nursing skills procedure manualll

1st released in November 6, 2012@ UoD College of Nursing (Male)

1 NURS 241 Nursing Skills Procedure: Manual

(cover page)

NURS 241 Nursing Skills Procedure: Manual



The NURS 241 Nursing Skills Procedure Manual

Is a compilation of

The University of Dammam, College of Nursing(Male) faculty.

1st edition 2012-2013

The author and contributor have prepared this work for the student nurses. Furthermore, no warranty, express or implied and

disclaim any obligation, loss as a consequence of the use and application of any contents of this activity.

THE AUTHORS, Nursing Course Coordinator: Dr. James M. Alo, RN, MAN, MAPsycho., PhD. Clinical Staff: Mr. Robin Easow, RN, MAN Mr. Abdullah Ghanem, RN, MAN Mr. Fhaied Mobarak, RN, MAPPC Mr. Shadi Alshadafan, RN, MAN Mr. Darwin Agman, RN Mr. Fathi Alhurani, RN



Preface

This manual will help the student learn knowledge and

demonstrate nursing skills related to the fundamental management

of patient care especially to patient with medical and surgical

impediments.

Special attention of the student to this manual will aid them in

developing, enhancing their learned skills from their dedicated

clinical staff.

The authors and contributors recognize the student as an

active participant who assumes a collaborative role in the learning

process. Content is presented to challenge the student to develop

clinical nursing skills.

NURS 241 TEAM

Course Coordinator:

Dr. James M. Alo

Clinical Staff:

Mr. Robin Easow

Mr. Abdullah Ghanem

Mr. Fhaied Mobarak

Mr. Shadi Alshadafan

Mr. Darwin Agman

Mr. Fathi Alhurani



NURS 241 Nursing Skills Procedure: Manual

TABLE OF CONTENTS

Sec. CONTENTS Page #

Cover Page

Acknowledgment

Preface

Handwashing 6

Measuring Body Temperature/ Vital Signs 9

-Oral Temperature Measurement 13

-Oral Temperature Measurement w/ E-Thermomemter 15

-Rectal Temperature Measurement w/ glass thermometer

15

-Rectal Temperature Measurement w/ e-thermometer 17

-Axillary Temperature Measurement w/ glass thermometer

18

-Axillary Temperature Measurement w/ e-thermometer

19

-Tympanic Membrane Measurement w/ e-thermometer

20

Advantages & Disadvantages of Selecting Temperature Measurement

21

Assessing Radial and apical Pulse 22

-Radial Pulse 25

-Apical Pulse 26

-Apical-Radial Pulse 28

Assessing Respiration 32

-Abnormal breathing patterns 34

Assessing BP 37

Applying and Removing sterile gloves 44

Changing an occupied bed 47

Changing an unoccupied bed 50

Body mechanics 55

Lifting an object from the floor 58

Positioning clients 59

Transferring patient from bed to chair 66

Bathing adult client 69

Collecting sputum specimen 76

Collecting and testing of urine 78

Collecting a specimen from indwelling catheter 84

Collecting and testing of stool 87

Obtaining a capillary blood specimen 89

Collecting samples from nose and throat 93

Collecting samples from nasal mucosa 96

Bandage and binders 97

Bandaging 99

-Types of bandage turns 102

-Types and purpose of binders 104



Shoulder immobilization 115

APPENDIX A /Performance Checklist 118

Handwashing 118

Applying and removing of gloves 120

Axillary temperature (electronic) 122

Rectal temperature (electronic) 124

Oral temperature (electronic) 126

Heart rate 128

Respiratory rate 132

Moving the client up in bed 134

Moving the client to lateral position 138

Body mechanics 140

Logrolling a client 143

Dangling a client 145

Applying and removing gloves, gowns and mask 147

Assessing Blood Pressure 148

Changing an Unoccupied Bed 151

Changing an \occupied Bed 152

REFERENCES 154



HANDWASHING

Introduction:

Hand washing is important in every setting, including hospitals. It is

considered one of the most effective infection control measures. There are two types

of microorganisms (bacteria) present on the hands: Resident bacteria, which cannot

be removed by hand washing. The second type is transient bacteria, which is easily

removed by hand washing.

It is important that hands be washed at the following time:

Before and after eating.

Before and after contact with any patient.

When handling patient’s food, blood, body fluids, secretions or excretions.

When there is contact with any object that is likely to be a reservoir of

organisms such as soiled dressings or bedpan.

After urinary or bowel elimination.

Purposes: Handwashing is performed to:

1. Remove the natural body oil and dirt from the skin.

2. Remove transient microbes, those normally picked up by the hands in the

usual activities of daily living.

3. Reduce the number of resident microbes, those normally found in creases of

the skin.

4. Prevent the transmission of microorganisms from client to client / from nurse

to family / from client to nurse.

5. Prevent the cross-contamination among clients.

Key Points:

Handwashing is a basic aseptic practice involved in all aspects of providing care to

persons who are sick or well. It becomes especially important when the client have

nursing diagnoses such as:

Potential for infection.

Altered body temperature.

Impaired skin integrity.



Equipment and Supplies

o Source of running water (warm if available)

o Soap o Soap dish

o Orangewood stick o Towel or tissue paper o Lotion

Procedure: STEPS RATIONALE

1 Stand in from of the sink. Do not allow your uniform to touch the sink during the washing procedure.

The sink is considered contaminated. Uniforms may carry organisms from place to place.

2 Remove jewelries. Remove watch 3-5 inch above wrist

Removal of jewelries facilitates proper cleansing. Microorganisms may accumulate in settings of jewelries.

3 Turn on water and adjust the force. Regulate the temperature until the water is warm. Do not allow water to splash.

Water splashed from the contaminated sink will contaminate your uniform. Warm water is more comfortable and has fewer tendencies to open pores and remove oils from the skin. Organisms can lodge in roughened and broken areas of chapped skin.

4 Wet the hands and wrist area. Keep hands lower than the elbows to allow water to flow toward the fingertips.

Water should flow from the cleaner area toward the more contaminated area. Hands are

more contaminated than the forearm.

5 Use about one teaspoon of liquid soap from the dispenser or lather thoroughly with bar soap. Rinse bar, and return it to soap dish.

Rinsing the soap removes the lather, which may contain microorganisms.

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6 With firm rubbing and circular motions, wash the palms and back of the hands, each finger, areas between the fingers, the knuckles, wrists, and forearms at least as high as contamination is likely to be present.

Friction caused by firm rubbing and circular motions helps to loosen the dirt and organisms which can lodge between the fingers, in skin crevices of knuckles, on palms and backs of the hands, as well as the wrist and forearms. Cleaning least contaminated areas (forearms and wrists) prevents spreading organisms from the hands to the forearms and wrists.

7 Continue this friction motion for 10 to 30 seconds.

Length of hand washing is determined by the degree of contamination.

8 Use fingernails of the other hand or use orangewood stick to clean under fingernails.

Organisms can lodge and remain under the nails where they can grow and be spread to others.

9 Rinse thoroughly. Running water rinses organisms and dirt into sink.

10 Dry hands and wrists with paper towel. Use paper towel to turn off the faucet.

Drying the skin well prevents chapping. Dry hands first because they are the cleanest and least contaminated area after hand washing. Turning the faucet off with a paper towel protects the clean hands from contact with a soiled surface.

11 Use lotion on hands if desired. Lotion helps to keep the skin soft and prevents chapping.

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MEASURING BODY TEMPERATURE or VITAL SIGNS

Objectives:

1. To measure the body temperature accurately and safely.

2. Recognize deviations from the normal.

Purposes:

1. To establish baseline data.

2. To identify if the body temperature is within normal range.

3. To determine changes in the body temperature in response to specific

therapies.

4. To monitor client’s at risk for alterations in temperature.

Types of Thermometers:

Clinical glass mercury

thermometers:

• Oral (long tip)

• Stubby

• Rectal

Electronic thermometer

Infra-red thermometer

(Tympanic thermometer)



Temperature sensitive strips

(Disposable thermometer strips)

(Liquid crystal thermometer)

Temperature Scales:

Celsius (centigrade) scale – normally extends from 34.0 to 42.0 C.

Fahrenheit scale – usually extended from 94 F to 108 F.

Factors affecting body temperature:

Age: children; old age. Stress

Sex: males; c females and

during menstruation.

Environment

Obesity

Diurnal variations. Food intake; fasting

Exercise Drugs or

Hormones Disturbance in hypothalamus



Ranges of normal temperature values and physiological consequences of abnormal body temperature.

Sites/Routes for temperature assessment:

1. Core temperature – is the temperature of the deep tissues of the body, such

as the cranium, thorax, abdominal and pelvic cavity.

2. Surface temperature – is the temperature of the skin, the subcutaneous tissue

and fat. It rises and falls in response to the environment; varies from 20 to

40 C.

Route Normal Reading Timing

Oral 37 C (98.6 F) 3 minutes

Axillary 37.5 C (99.6 F) 5 minutes

Rectal 36.4 C (97.6 F) – 36 .7 C (98

F)

1 minute

Tympanic - 1 – 2 sec.

Alterations in body temperature:

1. Pyrexia / hyperthermia / fever (above usual range).

2. Hyperpyrexia – very high fever.

3. Afebrile – no fever.



CONTRAINDICATIONS / CAUTIONS: A. Oral:

1. Children younger than 4 to 5 years.

2. Confused, combative or comatose individuals.

3. Irritable clients or with mental diseases.

4. With history of convulsive disorders.

5. Mouth breathers.

6. With oral infections or with injuries or conditions that prevent them from

closing their mouths fully.

7. Immediate post-op under anesthesia.

8. Surgery for nose and mouth.

9. Patient receiving oxygen therapy.

10. Wait at least 15 to 30 minutes after person smokes / drinks / eats.

B. Rectal:

1. With rectal or perineal injuries or surgeries.

2. With diarrhea, diseases of the rectum.

3. Patient with heart disease.

4. Lubricate the thermometer well and insert gently to avoid damage to the

mucosa or perforation of the rectum.

C. Axillary : NONE.

D. Tympanic: NONE.

Equipment:

Appropriate thermometer

Soft tissue papers

Lubricant (for rectal measurement only)

Pen, pencil, vital signs flow sheet or record form.

Disposable gloves, plastic thermometer sleeves or disposable probe covers.



Procedure: STEPS RATIONALE

1 Assess for signs and symptoms of temperature alterations and for factors that influence body temperature.

Physical signs and symptoms may indicate abnormal temperature. Nurse can accurately assess nature of variations.

2 Determine any previous activity that would interfere with accuracy of temperature measurement. When taking temperature, wait 20 to 30 minutes before measuring temperature if client has smoked or ingested hot or cold liquids or foods.

Smoking and hot or cold substances can cause false temperature readings in oral cavity.

3 Determine appropriate site and measurement device to be used.

Chosen on basis of preferred site for temperature measurement.

4 Explain why temperature will be taken and maintaining the proper position until reading is complete.

Clients are often curious about such measurements and should be cautioned against prematurely removing thermometer to read results.

5 Wash hands. Reduces transmission of microorganisms.

6 Assist client in assuming comfortable position that provides easy access to mouth.

Ensures comfort and accuracy of temperature reading.

7 Obtain temperature reading.

A. Oral temperature measurement with glass thermometer:

1 Apply disposable gloves. Maintains standard precautions when exposed to items soiled with body fluids. (e.g., saliva)

2 Hold end of glass thermometer with fingertips.

Reduces contamination of thermometer bulb.

3 Read mercury level while gently rotating thermometer at eye level, grasp tip of thermometer securely, stand away from solid objects, and sharply flick wrist downward. Continue shaking until reading is

below 35 C (96 F).

Mercury should be below 35 C. Thermometer reading must be below client’s actual temperature before use. Brisk shaking lowers mercury level of glass tube.

4 Insert thermometer into plastic sleeve or cover.

Protects from contact with saliva.



5 Ask client to open mouth and gently place thermometer under tongue in posterior sublingual pocket lateral to the center of lower jaw.

Heat from superficial blood vessels in sublingual pockets produces temperature reading.

6 Ask client to hold thermometer with lips closed. Caution against biting down the thermometer

Maintains proper position of thermometer during recording. Breakage of thermometer may injure mucosa and cause mercury poisoning.

7 Leave thermometer in place for 3 minutes or according to agency policy.

Studies vary as to proper length of time for recording. Holtzclaw (1992) recommends 3 minutes.

8 Carefully remove thermometer, remove and discard plastic sleeve cover in appropriate receptacle, and read at eye level. Gently rotate until scale appears.

Prevents cross contamination. Ensures accurate reading.

9 Cleanse any additional secretions on thermometer, by wiping with clean, soft tissue. Wipe in rotating fashion from fingers toward bulb. Dispose of tissue in appropriate receptacle. Store thermometer in appropriate storage container.

Avoids contact of microorganisms with nurse’s hands. Wipe from area of least contamination to area of most contamination. Glass thermometers should not be shared between clients unless terminal disinfection is performed between each measurement. Protective storage container prevents breakage and reduces risks of mercury spills.

10 Remove and dispose of gloves in appropriate receptacle. Wash hands.

Reduces transmission of microorganisms.



B. Oral temperature measurement with electronic thermometer.

1 Apply disposable gloves. (Optional) Use of probe covers, which can be removed without physical contact, minimizes needs to wear.

2 Remove the thermometer pack from charging unit. Attach oral probe to thermometer unit. Grasp top of stem, being careful not to apply pressure to ejection button.

Charging provides battery power. Ejection button releases plastic cover from probe.

3 Slide disposable plastic cover over thermometer probe until it locks in place.

Soft plastic cover will not break in client’s mouth and prevents transmission of microorganisms between clients.

4 Ask client to open mouth, then place thermometer probe under the tongue in posterior sublingual pocket lateral to center of lower jaw.

Heat from superficial blood vessels in sublingual pocket produces temperature reading. With electronic thermometer temperatures, in right and left posterior sublingual pocket are significantly higher than in area under front of tongue.

5 Ask client to hold thermometer probe with lips closed.

Maintains proper position of thermometer during recording.

6 Leave thermometer probe in place until audible signal occurs and client’s temperature appears on digital display; remove thermometer probe under client’s tongue.

Probe must stay in place until signal occurs to ensure accurate recording.

7 Push ejection button on thermometer stem to discard plastic cover into appropriate receptacle.


8 Return thermometer stem to storage well of recording unit.

Protects probe from damage. Automatically causes digital reading to disappear.

9 If gloves are worn, remove and dispose in appropriate receptacle. Wash hands.


10 Return thermometer to charger. Maintains battery charge.

C. Rectal temperature measurement with glass thermometer.

1 Draw curtain around bed and / or close room door. Assist client to Sim’s position with upper leg flexed Move aside bed linen to expose only anal area. Keep covered with sheet or blanket.

Maintain client’s privacy, minimizes embarrassment, and promotes comfort. Exposes anal area for correct thermometer placement.



2 Apply disposable gloves. Maintains standard precautions when exposed to items soiled with body fluids (e.g., feces).

3 Hold end of glass thermometer with fingertips.

Reduced contamination of thermometer bulb.

4 Read mercury level while gently rotating thermometer at eye level. If mercury is above desired level, grasp tip of thermometer securely, and stand away from solid objects, and sharply flick wrist downward. Continue shaking until reading is

below 35 C.

Mercury should be below 35 C. Thermometer reading must be below client’s actual temperature before client’s actual temperature before use. Brisk shaking lowers mercury level in glass tube.

5 Insert thermometer into plastic sleeve cover.

Protects from contact with feces.

6 Squeeze liberal portion of lubricant on tissue. Dip thermometer’s blunt end into lubricant, covering 2.5 cm (1 to 1 ½ inch) for adult.

Lubrication minimizes trauma to rectal mucosa during insertion. Tissue avoids contamination of remaining of remaining lubricant in container.

7 With non-dominant hand, separate client’s buttocks to expose anus. Ask client to breathe slowly and relax.

Fully exposes anus for thermometer insertion. Relaxes anal sphincter for easier thermometer insertion.

8 Gently insert thermometer into anus 3.5 cm (1 ½ inches) for adult. Do not force themselves.

9 If resistance is felt during insertion, withdraw thermometer immediately. Never force thermometer.

Prevents trauma to mucosa. Glass thermometers can break.

If thermometer cannot be adequately inserted into the rectum, remove the thermometer and consider alternative method for obtaining temperature.

10 Hold thermometer in place for 2 minutes or according to agency policy.

Prevents injury to client. Studies vary as to proper length of time for recording. Holtzclaw (1992) recommends 2 minutes.



11 Carefully remove thermometer, remove and discard plastic cover in appropriate receptacle and wipe off remaining secretions with clean tissue. Wipe in rotating fashion from fingers toward the bulb. Dispose of tissue in appropriate receptacle.

Prevents cross contamination. Wipe from area of least contamination to area of most contamination.

12 Read thermometer at eye level. Gently rotate until scale appears.

Ensures accurate reading.

13 Wipe client’s anal area with soft tissue to remove lubricant or feces and discard tissue. Assist client in assuming a comfortable position.

Provides for comfort and hygiene.

14 Store thermometer in appropriate storage container.

Glass thermometers should not be shared between clients unless terminal disinfection is performed between each measurement. Protective storage container prevents breakage and reduces risk of mercury spill.

15 Remove and dispose of gloves in appropriate receptacle. Wash hands.


D. Rectal temperature measurement with electronic thermometer.

1 Follow steps C-1 and C-2.

2 Follow steps C-5, 6, 7, 8, 9

3 Leave thermometer in place until audible signal occurs and client’s temperature appears on digital display; remove thermometer probe from anus.

Probe must stay in place until signal occurs to ensure accurate reading.

4 Push ejection button on thermometer stem to discard plastic probe cover into appropriate receptacle.


5 Return thermometer stem to storage well of recording unit.


6 Wipe client’s anal area with soft tissue to remove lubricant or feces and discard tissue. Assist client in assuming a comfortable position.

Provides comfort and hygiene.

7 Remove and dispose of gloves in appropriate receptacle.


8 Return thermometer to charger. Maintains battery charge.



E. Axillary temperature measurement with glass thermometer.


2 Draw curtain around bed and/or close door.

Provides privacy and minimizes embarrassment.

3 Assist client to supine or sitting position.

Provides easy access to axilla.

4 Move clothing or gown away from shoulder and arm.

Exposes axilla.

5 Prepares glass thermometer following steps A –2, 3.

Mercury must be below client’s temperature level before insertion.

6 Insert thermometer into the center of axilla, lower arm over thermometer, and place arm across chest.

Maintains proper position of thermometer against blood vessels in axilla.

7 Hold thermometer in place for 3 minutes or according to agency policy.

Studies as to proper length of time for recording vary. They concluded that changes after 3 minutes had little or no significance.

8 Remove thermometer, remove plastic sleeve, and wipe off remaining secretions with tissue. Wipe in rotating fashion from fingers toward bulb. Dispose of sleeve and tissue in appropriate receptacle.

Avoids nurse’s contact with microorganisms. Wipe from are of least contamination to area of most contamination.

9 Read thermometer at eye level. Ensures accurate reading.

10 Inform client of reading. Promotes participation in care and understanding of health status.

11 Store thermometer at bedside in protective covering container.

Glass thermometers should not be shared between clients unless terminal disinfection is performed between each measurement. Storage container prevents breakage and reduces risk of mercury spill.



12 Assist client in replacing clothing pr gown.

Restore sense of well-being.


F. Axillary temperature measurement with electronic thermometer.

1 Position client lying supine or sitting. Provides easy access to axilla.

2 Move clothing or gown away from shoulder and arm.

Provides optimal access to axilla.

3 Remove the thermometer pack from charging unit. Be sure oral probe (blue tip) is attached to thermometer unit. Attach oral probe to thermometer unit. Grasp top of stem, being careful not to apply pressure to ejection button.

Ejection button releases plastic cover from probe.

4 Slide disposable plastic cover over thermometer probe until it locks in place.

Soft plastic cover will not break in client’s mouth and prevents transmission of microorganisms between clients.

5 Raise client’s arm away from torso, inspect for skin lesion and excessive perspiration. Insert probe into the center of axilla, lower arm over thermometer, and place arm across chest.

Maintains proper position of probe against blood vessels in axilla.

6 Leave probe in place until audible signal occurs and client’s temperature appears on digital display.

Probe must stay in place until signal occurs to ensure accurate reading.

7 Remove probe from axilla.

8 Push ejection button on thermometer stem to discard plastic probe cover into appropriate receptacle.


9 Return probe to storage well of recording unit.


10 Assist client in assuming a comfortable position.

Restores comfort and promotes privacy.




G. Tympanic membrane temperature measurement with

electronic thermometer.

1 Assist client in assuming comfortable position with head turned toward side, away from the nurse.

Ensures comfort and exposes auditory canal for accurate temperature measurement.

2 Remove thermometer handheld unit from charging base, being careful not to apply pressure to ejection button.

Base provides battery power. Removal of handheld unit from base prepares it to measure temperature.

3 Slide disposable speculum cover over otoscope like tip until it locks into place.

Soft plastic probe cover prevents transmission of microorganisms between clients.

4 Insert speculum into ear canal following manufacturer’s instructions for tympanic probe positioning.

Correct positioning of the probe with respect to ear canal ensures accurate readings. The ear tug straightens the external auditory canal, allowing maximum exposure of the tympanic membrane.

a. Pull ear pinna upward and back for adult.

Some manufacturers recommend movement of the speculum tip in a figure – 8 pattern that allows the sensor to detect maximum tympanic membrane heat radiation. Gentle pressure seals ear canal from ambient air temperature.

b. Move thermometer in a figure–eight pattern.

c. Fit probe snug into canal and do not move.

d. Point toward nose.

5 Depress scan button on handheld unit. Leave thermometer probe in place until audible signal occurs and client’s temperature appear on digital display.

Depression of scan button causes infrared energy to be detected. Probe must stay in place until signal occurs to ensure accurate reading.

6 Carefully remove speculum from auditory meatus.



7 Push ejection button on handheld unit to discard plastic probe cover into appropriate receptacle.

Reduces transmission of microorganisms. Automatically causes digital readings to disappear.

8 Return handheld unit into charging base.

Protects probe from damage.

9 Assist client in assuming a comfortable position.

Restores comfort and sense of well being.


Recording and reporting:

Record temperature in vital signs flow sheet or record form.

Report abnormal findings to nurse in charge or physician.

ADVANTAGES AND DISADVANTAGES OF SELECTED TEMPERATURE MEASUREMENT, SITES, AND METHODS.

Advantages Disadvantages

Electronic Thermometer:

1 Plastic sheath unbreakable; ideal for children.

May be less accurate by axillary route.

2 Quick readings.

Tympanic Membrane Sensor:

1 Easily accessible site Hearing aids must be removed before measurements.

2 Minimal client repositioning required.

Should not be used for clients who have had surgery of the ear or tympanic membrane.

3 Provides accurate care reading. Requires disposable probe cover.

4 Very rapid measurements (2 to 5 sec.).

Expensive.

5 Can be obtained without disturbing or waking client.

6 Ear drum close to hypothalamus, sensitive to core temperature changes.

Oral: 1 Accessible; requires no position

changes. Affected by ingestion of fluids or foods, smoke, and oxygen delivery (Neff and others, 1992).



2 Comfortable for client. Should not be used with clients who have had oral surgery, trauma, history of epilepsy, or shaking chills.

3 Provides accurate surface temperature reading.

Should not be used with infants, small children, or confused, unconscious, or uncooperative client.

4 Indicates rapid change in core temperature.

Risk of body fluid exposure.

Axilla: 1 Safe and non-invasive. Long measurement time.

2 Can be used with newborns and uncooperative clients.

Requires continuous positioning by nurse.

Measurement lags behind core temperature during rapid temperature changes. Requires exposure of thorax.

Skin: 1 Inexpensive Lags behind other sites during

temperature changes, especially during hyperthermia.

2 Provides continuous reading Diaphoresis or sweat can impair adhesion.

3 Safe and non-invasive.

ASSESSING RADIAL AND APICAL PULSES

Definition: The pulse is a wave of blood created by contraction of the left ventricle

of the heart.

Objectives:

To establish baseline data for subsequent evaluation.

To identify whether the pulse is within normal range.

To determine whether the pulse rhythm is regular and pulse volume is

appropriate.

To compare the equality of corresponding peripheral pulses on each side of

the body.

To monitor and assess changes in the client’s health status.

To monitor clients at risk for pulse alterations. (e.g., clients with a history of

heart disease or having cardiac arrhythmias, hemorrhage, acute pain, infusion



of large volumes of fluids, fever).

Key Points:

Locate the pulse point properly.

Always count pulse for one full minute if dysrhythmias or other abnormality is

present.

Have another nurse locate and count the radial pulse while you auscultate the

apical pulse. Determine an apical-radial pulse rate by counting simultaneously

for one full minute.

Equipment:

Watch with a second hand or indicator.

If using Doppler/ultrasound stethoscope:

Transducer in the probe

Stethoscope headset

Transmission gel

Procedure:

STEPS RATIONALE

1 Determine need to assess radial or apical pulse:

a. Note risk factors for alterations in apical pulse

b. Assess for signs and symptoms of altered SV (stroke volume) and CO such as dyspnea, fatigue, chest pains, orthopnea, syncope, palpitations, jugular venous distension, edema of dependent body parts, cyanosis or pallor of skin.

Certain conditions place clients at risk for pulse alterations. Heart rhythm can be affected by heart disease, cardiac dysrhythmias, onset of sudden chest pain or acute pain from any site, invasive cardiovascular diagnostic tests, surgery, sudden infusion of large volume of IV fluids, internal or external hemorrhage, and administration of medications that alter heart function. Physical signs and symptoms may indicate alterations in cardiac functions.



2 Assess for factors that normally influence apical pulse rate and rhythm:

a. Age b. Exercise c. Position changes

d. Medications

e. Temperature f. Emotional Stress, anxiety,

fear

Allows nurse to accurately assess presence and significance of pulse alterations. Normal PR change with age. Physical activity requires an increase in CO that is met by an increase HR and SV. HR increases temporarily when changing from lying to sitting or standing position Anti-dysrhythmics, sympathomimetics, and cardiotonics affect rate and rhythms of pulse. Large doses of narcotic analgesics can slow HR; general anesthetics slow HR; CNS stimulants such as caffeine can increase the HR. Fever or exposure to warm environments increases HR; HR declines with hypothermia. Results in stimulation of the sympathetic nervous system, which increases the HR.

3 Determines previous baseline balance apical site.

Allows nurse to assess change in condition. Provides comparison with future apical pulse measurements.

4 Explain that PR or HR is to be assessed.

Activity and anxiety can elevate HR. Client’s voice interferes with nurse’s ability to hear sound when apical pulse is measured.


6 If necessary, draw curtain around bed and/or close door.

Maintains privacy.

7 Obtain pulse measurement.



A. Radial Pulse

STEPS RATIONALE

1 Assist client to assume supine position.

Provides easy access to pulse sites.

2 If supine, place client’s forearm along side or across lower chest or upper abdomen with wrist extended straight. If sitting, bend client’s

elbow 90 and support lower arm on chair on nurses’ arm. Slightly extend wrist with palms down.

Relaxed position of lower arm and extension of wrists permits full exposure of artery to palpation.

3 Place tips of first two fingers of hand over groove along radial or thumb side of client’s inner wrist.

Fingertips are most sensitive parts of hand to palpate arterial pulsations. Nurse’s thumb has pulsation that may interfere with accuracy.

4 Lightly compress against radius, obliterate pulse initially, and then relax pressure so pulse becomes easily palpable.

Pulse is more accurately assessed with moderate pressure. Too much pressure occludes pulse and impairs blood flow.

5 Determine strength of pulse. Note whether thrust of vessel against fingertips is bounding, strong, weak or thready.

Strength reflects volume of blood ejected against arterial wall with each heart contraction.

6 After pulse can be felt regularly, look at watch’s second and begin to count rate; when sweep hand hits number on dial, start counting with zero, then one, two, and so on.

Rate is determined accurately only after nurse is assured pulse can be palpated. Timing begins with zero. Count of one is first beat palpated after timing begins.

7 If pulse is regular, count rate for 30 seconds and multiply by 2,

A 30 second count is accurate for rapid, slow, or regular pulse rates.

8 If pulse is regular, count rate for 60 seconds. Assess frequency and pattern if irregularity.

Inefficient contraction of heart fails to transmit pulse wave, interfering with CO2, resulting in irregular pulse. Longer time ensures accurate count.



B. Apical pulse

1 Assist client to supine or sitting position. Move aside bed linen and gown to expose sternum and left side of chest.

Expose portion of chest wall for selection of auscultation.

2 Locate anatomical landmarks to identify the points of maximal impulse (PMI), also called the apical impulse. Heart is located behind and to left of sternum with base at top and apex at bottom. Find angle of Louis just below suprasternal notch between sternal body and manubrium; can be felt as a bony prominence. Slip fingers down each side of angle to find second intercostal space. (ICS).

Carefully move fingers down left side to the left midclavicular line (MCL). A light tap felt within an area 1 to 2 cm ( ½ to 1 inch) of the PMI is reflected from the apex of the heart

Use of anatomical landmarks allows correct placement of stethoscope over apex of heart, enhancing ability to hear heart sounds clearly. If unable to palpate the PMI, reposition client on left side. In the presence of serious heart disease, the PMI may be located to the left of the MCL, or at the sixth ICS.

3 Place diaphragm of stethoscope in palm of hand for 5 to 10 seconds.

Warming of metal or plastic diaphragm prevents client from being startled and promotes comfort.

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4 Place diaphragm of stethoscope over PMI at the fifth ICS, at left MCL, and auscultate for normal S1 and S2 heart sounds (heard as “lub dub”).

Allow stethoscope tubing to extend straight without kinks that would distort sound transmission. Normal S1 and S2 are high pitched and best heard with the diaphragm.

5 When S1 and S2 are heard with regularity, use watch’s second hand and begin to count rate; when sweep hand hits number on dial, start counting with zero, then one, two, and so on.

Apical rate is determined accurately only after nurse is able to auscultate sounds clearly. Timing begins with zero. Count of one is first sound auscultated after timing begins.

6 If apical rate is regular, count for 30 seconds and multiply by 2.

Regular apical rate can be assessed within 30 seconds.

7 If HR is irregular or client is receiving cardiovascular medications, count for 1 minute (60 seconds).

Irregular is more accurately assessed when measured over long intervals. Regular occurrence of dysrhythmias within 1 minute may indicate inefficient contraction of heart and alteration on cardiac output.

8 Discuss findings with client as needed.

Promotes participation in care and understanding of health status.

9 Clean earpieces and diaphragm of stethoscope with alcohol swab as needed.

Control transmission of microorganisms when nurses share stethoscope.


11 Compare readings with previous baseline and/or acceptable range of heart rate for client’s age.

Evaluates for change in condition and alterations.

12 Compare peripheral pulse rate with apical pulse rate and note discrepancy.

Differences between measurements indicate pulse deficit and may warn of cardiovascular compromise. Abnormalities may require therapy.

13 Compare radial pulse equality and note discrepancy.

Differences between radial arteries indicate compromised peripheral vascular system.



14 Correlate PR with data obtained from BP and related signs and symptoms (palpitations, dizziness).

PR and BP are interrelated.

Recording and reporting: Record PR with assessment site in nurses’ notes or vital signs flow sheet.

Measurement of PR after administration of specific therapies should be documented in narrative form in nurses’ notes.

Report abnormal finding to nurse in charge or physician.

C. Assessing the Apical-Radial Pulse

Normally, the apical and radial pulses are identical. Any discrepancy between two pulse rates needs to be reported promptly. An apical-radial pulse can be taken by two nurses to be more accurate at the same time with a signal of start and stop. A peripheral pulse (usually, the radial pulse) is assessed by palpation in all individuals except: Newborns and children up to 2 or 3 years (apical pulse is assessed). Very obese or elderly clients apical pulse is assessed. Individuals with a heart disease (apical pulse is assessed).

Procedure:

STEPS Rationale

1 Palpate the radial pulse while listening for apical pulse. Using both senses, determine if the apical and radial pulses are synchronous. If the apical and radial pulses are not synchronous, get a second nurse and

Identifies differences between pulsations and heart sounds.

2 Explain to the client that one nurse is counting his or her heart beats while the second counts his or her radial pulse.

Informs the client’s answers his or her questions because the unusual procedure may arouse his or her anxiety; simple straight forward explanations usually are helpful. Listen to the client’s fears or anxiety with empathy.

3 Prepare to monitor the apical pulse.

4 Direct the second nurse to locate and count the radial pulse.

5 Look at the watch dial. Note the location of the second hand and signal the second nurse to begin counting at “one, two …”

Synchronizes the count, essential to determine if deficit is present.

6 Count the remaining 60 seconds silently as the second nurse counts the radial pulse silently.

Ensures accuracy.



7 Say “Stop” when exactly 60 seconds have passed.

Ensures accuracy.

8 Reposition the client comfortable.

9 Record the apical and radial rates immediately. Note any deficits.

Ensures prompt and accurate documentation.

Applying moderate pressure

to accurately assess the pulse

Assessing the radial pulse

Mapping the apical pulse

Assessing apical pulse



Comparing radial pulse equality and

discrepancy.

Assessing pedal pulse



ASSESSING RESPIRATION

Respiration is a complex vital function with two complementary processes, the

internal and external respirations. Respiration is the act of breathing. One act of

respiration consists of one inhalation and on exhalation. Inhalation or inspiration is

the act of breathing in, and exhalation, or expiration, is the act of breathing out.

External respiration is a combination of movements delivering air to the body’s

circulatory system.

1. Ventilation 2. Conduction of air

3. Diffusion and 4. Perfusion.

Objectives/Purposes:

The respiratory rate is assessed to:

Determine the per minute rate on admission as a base for comparing future

measurements.

Monitor the effect of injury, disease or stress on the client’s respiratory

system.

Evaluate the client’s response to medications or treatments that affect the

respiratory system.

Key Points:

Assess the client for factors that could indicate respiratory variations.

Without telling the client what you are doing, watch the chest movements in

and out.

Count in each ventilatory movement as one respiration.

Count for 30 seconds or one full minute.

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Equipment:

Watch with second

hand.

Paper, pencil Vital signs record.

Observe the rate, rhythm, and depth of respiration. Normal respiration is regular in depth and rhythm.

Place hands on chest when respirations are difficult to count.



Abnormal Breathing Patterns

Procedure:

STEPS RATIONALE

1 Determine need to assess client’s respirations:

a Note risk factors for respiratory alterations.

Certain conditions place client at risk for alterations in ventilation detected by changes in respiratory rate, depth, and rhythm. Fever, pain, anxiety, diseases of chest wall or muscles, constrictive chest or abdominal dressings, gastric distention, chronic pulmonary disease (emphysema, bronchitis, asthma), traumatic injury to chest wall with or without collapse of underlying lung tissue, presence of a chest tube, respiratory infection (pneumonia, acute bronchitis), pulmonary edema, and emboli, head injury with damage to brain stem, and anemia can result in respiratory alteration.

b Assess for signs and symptoms of respiratory alterations such as bluish or cyanotic appearance of nail beds, lips, mucous membranes, and skin; restlessness, irritability, confusion, reduced level of consciousness; pain during inspiration; labored or difficult breathing; adventitious sounds, inability to breathe spontaneously; thick, frothy, blood-tinge, or copious sputum produced on coughing.

Physical signs and symptoms may indicate alterations in respiratory status related to ventilation.

2

Assess pertinent laboratory values:

a. Arterial blood gases (ABGs): normal ABGs (values may vary slightly within institutions.

Arterial blood gases measure arterial blood pH, partial pressure of O2, and CO2, and arterial O2 saturation, which reflects client’s oxygenation.

b. Pulse oxymetry (SpO2): normal SpO2 = 90% - 100%; 85% – 89% may be acceptable for certain chronic disease conditions less than 85% is abnormal.

SpO2 less than 85% is often accompanied by changes in respiratory rate, depth, and rhythm.



c. Complete blood count (CBC): normal CBC for adults (values may vary within institutions)

Complete blood count measures red blood cell count, volume of red blood cells, and concentration of hemoglobin, which reflects client’s capacity to carry O2.

1) Hemoglobin: 14 to 18 g/100 ml, males; 12 to 16 g/100 ml, females.

2) Hematocrit: 40% to 54%, males; 38% to 47%, females.

3) Red blood cell count: 4.6 to 6.2 million/μl, males; 4.2 to 5.4 million/μl, females.

3 Determine previous baseline respiratory rate (if available) from client’s record.

Allows nurse to assess for change in condition. Provides comparison with future respiratory measurements.

4 Be sure client is in comfortable position, preferably sitting or lying with the head of the bed elevated 45 to 60 degrees.

Sitting erect promotes full ventilatory movement.

Critical Decision Point:

Clients with difficulty of breathing (dyspnea) such as those with congestive heart failure or abdominal ascites or in late stages of pregnancy should be assessed in positions of greatest comfort. Repositioning may increase the work of breathing,

which will increase respiratory rate.

5 Draw curtain around bed and/or close door. Wash hands.

Maintains privacy. Prevents transmission of microorganisms.

6 Be sure client’s chest is visible. If necessary, move bed linen or gown.

Ensures clear view of chest wall and abdominal movements.

7 Place client’s arm in relaxed position across the abdomen or lower chest, or place nurse’s hands directly over client’s upper abdomen.

A similar position used during pulse assessment allows respiratory rate assessment to be inconspicuous. Client’s or nurse’s hand rises and falls during respiratory cycle.

8 Observe complete respiratory cycle (one inspiration and one expiration).

Rate is accurately determined only after nurse has viewed respiratory cycle.

9 After cycle is observed, look at watch’ s second hand and begin to count rate: when sweep hand hits number on dial, begin time frame, counting one with first full respiratory cycle.

Timing begins with count of one. Respirations occur more slowly than pulse; thus timing does not begin with zero.

10 If rhythm is regular, count number of respirations in 30 seconds and multiply by 2. If rhythm is irregular, less than 12, or greater than 20, count for 1 full minute.

Respiratory rate is equivalent to number of respirations per minute. Suspected irregularities require assessment for at least 1 minute.



11 Note depth of respirations subjectively assessed by observing degree of chest wall movement while counting rate. Nurse can also objectively assess depth by palpating chest wall excursion after rate has been counted. Depth is shallow, normal, or deep.

Character of ventilatory movement may reveal specific disease state restricting volume of air from moving into and out of the lungs.

12 Note rhythm of ventilatory cycle. Normal breathing is regular and uninterrupted. Sighing should not be confused with abnormal rhythm.

Character of ventilations can reveal specific types of alterations.

13 Replace bed linen and client’s gown. Restores comfort and promotes sense of well-being.


15 Discuss findings with client as needed. Promotes participation in care and understanding of health status.

16 If respirations are assessed for the first time, establish rate, rhythm, and depth as baseline if within normal range.

Used to compare future respiratory assessment.

17 Compare respirations with client’s previous baseline and normal rate, rhythm, and depth.

Allows nurse to assess for changes in client’s condition and for presence of respiratory alterations.

Recording and Reporting: Record respiratory rate and character in nurses’ notes or vital sign flow sheet.

Indicate type and amount of oxygen therapy if used by client during assessment. Measurement of respiratory rate after administration of specific therapies should be documented in narrative form in nurses’ notes.


Home care Considerations: Assess for environmental factors in the home that may influence client’s respiratory rate such as second-hand smoke, poor ventilation, or gas fumes.



ASSESSING BLOOD PRESSURE

Definition:

Blood pressure is the force exerted produced by the volume of blood pressing on the resisting walls of the arteries Blood pressure is commonly abbreviated BP. Its measurement is expressed as a fraction.

The numerator or the upper figure is the systolic pressure/ systole (the phase

during which the heart works or contracts) and the denominator or the lower figure is

the diastolic pressure/ diastole (the heart’s resting phase).

The pressure is expressed in millimeters of mercury, abbreviated mmHg. Thus a

recording of

120/80 means systolic blood pressure was measured at 120 mmHg and the diastolic

blood pressure was measured at 80 mmHg. The difference between two readings is

called pulse pressure.

Blood is circulated through a loop involving the heart and blood vessels.

Purposes: The blood pressure is assessed by:

1. Determine the systolic and diastolic pressure of the client during

admission in order to compare his current status with normal changes.

2. Acquire data that may be compared with subsequent changes that

may occur during the care of the client.

3. Assist in evaluating the status of the client’s blood volume, cardiac

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output and vascular system.

4. Evaluate the client’s response to changes in his medical condition as a

result of treatment with fluids or medications.

Key Points: 1. Blood pressure is the measurements of the pressure exerted by the

blood on the walls of the arteries. The rate and force of the heartbeat

determines the reading as the ventricles contract and rest.

2. Do no take BP reading on person’s arm if:

is injured/diseased.

Is on the same side of body where a female has had a radical

mastectomy.

has a shunt or fistula for renal dialysis, or is site for an

intravenous infusion.

Equipment and Supplies:

o Stethoscope o Blood pressure cuff of appropriate size

o Sphygmomanometer – an aneroid or a mercury manometer may be

available. The gauge should be inspected to validate that the needle

or mercury is within the zero mark.

o Alcohol swab o Paper, pencil, pen, V/S flow sheet or

record form

Procedure: AUSCULTATION METHOD

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STEPS RATIONALE


2 With client sitting or lying, position client’s forearm, supported if needed, with palms turned up.

If arm is unsupported, client may perform isometric exercise that can increase diastolic pressure 10%. Placement of arm above the level of the heart causes false low reading.

3 Expose upper arm fully by removing constricting clothing.

Ensures proper cuff application.

4 Palpate brachial artery. Position cuff 2.5 cm (1inch) above site of brachial pulsation (antecubital space). Center bladder of cuff above artery. With cuff fully deflated, wrap evenly and snugly around upper arm.

Inflating bladder directly over brachial artery ensures proper pressure is applied during inflation. Loose-fitting cuff causes false high readings.

5 Position manometer vertically at eye level. Observer should be no farther than 1 meter (approximately 1 yard) away.

Accurate readings are obtained by looking at the meniscus of the mercury at eye level. The meniscus is the point where the crescent-shaped top of the mercury column aligns with the manometer scale. Looking up or down at the mercury results in distorted readings.

6 Palpate brachial or radial artery with fingertips of one hand while inflating cuff rapidly to pressure 30 mmHg above point at which pulse disappears.

Identifies approximate systolic pressure and determines maximal inflation point for accurate reading. Prevents auscultatory gap. If unable to palpate artery because of weakened pulse, an ultrasonic stethoscope can be used.

7 Deflate cuff fully and wait 30 seconds.

Prevents venous congestion and false high readings.

8 Place stethoscope earpieces in ears and be sure sounds are clear, not muffled,

Each earpiece should follow angle of ear canal to facilitate hearing.

9 Relocate brachial artery and place bell or diaphragm (chest piece) of the stethoscope over it. Do not allow chest piece to touch cuff or clothing.

Proper stethoscope placement ensures optimal sound reception. Stethoscope improperly positioned causes muffled sounds that often result in false low systolic and false high readings.

10 Close valve of pressure bulb clockwise until tight.

Tightening of valve prevents air leak during inflation.

11 Inflate cuff to 30 mmHg above palpated systolic pressure.

Ensures accurate measurement of systolic pressure.

12 Slowly release valve and allow mercury to fall at rate of 2 to 3 mmHg/sec.

Too rapid or slow a decline in mercury level can cause inaccurate readings.

13 Note point on manometer when first clear sound is heard.

First Korotkoff sound indicates systolic pressure.



14 Continue to deflate cuff, noting point at which muffled or dampened sound appears.

Fourth Korotkoff sound involves distinct muffling of sounds and is recommended as indication of diastolic pressure in children. (Perloff and others, 1993).

15 Continue to deflate cuff gradually, noting point at which sound disappears in adults. Note pressure to nearest 2 mmHg.

Beginning of fifth Korotkoff sounds is recommended by American Heart Association as indication of diastolic pressure in adults. (Perloff and others, 1993).

16 Deflate cuff rapidly and completely. Remove cuff from client’s arm unless measurement must be repeated.

Continuous cuff inflation causes arterial occlusion, resulting in numbness and tingling of client’s arm.

17 If this is the first assessment of client, repeat procedure on other arm.

Comparison of BP in both arms detects circulatory problems (Normal difference of 5 to 10 mmHg exists between arms).

18 Assist client in returning to comfortable position and cover arm if previously clothed.

Restores comfort and promotes sense of well-being.


Promotes participation in care and understanding of health status.

20 Wash hands Reduces transmission of microorganisms.

21 Compare readings with previous baseline and/or acceptable value of BP for client’s age.

Evaluates for changes in condition and alterations.

22 Compare BP readings in both arms. Arm with higher pressure should be used for subsequent assessment unless contraindicated.

23 Correlate BP with data obtained from pulse assessment and related cardiovascular signs and symptoms.

Blood pressure and heart rate are interrelated.


Inform client of value and need for periodic re-assessment.

Record BP. Measurement of BP after admission of specific therapies

should be documented.




Applying and Removing Personal Protective Equipment (gloves, gown, mask) Purpose:

To protect health care workers and clients from transmission of potentially infective materials.

Assessment:

Consider which activities will be required while the nurse is in the clients room at this time.

Equipment:

Gown

Mask

Clean gloves Procedure:

STEPS Rationale

1. Verify client identity and introduce yourself, explain for the client what you are to do, why it is necessary, and how he or she can participate.

2. Perform hand hygiene.

3. Apply a clean gown: a) Pick up a clean gown,

and allow it to unfold in front of you without allowing it to touch any area soiled with body substances.

b) Slide the arms and the hands through the sleeves.

c) Fasten the ties at the neck to keep the gown in place.

d) Overlap the gown at the back as much as possible and fasten the waist ties

Overlapping securely covers the uniform at the back, waist ties keep the gown from falling away from the body, which can cause inadvertent soiling of the uniform.



4. Applying the face mask: a) Locate the top edge of

the mask; the mask usually has a narrow metal strip along the edge.

b) Hold the mask by the top two strings.

c) Place the upper edge of the mask over the bridge of the nose, and tie the upper ties at the back of the head or secure the loops around the ears.

d) Secure the lower edge of the mask under the chin, and tie the lower ties at the nape of the neck.

e) If the mask has a metal strip, adjust this firmly over the bridge of the nose

f) Wear the mask only once

g) Do not let a used mask hanging around the neck.

To be effective the mask must cover both the nose and the mouth, because the air moves in and out of both.

A sure fit prevents both the escape

and the inhalation of microorganisms around the edges of the mask.

Mask should used only once because it becomes ineffective when wet.

5. Apply clean gloves. If wearing gowns pull the gloves up to cover the cuffs of the gown.

To remove soiled PPE:



6. Remove the gloves first since they are the most soiled. If wearing gown that is tied in front undo ties before removing the gloves.

7. Perform hand hygiene Contact with microorganisms may

occur

8. Remove the gown when preparing to leave the room

a) Avoid touching soiled parts on the outside of the gown.

b) Grasp the gown along the inside of the neck and pull down over the shoulders. Do not shake the gown.

c) Roll up the gown with the soiled part inside, and discard it in the appropriate container .



9. Remove the mask a) Remove the mask at

the doorway to the clients room. If using respirator mask, remove it after leaving the room and closing the door.

b) If using mask with strings, first untie the lower strings

c) Untie the top string and, while holding the ties securely, remove the mask from the face. If side loops are presents , lift the side loops up and away from the ears and face. Do not touch the front of the mask.

d) Discard a disposable mask in the waste container

e) Perform proper hand hygiene again.

This prevents the top part of the mask from falling onto the chest.

The front of the mask through which the nurse has been breathing is contaminated.

Applying and Removing Sterile Gloves Purpose

To enable the nurse to handle or touch sterile objects freely without contaminating them.

To prevent transmission of potentially infective organisms from the nurse's hands to clients at high risk for infection.

Assessment

Review the client's record and orders to determine exactly what procedure will be performed that require sterile gloves. Check the client record and ask about latex allergies. Use nonlatex gloves whenever possible.

Equipment

Package of sterile gloves. Procedure:



Step Rationale

1. Perform hand hygiene

2. Open the package of sterile gloves

a. Place the package on a clean, dry surface.

b. Remove the inner package from the outer package.

c. Open the inner package as instructed, if no tabs are provided, pluck the flap so that the fingers do not touch the inner surface.

d. Grasp the glove for the dominant hand by its folded cuff edge on the palmer side with the thumb and first finger of the nondominant hand. Touch only the inside of the cuff.

e. Insert the dominant hand into the glove and pull the glove on. Keep the thumb of the inserted hand against the palm of the hand during the insertion.

f. Leave the cuff in place once the unsterile hand releases the glove.

Any moist on the surface could

contaminate the gloves.

To keep the inner surface sterile

Put the first glove on the dominant hand

The hands are not sterile. By touching

only the inside of the gloves, the nurse

avoids contaminating the outside.

If the thumb is kept against the palm, it is

less likely to contaminate the outside of

the glove.

Attempting to further unfold the cuff is

likely to contaminate the glove.



3. Put the second glove on the

nondominante hand

a. Pick up the other glove with the sterile gloved hand. Inserting the gloved fingers under the cuff and holding the gloved thumb close to the gloved palm

b. Pull on the second glove carefully. Hold the thumb of the gloved first hand as far as possible from the palm.

c. Adjust each glove so that it is fits smoothly, and carefully pull the cuffs up by sliding the fingers under the cuffs.

This helps prevent accidental

contamination by the bare hand.

In this position, the thumb is less likely to

touch the arm and become

contaminated.

4. Remove and dispose the gloves.

Same technique as removing non-sterile gloves.

Document that sterile technique was used in the procedure.



CHANGING AN OCCUPIED BED

PURPOSES 1. To conserve the client’s energy 2. To promote client comfort. 3. To provide a clean, neat environment for the client 4. To provide a smooth, wrinkle-free bed foundation, thus minimizing sources of

skin irritation

ASSESSMENT Rationale

1

Assess

Skin condition and need for a special mattress (e.g., an egg-crate mattress), footboard, bed cradle, or heel protectors)

2 Client’s ability to reposition self. This will determine if additional assistance is needed.

3 Determine presence of incontinence or excessive drainage from other sources indicating the need for protective waterproof pads.

4 Note specific orders or precautions for moving and positioning the client.

PLANNING Delegation Bed-making is usually delegated to UAP (Unlicensed Assistive Personnel). Inform. Inform the UAP to what extent the client can assist or if another person will be needed to assist the UAP. Instruct the UAP about the handling of any dressing and/or tubes of the client and also the need for special equipment (e.g., footboard, heel protectors), if appropriate.

EQUIPMENT 1. Two flat or one fitted and one flat sheet 2. Cloth draw sheet (optional) 3. One blanket 4. One bedspread 5. Pillowcase(s) for the head pillow(s) 6. Waterproof drawsheet or waterproof pads (optional) 7. Plastic laundry bag or portable lines hamper, if available

IMPLEMENTATION Preparation Determine what lines the client may already have in the room to avoid stockpiling of the unnecessary extra linens

This avoids stockpiling of unnecessary extra linens.

Performance Rationale

1 Prior to performing the procedure, introduce self and verify the client’s identity using agency protocol. Explain to the client what you are going to do, why it is necessary, and how he or she can cooperate.

2 Perform hand hygiene and observe other appropriate infection control procedures. Apply clean gloves if linens is soiled with body fluids.



3 Provide for client privacy.

4 Remove the top bedding.

a Remove any equipment attached to the linen, such as signal light.

b Loosen all top linen at the foot of the bed, and remove the spread and the blanket.

c Leave the top sheet over the client (the top sheet can remain over the client if it is being changed and if it will provide sufficient warmth), or replace it with a bath blanket as follows:

(1) Removing top linens under a bath

blanket.

a Spread the bath blanket over the top sheet.

b Ask the client to hold the top edge of the blanket.

c Reaching under the blanket from the side, grasp the top edge of the sheet and draw it down to the foot of the bed. Leaving the blanket in place. ( 1 )

d Remove the sheet from the bed and place it in the soiled linen hamper.

5 Change the bottom sheet and draw sheet.

a Raise the side rail that the client will turn toward. If there is no side rail, have another nurse support the client at the edge of the bed.

This protects clients from falling and allows them to support themselves in the side-lying position.

b Assist the client to turn on the side away from the nurse and toward the raised side rail.

(2) Moving soiled linen as close to the

client as possible.

Doing this leaves the near half of the bed free to be changed.

c Loosen the bottom linens on the side of the bed near the nurse.

d Fanfold the dirty linen (e.g., draw sheet and the bottom sheet toward the center of the bed. (2) As close to and under the client as possible.

e Place the new bottom sheet on the bed, and vertically fanfold the half to be used on the far side of the bed as close to the client as possible. (3) Tuck the sheet under the near half of the bed and miter the corner if a contour sheet is not being used.

(3) Placing new bottom sheet on half of the

bed.



f Place the clean drawsheet on the bed with the center fold at the center of the bed. Fanfold the uppermost half vertically at the center of the bed and tuck the near side edge under the side of the mattress. (4)

(4) Placing clean drawsheet on the bed.

g Assist the client to roll over toward you, over the fanfold bed linens at the center of the bed, onto the clean side of the bed.

h Move the pillows to the clean side for the client’s use. Raise the side rail before leaving the side of the bed.

i Move to the other side of the bed and lower the side rail.

j Remove the used linen and place it in the portable hamper.

k Unfold the fanfold bottom sheet from the center of the bed.

l Facing the side of the bed, use both hands to pull the bottom sheet so that it is smooth and tuck the excess under the side of the mattress.

m Unfold the drawsheet fanfold at the center of the bed and full it tightly with both hands. Pull the sheet in three divisions: (a) face the side of the bed to pull the middle division, (b) face the far top corner to pull the bottom division, and (c) face the far bottom corner to pull top division.

n Tuck the excess drawsheet under the side of the mattress.

6 Reposition the client in the center of the bed.

a Reposition the pillows at the center of the bed.

b Assist the client to the center of the bed. Determine what position the client requires or prefers and assist the client to that position.

7 Apply or complete the top bedding.

(5)Client hold top edge of sheet while nurse

removes bath blanket.

a Spread the top sheet over the client and either ask the client to hold the top edge of the sheet or tuck it under the shoulders. The sheet should remain over the client when the bath blanket or used sheet is removed. (5)

b Complete the top of the bed.

8 Ensure continued safety of the client.

a Raise the de rails. Place the bed in the low position before leaving the bedside.



b Attach the call light bed linen within the client’s reach

c Put items used by the client within easy reach.

9 Bed-making is not normally recorded. EVALUATION

Conduct appropriate follow up, such as determining client’s comfort and safety. Patency of all dranage tubes, and client’s access to call light to summon help when needed.

Reassess all tubing, oxygen apparatus, IV pumps, and so forth.

This prevents errors in supportive devices resulting from procedure.

CHANGING AN UNOCCUPIED BED

PURPOSES

1. To promote the client comfort

2. To provide a clean neat environment for the client

3. To provide a smooth, wrinkle-free bed foundation, thus minimizing sources of skin

irritation

STEPS Rationale

1

Assess Client’s health status to determine that the person can safely get out of bed.

In some hospital it is necessary to have a written order to get out of bed if the client has been in bed continuously.

2

Client’s BP, pulse and respirations if indicated.

Client may experience postural hypotension when moved from a lying position to standing to sitting, particularly if it is the first time out of bed for awhile.

3 Client’s mobility status. This may influence the need for additional assistance with transferring the client from the bed to a chair.

4 Tubes and equipment connected to the client. This may influence the need for additional linens or waterproof pads.

PLANNING Delegation Bed-making is usually delegated to UAP (Unlicensed Assistive Personnel). If appropriate, inform the UAP of the proper disposal method of linens that contain drainage. Ask the UAP to inform you immediately if any tubes or dressings become dislodged or removed. Stress the importance of the call light being readily available while the client is out of bed.



EQUIPMENT 8. Clean gloves, if needed 9. Two flat or one fitted and one flat sheet 10. Cloth draw sheet (optional) 11. One blanket 12. One bedspread 13. Pillowcase(s) for the head pillow(s) 14. Waterproof drawsheet or waterproof pads (optional) 15. Plastic laundry bag or portable lines hamper, if available

IMPLEMENTATION Preparation Determine what lines the client may already have in the room to avoid stockpiling of the unnecessary extra linens.

STEPS RATIONALE

1 If the client is in bed, prior to performing the procedure, introduce self and verify the client’s identity using agency protocol. Explain to the client what you are going to do, why it is necessary, and how he or she can cooperate.

2 Perform hand hygiene and observe other appropriate infection control procedures.


4 Place the fresh linen on the client’s chair or over bed table; do not use another client’s bed.

This prevents cross-contamination (the movement of microorganisms from one client to another) via soiled linen.

5 Assess and assist the client out of bed. This ensures client safety.

a Make sure that this is an appropriate and convenient time for the client to be out of bed.

b Assist the client to a comfortable chair.

6 Raise the bed to a comfortable working height.

7 Apply clean gloves if linens and equipment have been soiled with secretions and/or excretions.

8 Strip the bed.

a Check bed lines for any items belonging to the client, and detach the call bell or any drainage tubes from the linen.

b Loosen all bedding systematically, starting at the head of the bed on the far side and moving around the bed up to the head of the bed on the near side.

. Moving around the bed systematically prevents stretching and reaching and possible muscle strain.

c Remove the pillowcases, if soiled, and place the pillows on the bed-side near the foot of the bed.



d Fold reusable lines, such as the bedspread and top sheet on the bed, into fourths, First, fold the linen in half by bringing he top edge even with the bottom edge, and then grasp it at the center of the middle fold and bottom edges (1).

Folding linens saves time and energy when reapplying the linens on the bed and keeps them clean.

(1) Fold reusable linens into fourths when removing them from the bed.

e Remove the waterproof pad and discard it if soiled.

f Roll all soiled linen inside the bottom sheet, hold it away from your uniform, and place it directly in the linen hamper (2).

These actions are essential to prevent the transmission of microorganism to the nurse and others.

(2) Roll soiled linen inside bottom sheet and hold away from body.

g Grasp the mattress securely. Using the lugs if present, and move the mattress up to the head of the bed.

h Remove and discard gloves if used. Perform hand hygiene.

9 Apply the bottom sheet and draw sheet.

a Place the folded bottom sheet with its center fold on the center of the bed. Make sure the sheet is hem side down for a smooth foundation. Spread the sheet out over the mattress, and allow a sufficient amount of sheet at the top to tuck under the mattress. Place the sheet along the edge of the mattress at the foot of the bed and do not tuck it in (unless it is a contour or fitted sheet (3).

The top of the sheet needs to be well tucked under to remain securely in place, especially when the head of the bed is elevated.

(3) Placing bottom sheet on bed.

b Miler the sheet at the top corner on the near side (see figure 33-20) and tuck the sheet under the mattress, working from the head of the bed to the foot.



c If a waterproof drawsheet is used, place it over the bottom sheet so that the centerfold is at the centerline of the bed and the top and bottom edges extend from the middle of the client’s back to the area of the midthigh or knee. Fanfold the uppermost half of the folded draw sheet at the center or far edges of the bed and tuck in the edge (4).

(4) Placing clean drawsheet on bed.

d OPTIONAL: before moving to the other side of the bed, place the top linens on the hemside up, unfold them, tuck them in, and miter the bottom corners.

Completing one entire side of the bed at a time saves time and energy.

10

Move to the other side and secure the bottom linens.

a Tuck in the bottom sheet under the head of the mattress, pull the sheet firmly, and miter the corner of the sheet.

b Pull the remainder of the sheet firmly so that there are no wrinkles. Tuck the sheet in at the side.

Wrinkles can cause discomfort for the client and breakdown of skin. Tuck the sheet in at the side.

c Tuck in the drawsheets, if appropriate.

11

Apply or complete the top sheet, blanket, and spread.

a Place the top sheet, hem side up; on the bed so that its centerfold is at the center of the bed and the top edge is even with the top edge of the mattress.

b Unfold the sheet over the bed.

c Follow the same procedure for the blanket and the spread, but place the top edges about 15 cm (6 in.) from the head of the bed to allow a cuff of sheet to be folded over them.

d 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.

e Fold the top of the top sheet down over the spread, providing a cuff (7).

The cuff of a sheet makes it easier for the client to pull the covers up.

(7) Making a cuff of the top linens.



f Move to the other side of the bed and secure the bedding in the same manner.

12

Put clean pillowcases on the pillows as required.

a Grasp the closed end of the pillowcase at the center with one hand.

b 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.(8)

(8) Method for putting a clean pillowcase on a pillow.

c With the free hand, pull the pillowcase over the pillow.

d Adjust the pillowcase so that the pillow fits into the corners of the case and the seams are straight.

A smoothly fitting pillowcase is more comfortable than a wrinkled one.

e Place the pillows appropriately at the head of the bed.

13

Provide for client comfort and safety.

a Attach the signal cord so that the client can conveniently reach it. Some cords have clamps that attach to the sheet or pillowcase. Others are attached by safety pin. Most bed now have call light bottom on the side rail.

b 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.

This makes it easier for the client to get into the bed.

c Place the bedside table and the overbed table so that they are available to the client.

d 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.

14

Document and report pertinent data.

a Bed-making is not normally recorded.

b Recording any nursing assessments, such as the client’s physical status and pulse and respiratory rates before and after being out of bed, as indicated.



BODY MECHANICS

I. Definition:

Is the term used to describe the efficient, coordinated and safe use of the body to

move objects and carry out the ADL's. correct body mechanics would facilitate the

safe and efficient use of appropriate muscle group to maintain balance, reduce the

energy required, reduce fatigue, and decrease the risk of injury for both nurses and

clients, especially during transferring, lifting and reposition.

II. Effects of gravity on body balance.

A. Definition: Gravity means mutual attraction that the earth has for an object

and the object for the earth.

B. Principles of Body Balance:

1. Center of gravity is low.

2. Base support is wide.

3. Line of gravity pass through center of gravity and base of support.

C. Principles of body mechanics:

1. Center of gravity: is "the point at which all its mass is centered". An

area located in the pelvis about the level of the second sacral vertebra.

2. Base of support: "It is the area located at the base of an object". It

provides balance of equilibrium or stability especially the line of gravity

passes through the base of support and center of gravity.

3. Line of gravity: "It is an imaginary vertical line that passes through the



center of gravity and the base of support of an object". It passes behind

the ear, downward just behind the center of jip joint and then downward

slightly in front of the knee and ankle joint (it differs according to

skeletal build and curvatures in spine).

D. Example to maintain balance: 1. A box of 4 x 3 x 12 of lengths.

a. If placed on the side, measured 4 x 12 wide base → it is balanced.

b. If placed on the side, measured 3 x 12 narrow base → it is imbalanced.

2. A number of blocks: a. Placed on each other, the balance is maintained if column is

vertical. b. If placed in a zigzag, the weight distributed is unequal above

the lowest block; they will fall. Remember: Balance of the human body is much more complex than that of a

solid object, but in both instances governed by the laws of gravity. III. Principles of Body Mechanics:

1. "Maintain body balance and alignment". The stability of an object greater when there is:

a. Wide base of support. b. Low center of gravity passes through base of support and center of

gravity. Example: in helping the patient to move; praying, standing, sitting, and stooping.

2. "Work at a comfortable height". A comfortable working height for most people is between the waist level and the hip joint (pelvis). Working at a comfortable height helps to do the following:

a. Minimizes muscle strain when reaching an object at high or low level. b. Allows the body to remain aligned and balanced. c. Allows us easily to flex the hip and knee joints. d. Applies leverage to our work. Example: to place or remove object from a shelf that is higher than the head or near the floor – hand cranks.

3. "Keep the object close to your body". The force required to maintain body balance is greater when the line of gravity is farthest from the center of base of support. Example: a person holds a weight close to his body using less effort.

4. "Use of smooth coordinated movement". Muscles tend to act in groups rather than singly. Example: during breathing; during stooping (not bending); praying.

5. "Large muscles fatigue less quickly than small muscles". Example: large muscles as the muscle of the buttocks and thigh; small



muscle as sacrospinal muscle of the back. Remember: Less strain results when a heavy object is raised by flexing the knees rather than by bending from the waist.

6. "Set or prepare the muscles for action". The muscle is always in slight contraction. This condition is called muscle tone. If the nurse prepares her muscles for action prior to activity, she will protect her ligaments and muscles from strain and injury.

a. Not to lift more than what is safe, or get help. b. To take a deep breath. c. Tense or contract muscles (abdomen, pelvis, buttocks, and thigh). d. Let your breath out slowly as you lift the object. e. Put load down occasionally. f. Use proper body mechanics. g. Hold object close to the body.

7. "The use of good judgment in deciding which object you can lift or carry alone". If in doubt, do not attempt to lift alone, and get others to help you. Example: in moving a patient out of bed, either helpless or dependent to some extent on a wheelchair or trolley.

8. "The use of mechanical devices and other devices can lessen the amount of work required in movement".

Example: in using mechanical device, the nurse uses her arm as a lever. In using other devices as draw sheet, in moving helpless patient, the drawsheet should extend from superior aspect of patient's arm level to the inferior aspect of the buttocks. At least 2 nurses are needed. 9. "The amount of effort (force) required to move a body or an object depends

upon the resistance of the body or object as well as the pull of gravity". i.e., by utilizing the pull gravity rather than working against it. Example: It is easier for the nurse to lift a patient up in the bed when he is lying flat than in sitting position in which the resistance of the body is much greater.

10. " The friction between an object and the surface upon which the object is moved affects the amount of work needed to move the object". Friction: is a force that opposes, so that less energy is needed to move objects on smooth surfaces. Example: when lifting a patient up in bed, it is better to provide a smooth foundation upon which the patient can move.

11. "Pulling or sliding an object requires less than effort than lifting it". Because lifting necessitates moving against force of gravity. Example: if the nurse lowers the head of the bed before she helps the patient to move up in bed; less effort is required than when the head of the bed is raised.

12. "Using one's own weight to counteract a heavy object's weight (as patient) requires less energy in movement.

Example: if the nurse uses her own weight to pull or push a patient, her weight Increases the force applied to the movement".



IV. Benefits of applying principles of body mechanics:

A. Specific benefits: 1. Avoids muscle strain. 2. Uses energy efficiently.

B. General benefits. 1. The lungs and circulatory system work better. 2. The body is less easily tired by minimal muscle strain. 3. Work is less tiring and more efficient. 4. The mind is clearer, concentration is easier. 5. The physiological state is improved. 6. It gives a good impression on others.

LIFTING AN OBJECT FROM THE FLOOR

Purposes: Enables nurses to pick up an object from floor level without self injury. Two methods are presented. Contraindications: Assessment of the weight of the load is especially important. Persons with back problems should not use either of the following methods without first consulting with a physician. Learning/Teaching Guidelines: To teach correct body mechanics to clients or to auxiliary personnel:

1. Serve as a role model by always using good body mechanics. 2. Carefully demonstrate the specific method to be sued. 3. Provide information about the correct use of muscles and ways to use

leverage, and 4. Supervise use of the method by those whom you have taught.

Preliminary Activities: Assessment/Planning: ► Assess weight of the load to be lifted. ► Decide the lifting technique to be used. Procedure:

STEPS

Rationale/Discussion

1 Stand near object of the load to be lifted.

This stance places object nearer your center of gravity and provides

2 Put on internal girdle. Internal girdle helps protect intervertebral disks.

Method 1

a. Bend toward object by flexing all the hips and partially flexing at the knees.

This position lowers center of gravity.

b. Grasp object and bring it to thigh level by pulling with arm and shoulder, muscles while thigh and leg muscles provide an upward thrust.

Muscles share the workload. Back muscles remain contracted to protect the intervertebral disks.



c. Bring object to waist level by using the leg and thigh muscles for greater thrust while beginning to straighten the back.

This brings load as close as possible to center of gravity.

Method 2

a. Position feet 18 inches apart with left foot forward.

Position maintains wide base of support while allowing use of the left knee as a fulcrum.

b. Tuck chin in and squat down with back straight.

This protects intervertebral disks.

c. Grasp object with both hands, tipping it if necessary to attain balance.

This allows firm control of object.

d. Rest left elbow on left thigh, just above knee and apply pressure as needed to stand up. Straighten legs.

Position allows use of leverage.

POSITIONING CLIENTS

Definition:

Positioning are achieved by placing the body of their treatment or examination.

Different position are achieved by placing the body parts in correct alignment or

using the hospital bed the client’s body in desired position

Purposes:

1. Physical Examination. 2. Nursing treatment and tests. 3. Obtain specimens. 4. Operations



COMMON POSITIONS

Positions Description Areas Examined/Indications

Cautions

1

Standing

Arms are held relaxed at sides of the body; feet 6 to 8 inches apart, face should look straight ahead.

Body contour, posture balance, muscles and extremities.

Elderly and weak; patients may need support.

2

Sitting

Buttocks firmly on the edge of the bed, thighs well supported, knees bent, feet positioned flat against the floor.

1. Assessing vital signs. 2. Examination of the head and neck, posterior and anterior thorax. 3. Inspection and palpation of thyroid, breasts and axilla. 4. Auscultation of the lungs.

Elderly and weak; may require support.

3

Dangling position

The client sits on the side of the bed, with the feet dangling over its edge. The client dangles after remaining horizontal in bed for more than a day or two.

Same as the sitting position.

Same as above. Lightheadedness or vertigo may result when client sits up for the first time.



4

Dorsal recumbent

Back lying position with knees flexed and hips externally rotated; small pillow under the head. Flexed knees reduce tension on lower back and abdominal muscles and increase client comfort.

Abdomen and external genitalia.

May be difficult for clients who have cardio-pulmonary problems. The client should not raise arms over the head or clasp the hands behind the head because this increases contraction of the abdominal muscles.

5

Horizontal recumbent

Back lying position with legs extended; small pillow under the head.

1.Head, neck, axillae, anterior thorax, lungs, breasts, heart, extremities. 2. Peripheral pulses.

Not used for abdominal assessment because of the increased tension of abdominal muscles.

6

Dorsal (Supine)

Back lying without a pillow.

As for horizontal recumbent.

Tolerated poorly by clients with cardiovascular and respiratory problems. An alternate position is to raise the head of the bed. Clients with low back pains may unable to lie flat without flexing the knees. Risk for aspiration is greater with this position.



7

High Fowler’s

Head of bed 60º angle.

Thoracic surgery, severe respiratory conditions.

Need to support the popliteal vessels.

8 Fowler’s

Head of bed 45º angle, hips may or may not be flexed.

Post operative, gastrointestinal conditions, promotes lung expansion; As client rests, eats, or drink; has visitors, or wishes to read or watch TV.

9 Semi-

Fowler’s


Relieving cardiac, respiratory distress, and neurological conditions.

10 Low

Fowler’s


Necessary degree elevation for ease of breathing, promotes skin integrity, client comfort.

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11

Lithotomy

Back lying position with feet supported in stirrups; the hips should be in line with the edge of the table.

Female genitalia, rectum, and female reproductive tract.

May be difficult and tiring to elderly people and those with arthritis or joint deformities. This position is assumed immediately before it is needed because it is embarrassing and uncomfortable. The client is kept draped.

12

Genu-pectoral (knee-chest)

Kneeling position with torso at 90º angle to hips.

Rectal or vaginal examinations.

Uncomfortable position, tolerated poorly by clients who have cardiovascular or respiratory problems.

13 Standing, bent-over the examining table or Jack-knife position

This is more comfortable position then knee-chest.

Palpation of the prostate gland.

This position is assumed immediately before it is needed because it is embarrassing. Client with back problems may need assistance.

14 Lateral (side lying)

The client is supported on the right or left side with the opposite arm, thigh, and knee flexed and resting on the bed. A

Clients who are obese or older may not be able to tolerate this position for any length of time. Left: Rectum, vagina.



pillow is placed under the head to keep the head, neck, and spine in alignment. The upper arm is flexed at the hips and knee positioned on a small pillow.

Right: Rectal examination, administering enema or inserting a rectal tube.

15 Sim’s

The client is in semi-prone position on the right or left side with the opposite arm, thigh, and knee flexed and resting on the bed. The client’s weight is placed on the anterior ileum, humerus, and clavicle.

Improper positioning can cause unnecessary harm to clients, especially if they have pre-existing conditions such as peripheral vascular disease or diabetes. Positions that compromise peripheral blood flow may damage nerves as well.

16

Knee

-Gatc

h

Lower section of bed (under knees) slightly bent.

For client’s comfort; contraindicated for vascular disorders.

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17 Prone

Position

The client lying on abdomen, with the head turned to the side. This facilitates respiration and drainage of oral secretions. A pillow is placed under the head for comfort and relief from pressure.

Contraindicated in possible complications such as increasing intracranial pressure or cardiopulmonary disease.

18 Trendelenburg’s

Head of bed lowered and foot part raised.

Percussion, vibration, and drainage, (PVD) procedure.

19 Reverse

Trendelenburg’s

Bed frame is tilted up with foot of bed down.

Gastric condition prevents esophageal reflux.

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TRANSFERRING A PATIENT FROM BED TO CHAIR

Purpose:

To transfer a client from bed to chair, wheelchair or commode. Assessment: Before transferring patient assess the client the following:

1. The clients body size. 2. Ability to follow instructions. 3. Ability to bear weight. 4. Ability to position/reposition feet on floor. 5. Ability to push down with arms and lean forward. 6. Ability to achieve independent sitting balance. 7. Muscle strength. 8. Activity tolerance. 9. Joint mobility. 10. Presence of paralysis. 11. Presence of orthostatic hypotension. 12. No. assistants required.

Equipment:

1. Appropriate clothing. 2. Slippers or shoes with non skid soles. 3. Gait/transfer belt. 4. Chair, commode, wheelchair as appropriate to client need. 5. Slide/lift if needed.

Procedure:

STEPS RATIONALE

1 Identify the patient Provides patient safety.

2 Prior to performing the procedure , introduce self .Explain the procedure to the client, why it is necessary, and how he or she can participate.

Will help to reduce the anxiety of the client, and help build a trusting relationship with the client.

3 Gather the equipment. Provides organized approach to task

4 Perform hand hygiene .Apply gloves if performing rectal temperature.

To prevent risk of infection.

5 Provide for client privacy. To avoid insecurity and embarrassment.

6 Position the equipment appropriately.

a. Lower the bed to its lowest position. So that the clients feet will rest flat on the floor.

b. Lock the wheels of the bed. to keep the bed stationary.

c. Place the wheelchair parallel to the bed and as close to the bed as possible.

For easy movement.

d. Put the wheelchair on the side of the bed that allows the client to move toward his stronger side.

For easy transfer from bed to chair.



e. Lock the wheels of the wheelchair and raise the footplate.

So that the chair remains stationary while the client is being transferred.

5. Prepare and asses the client.

a. Assist the client to a sitting position at the side of the bed.

To transfer the patient to the wheel chair.

b. Asses the client for orthostatic hypotension before moving from bed.

If not assessed condition may worsen while transferring .

c. Assist the client in putting on a bath robe/appropriate clothing and nonskid slippers or shoes.

To prevent the client from fall and injury.

d. Place a gait/transfer belt snugly around the client's waist. Check that the belt is securely fastened.

The belt helps in easy transfer of the client without discomfort.

6. Give explicit instructions to the client. Ask the client to:

a. Move forward and sit on the edge of the bed with feet placed flat on the floor.

This brings the client's center of gravity closer to the nurses.

b. Lean forward slightly from hips . This brings the clients center of gravity more directly over the base of support and position the head and trunk in the direction of movement.

c. Place the foot of the stronger leg beneath the edge of the bed and put the other foot forward.

In this way the client can use the stronger leg muscles to stand and power the movement.

d. Place the client's hand on the bed's surface so that the client can push while standing.

This provides additional force for the movement and reduces the potential for strain on the nurses' back.

7. Position yourself correctly.

a. Stand directly in front of the client and to the side requiring the most support. Hold the gait/transfer belt with the nearest hand ;the other hand supporting the back of the clients shoulder.

Helps prevents loss of balance during transfer.

b. Lean your trunk forward from hips. Flex Your hips ,knees and ankles.

Helps prevents loss of balance during transfer.

c. Assume a broad stance, placing one foot forward and one back. Brace the client's feet with your feet .

To prevent the client from sliding forward or laterally.

8. Assist the client to stand and then move together towards the wheelchair.

Coordination allows easy transfer.



a. On the count of three or verbal instructions ask the client to push down against the mattress /side of the bed while you transfer your weight from one foot to the other(keeping your back straight) and stand upright moving the client forward into a standing position.

If there is in coordination in lifting it will be discomfortable for both the patient and the nurse.

b. Support the client in an upright position for a few moments.

This allows the nurse and client to extend the joints and provides the nurse with an opportunity to ensure the client is stable before moving from bed.

c. Together pivot your foot farthest from the chair or take a few steps towards the chair.

Pivoting the farthest foot will assist in balancing body and maintaining the centre of gravity.

9. Assist the client to sit.

a. Have the client back upto the wheelchair and place the client's legs against the seat

Minimizes the risk of client falling while sitting down.

b. Make sure the wheelchair brakes are on.

To securely allow the client to sit on the chair and prevent fall.

c. Have the client reach back and feel/hold the arms of the wheelchair.

To prevent falling.

d. Stand directly in front of the client .place one foot front and one back.

To equally distribute the centre of gravity.

e. Tighten your grasp on the transfer belt, and tighten your gluteal, abdominal, leg and arm muscles.

To securely hold the client while sitting and prevent fall.

f. Have the client sit down while you bend your knees/hips and lower the client onto the wheelchair seat.

Bending knees and hips prevents strain on the back of the nurse.

10. Ensure client safety.

a. Ask the client to push back into the wheelchair seat.

Provides a broader base of support and greater stability, minimizes the risk of falling from the wheelchair.

b. Remove the gait/transfer belt. To replace the equipment after use.

c. Lower the footplates and place the clients feet on them.

To give support to the feet.

Variation: For clients having difficulty in walking place the wheelchair at 45°angle to the bed.

This allows the client to pivot into the chair easily without much movement.



Variation : For transferring with a

belt and two nurses., position yourselves on both sides of the client, facing the same direction as the client. Flex your hips, knees, and ankles .Grasp the clients' transfer belt with the hand closest to the client, with the other hand supporting the client's elbows. coordinating , all three should pivot towards the wheelchair.

This can be used to move heavy patients easily.

Variation: For clients who cannot stand but are able to co-operate and possess sufficient upper body strength, use a sliding board to help them move without nursing assistance.

This method promotes client's sense of independence but also preserves your energy.

11. Wash hands To prevent cross infection.

12. Replace equipment. For further use.

13. Document information. For further follow up.

BATHING ADULT CLIENT

PURPOSES

1. To remove transient microorganisms, body secretions and excretion and dead skin

cells.

2. To stimulate circulation to the skin.

3. To promote sense of well-being.

4. To produce relaxation and comfort.

5. To prevent and eliminate unpleasant body odors.

ASSESSMENT

1. Physical or emotional factors (e.g. fatigue, sensitivity to cold, need for control, anxiety

or fear).

2. Condition of the skin (color, texture and turgor, presence of pigmented spots,

temperature, lesions, excoriation, abrasion, and bruises).areas of erythema (redness)

on the sacrum, bony prominences, and heels should be assessed for possible

pressure sores.

3. Presence of pain and need for adjunctive measures (e.g., an analgesic) before the

bath.

4. Range of motion of the joints.

5. Any other aspect of health that may affect the client’s bathing process (e.g., mobility,

strength, cognition).

6. Need for use of clean gloves during the bath.



Equipment Basin or sink with warm water (43 C˚ -46 C˚).

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.

Clean gloves, if appropriate (e.g., presence of body fluids or open lesions).

Personal hygiene articles (e.g., deodorants, powder, lotions).

Shaving equipment.

Laundry bag.

IMPLEMENTATION

Before start bathing your client you must be aware for the following

a. Purpose and type of bathing.

b. Self-care ability of the client.

c. Any position or movement precautions for the client.

d. Coordinate all aspects of health care and prevent unnecessary fatigue. Such as x-

ray or physical therapy…etc.

e. Client comfort level with being bathed by someone else.

f. Presence of all equipment and linens before starting bathing.

STEPS Rational Prepare the bed and position the

client appropriately

Position the bed at a comfortable working height. Lower the side rails on the side close to you. Keep the other side rail up. Assist the client to move near to you.

This avoids undue reaching and straining and promotes good body mechanics. And ensure patient safety

Place bath blanket over top sheet. Remove the top sheet from under the bath blanket by starting at client’s shoulder and moving linen down toward client’s feet.[ask the client to grasp and hold the top of bath blanket while pulling linen to the foot of the bed].

NOTE: if the bed linen is to be reused,

place it over the bed side chair. If it is to be changed, place it in the linen hamper, not on the floor.

The bath blanket provides comfort, warmth and privacy.

Remove client’s gown while keeping the client covered with bath blanket. Place gown in linen hamper.

Make a bath mitt with washcloth. A bath mitt retains water and heat better than cloth loosely held and prevents ends of washcloth from dragging across the skin



Making a bath mitt, triangular method. (A) Lay your hand on the washcloth; (B) fold the top corner over Your hand; (C) fold the side corners over your hand; (D) tuck the second corner under the cloth on the palm side to secure the mitt.

A B C D Making a bath mitt, rectangular method. (A) Lay your hand on the washcloth and fold one side over your hand; (B) fold the second side over your hand; (C) fold the top of the

cloth down and tuck it under the folded side against your palm to secure the mitt.

A B D

Wash the face.

Begin the bath at the cleanest area and work downward toward the feet.

Place towel under patient’s head.

Wash the patient’s eyes with water only and dry them well. Use a separate corner of the washcloth for each eye.

Using separate corners prevents transmitting micro-organisms from one eye to the other.

Wipe from the inner to the outer canthus.

This prevents secretions from entering the nasolacrimal ducts.

Ask whether the patient wants soap

used on the face.

Soap has a drying effect, and the face, which is exposed to the air more than other body parts, tends to be drier.

Wash, rinse, and dry the patient’s face, ears and neck.

Remove the towel from under the patient’s head.

Wash the arms and hands. (Omit the arms for a partial bath.)

Place a towel lengthwise under the arm away from you.

It protects the bed from becoming wet



Wash, rinse and dry the arm by elevating the patient’s arm and supporting the patient’s wrist and elbow. Use long, firm strokes from wrist to shoulder, including the axillary area.

Firm strokes from distal to proximal areas promote circulation by increasing venous blood return.

Apply deodorant or powder if desired. (Optional) Place a towel on the bed and

put a washbasin on it. Place the patient’s hands in the basin.

Many patients enjoy immersing their hands in the basin and washing themselves. Soaking loosens dirt under the nails. Assist the patient as needed to wash, rinse and dry the hands, paying particular attention to the spaces between the fingers.

Repeat for hand and arm nearest you. Exercise caution if an intravenous infusion is present, and check its flow after moving the arm.

Avoid submersing the IV site is not clear, transparent dressing.

A clear transparent dressing will keep water from an IV site; however, a gauze dressing becomes contaminated when it became wet with the water.

Wash the chest and abdomen. (Omit

the chest and abdomen for a partial bath. However, the areas under a woman’s breast may require bathing if this area is irritated or if the patient has significant perspiration under the breast.)

Place bath towel lengthwise over chest. Fold bath blanket down to the patient’s pubic area.

Keeps the patient warm while preventing unnecessary exposure of the chest.

Lift the bath towel off the chest, and bathe the chest and abdomen with your mitted hand using long, firm strokes (Figure 13-9). Give special attention to the skin under the breasts and any other skin folds particularly if the patient is overweight. Rinse and dry well.

Replace the towel when the areas

have been dried.

Wash the legs and feet. (Omit legs and feet for a partial bath.)



Expose the leg farthest from you by folding the towel toward the other leg being careful to keep the perineum covered.

Covering the perineum promotes privacy and maintains the patient’s dignity.

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.

Washing from the distal to proximal areas promotes circulation by stimulating venous blood flow.

Reverse the coverings and repeat for

the other leg.

Wash the feet by placing them in the basin of water.

Dry each foot. Pay particular attention

to the spaces between the toes. If you prefer, wash one foot after that leg before washing the other leg.

Obtain fresh, warm bathwater now or when necessary. Water may become dirty or cold.

Because surface skin cells are removed with washing, the bathwater from dark-skinned patients may be dark, however, this does not mean the patient is dirty.

Lower the bed and raise side rails when refilling basin.

This ensures the safety of the patient.

Wash the back and then the perineum.

Assist the patient into a prone or side-lying position facing away from you. Place the bath towel lengthwise alongside the back and buttocks while keeping the patient covered with the towel as much as possible.

This provides warmth and undue exposure.



Wash and dry the patient’s back, moving from the shoulders to the buttocks, and upper thighs, paying attention to the gluteal folds

Remove and discard gloves if used. Perform a back massage now or after

completion of bath.

Assist the patient to the supine position and determine whether the patient can wash the perineal area independently. If the patient cannot do so, cover the

patient as shown in picture and wash

the area.

Assist the patient with grooming aids

such as powder, lotion, or deodorant.

Use powder sparingly. Release as little as possible into the atmosphere.

This will avoid irritation of the respiratory tract by powder inhalation. Excessive powder can cause caking, which leads to skin irritation.

Help the patient put on fresh clothing.

Assist the patient to care for hair, mouth, and nails. Some people prefer or need mouth care prior to their bath.

Tub Bath/ Shower

Prepare the client and the tub. Fill the tub about one-third to one-half

full of water, put cold water in before hot. ( temperature 43-46C˚ )

Sufficient water is needed to cover the perineal area.

Cover all intravenous catheters or wound dressings with plastic coverings, and instruct the patient to prevent wetting these areas if possible.

Put a rubber bath mat or towel on the floor of the tub if safety strips are not on the tub floor.

These prevent slippage of the patient during the bath or shower.

Assist the patient into the shower or tub.



Assist the patient taking a standing shower with the initial adjustment of the water temperature and water flow pressure, as needed. Some patients need a chair to sit on in the shower because of weakness. Hot water can cause elderly people to feel faint due to vasodilation and decreased blood pressure from positional changes.

If the patient requires considerable assistance with a tub bath, a hydraulic chair may be required (see Variation below).

Explain how the patient can signal for help; leave the patient for 2–5 minutes, and place an “occupied” sign on the door. For safety reasons, do not leave a patient with decreased cognition or patients who may be at risk (e.g. history of seizures, syncope).

Assist the patient with washing and getting out of the tub or bath.

Wash the patient’s back, lower legs, and feet, if necessary.

Assist the patient out of the bath. If the patient is unsteady, place a bath towel over the patient’s shoulders and drain the water before the patient attempts to get out of it.

Draining the water first lessens the likelihood of a fall. The towel prevents chilling.

Dry the patient, and assist with follow-up care.

Assist the patient with grooming aids such as powder, lotion, or deodorant.

Assist the patient back to his or her room.

Discard the used linen in the laundry skip.

Place the “unoccupied” sign on the door.

Documentation:

Type of bath given (i.e. complete, partial, or self-help). Skin assessment, such as excoriation, erythema, exudates, rashes, drainage or skin

breakdown. Nursing interventions related to skin integrity. Ability of the patient to assist or cooperate with bathing. Patient response to bathing. Educational needs regarding hygiene. Information or teaching shared with the client or their family.



COLLECTING SPUTUM SPECIMEN

I. Definition:

Sputum – is the mucous secretion from the lungs, bronchi, and trachea. It is important to differentiate it from saliva, a watery substance located in the mouths of organisms, secreted by the Salivary Glands sometimes referred to as |”spit.” Healthy individuals do not produce sputum. Clients need to cough to bring sputum up from the lungs, bronchi, and trachea into the mouth in order to expectorate it into a collecting container.

II. Purposes:

1. For culture and sensitivity to identify a specific microorganism and its drug sensitivities.

2. For cytology to identify the origin, structure, function, and pathology of cells. Specimens for cytology often require serial collection of three early-morning specimens and are tested to identify cancer in the lung and its specific cell type.

3. For acid-fast bacillus (AFB), this also requires serial collection, often for 3 consecutive days, to identify the presence of tuberculosis (TB).

4. To assess the effectiveness of therapy. III. Supplies and Equipment:

Rationale

1. Sputum container with a tight cover For collecting the sputum; tight cover ensures that the outside of the container is free of sputum.

2. Facial tissues. Available for the client if there is excessive tearing or coughing following culture.

3. Identification labels. Prevents errors by correctly labeling the culture tube.

4. Laboratory requisition form. Informs the laboratory of the client’s identification or other required information.

5. Emesis basin Available in case the client gags and vomits following the throat culture.

OPTIONAL: Clean Gloves & Mask.

IV. Procedure:

STEPS Rationale

1 Wash hands then wear gloves & personal protective equipment.

To prevent spread of microorganisms and to avoid contact with the sputum.

2 Gather supplies and equipment. To save time, effort and energy.



3 Follow special precautions if tuberculosis is suspected, obtaining the specimen in a room equipped with a special airflow system or ultraviolet light.

If these options are not available, wear a mask capable of filtering droplet nuclei.

4 Explain to the client what will be done; instruct in whatever way is necessary.

Informs client; encourages participation and cooperation; lessens anxiety.

5 Draw the curtain or close the door to the room if the client desires privacy.

Provides privacy.

6 Position the client so that he or she is upright.

Place the client in an optimal position to fully expand thee lungs and forcefully expel air and secretions.

7 Give the specimen container properly labeled to the client with the cover removed. Warn not to touch the inside of the container.

Prevents contamination with microorganisms.

8 Encourage the client to take several deep breaths with full expiration.

Promotes full lung expansion to loosen and expel secretions.

9 Instruct the client to cough deeply, raising secretions from the deep airways.

Forces secretions into larger airways, facilitating their expulsion.

10 Instruct the client to expectorate directly into the container.

11 Instruct the client to repeat the deep breathing and coughing sequence until approximately 5 ml of sputum in the container. (Note: Clarify the amount with the agency laboratory).

Provides and adequate amount of sputum for diagnostic testing.

12 Provide comfort measures for the client as necessary.

13 Wash hands Limits transfer of microorganisms.

14 Send the specimen container to the laboratory according to the agency guidelines.

Ensures prompt analysis and accurate test results.



COLLECTION and TESTING of URINE

Definition: Urinalysis – the analysis of urine samples. It is a part of the examination of every patient at the beginning and during illness.

a. Amount of urine:

i. 1200 – 1500 ml / 24 ° = normal. 1. Less than 500 cc / 24 ° = oliguria.

2. More than 1500 cc / 24 ° = polyuria.

ii. Day volume is 2 – 3 times more than night volume.

b. Appearance / Clarity:

i. Normal urine is clear. ii. Turbid (cloudy) urine is not always pathologic. Normal urine

may develop turbidity on refrigeration or from standing at room temperature; bacteria ferment urine quickly at room temperature.

iii. Abnormally cloudy urine – due to pus, blood, epithelial cells, bacteria, fat, colloidal particles, phosphate, urates.

c. Odor:

i. Normal – faint aromatic odor. ii. Characteristic odors produced by ingestion of asparagus,

thymol. iii. Cloudy urine with ammonia odor – urea-splitting bacteria such

as Proteus, causing urinary tract infection. iv. Abnormally colored urine:



a) Turbid or smoky urine.

- may be from hematuria, spermatozoa, prostatic fluid, fat droplets, chyle.

b) Red or red brown. - may be due to blood pigments, porphyria, transfusion reaction, bleeding lesions on urogenital tract, some drugs.

c) Yellow-brown or green-brown.

- may reveal obstructive lesions of bile duct.

d. Reaction:

i. Reflects the ability of kidney to maintain normal hydrogen ion concentration in plasma and intracellular fluid; indicates acidity or alkalinity or urine.

ii. The pH should be measured in fresh urine, since the breakdown of urine to ammonia causes urine to become alkaline.

iii. Normal pH is around 6 (acidic); may vary from 4.6 – 7.5. iv. Urine acidity or alkalinity has relatively little clinical significance

unless the patient is on special diet or therapeutic program or is being treated for renal calculous disease.

v. Alkaline urine is often cloudy because of phosphate crystals.

e. Specific gravity:

i. Reflects thee kidney’s ability to concentrate or dilute urine; may reflect degree of hydration or dehydration.

ii. Normal specific gravity ranges from 1.005 – 1.025. iii. Specific gravity is fixed at 1.010 in chronic renal failure. iv. In a person eating a normal diet, inability to concentrate or

dilute urine indicates disease.

f. Osmolality: i. Osmolality is an indication of the amount of osmotically active

particles in urine (specifically, it is the number of particles per unit volume of water). It is similar to specific gravity, but is considered a more precise test. It is also easy to do – only 1 – 2 ml of urine is required.

ii. The unit osmotic measure is the osmole. Average values: Female: 300 – 1090 mosm / kg. Male: 390 – 1090 mosm / kg.

Normal Findings in Routine Urinalysis:

Element Findings

MACROSCOPIC

Color Pale straw or amber. More concentrated in the morning.

Odor Slightly aromatic.

Appearance Clear

Specific Gravity 1.010 – 1.025



pH 4.5 – 8.0 (average pH 6, 7- neutral, less than 7 acidic, greater than 7

alkaline). Protein None

Glucose None

Ketones None

Sugar None

MICROSCOPIC

RBCs 0 – 3 / high-power field

WBCs 0 – 4 / high-power field

Epithelial Cells Few

Casts None, except occasional hyaline casts

Crystals Present

Yeast Cells None

Parasites None Types of Urine Specimen:

1. Clean urine specimen or random routine urine specimen, or routine urinalysis can be collected with a client voiding naturally through a Foley catheter or urinary diversion collecting bag. The specimen should be clean but need not be sterile. It is commonly used to screen urinary and systemic pathologies. The elements of routine urinalysis are the macroscopic and microscopic.

2. Midstream specimen of clean voided or clean catch – to obtain a specimen relatively free of microorganisms growing in the lower urethra but the sterile procedure of catheterization is undesirable. Used for urine culture and sensitivity.

3. 24-Hour Urine – done when a large quantity of urine is necessary to analyze for protein and creatinine clearance.

4. Catheterized specimen – used for culture. 5. Indwelling catheter urine – urine is obtained from an indwelling catheter for

culture. 6. Double-voided specimen – used to accurate measurement of glucose and

ketones. 7. Use of Keto-Diastix, Multistix, Tes-Tape reagent strips – used to detect

glucose and ketones. Purposes:

1. The client understands the need for the urine specimen and will be able to provide a specimen unassisted in the future. 2. The client provides a clean or sterile urine specimen in the manner described by the nurses within a reasonable time.

Key Points:

1. Assess the client’s ability to collect specimen independently. 2. Determine the last time the client voided.



Obtaining a clean urine specimen or random urine specimen:

STEPS Rationale

Collection by the patient:

1 Give client the urine container properly labeled with client’s identification (name, medical record number, sex, age) [date and time of urine collection will be written after collection].

2 Instruct the patient on how to properly collect.

Provides the client with the information needed to collect specimen.

3 Send the urine to the laboratory immediately or within 2 hours with the properly filled up laboratory requisition form.

Ensures accurate testing and documentation.

Collection done by the nurse:

1 Wash hands. To prevent spread of microorganisms.

2 Collect needed supplies and equipment: a. Urine container properly labeled with Client’s identification. b. Urinal (male) or bedpan (female). c. Toilet tissues. d. Laboratory requisition form.

To save time, effort and energy.

3 Explain the purposes(s) and procedure of the test.

To gain client’s cooperation.

4 Put on disposable gloves, place urinal or bedpan in position. Instruct client to void.

5 Dry client’s urethral opening with tissue and after voiding.

Microorganisms thrive in wet areas.

6 Remove urinal and bedpan, cover, and take it into the bathroom or the utility room.

Ensures client’s comfort.

7 Put a designed amount of urine into the urine container and cover it tightly. Discard the remainder.

8 Clear the urinal and bedpan, put back to proper place. Discard gloves and wash hands.

Limits transfer of microorganisms.

9 Send to the laboratory immediately or within 2 hours with properly filled up laboratory form.

Ensures accurate testing and documentation.



Obtaining a midstream urine specimen:

A. Collection done by the patient:

1 Instruct the client on the purposes of urine collection and to prepare the needed supplies and equipment:

Cleansing the female urinary

meatus, spread the labia minora with one hand and with the other hand, cleanse the perineal area

from front to back.

Retract the foreskin if needed. Using a towelette,

cleanse the urinary meatus by moving in a circular motion from the center of the

uretral openining around the glans and down the distal portion of the shaft of the

penis.

a. Sterile urine container properly labeled with client’s identification.

b. Soap and water

c. Disposable washcloth.

d. Antiseptic solution

e. Sterile cotton balls

f. Laboratory requisition form

2 Instruct the client of the procedure.

a. Wash hands To prevent transfer of microorganisms.

b. Clean the perineal area around the urinary meatus using the disposable washcloth.

Removes most pathogenic organisms from the area around urethra, thus decreasing potential contamination of the urine specimen.

c. Wash hands again. Limits transfer of microorganisms.

d. Soak the cotton ball after one use.

e. Using a cotton ball, clean around external meatus with a single stroke.

Removes microorganisms from peri-urethral area.

f. Discard cotton ball after on use. Avoids contamination.

g. Continue the cleansing action discarding all used balls.

Removes microorganisms from the peri-urethral area.

h. Void a small amount; hold the urinary stream.

Flushes away microorganisms from urethra.

i. Void urine into the sterile specimen container, holding the container only on the outside.

Collects specimen with minimal contamination.

j. Stop voiding when container is about three-quarters full; void remaining urine in toilet, bedpan, or urinal. Cover the container tightly without touching the inside of the container.

Prevents overflow in specimen container.

k. Wash hands. Final hand wash is to remove any contamination of hands from possible contact with urine.

B. Collection done by the Nurse:

1 Wash hands and put on clean gloves. Limits transfer of microorganisms.



2 Gather needed supplies and equipment:


a. Sterile urine container.

b. Bedpan or urinal.

c. Sterile cotton balls.

d. Antiseptic soap.

e. Disposable washcloth.

f. Disposable gloves.

3 Explain purposes and procedure to the client.


4 Pull on the curtain or close the door. To provide privacy.

5 Put on disposable gloves.

6 Soak the cotton balls with antiseptic soap and set them aside.

Prepares equipment; client will not have to wait for this part of the procedure.

7 Place the female client on a bedpan. Place urinal under the male client’s penis.

8 Clean the area around the urinary meatus using disposable washcloth.

Removes microorganisms, a decreasing possible contamination of specimen.

9 Discard gloves, wash hands, and put on clean gloves.

Removes microorganisms that may be present after cleaning the perineal area.

10 Clean around the meatus (if client is male); clean from pubis to rectum (if client is female) with the cotton balls using single strokes.

Prevents fecal contamination of meatus.

11 Discard balls after single use. Repeat cleansing.

Prevents recontamination with used cotton balls.

12 Instruct the client to void a small amount of urine into the bedpan or urinal, then to hold the urine stream.

Washes away microorganisms in and around meatus.

13 Place a sterile specimen near urethra; instruct the client to void again.

Collects the specimen with few if any microorganisms.

14 When container is nearly full, instruct the client to hold the urine into the bedpan or urinal.

Prevents overflow from specimen container.

15 Instruct the client to void the remainder of the urine into the bedpan of urinal.

16 Lift the client from bedpan or remove urinal. Leave the client comfortable.

17 Close specimen container with a sterile top and without touching the inside of the container.

Prevents further contamination by microorganisms.

18 Discard gloves and wash hands. Limits transfer of microorganisms.

19 Send to laboratory immediately with properly filled up laboratory requisition form.



Collecting urine specimen from Indwelling Catheter:

1 Wash hands. To prevent the spread of microorganisms.

2 Prepare needed supplies and equipment:



b. Disposable 10 ml syringe with needle.

c. Antiseptic swab or alcohol swab.

d. Clamp.

e. Disposable clean gloves.

3 Explain the purposes and procedure to the client.


4 Pull the curtain or close the door. To provide privacy.

5 Put on disposable gloves.

6 Inspect the urinary drainage tubing for amount of urine in the tubing.

Determines if sufficient amount is present to withdraw for specimen.

7 Clamp the drainage tubing at least 3 in. below the sampling port (if it contains little urine) by using a U clamp or folding the tubing and securing a band around the fold.

Blocks urine from draining into the collecting bag; thus rubber accumulates a sufficient amount of specimen.

8 Leave the clamp in place for 30 minutes.

Allows enough time for urine to drain.

9 Locate the specimen port with an antiseptic swab.

Identifies the area designated for withdrawing urine from a drainage system.

10 Clean the port with an antiseptic swab. Removes microorganisms from the port.

11 Insert the needle of the 10 ml syringe through the port.

Obtaining a urine specimen from a retention catheter:

A. From a specific area near the end of the

catheter. B. From an access port in the tubing.

A B

12 Unclamp the tubing and withdraw the

required amount of urine.

For example, 3 mL for a urine culture or 30 mL for a routine urinalysis. (Depending on the system).

13 Transfer the urine to the specimen container.

If a sterile culture tube is used, make sure the needle or syringe does not touch the outside of the container to prevent recontamination.

14 Discard the syringe and needle in an appropriate sharps container.



15 Cap the container.

16 Remove gloves and discard. Perform hand hygiene.

17 Label the container, and send the urine to the laboratory immediately for analysis or refrigerator.

18 Record collection of the specimen and any pertinent observations of the urine on the appropriate records.

Collecting 24-hour urine specimen:

1 Collect the needed supplies and equipment.


a. Large size urine collector properly labeled with client’s identification.

b. Bedpan or urinal

c. Bucket with container or refrigerator.

d. Laboratory requisition form.

2 Explain the procedure to the client. Informs the client and gives instructions on what he or she is to do to help. Often the client is the key person in the success of a 24-hour collection because he or she reminds all people to save the urine.

3 Place the container in a large container filled with ice; place this on the client’s bathroom or nearby storage area.

Prevents the urine from deteriorating.

4 Instruct the client to void and discard the specimen.

5 Record the time and date of discarded specimen on the collection container. This is the starting time of the collection.

Ensures that all urine from this point on is collected.

6 Place all voided urine in the container during the next 24 hours.

Ensures that urine is saved; this is critical for the accuracy of the test.

7 Let client void (in toilet, bedpan, or urinal). Collect urine or pour urine from the bedpan or urinal into the urine container.

8 Send to the laboratory immediately with properly filled up laboratory requisition form.



Testing urine for contents (sugar and ketones):

A. Double-voided urine.

1 Prepare needed supplies and equipment.


a. Urine container properly labeled with client’s identification.

b. Tissue

c. Urinal or bedpan.

d. Water to drink.

2 Explain purpose and procedure to client.



4 Ask client to void and discard urine.

5 Let client drink water, around 8 oz.

6 Wait for 30 – 45 minutes.

7 Let client to void (in toilet, bedpan, or urinal). Collect urine or pour urine from the bedpan or urinal.

8 Send to the laboratory immediately with properly filled up laboratory requisition form.

To ensure accuracy.

Using reagent strip.

After dipping the reagent strip (dipstick) into fresh urine, wait the stated time period and compare the results to the

color chart.

1 Wash hands. To prevent the spread of microorganisms.

2 Prepare needed supplies and equipment



b. Reagent strip.

c. Disposable gloves (optional)

3 Explain to the client what will be done.

Informs the client.

4 Read instructions on the testing kit to determine how much urine is needed.

Instructs on how to use the test materials. Techniques vary with many different brands.

5 Wash hands and put on gloves. Limits transfer of microorganisms.

6 Collect the urine specimen.

7 Take the specimen to a work area.

8 Dip reagent strip in the urine specimen and pull it out immediately.

Strip contains chemicals that change colors when exposed to glucose and ketones.



9 Remove excess urine from the reagent strip.

10 Wait for 15 to 30 seconds depending on the manufacturer’s instructions.

11 Compare the strip’s color with that of the chart on the bottle.

The color scale measures the quality of glucose and ketones The range of the color scales extends from negative, trace, 1+, 2+, 3+.

12 Discard urine and reagent strip.

13 Remove gloves and wash hands.

14 Inform the client of the results and record.

COLLECTION and TESTING of STOOL

I. Introduction:

Stool specimen yields information related to functioning of the gastrointestinal system and its accessory organs. a. Test for ova and parasites (O & P) – indicates the presence of

gastrointestinal parasites and / or their eggs ova. b. Guaiac or Hemoccult or occult blood test – used to test presence of

blood in stool. Fecal Characteristics:

Character Normal Abnormal Cause

Color Infant: Yellow Adult: Brown – due to metabolism of bile pigments to stercobilin.

White or Clay Black or tarry Red (melena) Pale with fat

Absence of bile. Iron ingestion or upper GI bleeding. Lower GI bleeding, hemorrhoids. Malabsorption of fat.

Odor Pungent: affected by food type – results from the presence of indole and skatole, end products of protein catabolism by bacterial action in the large intestines.

Noxious change. Blood in feces or infection.

Consistency Soft, formed Liquid Hard

Diarrhea, reduced absorption. Constipation.



Frequency Infant: Breastfed – 4 to 6 x daily Bottle-fed – 1 – 3 x daily Adult: daily or 3 x per week.

Infant: more than 6 x / day or less than once every 1 – 2 days. Adult: More than 3 x a day or less than once a week.

Hypomotility or hypermotility.

Amount shape

150 Gm/day resembles diameter of rectum.

Narrow, pencil shaped.

Obstruction, rapid peristalsis.

Constituents Undigested food, dead bacteria, fat, bile pigment, cells lining intestinal mucosa, water.

Blood, pus, foreign bodies, mucus, worms.

Internal bleeding, infection, swallowed objects, irritation, inflammation.

II. Objectives: 1. The client understands the purpose of the diagnostic test, as evidenced by ability to explain it. 2. The client eliminates sufficient stool to provide a specimen for the diagnostic test. III. Key Points:

1. Assess the client’s understanding of the test and ability to collect the specimen independently. 2. Determine the time of the client’s last bowel movement. 3. Wearing disposable gloves use a tongue depressor to transfer stool from bedpan to specimen container. 4. Label specimen correctly. 5. Test specimen by following instructions on test packet. 6. Record results of specimen test in the health record.

IV. Supplies and Equipment:

Action Rationale

1. Bedpan, commode, ordinary collecting hat.

Provides receptacle for stool

2. Toilet tissue. Cleans perineal area after defecation.

3. Disposable gloves. Protects the nurse’s hands.

4. Tongue blades. Transfers stool from one container to another.

5. Specimen container. Collects stool for testing.

V. Procedure:

Action Rationale

Collecting s Stool Specimen:

1 Explain the purpose of the test to the client.

Informs the client and encourages participation.



2 Describe how the specimen is to be collected.

Instructs the client who is to collect own stool.

3 Instruct the client to save his or her stool in a bedpan and to discard toilet paper elsewhere.

Collects specimen that is free of urine, water, and toilet paper.

If the client is unable to collect specimen:

1 Wash hands. To prevent spread of microorganisms.

2 Gather the needed equipment and supplies; label the specimen container with appropriate identification and fill up the lab. request form.


3 Explain the purposes(s) and procedure of the test.

Informs the client and encourages participation.


5 Remove bedpan (or commode pan) with stool after the client evacuates.

6 Cover the bedpan and take it to the bathroom or dirty work area.

Removes stools from the client’s bed unit to minimize embarrassment or discomfort.

7 Use tongue blades to transfer stool from bedpan to a specimen container. Transfer as much as is required for the test. Place lid securely on the container.

8 Discard tongue blades and excess stool, wash bedpan.

9 Discard gloves and wash hands. Limits transfer of microorganisms.

10 Send specimen to the laboratory immediately.

Ensures accurate testing.

11 Record date and time of stool collection and results.

OBTAINING A CAPILLARY BLOOD SPECIMEN TO MEASURE

BLOOD GLUCOSE PURPOSES

1. To determine or monitor blood glucose levels of clients at risk for hyperglycemia or

hypoglycemia

2. To promote blood glucose regulation by the client

3. To evaluate the effectiveness of insulin administration



ASSESSMENT

Before obtaining a capillary blood specimen, determine:

1. The policies and procedures for the facility 2. The frequency and type of testing 3. The client’s understanding of the procedure 4. The client’s response to previous testing 5. Assess the client’s skin at the puncture site to determine if it is intact and the circulation

is not compromised. Color, warmth, and capillary refill. 6. Reviewed the client’s record for medications that may prolong bleeding such as

anticoagulants, or medical problems that may increase the bleeding response. 7. Assess the client’s self-care abilities that may affect accuracy of test results, such as

visual impairment and finger dexterity.

PLANNING

Delegation

Check the policy and procedure manual to determine who can perform this skill. It is

usually considered an invasive technique and one that requires problem solving and

application of knowledge. It is the responsibility of the nurse to know the results of the

test, and supervises unlicensed assistive personnel responsible for assisting the nurse.

EQUIPMENT

1. Blood glucose meter (glucometer) 2. Blood glucose reagent strip compatible with the

meter 3. 2 x 2 gauze 4. Antiseptic swab 5. Clean gloves 6. Sterile lancet ( a sharp device to puncture the skin) 7. Lancet injector (a string-loaded mechanism that

holds the lancet)

IMPLEMENTATION

Preparation

Review the type of meter and the manufacturer’s instructions.

Assemble the equipment at the bedside.

STEPS Rationale

1 Prior to performing the procedure, introduce self and verify the client’s identity using agency protocol. Explain to the client what you are going to do, why it is necessary, and how he or she can participate. Discuss how the results will be used in planning further care or treatments.

2 Perform hand hygiene and observe other appropriate infection control procedures (e. g., gloves).



3 Provide privacy. (1) Insert the test strip into the meter.

4 Prepare the equipment.

a Some meter turn on when a test strip is inserted into the meter ( 1 )

b Confirm the code number.

5 Select and prepare the vascular puncture site.

a Choose a vascular puncture site (e.g., the side of an adult’s finger). Avoid sites beside bone. Hold a finger in a dependent (below heart level) position. If the earlobe is used, rub it gently with a small piece of gauze.

These actions increase the blood flow to the area, ensure an adequate specimen, and reduce the need for a repeat puncture.

b Clean the site with the antiseptic swab or soap and water and allow it to dry completely.

Alcohol can affect accuracy and the site stings when punctured when wet with alcohol.

6 Obtain the blood specimen.

a Apply gloves.

b Place the injector, if used, against the site, and release the needle, thus permitting it to pierce the skin. Make sure the lancet is perpendicular to the site.

The lancet is designed to pierce the skin at a specific depth when it is a perpendicular position relative to the skin. (2).

c Prick the site with a lancet or needle, using a darting motion.

(2) Place the injector against

the site.

d Gently squeeze (but do not touch) the puncture site until a drop of blood forms. The size of the drop of blood can vary depending on the meter. Some meters require as little as 0.3 mL of blood to accurately test blood sugar.

e Hold the reagent strip under the puncture site until adequate blood covers the indicator square. The pad will absorb the blood and a chemical reaction will occur. Do not smear the blood. This will cause an inaccurate reading.

(3) Apply the blood to the test

strip.

- Some meters wick the blood by just touching the puncture site with the strip. (3)

f Ask the client to apply pressure to the skin puncture site with 2x2 gauze. Pressure will assist hemostasis.

7 Expose the blood to the test strip for the period and the manner specified by the manufacturer. As soon as the blood is placed on the test strip:



a Follow the manufacturer’s recommendations on the glucose meter and monitor for the amount of time indicated by the manufacturer.

The blood must remain in contact with the test strip for a prescribe time to obtain accurate results.

Some glucometers have the test strip placed in the machine before the specimen is obtained.

8 Measure the blood glucose.

a Place the strip into the meter according to the manufacturer’s instructions.

Refer to the specific manufacturer’s recommendations for the specific procedure.

b After the designed time, most glucose meters will display the glucose reading automatically. Correct timing ensures accurate results. (4).

(4) Read the results

c Turn off the meter and discard the test strip and 2x2 gauze in a biohazard container. Discard the lancet into a sharps container.

d Remove and discard gloves. Perform hand hygiene.

9 Document the method of testing and results on the client’s record. If appropriate, record the client’s understanding and ability to demonstrate the technique. The client’s record may also include a flow sheet on which capillary blood glucose results and the amount, type, route, and time of insulin administration are recorded. Always check if a diabetic flow sheet is being used for the client.

10

Check for orders for sliding scale insulin based on capillary blood glucose results. Administer insulin as prescribed.

EVALUATION

1. Compare glucose meter reading normal blood glucose level, status of puncture site, and

motivation of the client to perform the test independently. 2. Relate blood glucose reading to previous reading and the client’s current health status. 3. Report abnormal results to the primary care provider. Some agency may have a

standing policy to obtain a venipuncture blood glucose if the capillary blood glucose exceeds a certain value.

4. Conduct appropriate follow-up such as asking the client to explain the meaning of the results and/or demonstrating the procedure at the next scheduled test.

5. Prepare the client for home glucose monitoring and review frequency, record keeping, and insulin administration if appropriate.



Collecting Samples from the Nose or Throat

I. Introduction

The oronasopharyngeal cavity is lined with mucous membrane that secretes

mucus, moistening the membrane and the air that is inhaled. Lachrymal fluid and

saliva also drain into the cavity. Viral infections are common problems in the

upper airways, but bacterial infections occur as well. Because bacterial infections

can be treated pharmacologically, samples for cultures are taken of the upper

airway secretions to distinguish between viral and bacterial infections. When

bacteria are cultured, sensitivity tests determine the proper treatment.

II. Purposes:

1. The client can accurately report the reason for the culture and explain when

and how its result will be learned.

2. The client’s nose and throat are without discomfort or bleeding from taking the

culture as evidenced by his or her report and an inspection of the area.

III. Key Points: 1. Assess the client for evidence of respiratory infection.

2. Observe the client’s ability to cough deeply.

3. Place the client in high Fowler’s position.

IV. Supplies and Equipment:

Rationale

1. Sterile cotton-tipped or polyester-tipped swab or applicator in a culture tube.

Removes exudate from pharyngeal mucosa without contamination.

2. Tongue depressor.

Depresses tongue for better visualization of pharynx.

3. Penlight. Illuminates area to be cultured.

4. Facial tissues.

Available for the client if there is excessive tearing or coughing following culture.

5. Identification labels.

Prevents errors by correctly labeling the culture tube.



6. Laboratory requisition form. Informs the laboratory of the client’s identification or other required information.

7. Emesis basin. Available in case the client gags and vomits following the throat culture.

V. Procedure:

STEPS Rationale

Collecting Culture Samples from the Pharynx

1 Wash hands. Limits transfer of microorganisms.

2 Gather needed supplies and equipment. To save time, effort and energy.

3 Explain the exact procedure to the client. Tell him or her that a ticking sensation in the throat may be felt and that the client may even gag as the throat is swabbed.

Informs the client and encourages discussions of anxiety or discomfort. Prepares for the discomfort of the culture.


5 Instruct the client to sit upright or help into that position.

Allows easier view visualization of the access to the pharynx.

6 Place tissues and emesis basin within the client’s reach.

Prepares the client if need arises.

7 Ready the swab by loosening it from the culture tube; place it within reach.

Prepares the swab.

8 Depress the tongue with the tongue depressor while illuminating the pharynx with the penlight.

Permits visualization of the pharynx so that it can be inspected.

9 Inspect the pharynx for reddened or inflamed areas or patches of exudates.

10

Set the penlight aside and grasp the swab.

11

Insert the swab through the mouth, carefully avoiding the tongue, teeth, or cheeks.

Prevents contamination of the swab tip



12

Rub the swab quickly but firmly over the area of inflammation or patchy exudate.

Ensures collection of secretions from suspicious areas.

If no exudate is seen:

13

Rub the swab quickly but firmly over the nasopharyngeal area behind the uvula.

Ensures collection of secretions in an area representative of the entire pharynx.

14

Withdraw the swab quickly without touching the oral tissues.

Prevents contamination of the swab.

15

Replace the swab in the culture tube.

16

Insert the swab tip into the medium. Inserting the collected secretions directly into the medium ensures that the bacteria will survive until cultured by the laboratory.

17

Secure the top of the culture tube. Prevents contamination.

18

Discard the tongue blade.

19

Provide comfort measures for the client as necessary; facial tissues, a drink of water.

20

Wash hands. Limits transfer of microorganisms.

21

Secure labels to the culture tube. Prevents identification errors by the laboratory.

22

Send the culture to the laboratory according to agency guidelines.

Ensures accurate results.

B. Collecting Culture Samples from the nasal Mucosa




2 Gather needed supplies and equipment. To save time, effort and energy.

3 Explain the exact procedure to the client. Tell him or her that she will feel itching and discomfort or a desire to sneeze as the swab passes through the nose.

Informs the client of the procedure; encourages participation; prepares for the discomfort.

4 Pull on the curtain or close door. To provide privacy.

5 Instruct the client to sit upright or help into that position.

Allows easier visualization of the access to the nares.

6 Place tissues within the client’s reach. Prepares the client if need arises.

7 Ready the swab by loosening it from the culture tube; place it within reach.

Prepare the swab.

8 Instruct the client to blow his or her nose.

Prepare the swab.

9 Instruct the client to tilt head back. Allows easier access to the turbinates.

10

Inspect the nostrils to determine patency; using the penlight for illumination.

Determines which nostril to use; select the nostril without visible obstruction.

11

Insert the wire swab gently through the most patent nostril; avoid touching the nasal tissue.

Prevents contamination of the swab tip. A wire swab is preferable for this procedure because it is less likely to injure tissues. Bend the swab into a curve that permits easier entry before the package is opened.

12

Force the swab through the resistance met when it enters the turbinates.

Ensures that the swab tip rests against the tissues of the turbinates rather than the anterior nares.

13

Place the tip of the swab against the turbinate tissue and rotate.

Collects the secretions.

14

Withdraw the swab quickly without touching the sides of the nares.

Prevents contamination of the swab.

15

Replace the swab in the culture tube.



16

Insert the swab tip into the medium. Inserting the collected secretions directly into the medium ensures that the bacteria will survive until cultured by the laboratory.

17

Secure the top of the culture tube. Prevents contamination.

18

Provide comfort measures for the client as necessary; facial tissues, a drink of water.

19

Wash hands. Limits transfer of microorganisms.

20

Secure labels to the culture tube. Prevents identification errors by the laboratory.

21

Send the culture to the laboratory according to agency guidelines.

Ensures accurate results.

Insert the wire swab gently through the most patent nostril; avoid touching the nasal tissue.

BANDAGES AND BINDERS

Introduction / Definition:

A simple gauze dressing is often not enough to immobilize or provide support to a wound.

Bandages and binders are devices that secure large dressings, wrap body parts, provide

support to body areas and facilitate immobilization of the limits.

Bandage – is a strip or roll of material that is wrapped around a body part to support or

immobilize a body part, or to secure a dressing that cannot be taped to the skin.

Bandages are available in rolls of various widths and material including gauze, elasticized

knits, elastic webbing, flannel, and muslin.

Gauze – is used for bandages because it is light and porous and conforms to body parts;

permit air circulation to underlying skin to prevent maceration, inexpensive, and can be

discarded after one use.

Elastic bandage – adhere to the skin providing support and pressure and conform to body

parts.

A binder – is a broad bandage made of a shape and size to fit and supports the underlying

muscles or incisions or dressings on a body part; is made of cotton or muslin fabric that may

or may not be elasticized. Some binders have metal or plastic ribbing (stays) to prevent



bending and add additional support. Other binders are made of netting that stretches to

accommodate shape as they encircle the entire body to secure dressings.

Bandages and binders applied over or around dressings can provide extra protection

and therapeutic benefits by:

1. Creating pressure over a body part.

2. Immobilizing a body part.

3. Supporting a wound.

4. Reducing or preventing edema.

5. Securing a splint, or

6. Securing dressings.

Principles for Applying Bandages and Binders:

• Correctly applied bandages and binders do not cause injury to underlying or nearby

body parts or create discomfort for the client.

1. Inspect the skin for abrasions, edema, discoloration, or exposed wound edges.

2. Cover exposed wounds or open abrasions with sterile dressing.

3. Assess the condition of underlying dressings and change them if they are soiled.

4. Assess the skin of underlying body parts and parts that will be distal to the bandage

for signs of circulatory impairment; (coolness, pallor, or cyanosis, diminished or

absent pulses, swelling, numbness, and tingling) to provide a means for comparing

changes in circulation after bandage application.

BANDAGING

Techniques of Applying Bandages:

1. Circular turn – is used to anchor the bandage at its beginning and end. It may also be

used to bandage small areas such as finger and wrist.

2. Spiral turn – to cover part that is uniform in shape like upper arm or leg.

3. Spiral reverse – to bandage areas of the body that are not uniform in shape such as

lower leg.

4. Recurrent turn – used to cover distal ends such as the skull, distal end of the finger,

or the stump of an amputation.

5. Figure-of-eight turn – is used to support joint areas such as knees and elbows while

slowing some movement of the body part covered.

6. Spica turn – (modification of figure-of-eight turn) – used to cover larger areas such

as upper thigh of lower hip area / upper arm with shoulder.

Supplies and Equipment:

For Bandages:



1 Bandage of approximate materials, width,

and length.

Various conditions and purpose determine

the type of use of different bandage.

2 Dressing change supplies. Available to change dressing if required.

3 Safety pins, clips, or tape. Secure the bandage.

Key Points for Bandage Application:

Action Rationale

1 Position body parts to be bandaged in

comfortable position of normal

anatomical alignment.

Bandages can cause restriction in

movement. Immobilization in normal

functioning position reduces risks of

deformity or injury.

2 Prevent friction between and against

surfaces by applying gauze or cotton

padding.

Skin surfaces in contact with each other

(e.g., between toes or under breasts) can

rub against each other to cause abrasion or

chafting. Bandages over bony prominences

may rub against each other to cause

breakdown.

3 Apply bandages securely to prevent

slipping during movement.

Friction between bandages and skin can

cause skin breakdown.

4 When bandaging extremities, apply

bandage first at distal end and progress

toward trunk.

Gradual application of pressure from distal

toward proximal portion of extremity

promotes venous return and minimizes risk

of edema or circulatory impairment.

5 Apply bandages firmly, with equal

tension exerted over each turn on layer.

Avoid excess overlapping of bandage

layers.

Equal tension prevents unequal pressure

distribution over bandaged body part.

Localized pressure causes circulatory

impairment.

6 Position pins, knots, or ties away from

wound or sensitive skin areas.

Pins and ties used to secure bandages and

binders can exert localized pressure and

irritation.



Procedure for BANDAGING:

1 Explain the procedure and its purposes to

the client.

For the client to cooperate and participate.

2 Prepare all the materials needed. Organizes the procedure saving time,

effort and energy.


4 Close door or draw the curtains. Provide privacy.

5 Inspect the skin for abrasions, edema,

discoloration, or exposed wound edges.

• Assess the condition of underlying

dressings and change them if they are

soiled.

• Cover exposed wounds or open

abrasions with a sterile dressing.

6 Assess skin of underlying body parts that

will be distal to the bandage for signs of

circulatory impairment (coolness, pallor

or cyanosis, diminished or absent pulses,

swelling, numbness, and tingling.

Provide a means for comparing changes

in circulation after bandage application.

7 Assist the client to assume a comfortable

position, maintaining a position of normal

function for the body.

• Bandages on the lower extremities are

applied before the client sits or stands.

• An extremity may be elevated for 15 to

30 minutes before wrapping.

Prevents deformity and increase

circulation to the affected area.

To encourage adequate venous return.

8 Hold the bandage in the dominant hand

with the roll up.

Facilitates control when stretching and

unrolling the bandage.

9 Unroll 3 to 4 inches of the bandage.

10 Hold the end of the bandage in place on

top of the distal part using the fingers of

the non-dominant hand.

Maintains uniform tension.

11 Leave a portion of the distal part exposed,

such as the toes or fingers.

Allows later inspection and palpation of

distal parts for neuro-vascular assessment.

12 Bring the bandage down and around the

body part unrolling and stretching slightly

if elastic.



13 Wrap the bandage directly over the held

end and fasten it with safety pin, clip, or

tape.

Note:

• Use circular turns to begin and end a

bandage. This is called anchoring.

• In bandaging the foot, start at the side of

the foot so that the end will not cause

pressure over the bony area on the upper

foot or create discomfort on the bottom of

the foot when the patient walks.

Anchors the bandage at the end.

Provides security and support to the

bandage.

To wrap a Spica Bandage: 14 Anchor with two circular turns.

15 Bring the bandage up and around the body

part.

Varies the figure-8 turn used to cover

large areas.

16 Wrap bandage down and around the other

body part forming a figure-8.

Covers body areas such as thumb, groin,

breast, shoulder, and hip.

17 Continue in this pattern until the area is

covered. Leave tips of finger and toes

exposed.

Provides a means of checking circulation

in the bandaged extremity.

18 End with two circular turns.

19 Fasten with tape, safety pins, or clips. Prevents unwrapping.

For all bandage types: 20 Inspect bandage at frequent intervals for

intactness and constant tension; assess the

neurovascular status of the extremity.

Ensures the bandage is in place and is of

benefit to the client.



Cecil/Feb./08

Purpose or Use Description Type

Types of Bandage Turns



Spiral Reverse

Figure of Eight

Spica



BINDERS

Types and Purposes of binders:

1. The abdominal binder (straight) is used to

provide support and protection to the

abdomen. It is made of a rectangular fabric

(a bath blanket or draw sheet) and long

enough to encircle the body and extend from

the lower ribs to the symphysis pubis.

Commercially made binders are rectangular

and made from heavy fabric or elastic

with a Velcro closure.

2. The scultetus or many-tailed binder is also to provide support to the abdomen or to

secure dressings. This binder is made of flannel and has three to six tails on either side

of solid back. The tails are secured starting above the groin and alternated across the

abdomen to an area just below the ribs.

3. The breast binder is a vest with adjustable

straps and a front closure of safety pins.

Adjustments are made to provide a smooth

fit that does not interfere with respiration.

This binder is used to provide support the

breasts and thorax.

4. The double T-binder (A) is of the same

design as the single T-binder with the

addition of a second trip to aid in securing

rectal and perineal dressings for men. The

straps attached to the waist on either sides of

the penis and scrotum.

5. The single T-binder (B) is made of muslin.

Two narrow strips are sewn together at right

angles, one strip encircles the waist and the

other secures rectal or perineal dressings.

These are most often used for women.



6. The sling or triangular binder is made

commercially of muslin. Its purpose is to

provide support to the arm, shoulder, or

hand. Additionally, it limits movement while

not impairing circulation, and reduces edema

to the lower arm and hand.

Objectives:

1. The client’s abdominal or scultetus binder is properly applied as evidenced by the

ability to breathe normally; the presence of pulses distal to the binder, and intact skin

integrity.

2. The client’s T-binder is properly applied as evidenced by secured perineal or rectal

dressings, adequate scrotal support, and the client’s ability to remove and reapply the

binder when needed for elimination.

3. The client’s triangular binder (sling) is applied as evidenced by immobilization of the

arm, shoulder, and elbow as therapeutically prescribed without compromised

circulation.

4. The client’s binder provides adequate support to the body tissues without discomfort

to the client as evidenced by verbal and nonverbal responses.

Supplies and Equipment:

For Binders:

Gloves, if wound drainage is present.

Abdominal binder:

o Correct size cloth/elastic

straight binder

o Safety Pins (unless Velcro

closure or metal fasteners are

attached)

▪ T and double T Binders:

o Correct size

o Safety pins

▪ Breast binder:

o Correct size

o Safety pins (unless Velcro closure

or metal fasteners are attached)



Preparing for the application of a binder

STEPS

RATIONALE

1. Wash hands. Limits transfer of

microorganism.

2. Take supplies to the bedside.

3. Explain the procedure to the client. Promotes client cooperation and

understanding and reduces

anxiety.

4. Close door or draw bedside curtains. Provides privacy.

Procedure:

STEPS RATIONALE

1 Observe client with need for support of thorax

or abdomen. Observe ability to breath deeply

and cough effectively.

Baseline assessment determines

client’s ability to breathe and

cough. Impaired ventilation of

lung can lead to alveolar

atelectasis and inadequate arterial

oxygenation.

2 Review medical record if medical prescription

for particular binder is required and reasons

for application.

Application of supportive binders

may be used on nursing judgment.

In some situations, physician

input is required.

3 Inspect the skin for actual or potential

alterations in integrity. Observe for irritations,

abrasions, skin surfaces that rub against each

other, or allergic response to adhesive tape

used to secure dressing.

Actual impairments in skin

integrity can be worsened with

application of binder. Binder can

cause pressure and excoriation.

4 Inspect any surgical dressing. Dressing replacement or

reinforcement precedes

application of any binder.



Critical decision point:

Dressing should be clean, dry, and incision/wound should be entirely covered

by dressing.

5 Assess client’s comfort level, using analog

scale 0 to 10, and noting any objective signs

and symptoms.

Data will determine effectiveness

of binder placement.

Numerical

A 0 1 2 3 4 5 6 7 8 9 10

No pain Severe

pain

Descriptive

B No

pain

Mild

pain

Moderate

pain

Severe

pain

Unbearable

pain

Visual analog

C No pain Unbearable pain

Client designates a point on the scale corresponding to his perception of the

pain’s severity at the time of assessment.

6 Gather necessary data regarding size of client

and appropriate binder.

Ensures proper fit of binder.

7 Explain procedure to patient. Promote client’s understanding

and cooperation.

8 Teach skill to client or significant other. Reduces anxiety and ensures

continuity of care after discharge.

9 Wash hands and apply gloves. (if likely to

contact wound drainage).

Reduces transmission of

microorganisms.

10 Close curtains or room door. Maintains client’s comfort and

dignity.

11 Apply binder.

12 Remove gloves and wash hands. Prevents cross infection.

13 Observe site for skin integrity. Circulation and

characteristics of wound. (Periodically remove

binder and surgical dressing to assess wound

characteristics).

Determines that binder has not

resulted in complication to the

skin, wound or underlying organs.

14 Assess comfort level of client, using analog

scale of 0 to 10 and noting any objective signs

and symptoms.

Binders should not increase

discomfort.

15 Assess client’s ability to ventilate properly,

including deep, breathing and coughing.

Identifies any impaired ventilation

and potential pulmonary

complications.

16 Identify client’s need for assistance with

activities such as: hair combing, dressing, and

ambulating.

Mobility of upper extremities may

be limited depending on severity

and location of incision.



Recording and reporting: Report any skin irritation to nurse at between shift reports.

Record application of binder, condition of skin, circulation, integrity of dressing,

and client’s comfort level.

Report ineffective lung expansion to physician immediately.

Home care considerations:

Abdominal, T, and breast binders are washable and are placed over a line to dry.

Instruct care giver to avoid excessive pressure with binder application. Cecil/Feb./08

Applying a Breast Binder

1 Assist client in placing arms through

binder’s armholes.

Eases binder placement process.

2 Assist client to supine position in bed. Supine position facilitates normal

anatomical position of breasts;

facilitates healing and comfort.

3 Pad area under breasts if necessary. Prevents skin contact with undersurface.

4 Using Velcro closure tabs, or

horizontally placed safety pins, Secure

binder at nipple level first. Continue

closure process above and then below

nipple line until entire binder is closed.

Horizontal placements of pins may

reduce risk of uneven pressure or

localized irritation.

5 Make appropriate adjustments,

including individualizing fit if shoulder

straps and pinning waistline darts to

reduce binder size.

Maintains support to client’s breasts.

6 Instruct and observe skill development

in self care related to reapplying breast

binder.

Self care is integral aspect of discharge

planning. Skin integrity and comfort

level goals are insured.

Applying an Abdominal Binder

1 Position client in supine position with

head elevated and knees slightly

flexed.

Minimizes muscular tension on

abdominal muscles.

Supports the muscles and viscera,

reduces tension on an incision, if

present.

2 Fanfold binder to its midline. Reduces time client remains

uncomfortable position.

3 Instruct and assist client to roll away

from nurse toward raised side rail

while firmly supporting abdominal

incision and dressing with hands.

Aids in placement of the binder.

Reduces pain and discomfort.



4 Place fanfold ends of binder under

client.

Place fanfold binder under the client,

with its upper border at the waist and

lower border at the gluteal folds.

Permits placements and centering of

binder with minimal discomfort.

Ensures proper placement that does not

interfere with breathing, ambulation, or

defecation.

5 Instruct client to roll over folded ends.

6 Unfold and stretch ends out smoothly

on far side of bed.

Maintains skin integrity and comfort.

7 Reach over the client and straighten the

fanfolded binder until it is smooth and

wrinkle free. Adjust binder so that the

supine client is centered over binder

using symphysis pubis and costal

margins as lower and upper landmarks.

Assures placement of binder and is

comfortable for the client. A smoothly

applied binder is less likely to impair

skin integrity. Centers support from

binder over abdominal structures, which

reduces incidence of decreased lung

expansion.

8 Instruct client to roll toward the nurse

back into supine position and over the

fanfold binder.

Facilitates chest expansion and adequate

wound support when the binder is

closed.

Critical decision point:

Cover any exposed areas of incision or wound with sterile dressing.

9 Pad the bony prominences. Prevents skin breakdown from

prolonged pressure.

10 Check the dressing, if present, to

ensure that it covers wound edges.

Reinforce dressing if needed.

Limits potential for infection.

11 Bring the farthest portion of the binder

firmly over abdomen.

12 Place the nearest binder end over the

center of the abdomen, while holding

tension on the other binder.

Applies firm support against the

abdominal structures.

13 Close binder. Secure by placing safety

pins horizontally or secure the Velcro

closure from the distal to proximal

edges. Rub the Velcro surfaces firmly

together to ensure full contact.

Provide continuous support and comfort.

Enhances venous blood flow.

14 Place darts or tucks as needed to

provide a snug fit. Allow room for

breathing.

Provides tailored fit that is comfortable

and provides uniform support.

15 Assess client’s comfort level. Helps determine effectiveness of binder

application.

16 Adjust binder as necessary. Promotes comfort and chest expansion.



Applying Scultetus Binder

1 Complete steps 1 through 10 as before.

2 Bring the distal tail on the side

opposite you across the client’s

abdomen and hold it firmly against the

abdomen; if longer than the abdomen,

fold it back on itself.

Provides maximum upward support.

3 Bring the opposite tail across the

abdomen while maintaining tension on

the first tail.

Provides smooth, even surfaces of

tension against the abdomen.

4 Fasten the tail with safety pin or Velcro

or Repeat steps 11 through 12,

smoothing Away wrinkles, until all

tails are in place.

Reduces pressure areas from wrinkles.

5 Sculpture tail to accommodate body

shape.

Provides adequate support while

maintaining comfort.

6 Fasten visible tail ends with safety pins

or Velcro straps.

Secures binder in position with sufficient

pressure against the muscles to provide

support.

Applying a Single or Double T Binder

1 Prepare for the application.

2 Assist the client to a dorsal recumbent

position.

3 Have client raise hips.

4 Check or change the perineal rectal

dressing

5 Help the client to turn away from you. Positions client for proper placement of

the binder.

6 Place the horizontal band (waistband)

around the waist above the iliac crest.

7 Bring the remaining strap (perineal

strap) down the mid-back and through

the perineal area to the lower abdomen.

Secures dressing in place.

8 Attach the perineal strap to the waist

band by overlapping them and securing

with a horizontal safety pin.

Secures the strap in place.



If a double T-binder

1 Apply in the same manner but place

the perineal straps on either side of the

genitalia.

2 Observe the client for comfort as he

lies, sits, or stands.

Ensures adequate fit without discomfort

from rubbing or chafing of the binder.

3 Adjust dressings and binder as needed

for comfort and to reduce pressure and

rubbing.

Prevents skin breakdown by pressure

ischemia.

4 Instruct client to remove and reapply

binders as necessary.

Encourages independence.

Applying Single T and Double T Binders

1 Assist client to dorsal recumbent position,

with lower extremities slightly flexed and

hips rotated slightly outward.

Minimizes tension on perineal

organs.

2 Have client raise hips and place horizontal

band around client’s waist (or above iliac

crest) with vertical tails extending past

buttocks. Overlap waistband in front and

secure with safety pins.

Permits placement of binder. Secures

binder around client.

3 Complete binder application:

a. Bring remaining vertical strip over

perineal dressing and continue up and

under center front of horizontal band.

Bring ends over waist band and secure all

thickness with safety pin.

T binders provide support to perineal

muscles and organs and help

maintain placement of perineal or

suprapubic dressing.

4 Assess client’s comfort level with client in

lying, sitting, and standing positions.

Readjust front pins and tails as necessary,

ensuring that tails are not too tight.

Increase padding if any area rubs against

surrounding tissues.

Determines efficacy of binder to

maintain dressings and support

perineal structures.

5 Instruct client regarding removal of binder

before defecating or urinating and need to

replace binder after performing these

bodily functions.

Cleanliness of binders reduces

infection risk.



Applying a Triangular Bandage (Sling)

1 Prepare for application.

2 Close the door or draw bedside curtains. Provides privacy.

3 Place the client in a sitting position with

fingers higher than hand, hand higher

than the arm, and elbow flexed 90˚, in

correct alignment.

Allows easier application of the sling.

Elevation of the extremity increases

venous return.

4 Place the open end of the bandage on the

uninjured shoulder.

5 Place the open bandage under the

affected arm with the longest edge of the

hand.

Positions the bandage so that it can

be secured to immobilize the arm.

6 Bring bandage’s other point up over the

arm, across the affected shoulder, and

around the neck.

7 Adjust the arm for the correct angle

and alignment.

Assures adequate venous return and

reduces potential for edema.

8 Tie a square knot with the points at the

shoulder level.

Avoids exerting pressure on the neck by

the knot.

9 Support the wrist and hand of the

affected arm by manipulating the edge

of the bandage.

Lessens pressure of the bandage against

the hand and wrist, thus reducing the

potential for edema.



10 Fold the apex smoothly around the

elbow and fasten with a safety pin.

Provides adequate elbow support and

alignment.

11 Apply padding to areas where the

bandage presses against the soft

tissues. (This may happen around the

neck, the axilla, and between the wrist

and a cast.

Prevents development of pressure points

of sores.

12 Inspect the bandage for proper support

of the arm, alignment of the arm, and

pressure of the knot against the

shoulders, assess the neurovascular

condition of the skin and arms.

Detects improper alignment,

compromised circulation, or nerve

compression.

13 Instruct the client or caregiver to apply

the sling using these same steps.

Applying Collar and Cuff:

1 Secure the cuff to the client's wrist.

2 Place the collar around the client's neck

making sure it is secure but not restrictive.

3 Loop a strap through the cuff and collar to

suspend the wrist. The final position of the

elbow should be at slightly less than

degrees flexion.

Applying Commercial Sling:

1 Place the injured arm in the fabric holder with the elbow in the seamed corner.

2 Loop the attached strap across the chest toward the uninjured side, and loop it

behind the neck, and then down the chest to the D-rings at the wrist end of the

holder.

3 Pass the strap upward through the rings, and secure the Velcro edges together with

the elbow flexed as slightly less than 90 degrees.



Age-specific Considerations:

1. Slings are generally not suitable for children with fractures of the humerus or elbow.

The preferred treatment is a sling and swathe, plaster casting, or surgical

interventions. Subluxation of the radial heads

2. Additional padding behind the neck may be needed for an elderly patient to avoid

excessive pressure over the spine from the weight of the arm in the sling.

Complications of the Sling:

1. Compression of soft tissues in the back.

2. Increased edema of the distal limb as a result of greater than 90 degrees elbow flexion

in the sling.

Patient Education of the Sling:

1. Keep the knot positioned at the side of the neck and not directly over the spine to

avoid excessive pressure on blood vessels, nerves, and spinous processes.



2. Keep the hand above elbow level and open and close hand and wiggle fingers

frequently to prevent or decrease swelling.

SHOULDER IMMOBILIZATION

(also known as sling and swathe and Velpeau's bandage)

Indications:

1. To immobilize the clavicle, acromioclavicular joint, shoulder, or proximal humerus. A

sling and swathe is also useful for anterior dislocations of the shoulder.

2. To immobilize unstable fractures of the proximal humerus to prevent recurrent

dislocation as a result of contraction of the pectoralis major muscles (Velpau's

bandage.

3. Too provide greater immobilization than a sling alone because the chest wall acts as a

splint.

Equipment:

1. Commercial sling and swathe or

2. 2 to 3 triangular bandages to create a sling and swathe or

3. 3 to 4 of 6-inch wide elastic bandage or 3 to 4 M length of stockinette to create a

Velpau's bandage.

4. Safety pins.

5. Axillary padding (i.e., gauze dressing, bandage, cast padding).

Patient Preparation:

1. Pad the axilla on the affected side, across the chest where the arm will lie, and over

the opposite shoulder where the bandaging material will lie.

2. Flex the elbow on the injured side and place the forearm across the chest.

Procedure:

A. Shoulder Immobilizer.

Follow steps of "sling Application".

Apply the elastic band around the chest, and secure with the Velcro fastener.

Fasten the arm strap around the humerus, and then fasten the wrist strap around the

lower forearm.

B. Valpeau's Bandage.


1. Position the affected arm across the chest so that the hand rests on the opposite

shoulder.

2. Roll the bandage away from the injury beginning underneath the crossed arm in the

center of the chest, and pass the roll under the uninjured axilla.

3. Continue the roll diagonally behind the client's back and over the top of the affected



shoulder.

4. Roll downward diagonally over the folded arm and then loop the bandage behind the

elbow, across the middle of the humerus, and through the axilla.

5. Repeat the diagonal roll over the shoulder on the affected side, covering the upper

arm and supporting the elbow. Continue into the axilla.

6. Encircle the entire thorax and affected arm.

7. Continue the pattern of alternating the roll of the bandage over the shoulder and arm

with a pass around the torso.

Gilchrist Stockinette-Velpeau Sleeve:


1. Cut a piece of 4-inch wide stockinette into a 3 to 4 M (approximately 10 to 12 ft)

length. Make a horizontal alit halfway across the width of the stockinette

approximately on third from one end.

2. Insert the client's affected arm into longer end of stockinette until the axilla rests in

the slot.

3. Place the injured arm across the chest. Pass the long end of the stockinette around the

client's back, through the space between the injured arm and chest, and loosely drape

it over the client's forearm.

4. Pass the shorter end of the stockinette around the client's neck, loop it around the

wrist, and secure with a safety pin.

5. Pull the loose end of the stockinette tightly, wrap it around the affected arm, and

secure



APPENDIX A

HANDWASHING

PERFORMANCE CHECK LIST

Name: _________________________________ ID # _______________Date: ________

Objectives/Purposes: Hand washing is performed to:

1. Remove the natural body oil and dirt from the skin.

2. Remove transient microbes, those normally picked up by the hands in the usual

activities of daily living.

3. Reduce the number of resident microbes, those normally found in the skin.

4. Prevent the transmission of microorganisms from client to client / from nurse to family /

from client to nurse.

5. Prevent the cross-contamination among clients.

Equipment and Supplies

o Source of running water

(warm if available)

o Soap

o Soap dish

o Orangewood stick

o Towel or tissue paper

o Lotion

Procedure:

STEPS Scale Comments

5 4 3 2 1

1 Stand in from of the sink. Do not allow

your uniform to touch the sink during

the washing procedure.

2 Remove jewelries.

3 Turn on water and adjust the force.

Regulate the temperature until the water

is warm.

4 Wet the hands and wrist area. Keep

hands lower than the elbows to allow

water to flow toward the fingertips.



5 Use about one teaspoon of liquid soap

from the dispenser or lather thoroughly

with bar soap. Rinse bar, and return it to

soap dish.

6 With firm rubbing and circular motions,

wash the palms and back of the hands,

each finger, areas between the fingers,

the knuckles, wrists, and forearms at

least as high as contamination is likely

to be present.

7 Continue this friction motion for 10 to

30 seconds.

8 Use fingernails of the other hand or use

orangewood stick to clean under

fingernails.

9 Rinse thoroughly.

10 Dry hands and wrists with paper towel.

Use paper towel to turn off the faucet.

11 Use lotion on hands if desired.


TOTAL

Legend:

% Scale Description Verbal Description 93-100 5 Excellent Demonstrated all the time or outstandingly

86-92 4 Very Satisfactory Demonstrated in the fullest sense,

completely or absolutely 80-85 3 Satisfactory Demonstrated at a given time or good

enough

75-79 2 Fair Demonstrated rarely or in a fair manner

72-74 1 Poor Not demonstrated at anytime

COMMENTS:

Evaluator Signature Student Signature



DONING OF GLOVES

Performance Checklist

Name: id# Date:

Equipment:

Clean gloves

Trash receptacle

Procedure:

STEPS SCALE COMMENTS 1 2 3 4 5

1 Wash your hands.

2 Remove the gloves from the dispenser

3 Hold glove at wrist edge and slip fingers into

openings .Pull glove up to wrist

4 Place gloved hand under wrist of second

glove and slip fingers into opening

5 Remove glove by pulling off. touch only

outside of the glove at cuff,so that gole turns

inside out

6 Place rolled-up glove in palm of second hand

7 Remove second glove by slipping one

finger under glove edge and pulling down

and off so that glove turns inside out.

8 Dispose off gloves in proper container , not

at bedside.


TOTAL:

Legend:


86-92 4 Very Satisfactory Demonstrated in the fullest sense,

completely or absolutely

80-85 3 Satisfactory Demonstrated at a given time or good

enough



75-79 2 Fair Demonstrated rarely or in a fair manner


COMMENTS:




AXILLARY TEMPERATURE (ELECTRONIC )

Performance checklist

Name: id# Date:

Purpose:

To establish subsequent data for baseline evaluation.

To identify whether the core temperature is within normal range.

To determine changes in the core temperature in response to specific

therapies(medication, surgeries, etc.)

To monitor clients at risk of imbalanced body temperature.(eg. infection, extremes of

temperature exposure).

Assessment:

Clinical signs of fever/hyperpyrexia.

Clinical signs of hypothermia.

Equipment:

Electronic Thermometer.

Thermometer sheath or cover.

Towel if required.

Procedure:

STEPS SCALE COMMENTS 0 1 2

1 Identify the patient

2 Prior to performing the procedure introduce

self .Explain the procedure to the client, why

it is necessary, and how he or she can

participate.

3 Gather the equipment.

4 Perform hand wash.


6 Remove the clients arm and shoulder from

the sleeve of the gown to expose the axilla.

7 Make sure axillary skin is dry, If necessary

pat dry.

8 Place disposable protective sheath over

probe.

9 Place the probe in the centre of the axilla .

Fold the client's arm across chest. place until

audible signal of recording is heard.

10 Hold the probe in place until audible signal

of recording is heard.

11 Read the temperature reading dispose off the

probe cover by pressing the probe release

button.

12 Inform the client about the temperature

reading.



13 Wash hands.

14 Record reading.

15 Replace the thermometer in its charger or

holder.


TOTAL:

Legend:


86-92 Very Satisfactory Demonstrated in the fullest sense,



enough 75-79 Fair Demonstrated rarely or in a fair manner


COMMENTS:




RECTAL TEMPERATURE (ELECTRONIC )


Name: id# Date:

Purpose:


to identify whether the core temperature is within normal range.





Assessment:



Equipment:



Water soluble lubricant for rectal temperature.

Clean gloves for rectal temperature.

Procedure:






participate.


4 Perform hand wash .

5 Don gloves


7 Place client in semi- lateral position or Sims

position.

8 Place disposable protective sheath over probe

and lubricate it with a water soluble

lubricant.

9 With the dominant hand, grasp the

thermometer. With the other hand separate

the buttocks so that the anal sphincter is seen

clearly.



10 Instruct the client to take a deep breath and

gently insert the thermometer into the anus.(

about 3.8 cm in adult,2.5cm in child and

1.25cm in infants.)

11 Holding the thermometer in place ,let the

buttocks fall into place, keep holding until

audible signal of recording is heard.

12 Read the temperature reading dispose off the

probe cover by pressing the probe release

button.

13 Inform the client about the temperature

reading.

14 Remove Gloves and wash hands.

15 Record reading.


holder.


TOTAL:

Legend:





enough

75-79 Fair Demonstrated rarely or in a fair manner


COMMENTS:




ORAL TEMPERATURE (ELECTRONIC )


Name: id# Date:

Purpose:


To identify whether the core temperature is within normal range.





Assessment:



Equipment:



Procedure:


1 Identify the patient.




participate.


4 Perform hand wash .


6 Place disposable protective sheath over

probe.

7 .Grasp top of the probe's stem and place the

tip of the thermometer under the clients

tongue and along the gum line.

8 Instruct the client to keep mouth closed

around the probe.

9 Hold the probe in place until audible signal

of recording is heard.

10 .Read the temperature reading dispose off

the probe cover by pressing the probe release

button.

11 . Inform the client about the temperature

reading.

12 Wash hands.

13 Record reading.




holder.


TOTAL:

Legend:



completely or absolutely 80-85 1 Satisfactory Demonstrated at a given time or good

enough



COMMENTS:




Heart Rate


Name: id# Date:

Equipment:

Watch with a second hand or indicator.

If using Doppler/ultrasound stethoscope:

Transducer in the probe

Stethoscope headset

Transmission gel

Procedure:

STEPS 0 1 2 COMMENTS

1 Determine need to assess radial or apical

pulse:

c. Note risk factors for alterations in

apical pulse Assess for signs and symptoms of altered

SV (stroke volume) and CO such as

dyspnea, fatigue, chest pains,

orthopnea, syncope, palpitations, jugular

venous distension, edema of dependent

body parts, cyanosis or pallor of skin.

2 Assess for factors that normally influence

apical pulse rate and rhythm: a. Age

b. Exercise

c. Position changes

d. Medications

e. Temperature

f. Emotional Stress, anxiety, fear

3 Determines previous baseline balance apical

site.

4 Explain that PR or HR is to be assessed

5 Wash hands

6 If necessary, draw curtain around bed and/or

close door.



7 Obtain pulse measurement.

A. Radial Pulse

1.Assist client to assume supine position

2. If supine, place client’s forearm along

side or across lower chest or upper abdomen

with wrist extended straight. If sitting, bend

client’s elbow 90 and support lower arm on

chair on nurses’ arm. Slightly extend wrist

with palms down.

3.Place tips of first two fingers of hand over

groove along radial or thumb side of client’s

inner wrist.

4.Lightly compress against radius, obliterate

pulse initially, and then relax pressure so

pulse becomes easily palpable.

5.Determine strength of pulse. Note whether

thrust of vessel against fingertips is

bounding, strong, weak or thready.

6.After pulse can be felt regularly, look at

watch’s second and begin to count rate; when

sweep hand hits number on dial, start

counting with zero, then one, two, and so on.

If pulse is regular, count rate for 30 seconds

and multiply by 2,

If pulse is regular, count rate for 60 seconds.

Assess frequency and pattern if irregularity.

B. Apical pulse

1 Assist client to supine or sitting position.

Move aside bed linen and gown to expose

sternum and left side of chest.

2 Locate anatomical landmarks to identify the

points of maximal impulse (PMI), also called

the apical impulse. Heart is located behind

and to left of sternum with base at top and

apex at bottom.

Find angle of Louis just below suprasternal

notch between sternal body and manubrium;

can be felt as a bony prominence. Slip fingers

down each side of angle to find second

intercostal space. (ICS).

Carefully move fingers down left side to the

left midclavicular line (MCL).

A light tap felt within an area 1 to 2 cm ( ½

to 1 inch) of the PMI is reflected from the

apex of the heart



3 Place diaphragm of stethoscope in palm of

hand for 5 to 10 seconds.

4 Place diaphragm of stethoscope over PMI at

the fifth ICS, at left MCL, and auscultate for

normal S1 and S2 heart sounds (heard as “lub

dub”).

5 When S1 and S2 are heard with regularity, use

watch’s second hand and begin to count rate;

when sweep hand hits number on dial, start

counting with zero, then one, two, and so on.

6 If apical rate is regular, count for 30 seconds

and multiply by 2.

7 If HR is irregular or client is receiving

cardiovascular medications, count for

1 minute (60 seconds).


9 Clean earpieces and diaphragm of

stethoscope with alcohol swab as needed.

10 Wash hands.

11 Compare readings with previous baseline

and/or acceptable range of heart rate for

client’s age.

12 Compare peripheral pulse rate with apical

pulse rate and note discrepancy.

13 Compare radial pulse equality and note

discrepancy.

14 Correlate PR with data obtained from BP and

related signs and symptoms (palpitations,

dizziness).


TOTAL:

Legend:





enough





COMMENTS:




Respiratory Rate


Name: id# Date:

Equipment:

Watch with second hand. Paper, pencil Vital signs record.

Procedure:


1 Determine need to assess client’s

respirations:: A .Note risk factors for respiratory

alterations.

b. Assess for signs and symptoms of

respiratory alterations such as bluish or

cyanotic appearance of nail beds, lips,

mucous membranes, and skin;

restlessness, irritability, confusion,

reduced level of consciousness; pain

during inspiration; labored or difficult

breathing; adventitious sounds, inability

to breathe spontaneously; thick, frothy,

blood-tinge, or copious sputum

produced on coughing.

2 Assess pertinent laboratory values:

ABGs, (SpO2, CBC,

3 Determine previous baseline respiratory rate

(if available) from client’s record.

4 Be sure client is in comfortable position,

preferably sitting or lying with the head of

the bed elevated 45 to 60 degrees.

5 Wash hands

6 Draw curtain around bed and/or close door.

Wash hands.

7 Be sure client’s chest is visible. If necessary,

move bed linen or gown.



8 Place client’s arm in relaxed position across

the abdomen or lower chest, or place nurse’s

hands directly over client’s upper abdomen.

9 Observe complete respiratory cycle (one

inspiration and one expiration).

10 After cycle is observed, look at watch’ s

second hand and begin to count rate: when

sweep hand hits number on dial, begin time

frame, counting one with first full respiratory

cycle.

11 If rhythm is regular, count number of

respirations in 30 seconds and multiply by 2.

If rhythm is irregular, less than 12, or greater

than 20, count for 1 full minute.

12 If rhythm is regular, count number of

respirations in 30 seconds and multiply by 2.

If rhythm is irregular, less than 12, or greater

than 20, count for 1 full minute.

13 Note depth of respirations subjectively

assessed by observing degree of chest wall

movement while counting rate. Nurse can

also objectively assess depth by palpating

chest wall excursion after rate has been

counted. Depth is shallow, normal, or deep.

14 Note rhythm of ventilatory cycle. Normal

breathing is regular and uninterrupted.

Sighing should not be confused with

abnormal rhythm.

15 Replace bed linen and client’s gown.

16 Wash hands.



TOTAL:

Legend:





enough



COMMENTS:




Moving the Client up in the Bed


Supplies and Equipment: Turning sheet

Trapeze

Siderails

This is a bath blanket or sheet folded in half or

quarters and positioned under the client and over the

bottom bed liners. It is used for moving the client.

Provides the client with a means to move in bed.

Procedure: 1. Introduce yourself, verify the client identity, explain to the client what you are going

to do, why, how he-she can participate.

2. Perform hand hygiene.

3. Provide privacy

STEPS 0 1 2 Comments

1 Adjust the bed of the client:

a) Head of bed flat position or low as

the client can tolerate.

b) Raise the entire bed to the height

necessary to avoid bending down

when working with client.

c) Lock the wheels of the bed and raise

the rail on the side of the bed

opposite to you.

d) Remove the pillow from under the

client’s head and place it upright

against the headboard

2. For the client who is able to reposition

without assistance:

a) Stand by and instruct him to move

his self. Assess if the client can move

without friction of the skin.

b) Ask if positioning device required

(pillow)

3. For the client who is partially able to assist:

a) For the client who weigh less than

90kg, use a friction reducing device

and two to three assistants.

b) For the client who weigh more than

90 kg use a friction reducing device

and three assistants.



c) Ask the client to flex the hips and

knees and position the feet so that

they can be used effectively for

pushing.

d) Position the client’s arms on chest,

one arm folded on the other. Ask the

client to flex the neck during the

move and to keep the head off the

bed surface.

d. Use a friction reducing device and

assistants to move the client up in the

bed. Ask the client to push on the count

of three.



Legend:




4 Position yourself appropriately:

a) Stand at an angle to the side of the

bed with your feet about 2 ft. apart,

one foot on front of the other. Flex

the hip knees and ankles.

b) Tighten your gluteal, abdominal, leg

and arm muscles and rock from the

back leg to the front leg and back

again. Then shift your weight on the

front leg as the client pushes with

heels so that the client moves toward

the head of the bed.

5 For the client who is unable to assist:

( using turn sheet)

a) Place a drawsheet or a full sheet

folded in half under the shoulders to

the thighs. Each person rolls up or

fanfolds the turn sheet close to the

client\s body on either side.

b) Both individuals grasp the sheet

close to the shoulders and buttocks

of the client.

c) Assist the client to flex the knees.

Place the arms across the chest.

d) Position yourself as described

previously.

6 Ensure client comfort

Elevate the head of the bed and

provide appropriate support devices

for the client\s new position.

7 Document all relevant information, record:

a) Time and change of position moved

from and position moved to.

b) Any signs of pressure ulcer.

c) Use of support device.

d) Ability of the client to assist in

moving and turning.

e) Response of the client to moving or

turning (anxiety, discomfort,

dizziness)

TOTAL




enough



COMMENTS:




Moving the Client to Lateral or Prone Position


Procedure

STEPS 0 1 2 Comments

1 Position yourself and the client appropriately, other person

stand on the opposite side of the bed:

a) Adjust the bed of the client:

b) Head of bed flat position or low as the client can

tolerate.

c) Raise the entire bed to the height necessary to

avoid bending down when working with client.

d) Lock the wheels of the bed and raise the rail on the

side of the bed opposite to you.

e) Move the client closer to the side of the bed

opposite the side the client will face when turned.

Use a friction reducing device to pull the client to

the side of the bed.

f) While standing on the side of the bed nearest the

client; place the client near arm across the chest.

Abduct the client’s far shoulder slightly from the

side of the body and externally rotate the shoulder.

g) Place the client’s near ankle and foot across the far

ankle and foot.

h) The person on the side of the bed toward which the

client will positioned directly in the line with the

client\s waistline and as close to the bed as possible

2 Roll the client to the lateral position. The second person

standing on the opposite side of the bed helps roll the

client’s from the other side:

a) Place one hand on the client’s far shoulder and the

other hand on the client’s far hip.

b) Position the client on his or her side with the arms

and leg positioned and supported properly.



3 To turn the client to the prone position follow the

preceding steps with two exception:

a) Instead of abducting the arm, keep the client's arm

alongside the body for the client to roll over

b) Roll the client completely onto the abdomen.

c) Never pull a client across the bed while the client is

in the prone position

4 Document all relevant information:

a) Time and change of position moved from and

position moved to.

b) Any signs of pressure ulcer.

c) Use of support device.

d) Ability of the client to assist in moving and turning.

e) Response of the client to moving or turning

(anxiety, discomfort, dizziness)

TOTAL

Legend:





enough



COMMENTS:




BODY MECHANICS


Steps of Procedure Score

Comments 0 1 2

1 Collect your equipment

2 Wash your hands


4 Provide privacy

5 Introduce yourself to patient

6 LIFTING

Stand near object of the load to be lifted.

7 Put on internal girdle.

8

Method 1

Bend toward object by flexing all the hips and

partially flexing at the knees.

9

Grasp object and bring it to thigh level by pulling

with arm and shoulder, muscles while thigh and

leg muscles provide an upward thrust.

10

Bring object to waist level by using the leg and

thigh muscles for greater thrust while beginning

to straighten the back.

11

Method 2

Position feet 18 inches apart with left foot

forward.

12 Tuck chin in and squat down with back straight.

13 Grasp object with both hands, tipping it if

necessary to attain balance.

14

Rest left elbow on left thigh, just above knee and

apply pressure as needed to stand up. Straighten

legs.

15 PUSHING

Stand close to the object.

16 Place feet in a walking position (one is in front of

the other)

17 With hands placed on the object, flex elbows and

lean into the object.

18 Place the weight from the flexor to the extensor

portions of the leg.

19 Apply pressure using leg muscles.

20 PULLING

Stand close to the object.

21 Place feet in a walking position (one is in front of

the other)

22 Hold object and flex elbows and lean away from

the object.

23 Shift weight from the extensor to the flexor

portions of the leg.

24 Avoid sudden, jerky movements.



25 PIVOTING

Place one foot slightly ahead of the other.

26 Turn both feet at the same time, pivoting on the

heel of one foot and the toe of the other.

27 Maintain a good center of gravity while holding

or carrying the object.

28 Squat (bending at the hips and knees).

29 Avoid stooping (bending at the waist).

30

Use your leg muscles to return to an upright

position.

TOTAL

Legend:





enough



COMMENTS:




Logrolling a Client

Performance Checklist Student Name: University ID Number:

Procedure Date:

STEPS

0

1

2

Feedback

1. Prior to performing the procedure, introduce self and verify the client’s identity using agency protocol. Explain to the client what you are going to do, why it is necessary, and how he or she can participate.

2. Perform hand hygiene and observe other appropriate infection control procedures.

3. Provide for client privacy.

4. Position yourselves and the client appropriately before the move.

1) Place the client’s arms across the chest

5. Pull the client to the side of the bed.

1) Use a turn sheet or friction-reducing device to facilitate logrolling. First, stand with another nurse on the same side of the bed. Assume a broad stance with one foot forward, and grasp half of the fanfolded or rolled edge of the turn sheet or friction-reducing device. On a signal, pull the client toward both of you. (A)

2) One nurse counts: “One, two, three, go.” Then,

at the same time, all staff members pull the client to the side of the bed by shifting their weight to the back foot.



6. Move to the other side of the bed, and place supportive devices for the client when turned.

1) Place a pillow where it will support the client’s head after the turn.

2) Place one or two pillows between the client’s legs to support the upper leg when the client is turned.

7. Roll and position the client in proper alignment.

1) Go to the other side of the bed (farthest from the client), and assume a stable stance.

2) Reaching over the client, grasp the far edges of the turn sheet or friction-reducing device, and roll the client toward you. (B)

3) One nurse counts: “One, two, three, go. “ Then, at the same time, all nurses roll the client to a lateral position.

4) The second nurse (behind the client) helps turn the client and provides pillow supports to ensure good alignment in the lateral position.

5) Support the client’s head, back, and upper and lower extremities with pillows.

6) Raise the side rails and place the call bell within the client’s reach.

7. Document all relevant information. Record:

1) Time and change of position moved from and position moved to

2) Any signs of pressure areas 3) Use of support devices 4) Ability of client to assist in moving and

turning 5) Response of client to moving and turning

(e.g., anxiety, discomfort, dizziness).

Legend:


86-92 Very Satisfactory Demonstrated in the fullest sense, completely or absolutely


enough



COMMENTS:




Dangling A Client


Student Name: University ID Number:

Procedure Date:

STEPS

0

1

2

COMMENTS

1. Prior to performing the procedure, introduce self and verify the client’s identity using agency protocol. Explain to the client what you are going to do, why it is necessary, and how he or she can participate.

2. Perform hand hygiene and observe other appropriate infection control procedures.

3. Provide for client privacy.

4. Position yourself and the client appropriately before performing the move.

1) Assist the client to a lateral position facing you.

2) Raise the head of the bed slowly to its highest position.

3) Position the client’s feet and lower legs at the edge of the bed.

4) Stand beside the client’s hips and face the far corner of the bottom of the bed (the angle in which movement will occur). Assume a broad stance, placing the foot nearest the client and head of the bed forward. Lean your trunk forward from the hips. Flex your hips, knees, and ankles.

5. Move the client to a sitting position.



1) Place the arm nearest to the head of the bed under the client’s shoulders and the other arm over both of the client’s thighs near knees.

2) Tighten your gluteal, abdominal, leg, and arm muscles.

3) Pivot on the balls of your feet in the desired direction facing the foot of the bed.

4) Keep supporting the client until the client is well balanced and comfortable.

5) Assess vital signs (e.g., pulse, respirations, and blood

pressure) as indicated by the client’s health status.

6. Document all relevant information. Record:

1) Ability of client to assist in

moving and turning

2) Response of client to moving and turning (e.g., anxiety, discomfort, dizziness).

Legend:





enough



COMMENTS:




Applying and Removing Personal Protective Equipment (gloves, gown, mask)


Name: ___________________________ ID# _________ Date: ___________


1 Verify client identity and introduce yourself, explain for

the client what you are to do, why it is necessary, and

how he or she can participate.

2 Perform hand hygiene.

3 Apply a clean gown:

a. Pick up a clean gown, and allow it to unfold in

front of you without allowing it to touch any

area soiled with body substances.

b. Slide the arms and the hands through the sleeves.

c. Fasten the ties at the neck to keep the gown in place.

d. Overlap the gown at the back as much as possible and fasten the waist ties

4 Applying the face mask: a. Locate the top edge of the mask; the mask usually

has a narrow metal strip along the edge.

b. Hold the mask by the top two strings.

c. Place the upper edge of the mask over the bridge of the nose, and tie the upper ties at the back of the head or secure the loops around the ears.

d. Secure the lower edge of the mask under the chin, and tie the lower ties at the nape of the neck.

e. If the mask has a metal strip, adjust this firmly over the bridge of the nose

f. Wear the mask only once

g. Do not let a used mask hanging around the neck.

5 Apply clean gloves.

If wearing gowns pull the gloves up to cover the cuffs

of the gown

6 Remove the gloves first since they are the most soiled.

If wearing gown that is tied in front undo ties before

removing the gloves.

7 Perform hand hygiene



Legend:





enough

75-79 Fair Demonstrated rarely or in a fair manner 72-74 0 Poor Not demonstrated at anytime

COMMENTS:


8 Remove the gown when preparing to leave the room

a. Avoid touching soiled parts on the outside of the gown.

b. Grasp the gown along the inside of the neck and pull down over the shoulders. Do not shake the gown.

c. Roll up the gown with the soiled part inside, and discard it in the appropriate container.

9 Remove the mask

a) Remove the mask at the doorway to the client’s

room. If using respirator mask, remove it after leaving

the room and closing the door.

a. If using mask with strings, first untie the lower strings

b. Untie the top string and, while holding the ties securely, remove the mask from the face. If side loops are presents , lift the side loops up and away from the ears and face. Do not touch the front of the mask.

c. Discard a disposable mask in the waste container.

d. Perform proper hand hygiene again

Verbal description Description

- Able to perform 2

- Able to perform with assistance or

incomplete

1

- Cannot PERFORM at any time 0



ASSESSING BLOOD PRESSURE


Name: _________________________________________ ID# __________ Date: ______

PURPOSES:

1. To obtain a baseline measure of arterial blood pressure for subsequent evaluation

2. To determine the client’s hemodynamic status (e.g., stroke volume of the heart and blood

vessel resistance) 3. To identify and monitor changes in blood pressure resulting from a disease process and

medical therapy (e.g., presence or history of cardiovascular disease, circulatory shock, or

acute pain; rapid infusion of fluids or blood products).

ASSESSMENT

1. Signs and symptoms of hypertension (headache, ringing in the ears, flushing of face,

nosebleeds, fatigue)

2. Signs and symptoms of hypotension ( e.g., tachycardia, dizziness, mental confusion,

restlessness, and clammy skin, pale or cyanotic skin) 3. Factors affecting blood pressure (e.g., activity, emotional stress, pain, and time the client last

smoked or ingested caffeine)

PLANNING

- Blood pressure measurement may be delegated to UAP (Unlicensed assistive personnel).

The interpretation of abnormal blood pressure readings and determination of appropriate

responses are done by the nurse.

EQUIPMENT:

1. Stethoscope 2. Blood pressure cuff of the appropriate size

3. Sphygmomanometer

IMPLEMENTATION

Preparation 1. Ensure that the equipment is intact and functioning properly. Check for leaks in the

rubber tubing of the sphygmomanometer. 2. Make sure that the client has not smoked or ingested caffeine within 30 minutes prior

to measurement.



STEPS SCALE COMMENTS 0 1 2 COMMENTS

1 Explain to the client what you are going to do?

e. Why it is necessary, and how he or she can

cooperate.

f. Discuss how the results will be used in planning

further care or treatments.

2 Observe appropriate infection control procedures.


4 Position the client appropriately.

5 Wrap the deflated cuff evenly around the upper arm..

a. Locate the brachial artery.

b. Apply the center of the bladder directly over the artery.

6 If this is the client’s initial examination, perform a

preliminary palpatory determination of systolic

pressure.

a. Palpate the brachial artery with the fingers.

b. Close the knob clockwise.

c. Pump up the cuff until you no longer feel the

brachial pulse.

d. Release the pressure completely in the cuff, and wait

1 to 2 minutes before making further measurements.

7 Position the stethoscope appropriately.

d. Cleanse the earpieces with alcohol or recommended

disinfectant.

e. Insert the ear attachments of the stethoscope in your

ears so that they tilt slightly forward.

f. Ensure that the stethoscope hangs freely from the

ears to the diaphragm.

g. Place the bell side of the amplifier of the

stethoscope over the brachial pulse.

h. Hold the diaphragm with the thumb and index

finger.

8 Auscultate the client’s blood pressure.

e. Pump up the cuff until the sphygmomanometer

reads 30 mm Hg above the point where the brachial

pulse disappeared.

f. Release the valve on the cuff carefully so that the pressure decreases at the rate of 2 to 3 mm Hg per

second.

g. As the pressure falls, identify the manometer

reading at each of the five phases.

h. Deflate the cuff rapidly and completely.

i. Wait 1 to 2 minutes before making further

determinations.

9 If this is the client’s initial examination, repeat the

procedure on the client’s other arm.

10 Remove the cuff.

11 Wipe the cuff with an approved disinfectant.



12 Document and report pertinent assessment data

according to agency policy.

Verbal description Description

- Able to perform 2

- Able to perform with assistance or

incomplete 1

- Cannot PERFORM at any time 0

Legend:





enough



COMMENTS:





CHANGING AN UNOCCUPIED BED

Name:_________________________________________ID#____________Date:________

STEPS 0 1 2

1 If the client is in bed, prior to performing the procedure, introduce self and verify the client’s

identity using agency protocol. Explain to the client what you are going to do, why it is

necessary, and how he or she can cooperate.

2 Perform hand hygiene and observe other appropriate infection control procedures.


4 Place the fresh linen on the client’s chair or over bed table; do not use another client’s bed.

5 Assess and assist the client out of bed.

a Make sure that this is an appropriate and convenient time for the client to be out of bed.

b Assist the client to a comfortable chair.

6 Raise the bed to a comfortable working height.

7 Apply clean gloves if linens and equipment have been soiled with secretions and/or

excretions.

8 Strip the bed.

a Check bed linens for any items belonging to the client, and detach the call bell or any

drainage tubes from the linen.

b Loosen all bedding systematically, starting at the head of the bed on the far side and

moving around the bed up to the head of the bed on the near side.

c Remove the pillowcases, if soiled, and place the pillows on the bed-side near the foot of

the bed.

d Fold reusable lines, such as the bedspread and top sheet on the bed, into fourths, First,

fold the linen in half by bringing the top edge even with the bottom edge, and then grasp

it at the center of the middle fold and bottom edges.

e Remove the waterproof pad and discard it if soiled.

f Roll all soiled linen inside the bottom sheet, hold it away from your uniform, and place it

directly in the linen hamper.

g Grasp the mattress securely. Using the lugs if present, and move the mattress up to the

head of the bed.

h Remove and discard gloves if used. Perform hand hygiene.

9 Apply the bottom sheet and draw sheet.

a Place the folded bottom sheet with its center fold on the center of the bed. Make sure the

sheet is hem side down for a smooth foundation. Spread the sheet out over the mattress,

and allow a sufficient amount of sheet at the top to tuck under the mattress. Place the

sheet along the edge of the mattress at the foot of the bed and do not tuck it in (unless it

is a contour or fitted sheet.

b Miler the sheet at the top corner on the near side and tuck the sheet under the mattress,

working from the head of the bed to the foot.

c If a waterproof drawsheet is used, place it over the bottom sheet so that the centerfold is

at the centerline of the bed and the top and bottom edges extend from the middle of the

client’s back to the area of the midthigh or knee. Fanfold the uppermost half of the folded

draw sheet at the center or far edges of the bed and tuck in the edge.

d OPTIONAL: before moving to the other side of the bed, place the top linens on the

hemside up, unfold them, tuck them in, and miter the bottom corners.

10 Move to the other side and secure the bottom linens.

a Tuck in the bottom sheet under the head of the mattress, pull the sheet firmly, and miter

the corner of the sheet.

b Pull the remainder of the sheet firmly so that there are no wrinkles. Tuck the sheet in at

the side.



c Tuck in the drawsheets, if appropriate.

11 Apply or complete the top sheet, blanket, and spread.

a Place the top sheet, hem side up; on the bed so that its centerfold is at the center of the

bed and the top edge is even with the top edge of the mattress.

b Unfold the sheet over the bed.

c Follow the same procedure for the blanket and the spread, but place the top edges about

15 cm (6 in.) from the head of the bed to allow a cuff of sheet to be folded over them.

d 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.

e Fold the top of the top sheet down over the spread, providing a cuff.

f Move to the other side of the bed and secure the bedding in the same manner.

12 Put clean pillowcases on the pillows as required.

a Grasp the closed end of the pillowcase at the center with one hand.

b 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.

c With the free hand, pull the pillowcase over the pillow.

d Adjust the pillowcase so that the pillow fits into the corners of the case and the seams are

straight.

e Place the pillows appropriately at the head of the bed.

13 Provide for client comfort and safety.

a Attach the signal cord so that the client can conveniently reach it. Some cords have

clamps that attach to the sheet or pillowcase. Others are attached by safety pin. Most bed

now have call light bottom on the side rail.

b 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.

c Place the bedside table and the overbed table so that they are available to the client.

d 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.

14 Document and report pertinent data.

a Bed-making is not normally recorded.

b Recording any nursing assessments, such as the client’s physical status and pulse and

respiratory rates before and after being out of bed, as indicated.

Legend:





enough



COMMENTS:





CHANGING AN OCCUPIED BED


Name:_______________________________________ID#_______________________Date:_______________

_ STEPS 0 1 2

1 Prior to performing the procedure, introduce self and verify the client’s identity using agency protocol. Explain to the client what you are going to do, why it is necessary, and how he or she can cooperate.

2 Perform hand hygiene and observe other appropriate infection control procedures. Apply clean gloves if linens are soiled with body fluids.


4 Remove the top bedding.

a Remove any equipment attached to the linen, such as signal light.

b Loosen all top linen at the foot of the bed, and remove the spread and the blanket.

c Leave the top sheet over the client (the top sheet can remain over the client if it is being changed and if it will provide sufficient warmth), or replace it with a bath blanket as follows:

a Spread the bath blanket over the top sheet.

b Ask the client to hold the top edge of the blanket.

c Reaching under the blanket from the side, grasp the top edge of the sheet and draw it down to the foot of the bed. Leaving the blanket in place.

d Remove the sheet from the bed and place it in the soiled linen hamper.

5 Change the bottom sheet and draw sheet.

a Raise the side rail that the client will turn toward. If there is no side rail, have another nurse support the client at the edge of the bed.

b Assist the client to turn on the side away from the nurse and toward the raised side rail.

c Loosen the bottom linens on the side of the bed near the nurse.

d Fanfold the dirty linen (e.g., draw sheet and the bottom sheet toward the center of the bed. As close to and under the client as possible.

e Place the new bottom sheet on the bed, and vertically fanfold the half to be used on the far side of the bed as close to the client as possible. Tuck the sheet under the near half of the bed and miter the corner if a contour sheet is not being used.

f Place the clean drawsheet on the bed with the center fold at the center of the bed. Fanfold the uppermost half vertically at the center of the bed and tuck the near side edge under the side of the mattress.

g Assist the client to roll over toward you, over the fanfold bed linens at the center of the bed, onto the clean side of the bed.

h Move the pillows to the clean side for the client’s use. Raise the side rail before leaving the side of the bed.

i Move to the other side of the bed and lower the side rail.

j Remove the used linen and place it in the portable hamper.

k Unfold the fanfold bottom sheet from the center of the bed.

l Facing the side of the bed, use both hands to pull the bottom sheet so that it is smooth and tuck the excess under the side of the mattress.

m Unfold the drawsheet fanfold at the center of the bed and full it tightly with both hands. Pull the sheet in three divisions: (a) face the side of the bed to pull the middle division, (b) face the far top corner to pull the bottom division, and (c) face the far bottom corner to pull top division.

n Tuck the excess drawsheet under the side of the mattress.

6 Reposition the client in the center of the bed.

a Reposition the pillows at the center of the bed.

b Assist the client to the center of the bed. Determine what position the client requires or prefers and assist the client to that position.

7 Apply or complete the top bedding.

a Spread the top sheet over the client and either ask the client to hold the top edge of the sheet or tuck it under

the shoulders. The sheet should remain over the client when the bath blanket or used sheet is removed.

b Complete the top of the bed.

8 Ensure continued safety of the client.

a Raise the side rails. Place the bed in the low position before leaving the bedside.

b Attach the call light bed linen within the client’s reach

c Put items used by the client within easy reach.

9 EVALUATION

COMMENTS: ……………………………………………………………………………………………………………………………… Evaluator Signature: ____________________ Students' signature: _________________________



REFERENCES:

1. Kozier & Erbs, (2011). Fundamentals of Nursing. 9th Edition.

2. Potter & Perry, (2009). Fundamentals of Nursing, 7th Edition, by

Elsevier Faculty Development and Training.

3. Delaune S.C., & Ladner P.K. (2002). Fundamentals of Nursing/

Standards & Practice. 2nd Edition. Published by Delmar & Thomson

Learning.

4. Gaylene Bouska Altman.(2005). Delmars Fundamental & Advanced

Nursing Skills. 2nd Ed. Thomson and Delmar Learning.

5. Carol R. Taylor, (2009). Fundamentals of Nursing: The Art and Science

of Nursing Care (Fundamentals of Nursing: The Art & Science of

Nursing Care)

6. Kozier & Erb's, (2011). Fundamentals of Nursing with My Nursing Lab

and Pearson e-Text (Access Card) (9th Edition)

7. Potter &Perry, (2009). Clinical Nursing Skills and Techniques, 7th

Edition

By Anne Griffin Perry, Patricia A. Potter.

8. Springhouse, (2006). Fundamentals of Nursing Made Incredibly Easy!

(Incredibly Easy! Series).

9. Burton & Ludwig, (2010). Fundamentals of Nursing Care: Concepts,

Connections & Skills.

10. Mosby's Medical Dictionary, 9th Edition., ISBN: 978-0-323-08541-0.

11. Lippincott & Williams, (2006). Lippincott Manual of Nursing Practice:

Handbook, 3rd edition.

12. Kaplan Nursing, (2002). Th Basics; Essential Conten for International

Nurses. 2nd Edition.

nursing skills procedure manualll

Education

clinical nursing skills

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nursing course coordinator

manual cover page nurs

manual preface

learned skills

manual table of contents