 5

minutes) indicates a cessation of intestinal
motility.
6. Tympany over the stomach and gas-filled Large dull areas (associated with presence of
bowels; dullness, especially over the liver and fluid or a tumor)
spleen, or a full bladder
7. 6 to 12 cm (2 1/2 to 3 1/2 inches) in the Enlarged size (associated with liver disease)
midclavicular line; 4 to 8 cm (1 1/2 to 3 inches)
at the midsternal line
8. No tenderness; relaxed abdomen with Tenderness and hypersensitivity

smooth, consistent tension
Superficial masses
Localized areas of increased tension
9. Tenderness may be present near xiphoid Generalized or localized areas of tenderness

process, over cecum, and over sigmoid colon
Mobile or fixed masses
10. May not be palpable Enlarged (abnormal finding, even if liver is

smooth and not tender)
Border feels smooth
Smooth but tender; nodular or hard
11. Not palpable Distended and palpable as smooth, round,

tense mass (indicates urinary retention)
MUSCULOSKELETAL SYSTEM
1. Equal size on both sides of body Atrophy (a decreased in size) or hypertrophy

(an increased in size), asymmetry
2. No contractures Malposition of body part e.g., foot drop (foot

flexed downward)
3. No tremors Presence of tremors
4. Normally firm Atonic (lacking tone)
5. Smooth coordinated muscles Flaccidity (weakness or laxness) or spasticity

(sudden involuntary muscle contraction)
6. Equal strength on each side 25% or less normal strength

7. No deformities Bones misaligned
8. No tenderness or swelling Presence of tenderness or swelling (may

indicate fracture, neoplasms, or osteoporosis)
9. No swelling One or more swollen joints
No tenderness, swelling, crepitation, or Presence of tenderness, swelling, crepitation,

nodules or nodules
Joints move smoothly
10. Varies to some degree in accordance with Limited range of motion in one or more joints
person’s genetic makeup and dgree of
physical activity
NEUROLOGICAL SYSTEM
1. Test for cranial nerves
Cranial Nerve I - Olfactory (Sensory)
- Can identify smell. Has the sense of smell - Loss of sense of smell (anosmia)
Cranial Nerve II - Optic (Sensory)
- Able to read clearly (20/20) on both eyes. - Visual field defects (hemianopias) and
Visual fields are clear. decreased visual acuity or blindness
Cranial Nerve III - Oculomotor (Motor)
- Sphincter of pupil moves; ciliary muscles of - Dysconjugate gaze; gaze weakness or

lens moves paralysis; double vision; dilated pupil, with or
without impaired pupillary reaction to light;
inability to open the affected eyelid
Cranial Nerve IV - Trochlear (Motor)
- Moves eyeball downward and laterally - Dysconjugate gaze, gaze weakness or

paralysis, double vision
Cranial Nerve V - Trigeminal (Sensory)
- Impaired or absent corneal reflex, facial
- Presence of corneal reflex, can detect numbness, jaw weakness
sensitivity to superficial pain.
Cranial Nerve VI - Abducens (Motor)

- Dysconjugate gaze, gaze weakness or
- Lateral eye movement; conjugate movement; paralysis, double vision
sensation of skin and face
Cranial Nerve VII - Facial (Motor and

Sensory)
- Client can smile, whistle, elevates eyebrow, - Facial weakness, inability to completely close
frown, tightly close eyelids against resistance the eyelid, and impaired taste
Cranial Nerve VIII - Auditory (Sensory)
- Client has the equilibrium and sense of - Decreased hearing or deafness and impaired
hearing normally balance
Cranial Nerve IX - Glossopharyngeal (Motor
and Sensory)
- Client can swallow normally, can discriminate
between salt and sugar on posterior third of
the tongue - Difficulty in swallowing (dysphagia) and
impaired taste
Cranial Nerve X - Vagus (Motor and
Sensory)
- Gag reflex is present. Sensation in the

pharynx and larynx, no difficulty in swallowing,
vocal cords moves - Weak or absent gag reflex, difficulty
swallowing, aspiration, hoarseness, and
slurred speech (dysarthria)
Cranial Nerve XI - Accessory
- Can move head without difficulty, can shrug - Weak or absent shoulder shrug and inability
shoulder to turn the head to the side
Cranial Nerve XII - Hypoglossal
- Can protrude tongue, moves tongue up and

down and side to side
- Cannot protrude tongue, cannot move
tongue up and down and side to side
2. Test reflexes
Biceps Reflex
- Flexion at the elbow and contraction of the - No flexion at the elbow and no contraction of
biceps the biceps
Triceps Reflex
- Contraction of the triceps muscle and - No contraction of the triceps muscle and no
extension of the elbow extension of the elbow
Brachioradialis Reflex
- Flexion and supination of the forearm - No flexion and supination of the forearm
Patellar Reflex
- Contraction of the quadriceps and knee - No contraction of the quadriceps and no

extension knee extension
Achilles Reflex
- Produces a plantar flexion - No plantar flexion
Plantar (Babinski’s) Reflex
- All five toes bend downward; this reaction is - The toes spread outward and the big toe
negative Babinski’s response moves upward; a sign of abnormal Babinski’s
response
3. Gross Motor and Balance Tests
Walking Gait
- Has upright posture and steady gait with - Has poor posture and unsteady; irregular,
opposing arm swing; walks unaided; staggering gait with wide stance; bends legs
maintaining balance only from hips; has rigid or no arm movements
Romberg Test
Negative Romberg: may sway slightly but is Positive Romberg: cannot maintain foot
able to maintain upright posture and foot stance; moves the feet apart to maintain
stance stance
If client cannot maintain balance with the eyes
shut, client may have sensory ataxia (lack of
coordination of the voluntary muscles)
If balance cannot maintained whether the eyes

are open or shut , client may have cerebellar
ataxia
Standing on One Foot with Eyes Closed
- Maintains stance for at least 5 seconds - Cannot maintain stance for 5 seconds
Heel-Toe Walking
- Maintains heel-toe walking along a straight - Assumes a wider foot gait to stay upright
line
Toe or Heel Walking

- Cannot maintain balance on toes and heels
- Able to walk several steps on toes or heels
4. Fine Motor Tests for Upper Extremities
Finger-To-Nose Test
- Can repeatedly and rhythmically touches the - Misses the nose or gives slow response
nose
Alternating Supination and Pronation of

Hands on Knees
- Can alternately supinate and pronate hands - Performs with slow, clumsy movements and
at rapid pace irregular timing; has difficulty alternating from
supination to pronation
Finger To Nose and to the Nurse’s Finger
- Misses the finger and moves slowly
- Performs with coordination and rapidity
Fingers to Fingers
- Moves slowly and is unable to touch fingers
- Performs with accuracy and rapidity consistently
Fingers to Thumb (Same Hand)
- Rapidly touches each finger to thumb with - Cannot coordinate this fine discrete
each hand movement with either one or both hands
5. Fine Motor Tests for Lower Extremities
Heel Down Opposite Shin
- Demonstrates bilateral equal coordination - Has tremors or is awkward; heel moves off
shin
Toe or Ball Foot to the Nurse’s Finger
- Misses your finger; cannot coordinate
- Moves smoothly, with coordination movement
6. Light-Touch Sensation
- Light tickling or touch sensation - Anesthesia, hyperesthesia hypoesthesia, or

paresthesia
7. Pain Sensation
- Able to discriminate “sharp” and “dull” - Areas of reduced, heightened, or absent

sensations sensation (map them out for recording
purposes)
8. Temperature Sensation
- Able to discriminate between “hot” and “cold” - Areas of dulled or lost sensation (when
sensation sensations of pain are dulled, temperature
sense is usually also impaired because
distribution of these nerves over the body is
similar)
9. Position or Kinesthetic Sensation
- Can readily determine the position of fingers - Unable to determine the position of one or
and toes more fingers
10. Tactile Discrimination
One -and-Two-Point Discrimination
- Perception varies widely in adults over - Unable to sense whether one or two ares of
different parts of the body. Normally, a person the skin are being stimulated by pressure
can distinguish between a one-and-two-point
stimulus within the following minimum
distances:
Fingertips: 2.8 mm
Palms of Hands: 8-12 mm
Chest, forearm: 40 mm
Back: 50-70 mm
Upper arm, thigh: 75 mm
Toes: 3-8 mm
Stereognosis (Ability to Recognize Objects

by Touching Them)
- Recognizes common objects - Unable to recognize common objects
Extinction Phenomenon
- Both points of stimulus are felt - Failure to perceive to touch on one side of
the body when two symmetric ares of the body
are touched simultaneously (frequently noted
in clients with lesions of the sensory cortex)
FEMALE GENITALIA AND INGUINAL
Normal Findings Abnormal Findings
1. There are wide variations; generally kinky in Scant pubic hair (may indicate hormonal
the menstruating adult, thinner and straighter problem)
after menopause
Hair growth should not extend to the abdomen
Distributed in the shape of an inverse triangle
2. Pubic skin intact, no lesions Lice, lesions, scars, fissures, swelling,

erythema, excoriations, varicosities, or
Skin of vulva area slightly darker than the rest leukoplakia
of the body
Labia round, full, and relatively symmetric in

adult females
3. Clitoris does not exceed 1 cm in width and 2 Presence of lesions

cm in length
Presence of inflammation, swelling, or
Urethral orifice appears as a small slit and is
the same color as surrounding tissues discharge
No inflammation, swelling or discharge
4. No enlargement or tenderness Enlargement and tenderness
MALE GENITALIA AND INGUINAL
1. Triangular distribution, often spreading up Scant amount or absence of hair

the abdomen
2. Penile skin is intact Presence of lesions, nodules, swellings, or

inflammation
Appears slightly wrinkled and varies in color as
widely as other body skin
Foreskin easily retractable from the glans

penis
Small amount of thick white smegma between

the glans and foreskin
3. Pink and slitlike appearance Inflammation; discharge
Positioned at the tip of the penis Variation in meatal locations (e.g.,

hypospadias, on the underside of the penile
shaft, and epispadias, on the upper side of the
penile shaft)
4. Smooth and semifiirm Presence of tenderness, thickening, or

nodules
Is slightly movable over the underlying
structures Immobility
5. Scrotal skin is darker in color than that of Discolorations; any tightening of the skin (may
the rest of the body and is loose indicate edema or mass)
Size varies with temperature changes (the Marked asymmetry in size

dartos muscles contract when the area is cold
and relax when the area is warm)
Scrotum appears asymmetric (left testis is

usually lower than the right testis
6. Testicles are rubbery, smooth, and free of Testicles are enlarged, with uneven surface
nodules and masses (possible tumor)
Testis is about 2 x 4 cm (0.7 x 1.5 in.) Epididymis is non-resilient and painful
Epididymis is resilient, normally tender, and

softer than the spermatic cord
Spermatic cord is firm
7. No swelling or bulges Swelling or bulge (possible inguinal or femoral

hernia
8. No hernias Presence of hernias
RECTUM AND ANUS

1. Intact perianal skin; usually slightly more Presence of fissures (cracks), ulcers,
pigmented than the skin of the buttocks exconations, inflammations, abscesses,
protruding hemorrhoids (dilated veins seen as
Anal skin is normally more pigmented, reddened protrusions of the skin), lumps or
coarser, and moister than perianal skin and is tumors, fistula openings, or rectal prolapse
usually hairless (varying degrees of protrusion of the rectal
mucous membrane through the anus)
2. Anal sphincter has good tone Hypertonicity of the anal sphincter (may occur
in the presence of an anal fissure or other
lesions that causes contraction)
Hypotonicity of anal sphincter (may occur after

rectal surgery or result from a neurologic
deficiency
Rectal wall is smooth and not tender Rectal wall is tender and nodular
3. Brown color Presence of mucus, blood, or black tarry stool
REFERENCE:

NCM 100 H.A Procedure DPPERR

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Basic Cleaning Procedure

1. To reduce dust that lives on the room.

1. Clean from the ceiling to the floor.

1. Mop 4. Coconut husk 7. Gloves

1. To save time and energy and prevents spread of microorganisms.

1. To save time and effort.

1. To save time and effort.

1. To remove dust on the floor.

1. To facilitate easy removal of dirt on the floor.

1. To facilitate easy removal of dirt on the floor.

Procedure in cleaning a room:

1. To avoid the dust from reaching the furniture.

- It is considered one of the most effective infection control measures.

1. To reduce the number of microorganisms on hands.

1. Clean from least contaminated to most contaminated.

1. Soap 3. Disposable or 4. Tissue paper

1. To save time and effort.

- Basic skill of wearing gloves for routine of sterile procedure.

1. Sterile gloves (disposable)

1. To ensure the sterility of the gloves.

1. To promote the client’s comfort.

1. Mattress 4. Cotton Draw Sheet 7. Pillow

1. To prevent spreading of microorganisms.

1. To provide client’s comfort.

1. Wash hands thoroughly before starting the procedure.

1. Mattress 4. Cotton Draw Sheet 7. Pillow

1. To prevent spreading of microorganisms.

- This is a bed made with a patient occupying it.

1. To conserve the clients energy and maintain healthy status.

1. Observe body mechanics.

1. Mattress 5. Top Sheet 9. Dust Cloth

1. To avoid the spread of microorganisms.

Hot Water Bag Application

1. Measure the temperature of the water using a bath thermometer.

1. Hot water bag 3. Hot water 5. Pitcher

1. To remove transient microorganisms.

1. Always explain the procedure to the patient.

1. Ice bag 3. Cotton flannel 5. Wash cloth

1. To prevent the spread of microorganisms.

- Measurement of Physiologic functioning specifically temperature, pulse, respiration, and

1. To create a baseline data.

1. Pencil or Pen 4. Sphygmomanometer 8. Cotton Balls

1. To save time and energy

1. To establish baseline data for subsequent evaluation.

1. Observe professional ethics and cleanliness.

1. Watch with second 3. Antiseptic solution 6. Paper

1. To prevent the spread of microorganism.

- This procedure covers and offers an aspect of elimination by providing a barrier to

1. Bedpan/Urinal 3. Towel 5. Tissue paper

1. To save time and effort.

1. To clean the patient before the physician will visit him/her.

1. Medical handwashing should be done before and after the procedure.

1. Linens 6. Basin 11. Mouthwash

1. To save time and energy.

Cleansing Bed Bath

1. Basin 5. Patient’s gown 9. Gloves (if

1. To prevent the spread of microorganism.

1. To lower down body temperature.

1. Provide for patient’s privacy.

1. Washcloth for mitten 4. Bath blanket 7. Bath towel

1. To make sure if the client is not contraindicated with the procedure.

Special Mouth Care

1. Towel 4. Mouthwash 7. 2% Lysol solution