Review of Skills Notes

RLE SKILLS REVIEW
1. Vital Signs
2. Exercise And Massage
3. Positioning
4. Medical Handwashing
5. Urine Collection
6. Stool Collection
7. Sputum Collection
8. Perineal Care
9. Administering Oral Medications
10. Administering Intradermal Injection For Skin Tests
11. Administering Subcutaneous Injection
12. Administering Intramuscular Injection
13. NGT Insertion & Removal
14. Colostomy & Ileostomy Care
15. CBG
16. Eye Irrigation & Instillation
17. Ear Irrigation & Instillation
18. Crutch Walking
19. Seizure Precaution
20. Catheterization
VELEZ COLLEGE COLLEGE OF NURSING (Nursing Care Management 103 Skills Lab)
SKILLS LABORATORY MODULE NO. 17

NASOGASTRIC TUBE (NGT) INSERTION & REMOVAL
A Nasogastric Tube (NGT) and

advanced to the stomach.
LEARNING OBJECTIVES:
By the end of the module, the student will be able to:
1. Give the indications for NGT insertion.
2. Identify different types of nasogastric tubes.
3. Properly perform NGT Insertion.
4. Describe procedure for NGT removal
5. Apply principles of asepsis & infection control throughout the procedure.
6. Explain rationale for each step of the procedure accurately.
Important Information related to this Module:

A. Indications for NGT Insertion:
To remove gas and fluids from the stomach (decompression)
To diagnose GI motility and to obtain gastric secretions for analysis
To relieve and treat obstructions or bleeding within the GI tract
gavage feeding), hydration and medication when the oral
To provide a means for nutrition (______
route is not possible or contraindicated
To promote healing after esophageal or gastric surgery by preventing distention of the GI tract
and strain on the suture lines
lavage that have been ingested either accidentally or
To remove toxic substances (_______)
intentionally and to provide for irrigation
B. Types of Nasogastric Tubes: [may contain a radiopaque line to verify tube placement by x-ray]
Levin tube most commonly used for feeding; a rubber or

plastic tube that has a single lumen, a length of 42 to 50
inches (106.5 to 127 cm), and holes at the tip and along the
side.
Salem Sump or Anderson tube a double-lumen tube;
which could damage stomach lining; commonly used for

decompression, irrigations, and lavages. It is usually
connected to a Gomco suction machine.
112
Nursing Skills to Develop in this Module & Materials/Equipment Needed: [materials/items with an
asterisk (*) are the materials the students should bring during skills laboratory period]
NGT Insertion:
- Nasogastric Tube (normal adult sizes: Fr 12 to 18; international color-coding same with suction
catheters)*
- Facial tissues*
- Adhesive hypoallergenic tape*
- Tongue depressor*
- Water-soluble lubricant [single packet]*
- Sterile gloves*
- Stethoscope*
- Penlight*
- Towel or absorbent pad
- Emesis/kidney basin
- Cup or glass of water with straw or ice chips (if appropriate)
- Asepto syringe
- Rubber band
- Safety pin
- Ordered suction equipment
- Clamp for tubing
NGT Removal:
- Stethoscope*
- Disposable gloves*
- Asepto syringe
- Normal saline solution
- Towel or absorbent pad
- Materials for oral care & lubricant
Procedure Guidelines:
A. NGT Insertion:
1. Ask the patient if he has ever had nasal surgery, trauma, a deviated septum, or bleeding disorder.
2. Explain procedure to the patient, and tell how mouth breathing, panting, and swallowing will help in
passing the tube.
3. Place the patient in a ______________________;
sitting or High-Fowler's pos place a towel across chest.
4. Determine with the patient what sign he might use, such as raising the index finger, to indicate wait a
few moments because of gagging or discomfort.
5. Remove dentures; place emesis basin and tissues within the patient's reach.
6. With sterile package not yet opened, inspect for defects on the tube; look for partially closed holes or
rough edges.
7. Place rubber tubing in ice-chilled water for a few minutes to make the tube firmer. Plastic tubing may
already be firm enough; if too stiff, dip in warm water.
8. Have the patient blow nose to clear nostrils.
113
9. Inspect the nostrils with a penlight, observing for any obstruction. Occlude each nostril, and have the
patient breathe. This will help determine which nostril is more patent.
10. Prepare two tapes one long strip that is split lengthwise halfway [see illustration] and a short one.
11. Perform hand hygiene. Put on gloves.

12. After donning gloves, have coworker partially open the package of NGT. Making sure not to
contaminate your gloves, grasp tube and remove it from its package.
nose, earlobe, xiphoid and mark the tube
13. Maintaining sterility of tube, measure the patient's NEX (___________________),
appropriately [see illustration below]. Some tubes may be pre-marked to indicate length, but this may
not correlate exactly with the measurement obtained.
- The distance from the nose to the earlobe is the

first mark on the tube. This measurement
represents the distance to the nasal pharynx.
- When the tube reaches the xiphoid process (tip of
the breast bone) a second mark is made on the
tube. This measurement represents the length
required to reach the stomach.
14. With your dominant gloved hand, coil the first 3-4 inches (7-10 cm) of the tube around your fingers.
Have coworker open the packet of water-soluble lubricant and drop it on nondominant gloved hand
making sure not to contaminate glove.
15. Still holding the coiled tube with your dominant hand, coat its distal end with the lubricant. AVOID
occluding the tube's holes with lubricant.
16. Tilt back the patient's head before inserting tube into nostril, and gently pass tube into the posterior
nasopharynx, directing downward and backward toward the ear.
17. When tube reaches the pharynx, the patient may gag; allow patient to rest for a few moments.
18. Have the patient tilt head slightly forward. Offer several sips of water through a straw, or permit
patient to suck on ice chips, unless contraindicated. Advance tube as patient swallows.
19. Gently rotate the tube 180
___ degrees to redirect the curve.
114
20. Continue to advance tube gently each time the patient swallows.
21. If obstruction appears to prevent tube from passing, do not use force. Rotating tube gently may help. If
unsuccessful, remove tube and try other nostril.
22. If there are signs of distress such as gasping, coughing, or cyanosis, IMMEDIATELY remove tube.
23. Continue to advance the tube when the patient swallows, until the mark reaches the patient's nostril.
24. To check whether the tube is in the stomach:
- X-rays may be done to confirm tube placement.

______
- Obtain aspirate with 30 to 60 mL syringe & check for the pH. If stomach contents cannot be
aspirated, reposition the patient and attempt to aspirate again.
- Attach an Asepto syringe to the end of the NG tube. Place a stethoscope over the left upper
quadrant of the abdomen, and inject 5 to 10 mL of air while auscultating the abdomen.
- Ask the patient to talk or hum.
- Use the tongue blade and penlight to examine the patient's mouth especially an unconscious
patient.
25. After tube is passed and the correct placement is confirmed, attach the tube to suction (if indicated) or
clamp the tube. Remove gloves.
26. Anchor tube with hypoallergenic tape; attach unsplit end of long strip of tape to nose, and cross split
[see illustration below]
27. Anchor the tubing to the patient's gown. Use a rubber band to make a slip-knot to anchor the tubing
to the patient's gown. Secure the rubber band to the patient's gown using a safety pin [see illustration
below]. However, omit this step of the procedure for clients with psychiatric illness & suicidal
ideations.
115
28. After anchoring the tubing, perform hand hygiene.

29. Assure the patient that most discomfort he feels will lessen as he gets used to the tube.
30. Irrigate the tube at regular intervals (every 2 hours unless otherwise indicated) with small volumes of
prescribed fluid.
31. Cleanse nares and provide mouth care every shift.
32. Apply petroleum jelly to nostrils as needed, and assess for skin irritation or breakdown.
gastroesophageal reflux
33. Keep head of bed elevated at least 30 degrees to minimize ___________________.
34. Record the time, type, and size of tube inserted. Document placement checks after each assessment,
along with amount, color, consistency of drainage.
B. NGT Removal:
1. Verify the health care provider's order for removal.
2. Make sure that gastric drainage is not excessive in volume.
3. Make sure, by auscultation, that audible peristalsis is present.
4. Determine whether the patient is passing flatus; this indicates peristalsis.
Semi-Fowler's pos Then drape a towel or absorbent pad across her chest to
5. Help the patient into _______________.
protect her gown and bed linens from spills.
6. Using an Asepto syringe, flush the tube with 20
__ ml of air or normal saline solution to ensure that the
tube doesn't contain stomach contents that could irritate tissues during tube removal.
7. Apply disposable gloves.
8. n and remove tape from nose.
9. Clamp the tube by folding it in your hand.
10. Instruct the patient to _____________________.
take a deep breath and hold it in This maneuver closes the epiglottis.
11. Slowly, but evenly, withdraw tubing and cover it with a towel as it emerges. Covering the tubing helps
dispel patient's nausea. (As the tube reaches the nasopharynx, you can pull quickly)
12. Coil tube around gloved finger. Pull gloves over the coiled tube and discard it.
13. Provide the patient with materials for oral care and lubricant for nasal dryness.
14. Dispose of equipment in appropriate receptacle. Perform hand hygiene.
15. Document time of tube removal and the patient's reaction.
16. Continue to monitor the patient for signs of GI difficulties.
116
Special Considerations:
Similar to suction catheters, the international color code for the sizes of nasogastric & orogastric tubes
are: [NOTE: the larger the number, the larger the lumen]
French 5 (Fr 5) = Gray French 14 (Fr 14) = Green
French 8 (Fr 8) = Blue French 16 (Fr 16) = Orange
French 10 (Fr 10) = Black French 18 (Fr 18) = Red
French 12 (Fr 12) = White
If your patient lies unconscious, tilt her chin toward her chest to close the trachea. Then advance the
tube between respirations to ensure that it doesn't enter the trachea.
While advancing the tube in an unconscious patient (or in a patient who can't swallow), stroke the
patient's neck to encourage the swallowing reflex and facilitate passage down the esophagus.
While advancing the tube, observe for signs that it has entered the trachea, such as choking or
breathing difficulties in a conscious patient and cyanosis in an unconscious patient or a patient without
a cough reflex. If these signs occur, remove the tube immediately. Allow the patient time to rest; then
try to reinsert the tube.
Tincture of benzoin (if iodine allergy is not present) may be used to prep the skin on the bridge of the
_______________
nose. This acts as an adhesive as well as a skin prep.
After tube placement, vomiting suggests tube obstruction or incorrect position. Assess immediately to
determine the cause.
a risk for
secretions from the throat, which could cause respiratory complications. These complications may not
appear until after the tube is removed.
Sore throat or difficulty in swallowing may present as a symptom of inflammation of the insertion area.
This symptom should subside in 1 to 2 days. Lozenges or ice chips can be used to minimize discomfort.
In infants & young children, an orogastric tube (OGT) may be inserted instead of an NGT. Since tube
lumen is too narrow, a 5- or 10-mL luer-lock syringe is used instead of an Asepto.
References & Suggested Readings:

Altman, G.B. (2010). Fundamental & advanced nursing skills (3rd ed.). Clifton Park, NY: Delmar Cengage
Learning.
Nettina, S. & Mills, E.J. (2006). Lippincott manual of nursing practice (8th ed.). Philadelphia, PA:
Lippincott, Williams & Wilkins.
Schilling-McCann, J. (2009). (5th ed.). Philadelphia, PA: Lippincott,
Williams & Wilkins.
Smeltzer, S., Bare, B., Hinkle, J., & Cheever, K. (2010). -
surgical nursing (12th ed.). Philadelphia, PA: Wolter Kluwer Health/Lippincott, Williams & Wilkins.
Williams, L. & Hopper, P. (2003). Understanding medical-surgical nursing (2nd ed.). Philadelphia, PA:
F.A. Davis Company.
117

COLOSTOMY & ILEOSTOMY CARE
An ostomy is a surgically created opening that diverts stool to the outside of the body through an opening
colostomy
on the abdomen called a ________________. [see illustration below]
ileostomy is a surgically created opening between the ileum (usually the terminal ileum) of the
An ________________
small intestine and the abdominal wall. On the other hand, a colostomy is a surgically created opening
between any segment of the colon and the abdominal wall to allow fecal elimination. Colostomies can be
further classified as to which segment of the colon they are created [see illustration]. Ileostomies &
colostomies are also called bowel diversions.
B C
A
A. ascending colostomy
_________________
B. transverse colostomy
_________________
C. descending colostomy
_________________
D. cecostomy
_________________
E. sigmoid colostomy
_________________
F. ileostomy
_________________
F E
1. Give the indications & complications of colostomy & ileostomy creation or of a bowel diversion.
2. Describe the characteristics of a healthy stoma.
3. Perform ostomy care which includes removal of a soiled ostomy appliance, cleansing of stoma &
peristomal skin and fitting & application of a new ostomy appliance.
5. Discuss the standards of care guidelines in caring for a patient with an ostomy.
131

A. Indications for Bowel Diversion:
Usual Indications for a Colostomy
- May be performed as part of an abdominoperineal resection for rectal cancer
- A fecal diversion for unresectable cancer
- A temporary measure to protect an anastomosis
- Surgical treatment for inflammatory bowel diseases, trauma, ischemic bowel, cancer, and
congenital conditions
Usual Indications for an Ileostomy
ulcerative colitis
- ___________________________
Crohn's disease
- ___________________________
Familial polyposis
- ___________________________
Cancer
- ___________________________
Congenital Defects
- ___________________________
Trauma
- ___________________________
B. Complications of Bowel Diversion:

Mucocutaneous separation (between skin and stoma)
Stomal ischemia
Stomal stricture or stenosis (usually a long-term complication)
Stomal prolapse
Peristomal hernia
Peristomal skin breakdown from exposure to fecal output, allergic reaction to products, or infection,
such as candidiasis
C. Stoma Classifications:
1. End stoma = is formed when the proximal end

of the bowel is brought to the outside of the
abdominal wall.
Loop stoma
2. __________________ = is formed when a loop of
bowel, usually the transverse colon, is pulled to the
outside abdominal wall & a bridge is slipped under
the loop to hold it in place. An incisional slit is made in
the top of the exposed colon to allow stool to exit.
The entire loop of bowel is not cut through.
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3. Double-Barrel Stoma = is formed

___________________
when the bowel is completely
dissected and both ends of the colon
are brought to the outside abdominal
wall to form two separate stomas.
proximal
The _______________ stoma is the
functioning stoma that expels stool
distal
while ______________ stoma expels
mucous.
D. Location of Stoma and Character of Effluent:

Effluent = the collective term for the fecal discharge/drainage that comes out of a colostomy or
ileostomy. The consistency & character of the effluent is dependent on the location of the bowel where
the stoma is created. The table below summarizes this information:
LOCATION OF STOMA CHARACTER OF EFFLUENT

Liquid to mushy; contains protoeolytic enzymes w/c can be
Ileostomy harmful to the skin; drains freq (ave 4-5x per day); odor is
not offensive
Cecostomy, ascending colostomy Liquid to mushy; foul odor
Right transverse colostomy Mushy to semiformed; foul odor

Left transverse colostomy Semiformed, soft; foul odor
Soft to Hard formed; foul odor; discharge is reg and
Descending or sigmoid colostomy least freq (1/2x a day)
E. Types of Ostomy Appliance & Basic Parts:

An ostomy appliance is placed over the stoma to protect the skin, collect stool/effluent, and control
odor. [see illustration below]
133
E. Types of Ostomy Appliance & Basic Parts: [continued]

Skin barrier
One-Piece
1. __________________ appliance = consists of (already
a skin barrier that is already attached to the attached to
pouch pouch)
Pouch
Two-Piece
2. __________________ appliance = consists of a separate pouch with a flange and a separate skin
barrier with a flange (also called a wafer) where the pouch fastens to the barrier at the flange. The
pouch can be removed without the skin barrier/wafer.
POUCH WAFER
Flange of skin
Flange of pouch barrier/wafer
(flange of wafer (flange of pouch
fits here) fits here)
F. Types of Ostomy Pouch:
1. Drainable pouch = usually has a clamp (called

Bottom
a tail closure) where the end of the pouch is
opening of
folded over the clamp and clipped. This type
pouch
of pouch is usually used by people who need
(tail closure
to empty the pouch more than twice a day.
is folded &
clamped
here)
2. Closed pouch = is often used by people who

have a regular stoma discharge (as in a
sigmoid colostomy) and only have to empty
the pouch 1 or 2 times a day.
134
Materials/Equipment Needed: [materials/items with an asterisk (*) are the materials the students should
bring during skills laboratory period]
- Disposable gloves (2 pairs)*
- Two-piece drainable ostomy appliance (wafer & pouch)*
- Pen or pencil*
- Scissors (preferably curved)*
- Tail closure
- Toilet tissue, washcloth & towel
- Stoma measuring guide
- Stomahesive® paste or any skin barrier paste
- Stomahesive® powder (used if there is skin breakdown around stoma)
- Mild non-oily soap (optional)
- Odor-proof plastic bag
Procedure Guidelines
A. Changing an Ostomy Appliance:
1. Determine the need for an appliance change-
When do you change?
Change when there is a pouch leakage or discomfort @ or around the stoma, change the appliance
___________________________________________________________________________________
___________________________________________________________________________________
2. Select an appropriate time to change the appliance.
Avoid times close to meal or visiting hours. Ostomy odor and stool may reduce appetite or
embarrass the client.
Avoid times immediately after meals or the administration of any medications that may
stimulate bowel evacuation. It is best to change the pouch when drainage is least likely to occur.
3.
Explain to the client what you are going to do, why it is necessary, and how he or she can cooperate.
Provide for client privacy, preferably in the bathroom, where clients can learn to deal with the ostomy
as they would at home.
4. Assemble materials and equipment. Perform hand hygiene and apply clean gloves.
5. Assist the client to a comfortable sitting or lying position in bed or preferably a sitting or standing
position in the bathroom.
6. Empty the pouch and remove the ostomy skin barrier/wafer.
tail closure
Unclamp the ___________________of the drainable pouch and clean it (using soap & water) for
reuse. (refer to picture)
Empty the contents of the drainable pouch through the

bottom opening into a bedpan or toilet. Emptying before
removing the pouch prevents spillage of stool onto the
135
Peel the skin barrier/wafer off slowly, beginning at the top and working downward, while
Discard the soiled appliance in an odor-proof plastic bag.
7. Remove clean gloves and perform hand hygiene.

8. Assess the following:
Stoma color: The stoma should appear red, similar in color to the mucosal lining of the inner
cheek and slightly moist. A dusky bluish, purplish hue or pale stoma indicates
necrosis
inadequate blood supply a black stoma indicates ____________________.
____________________;
Stoma size & shape: Most stomas protrude slightly from the abdomen. Newly-created stomas
normally appear swollen or edematous, but swelling generally decreases over 2 or 3 weeks or
for as long as 6 weeks.
If the swelling fails to recede after 6 weeks, what does this indicate?
A problem occuring, such as blockage
_______________________________________________________________________________
Stomal bleeding: Touching the stoma normally causes slight bleeding- True? or False?
False
_________
Status of peristomal skin: Any redness and irritation of the peristomal skin the 5 to 13 cm (2 to
5 in.) of skin surrounding the stoma should be noted. Transient redness after removal of
adhesive is normal.
Amount & type of feces/effluent: Assess the amount, color, odor, and consistency. Inspect for
abnormalities, such as pus or blood.
Sensations ings, the client will not feel

anything when the stoma is touched. However, complaints of burning sensation under the skin
barrier may indicate skin breakdown. The presence of abdominal discomfort and/or distention
also needs to be determined.
9. Don a new pair of clean gloves.

10. Clean and dry the peristomal skin and stoma.
Use toilet tissue to remove excess stool.
Use warm water, mild soap (optional), and a washcloth to clean the skin and stoma.
Dry the area thoroughly by patting with a towel.
Apply Stomahesive® powder on weeping areas of peristomal skin as indicated for skin
breakdown.
11. Place a piece of tissue or gauze over the stoma, and change it as needed. This absorbs any seepage
from the stoma while the ostomy appliance is being changed.
12. Use the measuring guide to determine stoma size [see illustration below].
13. For appropriate size, choose a circle on the measuring guide 1/16 to 1/8 inch
the measuring guide)
14. After choosing the appropriate size on the measuring guide, trace pattern or appropriate circle
carefully onto paper backing of wafer using pen or pencil [see illustration below].
15. Cut the circular opening in the skin barrier. Bevel the edges to keep them from irritating the patient.
[as shown below].
16. Remove the paper backing from the wafer and moisten it or apply Stomahesive® paste, as needed,
along the edge of the circular opening [see illustration].
17. Remove tissue or gauze from stoma.
18. Center the wafer over the stoma, adhesive side down, and gently press it to the skin. Continue
applying pressure to peristomal skin for 60 seconds (1 minute) to ensure adherence of wafer to skin
and to allow drying of Stomahesive® paste [as shown below].
19. Gently press the flange of the pouch to the flange of the wafer until it snaps into place [as shown].
20. Fold the bottom opening of drainable pouch once onto the bar of the tail closure. Clamp by joining the
bar & hinge of the tail closure and lock by applying pressure on the finger tab [see illustration below].
Finger Tab
Bar
Hinge
21. Discard of used equipment, remove gloves and perform hand hygiene.
B. Emptying a Drainable Ostomy Pouch:

1. Empty the pouch when it is 1/3 to 1/2 full of stool or gas. If the pouch is allowed to get more than half
full of stool, the weight of the effluent will pull on the pouch and weaken the seal of the skin barrier.
2. Don clean gloves.
3. Hold the pouch over a bedpan or toilet. Lift the lower edge up.
4. Unclamp or unseal the pouch.
5. Drain the pouch.
6. Clean the inside of bottom opening of pouch with a tissue or a pre-moistened towelette.
7. If desired, the bottom portion of the pouch can be rinsed with cool tap water. Don't aim water up near
the top of the pouch because this may loosen the seal on the skin.
8. Apply the tail closure and seal the pouch.
9. Dispose of used supplies.
10. Remove clean gloves. Perform hand hygiene.
Most clinicians agree that an ostomy appliance should be changed at least once a week. If the skin is
erythematous, eroded, denuded, or ulcerated, the pouch should be changed every 24 to 48 hours to
allow appropriate treatment of the skin. More frequent changes are recommended if the client
complains of pain or discomfort.
A drainable pouch should be used for all colostomies or Ileostomies, especially during the first 8 weeks
after surgery.
Provide the following interventions for odor control:

- Encourage pouch hygiene through rinsing, keeping pouch tail free of effluent, airing of reusable
pouches, discarding odor-impregnated pouches.
- Recommend the use of pouch deodorants (such as spray deodorants & chlorophyll tablets),
room deodorizers, and oral deodorizers (such as buttermilk, yogurt & parsley).
- Never make a pinhole in a pouch to release gas which destroys the odor-proof seal.
- Instruct to minimize intake of food that increase odor of effluent: Enumerate as many as you
can-
fish, eggs, bear, and spices (garlic, onions)
_______________________________________________________________________________
_______________________________________________________________________________
Provide the following interventions for gas control:

- Suggest avoidance of straws, excessive talking while eating, chewing gum, and smoking to
reduce swallowed air.
- Beans and cabbage as well as carbonated beverages and eliminate
Instruct about gas-forming foods: ___________________________________________________
when appropriate. It takes about 6hrs for gas to travel from mouth to colostomy
_______________________________________________________________________________
_______________________________________________________________________________
- Recommend using arm over stoma to muffle gas sounds when appropriate.
Provide the following interventions to prevent ostomy blockage:

- Instruct patient to chew food well.
- Instruct to refrain from eating the following:
Green leafy vegetables (spinach, collards, mustards)
Cole slaw, sauerkraut
Celery
Corn, popcorn
Foods with non-digestible peels (apples, grapes, potatoes, membranes on citrus fruits)
Coconut
Mushrooms
Nuts
Dried fruits (raisins, figs, apricots)
Chinese vegetables
Meats with casings (sausage, hot dogs, bologna)
Encourage patient to verbalize feelings regarding the ostomy, body image changes, and sexual issues.
Inform patient of community resources, local and mail-order ostomy supply dealers, ostomy specialty
nurses, etc.
Colostomy irrigation is done to regulate bowel movements at a regular time. Candidates for
colostomy irrigation are those with more formed stool (descending or sigmoid portion of colon)

Learning.
Berman, A., Snyder, S., Kozier, B., & Erb, G. (2008).
process and practice (8th ed.). Upper Saddle River, NJ: Pearson Prentice Hall.
Schilling-McCann, J. (2002). Patient teaching reference manual. Philadelphia, PA: Springhouse
Corporation.
Williams & Wilkins.
Williams, L. & Hopper, P. (2003). Understanding medical-surgical nursing (2nd ed.). Philadelphia, PA:
F.A. Davis Company.

CAPILLARY BLOOD GLUCOSE (CBG) MONITORING
Capillary Blood Glucose (CBG) Monitoring, usually indicated in clients diagnosed with diabetes mellitus,
involves pricking a finger (or other alternate site) with a lancet device to obtain a small capillary blood sample,
applying the drop of blood onto a reagent strip, and determining the glucose concentration by inserting the
strip into a reflectance photometer or more commonly called blood glucose meter or glucometer, for an
au
of specimen and results are obtained instantly (usually in less than 2 minutes).
Self-Monitoring of Blood Glucose (SMBG) is a new trend in diabetes management which involves capillary
blood glucose monitoring performed solely by the client or a caregiver, at home & at work, with the objective
of collecting detailed information about blood glucose levels at many time points so as to enable maintenance
of a more constant glucose level by more precise therapeutic regimens. Apart from obtaining blood glucose
levels, SMBG requires the patient to keep a logbook of results (although most modern blood glucose meters
have a built-in memory). These SMBG results can be used by the patient to correct any deviations out of a
desired target range by changing his/her carbohydrate intake, exercising, or using more or less insulin. Client
teaching in SMBG is thus an important role to be played by the nurse.
1. Give the indications of CBG monitoring.
2. Perform capillary blood glucose (CBG) monitoring.
3. Apply principles of asepsis & infection control throughout the procedure.
Indications of CBG Monitoring:

To evaluate effectiveness of the medication regimen of clients with diabetes mellitus (i.e., insulin,
oral hypoglycemic agents)
To assess glucose excursion after meals (referred to as )
To assess glucose response to exercise regimen
To evaluate episodes of hypoglycemia and hyperglycemia to determine appropriate treatment
To distinguish between diabetic coma & non-diabetic coma
Also used to screen for neonatal hypoglycemia
Materials/Equipment Needed: [materials/items with an asterisk (*) are the materials the students should
bring during skills laboratory period]
- Blood glucose meter* with appropriate test/reagent strip (& calibrator, if needed)*
- Lancet/lancing device*
- Alcohol swab*
- Cotton ball* (& adhesive bandage; however, optional)
1
Explain the procedure to the patient and instruct him NOT to eat or drink hours prior to CBG
monitoring. Blood glucose levels are usually monitored three times a day before meals (TID ac) and at
bedtime (q HS).
Prepare the finger to be lanced by having the patient wash hands in warm water and soap. Washing in
warm water will increase the blood flow to the finger. Allow to air dry. For convenience, an alcohol swab
may be used to cleanse the finger. Alcohol must dry thoroughly (by air drying) before finger is lanced.
CLINICAL TIP: In diabetic clients with ineffective peripheral tissue perfusion (usually manifested as pallor &
cold clammy fingers), it is necessary to dilate the capillaries prior to obtaining blood sample by applying
warm, moist compresses to the hand for about 10 minutes (or until there is adequate blood flow to
as the earlobe may be used; however, site should NOT
be used when accuracy is critical (i.e., suspected hypoglycemia, before or after exercise, or before driving).
PEDIATRIC ALERT: Select the heel or great toe for an infant to obtain blood sample for CBG.
Don disposable gloves. Turn on the glucose meter. Prepare the meter by validating the proper calibration
with the strips to be used. (This usually involves matching a code number on the strip bottle to the code
registered on the meter.) Errors in glucose readings can result from miscalibrated or improperly coded
meters.
The meter will indicate its readiness for testing blood glucose by message or symbol. Some meters require
that the glucose test strip be inserted at this time.
To collect a sample from the fingertip with a disposable lancet (smaller than 2
mm), position the lancet on the side of the patient's fingertip, perpendicular to
the lines of the fingerprints (this area has lesser nerve endings). Pierce the skin
sharply and quickly to minimize the patient's anxiety and pain and to increase
blood flow. A lancet device or spring-loaded lancing pen may also be used for
convenience [see accompanying illustration].
After puncturing the fingertip, the puncture site to avoid diluting the sample with tissue
fluid. Wipe & DISCARD the first drop of blood to prevent serous fluid from causing a result.
Obtain a large, hanging drop of blood. Most inaccurate readings of blood glucose result from insufficient
blood samples.
Drop (& T smear) the blood carefully to the strip test area (varies by glucose
meter model). Some glucose meters require that the test area be covered
completely for accurate results. Others use only a small drop of blood inserted at
the side of the test strip [see accompanying illustration].
2
11. -
system require that the blood be
wiped off from the test strip with a firm stroke using a cotton ball at the
appropriate end time (usually 60 seconds). The strip is inserted into the meter for
the final result/reading [see accompanying illustration].
12. After collecting the blood sample, briefly apply pressure to the puncture site to prevent painful
extravasation of blood into subcutaneous tissues. Ask the adult patient to hold a dry cotton firmly over
the puncture site until bleeding stops.
13. After bleeding has stopped, you may apply a small adhesive bandage to the puncture site.
14. Do aftercare of equipment and discard used disposable items appropriately. DO NOT recap the used
lancet; discard it in the sharps container.
15. Do appropriate documentation and referral of results. A value of less than 60 mg/dL suggests
hypoglycemia and a value greater than 120 mg/dL suggests hyperglycemia.
16. For SMBG, instruct client to record CBG results on a logbook for future reference [see illustration below].
17. Most blood glucose meters also have an enclosed logbook or blood sugar diary for recording results [see
a sample logbook recording below]. Diabetes management software & online logbook software are also available
*on the insulin column in the example above, the number refers to the amount of insulin taken by the client in units; the h means
Humulin-R &; the L means Lente insulin
3
Precautions & Special Considerations:

An alternate term for CBG which is used in some institutions is HGT ( ).
BEFORE using reagent strips, check the expiration date on the package and replace outdated strips.
Check for special instructions related to the specific reagent. The reagent area of a fresh strip should
match the color of the block on the color chart (may vary from one device to another).
Protect the reagent strips from light, heat, and moisture. A desiccant may come with the strip
packaging to absorb moisture.
BEFORE using a blood glucose meter, calibrate it and run it with a control sample to ensure accurate
test results. Follow the manufacturer's instructions for calibration.
AVOID selecting cold, cyanotic, or swollen puncture sites to ensure an adequate blood sample. If you
can't obtain a capillary sample (even in alternate sites), perform venipuncture and place a large drop of
venous blood on the reagent strip. If you want to test blood from a refrigerated sample, allow the
blood to return to room temperature before testing it.
Newer blood glucose meters, such as the One Touch® Ultra®, require smaller amounts of blood; the
puncture may be done on the patient's arm instead of his finger.
Bear in mind that hematocrit may affect results of glucose testing because erythrocytes in the whole-
blood sample can alter the ratio of blood glucose to plasma glucose, as well as the flow of plasma and
delivery of oxygen into the test strip. Higher-than-normal hematocrit concentrations will
underestimate blood glucose levels, while lower-than-normal concentrations will overestimate levels.
Checking the hematocrit range specified by the device manufacturer is a key safety measure, especially
in the hospital setting so as to avoid discrepancies in the meter readings.
For clients on SMBG:
- Remind patients to clean their meters as directed and to wash their hands before testing.
- Patients engaging in high-altitude activities, particularly at low temperatures, should be alerted
of the potential for false high or low readings (there is clinical evidence that humidity, altitude &
temperature may affect accuracy of meter readings)
- The patient may opt to purchase an auto-coded blood glucose meter (a new variation of blood
glucose meters in which calibrating is no longer needed)
- Perform a return demonstration with the patient on technique for SMBG. Assess every 1 to 6
months to ensure procedure is done properly & that accurate readings are obtained.
- Inform client that diabetes cannot be cured but it can be managed. Through SMBG, therapeutic
management can be individualized, complications are promptly addressed & patient well-being
is maximized.
4

Hirsch, I., Bode, B., Childs, B., Close, K., Fisher, W., Gavin, J., ..., Verderese, C. (2008). Self-monitoring of
blood glucose (SMBG) in insulin- and non-insulin-using adults with diabetes: Consensus
recommendations for improving SMBG accuracy, utilization, and research. Medscape. Retrieved
June 5, 2010 from http://cme.medscape.com/viewarticle/581962
Corporation.
5
Eye Irrigation
Video Guide: https://www.youtube.com/watch?v=KjrCiRMW4Zo
Materials:
• A large syringe or a small receptacle with a pouring spout, such as a feeding cup with
Irrigating fluid, which is normal saline or clean water at room temperature.
• Towel or gauze swabs or cotton balls.
• A bowl or kidney basin.
1. Before beginning this procedure, always perform the following steps to ensure patient
safety.
2. I will make sure that I have read the doctor’s order.
3. I will wash my hands.
4. Ensure patient privacy.
5. I will then introduce myself use two patient identifiers to identify the patient.
6. And then, I will explain to the patient the procedure. Eye irrigation is used to clean the
eyes using normal saline solution.
7. I will also ask the patient if he/she has any allergies
8. I will then raise the patient’s bed as necessary, to a comfortable position for this
procedure.
1. I will double check the medication if I am using the correct solution, check the
medication expiration date and use the 6 rights of medication. These 6 rights include the
right patient, medication, dose, time, route and documentation and do the third check
of the medication at the bedside.
9. I will then position the patient in a supine if lying down, if standing up tilt the patient's
head slightly backward and provide support in patient's head.
10. Drape patient
11. I will perform hand hygiene and wear gloves.
12. Tilt patient's head slightly to the side to be irrigated.
13. Place the kidney basin beside the patient’s face, if patient can hold it then I will ask the
patient support the basin.
14. Assess eyes if there is drainage of sometype, if there is, I can use a wet cotton ball to
clean it from inner to outer canthus.
15. Fill bulb syringe. Hold the upper lid and lower lid apart.
16. Syringe is place a half an inch above the eye and aim it in the lower conjunctival sac. Aim
it from inner to outer. Be careful not to touch patient's eyes as this might bring injury or
spread infection. Then instill solution
17. When all done, I will get a dry cotton ball and wipe it from inner to outer canthus.
18. I will then get the drape, remove my gloves, and perform hand hygiene
19. I will then position the patient comfortably and raise side rails.
20. I will then thank the patient for his/her coordination.
21. I will then discard or store the materials.
22. I will then document as per agency policy, including the date, time, dose, route;
assessment of the eye before and after the irrigation, how much irrigation we used and
with what, how patient tolerated it, and the assessment after irrigation, did the patient
suffer other effects such as the eye being red, irritated, or other responses.
Eye Medication Instillation

Video Guide: https://www.youtube.com/watch?v=4lLG7GnTmBU
Materials:
• Non-sterile powder-free gloves
• Cotton swabs, tissues, or washcloths
• Eye drops at room temperature (which can besaline or non-medicated eye drops) or eye
ointment.
safety.
7. And then, I will explain to the patient the procedure, which is to apply drop by
drop administration of medication for eye drops.
8. I will then ask if patient if he/she has any allergies
9. I will also check the medication expiration date and use the 6 rights of medication.
These 6 rights include the right patient, medication, dose, time, route and
documentation and do the third check of the medication at the bedside.
10. I will then raise the bed as necessary.
11. I will then wear don gloves.
12. I will also assess his/her eye for any redness, or drainage.
13. If there is any, I will wash from the inner canthus to outer. I will do this by cleansing the
eyelids and lashes with cotton balls or warm washcloth moistened or soaked with
normal saline or water. Use each cotton ball or one side of the washcloth for only one
stroke, moving from the inner to the outer canthus of the eye).
14. Dry eyes using another cotton ball or cloth
15. In instilling the eyedrops, I will once again perform hand hygiene and apply gloves.
16. I will then ask the patient to look up.
17. With my nondominant hand, I will hold a clean tissue in the cheek bone below the lower
eyelid. I will press down using my thumb or forefinger then to press down against the
bony orbit to expose the conjunctival sac. I will remember to never press down directly
in the eyeball.
18. I will place my dominant hand in the patients forehead.
19. Holding the tip of the container 1-2 cm or 1/2 inch above the conjunctival sac, I will
instill the number of eyedrops. If ever the patient blinks or closes his eyes, and if the
eyedrops land in the outer margin of the eyelid, I will repeat the installation. When
using eyedrops that may have systemic effects, I will use a tissue to apply pressure to
the nasal lacrimal duct for 30-60 secs/eye. Again, I will remember to avoid putting
pressure in the eyeball.
20. Ask the patient to close his eyes gently and briefly.
21. Wipe excess to prevent possible skin irritation.
22. I will then thank the patient for his/her coordination.
23. Discard or store materials
24. I will then document as per agency policy, including the date, time, dose, route; which
eye the medication was instilled into; and patient’s response to procedure.
Ear Irrigation
Video Guide: https://www.youtube.com/watch?v=GBtNcgoqND4
Materials:
*You may have an actual patient or a substitute i.e. pillows for demonstration Bed
• Asepto or bulb syringe with Irrigating fluid (normal saline or clean water at room
temperature).
• Towel or gauze swabs or cotton balls
• A bowl or kidney basin.
safety.
6. And then, I will explain to the patient the procedure, which is to remove earwax that is
obstructing the ear canal or to remove a foreign object lodged in the ear canal, to
cleanse the canal of discharge, to soften and remove impacted cerumen, or to dislodge
a foreign object.
8. I will double check the medication if I am using the correct medication, check the
9. I will perform hand hygiene and wear clean gloves.
10. I will then position the client in a sitting position, and ask him/her to hold the basin
under her ear.
11. I will fill the bulb syringe with solution.
12. Straightening the auditory canal by pulling the pinna down and back for an infant and up
and back for an adult
13. Direct a steady, slow stream of solution against the roof of the auditory canal, using only
sufficient force to remove secretions. Do not occlude the auditory canal with the
irrigating nozzle. Allow solution to flow out unimpeded.
14. Ask client if temperature is also warm? Solution directed at the roof of the canal aids in
preventing injury to the tympanic membrane. Continuous in-and-out flow of the
irrigating solution helps prevent pressure in the canal
15. When the irrigation is completed, place a cotton ball loosely in the auditory meatus and
have the client lie on the side of the affected ear on a towel or an absorbent pad. The
cotton ball absorbs excess fluid. Gravity allows the remaining solution in the canal to
escape from the ear.
16. Discard equipment in appropriate area.
17. Wash your hands.
18. I will then document as per agency policy, including the date, time, dose, route; what
type of irrigation and which ear was irrigated, if left, right or both, assessment of the ear
before and after the application, and if the patient suffered from other responses. I will
also note volume and type of solution and the appearance of the return flow.
Ear Medication Instillation

Video Guide: https://www.youtube.com/watch?v=XdbegoveRYo
Materials:
• Clean non-sterile gloves
• Tissues
• Cotton tip applicator
• Ear drops (saline or non-medicated ear drops).
safety.
6. And then, I will explain to the patient the procedure, which is to apply drop by
drop administration of medication for the ears.
8. I will double check the medication if I am using the correct medication, check the
9. I will perform hand hygiene and wear clean gloves.
10. Unless contraindicated, I will position the client to the side that is unaffected, exposing
the affected ear.
11. For patients older than 3, gently pull the pinna up and back to straighten the ear canal.
For children below 3, pull the gently pull the pinna down and back
12. If the external canal is occluded by cerumen or drainage, I will gently remove it with a
cotton tip applicator. Taking care not to push down further the cerumen into the canal
13. Hold the dripper 1 cm into the canal or 1/2 inch above ear canal. Do not touch dropper
tip to ear. Touching the ear with the dropper tip will contaminate the dropper and the
medication.
14. And instill how many drops as prescribed.
15. Instruct patient to stay in the unaffected side by a few minutes.
16. Gently apply pressure to tragus of the ear for a few seconds, this help move medication
toward the tympanic ear.
17. If ordered, a cotton ball may be placed loosely in the ear canal. Cotton ball helps
prevent medication from escaping or leaking out from ear.
18. Remove gloves and assist patient to a comfortable and safe position.
19. If using a cotton ball, remember to return for 15 minutes to discard it.
20. Hand hygiene
21. Aftercare instructions: encourage patient to demonstrate self-administration and
provide any reinforcements.
22. I will then document as per agency policy, including the date, time, dose, route; what
medication was used, in what ear if left, right or both, assessment of the ear before and
after the application, and if the patient suffered from other responses.
Crutch Walking
SUMMARY / IMPORTANT:
Definition: Crutches are artificial supports and assists patients who need aid in walking
because of disease, injury, or a birth defect.
Purposes
> To assist client who cannot bear any weight on one leg.
> To assist client who have full weight bearing on both legs.
> Prevent injury to client who has difficulty in ambulation.
Parts
1. Rest Pad - for the axilla of the patient
2. Handle
3. Rubber Tips - to make sure the patient will not slip or slide
Proper Fit
Before a patient uses crutches for the first time, each crutch must be adjusted to the patient’s
height. Each crutch can be adjusted at the top and bottom. Below are some key concepts to
help you tell if the crutches fit your patient properly.
Mains points to remember:

• There should be a three fingerbreadths gap between the armpit (axillae) and crutch
rest pad when the patient holds the crutches.
• WHY? This prevents the patient from resting on the crutch rest pad while
using the crutches. The patient should place weight on the hand grips NOT
the crutch rest pad while ambulating. This prevents nerve damage that can
occur within the axillae region.
• The elbows should be flexed about 30 degrees when the hands are placed on
the hand grips
CRUTCH WALKING
1. Inform the client you will be teaching crutch ambulation.
Rationale: Reduces anxiety. Helps increase comprehension and cooperation, promotes
client independence.
2. Assess the client for strength, mobility, ROM, visual acuity, perceptual difficulties
and balance. Note: nurse and therapist often collaborate on this assessment.
Rationale: Helps determine the clients capabilities and amount of assistance required.
3. Adjust crutches to fit the client

1. Tripod Position
1. When a patient is ready to start ambulating with crutches, they will start in the tripod
position for proper balance
2. The tripod position is the position in which you stand when using crutches. It is also
the position in which you begin walking. To get into the tripod position, place the
crutch tips about 1 foot away to the side and in front of each foot. Stand on your
“good” foot (the one that is weight-bearing).
3. Each tip of the crutch will be about 1 foot away to the side of the feet diagonally .
2. Four-Point Gait
1. The 4-point gait) is used when the patient can bear some weight on both lower
extremities. this type of gait is similar to the two-point gait BUT the crutch and leg
move SEPARATELY rather than at the same time. Place the patient in the tripod
position and instruct him to do the following.
1. Move the right crutch forward.
2. Move the left foot forward.
3. Move the left crutch forward.
4. Move the right foot forward.
5. Repeat this sequence of crutch-foot-crutch-foot for desired ambulation.
3. Two-Point Gait
1. The 2-point gait (see figure 1-10) is used when the patient can bear some weight on
both lower extremities. the patient will move the injured side’s crutch (example right
crutch) at the SAME TIME as the non-injured leg (example left leg) AND then the
patient will move the non-injured side’s crutch (example left crutch) at the SAME
TIME as the injured leg (example right leg). Place the patient in the tripod position
and instruct him to do the following.
1. Move the right leg and left crutch forward together.
2. Move the left leg and the right crutch forward together.
3. Repeat this sequence for desired ambulation.
4. Three Point Gait Swing To

1. the patient will move both crutches forward and then SWING both legs forward to
the same point as the crutches.
5. Three-Point Gait Swing Through

1. Swing-through gait is used for patients with lower extremities that are paralyzed
and/or in braces. the patient will move both crutches forward and then SWING both
legs forward, PAST the crutches. Place the patient in the tripod position and instruct
him/her to do the following:
1. Move both crutches forward together about 6 inches.
2. Move both legs forward together about 6 inches.
3. Repeat the sequence in rhythm for desired ambulation
When Going Up and down the stairs, always remember “Good Leg goes to heaven and Bad
Leg goes to hell”
6. Going up the stairs

1. Going UP the stairs: the patient will move the “good” leg (hence non-injured leg) UP
onto the step FIRST and then will move the “bad” leg (hence injured leg) and crutches
up onto the step.
7. Going down the stairs

1. the patient will move both crutches down onto the step and then move the “bad” leg
(hence injured leg) DOWN and then move the “good” leg down.
Materials: ASSISTIVE DEVICES

There are three type of assistive devices to support ambulation for patients with
musculoskeletal disorders, one of which is are crutches. We also have your canes and
your walkers.
For this demonstration, we will be focusing on how to use crutches.
In each crutch since there are two, you have a rest pad for your armpit/axilla, then the handles,
and the rubber tips. This is made of rubber to make sure the patient will not slip or slide when
he or she uses the crutches. Also most of the crutches are adjustable already in terms of height.
So there are ways to lengthen the height, and also adjust the handle because it can also be
move up and down.
GUIDELINES WHEN MAKING SURE THE HEIGHT IS CORRECT:

• When it is in upright position, and the pt is also in upright positions, your crutches
should not directly touch the armpits, instead it should be atleast 3 fingerbreadths
between axilla and rest pad.
• Also the handle should not be too straight if held, it should have a 30 degree angle bend
of the elbows.
• Third, the tip should be rubber to make sure pt would not slip. There are some patients
that the tip of the crutches started to wear out or they use golf balls. That is
discouraged because that can be a risk for injury.
Supposing the patient is prescribed assistive devices and per the doctor’s order, as a nurse we
will teach a client on how to walk with crutches.
1. Before teaching a patient this procedure, I will still perform the following steps to
ensure patient safety.
2. I will make sure that I have read the doctor’s order
3. I will wash my hands
4. Ensure patient privacy
5. I will then introduce myself
6. I will use two patient identifiers to identify the patient
7. And then explain the purpose to the patient, that I will be teaching him or her how to
walk with crutches.
Now let us begin in the actual crutch walking

1. First, there is right positioning for your crutch, the tip should be 1 foot away or 12 inches
away from legs or feet, and it should be in an outer fashion and the legs should be here,
this is what we call as tripod position.
2. Before a patient makes use of his crutches, he should always make sure he is in a tripod
position to make sure that the patient is properly balance. So how should it be done?
Given the tripod means there is 3 quarters , the two quarters would be for the rubber
tips of your crutches. It should look like this (demonstrate) and it should be 1 foot away
from the patients feet. So that is what the tripod position looks like.
3. Now there are four different gait used in crutch walking, and it will dependent on how
the patient can carry his/her own weight.
A. FOUR POINT GAIT

The four point gait means there are four points: two points for the crutches and two points are
for the lower extremities, point one is the crutch on the involved side, point two is the
uninvolved leg, point three is the involved leg, and point four is the crutch on the uninvolved
side. The crutches and limbs are advanced separately, with three of the four points on the
ground and bearing weight any given time.
This gait pattern is used when there's lack of coordination, poor balance and muscle weakness
in both lower extremities, as it provides slow and stable gait pattern
This is indicated for patient who cannot support their upper bodies, or they may have weaker
legs, so to support their balance they have crutches
1. It can be either right or left crutch, but let us begin with the right crutch. If the right
crutch has move, the next one will be the opposite legs so the left leg.
2. Left crutch
3. right leg
4. Then now we are back in the tripod position so, begin again.
5. Right crutch
6. Left leg
7. Left crutch
8. Right leg
9. Right crutch
10. Left leg
11. Left crutch
12. Right leg
B. TWO-POINT GAIT
> This is similar to 4-point gait but instead of 4 different steps, the opposite crutch and the
opposite leg acting together simultaneously.
The crutches and the fractured leg are one point and the uninvolved leg is the other point. The
crutches and fractured limb are advanced as one unit, and the uninvolved weight-bearing limb
is brought forward to the crutches as the second unit . this gait pattern is less stable as only two
points are in contact with floor and good balance is needed to walk with 2 points crutch gait.
Right crutch, left leg

Left crutch, right leg
C. THREE POINT GAIT
This gait pattern is used when one side lower extremity (LE) is unable to bear weight (due to
fracture, amputation, joint replacement etc). It involves three points contact with the floor, the
crutches serve as one point, the involved leg as the second point, and the uninvolved leg as the
third point. Each crutch and the weight-bearing limb are advanced separately, with two of the
three points maintaining contact with the floor at any given time.
There are two types: Three Point Gait Swing To, and Three Point Gait Swing Through
THREE POINT GAIT SWING TO

> in here, the leg will swing to the same level of the crutches
When weight-bearing status is restricted to partial, toe-touch, or as tolerated, crutches are

necessary and help the patient step to the fractured limb by pushing down with the upper
extremities, thus transferring weight from the fractured limb to the assistive device.
Essentially, what will happen is:

> Both crutches in front
> Swing/slide both legs towards the level of crutches
> the patient should not exert or put his weight into the axilla because it may cause having
pressure ulcers into that area
> instead, the strength will be coming from the upper legs and the upper body
Both crutches in front

Swing towards the level of the crutches
Both crutches
Swing to
Both crutches
Swing to
THREE-POINT GAIT SWING THROUGH

> in here, the legs will go beyond the level of the crutches
The patient steps past the crutches with the weight-bearing lower extremity; the gait assumes a
two-point or three-point pattern.
Essentially, what will happen is:

> Put both crutches in front of the legs
> Swing/slide both legs beyond both crutches level
> crutches will move followed by both legs sliding/swinging beyond the level of the crutches
Crutches in front
Legs through or beyond the crutches
Crutches
Through
Crutches
Through
D. GOING UP/DOWN THE STAIRS

> we need to remember: GOOD LEG GOES TO HEAVEN. BAD LEG GOES TO HELL.
> in the event that the patient will go up the stairs, he should start with the good leg and then
the bad leg (injured leg)
> if going down the stairs, it will be the bad leg first then the good leg
> the crutches will go with the leg that will go first
GOING DOWN THE STAIRS

> BAD LEG GOES TO HELL
> crutches first followed by bad leg then the good leg
When you are going down, you want to lead with your injured side. This is because when going
down, the leg staying on the step is doing all the work. It is the one lowering you down
> supposing the left leg is the bad leg

> we can’t move the bad leg
Keep crutches under arms.

Remember to lift uninjured leg up first, then both crutches, then the injured leg.
Position yourself at the top of the stairs and face down the stairs
Hover the bad leg in front and remember that in this case, the left leg is the bad leg and thus
we cannot move this leg, supposing that it is injured
Move both crutches down one level of the stairs
Using the good leg as support, move down along the level of the crutches (bad leg is still
hovering)
Crutches down one level again
Good leg follows
Crutch
Good leg
Crutch
Good leg
And so on
Once a flat level/surface is reached, continue with either the swing to or the swing through
three-point gaits
GOING UP THE STAIRS

> GOOD LEG GOES TO HEAVEN
> good leg will go first, bad leg will then follow along with the crutches
When going up the steps, you want to step up with your uninjured side so you can power
yourself up. This is using a "step to" approach where each foot touches each step.
> still supposing the left leg is the bad leg
Keep crutches under arms.

Remember that you will place crutches onto step below then injured leg, then uninjured leg.
Position yourself at the bottom of the stairs and face the stairs
Hovering the left leg up as it is the bad leg in this scenario
Use the good leg (right leg) to move up one level of the stairs
Follow crutches on the same level
Good leg
Crutch
Good leg
Crutches
Good leg
And so on
Once a flat level/surface is reached, continue with either the swing to or the swing through
three-point gaits
After I'm done the teaching the client,, I will thank him/her for participating, do hand hygiene
and I'm going to go back to the clients record to document the activity.
Seizure Precautions
SUMMARY / IMPORTANT:
Seizure Precaution is needed to prevent any injury that may happen from seizures or
convulsions, such as falling off the bed, or worse, airway constriction
Indications:
Patients who have eclampsia
Various medical surgical cases
Procedure:
1. Perform handhygiene
2. Introduce yourself to the patient
3. Verify the identity of the patient
4. Inform the patient about what you are going to do
5. Check the following things:
• Make sure that the bed as pillow (For comfort, and to make sure that the head
is tilted)
• Make sure that the side rails are raised and add some pillows as well.
• Make sure that the bed is in the lowest position (In the event the patient falls
down, The height from the bed to the floor is not that high)
6. After preparing the bed, do not forget to prepare a few things
• Suction Machine - You should have it set already with its proper catheter
Oxygen
In the event that the seizure activity actually happened:

1. Make sure to time the seizures
• What time did it start?
• How long did it happen?
• What time did it end?
2. Make sure that the patient's airway is open by placing the patient in a sidelying
position.
3. Make sure to secure the head and the back as well
4. Make sure that the clothing is loosened. The clothing should not be too fit or too tight
because it can also constrict the airway.
5. In the event that there is a need for suction machine, suctioning can be done.
6. If the patient, if ever that the patient has a prescription or standing order of a
diazepam, it can be administered.
Materials:
- 2-3 Pillows
- Suction Machine
- Oxygen Machine
We will institute seizure precautions for patients who may have conditions such as in the
maternal-child nursing, for our eclampsia, for medical-surgical cases.
There are various reasons why patient have seizure, so it is best to prevent any injury that may
happen from seizure or convulsions, such as falling off the bed or worse, your airway aspiration.
safety.
5. I will then introduce myself.
6. I will use two patient identifiers to identify the patient.
7. And then explain to the patient that I am here for patient seizure precautions and I am here
to make sure that the environment is a safe place should any seizure occurs.
8. First, make sure the bed has a pillow, aside from the fact that it gives comfort, the pillow will
help in making sure that the head is slightly tilted, because if it’s flat, chances are that patient
may have secretions that may occlude the airway thus causing to have airway obstruction.
9. Side rails raised and put pillows in the side.
10. Supposedly and ideally the side rails already have an attached cushion to protect the
patient so that the patient will not be hurt by the hardness of the side rails.
11. But mostly here in our setting given that we don't have pads, so we put pillow.
12. If there are no side rails, we can place a pillow on both sides of the patient, and we can also
place the bed beside the wall so that it can be like a side rail, and we just have to put one more
pillow in the other side.
13. Next, make sure that the bed is in the lowest position. Purpose is to ensure that in an event
where a patient falls down during the seizure activity, the height from the bed to the floor is
not that high, minimizing the chances of acquiring injuries. Second, it is also useful for us nurses
when we are working because we don't have to bend to much or reach out too much when
taking care of them in seizure activities.
14. So apart from preparing the bed, we should prepare several things.
a. Suction machine, we should set it already with its proper catheter in place. This is needed for
when after the patient has a seizure, to remove any secretions.
b. Oxygen machine
A single seizure can have many causes, such as a high fever, lack of oxygen, poisoning, trauma,
a tumor, infection, or after brain surgery. Most seizures are controlled with medication.
11. In the event of seizure, we should take note what time it happened, how long, and what
time it ended, and of course the interventions we have done.
12. Make sure that there aren’t any sharp or hard objects in the patient’s place.
13. Ensure that airway is open by placing the patient in a side lying position.
14. Make sure to secure the head and back to prevent injuries.
15. And make sure is clothing is loosen, or not too fit or constricted.
16. If necessary, insert an oral airway and use suction to remove secretions. In event the need
of suctioning, you can do it already, whether it is oral and nasogastric if there is a need but
most of the time the oral suctioning will suffice.
Administer oxygen if the individual is in status epilepticus, is cyanotic or is in respiratory

distress. Some individuals may require rapid sequence intubation, but one should only use a
short-acting neuromuscular blocker to avoid masking of the seizure activity
17. After the seizure, assess him for respirations and a pulse. If they're present and he's
unresponsive, turn him onto his side to help keep his airway patent.
18. Take his vital signs
19. And there is also a practice in the earlier days, that we use spoon or tongue depressor, this
is not anymore applicable this time.
20. If the patient has a prescription or standing order of diazepam ,we can already use it during
this time, take note that diazepam is not mostly given during seizure activities, but it is a way to
insure that the airway is open and patent.
These are the things to remember for seizure precautions.

After the seizure episode ends and the patient has regained consciousness, I will explain to the
patient what happened, let him/her rest for a bit, and document on the nurses notes what time
it happened, how long, and what time it ended, and of course the interventions we have done.
PATIENT EDUCATION
Treatment of Seizures
Medicine can control most seizures. The right medicine at the right dose prevents seizures in
most people and lets them lead normal lives. The patient’s health care provider will prescribe
medicine based on his/her age and health history, how often he/she has seizures, and how
severe they are. The medicines might make him/her feel tired or dizzy and cause vision
problems at first.
To prevent seizures, encourage the patient to take his/her antiseizure medicine as directed and
never stop taking it abruptly. Get enough sleep, avoid alcohol, and learn relaxation techniques.
Don't play computer or electronic games for long periods because the flickering lights could
trigger a seizure. Avoid swimming or cooking alone, climbing to high places, or bathing in a
bathtub; a seizure during these activities would be very dangerous.
He/she may have an aura or another type of warning that he/she is going to have a seizure. If
so, immediately lie down in a safe place. Tell the patient to call his/her health care provider
after the seizure ends.
SKILLS LABORATORY M ODULE NO. 14

URINARY CATHETERIZATION
Urinary Catheterization
bladder via his or her urethra to allow urine to drain freely among other purposes.
1. Give the indications of urinary catheterization.
2. Discuss the types of urinary catheterization.
3. Describe urinary catheter & closed drainage system maintenance and care.
4. Describe how a catheterized urine specimen is obtained.
5. Perform indwelling catheter insertion on a male & female patient.
6. Perform indwelling catheter removal.
7. Perform condom catheter application.
8. Apply the principles of asepsis and infection control throughout the procedure.
9. Explain rationale for each step of the procedure.

Indications of Urinary Catheterization:
To relieve acute or chronic urinary retention

To allow continuous urine drainage when the urinary meatus is swollen from childbirth or local
trauma.
To drain urine preoperatively and postoperatively
To determine the amount of residual urine after voiding
To determine accurate measurement of urinary drainage in critically ill patients
Clients with urinary tract obstruction (by a tumor or enlarged prostate) and those with
neurogenic bladder paralysis caused by spinal cord injury or disease
Types of Urinary Catheterization:

catheterization uses a Foley bag catheter that remains in the bladder to provide
continuous urine drainage. A balloon inflated at the catheter's distal end prevents it from slipping out of
the bladder after insertion. [see illustration below]
166
catheterization involves the use of a straight plastic or rubber catheter
that is inserted into the urethra every 3 hours or more to empty the bladder. Once the bladder is empty,
the catheter is removed.
catheterization makes use of a latex or rubber catheter (condom catheter or also known
as Texas catheter) that fits over the penis and connects to a drainage bag.
catheterization involves an indwelling catheter that is inserted through an incision in
the lower abdomen directly into the bladder.
C. Urinary Catheter & Closed Drainage System Maintenance & Care:

Perform hand hygiene before and after handling any part of the system. Wear clean, disposable
gloves when handling the system.
Maintain unobstructed urine flow
- Keep the drainage bag in a dependent position, below the level of the bladder.
- Urine should not be allowed to collect in the tubing because a free flow of urine must be
maintained to prevent infection
Keep the drainage bag or closed drainage unit off the floor.
To empty the drainage bag:
- Perform hand hygiene and don gloves.
- Disinfect drainage port with antiseptic solution. Empty the bag in a separate collecting
receptacle for each patient being careful not to contaminate the drainage valve or spout.
Disinfect drainage port again.
Clean around the area where catheter enters urethral meatus (meatal-catheter junction) with
soap and water during the daily bath to remove debris.
AVOID using powders and sprays on the perineal area. Powder can encrust and cause soreness
and infection.
AVOID pulling on the catheter during cleaning. Backward and forward displacement of the
catheter introduces contaminants into the urinary tract.
D. Steps to Obtain a Catheterized Urine Specimen

Clamp the drainage tubing below the aspiration (sampling) port
for 30 minutes to allow urine to collect.
Clean the aspiration port with povidone-iodine or 70% alcohol.
Insert a sterile 21G needle (attached to a sterile syringe) into the
aspiration port of the catheter tubing [see illustration].
167
Aspirate a small volume of urine (about 5 to 10 mL).

Remove needle from syringe and release urine carefully into sterile specimen container.
Unclamp the drainage tube.
Send specimen to laboratory immediately.
Nursing Skills to Develop in this Module & Materials/Equipment Needed: [materials/items with an asterisk
(*) are the materials the students should bring during skills laboratory period]
Indwelling Catheter Insertion (male & female):

- Sterile gloves & clean disposable gloves*
- Sterile indwelling or 2-way Foley bag catheter (average adult sizes are Fr 16 to 18 for males & Fr 14 to
16 for females)*
- Sterile drainage collection bag or closed drainage unit*
- Sterile 10 mL disposable syringe with a luer-lock (not a slip tip)*
- Sterile water for injection (vial)*
- Two linen-saver or absorbent pads*
- Receptacle with cotton balls saturated with povidone-iodine solution (or other antiseptic solution
if patient is allergic to povidone-iodine)*
- Sterile water-soluble lubricant (single-use packet)*
- Adhesive tape*
- Soap* and water
- Washcloth
- Towel
- Optional: sterile urine specimen container, gooseneck lamp or flashlight, pillows or rolled blankets
or towels.
Indwelling Catheter Removal

- Absorbent cotton*
- Alcohol swabs*
- 10 mL syringe with a luer-lock (not a slip tip)*
Condom Catheter Application:

- Correct-sized condom or Texas catheter with enclosed double-sided tape or adhesive strip*
- Sterile drainage collection bag or closed drainage unit*
- Scissors (for trimming pubic hair)*
- Soap* and water
- Washcloth
- Towel
A. Indwelling Catheter Insertion (male & female):
1. Assess if patient has allergy to povidone-iodine solution. If positive, use another antiseptic solution.
2. Check the order on the patient's chart to determine if a catheter size or type has been specified.
3. Perform hand hygiene.
168
4. Select appropriate equipment, and assemble it at the patient's bedside.

5. Explain the procedure to the patient and provide privacy. Check
voided last. Percuss and palpate the bladder to establish baseline data. Ask if he/she feels the urge to
void.
6. Elicit assistance from a coworker or colleague to handle non-sterile items or open packages of sterile
items and to hold a flashlight or place a gooseneck lamp next to the patient's bed so that you can see
the urinary meatus clearly in poor lighting.
7. Place the female patient in dorsal recumbent position (with her knees flexed and separated and her
feet flat on the bed, about 2 feet apart). If client is unable to assume this position, she may be placed
on a side-lying position with upper leg flexed.
8. ELDER ALERT: The elderly patient may need pillows or rolled towels or blankets to provide support
with positioning.
9. Place the male patient in the supine position with his legs extended and flat on the bed. Ask the
patient to hold the position to give you a clear view of the urinary meatus.
10. Place the linen-saver or absorbent pads on the bed between the patient's legs and under the hips.
Drape the patient.
11. Don clean gloves. Use the washcloth to clean the patient's genital area and perineum thoroughly with
soap and water. Dry the area with the towel.
12. After drying, perform perineal care using the cotton balls saturated in povidone-iodine solution.
Urethral meatus should be thoroughly cleansed with povidone-iodine. Be more meticulous when
doing this procedure on an uncircumcised client, retracting the foreskin to clean the glans penis &
urethral meatus.
13. Remove clean gloves, and then perform hand hygiene.
14. Don sterile gloves. Save the paper enclosure of your sterile gloves by keeping it sterile and placing it
in an accessible area (this will be used as your sterile field later).
15. Have coworker partially open the package of a 10-mL disposable syringe. Making sure not to
contaminate your gloves, grasp syringe and remove it from its package. Tighten needle and aspirate
10 mL of air.
16. Have coworker open a vial of sterile water for injection using aseptic technique. While coworker holds
the vial, inject 10 mL of air into the vial and aspirate 10 mL of sterile water. Make sure fluid does not
drip on the paper enclosure of your sterile gloves.
169
17. Have coworker partially open package of sterile indwelling or Foley bag catheter. Grasp catheter and
remove it from its package using aseptic technique.
18. Inflate the indwelling catheter balloon with sterile water to inspect it for leaks. To do this, attach the
sterile water-filled syringe to the luer-lock (you will need the needle on the syringe if catheter inflation
port is not luer-lock), then push the plunger and check for seepage as the balloon expands. Aspirate
the sterile water to deflate the balloon. Also inspect the catheter for resiliency. Rough, cracked
catheters can injure the urethral mucosa during insertion, which can predispose the patient to
infection. Always make sure not to contaminate the catheter.
19. After checking, place sterile water-filled syringe on paper enclosure of sterile gloves (which will now
be called your sterile field). The catheter should still be on your gloved hand.
20. Have coworker partially open the drainage collection bag or closed drainage unit. Grasp entire unit
and remove it from its package. Secure tubing of the bag to the drainage port of the indwelling
catheter. Make sure all tubing ends remain sterile. Also make sure the clamp at the emptying port of
the drainage bag is closed to prevent urine leakage from the bag.
21. Have coworker hold the bag of the closed drainage unit (which is considered not sterile), as you hold
the catheter (now with tubing of closed drainage unit attached).
22. With your dominant gloved hand, coil the catheter (not including the tubing of the closed drainage
unit) around your fingers. Have coworker open the packet of water-soluble lubricant and drop it on
nondominant gloved hand making sure not to contaminate glove. Still holding the coiled catheter with
your dominant hand, coat its tip with the lubricant.
23. For the female patient, separate the labia majora and labia minora as widely as possible with the
thumb, middle, and index fingers of your nondominant hand (part of the gloved hand touching the
labia is now considered not sterile) so you have a full view of the urinary meatus. [see illustration
below]
170
24. For the male patient, hold the penis with your nondominant hand. If he's uncircumcised, retract the
foreskin. Then gently lift and stretch the penis to a 60- to 90-degree angle. Hold the penis this way
throughout the procedure to straighten the urethra [see illustration below].
25. Prepare to insert the lubricated catheter tip into the urinary meatus. To facilitate insertion by relaxing
the sphincter, ask the patient to cough as you insert the catheter. Tell him to breathe deeply and slowly
to further relax the sphincter and spasms. Hold the catheter close to its tip to ease insertion and control
its direction.
26. NURSING ALERT: NEVER force a catheter during insertion. Maneuver it gently as the patient bears down
or coughs. If you still meet resistance, stop and notify the physician. Sphincter spasms, strictures,
misplacement in the vagina (in females), or an enlarged prostate (in males) may cause resistance.
27. For the female patient, advance the catheter 2 to 3 inches (5 to 7.5 cm) while continuing to hold the
labia apart until urine begins to flow [see illustration below]. If the catheter is inadvertently inserted into
the vagina, leave it there as a landmark. Then begin the procedure over again using new supplies.
171
28. For the male patient, advance the catheter to the bifurcation and check for urine flow [see illustration
below]. If the foreskin was retracted, replace it to prevent compromised circulation and painful swelling.
29. When urine stops flowing, attach the saline-filled syringe to the luer-lock.
30. Push the plunger and inflate the balloon to keep the catheter in place in the bladder [see illustration
below].
31. NURSING ALERT: NEVER inflate a balloon without first establishing urine flow, which assures you that
the catheter is in the bladder.
32. Hang the collection bag below bladder level to prevent urine reflux into the bladder, which can cause
infection, and to facilitate gravity drainage of the bladder. Make sure the tubing doesn't get tangled in
the bed's side rails.
33. Tape the catheter to the female patient's inner thigh to prevent possible tension on the urogenital
trigone [see illustration below].
172
34. Secure the indwelling catheter to the male patient's abdomen or upper outer thigh [see illustration
below]. Properly securing the catheter prevents catheter movement and traction on the urethra.
Securement to the abdomen in males may prevent pressure on the scrotal-penile junction.
35. Assist client in wearing comfortable clothing.

36. Dispose of all used supplies properly.
37. Empty the collection bag at least every 8 hours. Excessive fluid volume may require more frequent
emptying to prevent traction on the catheter, which would cause the patient discomfort, and to prevent
injury to the urethra and bladder wall.
B. Indwelling Catheter Removal

1.
Explain the procedure and tell him that he may feel slight discomfort. Tell him that you'll check him
periodically during the first 4 to 6 hours after catheter removal to make sure he resumes voiding.
2. With alcohol swabs, remove adhesive tape securing the catheter.
3. Put on clean gloves. Attach the syringe to the luer-lock mechanism on the catheter.
4. Pull back on the plunger of the syringe. This deflates the balloon by aspirating the injected fluid. The
amount of fluid injected is usually indicated on the tip of the catheter's balloon lumen usually 10 mL.
5. Grasp the catheter with the absorbent cotton and gently pull it from the urethra. Instruct client to take
a deep breath as catheter is removed.
6. Coil catheter around gloved finger. Pull gloves over the coiled catheter and discard it.
7. Measure and record the amount of urine in the collection bag before discarding it.
9. Patient should be able to void freely in 4 to 6 hours after catheter removal. Assess the patient for
incontinence (or dribbling), urgency, persistent dysuria or bladder spasms, fever, chills, or palpable
bladder distention. Report these to the physician.
C. Condom (Texas) Catheter Application

2.
3. Position the client in a comfortable position, preferably a supine position, if tolerated by the client.
Raise the bed to a comfortable height for the nurse.
4. Don clean gloves.
5.
6. ient may require
an indwelling catheter if there is a significant amount of skin breakdown.
7.
clean thoroughly in folds.
8. rmal position.
9. Cut any excess hair around the base of the penis.
10. Rinse and dry the area.
11. Apply the double-
is applied 1 inch from the proximal end of the penis [see illustration below]. Don't let the edges of the
you may cut off circulation.
12. Position the rolled condom at the distal portion of the penis and unroll it, covering the penis and
double-sided strip of adhesive. Leave a 1- to 2-inch space between the tip of the penis and the end of
the condom.
174
13. Gently press the condom to the adhesive strip.

14.
the drainage bag attached to the leg [see illustration below].
15. Determine that the condom and tubing are NOT twisted.
16. Cover the client.
17. Dispose of the used equipment in appropriate receptacle and wash hands.
18. comfortable or appropriate
position.
19. every 4 hours. Remove gloves and
wash hands after procedure.
20. Remove the condom once a day to clean the area and assess the skin for signs of impaired skin
integrity.
Erection may occur as a normal physical response during the catheterization. This can be an embarrassing
moment for the male client. Deal with the situation professionally. Withhold the procedure and leave the
room; come back in 10 to 15 minutes to finish the procedure.
If the area for taping to secure the indwelling catheter is hairy, prepare and shave the area to prevent any
tion, and
possible erection during sleep.
DO NOT reattach a condom catheter if it falls off. It will not stick any better the second try. Start over with
a new strip and catheter.
175
Sometimes a cotton ball is placed at the opening of a female

inserting in the wrong pathway. Be sure to remove the cotton ball upon completion of the skill to prevent
unnecessary infection.
If female client is in the menstrual cycle when being placed with a urinary catheter, perineal care should
be administered daily to prevent urinary tract infection.
Depending on the length of catheterization, a bladder training or retraining may be ordered before
removal of an indwelling catheter. The physician usually orders that the drainage tube be clamped for 2
hours or until client feels the urge to void then tube is unclamped to facilitate urine flow and clamped
again after 30 minutes. The cycle is repeated until client feels the urge to void more frequently when
catheter is clamped. The physician then orders the indwelling catheter be removed.
In male clients with benign prostatic hypertrophy (BPH), a Coude catheter, a semi-rigid catheter that has
a curve or bend at the tip, may be used for urinary catheterization. The curved tip allows it to navigate
over the curvature of the prostate or any other urethral obstruction it may encounter.

Learning.
Perry, A.G. & Potter, P. (2010). Clinical nursing skills & techniques (7th ed.). St. Louis, MO: Mosby.
Corporation.
Williams & Wilkins.
Smeltzer, S., Bare, B., Hinkle, J., & Cheever, K. (2010). -surgical
nursing (12th ed.). Philadelphia, PA: Wolter Kluwer Health/Lippincott, Williams & Wilkins.
176

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RLE SKILLS REVIEW

SKILLS LABORATORY MODULE NO. 17

A Nasogastric Tube (NGT) and

Important Information related to this Module:

Levin tube most commonly used for feeding; a rubber or

Salem Sump or Anderson tube a double-lumen tube;

which could damage stomach lining; commonly used for

11. Perform hand hygiene. Put on gloves.

- The distance from the nose to the earlobe is the

- X-rays may be done to confirm tube placement.

28. After anchoring the tubing, perform hand hygiene.

References & Suggested Readings:

SKILLS LABORATORY MODULE NO. 21

Important Information related to this Module:

B. Complications of Bowel Diversion:

1. End stoma = is formed when the proximal end

3. Double-Barrel Stoma = is formed

D. Location of Stoma and Character of Effluent:

LOCATION OF STOMA CHARACTER OF EFFLUENT

Cecostomy, ascending colostomy Liquid to mushy; foul odor

Right transverse colostomy Mushy to semiformed; foul odor

E. Types of Ostomy Appliance & Basic Parts:

E. Types of Ostomy Appliance & Basic Parts: [continued]

F. Types of Ostomy Pouch:

1. Drainable pouch = usually has a clamp (called

2. Closed pouch = is often used by people who

Empty the contents of the drainable pouch through the

Discard the soiled appliance in an odor-proof plastic bag.

7. Remove clean gloves and perform hand hygiene.

Sensations ings, the client will not feel

9. Don a new pair of clean gloves.

17. Remove tissue or gauze from stoma.

B. Emptying a Drainable Ostomy Pouch:

10. Remove clean gloves. Perform hand hygiene.

Provide the following interventions for odor control:

Provide the following interventions for gas control:

Provide the following interventions to prevent ostomy blockage:

References & Suggested Readings:

SKILLS LABORATORY MODULE NO. 11

Indications of CBG Monitoring:

Precautions & Special Considerations:

References & Suggested Readings:

Eye Medication Instillation

Ear Medication Instillation

Mains points to remember:

3. Adjust crutches to fit the client

4. Three Point Gait Swing To

5. Three-Point Gait Swing Through

6. Going up the stairs

7. Going down the stairs

Materials: ASSISTIVE DEVICES

For this demonstration, we will be focusing on how to use crutches.

GUIDELINES WHEN MAKING SURE THE HEIGHT IS CORRECT:

Now let us begin in the actual crutch walking

A. FOUR POINT GAIT

Right crutch, left leg

C. THREE POINT GAIT

THREE POINT GAIT SWING TO

When weight-bearing status is restricted to partial, toe-touch, or as tolerated, crutches are

Essentially, what will happen is: