Professional Documents
Culture Documents
Determine:
The location of running water and soap or soap substitutes
Assemble the equipment:
Soap
Warm, running water
Disposable or sanitized towels
Wet the hands thoroughly by holding them under the running water, and apply
soap to the hands.
Hold the hands lower than the elbows, so that the water flows from the
arms to the fingertips.
If the soap is liquid, apply 2-4 ml (1 tsp). if it is bar soap, granules, or
sheets, rub them firmly between the hands
Thoroughly wash and rinse the hands.
Use firm, rubbing and circular movements to wash the palm, back and wrist of
each hand. Interlace the fingers and thumbs, and move the hands back and forth.
Continue this motion for 10 seconds.
Apply the soap and wash as described earlier in Step 6, maintaining the hands
uppermost.
After washing and rinsing, use a towel to dry one hand thoroughly in a rotating
motion, from the fingers to the elbows. Use a new towel to dry the other hand and
arm.
For the next items, evaluate the students in general according to the criteria. (5 as the
highest score)
5 4 3 2 1
Mastery
Orderliness
Proper attitude in assessing the client followed.
Ability to answer questions
Proper reporting observed.
Student’s signature: __________________
Evaluator’s Signature: __________________
Comments:_____________________________________________________________________
______________________________________________________________________________
3
Comments:_____________________________________________________________________
______________________________________________________________________________
4
For the next items, evaluate the students in general according to the criteria. (5 as the
highest score)
5 4 3 2 1
Mastery
Orderliness
Proper attitude in assessing the client followed.
Ability to answer questions
Proper reporting observed.
Student’s signature: __________________
Evaluator’s Signature: __________________
Comments:_____________________________________________________________________
______________________________________________________________________________
Comments:_____________________________________________________________________
______________________________________________________________________________
For the next items, evaluate the students in general according to the criteria. (5 as the
highest score)
5 4 3 2 1
Mastery
Orderliness
Proper attitude in assessing the client followed.
Ability to answer questions
Proper reporting observed.
Student’s signature: __________________
Evaluator’s Signature: __________________
Comments:_____________________________________________________________________
______________________________________________________________________________
Comments:_____________________________________________________________________
______________________________________________________________________________
CHECKLIST
Legend:
3-Very Satisfactory 0- Did not perform the procedure
2- Satisfactory 1- Needs Improvement
PROCEDURES 3 2 1 0
1. Wash hands/hand hygiene.
2. Explain procedure to client. Elicit client cooperation and participation.
3. Gather all necessary equipment. Provide for client privacy.
4. Secure adequate assistance to complete task safely.
5. Adjust bed to comfortable working height. Lower side rail on side of bed closest to
you.
6. Follow proper body mechanics guidelines:
When moving a client in bed, position bed so that your legs are slightly bent at
knees and hips.
Maintain natural curves in your back while lifting.
Position one foot slightly in front of other and spread feet apart to create a wide
base for balance.
When arms are placed under client, slowly lean backward onto your back leg
using your body weight to help you lift client to one side of bed.
Do not extend to rotate your back to move a client in bed.
If you cannot move client easily, always ask for and obtain assistance for the
safety of both you and the client.
Be sure floor is not slippery and that bed is locked.
Always use a turning sheet when rolling a client because this gives you better
support and control of client.
7. Position drains tubes and IVs to accommodate client’s new position.
8. Place or assist client into appropriate starting position. Monitor client status, and
provide adequate rest breaks or support as necessary.
Moving from Supine to Side-Lying Position
9. Move client from supine to side –lying position:
Slide your hands underneath client.
Move client to one side of bed by lifting client’s toward you in stages:
First the upper trunk;
Then the lower trunk;
Finally, the legs
Lift client’s body; do not drag client across sheets.
Roll client to side-lying position by placing client’s inside arm next to client’s
body with palm of hand against hip.
Cross clients outside arm and leg toward midline and logroll client toward you.
Use clients outside shoulder and hip for leverage while maintaining stability and
control of top arm and leg.
Maintaining Side-Lying Position
10. Repeat Action 1-8.
11. Use pillows to support client:
Place to support client’s head and arms.
Can be used topside leg, thigh, knee, ankle, and foot.
Move lower arm forward slightly at shoulder and bend elbow for comfort.
If client in unstable, placing a pillow against the back will provide additional
support and keep the client from rolling supine.
Moving from Side-Lying to Prone Position
12. Repeat Actions 1-8.
13. To move to Prone position:
Remove positioning towels, pillows, or others support devices.
Assess if client’s position needs to be adjusted to accommodate continued
movement into prone position.
Move client’s inside arm next to client’s body with palm against hip.
Roll client onto stomach using shoulder and hip as key points of control.
Place the head in a comfortable position to one side without excessive pressure
to sensitive areas.
10
Place pillows under trunk, as needed, to relieve pressure and increase comfort.
Place arms comfortably at client’s side and uncross legs with feet approximately
a foot apart.
Maintaining Prone Position
14. To maintain prone:
Use a shallow pillow or folded towel to support client’s heat comfortably.
Place pillow under abdomen to support back.
Place an additional pillow under lower leg to reduce pressure of toes and
forefoot against bed.
Moving from Prone to Supine Position
15. Repeat Actions 1-8.
16. To move from prone to supine:
Remove positioning towers or pillows.
Slide your hands underneath client.
Move client segmentally to one side of the bed to accommodate the new
position.
Position inside arm next to client’s body with client’s palm next to hip.
Roll client to supine position by logrolling the client toward you using the
client’s outside shoulder and hip for leverage.
Position client away from direction of roll to prevent undue pressure.
When client reaches supine, uncross, the arms and legs and place into anatomic
positions.
CHECKLIST
Legend:
3-Very Satisfactory 0- Did not perform the procedure
2- Satisfactory 1- Needs Improvement
PROCEDURES 3 2 1 0
Moving a Client up in Bed with One Nurse
1. Wash hands/hand hygiene.
2. Inform client of reason for the move and how to assist.
3. Elevate bed to just below waist height. Lower head of bed, if tolerated. Lower
side rails on your side.
4. Remove the pillow. Place against headboard.
5. Have client fold arms across chest.
6. Have client hold on to overhead trapeze, if available.
7. Have client bend knees and place feet flat on bed.
8. Stand at an angle to head of bed with feet apart, facing head of bed, and knees
bent.
9. Slide one hand and arm under client’s shoulder, the other under client’s thigh.
10. Rock forward toward head of bed, lifting client with you. Have client push
with legs.
11. If client has trapeze, have client pull up holding onto trapeze as you move
client upward.
12. Repeat these steps until client is moved up high enough in bed.
13. Returns client’s pillow under the bed.
14. Elevate head of bed, if tolerated by client.
15. Assess client for comfort.
16. Adjust the client’s bedclothes as needed for comfort.
17. Lower bed and elevate side rails.
18. Hand hygiene.
Moving a Client up in Bed with Two or More Nurses
19. Hand hygiene.
20. Inform client of reason for the move and how to assist.
21. Elevate bed to just below waist height. Lower head of bed if tolerated by
client. Lower side rails.
22. With two nurses, place turn or draw sheet under client’s back and head.
23. Roll up draw sheet on each side until it is next to client.
24. Follow Actions 4-7.
25. The nurses stand on either side of bed, at an angle to head of bed, with knees
flexed and feet apart in wide stance.
26. The nurses hold their elbows as close as possible to their bodies.
27. The lead nurse will give signal to move: 1-2-3 go. The nurses will lift up (off
of bed) on turn or draw sheet and forward (toward head of bed) in one smooth
motion. The move is coordinated to transfer client toward head of bed.
Simultaneously, have client push with legs or pull using trapeze.
28. Repeat until client is moved upright enough in bed to be comfortable.
29. Return client’s pillow under head.
30. Elevate head of bed, if tolerated by client.
31. Assess client for comfort.
32. Adjust client’s bedclothes for comfort.
33. Lower bed and elevate side rails.
34. Wash hands/hand hygiene.
For the next items, evaluate the students in general according to the criteria. (5 as the
highest score)
12
5 4 3 2 1
Mastery
Orderliness
Proper attitude in assessing the client followed.
Ability to answer questions
Proper reporting observed.
Student’s signature: __________________
Evaluator’s Signature: __________________
Comments:_____________________________________________________________________
______________________________________________________________________________
Legend:
3-Very Satisfactory 0- Did not perform the procedure
2- Satisfactory 1- Needs Improvement
PROCEDURES 3 2 1 0
1. Inform client about desired purpose and destination.
2. Assess client for ability to assist with transfer and presence of cognitive or
sensory deficits.
3. Lock bed in position. Hand hygiene.
4. Place any splints, braces, or other devices on client.
5. Place shoes or slippers on client’s feet.
6. Lower height of bed to lowest possible position.
7. Slowly raise head of bed if not contraindicated by client’s condition.
8. Place one arm under client’s legs and one arm behind client’s back. Slowly pivot
client so client’s legs are dangling over edge of bed and client is in a sitting
position on edge of bed.
9. Allow client to dangle for 2 to 5 minutes. Help support client, if necessary.
10. Bring chair or wheelchair close to side of bed. Place at 45 angle to bed. If
client has a weaker side, place chair or wheelchair on client’s strong side.
11. Lock wheelchair brakes and elevate foot pedals. For chairs, lock brakes, if
available.
12. If using a gait belt to assist client, place it around client’s waist.
13. Assist client to side of bed until feet are firmly on floor and slightly apart.
14. Grasp sides of gait belt or place your hands just below client’s axilla. Using a
wide stance, bend your knees and assist client to standing position.
15. Stand close to client, pivot until client’s back is toward chair.
16. Instruct client to place hands on arm supports or place client’s hand on arm
supports of chair.
17. Bend at knees and ease client into a sitting position.
18. Assist client to maintain proper posture. Support weak side with pillow, if
needed.
19. Secure safety belt, place client’s feet on feet pedals, and release brakes if
moving client immediately. Make sure tubes and lines, arms and hands are not
pinched or caught between client and chair. If client is sitting in chair, offer a
footstool, if available.
20. Wash hands/hand hygiene.
For the next items, evaluate the students in general according to the criteria. (5 as the
highest score)
5 4 3 2 1
Mastery
Orderliness
Proper attitude in assessing the client followed.
Ability to answer questions
Proper reporting observed.
Student’s signature: __________________
Evaluator’s Signature: __________________
Comments:_____________________________________________________________________
______________________________________________________________________________
Legend:
3-Very Satisfactory 0- Did not perform the procedure
2- Satisfactory 1- Needs Improvement
PROCEDURES 3 2 1 0
Transferring a Client with Minimum Assistance
1. Inform client about desired purpose and destination. Hand hygiene.
2. Raise the height of bed to 1 inch higher than the stretcher and lock brakes of bed.
3. Instruct client to move to side of bed close to stretcher. Lower side rails of bed
and stretcher. Leave side rails on opposite side up.
4. Stand at outer side of stretcher and push it toward bed.
5. Instruct client to move onto stretcher providing assistance, as needed.
6. Cover client with sheet or bath blanket.
7. Elevate side rails on stretcher and secure safety belts about client. Release brakes
of stretcher
8. Stand at head of stretcher to guide it when pushing.
9. Hand hygiene.
Transferring a Client with Maximum Assistance
10. Repeat Actions 1 and 2.
11. Assess amount of assistance required for transfer. Usually 2 to 4 staff members
are required for maximally assisted transfer.
12. Lock wheels of bed and stretcher.
13. Have one nurse stand close to client’s head.
14. Logroll client (keep in straight alignment) and place a lift sheet under client’s
back, trunk and upper legs. The lift sheet can extend under head if client lacks head
control abilities.
15. Empty all drainage bags (e.g., T-tube, Hemo Vac, Jackson-Pratt). Record
amounts. Secure drainage system to client’s gown before transfer.
16. Move client to edge of bed near stretcher. Lift client up and over to avoid
dragging.
17. Because client is now on side of bed with side rail down, the nurse on
nonstretcher side of bed holds stretcher side of lift sheet up ( by reaching across the
client’s chest) to prevent client from falling onto stretcher or off bed.
18. Place pillow or slider board to overlap bed and stretcher.
19. Have staff members grasp edges of lift sheet. Be sure to use good body
mechanics.
20. On count of 3, have staff members pull lift sheet and client onto stretcher.
21. Position client on stretcher, place pillow under head, and cover with a sheet.
22. Secure safety belts and elevate side rails of stretcher.
23. If IV pole is present, move it from bed IV pole to stretcher IV pole after client
transfer.
24. Wash hands/hand hygiene.
For the next items, evaluate the students in general according to t2he criteria. (5 as the
highest score)
5 4 3 2 1
Mastery
Orderliness
Proper attitude in assessing the client followed.
Ability to answer questions
Proper reporting observed.
Student’s signature: __________________
Evaluator’s Signature: __________________
Comments:_____________________________________________________________________
______________________________________________________________________________
Unfold the sheet over the bed. Optional: Make a fold in the sheet to
provide additional room forthe clients feet.
vertical toe pleat: make a fold in the sheet 5-10 cm (2-4in) perpendicular
to the foot of the bed.
Horizontal toe pleat: Make a fold in the sheet 5-10 cm (2-4 in) across the
bed near the foot.
Follow the same procedure for blanket and the spread, but place the top
edges about 15 cm (6in) from the head of the bed to allow a cuff of sheet
to be folded over them. Tuck in the sheet, blanket, and spread at the foot of the
bed, and miter the corner using all three layers of linen. Leave the sides of the
top sheet, blanket, and spread hanging freely, unless toe pleats were provided.
Fold the top of the top sheet down over the spread, providing a cuff.
Move to the other side of the bed, and secure the top bedding in the same manner.
10.Put clean pillowcases On the pillows as required. Grasp the closed end of the
pillowcase at the center with one hand. Gather up the sides of the Pillowcase and
place them over the hand grasping the case. Then grasp the center of one short
side of the pillow through the pillowcase. With the free hand, pull the pillowcase
over the pillow. Adjust the pillowcase so that the pillow fits into the corners of
the case and the seams are straight. Place the pillows appropriately at the head of
the bed.
11.Provide for client comfort and safety. Attach the signal cord so that the client
can conveniently use it. If the bed is currently being used by a client, either fold
back the top covers at one side or fanfold them down to the center of the bed.
Place the bedside table and the overbed table so that they are available to
the patient. Leave the bed in the high Position if the client is returning by
stretcher, or place in the low Position if the client is returning to bed after
being up.
12. Document and report pertinent data.
Variation : Surgical Bed
Strip the bed.
Place and leave the pillows on the bedside chair.
Apply the bottom linens as for an unoccupied bed. Place a bath blanket on the
foundation of the bed, if this is agency practice.
Place the top covers on the bed as you would for an unoccupied bed. Do not tuck
them in, miters the corners, or make a toe pleat.
Make a cuff at the top of the bed as you would for an unoccupied bed. Fold the
top linens up from the bottom.
On the side of the bed where the client will be transferred, fold up the two outer
corners of the top linens so they meet in the middle of the bed forming a triangle.
Pick up the apex of the triangle, and fanfold the top linens lengthwise to the other
side of the bed.
Leave the bed in high position with the side rails down.
Lock the wheels of the bed if the bed is not to be moved.
For the next items, evaluate the students in general according to the criteria. (5 as the
highest score)
5 4 3 2 1
Mastery
Orderliness
Proper attitude in assessing the client followed.
Ability to answer questions
Proper reporting observed.
Student’s signature: __________________
Evaluator’s Signature: __________________
Comments:_____________________________________________________________________
______________________________________________________________________________
Name: _________________________________ Date: _____________ Section/Group:________
Changing an Occupied Bed
CHECKLIST
Legend:
3-Very Satisfactory 0- Did not perform the procedure
17
Comments:_____________________________________________________________________
______________________________________________________________________________
Comments:_____________________________________________________________________
______________________________________________________________________________
PROCEDURES 3 2 1 0
Assess:
Inspect lips, gums, oral mucosa, and tongue from deviations form normal
Identify presence of oral problems such as tooth carries, halitosis,
gingivitis, lose or broken teeth.
Asses for gag reflex when appropriate
Assemble equipment and supplies:
Towel
Tissue or piece of gauze to remove denture (optional)
Denture container
Rubber tipped bulb syringe
Suction catheter with suction apparatus (optional)
Foam swabs and clean solution for cleaning the mucus membranes
Petroleum jelly
Bite block to hold the mouth open and teeth apart (optionl)
Disposable gloves
Curved basin or emesis basin
Tooth brush
Cup of tepid water
Toothpaste
Mouthwash
Procedure
Explain to the client what you are going to do, why it is necessary, and how she
can cooperate.
Wash hands and observe other appropriate infection control procedures.
Provide for client privacy.
Prepare the client and the environment.
Position the unconscious client in a side lying position, with the head of the bed
lowered.
Place the towel under the clients chin
Place the curved basin against the clients chin and lower cheek to receive the
fluid form the mouth
Put on gloves
Clean the teeth and rinse the mouth
If the client has natural teeth, brush the teeth. If the client has artificial teeth,
clean them as prescribe in the variation component*****
Rinse the clients by drawing about 10 ml of water or alcohol free mouth wash
into the syringe and injecting it gently into each side of the mouth.
Watch carefully to make sure that all the rinsing solution has run out of the
mouth into the basin. If not, suction the fluid from the mouth
Repeat rinsing until the mouth is free form tooth paste if used.
Inspect and clean the oral tissues
If the tissues appear dry or unclean, clean them with the foam swabs or gauze and
cleaning solution, following agency policy.
Picking up moistened foam swab, wipe the mucous membrane of one cheek. If no
foam swabs are available, wrap a small gauze square around a tongue blade and
moisten it. Discard the swab or tongue blade in a waste container and, with a
fresh one, clean the next area.
Clean all the mouth tissues in an orderly progression, using separate applicators:
the cheeks, roof of the mouth, base of the mouth, and tongue.
another mouth care product that does not have petroleum in it.
Document:
Assessment of the teeth tongue, gums, and oral mucosa
Any problems such as sores or inflammations or swelling of the gums.
For the next items, evaluate the students in general according to the criteria. (5 as the
highest score)
5 4 3 2 1
Mastery
Orderliness
Proper attitude in assessing the client followed.
Ability to answer questions
Proper reporting observed.
Student’s signature: __________________
Evaluator’s Signature: __________________
Comments:_____________________________________________________________________
______________________________________________________________________________
PROCEDURES 3 2 1 0
Assess for presence of:
Irritation, excoriation, inflammation, swelling
Excessive discharge
Odor pain or discomfort
Urinary or fecal incontinence
Recent rectal or perineal surgery
Indwelling catheter
Determine:
Perineal genital hygiene practices
Self care abilities
Whether the client is experiencing any discomfort in the perineal genital
area.
Procedure
Explain to the client what you are going to do, why it is necessary, and how she
can cooperate.
Wash hands and observe other appropriate infection control procedures.
Provide for client privacy.
Prepare the client and the environment.
Fold the top bed linen to the foot of the bed and fold the gown up to exposed
genital area.
Place a bath towel under the client’s hips.
Position and drape the client and clean the upper and inner thighs
For females
Position in a back lying position with the knees flexed and spread well apart.
Cover her body and legs with a bath blanket. Drape the legs by tucking the
bottom corners of the bath blanket under the inner sides of the legs. Bring the
middle portion of the base of the blanket up over the pubic area.
Put on gloves, and wash and dry the upper inner thighs.
For males
Position the male client in a supine position with knees slightly flexed and hips
slightly externally rotated.
Put on gloves, and wash and dry the upper inner thighs
Inspect the perineal area
24
Comments:_____________________________________________________________________
______________________________________________________________________________
PROCEDURES 3 2 1 0
Assess:
Condition of the skin
Fatigue
Presence of pain and need for adjunctive measures before the bath
Range of motion of the joints
Any other aspect of health that may affect the client’s bathing process
Assemble equipment and supplies:
Basin or sink with warm water
Soap and soap dish
Linens: bath blanket, two bath towels, washcloth, clean gown, or
pajamas or clothes as needed, additional bed linen and towels, if
required
Gloves, if appropriate
Personal hygiene articles
Shaving equipment for male clients
Table for bathing equipment
Laundry hamper
Determine:
The purpose and type of bath the client needs
Self-care ability of the client
Any movement or positioning precautions specific to the client
Other care the client may be receiving
Client’s comfort level with being bathed by someone else
Procedure
Explain to the client what you are going to do, why it is necessary, and how she
can cooperate.
Wash hands and observe other appropriate infection control procedures.
Provide for client privacy.
Prepare the client and the environment.
Invite a family member or significant other to participate, if desired
Close windows and doors to ensure the room is a comfortable temperature.
Offer the client a bedpan or urinal, or ask whether the client wishes to use the
toilet or commode.
Encourage the client to perform as much personal self-care as possible.
During the bath, assess each area of the skin carefully.
For a Bed Bath
Prepare the bed and position the client appropriately.
Position the bed at a comfortable working height. Lower side rail on the side
close to you. Keep the other side rail UP. Assist the client to move near you.
Place bath blanket over top sheet. Remove the top sheet from under the bath
blanket by starting at client’s shoulders and moving linen down towards client’s
feet. Ask the client to grasp and hold the top of the bath blanket while pulling
linen to the foot of the bed.
Note: If the bed linen is to be reused, place it over the bedside chair. If it is to be
changed, place it in the linen hamper.
Make a bath mitt with the washcloth.
Wash, rinse and dry the arm by elevating the clients arm and supporting the
client’s wrist and elbow.
Apply deodorant or powder if desired.
Optional: place a towel on the bed and put a washbasin on it. Place the client’s
hands in the basin. Assist the client as needed to wash, rinse and dry her hands,
paying particular attention to the spaces between her fingers.
Repeat for hand and arm nearest you.
Wash the chest and the abdomen.
Place bath towel lengthwise over chest. Fold bath blanket down to the client’s
pubic area.
Lift the bath towel off her chest, and bathe her chest and abdomen with your
mitted hand, using long, firm strokes. Rinse and dry well.
Replace the bath blanket when the areas have been dried.
Wash the legs and feet.
Expose the leg farthest from you by folding the bath blanket towards the other
leg, being careful to keep the perineum covered.
Lift leg and place the bath towel lengthwise under the leg. Wash, rinse and dry
the leg, using long, smooth, firm strokes from the ankle to the knee to the thigh.
Reverse the coverings and repeat for the other leg.
Wash the feet by placing them in the basin of water.
Dry each foot.
Obtain fresh, warm, bathwater now or when necessary.
Wash the back and then the perineum.
Assist the client into a prone or side-lying position facing away from you. Place
the bath towel lengthwise alongside the back and buttocks while keeping the
client covered with the bath blanket as much as possible.
Wash and dry the client’s back, moving from the shoulders to the buttocks, and
upper thighs, paying attention to the gluteal folds.
Perform a back massage now or after completion of bath.
Assist the client to the supine position and determine whether the client can
wash the perineal area independently. If she can not do so, drape the client and
wash the area.
Assist the client with grooming aids such as powder, lotion or deodorant.
Use powder sparingly. Release as little as possible into the atmosphere.
Help the client put on a clean gown or pajamas.
Assist the client to care for hair, mouth and nails.
For the next items, evaluate the students in general according to the criteria. (5 as the
highest score)
5 4 3 2 1
Mastery
Orderliness
Proper attitude in assessing the client followed.
Ability to answer questions
Proper reporting observed.
Student’s signature: __________________
Evaluator’s Signature: __________________
Comments:_____________________________________________________________________
______________________________________________________________________________
For the next items, evaluate the students in general according to the criteria. (5 as the
highest score)
5 4 3 2 1
Mastery
Orderliness
Proper attitude in assessing the client followed.
Ability to answer questions
Proper reporting observed.
Student’s signature: __________________
Evaluator’s Signature: __________________
Comments:_____________________________________________________________________
______________________________________________________________________________
Allergies to medication
Specific drug action, side effects, and adverse reactions
Client’s knowledge and learning needs about the medication
Status and appearance of subcutaneous site for lesions, erythema,
swelling, ecchymosis, inflammation, and tissue damage from previous
injections.
Ability of client to cooperate during the injection
Previous injection sites used
Assemble equipment and supplies:
MAR or computer printout
Vial or ampule of the correct sterile medication
Syringe and needle
Antiseptic swabs
Dry sterile gauze for opening an ampule (optional)
Disposable gloves
Check the MAR.
Check the label on the medication carefully against the MAR to make sure that
the correct medications is being prepared.
Follow the three checks for administering medications. Read the label on the
medication:
When it is taken from the medication cart
Before withdrawing the medication
After withdrawing the medication
Organize the equipment.
Procedure
Wash hands and observe other appropriate infection control procedures.
Prepare the medication from the ampule or vial for drug withdrawal.
See procedure 33–2 (ampule) or 33–3 (vial)
Provide for client privacy.
Prepare the client.
Check the client’s identification band.
Assist the client to a position in which the arm, leg, or abdomen can be relaxed,
depending on the site to be used.
Obtain assistance in holding an uncooperative client.
Explain the purpose of the medication and how it will help, using language
that the client can understand. Include relevant information about effects
of the medication
Select and clean the site.
Select a site free of tenderness, hardness, swelling, scarring, itching, burning,
and localized inflammation.
Select a site that has not been used frequently
Put on gloves
As agency protocol indicates, clean the site with an antiseptic swab. Start at the
center of the site and clean in a widening circle to about 5cm (2in). Allow the
area to dry thoroughly
Place and hold the swab between the third and fourth fingers of the
nondominant hand, or position the swab on the client’s skin above the intended
site.
Prepare the syringe for injection
Remove the needle cap while waiting for the antiseptic to dry.
Inject the medication.
Grasp the syringe in your dominant hand by holding it between your thumb and
fingers. With palm facing to the side or upward for a 45–degree angle insertion,
or with the palm downward for a 90–degree angle insertion, prepare to inject.
Using the nondominant hand, pinch or spread the skin at the site, and insert the
needle, using the dominant hand and a firm steady push.
When the needle is inserted, move your nondominant hand to the end of the
plunger.
30
Comments:_____________________________________________________________________
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Comments:_____________________________________________________________________
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Comments:_____________________________________________________________________
______________________________________________________________________________
For the next items, evaluate the students in general according to the criteria. (5 as the
highest score)
5 4 3 2 1
Mastery
Orderliness
Proper attitude in assessing the client followed.
Ability to answer questions
Proper reporting observed.
Student’s signature: __________________
Evaluator’s Signature: __________________
Comments:_____________________________________________________________________
______________________________________________________________________________
Comments:_____________________________________________________________________
______________________________________________________________________________
Comments:_____________________________________________________________________
______________________________________________________________________________
Comments:_____________________________________________________________________
______________________________________________________________________________
Comments:_____________________________________________________________________
______________________________________________________________________________
Preparation
Be guided with the purpose and principles of home visit.
Check the completeness of the public health bag including its
arrangements.
Procedure
1.Upon arrival, place the bag on the table lined with a clean paper. The clean side
must be out and the folded part, touching the table.
2. Ask for a basin of water or a glass of a drinking water if tap water is not
available.
3. Open the bag and take out the towel and soap
4. Wash hands using soap and water. Wipe to dry.
5. Take out the apron from the bag and put it on with the right side out.
6. Put out all the necessary articles needed for the specific care.
7. Close the bag and put it in one corner of the working area.
8. Proceed in performing the necessary nursing care and treatment.
9. After giving the treatment, clean all things that were used and perform hand
washing.
10. Open the bag and return all things that were used in their proper places after
cleaning them.
11. Remove apron, folding it away from the person, the soiled side in and the
clean side out. Place it in the bag.
12. Fold the lining, place it inside the bag and close the bag.
13. Take the record and have a talk with the mother. Write down all the necessary
data that were gathered, observations, nursing care and treatment rendered. Give
instructions for care of patients in the absence of the nurse.
14. Make appointment for the next visit (either home or clinic) taking note of the
date and time
For the next items, evaluate the students in general according to the criteria.
(5 as the highest score)
5 4 3 2 1
Mastery
Orderliness
Proper attitude in assessing the client followed.
Ability to answer questions
Proper reporting observed.
43
For the next items, evaluate the students in general according to the criteria.
(5 as the highest score)
5 4 3 2 1
Mastery
Orderliness
Proper attitude in assessing the client followed.
Ability to answer questions
Proper reporting observed.
For the next items, evaluate the students in general according to the criteria.
(5 as the highest score)
5 4 3 2 1
Mastery
Orderliness
Proper attitude in assessing the client followed.
Ability to answer questions
Proper reporting observed.
PROCEDURES 3 2 1 0
1. Prepare the client
a. Identify the patient and introduce self.
46
Comments:_____________________________________________________________________
______________________________________________________________________________
Monitoring of Labor
CHECKLIST
Legend:
3-Very Satisfactory 0- Did not perform the procedure
2- Satisfactory 1- Needs Improvement
PROCEDURES 3 2 1 0
1. Prepare the client
47
For the next items, evaluate the students in general according to the criteria.
(5 as the highest score)
5 4 3 2 1
Mastery
Orderliness
Proper attitude in assessing the client followed.
Ability to answer questions
Proper reporting observed.
Student’s signature: __________________
Evaluator’s Signature: __________________
Comments:
_________________________________________________________________________
______________________________________________________________________________
_____
nurse, that person could help support the woman in position, assist
with coaching and compliment her on her efforts.
3. Wash hands and put on gloves.
4. As the head begins to crown, you should do the following:
a. Instruct the woman to pant.
b. Place a napkin or an OS into the perineum for support.
c. Place the flat side of your hand on the exposed fetal head and apply
gently pressure toward the vagina to prevent the head from popping
out.
5. After the birth of the head, check for an umbilical cord. If the cord
is around the baby’s neck, try to slip it over the baby’s head or pull it
gently to get some slack so that you can slip it over the shoulders.
6. Support the head as restitution (external rotation) occurs. After
restitution, with one hand on each side of the baby’s head, exert gentle
pressure downward so that the anterior shoulder emerges under the
symphysis pubis and acts as a fulcrum; then as gentle pressure is
exerted on the opposite direction, the posterior shoulder, which has
passed over the sacrum and coccyx, emerges.
7. Be alert! Do the Mauricius maneuver. (downward then up)
8. Cradle the baby’s head and back in one hand and the buttocks in the
other. Keep the baby’s head down to drain secretions.
9. Dry the baby quickly to prevent rapid heat loss.
10. Place the baby on the mother abdomen, cover the baby. Clamp the
cord and cut. (when the pulsations stopped)
11. Wait for the placenta to separate. Do the Brant-Andrews
maneuver.
12. Check for the placental membranes for its completeness or any
abnormality. Remind the circulating nurse to check the patient’s blood
pressure and to give methergine.
13. Check the firmness of the uterus.
14. Check for any lacerations and bleeding.
15. DO the after care and put the mother’s diaper.
For the next items, evaluate the students in general according to the criteria.
(5 as the highest score)
5 4 3 2 1
Mastery
Orderliness
Proper attitude in assessing the client followed.
Ability to answer questions
Proper reporting observed.
For the next items, evaluate the students in general according to the criteria.
(5 as the highest score)
5 4 3 2 1
Mastery
Orderliness
Proper attitude in assessing the client followed.
Ability to answer questions
Proper reporting observed.
Student’s signature: __________________
Evaluator’s Signature: __________________
Comments:
_________________________________________________________________________
______________________________________________________________________________
_____
defecate. Have bedpan, commode, or nearby bathroom ready for his or her
use.
3. Perform hand hygiene.
4. Add enema solution to container. Release clamp and allow fluid to
progress through tube before reclamping.
5. Position waterproof pad under patient.
6. Provide privacy. Position and drape patient on the left side (Sim’s
position) with anus exposed or on back, as dictated by patient comfort and
condition.
7. Put on disposable gloves.
8. Elevate solution so it is 45 cm (18 inches) above level of patient’s anus.
Plan to administer solution slowly over a period of 5-10 minutes.
Container may be hung on IV pole or held in the nurse’s hands at the
proper height.
9. Generously lubricate the last 5-7 cm (2-3 inches) of the rectal tube. A
disposable enema set may have a prelubricated rectal tube.
10. Lift buttock to expose anus. Slowly and gently insert rectal tube 7-10
cm (3-4 inches). Direct it in an angle pointing toward the umbilicus.
11. If the tube meet resistance while inserting it, permit a small amount of
solution to enter, withdraw tube slightly, then continue to insert it. Do not
force tube entry. Ask pt to take several deep breaths.
12. Introduce solution slowly over a period of 5-10 minutes. Hold tubing
all the time solution being instilled.
13. Clamp tubing or lower container if patient has the desire to defecate or
cramping occurs. Patient also may be instructed to take small fast breaths
or to pant.
14. After solution has been given, clamp tubing and remove tube. Have
paper towel ready to receive tube as it is withdrawn. Have patient retain
solution until the urge to defecate becomes strong, usually in about 5-15
minutes.
15. Remove disposable gloves from inside out and discard.
16. When patient has a strong urge to defecate, place him or her in sitting
position on bedpan or assist to commode or bathroom.
17. Record character of the stool and patient’s response to the enema,
Remind patient not to flush commode before nurse inspects results of
enema.
18. Assist patient, if necessary with cleaning of anal area. Offer washcloth,
soap, and water to wash his or her hands.
19. Leave patient clean and comfortable. Care for equipment properly.
20. Perform hand hygiene.
For the next items, evaluate the students in general according to the criteria. (5 as the highest score)
5 4 3 2 1
Mastery
Orderliness
Proper attitude in assessing the client followed.
Ability to answer questions
Proper reporting observed.
Student’s signature: __________________Evaluator’s Signature: ________________
Comments:_____________________________________________________________________
Name: _________________________________ Date: _____________ Section/Group:________
Measuring Blood Glucose Levels
CHECKLIST
Legend:
3-Very Satisfactory 0- Did not perform the procedure
2- Satisfactory 1- Needs Improvement
PROCEDURES 3 2 1 0
1. Review orders, identify client, and review manufacturer’s instructions for meter
usage.
2. Wash hands/hand hygiene.
3. Assemble equipment at bedside.
4. Have client wash hands with soap and water and position client comfortably in a
52
Comments:_____________________________________________________________________
______________________________________________________________________________
REFERENCES: