L2RLE eBOOK
L2RLE eBOOK
L2RLE eBOOK
LEVEL 2:
NURSING SKILLS
A.Y. _______ - _______
NAME OF STUDENT:
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NAME OF STUDENT:
YEAR/SECTION:
3. First Aid 12
1 SEMESTER,
4. Intradermal Injection 14
5. Intramuscular Injection 16
6. Subcutaneous Injections 18
7. Breast Examination 20
8. Leopold’s Maneuver 22
Summary of Grades 24
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PAGE
TABLE OF CONTENT NUMBER
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UNIVERSITY OF MAKATI
VISION
We envision the University of Makati as the primary instrument where
University education and Industry training programs interface to mold Makati
youth into productive citizens and IT-enabled professionals who are exposed to
the cutting edge of technology in their areas of specialization. The University
shall be the final stage of Makati City's integrated primary level to university
educational system that allows its less privileged citizens to compete for high
paying job opportunities in its business and industries.
MISSION
To achieve our vision, University of Makati shall mold highly competent
A.Y. 2020-2021
professionals and skilled workers from the children of poor Makati residents
1 SEMESTER,
VISION
The College of Allied Health Studies is dedicated to becoming the top of the
mind innovative provider of relevant and needs based-health care education.
MISSION
Development of health care industry workforce that is resilient to its dynamics;
and who are competent, creative and socially responsible.
st
CORE VALUES
• Resiliency
• Competence
• Creativity
• Social Responsibility
CENTER OF NURSING
VISION-MISSION
The Center supports the College’s vision in becoming the top of mind
innovative provider of relevant and needs-based education by producing
graduate nurses who are fully competent in delivering standard and quality
nursing care, as well as expanded nursing career roles, integrating theory,
practice, and values.
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NP 4 - Community
A.Y. 2020-2021
1 SEMESTER,
Health Nursing 1
st
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NAME OF STUDENT:
Correctly Needs
Not Done
SKILL: BAG TECHNIQUE RATIONALE Done Improvement
(0)
(2) (1)
ASSESSMENT
1. Assess the family health record.
2. Assess the health needs of the client and
family.
3. Assess the articles, supplies which may be
used to answer emergency needs.
4. Assess for the arrangements of the contents
of the bag.
5. Assess the environment and look for a flat
surface.
PLANNING / EXPECTED OUTCOMES:
A.Y. 2020-2021
infection.
7. To render effective nursing care.
MATERIALS:
8. CHN/ PHN Bag
9. Paper or plastic lining
10. Plastic (waste receptacle)
11. Apron
12. Hand towel in plastic bag
13. Liquid soap or soap with soap dish
14. Thermometer
15. 2 scissors (surgical and bandage)
16. 2 forceps (curved and straight)
17. Syringes (5mL, 3mL, 1mL)
18. Hypodermic needles (g. 18, 20, 22, 23 and
25)
19. Sterile dressing
20. Sterile cord clamp
21. Sterile gloves (5 pairs)
22. Clean gloves (5 pairs)
23. Tape measure
24. Baby’s scale
25. Adhesive tape (micropore)
26. 2 test tubes
st
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touching the table). Tuck the strap beneath
the bag
42. Ask for a basin of water, if faucet is not
available. Place it outside the working area
43. Open the bag, take the plastic linen and
spread over the work field area (folded part
out of the paper lining)
44. Take out the hand towel, soap & apron,
leaving the plastic wrappers of the towel and
soap dish inside the bag. Place the towel,
soap dish and apron at the corner with the
confines of the linen.
45. Perform hand washing, pat dry with towel.
46. Put on the apron right side out and wrong
side with crease touching the body.
47. Put out the things most needed for the
specific case.
48. Place the waste bag outside the work area.
49. Close the bag
50. Proceed to the specific nursing care or
treatment
51. After completing nursing care, clean with
alcohol to cleanse materials used
AFTER CARE:
52. Perform hand washing again
53. Open the bag and put back all the articles in
A.Y. 2020-2021
1 SEMESTER,
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NAME OF STUDENT:
ASSESSMENT
1. Verify the physician’s order
2. Assess the situation to determine the need
for wound cleaning and a dressing change.
3. Assess the patient’s level of comfort and the
need for analgesics before wound care.
4. Assess if the patient experienced any pain
related to prior dressing changes and the
effectiveness of interventions employed to
minimize the patient’s pain.
5. Assess the current dressing to determine if it
is intact.
6. Assess for excess drainage, bleeding, or
A.Y. 2020-2021
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28. Review the medical orders for wound care or Reviewing the order and plan of
the nursing plan of care related to wound care validates the correct patient
care. and correct procedure.
29. Gather the necessary supplies and bring to Preparation promotes efficient time
the bedside stand or overbed table. management and organized
approach to the task. Bringing
everything to the bedside
conserves time and energy.
30. Perform hand hygiene and put on PPE, if Hand hygiene and PPE prevent
indicated. the spread of microorganisms.
PPE is required based on
transmission precautions.
31. Identify the patient. Identifying the patient ensures the
right patient receives the
intervention and helps prevent
errors.
32. Close curtains around bed and close door to This ensures the patient’s privacy.
room if possible. Explain what you are going Explanation relieves anxiety and
to do and why you are going to do it to the facilitates cooperation.
patient.
33. Assess the patient for possible need for Pain is a subjective experience
nonpharmacologic pain reducing influenced by past experience.
interventions or analgesic medication before Wound care and dressing changes
wound care dressing change. Administer may cause pain for some patients.
appropriate prescribed analgesic. Allow
enough time for analgesic to achieve its
A.Y. 2020-2021
effectiveness.
1 SEMESTER,
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over gauze sponges over a container for
small cleaning jobs, or into a basin for more
complex or larger cleaning.
43. Put on sterile gloves Use of sterile gloves maintains
surgical asepsis and sterile
technique and reduces the risk for
spreading microorganisms.
44. Clean the wound. Clean the wound from top Cleaning from top to bottom and
to bottom and from the center to the outside. center to outside ensures that
Following this pattern, use new gauze for cleaning occurs from the least to
each wipe, placing the used gauze in the most contaminated area and a
waste receptacle. Alternately, spray the previously cleaned area is not
wound from top to bottom with a contaminated again. Using a single
commercially prepared wound cleanser. gauze for each wipe ensures that
the previously cleaned area is not
contaminated again.
45. Once the wound is cleaned, dry the area Moisture provides a medium for
using a gauze sponge in the same manner. growth of microorganisms. The
Apply ointment or perform other treatments, growth of microorganisms may be
as ordered. inhibited and the healing process
improved with the use of ordered
ointments or other applications.
46. If a drain is in use at the wound location, Cleaning the insertion site helps
clean around the drain. (Refer to care for prevent infection.
Penrose drain, T-tube drain, Jackson-Pratt
drain and Hemovac drain).
A.Y. 2020-2021
47. Apply a layer of dry, sterile dressing over the Primary dressing serves as a wick
1 SEMESTER,
wound. Forceps may be used to apply the for drainage. Use of forceps helps
dressing. ensure that sterile technique is
maintained.
48. Place a second layer of gauze over the A second layer provides for
wound site. increased absorption of drainage.
49. Apply a surgical or abdominal pad (ABD) The dressing acts as additional
over the gauze at the site as the outermost protection for the wound against
layer of the dressing. microorganisms in the
environment.
50. Remove and discard gloves. Apply adhesive Proper disposal of gloves prevents
tape or roller gauze to secure the dressings. the spread of microorganisms.
Alternately, many commercial wound Tape or other securing products
products are self-adhesive and do not are easier to apply after gloves
require additional tape. have been removed.
51. After securing the dressing, label dressing Recording date and time provides
with date and time. Remove all remaining communication and demonstrates
equipment; place the patient in a comfortable adherence to plan of care. Proper
position, with side rails up and bed in the patient and bed positioning
lowest position. promote safety and comfort.
52. Remove PPE, if used. Perform hand Removing PPE properly reduces
hygiene. the risk for infection transmission
and contamination of other items.
Hand hygiene prevents the spread
of microorganisms.
st
53. Check all wound dressings every shift. More Checking dressings ensures the
frequent checks may be needed if the wound assessment of changes in patient
is more complex or dressings become condition and timely intervention to
saturated quickly. prevent complications.
DOCUMENTATION:
54. Document the location of the wound and that
the dressing was removed.
55. Record your assessment of the wound
including approximation of wound edges,
presence of sutures, staples or adhesive
closure strips, and the condition of the
surrounding skin.
56. Note if redness, edema, or drainage is
observed.
57. Document cleansing of the incision with
normal saline and any application of
antibiotic ointment as ordered.
58. Record the type of dressing that was
reapplied.
59. Note pertinent patient and family education
and any patient reaction to this procedure,
including patient’s pain level and
effectiveness of nonpharmacologic
interventions or analgesia if administered.
EVALUATION:
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60. The expected outcome is met when the
patient exhibits a clean, intact wound with a
clean dressing in place.
61. The wound is free of contamination and
trauma.
62. Patient reports little to no pain or discomfort
during care.
63. Patient demonstrates signs and symptoms of
progressive wound healing.
TOTAL
/ 126
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NAME OF STUDENT:
Correctly Needs
Not Done
SKILL: FIRST AID RATIONALE Done Improvement
(0)
(2) (1)
ASSESSMENT
1. Assess if the scene is safe
2. Assess the client's condition to be sure the The condition of the client may
order of the health care provider is have changed.
appropriate.
3. Assess the client's age. As pediatric/geriatric clients may
have special needs.
4. Assess the client’s understanding of the
purpose of the intervention
PLANNING / EXPECTED OUTCOMES:
5. To prevent further complications
6. The client will be able to discuss the purpose
of the intervention
7. The client will encounter minimum
A.Y. 2020-2021
discomfort.
1 SEMESTER,
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33. Elevate the extremity or the splinted part, if
possible
34. Remove PPE and dispose to the proper
receptacle
35. Advise patient to seek medical evaluation or
call EMS, if necessary
BURN
36. Remove watches, rings and bracelet on the To prevent any further injury cause
affected limb. And put to a properly labelled by possible swelling.
container.
37. Flush the burned area with cool running
water for several minutes. Do not use ice.
38. Apply a light gauze bandage. Do not break Do not apply ointments, butter, or
any blisters that may have formed. oily remedies to the burn.
39. Classify the degree and depth of a burn. Use The extent of burn, clinically
rule of nines to determine the measurement referred to as the total surface area
or extent of burn. (Lund and Browder Chart burned, is defined as the
is used for children younger than 10 years). proportion of the body burned.
40. Call EMS for serious burns The severity of burn is based on
depth and size.
NOSEBLEED
41. Ask the patient to lean forward Do not ask the patient to lean back
42. Pinch the nose just below the bridge Do not pinch the nostril closed by
pinching lower.
43. Check after five minutes to see if bleeding If not, continue pinching and check
has stopped. after another 10 minutes.
A.Y. 2020-2021
1 SEMESTER,
REMARKS:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
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NAME OF STUDENT:
ASSESSMENT
1. Assess the 10 Rights of Medication
Administration
2. Verify the physician’s order
3. Assess the client’s allergies to medication
4. Check the specific drug action, side effects,
interactions and adverse effects.
5. Check the appearance of injection site.
(redness, hair distribution, skin condition)
6. Assess client’s knowledge about the
procedure.
PLANNING / EXPECTED OUTCOMES:
7. The client will experience minimal discomfort
A.Y. 2020-2021
PERFORMANCE
20. Perform hand hygiene. Don gloves.
21. Prepare the medication to be administered.
22. Prepare the client. Identify the correct patient
using two identifiers.
23. Explain the procedure to the client. Information can facilitate
•Explain that the medication will produce a acceptance of and compliance with
small wheal or bleb. (A wheal/ bleb is a the therapy.
small raised area like a blister.
•Explain that the client will feel a slight prick
as the needle enters the skin.
•Explain that once the medication is
administered, the client should not touch the
area and that it will be interpreted at a
particular time. (Medication test: after 30
minutes; Mantoux test: 24-48 hours)
24. Provide for privacy.
25. Assist/ place the client in a comfortable
position.
SKIN PREPARATION
26. Select an appropriate site.
27. Cleanse the skin at the site using a firm
circular motion starting at the center and
widening the circle outward. Allow the area to
dry thoroughly.
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SYRINGE PREPARATION
28. Remove the needle cap while waiting for the
antiseptic to dry.
29. Expel any air bubbles from the syringe.
*Small bubbles that adhere to the plunger
are of no consequences.
30. Grasp the syringe in your dominant hand,
close to the hub, holding it between the
thumb and forefinger.
31. Hold the needle almost parallel to the skin
surface, with the bevel of the needle up.
INJECTION PREPARATION
32. Assist the client to a comfortable position
33. Discard the uncapped needle and syringe in
a sharps container
34. With the nondominant hand, pull the skin at Taut skin allows for easier entry of
the site until it is taut. the needle hence less discomfort
for the client.
35. Insert the tip of the needle far enough to
place the bevel through the epidermis into the
dermis. The outline of the needle should be
visible under the skin.
36. Stabilize the syringe and needle. Slowly inject
the medication producing the wheal/ bleb.
37. Withdraw the needle, gently wipe the Massage can disperse the
injection site with clean dry cotton. Do not medication into the tissue or out
A.Y. 2020-2021
38. Dispose the syringe and needle into the Prevent needle stick injury.
sharp’s container.
DO NOT RECAP THE NEEDLE.
39. Remove and discard gloves.
40. Perform hand hygiene.
41. Encircle the wheal, note the time of injection,
name of medication and initials of the nurse.
DOCUMENTATION:
42. Document the relevant information:
medication, time, site, route and nursing
assessment.
EVALUATION:
43. Evaluate the client’s response to the
procedure. The client verbalized
understanding of the procedure.
44. Evaluate the site after 30 mins depending on
the test. Measure the area of redness and
induration.
45. The client experienced minimal discomfort
during the procedure.
TOTAL
/ 90
st
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NAME OF STUDENT:
Correctly Needs
SKILL: INTRAMUSCULAR Not Done
RATIONALE Done Improvement
(0)
INJECTION (2) (1)
ASSESSMENT
1. Assess the 10 rights of giving medication
2. Review the physician’s orders
3. Review information regarding the drug
ordered such as action, purpose, time, of
onset and peak action, normal dosage,
common side effects, and nursing
implications
4. Assess the client for factors that may
influence any injection, such as circulatory
shock, reduced local tissue perfusion, or
muscle atrophy
5. Assess for previous intramuscular injections
6. Assess for the indications for intramuscular
injections
A.Y. 2020-2021
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31. Don clean gloves.
32. Cleanse the skin at the site using a firm
circular motion starting at the center and
widening the circle outward (about 5cm).
Allow the area to dry thoroughly.
SYRINGE PREPARATION
33. Remove the needle cap while waiting for the
antiseptic to dry.
34. *IF USING A PRE-FILLED UNIT-DOSE Medication left on the needle can
MEDICATION: cause pain when it is tracked
Take caution to avoid dripping medication on through the subcutaneous tissue.
the needle prior to injection. If this occurs,
wipe the medication off the needle with a
sterile gauze or replace the needle.
INJECTION PROCEDURE
35. While holding the swab/ cotton ball between Pulling the skin and subcutaneous
the fingers of the nondominant hand, use the tissue or pinching the muscle make
ulnar side to pull the skin approximately it firmer and facilitates needle
2.5cm into the side, or pinch the muscle for insertion.
emaciated infant or child.
36. Hold the syringe between thumb and
forefinger using the dominant hand like a
pen/ dart.
37. Inject the needle quickly and smoothly at a using a quick motion lessens the
90-degree angle. client’s discomfort.
38. Hold the barrel of the syringe steady with
A.Y. 2020-2021
39. The dominant hand will aspirate by pulling if the needle is in a small blood
back on the plunger. Aspirate for 5 – 10 vessel, it takes time for blood to
seconds. appear. If blood appears, withdraw
the needle and discard the syringe
and prepare a new set.
40. Inject the medication steadily and slowly injecting medication slowly
(approx. 10 seconds per mL) while holding promotes comfort and allows time
the syringe steadily. for tissue to expand and begin
absorption of the medication.
Holding of the syringe steadily will
minimize the discomfort.
41. Withdraw the needle quickly at the same
angle of insertion
42. With the nondominant hand, apply pressure massaging the site may cause the
on the site. Do not massage the area. leakage of the medication from the
site of injection.
43. Assist the client to comfortable position.
44. Discard the uncapped needle and syringe
into the sharp container.
45. Remove gloves and perform hand hygiene.
DOCUMENTATION:
46. Document the relevant information:
medication, time, site, route and nursing
st
assessment.
EVALUATION:
47. Evaluate the client’s response to the
procedure. The client verbalized
understanding of the procedure.
48. Evaluate the effectiveness of the medication
at the time it is expected to act.
49. The client experienced minimal discomfort
during the procedure.
TOTAL
/ 98
Computation: Raw Score / Total Score X 100 = FINAL GRADE
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NAME OF STUDENT:
ASSESSMENT
1. Assess the 10 Rights of Medication
Administration
2. Verify the physician’s order
3. Assess the client’s allergies to medication
4. Check the specific drug action, side effects,
interactions and adverse effects.
5. Check the appearance of injection site and
tissue integrity. (redness, hair distribution,
skin condition)
6. Assess client’s knowledge about the
procedure and willingness to participate.
7. Previous injection sites
PLANNING / EXPECTED OUTCOMES:
A.Y. 2020-2021
PERFORMANCE
21. Perform hand hygiene. Don gloves.
22. Prepare the medication to be administered.
23. Prepare the client. Identify the correct patient
using two identifiers.
24. Explain the procedure to the client. Information can facilitate
acceptance of and compliance with
the therapy.
25. Provide for privacy.
26. Assist/ place the client in a comfortable
position.
SELECT, LOCATE AND CLEAN THE SITE
27. Select an appropriate site. If the injections Changing sites can reduce the
are to be frequent, alternate the sites. discomfort of intramuscular
injections.
28. Don clean gloves.
29. Cleanse the skin at the site using a firm
circular motion starting at the center and
widening the circle outward (about 5cm).
Allow the area to dry thoroughly.
SYRINGE PREPARATION
30. Remove the needle cap while waiting for the
antiseptic to dry.
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31. *IF USING A PRE-FILLED UNIT-DOSE Medication left on the needle can
MEDICATION: cause pain when it is tracked
Take caution to avoid dripping medication on through the subcutaneous tissue.
the needle prior to injection. If this occurs,
wipe the medication off the needle with a
sterile gauze or replace the needle.
INJECTION PROCEDURE
32. Grasp the syringe in your dominant hand by
holding it between your thumb and fingers.
33. With the nondominant hand, pinch or spread
the skin at the site.
34. With palm facing to the side or upward for a
45-degree angle insertion, prepare to inject.
35. Insert the needle using the dominant hand
and a firm steady push.
36. Hold the barrel of the syringe steady with
your nondominant hand.
37. The dominant hand will aspirate by pulling
back on the plunger.
38. Inject the medication steadily and slowly Injecting medication slowly
(approx. 10 seconds per mL) while holding promotes comfort and allows time
the syringe steadily. for tissue to expand and begin
absorption of the medication.
Holding of the syringe steadily will
minimize the discomfort.
39. Remove the needle smoothly, pulling along Depressing the skin places counter
A.Y. 2020-2021
the line of the insertion while depressing the traction on it, minimizing the
1 SEMESTER,
skin with your nondominant hand. client’s discomfort when the needle
is withdrawn.
40. Apply pressure on the site with the cotton
swab.
41. Assist the client to comfortable position.
42. Discard the uncapped needle and syringe
into the sharps container.
43. Remove gloves and perform hand hygiene.
DOCUMENTATION:
44. Document the relevant information:
medication, time, site, route and nursing
assessment.
EVALUATION:
45. Evaluate the client’s response to the
procedure. The client verbalized
understanding of the procedure.
46. Evaluate the effectiveness of the medication
at the time it is expected to act.
47. The client experienced minimal discomfort
during the procedure.
TOTAL
/ 94
st
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NAME OF STUDENT:
Correctly Needs
Not Done
SKILL: BREAST EXAMINATION RATIONALE Done Improvement
(0)
(2) (1)
ASSESSMENT
1. Ask the client’s age, menstrual period,
number of pregnancies and lactation
2. Assess the client’s breast for obvious lumps,
nodules, or lesions
3. Assess the client’s previous breast surgeries
4. Assess the amount and color of breast
discharges
5. Assess for anxiety, restlessness and fear of
the procedure
6. Assess the client’s understanding of the of
the procedure
PLANNING / EXPECTED OUTCOMES:
A.Y. 2020-2021
to the client
8. Client’s anxiety will be minimal during
procedure
9. Client’s breast will be free of redness and
excoriation
MATERIALS:
10. Antimicrobial soap
11. water
12. Clean gloves
13. Drape sheet or blanket
14. screen
IMPLEMENTATION:
15. Identify the client, introduce yourself and
explain the procedure
16. Ask the client’s menstrual period
17. Provide privacy. Expose only the area to be
examined
18. For male examiner, ask someone to be with
while performing the procedure
19. Wash and warm hands. Don clean gloves if
necessary
20. Ask the patient to sit and raise arm over her
head (one arm at a time)
st
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then up to the clavicle using the same
systematic pattern
34. Palpate the nipple, note for the elasticity and
check for discharges
35. Drape the breast and proceed to the other
using the same technique
MALE:
36. Inspect for symmetry and size
37. Inspect each nipple and areola for nodules
38. Check for axillary’s lymph nodes in the
same technique you used for female clients
39. Make sure male patients arm remains on
the side
40. If the breast appears to be large at the
areola, try to distinguish some fats from the
firm disc of tissue
41. Wash hands
42. Document necessary findings such as color,
contour, symmetry description of nodules
EVALUATION:
43. Presence of lymph, nodules, lesions, color,
and discharges was noted
44. Client’s anxiety was minimal during the
procedure
45. Procedure was performed without trauma to
the patient
A.Y. 2020-2021
1 SEMESTER,
TOTAL
/ 90
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NAME OF STUDENT:
Correctly Needs
Not Done
SKILL: LEOPOLD’S MANUEVER RATIONALE Done Improvement
(0)
(2) (1)
ASSESSMENT
51. Assessment of the maternal pelvis’ shape
52. Assess the need for cesarean section
53. Assess the presenting part into the maternal
pelvis, extent of flexion of the fetal head,
estimated fetal weight and size,
54. Determine if complication will occur during
delivery
55. Determine the fetal position in the maternal Accuracy is greatest after 36
abdomen. weeks of gestation
56. Identify the upper and lower fetal poles
namely, the proximal and distal fetal parts.
PLANNING / EXPECTED OUTCOMES:
57. Patient verbalizes decrease discomfort
A.Y. 2020-2021
procedure performed
59. Patient remains free from injury
60. Patient exhibits no untoward incident
MATERIALS:
61. Clean gloves
62. Soap or Alcohol
IMPLEMENTATION:
63. Verify the physician’s order
64. Perform hand hygiene and put on PPE, if Hand hygiene and PPE prevent
indicated. the spread of microorganisms.
PPE is required based on
transmission precautions.
65. Identify the patient Identifying the patient ensures the
right patient receives the
intervention and helps prevent
errors.
66. Instruct the patient to empty her bladder Patient will be comfortable and the
before the procedure. contour of the fetus is not
obscured.
67. Close curtains around bed and the door to This ensures the patient’s privacy.
room, if possible.
68. Position the patient. Back slightly elevated. Relieve the stress on the patient.
Put her in a comfortable position with her
st
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75. Steady the uterus with one hand and palpate The fetal arms and legs feel like
the fetus with the other, looking for the back irregular bumps. The fetus may
on one side and extremities on the other. kick if awake and active.
THIRD MANEUVER (LOWER FETAL POLE AND DESCENT INTO
PELVIS)
76. Face the woman’s feet.
77. Place the flat palmar surfaces of the Again, the fetal head feels very
fingertips on the fetal pole just above the firm and globular; the buttocks feel
pubic symphysis. firm but irregular, and less globular
78. Palpate the presenting fetal part for texture than the head.
and firmness to distinguish the head from the
buttock. In a vertex or cephalic
79. Judge the descent, or engagement, of the presentation, the fetal head is the
presenting part into the maternal pelvis. presenting part.
80. Alternatively, use the Pawlik grip by grasping
the lower fetal pole with the thumb and If the most distal part of the lower
fingers of one hand to assess the presenting fetal pole cannot be palpated, it is
part and descent into pelvis; however, this usually engaged in the pelvis.
technique tends to be uncomfortable to the
gravid patient. If you can depress the tissues over
the maternal bladder without
touching the fetus, the presenting
part is proximal to your fingers.
FOURTH MANEUVER (FLEXION OF THE FETAL HEAD)
81. This maneuver assesses the flexion or If the cephalic prominence juts out
extension of the fetal head, presuming that along the line of the fetal back, the
A.Y. 2020-2021
pelvis.
82. Still facing the woman’s feet, with your hands If the cephalic prominence juts out
positioned on either side of the gravid uterus, along the line of the fetal anterior
identify the fetal front and back sides. side, the head is flexed.
83. Using one hand at a time, slide your fingers
down each side of the fetal body until you
reach the “cephalic prominence,” that is,
where the fetal brow or occiput juts out.
EVALUATION:
84. Patient verbalizes knowledge regarding the
procedure
85. No untoward incident for both patient
86. Patient remains free from injury
87. Patient tolerate the procedure
TOTAL
/ 74
REMARKS:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
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NAME OF STUDENT:
Bag Technique
First Aid
A.Y. 2020-2021
1 SEMESTER,
Intradermal Injection
Intramuscular Injection
Subcutaneous
Injections
Breast Examination
Leopold’s Maneuver
TOTAL
st
___________________________________
STUDENT’S NAME AND SIGNATURE
YEAR/GROUP/SECTION: __________
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NP 7 - Care of Mother,
A.Y. 2020-2021
1 SEMESTER,
Child, Adolescent
(Well Client)
st
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NAME OF STUDENT:
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113. Pour the required number of tablets or Avoids wasting expensive
capsules into the bottle cap and transfer it to medications and avoids
the medication cup without touching them. contamination of medication.
114. Scored tablets may be broken, if necessary, Tablets that are not scored are not
using gloved hands or with a pill cutting meant to be broken as this would
device. reduce the effectiveness of the
tablet.
115. Unit dose tablet should be placed directly The wrapper maintains cleanliness
into the medicine cup without opening it until and identification until it is
it is administered to the client. administered.
116. For clients with difficulty in swallowing, some A large tablet is usually easier to
tablets may be crushed into a powder using swallow if it is ground and mixed
a mortar and pestle then mixed in a small with soft food.
amount of soft foods.
To prepare a liquid medication:
117. Remove the bottle cap from the container Placing the bottle cap upside down
and place cap upside down on the cart. prevents contamination of the
inside of the container.
Hold the bottle with the label up and the Holding the bottle with the label up
medication cup at eye level while pouring. keeps spilled liquid from
obliterating the label.
Fill the cup to the desired level using the Holding the medication cup at eye
surface or base of the meniscus as the level ensures accurate dose.
scale, not the edge of the liquid cup.
A.Y. 2020-2021
1 SEMESTER,
Wipe lip of bottle with paper towel. Wiping the lid of the bottle prevents
the bottle cap from sticking.
118. Double-check the MAR with the prepared Reduces error; ensures
drugs. Place the MAR with the client’s identification and safety of the
medications and do not leave the drugs medications.
unattended.
Administration of medication:
119. Via oral route
120. Observe the correct time to give the Ensures the therapeutic effect of
medication. Identify the client. the drug. To confirm that the
medication will be given to the right
client.
121. Check the drug packaging if it is present to Prevents giving the wrong
ensure the medication type and dosage. medication or wrong dose.
122. Reassess the client's condition and form of Allows the nurse to determine the
the medication. route of administration and to know
if this route is appropriate.
123. Explain the purpose of the drug and ask if Improves compliance with drug
the client has any questions. therapy.
124. Assist the client to a sitting or fowler's Prevents aspiration during
position. swallowing.
125. Allow the client to hold the medication cup or So that the client becomes familiar
tablet. with medications.
st
126. Instruct the client to place the medication in Promotes client comfort in
the mouth and swallow when able to do so. swallowing the medication.
Give a glass of water or other liquid and
straw, if needed.
For sublingual medication:
127. Instruct client to place medication under the Drug is absorbed through the
tongue and allow it to dissolve completely. mucous membranes into the blood
vessels so that if it swallowed, the
drug may be destroyed by gastric
juices.
For buccal medication:
128. Instruct client to place the medication in the Promotes local activity on mucous
mouth against the cheek until it dissolves membranes.
completely.
For medication given thru NGT:
129. Crush tablet or open capsules and dissolve Allows medication administration
powder with 20 to 30 ml of warm water in a via NGT or feeding tube. Ensures
cup. Check placement of the feeding tube that the medication is absorbed
before instilling anything into the tube. and utilized correctly.
130. Remain with the client until each medication To ensure the client receives the
has been swallowed or dissolved. dose and does not save it or
discard it.
131. Assist the client into a comfortable position. Maintains client’s comfort.
132. Remove gloves and dispose of soiled Reduces transfer of
supplies. microorganisms.
133. Document the administration on the MAR. Prevents administration error.
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134. Clean the work area. Wash hands. Reduces transmission of
microorganisms.
EVALUATION:
135. The client was able to swallow the
prescribed medication.
136. The client was able to explain the purpose
and schedule for taking the medication.
137. The client has no gastrointestinal discomfort
or alteration in function.
138. The client showed the desired response to
the medication such as pain relief, regular
heart rate, or stable blood pressure.
TOTAL
/ 102
____________________________________________________________________________________
st
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NAME OF STUDENT:
ASSESSMENT
1. Assess the 10 rights of medications. Prevent errors in medication
administration.
2. Assess the client's eye and ear condition. Reassessing the client prior to
every medication dose prevents
possibly injuring the client.
3. Assess the medication order for what part of Prevents error in medication
the eye or ear. administration.
PLANNING / EXPECTED OUTCOMES:
4. The client will receive the right dose,
medication, dosage, route and time.
5. The client will encounter minimum discomfort
during the administration.
A.Y. 2020-2021
20. With the dominant hand, hold the eye Reduces risk of touching the eye
medication ½ to ¾ inch above the eyeball; structure and causing injury. Rest
rest hand on client’s forehead. the hands on client’s forehead to
stabilize.
21. Holding the eye medication, squeeze the Prevents injury to the cornea.
prescribed drop/s of medication on the lower
conjunctival sac. If administering eye
ointment, apply from inner to outer canthus.
22. Instruct the client to close eyes gently and Distributes solution over
blink several times. conjunctival surface and anterior
eyeball
23. Apply gentle pressure over the opening to Nasal occlusion prevents systemic
the nasolacrimal duct. absorption of medication through
the mucous membrane of the
nose.
24. Provide the patient with a clean tissue to be A clean tissue may be used to
placed below the lower lid absorb the medication that may
escape from the eye and roll down
the face.
25. Remove gloves. Wash hands. Reduces transmission of
microorganisms.
26. Record on the MAR the route, site (which Provide documentation that the
eye), time administered. medication was given.
Instilling ear drops:
27. Follow steps from 12 to 16.
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28. Place client’s face on the side with the This prevents loss of any
affected ear. medication from the effect of
gravity.
29. Straighten ear canal by pulling the pinna Straightening the ear canal helps
down and back for children and upward and the medication to reach the lowest
outward in adults. area of the ear canal and become
distributed over all the surfaces in
the outer ear.
30. Instill the drops into the ear canal by holding Touching the tip of the dropper to
the dropper at ½ inch above the ear canal. the skin contaminates the dropper.
31. Ask the client to maintain the position for 2-3 Maintaining the position allows
minutes then place on comfortable position. time for medication to flow into the
lowest area of the ear canal,
avoiding the possibility of
excessive loss from the ear.
32. Remove gloves. Wash hands. Reduces the transmission of
microorganisms.
EVALUATION:
33. The client received the right dose,
medication, route and time.
34. The client encountered minimum discomfort
during the administration.
35. The client received the maximum benefit
from the medication.
TOTAL
/ 70
A.Y. 2020-2021
1 SEMESTER,
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NAME OF STUDENT:
ASSESSMENT
1. Assess the ten rights of medication To prevent medication
administration. administration error.
2. Assess the client's need and Allows nurse to determine
appropriateness for rectal and vaginal effectiveness of the medication.
medication.
3. Consider any adjustment that maybe taken.
4. Observe the client for desired therapeutic
effect or adverse reactions.
PLANNING / EXPECTED OUTCOMES:
5. The client will receive the right medication,
dose, route and time.
6. The client will encounter minimum discomfort
A.Y. 2020-2021
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26. Document procedure. Communicates with other
healthcare team the effectives of
treatment.
Administering rectal suppository:
27. Place client in left lateral position for rectal To facilitate adequate viewing and
suppository. easy insertion of suppository.
28. Place side rails up. To ensure safety of the client.
29. Drape the client. To maintain privacy.
30. Bring materials to bed side and provide Prevents numerous trips to gather
adequate lighting. supplies and helps the procedure
flow smoothly.
31. Lower side rails. To facilitate easy access to the
client.
32. Place patient comfortably in side lying The descending colon is on the left
position. side; this is a more anatomically
correct position.
33. Expose patient's buttocks and assess the To assess the need for perineal
client’s peri-anal skin condition. care prior to medication
administration.
34. Wash hands and apply gloves. Gloves acts as barrier from contact
with stool within the rectum.
35. Open the medication package. To expose the medication from the
wrapper.
36. Instruct the client to take slow deep breath. To relax the sphincter muscle and
Inhale thru the nose and exhale thru the
mouth while inserting the suppository and tell prevent expulsion.
A.Y. 2020-2021
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NAME OF STUDENT:
Correctly Needs
Not Done
SKILL: OXYGEN ADMINISTRATION RATIONALE Done Improvement
(0)
(2) (1)
ASSESSMENT
1. Assess environment for oxygen safety
administration.
2. Assess immediate respiratory status.
3. Identify type of oxygen equipment and
source.
PLANNING / EXPECTED OUTCOMES:
4. Ensure proper concentration of oxygen.
5. Provide for adequate O2 humidification.
6. Ensure a patent airway.
7. Observe the client's reaction to 0₂ therapy.
8. Ensure the client's comfort.
MATERIALS:
9. oxygen apparatus or source
A.Y. 2020-2021
1 SEMESTER,
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A.Y. 2020-2021
1 SEMESTER,
st
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NAME OF STUDENT:
Correctly Needs
Not Done
SKILL: EINC RATIONALE Done Improvement
(0)
(2) (1)
encouragement
1 SEMESTER,
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26. Removed first set of gloves and
decontaminated them properly (in
0.5%chlorine solution in 10 mins.)
27. Palpated umbilical cord to check for
pulsations
28. After pulsation stopped, clamped cord using
the plastic cord or cord tie 2 cm. from the
base.
29. Placed the instrument clamp 5 cm. from the
base.
30. Cut near plastic clamp not midway
31. Performed the remaining steps
32. Waited for a strong uterine contraction then
applied controlled cord traction and counter
traction on the uterus, continuing until
placenta was delivered.
33. Massaged uterus until it is firm
34. Inspect lower vagina and perineum for
lacerations/tears and repaired
lacerations/tears necessary
35. Examined the place for completeness and
abnormalities
36. Cleaned the mother, flushed the perineum
and applied perineal pad/cloth
contracted.
38. Disposed of the placenta in a leak-proof
container or plastic bag.
39. Decontaminated (soaked in 0.5% chlorine
solution) before cleaning, decontaminated
2nd pair of gloves before disposal, stating
that decontamination lasts for at least 10
mins.
40. Advised mother to maintain skin to skin
contact. Baby should be prone on mother’s
chest/ in between the breasts with the head
turned to side
15-90 MINUTES
41. Advised mother to observe for feeding cues
(cited examples of feeding cues)
42. Supported mother, instructed her on
positioning and attachment
43. Waited for FULL BREASTFEED to be
completed
44. After complete breastfeed, administered eye
ointment (first), did thorough physical
examination, then give Vit K, hepatitis B
and BCG injections (simultaneously
st
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A.Y. 2020-2021
1 SEMESTER,
st
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NAME OF STUDENT:
ASSESSMENT
1. Assess the patient when was the last bowel
movement and the amount, color and
consistency of the feces.
2. Presence of abdominal distention Distended abdomen appears
swollen and feels firm rather than
soft when palpated.
3. Assess whether the patient has sphincter
control.
4. Assess whether the patient can use a toilet
or commode or must remain in bed and use
a bed pan.
PLANNING / EXPECTED OUTCOMES:
A.Y. 2020-2021
15. Perform hand hygiene and put on PPE’s To ensure the right patient and
st
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through the tube to relax the internal anal
sphincter.
21. Never force tube or solution entry. Withdraw
the tube. Check for any stool that have
blocked the tube during insertion.
22. Slowly administer the enema solution: The higher the solution container is
A. Compress a pliable container by hand. held above the rectum, the faster
B. During low enemas: Hold or hang the the flow and the greater the force
solution container no higher than 30 cm pressure in the rectum.
(12inch) above the rectum.
C. During high enemas: Hang the solution The fluid must be instilled farther to
container about 45 cm (18inch). clean the entire bowel.
23. Administer fluid slowly, if the patient Administering enema slowly and
complains of fullness or pain, lower the stopping the flow momentarily
container or use the clamp to stop the flow decreases the like hood of
for 30 seconds, then restart the flow at a intestinal spasm and premature
slower rate. ejection of solution.
24. If you are using a plastic commercial
container, roll it up as the fluid is instilled.
This prevents subsequent suctioning of
solution.
25. After the solution has been instilled or when
the patient cannot hold any more and feels
the desire to defecate; close the clamp and
remove the enema tube from the anus.
Place enema tube in a disposable towel as
A.Y. 2020-2021
26. Ask the patient to remain lying down. It is Because gravity promotes
easier for the patient to retain enema when drainage and peristalsis.
lying down than sitting or standing.
27. Request the patient retain the solution for This amount of time usually allows
appropriate amount of time, 5 to 10 minutes muscle contractions become
for cleansing enema or at least 30 minutes sufficient to produce good result.
for retention enema. Promotes comfort.
28. Assist the patient to defecate.
29. Assist the patient returned to bed and raise
side rails afterwards
30. Document amount and type of enema
solution used; amount, consistency and color
of stool.
31. Verify doctor’s order and gather the To identify the right patient and
equipment conserves energy and time.
EVALUATION:
32. The patient verbalizes decreased discomfort
and abdominal distention.
33. Patient remain free from any evidence of
trauma to rectal mucosa.
34. Patient verbalizes knowledge after the
procedure.
TOTAL
st
/ 68
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NAME OF STUDENT:
Correctly Needs
Not Done
SKILL: SURGICAL HANDWASHING RATIONALE Done Improvement
(0)
(2) (1)
ASSESSMENT
1. Prepare yourself.
2. Put on-surgical attire (scrub suit garment).
MATERIALS:
9. Liquid cleanser solution
10. Sterile scrub brush
11. Surgical cap or hood
12. Shoe coverings / new slip-on shoes
13. Surgical mask
14. Sterile towel
IMPLEMENTATION:
15. Gather all the materials needed.
16. Gather all the materials needed.
17. Turn on water faucet and check for water’s
temperature.
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EVALUATION:
30. Confirm that the scrubbing procedure is from
8-10 minutes only.
31. Confirm that the scrubbing procedure is
done aseptically.
32. Confirm that right stroke and technique are
practiced.
TOTAL
/ 64
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NAME OF STUDENT:
ASSESSMENT
1. Assess the surrounding environment.
2. Assess the condition of your hands.
PLANNING / EXPECTED OUTCOMES:
3. The caregiver will don a sterile gown and
gloves without compromising their sterility.
MATERIALS:
4. Sterile gown
5. Clean face mask
6. Sterile gloves
IMPLEMENTATION:
Gowning:
A.Y. 2020-2021
Closed Gloving:
12. With hands still inside the gown sleeves,
open the inner wrapper of the sterile gloves.
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the glove remains above the cuff of the
gown’s sleeve.
19. Interlock gloved fingers and secure fit.
TOTAL
/ 38
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NAME OF STUDENT:
ASSESSMENT
1. Determine the area to be shaved. Allows the nurse to verify the
appropriateness of the type of
enema ordered
2. Assess the physical condition of the client. Allows the nurse to plan the
Determine if the client has bowel sounds. procedure with the client’s
Assess for history of constipation, limitations in mind.
hemorrhoids or diverticulitis.
3. Assess the client’s mental state, including To ensure if the client can
ability to understand and cooperate with the comprehend and cooperate with
procedure. the procedures.
PLANNING / EXPECTED OUTCOMES:
4. Client’s rectum will be free of feces and
A.Y. 2020-2021
flatus.
1 SEMESTER,
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through the mouth) while you insert the
rectal tube or nozzle of small volume enema.
33. Spread the buttocks with your non-dominant
hand while the other hand gently inserts the
rectal tube approximately 4-6 inches into the
rectum. If using a small volume enema,
squeeze the container gently holding the
solution until all are instilled.
34. Open the clamp and infuse the solution
slowly while assessing the client.
35. When solution has been completely
administered or when the client cannot hold
any more fluid, clamp the tubing.
36. Remove the tubing slowly while instructing
the client to take deep breaths and set aside
away from bed.
37. Have the client retain the solution until the
urge to eliminate.
38. Turn the client to supine and assist to bed
pan.
39. Remove bed pan.
40. Remove gloves, return and dispose
materials to proper waste receptacle and
wash hands.
41. Document procedure and client’s response.
EVALUATION:
A.Y. 2020-2021
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NAME OF STUDENT:
ASSESSMENT
1. Assess the need for catheterization. To make certain the procedure is
appropriate for the client’s
condition.
2. Determine the type of catheterization To ensure the proper procedure is
ordered. carried out.
3. Assess the ability of the client to perform To reduce the transmission of
perineal wash before catheterization. microorganisms.
To promote independence and
cooperation.
4. Assess if the client can tolerate supine or To facilitate visualization of the
dorsal recumbent position perineum and determine if the
client can hold still during the
A.Y. 2020-2021
procedure.
1 SEMESTER,
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33. Set the bed to a comfortable height to work Promotes proper body mechanics
and lower side rail near you. and ensures client’s safety.
34. Wash hands. Hand hygiene deters spread of
microorganisms.
35. Stand on the client’s right side if you are right Observe proper body mechanics.
– handed or on the other side if left-handed.
36. Place an underpad.
I. MALE:
37. Assist the client to a supine position with Relaxes muscles and allows
legs spread and feet apart. visualization of the area to facilitate
insertion of the catheter.
To expose genitalia.
38. Drape the client appropriately exposing only To provide privacy and establish a
the penis. sterile field.
39. Open the sterile gloves. Set aside the inner
wrapper and use the outer wrapper for the
cotton balls soaked with povidone iodine.
40. Apply clean gloves and cleanse perineal Removes dirt and minimizes the
area. With your nondominant hand, gently risk of urinary tract infection by
grasp the penis perpendicular to the body removing surface pathogens.
and retract the foreskin (if uncircumcised).
41. With your other hand, cleanse the glans Moving from the meatus towards
penis with antimicrobial cleanser or the base of the glans penis
povidone-iodine solution in a circular motion prevents transfer of
from inner to outer aspect then dispose used microorganisms to the meatus.
cotton ball.
A.Y. 2020-2021
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56. Instruct the client to take several deep The catheter can enter the bladder
breaths (inhale through the nose and exhale easily when the client’s sphincter
thru the mouth) while steadily inserting the relaxes.
catheter about 6-8 inches with the other
hand until urine flow is noted. (In straight
catheter insertion, pull–out the catheter after
the bladder has been emptied completely.)
57. Advance the catheter from 1-2 inches more Advancing an indwelling catheter
when urine flow is noted. Do not force to an additional 1-2 inches ensures
insert the catheter further if you meet placement in the bladder and
resistance then notify physician before facilitates inflation of the balloon
proceeding with the procedure. without damaging the urethra.
58. Re-attach the water-filled syringe to the Ensures retention of the balloon.
inflation port. Inflate the retention balloon Retention catheters are available
with 8-10 cc of NSS for anchorage. with a variety of balloon sizes. Use
a catheter with the appropriate size
balloon.
59. If the client experiences pain during balloon If there is presence of pain, the
inflation, deflate the balloon and insert the inflated balloon may still be at the
catheter farther into the bladder. If the pain urethra. Continuing the procedure
continues with balloon inflation, remove the may cause tissue damage.
catheter and notify the client’s health care
provider.
60. Once the balloon has been inflated, gently Maximizes continuous bladder
pull the catheter until the retention balloon is drainage and prevents urine
resting against the bladder neck. leakage around the catheter.
A.Y. 2020-2021
61. Tape the catheter unto the lower abdomen Prevents excessive traction from
1 SEMESTER,
or upper part of the thigh with enough slack the balloon rubbing against the
that will not pull on the bladder. bladder neck, inadvertent catheter
removal, or urethral erosion; this
prevents pressure on the
penoscrotal angle.
62. Place the drainage bag below the level of the Maximizes continuous drainage of
bladder. Do not let it rest on the floor. urine from the bladder (drainage is
prevented when the drainage bag
is placed above the abdomen).
63. Remove gloves, dispose soiled materials Prevents transfer of
and wash hands. microorganisms.
64. Drape and help the client adjust position. Promotes client comfort and
Lower bed. safety.
65. Document the procedure. Document urine's character,
amount, color/odor and the client's
response to the procedure.
Monitor urinary status.
II. FEMALE:
66. Assist the client to a supine position with Relaxes muscles and allows
knees flexed and feet apart. (dorsal visualization of the area to facilitate
recumbent) insertion of the catheter.
To expose genitalia.
67. Drape the client appropriately exposing only To provide privacy and establish a
st
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NSS vial with alcohol swab. Apply negative
pressure principle in withdrawing solution by
injecting needle into the rubber port of the
vial and instill air into the solution as the
same amount of solution to be withdrawn
and aspirate 8-10 cc. Keep syringe with NSS
inside its wrapper.)
74. Cut adhesive tape to be used in securing the
catheter.
75. Open the catheter using sterile technique.
76. Open urine bag using the sterile technique.
77. Open inner wrapper of sterile gloves. Utilize
wrapper as sterile field. Cut the lubricant
package and pour sufficient amount onto the
sterile surface avoiding the tip to touch
sterile field.
78. Don sterile gloves. Prevents contamination of the
sterile equipment and the sterile
field.
79. Designate the non-dominant hand as clean Tests the patency of the retention
hand and the dominant hand as sterile. balloon. Detaching the syringe
prevents accidental inflation during
catheter insertion.
80. Open the inner wrapper of the catheter and To avoid exposing the client to
coil it around the sterile hand while pulling ascending infection from an open-
out. ended catheter.
A.Y. 2020-2021
81. Take hold of the syringe filled with 8-10 cc To prevent dangling on unsterile
1 SEMESTER,
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Monitor urinary status.
EVALUATION:
94. The catheter was inserted with minimal
discomfort.
95. The client's bladder was emptied without
complication.
96. The nurse maintain sterility throughout the
procedure.
TOTAL
/ 192
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NAME OF STUDENT:
ASSESSMENT
1. Identify the need for the urine test. To determine the amount of urine
to be collected.
2. Assess the client's understanding of the To determine amount of instruction
procedure. needed.
3. Identify the type of collecting tubing attached To determine the site and the
to the indwelling catheter. appropriate technique to be used
in obtaining a specimen.
PLANNING / EXPECTED OUTCOMES:
4. Client will verbalize understanding of the
reason for the procedure.
5. Specimen is obtained using the sterile
container in a timely manner.
A.Y. 2020-2021
MATERIALS:
7. Sterile specimen container
8. Kelly clamp (if nonserrated clamp is
unavailable)
9. 10 cc syringe with needle
10. Clean gloves
11. Povidone-iodine swab
12. Alcohol swab
IMPLEMENTATION:
13. Verify physician's order for the procedure.
14. Identify client and introduce self. Explain To be sure you are performing the
procedure. procedure on the correct patient.
15. Assemble all the materials needed. Provide Organizes work.
privacy.
16. Clamp the tubing 3 inches below the To allow urine to collect.
sampling port for 15-30 minutes.
17. Wash hands. To prevent the spread of
microorganisms.
18. Lower side rails near you.
20. After 15-30 minutes, disinfect sampling port To prevent the introduction of
with alcohol and povidone-iodine swab microorganisms into the system.
respectively or according to institution’s
policy.
21. Open 10 cc syringe and inject needle into Obtain specimen with sufficient
the sampling port of catheter at 45-degree- volume for most urine tests. 10 ml
angle without penetrating tubing thru and of urine is needed for most
thru. urinalysis.
22. Remove clamp and rearrange tubing. Re-establishes urine flow and
drainage into the system.
23. Label specimen container with client’s name, Ensures accuracy of the result for
room or bed number, specimen type, date the right patient.
and time collected.
24. Send specimen to the laboratory not longer Ensures accuracy of the result.
than 2 hours together with the request slip.
25. Dispose used supplies in appropriate waste Reduces transmission of
receptacle and wash hands. microorganisms.
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EVALUATION:
27. Client verbalized understanding of the
reason for the procedure.
28. Specimen was obtained using the sterile
container in a timely manner.
29. Specimen remained uncontaminated.
TOTAL
/ 58
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NAME OF STUDENT:
ASSESSMENT
1. Determine previous history of incontinence, Assess client for temperature,
infection, urinary patterns, fluid intake and current condition of urinary
rationale for current treatments. meatus, perineal area and urine
character.
2. Assess client's understanding of the To participate in care to the best of
procedure. his/her ability.
3. Assess room set up to determine ability of To facilitate client’s easy return to
the client to reach bathroom or bedside normal voiding patterns if catheter
commode. will remain out.
PLANNING / EXPECTED OUTCOMES:
4. Catheter will be removed intact.
5. Client will void within 8 hours of removal
A.Y. 2020-2021
area.
19. Put on gloves. Practices standard precautions.
20. Insert underpad under the buttocks and Prevents bed from becoming
thighs. soiled.
21. Empty urine in tubing into the urine bag. Prevents leakage from catheter
onto client when the catheter is
removed.
22. Remove any tape that maybe holding the Allows for easy removal of
catheter in the abdomen or inner thigh. catheter.
23. Grab syringe from its wrapper and insert into Keeping port intact ensures the
the anchor balloon port. (Keep anchor port of ability to drain the contents of the
the catheter straight as you insert the syringe ballon.
needle if port requires needle).
24. Deflate catheter anchor balloon by aspirating Aspirating twice ensures fully
10 cc of fluid twice until depression is seen in deflated balloon.
the port when all contents are evacuated.
25. Ask the client to take several deep breaths if
able, while gently removing the catheter. Damage to the urethra may occur
if the balloon is not fully deflated.
26. Stop if you meet resistance and recheck the
balloon port for further deflation.
27. Note any sediments, mucus, or blood that Assesses for any indications of
may be on the catheter. Culture catheter tip infection or trauma related to the
when ordered and as necessary by cutting it catheter.
off with sterile scissors and placing it on a
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sterile specimen container and send to
laboratory.
28. Cleanse the perineal area. Provides comfort and reduces
transmission of microorganisms.
29. Remove gloves, dispose used articles and To prevent the spread infection.
wash hands.
30. Assist the client to position of comfort.
31. Assess and document the procedure – time Communicates with other
of removal, size of the catheter used, urine healthcare team the effectives of
amount, color and consistency and client’s treatment.
response.
32. Instruct the client to drink oral fluids as
tolerated or as prescribed and to call when It is important to determine that
needing to void. client has returned to usual voiding
pattern or other interventions will
need to be implemented.
33. Monitor time and amount of first voiding.
Offer bedpan or urinal if unable to go to
comfort room.
34. Refer to health provider if unable to void Allows assessment and
within 8 hours after catheter removal. intervention to determine the cause
of the client’s inability to void after
the catheter is removed.
EVALUATION:
35. Catheter was removed intact.
36. Client voided within 8 hours of removal
A.Y. 2020-2021
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NAME OF STUDENT:
EINC
Enema Administration
Surgical Handwashing
Gowning and Gloving
(closed method)
Skin Preparation for
Surgery
Urinary
Catheterization (Male
& Female)
Obtaining a urine
specimen from a
closed-drainage
system
Removing Indwelling
st
Catheter
TOTAL
___________________________________
STUDENT’S NAME AND SIGNATURE
YEAR/GROUP/SECTION: __________
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NP 9 - Care of Mother,
A.Y. 2020-2021
1 SEMESTER,
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NAME OF STUDENT:
ASSESSMENT
1. Check the written order for the type of IV To determine the optimal needle
solution to be infused and the rate of flow. size and type to use and ensure
accurate administration.
2. Review information regarding the insertion of To insert the catheter and
the IV and nursing implications. administer the solution safely.
3. Know the hospital policy regarding who may Many agencies require that nurses
start an IV. have special training before they
can perform this procedure.
4. Check all additives in the solution and other So that there will be no
medications. incompatibilities of additives with
the solution.
5. Assess the client's veins. To optimize planning of the IV site.
A.Y. 2020-2021
6. Check the client's fluid, electrolyte and To provide baseline data for
1 SEMESTER,
20. Tourniquet
21. Alcohol swab
22. Splint
23. IV stand
24. Micropore
25. Kidney basin
IMPLEMENTATION:
I. Setting-Up:
26. Verify physician’s order and make IV label.
27. Observe 10 rights when preparing and
administering intravenous fluid.
28. Identify client and introduce self. Explain the
procedure to the client and or significant
other.
29. Assess client’s vein: choose appropriate
vein; location and size condition.
30. Wash hands and maintain asepsis
throughout the preparation and during
therapy.
31. Prepare necessary materials for the
procedure.
32. Check the sterility and integrity of the IV
solution, IV set and other devices.
33. Place IV label on IVF bottle the client’s
name, room / bed number, solution, drug
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incorporation if any, bottle sequence and
duration.
34. Open the seal of the IVF solution aseptically.
35. Open IV set aseptically and close IV clamp.
36. Spike the IV set aseptically into the rubber
port of the IVF.
37. Fill drip chamber to at least half and prime
the tubing aseptically.
38. Remove air bubbles if any and put back the
cover to the distal end of the IV tubing.
II. Changing an IV infusion:
39. Verify physician’s order in doctor's order
sheet. Countercheck IV label, sequence,
type, amount, additives and duration of
infusion.
40. Observe the 10 rights.
41. Identify client and introduce self. Explain the
procedure.
42. Assess IV site for redness, swelling and
pain, etc... Check date of IV insertion. Re-
site l if 48-72 hours has lapsed.
43. Check date of changing IV tubings, change if
due for changing. Change tubings within 72
hours.
44. Wash hands before and after the procedure.
45. Prepare the necessary materials.
A.Y. 2020-2021
1 SEMESTER,
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71. IV site remains free of swelling and
inflammation.
TOTAL
/ 142
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NAME OF STUDENT:
Correctly Needs
Not Done
SKILL: SETTING THE FLOW RATE RATIONALE Done Improvement
(0)
(2) (1)
ASSESSMENT
1. Check written doctor's order for the IV to be To determine the optimal needle
infused and the desired flow rate. site and type to use and ensure
accurate administration.
2. Review information regarding the insertion of To insert the catheter and
the IVF and nursing implications. administer the solution safely.
3. Assess the patency of the IV line. To optimize planning of the IV site.
4. Assess the skin at the IV site. To optimize planning of the IV site.
5. Assess the client's understanding of the IV So that client teaching can be used
infusion. to decrease anxiety
complication.
1 SEMESTER,
IMPLEMENTATION:
11. Verify physician’s order for the IV solution
and rate of infusion.
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EVALUATION:
24. Drug was infused into the vein without
complications.
25. IV site remained free of swelling and
inflammation.
26. Client was able to discuss the purpose of the
drug.
TOTAL
/ 52
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NAME OF STUDENT:
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30. Disinfect the rubber port of the diluents with
alcoholised cotton ball.
31. Aspirate the right amount of diluent. (use 1:1
ratio such that 100 mg of drug is to 1 cc
diluent or according to institution policy).
32. Disinfect the rubber port of the medication
and dilute.
33. Aspirate the right drug dose.
34. Disinfect the Y -injection port of the IV
administration set and pierce the needle
through the bull's eyed rubber port.
35. Kink the tubing from the IV bottle and push
IV drug slowly as ordered or as per
manufacturer's instructions. Observe
precautionary measures during drug
administration.
36. Remove the needle and discard
appropriately.
37. Regulate rate of IV fluid infusion as ordered
(if needed).
38. Reassure patient and observe for signs and
symptoms of adverse drug reaction, if any.
39. Discard sharps and other waste according to
MMDA ordinance #16.
40. Document in patient's chart and endorse
accordingly.
A.Y. 2020-2021
Heparin-lock Device:
1 SEMESTER,
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60. The drug was infused into the vein without
complications.
61. The IV site remained free of swelling and
inflammation.
62. The client was able to discuss the purpose of
the drug.
63. Any adverse reactions to the drug were
identified.
TOTAL
/ 126
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NAME OF STUDENT:
ASSESSMENT
1. Observe the 10 rights in administering
medication.
2. Check the health provider's order for the
client, medication, dosage and time of,
administration.
3. Review the information regarding the drug
including action, purpose, side effects,
normal dose, and peak onset and nursing
implications in order to administer the drug
safely.
4. Determine the additives in the solution of an
existing IV line to determine if the medication
A.Y. 2020-2021
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30. Remove the cover of the airway of the
administration set, disinfect with alcohol and
I incorporate prepared drug into the airway.
Recap airway after.
31. For administration set that has no airway, put
down the bottle, kink the IV tubing or clamp
the tubing. Remove the administration set
from the bottle aseptically. Disinfect the
bottle's rubber stopper; incorporate the right
drug to the IVF bottle aseptically. Return the
administration set to IVF bottle aseptically.
Swirl the bottle to mix the drug with the IVF
and regulate the flow rate as ordered.
32. Swirl the IV bottle to mix the drug with the
IVF and regulate the flow rate as ordered.
33. Observe and reassure the patient.
34. Document in the patient's chart.
35. Discard sharps and other wastes according
to MMDA Ordinance #16.
36. Wash hands.
II. Drug incorporation into solu-set:
37. Repeat steps 23-28.
38. Check present IV fluid label, level, and the
incorporated medicine if any in the IV bottle.
39. Aspirate prepared right drug with correct
dosage.
A.Y. 2020-2021
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NAME OF STUDENT:
ASSESSMENT
1. Check the order for the medication, dosage,
time and route of administration.
2. Review information regarding the drug.
3. Determine the additives in the solution an
existing line.
4. Assess the placement of the IV catheter in
the vein.
5. Assess the skin at the IV site.
the procedure.
22. Determine whether the ordered additives are
compatible with the IV solution and with each
other.
23. Assemble all materials needed. Wash
hands. Apply gloves.
24. Hang medication bag.
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EVALUATION:
34. Drug was infused into the vein without
complications.
35. IV site remained free of swelling and
inflammation.
36. Client was able to discuss the purpose of the
drug.
TOTAL
/ 72
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NAME OF STUDENT:
ASSESSMENT
1. Determine when dressing was last changed. Provides information regarding
Dressing should be labeled to include date length of time that present dressing
and time applied, size and type of venous has been in place. In addition, you
access device (VAD), and date VAD was are able to plan for dressing
inserted. change
2. Observe present dressing for moisture and Moisture is medium for bacterial
intactness. Determine if moisture is from site growth and renders dressing
leakage or external source. contaminated. Non-adhering
dressing increases risk for
bacterial contamination to
venipuncture site or displacement
of IV catheter.
3. Observe IV system for proper functioning or Unexplained decrease in flow rate
complications (e.g., current flow rate, tubing, indicates problems with VAD
A.Y. 2020-2021
(optional)
13. Sterile transparent semipermeable dressing
14. Sterile 2 × 2 or 4 × 4 inch gauze pad
IMPLEMENTATION:
15. Explain procedure and purpose to patient Decreases anxiety, promotes
and family caregiver. Explain that patient will cooperation, and gives patient time
need to hold affected extremity still. Explain frame around which to plan
how long procedure will take. personal activities.
16. Perform hand hygiene. Collect equipment. Reduces transmission of
Apply clean gloves. microorganisms. Infections related
to IV therapy are most often
caused by catheter hub
contamination; thus, you need to
use careful technique throughout
dressing change
17. Identify patient using two identifiers (i.e., Ensures correct patient. Complies
name and birthday or name and account with The Joint Commission
number) according to agency policy. standards and improves patient
Compare identifiers with information on safety
patient’s identification bracelet.
18. Remove dressing. Technique minimizes discomfort
during removal. Use alcohol swab
on transparent dressing next to
patient’s skin to loosen dressing.
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19. For transparent semipermeable dressing:
Remove by pulling up one corner and pulling
side laterally while holding catheter hub with
nondominant hand (see illustration). Repeat
on other side. Leave tape or catheter
stabilization device that secures IC catheter
in place.
20. For gauze dressing:
Stabilize catheter hub while loosening tape
and removing old dressing one layer at a
time by pulling toward insertion site. Leave
tape that secures VAD to skin intact. Be
cautious if IV tubing becomes tangled
between two layers of dressing.
21. Observe insertion site for signs and Presence of complication indicates
symptoms of IV-related complications need to remove VAD at current
(tenderness, redness, swelling, exudate, or site.
complaints of pain). If complication exists or
if ordered by health care provider,
discontinue infusion
22. Prepare new sterile tape strips for use. If IV Exposes venipuncture site.
is infusing properly, gently remove tape or Stabilization prevents accidental
stabilization device securing VAD. Stabilize displacement of VAD. Adhesive
VAD with one finger. Use adhesive remover residue decreases ability of new
to clean skin and remove adhesive residue if tape to adhere securely to skin.
necessary.
A.Y. 2020-2021
23. While stabilizing IV, clean insertion site with Allowing antiseptic solutions to air-
1 SEMESTER,
30. Observe function, patency of IV system, and Validates that IV is patent and
flow rate after changing dressing. functioning correctly. Manipulation
of catheter and tubing will affect
rate of infusion.
31. Inspect condition of short peripheral site for Complications such as phlebitis
signs and symptoms of IV-related and infiltration require removal of
complications (e.g., redness, complaints of short peripheral catheter and
pain, swelling, or exudate). insertion of new catheter at new
site above area of complication or
other extremity.
32. Monitor patient’s body temperature. Elevated temperature indicates
infection that can be associated
with contamination of venipuncture
site or septicemia.
TOTAL
/ 96
Computation: Raw Score / Total Score X 100 = FINAL GRADE
Clinical Instructor: ____________________________________
REMARKS: %
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
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NAME OF STUDENT:
Correctly Needs
Not Done
SKILL: BLOOD TRANSFUSION (BT) RATIONALE Done Improvement
(0)
(2) (1)
ASSESSMENT
1. Check the physician's order. The order
includes the type of blood product, the
number of units and the period over which
the product is to be infused.
2. Check the existing IV infusion or heparin lock
for patency and needle size, or initiate an IV
infusion with a g19 size or larger bore needle
or other means of entering the veins. A 20 to
23 gauge needle may be used for infants
and other patients with small veins.
PLANNING / EXPECTED OUTCOMES:
A.Y. 2020-2021
correct rate.
4. The vital signs will be within normal limits.
5. Will be able to correct fluid imbalance.
MATERIALS:
6. prescribed medication for pre-BT meds
7. plain normal saline solution
8. sterile syringe
9. sterile large bore needle
10. blood unit (FWB, PRBC, platelet
concentrate, etc.)
11. antiseptic swab
12. label for IVF and BT bag
13. Medication Administration Record (MAR)
14. IV tray
15. Blood filter set
16. IV tubing
17. Clean gloves
IMPLEMENTATION:
18. Verify physician’s order.
19. Observe the rights of the patient when
preparing and administering any blood
component.
st
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30. Prepare equipment needed for BT.
31. Initiate an IV line with PNSS and regulate at
keep vein open (KVO) rate.
32. Open compatible blood set aseptically and
wear gloves.
33. Spike blood bag carefully. Fill the drip
chamber halfway and prime the tubing.
Remove air bubbles if any. Use g 18 or 19
for side drip.
34. Disinfect the Y injection port of the PNSS IV
tubing and insert the needle from the BT
administration set and secure with adhesive
tape.
35. Regulate the PNSS fluid while transfusion is
going on.
36. Transfuse the blood via the injection port at
10-15 drops initially for 15 minutes.
37. Observe client on an ongoing basis for any
untoward signs and symptoms such as
flushed skin, chills, elevated temperature,
itchiness, urticaria, and dyspnea.
38. Regulate the blood at ordered rate if no
transfusion reaction is noted.
39. If any occurs, stop the transfusion, open the
IV line with PNSS and report to physician
immediately.
A.Y. 2020-2021
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NAME OF STUDENT:
ASSESSMENT
1. Prevention of arrest
2. Early, high-quality CPR
3. Rapid activation of the EMS system or
response team to get help on the way
quickly – no matter the patient’s age
4. Effective, advanced life support
5. Integrated post-cardiac arrest care
6. Activation of Emergency Response System,
if unwitnessed, care first; if witnessed, call
first.
PLANNING / EXPECTED OUTCOMES:
7. Know when to STOP. Patient has
A.Y. 2020-2021
spontaneous circulation.
1 SEMESTER,
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do not wish them to appear on the workbook, please contact us and they will be promptly removed.
24. When patient has spontaneous movement or
5 cycles of High Quality CPR was done. Do
a quick check of patients pulse on the carotid
artery nearest you.
25. If patient is still without pulse, continue with Remember to always provide high
High Quality CPR. quality CPR.
Patient has pulse
26. Position patient in a left lateral recumbent Keep the patient’s airway open and
position clear to ease breathing and to help
avoid having the casualty aspirate
saliva or vomitus.
27. Check status of patient and pulse time to
time.
28. If patient is not breathing, give rescue
breathing every 3 to 5 seconds (about 15-30
breaths per minute).
29. Check pulse every 2 minutes. If patient’s
pulse is unpalpable, return patient in a
supine position, and start High Quality CPR.
EVALUATION:
30. Do secondary assessment. Used to determine the injury, how
the injury occurred, how severe the
injury is and to eliminate further
injury.
31. Document the procedure. Endorse
everything to the EMS Personnel.
A.Y. 2020-2021
TOTAL
1 SEMESTER,
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do not wish them to appear on the workbook, please contact us and they will be promptly removed.
NAME OF STUDENT:
ASSESSMENT
1. Prevention of arrest
2. Early, high-quality CPR
3. Rapid activation of the EMS system or
response team to get help on the way
quickly – no matter the patient’s age
4. Effective, advanced life support
5. Integrated post-cardiac arrest care
6. Activation of Emergency Response System,
if unwitnessed, care first; if witnessed, call
first.
PLANNING / EXPECTED OUTCOMES:
7. Know when to STOP. Patient has
A.Y. 2020-2021
spontaneous circulation.
1 SEMESTER,
tapping the infant’s foot. And shouts “Baby, tapping the foot of the infant elicit
Baby, are you ok?” on both ears stimuli
Unresponsive patient
21. Call for “Help and get me an AED”
22. Simultaneously, open airway (head-tilt/chin- ABC for responsive patients. CAB
lift for patient without spinal injury; modified for unresponsive patients. Checks
jaw thrust for patient suspected of spinal for breathing and brachial pulse
injury), check for obstruction, check for simultaneously at least 5 seconds,
breathing and pulse check in the brachial but not more than 10 seconds.
pulse of the infant nearest you.
23. Immediately start chest compressions using Finger position on the center on
correct finger placement at the proper rate the lower half of the sternum about
and depth, allowing for full chest recoil. 1 finger-width below the nipple line.
With a depth of at least 1 to 1 ½
inches. 30 compression, at a rate
of 100-120 per minute. Allow chest
recoil. Expose chest for better
visualization.
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26. Maintain High Quality CPR. Push Hard. Push Fast. Allow Chest
Recoil. Avoid Excessive Ventilation
and Avoid Interruption on
Compression.
Integration of team member
27. A team member comes back with an AED Note: The purpose of this is to
and Bag valve mask. The AED and Bag check the competency of the first
valve mask is positioned near the first responder.
responder. Second responder position
himself on the opposite side of the patient. Second responder should put the
AED to lessen interruption to CPR.
28. Second responder will switch with the first
responder. Second responder will count 3-2- This is done if EMS personnel
1, then they will switch. Second responder assumes responsibility from a lay
will resume High Quality CPR with his two provider.
thumbs centered on the lower half of
sternum about 1 finger-width below the
nipple line.
29. First responder will turn on the AED. Plug in The AED when turn on, a voice
connectors to the machine, peal of the pads prompt will provide the necessary
and apply pad 1, in the center of the anterior steps.
chest, and pad 2, on the infant’s back Proper positioning of pads is
between the scapulae. If patient’s chest is necessary to properly assess the
wet, wipe first before applying the pads. cardiac rhythm.
A.Y. 2020-2021
30. AED analysis. First responder says “clear” Ensures no one is touching the
1 SEMESTER,
and hovers hands a few inches above chest patient during analysis.
during analysis.
31. Shock advised. First responder says “clear”, Ensures no one is touching the
other team member says “clear”, first patient while shock being
responder says “shocking at 3, 1-2-3” delivered. Depresses shock button
presses shock button to deliver shock “shock within 10 seconds.
deliver, resume High Quality CPR”
32. Second rescuer continues with 10 cycles of Immediately following shock
High Quality CPR (15 compression:2 resume CPR starting with
ventilation). While first responder position compression until prompted by the
himself on top of head with bag valve mask AED for analysis
on hand.
33. After 15 compression, first responder opens Head-tilt/chin-lift past a neutral
airway from top of head by using the position. Ventilation duration of 1
appropriate technique and gives 2 second, with visible chest rise.
ventilations using the infant BVM. Position Delivered in 5-7 seconds only.
the bag valve mask, 2 hands using E-C Squeezes bag enough to make
technique. chest rise; does not fully squeeze
bag avoiding over inflation.
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41. Check pulse every 2 minute. If patient’s
pulse is unpalpable, return patient in a
supine position, and start High Quality CPR.
EVALUATION:
42. Do secondary assessment. Used to determine the injury, how
the injury occurred, how severe the
injury is and to eliminate further
injury.
43. Document the procedure.
TOTAL
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do not wish them to appear on the workbook, please contact us and they will be promptly removed.
NAME OF STUDENT:
ASSESSMENT
1. Assess the 10 rights in medication
administration.
2. Assess the client's respiratory status.
3. Evaluate the history of the episode of client's
distress.
4. Assess the client's ability to use the
nebulizer.
5. Assess the medications the client is currently
taking.
6. Assess the client's knowledge regarding the
use of nebulizer.
PLANNING / EXPECTED OUTCOMES:
A.Y. 2020-2021
exchange.
8. Breathing pattern will become effective.
9. The client will demonstrate understanding of
the need for nebulization.
10. The client will not experience the adverse
effects secondary to medication interaction.
11. The client's anxiety level will decrease
following treatment.
MATERIALS:
12. nebulization kit
13. nebulizer machine
14. nebules or medication for nebulization
15. paper towel
IMPLEMENTATION:
16. Verify physician’s order.
17. Gather all the materials needed
18. Identify client. Introduce yourself. Explain the
procedure.
19. Place client on high fowlers position
20. Wash hands.
21. Set up the nebulizer machine
22. Open the wrapper of the nebulization kit and
attach to the machine.
st
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35. The client experienced improved gas
exchange.
36. Breathing pattern became effective.
37. The client demonstrated understanding of
the need for nebulization.
38. The client experienced the adverse effects
secondary to medication interaction.
39. The client's anxiety level decreased following
treatment.
TOTAL
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NAME OF STUDENT:
Administering
1 SEMESTER,
___________________________________
STUDENT’S NAME AND SIGNATURE
YEAR/GROUP/SECTION: __________
st
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