SACR - Manual of Nursing Procedure

HANDWASHING
Definition:
Handwashing is the rubbing together of all surfaces and crevices of the hands using soap,
chemical and water.
Purposes:
1. To reduce the number of microorganisms present in the hands.
2. To reduce the risk of transmission of microorganisms from the Nurse to patient.
3. To reduce cross-contamination among patients.
4. To reduce the risk of transmission of infectious organisms to oneself.
Equipment/Materials:
Soap Blue stick/nail file
Tap Water Paper or cloth towels
Warm running water
ACTION RATIONALE
1. Gather all articles needed. For efficient management of time and effort.
2. Remove jewelries and wristwatches; roll Provide access to skin surfaces for cleaning.
sleeves above forearms. Facilitates cleaning of fingers, hands and
forearms.
3. Assess hands for hangnails, cuts or breaks Intact skin acts as a barrier to microorganisms.
in the skin and areas that are heavily soiled. Breaks in skin integrity facilitates development
of infection and should receive extra attention
during cleaning.
4. Turn on the faucet. Adjust the flow and Running water washes away microorganisms;
temperature of water. Water should be warm water removes natural skin oils more
warm. effectively than does hot water.
5. Wet hands and wash the forearms by Water should flow from the least
holding under running water. Keep hands contaminated to the most contaminated areas
and forearms in the down position with of the skin. Hands are considered more
elbows straight. Avoid splashing water and contaminated than arms. Splashing of water
touching the sides of the sink. facilitates transfer of microorganisms.
Touching of any surface during handwashing
contaminates the skin.
6. Apply soap and lather thoroughly. Rinse Lathering facilitates removal of
soap under water and drop to soap dish. microorganisms. Rinsing soap removes
microorganisms, and dropping of the soap
prevents hands from further contamination.
7. Thoroughly rub hands together for about Friction, mechanically removes
10-15 seconds. Interlace fingers and microorganisms from the skin surface. Friction
thumbs and move back and forth to wash loosens dirt from soiled areas.
between digits.Rub palms and back of hands
in circular motion. Special attention should
be given to areas such as the knuckles and
fingernails which are known to harbor
microorganisms. Nailbeds are areas which usually harbor
Use a nail file to clean nailbeds. microorganisms.
8. Rinse the hands keeping them in the down Water flow rinses away dirt and
position and elbows straight. Rinse in the microorganisms.
direction from forearms to wrist and to
fingers.
9. Pat hands and forearms to dry thoroughly. Patting prevents chapping of skin. Drying from
Dry starting from the fingers to the wrist cleanest to least clean area prevents transfer
ACTION RATIONALE
and to the forearms. Discard the paper of microorganisms to cleanest area.
towels in the proper receptacle.
10. Turn off the faucet, with a clean, dry paper Prevents contamination of the already clean
towel. hands by a less clean faucet.
POSITIONING AND DRAPING
Definition:
It is the technique of placing the patient on bed or examination table safely, comfortably,
conveniently and effectively in preparation for any procedure.
Purposes:
1. To assist the patient to assume a position that would best afford adequate space and
easy movement during the examination and/or procedure.
2. To provide safety, comfort and privacy during the examination.
Special Consideration:
1. The methods of draping vary with the condition of the patient, the position of the
patient, the examination to be done and the room temperature.
2. Draping should be loose enough to allow quick change of position.
3. Draping should consider the patient's individual make-up
4. Positioning depends upon the condition of the patient and the part to be examined.
Preparation:
A. Equipment/Materials: Draping sheet, or bed sheet.
B. Patient and Unit

1. Explain the procedure to the patient
2. Adjust the height of the bed or the examining table.
3.
ACTION RATIONALE
A. Erect (standing or up-right) This is convenient for examination of the
1. Assist the patient to stand with either alignment of the vertebral and spinal column.
slippers on or with bare feet on a piece of Patient is allowed to walk to observe the gait.
paper. Erect position facilitates the examination.
Slippers or the paper placed under the feet,
protect them from dirt.
2. Untie the gown and leave the uppermost Such procedure facilitates examination of the
tape. Fold back the gown over both body contours.
shoulders toward the front.
B. Horizontal Recumbent (Dorsal position) The hands are either placed on the sides or
1. Replace the top sheet with a draping slightly flexed on the sides above the head.
sheet. (The top sheet may be used in the This provides privacy and facilitates changes of
absence of a draping sheet). position.
2. Assist the patient to lie flat on his/her back This affords better muscle relaxation.
with the legs together, extended or slightly
flexed.
3. Place one pillow under the head and a This promotes comfort and prevents
smaller one may be placed under the hyperextension of the knees.
knees.
4. Place the arms along the sides of the body This provides comfort and prevents
or comfortably flexed on the sides. interferences during the examination of the
lower extremities especially when the arms
are flexed.
ACTION RATIONALE
C. Dorsal Recumbent: The dorsal recumbent position is indicated for
1. Replace the top sheet with the draping examination of the abdomen, pelvis, vagina
sheet. and rectum.
2. Assist the patient to lie flat on his/her back. This position is also appropriate for perineal
care, catheterization and other treatments,
involving the pelvic region.
3. Separate the legs; flex the knees so that the Flexion of the knees relaxes the abdominal
soles of the feet are flat on the bed. Place muscles.
the arms either above the head or flex with
the hands on the chest.
4. Place one pillow under the head. This is done for comfort.
5. Bring the patient to the edge of the bed. Working close to the patient prevents
overstraining of the back muscles.
6. Place the draping sheet diagonally on the Folding back the top corner over the chest
patient in such a way that the opposite prevents inconvenience and smothering of the
corners cover the legs. Fold back the top patient.
corner over the chest.
7. Wrap the corner on the right side around This prevents exposure of the lower
the right foot. Do the same with the left extremities and holds the drape in place.
side.
8. Fold the lower corner of the sheet back on Having the lower corner of the sheet loose
the abdomen to expose the part to be facilitates exposure of the part to be
examined when the doctor is ready to do examined, ready when the doctor arrives.
so.
D. Dorsal Lithotomy Dorsal lithotomy position is for examination of
1. Assist the patient to lie on his back. the abdomen, pelvic and perineal areas. Also
in delivery and D & C.
2. Insert the legging or stockinettes PRN. Stockinettes provide warmth and cover for the
legs, and protect the skin from irritation.
3. Adjust the stirrups according to the size of Properly adjusted stirrups prevents injury and
the patient. discomfort.
4. Separate the legs and flex the thighs Such a position allows good exposure of the
towards the abdomen. Elevate the lower vulva.
legs and support them with the stirrups.
5. Draw down the buttocks to the folding This facilitates the insertion of instruments.
edge of the table.
6. Raise the arms above the head or flex them To provide comfort and to prevent
with the hands on the chest. interference during the examination.
7. Drape as in dorsal recumbent. Preferably To provide privacy for the patient.
use the lithotomy drape.
E. Sims (Lateral) This position is best for rectal or colon
1. Assist the patient to lie on either side, procedures, as in giving enema or during
preferably on the left with the body examination as in proctosigmoidoscopy.
inclined forward.
2. Extend the left arm behind the back and This position provides comfort and prevents
flex the elbow of the right arm forward. injury.
3. Flex the right thigh towards the abdomen This facilitates the separation of the buttocks.
with the knee drawn up higher than the
left knee which is only slightly flexed.
4. Lay out the draping sheet as in horizontal Proper draping provides comfort and privacy.
ACTION RATIONALE
recumbent position. Fold back and or
gather the side of the sheet to expose the
area to be examined.
F. Prone This position is for examination of the spine
1. Help the patient to assume the horizontal and back. This is preparatory to the desired
recumbent position. position.
2. Assist the patient to turn over on his This is done to provide comfort, convenience
abdomen.
3. Turn the head to one side. and prevent smothering.
4. Place the arms at the sides or flex or extend This is done to provide comfort, convenience
upwards. and to
prevent smothering.
5. Allow the feet to hang over the edge of the This prevents plantar flexion
mattress or support on a pillow high
enough to keep the toes from touching the
bed.
G. Fowlers
1. Place the patient in a horizontal recumbent This is for patients recovering from general
position. anesthesia.
2. Elevate the head of the bed to This is to provide comfort and facilitates
approximately 45⁰ angle. various procedures.
3. Flex the knees slightly and support them Flexion prevents hyper-extension of the knees
with knee rolls. and prevents slipping from the bed.
4. Drape as in dorsal horizontal. Proper draping provides comfort and privacy.
H. Trendelenburg
1. Assist the patient to a horizontal Done for certain types of shocks, surgical
recumbent position. procedures and postural drainage.
2. Elevate the foot of the bed so that the
lower trunk is higher than the head and
shoulders.
3. Support the shoulders and knees. The weight of the body is pulled downwards
by gravity. Support will prevent the patient
from slipping out of the bed.
4. Drape as in horizontal recumbent. To provide comfort and privacy.
I. Knee Chest (Genupectoral) This is preparatory for assuming the desired
1. Place the patient on a prone position. position.
2. Assist him to kneel with the knees slightly
separated.
3. Assist patient to bend forward so that the This is for rectal and vaginal examination and
chest is resting on the bed and the thighs as a form of exercise for some gynecological
are perpendicular to the legs. conditions.
4. Turn the head to one side and place the This is for support, convenience and prevents
arms either above head or flex at the smothering.
elbow and rest along the side of the head.
5. Drape the patient properly so that only the Proper draping provides comfort and privacy.
area to be examined is exposed.
DORSAL RECUMBENT DORSAL LITHOTOMY
SIMS LATERAL PRONE
TRENDELENBURG
KNEE CHEST (Genupectoral)
TAKING OF VITAL SIGNS
Definition:
It is the measurement of body temperature, respiration, pulse and blood pressure.
Purposes:
1. To determine the course of the illness. This will serve as a guide in meeting the needs
of the patient.
2. To provide an opportunity to observe the general condition of the patient.
3. To aid the physician in making the diagnosis and planning of patient care.
General Considerations:
1. Before taking the vital signs, make sure that the patient is rested
2. The frequency of taking the vital signs depends on the condition of the patient and
hospital or agency policy.
3. For significant changes in the baseline reading of the vital signs, it is a must to report
them to the physician or head nurse.
4. Explain the procedure to the patient to allay feelings of fear, and anxiety and to ensure
cooperation.
Temperature:
It is the balance between the body heat produced and heat lost.
Special Considerations:
1. Remember that temperature is usually taken by mouth unless otherwise ordered or is
contraindicated.
2. Stay with the patient until the temperature has been taken and make sure that the
thermometer is inside the mouth.
3. Provide patients with their own thermometer.
4. Use the appropriate kind of thermometer and appropriate route of taking temperature
5. When patient has diarrhea, rectal route is not allowed
6. When taking the temperature by the axillary route, make sure the axilla is dry and the
bulb of the thermometer is in the hollow of the axilla.
7. Remember that oral temperature is NOT taken on the following conditions:
a. when there is respiratory obstruction or other conditions that prevent patient from
closing the mouth.
b. when mouth is dry, parched and inflamed
c. when patient underwent oral and nasal surgery
d. when patient is a mouth breather
Oral Method
Articles: Oral thermometer in a bottle of chemical solution, cotton balls, wristwatch with
seconds hand, record notebook.
ACTION RATIONALE
1. Review medical record for baseline data This establishes parameters for the patient's
and factors that influence vital signs. normal measurements, as it provides the
nurse with an objective clinical data base to
direct decision making.
2. Explain the procedure to patient, Encouraging participation allays anxiety,
encourage to remain still and refrain from ensures accurate measurement.
drinking, eating and smoking prior to the Cold and hot liquids and smoking may cause
procedure. alteration in circulation and body
temperature.
3. Gather equipment and provide privacy. Facilitates organized assessment and
measurement. Eliminates embarrassment.
4. Wash hands. Apply gloves when necessary. Hands are washed before and after every
contact with a patient to reduce transmission
of microorganisms.
Gloves serve as barrier and protection from
bodily secretions.
Gloving is a universal precaution.

5. Position patient either on a sitting or lying This promotes comfort and improves site
position. access for all measurements, activity and
movement.
ACTION RATIONALE
Oral Temperature is the body temperature measured through the oral route.
1. Select the correct thermometer and bring This is to identify the correct device; some
to the bedside. thermometers are color coded : blue colored
tip (oral), red colored tip (rectal)
2. Remove thermometer from storage Cleansing removes disinfectant that can
container and wash / cleanse under cold or irritate oral mucosa. Cold or tap water
tap water. prevents the expansion of the mercury.
3. Dry the thermometer with a tissue wipe Wiping is from the area least contaminated to
from the bulb towards the stem. the most contaminated.
4. Read thermometer level by locating Thermometer reading should initially be lower

mercury level. than the normal body temperature to assure
It should read 35.5 o C. accurate reading.
5. If the thermometer reading is not below Shaking briskly lowers the mercury level to
body temperature, grasp the thermometer below body temperature. Make sure however
with thumb and forefinger and shake that this is done in an open space to prevent
vigorously by snapping the wrist in a hitting the thermometer on anything and
downward motion to move mercury to a cause it to break.
level below normal.
6. Ask patient to open the mouth and insert Ensures contact with large blood vessels under
the thermometer under the tongue the tongue. Prevents environmental air from
making sure that the tip of the coming in contact with the bulb, which may
thermometer is in a position that will not alter accurate reading.
puncture the tongue, and then ask patient
to keep lips closed.
7. Leave the thermometer in place as It must stay long enough to ensure an
specified by the agency policy - usually 3 – accurate reading.
5 minutes.
8. Remove thermometer. Wipe with tissue Wiping is from an area least contaminated to
wipes starting from the stem to the end of the most contaminated area.
the bulb.
9. Read at eye level. Rotate slowly until Ensures accurate reading
mercury level is visualized.
10. Shake thermometer down, cleanse with Mechanical cleansing removes secretions that
soap and tap water and return to storage promote growth of microorganisms. The use
container. of hot water to wash the thermometer may
cause coagulation of secretions, and breakage
of the thermometer.
11. Remove and dispose gloves in a Reduces transmission of microorganisms.
receptacle. Wash hands.
12. Document reading and indicate route as Accurate documentation by route allows for
OT (for oral temperature) comparison of data.
13. Wash hands. Reduces transmission of microorganisms.
Rectal Temperature is the body temperature measured through the rectal route
1. Repeat actions as in the oral route Nos. 1-5
2. Position patient with knees flexed. Drape Proper positioning ensures visualization of the
accordingly ensuring privacy. anus. Flexing relaxes muscles for easy
insertion.
3. Place tissue wipes for easy reach. Apply Tissue wipes are used to cleanse the
gloves. thermometer after removing from insertion
site.
4. Prepare the thermometer. Lubricate tip Lubricating the tip facilitates easy insertion.
with KY jelly.
5. With dominant hand, grasp the Aids in visualization of anus.
thermometer. With other hand, separate
the buttocks to expose anus.
6. Instruct patient to take a deep breath and Relaxes the anal sphincter. Gentle insertion
slowly insert the rectal thermometer at a reduces discomfort and trauma to the mucous
desired length -Infant (0.5 inches) Adult membrane.
(1.5 inches). If resistance is felt do not
force insertion.
7. Hold thermometer in place for 2 minutes. Prevents trauma to mucosa and breakage of
glass thermometer.
8. Wipe secretions off with tissue wipes. Removes secretions and fecal material that
may interfere with proper visualization of
mercury level.
9. Read thermometer reading. Inform patient Promotes participation.
of the result.
10. While holding thermometer on one hand, Prevents contamination of clean objects with
use the other hand to wipe anal area with soiled thermometer, prevents skin irritation
tissue wipes to remove the lubricant or and promotes patient comfort. Prevents
feces. Dispose of soiled tissue wipes. embarrassment.
11. Cleanse thermometer. Reduces transmission of microorganisms.
12. Remove and dispose of gloves in
receptacle.
13.Wash hands.
Record reading and indicate route as RT. Accurate documentation by route allows for
comparison of data.
Axillary temperature is the body temperature measured through the axillary route
1. Repeat actions as in the oral route Nos. 1 - 5 Rationale Nos. 1-5
2. Slip patiient's arm and shoulder from one Exposes axillary area.
sleeve of gown. Avoid exposing chest. Provide comfort and privacy.
3. Make sure axillary skin is dry and if Removes moisture that can lead to a false low
necessary, pat only to dry. reading.
Patting prevents creating friction that may
increase the heat of the axilla, hence a false
high reading.
4. Prepare thermometer.
5. Place thermometer at the center of the To make sure that the thermometer gets in
axilla. Fold patient's arm and place folded contact with the axillary blood vessels and to
arm across the chest. keep the device in proper position.
1. Repeat actions as in the oral route Nos. 1 - 5 Rationale Nos. 1-5
6. Leave thermometer in place for 5-10 To ensure accurate reading.
minutes.
7. Remove and read thermometer. Allows accurate reading of temperature.
8. Inform patient of temperature reading. Promotes patient's participation in the care.
9. Cleanse glass thermometer. Shake Prevents transmission of microorganisms.
thermometer down and cleanse glass
thermometer with soapy water and rinse
with cold water.
10. Record reading and indicate route as AT. Promotes accurate documentation.
11. Wash hands. To prevent transmission of microorganisms.
RECTAL TEMPERATURE
AXILLARY TEMPERATURE
PULSE RATE
Definition:
The pulse is the expansion of the arterial walls occurring with each ventricular contraction. The
pulse rate is the number of movements of the radial artery counted for 1 full minute.
Purposes:
1. To count the number of times that the heart beats per minute.
2. To obtain information regarding condition of the heart action and the patient's general
condition.
1. One complete rise and fall of the arterial wall is considered as one beat or one count.
2. Take the pulse at a convenient site for the patient and the nurse.
3. When taking the pulse, note the rate, rhythm, volume and quality of arterial wall.
4. Do not take pulse when the patient is restless or when a child is crying.
5. If peripheral pulse is difficult to obtain, take the apical or cardiac rate.
Equipment/Materials: Watch with seconds hand, small notebook and pen.
ACTION RATIONALE
1. Make the patient rest his arm alongside of This position places the radial artery on the
his body with the wrist extended and the inner aspect of the patient's wrist. The nurse's
palm of the hand downwards. fingers rest conveniently on the artery with
the thumb in position on the outer aspect of
the patient's wrist.
2. Place the 2nd and 3rd finger along the radial The fingertips, sensitive to touch will feel the
artery and press them gently against the pulsation of the patient's radial artery.
radius.
If the thumb is used for palpating the patient's
pulse, the nurse may feel her own pulse.
3. Apply only enough pressure so that you can Moderate pressure allows the nurse to feel
feel the patient's pulsating artery distinctly. the superficial radial artery expand and
contract with each heartbeat; too much
pressure will make it imperceptible.
4. Using a watch with seconds hand, count the Sufficient time is necessary to obtain accurate
number of pulsation felt on the patient's rate.
artery for one full minute.
5. If the pulse rate is abnormal, repeat the Repeating the count is necessary to allow
counting in order to determine accurately regular timing between beats.
the rate the quality and rhythm of the
pulse.
Assessing Pulse Rate

1. Palpate the radial pulse 2. Count the pulse.
3. Auscultate the apical pulse: apex area

RESPIRATORY RATE
Definition:
Respiration is the process by which oxygen and carbon dioxide interchange, manifested
externally in the rise and fall of the chest. Respiratory rate is measured by counting the number
of times the chest rises and falls for 1 full minute.
Purposes:
1. To obtain the respiratory rate per minute
2. To obtain an information of the patient's respiratory status and general condition.
1. Note the rate, depth and character of respiration.
2. Note the color of the patient and observe actual breathing while taking the respiration.
3. Take care that the patient is not aware that his respiratory rate is being taken. Rate may
be altered when patient is conscious that breathing is being observed.
ACTION RATIONALE
2. Make sure that the chest movement is Facilitates observation of chest wall and
visible. Patient may need to remove heavy abdominal movements.
clothing.
3. Observe one complete respiratory cycle. If Helps determine what constitutes a breath.
it is more convenient, place the patient's Helps to determine what to count. Hand rises
hand across his/her abdomen. Place your and falls with inspiration and expiration.
hand over the patient's wrist.
Facilitates counting without making patient
conscious that respiratory rate is being taken.
This may alter accurate respiratory rate.
4. Start counting with first inspiration while Counting for 1 full minute will give accurate
looking at the watch. Count for 1 full results.
minute.
5. Observe the character of the respiration:
a. depth (shallow, normal deep) Reveals volume of air movement into and out
b. rhythm (regular or interrupted) of the lungs.
6. Record rate and character of respiration. Ensures accurate observation and

documentation.
BLOOD PRESSURE
Definition:
The pressure that is exerted on the wall of the arteries when the left ventricle of the heart
pushes blood into the aorta.
Purposes:
1. To measure the systolic, diastolic and pulse pressures
2. To determine certain physiologic changes that may occur
3. To determine the pumping action of the heart.
4. To aid in diagnosis
5. To evaluate the general condition of the patient.
1. Keep patient physically and emotionally rested before taking the blood pressure.
2. For repeated reading, take the blood pressure on the same arm, same position and
same time of the day.
3. Take the blood pressure reading as quickly as possible to prevent venous conception.
4. Allow 20-30 seconds for venous circulation to return to normal if repeated reading is
necessary.
5. Report promptly to the physician or to the head nurse any significant change in blood
pressure reading.
6. Size of cuff should be appropriate to the size of the patient's arm.
ACTION RATIONALE
1. Place the patient in a comfortable position This position places the brachial artery in such
with the arms supported and the palm a way that the stethoscope can rest on it
upward. conveniently in the ante cubital area.
2. Roll patients gown above the elbow, place Proper placement of the cuff and pressure
the cuff so that the inflatable bag is applied directly over the artery will yield most
centered over the brachial artery. The accurate reading.
lower edge of the cuff is 2cm above the
ante-cubital fossa.
3. Wrap the cuff smoothly around the arm A twisted cuff and wrapping could produce
and tuck end of cuff securely under the unequal pressure and thus an inaccurate
preceding wrapping. reading.
4. Use the fingertips to feel for a strong Locating the artery allows the stethoscope to
pulsation in the antecubital space/fossa. be placed for maximum auscultation.
5. Place the stethoscope firmly but lightly Sound transmission can be distorted when
over the brachial artery. stethoscope is misplaced.
6. The cuff is inflated at above 20 mm. more Systolic pressure is that point at which the
than the systolic pressure of the patient. blood in the brachial artery is first able to
Using the value on the bulb releases air at force its way through against the pressure
a rate of 2-3 mm Hg per heartbeat. exerted on the vessel by the cuff of the
manometer.
7. Record first audible heart sound as systolic
and the last as diastolic. Continue to
release the air in the cuff evenly and
gradually. Sounds may become muffled.
Allow the remaining air to escape, quickly
remove the cuff and clean the equipment.
1. Proper position for blood pressure assessment. 2. Place the blood pressure cuff.
3. Palpate the brachial pulse 4. Proper placement of diaphragm of stethoscope
5. Ensure that the gauge starts at zero 6. Measure systolic blood pressure.
7. Measure the diastolic pressure

BED MAKING
Definition:
Bed making is the art and systematic step-y-step set of procedures in preparing the bed to be
used by a patient for the duration of her/his confinement in a hospital, using specific equipment
and materials according to specific purposes.
General Considerations in bedmaking

1. Wash hands thoroughly before making the bed and after handling a patient's bed linen.
2. Linen and equipment that have been soiled with secretions and excretions harbor
microorganisms that can be transmitted to others directly or by the nurse's hand or
uniform.
3. Hold soiled linen away from uniform, and not allowing them to get in touch with the
uniform.
4. Linen is never placed from a patient’s bed to another patient's bed.
5. Soiled linen is placed directly in a portable linen hamper or inserted into a pillowcase
and tucked at the end of the bed before disposal in the linen hamper.
6. Fold soiled linen away from people and with minimum movement to prevent the
microorganisms possibly present in the linen, from flying with the air circulating in the
room or unit.
7. When making and stripping a bed, conserve time and energy by finishing one side as
completely as possible before working on the other side.
8. To avoid unnecessary trips to the linen supply area gather all needed linen before
starting the procedure and arrange according to use.
9. If the bed is of the Hi-Low type, adjust accordingly
10. Remember that placement of the rubber sheet will depend upon the patient's need.
11. Apply the principles of body mechanics.
CLOSED BED
Definition:
A closed bed is one which is unoccupied and covered entirely by the top sheet and bedspread.
Purpose:
To prepare a comfortable and safe bed ready to receive a patient.
1. Before starting the procedure see to it that all the pieces of linen are on hand and are
arranged according to use.
2. If the bed is of the Hi-Low type, adjust the height accordingly.
3. Finish one side of the bed at a time.
4. Remember that placement of the rubber sheet will depend upon the patient's need.
5. Leave the patient's unit in order.
6. Apply the principles of body mechanics while making the bed.
Preparation:
A. Equipment/Materials: Assemble the following at the bedside and arrange according to use:
2 bed sheets
1 rubber sheet
1 draw sheet
1 bedspread (optional)
1 pillow case or more as needed
1 Inner pillow case
1 mattress cover (if necessary)
UNIT BED:
1. Place the bed in a position which will allow adequate work space.
2. Lower the back and knee rests, and lock casters.
3. Turn the mattress, stretch or change the mattress cover if necessary.
ACTION RATIONALE
1. Stand on the right side and face the bed in Facing the direction of activity keeps the
order to avoid overreaching and twisting of muscle groups in proper position, hence be
the body. able to function efficiently without strain.
2. Hold it at its centerfold, place the bottom Opening large pieces of linen on a surface,
sheet at the foot part of the bed, keeping instead of holding them up at shoulder level,
the wider hem in line with the edge of the prevents hyper extension of the back.
mattress.
Lifting involves overcoming the pull of gravity
Unfold, and move towards the head part, against the object.
keeping the centerfold along the center of
the bed. Using the centerfold as a guide ensures equal
length of the sheet on both sides of the bed.
3. Tuck the excess length of the bottom sheet Tucking the sheet under the mattress secures
under the head part of the mattress, and it in place and prevents wrinkles.
make a half mitered corner. A mitered corner presents a neat appearance.
4. Place one foot forward, flex the knees, and Flexing the knees shifts the work to the
ACTION RATIONALE
while rocking backward, tuck the sheet longest and strongest muscle and keeps the
along the side of the bed. back in good alignment.
Rocking backward or forward utilizes the

weight of the body as a force and reduces the
effort expended by the muscles.
5. If needed, place the rubber sheet followed The rubber sheet serves as an excellent
and covered by the draw sheet. Tuck them protector to prevent the soiling of the
together under the mattress. mattress and the beddings.
The draw sheet will prevent skin irritation

which may be caused by a direct contact with
the rubber.
6. Unfold the top sheet, wrong side up at the Tucking the sheet under the mattress secures
head-part of the mattress, with the it in place and prevents wrinkles.
centerfold at the center of the bed.
Tuck it at the foot part and make a half A mitered corner presents a neat appearance.
mitered corner.
7. Go to the other side to finish the bed. Finishing each side of the bed one at a time
saves time and energy.
8. Make the half-mitered corner of the Tucking the sheet under the mattress secures
bottom sheet at the head part. in place and prevents wrinkles.
A mitered corner presents a neat appearance.
9. Pull the bottom sheet tightly grasping the The longest and strongest muscles of the body
sheet with the palms downward so that produce the most efficient action.
the action is produced by the arm and the
shoulders. A firm and neat bed is conducive to rest.
Lumps and creases in the bed produce uneven

pressure and may predispose to impaired skin
circulation.
10. Do the same with the rubber and the draw The rubber sheet serves as an excellent
sheets. protector to prevent the soiling of the
beddings.
the rubber.
11. Tuck the top sheet at the foot part of the Tucking the sheet under the mattress secures
bed and make the half-mitered corner. in place and prevents wrinkles.

12. Get the pillow and fluff its contents. Fluffing distributes evenly the contents of the
pillow, and an even pillow promotes comfort.
13. Put on the pillow case this way: This promotes a systematic less effort
a. If both ends of the pillow case are open – performance.
insert one arm through the pillow case.
Pull in the pillow by grasping it at one end,
while the other hand adjusts the pillow
case.
b. If only one end is open – invert the pillow
case and hold one corner from the inside.
With the same hand, grasp one corner of
the pillow while the other hand adjust
ACTION RATIONALE
pillow case on the pillow.
14. Place the covered pillows on the head part Placing pillows under the top sheet protects
of the bed and under the top sheet. them from dust and lint.
15. Cover with the bedspread and tuck it at The bedspread protects the beddings from
the foot part. dust and gives the bed an attractive
appearance.
OPEN BED
Definition:
It is an unoccupied bed with the top sheet folded back, ready for patient occupancy.
ACTION RATIONALE
1. Fold the bedspread and set it aside. Setting the bedspread aside removes
hindrance to patient's movements, and
prevents it from being soiled.
2. Fold back the top sheet 12 – 18 inches from Folding back the top sheet affords easy
the head part and either. transfer of the patient to the bed and provides
a. fanfold it towards the foot part or adequate covering up to the patient's chest.
b. fold one side obliquely across the bed.
3. Arrange the pillows such that the seam of
the pillow case is underneath or towards Seams cause pressure and discomfort.
the head part of the bed.
Types of bed
Unoccupied bed
a. Open bed: top covers are folded back to make it easier for the patient to get in.
b. Closed bed: top sheet, blanket and bedspread are drawn up to the top of the bed and under
the pillows.
Purposes:
1. To promote the patient's comfort.

2. To provide a clean, neat environment for the patient.
3. To provide a smooth, wrinkle-free bed , thus minimizing sources of skin irritation.
Occupied bed
It is a bed that is made with a patient in it.
Purposes:
1. To conserve the patient's energy and maintain current health status

2. To change wet or soiled beddings for the safety and comfort of the patient
3. To provide a clean, neat environment for the patient
4. To provide a smooth wrinkle-free bed, thus minimizing sources of skin irritation.
Post-operative bed (Recovery or Anesthetic Bed)
It is a bed which has been prepared to receive and to meet the needs of a patient recovering
from anesthesia, after either surgery or diagnostic procedure.
Purposes:
1. To provide a bed where the patient can be transferred readily while recovering from
anesthesia.
2. To provide comfort and warmth thus maintaining body heat and preventing the risk of
shock and pneumonia.
3. To protect the beddings from getting soiled.
See to it that the bed protectors are placed according to patient's needs.
Bottom sheet
Rubber sheet
Draw sheet
Top sheet
Blanket (optional)
Tissue wipes
Emesis basin
I.V. Stand
Drainage bottles (if necessary)
BP apparatus and stethoscope
Oxygen therapy equipment (if necessary)
Suction apparatus (if necessary)
CLOSED BED
Preparation:
Assemble at the bedside and arrange according to use the following:

1 bottle sheet
1 rubber sheet
1 draw sheet
1 top sheet
2 pillowcases
Bedspread (optional)
BED
1. Place the bed in a position that will allow adequate work space
2. Lower the back and knee rests, and lock casters.
3. Turn the mattress, stretch or change the mattress cover if necessary.
ACTION RATIONALE
1. Stand on the right side and face the bed in Facing the direction of the activity keeps the
order to avoid overreaching and twisting of muscle groups in position to function
the bed. efficiently without strain.
2. Hold linen at its centerfold, place the Opening large pieces of linen on a surface,
bottom sheet at the foot of the bed, instead of holding them up at shoulder level,
keeping the wider hem in line with the prevents hyperextension of the back.
edge of the mattress.
Unfold, and move towards the head part, Lifting involves overcoming the pull of gravity
keeping the centerfold along the center of against the object.
the bed. Using the centerfold as a guide ensures equal
length of the sheet on both sides of the bed.
3. Tuck the excess length of the bottom sheet Tucking the sheet under the mattress secures
under the head part of the mattress and it in place and prevents wrinkles.
make a half mitered corner. A mitered corner presents a neat appearance.
4. Place one foot forward, flex the knees, and Flexing the knees shifts the work to the
while rocking backward, tuck the sheet longest and strongest muscle and keeps the
along the side of the bed. back in good alignment.
Rocking backward or forward utilizes the
weight of the body as a force and reduces the
effort expended by the muscles.
5. If needed place the rubber sheet followed The rubber sheet serves as an excellent
and covered by the draw sheet. Tuck them protection of the mattress and the beddings.
together under the mattress. The draw sheet will prevent skin irritation that
may be caused by a direct contact with the
rubber.
6. Unfold the top sheet, wrong side up at the Tucking the sheet under the mattress secures
head part of the mattress, with the it in place and prevents wrinkles.
centerfold at the center of the bed.
Tuck it at the foot part and make a half A mitered corner presents a neat appearance.
mitered corner.
7. Go to the other side to finish the bed. Finishing one side of the bed at a time saves
time and energy.
ACTION RATIONALE
8. Make the half-mitered corner of the Tucking the sheet under the mattress secures
bottom sheetat the head part. it in place and prevents wrinkles.
9. Pull the bottom sheet tightly grasping the The longest and strongest muscles of the body
sheet with the palms downward so that the produce the most efficient action.
action is produced by the arm and the
shoulders. A firm and neat bed is conducive to rest.
Lumps and creases in the bed produce uneven

pressure and may predispose to impaired skin
circulation.
10. Do the same with the rubber and the draw The rubber sheet serves as an excellent
sheets. protector to prevent the soiling of the
beddings.

the rubber.
11. Tuck at the top sheet at the foot part of Tucking the sheet under the mattress secures
the bed and make the half-mitered corner. it in place and prevents wrinkles.

12. Get the pillow and fluff its contents. Fluffing distributes evenly the contents of the
pillow, and an even pillow promotes comfort.
13. Put on the pillowcase this way:
a. If both end of the pillowcase are open

– insert one arm through the pillowcase.
Pull the pillow by grasping it at one
end, while the other hand adjusts
the pillowcase.
b. If only one end is open – invert the
pillowcase and hold one corner from
the inside. With the same hand,
grasp one corner of the pillow while
the other hand adjusts the pillowcase on
the pillow.
14. Place the covered pillow on the head part Placing pillows under the top sheet protects
of the bed and under the top sheet. them from dust.
15. Cover with the bedspread and tuck it at The bedspread protects the beddings from
the foot part. dust and gives the bed an attractive
appearance.
OPEN BED
ACTION RATIONALE
1. Fold back the top sheet 12-18 inches from Folding back the top sheet affords easy
the head part and either. transfer of the patient to the bed and provides
adequate covering up to the patient's chest.
a. Fanfold it towards the foot par or
b. Fold one side obliquely across the bed
2. Arrange the pillow such that the seam of Seams cause pressure and discomfort.
the pillowcase is underneath or towards
ACTION RATIONALE
the head part of the bed.
POST-OPERATIVE BED (RECOVERY OR ANESTHETIC BED)
ACTION RATIONALE
1. Place the bottom sheet as in the closed The same as # 2, 3, 4 of closed bed.
bed.
2. Place the rubber and draw sheets according The same as # 5 of closed bed. The site of
to patient's needs. operation determines the placement of the
rubber protector.
3. Spread the top sheet. If needed, spread a Adequate covers ensures body warmth.
blanket over the top sheet. Fold back Placing the blanket over the top sheet will
together their excess length at the foot prevent skin irritation that maybe caused by
part, in line with the edge of the mattress. woolen fibers.
4. Fanfold the top sheet (with the blanket, if The same as # 1 of open bed.
used) either towards the foot part or to
one side of the bed.
Folding should be away from the door.
5. Spread a bath towel at the head part and The bath towel provides additional protection
secure it with safety pins. for the bottom sheet and the mattress from
soiling.
6. Place the pillow leaning against the bed– A pillow placed against the bed bar will protect
bar at the head part of the bed. the head of a restless patient from possible
injury.
Such an arrangement ensures the required flat
position following most surgeries.
7. Place the IV stand at the head or foot part Having all equipment ready and properly
of the bed and drainage bottles at either arranged will ensure efficiency, safety and
side. comfort of the post- anesthesia patient.
OCCUPIED BED
1. To provide a change of position and to afford an opportunity to inspect the patient's

body.
2. Maintain correct body alignment and minimize patient's exertion by:
a. Effective workmanship
b. Observing precautions in turning or lifting the patient
c. Being careful not to jar the bed.
d. Raising the mattress at a minimum height to tuck the mattress.
3. If needed, secure assistance
Patient and unit
1. Inform the patient about the procedure

2. Provide privacy – close the door if the patient is in private room; screen the bed if in
general ward.
3. Remove unnecessary articles on the bed, such as extra pillows, blankets, hot water bags,
etc.
4. Retain one pillow under the patient's head if a flat position is not tolerated.
5. Lower the back and knee rests if condition of the patient allows.
ACTION RATIONALE
1. Loosen the beddings from the head to the This is in preparation for making one part of
footp art and move or turn the patient the bed.
towards the nurse.
2. Go to other side and loosen the beddings The same as # 1
from the foot to the head part.
3. Roll beddings separately towards the Rolling soiled linen separately towards the
center with the bottom linen well placed center:
under the patient.
a. Allows preparation of the half part of the
bed
b. Confines organism thereby preventing
their spread
c. Prevents the loss of some articles.
4. Lay out the bottom sheet and tuck it as in a The same as in closed bed.
closed bed.
5. Roll out rubber sheet or replace it with The same as in closed bed.
another if it soiled.
Cover with a draw sheet and tuck them
together under the mattress.
6. Change the top sheet by spreading it over The same as open bed.
and folding back 12-18 inches from the
head part.
7. Pull out dirty top sheet towards foot part. Removing the dirty top sheet under the clean
one prevents unnecessary exposure of the
patient.
8. Move the patient over to the prepared part The same as for # 1
and make the half-mitered corner.
9. Go to other side and remove the dirty linen. The same as in closed bed.
10. Spread out the other half of the bottom, The same as in closed bed.
ACTION RATIONALE
rubber and draw sheets.
11. Proceed as in making a closed bed. The same as in closed bed.
12. Make the half-mitered corner of the top The same as in closed bed.
sheet at the foot part.
13. Change the pillowcase and put the pillow This provides a clean and comfortable pillow.
back under the patient's head.
14. Make the patient comfortable and leave A comfortable position, and a clean and
the unit in order. orderly patient's unit is conducive to therapy.
15. Discard dirty linen into hamper. The prompt removal of the soiled linen
prevents the spread of pathogens.
How to make a miter:
Purpose: To secure the bed clothes while the bed is occupied
Procedure:
1. Tuck the bed cover firmly under the mattress at the bottom of top part of the bed.
2. Lift the bed over so that it forms a triangle with the side edge of the bed and the edge of
the bed cover is parallel to the end of the bed.
3. Tuck the part of the cover under the mattress while holding the cover at the upper part
against the mattress.
4. Bring the upper part down toward the floor while the other hand holds the fold of the
cover against the side of the mattress.
5. Remove the hand and tuck the remainder of the bed cover under the mattress.
MAKING AN UNOCCUPIED BED
1. Bundling soiled linens in bottom sheet and holding 2. Placing clean linens to begin bed making.
them away from body.
3. Placing draw sheet on bed. 4. Folding triangular linen fold down over side of mattress.
5.Tucking end of triangular linen fold under 6. Pulling bottom sheet tightly
mattress to complete mitered corner. on opposite side of bed.
7. Beginning to make mitered corner by 8. Laying triangular fold on top of

creating a triangular fold. bed.
9. Tucking end of sheet under mattress. 10. Mitering corner of top sheet and spread.
11. Cuffing top linens. 12. Placing pillow on bed.
13. Securing signal device to bed.

Making an Occupied Bed
1. Removing top linens from under bath 4. Aligning clean bottom sheet on half of
blanket. bed.
2. Moving soiled linen as close to patient as 5. Tucking bottom sheet and drawsheet
possible. tightly.
1. Removing top linens from under bath 4. Aligning clean bottom sheet on half of
blanket. bed.
3. Opening and folding clean linens. 6. Removing soiled bottom linens from other
side of bed.
7. Removing bath blanket from under top linens.

THERAPEUTIC BATHS
Definition:
A therapeutic bath is done to produce a specific effect. It consists of the immersion of the
entire body or a part of it in water or wetting the body surface with the use of a washcloth or a
sponge. The desired effect depends upon the temperature of the water or medications added.
Cold or Tepid Sponge Bath:
Definition:
It is a type of therapeutic bath done by sponging the body with washcloth wrung from cold or
tepid water. It is usually ordered by physicians and given for physical effects, such as to soothe
an irritated skin or to treat an area.
If cold, the temperature of the water is 55-60 degrees F.
If tepid, the temperature is 80-98.6 degrees F
Considerations:
1. Avoid chilling by:

a. providing adequate cover during the procedure
b. avoiding draft
c. placing a hot water bag over the feet.
2. Minimize patient movement.
3. Avoid producing friction. Use long light strokes in sponging and drying body parts. Do
not rub, just pat.
4. Be sure that there are two or more washcloth
5. Keep the washcloths adequately saturated and sponge each body area two or three
times.
6. Make sure that there is an ice bag over the head at the start of the procedure
7. For maximum effectiveness
a. make the bath last 25-30 minutes, using the correct technique.
b. keep saturated wash cloth over the axillary and inguinal areas.
8. Take temperature before and thirty minutes after the procedure.
Pitcher or tap water Patient's gown/pajamas
Basin Rubbing alcohol
Ice cap with cover Bath thermometer
Hot water bag with cover Linen as needed
Washcloths or face towel – 2 or more Bed screen if in a general ward
B. Patient and Unit
Proceed as in bed bath
ACTION RATIONALE
1. Loosen the sheet. (This may be replaced by A loosened top sheet will facilitate draping
a bath blanket). and change of patient's position.
2. Assist the patient to the side of the bed for Working close to an object prevents
convenience and ease in working. overreaching which causes muscle strain.
3. Remove patient's clothing under cover of To maintain privacy
the sheet or blanket.
4. Pour tap water into the basin and test its The therapeutic effect of the procedure
temperature. depends largely upon the correct temperature
of the water.
5. Soak wash cloths. To allow them to cool. Testing temperature
prevents burn.
6. Place ice cap over the head and hot water The ice cap over the head will prevent cerebral
bag over the feet. congestion and provide comfort.
The hot water bag will prevent chilly
sensation. Shivering may increase body
temperature.
7. Spread bath towel across the chest. To make the towel readily available for drying.
8. With the washcloth adequately saturated, Adequately saturated wash cloth ensures
sponge the face and neck 2 or 3 times using further lowering of body temperature.
a different washcloth each time.
9. Dry lightly. Temperature of the skin is lowered because
vaporization of the water takes up heat from
it. Using a different washcloth each time
allows the used washcloth to cool
10. Using the above mentioned technique, To avoid friction – since friction produces heat
continue sponging the whole anterior and will tend to increase temperature.
surface of the body in the following
ACTION RATIONALE
sequence. Sponging the whole anterior surface of the
a. Chest body as described will prevent unnecessary
b. Abdomen movement of the patient. Movement entails
c. near arm up to the fingers muscular actions which increases metabolism
d. far arm with resultant heat production.
e. far leg up to the dorsum of foot
f. near leg
g. change the water as often as necessary.
11. Apply alcohol (just enough in order to dry Alcohol cools the skin better than water
immediately) to each area sponged, except because it vaporizes rapidly, taking up heat
the face. from the body.
12. Assist the patient to turn to side with the To prepare to do the procedure on the
back towards the nurse. posterior part of the body.
13. Sponge the entire posterior part of the
body in the same manner as the anterior.
14. Replace the gown and make the patient
comfortable.
15. Change beddings if necessary The linen may be wet after the procedure.
16. Leave ice cap and hot water bag in place To allow the bag to adjust to changes in
for 30 minutes more. temperature
17. Clean and return used equipment.
18. Take the temperature after 30 minutes Prolonged exposure to water may cause
vasodilation or drop in blood pressure which
can result in light headedness or dizziness.
Chart:
Document pertinent data Time
Temperature Type of bath given
Effect
Alcohol Sponge Bath:

It is a type of therapeutic bath which consists in sponging the body with wash cloth wrung from
a mixture of alcohol and ordinary tap water. The proportion is one part alcohol to 3 parts water
if the stock of alcohol is 70%
Purposes:
To reduce body temperature
To refresh the patient thereby promoting comfort
The same as in cold and Tepid Sponge Bath
Technique:
The technique is the same as in tepid sponge bath.
Alcohol is added to the water after sponging the face.
HYGIENIC BATH (BED BATH)
Definition:
It is a bath given to a patient in bed.
Purposes:
1. To remove accumulated oil, perspiration, dead skin cells and some bacteria
2. To stimulate circulation and aid in elimination
3. To provide for an opportunity for the nurse to assess ill patients.
4. To produce a sense of well being
5. To provide for an opportunity for nurse-patient interaction
6. To help the patient have some form of movement and exercise
7. To prevent or eliminate unpleasant body odors.
1. Avoid unnecessary exposure and chilling
a. Expose, wash, apply soap, rinse, and dry one part of the body at a time.
b. Avoid draft
c. Use correct temperature of water. Temperature for adult is 37.7 to 46 oC (100-
115oF); for infants – 40.5oC (105oF)
2. Observe the patient's body closely for physical signs such as: rashes, swelling,
discolorations, pressure sores, burns, abnormal discharges, body lice, etc.
3. Observe the patient's body closely for physical signs such as: rashes, swelling,
discolorations, pressure sores, burns, abnormal discharges, body lice, etc.
4. Give special attention to the following body areas: behind the ears, axilla, under the
breasts, umbilicus, pubic region, groin and the spaces between the fingers and toes.
5. Do the bath quickly but unhurriedly, use even, smooth but firm strokes.
6. Use adequate amount of water and change as frequently as necessary
7. If indicated or needed, do such procedure as vaginal douche, enema, shampoo, oral
care, etc., before the bath.
Preparation:
A. Equipment/Materials:
Basin with warm water

Laundry hamper
Soap and soap dish
Blue stick
Clean linen in the order of use (if nurse plans to make a bed as well)
Bath blanket, towels, and washcloth
Clean gown or pajamas
Necessary toiletries. (Toothbrush and toothpaste or powder, deodorant, comb, etc).
Clean gloves
B. Patient and Unit
Explain the procedure to the patient

Invite a significant other to participate in the procedure
Provide a comfortable environment by adjusting the temperature and ventilation of the room.
Provide privacy by screening the bed if in the general ward or if in the private room request
visitors to leave the room.
Remove unnecessary articles on the bed and clear up the work area
Arrange all needed materials within reach. Line a chair or table with newspaper where the
basin will be placed.
ACTION RATIONALE
1. Position the patient for the bath (usually the Positioning the patient appropriately is for the
supine position is used unless the patient patient's comfort and safety.
cannot tolerate it. Semi-fowler's or even
high fowler's position).
Working close to the patient prevents over-
Assist the patient to the side of the bed for reaching which causes muscle strain.
convenience and ease in working.
2. Remove the top linen and replace it with Loosened top sheet will facilitate draping and
the bath blanket. If the bed linen is to be change of patient's position. This also prevents
reused, place it over the bedside chair or at wetting the top sheet.
the bed's foot part. If it is to be changed,
place it in the linen hamper.
3. Remove patient's gown under bath blanket To maintain privacy.
4. Fill the basin with one half to two-thirds full Adequate amount of water in the basin ensures
of comfortably warm water. good rinsing. The use of warm water prevents
chilling.
5. Spread the bath towel across the patient's This prevents wetting of the bed linen and
chest over the bath blanket. towel becomes readily available for dying the
face.
6. Wet the washcloth and squeeze out excess Squeezing out excess water prevents wetting of
water bed linen.
7. Make a bath mitt by wrapping the Arranging the washcloth into a bath mitt
washcloth around the palm and fingers. prevents loose cold ends of the cloth from
dragging over the patient's skin.
8. Start washing the patient's farther eye with This method of removing dirt prevents possible
ACTION RATIONALE
water only. Wipe from inner to outer cross infection of the eyes.
canthus. Do the same to the near eye using
the separate corner of the washcloth.
9. Ask whether the patient wants soap used Soap lowers the surface tension of the water
on the face. and helps it to unite quickly with the oil and dirt
on the skin.
10. Wash, apply soap, rinse (2 or 3 times) the Gentle but firm strokes in washing the face
patient's face, neck, ears, and back of the makes the patient feels clean.
ears using gentle but firm circular stroke.
11. Pat dry the area using the towel spread Rinsing two or three times removes the soap,
across the patient's chest. which is left on the skin may cause irritation
and itching.
12. Expose the far arm by tucking the bath Washing the far arm first avoids leaning over or
blanket under the patient's side. dripping dirty water on the part that is already
clean.
Spread the towel lengthwise under the Spreading the bath towel prevents wetting the
farther arm. bed linen.
Wash, soap, rinse the arm using long firm This stroke increases venous return.
stroke from distal to proximal area paying The axilla, unlike other skin areas has a neutral
particular attention to the antecubital area reaction, which makes it less resistant to
and axilla. bacterial growth. It also has numerous sweat
Pat dry using the bath towel. glands that secrete fatty and odorous
Do the same to the near arm. substances as well as sweat.
13. Place a towel near the patient's near Washing hands in water ensures a more
hands. thorough cleaning.
Put the basin with warm water and assist
the patient to wash, rinse and dry hands,
paying particular attention to the spaces
between the fingers.
14. Use a blue stick to clean under the nails if Changing the water as often as necessary
needed. ensures good rinsing and maintains the desired
Change the water and when necessary. temperature.
ACTION RATIONALE
15. Spread the towel over the chest and Body area with folds or creases are more likely
abdomen. to accumulate dirt and bacteria.
Fold the bath blanket down to the patient's
pubic area.
Wash, rinse and dry the chest and
abdomen, giving special attention to the
skin fold under the breasts.
16. Keep the chest and abdomen covered with Keeping the chest and abdomen covered
towel while washing and rinsing. prevents unnecessary exposure and chilling.
17. Replace the bath blanket on the areas that
have been dried.
18. Wrap the near leg and feet with bath This method avoids unnecessary exposure
blanket ensuring that the pubic area is well especially to draft.
covered. Remove the bath blanket from
the far leg tucking it under the near leg and
up around the hip to avoid exposure and
drafts.
Spread the towel lengthwise under the
entire far leg.
Flex the knee of the far leg to be washed.
19. Wash and rinse the leg using long firm This stroke increases venous return.
stroke from the ankle to the knee then to
the thigh giving special attention to the
popliteal and inguinal area.
20. Do not rub the muscle hard enough. Rubbing the muscle hardly may potentially
Wash the near leg in the same way. dislodge clots that may have formed in the
Replace the bath blanket. large deep veins.
21. Flex both knees and expose the feet of
patient. Spread a towel under the feet.
Place a basin with warm water on the
towel between the legs.
Lift the farther foot with the heel on the
palm of the hand and lower it slowly into
the water.
Soap, rinse and dry well paying particular
attention to the spaces between the toes.
22. If you prefer, wash far foot right after Drying the foot, giving special attention to the
washing the far leg. areas between the toes prevents irritation and
Change the water as necessary. injury to the skin.
ACTION RATIONALE
23. Rub the back with lotion. Back rub stimulates circulation.. It also relieves
muscle tension, promotes physical and mental
relaxation, provides relief from pain and
relieves insomnia.
24. Assist the patient to supine position and To encourage participation from the patient.
determine whether the patient can wash
the perineal-genital area independently. If
the patient cannot do so, drape the patient
and wash the area accordingly. (As in
perineal care).
25. Assist the patient with grooming putting To restore patient back to a comfortable
on clean gown or pajamas. condition.
26. Replace the bath blanket with the top
sheet or proceed to perform the occupied
bed.
27. Discard dirty linen into the hamper; clean To restore the unit back to its orderly condition.
and return used equipment and leave the
area in order.
28. Document pertinent data (assessed data, Any procedure done to the patient is
reaction of client, type of bath given, etc). documented, as basis for decision making in the
continuity of care.
1. Folding washcloth in thirds around hand 4.Washing from the inner corner of the
to make a bath. eye outward.
2. Straightening washcloth before folding 5. Exposing the far arm and washing it.
into mitt.
3. Folding ends over and tucking ends under 6. Soaking hand in basin.
folded washcloth into palm.
7. Washing the chest area, including the axilla. 10. Soaking the foot in basin.
8. Washing the abdomen, with perineal 11.Washing the upper back

and chest areas covered. .
9. Washing and drying far leg, keeping the 12.Assisting the patient with an IV to put
Other leg covered. on a new gown.
HIP OR SITZ BATH
Definition:
A therapeutic bath which consists in the immersion of the pelvic region and the upper thighs in
a tub of hot water.
Purposes:
1. To minimize congestion and pain in the pelvic region

2. To relieve pain and hasten healing after a hemorrhoidectomy, episiotomy, etc.
3. To cleanse and soothe the perineal or vaginal area after child birth, surgery and from
local irritation of fissures.
4. To induce urination in some cases of urinary retention
5. To produce muscular relaxation
1. Be sure that there is a written order from the physician.

2. Follow the prescribed duration but discontinue if the patient shows any signs of
untoward reaction.
3. Check the patient's pulse and respiratory rate before and during treatment.
4. Protect the patient from chilling by:
a. protecting her/him from draft
b. covering the patient adequately during the procedure.
c. maintain the correct temperature of the water 110-115oF
5. Remove the post-hemorrhoidectomy dressings before doing the immersion and re-
dress the wound after the procedure.
6. Let the patient void before the procedure.
7. Keep the patient comfortable throughout the procedure:
8. Place the rubber ring on the tub if patient has perineal wound (as in
hemorrhoidectomy)
Preparation:
A. Equipment/Materials:
Sitz tub, bath tub or big deep basin Blankets – 2

Rubber ring Bed screen – PRN
Pitchers of water Gown
a. one with tap water Newspaper
b. another with hot water Dressing tray PRN
Ice cap with cover
B. Patient and Unit
Assemble equipment at patient's bedside.

Explain procedure to the patient
Screen the bed if in a general ward. Close windows and turn off electric fans or air conditioner
Remove perineal dressings.
Make patient void
Line the floor with newspaper.
Place the sitz tub conveniently near the bed and line its rim with a bath towel.
Place rubber ring if necessary (if using an improvised tub, position it in such a way as to provide
safety and comfort)
Place a chair lined with bath blanket near the tub and have a bath towel ready for use.
Fill the tub 1/3 full with hot and tap water and check temperature.
ACTION RATIONALE
1. Assist the patient to get out of bed. Assisting the patient properly while getting out
of bed will prevent accidents, and provides
assurance of safety to patient.
2. Take the pulse rate and respiratory rates Change in position may temporarily alter the
vital signs.
3. Drape the blanket around patient's This provides privacy and prevents chilling.
shoulders
4. Remove rectal dressing The dressing creates a barrier between the
perineum and the therapeutic water on the
sitz tub.
5. Assist the patient to sit slowly in the tub. To prevent accident and allow the patient to
adjust the temperature of the water.
Enclosing the tub with blanket prevents the

Arrange the blanket so as to enclose the rapid cooling of the water and provides
tub. privacy.
6. Place the ice cap cover the bed. The ice cap over the head, will prevent
cerebral hypoxia due to the drawing of the
blood to the pelvic area.
7. Immerse feet in a basin with hot water or The hot water bag will equalize circulation and
apply hot water bag under the feet. prevent chilly sensation.
8. Add hot water to the tub letting the stream To keep water at desired temperature.
ACTION RATIONALE
of water pass between the nurse’s hand The Nurse is able to test the temperature of
and the rim of the tub and stir. the water in order to prevent scalding.
Stirring the water will diffuse heat.
9. Observe the patient closely for untoward Heat applied over the pelvic area can attract
symptoms. so much blood thereby diminishing the blood
supply in the vital centers and as a result
produce symptoms of faintness or weakness.
10. As soon as treatment is over, assist the Assisting the patient will prevent falls and
patient to get out of the tub and to sit on helps conserve energy.
the chair lined with blanket.
11. Dry the patient thoroughly. To prevent chilling.
Put on the gown.
12. Assist the patient back to bed and make To provide safety & comfort.
him comfortable.
13. Re- dress the wound if indicated. To protect the wound.
14. Retain the ice cap and hot water bag for 30 To stabilize circulation.
minutes more.
15. Clean and return used equipment To prepare them for the next use.
according to agency policy.
16. Make the patient comfortable making sure To provide safety and comfort.
beddings are dry.
17. Discard used perineal pads and used To prevent clogging of toilet bowl and sewage
cotton balls on the waste receptacle with pipes.
cover, making sure they are not drained
into the toilet bowls, etc.
18. Clean the equipment according to hospital To prepare for next use.
policy.
MASSAGE THERAPY PROCEDURE
FOR MOBILITY – IMPAIRED PATIENTS
Rationale: The application of manual techniques, and adjunctive therapies, for the purpose of
effecting the well-being of the patient ( ref: Massage Therapy Foundation).
Purposes:
1. For relaxation or release of tight muscles.
2. For emotional comfort and stress management.
3. For improvement of circulation and lymphatic drainage or for release of toxins.
4. For pain relief.
Preparation:
1. Assess and determine:

2. Previous and present assessment of the skin condition.
3. Any movement or positioning precautions specific to the patient.
4. Range of motion of the joints.
5. Arrange for a quiet environment with no interruptions to promote maximum effect.
ACTION RATIONALE
1. Explain to the patient what will be done, why it To gain patient’s cooperation and facilitates the
is carrying out of the procedure efficiently.
necessary, and how the patient can cooperate.
2. Wash hands and observe other appropriate To prevent infection by observing medical asepsis.
infection control
procedures.
3. Provide for patient’s privacy. A patient who is physically relaxed will usually
experience less discomfort.
4. Prepare the patient and the environment:
a. Close windows and doors to This provides privacy and prevents chilling. Air
ensure that the room is in a currents increase loss of heat from body by
comfortable temperature. convection.
b. Assist the patient to move near the This avoids undue reaching and straining and
side of the bed, within your reach, promotes good body mechanics.
and adjust the bed to a
comfortable working height.
To ensure maximum comfort.
c. Establish which position the
patient prefers. Facilitates ease in massage procedure and
ACTION RATIONALE
maintains privacy.
d. Expose the back from the
shoulders to the sacral area
(buttocks).
5. Massage the back:
a. Warm your hands by gently rubbing them Cold hands can startle the patient when placed on
together. the back.
b. Using your palm, begin at the sacral area

(buttocks), using slow, smooth circular If the movements are performed too quickly, this
strokes. will not help the patient relax and tender areas will
be missed.
It should not be rushed as it is during this phase that

you need to begin to focus on any abnormalities of
the tissues that may require further attention later
in the massage.
c. Move your hands up the center of Use the sensory pad of the thumb to grasp the skin
the back and then both scapulae and to move this over the underlying surface to feel
(shoulder blades). for any abnormalities (trigger points) to the tissue
concerned. This allows us to palpate, particularly
around bony structures and feel for smaller
abnormalities in the tissues. Mobilizes fluids,
stretching muscle fibers, and induces relaxation.
Mobilizes fluids, stretching muscle fibers, and

induces relaxation.
d. Massage in a circular motion over the

scapulae.
ACTION RATIONALE
a. Move your hands down the sides Mobilizes fluids, stretching muscle fibers, and
of the back. induces relaxation.
b. Massage the areas over the right

and left iliac crests (hip bone).
c. Apply firm, continuous pressure

without breaking contact with the
patient’s skin.
d. Repeat the above steps for 3 – 5

minutes obtaining more areas as
necessary.
e. While massaging the back, assess

Stimulates circulation and produces a reflex action
for skin redness, tenderness,
on nerves producing a soothing effect.
muscle spasms, and areas of
decreased circulation.
Provides for an opportunity to inspect the

patient’s body from any signs of skin
lesions/abnormality.
ACTION RATIONALE
6. Massage the arms and legs:
a. Slowly elevate the patient’s

arm/legs, support the wrist/ankle,
and elbow/ knee. Supporting the joints removes undue strain to the
structures and prevents injury.
b. Using your palm, apply firm, long

strokes from the wrist/ ankle going
to the shoulders/ inguinal, repeat
the stroke to the sides of the hand/ Carried out with the main pressure being directed
legs, maintaining the gentle but towards the heart. This helps increase venous and
firm pressure. lymphatic flow.
c. Repeat on the other hand/ leg.
7. Assess and document the skin condition after Provides information about the patient’s response
the massage. to the procedure.
HEAT & COLD APPLICATION
APPLICATION OF ICE CAP

Purposes:
1. To lower temperature
2. To relieve pain
3. To control bleeding
4. To arrest inflammatory process – thereby minimizing congestion and swelling.
1. Refill the ice cap as soon as the ice melts.

2. Make sure the ice cap is covered and free from leaks
3. Observe for bluish discoloration and mottling of the skin over the area of application.
4. Apply the ice cap intermittently at intervals of one hour to attain the desired local
effects.
5. Fill the ice cap 1/3 to ½ full only.
6. Remove air from the ice cap
7. Provide support for the ice cap that is applied over a tender area.
Ice cap with stopper

Linen cover
Ice chips or cubes
ACTION RATIONALE
1. Fill the ice cap 1/3 to ½ full with ice cubes. To prevent discomfort from the weight of the
bag.
1/3 – for application over the pericardium and
abdomen.
½ – for application to other areas.
2. When filled with ice cubes, lay the ice cap Air is a poor conductor of heat and will
over a flat surface; press gently to expel the interfere with the reduction of heat from the
air. body surface. Warm air l melts ice faster.
3. Screw-on the stopper tightly and invert the To test for leak and prevent it since may wet
ice cap. the patient and cause chilling.
4. Dry the ice cap and cover with a hand towel The linen cover absorbs the condensate that
or any appropriate piece of linen. forms on the surface of the bag.
ACTION RATIONALE
To provide comfort.
5. Bring the ice cap to the patient and apply it
over the prescribed area.
6. Refill as soon as the ice cubes melt. Melted ice loses its expected effect.
7. Inspect the area of application frequently. Cold, causes vasoconstriction, and prolonged
application may lead to circulatory
impairment.
8. When the treatment is discontinued, empty The ice cap may serve as a source of
the ice cap and wash it with soap and contamination for other patients.
water.
9. Dry the ice cap. Inflate it with air and hang. Inflating and hanging it will prevent the inner
surfaces (of the ice cap) from adhering to each
other.
Record on the Chart:

Time Duration
Purpose Effect on the patient
N.B. The same principle and procedures apply in ice collar application.
APPLICATION OF HOT WATER BAG
Purposes:
1. To provide warmth
2. To relieve pain and congestion
3. To produce local vasodilatation
4. To hasten suppuration
5. To produce muscular relaxation
1. Secure a written order from the physician (only in cases of chills, or when it is a part of
another procedure can hot water bag be applied without a written order).
2. Fill the hot water bag one half to two thirds full.
3. Test it for leaks and cover the hot water bag prior to application.
4. Always test the temperature of the water before filling up the bag.
5. Refill the hot water bag as necessary. Do not allow the patient's watcher to refill the
hot water bag.
6. Inspect the area of application as frequently as possible
7. Never fill up a hot water bag direct from a hot faucet or kettle. Use a cup or dipper to
scoop hot water to refill.
8. Refrain from applying hot water bag to children, elderly, comatose patients and
patients under spinal anesthesia.
Temperature of the water:

a. Infants and children: 105-115  F
b. Adults: 115-125  F
Hot water bag with stopper

Bath thermometer
Linen cover
Pitcher of hot water
ACTION RATIONALE
1. Fill the bag with hot water one half to two Filling the bag one half to two thirds full only,
thirds full. will prevent discomfort from pressure due to
the weight of the water.
2. Expel the air by: Air is a poor conductor of heat and will add
a. laying the bag against a flat surface and bulk to the bag.
allowing the water to reach the opening
ACTION RATIONALE
b. folding the bag until the water reaches
the opening.
3. Screw on the stopper tightly and invert the To prevent and test for leaks which may scald
bag. the patient. Water is a good conductor of
heat.
4. Cover or wrap the bag with a towel or may The linen cover will act as insulator to prevent
appropriate piece of linen. burns and will help retain heat longer.
5. Bring the bag to the patient. Apply it over Applying the bag slowly will give the patient
the prescribed area gradually noting the time to test the temperature of the bag.
patient's immediate reaction.
6. Refill the bag as necessary. Refills are necessary to maintain the desired
temperature.
7. Observe the area of application. This is done as a safety measure.
Hyperenia indicates discontinuance of the
procedure.
8. When the procedure is discontinued, Hot water bags can serve as medium for the
empty bag and wash with soap and water. transfer of microorganisms.
9. Dry. Inflate with air and hang. Inflating and hanging it will prevent the inner
surface from adhering to each other.
Record on the chart:

Time Duration
Purpose Effect on the patient
HOT WATER BAG

COLD COMPRESS
Definition:
It is the application of wet moist dressing to a body area or areas.
Purposes:
1. To relieve pain
2. To prevent discoloration and swelling, etc.
Bowl with ice cubes and or cold water

Sterile gauze, sterile rags or cloth
Rubber sheet – depending on what part to be applied (PRN)
Patients Preparation:
Explain the purpose of the application

Place the patient in a comfortable position
Action:
1. Place or soak 4 pieces of gauze in the bowl of water with ice cubes.
2. Get 2 pieces of gauze, squeeze a little and place over the area as quickly as you can.
3. Have 2 other pieces of gauze ready for changing.
4. Change the compress as it warms up in contact with the area. Compress may be
changed as often as necessary.
5. Duration of treatment is 15-20 minutes usually, or as ordered.
Precaution:
Do not leave the patient alone especially if the treatment is continuous.
After Care of Equipment Used:

Wash gauze and basin. Dry and store in their proper place.
After Care of Patient:

Keep the affected area dry. Place the patient in a comfortable position.
Record:The time, date, part or area applied and duration.

HOT COMPRESS
Definition:
It is the application of a warm moist dressing to a body area or areas.
Purposes:
1. To warm the skin or surface areas.
2. To aid in the process of suppuration.
3. To relieve pain.
Pieces of gauze squares, sterile cloth or face towel
Bowl with hot water or prescribed solution.
Example: Boric acid, zephiran solution, etc.
2 sterile or clean forceps or sterile towel
Rubber sheet (PRN)
Patients Preparation:
Explain the purpose of the procedure to the patient.
Position the patient comfortably, exposing the desired area.
Action:
1. Immerse or soak compresses on the bowl with hot water using forceps to squeeze (to
protect hands from burning).
2. A towel can also be used to squeeze the gauze or cloth.
3. Change compress as often as necessary.
After Care of Patient and Equipment:

The same as that for cold compress.
Record:
Date, time, area applied and duration.
Precaution:
a. For continuous application, inspect the area frequently for burning.
b. Do not leave the patient even if the application is only for 15-20 minutes.
c. Prepare enough hot water ready for use.
PREPARATION AND ADMINISTRATION OF DRUGS
Definition:
Drug or medicine is a chemical agent which acts to maintain, improve and restore physiologic
processes of the body.
Purposes:
1. To maintain and promote health
2. To restore physiologic processes
3. To aid in diagnosis
4. To provide palliative effect
5. To supply substances which are deficient
6. Example: insulin
7. To help prevent disease.
General Consideration:
1. Make sure the physician's order is complete and well understood before carrying it out.
2. Know the patient's condition and all other factors related to the proper use of the drug
3. Be alert for signs of allergy and idiosyncrasies manifested by the patient.
4. Know the purpose and therapeutic effect of each drug ordered.
5. Be familiar with standard abbreviation and symbols commonly used.
6. Verbal orders are accepted in extreme emergencies and only a registered nurse may
assume the responsibility for carrying out the order.
7. Observe the Five Plus Five Rights in giving each medication namely: the right patient,
the right drug, the right dose, the right time, the right route, the right assessment, the
right documentation, the patient's right to education, the right evaluation, and the
patient's right to refuse and the method of administration.
8. Always clarify any order that is not clear or doubtful before executing it.
9. Verify if drug needs to be delayed or omitted for specific period of time, if diagnostic
procedure or operation is to be done.
10. Do not leave medicine with the patient to take by himself.
11. Do not give drug that shows physical changes or deterioration.
12. The nurse who prepares the medication must be the nurse in-charge
13. The nurse who prepares the medication must be responsible for administering and
recording it. Never endorse it to another nurse
14. Always observe asepsis in preparing and administering drugs.
15. Poisonous drugs should be labeled clearly as POISON and kept separately. Never mix
with other drugs.
16. Full concentration is necessary while preparing and administering drugs. Never allow
interruptions.
17. Be able to use with accuracy either the metric or apothecary unit of measurement
18. Always use the corresponding medication card for each drug prepared and administered
19. Make sure that a written computation for dosage is checked and signed by the nurse in-
charge.
20. Notify the nurse-in-charge immediately for any drug that cannot be given or taken by
the patient.
RULES FOR GIVING MEDICINE

To guard against inaccuracy in handling and dispensing drugs and to protect the patient from
the adverse effects of a mistake in medication, the following regulations must be learned,
understood and practiced by each nurse assigned to the care of the patient.
General Rules:
1. Observe the Five-plus-Five rights in giving each medication: the right patient, the right
drug, the right dose, the right time, the right route, the right assessment, the right
documentation, the patient's right to education, the right evaluation, and the patient's
right to refuse and the method of administration.
2. Consult the head nurse if a written order is not clear, not legible or not signed by the
doctor.
3. Wash hands thoroughly before measuring or preparing a medication.
4. Make certain that all equipment are clean.
5. When giving pills or tablets, place in proper container directly from bottle. Do not touch
them with your hands.
6. Determine if medication is to be delayed or omitted for a specific length of time, as in X-
ray examination or basal metabolism test.
7. Never leave the medicine cabinet unlocked.
8. Do not return to stock supply, excess medicine or medicine refused by a patient.
9. Do not use a drug that differs from the normal in color, odor consistency.
10. Provide drinking tubes for irritating drugs and for those likely to stain the teeth.
11. Do not pour a drug from one bottle to another
12. Never give two or more drugs at one time, unless they are so ordered.
13. Do not permit one patient to carry medicine to another
14. Know the minimum and maximum dose of the medication being given
15. An error in medication must be reported immediately to the nurse-in-charge.
16. Always provide a drink of fresh water to the patient immediately after giving an oral
medication, unless contraindicated.
17. The nurse who prepares the medicine should administer it and do the necessary
recording.
18. Narcotics should always be locked and endorsed in each shift.
Guide to the Administration of Some Specific Agents
1. Cough syrups are given undiluted in small amount and in frequent doses. Do not give
water after taking a cough syrup.
2. Laxative or cathartics are given between meals and on an empty stomach; those that act
quickly should be given just before breakfast, and those requiring a longer time for
action should be given at night.
3. Bitter or unpleasant tasting drugs are given in capsule form, as a coated pill or in
effervescent preparations.
4. Oils are given in encapsulated form when possible. Oils taken in liquid form should be
chilled, as cold lessens sensitivity of the taste buds and helps to disguise the unpleasant
taste. Oils of a very disagreeable flavor, such as castor oil, should be mixed with orange
juice and a small amount (¼ teaspoonful)of sodium bicarbonate. The mixture should be
given to the patient while it is effervescing.
5. Drugs that will be destroyed by digestive juices are given in enteric-coated pills
6. Drugs are given several hours after meals for rapid action
7. Drugs to aid digestion are given one-half hour before meals.
8. Iron, mercury and iodide preparation are given well diluted. They should be given
through a glass tube or a straw as they discolor, and are destructive to the teeth.
9. Sedative are given with warm milk to increase and hasten the desired effect of the drug.
10. Bitter stomachics, given to stimulate the appetite, should be given undiluted and with
no attempt to disguise their taste.
Rules for Measuring Medications
1. Measure the exact amount of drug ordered, using a calibrated measure.

2. Do not converse with anyone while preparing the medication
3. Make sure that medicine glasses are dry before pouring or measuring the medication
4. Cleanse the mouth of every bottle after use before replacing its cover.
5. Measure in drops, if ordered as drops; and measure in minims if ordered as minims.
6. Hold the medicine glass at eye level with the container from which medicine is to be
poured.
Rules Regarding Labels
1. Give medications only from clearly labeled containers

2. For each dose of medicine prepared, read the label three times: a) before removing the
bottle from the medicine cabinet, b) before pouring the measured amount of the drug,
and c) before replacing the bottle back to the medicine cabinet.
3. Never give a drug from an unmarked bottle or box.
4. Pour medicine from the bottle, on the side opposite the label.
5. Labels on medicine containers should be changed only by the pharmacists.
6. If a drug has two commonly used names, both names should appear on the label.
Rules for Giving Medications
1. Give the medication at the time for which it is ordered.

2. Always identify the patient before giving the medication
3. If medication is refused, or cannot be administered, notify the head nurse.
4. Remain at the bedside until the patient has taken the medication
5. Administer only those medicines which you have measured and poured.
6. Never give two drugs together, unless specifically ordered. Different drugs taken at the
same time may form a chemical compound that can be injurious to the patient.
7. When a patient goes to the operating room, all orders for medication are discontinued.
New orders for post-operative medications will be written by the doctor.
8. When special tests are being done, medications due at the particular time are omitted,
they are resumed when next due.
9. A mistake in medication must be reported immediately to the nurse in charge.
Rule for Recording Drugs Administered
1. Record if an ordered medication is refused or if it cannot be administered

2. Record each dose of medicine soon after it is administered.
3. Use standard abbreviations in recording medications
4. Record only those medicines which you have administered.
5. Record time, kind and dose of drug given.
6. Record effect, especially any unusual effect, of medication.
7. Never record a medication as given before it has been administered.
CARE OF DRUGS AND MEDICINE CABINET
Bottles, boxes and other containers must be kept closed. Liquid medicines may evaporate if
bottles are left open. Some pills and tablets tend to disintegrate if exposed to the air.
Ointment, salves, liniments, talcum powder, rubbing alcohol and other similar supplies should
be kept in a separate compartment of the medicine cabinet.
Oils, such as castor oil and viosterol, antibiotics suspension as well as serum, vaccines and liver
extracts should be kept in the refrigerator. Extreme cold prevents them from becoming rancid
and makes the oil preparations a little more palatable.
Emergency drugs, such as stimulants, should be kept in a box or on a tray where they are
readily obtainable for emergency use.
Labels that are defaced or soiled should be changed by the pharmacist.

Each nurse who prepared a medication should be extremely careful to replace the bottle or
container on the exact place from which she took it. Unauthorized rearranging of medicines is
often the cause of errors in medication.
Drugs that are unusual in appearance, color, odor or consistency should be returned to the
pharmacy to be discarded.
Floor drugs should be checked twice daily so the supply remains constant. There should be two
containers for each floor drug so that one is available while the other is in the pharmacy for
refilling.
Unused drugs for a patient who is for discharge from the hospital should be sent to the
pharmacy so that these can be deducted from the patient's account.
If medicines are sent with a patient to be taken at home , complete direction for measuring and
taking should be placed on the container.
Medication Area:
To give proper care of drugs, each nursing department within the hospital should be provided
with a suitable medication area with the following facilities:
1. A suitable cabinet:
a. large enough to accommodate all the drugs to be stored there
b. shallow, so that only two rows of bottles or other containers can be placed, for easy
location of the medicine.
c. should be locked at all times, and the key accessible only to authorized personnel, to
prevent mishandling of the drugs. (The key should always be with the Nurse
designated to keep it throughout the shift.)
d. with a separate compartment where opiates and other narcotics can be kept.
2. A small sink or lavabo with running water

3. Adequate lighting for the reading of the medicine labels.
Other Important considerations:
1. If the medicine cabinet contains stock supplies for use by all patients, the containers
should be arranged so that general classifications of drugs are stored together according
to the form in which they are used, e.g. as pills, capsules, powder, ointment, liquids, etc.
If the different preparations in each category are arranged in alphabetical order, they
may be located according to the case.
2. Drug for internal use are usually placed in the medicine cabinet in the center just above
the working space and sink compartment.
3. External remedies and poisons should be kept in a separate compartment or in a

different cabinet. All poisonous drugs should bear a POISON label and should be kept in
bottles or containers that have distinctive shape and roughened surface.
ADMINISTRATION OF ORAL MEDICATIONS
Definition:
Oral Medication is the administration of drugs by mouth or by the oral route, for systemic
effect. It may be in the form of pills, tablets, capsule, liquid.
Purpose:
To prepare and administer oral medications safely for systemic effect and derive maximum
therapeutic effectiveness from them.
Medicine card with the Patient's Name

Room No.
Date Started
Name of Drug, Dose
Route of Administration
Hours of Administration
Medicine Glass
Medicine Tray
ACTIONS:
1. Check medicine cards with Physician's order sheet at the patient's chart, for a written
order or any changes in the order. Re-check with the medication/standing order and
Kardex.
2. Arrange the cards on the medication tray according to the following:
a. Location of patient
b. Time of Administration
c. Condition of patient (more serious patients require more time for administering
medications therefore should be scheduled last)
3. Make sure that medicine glasses are clean and dry, to avoid altering the appearance,
form, and strength of the medicine
4. Place each medication in separate containers with the corresponding card behind.
5. Read label 3 times when preparing drugs. Observe the 5 R's in administering drugs.
6. Carry medication tray to patient's bedside. Keep medication in sight at all times.
7. Ascertain patient's identity before administering medications. Check Room or Bed card,
call out patient's name, check I.D. Band, etc.
8. Give medications one at a time. Give liquid medications and cough syrup last.
9. Remain with the patient until all medications have been swallowed. Never leave any
medications at patient's bedside, for patient to take as he pleases.
10. File medicine cards on the card rack in the compartment indicating the next hour if for
immediate administration, except those for AC, PC, HS, PHN.
11. Record all medications given immediately after administration.
Precaution:
1. Know the common or usual dosages and route of the administration of drugs commonly
ordered.
2. Mix with water, drugs that will discolorize the teeth or damage the enamel,
3. Irritating drugs are given with foods or after meals, and give through a drinking straw.
Example: Enteric-coated drugs, salicylates, other liquid vehicle . Ex. HCL, Lugol's
solution.
4. Check for any drug allergy or idiosyncrasy of the patient.
5. Determine level of consciousness, presence of gag reflex to ascertain whether patient is
capable of swallowing the medication.
6. Never administer drugs prepared by another nurse.
Contraindications to Oral Medication:
a. Nausea and vomiting

b. Stuporous, unconscious, irrational patients and those with mental clouding
c. Obstructive disease conditions affecting the mouth and esophagus
d. Bleeding from the GI tract, hematemesis
After Care of Medicine Glasses:
a. Separate contaminated medicine glasses for disinfection prior to washing

b. Wash medicine glasses, with soap and water after each use.
c. Dry thoroughly in preparation for the next use
1. The initial dose of newly ordered medication should be started as soon as drug is
available unless a specified time for starting it, is given. The next dose should be given
according to standard practice.
2. Standing order medications and treatments are canceled /discontinued under the
following circumstances:
a. When a patient goes to surgery, laboratory, delivery
b. When the patient manifests signs of allergic reaction to the drug
c. According to the policy for narcotics and antibiotics approved by the Medical Staff
3. Follow the shape of the medicine card as follows:
a. Treatment
b.
Parenteral
c. Oral
4. Follow as much as possible the standard

hours for administering drugs:
TIME
OD 8:00 am
BID 8:00 a.m. -
6:00 p.m.
TID 8:00 a.m. - 12:00 p.m. - 6:00 p.m.
QID 8:00 a.m. - 12:00 Noon – 4:00 p.m. - 8:00
p.m.
AC 30 minutes before meals
PC 1 hour after meals
HS 8:00 p.m.
q 2 hrs. 8-10-12-2-4-6-8
q 3 hrs. 9-12-3-6-9-12
q 4 hrs. 8-12-4-8-12
q 6 hrs. 6:00 a.m. 12:00 p.m. 6:00 p.m. 12:00 mn
q 8 hrs. 8:00 a.m. 4:00 p.m. 12:00 mn
q 12 hrs. 8:00 a.m. - 8:00 p.m.
5. Confer with another nurse regarding dosage and amount for preparing medicines such
as narcotics, pre-medications and insulin.
6. Patients should not be allowed to keep medications at the bedside: Medicines taken
outside should be sent home or given to head Nurse for safekeeping.
7. Medications being taken by the patient prior to admission are discontinued on
admission and referred to attending Physician.
8. Medication cards for new orders which will be started by the incoming shift, should be
placed in the card rack within the compartment To be Started and endorsed properly.
9. Whenever in doubt about dosages, frequency, patient identity, interpretation of orders,
always clarify with the next higher authority.
10. For errors in drug administration, report to your immediate superior and accomplish an
incident report.
Documentation/Charting:
a. Record accurately, promptly and legibly
b. Record given medication only as soon as administered.
c. When signing for medicine administered, affix your initials after the time it was given.
d. Encircle the time and affix your initials if medicines were not administered.
e. Record single, stat, Pre-op medication on the corresponding spaces.
f. To discontinue standing order medications, write a diagonal line on the blank spaces
the word Discontinued; the date it was discontinued; and affix signature.
g. Always chart medications using the medicine card as guidelines. Do not chart from
memory
h. Observe and record any patent's untoward or unfavorable reaction to the medication.
Narcotics:
1. Narcotic cabinet should be locked at all times with the H.N./C.N./Medication Nurse
responsible.
2. Narcotic count must be made every shift, between incoming and outgoing medication
nurse
3. Always update the narcotic sheet and DDB forms of the unit.
4. Narcotics are automatically discontinued after the 3rd day of consecutive administration,
unless reordered.
5. Whenever narcotics are spilled accidentally or purposely discarded, an incident report
must be filled up and submitted to Nursing Service.
6. Whenever a narcotic is lost for whatever reason, a written report should be made right
away by the Medication/Charge Nurse. Note: There is a legal implication with
corresponding penalty, for lost narcotics.
ADMINISTRATION OF PARENTERAL MEDICATIONS
Definition:
The introduction of a small amount of solution by means of a syringe and needle into the loose
tissue under the skin.
Purposes:
1. To secure rapid absorption of the drug

2. To prevent the destruction of the drug by the action of digestive secretions and
enzymes, if taken by the oral route.
3. To administer drug when patient is unable to take it by mouth.
General Consideration:
1. Observe the basic principles in the General Instructions for the administration of
medicines.
2. Report immediately any untoward effect of the drug.
3. Observe strict asepsis.
4. Avoid dangers such as:
a. Causing an abscess
b. Breaking the needle in the tissue
c. Striking a bone
d. Capillary tissue damage
5. Needle should be sharp
Drugs prescribed and the corresponding medicine cards

Hypodermic tray lined with sterile towel
Bottle of distilled water as solvent
Sterile needles 23-25 gauge ½-5/8 inch
Sterile syringe (size depends on amount of solution)
Sterile needle gauge 18 and 19 for aspiration of distilled water
Container with cotton balls soaked in 70% alcohol
Container for used needles and syringes
Container for used cotton balls and waste
Sterile pick up forceps
Preparation of the Patient:
1. Explain the purpose and nature of the treatment to the patient

2. Keep patient warm and relaxed in a sitting or recumbent position to reduce fear,
discomfort, pain and tension
3. Expose area of injection (either the outer aspect of the arms or thighs)
4. Cleanse area about 3 inches in diameter vigorously with alcohol sponge
N.B. Sites for hypodermic injection

anterior thigh
subscapular region
deltoid
fatty part of abdomen/breast
Procedure:
A. Preparing a hypodermic tablet for injection
1. Check order
2. Have the prescribed drug on hand (if it is a narcotic, check with another nurse).
Compute the appropriate dosage, or amount of drug to be administered.
3. Place medicine card on hypodermic tray
4. Wash your hands
5. Pick up syringe carefully. Separate barrel from piston.
6. Place hypodermic tablet inside the barrel of the syringe, either by the use of a dry sterile
forceps or by tapping the tablet into the syringe direct from the container. (Note:Tablet
dissolves faster if crushed before it is placed in the barrel of the syringe, but observe
aseptic or sterile technique if the tablet is to be crushed.)
7. Place piston into barrel
8. Attach gauge 20 needle with sterile forceps to the syringe
9. Cleanse rubber tip of the bottle of distilled solvent with alcohol sponge.
10. Aspirate required amount of solvent
11. Agitate or shake to dissolve the tablet.
12. Change needle with either gauge 25 or 23 depending upon the turgor of the skin, size
and condition of the patient.
13. Place syringe on the hypodermic tray between the layers of sterile towel.
14. Discard the amount of drugs not needed.
B. Preparing Hypodermic Injection from an Ampule
1. Have prescribed drug on hand

2. Arrange medicine card on hypodermic tray, with the corresponding drug.
3. Wash your hands
4. Pick up syringe, attach needle (gauge 18 or 19) to syringe using sterile forceps
5. Place syringe between layers of sterile towel
6. Shake ampule downwards or snap the stem of the ampule with the nails of the thumb
and middle finger, so that the entire solution is collected into the body of the ampule.
7. Cleanse neck of ampule scratcher file with alcohol sponge
8. Hold ampule firmly against a sterile piece of gauze or cotton. Scratch on the stem
around the neck of the ampule.
9. Break the top of the ampule between sterile gauze or cotton by bending it backward,
exerting pressure on top above the filed portion.
10. Discard the piece of cotton or gauze and the stem
11. Place the open ampule on the work table
12. Take syringe with the sterile forceps and attach the aspirating needle
13. Withdraw the solution either by -
a. Holding the ampule between the 2nd and 3rd fingers of the left hand with palm up,
insert into ampule, balance syringe between thumb and little finger of the left hand.
Withdraw solution.
b. Placing the ampule down, insert needle into the ampule and aspirate the solution.
14. Change aspirating needle with a gauge 25 or 23 needle
15. Place syringe on hypodermic tray between layers of sterile towels.
C. Preparing a Drug from a Rubber-Capped Vial
1. Proceed as in Procedure B, #1-4

2. Remove the outlined circular portion of the metal cap or vial by means of a file or scissor
3. Cleanse rubber cover with alcohol sponge
4. Attach aspirating needle to sterile syringe
5. Draw air equivalent to the amount of solution to be aspirated from vial
6. Insert needle to rubber cover of the vial
7. Invert vial, force the air from the syringe into the vial
8. Withdraw the required amount to be injected
9. Proceed as in No. 12 and 13 of Procedure A.
Administration of the Drug:
1. Carry tray to the patient's room

2. Check name of patient at the door or bedside with name on Medicine Card.
3. Address the patient by name. Prepare the patient as in oral medication.
4. Get syringe, tighten needle, expel air and hold syringe with right hand.
5. Grasp skin firmly with thumb and fingers of left hand.
6. Insert needle at angle of 30o to 60o into the subcutaneous tissue.
7. Release grasp on skin. Pull back gently on the plunger of the syringe to determine
whether the needle is in a blood vessel.
8. If no blood appears, place syringe between forefinger and middle finger.
9. Exert pressure on the handle of the plunger with the thumb and then inject the solution
slowly.
10. Withdraw needle quickly. Massage injection site, gently by rubbing with alcohol sponge
in a deep circular motion.
11. Make patient comfortable.
After Care of Equipment:
a. Rinse syringe and needles with cold water, soap and rinse again.
b. Flush needles with cold water, soap solution, then cold water.
c. Place them in a container for used needles and syringes.
d. Sterilize them accordingly.
Note: Test needles for sharpness and patency. Discard needles that are bent and dull.
Record:
Time of injection
Name of the drug
Amount and dose of the drug
Site of injection
Reaction of the patient
Example: Regular insulin 15 U injected (H) into the outer aspect of left arm.
PREPARING A DRUG FROM RUBBER CAPPED VIAL
1.First, make sure that you have all of the supplies that you will need.
2. Wash hands.
3. Remove the outlined circular portion of the metal cap or vial by means of a file or scissors and
disinfect rubber cover wit alcohol sponge.
4. Attach aspirating needle to sterile syringe
5. Draw air equivalent to the amount of solution to be aspirated from vial
6. Insert needle to rubber cover of the vial

7. Invert vial, force the air from the syringe into the vial. Withdraw the required amount to be
injected
INTRADERMAL OR INTRACUTANEOUS INJECTION
Definition:
The introduction of a solution by means of a syringe and needle into the superficial layers of the
skin.
Purposes:
1. To determine the susceptibility to disease and infection. Example: Schick Test, dick Test
Mantoux Test
2. To inject drug for therapeutic treatment. Example: anti-rabies serum in hydrophobia
3. To test for specific allergic reaction. Example: Sensitivity test for penicillin
4. To produce anesthesia. Example: Xylocaine infiltration into the skin
Hypodermic tray Sterile tuberculin or 1 cc syringe

Medicine card Sterile pick-up forceps
Solution prescribed Containers of sterile cotton balls moistened
Sterile needle gauge 25/26/27 ¼ inch long in 70% alcohol
Aspirating needle gauge 18-19 Waste container for used cotton balls
Distilled water Container for used needles and syringes
The same as in Subcutaneous Injection.
Site of injection is the inner aspect of the forearm. Cleanse as in Subcutaneous Injection.
The same procedure as in Subcutaneous Injection No. 1-2.
Expose site of injection as indicated in No. 1 selecting area which is not very hairy.
Cleanse area with cotton sponge soaked in alcohol 70%.
Procedure:
1. Prepare antibiotics or vitamin preparation by mixing 2 cc of distilled water to vial. Shake

and get 0.1 cc of the solution.
2. Add 0.9 cc distilled water.
3. Site is the antecubital fossa. Stretch skin taut by pulling skin to the back of arm with the
left hand. Pick up syringe and inject into the skin. This can be done by holding the
syringe between the thumb and 3 first fingers and thrusting the needle almost parallel
to the skin about 15%.
4. Inject solution slowly (about 0.01 cc).
5. Withdraw needle. If injection is done to test sensitivity to drugs or susceptibility to
infection, don't massage the site of injection.
6. Observe for wheal formation. A positive reaction consists of a pale, tense swelling
showing irregularity of the periphery (pseudopods) surrounded by a zone (erythema)
and with itchiness at the site of injection. Encircle the site.
7. After 30 minutes check for any signs of allergy
After Care of Equipment: The same as in Subcutaneous Injection.
Record:
1. Time
2. Solution and amount
3. Purpose of injection
4. Result
INTRAMUSCULAR INJECTION
Definition:
The introduction of a solution by means of a syringe and needle into the layers of the muscles,
hence intramuscular.
Purposes:
To administer a medication that is irritating; needs rapid absorption; and the quantity or
volume is large
The same as in subcutaneous injection
Medication ordered and medicine card

Hypodermic tray with sterile towel
Sterile needles gauge 22-23, 1-1/2 inch long gauge 25 (for children ¾ to 1 inch.)
Sterile syringes sizes depends upon the amount of solution
Container with cotton balls
Receptacle for used cotton balls or waste
Receptacle for used needles and syringes
Sterile pick-up forceps
The same as in subcutaneous injection No. 1

Usual areas of injection are:
a. Upper outer quadrant of buttocks (Gluteal Muscle)
b. Outer aspect of the upper arm (Deltoid Muscle)
c. Anterior thigh (when the amount of the drug to be injected is small)
Cleanse site of injection as in subcutaneous injection
Procedure:
1. Assemble syringe and needle and prepare medication

2. Prepare patient
3. Place the patient on a side lying position with one knee flexed.
4. Determine the site of puncture (inner angle of the upper outer quadrant). This area is
divided into equal parts vertically and horizontally. Determine site of puncture as
illustrated below:
5. Cleanse site with cotton ball soaked with alcohol.
6. Press the muscle tissue down firmly, using the thumb and the first two fingers of the left
hand to the direction of the thigh.
7. Hold the syringe with the right hand between thumb and first 3 fingers.
8. Quickly thrust the needle perpendicularly to the gluteus muscle at an angle of 90
degrees.
9. Release pressure of the left hand.
10. Aspirate and make sure the needle is not in a blood vessel before the drug is injected.
11. Inject drug slowly.
12. Remove needle quickly. Apply pressure with cotton sponge over site of puncture, and
then massage the area.
13. Make patient comfortable.
After Care of the Equipment:

The same as in subcutaneous Injection
Record:
1. Time 4. Manner of administration
2. Name of drug 5. Site of injection
3. Amount and dose of drug 6. Reaction of patient
ADMINISTRATION OF VAGINAL MEDICATIONS
Definition:
Insertion of medication via the vagina in the form of creams, suppositories, foams, and jellies to
treat infections, irritations or pruritus.
Patient can have allergic reactions to vaginal medications or the gloves. Assess for reactions. If
redness persists, it may be an allergic reaction instead of a reaction to the infection process.
Vaginal medications: cream, foam, jelly or suppository

Applicator (if needed)
Water-soluble lubricating jelly (for suppository)
Gloves
Perineal pad
Paper towel, toilet tissue
Wash cloth and warm water (optional)
ACTION RATIONALE
1. Verify orders. Prevents medication errors.
2. Ascertain if the patient has ever had vaginal Enables understanding of the procedure and
medications before, and understands the eliminates complaints.
procedure.
3. Ask the patient to void. Provides for patient comfort during the
procedure
4. Wash hands Reduces microorganisms present in the hands
of the Nurse.
5. Arrange equipment at patient’s bedside. Promotes organized actions.
6. Provide complete privacy by closing door This procedure can be embarrassing.
and
curtains.
7. Assist the patient into a dorsal recumbent Allows positioning for administration and for
position the medication to remain in vagina.
or sim's position.
8. Drape the patient as appropriate : over the Provides privacy. Prevents linen from
ACTION RATIONALE
abdomen and lower extremities. Provide becoming soiled.
towel or protective pad on the bed.
9. Don the gloves, and assess the perineal Decreases risk of transmission of
area for redness, inflammation, discharge microorganisms. Provide baseline data.
or foul odor.
10. If applying suppository with applicator – The medication is prepared for insertion.
Remove the suppository from the foil; Lubricant provides comfort and ease of
apply water soluble lubricant on the insertion.
applicator and the suppository.
With non-dominant hand retract the labia, Medication must be inserted completely to
and with dominant hand, insert the infiltrate the entire vagina. When medication
applicator 2 to 3 inches into the vagina, is deposited at the posterior end of the vagina,
sliding the applicator posteriorly. Push gravity will allow the medication to move
the plunger to administer the medication. toward the orifice.
With the suppository, insert the tapered

end first with the index finger along the
posterior wall of the vagina.
Note: If preferred, glove fingers may be

used.
11. Withdraw the applicator and place on a Reduces the transmission of microorganisms.
towel.
12. Wipe and clean the patient's perineal area, Provides comfort for patient and avoids
including the labia, from the front to the spread of infective agents to the perineal area.
back with toilet tissue.
13. Apply a perineal pad. Protects the patient from discomfort of
drainage and spread of infection or irritation
to perineal area.
14. Remove gloves and wash hands. Reduces the transmission of microorganisms.
15. Instruct the patient to remain flat for at Allows complete or effective infiltration of the
least 30 minutes. medication on the vaginal mucous
membranes.
16. Record administration of medication. Provides documentation as basis for decisions
in the continuity of care.
DOCUMENTATION:
a. Document the procedure performed and the results.

b. Note any unusual findings or patient's complaints.
c. Document patient's response to treatment
d. Document patient's signs and symptoms associated with vaginal conditions.
ADMINISTERING RECTAL MEDICATIONS
Definition:
Insertion of medications into the rectum in the form of suppositories.
1. The sphincter muscle around the rectum may start to contract as a normal response to
the insertion of medication bottle tip. Wait a few seconds until the muscle relaxes
before instilling the medication.
2. Special attention should be given to the patient with a rectal fistula. Observe for signs of
perforation such as leaking in the perineal area and abdominal cramping.
3. If excoriation is present, protect the skin with topical creams or lubricants as allowed by
institutional policy prior to administration of suppositories.
Medications (suppository)
Water soluble lubricant
Gloves
Tissue or wash cloth
Bedpan (if client is physically immobile)
Towel or pads
ACTION RATIONALE
1. Assess the patient's need for medications. Allows nurse to determine effectiveness of the
medications.
2. Check the doctor's order. Verify correct Ensures accuracy and eliminates chance of
patient, medications, dose, route and time. medication error.
3. Check for any drug allergies. Eliminates risk of allergic reactions.
4. Gather the equipment and materials Prevents repeated trips in order to gather
needed for the procedure before entering supplies and facilitates the smooth flow of the
the patient's room. procedure.
5. Assess the patient's readiness to receive Promotes privacy and maintains self-image.
the medications. Encourage visitors to
leave until the procedure is completed.
ACTION RATIONALE
7. Apply disposable gloves. Prevents contact with fecal materials.
8. Ask the patient’s name and check Ensures correct patient.
identification band.
9. Assist patient to assume the correct The descending colon is on the left side; this is
position: Side-lying Sim's position, a more anatomically correct position. This
preferably on the left side with upper leg position exposes the anus to identify
drawn up toward the chest. placement. Pads can provide comfort to
Provide protection under the patient’s patient who may fear soiling the linen.
buttocks such as towel or pad.
10. Remove suppository from wrapper and Lubrication eliminates friction and discomfort.
lubricate rounded end along with insertion
finger.
11. Tell patient that he or she will experience a Prepares the patient for administration.
pull sensation and pressure during the Relaxes the rectal sphincter.
administration.
Encourage slow deep breaths.
12. Retract the buttocks with nondominant Slow insertion minimizes the pain. Correct
hand, visualizing the anus. Using the placement ensures adequate absorption and
dominant index finger, slowly and gently less chance for expulsion of medication.
insert the suppository through the anus,
past the internal sphincter and against the
rectal wall.
13. Remove finger and wipe patient's anal Removes lubricant externally. Promotes
area with a wash cloth or tissue. cleanliness and comfort.
14. Discard gloves and wash hands. Reduces transfer of microorganisms.
15. Instruct patient to stay for about 10 Keeps suppository or medicated fluid in place
minutes in bed and to lie on the left side. for better absorption.
16. Place call light within patient's reach if Gives patient control over the situation and
administering suppository containing nurse’s response once sensation to defecate is
laxative, to assist the patient as soon as felt.
the sensation to defecate is felt.
17. Record administration of medication Provides documentation for administration of
medication.
DOCUMENTATION:
a. Record on the Chart the name of medication, dosage, route of administration, time
administered and initials or signature of nurse administering medications.
b. Note down the time and the patient’s complaints, medication administered, outcome of
treatment and nurse’s signature.
LEOPOLD'S MANEUVERS
Purpose:
Systematically observing and palpating the abdomen to determine fetal presentation and
position.
ACTION RATIONALE
1. Prepare the patient.
a. Explain the procedure. Explanation reduces anxiety and enhances
cooperation
b. Instruct the patient to empty her bladder. Doing so promotes comfort and allows for
more productive palpation because fetal
contour will not be obscured by a distended
bladder.
c. Position the patient supine with knees Flexing the knees relaxes the abdominal
slightly flexed. Place a small pillow or muscles. Using a pillow or towel tilts the
rolled towel under one side. uterus off the vena cava, thus preventing
supine hypotension syndrome.
d. Wash your hands using warm water. Handwashing prevents the spread of possible
infection. Using warm water aids in patient
comfort and prevents tightening of abdominal
muscles.
Observe the patient’s abdomen for the The longest diameter (axis) is the length of the
longest diameter and where fetal movement is fetus. The location of activity most likely
apparent. reflects the position of the feet.
2. Perform the first maneuver This manuever determines whether fetal head
or breech is in the fundus.
a. Stand at the foot of the patient, facing her, Proper positioning of hands ensures accurate
and place both hands flat on her abdomen. findings.
b. Palpate the superior surface of the fundus. When palpating, a head feels more firm than a
Determine consistency, shape, and breech. A head is round and hard; the breech
mobility. is less well defined. A head moves
independently of the body; the breech moves
only in conjunction with the body.
3. Perform the second maneuver. This maneuver locates the back of the fetus.
a. Face the patient and place the palms of Proper positioning of hands ensures accurate
ACTION RATIONALE
each hand on either side of the abdomen. findings.
b. Palpate the sides of the uterus. Hold the This method is most successful in determining
left hand stationary on the left side of the the direction the fetal back is facing. One
uterus while the right hand palpates the hand will feel a smooth, hand, resistant
opposite side of the uterus from top to surface (the back), while on the opposite side,
bottom. Then hold the right hand steady, a number or angular nodulations (the knees
and repeat palpation using the left hand on and elbows of the fetus) will be felt.
the left side.
4. Perform the third maneuver. This maneuver determines the part of the
fetus at the inlet and its mobility.
a. Gently grasp the lower portion of the If the presenting part moves upward so an
abdomen just above the symphysis pubis examiner's hands can be pressed together, the
between the thumb and index finger and presenting part is not engaged (not firmly
try to press the thumb and finger together. settled into the pelvis). If the part is firm, it is
Determine any movement and whether the the head; if soft, and then it is breech.
part is firm or soft.
5. Perform the fourth maneuver. This maneuver determines fetal attitude and
degree of fetal extension into the pelvis;
should only be done if fetus is in cephalic
presentation. Information about the infant's
anteroposterior position may also be gained
from this final maneuver.
a. Place fingers on both sides of the uterus The fingers of one hand will slide along the
approximately 2 inches above the inguinal uterine contour and meet no obstruction,
ligaments, pressing downward and inward in indicating the back of the fetal neck. The
the direction of the birth canal. Allow fingers other hand will meet an obstruction an inch or
to be carried downward. so above the ligament-this is the fetal brow.
The position of the fetal brow should
correspond to the side of the uterus that
contained the elbows and knees of the fetus.
If the fetus is in a poor attitude, the examining
fingers will meet an obstruction on the same
side as the fetal back. That is, the fingers will
touch the hyperextended head. If the brow is
very easily palpated (as if it lies just under the
skin), the fetus is probably in a posterior
position (the occiput is pointing toward the
woman's back).
PERINEAL – GENITAL – CARE
Definition:
It is a procedure rendered to the female and male external genitals, which aims to promote
hygiene. Also referred as perineal care or peri-care.
Purposes:
To remove normal perineal secretions and odor.

To prevent infection
To promote patient comfort
presence of irritation pain or discomfort

excoriation presence of urinary or fecal incontinence
inflammation recent rectal or perineal surgery
swelling presence of indwelling catheter
excessive discharge perineal-genital hygiene practices
odor self-care abilities
A. Perineal-genital care:
Bath towel
Bath blanket
Disposable gloves
Solution bottle, pitcher, or container filled with warm water or a prescribed solution
Bedpan to receive rinse water
Moisture-resistant bag or receptacle for used cotton swabs
Perineal pad
B. If perineal-genital is to be done with bed bath:

Bath towel
Bath blanket
Disposable gloves
Bath-basin two-thirds filled with water at 43 C to 46 C (110 F to 115 F)
Soap
Washcloth
Protective ointment as required
PROCEDURE FOR NORMAL SPONTANEOUS DELIVERY
Definition:
The actual expulsion of the products of conception from the maternal body.
Purpose:
1. To maintain the physiologic stability of the patient throughout the stage of labor.
2. To prevent complications before, during and after labor and delivery both to the mother
and to the baby.
1. Help the parturient patient participate to the extent she wishes in the delivery of her
infant, and to meet her goals.
2. Conserve the patient’s energy by helping her in controlling the discomforts of labor and
delivery.
3. Relaxation and reduction of stress increases the patient's ability to cope with labor.
4. The patient should be assisted in controlled chest breathing during contractions and to
relax between contractions.
5. The patient is discouraged to bear down until cervical dilation is complete.
6. Monitor closely the progress of labor and be aware of the warning signs for the second
stage of labor.
7. Respect and promote the patient and her support persons’ activities, orient them to the
area.
ACTION RATIONALE
1. Assist the patient into a lithotomy position Extremities are lifted up together to maintain
on the delivery table, with both legs raised a balance in movement, that will prevent
together slowly on the stirrups. The same trauma to the uterine ligaments as well as
should be done when straightening the legs back or leg cramps.
or putting them down after delivery.
2. Encourage the patient to do strong push This is the best time to perform strong push to
with each contraction. At the beginning of facilitate descent of the baby.
a contraction, the patient is asked to take
two short breaths, then to hold her breath
and bear down at the peak of the
contraction.
3. Tell the patient to use blow breathing This is done to prevent pushing between each
pattern between each contraction. contraction.
ACTION RATIONALE
4. As soon as the head crowns, the patient is To prevent rapid delivery of the fetus. Rapid
instructed not to push anymore, instead delivery of the fetal head must be prevented
she is advised to pant (rapid shallow because it is followed by a rapid change of
breathing) pressure with the molded fetal skull which
may result in dural or subdural tears, and may
cause vaginal or perineal laceration.
5. Perform Ritgen's maneuver by supporting This will not only prevent lacerations of the
the perineum with the palm against the fourchette but will also bring the fetal chin
rectum. down the chest so that the smallest diameter
of the fetal head is the one presented at the
birth canal.
6. Assist in episiotomy as needed. Done for the following reasons:
primarily to prevent laceration
prevent prolonged and severe stitching of the
muscle supporting the bladder and rectum
reduce duration of 2nd stage of labor
enlarge vaginal outlet in breech presentation
of forcep delivery.
Spare the infant's head from prolonged
pressure which may result to brain damage,
especially in premature baby.
7. As soon as head is born, suction oral This is to expedite drainage and prevents
pharynx with small bulb syringe. aspiration of amniotic fluid, mucus, and
maternal blood.
8. Suction nostrils next. To prevent inspiration following stimulation of
the nostrils before it is cleared of secretions.
9. As soon as the head has been delivered, This is done to avoid cord compression while
insert the two fingers into the vagina to baby's body is being delivered, or accidental
inspect for a loop of cord around the neck. pulling which may result in detaching of the
If present and loose enough, slip it down cord from its attachment either from the base
the shoulder; if too tight, apply 2 clamps of the placenta or from the baby's navel.
an inch apart before cutting the cord
between the clamps.
10. After external rotation, give a gentle, Lateral traction to deliver the shoulder can
steady downward pull in order to deliver lead to nerve injuries.
the anterior shoulder and then a gentle
upward lift to deliver the posterior
shoulder.
11. While supporting the baby’s head and neck This is to prevent injury since the baby's body
ACTION RATIONALE
with one hand, glide the other hand will surely be slippery.
towards the body, and then grasp both
ankles of the baby.
12. Take note of the time the baby is For proper documentation of the event, the
delivered. precise time that the entire baby's body is out
of the mother is considered as the time of
birth.
13. Immediately after delivery, the baby is This is done so that the blood from the
held below the level of the mother's vulva. placenta can enter the infant's body on the
basis of gravity flow.
14. Place the baby on top of the mother's The baby's presence on the mother's
abdomen. abdomen stimulates the release of oxytocin
from the posterior pituitary thus stimulating
uterine contraction which aid in placental
separation.
15. Apply 2 clamps to the umbilical cord as its It is believed that 50 – 100 ml of blood flows
pulsation ceases. Cutting of the cord is from the placenta to the newborn at this time.
done when pulsation has stopped.
16. The mother is informed of her baby's sex Maternal and infant bonding is initiated as
and is allowed to hold and inspect her soon as the mother has eye-to-eye contact
baby as she wishes. with her baby.
17. Wait for the signs that placenta has An attempt to deliver the placenta prior to its
separated before attempting to deliver the voluntary separation from the uterine wall is
placenta. futile
and may tear the cord, separate the placenta
or invert the uterus.
18. When the placenta has separated and the Expression of the placenta should be done
uterus is firmly contracted,the patient is when uterus is hard, otherwise the organ may
asked to bear down as the placenta is being be turned inside out, known as uterine
slowly pulled to be delivered. inversion. Gentle pushing of the mother will
produce intra-abdominal pressure that may
expel the placenta.
19. Once placenta is out, it is carefully To make sure that the expelled placenta is
inspected. intact. If a piece is left inside the uterus, it
may cause subsequent hemorrhage.
20. Determine the degree of uterine Gentle massage and ice cap on hypogastrium
contraction and perform initial nursing will stimulate uterine contraction.
intervention for signs of non-contracting or
boggy uterus which includes gentle
ACTION RATIONALE
massage of fundus. An ice cap will also
help.
21. Administer oxytocics as ordered. To ensure contraction, thus prevent
hemorrhage.
22. Assess or monitor BP of the mother who A common side effect of oxytocics, specifically
has received oxytocics. ergot derivatives, is hypertension.
23. Inspect perineum for lacerations. If the uterus is firm and bleeding comes out in
spurts, this is an indication of lacerations
24. Assist the doctor during the episiorrhaphy. Lacerations if not repaired can lead to oozing
of bright red blood from the lacerated part of
the perineum.
25. Evacuate blood clots and watch for signs of Non-contraction of uterus after placental
placental fragments. delivery may be caused by either blood clots
or retained placental tissues.
26. Fundus check is done every 15 minutes. To monitor uterine contraction.
27. Perform perineal care aseptically and apply The perineal pad will not only provide comfort
perineal pad appropriately. to the mother but serves as basis for
monitoring lochial discharge.
28. Keep the mother dry, offer clean After the delivery, the mother will experience
clothing/gown and warm blanket. chills and shaking sensation. Keeping her dry
will minimize feeling of chills and will make her
more comfortable.
29. Perform after care of the delivery room, For a more systematic admission of the next
instruments and articles. patient for DR procedure.
30. Do charting comprehensively. For detailed documentation.
Perineal Skin Prep
CARE OF THE NEWBORN
Definition:
The immediate care given to the newborn baby.
Purposes:
1. To establish and maintain a patent airway

2. To maintain appropriate body temperature
3. To assess the newborn
4. To provide appropriate nursing care
5. To prevent complications
1. Never stimulate the baby to cry until all secretions have been drained out.
2. Position the newborn properly to prevent aspiration
3. Dry and wrap the newborn to prevent chilling.
4. Identify the newborn properly.
5. Observe extra care when administering medications.
Gloves Tape measure

Suction machine Terramycin ointment
Bulb syringe Vitamin K (Phytomenadione)
Suction tip Tuberculin syringe
Basin with lukewarm water Rectal thermometer
Baby soap Stamp pad
Bay oil Wrist & crib tags
Baby blanket Crib
Triangular binder Droplight
Forceps/clamps Baby's layette
Cottonballs with alcohol Cap
Cottonballs with betadine solution Mittens
Dry cottonballs Dress
Sterile gauze Diaper
Plastic cord clamp Booties
Scissors or surgical blade Baby blanket
Weighing scale Clips/pins
ACTION RATIONALE
1. Assemble all necessary articles/equipment For easy performance of the procedure.
for suctioning, bathing, cord dressing,
measuring, medication, taking of vital signs
and providing proper identification.
2. Receive and place baby in a crib in a To drain excess fluids from the lungs by
Trendelenberg position under droplight. gravity.
3. Perform APGAR scoring. To assess the health status of the baby.
4. Gently suction oronasopharyngeal To remove secretions and prevent aspiration.
secretions using a suction apparatus.
5. Perform oil bath. To spread the vernix caseosa.
6. Check the water temperature, and then To prevent chilling, if cold water will be used.
bathe the baby.
7. Expose, wash, soap, rinse and pat drying To prevent chilling and to gradually acquaint
each part quickly but gently. the newborn to the different procedures and
routines of care, a sudden change, different
from the comfortable situation inside the
mother’s womb.
8. Diagonally wrap baby with a baby blanket To mummify the baby, thus preventing it from
or diaper and secure the knees with a excessive movements.
folded triangular binder.
9. Perform medical handwashing and pour To maintain aseptic technique.
alcohol on hands.
10. Get sterile gauze to hold the forceps To prevent contamination.
clamping the umbilical cord.
11. Paint around the base of the cord with To disinfect the umbilical area.
cotton ball dipped in betadine solution,
three times.
12. Discard each cotton ball after every To maintain aseptic technique.
circular stroke.
13. Paint the umbilical cord from base To disinfect the umbilical cord.
upwards three times.
14. Discard each cotton ball after every To maintain aseptic technique.
upward stroke.
15. Get another sterile gauze and press firmly To flatten the umbilical cord before cutting it.
the umbilical cord in an upward direction.
16. When the cord is thin and flattened, apply To prevent backflow of blood to the umbilical
the cord clamp just above the base area.
ACTION RATIONALE
excluding any part of the baby's skin.
17. Cut the umbilical cord just above the To prevent the cord clamp from slipping off
clamp using a pair of scissors previously the umbilical cord.
soaked and rinsed in an antiseptic solution.
18. Paint the umbilical cord with iodine or To disinfect the area.
betadine.
19. Decolorize the area around the umbilical To clean the area and prevent it from staining.
cord with cotton ball soaked with alcohol.
20. Weigh baby on the weighing scale. To check any abnormalities in weight.
21. Take the anthropometric measurements. To determine any abnormalities.
22. Dress up baby. To avoid undue exposure and chilling of the
newborn.
23. Apply ophthalmic ointment on both eyes. To prevent ophthalmic neonatorum.
24. Inject 0.1 cc (for full term newborn) or 0.05 To increase the clotting factor in blood.
cc (for pre-term newborn) for vitamin K at
the left vastus lateralis.
25. Take vital signs and footprints. For baseline data and identification.
26. Counter check wrist tag with crib tag. For proper identification.
27. Wrap baby with clean and warm blanket. To provide warmth and comfort.
28. Place baby in crib under droplight. To provide warmth.
HOME VISIT
Definition:
Home Visit is a professional face to face contact made by the a Nurse to the client or the family
to provide necessary health care activities and to further attain an objective of the agency.
Purposes:
1. To make use and apply the principles in preparing for a Home Visit.
2. To identify the factors to be considered in determining the frequency of home Visit.
3. To implement the steps in home visit.
ACTION RATIONALE
A. Planning the Home Visit
1. Write the purpose of the home visit. Aid to achieve the best result in planning a
home visit.
2. Take time to read the records to establish To make use of all available information about
purpose of the home visit. the client and his/her family: knowledge about
the Health Center personnel, including those
from other agencies that may have rendered
service to a particular client or family.
3. Take note that plans revolve around the The client is the focus and reason for the visit.
client's needs.
B. Approach and Introduction
1. Introduce self and make the client know This promotes orientation and direction of the
the role of a Public health Nurse, and the visit to the client and to his/her family.
purpose of the visit.
2. Make client feel at ease by showing a To establish trust between the nurse and the
comfortable attitude (friendly attitude) family.
3. Make use of a friendly and welcoming This creates goodwill to the client and his/her
approach. family.
4. Assess relationship within the household. Facilitates establishing rapport with the client
and his/her family.
5. Two-way communication is established Allows the client the opportunity to verbalize
(each expressing feelings openly) things the way they appear to him or her.
ACTION RATIONALE
C. Activity of the Visit
1. Planned activity implemented (direct care, Positive impact from the nurse keeps the
demonstration, health teaching, and client informed, encouraged, or coached.
anticipatory guidance).
2. Adopt nursing procedure to home The nurse, when appropriate, maintains
situation. physical contact with the client thus reassures
and comforts the client.
Professionalism and efficiency decreases the

anxiety of the client.
D. Closing the Home Visit
1. Ask the client to summarize the session Verifies accuracy and agreement between the
nurse and the client
2. Terminate with a brief review of important Closing of the visit establishes and obtains the
points. needed information.
3. Stress the positive aspects that emphasizes Reassures the client that the nurse has
family strength. listened during their interaction.
4. Reiterate the planned activity to the family Clears the way for new ideas and helps, the
that will be carried out in his/her absence. client to note progress and forward direction.
5. Together with the family, plan for the Maintain rapport and trust for facilitating
next visit (date, time, and convenience). future interaction.
E. Recording the Home Visit
1. Describe the situation Systematically uses the scientific problem-
solving method for decision-making (Watson's
Human Caring Theory, 1979)
2. Describe the activities/services rendered. To develop a helping relationship (human
care) (Watson's Human Caring Theory, 1979)
3. Describe the client’s attitude/response Promotes and accept expression of positive
and negative feelings (Watson's Human Caring
Theory, 1979)
The nurse can avoid asking questions for
which answers have already been supplied.
4. Describe the plan to be followed on the Provides interdependence that involves one's
next visit. relations with significant others and support
which provides help and attention (Roy's
adaptation Theory, 1997 pg. 46)
5. Write the documentation in the third This is a more appropriate way of recording in
ACTION RATIONALE
person detail the account of the Nurse-Client
interaction.
6. Note that the family will be ready to carry Denotes the role function mode which is
out the next visit. determined by integrity and require the
performance of the duties based on a given
situation to the client and to his/her family.
(Roy's adaptation Theory, 1997, pg. 46)
THE BAG TECHNIQUE
Definition:
The bag technique is a tool by which the Nurse during the home visit will enable her to
perform a nursing procedure with ease and deftness, to save time and effort, with the end in
view of rendering effective nursing care to clients in their homes.
The Public Health Nurse Bag is an essential and indispensable equipment of a Public
Health Nurse which she carries along during her home visits. It contains basic medications and
articles which are necessary for giving care.
Principles of bag technique:
1. Performing the bag technique will minimize, if not prevent the spread of infection.
2. It saves time and effort in the performance of nursing procedures
3. The bag technique should show the effectiveness of total care given to an individual or
family in the home setting.
4. The bag technique can be performed in a variety of ways depending on the agency's
policy, the home situation, or as long as principles of avoiding transfer of infection is
observed.
Paper lining Baby's scale

Extra paper for making waste bag Alcohol lamp
Plastic/linen lining 2 test tube
Apron Test tube holders
Hand towel Solutions of:
Soap in a soap dish 70% alcohol
Thermometer (oral and rectal) Betadine
2 pairs of scissors (surgical and bandage) Hydrogen peroxide
2 pairs of forceps (curved and straight) Ophthalmic ointment
Disposable syringes with needles (g. 23 & 25)
Hypodermic needles g. 19,22,23,25
Sterile dressing
Cotton balls (dry and with alcohol) Zephiran solution
Cord clamp
Micropore plaster
Tape measure
1 pair of sterile gloves Spirit of ammonia
Sphygmomanometer and stethoscope
are carried separately.
Acetic acid
Benedict's solution
1. The bag should contain all the necessary articles, supplies and equipment that will be
used to answer emergency needs.
2. The bag and its contents should be cleaned very often, the supplies replaced, and ready
for use anytime.
3. The bag and its contents should be well protected from contact with any article in the
client's home. Consider the bag and its contents as clean and sterile, while articles that
belong to the clients as dirty and contaminated.
4. The arrangement of the contents of the bag should be according to what is most
convenient to the user, to facilitate efficiency and avoid confusion.
ACTION RATIONALE
1. Upon arrival at the client's home, place the To protect the bag from getting contaminated.
bag on the table lined with a clean paper.
The clean side must be out and the folded
part, touching the table.
2. Ask for a basin of water or a glass of To be used for handwashing.
drinking water if tap water is not available.
3. Open the bag and take out the towel and To prepare for handwashing.
soap.
4. Wash hands using soap and water, wipe to To prevent infection from the care provider to
dry. the client.
5. Take out the apron from the bag and put it To protect the nurse's uniform.
on with the right side out.
6. Put out all the necessary articles needed for To have them readily accessible.
the specific care.
7. Close the bag and put it in one corner of To prevent contamination.
the working area.
8. Proceed to performing the necessary To give comfort and security and hasten
nursing care and treatment. recovery.
9. After giving the treatment, clean all things To protect the caregiver and prevent infection.
that were used and perform handwashing.
10. Open the bag and return all things that To prepare them for the next visit.
were used in their proper places after
cleaning them.
ACTION RATIONALE
11. Remove apron, folding it away from the
person, the soiled side in and the clean side
out. Place it in the bag.
12. Fold the lining, place it inside the bag and
close the bag.
13. Take the record and have a talk with the As reference for the next visit.
Mother. Write down all the necessary data
that were gathered, observations, nursing
care and treatment rendered. Give
instructions for care of client in the
absence of the nurse.
14. Make appointment for the next visit For follow-up care.
(either home or clinic) taking note of the
date and time.
CARDIOVASCULAR ASSESSMENT
Definition:
Cardiovascular assessment is a process of looking at the heart and the blood vessels and
related systems, to assess their functions and capacity to sustain life.
Indications:
1. To determine the functioning capacity of the cardiovascular system in relation to the

different system it supplies.
2. To determine and note the adverse effects of certain drugs on the cardiovascular
system, as well as the complications of certain disorders, for immediate management.
1. Acutely ill patients may require a more in-depth assessment of certain systems
2. Assessment in acute life-threatening situations should be prioritized in order to address
their adverse effects on related areas immediately, and as soon as possible thereafter,
the less life-threatening needs.
3. After the initial detailed assessment has been obtained for baseline data, a quick
assessment of problem areas noted from initial assessment may be performed each
shift. A detailed assessment may then be performed periodically (every 24 to 72 hours
depending on the agency's policy and patient's state of health).
4. For geriatric and Pediatric patients:
a. Normal development stage and physiologic changes must be taken into consideration
when assessing the patient.
b. Although most of the information in the history may be obtained from the parents and
significant others, the child's and the elders’ perspective regarding illness and care will
be valuable throughout treatment plan.
c. Color changes in persons may be best observed in areas of minimal pigmentaiton –

sclera, conjunctiva, nail beds, palms and soles and the mucosal areas. Consider,
however, that a bluish hue may be normal for persons of Mediterranean or African
descent.
Stethoscope Appropriate assessment form/notebook

Sphygmomanometer Ruler
Watch with second hand Weighing Scale
Pen Gown/Drape or sheet
General Principles:
1. A complete or partial physical examination is conducted following a careful
comprehensive or thorough nursing history.
2. It must be conducted in a quiet, well-lit room with considerations for patient's privacy
and comfort.
3. Whenever possible, begin with the patient in a sitting position, so that the front and
back can be examined.
4. Completely expose the part to be examined but drape the rest of the body
appropriately.
5. Conduct the examination systematically from head to foot so as not to miss observing
any system or body part in relation to cardiovascular assessment.
6. While examining each region, consider the underlying anatomical structures, their
functions, and possible abnormalities.
7. Since the body is bilaterally symmetrical, for the most part, compare findings on one
side with those on the other. (e.g. Arterial pulse assessment)
8. Explain all procedures to the patient prior to and while the examination is being
conducted so as to avoid alarming or worrying the patient, and to encourage his
cooperation.
9. Techniques for examination and assessment are as follows: Inspection, Palpation,
Percussion and Auscultation, except when one tries to examine the abdomen
(Inspection, Auscultation, Percussion and Palpation)
10. A cardiac physical examination should include the following:
a. Effectiveness of the heart as a pump. (Check for Pulse pressure, cardiac enlargement,
murmurs, and gallop)
b. Filling volumes and pressures (Check for Jugular Vein Distention, presence/absence of
congestion in the lungs, peripheral edema, and postural changes in blood pressure)
c. Cardiac Output (Check for cognition, heart rate, pulse pressure, color and texture of the skin,
and urine output)
d. Compensating Mechanisms (check for sudden increase in the heart rate)
Cardiovascular physical assessment covers the following areas:

a. General appearance g. Heart
b. Cognition h. Extremities
c. Skin i. Lungs
d. Blood Pressure j. Abdomen
e. Arterial Pulses
f. Jugular Vein Pulsation and Pressure
There are two components of a cardiovascular assessment

a. Health history
b. Physical Examination
ACTIONS RATIONALE/INDICATION
1. Wash hands and organize your equipment Reduces microorganism transfer.
Promote efficiency
2. Explain procedure to patient, emphasizing Decreases anxiety
importance of the accuracy of data. Increases compliance
3. Provide privacy Minimizes embarrassment
I. Health History
4. Obtain health history by interviewing patient Provides baseline data for future reference when
using therapeutic communication techniques. providing care.
Include the following areas: Identifies the client

a. Biographical information (name, age, sex,
race, marital status, informant).
b. Chief complaint (as stated in patient's own Explains why the patient sought health care and
words). what the problem means to him.
c. Family history (ask if patient's family Identifies hereditary factors that may affect health
members were diagnosed with coronary status. This estimates the risk of cardiac disease
artery disease, hypertension, for the client.
hyperlipidemia, diabetes, etc).
d. Risk factors – smoking, high serum Identifies the factors that have increased the risk
cholesterol, hypertension, obesity, of progression/ development of the disease.
sedentary lifestyle, stress, male sex,
alcohol.
e. Past Medical and Surgical history (date and Serves as a baseline and guide for treatment
description of problems, previous decisions.
hospitalization, previous illness, allergies, Identifies potential problems related to the
current medications and the time of last present complaints.
dose)
f. 1 History of present illness/problem (date of Defines the details of manifestations of the
onset, detailed description of the problem: problems.
nature, location, severity, and duration as well Helps define diagnosis
as associating, contributing and precipitating
factors)
For chest pain – assess the following: Excruciating pain radiating to back and flanks
– from acute dissecting aneurysms of the
i. Nature and intensity (Ask the patient aorta.
to describe in his own words what the
pain is like – dull, sharp, crushing,
burning, heaviness, ache, pressure?)
ii. Onset and duration (When did the pain Sharp epicardial pain (over and around the
start? How long did the pain episode heart area) radiating to the left shoulder and
last?) upper back, aggravated b respiration indicates
acute pericarditis.
iii. Location and Radiation (Ask the Positive Levines sign is indicative of diffused
patient to point to the area where it visceral pain associated with unstable cardiac
hurts most. Positive Levine sign: disease.
clenched fist brought to patient's
chest is indicative of diffused visceral
pain associated with unstable cardiac
disease – Ask the patient if the pain
seems to travel most commonly
radiating to the left arm, jaw, back,
and abdominal region)
iv. Precipitating and Relieving factors

(What activity was the patient doing
just prior to pain? What relieves the
pain – rest, medications, change of
position?
v. Associated signs and symptoms
(observe for nausea, diaphoresis,
dyspnea, fatigue, palpitations,
disorientation)
f.2. Dyspnea – assess the following:

i. What precipitates or relieves
dyspnea?
ii. How many pillows does the patient
sleep with at night? (Several pillows is
indicative of advanced heart failure)
f.3. Palpitations – assess the following: It may be a sign of left ventricular failure or
i. Do you ever feel your heart pound, transient congestive heart failure. (Exertional
beat too fast, or skip beats? dyspnea, and Paroxysmal Nocturnal
Orthopnea)
ii. Do you feel dizzy or faint when you
experience these sensations? Patient may complain of pounding, jumping
sensations in the chest due to
iii. What do you do to relieve these tachydysrhythmias or sensation of skipped
sensations? beats usually due to premature atrial or
ventricular beats.
f.4. Weakness/Fatigue – assess the following:
i. What activities can you perform The beats are unable to provide sufficient
without becoming tired? blood to meet the increased metabolic needs
of cells.
ii. What activities cause you to become
tired? As heart disease advances, fatigue is
precipitated by less effort.
f.5. Dizziness and Syncope – assess the
following:
i. How many episodes of syncope/near The manifestations are due to a fall in the
syncope have you experienced? cardiac output thus decreasing blood supply
to the brain.
ii. Did a hot room, hunger, sudden
position change, or pressure on your Dysrhythmias related to cardiac disease may
neck precipitate the episode? cause syncope.
II. PHYSICAL ASSESSMENT

5. Assess general appearance.
6. Obtain height and weight. Provides ojective cues about the general
state of health.
7. Check for cognition – assess the following: These would manifest the ability of the heart
a. Level of distress to propel blood to the brain (cerebral
b. Level of consciousness perfusion).
c. Thought process
8. Obtain vital signs.
a. Determine the Heart rate. Comparison will tell the examiner if pulse
defict is occuring (deifference between apical
pulse and radial pulse) The farther the pulse
is to the heart the lower is its quality.
i. Take the heart rate using the apical To be able to detect any abnormalities such
area and the radial area. as skipped beats.
To prevent omission of other important
ii. Take it for 1 full minute. findings.
iii. Note for regularity.
Irregular rhthm may indicate a
malfunctioning SA node or abnormalities in
impulse conduction secondary to cardiac
problems like MI, Heart failure.
b. Monitor Blood Pressure These may be affected by cardiac output,
distention of the arteries, volume, velocity
and viscosity of the blood.
i. Take BP on both arms and note 5 mmHg difference is normal
differences.
ii. Determine the Pulse Pressure (Systolic To evaluate cardiac output (30 – 40 mmHg is
minus diastolic pressure) normal; less than 30 mmHg indicates
decreased cardiac output; Anxiety, Exercise
and Bradycardia may increase the pulse
iii. Note the presence of Pulsus Alterans pressure).
(loud sounds alternate with soft Hallmark of left ventricular failure.
sounds with each auscultatory beat).
Cardinal sign of cardiac tamponade ( a
cardiac emergency).
Autonomic compensatory factors for upright

posture are inadequate due to volume
Note presence of Paradoxus (Abnormal fall in depletion, bed rest, and/or neurological
BP during inspirations) disease.
c. Assessfor Postural / Orthostatic

Hypotension (prompt hypotension
that occurs with assumption of the
upright position)
i. Note changes in heart rate and BP
in at least two of the three
positions lying, sitting (45 degrees
angle – head part and 90 degrees
angle – head part), standing; allow
at least 3 minutes between
position changes before obtaining
rate and pressure.
9. Assess the Skin Warm/dry skin indicates adequate cardiac
a. Palpate for temperature and evidence output.
of diaphoresis.
Cool, clammy skin indicates compensatory
vasoconstriction due to low cardiac output.
b. Observe for the presence of the
following:
i. Pallor – A decrease in the color of
the skin noted on distal areas. Best
observed on the fingernails, lips
and oral mucosa.
ii. Cyanosis – bluish discoloration of
the skin and mucous membranes. Indicative of low oxygen saturation of arterial
• Central cyanosis – noted on blood which may be evident in heart failure
the tongue, buccal mucosa and or pulmonary edema.
lips.
Indicative of reduced blood flow through the
extremities due to vasoconstriction due to
• Peripheral cyanosis – noted on cold exposure or obstructive peripheral
the distal aspects of vascular disease.
extremities, tip of the nose,
lips and ear lobes Indicative sign of right-sided heart failure or
chronic hemolysis from prosthetic heart
valve.
iii. Jaundice – yellow discoloration of
the sclera of the eyes and/ or skin. Commonly associated with hyoerlipidemia
and coronary artery disease.
Thin brown lines in nailbed are associated

with congenital heart disease and cor
iv. Xanthelasma – yellowish slightly pulmonale.
raised plaque (fatty deposits)
evident on the skin usually found
along the nasal portion of one or
both eyelids.
c. Inspect nailbeds for splinter Indicative of dehydration due to volume

hemorrhages and clubbing (swollen depletion or overloading due to heart failure.
nail base and loss of normal angle).
d. Check for skin turgor.
i. Adult – check along the forehead
and the sternum.
ii. Pedia – check along the abdominal

area and the inner portion of the
thigh.
e. Check for presence of ecchymosis Indicative of bleeding problems or ruptured
(bruise) vessels.
f. Check for the presence of wounds and Non-healing wound would indicate arterial
scars. occlusion problems. Scars would tell the
examiner whether the patient has undergone
cardiac surgery or vascular repair.
10. Examine the arterial pulses bilaterally This gives an estimate of stroke volume.
focusing on the rate, rhythm and quality.
Take note of the following:
a. Amplitude (fullness), which depends

on pulse pressure.
b. Small volume pulse.
c. Large volume pulse May be from low stroke volume and
peripheral vasoconstriction (MI, shock,
constrictive pericarditis, vasoconstrictive
drugs)
Take into consideration the following factors:
Age, Gender, Exercise, Fever, Medications, May be from large stroke volume (Aortic
Hypovolemia. Stress, Position, Pathology and regurgitation, pregnancy, thyrotoxicosis,
Pulse sites. radycardia, patent ductus arteriosus)
The pulse sites to be assessed are as follows:

i. Temporal pulse
Used when radial pulse is not accessible.
ii. Carotid pulse
Reveals character of pulse in the proximal
aorta and provides indication of an
abnormality causing disease of left ventricle.
iii. Radial pulse
Readily accessible and is often used to get
the pulse rate.
iv. Apical pulse
Routinely used for infants and children up to
3 years of age.
v. Brachial pulse
Used to determine discrepancies and when
cardiac drugs are given.
vi. Femoral/ Inguinal pulse
Measures blood pressure. Often used during
arrest of infants.
vii. Popliteal pulse
Used in cases of cardiac arrest. Determines
circulation in the leg.
viii. Dorsalis pedis pulse
Used to determine circulation to the lower
ix. Posterior tibialis pulse leg.
x. Pulse Quality is noted as follows: Used to determine circulation to the foot.
▪ 0 – pulse not palpable or absent
▪ + 1 – weak, thready pulse, difficult to
palpate; obliterated with pressure
▪ +2 – diminished pulse; cannot be
obliterated
▪ +3 – eas to palpate, full pulse; cannot
be oliterated
▪ + 4 – strong, bounding pulse; ma be
abnormal
11. Assess respiration. Taking note of the Increases during compensatory response
rate, depth and respiratory pattern. wherein the lungs try to cope with oxygen
perfusion problems brought about by
decreased blood flow.
12. Assess the jugular vein pulse. Increased Jugular Vein Pressure and positive
jugular vein distention is indicative of right
sided heart failure. At 45 degrees, the
internal jugular vein should not be visible, or
a. Place the patient in a supine position higher than 3 cm.
with a small pillow underneath the
head.
b. Identify the internal jugular vein.
c. Elevate the head of the bed slowly up
to that point whering you can still
visibly see the jugular vein.
d. Get a ruler, place it at the sternal
angle.
e. Get another ruler or tongue depressor
and measure the vertical line (height)
between the sternal angle and the
highest level of pulsation.
13. Assess the heart through the chest wall.
The examiner must visualize the position of This will give the examiner an idea where the
the heart under the sternum and the ribs and heart might be located.
know certain landmark for identification of
specific structures and significant findings.
The following are the areas to be assessed:

a. Aortic area – 2nd intercostal space to
the right of the sternum
b. Pulmonic area – 2nd intercostal space to
the left of the sternum
c. Erb’s point – 3rd intercostal space to the
left of the sternum
d. Tricuspid area – 4th and 5th intercostal For some patients who are dextrocardic ( as
spaces to the left of the sternum confirmed in x – rays), the apex of the heart
is found pointing to the right and downward.
e. Apical / Mitral area – 5th intercostal
space left midclavicular line, the PMI,
point over the apex of the heart where
the apical pulse can be clearly heard.
f. Epigastric area – below the xiphoid
process
Inspection
a. Inspect the pericardium for any bulging, Normally there are no bulges.
heaving, or thrusting. Bulging might be indicative of cardiomegaly.
Heaving or thrusting migt be present in
patients with severe Mitral/Tricuspid valve
stenosis and regurgitation.
b. Look for the apical impulse An apical impulse may or ma not be
approximately in the 5th or 6th observable.
intercostals space at the midclavicular
line.
c. Note any other pulsation. Tangential There should be no other pulsations.
lighting is most helpful in detecting
pulsation.
Pulsations
a. Use the ball of the hand to detect Thrills sould not be present. This may
vibrations, or thrills, which ma be indicate incomplete closure of the valves and
caused b murmurs. Use the fingertips presence of regurgitation such as moderate
and/ or palmar surface to detect mitral/tricuspid valve stenosis and
pulsations. regurgitation.
b. Palpate for thrills and pulsation in Ordinarily, no heaving of the ventricle is felt,
each area (aortic, pulmonic, tricuspid, except possibly in the preganant female.
erb’s point, mitral and epigastric).
b.1. Begin in the aortic area and proceed
downward to the apex of the heart.
(The mitral area is considered the
apex of the heart).
b.2. In the tricuspid area, use the palm of
the hand to detect for any heaving or
thrusting of the pericardium.
b.3. In the mitral area, palpate for the
apical beat; identify the point of
maximal impulse (PMI) and note its
size.
Percussion
a. Outline the border of the heart or This gives the examiner an idea whether
area of cardiac dullness. cardiomegal might be present or mediastinal
shifting has occurred
b. Percuss outward from the sternum
with the stationary finger parallel to
the intercostals space until dullness is
no longer heard. Measure the
distance from the midsternal line in
centimeters.
Auscultation
a. Place the stethoscope in the pulmonic This is a systematic approach from the base
or aortic area. of the heart to the apex.
b. Begin by identifying the 1st (S1) and To aid the examiner in becoming familiar
2nd (S2) heart sounds. with the heart sounds of the patient as
baseline and e able to detect any
abnormalities along the course of
assessment.
In the aortic and pulmonic areas = S2 is

usually louder than S1.
In the tricuspid area, S1 and S2 are of the
most equal intensity and in the mitral area,
S1 is often slightly louder than S2.
c. Once the heart sounds are identified,
count the rate and note the rhythm. Normally, the heart sounds are regular, with
the rate of 6- - 100 (adult0. In the athlete or
jogger, the resting pulse may be 40-60 beats
per minute.
For children, the rate depends on the age of
d. Once rate and rhythm are the child.
determined, listen on each areas
systematically, first with the Occasionally, there may e splitting of S2 in
diaphragm and then with the bell. the pulmonary area. This is normal. Splitting
of S2 is best heard at the end of inspiration,
when right ventricular stroke volume is
sufficiently increased to delay closure of the
i. In aech area, listen to S1 and the to aortic valve.
S2 for intensity and splitting.
ii. Listen to the intervals one at a time

and note for any extra sounds or
murmurs. There are usually no extra sounds heard.
14. Assess the extremities and note for the
following:
a. Capillary refill time Provides the basis for estimating the rate of
peripheral perfusion.
Normally it is less than 3 seconds.
b. Vascular changes such as decreasing Gives a picture of the vessels, whether blood
quality of pulse, discomfort or pain, can still flow and reach the distal ends.
paresthesia, numbness, decrease in
temperature, pallor and loss of
movement.
Gives a picture of the structure of the blood
c. Presence of hematoma on puncture vessels and how fast coagulation and reapir
sites. takes place.
Indicative of volume overload-right sided

heart failure
d. Peripheral edema – distinguish pitting
from non-pitting and describe the
degree of edema in terms of depth in
pitting edema (grading depends on
what the hospital uses for grading, in
mm or in seconds)
Grading according to dept in mm
I – 2 mm deep
II – 4 mm deep
III – 6 mm deep
IV – 8 mm deep
15. Observe for the presence of the following
respirator manifestations:
a. Tachypnea Rapid, shallow breathing ma be noted in

patients who have heart failure or those who
are extremely anxious.
b. Cheyne-Stoke respiration (Note This indicates a decreased cerebral perfusion
for the duration of apnea) affecting the medulla oblongata.
c. Hemoptysis Pink, frothy sputum is indicative of acute

pulmonary edema brought about by cardiac
failure (Cor pulmonale)
d. Cough A dry, hacking cough from irritation of the

small airways is common in patients with
pulmonary congestion from heart failure.
e. Crackles Commonly seen in patiients with heart

failureor atelectasis associated with bed rest
– splinting from ischemic pain.
f. Wheezes Onl caused by compression of the small

airways by interstitial pulmonary edema.
16. Check for the presence of Hepatojugular This is indicative of portal congestion due to
reflux. right – sided heart failure.
a. Place the patient in recumbent

position.
Make sure the patient is in a relaxed
position.
b. Place your left hand beneath the RUQ

(at the back) and press firmly over the
RUQ for about 30 to 60 seconds and
note for a rise of 1 cm or more on the
Jugular Pulsations.
After care: Place the patient in a comfortable position and drape accordingly.
Documentation:
The following should be noted on the patient's chart:

a. Time of assessment
b. Informant
c. Chief complaint
d. Information from patient history
e. Detailed description of abnormalities
f. Reports of abnormal subjective data (e.g. pain, nausea)
g. Priority areas of assessment
h. Assessment procedure deferred to a later time and the reason why it was deferred
i. Ability of the patient to assist with assessment
STARTING AN INTRAVENOUS INFUSION
Definition:
Intravenous infusion is a method of replacing fluid loss, or correcting an electrolyte

imbalance. Intravenous infusions are used when patients need fluids, electrolytes, medications,
or nutritional supplements that cannot be taken orally or need to be given continuously.
Purposes:
1. To supply fluid when patients are unable to take in an adequate volume of fluid by
mouth.
2. To provide salts needed to maintain electrolyte balance.
3. To provide glucose (dextrose), the main fuel for metabolism
4. To provide water-soluble vitamins and medications
5. To establish a lifeline for rapidly needed medications
Before starting an infusion, the nurse must determine the following:
1. The exact orders (type of solution, the amount to be administered, rate of flow)
2. Whether the patient has any allergies (e.g. to tape or povidone -iodine)
3. The agency protocol about shaving the area before a venipuncture.
Infusion set
Container sterile parenteral solution
IV pole
Adhesive or non allergenic tape
Clean gloves
Tourniquet
Antiseptic swab
Antiseptic ointment, such as Povidone – Iodine (Betadine)
Intravenous catheter
Gauze squares or other appropriate dressings
Arm splint, if required
Towel or pad
ACTION RATIONALE
1. Prepare the patient. Explain the procedure. Patients often want to know how long the
process will last; eliminates anxiety.
2. Wash or disinfect your hands To minimize the transfer of microorganisms.
3. Open and prepare the infusion set.
ACTION RATIONALE
a. Remove tubing from the container and
straighten it out.
b. Slide the tubing clamp along the tubing
until it is just below the drip chamber
to facilitate its access.
c. Close the clamp.
d. Leave the ends of the tubing covered This will maintain the sterility of the ends of
with the plastic caps until the infusion the tubing.
is started.
4. Spike the solution container.
a. Remove the protective cover from
the entry site of the bag.
b. Remove the cap from the spike, and
insert the spike into the insertion
site of the bag or bottle (follow
manufacturer's instructions).
5. Hang the solution container on the pole. This height is needed to enable gravity to
a. Adjust the pole so that the overcome venous pressure and facilitate flow
container is suspended about 1 m of the solution into the vein.
(3ft). Above the client's head
6. Partially, fill the drip chamber with The drip chamber is partially filled with
solution. solution to prevent air from moving down the
a. For a flexible drip chamber squeeze tubing.
the chamber gently until it is half
full of solution.
b. For a firm drip chamber. The
chamber will usually fill
automatically.
7. Prime the tubing.
a. Remove the protective cap and hold The tubing is primed to prevent the
the tubing over a container. introduction of air into the patient’s vein. Air
Maintain the sterility of the end of bubbles in large amounts (eg. 10 ml) can
the tubing and the cap. create emboli in the bloodstreams. However,
b. Release the clamp and let the fluid air bubbles smaller than 0.5 ml usually do not
run through the tubing until all cause problems in peripheral line.
bubbles are removed. Tap the
tubing if necessary with your fingers
to help the bubbles move.
c. Reclamp the tubing and replace the
tubing cap, maintaining sterile
technique.
ACTION RATIONALE
d. For caps with air vents, do not
remove the cap when priming the
tubing. The flow of solution
through the tubing will cease when
the cap is moist with one drop of
solution.
8. Apply appropriate labels to the solution For proper identification of the patient.
container. Include the patient's name,
date and note time the infusion started.
9. Wash hands. To eliminate the transfer of microorganisms
that could cause infection.
10. Select and prepare the venipuncture site. Veins can become sclerotic from irritation by
Starting at the distal end of the vein, select the infusion or needle. Sclerosis may then
a site by palpating accessible veins. interfere with venous flow. If so, use more
proximal parts of the veins.
11. Dilate the vein.
a. Place the extremity in a dependent Gravity slows venous return and distends the
position (lower than the patient's veins.
heart)
b. Apply a tourniquet firmly 15-20 cm. (6- Distending the veins makes it easier to insert
8 in) above the venipuncture site. The the needle properly.
tourniquet must be tight enough to
obstruct venous flow but not so tight Obstructing arterial flow inhibits venous filling.
that it will occlude arterial flow. If a radial pulse can be palpated, the arterial
flow is not obstructed.
c. If the vein is not sufficiently dilated:
i. Massage or stroke the vein distal to This action helps fill the vein.
the site and in the direction of the
venous flow toward the heart.
ii. Encourage the patient to clench and Contracting the muscles compresses the distal
uncleanch the fist rapidly. veins, forcing blood along the veins and
distending them
iii. Lightly tap the vein with your fingertips. Tapping may distend the vein.
d. If the above steps fail to distend the Heat dilates superficial blood vessels, causing
vein so that it is palpable, remove the them to fill.
tourniquet, and apply heat to the
entire extremity for 10-15 min. Then
repeat the steps above.
ACTION RATIONALE
12. Don clean gloves and clean the Gloves protect the nurse form contamination
venipuncture site. by the patient's blood.
a. Clean the skin at the site of entry with To lessen the microorganisms present on the
a topical antiseptic swab (eg. Alcohol) site of entry.
and then an anti-infective solution such
as povidone-iodine. (Betadine)
b. Use a circular motion, moving from the This motion carries microorganisms away from
center outwards for several inches. the site of entry.
c. Permit the solution to dry on the skin. Povidone-Iodine should be in contact with the
skin for 1 minute to be effective.
13. Insert the catheter and initiate the
infusion.
a. Use one thumb to pull the skin taut This stabilizes the vein and makes the skin taut
below the entry site. for needle entry. It can also make initial tissue
b. Insert the catheter by the direct or penetration less painful.
indirect method. The direct method is
preferred for larger veins and the
Indirect method for smaller veins
c. For the direct method, hold the needle
catheter over the desired venipuncture
site with the level up, at a 15-30
degree angle and insert the catheter
through the skin, into the vein in one
thrust.
d. For the indirect method, hold the
needle at a 30 – 40 angle, pierce the
skin, then reduce the angle until it is
almost parallel to the skin and advance
the needle into the vein. Sudden lack
of resistance is felt on the vein.
e. Once blood appears in the lumen of
the needle or you feel the lack of
resistance, then advance the needle so
that it is inserted 2.5 cm (1 in).
f. Release the tourniquet.
g. Remove the protective cap from the
distal end of the tubing, and hold it
ready to attach to the catheter,
maintaining the sterility at the end.
ACTION RATIONALE
h. Attach the end of the infusion tubing
to the catheter hub.
14. Tape the catheter.
a. Place a small gauze dressing under the This will support the catheter in position.
hub.
b. Tape the catheter by the U method or
according to manufacturer's
instructions. Using three strips of
adhesive tape, each about 7.5 cm (1 in)
long.
i. Place one strip, sticky side up, under
the catheter's hub.
ii. Hold each end over so that the
sticky sides are against the skin.
iii. Place second strip, sticky side down,
over catheter hub.
iv. Place third strip, sticky side down,
over tubing hub.
15. Dress and label the venipuncture site and
tubing according to agency policy.
a. In some agencies, the nurse puts a
small amount of antiseptic ointment,
such as Povidone-Iodine, over the
venipuncture site, and then a gauze
square. In other agencies, a sterile
transparent occlusive dressing is
applied after the ointment.
b. Remove soiled gloves and discard This permits assessment of the site without
appropriately. disturbing the dressing. This type of dressing
can be left on for 72 hours, and then changed.
c. Loop the tubing, and secure it to the Looping and securing the tubing prevent the
dressing with tape. weight of the tubing or any movement from
pulling on the needle or catheter.
d. Label on a piece of tape, the date and

time of insertion, type and gauge of
needle or catheter used, and your
initials. Apply the tape over the
venipuncture dressing.
ACTION RATIONALE
16. Ensure appropriate infusion flow
a. Apply a padded arm board (folded
towel on a board) to splint the elbow
or wrist joint, as needed.
b. Adjust the infusion rate of flow To keep the venipuncture site intact.
according to the order.
17. Label the IV tubing
a. label tubing with date, time of The tubing is labeled to ensure that it is
attachment and initials. This labeling changed at regular intervals (ex. Every 24.72
may also be done when the infusion is hours according to agency policy).
started.
18. Document relevant data, including
assessment.
a. Record the start of the infusion on the Documentation as basis for evaluation and
patient's chart. Some agencies provide continuity of care.
a special form for the purpose. Include
the date and time of the venipuncture,
amount and type of solution used,
including any additives (e.g. kind and
amount of medications); absorption
time, container number; drip rate, type
and gauge of the needle or catheter;
venipuncture site; and the patient's
general response.
Illustration 1: TOP: Dorsum of the
hand BOTTOM: Dorsal Plexus of
the foot
SITES FOR IV INSERTION
CHANGING INTRAVENOUS BAG OR BOTTLE
Definition:
Replacement of the intravenous solution containers when only a small amount of fluid remains
in the drip chamber.
Purposes:
To maintain the flow of required fluids.
Container with the correct kind and amount of intravenous solution
Obtain the correct bag or bottle of fluid, using the three checks. The three checks to ensure
that it is the correct fluid ordered.
1. The right patient receives the right IV fluid at the right time
2. The correct IV fluid is infusing at the right time
3. The IV dressing is intact. The site is clear.
ACTION RATIONALE
1. Wash or disinfect your hands. To prevent or minimize the transfer of
microorganisms that could cause infection.
2. Identify the patient, using 2 identifiers. To make sure that the right patient receives
the IV fluids.
3. Explain what you are going to do, if Explaining what will be done helps to alleviate
appropriate. There may be no need to the patient's anxiety or fear. It is also an
awaken the patient if he or she is asleep excellent time for patient teaching.
because you can change the container
without disturbing the patient. The
companion may be asked to ensure the
identity of the patient.
4. Remove the cover from the entry port and So that it will be within easy reach for
place the IV bag or bottle on the bedside connection.
ACTION RATIONALE
stand or table.
5. Turn off the IV flow using the slide or To prevent the drip chamber to be empty
screw clamp, or if the IV is on a pump, while in the process of changing the bag.
turn the pump to the correct mode.
6. Invert the old IV bag or bottle To prevent any remaining fluid from spilling on
the floor.
7. Remove the tubing spike from the old IV Touching the tubing will contaminate it and
bag. Be careful not to contaminate the consequently contaminate the fluid.
tubing spike by touching it with your hand.
8. Insert the tubing spike into the new IV bag To gain access to the fluid in the new IV bag or
or bottle. bottle, and resume intravenous infusion.
9. Invert the new bag and hang it on the IV For convenience and safety.
pole.
10. Turn on the flow and regulate the rate. For each IV bag or bottle, the IV rate should be
verified and checked so that the IV is infusing
at the ordered rate.
12. Wash or disinfect your hands. To minimize the transfer of microorganisms
that could cause infection.
13. Document:
a. Time of IVF change and exact contents Documentation as basis for evaluation and
of new IV bag/bottle. continuity of care.
b. Volume of fluid infused from the
previous IV bag/bottle.
c. Assessment of IV site and dressing
according to the policies of the hospital
or facility.
d. The right patient received the right IVF
at the right time.
e. The right IVF is infusing at the right
rate.
f. The IV dressing it intact, and the site is
clear.
DISCONTINUING AN INTRAVENOUS INFUSION
Important: Infusions are usually discontinued for any of the following reasons:
1. The patient's oral fluid intake and hydration status are satisfactory, therefore no further
IV solutions are ordered.
2. There is a problem with the infusion that cannot be fixed.
3. The medications administered by the intravenous route (e.g antibiotics) are no longer
required.
1. Before removing a catheter or needle from the vein, determine whether a sterile
injection cap (heparin or saline lock) should be attached to the catheter so that
intravenous medications can be administered intermittently.
2. Assess appearance of the venipuncture site and take note of any bleeding, as well as the
amount of fluid infused.
Equipment/Marerials:
Clean gloves
Dry or antiseptic – soaked swabs according to agency practice.
Small sterile dressing and tape
ACTION RATIONALE
1. Prepare the equipment
a. Clamp the infusion tubing. Clamping the tubing prevents the fluid from
flowing out of the needle, on the patient, or
on the bed.
b. Loosen the tape at the venipuncture Movement of the needle can injure the vein
site while holding the needle firmly and and cause discomfort to the patient. Applying
applying counter pressure on the skin counter pressure prevents pulling the skin
at the venipuncture site. and causing discomfort.
c. Don clean gloves, and hold a sterile Gloves prevent direct contact with the
gauze on the venipuncture site. patient's blood.
The Sterile gauze prevents contamination of
the venipuncture site.
2. Withdraw the needle or catheter from the
vein.
a. Withdraw the needle or catheter by Pulling out in line with the vein prevents injury
pulling it out along the line of the vein. to the vein.
ACTION RATIONALE
b. Immediately apply firm pressure to the Pressure helps stop the bleeding and prevent
site, using sterile gauze, for 2-3 hematoma formation.
minutes.
c. Raise the patient's arm or leg above Raising the limb decreases blood flow to the
the level of the body if any bleeding area.
persists.
3. Examine the catheter removed from the If a piece of tubing remains in the patient's
patient. vein it could move centrally (toward the heart
a. Check the catheter to make sure it is or lungs) and cause serious problem.
intact.
b. Report a broken catheter to the nurse

in charge or physician immediately.
c. If the broken piece can be palpated, Application of a tourniquet decreases the

apply a tourniquet above the insertion possibility of the piece moving, until a
site. physician is notified.
4. Cover the venipuncture site. To protect the venipuncture site from
a. Apply the sterile dressing. contamination.
b. Discard the IV solution container, if
infusion is to be discontinued and
discard the used supplies
appropriately.
5. Document all relevant information. Documentation as basis for evaluation and
a. Record the amount of fluid infused on continuity of care.
the I & O record of the chart, according
to agency or hospital practice. Include
the type of solution used, the time
when the infusion was discontinued
and the patient's response.
ADMINISTERING A BLOOD TRANSFUSION
Definition:
A blood transfusion is the intravenous administration of a component of blood or whole blood.
Purposes:
1. To increase blood volume after surgery, trauma or hemorrhage

2. To increase the number of RBC in a patient with severe anemia
3. To provide platelets to patients with low platelet counts after treatment e.g.
chemotherapy
4. To provide clotting factors in plasma,
5. To replace plasma proteins such as albumin
1. Assess the patient and validate the indication for blood transfusion.
2. Review the patient’s blood transfusion history and note for any reactions or pre
transfusion medications to be given.
3. Review the baseline vital signs on the patient's medical record to compare with those
during the transfusion.
4. Assess the integrity and patency of the venous access and ensure that it is in place, so
that the transfusion will be completed without infiltration of the IV site.
5. Verify that a large-bore catheter (G18 or 19) is to be used. This prevents hemolysis since
RBCs are large and will not flow through a small – bore needle.
6. Review institution policies and procedures for the administration of blood products.
Each institution has its own policies to ensure safe administration of blood products.
7. Ensure that the patient has signed an informed consent for the procedure.
Blood transfusion set and filter

IV solution of 0.9% NACL (Normal Saline)
Disposable gloves
Infusion pump if compatible with the specific blood product
Tape
Leukocyte – depleting filter, if ordered
Blood component infusion rates
Product Infusion Rate
Red blood cells 1 unit over 2-3 hours (< 4 hours)

Platelets 30-60 minutes or more slowly (< 4 hours)
Fresh frozen plasma 200 ml / hr. or more slowly
Cryoprecipitate 1 – 2 ml/min.
ACTIONs RATIONALE
1. Verify the physician’s order for the Blood must be ordered by an authorized
transfusion health care provider.
2. If a venipuncture is necessary, refer to the Ensures a patent and adequate vein for
procedure on venipuncture. infusion of blood.
3. Explain procedure to the patient Ensures that patient understands the
procedure and minimizes anxiety.
4. Review side effects (dsypnea, chills, Prompt reporting of a side effects will lead to
headache, chest pain, itching, etc) with earlier discontinuation of transfusion and
patient and ask him or her to report these minimizes untoward reactions.
to the nurse.
5. Have the patient sign consent forms Most institutions require the patient to sign a
consent form.
6. Obtain baseline vital signs To provide basis for comparison in the
assessment of untoward reactions to the
transfusion.
7. Obtain the blood product from the blood Delay in initiating the infusion will promote
bank within 30 minutes prior to the bacterial growth and destruction of RBC.
infusion.
8. Verify and record the blood product and Strict verification procedures will reduce the
clarify with another nurse, the following:. risk of administering blood products to the
wrong patient. If there is an error during the
a. Patient's name, blood group, RH type procedure, notify the blood bank and do not
b. cross-match compatibility administer the product.
c. donor blood group and RH type
d. unit and hospital number
e. expiration date and time on blood bag
f. type of blood product compared with
health care provider's order
g. presence of clots in blood
ACTIONs RATIONALE
9. Instruct patient to empty the bladder. A urine specimen after initiation of the
transfusion might be needed if a transfusion
reaction occurs.
10. Wash hands and put on gloves Reduces transfusion of microorganisms and
eliminates risk of being infected with HIV,
hepatitis or blood-borne bacteria.
11. Open blood administration kit and move Closed roller clamps prevents accidental
roller clamps to OFF position. spilling of blood.
12. For Y – tubing set: The Y-tubing allows the nurse to switch from
infusing NSS to blood. This is especially helpful
when multiple transfusions are given. Follow
institutional guidelines for the number of units
that can be given before tubing needs to be
changed.
a. Spike the Normal Saline bag and open Dextrose Solutions are not used with blood
the roller clamp on the Y-tubing transfusion Dextrose promotes clotting of the
connected to the bag and the roller donor blood.
clamp on the unused inlet tube until
tubing from the Normal Saline bag is
filled. Close clamp on unused tubing.
b. Squeeze sides of drip chamber and A correctly filled chamber enables an accurate
allow filter to partially fill. drip count.
Removes all air from tubing system
c. Open lower roller clamp and allow
tubing to fill with Normal Saline to the
hub.
d. Close lower clamp Prevents wastage of IV fluid.
e. Invert blood bag once or twice. Spike Equal distribution of cells prevents clumping,
blood bag and open clamps on inlet which can lead to clotting of cells. Fragile
tube to allow blood to cover the filter blood cells may be damaged if they drop on an
completely. uncovered filter.
f. Close lower clamp. Prevents blood from flowing until tubing is

attached to venous catheter.
For single – tubing set:
13. Spike blood unit Connects tubing to blood unit.

ACTIONs RATIONALE
14. Attach tubing to venous catheter using Allows the blood product to be infused into
sterile precautions and open the lower the patient's vein.
clamp
15. Infuse the blood at a rate of 2-5 ml/min. Packed RBC usually can run for 1 ½ – 2 hours
According to the health care providers and whole blood can run for 2-3 hours.
order.
16. Remain with patient for the first 15-30 If a reaction occurs, it generally happens
minutes, monitoring vital signs every 5 during the first 15-30 minutes. Change in vital
minutes for 15 minutes and every 15 min. signs is indicative of transfusion reaction.
for 1 hour, and then hourly until 1 hour
after the infusion is completed or
according to the policy of the institution.
17. After the blood has been infused, allow The allow the complete infusion of the
the tubing to be flushed with normal remaining blood in the tubing.
saline.
18. Appropriately dispose of bag, tubing and Reduces transmission of microorganisms
gloves. Wash hands
19. Document the procedure Ensures accurate records.
Evaluation:
▪ Observe for signs of transfusion reaction

▪ Observe patient and laboratory values to determine response to transfusion.
▪ Monitor patient for signs and symptoms of fluid overload
Documentation:
▪ Record patient‘s name; ID number; blood component and component number; names
of individuals verifying blood component; name of individual starting and ending the
transfusion; time started and ended; volume transfused; and reaction if any.
▪ Record date, time, type and amount of blood product administered.
▪ Document the condition of the venipuncture site and the patency of the IV line.
▪ Describe patient's response to transfusion, including change in laboratory values and
recovery from the symptoms.
▪ Record volume of blood component transfused and urine output, if indicated and
necessary.
▪ Record additional medication given to prevent or manage transfusion complications (ex.
Acetaminophen, Diphenhydramine, Furosamide)
▪ Document the diagnosis and the treatment for any transfusion reaction.
Administering a Blood Transfusion
1. Prime in-line filter 2. Start transfusion slowly
3. Assess vital signs

CENTRAL VENOUS PRESSURE (CVP)
CATHETER INSERTION and HEMODYNAMIC MONITORING)
Assisting in INSERTION OF CENTRAL VENOUS PRESSURE CATHETER
Definition:
(CVP) Central Venous Pressure catheter is a multiple lumen radiopaque catheter

inserted into the major veins of the body: jugular vein, subclavian vein, and femoral veins.
Purpose:
To provide a route for the administration of medications and nutritional support that
should not be given via a peripheral route or when standard peripheral routes cannot be used
or are contraindicated. Likewise, through this catheter, the central venous pressure may be
measured and monitored.
1. Venous pressure is usually elevated in congestive heart failure; acute or chronic

constrictive pericarditis; venous obstructions by a clot in veins or external pressure
against a vein.
2. Observe strict infection precaution when performing the procedure considering the
location of the site, the large opening for insertion, and that fluids with high glucose
content increase patient’s vulnerability to infection.
3. A plastic catheter is threaded usually through an arm or neck vein, into the superior
vena cava just before it enters the right atrium of the heart.
4. Measurement of the pressure at the tip of the catheter provides an index of the right
atrial filling pressure.
5. Central venous pressure line insertion is a procedure only physicians and specially
trained Critical Care Nurses or Registered Nurses, are authorized to perform. This
procedure is not delegated to unlicensed personnel.
Sterile gloves Sterile hyponeedle G 18 – 20

Sterile gauze 4x4, 2x2 Sterile cotton balls
Manometer Xylocaine/Lidocaine 2%
3 way stopcock Suture with needle holder
Antiseptic (Betadine) Sterile saline solution
Sterile syringe 5, 10, 20cc Micropore tape
Catheter insertion kit (central line with introducer, guide wire, dilators, blade, towels & drapes)
ACTION RATIONALE
1. Perform hand hygiene and organize Reduces microorganism transfer and
equipment promotes efficiency.
2. Arrange supplies on tray, using appropriate Promotes efficiency in movement, and time
size of gloves for physician. management.
3. Reinforce explanation of procedure to Minimizes patient’s anxiety.
patient. Clarify that his/her face will be
covered with towels or drapes but that you
will be nearby.
4. Prior to the Central venous pressure Dilates vessels in upper trunk and neck; puts
line insertion, put the bed and patient in less pressure on diaphragm and facilitates
Trendelenberg position. If patient has breathing.
respiratory distress, place in supine
position with feet elevated 45 to 60
degrees.
5. Hold patient's hands; get assistance and Provides comfort; prevents disruption of
restrain both hands if patient is restless or procedure or contamination of sterile field.
confused.
6. Inform patient of the process of the Prepares patient for the discomfort; helps to
procedure, particularly when needle decrease startle reaction.
insertion is to occur.
7. Monitor patient for respiratory distress, Allows for early detection of complications
complaints of chest pain, dysrhythmias, or such as pneumothorax, or air embolism.
other problems.
8. After the vein has been punctured and the Prevents air from being sucked into the vein
physician has removed the syringe from the by increasing intrathoracic pressure.
insertion needle and inserted a guidewire
through the needle (central line) instruct
the patient to take a deep breath and to
bear down (Valsalva maneuver) while the
guidewire is being inserted.
9. As the multilumen central venous pressure Indicates the presence of the catheter in the
catheter is inserted over the guidewire into vein and removes air from the catheter tubing
the vein, and the guidewire is withdrawn, before infusion of fluid.
observe for blood backing up into the
lumen of the catheter aseptically aspirate
air from the catheter and then flush saline
through each lumen.
10. Apply IV lock and cap to the lumen of the Maintains sterility of the lumen and
ACTION RATIONALE
catheter. establishes a closed system to minimize blood
loss and the introduction of air.
11. Once the catheter is in place and sutured, Protect IV site from air, leaks, and
apply sterile gauze or transparent dressing microorganism contamination, but keep the
and if needed tape dressing ecurely. catheter tubing and insertion site visible.
12. Arrange for chest x-ray and then begin Verifies that the catheter tip is in the vena
regular infusion rate after catheter position cava or right atrium before large amounts of
has been confirmed. fluid are infused.
13. Position patient appropriately; instruct to Promotes patient’s feeling of safety; allows
verbalize or report any respiratory distress early detection of complications.
or pain.
14. Record the procedure done For documentation purposes.
Different types of CVP Catheters
ELECTROCARDIOGRAPHY (ECG)
Definition:
Graphic representation of electrical impulses generated by the heart during a cardiac

cycle; identifies abnormalities that interfere with electrical conduction through cardiac tissue.
Indication:
1. Diagnosis of overt or suspected cardiovascular disease. Follow-up recordings are

indicated when there is a change in clinical status.
2. Assessing the results of therapy
3. In subjects at risk of heart disease, usually below 40 years old, without evidence of
cardiovascular disease but with two or more of the following risk factors: a)
hypercholesterolemia; b) diabetes; c) obesity; d) smoking; e) hypertension; or f)
family history of heart disease. Frequent follow-up recording is usually not indicated
unless signs or symptoms of heart disease appear.
4. In selected subjects with fewer risk factors whose occupations magnify the
consequences of a heart attack or arryhythmia (e.g., commercial airline pilots or bus
drivers).
5. Before surgical intervention as an aid in the diagnosis and management of preoperative
conditions or subsequent postoperative complications. However, it should be
emphasized that definitive data regarding the utility of electrocardiography as a routine
baseline preoperative procedure may not be available.
6. Assessing cardiac effects of systemic diseases or conditions such as renal failure, diabetic
acidosis and hypothermia, electrolyte abnormalities and potential cardiotoxic effects of
drugs.
1. Positioning is particularly important when serving patients with chest deformities or

large breasts. Patients maybe asked to displace the breasts to ensure proper electrode
placement.
2. While obtaining a 12-lead ECG, the patient should be as still as possible in a semi-
reclined position, breathing normally. Any repetitive movement will cause artifact and
could lead to inaccurate interpretation of ECG.
3. Comparisons of ECG taken at different times will be valid only when electrode
placement is accurate and identical at each test.
4. Jewelries or any metals attached to the patient's body should be removed before the
procedure as this may interfere with the electrical current of the machine or give
inaccurate result. Patient's with internal or external fixators or any metal device needed
for physiologic support can proceed with the test but must be noted or documented.
ECG machine
Electrode paste gel
ECG leads or electrodes
Alcohol wipes
Razor
Tissue paper
ACTION RATIONALE
1. Verify physician' order. The procedure should be validly indicated
2. Identify patient by checking arm band and To ensure performing the procedure on the
having patient state the name. (if able to right patient.
do so).
3. Introduce yourself to patient, including Patients have the right to know what will be
both name and title or role,and explain done and by whom. (Note: Some patients may
what you plan to do. hesitate to allow students to perform the
procedure).
4. Explain the procedure and the reason it is Understanding what is being done enhances
to be done in terms the patient can patient's ability and willingness to cooperate.
understand. The patient has the right to relevant, current
and understandable information.
5. Wash hands. Handwashing is the most important technique
in precaution and control of the transmission
of microorganisms.
6. Gather the materials needed. To promote organized movements and time
7. Adjust the bed to appropriate height and management.
lower side rail on the side nearest you. This minimizes muscle strain on care givers
and helps
prevent injury and fatigue.
8. Provide privacy for patient. Position and To gain the trust of the patient.
drape as needed (supine or semi reclined).
9. Perform the procedure:
a. Cleanse and prepare skin; wipe site Facilitates the adherence of the leads to chest
with alcohol. or extremity.
b. Apply electrode paste and attach Position of leads promotes proper display of
leads for 12-lead ECG. (four leads ECG on paper.
are placed on the limbs and six leads
are placed on the chest)
(i) Limb leads – electrodes should be To ensure good contact between the skin and
placed on a flat surface above the the electrodes for the limb leads.
wrists or ankles.
(ii) Chest (Pericardial leads)
V1 – Fourth intercostals space (ICS) at
right sternal border
V2 – Fourth ICS at left sternal border
V3 – Midway between V2 and V4
V4 – Fifth ICS at midclavicular Line
V5 – Left anterior axillary line at level
of V4 horizontally
V6 – Left midaxillary line at level of
V4 horizontally
c. Obtain tracing; 12 lead ECG may be Transfers electrocardiac conduction on ECG

obtained without removing tracing paper for subsequent analysis by
pericardial leads cardiologist
d. Disconnect leads, wipe excess Promotes hygiene and comfort
electrode paste from chest and wash
hands. Assist patient to a position of
comfort.
e. Deliver ECG tracing to physician. For interpretation and aid in establishing
diagnosis.
10. Store or remove and dispose soiled To keep the unit orderly and prepare for the
supplies and equipment. next patient.
11. Wash hands For self hygiene, and prevent spread of
possible contamination.
12. Document patient’s response and For continuous follow-up and assessment
expected or unexpected outcomes.
CAPILLARY BLOOD GLUCOSE (CBG)
Definition:
Blood glucose monitoring is a measurement of glucose in the blood that can be done at
any time by the aid of a portable measuring machine. It can be a self-test for the diabetic.
Purpose:
1. To determine level of glucose in blood

2. To promote stricter blood glucose regulation or management.
3. To evaluate the impact of food, activity or medications on diabetes.
4. To identify when changes in the treatment plan are needed.
1. Plan time for patient teaching during the blood glucose testing procedure.
2. If the patient is a child, consider the developmental stages and assess the child's ability
to understand and perform the procedure.
3. Reinforce teaching including family members.
Blood glucose monitor

Test strips for blood glucose monitor
Non- sterile gloves
Lancet
Automatic lancet device
Alcohol wipes
Watch with seconds hand
Receptacle for sharps and other wastes.
ACTION RATIONALE
1. Perform hand hygiene and organize Reduces microorganism transfer, promotes
equipment. efficiency
2. Explain procedure to patient and inquire Promotes cooperation and sense of
about finger preference for puncture site. involvement and control
3. Calibrate glucose machine: Ensures that results obtained are accurate
a. Turn machine on and put glucose strip
on the monitor.
ACTION RATIONALE
b. Compare number/code on machine
with number on bottle or box of test
strips.
4. Remove chemical strip from container and Prevents delay once sample is obtained
place it in the glucose testing machine
(following the manufacturer's instructions
guide).
5. Load lancet in lancet device; set trigger Prepares injector for lancet puncture
6. Don gloves Prevents direct exposure to blood
7. Hold preferred finger down and squeeze Promotes blood flow in area for ease in
gently from lower digit to fingertip. specimen collection.
8. Wipe puncture site with alcohol pad. Removes dirt and skin oils and decreases
microorganisms.
9. Place injector against the side of the finger
where there are lesser nerve endings and Facilitates obtaining sufficient amount of
release trigger. blood with minimal pain.
10. Wipe away the first drop of blood from the This drop may impede accurate results
site. because it may contain a large amount of
serous fluid.
11. Gently squeeze the site to produce a large The drop of blood should be sufficient enough
drop of blood. to cover the test pad on the reagent strip. (Do
not contaminate site by touching it).
12. Hold chemical strip under puncture site Ensures that indicator squares are covered
and apply blood on the strip. The droplet with blood; prevents uneven exposure of
should drop on the strip without smearing. indicators, which would lead to inaccurate
results.
13. If necessary, press the timer button of Activates timing mechanism as necessary.
machine as soon as blood has covered ( Note: Timing differs from machine to
indicator the squares on the test strip. machine, depending on manufacturer.)
Most machines automatically begin timing
and require no action to start timing once
the blood makes contact with the strip.
14. Apply pressure to puncture site using To stop the bleeding. Reduces risk of needle
alcohol- soaked cotton ball, until bleeding prick infection and injury.
stops.
15. When timer indicates that the appropriate Ensures accurate reading.
time has been reached, read glucose value
on digital screen.
ACTION RATIONALE
16. Discard soiled materials and gloves in Reduces risk of infection transmission.
proper container.
17. Record results on glucose flow sheet; Maintain record of glucose levels.
notify physician for abnormalities and
administer insulin if indicated.
18. Position patient appropriately. Promotes comfort and safety.
19. Wash hands after the procedure. Reduces transfer of microorganisms.
ADMINISTRATION OF OXYGEN
Purpose:
To provide the amount of Oxygen necessary to prevent or overcome hypoxia.
1. Observe Oxygen safety precaution:

a. Place a warning signage “Oxygen ON - NO SMOKING” in clear view.
b. Keep open flames and sparks away from where the Oxygen is being administered
c. Use cotton blankets instead of woolen materials, in order to eliminate static electricity.
d. Discontinue temporarily the Oxygen flow when electrical equipment such as X-ray, ECG
apparatus, etc. are in use.
e. If a local application of heat is indicated, avoid the use of electrical heating pad.
f. If using Oxygen supplied in cylinder, refrain from using oil or grease on any part of the
equipment.
2. Insure proper concentration of Oxygen by:

a. Checking frequently Oxygen supply and rate of Oxygen flow.
b. Avoiding leakage
3. When using a newly-opened cylinder, crack the valve before bringing to the patient's
bedside.
4. Provide for adequate humidification of Oxygen
5. Insure a patent airway
6. Observe patient’s reaction to Oxygen therapy.
7. Insure the patient’s comfort.
ADMINISTRATION OF OXYGEN BY NASAL CATHETER AND/OR CANNULA
Definition:
It is the administration of Oxygen by the use of nasal catheter or nasal cannula.
1. Keep the catheter patent by frequent cleaning or changing as necessary.

2. Check for leaks in the humidifier and maintain desired amount of water.
3. Observe for occurrence of abdominal distention, dyspnea, cyanosis or any untoward
reaction.
4. Maintain frequent naso-oral hygiene.
Oxygen cylinder
Oxygen regulator
Bubbling bottle with rubber tubings
Adjustable wrench
Nasal Catheter Fr. 12 or 14 (for adult)
Fr. 8 or 10 (for children)
Plaster
Patient and Unit:

1. Instruct the patient on safety precautions
2. Explain the importance of the therapy
ACTION RATIONALE
1. If using oxygen cylinder, crack the valve Cracking blows out particles of dust which may
before bringing to the patient's bedside. have lodged at the opening of the tank. It is
Attach regulator making sure there is no also a way of checking the condition of the
leakage. Tighten notch with an adjustable oxygen tank and the regulator.
wrench.
If using piped-in Oxygen, attach regulator The regulator provides information as to

directly to oxygen outlet on the wall. content and rate of oxygen flow.
2. Attach the tubing connected to the Oxygen when passing through water is
immersed tube of the bubbling bottle and humidified thus prevents drying up and
connect to oxygen outlet. irritation of mucous membranes.
ACTION RATIONALE
3. Connect the nasal catheter Fr. 12-14 to the A small catheter can easily pass through the
other tubing of the bubbling bottle. nose causing less discomfort for patient.
4. Before inserting the nasal cannula, measure The estimated length is equivalent to the
the distance from the tip of the nose to the distance from the entrance of the nose to the
ear lobe. This represents the desired length oropharynx.
of the catheter to be inserted.
5. Open the tank valve. Adjust the flow liter Relief of hypoxia necessitates administration
to desired rate as specified by the physician of adequate concentration of Oxygen.
or at 4-6 L/min.
Test Oxygen flow prior to catheter insertion. High rates of Oxygen flow produces irritation
and dryness of mucous membrane due to
forceful stream exerted against it.
6. Hold the catheter up and allow to drop This prevents friction which may irritate
naturally. Locate the tip and apply water mucous membrane.
soluble lubricant, or dip in clean water. The use of water or water soluble lubricant
prevents harmful effects as lipoid pneumonia.
7. With the patient's nose tip held up or chin Such action facilitates catheter insertion from
raised, gently insert the catheter tip into the nares to oropharynx passing it beneath the
the nares downward. concha inferior.
Move catheter till the point measured (as Gag reflex is stimulated if catheter is inserted
in step no. 4 ) is reached – the oropharynx. beyond oropharynx.
8. Check position of catheter by instructing It should be behind the uvula to favor easy
patient to open mouth. Depress tongue inspiration of oxygen stream.
and see if catheter tip is visible behind the Moist nasal mucosa and weight of the
uvula. If not, adjust. catheter may cause it to get dislodged if not
anchored properly.
9. Secure catheter in place with a tape with a To prevent the nasal cannula from being
slight upward pull to side of patient's accidentally pulled out. For easy cleaning of
cheek or on the bridge of the nose. nasal secretions that may collect, and clog the
opening of the catheter.
10. Inspect Oxygen and patency of oxygen Prolonged irritation can cause ulceration of
catheter at frequent intervals. Clean or mucous membranes.
change P.R.N. For reinsertion, insert in
opposite nostril.
11. After the procedure, record. Documentation as basis for evaluation and
a. time therapy was started continuity of care.
b. the treatment done
c. rate of Oxygen flow per minute
d. method of administration
ACTION RATIONALE
e. reaction of patient to the therapy
Note color, respiration and pulse.

OROPHARYNGEAL AND/OR NASOPHARYNGEAL SUCTION
SUCTIONING
Definition:
It is a method of aspirating mucus or other secretions and/or fluids from the nose,
mouth, and pharynx, using a suction catheter attached to a suction apparatus.
Purpose: To maintain patent airway on patient whose swallowing reflex is limited as in cases
of:
a. A patient recovering from anesthesia

b. An unconscious patient
c. A critically ill patient
1. Suction catheter maybe inserted through the nostril if the mouth cannot be opened or
access through the teeth is impossible.
2. Coughing is encouraged while the catheter is being inserted in order to expel mucus
blocking the bronchi.
3. Switch off the Suction or pinch the suction catheter when inserting it.
4. Patient should be given a chance to breathe in between suctioning to avoid creating
oxygen deficit. Limit period of suctioning at 20 seconds interval.
Suction machine Tongue depressor PRN

Catheter Tissue paper
Bottle with tap water
ACTION RATIONALE
1. Assemble equipment and take to the Good organization of work will prevent
bedside. unnecessary loss of time and energy.
2. Check suction machine's working condition This prevents unnecessary discomfort to
by connecting catheter and test by patient.
suctioning water from a clean bottle.
3. Positioning: To facilitate drainage of secretion, in a most
a. Unconscious patients: head flat on one comfortable manner.
side.
b. Alert and conscious patients: semi-
ACTION RATIONALE
fowler's or sitting position with head tilted
forward.
4. Clean nares of mucus if suctioning is To get rid of obstacle hence facilitate the
through the nose. suctioning.
5. Grasp catheter about 6 inches from the tip To eliminate sucking of mucosal lining.
and gently pass it into the mouth and down
into the throat with the suction switched
off.
6. Apply suction intermittently while moving To minimize discomfort for the patient.
the catheter around gently to aspirate
mucus using a Y connector or Y – type
suction catheter , while doing so place
finger over the control bent intermittently.
7. Continue suctioning until no more To maximize the opportunity for carrying out
secretions can be aspirated. the purposes of suctioning and to do it very
efficiently at the given opportunity; and to
make it worth the discomfort experienced by
the patient at the given moment.
8. Withdraw the catheter, rinse and place in a To minimize the possibility of harboring
bottle with antiseptic solution. Label the microorganisms.
bottle oral/nasal. This facilitates proper identification or
recognition of the equipment by all the
members of the health team.
9. Switch OFF the suction apparatus, place Every procedure ends with clearing up the
connecting tube neatly out of the way, and bedside , and keeping patient comfortable.
make patient comfortable.
10. Empty suction collection bottle frequently. To eliminate possible area for harboring of
microorganisms, and prevent from being
sucked into the apparatus.
Different Types
of Catheter
DIFFERENT TYPES OF CATHETER
Nasopharyngeal
Nasopharyngeal
TRACHEOSTOMY CARE
Definition:
A tracheostomy is an external opening on the anterior aspect of the neck and on the trachea,
surgically made through a vertical incision to permit an insertion of a tracheostomy tube through which
the patient may breathe and or be connected to a mechanical ventilator.
Indications:
1. To bypass an upper airway obstruction

2. To allow removal of tacheobronchial secretions
3. To permit the long-term use of mechanical ventilation
4. To prevent aspiration of oral or gastric secretions in paralyzed patients (by closing the opening
of the trachea from the esophagus)
5. To replace an endotracheal tube
1. Never remove the outer cannula. Change or replacement is done only by the doctor. If
accidentally expelled, keep airway open with a hemostat.
2. Always keep an extra, complete tracheostomy tube set at the bedside, and a forcep or tracheal
dilator or obturator
3. If the patient shows signs of cyanosis and dypsnea, or the tube becomes dislocated, call the
doctor at once.
4. Perform oral hygiene consistently.
5. Always have signal light within reach
Minor dressing tray (or tracheostomy dressing tray, if available)

Sterile pipe cleansers (3 or 4) (or trach brush)
Sterile cotton-tipped applicators (6 to 8 pcs.)
Tracheostomy dressing (trach sponge).
(Note: A modified or cut out 4x4 gauze should not be used as a trach sponge, because small
cut fibers could enter the stoma and tracheostomy tube opening)
Hydrogen peroxide
Sterile normal saline
Clean gloves
Sterile gloves
Garbage container near patient’s bedside
Twll tape
Trach ties
Scissors
Care of a Patient with a Tracheostomy Tube
ACTION RATIONALE
1. Gather all the needed equipment and materials. Everything needed to care for a tracheostomy
should be readily on hand for the most effective
care.
Take note to prepare the specified tracheostomy A cuffed tube prevents air from leaking during
tube. A cuffed tube (air injected into the cuff) is positive-pressure ventilation and also prevents
required during mechanical ventilation. A low- tracheal aspiration of gastric contents. An
pressure cuff is most commonly used. adequate seal is indicated by the disappearance of
the harsh gurgling sound or air coming from the
throat. Low-pressure cuffs exert minimal pressure
on the tracheal mucosa and thus reduce the
danger of tracheal ulceration and stricture.
2. Provide patient and family with instructions on The tracheostomy dressing is changed as needed
the key points for tracheostomy care, beginning to keep the skin clean and dry. To prevent
with how to inspect the tracheostomy dressing potential breakdown. Moist or soiled dressings
for moisture or drainage. should not remain on the skin.
3. Perform hand hygiene. Hand hygiene reduces bacteria on hands.
4. Explain procedure to patient and family as A patient with a tracheostomy is apprehensive
appropriate. and requires ongoing assurance and support.
5. Put on clean gloves; remove and discard the Observing body substance isolation reduces cross-
soiled dressing in a biohazard container. contamination from soiled dressings.
6. Prepare sterile supplies, including hydrogen Having necessary supplies and equipment readily
ACTION RATIONALE
peroxide, normal saline solution or sterile available allows the procedure to be completed
water, cotton-tipped applicators, dressing, and efficiently.
tape.
7. Put on sterile gloves. (Although, some Sterile equipment minimize transmission of
physicians allow clean technique only for long- surface flora to the sterile respiratory tract. Clean
term tracheostomy patients in the home). technique may be used in the home because
exposure to potential pathogen is less likely to
happen unlike in the hospital.
8. Cleanse the wound and the plate of the Hydrogen peroxide is effective in loosening
tracheostomy tube with the sterile cotton- hardened secretions.
tipped applicators moistened with hydrogen
peroxide. Rinsing with saline washes away the detached
hardened secretions and serves as supplementary
Rinse with sterile saline solution. disinfectant.
9. Soak inner cannula in peroxide. Rinse with Soaking loosens and removes secretions from the
sterile saline solution. inner lumen of the tracheostomy tube.
10. Remove soiled twill tape with clean tape, after This taping technique provides a double thickness
the new tape is in place. Place clean twill tape of tape around the neck and is needed because
in position to secure the tracheostomy tube by the tracheostomy tube can be dislodged by
inserting one end of the tape through the side movement or by forceful cough if left unsecured.
opening of the outer cannula. Take the tape
around the back of the patient's neckand A dislodged tracheostomy tube is difficult to
thread it through the opposite opening of the reinsert, and respiratory distress may occur.
outer cannula. Bring both ends around so that Dislodgement of a new tracheostomy is
they meet on one side of the neck. Tighten the considered a medical emergency.
tape enough to insert two fingers. Secure it
with a knot.
For a newly-inserted tracheostomy tube, two
people should assist with tape changes.
11. Remove old tapes and discard in a biohazard Tapes with old secretions may harbor bacteria.
container.
12. Although some long-term tracheostomy with Healed tracheostomy with minimal secretions do
healed stomas may not require a dressing, not need a dressing. Dressings that shred are not
other tracheostomy may need. In such cases, used around a tracheostomy because of the risk
use a sterile tracheostomy dressing, fitting it that pieces of the residual, lint or thread may get
securely under the twill tapes and the flange of into the tube, and eventually into the trachea,
the tracheostomy tube so that the incision is causing obstruction or abscess formation. Special
covered. dressing that does not shred is preferred.
After Care
1. Wash all equipment used in warm soapy water and rinse
2. Arrange skin tray and return to proper place
3. Replace dirty linen used
Documentation
Document the care given including:
1. Assessment of secretions
2. Dressing and stoma
3. Patient's tolerance of the procedure.
ASSISTING WITH THORACENTESIS
Definition:
Thoracentesis is a procedure to remove fluid from the space between the lining of the outside of the lungs
(pleura) and the wall of the chest, where normally very little fluid is present.
Indication: In conditions that need obtaining specimen to establish a diagnosis, and to ease discomfort:
1. New effusion: On onset of presence of fluid in the chest without obvious cause.
2. Infection: When fluid is suspected to be present in the chest.
3. Cancer: Some cancers spread and cause fluid to build up in the chest.
4. Large build up of fluid can be painful and interfere with breathing. Removing some fluid may decrease
discomfort.
1. Always have a stimulant ready on hand. It is sometimes given as a preliminary preparation.

2. Maintain aseptic technique throughout the entire procedure.
3. Observe the patient for coughing or difficulty of breathing during the procedure
A. Tray with the following sterile articles:

1. Syringes 50 cc (1); 5 cc (1)
2. Test tube
3. Needles: gauge 18; 20, 22, 23 (2 pcs/size)
4. Three-way valve
5. Rubber tubing: 10 inches
6. Sterile gloves
7. Kidney basin
8. Rubber protector
9. Several packs of OS
10. Several sterile towels
11. Adhesive plaster and bandage scissors
12. Pail or empty dextrose bottle
B. Skin Tray
1. Bottle with alcohol

2. Bottle with merthiolate or betadine
3. Bottle with Benzene or ether
4. Bottle with sterile cotton balls
5. Sterile pick up forceps
6. Xylocaine 1-2%
ACTION RATIONALE
1. Wash hands before the baseline data assessment, Reduces the transmission of microorganisms
and as necessary throughout the preparation,
the procedure, and follow-up
ACTION RATIONALE
2. Identify patient and obtain baseline data and Prevents performing an invasive procedure on the
medical history, paying close attention to wrong patient. Provides a baseline data for comparison
respiratory status and vital signs. after the procedure to assess tolerance and
improvement of clinical status.
3. Be sure a signed consent has been completed. Reduces legal risks for the Nurse, Physician or qualified
practitioner and ensures that the patient has been
informed of procedure and risks.
4. Review necessary pretest and keep information Enables the physician or qualified practitioner to
available at the bedside identify the appropriate site on which to perform the
thoracentesis. Assists the nurse in proper positioning of
the patient
4. Prepare the needed corresponding correct labels and Reduces risk of incorrect labeling or handling of
requisitions for laboratory procedures. Check that specimens obtained during the procedure. Sample is
the patient's correct name and identification correctly identified with patient's name and
number are listed on each label and requisition. identification number.
6. Review patient teaching and assess anxiety Provides re-enforcement of instructions given earlier
and an opportunity for anxiety-reducing techniques.
(e.g., relaxation, guide imagery).
7. Re-identify patient, assess allergy history and Ensures that medication is administered to the correct
pre-medicate as ordered. patient and that there is no history of allergic reaction
to the medication.
Pre-medications for a thoracentesis are usually for
sedation, pain control and to suppress cough.
8. Prepare the necessary equipment and sterile field. Provides a safe, organized approach to the procedure.
Make sure prepackaged trays have all the Prevents introduction of microorganisms into the
necessary supplies. pleural cavity.
9. Assist in patient positioning: Ensures that the diaphragm is free to rise and fall, and
a. Sitting at the edge of the bed with arms on the access to the pleural cavity through the intercostals
bedside table. spaces, is facilitated.
b. Straddling the back of a chair, with arms
supported on the back of the chair
c. After the procedure: Lying on the unaffected
side.
10. Assist throughout the procedure with patient Decreases risk of complications as a result of patient’s
positioning; assessment of vital signs; providing uncontrolled movement and the sterile field becoming
reassurance to patient; management of supplies, and contaminated.
maintenance of sterile field and technique.
a. The physician or qualified practitioner will
perform the procedure.
11. Upon completion of procedure:
a. Apply occlusive dressing to thoracentesis site. * Prevents the entry of air into the pleural cavity
b. Keep patient in comfortable position on * Bed rest is recommended for at least 1 hour following
unaffected side. a thoracentesis
c. Dispose properly contaminated disposables * Ensures observance of infection control and proper
and reusable supplies and equipment disposal of contaminated items.
d. Label and send out specimen for testing as * Ensures availability of laboratory data necessary to
ordered. evaluate patient's health status.
ACTION RATIONALE
12. Assess patient for complications. Prevents complications and untoward problems.
Facilitates anticipating necessary interventions.
13. Wash hands. Reduces the transmission of microorganisms
After Care of the Patient

1. Keep patient quiet in bed in recumbent/lying position.
2. Watch the sputum for streaks of blood.
3. Watch and observe patient's color, pulse and respiration since the treatment involves a very vital organ.
After Care of the Equipment

1. Wash all equipment used in warm soapy water and rinse.
2. Arrange procedure tray and return to proper place
3. Replace dirty linen used.
Documentation/Record
1. Time of treatment
2. Physician who performed
3. Amount, color and character of fluid withdrawn
4. Any abnormal condition
5. Indicate if specimen is for laboratory analysis
CHEST DRAINAGE SYSTEM/CLOSED TUBE THORACOTOMY
Definition:
Chest Drainage system is a closed system designed to drain out air, and fluid from the pleural cavity while
restoring or maintaining the negative intrapleural pressure needed to keep the lungs properly expanded.
Indications:
Removal of air, and fluid from the pleural cavity to allow for re-expansion of the lungs and restoration of
normal negative pressure in the pleural space.
1. Set up the closed drainage system below the level of the chest tube insertion site.
2. Keep the closed drainage system on a flat, sturdy surface so it is not tipped over. If the system is knocked
over, the water seal may be lost, causing the introduction of air into the client's chest. (In most hospitals,
the drainage bottle is taped securely to the floor).
3. If the drainage system has a large and persistent air leak, the water seal level will evaporate quickly and
need to be assessed frequently.
4. If the chest tube was in place for lung re-expansion, pneumothorax or drainage, auscultate and percuss
the lungs and compare sides for inequality.
5. Precautions must be taken when moving the patient and the bed to avoid pulling the chest tube.
Insertion of Chest Catheter:
• Pair of gloves
• Sterile drape
• Betadine solution
• Vial of 1% lidocaine
• Alcohol sponge
• 10 cc syringe
• g 22 x 1 inch needle and g 225/8 needles
• Sterile forceps
• 1 rubber tipped clamped
• Sterile gauze
• Sterile 4 x 4
• Plaster
• Scissors
• Chest tube: French 16 – 20 catheter: for air or serous drainage
French 28 – 40 catheter: for serous, thick or purulent drainage
• Trocar
• Suture kit
• Thoracic drainage system with its collection tubes
MANAGING A CLOSED TUBE THORACOTOMY
ACTION RATIONALE
1. Fill the water-sealed chamber with sterile water. Allows air and fluid to escape into a drainage bottle
2. Assess that the water-sealed chamber is filled The water-sealed chamber prevents air from
to the mark level. returning to the pleural cavity. If it is not maintained
at the mark level, air could be drawn into the cavity.
3. Assess for an air leak by watching for bubbling in An air leak can indicate a new or persistent
the water-sealed chamber by having the patient pneumothorax.
take a deep breath and cough.
4. Assess that all connections at site are spiral The spiral taping prevents the tubing from pulling
wrapped with silk tape. apart and the silk tape is a strong adhesive.
5. Assess the chest tube dressing every shift and The dressing provides an occlusive seal to the site,
change the dressing every 24 and 48 hours. preventing air from being drawn in. Changing the
Record the date and time of the last dressing dressing every 24 and 48 hours will prevent infection
change directly on the dressing. at the site.
6. Every 8 hours, or depending upon the orders, The amount and color of the drainage will indicate
assess the drainage output from the chest tube, any bleeding. Monitoring overall output will indicate
noting the color and amount. when the chest tube may be removed.
7. Assess that the drainage system is safely on the The drainage system needs to be lower than the
floor, lower than the patient or hung off at the patient to ensure adequate drainage and the system
end of the bed to prevent tipping of the system. needs to be safe from tipping to prevent a disruption
in the amount of suction.
8. Assess that the tubing is free from kinks and Any kinks or dependent loops interfere with the
dependent loops and is not pinned to the bed drainage of the chest tube to prevent accidental
linens. dislodging of the chest tube, the tube should never be
pinned to the bed linen.
9. Ensures that a bottle of sterile water or saline is It is used to refill the water seal and suction chambers
at the bedside. as needed.
10. Apply an occlusive dressing in the event that the An occlusive dressing can prevent the risk of
chest tube accidentally falls out or is accidentally pneumothorax.
pulled out.
11. To ensure that patency is maintained: NEVER Milk Milking of stripping can cause an increase of pressures
or strip the tube. up to 400 cm water, which can cause vasculature and
damage to lung tissue.
POST OPERATIVE VIEW
REMOVING A CHEST TUBE
• Sterile gloves
• Vaseline gauze
• Sterile 4 x 4 pads
• Foam tape
• Disposable waterproof absorbing pads
• Sterile scissors, suture removal kit
• Chest tube clamps
• Pain medication
ACTION RATIONALE
1. Gather all equipment needed. Ensures that everything is available for the physician
and does not prolong the procedure, and
consequently less discomfort to the patient.
2. Wash hands Reduces transmission of microorganisms
3. Administer Pre-medication as prescribed. Decreases the discomfort or pain accompanying the
pulling out of the chest tube.
4. Assist the patient into bed and place in accessible Ensures safe and comfortable position for chest tube
and comfortable position for chest tube removal removal.
5. Reassure patient and explain the entire procedure. Decreases anxiety and alleviates fears.
6. Assess the effects of premedication on respiratory Monitors for possible respiratory depression.
status.
7. Apply gloves Decreases risk of exposure to body fluids.
8. Assist the physician. Facilitates safe removal of the chest tube.
9. Once the tube is out and the dressing is applied. Reduces risk of pneumothorax.
check that the dressing is secure and air tight.
The dressing should not be removed for 24 hours;
if the drainage is soaking through, reinforce with 4
x 4 pads and foam tapes.
10. Check that the chest tube and accessories are Ensures correct handling of biohazards and decreases
disposed properly in the biohazard waste can. risk of exposure.
11. Discard the gloves properly and wash hands. Reduces transmission of microorganisms
12. Observve and assess the patient’s condition Ensures early recognition of a post chest tube removal
closely for 30 minutes. Watch for signs of pneumothorax, and consequently immediate and
pneumothorax - rapid heart rate; decreased efficient intervention.
breath sounds; increased shortness of breath;
decreased oxygen saturation; and chest pain or
pain with inspiration. Assess the dressing make
sure it is dry and intact.
MANTOUX TEST
Tuberculin Skin Test/Purified Protein Derivative Test (PPD)-
Definition:
Inoculation of tubercle bacillus extract (tuberculin) into the intradermal layer of the inner aspect of the forearm.
Indication:
To detect for the presence of tubercle mycobacterium infection and determine if the infection is active or inactive.
1. False – positive reaction may occur in those infected with any mycobacterium other than the tubercle mycobacterium
and have received the Bacille Calmette Guerin (BCG) vaccine.
2. False – negative reaction may occur in those with HIV infection; overwhelming miliary or pulmonary TB; severe or
febrile illness; measles or other viral infections; Hodgkin's disease; sarcoidosis; and liver-virus.
Purified protein derivative (PPD) tuberculin antigen; intermediate strength

Tuberculin syringe
Short 1.25 cm (½ inch); 26 or 27 gauge steel needle
Alcohol sponge
Gloves
Mask (optional)
ACTION RATIONALE
1. Determine if the patient has ever had BCG vaccine; Any of these may cause false readings.
recent viral disease; immunosupression by a
disease; and drugs with steroids.
PERFORMANCE PHASE
1. Draw up PPD -tuberculin into tuberculin syringe. Follow the manufacturers' directions. Each 0.1 mL dose should
contain 5 tuberculin units (TU of PPD -tuberculin). Use the
antigen immediately to avoid absorption onto the plastic
/glass syringe.
2. Don gloves. In compliance with universal/standard infection control
precaution.
3. Cleanse the skin of the inner aspect of forearm with To reduce the pathogenic microorganisms present on the skin.
alcohol. Allow to dry.
4. Stretch the skin taut. For accurate location of the site – superficial layer of the skin.
5. Hold the tuberculin syringe close to the skin so the This reduces the needle angle at the skin surface and
hub of the needle touches it as the needle is facilitates the injection of tuberculin just beneath the surface
introduced, bevel up. of the skin.
6. Inject the tuberculin into the superficial layer of the If no wheal appears (the injection must have been made deep
skin to form a wheal 6 mm to 10 mm in diameter. ), inject again at another site at least 5 cm (2 inches) away.
7. Immediately place disposable needle and syringe To prevent accidental prick hazards.
into the container for sharps.
ACTION RATIONALE
FOLLOW-UP PHASE
To Read the Test:

1. Read the test within 48 to 72 hours when the Tuberculin skin tests are tests of delayed hypersensitivity.
induration is most evident.
2. Have a good light available. Flex the forearm slightly For accurate assessment and interpretation of test reaction.
at the elbow.
3. Inspect for the presence of induration; inspect from Induration refers to hardening or thickening of tissues.
a side view against the light; inspect by direct light.
4. Palpate; Lightly rub the fingers across the injection Erythema (redness) without induration is generally considered
site from the area of normal skin to the area of to be of no significance.
induration. Outline the diameter of induration.
5. Measure the maximum transverse diameter of The Extent of induration is measured in diameters and
induration (not the erythema ) in millimeters with a recorded.
flexible ruler.
a. Induration of 5 mm or more in diameter. Considered positive in those:
a. with known HIV or unknown HIV but with risk
factors for HIV.
b. who have had recent contact with active tuberculosis.
c. who have fibrotic changes on chest x-ray, consistent
with healed TB.
b. Induration of 10 mm or more in diameter. Considered positive in:
a. Those with certain medical conditions (diabetes
mellitus; silicosis; head and neck cancer; leukemia;
and end-stage renal disease.
b. Those who have undergone gastrectomy, and
prolonged corticosteroid therapy).
c. Foreign-born people from areas of the world where TB is
common ( Asia, Africa, Latin America).
d. Medically under-served low-income populations.
d. Residents of long-term care facilities.
e. Children less than 4 years of age.
f. Those who do not meet the above categories
but who have other risk factors for
tuberculosis - homelessness, alcoholism,
malnutrition, and care giving jobs.
3. Induration of 15 mm or more in diameter. Considered positive in those who do not fall under the above
categories.
Evaluation of aftercare:
• Standard precautions observed; patients relieved of fever and dyspnea; proper disposal of respiratory
secretions.
Documentation: (Nurses' Notes)
• Date, time and site of the injection

• When to read the wheal and the proper measurement of this.
(Reading should be within 48 -72 hrs.)
SPUTUM SPECIMEN
Definition:
A simple diagnostic tool which consists of collecting sputum specimen of patients manifesting the signs
and symptoms of upper respiratory infection and other viral infections, involving the respiratory system. The
sputum is placed in a culture medium to allow the pathogenic microorganisms to grow. The microorganisms are
identified, thereby diagnosis is established and appropriate therapy is prescribed.
Preparatory Phase:
• Review the orders for the culture requested, so that repeat cultures are avoided.
• Assess the patient’s understanding of the purpose of the procedure so that the patient will be able to
cooperate
• Identify whether the patient has received recent antimicrobials, if so obtain the specimen prior to
treatment, if possible
•
(Estimated time to complete the skill: 5 – 10 min.)
Client Education Needed:
1. Teach patients the rationale for the procedure

2. The procedure is generally painless
3. Discuss the time delay for the culture results
4. Remind the patient that the culture collection requires cooperation
• Sputum specimens may be obtained by an ancillary personnel.

• The sputum is collected directly into a sterile cup or obtained via a specimen trap connected to suction;
and sent to the laboratory.
• Avoid specimen collection immediately after meals.
• Observe Standard Precautions when handling the specimen: don gloves, wear mask, wash hands.
• Educate the patient regarding the importance of obtaining a real sputum specimen and not saliva.
Sputum has a diagnostic value hence the proper amount is important. Sending an inadequate specimen
delays the procedure and application of the appropriate treatment.
• If the specimen will not be sent to the laboratory immediately, store it in a cool place to prevent growth of
microorganisms, that may mislead the real diagnosis.
• Sputum specimen is best collected right after the patient awakens, before ingesting anything by mouth
(including fluids), and before brushing teeth or rinsing the mouth. If the client has eaten or brushed teeth,
rinse with water, wait for 15 – 30 minutes before collecting a sputum specimen.
• It is essential to ensure an adequate specimen by making the patient cough effectively to force out
sputum. Nebulization with saline solution may be necessary to facilitate adequate sputum production.
• If a specimen was collected and found unlabeled with the time collected discard and obtain a new
specimen.
• Copious amount of purulent sputum mixed with blood may be associated with bronchiectasis; pink
sputum is suggestive of pulmonary edema fluid. Currant jelly sputum may be indicative of necrotizing
pneumonia; putrid sputum, which is foul smelling, is found in lung abscesses.
• If the patent is on antimicrobial therapy, specimen results will be of limited value because of suppression
of microbials.
• Repeated sputum specimen may be of limited value in some conditions. For certain specimens, such as
those for mycobacteria, three consecutive first specimens (not poled) are optimal.
• If hemoptysis is present it is diagnostic value. Chart the description and notify the appropriate staff.
• Sputum cytology may be used to identify certain cell types in cancer. A negative cytology result does not
rule out disease.
Sterile specimen tube and cup

Facial tissue
Clean, disposable latex free gloves
ACTION RATONALE
COLLECTING A SPUTUM CULTURE
1. Explain to the patient that the specimen must be Promotes patient’s cooperation
sputum, coughed out from the back of the throat
or lungs.
2. Have a sterile specimen cup ready for the sample The specimen must be collected in a sterile cup to
and some tissue paper at hand. prevent contamination.
3. Have the patient take several deep breaths and Helps to loosen secretions.
then cough deeply.
4. Have the patient expectorate the sputum into the Prevents contamination of the specimen
sterile cup without touching the inside of the cup.
5. Place the lid on the specimen container without Prevents contamination of the specimen.
touching the inside of the lid or the container.
6. Provide the patient with tissue paper and make Promotes patient comfort.
him/her comfortable.
ALTERNATIVE SPUTUM COLLECTION METHOD
Generally used if the patient is unable to expectorate an adequate sample.
1. Obtain a sterile suction catheter and an in-line Prevents contamination of the specimen.
sputum collection container.
2. Provide the patient with warm humidified air for Helps to loosen secretions in the lungs.
about 20 minutes if it is not contraindicated by the
patien's condition.
3. Hook up the sputum collector to the suction tubing Prepare the equipment prior to having the client
and a suction device. Hook up the suction catheter cough.
to the sputum collector.
4. If the patient is able to cooperate, have him/her take Loosens the secretions and brings them up to the
several deep breaths and cough. back of the throat.
5. While the patient is coughing out sputum, carefully Obtains a sterile specimen that is not contaminated
insert the catheter either orally or nasopharyngeally with saliva.
into the back of the throat and suction the sputum
into the specimen container.
6. Safely dispose of the suction catheter. Prevents the spread of microorganisms.
7. Close the specimen container. Prevents contamination of the specimen
ACTION RATONALE
8. Provide tissue paper or other measures for patient's Promotes patient comfort.
comfort.
10. Label each specimen with the patient's name. Promotes the correct diagnosis for the right patient.
11. Send the specimen to the laboratory. To complete the diagnostic procedure and obtain
accurate result.
Evaluation and aftercare:
• An adequate specimen was obtained.

• The procedure was performed with a minimum of trauma to the patient
Documentation: (Nurses' Notes)

• Record the date and time the specimen was obtained, as well as the mode of collection (direct to the sterile
cup or via a suction, aided by nebulization) and other significant observations during he process of the
collection.
• Note any bleeding or obvious trauma as a result of the procedure
• Note in the Chart the description and time the specimen was collected. Note if the specimen is the first
morning specimen, not pooled secretions.
NASOGASTRIC TUBE INSERTION
Definition:
It is the insertion of a nasogastric tube through one of the nostrils down to the nasopharynx, and into the alimentary tract. In some
cases, the tube is passed through the mouth and pharynx.
A nasogastric tube (NGT) is made of firm, clean plastic material which comes in three sizes: adult; pedia and infants. Size is
determined and expressed as French with the corresponding number. The larger the number the bigger the size of the tube e.g. Fr. 16 is larger
than Fr. 14.
Purposes:
1. To decompress the stomach to relieve pressure and prevent vomiting.

2. To provide a means for irrigating the stomach (lavage)
3. To provide access to gastric specimen for laboratory analysis
4. To provide a route for delivering liquid enteral feedings (gavage) for patients who cannot swallow or ingest adequate calorie intake.
1. Identify patient's need for nasogastric intubation and type of tube to be inserted.
2. Assess patient's mental status and ability to understand and cooperate with the procedure.
3. Review medical history for nosebleeds, deviated septum, nasal surgery.
4. Assess nostrils for size, lesions, obstructions, or deformities.
Large-bore or small-bore nasogastric tube

Guidewire or stylet for small-bore tube
Solution basin filled with warm water (if a plastic tube is being used) or ice (if a rubber tube is being used)
Hypo-allergenic adhesive tape, 2.5 cm (1 in.) wide
Clean gloves
Water soluble lubricant
Facial tissues
Glass of water and drinking straw
20 to 50 ml syringe with an adapter
Basin
pH test strip or meter
Stethoscope
Disposable pad or towel
Clamp or plug (optima)
Suction apparatus (if required)
Gauze square or plastic specimen bag and elastic band
Safety pin and elastic band
ACTION RATIONALE
1. Identify the patient and explain that the procedure is not The Patient is more cooperative when the procedure is understood.
painful, but uncomfortable because the gag reflex is usually
stimulated.
2. Provide privacy by closing curtains or room door. Privacy decreases embarrassment.
Raise bed to high-Fowler's position, cover chest with towel and
place emesis basin nearby. Elevating the head prevents the occurrence of aspiration.
3. Wash hands, and put on gloves. Determine length of tubing to This measure determines approximately the length of the esophagus
be inserted by measuring NG tube from tip of nose to tip of ear from nares to stomach, which varies among patients.
lobe then to tip of xiphoid process. Mark tubing with adhesive
tape or note striped marking already on the tube.
4. Lubricate tip of tube with water-soluble lubricant. A water-soluble lubricant can be reabsorbed and will not cause
respiratory complications in case the tube inadvertently enters the
respiratory tract.
For this reason, an oil-based lubricant should not be used.
5. Gently insert tube into the nostril preferred. Following the natural contour or route prevents trauma to nasal
Advance it toward the posterior pharynx. mucosa.
6. Make patient tilt head forward and serve drinking Forward tilt of head facilities passage of tube into esophagus and not
water and instruct to drink slowly. Advance tube the larynx.
without using force as patient swallows. Advance
tube further until desired insertion length is Swallowing opens the epiglottis and closes the larynx hence, facilitates
reached. accurate tube passage into the esophagus, or the alimentary tract.
7. Temporarily tape the tube to the patient's nose;
then assess placement of the tube: Gastric content is yellow to green and usually released in amounts
a. Aspirate gastric content with 20-50 ml syringe and test pH. greater than 10 ml; pH is acidic.
b. Auscultate over epigastrium while injecting 10 to 20 ml air Bubbling is heard if tube is in the stomach.
into NG tube.
c. If feeding tube is placed, x-ray confirmation of placement is

required before day feeding is administered.
8. If placement in stomach is not verified, untape tube, advance To ensure accuracy and safety.
tube 5 cm, and repeat assessment in step 7.
9. Secure tube by taping to the bridge of patient's nose. Correct taping prevents the tube from getting dislodged, pulled out
Anchor nasogastric tube to patient's gown. and causing trauma to the nostril.
10. Clamp end of tubing or attach to suction, as prescribed. Suction facilitates drainage.
11. Wash hands, provide for patient's comfort and remove A procedure is fully accomplished by routine aftercare, and
equipment. restoring patient comfort and safety.
12. Establish and document a nursing plan for daily A Nursing Care Plan facilitates organized activities and ensures
care of the nasogastric tube: Nurse and patient safety.
Documentation ensures organized and efficient continuity of care.
a. Inspect nostril for irritations
b. Cleanse nostril frequently
c. Change adhesive as required to prevent skin irritation or

pressure sores on nostril from the tube.
d. Increase frequency of oral care because patients with

NGT often breathe through the mouth and put on NPO.
Lifetime consideration: Measure tube length from the tip of the nose to tip of ear lobe, then to the point
halfway between the xiphoid process and the umbilicus.
Inserting a Nasogastric Tube
1. Place patient in semi-to high Fowler’s position in 4. Begin insertion with patient positioned with head up.
preparation for tube insertion.
2. Measure NG tube from nostril to tip of earlobe. 5. Advance tube while patient drops chin to chest and
swallows.
3. Measure NG tube from tip of earlobe to xiphoid 6. Aspirate to obtain gastric fluid.
process.
7. Make a 2 inch cut into a 4 inch strip of tape. 10. Attach NG tube to wall suction.
8. Apply tape to patient’s nose. 11. Patient with NG tube securelytaped.
9. Wrap split ends around NG tube.
GASTRIC GAVAGE
Definition:
Refers to the introduction of nourishment into the stomach through the NGT - a tube inserted
into the esophagus and stomach through the nose or the mouth.
A nasogastric tube (NGT) is made of firm, clean plastic material which comes in three sizes:
adult; pedia and infants. Size is determined by the term French with the corresponding number. The
larger the number the bigger the size of the tube e.g. Fr. 16 is larger than Fr. 14.
Purposes:
To introduce liquid food or medicine into the stomach in the following conditions:
1. When patient refuses food due to a real physical inability or psychopathological conditions.
2. When patient is unconscious
3. When conditions of the mouth and stomach and esophagus make mastication and swallowing
difficult or impossible
4. When operations of the stomach and the digestive tract make it desirable to keep them clean or
rested.
1. False teeth should be removed before starting the procedure

2. Watch patient carefully for aspiration or regurgitation of fluids.
3. Position: Sitting or semi-Fowler's position – to allow gravity to empty the stomach after
feeding and prevent aspiration.
4. Solution should be approximately at body or room temperature.
@ Not warm: milk products with added nutrients can be an ideal medium for the growth of
bacteria.
@ Refrigerator temperature: can cause cramping
@ Cold formula: increases chances of diarrhea
5. When tube feeding is initiated, the formula may be diluted (to regulate the consistency) and in
amount
(to regulate the volume) . In this way, the feeding is gradually increased in
strength(consistency) and amount (volume). Diarrhea results from sudden change in
consistency and volume of the feeding.
6. Render frequent nasal and oral hygiene.
7. Avoid introducing air into the feeding tube before, during and after feeding. This can cause
unnecessary feeling of fullness and discomfort on the patient.
8. Do not hurry the feeding – this can cause distention and discomfort.
Formula for Tube Feeding:
● Commercially prepared formula: 1.5 or 2 kcal/ml

● Standard formula: contains protein, vitamins, minerals, carbohydrates and polyunsaturated fats
● Lactose-free formula: – for lactose-intolerant persons who develop diarrhea easily.
● Formula prepared by the dietary department: eggs, salt, milk, corn syrup, blenderized
vegetables, fruit juice and water. Pureed meat and cereals are added.
Administering Medicines with tube feeding:
• It is best to give medicines at the beginning of the feeding and should not be dissolved with the
formula, to ensure that the medicines shall be administered in its entire complete dose and on
time even if the feeding has not been completed for whatever reason, depending on patient’s
condition.
• Flush the tubes thoroughly with water after the administration – to avoid obstruction of the
tube and to ensure that the medicine is in the stomach.
1. Tray with:
a. levine's tube (nasogastric tube) in a bowl of cracked ice
b. lubricant (KY)
c. medicine glass with water
d. gloves
e. safety pin
f. glass with ice chips
g. gauze package
h. adhesive tape
i. syringe
j. spoon
k. kidney basin
l. paper wipes
m. bandage scissors
2. Rubber protector
3. Treatment towel
4. Tray with
a. glass with the prescribed liquid for feeding
b. 50 cc asepto-syringe or funnel
c. clamp
PROCEDURE FOR GAVAGE/TUBE FEEDING:
ACTION RATIONALE
A. Assessment
ACTION RATIONALE
1. Check attending physician’s order. To ensure veracity of order; accuracy in the type
of feeding; amount or volume; frequency, etc.
2. Read any observation about previous feeding To provide a clear idea of patient's tolerance for
noted on the patient's chart. the procedure.
B. Planning
3. Wash hands For infection control

4. Identify whether the patient is to be fed using
the A rate-controlled pump is used to deliver tube
intermittent or continuous method. feeding at a precise rate or through very small-
If continuous method is used, determine if diameter tubes.
feeding pump is at the bedside or is available.
5. Gather the equipment, regardless of the
method
to be follwed. To protect patient from bacterial growth in the
equipment.
6. Change Feeding tube every 24 or 72 hrs
To facilitate monitoring of appropriate time and
7. Label the equipment with the date and frequency for changing of the equipment.
time it was changed.
C. Implementation
6. Identify the patient To ensure that you are carrying out the procedure
for the correct patient.
7. Explain the procedure to the patient.
8. Place the patient in a semi-Fowler's position. To allow gravity to empty the stomach after
feeding and prevent aspiration.
9. Put on clean gloves To comply with standard precaution.
10. Test for the correct position and patency of
the
tube and for residual formula. Check at intervals even during the feeding. The
tube may have been dislodged.
a. Check the position and patency of
tube, through the following:
◼ Most reliable method: aspiration
method - aspirate small amount of
gastric content.
◼ Auscultatory Method: introduce a
small amount of air through the
tube and with the stethoscope
placed on the epigastrium, listen.
Gurgling sounds indicate that the
ACTION RATIONALE
tube is in the stomach.
b. Check for residuals - refers to aspirating When there is a large residual, the patient is more
the contents of the stomach to likely to have regurgitation of formula through
determine whether there is a residual the gastric sphincter into the esophagus and from
formula from the last feeding. there maybe aspirated into the lungs causing
aspiration pneumonia.
11. Administer small amount of water first, then To ensure tube is patent and safe for
any medications ordered and the formula, administering medication and introduce feeding
last. Follow with water. formula.
To rinse the formula out of the tubing into the

stomach, and to ensure that what is left in the
tube is the water. Formula left in the tube may
harbor microorganisms.
12. After the feeding, put on clean gloves,
disconnect the administration tube from the
patient's feeding tube, clamp the tube tightly
or plug it. Discard the gloves.
13. Reposition the patient in low or semi- To prevent aspiration into the lungs, in case
Fowler's position. vomiting occurs.
◼ If comatose, turn to Sim's lateral
14. Wash your hands To keep hands clean and ready for other
procedures.
D. Evaluation
15. Return to the patient approximately 30
minutes after, to assess condition and To make sure the feeding has been retained and
response to the procedure. the patient responded well and in comfortable
condition.
E. Documentation
16. Documentation on medication sheet or Documentation as basis for continuity of care.

progress notes: Date,time, type and amount
of formula, amount of water, and patient's
response.
To determine appropriate response to
◼ Measure I & O treatment.
COMPLICATIONS OF TUBE FEEDING
1. Diarrhea can compromise nutritional and electrolyte status due to the following possible causes.
a. High osmolarity
b. Lactose content
c. Too rapid feeding
d. Too cold formula
e. Adverse reaction to medication
2. Dry mouth, sore throat, thirst and feeling of deprivation, hence the need for frequent mouth
care.
GASTRIC LAVAGE
Definition:
The method of washing out the stomach contents by first introducing then withdrawing
prescribed solutions through the NGT inserted into the stomach.
Purposes:
1. For diagnosis
2. For therapeutic indications
a. removing ingested food or toxic substances in conditions with persistent vomiting

b. removing irritants or poison taken by mouth
c. reducing inflammation and removing excess mucus as a result of gastritis
3. To cleanse the stomach pre-and post-operatively.
1. Remove dentures before inserting the tube

2. Be certain that tube is in the stomach and not in the trachea before administering any solution
3. Clamping off the tube is very important when withdrawing the tube to prevent aspiration of
liquid from the end of the tube into the lungs
4. Observe for sudden pain or weakness following insertion as this may indicate perforation of pre-
existing lesions.
Contraindications:
1. Ulcerations with hemorrhage or following very severe hemorrhage of the stomach due to ulcer
or carcinoma.
2. Uncompensated cardiac disease
3. Advanced TB
4. Apoplexy (copious extravasation of blood into an organ or sudden massive hemorrhage)
Solutions commonly Used:
1. Plain sterile water; Normal saline, sodium bicarbonate 2% (2 Gms of soda:1000 cc sterile water);
Potassium permanganate solution 1:10,000; Tanic acid, silver nitrate 1%)
2. Temperature: 100 – 105 degrees F
3. Quantity: 2 – 6 L - for cleansing, as much solution as is necessary until the return flow is clear.
ACTION RATIONALE
1. Prepare warm solution at 100 – 105 degrees F Warm solution prevents trauma of the gastric
ACTION RATIONALE
mucosa.
2. Instruct patient to swallow during tube Lessen discomfort and facilitates insertion of the
insertion tube.
3. Position in sitting if alert or dorsal recumbent Facilitate insertion of tube.
if weak.
- pillows under shoulder with head
slightly forward.
4. Put towel over chest To protect from spills
5. Place kidney basin and tissue papers on To provide receptacle.
overhead table in front of the patient.
6. Measure from xiphoid process of sternum to To determine the accurate measurement of the
tip of nose and lobe of ear. length of the tube to be inserted.
7. Lubricate tip of tube Reduce friction between the mucous membrane
and tube.
8. Insert into nostril aiming downward, if with
resistance, instruct to swallow and deep
breathe.
9. Advance tube with each swallow.
10. Test if tube is in place. Use aspiration or auscultatory methods
11. Pour solution into funnel / syringe, hold it To act as a start for siphonage.
above 12 inches, then lower the tube into the
kidney basin before the solution has entered
the stomach and siphon.
12. Repeat irrigation until flow from stomach is
clear or ordered amount of solution has been
used.
13. Clamp off tube and withdraw quickly. To avoid aspiration of fluid into trachea.
14. Make the patient comfortable
15. Document: Time, nature, amount and
strength of solution used, character of the
return flow and if as was expelled, specimen
saved, etc.
PERCUTANEOUS ENDOSCOPIC GASTROSTOMY (PEG) TUBE FEEDING
Definition:
Percutaneous endoscopic gastrostomy (PEG) is a surgical procedure to attach a feeding tube

without having to perform a surgical opening on the abdomen (laparotomy). A gastrostomy (a surgical
opening into the stomach) is made percutaneously (through the skin) using an endoscope (a flexible,
lighted instrument) to determine where to place feeding tube in the stomach and secure it in place.
Purpose:
The aim of PEG is to aid in feeding when swallowing is difficult or not possible. Whatever the age
of the patient or their medical condition, the purpose of PEG is to provide fluids and nutrition directly into
the stomach.
1. Solution should be approximately at body temperature

2. When patient coughs during feeding, kink tube for a while.
3. Clean and change dressing of the insertion site daily.
Tray with:
a. Prescribed solution for feeding
b. Asepto syringe
c. Water
PROCEDURE RATIONALE
1. Remove the cap from the tube and unclamp Provides system for delivery of feeding.
the tube.
2. Attach a 5 or 10 cc syringe to the tube and To check for reflux.
gently aspirate back until there is a mild
amount of back pressure.
3. Note the amount aspirated then slowly return If greater than 25% of the previous feeding
it back. volume is still present do not feed the patient at
this time.
4. Warm the food at body temperature. Warm solution prevents trauma of gastric
mucosa.
5. Connect syringe barrel to the free end of the This prevents air from entering the stomach
tube.
6. Slowly pour solution into the syringe. The patient should receive the correct feeding
(Amount depends on doctor's order). formula and correct volume at the correct time
period.
PROCEDURE RATIONALE
7. Follow solution with enough water. To rinse the lumen of the tube to prevent clog
up.
8. Disconnect syringe from the tube and close This prevents air from entering the stomach and
clamp of tubing. reduces risk of gas accumulation. Maintain
patency of feeding tube.
DOCUMENT:
1. Name of solution and amount used for feeding
2. Time of giving solution for feeding.
3. Patient's reaction to feeding.
OSTOMY CARE
Definition:
Ostomy Care: a systematic procedure rendered to patients with ostomy.

Stoma: an opening created through the body surface; in this case, do drain bowel contents.
Ostomy Pouch: a collection bag (pouch) to collect fecal contents from incontinent ostomies. Pouches
are applied directly to abdominal skin and require skin barrier for application. Skin barriers are sized
according to stoma dimensions.
Colostomy: surgically created opening of the colon through the abdominal surface, for the emptying
bowel contents.
Ileostomy: surgically created opening of the ileum through the abdominal surface, for emptying bowel
contents.
Indications:
➢ An ostomy is indicated for treatment of patients with bowel problems such as tumors, bowel
cancer, inflammatory bowel disease, or severe abdominal trauma or wounds.
Pouch set with accessories

Stoma measuring guide
Pen or pencil
Stoma powder or paste (if drainage is watery to pasty or stoma secrets excess mucus)
Scissors
Closure clamp
Warm water or pouch cleaning solution
Mild soap (optional)
Wash cloth or cotton balls and towel
Toilet or bedpan
Plastic bag or receptacle
Disposable gloves
Facial tissue or gauze pad
Optional: Ostomy belt, paper tape, skin shaving equipment, liquid skin sealant, pouch deodorant
Safety razor
ACTION RATIONALE
1. Determine the need for pouch change
◆ Assess the used appliance for leakage of Effluent can irritate the peristomal skin.
effluent.
A burning sensation may indicate breakdown
◆ Ask the patient about any discomfort on or beneath the face plate of the pouch.
around the stoma.
When the fluid level in the bag becomes too high,
◆ Assess the fullness of the pouch. Pouches the weight of it may loosen the faceplate and
ACTION RATIONALE
need to be emptied when they are one- separate from the skin, causing the effluent to
third to one-half full. leak and irritate the peristomal skin.
Disposable ostomy pouch can be changed every

◆ If there is pouch leakage or discomfort at 3-7 days or whenever the effluent leaks or it
or around the stoma, change the pouch. cannnot be rinsed completely. If the skin is
eroded or ulcerated, change the pouch every 24-
48 hours to allow appropriate treatment of the
skin.
2. Select a appropriate time

◆ Avoid times close to meal or visiting hours. Ostomy odor or effluent may reduce appetite or
embarrass the patient.
◆ Avoid times immediately after the Changing the pouch is facilitated when the ostomy
administration of any medication. is least likely to function, usually between 2 and 4
hours after meals.
◆ Gather all needed equipment. When all needed equipment are present, the
procedure would most likely be organized,
efficient and less distressing to the patient.
◆ Wash hands. Universal precaution for protection of the Nurse.
3. Prepare the patient and support person

◆ Explain the procedure to the patient and Patient and support persons are often
support persons. (Also explain as the participative and supportive if properly informed.
procedure is being performed). This will prepare the patient to perform the
procedure himself.
◆ Provide privacy, preferably in the
bathroom, where patients can learn to It is distressful for the patient if there are other
deal with it as they would at home. persons in the room, who may show repugnance
and feel uncomfortable.
◆ Don gloves, and unfasten the belt if one is
being worn. Ostomy effluent might have enzymes that are
irritating to the skin. The gloves protect the nurse
from potential infection and injury.
4. Shave the peristomal skin of well-
established ostomies as needed. If the hair is allowed to grow and is regularly pulled
◆ Use an electric or safety razor on a regular out when the appliance and skin barrier are
basis to remove excessive hair growth. removed, hair follicles can become irritated or
infected. Furthermore, excessive hair can
interfere with adhesive action.
2. Select a appropriate time
◆ Avoid times close to meal or visiting hours. Ostomy odor or effluent may reduce appetite or
embarrass the patient.
◆ Avoid times immediately after the Changing the pouch is facilitated when the ostomy
administration of any medication. is least likely to function, usually between 2 and 4
hours after meals.
◆ Gather all needed equipment. When all needed equipment are present, the
procedure would most likely be organized,
efficient and less distressing to the patient.
◆ Wash hands. Universal precaution for protection of the Nurse.
5. Empty and remove the pouch

◆ Empty the pouch contents through the Emptying before pouch removal prevents spillage
bottom opening into the bedpan. on the patient's skin
◆ Assess the consistency and amount of Ileostomy and ascending colostomy produces
effluent. liquid fecal drainage. Transverse colostomy
produces mushy drainage. Descending colostomy
produces increasingly solid fecal content. Pus and
blood should not be present in the effluent.
◆ Peel the bag of slowly while holding the Holding the skin taut minimizes client discomfort
patient's skin taut. and prevents skin abrasion.
◆ If the appliance is disposable, discard it in These prevent contamination of other materials

a moisture-proof bag. by the effluent.
6. Clean and dry the peristomal skin and
stoma.
◆ Use toilet to remove excess stool. This prevents soiling of proximal skin tissue and
excoriation of the peristomal skin.
◆ Use warm water, mild soap (optional), and Soap is sometimes not advised because it can be
cotton balls or a wash cloth and towel to irritating to the skin.
clean the skin and stoma.
◆ Use a special skin cleanser to remove This emulsifies the stool, making removal less
dried, hard stool. damaging to the skin.
◆ Dry the area thoroughly by patting with a Excessive rubbing can cause skin abrasion.
towel or cotton swab.
7. Assess the stoma and peristomal skin
◆ Inspect the stoma for color, size, shape and Stomas should appear red, slightly protruding
bleeding. from the abdomen. Will remain swollen for 2-6
weeks and bleed slightly initially when touched.
◆ Inspect the peristomal skin for any redness, Transient redness after the removal of adhesive is
ulceration or irritation. normal.
◆ Place a piece of tissue or gauze pad over the This absorbs any seepage from the stoma.
stoma and change it as needed.
8. Apply paste-type skin barrier if needed.
◆ Fill in abdominal creases or dimples with This establishes a smooth surface for application
paste. of the skin barrier and pouch.
Wet surfaces may interfere with the adhesive

◆ Allow the paste to dry for 1-2 minutes or action of the appliance.
as recommended by the manufacturer.
9. Prepare and apply the skin barrier
(peristomal seal)
For solid wafer or disc skin barrier:

◆ Use the guide to measure the size of the The Guide help save time, and is accurate.
stoma.
◆ On the backing of the skin barrier, trace a

circle the same size as the stomal opening.
A template aids other nurses and the patient with
◆ Make a template (mold) of the stomal
future appliance change. However, the templates
pattern. Between 6 weeks and 1 year
would need to be adjusted as the stoma size
after surgery, the stoma will shrink to its
decreases.
permanent size.
This minimizes the risk of effluent contacting

◆ Cut out the traced stomal pattern to make
peristomal skin.
an opening in the skin barrier. Make the
opening no more than 0.3 – 0.4 cm (1/8 to
1/6 in) larger than the stoma.
◆ Remove the backing to expose the sticky This prevents contact with the skin sealant.
adhesive side.
◆ Center the skin barrier over the stoma,and Excessive wrinkles or bubbles can lead to easy
gently press it on the patient's skin, detachment of the pouch and seepage of the
smoothing out any wrinkles or bubbles. effluent.
For liquid skin sealant.

7. Assess the stoma and peristomal skin
◆ Inspect the stoma for color, size, shape and Stomas should appear red, slightly protruding
bleeding. from the abdomen. Will remain swollen for 2-6
weeks and bleed slightly initially when touched.
◆ Inspect the peristomal skin for any redness, Transient redness after the removal of adhesive is
ulceration or irritation. normal.
◆ Place a piece of tissue or gauze pad over the This absorbs any seepage from the stoma.
stoma and change it as needed.
◆ Cover the stoma with the gauze pad. This prevents contact with skin sealant.
◆ Either wipe the product evenly around the
peristomal skin, or use a brush to apply a
thin layer of the liquid plastic coating to the
same area.
◆ Allow the skin barrier to dry until it no
longer feels tacky.
10. Fill in exposed skin around an irregularly
shaped stoma.
◆ Apply paste to any exposed skin area. Use Alcohol may cause stinging or burning sensation.
a non-alcohol based product, if the skin is The powder creates a barrier or seal. Do not use
excoriated. Also, sprinkle peristomal the sealant, on the skin. It can burn the skin if
powder on the skin, wipe off the excess and excoriated.
dab with powder using moist gauze or an
applicator moistened with a liquid skin
sealant.
11. Prepare and apply the clean pouch.
◆ Remove the tissue from the stoma before
applying the pouch.
For a disposable pouch with adhesive square:

◆ If the pouch does not have a pre-cut
The opening is made slightly larger than the
opening, trace a circle 1/8 to 1/6 inch stoma to prevent rubbing, cutting, or trauma to
larger than the stomal size on the the stoma. The stoma has no pain receptors.
adhesive square.
A hole in the pouch causes leakage of the
◆ Cut out a circle in the adhesive. Take care effluent irritating the skin or soiling clothing.
not to cut any portion of the pouch.
◆ Peel of the backing from the adhesive
seal.
◆ Center the opening of the pouch over the
patient's stoma, and apply it directly onto
the skin barrier. Wrinkles allow seepage of the effluent, which
◆ Gently press the adhesive backing onto can irritate the skin or soil clothing.
the skin and smoothen the wrinkles,
working from the stoma outward. Removing the air helps the pouch lie flat against
◆ Remove the air from the pouch. the abdomen. However, leave a bit of air in the
pouch to allow drainage to fall to the bottom.
For patient comfort.
◆ Place a deodorant in the pouch (optional).
For a neat appearance.
◆ Close the pouch by turning up the bottom
a few times, fan-folding its end lengthwise
and securing it with a rubber band or tail
closure clamp.
For a reusable pouch with faceplate attached.
◆ Apply either adhesive cement or a double- To keep the pouch in place securely.
faced adhesive disc to the faceplate of the
appliance, depending on the type of
appliance being used. Follow the
manufacturer's directions.
◆ Insert a coiled paper guide-strip (15 cm

The guide-strip helps you center the appliance
strip of 1.3 cm wide paper) into the
over the stoma and prevent pressure or irritation
faceplate opening. The strip should
to the stoma by an ill-fitting appliance.
protrude slightly from the opening and
expand to fit it.
◆ Using the guide-strip center the faceplate

over the stoma.
◆ Firmly press the adhesive seal to the

peristomal skin. The guide-strip will fall
11. Prepare and apply the clean pouch.
◆ Remove the tissue from the stoma before
applying the pouch.
For a disposable pouch with adhesive square:

◆ If the pouch does not have a pre-cut
The opening is made slightly larger than the
opening, trace a circle 1/8 to 1/6 inch stoma to prevent rubbing, cutting, or trauma to
larger than the stomal size on the the stoma. The stoma has no pain receptors.
adhesive square.
A hole in the pouch causes leakage of the
◆ Cut out a circle in the adhesive. Take care effluent irritating the skin or soiling clothing.
not to cut any portion of the pouch.
◆ Peel of the backing from the adhesive
seal.
◆ Center the opening of the pouch over the
patient's stoma, and apply it directly onto
the skin barrier. Wrinkles allow seepage of the effluent, which
◆ Gently press the adhesive backing onto can irritate the skin or soil clothing.
the skin and smoothen the wrinkles,
working from the stoma outward. Removing the air helps the pouch lie flat against
◆ Remove the air from the pouch. the abdomen. However, leave a bit of air in the
pouch to allow drainage to fall to the bottom.
◆ Place a deodorant in the pouch (optional).
For a neat appearance.
◆ Close the pouch by turning up the bottom
a few times, fan-folding its end lengthwise
and securing it with a rubber band or tail
closure clamp.
into the pouch; commercially prepared
guide-strips will dissolve in the pouch.
◆ Place a deodorant in the bag if the bag is
not odor-proof. Ostomy belt further secures the pouch.
◆ Close the end of the pouch with the

designated clamp.
◆ Attach the pouch belt, and fasten it

around the patient's waist (optional).
For a reusable pouch with a detachable faceplate
◆ Note allergies and results of tape patch test To anticipate interventions.
performed before the surgery.
◆ Apply a skin sealant to the faceplate before This makes if easier to remove the adhesive disc
attaching the adhesive disc. from the face plate.
◆ Remove the protective paper strip from

one side of the double-faced adhesive disc.
◆ Apply the sticky side to the back of the

faceplate.
◆ Remove the remaining protective paper

strip from the other side of the adhesive
disc.
◆ Center the faceplate over the stoma and

skin barrier, then press and hold the
faceplate against the patient's skin for a
few minutes to secure the seal.
◆ Press the adhesive around the

circumference of the adhesive disk.
◆ Tape the faceplate to the patient's

abdomen using four or eight 7.5 cm strip of
hypoallergenic tape.
◆ Stretch opening at the back of the

pouch,and position it over the base of the
faceplate. Ease it over the faceplate flange.
◆ Place the lock ring between the pouch and

the faceplate flange to seal the pouch
against the faceplate.
◆ Close the base of the pouch with the

appropriate clamp.
◆ Attach the pouch belt, and fasten it around

the patient's waist (optional).
After Care:
◼ Discard disposable bags in the plastic bags before placing in the waste container.
◼ If fecal material is in liquid form, measure its volume before emptying the feces into a toilet or
hopper.
◼ Wash reusable bags with cold water and mild soap, rinse and dry.
◼ Remove and discard gloves.
Documentation:
◼ Report and document any increase in the stoma size, change in color is indicative of circulatory
impairment, and presence of skin irritation or erosion.
◼ Record on the chart
• discoloration of the stoma
• appearance of the peristomal skin
• amount and type of drainage
• patient's fatigue, discomfort, ad significant behavior about the ostomy
INSERTING A RECTAL TUBE
Definition:
A rubber tube is inserted into the anal opening into the rectum for a therapeutic or diagnostic purpose.
Purpose:
To stimulate peristalsis and to provide a passageway for gas to escape.
1. Older patients may have more rectal mucosa.
2. Confused patients may become agitated with the presence of the tube.
3. For children, use a tube with an appropriate size for the child.
4. Leaving a rectal tube in place may not be appropriate for very small children.
5. Teenagers may be embarrassed to pass out flatus.
Rectal tube or catheter French 22 to 30
Lubricant
Gloves
Rubber sheet
ACTION RATIONALE
1. Verify doctor's order Ensures that the insertion of a rectal tube is done to
the right patient
2. Explain procedure and rationale for insertion of Explanation helps to decrease anxiety and promotes
rectal cooperation
tube.
3. Assemble the equipment Organization facilitates efficient performance of
task.
4. Wash hands and apply gloves Protects nurse from microorganisms present in the
feces
5. Put rubber sheet under the patient Protects bed linen
6. Place patient inside lying position. Drape properly Provides privacy
7. Lubricate approximate 4 inches of the rectal tube Facilitates entry of the catheter to the anal canal
8. Gently insert the catheter into the anal canal Removes flatus and helps stimulate peristalsis.
approximately 4 to 6 inches for an adult.
9. Leave rectal tube in place no longer than 20 May cause damage to intestinal mucosa if left in
minutes. place longer.
Tube maybe taped in place
10. Monitor for any change in heart rate while tube is May stimulate a vagal response, causing a decrease
in in heart rate
place.
ACTION RATIONALE
11. Discontinue the rectal tube when gas is relieved Ensures that the patient no longer has the need for
the intervention
12. Have the patient take a slow, deep breath inhaling Helps to relax anal sphincter.
through the nose and exhaling through the mouth
while
removing the rectal tube.
13. Dispose of contaminated rectal tube properly Infection control standard.
14. Assist to clean perineal area if necessary Promotes patient comfort.
15. Remove gloves from inside out and discard. Keeps contaminated portion contained within the
gloves.
16. Wash hands. Prevents the spread of microorganisms.
17. Document size of rectal tube; length of time the Basis for evaluation and continuity of care.
tube
was left in place; color; amount and consistency of
any stool removed; flatus released; and patient's
reaction to the procedure.
Inserting A Rectal Tube.
1. Lubricating rectal tube. 4. Assessing patient’s apical heart rate with
stethoscope
2. Separating the patient’s buttocks, getting ready to 5. Wrapping contaminated rectal tube in paper towel
insert rectal tube. to discard.
3. Securing waterproof pad to end of rectal tube already

inserted.
ADMINISTERING ENEMA
Definition:
It is the procedure of introducing a solution inserted into the rectum and sigmoid colon.
Purpose:
To remove feces and/or release flatus.
Cleansing enema promotes peristalsis by stimulating the colon and rectum and causing intestinal
distention due to the fluid introduced in large volume.
Indication:To remove feces from the colon.
1. Older patients may have impaired mobility; may need much encouragement to maintain the
position desired; will need a bedside commode or a bedpan; may desire to protect privacy and
dignity.
2. Children may be too young to understand why an enema has to be administered and cause much
anxiety.
3. Maintain correct temperature of the solution.
4. Enema nozzle should be well lubricated and is inserted only 2 to 3 inches in children and 1 to 1.5
inches in infants.
5. Only isotonic solution should be used.
Enema set
Tissue paper
Lubricant
Soap and towel
IV pole
Additives as ordered
Rubber sheet
Bedside commode or bedpan (if client is not able to ambulate)
Disposable gloves
ACTION RATIONALE
Large – Volume Cleansing Enema
1. Verify doctor's order. Ensures that the proper enema is administered
to the right patient.
2. Gather necessary equipment. Facilitates efficientperformance of task.
3. Explain procedure to patient Helps to minimize anxiety.
ACTION RATIONALE
4. Warm solution to a desired temperature Prevents chilling the patient. Enemas work best
when solution is warm.
5. Wash hands. For protection of the Nurse and reduce the
transmission of the microorganisms.
6. Put enema solution on the enema can. Release To expel the air from the tubing, to ensure that
clamp and allow solution to progress through only the solution is introduced and not air which
the tube before reclamping. could cause intestinal distention and discomfort.
7. Put rubber sheet under the patient Protects bed linen
8. Provide for privacy. Position and drape the Facilitates flow of solution into the rectum and
patient on the left side (Sim's position). colon. Sim's position provides the best exposure
of the anus.
Left side position follows the anatomical position
of the colon.
9. Apply gloves. Prevents contact with feces.
10. Hang enema can on the IV pole, not higher Gravity forces the solution to enter the intestine
than 18 inches above the level of anus. at a regulated rate eliminating unnecessary
discomfort to the patient.
11. Lubricate the end of rectal tube for 2 to 3 Facilitates easy passage of the rectal tube
inches. through the anal canal and prevents injury to the
mucosa.
12. Lift buttocks to expose the anus. Slowly and This follows the normal intestinal contour.
gently insert the tube 2 to 3 inches through the
anus. Aim the rectal tube towards the
umbilicus.
13. Ask the patient to take several deep breaths. Deep breathing helps relax the anal sphincter.
14. Slowly administer the .solution Eliminates intestinal spasms and cramps.
15. After solution has been given or when the The urge to defecate indicates that the sufficient
patient cannot hold anymore the fluid, clamp amount of fluid has been administered.
tubing and remove tube, disposing of it
properly.
16. Remove gloves from inside out and discard. Protects the nurse from contact with any
microorganisms.
17. Assist in a sitting position on bedpan or assist Sitting position facilitates defecation.
to commode or bathroom.
18. Assist patient if necessary with cleaning of anal Promotes comfort to patient.
area.
19. Care for equipment properly Eliminates the spread of microorganisms.
20. Wash hands Protection of the Nurse and eliminates the
spread of microorganisms.
ACTION RATIONALE
21. Document time, amount and type of enema, Proper documentation facilitates continuity of
solution used, character of stool,and patient's care.
reaction to the procedure.
Small – Volume Prepackaged Enema
1. Verify doctor's orders. Ensures that the proper enema is administered
to the right patient.
3. Remove prepackaged enema from packaging. Prepares the enema for use.
4. Explain procedure to patient. Explanation helps to minimize anxiety.
5. Apply gloves. Protects hands from exposure to feces.
6. Place rubber sheet under the patient. Protects the bed linen.
7. Provide for privacy. Position and drape the Facilitates flow of solution into the rectum and
patient on the left side (Sim's position) or you colon. Sim's position provides the best exposure
may use the knee-chest position. of the anus.
8. Remove the protective cap from the nozzle and Prevents trauma to the rectal mucosa.
inspect the nozzle for lubrication. If the
lubrication is not adequate, add more.
9. Squeeze the container gently to remove any air Reduces introduction of air into the rectum.
and prime the nozzle.
10. Have the patient take a deep breath. Relaxes the rectal sphincter. Pointing the nozzle
Simultaneously insert the nozzle gently into the toward the umbilicus positions the nozzle away
anus, pointing the nozzle toward the umbilicus. from the rectal walls.
11. Squeeze the container until all the solution is Allows the patient to get the full benefit of the
instilled. solution.
12. Remove the nozzle from the anus and dispose Prevents the spread of microorganisms.
of it
properly.
13. When the patient has retained the enema for Patient will be prepared to expel the fluid and
the feces.
prescribed length of time, assist to the
bedside,
commode or toilet or onto the bedpan.
14. Assist to clean the perineal area if needed. Prevents skin breakdown or excoriation:
promotes comfort.
15. Remove gloves and wash hands. Reduces transmission of microorganisms.
16. Document time and type of enema given, Proper documentation facilitates continuity of
character care.
of stool,and patient's
BREAST SELF-EXAMINATION
Definition:
Inspection by the patient of her own breasts to look for any change in size or shape; lumps or thickening; any rashes or other skin irritations;
dimpled or puckered skin; any discharge or change in the nipples.
Purposes:
It can play an important role in early detection of disease resulting in a greater chance of not incurring complex treatment.
ACTION RATIONALE
Standing position (Inspection before a mirror)
1. Stand and face the mirror with your arm relaxed at To look for any flattening on the side view, of either side.
your sides or hands resting on the hips; then turn
to the right and the left for a side view (look)
2. Bend forward from the waist with arms raised over To check for symmetry of the breasts.
the head
3. Stand straight with the arms raised over the head To look for free movement of the breasts over the chest wall.
and move the arms slowly up and down at the
sides.
4. Press your hands firmly together at chin level while To check for symmetry of the breasts.
the elbows are raised to shoulder level.
5. Palpation: Standing To check for lumps.
6. Repeat the examination of both breast while upright This position makes it easier to check the area where a large
with one arm behind your head. percentage of breast cancer are found the upper outer part of the
breast and toward the armpit.
7. Palpation: Lying position Optional: Do the upright BSE in the shower. Soapy hands glide more
easily over wet skin
8. Place a pillow under your right shoulder and place This position distributes breast tissue more evenly on the chest.
the right hand behind your head.
9. Use the finger pad (tips) of the three middle fingers
(held together ) on your left hand to feel for lumps.
Step 1
Begin by looking at your breasts in the mirror with your shoulders straight and your arms on your hips.
Here's what you should look for:
• Breasts that are their usual size, shape, and color.
• Breasts that are evenly shaped without visible distortion or swelling.

If you see any of the following changes, bring them to your doctor's attention:
• Dimpling, puckering, or bulging of the skin.
• A nipple that has changed position or become inverted (pushed inward instead of sticking out).
• Redness, soreness, rash, or swelling.
Step 2 and 3
Raise your arms and look for the same changes.

While you are before the mirror, gently squeeze each nipple between your finger and thumb
and check for nipple discharge (this could be a milky or yellow fluid or blood).
Step 4
Feel your breasts while lying down, using your right hand to feel your left breast and then your left hand to feel your right breast. Use a firm,
smooth touch with the first few fingers of your hand, keeping the fingers flat and together.
Cover the entire breast from top to bottom, side to side—from your collarbone to the top of your abdomen, and from your armpit to your
cleavage.
Step 5
Finally, feel your breasts while you are standing or sitting. Many women find that the easiest way to feel their breasts is when their skin is wet
and slippery, so they like to do this step in the shower. Cover your entire breast, using the same hand movements described in Step 4.
FEMALE CATHETERIZATION
Definition:
The introduction of a catheter through the urethra to the bladder for the purpose of withdrawing urine.
Purpose:
1. To prevent or relieve over distention of the bladder owing to the inability to urinate.
2. To empty the bladder as a measure preparatory to instillation, irrigation or operation or when obstetrical
or post-operative condition contraindicate a voluntary urination in the normal way.
3. To secure urine free of other genital secretions when it is needed for analysis or culture.
4. To remove residual urine
5. Sometimes, to prevent bed wetting if the patient is incontinent.
Screen (if in the ward)

Flushing tray
Bedpan
Rubber sheet
Catheterization tray with the following
Catheter
Lubricant
Sterile gloves
Kidney basin
Flashlight
Specimen bottle
Action:
1. Bring all equipment and materials to the bedside.

2. Prepare patient psychologically
3. Make the patient assume a supine position with knee flexed and apart. Render external douche.
4. Place kidney basin, flashlight and specimen bottle in a convenient position.
5. Open the tray and expose the sterile catheter. If you are alone, place or put a small amount of lubricant
in a sterile gauze inside the tray. If you have a companion, ask her to apply lubricant aseptically.
6. Put on your gloves, pick up the sterile catheter and then lubricate.
7. With one hand hold the catheter, with the other hand open the labia minora using the thumb and the
index finger.
8. Keep the labia apart insert the catheter gently. If the passage is obstructed, such as by the urethral
muscle contraction, withdraw the catheter slightly and wait until the muscle has relaxed, then continue
until the bladder is reached.
9. Direct the open end of the catheter to the kidney basin or specimen bottle.
10. Hold the catheter steady during the outflow. When necessary, press the public area with your forearm to
let more urine come out.
11. When there is no more urine coming out, withdraw the catheter gently, then placed soiled catheter into
the kidney basin. If urine is for examination, label the bottle.
12. If catheter is to be kept indwelling, use foley bag catheter. Inflate balloon with 5 cc of sterile water,
connect to a bedside drainage bottle. Anchor catheter to patient's thigh with the use of adhesive tapes.
13. If urine is for examination, label and send to the laboratory.
After Care of Equipment:
Wash well, rinse, dry and return to central supply room.
Chart:
Record date, time amount of urine withdrawn, character of urine, and patient's reaction.
After Care of patient:
Place the patient in a comfortable position

Precautions:
1. Never catheterize a patient unless ordered.
2. Be extra careful. Do not make any break in the membrane lining. Locate the meatus and aim accurately
before attempting to insert the catheter. Insert without force. Do not proceed if there is resistance or
obstruction, and then try again.
MALE CATHETERIZATION
The same as in female catheterization but with the addition of a disinfecting solution like Zephiran
Chloride 1:1000. Mercurochrome etc.
Action:
1. Bring all equipment and materials to the bedside

2. Prepare patient psychologically and physically
3. Sterilize glans penis with disinfecting solution. Wash hands.
4. Open the tray and expose the urethral catheter
5. Put on your gloves, pick up sterile catheter.
6. Lubricate it with the lubricant available
7. Stretch and position the penis upward so as to have urethra as straight as possible.
8. With the thumb and index fingerof the left hand, gently retract the prepuce to expose the glands and
meatus.
9. Insert catheter gently, advance slowly to follow the regular course of the urethra. If the onward
movement is obstructed, as caused by the contraction of the muscle, when a curve is reached, withdraw
the catheter a little and wait until the muscle has relaxed, or rotate it, then try again. Entry into the
bladder is generally indicated by the flow of urine. Direct the open end of the catheter into a kidney basin
or specimen bottle.
10. After removal of the catheter, cleanse with sterile water the glans and meatus and then dry.
11. Keep the patient in a comfortable position.
12. Wash hands and do after care.
Precaution:
1. Prevent unnecessary exposure

2. Never catheterize a patient unless ordered
3. Be careful not to cause a break in the membrane lining
4. Never use force in inserting the catheter.
Note: See #12 and#13 on female catheterization

ORTHOPEDIC ASSESSMENT
(Musculoskeletal Assessment)
Definition:
A well-organized procedure used to examine and gather information about the musculoskeletal condition
and related organ systems.
Purposes:
1. To fully and clearly understand the patient's problems (from the patient's perspective) and the physical
basis for the symptoms that have caused the patient to complain.
2. To provide a sequential method of assessment to ensure that nothing is overlooked.
3. To enable professional nurses/ students to provide effective and efficient comprehensive nursing care to
the patients with orthopedic problems.
4. To establish a systematic information data in order to minimize unnecessary position changes on the part
of the patient and nurse.
5. To establish a thorough physical examination.
Tape measure
Ruler
Percussion/Reflex Neurologic Hammer
Goniometer
Examination table
Examinaiton room
Drape
1. A well-organized assessment of the musculoskeletal system will enable the examiner to perform efficiently
without overlooking any body part ( to focus on one part at a time is very important) and less tiring for the
patient.
2. It is important for the examiner to understand and know the wide range of variables in what is considered
normal, and the pre-requisites for orthopedic assessment such as:
a. patient's history
b. demographic data
c. current health (chief complaint)
d. past medical history
e. family history
f. psychosocial history
g. exercise
3. The patient's participation is necessary in the assessment process. The procedure should be explained
thoroughly.
4. It is important that the patient is relaxed.
5. Obtain consent if needed
6. The examiner usually does not palpate arbitrarily, but searches out for specifics landmarks, on which to
base significant findings.
7. The patient's privacy should be maintained throughout the procedure.
a. the procedure should be in a private assessment area

b. the patient should be wearing minimal clothing enoughl not to hinder the examination:
− male patients should wear only shorts
− female patients should wear only bra or halter top and shorts
8. The orthopedic assessment of the musculoskeletal system is evaluated in 4 different methods/components:
a. Inspection and Palpation

b. Measuring Range of Motion
c. Assessing Muscle strength
d. Assessing for associated neurovascular impairment
9. Finish all the 4 components before making the patient change position in order to keep the examination
organized and less tiring to the patient.
A. Inspection and Palpation
Inspection:
• note for muscle tone: the state of tension in a muscle at rest

• muscle should be bilaterally equal in size
- difference of < 1 cm in limb circumference is normal
- atrophy is abnormal
- hypertrophy in dominant side is normal
- decreased limb circumference post cast removal is normal
• inspect for symmetry/alignment; swelling; deformity; decreased/increased muscle mass.
Palpation:
• palpate muscle groups gently from proximal to distal, for firmness

• palpate bones for any obvious deformity, fracture, and dislocation
• palpate muscle for masses, spasm , and tenderness
• palpate joints for stability, swelling, tenderness, and warmth
B. MEASURING RANGE OF MOTION
• It is essential to memorize or have a copy of the normal range of motion for each joint, in order to quickly
know if the patient has a deformity.
• Record the patient's R.O.M. of joints and compare to normal range
◼ NECK JOINT - ulnar flexion 30 - 50

- flexion 45
- extension 55 ◼ KNEE JOINT
- lateral flexion 40 - flexion 130
- rotation 70 - extension 130
- hyper extension10 - hypertension 0
◼ SHOULDER JOINT ◼ ANKLE JOINT

- flexion 180 - flexion (dorsiflexion) 20
- extension 180 - extension (plantar flexion) 45 -
- hyperextension 50 50
- abduction 180 - inversion 10 - 30
- anterior adduction 230 - eversion 10 - 20
- posterior adduction 230
- horizontal flexion 130 – 135 ◼ HIP JOINT
- horizontal extension 45 - flexion 120
- external rotation 90 - extension 120
- internal rotation 90 - hyperextension 30 - 50
- circumduction 360 - abduction 45 - 50
- adduction 20 - 30
◼ ELBOW JOINT - external rotation 90
- flexion 150 - 160 - internal rotation 90
- extension 150 - 160 - circumduction 360
- hyperextension 0
- pronation 90 ◼ TRUNK JOINT
- supination 90 - flexion 70 - 90
- extension 70 - 90
◼ WRIST JOINT - lateral flexion 35
- flexion 80 - 90 - rotation 30 - 45
- extension 80 - 90 - hyper extension 20 - 30
- hyperextension 70 - 90
- radial flexion 20
C. GRADING MUCLE STRENGTH
• assess muscle strength while putting joint through active R.O.M.

• repeat R.O.M. while applying resistance
• rate muscle strength numerically
NUMERICAL VALUE FUNCTION DESCRIPTION

0 Zero 0% Muscle is paralyzed with no visible
Contraction sign of palpable contraction
1 TRACE 10% Contraction is palpable but muscle

does not move
2 POOR 25% Full ROM is present with the joint

supported to eliminate gravity
Full ROM is present with gravity as

3 FAIR 50% the only resistance
Full ROM is present against

4 GOOD 75% moderate resistance
Full ROM is present against normal

5 NORMAL 100% resistance.
ASSESSING MUSCLE STRENGTH
MAJOR MUSCLE GROUPS TECHNIQUE
● DELTOID Push down patient’s arm while it is held up and patient resists
● BICEPS Hold patient’s arm in extension while it is fully extended and patient flexes
arm
● TRICEPS Keep patient’s arm in flexion while it is flexed and patient extends arm
● WRIST & FINGER Push patient’s fingers together while patient spreads them and resists
● GRIP STRENGTH Pull your own crossed index and middle fingers out from the patient's grasp.
● HIP MUSCLES Hold down patient's leg while it is fully extended and while patient lifts it off
the table (patient is in supine position)
● HIP MUSCLE (ABDUCTION) Prevent patient from spreading legs apart against resistance applied to the
lateral surface of the knees. (patient in supine position with legs extended)
● HIP MUSCLE (ADDUCTION) Prevent patient from bringing legs together against resistance applied to the
medial surface of the knees. (patient in supine position with legs extended)
● HAMSTRINGS Straighten patient's knees while in supine position with knees flexed and
resists.
● QUADRICEPS Flex patient's knees while in supine position with knees partially in extension
and resists.
● ANKLE and FOOT MUSCLE Dorsiflex patient's foot while patient resists
*To evaluate the circulatory and neurologic status use the 5 P's (Paralysis, Pain, Pulse, Paresthesia, Pallor)
Paralysis
- for the arm or leg assess mobility in the first intact joint distal to the fracture.
Pain
a. determine the location and degree of pain
b. ascertain if the patient is relieved by analgesic meds.
Pulse
a. assess the peripheral pulses especially those near the injury
b. always compare bilateral pulses
c. congenital unilateral or bilateral lack of the dorsalis pedis pulse is normal
Paresthesia
- note any decrease or increase in sensation; absence of sensation; and numbness or tingling sensation
Pallor
a. check the capillary refill (normal value 3 – 5 second)
b. carefully check the skin color and temperature of the injured extremity
- pallor above the injured site indicates venous impairment

- pallor below the injured site indicates arterial impairment
10. When assessing your patient, check each joint for the following signs and symptoms.
a. Pain or tenderness i. Synovial fluid

b. Full range or motion j. Swelling or deformity
c. Abnormal mobility k. Instability
d. Temperature (warmth) l. Ankylosing (joint immobility)
e. Redness m. Thickened synovial membrane
f. Pain of Motion n. Bony enlargement
g. Crepitation o. Congenital defects
h. Discoloration
11. Observe for the condition of tissues surrounding the joint such as:
a. Spasm d. Skin Changes

b. Muscle atrophy e. Swelling
c. Subcutaneous nodules f. Contractures
12. Assess patient's muscle function in this order:
a. Neck f. Hip
b. Shoulder g. Knee
c. Elbow h. Ankle/foot
d. Hand i. Toes
e. Fingers
13. However, if the patient is injured, begin by assessing muscle movement at joints distal to the affected area.
For example, if the part injured is the forearm, assess his finger joints first, and then his wrist joints.
After that, proceed with the assessment in usual order.
14. When assessing patient's muscle strength consider these factors.
a. Is his strength appropriate for his size, age and physical condition?
b. Is his muscle strength equal symmetrically?
c. Carefully document all findings, including muscle strength rating on the hospital's
assessment form.
15. Exercise caution: Conduct range-of-motion tests only if certain that the patient's vertebrae are intact.
16. Percussion is a part of the assessment to the test for fluid in a joint cavity and to identify tenderness.
Auscultation is to determine vascular abnormality and crepitus.
17. During the inspection, observe the person's posture, general appearance and body build; body contours; body
alignment; cervical, thoracic, and lumbar spine.
18. Also observe the relationships of various body parts to each other e.g. relationship of feet to legs, legs to
hips, and hips to pelvis.
19. While observing movement and gait, watch for gait patterns associated with specific disorders; objective
evidence of discomfort; indications of joint stiffness or muscle weakness; lack of coordination; and
deformities.
20. Observe the person's stance and note any deformities:
a. kyphosis i.e. abnormally increased roundness of the thoracic curve
b. Scoliosis i.e. obvious lateral deformity of the spine
c. Lordosis i.e. abnormal increase in the lumbar curve
d. Genu varum (us) - “bowed” legs
e. Genu valgum (us) - “knock-knees”
The terms varus and valgus refer to the direction in which the apex of a deformity lies in relationship to the
midline.
Varus deformity: the apex of the deformity points away from the midline.
Valgus deformity: points toward the midline
21. Perform Local Assessment. This focuses primarily on the person's specific problem.
22. Make comparisons between affected and nonaffected sides of the body.
Ex. If the disorder involves the right knee, compare the right knee with the left.
23. Always include the aspects of neurological assessment in musculoskeletal assessment
a. integrity of skin sensation
b. strength of muscle
Performing Orthopedic Assessment
ACTION RATIONALE
1. If the patient is consulting on an out-patient basis, This would provide baseline data which will aid the
observe patient's gait while entering the future examination findings. The gait should be
examination room. smooth with rhythmic displacement of body parts.
2. Let the patient sit down and examine the head, This will provide the opportunity to rest and relax
neck, shoulder and upper extremities. Observe for
the:
a. patient's posture Abnormal patient's posture obviously indicates

musculoskeletal problem.
b. facial expression Facial expressions such as grimacing indicate the

sensation of pain or discomfort.
c. skin color Change in skin color such as pallor or cyanosis

indicates circulatory problem.
ACTION RATIONALE
d. level of consciousness Change in level of consciousness may suggest

neurologic problems probably secondary to
musculoskeletal injury.
e. placement of arms and legs This will determine patient's mannerisms, habits which
would have caused the problem/s.
3. Explain the procedure to the patient Discuss the procedure in a reassuring, conversational
way. This will promote relaxation to the patient. The
examiner will be able to obtain accurate assessment if
the patient's muscles are relaxed.
4. Remove patient's gown. This will allow proper exposure of the body part being
Men should wear shorts. examined while maintaining privacy.
Preferably, women should wear bra and
halter/shorts.
5. Perform handwashing To prevent transfer of pathogenic microorganisms
from the examiner's hands to the patient especially if
the patient has open or compound fracture.
6. Instruct the patient to stand putting equal weight By gravity, standing position will put body weight on
on both feet. Check posture. the feet, thus facilitate evaluation of posture.
7. Let the patient walk normally across the room.
• Check for gait; limping; unequal Abnormal gait; limping and unequal weight
weight distribution on both feet. distribution on both feet indicate musculoskeletal
• As you assess the gait, note for his stance problem which should be given particular attention
(position of his foot on the floor) and swing and proper clinical correlation.
(movement of his leg swinging forward)
• Note the associated movements of his arm and
legs.
• Is his gait smooth, coordinated, and rhythmic?
• Or does he limp or stumble?
• Observe his gait (if possible) both with and
without any ambulation aids he uses, such as
crutches, braces, or a walker.
• Listen to his walk for any flopping, dragging, or Flopping indicates foot drop.
scraping or stomping. Dragging or scraping indicates spasticity
Stomping indicates ataxia.
8. Again for signs of pain or stiffness.
9. Instruct the patient to walk with toes. Walking on toes is the best way to test early foot
plantar flexion weakness while walking on heels is the
10. Walk back with heels. most sensitive way to test for foot weakness in
dorsiflexion of the ankles.
11. Le the patient squat like a baseball catcher and To detect abnormality in the strength of the lower
stand quickly extremities.
12. Inspect the spine. Look for asymmetry across the To detect scoliosis.
back.
13. Inspect the shoulder. Check for symmetry of both This is to examine clavicular fracture and shoulder
shoulders and the midline area. dislocation.
14. Observe hips and back To determine presence of hip dislocation.
15. Instruct the patient to join hands together and To test spine flexion and detect asymmetry on the
bend forward back and thoracic area.
16. Observe for increase rounding of the back Increase rounding means a developing kyphosis – an
abnormal increased roundness of the thoracic curve or
hump.
17. Le the patient bend towards the right side. Do the To determine lateral flexion of the spine.
same with the left.
ACTION RATIONALE
18. Instruct to bend backward as far as he can This is to check for spine extension.
19. Let the patient sit at the side/edge of the This position will facilitate examination of the chest
examination table with feet dangling. area and cervical spine.
20. Advise the patient to turn the neck towards his To test for cervical rotation.
right side. Do the same to the left.
21. Inform the patient to bend the neck to the right. To test for lateral flexion of the cervical spine
Do the same to the left.
22. Ask the patient to touch the chest with his chin. This is to test for cervical flexion.
23. Then ask to bend the neck backward as far as he To test for cervical extension.
can
24. Place tape measure across the nipple line. Then, To determine range of motion of the thoracic cage
advise the patient to make a deep breath in and
out. Measure the chest expansion by recording
the chest circumference.
25. Raise the right hand to the side. Do the same To determine the range of motion in the shoulder
with the left hand. joint. This is to rest for adduction. To check for
adduction.
26. Place the right hand towards the midline This is to test for the internal rotation of the shoulder.
27. Place the right hand in front to touch the To test for external rotation.
opposite shoulder (left shoulder)
28. Then touch the scapula. This is to test for shoulder flexion.
29. Raise the right hand forward. Do the same with This is to test for shoulder extension.
the left.
30. Bend the elbow back. This is to test elbow joint flexion.
31. Straight elbow To determine for elbow joint extension and triceps
muscles.
32. Flex elbow up to the chin level. To test for elbow flexion and strength of biceps.
33. Flex elbow tight at waist level. Open palms. To test for supination.
34. Position palms down To test for pronation.
35. Flex wrist. To determine wrist joint flexion which indicates
wristdrop.
36. Extend wrist as far as the patient can. To determine wrist extension.
37. Palms down and spread fingers as the patient The patient should be able to abduct all his little
can. fingers. Failure to do so may suggest damage of the
ulnar nerve caused by ulnar fracture.
38. Make the patient hyperextend his thumb. If he cannot, the patient may have radial nerve
damage which is commonly caused by humeral
fracture.
39. Finders together. To check for finger adduction.
40. Palms up and close To test all the wrist joint and fingers.
41. Open palm and let the small finger and thumb Failure to perform opposition of the thumb and small
touch each other. finger indicates median nerve damage.
42. Get the percussion hammer and check for
reflexes of the:
(Reflex is tested by tapping a partially flexed
tendon in a relaxed patient. This is graded
numerically)
a. Biceps and brachioradialis To test reflexes of the upper extremities.

ACTION RATIONALE
b. Pattelar and Archille's This is a test for the reflexes of the lower extremities.
Tendon reflex
NUMERICAL DESCRIPTION VALUE

0 No reflex response
+1 Minimal activity (hypoactive)
+2 Normal response
+3 More active than normal
+4 Maximum activity (hyperactivity)
43. Make patient put his gown on again. To provide warmth and privacy
44. Instruct the patient to lie down. Inspect the This is the best position to determine abnormalities of
hips, knees ankle and feet. the lower extremities.
45. Get the tape measure and measure the right leg This is the accurate way of measuring the leg length.
from the anterior iliac spine to the medial
malleolus. Then, perform it on the other leg.
46. Then, test the range of motion of the hip joint. To test for hip flexion and hamstring tightness
Raise the right leg as far as the patient can.
47. Extend the left leg to the left side of the body. To test for hip adduction.
48. Then, bring back the leg towards the midline. To test for hip adduction especially gluteus muscles.
49. Passively flex right knee. To test for knee flexion and hamstring muscles.
50. Passively extend the knees. To test for extensor muscles - the quadriceps
51. Inspect right foot. Observe toes and nailbeds for To detect circulatory problem.
any obvious cyanosis or discoloration. Note any
deformities; nodules; calluses; or corns.
Compress the sides of the forefoot.
52. Push the right foot toward the midline. To test for internal rotation of the hip joint.
53. While the knee is still flexed, gently pull the foot To test for external rotation of the hip joint.
away from the midline of the body. Do to the
other side.
54. Test the foot by instructing the patient to point To test for plantar flexion of the ankle (flexion of the
the toes to the foot part of the bed (foot rails) ankle). If the patient is unable to plantarflex his
ankle, possible tibial nerve damage is present
common in patient with fracture of the tibia.
55. Then, point the toes towards the face of the For dorsiflexion/ankle extension testing. If the patient
patient/towards the head rails of the patient. is unable to dorsiflex his ankle, a peroneal nerve
damage is suspected usually caused by fracture of the
fibula.
56. Palpate metatarsophalangeal joints by To test for tenderness in the metatarsophalangeal
compressing each joint between your thumb and joints.
forefinger. Evaluate range-of-motion of toe
joints. Repeat the process on the other foot. To detect a plantar wart.
57. Palpate his ankle joint's anterior surface, ankle's To detect subcutaneous nodules.
bony prominences (lateral and medial
58. Point the toes inward. To test ankle inversion.
43. Make patient put his gown on again. To provide warmth and privacy
44. Instruct the patient to lie down. Inspect the This is the best position to determine abnormalities of
hips, knees ankle and feet. the lower extremities.
45. Get the tape measure and measure the right leg This is the accurate way of measuring the leg length.
from the anterior iliac spine to the medial
malleolus. Then, perform it on the other leg.
46. Then, test the range of motion of the hip joint. To test for hip flexion and hamstring tightness
Raise the right leg as far as the patient can.
47. Extend the left leg to the left side of the body. To test for hip adduction.
59. Then, toes outward. This is an ankle inversion test.
60. The next step is toes up. To check for toe extension.
61. Have the patient lie on his abdomen. Flex the To check for hip flexion.
right knee as far as the patient could as you
support the right buttocks. To check for knee extensors.
62. Then, instruct the patient to lie on his back. Test Using muscle strength grading system will guide the
for the muscle strength by instructing to extend nurse baseline data for future comparison.
the knee against resistance. Compare one side
with the other. (Please refer to Grading Muscle
Strength discussed in the special consideration)
TRACTION
Definition:
Traction refers to the pulling force applied to a part of the body or an extremity with a counteraction pull
in the opposite direction.
In straight or running traction, counteraction is supplied by the patient’s body with the bed in one of the
following positions:
1. flat
2. tilted away from the traction pull
3. altered by elevating the head and/or the knees.
Purpose:
To regulate or temporarily suspend the movement of an injured part thereby enabling bone and soft tissue to heal.
Indications:
It can be used in a variety of conditions as a method of treatment:
1. Relieving pain/or muscle spasm

2. Restoring and maintaining alignment of bone following fracture
3. Gradually correcting deformities due to contracted soft tissue
4. Resting a diseased or inflamed joint while maintaining it in a traction position
5. As pre-operative measure before internal fixation
6. As a postoperative measure to maintain the desired position
Principles of Traction
1. Traction must have an opposite pull or counteraction

2. Be free from any friction
3. Follow the established line of pull - the line of pull must be in line with the deformity
4. Traction must be continuous.
5. Applied to a patient in a supine position.
Skin Traction
The application of a pulling force to the skin from where it is transmitted to the muscle and then to the bones.
Types of Skin Extension
1. Adhesive skin extension are used on intact skin in good condition

Material: Non-stretch Elastoplast with padding to protect bony prominences
Example: Bryant traction, dunlop, bucks extension
2. Non-adhesive extension are used on fragile skin

Material: canvas, slings, leathers and straps with buckles and laces.
Example: Head halter traction, hammock suspension in traction, pelvic traction, anklet traction.
ACTION RATIONALE
A. Adhesive type:
1. Explain the procedure to the patient To obtain the patient’s consent and cooperation.
2. Ensure privacy for the patient while Maintain patient’s dignity.
carrying out the procedure.
3. Ensure that the affected part is clean and the To prevent infection from developing.
skin intact.
4. Shave any limb covered by thick, tough To ensure that adhesive sticks to the skin and not to
hair. the hair. The part affected will be sore if the traction
is applied to the hair follicles.
5. If possible, leave the ankle joint free. To allow full plantar flexion and dorsiflexion of the foot
in order to prevent stiffness and deformity.
6. If the lower limb is for traction apply pieces of felt To protect them from friction. To prevent the
or latex foam to the and other bony prominences. development of pressure ulcers.
7. Leave the patellae and the knee 10-15 of full To prevent limb deformity and joint stiffness
flexion.
8. The limb maybe painted or sprayed with tincture of To reduce moisture through perspiration. To increase
benzoin compound. the adhesive quality of the material used.
9. Apply the extension strapping and bandage without To prevent discomfort. To prevent skin deterioration
fold or creases. under the strapping.
10. Ensure that the part affected is in the correct To prevent limb deformity.
anatomical position e.g. feet and patellae pointing
upwards when patient is in the supine position
11. Check the temperature and color of the extremity To ensure that the tension of strapping is correct and
affected as required, together with the degree of that circulation and nerve pathways to the extremity
sensation and movement. are not being compromised.
B. Non-adhesive type:
1. Explain the procedure to the patient To obtain the patient’s consent and cooperation.
2. Ensure privacy for the patient while carrying out the Maintain patient’s dignity.
procedure.
3. Ensure that the affected part is clean and the skin To prevent infection from developing.
intact.
4. If possible, leave the ankle joint free. To allow full plantar flexion and dorsiflexion of the foot
in order to prevent stiffness and deformity.
5. If the lower limb is for traction apply pieces of felt To protect them from friction. To prevent the
or latex foam to the and other bony prominences. development of pressure ulcers.
6. Leave the patellae and the knee 10-15 of full To prevent limb deformity and joint stiffness
flexion.
7. Apply the extension strapping and bandage without To prevent discomfort. To prevent skin deterioration
fold or creases. under the strapping.
8. Ensure that the part affected is the correct To prevent limb deformity.
anatomical position e.g. feet and patellae pointing
upwards when patient is in the supine position
9. Check the temperature and color of the extremity To ensure that the tension of strapping is correct and
affected as required, together with the degree of that circulation and nerve pathways to the extremity
sensation & movement. are not being compromised.
Removing Skin Traction:
Care must be taken to avoid skin damage during removal of adhesive extension. Pulling the edges back
slowly, while pulling the skin taut is less damaging than trying to remove the adhesive quickly. Analgesia may be
required. Adhesive solvent should be used when necessary. Manual traction should be maintained unless
treatment is to be discontinued.
SKELETAL TRACTION
Definition:
Set of orthopedic contraption applied directly to the bones by means of pins, wires or traction screws.
Skeletal Traction with their corresponding
Indications:
1. Skeletal traction using Kirsliner's wire and Steinmans pin:

Conditions affecting the femur, hip tibia, and supracondylar humerus
2. Crutchfield tong or Vinks skull caliper:
Conditions affecting the cervical spine
• fracture board
• 4 vertical bars
• 2 horizontal bars
• 1 diagonal bar
• 2 straight or cross bar
• 1 curve bar
Application of Balanced Skeletal Traction
Steps:
1. Verify doctor's order.

2. Inform the patient about the need and purpose of the procedure.
3. Preparation:
a. Identify the different parts of the orthopedic bed
b. Assemble the needed equipment: Thomas splint & Pearson Attachment
* medial side (lower portion)
* lateral sid
* medial upright
* upper portion
c. Identify accurately the affected extremity
◆ Where to stand on the demo side: look for the last pulley and stand on that side.
4. Mount the Thomas & Pearson on the rest splint
5. Principles in the application of slings:
1. Not too tight not too loose

2. One (1) inch distance in between the slings to promote aeration or ventilation
3. Popliteal and heel portion should be free from any sling.
4. Smooth and right side should come in contact with the patient's skin
5. Provide or apply Two (2) longer and wider slings for the thigh portion and three (3) for the leg
area.
◆ How to apply sling - start from the medial side towards the lateral side, secure both
ends together; fan fold nicely on the lateral aspect and secure with a pin or clip.
Observe the principle of not too tight not too loose and the patient's extremity not to get
in touch with the pin.
◆ The thigh rope should be attached to the medial aspect as well as to the lateral aspect.
6. Insertion of the apparatus under the affected extremity will need three (3) manpower:
1. Insert the entire apparatus under the affected extremity

2. Manual traction to be released after the completion of traction weight on the third (3rd)
pulley.
3. Lift the affected extremity:
- Simultaneous at the count of three (3)
◆ Instruction to the patient: Hold on to the trapeze bar, flex the unaffected leg at the
count of three (3), the three (3) manpower to do their work simultaneously.
6. Application of Traction Weight

◆ Attach the rope to the Steinman pin holder to run along the third (3 rd) pulley and attach the
prescribed weight.
◆ Check the principles of sling application, and make the necessary adjustments, check also the
alignment.
7. Apply suspension traction

◆ Attach one (1) end of the thigh rope to the lateral aspect of the ischial ring with a slip knot.
◆ Attach suspension rope on the mid part of the thigh rope, to the first (1st) pulley insert
suspension weight, hang it on the first (1st) pulley, pass it on the second (2nd) pulley under the
rest splint clove hitch knot on the Thomas splint and another clove hitch knot on the Pearson,
close it with a knot to secure it.
◆ Be sure to maintain the traction rope inside, and the suspension weight should be outside.
8. Remove the rest splint
9. Apply foot support
10. Check the Principles of traction. Emphasizing the five (5) Principles of Traction and Discuss the Nursing
Care.
Swing the patient to and fro, side to side to check the efficiency of traction.
1. Patient should be on dorsal recumbent position

2. Line of pull should be in line with the deformity
3. Positioning of a diagonal bar and positioning of a pulley:
* First (1st) pulley should be in line with the thigh, 2nd pulley should be in line with the knee or
screw. Third (3rd) pulley should be in line with the first (1st) and second (2nd) pulley.
* Should be continuous, with emphasis on the importance of manual traction
4. To avoid Friction: Rope should be running along the groove of the pulley; knots should be away
from the pulley; weight should be hanging freely.
5. Observe for wear and tear of rope and bags.
6. The patient's body weight serves as counter traction.
Removal of Traction:
1. Apply rest splint

2. Hang suspension weight on the first (1st) pulley.
3. For complete removal of suspension weight: remove the knot on the Pearson and Thomas
4. For manual traction on the steinman pin holder: remove the traction weight on the third (3rd) pulley,
secure the traction rope on the rest splint, and another on the Thomas and Pearson attachment
Nursing Care of Patients with Traction
1. Assessment: assess the patient for level of understanding and consciousness.

2. Provision of general comfort:
a. skin care – head to toe, focus on the sponging of the affected extremity.
Guide for sponging:
* Prepare 2 basins with face towel and soap
* Remove sling one by one and sponge
* Remove the foot support and sponge
b. Changing of linen.
c. Provide bedpan as needed. Serve bedpan on the unaffected side, provide pillow at the back and
provide privacy.
d. Perineal care
3. Potential complications and corresponding interventions:

a. Upper respiratory ( e.g. pneumonia):
bronchial tapping and deep breathing
b. Bedsore: good perineal care; proper skin care and turning and lifting buttocks once in a while.
c. Urinary and kidney problem : good perineal care and increase in fluid intake.
d. Bowel complication ( e.g. fear of apparatus, no privacy, lack of fluids): perineal care.
e. Pin site infection: (S/S of infection - loosening pin tract; pus coming out; foul smell; fever):aseptic
technique and proper referral to Dr. in charge
f. Deformity: (contracted knee, atrophy of muscles, foot drop, joint contractures).
4. Provision of Exercises:
a. ROM exercises with the use of trapeze
b. Deep breathing exercises
C. Static quadriceps exercises, alternative contractions and relaxation of quadriceps muscles.
d. Toes pedal exercises.
5. Nutritional Status - depending on the status of patient
6. Psychological Aspect – fear of unknown, fear of death, fear of the apparatus, fear of losing job, financial
fear.
7. Provision of supportive therapy
- Offer book to read; radio or T.V.; explore patient’s interests.
8. Spiritual Aspect – know his religion, encourage relatives to facilitate providing spiritual counselling, visits
from the chaplain, or pastoral care minister, etc.
9. Diversional activities – divert attention.
CARE OF THE DYING AND THE DEAD
Definition:
The physical and spiritual care rendered to a patient with irreversible health condition, preparing her/him
to cross over from life to death.
Purposes:
1. To minister to the physical, psychological, emotional and spiritual needs of the dying patient.
2. To prepare the body after death with dignity and respect by providing all the means to:
a. Conserve the physical contour.
b. Make the body presentable
c. Provide accurate identification.
Equipment/Materials
post-mortem kit
clean gloves
soap
wash cloth
towels
basin
clean gown/mortuary gown
clean linen
clean dressing or ostomy bag (if wound is present)
disposable pads
shroud or sheet
identification tags
masking tape
1. Be certain of the Faith or Religion and religious beliefs of the patient. On this you can base your total plan
of care for a dying patient.
2. Do everything possible for the comfort of the patient and his relatives.
3. Observe patient’s condition closely and inform physician. Assist in the usual life-saving medical
interventions: CPR, etc. Note: At this point , the Nurse attends to both the physical and spiritual
interventions, hence is expected to be very creative and to display a wide range of perspective and quick
decision-making, i.e. the heart and the mind guide her/his action.
4. If Catholic:
a. Prepare or encourage patient to see the Chaplain/Priest for spiritual accompaniment and the
reception of the Sacraments (Confession and Holy Eucharist).
b. Prepare patient for the Chaplain’s visit (Confession and Holy Communion) (Note: For a Catholic
Nurse it is part of the total patient care to be around and to introduce the Chaplain to the
patient and relatives when he comes to see the patient to administer the Sacraments. The Nurse
is encouraged to participate in the ritual as much as possible).
c. If patient is in a serious irreversible condition or to undergo surgical procedure, suggest to
patient and to relatives to call the Chaplain for the Sacrament/Anointing of the sick. Document.
d. When there is danger of a child or fetus dying without Baptism, anyone can administer emergency
Baptism, following this procedure:
* Pour plain tap water over the forehead of the child and at the same time say the
words, “I BAPTIZE YOU (say the name of the child), IN THE NAME OF THE FATHER,
AND OF THE SON, AND OF THE HOLY SPIRIT.” Note: Amen is not said.
e. In case of doubt, whether the child has been baptized or not, conditional Baptism is administered:
*Pour plain tap water on the forehead and say, “IN CASE YOU HAVE NOT RECEIVED THE
SACRAMENT, I BAPTIZE YOU (name of the patient), IN THE NAME OF THE FATHER,
AND OF THE SON, AND OF THE HOLY SPIRIT.” Note: Amen is not said.
f. Inform or make a report to the Chaplain about the Baptism administered. This is reported to the
nearest Parish Church, for proper recording. Ask the Chaplain where the relatives can get the
certificate of Baptism.
g. If the Baptism was administered in the absence of the relatives, inform them and instruct them
how and where to get the certificate of Baptism.
5. If non-Catholic, ask relatives to get their Minister. Assist them in any way possible.
6. If death is imminent make sure the patient has received the Anojnting of the sick, inform Chaplain and
assist in the final ritual.
7. When declared dead officially by the authorized physician, inform the relatives and begin the post mortem
care.
8. Consider the feelings, wishes and the ways of grieving of the relatives.
9. Carry out procedure quietly, quickly and respectfully.
10. If possible, the other patients, (if in a common ward) need not know about the death.
ACTION RATIONALE
A. Preparation of the Body
1. Verify if the vital functions have ceased. Declaring death should be certain.
2. Notify the people and departments concerned. For appropriate implementation of administrative
standard post mortem procedures.
3. Plan for any religious or cultural rituals if desired To respect the Religious beliefs of the patient and
by the family. family.
4. If the patient is in a common ward, pull the curtains To provide privacy for the family and friends.
and close the door.
5. Wash your hands For infection control
6. Gather the equipment needed. To save time and effort and for systematic
performance of the procedure
7. Post on the door, the signage: NO VISITORS – To ensure privacy.
CHECK AT NURSES’ STATION
8. Place the body in supine position, the arms at the To prevent the possibility of the underlying hand and
patient’s side with the bed flat. other parts from becoming discolored and indented.
9. Place a low pillow under the head. This prevent the already unoxygenated blood from
pooling in the face which can cause discoloration.
10. Gently hold your index fingers on the eyelids for a To close the patient’s eyes.
few seconds.
11. Remove the patient’s watch and other jewelry Regardless of monetary worth, these items are
items. Make an itemized list of all the patient’s important to the family.
belongings.
12. Chart the disposition of jewelry duly acknowledged For accountability and for legal protection of the
and with signature affixed by a responsible staff.
member of the patient’s family.
13. Put on clean gloves To prevent getting contaminated by body secretions.
14. Wash dentures and place inside the mouth. To preserve the person’s natural appearance
15. Place a small towel under the chin. To support the mouth and kept closed.
16. Remove IV lines, NGT, oxygen equipment, etc To facilitate carrying out efficiently, the post mortem
procedures.
17. Drain the bladder by pressing on the lower Leaking orifices pose a health hazard to persons
abdomen coming in contact with the dead body.
18. Remove soiled dressing and ostomy bags and To contain possible leakage from wound sites.
replace with clean ones.
19. Wash the soiled areas. For aesthetic reasons.
Pat the body dry. Brisk rubbing may cause undue discoloration of the
tissues.
20. Place other disposable pads in the perineal area. To absorb any stool or urine released as the sphincter
muscles relax.
21. Remove and discard gloves. To avoid getting contaminated with secretions
22. Put a clean gown on patient. Say the prayer For aesthetic reasons, and respect for the dead
while doing so, repeating as needed. (Eternal rest person.
grant unto her/him O Lord and let perpetual shine
upon her/him. May she/he rest in peace. Amen).
23. Leave wrist identification band in place. This is It serves as an excellent method of identifying the
removed only if it is restricting the arm. body.
24. Attach a second identification tag at the ankle or It is prudent to have two pieces of identification
great toe. attached to the body in case one becomes detached
and lost. The ankle or great toe is an appropriate area
because any markings on the skin there will not be
noticeable when the body is viewed.
25. If the family and friends intend to view the body
replace the top linens (top sheet, bed spread and To give the bed a fresh and clean appearance.
pillow case)
26. Fill out death notice in quadruplicate For record and legal purposes.
27. Send body down to the morgue To facilitate release of the body to the family or
mortuary service.
28. Send death certificate to the medical record section For legal purposes.
after accomplishing patient’s data.
After Care of Equipment/Materials:
1. Strip the bed and unit as on discharge of a patient.

2. If patient was a communicable case, observe the necessary precautionary measures.
3. Return equipment used to their proper places.
4. Wash hands thoroughly.
Record:
1. Time of death:
2. Physician who pronounced patient’s death.
3. Time of transfer to the morgue Note: Most hospitals follow the policy that the dead body is not made
to stay in the ward or unit for more than one (1) hour.
Sample of Tag:
ST. ANTHONY COLLEGE HOSPITAL

Name:
_____________________________________________
Age: ____ Sex: ______________ Nationality:
_____________
Attending Physician:
__________________________________
Date of Death: ________________ Time:
_________________
Pronounce Dead by:
__________________________________
Packed by: _________________________________________

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HANDWASHING

A. Equipment/Materials: Draping sheet, or bed sheet.

B. Patient and Unit

SIMS LATERAL PRONE

TAKING OF VITAL SIGNS

It is the measurement of body temperature, respiration, pulse and blood pressure.

Gloving is a universal precaution.

4. Read thermometer level by locating Thermometer reading should initially be lower

Equipment/Materials: Watch with seconds hand, small notebook and pen.

Assessing Pulse Rate

3. Auscultate the apical pulse: apex area

6. Record rate and character of respiration. Ensures accurate observation and

3. Palpate the brachial pulse 4. Proper placement of diaphragm of stethoscope

7. Measure the diastolic pressure

General Considerations in bedmaking

To prepare a comfortable and safe bed ready to receive a patient.

Rocking backward or forward utilizes the

The draw sheet will prevent skin irritation

Lumps and creases in the bed produce uneven

A mitered corner presents a neat appearance.

1. To promote the patient's comfort.

1. To conserve the patient's energy and maintain current health status

Assemble at the bedside and arrange according to use the following:

Lumps and creases in the bed produce uneven

The draw sheet will prevent skin irritation

A mitered corner presents a neat appearance.

a. If both end of the pillowcase are open

POST-OPERATIVE BED (RECOVERY OR ANESTHETIC BED)

1. To provide a change of position and to afford an opportunity to inspect the patient's

Patient and unit

1. Inform the patient about the procedure

How to make a miter:

Purpose: To secure the bed clothes while the bed is occupied

7. Beginning to make mitered corner by 8. Laying triangular fold on top of

11. Cuffing top linens. 12. Placing pillow on bed.

13. Securing signal device to bed.

7. Removing bath blanket from under top linens.

Cold or Tepid Sponge Bath:

1. Avoid chilling by:

B. Patient and Unit

Proceed as in bed bath

Alcohol Sponge Bath:

It is a bath given to a patient in bed.

Basin with warm water

B. Patient and Unit

Explain the procedure to the patient

8. Washing the abdomen, with perineal 11.Washing the upper back

1. To minimize congestion and pain in the pelvic region

1. Be sure that there is a written order from the physician.

Sitz tub, bath tub or big deep basin Blankets – 2

Assemble equipment at patient's bedside.

Enclosing the tub with blanket prevents the

1. Assess and determine:

b. Using your palm, begin at the sacral area

It should not be rushed as it is during this phase that

Mobilizes fluids, stretching muscle fibers, and

d. Massage in a circular motion over the

b. Massage the areas over the right

c. Apply firm, continuous pressure