FON-I Skill Manual - BSN 2nd Batch

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Fundamentals of Nursing I
Skill Manual
Milestone College of Nursing
Kallar Kahar
BSN 2nd Batch
Total Credits skills : 2.0
Course Coordinator : Mr. Mr. Aitzaz Ijaz
Course Faculty : Mr. Aitzaz Ijaz
Timings : See Master Schedule
Student Name : _________________________________________
Roll Number : _________________________________________

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Clinical Objectives of Fundamental of Nursing:
1. Identify the roles and functions of health care team members.

2. Describe the functions of the various departments in a hospital.
3. Describe the physical setup of a ward
4. Utilize techniques of therapeutic communication skills with patient and health team members.
5. Collect patients’ data through interview.
6. Observe the coordination of patients’ care between the health team members.
7. Identify different forms used for documentation in patients’ care.
8. Utilize appropriate hospital forms for documentation.
9. Assess, document, and identify variations in Vital Signs
10. Discuss the observations for different Vital Signs patterns.
11. Develop problem list based on patients’ assessments and rationalize each problem identified.
12. Document assessment of patients’ problems/needs by using Maslow’s Hierarchy of human
needs at a beginning level.
13. Develop Nursing care plan based on priority patients’ problem by following all the six
components of nursing process.
14. Observe the process of admission of a patient in hospital.
15. Orient a patient to hospital environment.
16. Assist in transfer of patients from one unit to another unit and department.
17. Assist in preparing patients and family for discharge.
18. Document the discharge of patients from the hospital.
19. Observe various legal forms/documents used in the admission process
20. Observe patients’ reactions to hospitalization and give assistance as needed.
21. Demonstrate occupied and unoccupied bed making.
22. Assess the need of personal hygiene care for selected patients and provide care accordingly.
23. Document patients’ assessment and care provided.
24. Utilize skills to maintain healthy nails and feet
25. Demonstrate use of following safety measures for patients:
• Side rails
• Restraints
• Hand washing
26. Demonstrate application of body mechanics when moving and lifting patient.
27. Demonstrate range of motion exercises on a patient.
28. Provide back care to bed ridden patients.
29. Assist in transferring patients from bed to bed, bed to chair and bed to stretcher.
30. Utilize different comfort devices in patients’ care.
31. Assist patients with different types of positions.
32. Demonstrate characteristics of a professional nurse.
33. Assist patients in maintaining proper body alignment in bed
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FON-I Lab Planning

Timing (See Master Schedule)
Dates / Faculty Page

Week FON-I Skills Demonstration #
• Medical Hand Washing
1st Week FON-1 Team 04
• (Demonstration & Practice / sign off)
• Back care
2nd Week FON-1 Team 28
• Hand & Foot Care 30
3rd Week FON-1 Team
• (Demonstration & Practice / sign off) 31
• Therapeutic Communication (Interviewing Skills)
4th Week FON-1 Team 08
• Mouth Care of an Unconscious Client
• Bed Making (unoccupied) & (occupied)
• Shampooing
8th Week Mid Term FON-1 Team
9th Week Restarting Classes FON-1 Team
• Bed Bath 10
10th Week FON-1 Team
• (Demonstration & Practice / sign off) 14
• Assessing Temperature
33
• Assessing Pulse
11 Week
th
FON-1 Team 38
• Assessing Respiration
41
12th & 13th • Assessing Blood Pressure
Week
FON-1 Team 43
• Measurement of Height and Weight
• BLS
• Admission, transfer & discharge of a patient in hospital
• Role Play
17th Week Revision FON-1 Team
18th Week VIVA/Practical External
Evaluation Criteria
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MEDICAL HAND WASH
1. PURPOSES
 To reduce the number of microorganisms on hands.
 To reduce the risk of transmission of microorganisms to client and family
members.
 To reduce the risk of cross contamination among client, health care workers and
personal contacts.
 To reduce the risk of transmission of infectious organisms to one self.
2. EQUIPMENT
 Soap/ Disinfect solution
 Hand towel or tissue paper
PROCEDURE
S# Steps Rationale S U
1. Check hands for break in the skin. (And For your protection. Cuts & abrasion can be
apply waterproof dressing over cuts) contaminated & cannot be easily cleaned.
2. File Nails short. Short nails are less likely to harbor
microorganisms, scratch client, or Puncture
gloves.
3. Remove any nail varnish Inhibits effective hand washing by
potentially harboring bacteria.
4. Remove all jewelry Microorganisms can lodge in jewelry and
(rings, bangles, wristwatch) removal facilitates proper cleaning Provide
complete access to hands.
5. Stand in front of the sink, keeping hands Inside the sink is contaminated. Reaching
and uniform away from the sink surface. over sink increases risk of touching
contaminated edge.
6. Wash hands in the following sequence
6.1 Turn on the water tap, using towel Tap handle is considered contaminated,
paper. organisms can be transferred.
Adjust the flow, run the water flow rate at Water will not splash on uniform.
medium speed. Plugholes are contaminated with
Water should always be away from the microorganisms that could be transferred to
plughole the environment or user if splashing occurs.
6.2 Wet hands, holding hands lower than Water should flow from least contaminated
elbow. area (lower arms) to the most contaminated
area (hands).
6.3 Wet all surfaces of the hand & wrists Soap applied directly to dry hands can cause
damage to skin. The water also quickly mixes
with soap to assist speedy hand washing.
6.4 If a soap bar is used, rinse it. Using Soap cleanses by emulsifying fat and oil and
firm, rubbing & circular movements wash lowering surface tension.
hands. Lather helps removal of microorganisms. All
6.6 Apply soap & water to all surfaces of surface areas on hands are cleaned, any S U
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the hands. missed can be a source of cross infection.

Rinse bar soap before returning to the dish A moist & lathered soap bar permits
microorganisms to travel & grow. Use
friction – 1 minute. Friction removes micro-
organisms mechanically from the skin
surface. Friction
loosens dirt from soiled areas
6.7 Palm to Palm
6.8 Right palm over left dorsum and left

palm over right dorsum
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6.9 Palm to palm fingers interlaced
6.10 Back of fingers to opposing palms S U

with fingers interlocked.
6.11 Do the rotation rubbing of the thumb

of both hands
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6.12 Wards with clasped fingers of right

hand in left palm and vice versa
6.13 Thoroughly wash soap off and rinse A residue of soap can lead to irritation &
hands. Make sure hands are down & damage skin. Hence damaged skin does not
elbows up. provide protection and can cause cross
infection.
7 Dry hands thoroughly, including between Moisture can easily damage and promote
fingers growth of organisms
8 Turn off tap using paper towel Will prevent recontamination of washed
fingers
Date Sign off in Skill Lab Faculty Signature

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THERAPEUTIC COMMUNICATION (INTERVIEW)

1. PURPOSE
 To utilize data for future intervention.
 Give & receive information.
 Provide basis for the nurse- client relationship.
 To provide health teaching and assist clients in problem solving.
 Facilitate & implement the nursing process.
2. EQUIPMENT
 Quiet & uninterrupted environment
 Aids: Paper/ Pen Cue Cards
 Comfortable chair/bed for client & chair for Nurse
PROCEDURE
S.# Step Rationale S U
Preparatory Phase
1. Arrange for an uninterrupted time block Interruptions disrupt the process
2. Prepare yourself to be an effective Facilitate successful communication
communicator (decide what information you
wish to discuss/ any communication barriers
like language/ time span for interview)
Review the principles of therapeutic
communication
3. Identify the client. Give required care to the right client
Introductory Phase
4. Introduce self. Helps minimize anxiety and to gain
cooperation from client.
5. ASSESS AND ESTABLISH A Facilitates more exchange of

COMFORTABLE ENVIRONMENT. information without fear and anxiety
5.1Privacy/Space/Lighting/Noise/Ventilation
5.2 Attempt to put client at ease by Facilitates communication process
decreasing physical discomforts (pain, through client comfort
nausea)
5.3 Explain the purpose of interviewing This gives a guide to the
communication, the client will also
be focused in his communication
6. Sit in a comfortable chair close to the client. Ensures that the interviewer is giving
Assume relaxed but attentive posture maximum attention
7. Maintain eye contact throughout interview. Ensures that the interviewer is giving
maximum attention
Working Phase
8. USE APPROPRIATE COMMUNICATION Assists in establishing rapport with S U
the client that promotes free
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SKILLS: exchange of information.

 Asking related questions Communicates positive regard for
(open/closed) the client.
 Ask one question at a time. Builds trust and client compliancy
 Active listening
 Conveying acceptance
 Clarifying
 Focusing
 Stating observations
 Maintaining silence
 Use assertiveness
9. At regular intervals during the session, Feedback provides the client with
provide feedback to the client that repeats the chance to correct any
what they have told you. Request misunderstandings that may occur.
clarification when needed Feedback allows nurse to
communicate active listening
10. Monitor verbal/ non- verbal messages (client Allows further clarification of
and yourself) messages conveyed.
Allows nurse to identify her/his own
feelings or thoughts they or client
may be reluctant to share
11. If a communication session is interrupted, Reduces confusion.
terminate session if interruption is high Establishes the importance of the
priority or client’s request. Re- schedule to communication.
complete the interview
Termination Phase
12. Terminate through summarizing with the Summary signals close of
client what was discussed in the interview. interaction, allow nurse & client to
depart with the same idea.
NB: GUIDELINES
a. Listen to what and how the client communicates.
b. Non- verbal cues: personal appearance, intonation, facial expressions, posture/gait,
gesture, touch
c. Know your own attitude to client/situation.
d. Guide the interview dependent on client’s condition & response.
e. Establish & understand the purpose of the interview: without this the
communication is casual & shallow.

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MAKING AN UNOCCUPIED BED
PURPOSES
• To provide client comfort.
• To provide a clean, neat environment for the client.
• To provide a smooth, crease free bed foundation, thus
minimizing sources of skin irritation.
EQUIPMENT:
• Two large sheets.
• Draw sheet.
• Pillow cases
• Hamper bag
• Chair
• Blanket (optional)
• Mackintosh(optional)
PROCEDURES
S# STEPS RATIONALE S U
1 Identify the correct client. To give care to the right client.
2 Check from assigned RN/ client’s chart/ Ensure client’s safety.
Kardex/ SBAR for orders or specific Ensure use of proper body
precautions for positioning & moving mechanics for Nurse and client.
client. SBAR= (Situation Background
Activity Recommendations)
3 Collect equipment and supplies. Facilitates a smooth procedure.
Maintains time management &
efficiency for Nurse.
4 Place the fresh linen on the client’s bed Facilitates smooth procedure.
table in order of use at the foot end of bed.
5 Place linen hamper bag in a convenient Facilitates proper disposal of soiled
place. linens.
6 Explain procedure to the client. Minimizes client's anxiety.
Promotes client cooperation.
7 Draw room curtains around the bed or Maintain privacy, thus promoting
close the door. emotional and physical comfort for
client.
8 Assist client to a safe, comfortable chair. Increases client’s comfort.
Decrease risk of injury for client.
9 Adjust bed in working position and lock Promote good body mechanics for
the bed. nurse.
Ensures client safety.
10 Loosen all linen starting from head end of Facilitates smooth procedure.
the bed from the working side.
Fan fold soiled linen from sides to middle Linen is folded from cleanest area to S U
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11 of bed. most soiled to prevent cross

contamination.
12 Remove the used linen and place them in Reduces transmission of
the linen hamper bag. microorganisms.
13 Fan folds half of the clean bottom sheet Provides maximum fit of sheets &
vertically. Tuck and miter the corner at the decrease chances of creases in bed
head end and tuck in the working side sheet.
Mitering corners secures the bed
sheet tightly to the mattress and less
chance of creases in bed sheet which
can cause skin irritation.
14 Place the mackintosh and the draw sheet Provides maximum fit of sheets &
vertically at the center of the bed and tuck decrease chances of creases in
them firmly. sheets.
15 Move on to the other side and lower the Provides easy access to bed for
side rail (if not already down). procedure.
16 Pull the bottom sheet, mackintosh and the Provides comfort.
draw sheet firmly.
17 Miter the head end corner of the bottom Mitering corners secures the bed
sheet and tuck it in. sheet tightly to the mattress and less
18 Tuck mackintosh and draw sheet firmly Provides maximum fit of sheets &
decrease chances of creases in bed
sheets.
19 Change the pillow case. Minimizes risk of microorganism
(a)Remove soiled pillow case by grasping transmission.
the closed end with one hand and slipping
the pillow out with the other. Place soiled Promotes a clean pillow case
pillowcase in hamper. without needing to shake the pillow
(b) Apply clean pillowcase. With one thereby increasing the risk of cross
hand, grasp the close end of the contamination.
pillowcase. Gather the pillowcase and turn
it inside out over your hand. With the
same hand grasp the middle of the one end
of the pillow. In the other hand, pull the
case over the length of the pillow. The
corners of the pillow should fit firmly into
the corners of the pillowcase.
(c) Reposition pillow at the center of the
bed, turning the opening away from the
door/main entrance.
20 Assist the client back into the bed and to a Promote Client comfort.
comfortable position.
21 Spread the top sheet over the patient. A Promote Client comfort.
S U
blanket may be used if appropriate. Ensure client warmth.
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22 Ask the patient to slightly flex the knees Permits Nurse in making the toe
pleat in top sheet easier.
23 Make a vertical toe pleat by grasping the Provides additional space for the
top sheet over the client's toes and pull client's feet to move under the tight
upward, and then make a small fanfold in top sheet.
the sheet.
24 Tuck the foot end of top sheet and miter Mitering corners secures the bed
the corners. sheet tightly to the mattress and less
25 Fold 6 inches of the top sheet to make a Makes it easier for the patient to pull
cuff. the sheet up
26 Adjust call bell and return bed to a Provides client safety and comfort
comfortable position with side rails up.
27 Place over bed table and chair in proper Promotes sense of wellbeing and
place, arranging personal items within minimizes exertion on the client
easy reach on bedside table.
28 Replace all equipment. Ensures readiness for next use.
29 Wash hands. Reduces the risk of transmission of
microorganisms.
30 Document in the nursing notes: Provides evidence of Nursing care
• Date/Time Provides assessment of client’s
• Procedure health status on activity.
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Making a toe pleat

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MAKING AN OCCUPIED BED
1. PURPOSES
• To conserve client’s energy and maintain current health status.
• To provide client comfort.
• To provide a clean, neat environment for the client.
• To provide a smooth, wrinkle free bed foundation, thus
minimizing sources of skin irritation.
2. EQUIPMENT
• Two large sheets.
• Draw sheet.
• Pillow cases
• Hamper bag
• Chair Blanket (optional)
• Mackintosh(optional)
3. PROCEDURES
1 Identify the correct client. To give care to the correct client.
2 Check from assigned RN/client’s chart/ Ensure client’s safety.
Kardex/ SBAR for orders or specific Ensure use of proper body mechanics for
precautions for positioning and moving Nurse and client.
client. SBAR= (Situation Background Activity
Recommendations)
3 Collect equipment and supplies Efficient time management for Nurse.
Provides easy access to items for Nurse.
4 Place the fresh linen on the client’s chair Facilitates smooth procedure.
in order of use, at the foot end of bed.
5 Place linen hamper bag in a convenient Facilitates proper disposal of soiled S U
place linens.
6 Explain procedure to the client. Reduces anxiety for both client & Nurse.
7 Wash hands. Prevents risk of transmission of
microorganisms.
Don gloves. Prevents risk of transmission of
microorganisms.
8 Draw room curtains around the bed or Maintaining privacy, thereby promoting
close the door. emotional and physical comfort for client.
9 Adjust bed in working position and lock Ensure good body mechanics and safety
the bed. of Nurse.
Assist the client to turn facing away Protects accidental fall of client.
10 from you. Raise the side rails of that Provides space to place clean linens.
side. Reposition the pillow.
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11 Loosen all linen starting from head end Facilitates smooth procedure.
of the bed from the working side.
12 Fan folds soiled linen near the client. Provides maximum space for clean linen.
13 Fan folds half of the clean bottom sheet Keeps soiled linen together.
vertically as close to the client as
possible. Provides comfort when the client later
Tuck and miter the corner at the head rolls to the other side.
end and tuck in the working side. Provides maximum fit of sheets &
decrease chances of wrinkles in sheets.
14 Place the mackintosh and the draw sheet Draw sheet eliminates irritating creases
vertically at the center of the bed and and folds.
tuck them firmly. Draw sheet is necessary for facilitate
lifting/ positioning clients while in bed.
15 Assist the client to roll over onto the Prevents accidental fall.
side facing towards you. Position client off soiled linen.
Reposition the pillow.
Raise the side rail.
16 Move on to the other side and lower the Provides easy access to bed to change bed
side rail. linen.
17 Remove the used linen by rolling them Reduces risk of transmission of
into a bundle & placing in the linen microorganisms.
hamper bag.
18 Pull the bottom sheet, mackintosh and Provides client comfort.
the draw sheet firmly.
19 Miter the head end corner of the bottom Mitering corners secures the bed sheet
sheet and tuck it in. tightly to the mattress and less chance of
creases in bed sheet which can cause skin
irritation.
20 Tuck mackintosh and draw sheet firmly Decreases chance of creases in bed sheet
which can cause client's skin irritation.
21 Change the pillow case (refer to Maintains patient’s comfort
unoccupied bed making procedure). Minimizes risk of microorganism
transmission.
Reposition pillow at the center of the Promotes a clean pillow case without
bed, turning the opening away from the needing to shake the pillow thereby
door/main entrance. increasing the risk of cross contamination. S U
22 Assist the client to a comfortable Provides client comfort.
position.
23 Spread the top sheet over the client (You Provides client comfort.
may ask client to hold it while removing Provides client privacy.
the used sheet). A blanket may be used Provides warmth for client.
if required
24 Ask the client to slightly flex the knees Permits Nurse in making the toe pleat in
top sheet easier.
25 Make a vertical toe pleat (refer to Provides additional space for the client's
unoccupied bed making procedure). feet to move under the tight top sheet.
16
26 Tuck the foot end of top sheet and miter Mitering corners secures the bed sheet
the corners tightly to the mattress and less chance of
creases in bed sheet which can cause skin
irritation.
27 Fold 6 inches of the top sheet to make a Makes it easier for client to pull sheet up.
cuff
28 Adjust call bell and return bed to a Provides clients safety and comfort
comfortable position and side rails up
29 Place over bed table and chair in proper Promotes sense of wellbeing and
place, arranging personal items within minimizes exertion on the patient
easy reach on bedside table.
30 Replace all equipment Ensures readiness for next use.
31 Wash hands Prevents transmission of micro-organisms
32 Document the procedure in the nursing Provides evidence of Nursing care
notes. Provides assessment of client’s health
status.

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SHAMPOOING
1. PURPOSES:
• To maintain client's good hygiene status.
• To stimulate the blood circulation to the client's scalp through massage.
• To increase the client's sense of wellbeing.
• To prevent client's chance of lice infestation.
2. EQUIPMENTS:
• Bath Towels 1- 2
• Face towel or wash cloth
• Shampoo or soap
• 1 wash basin/l bucket
• 1 wash basin and mug
• Plastic Apron
• Plastic sheet (mackintosh)
• Cotton balls in a container.
• Wide tooth comb / soft bristle brush
• Linen hamper bag.
• Bedside/ chair-side table
• Clean bed linen.
• Bath Thermometer (optional)
• Non- sterile gloves
3. PROCEDURE.
1. Identify the client. Give care to the right client.
2. Assess the need for shampooing. Certain medical condition could place patient
Assess client's medical condition & at risk for injury during procedure because of
health status. positioning, exposure to moisture or
manipulation of head and neck.
Assess client has any allergies to Prevent adverse reactions to procedure.
certain shampoos.
3. Assess client's ability to perform/ Nurse is able to determine & plan how the
assist with procedure procedure will be performed.
4. Explain procedure to client. Minimizes anxiety for both Nurse & Client.
Shows respect for the client.
5. Wash hands & apply gloves. Prevents the risk of transmission of
microorganisms.
6. Collect equipment and arrange them Efficient time management for Nurse.
in convenient place Provides easy access to items for Nurse.
7. Prepare the environment. Maintain privacy.
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Draw curtain and close door. Avoid client from feeling chilling. Air current S U
Switch off fan or close any open from fan or open window can increases loss of
windows. body heat through convection.
8. Place one basin on over bed table Prevents wetting of bed & bed linen.
and the other basin on chair.
9. Adjust bed to working position. Ensures Nurse's proper body mechanics and
prevent strain on Nurse's back.
10 Assist the client's head to the edge of Ensures Nurse's proper body mechanics and
bed from which you will work. prevent strain on Nurse's back.
Prevents unnecessary reaching for the Nurse.
11 Remove the pillow from client's Helps to drain off the water easily and keeps
head and place it under the mattress the client's shoulders dry.
on the opposite head end.
12. Spread the mackintosh lined with Prevents wetting of bed linen.
bath towel under client's head and
shoulders.
13. Place the trough over towel allowing Prevents wetting of bed and the floor.
one end fall into the bucket / basin.
14. Remove pins and ribbons from the Results in more thorough cleansing of client's
hair. hair.
Removes tangles, loosens dead cells & debris
Brush or comb hair. from client's hair.
Enables any abnormalities in the scalp & hair
to be identified.
15. Observe the client's scalp, nape & Enables any abnormalities in the scalp & hair
hair. to be identified.
Assess client's hair for color, texture,
distribution scalping. Also for nits, Determine need for further intervention.
lice, dandruff & boils.
16 Offer a wash cloth to the client's Prevents water/shampoo irritating the client's
hand to assist in wiping away eyes.
possible water /shampoo getting into
the eyes. Prevents moisture collecting in the ear canal.
Offer cotton wool to plug client's
ears.
17. Fill basin ¾ full with warm water Promotes client comfort and prevents
and check water temperature with accidental burning of client's scalp.
your inner aspect of wrist as
tolerated (40° C to 43° C or 1000 F). Warm water promotes blood circulation in
(you can use bath thermometer) client's scalp area.
18. Wear apron to cover the uniform Prevents nurse's uniform to get wet.
19. Fill mug from large basin of water. Smaller container is easier to handle &
Pour the warm water over the prevents splashing.
client's hair carefully, moistening Moistened hair facilitates the cleansing action
thoroughly. of the shampoo.
20. Pour shampoo into hand and apply Facilitates even distribution of shampoo.
19
to client's hair and scalp.

21 Massage scalp well with your finger The pads of the fingers are used so that finger
pads for 3 - 5 minutes. nails will not scratch the scalp. S U
Start at hairline and work towards Shampoo lather helps remove dirt & excess oil
nape of neck. from scalp and hair.
Lift head slightly with one hand to Stimulates the blood circulation in the scalp
wash back of the head. area.
Then Shampoo the sides of the head.
22. Rinse hair by using mug to pour Removes shampoo & debris.
warm water over the hair & scalp. Shampoo remaining in the hair when dry will
Rinse well, especially behind the irritate the client's scalp.
client’s ears and base of client's Shampoo deposits accumulate easily behind
scalp. the ears and base of scalp.
23. Repeat shampooing, scalp Promotes thorough cleansing of hair.
massaging and rinsing hair until they Gives a chance to observe any abnormalities
are clean. with client's scalp area.
Massaging relaxes clients’ scalp & shoulder
muscles.
24. Gently squeeze maximum water out Facilitates removal of excess water in hair,
of hair and remove the trough. thereby decreasing the chances of wetting
client’s clothes and dry linen.
25. Wrap patient's hair in the towel. Dry Absorbs excess water from client’s hair & scalp
patient’s face with cloth to protect while stimulating blood circulation in the area.
eyes. Dry off any moisture along Retained moisture may cause client cooling
neck or shoulder. and chills.
26. Remove cotton plug from the ear. Promote client comfort.
27. Dry hair well. Retained moisture cause cooling and chills.
28. Position patient comfortably. Promote client comfort.
Replace pillow.
29. Place clean towel around client's Prevents tangles and pulling of hair.
nape (or over shoulder if sitting) and
start combing the hair. Stimulates blood circulation in scalp area.
Comb or brush by beginning at the
ends and up to scalp. Be gentle &
take your time.
30. Arrange the hair in a pleasant simple Maintaining attractive grooming increases
style (as patient's choice). client's state of wellbeing.
31. Remove towel.
32. Reposition client comfortably Provides client comfort. Provides client safety.
33. Adjust bed according to patient's Provides safety of the patient.
comfort.
34. Clean and return all equipment in Ensures readiness for next use.
assigned area. Provides a clean environment.
35. Keep client's area neat & tidy Promotes environmental safety
36. Wash hands. To prevent cross contamination
Document in nurse’s notes
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Date, Time.
Type of hygiene care given.
Condition of hair and scalp
Evidence of nursing care given to
client condition.
Patient’s response.

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MOUTH CARE OF AN UNCONCIOUS
1. PURPOSES:
• To maintain an intact and well-hydrated lips, tongue and mucus membranes of the
mouth.
• To remove secretions from oral cavity.
• To prevent foul breathing, dental carries and infection.
• To enhance the client's feelings of wellbeing.
2. EQUIPMENT:
• Kidney basin (Emesis basin)
• Face towel.
• Tissue roll.
• Disposable/ latex gloves.
• Tongue depressor (Padded)
• Mouth applicator/ Artery forceps.
• Mouth gag (padded)
• Gauze swabs (pack)
• Gallipots.
• Paper bag/ trash bin.
• Large tray.
• Petroleum jelly.
• Glass with water.
• Pair of scissors.
• Cotton balls.
• Pyodine Mouth wash.
• Torch.
• Suction tube
3. PROCEDURE:
S.# STEPS RATIONALE S U
1. Identify the client. To give care to right client.
2. Explain the procedure to client and Minimizes anxiety for both Nurse &
family member (if present). Client.
Provide meaningful stimulation to
unconscious client. Unconscious client
may retain ability to hear.
3. Collect equipment and check for Facilitates a smooth procedure.
working condition. Maintain time management & efficiency
for Nurse.
4. Adjust the bed to working position; Maintains good body mechanics for Nurse.
lower the side rails of working side.
5. Wash hands. Minimizes transmission of
microorganisms.
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6. Place patient in side lying position with Prevents aspiration of saliva.

head of the bed lowered.
7. Draw curtains or close the door. Maintains clients’ privacy. S U
8. Place towel under patient's face and Receives secretions and to prevent soiling
kidney dish under patient's chin. of bed linen.
9 Wear gloves. Minimizes transmission of
microorganisms. .
10 Inform the patient and retract patient's Avoids biting down by unconscious patient
upper and lower teeth with padded and to provide access to oral cavity.
tongue blade between back molars.
11 Assess the oral cavity for dry mucosa, Provides baseline data.
blisters, sores or inflammation. Determine need for further interventions.
12 Insert mouth gag to open client mouth
(2nd Nurse holds it).
NOTE: (Never put your fingers in an
unconscious clients’ mouth).
13 Perform the following steps:
a. Put single folded guaze piece under
an open artery forcep.
- Cover the right artery forcep blade jaw
with the right sided gauze and vice
versa.
- Draw close the artery forcep jaws
together and make sure if the artery
forcep is locked with the rachad.
b. Dip the tongue blade (padded) or Mechanical action removes food particles
mouth applicator in Pyodine solution, between the teeth and chewing surfaces.
squeezes it and clean.
c. Chewing and inner surfaces first. Swabbing helps to remove secretions and
d. Outer tooth surfaces. crust from mucosa and moistens it.
e. Swab roof of mouth and inside
cheeks.
f. Gently swab the tongue.
14 Moisten the tongue blade/ applicator in Proper cleaning. It helps to remove
clean water to rinse several times. Pyodine that can be irritating to mucosa of
the mouth cavity.
15 Remove the mouth gag, gently Client comfort.
supporting lower jaw and informing the
client that procedure is finished
16 Remove the towel and kidney dish.
17 Apply thin layer of petroleum jelly to Moisten lips mucosa.
lips.
18 Remove gloves and wash hands. Minimizes transmission of
microorganisms.
19 Adjust bed to original place and make
client comfortable.
26
20 Raise the side rails Ensure client safety

21 Return equipment to designated place Keep client environment neat and reduces
transmission of infection.
22 Document in nurses notes about oral Evidence of Nursing care given and
assessment and the care given. clients’ condition. Protects Nurse legally.

27
Yaunker with Suction Dia

28
HYGIENE CARE: COMPLETE OR PARTIAL BED BATH
1. PURPOSES:
• To remove transient microorganisms, body secretions, excretions, and dead skin cells
From the clients’ body.
• To stimulate clients’ peripheral circulation.
• To improve clients’ self-esteem & wellbeing.
• To promote relaxation and comfort for client.
• To prevent or eliminate unpleasant body odors.
2. EQUIPMENT:
• Bath Basin (one)
• Bath towel (two)
• Soap with soap dish.
• Mittens/wash cloth.
• Bed linen.
• Gown and pajama.
• Linen hamper bag.
• Comb or brush.
• Lotion.
• Gloves (disposable).
• Bath Thermometer (optional)
3. PROCEDURE:
S. # STEPS RATIONALE S U
1. Identify the client. To give care to the correct client
2. Explain procedure to client. Minimizes anxiety for both Nurse &
Client.
3. Assess client’s level of independence Participation improves clients’ self-
and involvement in procedure. esteem.
Encourage client to assist in bathing S U
procedure.
Explain to client the need for routine
cleanliness.
4. Arrange equipment in convenient place. Easy access and order of equipment
prevents waste of time and energy and
prevents interruption during procedure.
5. Prepare environment for procedure. Maintains privacy.
Close the doors or draw curtains. Avoids chilling. Air current increases
Turn off fans & close windows. the loss of body heat by convection.
Ask client if they need to go to
29
washroom before you begin the bathing Facilitates a smooth procedure.

procedure.
6. Keep side rails up while away from the Raising side rails maintains client's
clients’ bedside. safety as Nurse leaves beside.
7. Adjust bed to working position. Ensures proper body mechanics and
prevents strain on Nurse's back.
8. Wash hands. Prevents risk transmission of
microorganisms
10. Assist with oral hygiene as necessary
(Refer to "mouth care" procedure)
11. Position client comfortably. Move Promotes good body mechanics.
towards the side close to Nurse. Facilitates access to client for care.
12. Fill basin 2/3 with warm water. Check Promotes comfort, relaxes muscles, and
water temperature with your inner prevents accidental bur n of client’s
aspect or wrist. (41°C and 43°C or skin.
105°F to 109°F. Allow client to check
water temperature.
13. Remove gown and pajama (Remove Facilitates full accessibility to clients’
clothing according to client's body parts for bathing.
convenience). If client has intravenous
lines ask for help.
14. Drape client with top sheet. Maintain client privacy.
Prevents excessive exposure of client.
15. Spread towel across clients’ chest on top Prevents linen from getting soiled or
of sheet. wet.
16. Wash clients’ eyes with water only and Prevents transmitting of
dry them well. Use separate corner of microorganisms from one eye to the
washcloth for each eye. other.
17. Wipe the clients’ eyes from the inner to Prevents secretions from entering the
the outer canthus. nasolacrimal ducts.
18. Wash clients’ face, ears, and neck with Soap lowers surface tension thus
soap (if client allows). facilitates removal of debris and
bacteria.
Client may not use soap on face.
19. Rinse each part of the face, ears and Removes soap and microorganisms.
neck with the other wash cloth. Pat Moisture promotes bacterial growth.
them dry. Pat dry reduces skin irritation.
20. Expose the far arm of the patient. Place Eliminates contamination of the area
bath towel length wise under arm. once it is washed.
Protects the bed linen from becoming
wet.
Maintains client privacy.
21. Wash arm using long, firm strokes from Soap lowers surface tension thus
distal to proximal areas (fingers to facilitates removal of debris and
axilla). bacteria. Long, inner strokes from
distal to proximal area increases
30
venous return.
22. Rinse and dry arm and axilla Removes soap and microorganisms.
thoroughly. Drying prevents bacterial growth. S U
23. Repeat steps 20 to 22 for the other arm.
24. Place towel directly on bed and put the Soaking allows hands to soften the
basin on it. Immerse clients’ hands in nails. Soaking loosens debris from the
water. Allow hands to soak for 3 to 5 skin and nails.
minutes.
25. Assist client to wash, rinse, and dry Perspiration and soil present between
hands paying particular attention to fingers may damage the skin.
interdigital spaces. Promotes privacy.
26. Change the water and check Maintains clients’ comfort.
temperature of water with inner aspect Maintains clients’ safety by preventing
of wrist. Change water more frequently accidental burn.
if it becomes dirty or cool.
27. Cover clients’ chest with bath towel and Facilitates unnecessary exposure of
fold top sheet down to umbilicus. With client.
one hand, lift edge of towel away from Maintain clients’ respect.
chest. With mitten hand, bath chest
using circular strokes. Take special care Towel maintains warmth and privacy.
to wash skin folds under female's
breasts. Keep clients’ chest covered Perspiration and debris collects easily
between washing and rinsing. Dry well. in areas of skin folds and may damage
the skin.
28. Keep towel over chest. Fold top sheet Facilitates unnecessary exposure of
down to the pubic region. client.
Maintain clients’ respect.
29. Bath abdomen with mitten hand, giving Soap lowers surface tension thus
special attention to umbilicus and facilitates removal of debris and
abdominal folds. Use circular strokes. bacteria.
Rinse and dry well. Keep clients’
abdomen covered between washing and Maintain clients’ respect and privacy.
rinsing.
30. Pull top sheet back to neck and remove Maintain clients’ privacy, comfort and
bath towel. give warmth.
31. Expose far leg of client and place bath Prevents contamination of the area
towel length wise under the leg. once it is clean.
Protects bed linen from becoming wet.
Flex clients’ leg slightly at knee Joint. Support clients’ joints to prevent
fatigue & strain.
32. Wash legs using long, firm strokes from Soap lowers surface tension thus
ankle to thigh. Rinse and dry well facilitates removal of debris and
bacteria. Long, firm strokes from distal
to proximal area increases venous
return.
31
33. Repeat steps 30 to 32 for the other leg

34. Place basin on bed and allow feet to Soaking softens nails, loosens debris
soak for 3 - 5 minutes. beneath nails and enhances feeling of
cleanliness.
35. Wash feet paying particular attention to Moisture, perspiration and debris
interdigital spaces. Rinse and dry well. present between toes may damage skin.
36. Change water and check its temperature Maintains clients’ comfort and prevents S U
with inner aspect of wrist. (41 ° - 43°C accidental burn.
or 105F° -109°F).
37. Assist client to turn on to other side. Expose back and buttocks for bathing.
Place towel length wise along with
clients’ back.
38. Wash back using circular strokes from Promotes relaxation and prevents skin
shoulder to buttocks. Rinse and dry breakdown. (Prolong pressure on bony
thoroughly. Pay special attention to prominence may impair circulation and
clean gluteal folds. Observe for any lead to development of decubitus
redness or skin breakdown. ulcer).
39. Provide back care. (Refer "Back care"
procedure).
40. Change water and check water Maintains patient's comfort and
temperature with the inner aspect of prevents accidental burn.
wrist. (41 ° - 46° C or 105° - 109°P).
41. Assist client to turn in supine position. Prevents unnecessary exposure.
Cover chest and upper extremities with Patients may prefer to wash their own
towel and lower extremities with top genitalia.
sheet. Expose only genitalia. Wash,
rinse and dry perineum. If client can
wash, assist client. Give special
attention to skin folds. (Refer to
"perineal care" procedure).
42. Change bed linen, (refer "occupied bed Prevents infection and promotes
making" procedure) comfort.
43. Assist client to put on clean clothing. Maintains clients’ feeling of warmth,
Comb/ brush hair and make him/ her and comfort.
comfortable. Promotes client’s self- esteem.
44. Perform hand and foot care. ("Refer
hand and foot care" procedure).
45. Adjust bed according to clients’ comfort Ensures clients’ safety.
and raise side rails.
46. Clean and replace equipment. Ensures readiness for next use.
Maintains medical asepsis
47. Keep clients’ area neat and tidy. Promotes environmental safety.
48. Wash hands Prevents risk of cross infection
49. Document in nursing notes Evidence of Nursing care given and
32
• Date/ time, patient's condition during and after

• Type of hygiene care given. procedure.
• Any pertinent observation Protects Nurse legally.
• Clients’ response.

33
34
BACK CARE
1. PURPOSES:
• To promote relaxation and comfort.
• To stimulate circulation.
• To relieve muscle tension.
• To assess skin condition.
• To decrease risk of skin breakdown.
• To increase the effectiveness of the Nurse- Client relationship.
2. EQUIPMENT
• Lotion
• Bath towel
• Soap if
• Basin with warm water necessary
• Mittens
• Gloves (optional)
3. PROCEDURE
S STEPS RATIONALE S U
#
1. Identify the client. To give care to the correct client.
2. Assess the need for back care. Determines clients’ potential for benefit
from a back rub, signs of fatigue,
movement reflecting muscle stiffness.
3. Explain procedure and desired position to Minimizes anxiety for both Nurse & Client.
the client. Shows respect for the client.
4. Collect equipment and arrange it in Facilitates a smooth procedure.
convenient place. Promotes time management & efficiency
for Nurse.
5. Draw curtain or close door and put off fans. Maintains privacy.
Avoids chilling & decreases the loss of
body heat by convection.
6. Adjust bed to working position. Ensures good body mechanics for Nurse.
7. Wash hands. Prevents risk of transmission of
microorganisms.
8. Turn client to lateral or prone position with Provides easy access to clients’ back full
back facing towards Nurse. exposure of area needed for nursing care.
9. Expose clients’ back from shoulder to Prevents unnecessary exposure of body
buttocks. Cover remaining part of the body parts. Privacy promotes relaxation.
10. Clean back if required (refer "bed bath"
procedure). S U
11. Observe clients’ skin for any discoloration Determine the need for possible further
and skin break down, paying specific interventions.
35
attention to the bony prominence areas. Assess for pressure point problems.
12. Prevents friction.
Pour small amount of lotion into hands and Promotes comfort.
rub hands together to warm the lotion. Prevents the shock of cold lotion being
applied to back.
13. Massage the sacral area in circular motion. Gentle, firm strokes promote relaxation.
Perform Effleurage which is circular firm
strokes. Move up along the massage at the Continues contact with skin is soothing and
region of spine, scapula and surrounding stimulates circulation to tissues.
muscles.
Do not allow hands to leave patient's skin. Enhance circulation in bony prominence
Continue massage, moving down the sacral areas
area and repeat for 3 minutes Pay special
attention to bony prominence.
14. Perform Petrissage which is grabbing of Increases circulation to muscles
the muscle fold with the hands. Releases tension increasing relaxation
Knead first up the vertebral column and feelings.
then over the entire back. Decreases any pain, if felt by client.
Stimulates nerve ending, stimulates
Perform Tapotement technique.
decongestion and increases blood flow.
Tapotement technique involves cupping
formation with the hands and application of
gentle pressure all over the back region
starting from scapula towards lower back.
15. End massage with long stroking Long stroking is most soothing of massage
movements. movements.
Lessen the pressure with each massage The light relaxing stroke movements
stroke and tell client you are ending the signals the end of the massage.
massage.
16. If client is lying on side, ask client to turn to To cover the whole surface area of clients’
opposite side, and massage the other side. back.
17. Excess lotion can be an irritating to clients’
Wipe excess lotion with bath towel. skin.
Assist the client to tie the gown or pajamas. Prevents unnecessary exposure of the
client.
18. Remove gloves (if worn), discard Decrease risk of transmission of
appropriately. microorganisms.
19. Make client comfortable. Maintain client comfort.
20. Clean and replace equipment in their proper Ensures readiness for next use.
places. Maintains medical asepsis.
21. Prevent the risk transmission of
Wash hands.
microorganisms.
22. Document in nurse’s notes: Evidence Nursing care given and clients’
• Date/ time. condition.
• Procedure performed any pertinent Protects Nurse legally.
observation.
36
• Patient response.
Long & Deep Stroking (Effleurage) Squeezing soft tissues & muscles (Petrissage)
Circular Strokes Kneading

37
38
PROVIDING HAND AND FOOT CARE
1. PURPOSES
• To maintain the skin integrity of the client's feet and hand.
• To prevent client's hand and feet from infections.
• To prevent foot odor.
• To maintain function & structure of the two main body areas needed for mobility &
ADLs.
• To stimulate circulation in client’s extremities.
• To promote client cleanliness.
2. EQUIPMENT
• Wash basin containing warm water
• Towel 1-2
• Soap
• Nail clipper with file
• Newspaper / Mackintosh
• Lotion
• Kidney dish (Large)
• Mitten/Disposable gloves
• Foot stool
• Bath thermometer (optional)
3. PROCEDURE:
3.1. FOOTCARE:
1. Identify the client. To givs care to the right client.
2. Explain procedure to client. Promotes client cooperation
Confirms client has no allergies to lotions/soap.
3. Wash hands and Don gloves. Prevents the risk of microorganism’s
(if required) transmission.
4. Arrange equipment in convenient Facilitates a smooth procedure.
place Maintain time management & efficiency for
Nurse. S U
Easy access to equipment prevents delay and
interruption during procedure
5. Place ambulatory client in sitting Facilities immersing of client's feet in wash
position in a chair, or on the bed. basin. Ensures safety & maximizes client's
(Provide assistance as required). ability to assist.
6. Fill basin with warm water. Check Warm water soften nail and promotes
temperature with your inner aspect of circulation.
39
wrist (400C to 430C or1050 to 1100 F Maintain client safety- prevents accidental burn.
approx.) Maintain client comfort.
7. Place wash basin on Mackintosh or Prevents wetting of bed.
newspaper at Footstool.
8. Place client’s feet in basin. Allow Soaking softens nails & skin of client's feet.
feet to soak for 10 to 20 minutes. Loosens debris under toenails.
Relaxes feet muscles.
9. Cut nails straight across. Prevent in growing toenails.
10. Push cuticles back gently with filer Reduces incidence of inflamed cuticles
Cuticles function to prevent infection.
11. Clean nails as required with nail filer. Removes excess debris that harbors
microorganisms.
12. Wash it with soap by lifting one foot Promotes cleanliness.
at a time. Pay particular attention to Loosens debris especially interdigital areas.
interdigital areas. Rinse feet well.
13. Remove feet from basin, and place Towel absorbs excess moisture
them on towel.
14. Dry feet thoroughly by patting then Harsh rubbing can damage skin.
gently rubbing the foot with towel. Thorough drying reduces risk of infection.
Apply lotion.
15. Apply lotion if required Lotion moistures & softens skin. It also
lubricates dry skin by helping to retain moisture
3.2. HAND CARE:
1. Identify the client. Gives care to the right client.
2. Wash hands and Don gloves Prevents the risk of microorganisms’
transmission.
3. Arrange equipment on over bed Facilitates a smooth procedure.
table Promotes time management & efficiency for
Nurse.
4. Explain the procedure to the client. Promotes client cooperation and participation
5. Assist client to sit in a bedside chair. Client's position facilitates the immersing of
Help bed rest client to a supine hand in basin. Plastic sheet protects bed from
position with head of bed elevated. getting wet. S U
6. Adjust over bed table to lowest Promotes safety for both Nurse & client.
position. Easy access prevents accidental spills.
7. Fill large kidney dish with warm To prevent from burn and frostbite.
water. Check the temperature of Warm water soften nail and promotes
water with your wrist at (400 C to circulation.
0 0 0
43 C – 105 to 110 C) Client safety.
8. Instruct client to place fingers in Prolonged positioning can cause discomfort
large kidney dish and place arms in a unless good body alignment is maintained.
comfortable position.
40
9. Allow fingernails to soak for 10 to Softening of cuticles ensures easy removal of

15 minutes. Wash it with soap. dead cells.
Remove kidney dish and dry fingers Loosens debris especially interdigital areas.
thoroughly. Rinse the hand well.
10 Cut nails short & straight Prevents ingrown toe nails.
11. Clean gently under fingernails with Nail filer removes debris under that harbors
file while fingers are immersed. microorganisms.
Push cuticles back gently with filer. Reduces incidence of inflamed cuticles.
Remove kidney dish and dry fingers. Thorough drying impedes fungal growth.
12. Move over bed table away from
client.
13. Apply lotion to hands. Lotion lubricates dry skin by helping to Retain
Assist client back to bed and into moisture.
comfortable position. Client comfort.
14. • Document in nurse’s notes: Evidence of Nursing care given and client's
• Client’s response health condition.
• Presence of abnormalities, Protects Nurse legally.
• Any requiring additional
therapy, any signs of
inflammation or break in the
skin.
NB: Assess skin & function of major body parts whilst facilitating Nursing care.
Observe color, shape, texture (touch sensation, dryness, blisters, peripheral pulses, capillary
refill).

41
ASSESSING A CLIENT’S TEMPERATURE

1. PURPOSE:
 Determine status of thermoregulation.
 Screen for changes in temperature alterations.
 Assess client at risk for elevated temperature.
2. EQUIPMENTS:
ORAL temperature:
 Rectangular tray containing with
 Appropriate type of thermometer
 Alcohol swabs OR Galipot /tissue or cotton balls/ small kidney tray/ jar of
antiseptic solution (Dettol 1 %, savlon 2% or alcohol 70% or of soapy solution) and jar of
clean water.
 Watch with second hand.
 Black pen.
 Piece of blank paper / flow sheet.
Additional equipment for AXILLARY temperature:

 Towel/tissue for drying the axilla area.
Additional equipment for RECTAL temperature:
 Thermometer (rectal).
 Lubricant (KY jelly).
 Disposable gloves.
 Tissue paper.
PROCEDURE
S. STEPS RATIONALE S U
#
1 Wash hands. Reduce chances of microorganism
transmission
2 Collect equipment. Saves time and energy.
3 Check thermometer for damaged bulb. Damaged equipment will give
inaccurate measurement.
Client/ Nurse safety
4 Identify the client. To give care to the correct client.
5 Explain the procedure to the client. Relieves client’s anxiety and promotes
client cooperation.
6 Assess the site for temperature. Helps in identifying the most
appropriate site for reading
temperature.
7 Select appropriate tip thermometer (blue for Identifies correct device
oral/axilla & red for rectal)
42
8 If thermometer is in the case:

Take out thermometer from the case. S U
Wash the thermometer with soap and water
from bulb end to finger end in firm twisting
motion
Rinse it with cold water.
Dry with cotton swab/ tissue from bulb end
towards finger end using finger twisted Reduces chances of cross
motion contamination
If thermometer is in bottle:
Remove the thermometer from the storage
container and cleanse bulb’s end towards the
fingertips Wipe the area from least contaminated
Use tissue to dry thermometer from the bulb to most contaminated area.
end towards the fingertips
If using alcohol swabs:
Open new packet of alcohol swab and
swiping in a twisting motion from bulb to
fingertips sterile the thermometer. Dispose of Wipe the area from least contaminated
alcohol swab. to most contaminated area.
9 Read thermometer at eye level. Locate the Mercury should be below 35°c.
mercury level. It should be at 35.5c (96F) Thermometer reading must be below
client's normal body temperature
before use.
10 If the reading is not below normal This moves the mercury level below
measurement, grasp the thermometer with 35C.Glass thermometer break easily,
the thumb and forefinger FIRMLY and shake make sure hold firmly and that
vigorously by snapping the wrist in a nothing in the environment comes in
downward motion. contact with thermometer when
shaking.
ORAL METHOD
11 Ensure client has not taken hot /cold fluids Cold/hot liquids and smoking alter
and not smoked for at least 10-15 minutes circulation and body temperature.
(or according to the policy).
12 Ensure accurate measurement reading
Give client following instructions before
placing thermometer in place:
 When thermometer will be placed in
mouth cavity to close his/ her mouth
carefully with lips hold firmly
together
 Avoid biting down on the
thermometer
 Refrain from speaking while
thermometer in mouth cavity
43
13 Ensures contact of thermometer with

Place thermometer under the tongue at a the blood in larger blood vessels under
45°angle in a position that allows the bulb to S U
the tongue thereby reflect the core
rest against the tongue tissue. temperature of client.
14 Leave thermometer in place for 2-3minutes The thermometer must stay in place
(according to hospital policy) long enough to get accurate reading
15 15.1 CAREFULLY grasp the stem of the Prevent thermometer from falling out
thermometer, asks the client to open his/ her or breaking and less likely to chip on
mouth. Remove the thermometer. the client’s teeth or break the
thermometer.
15.2 Wipe thermometer with a tissue or new
alcohol swab from the fingertips to the bulb Mucous on the thermometer may
end. interfere with ability to read
measurement. Wipe the area from
least contaminated to most
contaminated area.
16 Read the thermometer at eye level (by Ensures accurate reading
slowly rotating thermometer until mercury is
visualized)).
17 Inform client of temperature reading Promotes participation in care and
understanding of health status.
18 Shake the thermometer mercury level down.
If necessary, cleanse the glass thermometer
with soapy water, rinse under cold water and
return to storage container.
19 Wash Hands. Reduce chances of transmission of
microorganisms.
20 Record measurement on flow sheet with Promotes continuity of care.
black pen. Timely documentation and reporting
Report if any abnormality in reading. ensures accurate therapeutic
intervention, if needed
AXILLARY METHOD
21. Repeat skill steps 1-10
22. Close curtains around client bed/chair and Ensure privacy and dignity for client
remove client’s clothing from arm sleeve on Expose axilla area
one side to expose axilla area only (avoid
exposing the chest).
23. Ensure that axilla is dry. If necessary pat dry. Moisture conducts heat, and may give
an in accurate reading
24. Place the thermometer in center of axilla, Maintains proper position of
lower the client's arm over the thermometer, thermometer against blood vessels.
and place the forearm across the client’s Movement can displace thermometer S U
chest. can give false reading and
Gently hold the arm in place (if required). thermometer can fall and break
25. Leave the thermometer in place for a The thermometer must stay in place
44
minimum of 3-5 minutes (or hospital long enough to get accurate reading
policy).
26. Repeat skill steps 16-19.
RECTAL METHOD
27. Repeat skill steps 1- 10
28. Close curtains around client bed and remove Ensure privacy and dignity for client
client’s lower clothing from hip to knee.
29. Place client on side (Sim’s position) with Proper position will allow
knees flexed. Adjust sheet to expose only the visualization of area. Flexing the
anal area. knees allow muscle relaxation for easy
insertion of thermometer.
30. Place tissues and a dustbin in easy reach and Tissues are needed to wipe anal area
apply gloves. after removing thermometer.
31. Lubricate the tip of the rectal (red) Promotes easy insertion.
thermometer
32. Instruct the client to take a deep breath, then Relaxes the anal sphincter.
GENTLY insert thermometer Promote client comfort and prevents
mucous membrane damage
33. Hold in place for 2 minutes (or as hospital Maintains proper position of
policy) thermometer against blood vessels.
Movement can displace thermometer
can give false reading and
thermometer can fall and break.
34. Remove GENTLY and wipe secretions with Mucous/fecal material on the
a tissue. Dispose of used tissue thermometer may interfere with ability
to read measurement. Wipe the device
from least contaminated to most
contaminated area.
35. Read the thermometer at eye level (by Ensures accurate reading
slowly rotating thermometer until
Mercury is visualized).
36. Inform client of temperature reading Promotes participation in care and
37. While holding the thermometer in one hand, Prevents contamination of clean
with the other wipe the anal area with the objects with soiled thermometer,
tissues to remove any fecal/mucous or decreases skin irritation, promotes S U
lubricant. client comfort
Dispose of soiled tissues. Re- cover client.
38. Cleanse thermometer as above Reduce cross contamination
39. Dispose of gloves and wash hands Reduce cross contamination
40. Re-position client if you have not done so Client comfort
already
41. Record measurement on flow sheet with Promotes continuity of care.
45
Report if any abnormality in reading. ensures accurate therapeutic


46
ASSESSING CLIENT’S PULSE RATE
1. PURPOSES:
 Obtain a base line of heart rate and rhythm.
 Assess client’s cardiovascular status.
 Assess local blood flow to the hand.
 Monitor heart response to various pathologic conditions & therapies.
 To evaluate effects of medication on heart function.
 To assess effects of exercise/activity on heart function.
2. EQUIPMENT:
 Paper or flow sheet
 Pen (red ink)
3. PROCEDURE:
(RADIAL PULSE)
1. Wash Hands Reduce transfer of microorganisms
2. Identify the client. To give care to the correct client.
3. Determine which extremity is most Already impaired extremity can
appropriate for reading. Do not take cause compromise in circulation and
reading on injured/painful extremity inaccurate reading.
4. Explain procedure to client. If need be Gains cooperation, reduced cltient's
inform client reason for chosen site for anxiety
measurement.
5. Place client in a comfortable position. Relaxed position of lower arm and
Rest client's arm alongside his body with extension of wrist permits full
the wrist extended and the palm of the exposure of artery for palpation.
hand downward or inward
Placing the client’s hand over the
OR chest will facilitate later respiratory
assessment without undue attention
Flex client’s elbow & place he lower part to the nurse’s action (it is difficult to
of the arm across the chest maintain normal RR when someone
is observing)
6. Support the client’s wrist by grasping the Fingertips are most sensitive parts of
outer aspect with your thumb. Place tips hand to palpate arterial pulsation.
of index & middle fingers over groove Thumb has pulsation that may
along radial or inner aspect of client’s interfere with accuracy
wrist. (Thumb side of client wrist)
7. Lightly compress against radius; press Pulse is more accurately assessed S U
47
pulse initially, and then relax pressure so with moderate pressure. Applying
pulse becomes easily palpable. light pressure prevents blood flow
occlusion
8. Identify pulse rhythm and determine pulse Determine if pulse is regular or
volume irregular.
Determine quality of pulse strength
as weak, normal, strong or
bounding.
9. Count the pulse rate using a watch with a Sufficient time is necessary to assess
second hand. the rate, rhythm and amplitude of
Count the number of beats for a full 1 the pulse.
minute.
10. Inform client of the reading (depends on Promotes participation in care and
client’s condition) understanding of health status.
11. Wash hands. Reduces transmission of
microorganisms
12. Record pulse on flow sheet with red pen Promotes continuity of care.
Record rhythm and amplitude in nurse's Timely documentation and reporting
notes (only if abnormal). ensure accurate therapeutic
Student needs to be able to assess the following peripheral pulses for palpability.
 Temporal
 Carotid
 Brachial
 Radial
 Femoral
 Popliteal
 Posterior tibial
 Dorsalis pedis

48
DIAGRAM: POSSIBLE PULSE SITES FOR ASSESSMENT

49
ASSESSING CLIENT’S RESPIRATION RATE
1. PURPOSES:
 Acquire base line measure of respiration.
 Assess a respiratory status in relationship to respiratory and cardiovascular
function.
 Determine the influence of various pathologic conditions and therapies on
respirations.
 Evaluate effects of medication and activity on respiratory status.
2. EQUIPMENT:
 Flow sheet
 Pen (black)
3. PROCEDURE:
S. # STEPS RATIONALE S U
1. Wash hands. Reduce transfer of microorganisms
2. Identify the client. To give required care to the right
client.
3. Be sure client's chest is visible. Remove Facilitate observation of chest wall
bed linen or heavy clothing. & abdominal movements.
4. Assess client's activity prior to checking A client who has been exercising
respiration. will need to rest for few minutes to
permit the accelerated respiratory
rate return to normal.
5. Relaxed position will allow for
Place client in a comfortable position.
accurate measurement
6. a. Place the client’s hand across his Determine what constitutes a breath
abdomen or chest and place your own and what to count. Hand rises &
hand over clients’ wrist. If possible, falls with the inspiration and
client should not know you are taking expiration.
his respiration. Placing your hand on the
client’s wrist gives the appearance of Awareness of respiratory rate
taking pulse and turns the client’s assessment would cause the patient
attention away from your respiratory voluntarily to alter the respiratory
assessment. pattern.
7. Observe the character of respirations:
Depth: by degree of chest wall Accuracy of reading
movement (shallow, normal, deep) Reveals volume of air movement
Rhythm of cycle: (regular or into and out of the lungs
interrupted)
8. Start counting with the first inspiration Respiratory Rate is one full cycle S U
50
while looking at the second hand of (inspiration & expiration)

watch. Count respiration rate for 1 Positioning must stay in place long
minute enough to get accurate reading
9. Inform client of respiration rate reading Promotes participation in care and
10. Re-position client if you have not done Client comfort
so already
11. Record measurement on flow sheet with Promotes continuity of care.
Report if any abnormality in reading. ensure accurate therapeutic

51
ASSESSING ARTERIAL BLOOD PRESSURE
1. PURPOSES:
 Maintain a base line measure of arterial pressure.
 Monitor response of the circulatory system to various pathologic conditions and
therapies.
 Maintain hemodynamic status of a client
2. EQUIPMENT:
 Sphygmomanometer (B.P apparatus) with bladder & cuff (Appropriate size).
 Stethoscope
 Alcohol swabs.
 Flow sheet.
 Black pen
3. PROCEDURE:
S.# STEPS RATIONALE S U
1. Identify the client. To give care to the Correct client.
2. Explain procedure calmly to client. Ask Reduces anxiety and gains cooperation.
the client to rest for at least 5minutes if Exercise or smoking can cause false
possible before taking measurement elevation in BP measurement
3. Collect equipment. Save time and energy
4. Have client in sitting or supine position. Promotes comfort and relaxes client.
Provides accurate reading.
5. Determine which extremity is most Cuff inflation can interrupt blood flow
appropriate for reading. Do not take temporarily and in already impaired
reading on injured/painful extremity or extremity can cause compromise in
where an IV line is running. circulation.
6. Select appropriate cuff there should not Provides even pressure on artery for
be any overlapping. accurate measurement.
7. Move clothing away from upper aspect Provides even pressure on artery for
of arm accurate measurement.
8. Wash hands. Reduce transfer of microorganisms
.
9. Be sure that the manometer is Ensures accurate reading of mercury
positioned vertically at eye level. level.
10. Make sure to unlock the mercury Equipment must function properly to
column. Make sure bladder cuff is obtain an accurate reading
deflated and pump valve moves freely
11. Locate brachial artery in the ante cubital Designates place for stethoscope/baseline
space pulse measurement
12. Support or position client's fore-arm at Blood pressure increases when the arm is
S U
heart level, extending the elbow with below heart level and decreases when the
52
palm turned upward. arm is above heart level.
13. Wrap the cuff smoothly & evenly over Ensures even pressure distribution over
the upper arm by placing the lower edge the brachial artery. Too loose/ tight cuff
of the cuff 2.5 cm (1-2 inches) above will give inaccurate reading.
the antecubital space, with the centre of
the cuff over the brachial artery.
14. Clean stethoscope earpiece & chest Reduces transfer of microorganisms
piece with alcohol swab. Insert the Enhance sound transmission. Tapping is
earpieces of the stethoscope into the done to check whether the sound is
ears and check the diaphragm by audible & stethoscope is functioning
tapping. properly
15. Check for Baseline blood pressure Baseline is the strong predictor of
measurement as follows. response to therapy and patient’s ability
Locate brachial or radial pulse with one to reach BP goals
hand & place the bell or diaphragm
Sounds can be muffled by interruption of
chest piece directly over the pulse. It
cuff or clothes. Sound is best heard
should be directly in contact with the
skin (not clothes or cuff) directly over artery.
16. Close the valve of the bulb (turn Ensures accurate measurement of systolic
clockwise). pressure.
Inflate the cuff noting the level of
mercury where pulse disappears
17. Deflate cuff (turn the valve anti Prevents venous congestion and false
clockwise) quickly and wait for 30 secs; high reading.
tighten the valve.
18. Relocate brachial artery and place the Proper stethoscope placement ensures
diaphragm of stethoscope over the optimal sound reception. Improper
brachial pulse and hold it in place position of diagram causes muffled
(Remember do not let the diaphragm sounds and often results in false low
touch the cuff or client's clothing). systolic and false high diastolic readings
19. Inflate the cuff to 30 mmHg above Ensures the cuff is inflated to a pressure
where the pulse disappeared. greater than the cuff systolic pressure
systolic pressure
(Done if it is the initial examination)
20. Slowly release the valve and allow Maintain constant release of pressure to
mercury to fall at the rate of 2-3 mmHg ensure hearing accurate sounds and gain
per sec. accurate measurement
21. Listen for the 5 phases of Korotkoff’s
sounds while noting the manometer
reading (see note). The first clear sound First sound indicates the systolic pressure.
is heard is considered systolic reading.
22.. Continue to deflate cuff gradually Last sound indicates the diastolic
noting point at which sounds disappear. pressure. S U
Phase V of Korotkoff sounds
53
23. Deflate cuff rapidly and completely. Prevents arterial occlusion resulting in
Remove cuff from client's arm. numbness and tingling of client's arm.
24. Assist client to a comfortable position. Ensures client's comfort.
Re- dress the extremity uncovered for
cuff placement.
25. Inform client of the reading (depends on Promotes participation in care and
client’s conditions) understanding of health status.
26. Record accurately in the flow sheet Timely documentation and reporting
according to hospital policy. Report any ensure accurate therapeutic intervention,
abnormal findings to nurse in charge or if needed
physician
27. Wash hands. Reduces transmission of microorganisms.
Diastolic: when heart is filled with blood & relaxed. The last sound heard when taking BP
Systolic: when heart ventricles contract and blood is forced outward. The first sound heard when
taking BP
Korotkoff Sounds: I. Faint, clear tapping sound increases in intensity

II. Swishing sound
III. Intense sound
IV. Abrupt distinct muffled sound
V. Sound disappears

54
MEASUREMENT OF CLIENT’S HEIGHT AND WEIGHT

1. PURPOSES:
 To provide a general measure of health to ensure appropriate care.
 To provide a base line comparison in nutritional status.
 To provide a measurement of client’s fluid status.
 To calculate drug dose.
2. EQUIPMENT:
 Weighing scale/ Measuring tape
 Flow sheet
 Initial assessment form
 Black pen
3. PROCEDURE:
1. Calibrate scale by setting weight on zero. Calibrated scale ensures accurate
measurements.
2. Identify the client and explain the procedure Gives care to right client. Client
compliance
3. Ensure that client has voided. Ensures accurate reading
Ask client to remove (shoes, heavy jewelry and extra
clothing).
4. Measures weight:
Instruct client to: Stand on the center of platform Client's movement causes
facing away from the scale and remain still. balance beam to oscillate and
Note the weight reading for the client on scale. may result in inaccurate reading.
5. Record Weight in flow sheet Repeated weight measurements
documented in sheet comparison
6. Measures height:
Have client keep stand on scale platform, facing away Client position encourages
from scale. keeping head erect. Erect posture
Instruct client to: ensures accurate reading.
Stand erect, with heels together. Buttocks should
touch to scale stick. Look straight ahead.
Raise metal rod on weighing scale, until it rests on top
of the client's head. Height is measured by placing
smooth, flat surface against crown or vertex of head.
Read height in inches/cm as recorded on height scale. Accurate reading
7. Record height on assessment form. Repeated weight measurements
Ask the client to step down and assist back to documented in flow sheet for
bed/chair comparison
Reduces risk of client injury and
promotes client comfort
55
What is your BMI? ________________

56

57
ADMISSION TRANSFER & DISCHARGE PROCESS
PURPOSES
• To Recognize and demonstrate established procedures for admitting transferring and
discharging a patient at a healthcare facility
• Assess the importance of observing the patient's general physical condition, appearance,
and behavior
• Communicate what information must be documented concerning the admission, transfer,
or discharge of a patient
PROCESS
Preparing the Patient's Room
I. Before a patient is admitted, make sure the room is ready for his/her arrival
II. Check necessary equipment
a. Admission checklist
b. Pen or pencil
c. Gown or pajamas (if the patient is to be put to bed)
d. Portable scale
e. Thermometer
f. Sphygmomanometer
g. Stethoscope
h. Envelope for the patient's valuables
III. Make sure there is adequate light and proper ventilation
IV. Open the bed for patients by fan-folding the covers back, and attach the signal cord
within easy reach.
V. Ensure patient supplies and equipment’s are present.
a. Washbasin
b. Emesis basin
c. Soap
d. Towels
e. Lotion
f. Bedpan and cover
g. Urinal for male patients.
h. other equipment may be brought to the unit to meet the needs of a particular
patient.
For example, one patient may need an overbed trapeze, or an intravenous pole.
VI. Make a final survey of the room to be sure it is clean, neat and orderly.
Greeting the Patient
• Admission procedures depend on the policy of the healthcare facility .In some healthcare
facilities; the patient is taken directly to the room, where the actual admission process
begins.Most larger facilities, however, start the admission process in the admitting office.
• A preliminary interview of the patient is done to obtain the necessary medical and
financial information.
58
• It is important for the family to remain with the patient for this interview.
• If an ID bracelet is used, it may be placed on the patient's wrist at this time.
• The patient's first impression of the facility will depend on how he/she is greeted.
1. Greet each patient in a friendly, cheerful manner.

2. Introduce yourself, and take the patient to their room.
3. If the patient has a friend or relative with him/her, invite them to Accompany you to the room.
4. Introduce the patient to other patients in the room.
THE ADMISSION PROCEDURE
1. Help the patient become familiar with the new surroundings.

2. Explain the facility's policy on visitors, the procedure for mail, and the use of the
television and telephone.
3. Demonstrate how to use
a. Intercom and signal cord system
b. Remote-control television
c. Automatic bed controls
4. Tell the patient when meals are served
5. Answer any questions he/she has about daily routine.
6. Show the patient where supplies and equipment are located in the bedside stand.
7. Have the patient put personal articles and other small belongings in the drawer of the
bedside stand where they can be reached easily.
8. Depending on the procedure used in the healthcare facility, the Patient may be allowed to
keep his/her clothes and suitcase in the room, or the family may be asked to take them
home and return them when the patient is discharged.
9. In a healthcare facility, the patient's clothing and other belongings will be marked with
the patient's name and room number.
10. Make a list of the clothing, have the patient or a member of the family sign the list, and
give it to the nursing supervisor to include in the patient's chart.
11. If the patient has brought valuables, suggest that a relative take them home.
a. Valuables should be placed in an envelope—properly labeled with the patient's
name, room date, and a complete description of the articles included.
b. The list of valuables should also be given to the nursing supervisor to record in
the patient's chart.
c. The envelope will be kept in a safe until the patient is ready to go home.
12. Screen or curtain off the bed or close the door to a private room.
13. Ask the patient to put on a hospital gown, or a gown or pajamas brought from home.
14. Assist the patient as needed. If the patient wants a family member to be present, invite the
person in.
15. Assess the patient's general physical condition, appearance, and behavior as the
admission process is continued.
16. Observe the patient for unusual conditions
a. Cuts or bruises
b. Loss of function
c. Signs of weakness
59
d. Any prosthesis
e. Other physical complaints the patient may have.
17. Record vital signs
18. Ask about previous hospitalizations, allergies, or diseases other than the one for which
the patient is being admitted.
19. Record all information and observations on the admissions checklist
20. Records taken during admission should be thorough with as much pertinent information
about the patient as possible.
21. In acute care hospitals, the patient must provide a urine specimen.
22. Assist the patient to the bathroom, or offer the bedpan or urinal as needed.
23. Pour the urine specimen from the bedpan or urinal to the specimen bottle, and replace the
cap.
24. Label the specimen with the patient's name, doctor's name,and room number, and send it
to the laboratory along with the requisition for the admission urine test.
25. Always wash your hands after handling urine specimens.
26. Make the patient comfortable.
27. If the patient is ambulatory, he/she may wish to sit up and visit with family members.
28. In an acute care hospital, the patient is put to bed.
29. Raise the side rails if the nursing supervisor orders it—side rails may be needed if the
patient cannot or should not get out of bed unassisted, or if the patient's bed is not in the
lowest position.
30. Give the patient water if it is allowed.
31. Make sure the patient can reach the signal cord and anything else he/she might need
while you are not in the room.
32. Remove the screen or curtains surrounding the patient, or open the door so others will
know you are finished.
33. Tell family members they may return to the patient's room.
34. If the patient is unconscious or unable to answer the admission questions have a family
member help you with the information needed on the admission checklist.
35. Get as much information as you can about the patient.
36. Always be courteous and helpful to the patient and the patient's family.
37. Don't rush the patient through the admission process.
38. Allow the patient time to get acquainted with you and the healthcare setting.
39. Create an atmosphere of warmth and understanding for the patient and the patient's
family.
40. Record the Admission Data
41. Complete the admission checklist
42. Fill in the date and time of admission
Method of admission - the way the patient came into the room
1. Wheelchair
2. Ambulatory
3. Stretcher
Observations or unusual conditions noted
1. Chief complaint of the patient
2. Be brief but complete, and write legibly
60
TRANSFERRING THE PATIENT
A patient may be transferred from one room to another within the healthcare facility for several
reasons.
1. Sometimes the transfer is made at the patient's request
• A different type of room (such as a private room)
• A transfer for personal reasons, such as to find a more compatible roommate
2. Medical staff may request it.
• The physician may request the patient be transferred from one level of nursing care to
another because of a change in the patient's condition that might require more or less
specialized care.
• The patient may be moved into intensive care when his/her condition becomes more
critical
• Transferred into a regular medical floor when his/her condition improves.
3. Sometimes the nursing staff will transfer a patient closer to the nursing station where the
patient's condition can be supervised more closely.
4. The patient may also be transferred if the room location or equipment in the room is
needed for a more critically ill patient.
5. If the patient did not ask to be transferred, he/she may be upset, especially if the patient
does not understand the reason for the transfer.
RESPONSIBILITIES
1. Make sure all the patient's belongings are transferred with him/her
• Collect the belongings and any equipment that will be moved
• Check with the nursing supervisor before moving any equipment to another floor
• Check drawers, closets, tables, windowsills, the bathroom, and the bed covers for articles
that might be forgotten
2. The nurse will collect the patient's chart and medicines.
3. The ward clerk will make the necessary changes in the patient's records, billing charges, and
other forms.
4. You or the nurse will post the transfer on the patient's chart.
• Include the time
• Room numbers transferred from and to
• The reason for the transfer
• The patient's attitude toward the move should also be charted.
Moving the Patient

1. Before moving the patient, make sure the new room or floor is ready to receive the patient.
2. If the patient is moved in the bed, personal belongings can be placed on the bed.
3. The patient should be in a comfortable position with the side rails raised.
61
4. If the patient is moved by stretcher or wheelchair, move the patient first. Then move the
patient's belongings on a cart.
Fall prevention
• To prevent falls, never leave the patient alone in the hallway when ou are transferring
him/her to another floor.
When the patient arrives at the new room
1. Introduce the patient to the personnel who will be caring for them and their new roommates
2. Orient the patient to the new room
3. Assist the patient into the bed or a comfortable chair, attach the signal cord within easy reach,
and make sure the patient is comfortable before leaving.
After transferring the patient in the new unit

1. return any wheelchair or stretcher used to transport the patientto the proper place
2. Clean the patient’s room
3. Report to the nursing supervisor when the room is ready for another patient.
PLANNING FOR THE PATIENT'S DISCHARGE
There are many things to consider when planning for the patient's Discharge.
• If the illness has not been long, complicated, or severe, no special preparation is made
other than general health instructions and information concerning the actual discharge
(such as the time and date the patient will be discharged).
• For other patients, the discharge process is more complicated.
• The patient's attitude towards discharge and continued progress toward recovery must be
considered.
• If being discharged to home, the patient may need reassurance that recovery will continue
at home.
• The patient may be concerned about being able to manage for himself/herself.
• These worries may keep the patient from looking forward to leaving the healthcare
facility.
• The patient may wonder what kinds of treatment, if any, will be needed at home and how
it will be done.
• Provisions for special nursing care, such as provided by visiting nurses, may be needed
for the patient who is unable to manage his/her own hygiene and personal care.
• An important consideration may be whether help will be required for meals, grocery
shopping, etc., for a patient living alone and how long such help will be needed.
62
Planning for the patient's discharge involves the entire healthcare team.
• The patient, the family, the medical and nursing staff, and other personnel working in the
facility (such as the social worker and dietician) work together to coordinate the patient's
discharge.
• The doctor plans the discharge with the patient and leaves a written order on the patient's
chart.
• The nurse makes sure the discharge order has been written by the doctor.
• The nurse will then make the necessary arrangements with other departments to prepare
for the patient's discharge.
• The nurse will also make sure the patient has been given instructions by the doctor for
home care and understands the instructions.
(1) Taking medications
(2) Exercise programs
(3) Physical therapy
(4) Changing dressings
(5) Giving injections
(6) Respiratory treatments that will be continued at home.
• If possible, the nurse will give the patient a written copy of the instructions, such as a
copy of the diet or an appointment card for a return visit to the doctor
• The family must be notified of the patient's discharge time so they can make
arrangements for transportation.
Patient care does not end when the patient is discharged.
• The patient may receive visits from a home health agency to supervise the care and
treatment.
• The patient's home care should make use of existing community resources so the patient
and the family will not have to undertake the financial and emotional burden of extensive
home nursing care alone.
• The patient who is not yet ready to care for himself/herself at home may be discharged
from a hospital to an extended care facility.
• When the patient's condition indicates the need for long-term nursing care, he/she may be
discharged directly to a residential facility.
The Procedure for Discharge

• Always check with the nursing supervisor to be sure the patient has officially been
discharged by the doctor.
• Sometimes the doctor will discharge the patient on the day the order is written.
• Other times the patient will know several days before.
On the day the patient is to be discharged
• Check when the patient will be leaving

• Set up a schedule for the patient's care so that the patient does not become too tired.
• Allow for a rest period between the bath and packing
• Make sure the patient is ready when family members arrive
63
• As you help the patient with her/his care, make sure the instructions are understood about
home care and follow-up visits.
• Have the nurse answer any questions the patient has.
• Ask a family member to check with the business office – this person will be given a
release paper stating financial matters for the patient have been taken care of and the
patient is ready for discharge.
• Help the patient into a wheelchair, and wheel him/her to the entrance of the healthcare
facility nearest the car.
i. Ask the family to drive up to the entrance.
ii. To avoid injuries, do not leave the patient unattended until the family members have
arrived with their car, and help the patient into the car.
iii. Make sure all the patient's belongings are put in the car.
iv. Say goodbye and wish the patient well.
v. Return the wheelchair to its proper place.
vi. Your final responsibility is the terminal cleaning of the patient's unit.
Chart the Patient’s Discharge
The following information should be charted

a. The date and time the patient was discharged
b. The way the patient left the healthcare facility
c. Any special instructions, diet, or medications the patient is to continue after
discharge.
d. A notation should also be made on the chart that the patient's personal belongings
were sent with the patient

64
BASIC LIFE SUPPORT

PROCEDURE:
The lifesaving interventions of BLS are primarily for the purpose of maintaining circulation and
oxygenation of the brain and other vital organs until Advanced Cardiac Life Support (ACLS) or
other interventions can be initiated by trained healthcare providers.
CPR: for adults

CAB-D
(Circulation, Airway, Breathing, and Defibrillate)
There is a common acronym in BLS used to guide providers in the appropriate steps to assess
and treat patients in respiratory and cardiac distress. This is CAB-D (Circulation, Airway,
Breathing, and Defibrillate)
Sr STEPS S U
Assessment & Activation
1 Check scene safety
2 Checks for responsiveness by tapping and shouting
3 Shouts for help/directs someone to call for help and
get AED/defibrillator (CALL ON 3000)
4 Checks carotid pulse for 10 sec. Checks for no breathing or no normal
breathing (only gasping)
– Scans from the head to the chest for a minimum of 5 seconds and no
more than 10 seconds
5 Position patient on hard surface in supine position
If patient is at road side suspecting of supine injury then do not move.
6 Begin 5 cycles of CPR (lasts approximately 2 minutes).
Start with chest compressions:
• Provide 100 to 120 compressions per minute. This is 30

compressions every 15 to 18 seconds.
• Place your palms midline, one over the other, on the lower 1/3 of
the patient’s sternum between the nipples.
• lock your arms.
• Using two arms press to a depth of 2 to 2.4 inches (5-6cm) or
more on the patient’s chest.
• Press hard and fast.
• Allow for full chest recoil with each compression.
• Allow for only minimal interruptions to chest compressions.
1 cycle of adult CPR is 30 chest compressions to 2 rescue breaths.

If two providers are present: switch rolls between compressor and rescue
65
breather every 5 cycles.

7 Provides 2 breaths by using a barrier device
1. Opens airway adequately
2. Uses a head tilt–chin lift maneuver or jaw thrust
S U
3. Delivers each breath over 1 second
4. Delivers breaths that produce visible chest rise
5. Avoids excessive ventilation
8 Check pulse for 10 sec, check for response, if no response Compressions
resumed immediately
9 CPR should be continued by a healthcare provider until return of
spontaneous circulation (ROSC) or until termination of efforts
11 Recovery position (lateral recumbent or 3/4 prone position):
This position is used to maintain a patent airway in the unconscious

person.
• place the patient close to a true lateral position with the head
dependent to allow fluid to drain.
• Assure the position is stable.
• Avoid pressure of the chest that could impairs breathing.
• Position patient in such a way that it allows turning them onto
their back easily.
• Take precautions to stabilize the neck in case of cervical spine
injury.
Continue to assess and maintain access of airway.

Avoid the recovery position if it will sustain injury to the patient.

66
Recovery Position
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72
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REFERENCE LIST
Kozier, B., Erb, G., Blais, K., & Watkinson, J.M. (2020). Fundamentals of Nursing: Concepts,
Process & Practice (11th Ed.). California: Addison Wesley.
Perry G & Potter P (2017). Clinical Nursing Skills and Techniques (7th Ed). Missouri: C.V.
Mosby Co Publishers
Roe, S. (2003). Delmar’s Clinical Nursing Skills & Concepts. Canada: Thomson

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1

BSN 2nd Batch

Total Credits skills : 2.0

Course Coordinator : Mr. Mr. Aitzaz Ijaz

Course Faculty : Mr. Aitzaz Ijaz

Timings : See Master Schedule

Student Name : _________________________________________

Roll Number : _________________________________________

Clinical Objectives of Fundamental of Nursing:

1. Identify the roles and functions of health care team members.

FON-I Lab Planning

Dates / Faculty Page

MEDICAL HAND WASH

the hands. missed can be a source of cross infection.

6.8 Right palm over left dorsum and left

6.9 Palm to palm fingers interlaced

6.10 Back of fingers to opposing palms S U

6.11 Do the rotation rubbing of the thumb

6.12 Wards with clasped fingers of right

Date Sign off in Skill Lab Faculty Signature

THERAPEUTIC COMMUNICATION (INTERVIEW)

5. ASSESS AND ESTABLISH A Facilitates more exchange of

SKILLS: exchange of information.

Date Sign off in Skill Lab Faculty Signature

MAKING AN UNOCCUPIED BED

11 of bed. most soiled to prevent cross

Making a toe pleat

Date Sign off in Skill Lab Faculty Signature

MAKING AN OCCUPIED BED

Date Sign off in Skill Lab Faculty Signature

to client's hair and scalp.

Date Sign off in Skill Lab Faculty Signature

MOUTH CARE OF AN UNCONCIOUS

6. Place patient in side lying position with Prevents aspiration of saliva.

20 Raise the side rails Ensure client safety

Date Sign off in Skill Lab Faculty Signature

Yaunker with Suction Dia

HYGIENE CARE: COMPLETE OR PARTIAL BED BATH

washroom before you begin the bathing Facilitates a smooth procedure.

33. Repeat steps 30 to 32 for the other leg

• Date/ time, patient's condition during and after

Date Sign off in Skill Lab Faculty Signature

Date Sign off in Skill Lab Faculty Signature

Circular Strokes Kneading

PROVIDING HAND AND FOOT CARE

3.2. HAND CARE:

9. Allow fingernails to soak for 10 to Softening of cuticles ensures easy removal of

Date Sign off in Skill Lab Faculty Signature

ASSESSING A CLIENT’S TEMPERATURE

Additional equipment for AXILLARY temperature:

8 If thermometer is in the case:

13 Ensures contact of thermometer with

Report if any abnormality in reading. ensures accurate therapeutic

Date Sign off in Skill Lab Faculty Signature

ASSESSING CLIENT’S PULSE RATE

Date Sign off in Skill Lab Faculty Signature

DIAGRAM: POSSIBLE PULSE SITES FOR ASSESSMENT

ASSESSING CLIENT’S RESPIRATION RATE

while looking at the second hand of (inspiration & expiration)

Date Sign off in Skill Lab Faculty Signature