Nursing Skills Procedure Manual

NURS 241 Nursing Skills Procedure: Manual

(cover page)
1st released in November 6, 2012@ UoD College of Nursing (Male)
The NURS 241 Nursing Skills Procedure Manual

Is a compilation of
The University of Dammam, College of Nursing(Male) faculty.
1st edition 2012-2013
The author and contributor have prepared this work for the
student nurses. Furthermore, no warranty, express or implied and
disclaim any obligation, loss as a consequence of the use and
application of any contents of this activity.
THE AUTHORS,
Nursing Course Coordinator:
Dr. James M. Alo, RN, MAN, MAPsycho., PhD.
Clinical Staff:
Mr. Robin Easow, RN, MAN
Mr. Abdullah Ghanem, RN, MAN
Mr. Fhaied Mobarak, RN, MAPPC
Mr. Shadi Alshadafan, RN, MAN
Mr. Darwin Agman, RN
Mr. Fathi Alhurani, RN
Preface
This manual will help the student learn knowledge and
demonstrate nursing skills related to the fundamental management
of patient care especially to patient with medical and surgical
impediments.
Special attention of the student to this manual will aid them in
developing, enhancing their learned skills from their dedicated
clinical staff.
The authors and contributors recognize the student as an
active participant who assumes a collaborative role in the learning
process. Content is presented to challenge the student to develop
clinical nursing skills.
NURS 241 TEAM

Course Coordinator:
Dr. James M. Alo

Clinical Staff:
Mr. Robin Easow

Mr. Abdullah Ghanem
Mr. Fhaied Mobarak
Mr. Shadi Alshadafan
Mr. Darwin Agman
Mr. Fathi Alhurani

TABLE OF CONTENTS
Sec.
CONTENTS
Page #
Cover Page
Acknowledgment
Preface
Handwashing
6
Measuring Body Temperature/ Vital Signs
9
-Oral Temperature Measurement
13
-Oral Temperature Measurement w/ E-Thermomemter
15
-Rectal Temperature Measurement w/ glass
15
thermometer
-Rectal Temperature Measurement w/ e-thermometer
17
-Axillary Temperature Measurement w/ glass
18
thermometer
-Axillary Temperature Measurement w/ e19
thermometer
-Tympanic Membrane Measurement w/ e20
thermometer
Advantages & Disadvantages of Selecting Temperature
21
Measurement
Assessing Radial and apical Pulse
22
-Radial Pulse
25
-Apical Pulse
26
-Apical-Radial Pulse
28
Assessing Respiration
32
-Abnormal breathing patterns
34
Assessing BP
37
Applying and Removing sterile gloves
44
Changing an occupied bed
47
Changing an unoccupied bed
50
Body mechanics
55
Lifting an object from the floor
58
Positioning clients
59
Transferring patient from bed to chair
66
Bathing adult client
69
Collecting sputum specimen
76
Collecting and testing of urine
78
Collecting a specimen from indwelling catheter
84
Collecting and testing of stool
87
Obtaining a capillary blood specimen
89
Collecting samples from nose and throat
93
Collecting samples from nasal mucosa
96
Bandage and binders
97
Bandaging
99
-Types of bandage turns
102
-Types and purpose of binders
104
APPENDIX A
Shoulder immobilization
/Performance Checklist
Handwashing
Applying and removing of gloves
Axillary temperature (electronic)
Rectal temperature (electronic)
Oral temperature (electronic)
Heart rate
Respiratory rate
Moving the client up in bed
Moving the client to lateral position
Body mechanics
Logrolling a client
Dangling a client
Applying and removing gloves, gowns and mask
Assessing Blood Pressure
Changing an Unoccupied Bed
Changing an \occupied Bed
REFERENCES
115
118
118
120
122
124
126
128
132
134
138
140
143
145
147
148
151
152
154
HANDWASHING
Introduction:
Hand washing is important in every setting, including hospitals. It is
considered one of the most effective infection control measures. There are two types
of microorganisms (bacteria) present on the hands: Resident bacteria, which cannot
be removed by hand washing. The second type is transient bacteria, which is easily
removed by hand washing.
It is important that hands be washed at the following time:
Before and after eating.
Before and after contact with any patient.
When handling patients food, blood, body fluids, secretions or excretions.
When there is contact with any object that is likely to be a reservoir of

organisms such as soiled dressings or bedpan.
After urinary or bowel elimination.
Purposes: Handwashing is performed to:

1. Remove the natural body oil and dirt from the skin.
2. Remove transient microbes, those normally picked up by the hands in the
usual activities of daily living.
3. Reduce the number of resident microbes, those normally found in creases of
the skin.
4. Prevent the transmission of microorganisms from client to client / from nurse
to family / from client to nurse.
5. Prevent the cross-contamination among clients.
Key Points:
Handwashing is a basic aseptic practice involved in all aspects of providing care to
persons who are sick or well. It becomes especially important when the client have
nursing diagnoses such as:
Potential for infection.
Altered body temperature.
Impaired skin integrity.
Equipment and Supplies

o Source of running water
(warm if available)
o Soap
o Soap dish
o Orangewood stick
o Towel or tissue paper
o Lotion
Procedure:
1
STEPS
Stand in from of the sink. Do not
allow your uniform to touch the sink
during the washing procedure.
Remove jewelries. Remove watch 35 inch above wrist
Turn on water and adjust the force.

Regulate the temperature until the
water is warm. Do not allow water to
splash.
Wet the hands and wrist area. Keep

hands lower than the elbows to
allow water to flow toward the
fingertips.
Use about one teaspoon of liquid

soap from the dispenser or lather
thoroughly with bar soap. Rinse bar,
and return it to soap dish.
RATIONALE
The sink is considered
contaminated. Uniforms may carry
organisms from place to place.
Removal of jewelries facilitates
proper cleansing. Microorganisms
may accumulate in settings of
jewelries.
Water splashed from the
contaminated sink will contaminate
your uniform. Warm water is more
comfortable and has fewer
tendencies to open pores and
remove oils from the skin.
Organisms can lodge in roughened
and broken areas of chapped skin.
Water should flow from the cleaner
area toward the more
contaminated area. Hands are
more contaminated than the
forearm.
Rinsing the soap removes the

lather, which may contain
microorganisms.

6
With firm rubbing and circular

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

circular motions helps to loosen the
dirt and organisms which can lodge
between the fingers, in skin crevices
of knuckles, on palms and backs of
the hands, as well as the wrist and
forearms. Cleaning least
contaminated areas (forearms and
wrists) prevents spreading
organisms from the hands to the
forearms and wrists.
Continue this friction motion for 10

to 30 seconds.
Use fingernails of the other hand or

use orangewood stick to clean
under fingernails.
Rinse thoroughly.
Length of hand washing is

determined by the degree of
contamination.
Organisms can lodge and remain
under the nails where they can grow
and be spread to others.
Running water rinses organisms and
dirt into sink.
Drying the skin well prevents
chapping. Dry hands first because
they are the cleanest and least
contaminated area after hand
washing. Turning the faucet off with
a paper towel protects the clean
hands from contact with a soiled
surface.
Lotion helps to keep the skin soft
and prevents chapping.
9
10
Dry hands and wrists with paper

towel. Use paper towel to turn off
the faucet.
11
Use lotion on hands if desired.
MEASURING BODY TEMPERATURE or VITAL SIGNS

Objectives:
1. To measure the body temperature accurately and safely.
2. Recognize deviations from the normal.
Purposes:
1. To establish baseline data.
2. To identify if the body temperature is within normal range.
3. To determine changes in the body temperature in response to specific
therapies.
4. To monitor clients at risk for alterations in temperature.
Types of Thermometers:
Clinical glass mercury
thermometers:
Oral (long tip)
Stubby
Rectal
Electronic thermometer
Infra-red thermometer
(Tympanic thermometer)
10
Temperature sensitive strips

(Disposable thermometer strips)
(Liquid crystal thermometer)
Temperature Scales:
Celsius (centigrade) scale normally extends from 34.0 to 42.0 C.
Fahrenheit scale usually extended from 94 F to 108 F.
Factors affecting body temperature:
Age: children; old age.
Stress
Sex: males; c females and
Environment
Obesity
during menstruation.
Diurnal variations.
Food intake; fasting
Exercise
Drugs or
Hormones
Disturbance in hypothalamus
11
Ranges of normal temperature values and

physiological consequences of abnormal body temperature.
Sites/Routes for temperature assessment:

1. Core temperature is the temperature of the deep tissues of the body, such
as the cranium, thorax, abdominal and pelvic cavity.
2. Surface temperature is the temperature of the skin, the subcutaneous tissue
and fat. It rises and falls in response to the environment; varies from 20 to
40 C.
Route
Normal Reading
Timing
Oral
37 C (98.6 F)
3 minutes
Axillary
37.5 C (99.6 F)
5 minutes
Rectal
36.4 C (97.6 F) 36 .7 C (98
1 minute
F)
Tympanic
Alterations in body temperature:

1. Pyrexia / hyperthermia / fever (above usual range).
2. Hyperpyrexia very high fever.
3. Afebrile no fever.
1 2 sec.
CONTRAINDICATIONS / CAUTIONS:
A. Oral:
1. Children younger than 4 to 5 years.
2. Confused, combative or comatose individuals.
3. Irritable clients or with mental diseases.
4. With history of convulsive disorders.
5. Mouth breathers.
6. With oral infections or with injuries or conditions that prevent them from
closing their mouths fully.
7. Immediate post-op under anesthesia.
8. Surgery for nose and mouth.
9. Patient receiving oxygen therapy.
10. Wait at least 15 to 30 minutes after person smokes / drinks / eats.
B. Rectal:
1. With rectal or perineal injuries or surgeries.
2. With diarrhea, diseases of the rectum.
3. Patient with heart disease.
4. Lubricate the thermometer well and insert gently to avoid damage to the
mucosa or perforation of the rectum.
C. Axillary : NONE.
D. Tympanic: NONE.
Equipment:
Appropriate thermometer
Soft tissue papers
Lubricant (for rectal measurement only)
Pen, pencil, vital signs flow sheet or record form.
Disposable gloves, plastic thermometer sleeves or disposable probe covers.
12
13
Procedure:
1
3
4
STEPS
Assess for signs and symptoms of
temperature alterations and for
factors that influence body
temperature.
Determine any previous activity that
would interfere with accuracy of
temperature measurement. When
taking temperature, wait 20 to 30
minutes before measuring
temperature if client has smoked or
ingested hot or cold liquids or foods.
Determine appropriate site and
measurement device to be used.
Explain why temperature will be
taken and maintaining the proper
position until reading is complete.
Wash hands.
Assist client in assuming

comfortable position that provides
easy access to mouth.
Obtain temperature reading.
RATIONALE
Physical signs and symptoms may
indicate abnormal temperature.
Nurse can accurately assess nature
of variations.
Smoking and hot or cold substances
can cause false temperature
readings in oral cavity.
Chosen on basis of preferred site for

temperature measurement.
Clients are often curious about such
measurements and should be
cautioned against prematurely
removing thermometer to read
results.
Reduces transmission of
microorganisms.
Ensures comfort and accuracy of
temperature reading.
A. Oral temperature measurement with glass thermometer:

1
Apply disposable gloves.
Hold end of glass thermometer with

fingertips.
Read mercury level while gently
rotating thermometer at eye level,
grasp tip of thermometer securely,
stand away from solid objects, and
sharply flick wrist downward.
Continue shaking until reading is
below 35 C (96 F).
Insert thermometer into plastic
sleeve or cover.
Maintains standard precautions

when exposed to items soiled with
body fluids. (e.g., saliva)
Reduces contamination of
thermometer bulb.
Mercury should be below 35 C.
Thermometer reading must be
below clients actual temperature
before use. Brisk shaking lowers
mercury level of glass tube.
Protects from contact with saliva.
14

5
Ask client to open mouth and gently

place thermometer under tongue in
posterior sublingual pocket lateral to
the center of lower jaw.
Heat from superficial blood vessels

in sublingual pockets produces
Ask client to hold thermometer with

lips closed. Caution against biting
down the thermometer
Leave thermometer in place for 3

minutes or according to agency
policy.
Carefully remove thermometer,
remove and discard plastic sleeve
cover in appropriate receptacle, and
read at eye level. Gently rotate until
scale appears.
Cleanse any additional secretions
on thermometer, by wiping with
clean, soft tissue. Wipe in rotating
fashion from fingers toward bulb.
Dispose of tissue in appropriate
receptacle. Store thermometer in
appropriate storage container.
Maintains proper position of

thermometer during recording.
Breakage of thermometer may
injure mucosa and cause mercury
poisoning.
Studies vary as to proper length of
time for recording. Holtzclaw (1992)
recommends 3 minutes.
Prevents cross contamination.
Ensures accurate reading.
10
Remove and dispose of gloves in

appropriate receptacle. Wash
hands.
Avoids contact of microorganisms

with nurses hands. Wipe from area
of least contamination to area of
most contamination. Glass
thermometers should not be shared
between clients unless terminal
disinfection is performed between
each measurement. Protective
storage container prevents
breakage and reduces risks of
mercury spills.
microorganisms.
15
B. Oral temperature measurement with electronic thermometer.

1
Apply disposable gloves. (Optional)
Remove the thermometer pack from

charging unit. Attach oral probe to
thermometer unit. Grasp top of
stem, being careful not to apply
pressure to ejection button.
Slide disposable plastic cover over
thermometer probe until it locks in
place.
5
6
10
Use of probe covers, which can be

removed without physical contact,
minimizes needs to wear.
Charging provides battery power.
Ejection button releases plastic
cover from probe.
Soft plastic cover will not break in

clients mouth and prevents
transmission of microorganisms
between clients.
Ask client to open mouth, then place Heat from superficial blood vessels
thermometer probe under the
in sublingual pocket produces
tongue in posterior sublingual
temperature reading. With electronic
pocket lateral to center of lower jaw. thermometer temperatures, in right
and left posterior sublingual pocket
are significantly higher than in area
under front of tongue.
Ask client to hold thermometer
probe with lips closed.
thermometer during recording.
Leave thermometer probe in place
Probe must stay in place until signal
until audible signal occurs and
occurs to ensure accurate
clients temperature appears on
recording.
digital display; remove thermometer
probe under clients tongue.
Push ejection button on
thermometer stem to discard plastic microorganisms.
cover into appropriate receptacle.
Return thermometer stem to storage Protects probe from damage.
well of recording unit.
Automatically causes digital reading
to disappear.
If gloves are worn, remove and
dispose in appropriate receptacle.
microorganisms.
Wash hands.
Return thermometer to charger.
Maintains battery charge.
C. Rectal temperature measurement with glass thermometer.

1
Draw curtain around bed and / or

close room door. Assist client to
Sims position with upper leg flexed
Move aside bed linen to expose only
anal area. Keep covered with sheet
or blanket.
Maintain clients privacy, minimizes

embarrassment, and promotes
comfort. Exposes anal area for
correct thermometer placement.
16

2
Apply disposable gloves.
Maintains standard precautions

when exposed to items soiled with
body fluids (e.g., feces).
Hold end of glass thermometer with

fingertips.
Read mercury level while gently
rotating thermometer at eye level. If
mercury is above desired level,
grasp tip of thermometer securely,
and stand away from solid objects,
and sharply flick wrist downward.
Continue shaking until reading is
below 35 C.
Insert thermometer into plastic
sleeve cover.
Squeeze liberal portion of lubricant
on tissue. Dip thermometers blunt
end into lubricant, covering 2.5 cm
(1 to 1 inch) for adult.
Reduced contamination of
thermometer bulb.
Mercury should be below 35 C.
Thermometer reading must be
below clients actual temperature
before clients actual temperature
before use. Brisk shaking lowers
mercury level in glass tube.
5
6
Protects from contact with feces.

Lubrication minimizes trauma to
rectal mucosa during insertion.
Tissue avoids contamination of
remaining of remaining lubricant in
container.
Fully exposes anus for thermometer
insertion. Relaxes anal sphincter for
easier thermometer insertion.
With non-dominant hand, separate

clients buttocks to expose anus.
Ask client to breathe slowly and
relax.
Gently insert thermometer into anus

3.5 cm (1 inches) for adult. Do not
force themselves.
If resistance is felt during insertion,
Prevents trauma to mucosa. Glass
withdraw thermometer immediately. thermometers can break.
Never force thermometer.
If thermometer cannot be adequately inserted into the rectum, remove the

thermometer and consider alternative method for obtaining temperature.
10
Hold thermometer in place for 2

policy.
Prevents injury to client. Studies

vary as to proper length of time for
recording. Holtzclaw (1992)
recommends 2 minutes.
17

11
12
13
14
15
Carefully remove thermometer,

remove and discard plastic cover in
appropriate receptacle and wipe off
remaining secretions with clean
tissue. Wipe in rotating fashion from
fingers toward the bulb. Dispose of
tissue in appropriate receptacle.
Read thermometer at eye level.
Gently rotate until scale appears.
Prevents cross contamination. Wipe

from area of least contamination to
area of most contamination.
Wipe clients anal area with soft

tissue to remove lubricant or feces
and discard tissue. Assist client in
assuming a comfortable position.
Store thermometer in appropriate
storage container.
Provides for comfort and hygiene.

appropriate receptacle. Wash
hands.
Glass thermometers should not be

shared between clients unless
terminal disinfection is performed
between each measurement.
Protective storage container
prevents breakage and reduces risk
of mercury spill.
microorganisms.
D. Rectal temperature measurement with electronic thermometer.

1
2
3
7
8
Follow steps C-1 and C-2.

Follow steps C-5, 6, 7, 8, 9
Leave thermometer in place until
audible signal occurs and clients
temperature appears on digital
display; remove thermometer probe
from anus.
thermometer stem to discard plastic
probe cover into appropriate
receptacle.
Return thermometer stem to storage
well of recording unit.
Wipe clients anal area with soft
tissue to remove lubricant or feces
and discard tissue. Assist client in
assuming a comfortable position.
appropriate receptacle.
Return thermometer to charger.

occurs to ensure accurate reading.
microorganisms.
Protects probe from damage.

to disappear.
Provides comfort and hygiene.
microorganisms.
Maintains battery charge.
18
E. Axillary temperature measurement with glass thermometer.
Wash hands.
Draw curtain around bed and/or

close door.
Assist client to supine or sitting
position.
Move clothing or gown away from
shoulder and arm.
Prepares glass thermometer
following steps A 2, 3.
Insert thermometer into the center of
axilla, lower arm over thermometer,
and place arm across chest.
3
4
5
6
Hold thermometer in place for 3

policy.
Remove thermometer, remove

plastic sleeve, and wipe off
remaining secretions with tissue.
Wipe in rotating fashion from fingers
toward bulb. Dispose of sleeve and
tissue in appropriate receptacle.
Read thermometer at eye level.
Inform client of reading.
9
10
11
Store thermometer at bedside in

protective covering container.
microorganisms.
Provides privacy and minimizes
embarrassment.
Provides easy access to axilla.
Exposes axilla.
Mercury must be below clients
temperature level before insertion.
thermometer against blood vessels
in axilla.
Studies as to proper length of time

for recording vary. They concluded
that changes after 3 minutes had
little or no significance.
Avoids nurses contact with
microorganisms. Wipe from are of
least contamination to area of most
contamination.

Promotes participation in care and
understanding of health status.
Glass thermometers should not be
shared between clients unless
terminal disinfection is performed
between each measurement.
Storage container prevents
breakage and reduces risk of
mercury spill.
19

12
13
Assist client in replacing clothing pr

gown.
Wash hands.
Restore sense of well-being.

microorganisms.
F. Axillary temperature measurement with electronic thermometer.

1
2
3
7
8
10
11
Position client lying supine or sitting.

Move clothing or gown away from
shoulder and arm.
Remove the thermometer pack from
charging unit. Be sure oral probe
(blue tip) is attached to thermometer
unit. Attach oral probe to
thermometer unit. Grasp top of
stem, being careful not to apply
pressure to ejection button.
Slide disposable plastic cover over
thermometer probe until it locks in
place.
Provides easy access to axilla.

Provides optimal access to axilla.
Ejection button releases plastic
cover from probe.
Soft plastic cover will not break in

clients mouth and prevents
between clients.
Raise clients arm away from torso,
Maintains proper position of probe
inspect for skin lesion and excessive against blood vessels in axilla.
perspiration. Insert probe into the
center of axilla, lower arm over
thermometer, and place arm across
chest.
Leave probe in place until audible
signal occurs and clients
temperature appears on digital
display.
Remove probe from axilla.
thermometer stem to discard plastic microorganisms.
probe cover into appropriate
receptacle.
Return probe to storage well of
recording unit.
to disappear.
Assist client in assuming a
Restores comfort and promotes
comfortable position.
privacy.
Wash hands.
microorganisms.
20
G. Tympanic membrane temperature measurement with

electronic thermometer.
Assist client in assuming
Ensures comfort and exposes
comfortable position with head
auditory canal for accurate
turned toward side, away from the
temperature measurement.
nurse.
Remove thermometer handheld unit Base provides battery power.
from charging base, being careful
Removal of handheld unit from base
not to apply pressure to ejection
prepares it to measure temperature.
button.
Slide disposable speculum cover
Soft plastic probe cover prevents
over otoscope like tip until it locks
into place.
between clients.
Insert speculum into ear canal
Correct positioning of the probe with
following manufacturers instructions respect to ear canal ensures
for tympanic probe positioning.
accurate readings. The ear tug
straightens the external auditory
canal, allowing maximum exposure
of the tympanic membrane.
a. Pull ear pinna upward and back
for
Some manufacturers recommend
adult.
movement of the speculum tip in a
b. Move thermometer in a figure figure 8 pattern that allows the
sensor to detect maximum tympanic
eight pattern.
membrane heat radiation. Gentle
c. Fit probe snug into canal and
pressure seals ear canal from
do not move.
ambient air temperature.
d. Point toward nose.
Depress scan button on handheld

unit. Leave thermometer probe in
place until audible signal occurs and
clients temperature appear on
digital display.
Carefully remove speculum from

auditory meatus.
Depression of scan button causes

infrared energy to be detected.
21

7
Push ejection button on handheld

unit to discard plastic probe cover
into appropriate receptacle.
Return handheld unit into charging

base.
Assist client in assuming a
comfortable position.
Wash hands.
9
10
microorganisms. Automatically
causes digital readings to
disappear.
Restores comfort and sense of well
being.
microorganisms.
Recording and reporting:
Record temperature in vital signs flow sheet or record form.
Report abnormal findings to nurse in charge or physician.
ADVANTAGES AND DISADVANTAGES OF SELECTED

TEMPERATURE MEASUREMENT, SITES, AND METHODS.
Advantages
Disadvantages
Electronic Thermometer:
1
2
Plastic sheath unbreakable; ideal

for children.
Quick readings.
May be less accurate by axillary route.
Tympanic Membrane Sensor:

1
Easily accessible site
Minimal client repositioning

required.
3
4
Provides accurate care reading.

Very rapid measurements (2 to 5
sec.).
Can be obtained without disturbing
or waking client.
Ear drum close to hypothalamus,
sensitive to core temperature
changes.
5
6
Hearing aids must be removed before

measurements.
Should not be used for clients who have
had surgery of the ear or tympanic
membrane.
Requires disposable probe cover.
Expensive.
Oral:
1
Accessible; requires no position

changes.
Affected by ingestion of fluids or foods,

smoke, and oxygen delivery (Neff and
others, 1992).

2
Comfortable for client.
Provides accurate surface

Indicates rapid change in core

temperature.
Should not be used with clients who

have had oral surgery, trauma, history of
epilepsy, or shaking chills.
Should not be used with infants, small
children, or confused, unconscious, or
uncooperative client.
Risk of body fluid exposure.
Axilla:
1
2
Safe and non-invasive.

Can be used with newborns and
uncooperative clients.
Long measurement time.

Requires continuous positioning by
nurse.
Measurement lags behind core
temperature during rapid temperature
changes. Requires exposure of thorax.
Skin:
1
Inexpensive
Provides continuous reading
Safe and non-invasive.
Lags behind other sites during

temperature changes, especially during
hyperthermia.
Diaphoresis or sweat can impair
adhesion.
ASSESSING RADIAL AND APICAL PULSES

Definition: The pulse is a wave of blood created by contraction of the left ventricle
of the heart.
Objectives:
To establish baseline data for subsequent evaluation.
To identify whether the pulse is within normal range.
To determine whether the pulse rhythm is regular and pulse volume is

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

the body.
To monitor and assess changes in the clients health status.
To monitor clients at risk for pulse alterations. (e.g., clients with a history of
heart disease or having cardiac arrhythmias, hemorrhage, acute pain, infusion
22
23

of large volumes of fluids, fever).
Key Points:
Locate the pulse point properly.
Always count pulse for one full minute if dysrhythmias or other abnormality is
present.
Have another nurse locate and count the radial pulse while you auscultate the
apical pulse. Determine an apical-radial pulse rate by counting simultaneously
for one full minute.
Equipment:
Watch with a second hand or indicator.
If using Doppler/ultrasound stethoscope:
Transducer in the probe
Stethoscope headset
Transmission gel
Procedure:
1
STEPS
Determine need to assess radial or
apical pulse:
a. Note risk factors for
alterations in apical pulse
b. Assess for signs and
symptoms of altered SV
(stroke volume) and CO such
as dyspnea, fatigue, chest
pains, orthopnea, syncope,
palpitations, jugular venous
distension, edema of
dependent body parts,
cyanosis or pallor of skin.
RATIONALE
Certain conditions place clients at
risk for pulse alterations. Heart
rhythm can be affected by heart
disease, cardiac dysrhythmias,
onset of sudden chest pain or acute
pain from any site, invasive
cardiovascular diagnostic tests,
surgery, sudden infusion of large
volume of IV fluids, internal or
external hemorrhage, and
administration of medications that
alter heart function.
indicate alterations in cardiac
functions.
24

2
Assess for factors that normally

influence apical pulse rate and
rhythm:
a. Age
b. Exercise
c. Position changes
Allows nurse to accurately assess

presence and significance of pulse
alterations.
Normal PR change with age.
Physical activity requires an
increase in CO that is met by an
increase HR and SV. HR increases
temporarily when changing from
lying to sitting or standing position
d. Medications
e. Temperature
f. Emotional Stress, anxiety,

fear
Determines previous baseline

balance apical site.
Explain that PR or HR is to be
assessed.
Wash hands.
If necessary, draw curtain around

bed and/or close door.
Obtain pulse measurement.
Anti-dysrhythmics,
sympathomimetics, and cardiotonics
affect rate and rhythms of pulse.
Large doses of narcotic analgesics
can slow HR; general anesthetics
slow HR; CNS stimulants such as
caffeine can increase the HR.
Fever or exposure to warm
environments increases HR; HR
declines with hypothermia.
Results in stimulation of the
sympathetic nervous system, which
increases the HR.
Allows nurse to assess change in
condition. Provides comparison with
future apical pulse measurements.
Activity and anxiety can elevate HR.
Clients voice interferes with nurses
ability to hear sound when apical
pulse is measured.
microorganisms.
Maintains privacy.
25
A. Radial Pulse
STEPS
Assist client to assume supine
position.
If supine, place clients forearm
along side or across lower chest or
upper abdomen with wrist extended
straight. If sitting, bend clients
elbow 90 and support lower arm on
chair on nurses arm. Slightly extend
wrist with palms down.
RATIONALE
Provides easy access to pulse sites.
Place tips of first two fingers of hand

over groove along radial or thumb
side of clients inner wrist.
Lightly compress against radius,

obliterate pulse initially, and then
relax pressure so pulse becomes
easily palpable.
Determine strength of pulse. Note
whether thrust of vessel against
fingertips is bounding, strong, weak
or thready.
After pulse can be felt regularly, look
at watchs second and begin to
count rate; when sweep hand hits
number on dial, start counting with
zero, then one, two, and so on.
If pulse is regular, count rate for 30
seconds and multiply by 2,
If pulse is regular, count rate for 60
seconds. Assess frequency and
pattern if irregularity.
Fingertips are most sensitive parts

of hand to palpate arterial
pulsations. Nurses thumb has
pulsation that may interfere with
accuracy.
Pulse is more accurately assessed
with moderate pressure. Too much
pressure occludes pulse and
impairs blood flow.
Strength reflects volume of blood
ejected against arterial wall with
each heart contraction.
1
2
7
8
Relaxed position of lower arm and

extension of wrists permits full
exposure of artery to palpation.
Rate is determined accurately only

after nurse is assured pulse can be
palpated. Timing begins with zero.
Count of one is first beat palpated
after timing begins.
A 30 second count is accurate for
rapid, slow, or regular pulse rates.
Inefficient contraction of heart fails
to transmit pulse wave, interfering
with CO2, resulting in irregular
pulse. Longer time ensures accurate
count.
26
B. Apical pulse
1
Assist client to supine or sitting

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

side to the left midclavicular line
(MCL).
A light tap felt within an area 1 to 2
cm ( to 1 inch) of the PMI is
reflected from the apex of the heart
Place diaphragm of stethoscope in
palm of hand for 5 to 10 seconds.
Expose portion of chest wall for

selection of auscultation.
Use of anatomical landmarks allows

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

diaphragm prevents client from
being startled and promotes
comfort.
27

4
Place diaphragm of stethoscope

over PMI at the fifth ICS, at left
MCL, and auscultate for normal S1
and S2 heart sounds (heard as lub
dub).
Allow stethoscope tubing to extend

straight without kinks that would
distort sound transmission. Normal
S1 and S2 are high pitched and best
heard with the diaphragm.
When S1 and S2 are heard with

regularity, use watchs second hand
and begin to count rate; when
sweep hand hits number on dial,
start counting with zero, then one,
two, and so on.
If apical rate is regular, count for 30
seconds and multiply by 2.
If HR is irregular or client is
receiving cardiovascular
medications, count for
1 minute (60 seconds).
Apical rate is determined accurately

only after nurse is able to auscultate
sounds clearly. Timing begins with
zero. Count of one is first sound
auscultated after timing begins.
6
7
8
9
Discuss findings with client as

needed.
Clean earpieces and diaphragm of
stethoscope with alcohol swab as
needed.
10
Wash hands.
11
Compare readings with previous

baseline and/or acceptable range of
heart rate for clients age.
Compare peripheral pulse rate with
apical pulse rate and note
discrepancy.
12
13
Compare radial pulse equality and

note discrepancy.
Regular apical rate can be assessed

within 30 seconds.
Irregular is more accurately
assessed when measured over long
intervals.
Regular occurrence of dysrhythmias
within 1 minute may indicate
inefficient contraction of heart and
alteration on cardiac output.
Control transmission of
microorganisms when nurses share
stethoscope.
microorganisms.
Evaluates for change in condition
and alterations.
Differences between measurements
indicate pulse deficit and may warn
of cardiovascular compromise.
Abnormalities may require therapy.
Differences between radial arteries
indicate compromised peripheral
vascular system.
28

14
Correlate PR with data obtained

from BP and related signs and
symptoms (palpitations, dizziness).
PR and BP are interrelated.

Record PR with assessment site in nurses notes or vital signs flow sheet.
Measurement of PR after administration of specific therapies should be
documented in narrative form in nurses notes.
Report abnormal finding to nurse in charge or physician.
C. Assessing the Apical-Radial Pulse

Normally, the apical and radial pulses are identical. Any discrepancy between two
pulse rates needs to be reported promptly. An apical-radial pulse can be taken by
two nurses to be more accurate at the same time with a signal of start and stop.
A peripheral pulse (usually, the radial pulse) is assessed by palpation in all
individuals except: Newborns and children up to 2 or 3 years (apical pulse is
assessed).
Very obese or elderly clients apical pulse is assessed.
Individuals with a heart disease (apical pulse is assessed).
Procedure:
1
3
4
5
STEPS
Palpate the radial pulse while
listening for apical pulse. Using both
senses, determine if the apical and
radial pulses are synchronous. If the
apical and radial pulses are not
synchronous, get a second nurse
and
Explain to the client that one nurse
is counting his or her heart beats
while the second counts his or her
radial pulse.
Prepare to monitor the apical pulse.

Direct the second nurse to locate
and count the radial pulse.
Look at the watch dial. Note the
location of the second hand and
signal the second nurse to begin
counting at one, two
Count the remaining 60 seconds
silently as the second nurse counts
the radial pulse silently.
Rationale
Identifies differences between
pulsations and heart sounds.
Informs the clients answers his or

her questions because the unusual
procedure may arouse his or her
anxiety; simple straight forward
explanations usually are helpful.
Listen to the clients fears or anxiety
with empathy.
Synchronizes the count, essential to

determine if deficit is present.
Ensures accuracy.
29

7
8
9
Say Stop when exactly 60 seconds Ensures accuracy.

have passed.
Reposition the client comfortable.
Record the apical and radial rates
Ensures prompt and accurate
immediately. Note any deficits.
documentation.
Applying moderate pressure

to accurately assess the pulse
Assessing the radial pulse
Mapping the apical pulse
Assessing apical pulse
30
Comparing radial pulse equality and

discrepancy.
Assessing pedal pulse
31
ASSESSING RESPIRATION
Respiration is a complex vital function with two complementary processes, the
internal and external respirations. Respiration is the act of breathing. One act of
respiration consists of one inhalation and on exhalation. Inhalation or inspiration is
the act of breathing in, and exhalation, or expiration, is the act of breathing out.
External respiration is a combination of movements delivering air to the bodys
circulatory system.
1. Ventilation
2. Conduction of air
3. Diffusion and
4. Perfusion.
Objectives/Purposes:
The respiratory rate is assessed to:
Determine the per minute rate on admission as a base for comparing future
measurements.
Monitor the effect of injury, disease or stress on the clients respiratory

system.
Evaluate the clients response to medications or treatments that affect the

respiratory system.
Key Points:
Assess the client for factors that could indicate respiratory variations.
Without telling the client what you are doing, watch the chest movements in
and out.
Count in each ventilatory movement as one respiration.
Count for 30 seconds or one full minute.
32
33
Equipment:
Watch with second
Paper, pencil
Vital signs record.
hand.
Observe the rate, rhythm, and depth of respiration.

Normal respiration is regular in depth and rhythm.
Place hands on chest when respirations are difficult to count.
34

Abnormal Breathing Patterns
Procedure:
STEPS
1 Determine need to assess clients
respirations:
a Note risk factors for respiratory
alterations.
b Assess for signs and symptoms of

respiratory alterations such as bluish or
cyanotic appearance of nail beds, lips,
mucous membranes, and skin;
restlessness, irritability, confusion,
reduced level of consciousness; pain
during inspiration; labored or difficult
breathing; adventitious sounds, inability
to breathe spontaneously; thick, frothy,
blood-tinge, or copious sputum
produced on coughing.
2 Assess pertinent laboratory values:
a. Arterial blood gases (ABGs): normal
ABGs (values may vary slightly within
institutions.
b. Pulse oxymetry (SpO2): normal SpO2 =

90% - 100%; 85% 89% may be
acceptable for certain chronic disease
conditions less than 85% is abnormal.
RATIONALE
Certain conditions place client at

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

arterial blood pH, partial pressure of
O2, and CO2, and arterial O2
saturation, which reflects clients
oxygenation.
SpO2 less than 85% is often
accompanied by changes in
respiratory rate, depth, and rhythm.
35

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

blood cell count, volume of red
blood cells, and concentration of
hemoglobin, which reflects clients
capacity to carry O2.
1) Hemoglobin: 14 to 18 g/100 ml, males;

12 to 16 g/100 ml, females.
2) Hematocrit: 40% to 54%, males; 38% to
47%, females.
3) Red blood cell count: 4.6 to 6.2 million/l,
males; 4.2 to 5.4 million/l, females.
3 Determine previous baseline respiratory
rate (if available) from clients record.
4 Be sure client is in comfortable position,

preferably sitting or lying with the head of
the bed elevated 45 to 60 degrees.
Allows nurse to assess for

change in condition. Provides
comparison with future
respiratory measurements.
Sitting erect promotes full
ventilatory movement.
Critical Decision Point:

Clients with difficulty of breathing (dyspnea) such as those with congestive heart
failure or abdominal ascites or in late stages of pregnancy should be assessed in
positions of greatest comfort. Repositioning may increase the work of breathing,
which will increase respiratory rate.
5
6
7
Draw curtain around bed and/or close

door. Wash hands.
Be sure clients chest is visible. If
necessary, move bed linen or gown.
Place clients arm in relaxed position
across the abdomen or lower chest, or
place nurses hands directly over clients
upper abdomen.
Observe complete respiratory cycle (one
inspiration and one expiration).
After cycle is observed, look at watch s

second hand and begin to count rate:
when sweep hand hits number on dial,
begin time frame, counting one with first
full respiratory cycle.
10 If rhythm is regular, count number of
respirations in 30 seconds and multiply
by 2. If rhythm is irregular, less than 12,
or greater than 20, count for 1 full
minute.
9
Maintains privacy. Prevents

transmission of microorganisms.
Ensures clear view of chest wall and
abdominal movements.
A similar position used during pulse
assessment allows respiratory rate
assessment to be inconspicuous.
Clients or nurses hand rises and
falls during respiratory cycle.
Rate is accurately determined only
after nurse has viewed respiratory
cycle.
Timing begins with count of one.
Respirations occur more slowly than
pulse; thus timing does not begin
with zero.
Respiratory rate is equivalent to
number of respirations per minute.
Suspected irregularities require
assessment for at least 1 minute.
36

11 Note depth of respirations subjectively
assessed by observing degree of chest
wall movement while counting rate.
Nurse can also objectively assess depth
by palpating chest wall excursion after
rate has been counted. Depth is shallow,
normal, or deep.
12 Note rhythm of ventilatory cycle. Normal
breathing is regular and uninterrupted.
Sighing should not be confused with
abnormal rhythm.
13 Replace bed linen and clients gown.
14 Wash hands.
15 Discuss findings with client as needed.
16 If respirations are assessed for the first
time, establish rate, rhythm, and depth
as baseline if within normal range.
17 Compare respirations with clients
previous baseline and normal rate,
rhythm, and depth.
Character of ventilatory movement

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

specific types of alterations.
Restores comfort and promotes

sense of well-being.
microorganisms.
Used to compare future respiratory
assessment.
Allows nurse to assess for changes
in clients condition and for
presence of respiratory alterations.
Recording and Reporting:
Record respiratory rate and character in nurses notes or vital sign flow sheet.
Indicate type and amount of oxygen therapy if used by client during
assessment. Measurement of respiratory rate after administration of specific
therapies should be documented in narrative form in nurses notes.
Home care Considerations:

Assess for environmental factors in the home that may influence clients respiratory
rate such as second-hand smoke, poor ventilation, or gas fumes.
ASSESSING BLOOD PRESSURE
Definition:
Blood pressure is the force exerted produced by the volume of blood pressing on
the resisting walls of the arteries Blood pressure is commonly abbreviated BP. Its
measurement is expressed as a fraction.
The numerator or the upper figure is the systolic pressure/ systole (the phase
during which the heart works or contracts) and the denominator or the lower figure is
the diastolic pressure/ diastole (the hearts resting phase).
The pressure is expressed in millimeters of mercury, abbreviated mmHg. Thus a

recording of
120/80 means systolic blood pressure was measured at 120 mmHg and the diastolic
blood pressure was measured at 80 mmHg. The difference between two readings is
called pulse pressure.
Blood is circulated through a loop involving the heart and blood vessels.
Purposes: The blood pressure is assessed by:

1. Determine the systolic and diastolic pressure of the client during
admission in order to compare his current status with normal changes.
2. Acquire data that may be compared with subsequent changes that
may occur during the care of the client.
3. Assist in evaluating the status of the clients blood volume, cardiac
37
38

output and vascular system.
4. Evaluate the clients response to changes in his medical condition as a
result of treatment with fluids or medications.
Key Points:
1. Blood pressure is the measurements of the pressure exerted by the
blood on the walls of the arteries. The rate and force of the heartbeat
determines the reading as the ventricles contract and rest.
2. Do no take BP reading on persons arm if:
is injured/diseased.
Is on the same side of body where a female has had a radical

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

intravenous infusion.
Equipment and Supplies:

o Stethoscope
o Blood pressure cuff of appropriate size
o Sphygmomanometer an aneroid or a mercury manometer may be

available. The gauge should be inspected to validate that the needle
or mercury is within the zero mark.
o Alcohol swab
o Paper, pencil, pen, V/S flow sheet or

record form
Procedure: AUSCULTATION METHOD

STEPS
1
2
3
4
7
8
10
11
12
13
RATIONALE
microorganisms.
With client sitting or lying, position If arm is unsupported, client may
clients forearm, supported if needed, perform isometric exercise that can
with palms turned up.
increase diastolic pressure 10%.
Placement of arm above the level of
the heart causes false low reading.
Expose upper arm fully by removing Ensures proper cuff application.
constricting clothing.
Palpate brachial artery. Position cuff Inflating bladder directly over brachial
2.5 cm (1inch) above site of brachial artery ensures proper pressure is
pulsation (antecubital space). Center applied during inflation. Loose-fitting
bladder of cuff above artery. With
cuff causes false high readings.
cuff fully deflated, wrap evenly and
snugly around upper arm.
Position manometer vertically at eye Accurate readings are obtained by
level. Observer should be no farther looking at the meniscus of the mercury
than 1 meter (approximately 1 yard) at eye level. The meniscus is the point
away.
where the crescent-shaped top of the
mercury column aligns with the
manometer scale. Looking up or down
at the mercury results in distorted
readings.
Palpate brachial or radial artery with Identifies
approximate
systolic
fingertips of one hand while inflating pressure and determines maximal
cuff rapidly to pressure 30 mmHg inflation point for accurate reading.
above point at which pulse Prevents auscultatory gap. If unable to
disappears.
palpate artery because of weakened
pulse, an ultrasonic stethoscope can
be used.
Deflate cuff fully and wait 30 Prevents venous congestion and false
seconds.
high readings.
Place stethoscope earpieces in ears Each earpiece should follow angle of
and be sure sounds are clear, not ear canal to facilitate hearing.
muffled,
Relocate brachial artery and place Proper
stethoscope
placement
bell or diaphragm (chest piece) of the ensures optimal sound reception.
stethoscope over it. Do not allow Stethoscope improperly positioned
chest piece to touch cuff or clothing. causes muffled sounds that often
result in false low systolic and false
high readings.
Close valve of pressure bulb Tightening of valve prevents air leak
clockwise until tight.
during inflation.
Inflate cuff to 30 mmHg above Ensures accurate measurement of
palpated systolic pressure.
systolic pressure.
Slowly release valve and allow Too rapid or slow a decline in mercury
mercury to fall at rate of 2 to 3 level can cause inaccurate readings.
mmHg/sec.
Note point on manometer when first First Korotkoff sound indicates systolic
clear sound is heard.
pressure.
Wash hands.
39
40

14
Continue to deflate cuff, noting point Fourth Korotkoff sound involves

at which muffled or dampened sound distinct muffling of sounds and is
appears.
recommended
as
indication
of
diastolic pressure in children. (Perloff
and others, 1993).
15
Continue to deflate cuff gradually,

noting point at which sound
disappears in adults. Note pressure
to nearest 2 mmHg.
16
Deflate cuff rapidly and completely.

Remove cuff from clients arm unless
measurement must be repeated.
If this is the first assessment of
client, repeat procedure on other
arm.
17
18
19
20
21
22
23
Beginning of fifth Korotkoff sounds is

recommended by American Heart
Association as indication of diastolic
pressure in adults. (Perloff and others,
1993).
Continuous cuff inflation causes
arterial
occlusion,
resulting
in
numbness and tingling of clients arm.
Comparison of BP in both arms
detects circulatory problems (Normal
difference of 5 to 10 mmHg exists
between arms).
Restores comfort and promotes sense
of well-being.
Assist
client in
returning
to
comfortable position and cover arm if
previously clothed.
Discuss findings with client as Promotes participation in care and
needed.
Wash hands
Reduces
transmission
of
microorganisms.
Compare readings with previous Evaluates for changes in condition and
baseline and/or acceptable value of alterations.
BP for clients age.
Compare BP readings in both arms.
Arm with higher pressure should be
used for subsequent assessment
unless contraindicated.
Correlate BP with data obtained from Blood pressure and heart rate are
pulse assessment and related interrelated.
cardiovascular signs and symptoms.
Inform client of value and need for periodic re-assessment.
Record BP. Measurement of BP after admission of specific therapies

should be documented.
41

Applying and Removing Personal Protective Equipment (gloves, gown, mask)
Purpose:
To protect health care workers and clients from transmission of potentially
infective materials.
Assessment:
Consider which activities will be required while the nurse is in the clients room
at this time.
Equipment:
Gown
Mask
Clean gloves
Procedure:
1.
STEPS
Verify client identity and
introduce yourself, explain for
the client what you are to do,
why it is necessary, and how
he or she can participate.
2.
Perform hand hygiene.
3.
Apply a clean gown:

a) Pick up a clean gown,
and allow it to unfold in
front of you without
allowing it to touch any
area soiled with body
substances.
b) Slide the arms and the
hands through the
sleeves.
c) Fasten the ties at the
neck to keep the gown
in place.
d) Overlap the gown at the
back as much as
possible and fasten the
waist ties
Rationale
Overlapping securely covers the

uniform at the back, waist ties keep
the gown from falling away from the
body, which can cause inadvertent
soiling of the uniform.
42

4.
5.
Applying the face mask:

a) Locate the top edge of
the mask; the mask
usually has a narrow
metal strip along the
edge.
b) Hold the mask by the
top two strings.
c) Place the upper edge of
the mask over the
bridge of the nose, and
tie the upper ties at the
back of the head or
secure the loops
around the ears.
d) Secure the lower edge
of the mask under the
chin, and tie the lower
ties at the nape of the
neck.
e) If the mask has a metal
strip, adjust this firmly
over the bridge of the
nose
f) Wear the mask only
once
g) Do not let a used mask
hanging around the
neck.
To be effective the mask must cover

both the nose and the mouth,
because the air moves in and out of
both.
A sure fit prevents both the escape

and the inhalation of microorganisms
around the edges of the mask.
Mask should used only once because
it becomes ineffective when wet.
Apply clean gloves.

If wearing gowns pull the
gloves up to cover the cuffs of
the gown.
To remove soiled PPE:
43

6.
Remove the gloves first since

they are the most soiled. If
wearing gown that is tied in
front undo ties before
removing the gloves.
7.
Perform hand hygiene
8.
Remove the gown when

preparing to leave the room
a) Avoid touching soiled
parts on the outside of
the gown.
b) Grasp the gown along
the inside of the neck
and pull down over the
shoulders. Do not
shake the gown.
c) Roll up the gown with
the soiled part inside,
and discard it in the
appropriate container .
Contact with microorganisms may

occur
44

9.
Remove the mask

a) Remove the mask at
the doorway to the
clients room. If using
respirator mask,
remove it after leaving
the room and closing
the door.
b) If using mask with
strings, first untie the
lower strings
c) Untie the top string and,
while holding the ties
securely, remove the
mask from the face. If
side loops are presents
, lift the side loops up
and away from the ears
and face. Do not touch
the front of the mask.
d) Discard a disposable
mask in the waste
container
e) Perform proper hand
hygiene again.
This prevents the top part of the

mask from falling onto the chest.
The front of the mask through which

the nurse has been breathing is
contaminated.
Applying and Removing Sterile Gloves
Purpose
To enable the nurse to handle or touch sterile objects freely without
contaminating them.
To prevent transmission of potentially infective organisms from the nurse's
hands to clients at high risk for infection.
Assessment
Review the client's record and orders to determine exactly what procedure will
be performed that require sterile gloves. Check the client record and ask
about latex allergies. Use nonlatex gloves whenever possible.
Equipment
Package of sterile gloves.
Procedure:
45

Step
Rationale
1. Perform hand hygiene
2. Open the package of sterile gloves
a. Place the package on a clean, dry

b.
c.
d.
e.
f.
surface.
Remove the inner package from
the outer package.
Open the inner package as
instructed, if no tabs are provided,
pluck the flap so that the fingers
do not touch the inner surface.
Grasp the glove for the dominant
hand by its folded cuff edge on
the palmer side with the thumb
and first finger of the
nondominant hand. Touch only
the inside of the cuff.
Insert the dominant hand into the
glove and pull the glove on. Keep
the thumb of the inserted hand
against the palm of the hand
during the insertion.
Leave the cuff in place once the
unsterile hand releases the glove.
Any moist on the surface could

contaminate the gloves.
To keep the inner surface sterile
Put the first glove on the dominant hand
The hands are not sterile. By touching

only the inside of the gloves, the nurse
avoids contaminating the outside.
If the thumb is kept against the palm, it is

less likely to contaminate the outside of
the glove.
Attempting to further unfold the cuff is

likely to contaminate the glove.
46

3. Put the second glove on the
nondominante hand
a. Pick up the other glove with the

sterile gloved hand. Inserting the
gloved fingers under the cuff and
holding the gloved thumb close to
the gloved palm
b. Pull on the second glove
carefully. Hold the thumb of the
gloved first hand as far as
possible from the palm.
c. Adjust each glove so that it is fits
smoothly, and carefully pull the
cuffs up by sliding the fingers
under the cuffs.
This helps prevent accidental

contamination by the bare hand.
In this position, the thumb is less likely to

touch the arm and become
contaminated.
4. Remove and dispose the gloves.
Same technique as removing

non-sterile gloves.
Document that sterile technique
was used in the procedure.
47
CHANGING AN OCCUPIED BED

PURPOSES
To conserve the clients energy
To promote 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
ASSESSMENT
Rationale
Assess
1 Skin condition and need for a special mattress
(e.g., an egg-crate mattress), footboard, bed
cradle, or heel protectors)
2 Clients ability to reposition self.
This will determine if additional
assistance is needed.
3 Determine presence of incontinence or excessive
drainage from other sources indicating the need
for protective waterproof pads.
4 Note specific orders or precautions for moving and
positioning the client.
PLANNING
Delegation
Bed-making is usually delegated to UAP (Unlicensed Assistive Personnel). Inform. Inform the UAP to
what extent the client can assist or if another person will be needed to assist the UAP.
Instruct the UAP about the handling of any dressing and/or tubes of the client and also the
need for special equipment (e.g., footboard, heel protectors), if appropriate.
EQUIPMENT
1. Two flat or one fitted and one flat sheet
2. Cloth draw sheet (optional)
3. One blanket
4. One bedspread
5. Pillowcase(s) for the head pillow(s)
6. Waterproof drawsheet or waterproof pads (optional)
7. Plastic laundry bag or portable lines hamper, if available
1.
2.
3.
4.
IMPLEMENTATION
Preparation
Determine what lines the client may already have
in the room to avoid stockpiling of the
unnecessary extra linens
Performance
1 Prior to performing the procedure, introduce self
and verify the clients identity using agency
protocol. Explain to the client what you are going
to do, why it is necessary, and how he or she can
cooperate.
2 Perform hand hygiene and observe other
appropriate infection control procedures. Apply
clean gloves if linens is soiled with body fluids.
This avoids stockpiling of

unnecessary extra linens.
Rationale
48

3
4
Provide for client privacy.

Remove the top bedding.
a Remove any equipment attached to the linen,
such as signal light.
b Loosen all top linen at the foot of the bed, and
remove the spread and the blanket.
c Leave the top sheet over the client (the top
sheet can remain over the client if it is being
changed and if it will provide sufficient
warmth), or replace it with a bath blanket as
follows:
a Spread the bath blanket over the top sheet.
b Ask the client to hold the top edge of the
blanket.
c Reaching under the blanket from the side,
grasp the top edge of the sheet and draw it
down to the foot of the bed. Leaving the
blanket in place. ( 1 )
d Remove the sheet from the bed and place
it in the soiled linen hamper.
Change the bottom sheet and draw sheet.
a Raise the side rail that the client will turn
toward. If there is no side rail, have another
nurse support the client at the edge of the bed.
b
c
d
(1)
Removing top linens under a bath

blanket.
This protects clients from falling

and allows them to support
themselves in the side-lying
position.
Assist the client to turn on the side away from

the nurse and toward the raised side rail.
Loosen the bottom linens on the side of the
bed near the nurse.
Fanfold the dirty linen (e.g., draw sheet and
the bottom sheet toward the center of the bed.
(2) As close to and under the client as
possible.
(2)
Moving soiled linen as close to the

client as possible.
Doing this leaves the near half of

the bed free to be changed.
e
Place the new bottom sheet on the bed, and

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

bed.
49

f
Place the clean drawsheet on the bed with the

center fold at the center of the bed. Fanfold the
uppermost half vertically at the center of the
bed and tuck the near side edge under the
side of the mattress. (4)
(4)
Placing clean drawsheet on the bed.
Assist the client to roll over toward you, over

the fanfold bed linens at the center of the bed,
onto the clean side of the bed.
h Move the pillows to the clean side for the
clients use. Raise the side rail before leaving
the side of the bed.
i Move to the other side of the bed and lower
the side rail.
j Remove the used linen and place it in the
portable hamper.
k Unfold the fanfold bottom sheet from the
center of the bed.
l Facing the side of the bed, use both hands to
pull the bottom sheet so that it is smooth and
tuck the excess under the side of the mattress.
m Unfold the drawsheet fanfold at the center of
the bed and full it tightly with both hands. Pull
the sheet in three divisions: (a) face the side of
the bed to pull the middle division, (b) face the
far top corner to pull the bottom division, and
(c) face the far bottom corner to pull top
division.
n Tuck the excess drawsheet under the side of
the mattress.
Reposition the client in the center of the bed.
a Reposition the pillows at the center of the bed.
b Assist the client to the center of the bed.
Determine what position the client requires or
prefers and assist the client to that position.
Apply or complete the top bedding.
a Spread the top sheet over the client and either
ask the client to hold the top edge of the sheet
or tuck it under the shoulders. The sheet
should remain over the client when the bath
blanket or used sheet is removed. (5)
(5)Client hold top edge of sheet while nurse

removes bath blanket.
b Complete the top of the bed.

Ensure continued safety of the client.
a Raise the de rails. Place the bed in the low
position before leaving the bedside.
50

Attach the call light bed linen within the clients
reach
c Put items used by the client within easy reach.
9 Bed-making is not normally recorded.
EVALUATION
b
Conduct appropriate follow up, such as determining

clients comfort and safety. Patency of all dranage
tubes, and clients access to call light to summon
help when needed.
Reassess all tubing, oxygen apparatus, IV pumps,
and so forth.
This prevents errors in

supportive devices resulting from
procedure.
CHANGING AN UNOCCUPIED BED

PURPOSES
1. To promote the client comfort
2. To provide a clean neat environment for the client
3. To provide a smooth, wrinkle-free bed foundation, thus minimizing sources of skin
irritation
STEPS
Rationale
Assess
1
Clients health status to determine that the person

can safely get out of bed.
Clients BP, pulse and respirations if indicated.
Clients mobility status.
Tubes and equipment connected to the client.
In some hospital it is necessary

to have a written order to get out
of bed if the client has been in
bed continuously.
Client may experience postural
hypotension when moved from a
lying position to standing to
sitting, particularly if it is the first
time out of bed for awhile.
This may influence the need for
additional assistance with
transferring the client from the
bed to a chair.
This may influence the need for
additional linens or waterproof
pads.
PLANNING
Delegation
Bed-making is usually delegated to UAP (Unlicensed Assistive Personnel). If appropriate, inform the
UAP of the proper disposal method of linens that contain drainage. Ask the UAP to inform
you immediately if any tubes or dressings become dislodged or removed. Stress the
importance of the call light being readily available while the client is out of bed.
51

EQUIPMENT
8. Clean gloves, if needed
9. Two flat or one fitted and one flat sheet
10. Cloth draw sheet (optional)
11. One blanket
12. One bedspread
13. Pillowcase(s) for the head pillow(s)
14. Waterproof drawsheet or waterproof pads (optional)
15. Plastic laundry bag or portable lines hamper, if available
IMPLEMENTATION
Preparation
Determine what lines the client may already have in the room to avoid stockpiling of the
unnecessary extra linens.
2
3
4
6
7
8
STEPS
If the client is in bed, prior to performing the
procedure, introduce self and verify the clients
identity using agency protocol. Explain to the
client what you are going to do, why it is
necessary, and how he or she can cooperate.
Perform hand hygiene and observe other
appropriate infection control procedures.
Place the fresh linen on the clients chair or over
bed table; do not use another clients bed.
Assess and assist the client out of bed.

a Make sure that this is an appropriate and
convenient time for the client to be out of bed.
b Assist the client to a comfortable chair.
Raise the bed to a comfortable working height.
Apply clean gloves if linens and equipment have
been soiled with secretions and/or excretions.
Strip the bed.
a Check bed lines for any items belonging to the
client, and detach the call bell or any drainage
tubes from the linen.
b Loosen all bedding systematically, starting at
the head of the bed on the far side and moving
around the bed up to the head of the bed on
the near side.
c Remove the pillowcases, if soiled, and place
the pillows on the bed-side near the foot of the
bed.
RATIONALE
This prevents crosscontamination (the movement of

microorganisms from one client
to another) via soiled linen.
This ensures client safety.
. Moving around the bed

systematically prevents
stretching and reaching and
possible muscle strain.
52

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

energy when reapplying the
linens on the bed and keeps
them clean.
(1) Fold reusable linens into fourths when

removing them from the bed.
e Remove the waterproof pad and discard it if

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

prevent the transmission of
microorganism to the nurse and
others.
(2) Roll soiled linen inside bottom sheet and hold

away from body.
g Grasp the mattress securely. Using the lugs if

present, and move the mattress up to the head
of the bed.
h Remove and discard gloves if used. Perform
hand hygiene.
Apply the bottom sheet and draw sheet.
a Place the folded bottom sheet with its center
fold on the center of the bed. Make sure the
sheet is hem side down for a smooth
foundation. Spread the sheet out over the
mattress, and allow a sufficient amount of
sheet at the top to tuck under the mattress.
Place the sheet along the edge of the mattress
at the foot of the bed and do not tuck it in
(unless it is a contour or fitted sheet (3).
b Miler the sheet at the top corner on the near
side (see figure 33-20) and tuck the sheet under the
mattress, working from the head of the bed to
the foot.
The top of the sheet needs to be well tucked

under to remain securely in place, especially
when the head of the bed is elevated.
(3) Placing bottom sheet on bed.
53

c
If a waterproof drawsheet is used, place it over

the bottom sheet so that the centerfold is at the
centerline of the bed and the top and bottom
edges extend from the middle of the clients
back to the area of the midthigh or knee.
Fanfold the uppermost half of the folded draw
sheet at the center or far edges of the bed and
tuck in the edge (4).
(4) Placing clean drawsheet on bed.
1
0
1
1
d OPTIONAL: before moving to the other side of

the bed, place the top linens on the hemside
up, unfold them, tuck them in, and miter the
bottom corners.
Move to the other side and secure the bottom
linens.
a Tuck in the bottom sheet under the head of the
mattress, pull the sheet firmly, and miter the
corner of the sheet.
b Pull the remainder of the sheet firmly so that
there are no wrinkles. Tuck the sheet in at the
side.
Completing one entire side of the

bed at a time saves time and
energy.
Wrinkles can cause discomfort

for the client and breakdown of
skin. Tuck the sheet in at the
side.
c Tuck in the drawsheets, if appropriate.

Apply or complete the top sheet, blanket, and
spread.
a Place the top sheet, hem side up; on the bed
so that its centerfold is at the center of the bed
and the top edge is even with the top edge of
the mattress.
b Unfold the sheet over the bed.
c
Follow the same procedure for the blanket and

the spread, but place the top edges about 15
cm (6 in.) from the head of the bed to allow a
cuff of sheet to be folded over them.
d Tuck in the sheet, blanket, and spread at the
foot of the bed, and miter the corner, using all
three layers of linen. Leave the sides of the top
sheet, blanket, and spread hanging freely
unless toe pleats were provided.
e Fold the top of the top sheet down over the
spread, providing a cuff (7).
The cuff of a sheet makes it

easier for the client to pull the
covers up.
(7) Making a cuff of the top linens.
54
f
1
2
Move to the other side of the bed and secure

the bedding in the same manner.
Put clean pillowcases on the pillows as required.
a Grasp the closed end of the pillowcase at the
center with one hand.
b Gather up the sides of the pillowcase and
place them over the hand grasping the case.
Then grasp the center of one short side of the
pillow through the pillowcase.(8)
(8) Method for putting a clean pillowcase on a

pillow.
1
3
1
4
With the free hand, pull the pillowcase over the

pillow.
d Adjust the pillowcase so that the pillow fits into
the corners of the case and the seams are
straight.
e Place the pillows appropriately at the head of
the bed.
Provide for client comfort and safety.
A smoothly fitting pillowcase is

more comfortable than a wrinkled
one.
a Attach the signal cord so that the client can

conveniently reach it. Some cords have clamps
that attach to the sheet or pillowcase. Others
are attached by safety pin. Most bed now have
call light bottom on the side rail.
b If the bed is currently being used by a client,
This makes it easier for the client
either fold back the top covers at one side or
to get into the bed.
fanfold them down to the center of the bed.
c Place the bedside table and the overbed table
so that they are available to the client.
d Leave the bed in the high position if the client
is returning by stretcher, or place in the low
position if the client is returning to bed after
being up.
Document and report pertinent data.
a Bed-making is not normally recorded.
b Recording any nursing assessments, such as
the clients physical status and pulse and
respiratory rates before and after being out of
bed, as indicated.
BODY MECHANICS
I. Definition:
Is the term used to describe the efficient, coordinated and safe use of the body to
move objects and carry out the ADL's. correct body mechanics would facilitate the
safe and efficient use of appropriate muscle group to maintain balance, reduce the
energy required, reduce fatigue, and decrease the risk of injury for both nurses and
clients, especially during transferring, lifting and reposition.
II. Effects of gravity on body balance.
A. Definition: Gravity means mutual attraction that the earth has for an object
and the object for the earth.
B. Principles of Body Balance:
1. Center of gravity is low.
2. Base support is wide.
3. Line of gravity pass through center of gravity and base of support.
C. Principles of body mechanics:
1. Center of gravity: is "the point at which all its mass is centered". An
area located in the pelvis about the level of the second sacral vertebra.
2. Base of support: "It is the area located at the base of an object". It
provides balance of equilibrium or stability especially the line of gravity
passes through the base of support and center of gravity.
3. Line of gravity: "It is an imaginary vertical line that passes through the
55

center of gravity and the base of support of an object". It passes behind
the ear, downward just behind the center of jip joint and then downward
slightly in front of the knee and ankle joint (it differs according to
skeletal build and curvatures in spine).
D. Example to maintain balance:
1. A box of 4 x 3 x 12 of lengths.
a. If placed on the side, measured 4 x 12
wide base it is balanced.
b. If placed on the side, measured 3 x 12

narrow base it is imbalanced.
2. A number of blocks:
a. Placed on each other, the balance is maintained if column is
vertical.
b. If placed in a zigzag, the weight distributed is unequal above
the lowest block; they will fall.
Remember: Balance of the human body is much more complex than that of a
solid object, but in both instances governed by the laws of gravity.
III. Principles of Body Mechanics:
1. "Maintain body balance and alignment".
The stability of an object greater when there is:
a. Wide base of support.
b. Low center of gravity passes through base of support and center of
gravity.
Example: in helping the patient to move; praying, standing, sitting, and
stooping.
2. "Work at a comfortable height".
A comfortable working height for most people is between the waist level and
the hip joint (pelvis). Working at a comfortable height helps to do the
following:
a. Minimizes muscle strain when reaching an object at high or low level.
b. Allows the body to remain aligned and balanced.
c. Allows us easily to flex the hip and knee joints.
d. Applies leverage to our work.
Example: to place or remove object from a shelf that is higher than the
head or
near the floor hand cranks.
3. "Keep the object close to your body".
The force required to maintain body balance is greater when the line of
gravity is farthest from the center of base of support.
Example: a person holds a weight close to his body using less effort.
4. "Use of smooth coordinated movement".
Muscles tend to act in groups rather than singly.
Example: during breathing; during stooping (not bending); praying.
5. "Large muscles fatigue less quickly than small muscles".
Example: large muscles as the muscle of the buttocks and thigh; small
56

muscle as sacrospinal muscle of the back.
Remember: Less strain results when a heavy object is raised by flexing the
knees rather than by bending from the waist.
6. "Set or prepare the muscles for action".
The muscle is always in slight contraction. This condition is called muscle
tone.
If the nurse prepares her muscles for action prior to activity, she will protect
her ligaments and muscles from strain and injury.
a. Not to lift more than what is safe, or get help.
b. To take a deep breath.
c. Tense or contract muscles (abdomen, pelvis, buttocks, and thigh).
d. Let your breath out slowly as you lift the object.
e. Put load down occasionally.
f. Use proper body mechanics.
g. Hold object close to the body.
7. "The use of good judgment in deciding which object you can lift or carry
alone".
If in doubt, do not attempt to lift alone, and get others to help you.
Example: in moving a patient out of bed, either helpless or dependent to
some extent on a wheelchair or trolley.
8. "The use of mechanical devices and other devices can lessen the amount of
work required in movement".
Example: in using mechanical device, the nurse uses her arm as a lever.
In using other devices as draw sheet, in moving helpless patient, the drawsheet
should extend from superior aspect of patient's arm level to the inferior
aspect of the buttocks. At least 2 nurses are needed.
9. "The amount of effort (force) required to move a body or an object depends
upon the resistance of the body or object as well as the pull of gravity".
i.e., by utilizing the pull gravity rather than working against it.
Example: It is easier for the nurse to lift a patient up in the bed when he is
lying flat than in sitting position in which the resistance of the body is much
greater.
10. " The friction between an object and the surface upon which the object is
moved affects the amount of work needed to move the object".
Friction: is a force that opposes, so that less energy is needed to move
objects on smooth surfaces.
Example: when lifting a patient up in bed, it is better to provide a smooth
foundation upon which the patient can move.
11. "Pulling or sliding an object requires less than effort than lifting it".
Because lifting necessitates moving against force of gravity.
Example: if the nurse lowers the head of the bed before she helps the
patient to move up in bed; less effort is required than when the head of the
bed is raised.
12. "Using one's own weight to counteract a heavy object's weight (as patient)
requires less energy in movement.
Example: if the nurse uses her own weight to pull or push a patient, her
weight Increases the force applied to the movement".
57
IV. Benefits of applying principles of body mechanics:

A. Specific benefits:
1. Avoids muscle strain.
2. Uses energy efficiently.
B. General benefits.
1. The lungs and circulatory system work better.
2. The body is less easily tired by minimal muscle strain.
3. Work is less tiring and more efficient.
4. The mind is clearer, concentration is easier.
5. The physiological state is improved.
6. It gives a good impression on others.
LIFTING AN OBJECT FROM THE FLOOR

Purposes: Enables nurses to pick up an object from floor level without self injury.
Two methods are presented.
Contraindications: Assessment of the weight of the load is especially important.
Persons with back problems should not use either of the following methods without
first consulting with a physician.
Learning/Teaching Guidelines: To teach correct body mechanics to clients or to
auxiliary personnel:
1. Serve as a role model by always using good body mechanics.
2. Carefully demonstrate the specific method to be sued.
3. Provide information about the correct use of muscles and ways to use
leverage, and
4. Supervise use of the method by those whom you have taught.
Preliminary Activities:
Assessment/Planning:
Assess weight of the load to be lifted.
Decide the lifting technique to be used.
Procedure:
1
2
STEPS
Stand near object of the load to be
lifted.
Put on internal girdle.
Rationale/Discussion
This stance places object nearer your
center of gravity and provides
Internal girdle helps protect intervertebral
disks.
Method 1
a. Bend toward object by flexing all the
This position lowers center of gravity.
hips and partially flexing at the knees.
b. Grasp object and bring it to thigh level Muscles share the workload. Back
by pulling with arm and shoulder,
muscles remain contracted to protect
muscles while thigh and leg muscles
the intervertebral disks.
provide an upward thrust.
58
59

c. Bring object to waist level by using the
leg and thigh muscles for greater
thrust while beginning to straighten
the back.
a.
b.
c.
d.
This brings load as close as possible

to center of gravity.
Method 2
Position feet 18 inches apart with left
Position maintains wide base of
foot forward.
support while allowing use of the left
knee as a fulcrum.
Tuck chin in and squat down with
This protects intervertebral disks.
back straight.
Grasp object with both hands, tipping
This allows firm control of object.
it if necessary to attain balance.
Rest left elbow on left thigh, just
Position allows use of leverage.
above knee and apply pressure as
needed to stand up. Straighten legs.
POSITIONING CLIENTS
Definition:
Positioning are achieved by placing the body of their treatment or examination.
Different position are achieved by placing the body parts in correct alignment or
using the hospital bed the clients body in desired position
Purposes:
1. Physical Examination.
2. Nursing treatment and tests.
3. Obtain specimens.
4. Operations
60
COMMON POSITIONS
Positions
Description
Areas
Examined/Indications
Cautions
1
Arms are held
relaxed at sides
of the body; feet
6 to 8 inches
apart, face
should look
straight ahead.
Body contour, posture

balance, muscles and
extremities.
Elderly and
weak; patients
may need
support.
Standing
2
Buttocks firmly on
the edge of the bed,
thighs well
supported, knees
bent, feet positioned
flat against the floor.
Sitting
1. Assessing vital
signs.
2. Examination of
the head and
neck, posterior
and anterior
thorax.
3. Inspection and
palpation of
thyroid, breasts
and axilla.
4. Auscultation of
the lungs.
Elderly and weak;

may require
support.
Dangling
position
The client sits on

the side of the bed,
with the feet
dangling over its
edge. The client
dangles after
remaining
horizontal in bed for
more than a day or
two.
Same as the
sitting position.
Same as above.
Lightheadedness or
vertigo may result
when client sits up for
the first time.
61

4
Dorsal recumbent
Back lying
position with
knees flexed
and hips
externally
rotated; small
pillow under
the head.
Flexed knees
reduce tension
on lower back
and abdominal
muscles and
increase client
comfort.
Abdomen and May be difficult

external
for clients who
genitalia.
have cardiopulmonary
problems. The
client should
not raise arms
over the head
or clasp the
hands behind
the head
because this
increases
contraction of
the abdominal
muscles.
Horizontal recumbent
Back lying
position with
legs
extended;
small pillow
under the
head.
1.Head, neck,
axillae,
anterior
thorax,
lungs, breasts,
heart,
extremities.
2. Peripheral
pulses.
Not used for

abdominal
assessment
because of the
increased
tension of
abdominal
muscles.
6
Back lying
without a
pillow.
As for
horizontal
recumbent.
Dorsal (Supine)
Tolerated poorly
by clients with
cardiovascular
and respiratory
problems. An
alternate position
is to raise the
head of the bed.
Clients with low
back pains may
unable to lie flat
without flexing
the knees. Risk
for aspiration is
greater with this
position.
62

7
Head of bed 60 angle.
Thoracic surgery,
severe respiratory
conditions.
High Fowlers
8
Fowlers
Head of
bed 45
angle, hips
may or
may not be
flexed.
SemiFowlers
Head of bed
30 angle.
Post operative,
gastrointestinal
conditions,
promotes lung
expansion; As
client rests, eats,
or drink; has
visitors, or wishes
to read or watch
TV.
9
Relieving
cardiac,
respiratory
distress, and
neurological
conditions.
10
Low
Fowlers
Head of bed Necessary

15 angle.
degree
elevation for
ease of
breathing,
promotes skin
integrity,
client comfort.
Need
to
suppor
t the
poplite
al
vessel
s.
63

11
Lithotomy
Back lying
position
with feet
supported
in
stirrups;
the hips
should be
in line
with the
edge of
the table.
Female
genitalia,
rectum, and
female
reproductive
tract.
May be difficult
and tiring to
elderly people
and those with
arthritis or joint
deformities.
This position is
assumed
immediately
before it is
needed
because it is
embarrassing
and
uncomfortable.
The client is
kept draped.
12
Kneeling
Rectal or
position
vaginal
with torso at examinations.
90 angle to
hips.
Genu-pectoral
(knee-chest)
Uncomfortable
position,
tolerated poorly
by clients who
have
cardiovascular or
respiratory
problems.
13
Standing,
bent-over
the
examining
table or
Jack-knife
position
14
Lateral
(side
lying)
This is more comfortable

position then knee-chest.
The client is
supported on
the right or left
side with the
opposite arm,
thigh, and
knee flexed
and resting on
the bed. A
Palpation
of the
prostate
gland.
Clients who are

obese or older
may not be able
to tolerate this
position for any
length of time.
Left: Rectum,
vagina.
This position is
assumed
immediately
before it is
needed because
it is
embarrassing.
Client with back
problems may
need assistance.

pillow is
placed under
the head to
keep the head,
neck, and
spine in
alignment. The
upper arm is
flexed at the
hips and knee
positioned on
a small pillow.
15
Sims
1
6
Knee
Gatc
h
The client is in
semi-prone
position on the
right or left side
with the
opposite arm,
thigh, and knee
flexed and
resting on the
bed. The
clients weight
is placed on the
anterior ileum,
humerus, and
clavicle.
Right: Rectal
examination,
administering
enema or
inserting a rectal
tube.
Improper
positioning can
cause
unnecessary
harm to clients,
especially if they
have pre-existing
conditions such
as peripheral
vascular disease
or diabetes.
Positions that
compromise
peripheral blood
flow may
damage nerves
as well.
Lower For clients comfort;

sectio contraindicated for
n of
vascular disorders.
bed
(under
knees)
slightl
y bent.
64

17
Prone
Position
The client
lying on
abdomen,
with the
head turned
to the side.
This
facilitates
respiration
and
drainage of
oral
secretions.
A pillow is
placed
under the
head for
comfort and
relief from
pressure.
Contraindicated
in possible
complications
such as
increasing
intracranial
pressure or
cardiopulmonary
disease.
18
Trendelenburgs Head of
bed
lowered
and foot
part raised.
Percussion,
vibration, and
drainage,
(PVD)
procedure.
Reverse
Bed frame
Trendelenburgs is tilted up
with foot of
bed down.
Gastric
condition
prevents
esophageal
reflux.
19
65
66
TRANSFERRING A PATIENT FROM BED TO CHAIR

Purpose:
To transfer a client from bed to chair, wheelchair or commode.
Assessment:
Before transferring patient assess the client the following:
1. The clients body size.
2. Ability to follow instructions.
3. Ability to bear weight.
4. Ability to position/reposition feet on floor.
5. Ability to push down with arms and lean forward.
6. Ability to achieve independent sitting balance.
7. Muscle strength.
8. Activity tolerance.
9. Joint mobility.
10. Presence of paralysis.
11. Presence of orthostatic hypotension.
12. No. assistants required.
Equipment:
1.
2.
3.
4.
5.
Appropriate clothing.
Slippers or shoes with non skid soles.
Gait/transfer belt.
Chair, commode, wheelchair as appropriate to client need.
Slide/lift if needed.
Procedure:
1
2
3
4
5
6
a.
b.
c.
d.
STEPS
Identify the patient
Prior to performing the procedure ,
introduce self .Explain the procedure
to the client, why it is necessary, and
how he or she can participate.
Gather the equipment.
Perform hand hygiene .Apply gloves
if performing rectal temperature.
RATIONALE
Provides patient safety.
Will help to reduce the anxiety of
the client, and help build a trusting
relationship with the client.
Provides organized approach to
task
To prevent risk of infection.
To avoid insecurity and
embarrassment.
Position
the
equipment
appropriately.
Lower the bed to its lowest position. So that the clients feet will rest flat
on the floor.
Lock the wheels of the bed.
to keep the bed stationary.
Place the wheelchair parallel to the For easy movement.
bed and as close to the bed as
possible.
Put the wheelchair on the side of the For easy transfer from bed to chair.
bed that allows the client to move
toward his stronger side.
67

e.
5.
a.
b.
c.
d.
6.
a.
b.
c.
d.
7.
a.
b.
c.
8.
Lock the wheels of the wheelchair

and raise the footplate.
Prepare and asses the client.
Assist the client to a sitting position
at the side of the bed.
Asses the client for orthostatic
hypotension before moving from
bed.
Assist the client in putting on a bath
robe/appropriate
clothing
and
nonskid slippers or shoes.
Place a gait/transfer belt snugly
around the client's waist. Check that
the belt is securely fastened.
Give explicit instructions to the client.
Ask the client to:
Move forward and sit on the edge of
the bed with feet placed flat on the
floor.
Lean forward slightly from hips .
Place the foot of the stronger leg

beneath the edge of the bed and put
the other foot forward.
Place the client's hand on the bed's
surface so that the client can push
while standing.
Position yourself correctly.
Stand directly in front of the client
and to the side requiring the most
support. Hold the gait/transfer belt
with the nearest hand ;the other
hand supporting the back of the
clients shoulder.
Lean your trunk forward from hips.
Flex Your hips ,knees and ankles.
So that the chair remains stationary

while the client is being transferred.
To transfer the patient to the wheel
chair.
If not assessed condition may
worsen while transferring .
To prevent the client from fall and
injury.
The belt helps in easy transfer of
the client without discomfort.
This brings the client's center of

gravity closer to the nurses.
This brings the clients center of
gravity more directly over the base
of support and position the head
and trunk in the direction of
movement.
In this way the client can use the
stronger leg muscles to stand and
power the movement.
This provides additional force for
the movement and reduces the
potential for strain on the nurses'
back.
Helps prevents loss of balance
during transfer.
Helps prevents loss of balance

during transfer.
Assume a broad stance, placing one To prevent the client from sliding
foot forward and one back. Brace the forward or laterally.
client's feet with your feet .
Assist the client to stand and then Coordination allows easy transfer.
move
together
towards
the
wheelchair.
68

a.
b.
On the count of three or verbal

instructions ask the client to push
down against the mattress /side of
the bed while you transfer your
weight from one foot to the
other(keeping your back straight)
and stand upright moving the client
forward into a standing position.
Support the client in an upright
position for a few moments.
If there is in coordination in lifting it

will be discomfortable for both the
patient and the nurse.
This allows the nurse and client to

extend the joints and provides the
nurse with an opportunity to ensure
the client is stable before moving
from bed.
c. Together pivot your foot farthest Pivoting the farthest foot will assist
from the chair or take a few steps in balancing body and maintaining
towards the chair.
the centre of gravity.
9. Assist the client to sit.
a. Have the client back upto the Minimizes the risk of client falling
wheelchair and place the client's while sitting down.
legs against the seat
b. Make sure the wheelchair brakes are To securely allow the client to sit on
on.
the chair and prevent fall.
c. Have the client reach back and To prevent falling.
feel/hold the arms of the wheelchair.
d. Stand directly in front of the client To equally distribute the centre of
.place one foot front and one back.
gravity.
e. Tighten your grasp on the transfer To securely hold the client while
belt, and tighten your gluteal, sitting and prevent fall.
abdominal, leg and arm muscles.
f. Have the client sit down while you Bending knees and hips prevents
bend your knees/hips and lower the strain on the back of the nurse.
client onto the wheelchair seat.
10. Ensure client safety.
a. Ask the client to push back into the Provides a broader base of support
wheelchair seat.
and greater stability, minimizes the
risk of falling from the wheelchair.
b. Remove the gait/transfer belt.
To replace the equipment after use.
c. Lower the footplates and place the To give support to the feet.
clients feet on them.
Variation:
For
clients
having This allows the client to pivot into
difficulty in walking place the the chair easily without much
wheelchair at 45angle to the bed.
movement.
69

Variation : For transferring with a
belt and two nurses., position
yourselves on both sides of the
client, facing the same direction as
the client.
Flex your hips, knees, and ankles
.Grasp the clients' transfer belt with
the hand closest to the client, with
the other hand supporting the client's
elbows. coordinating , all three
should pivot towards the wheelchair.
Variation: For clients who cannot
stand but are able to co-operate and
possess sufficient upper body
strength, use a sliding board to help
them
move
without
nursing
assistance.
11. Wash hands
12. Replace equipment.
13. Document information.
This can be used to move heavy

patients easily.
This method promotes client's

sense of independence but also
preserves your energy.
To prevent cross infection.

For further use.
For further follow up.
BATHING ADULT CLIENT

PURPOSES
1. To remove transient microorganisms, body secretions and excretion and dead skin
cells.
2. To stimulate circulation to the skin.
3. To promote sense of well-being.
4. To produce relaxation and comfort.
5. To prevent and eliminate unpleasant body odors.
ASSESSMENT
1. Physical or emotional factors (e.g. fatigue, sensitivity to cold, need for control, anxiety
or fear).
2. Condition of the skin (color, texture and turgor, presence of pigmented spots,
temperature, lesions, excoriation, abrasion, and bruises).areas of erythema (redness)
on the sacrum, bony prominences, and heels should be assessed for possible
pressure sores.
3. Presence of pain and need for adjunctive measures (e.g., an analgesic) before the
bath.
4. Range of motion of the joints.
5. Any other aspect of health that may affect the clients bathing process (e.g., mobility,
strength, cognition).
6. Need for use of clean gloves during the bath.
70

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

Soap and soap dish.
Linens: bath blanket, two bath towels, washcloth, clean gown or pajamas or clothes
as needed, additional bed linen and towels, if required.
Clean gloves, if appropriate (e.g., presence of body fluids or open lesions).
Personal hygiene articles (e.g., deodorants, powder, lotions).
Shaving equipment.
Laundry bag.
IMPLEMENTATION
Before start bathing your client you must be aware for the following
a.
b.
c.
d.
Purpose and type of bathing.

Self-care ability of the client.
Any position or movement precautions for the client.
Coordinate all aspects of health care and prevent unnecessary fatigue. Such as xray or physical therapyetc.
e. Client comfort level with being bathed by someone else.
f. Presence of all equipment and linens before starting bathing.
STEPS
Rational
Prepare the bed and position the

client appropriately
Position the bed at a comfortable
working height. Lower the side rails on
the side close to you. Keep the other
side rail up. Assist the client to move
near to you.
Place bath blanket over top sheet.
Remove the top sheet from under the
bath blanket by starting at clients
shoulder and moving linen down
toward clients feet.[ask the client to
grasp and hold the top of bath blanket
while pulling linen to the foot of the
bed].
This avoids undue reaching and straining

and promotes good body mechanics. And
ensure patient safety
The bath blanket provides comfort, warmth
and privacy.
NOTE: if the bed linen is to be reused,

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

the client covered with bath blanket.
Place gown in linen hamper.
Make a bath mitt with washcloth.
A bath mitt retains water and heat better

than cloth loosely held and prevents ends
of washcloth from dragging across the skin
71
Making a bath mitt, triangular method. (A) Lay your hand on the washcloth; (B) fold
the top corner over
Your hand; (C) fold the side corners over your hand; (D) tuck the second corner under
the cloth on the palm side to secure the mitt.
Making a bath mitt, rectangular method. (A) Lay your hand on the washcloth and fold
one side over your hand; (B) fold the second side over your hand; (C) fold the top of the
cloth down and tuck it under the folded side against your palm to secure the mitt.
Wash the face.
D
Begin the bath at the cleanest area and
work downward toward the feet.
Place towel under patients head.

Wash the patients eyes with water only Using separate corners prevents
and dry them well. Use a separate
transmitting micro-organisms from one eye
corner of the washcloth for each eye.
to the other.
Wipe from the inner to the outer
canthus.
This prevents secretions from entering the

nasolacrimal ducts.
Ask whether the patient wants soap

used on the face.
Soap has a drying effect, and the face,

which is exposed to the air more than
other body parts, tends to be drier.
Wash, rinse, and dry the patients face,

ears and neck.
Remove the towel from under the
patients head.
Wash the arms and hands. (Omit the
arms for a partial bath.)
Place a towel lengthwise under the arm
away from you.
It protects the bed from becoming wet
72

Wash, rinse and dry the arm by
elevating the patients arm and
supporting the patients wrist and elbow.
Use long, firm strokes from wrist to
shoulder, including the axillary area.
Apply deodorant or powder if desired.

(Optional) Place a towel on the bed and
put a washbasin on it. Place the
patients hands in the basin.
Repeat for hand and arm nearest you.

Exercise caution if an intravenous
infusion is present, and check its flow
after moving the arm.
Avoid submersing the IV site is not
clear, transparent dressing.
Firm strokes from distal to proximal areas

promote circulation by increasing venous
blood return.
Many patients enjoy immersing their hands

in the basin and washing themselves.
Soaking loosens dirt under the nails.
Assist the patient as needed to wash, rinse
and dry the hands, paying particular
attention to the spaces between the
fingers.
A clear transparent dressing will keep
water from an IV site; however, a gauze
dressing becomes contaminated when it
became wet with the water.
Wash the chest and abdomen. (Omit

the chest and abdomen for a partial
bath. However, the areas under a
womans breast may require bathing
if this area is irritated or if the
patient has significant perspiration
under the breast.)
Place bath towel lengthwise over
chest. Fold bath blanket down to the
patients pubic area.
Lift the bath towel off the chest, and
bathe the chest and abdomen with
your mitted hand using long, firm
strokes (Figure 13-9). Give special
attention to the skin under the breasts
and any other skin folds particularly if
the patient is overweight. Rinse and
dry well.
Keeps the patient warm while preventing

unnecessary exposure of the chest.
Replace the towel when the areas

have been dried.
Wash the legs and feet. (Omit legs
and feet for a partial bath.)
73

Expose the leg farthest from you by
folding the towel toward the other leg
being careful to keep the perineum
covered.
Lift leg and place the bath towel
lengthwise under the leg. Wash, rinse
and dry the leg using long, smooth,
firm strokes from the ankle to the knee
to the thigh.
Covering the perineum promotes privacy

and maintains the patients dignity.
Washing from the distal to proximal areas
promotes circulation by stimulating venous
blood flow.
Reverse the coverings and repeat for

the other leg.
Wash the feet by placing them in the
basin of water.
Dry each foot. Pay particular attention

to the spaces between the toes. If you
prefer, wash one foot after that leg
before washing the other leg.
Obtain fresh, warm bathwater now or
when necessary. Water may become
dirty or cold.
Lower the bed and raise side rails
when refilling basin.
Wash the back and then the
perineum.
Assist the patient into a prone or sidelying position facing away from you.
Place the bath towel lengthwise
alongside the back and buttocks while
keeping the patient covered with the
towel as much as possible.
Because surface skin cells are removed

with washing, the bathwater from darkskinned patients may be dark, however,
this does not mean the patient is dirty.
This ensures the safety of the patient.
This provides warmth and undue

exposure.
74

Wash and dry the patients back,
moving from the shoulders to the
buttocks, and upper thighs, paying
attention to the gluteal folds
Remove and discard gloves if used.

Perform a back massage now or after
completion of bath.
Assist the patient to the supine position
and determine whether the patient can
wash the perineal area independently.
If the patient cannot do so, cover the
patient as shown in picture and wash
the area.
Assist the patient with grooming aids

such as powder, lotion, or deodorant.
Use powder sparingly. Release as little
as possible into the atmosphere.
This will avoid irritation of the respiratory

tract by powder inhalation. Excessive
powder can cause caking, which leads to
skin irritation.
Help the patient put on fresh clothing.
Assist the patient to care for hair,

mouth, and nails. Some people prefer
or need mouth care prior to their bath.
Tub Bath/ Shower

Prepare the client and the tub.
Fill the tub about one-third to one-half
full of water, put cold water in before
hot.
( temperature 43-46C )
Cover all intravenous catheters or
wound dressings with plastic
coverings, and instruct the patient to
prevent wetting these areas if
possible.
Put a rubber bath mat or towel on the
floor of the tub if safety strips are not
on the tub floor.
Assist the patient into the shower
or tub.
Sufficient water is needed to cover the

perineal area.
These prevent slippage of the patient

during the bath or shower.

Assist the patient taking a standing
shower with the initial adjustment of
the water temperature and water flow
pressure, as needed. Some patients
need a chair to sit on in the shower
because of weakness. Hot water can
cause elderly people to feel faint due
to vasodilation and decreased blood
pressure from positional changes.
If the patient requires considerable
assistance with a tub bath, a
hydraulic chair may be required (see
Variation below).
Explain how the patient can signal for
help; leave the patient for 25
minutes, and place an occupied sign
on the door. For safety reasons, do
not leave a patient with decreased
cognition or patients who may be at
risk (e.g. history of seizures,
syncope).
Assist the patient with washing
and getting out of the tub or bath.
Wash the patients back, lower legs,
and feet, if necessary.
Assist the patient out of the bath. If
the patient is unsteady, place a bath
towel over the patients shoulders and
drain the water before the patient
attempts to get out of it.
Draining the water first lessens the

likelihood of a fall. The towel prevents
chilling.
Dry the patient, and assist with

follow-up care.
Assist the patient with grooming aids
such as powder, lotion, or deodorant.
Assist the patient back to his or her
room.
Discard the used linen in the laundry
skip.
Place the unoccupied sign on the
door.
Documentation:
Type of bath given (i.e. complete, partial, or self-help).
Skin assessment, such as excoriation, erythema, exudates, rashes, drainage or skin
breakdown.
Nursing interventions related to skin integrity.
Ability of the patient to assist or cooperate with bathing.
Patient response to bathing.
Educational needs regarding hygiene.
Information or teaching shared with the client or their family.
75
76
COLLECTING SPUTUM SPECIMEN

I.
Definition:
Sputum is the mucous secretion from the lungs, bronchi, and
trachea. It is important to differentiate it from saliva, a watery
substance located in the mouths of organisms, secreted by the Salivary
Glands sometimes referred to as |spit. Healthy individuals do not
produce sputum. Clients need to cough to bring sputum up from the
lungs, bronchi, and trachea into the mouth in order to expectorate it
into a collecting container.
II.
Purposes:
1. For culture and sensitivity to identify a specific microorganism and its
drug sensitivities.
2. For cytology to identify the origin, structure, function, and pathology of
cells. Specimens for cytology often require serial collection of three
early-morning specimens and are tested to identify cancer in the lung
and its specific cell type.
3. For acid-fast bacillus (AFB), this also requires serial collection, often for
3 consecutive days, to identify the presence of tuberculosis (TB).
4. To assess the effectiveness of therapy.
III.
Supplies and Equipment:
1. Sputum container with a tight cover
2. Facial tissues.
3. Identification labels.
4. Laboratory requisition form.
5. Emesis basin
Rationale
For collecting the sputum; tight cover
ensures that the outside of the
container is free of sputum.
Available for the client if there is
excessive tearing or coughing following
culture.
Prevents errors by correctly labeling the
culture tube.
Informs the laboratory of the clients
identification or other required
information.
Available in case the client gags and
vomits following the throat culture.
OPTIONAL: Clean Gloves & Mask.

IV.
1
2
Procedure:
STEPS
Wash hands then wear gloves &
personal protective equipment.
Gather supplies and equipment.
Rationale
To prevent spread of microorganisms
and to avoid contact with the sputum.
To save time, effort and energy.
77

3
10
11
12
13
14
Follow special precautions if

tuberculosis is suspected,
obtaining the specimen in a room
equipped with a special airflow
system or ultraviolet light.
Explain to the client what will be
done; instruct in whatever way is
necessary.
Draw the curtain or close the
door to the room if the client
desires privacy.
Position the client so that he or
she is upright.
Give the specimen container
properly labeled to the client with
the cover removed. Warn not to
touch the inside of the container.
Encourage the client to take
several deep breaths with full
expiration.
Instruct the client to cough
deeply, raising secretions from
the deep airways.
Instruct the client to expectorate
directly into the container.
Instruct the client to repeat the
deep breathing and coughing
sequence until approximately 5
ml of sputum in the container.
(Note: Clarify the amount with the
agency laboratory).
Provide comfort measures for the
client as necessary.
Wash hands
Send the specimen container to
the laboratory according to the
agency guidelines.
If these options are not available, wear

a mask capable of filtering droplet
nuclei.
Informs client; encourages participation

and cooperation; lessens anxiety.
Provides privacy.
Place the client in an optimal position to

fully expand thee lungs and forcefully
expel air and secretions.
Prevents contamination with
microorganisms.
Promotes full lung expansion to loosen

and expel secretions.
Forces secretions into larger airways,
facilitating their expulsion.
Provides and adequate amount of

sputum for diagnostic testing.
Limits transfer of microorganisms.

Ensures prompt analysis and accurate
test results.
COLLECTION and TESTING of URINE

Definition:
Urinalysis the analysis of urine samples. It is a part of the examination of every
patient at the beginning and during illness.
a. Amount of urine:
i. 1200 1500 ml / 24 = normal.
1. Less than 500 cc / 24 = oliguria.
2. More than 1500 cc / 24 = polyuria.
ii. Day volume is 2 3 times more than night volume.

b. Appearance / Clarity:
i. Normal urine is clear.
ii.
Turbid (cloudy) urine is not always pathologic. Normal urine
may develop turbidity on refrigeration or from standing at room
temperature; bacteria ferment urine quickly at room
temperature.
iii.
Abnormally cloudy urine due to pus, blood, epithelial cells,
bacteria, fat, colloidal particles, phosphate, urates.
c. Odor:
i. Normal faint aromatic odor.
ii.
Characteristic odors produced by ingestion of asparagus,
thymol.
iii.
Cloudy urine with ammonia odor urea-splitting bacteria such
as Proteus, causing urinary tract infection.
iv. Abnormally colored urine:
78
79

a) Turbid or smoky
urine.
- may be from hematuria,

spermatozoa, prostatic fluid, fat
droplets, chyle.
- may be due to blood pigments,
porphyria, transfusion reaction,
bleeding lesions on urogenital tract,
some drugs.
- may reveal obstructive lesions of
bile duct.
b) Red or red brown.
c) Yellow-brown or
green-brown.
d. Reaction:
i. Reflects the ability of kidney to maintain normal hydrogen ion
concentration in plasma and intracellular fluid; indicates acidity
or alkalinity or urine.
ii.
The pH should be measured in fresh urine, since the
breakdown of urine to ammonia causes urine to become
alkaline.
iii.
Normal pH is around 6 (acidic); may vary from 4.6 7.5.
iv. Urine acidity or alkalinity has relatively little clinical significance
unless the patient is on special diet or therapeutic program or
is being treated for renal calculous disease.
v.
Alkaline urine is often cloudy because of phosphate crystals.
e. Specific gravity:
i. Reflects thee kidneys ability to concentrate or dilute urine;
may reflect degree of hydration or dehydration.
ii.
Normal specific gravity ranges from 1.005 1.025.
iii.
Specific gravity is fixed at 1.010 in chronic renal failure.
iv. In a person eating a normal diet, inability to concentrate or
dilute urine indicates disease.
f. Osmolality:
i. Osmolality is an indication of the amount of osmotically active
particles in urine (specifically, it is the number of particles per
unit volume of water). It is similar to specific gravity, but is
considered a more precise test. It is also easy to do only 1
2 ml of urine is required.
ii.
The unit osmotic measure is the osmole.
Average values: Female: 300 1090 mosm / kg.
Male: 390 1090 mosm / kg.
Normal Findings in Routine Urinalysis:
Element
Findings
MACROSCOPIC
Color
Odor
Appearance
Specific Gravity
Pale straw or amber.

More concentrated in the morning.
Slightly aromatic.
Clear
1.010 1.025
80

pH
4.5 8.0
Protein
Glucose
Ketones
Sugar
None
None
None
None
(average pH 6, 7- neutral, less than 7 acidic, greater than 7
alkaline).
MICROSCOPIC
RBCs
WBCs
Epithelial Cells
Casts
Crystals
Yeast Cells
Parasites
0 3 / high-power field
0 4 / high-power field
Few
None, except occasional hyaline casts
Present
None
None
Types of Urine Specimen:

1. Clean urine specimen or random routine urine specimen, or routine urinalysis
can be collected with a client voiding naturally through a Foley catheter or
urinary diversion collecting bag. The specimen should be clean but need not
be sterile. It is commonly used to screen urinary and systemic pathologies.
The elements of routine urinalysis are the macroscopic and microscopic.
2. Midstream specimen of clean voided or clean catch to obtain a specimen
relatively free of microorganisms growing in the lower urethra but the sterile
procedure of catheterization is undesirable. Used for urine culture and
sensitivity.
3. 24-Hour Urine done when a large quantity of urine is necessary to analyze
for protein and creatinine clearance.
4. Catheterized specimen used for culture.
5. Indwelling catheter urine urine is obtained from an indwelling catheter for
culture.
6. Double-voided specimen used to accurate measurement of glucose and
ketones.
7. Use of Keto-Diastix, Multistix, Tes-Tape reagent strips used to detect
glucose and ketones.
Purposes:
1. The client understands the need for the urine specimen and will be able
to provide a specimen unassisted in the future.
2. The client provides a clean or sterile urine specimen in the manner
described by the nurses within a reasonable time.
Key Points:
1. Assess the clients ability to collect specimen independently.
2. Determine the last time the client voided.
81

Obtaining a clean urine specimen or random urine specimen:
STEPS
Collection by the patient:
1 Give client the urine container
properly labeled with clients
identification (name, medical
record number, sex, age) [date
and time of urine collection will
be written after collection].
2 Instruct the patient on how to
properly collect.
3 Send the urine to the laboratory
immediately or within 2 hours
with the properly filled up
laboratory requisition form.
Collection done by the nurse:
1 Wash hands.
2 Collect needed supplies and
equipment:
a. Urine container properly
labeled with
Clients identification.
b. Urinal (male) or bedpan
(female).
c. Toilet tissues.
d. Laboratory requisition form.
3
Explain the purposes(s) and
procedure of the test.
4 Put on disposable gloves, place
urinal or bedpan in position.
Instruct client to void.
5 Dry clients urethral opening
with tissue and after voiding.
6 Remove urinal and bedpan,
cover, and take it into the
bathroom or the utility room.
7 Put a designed amount of urine
into the urine container and
cover it tightly. Discard the
remainder.
8 Clear the urinal and bedpan, put
back to proper place. Discard
gloves and wash hands.
9 Send to the laboratory
immediately or within 2 hours
with properly filled up laboratory
form.
Rationale
Provides the client with the information

needed to collect specimen.
Ensures accurate testing and
documentation.
To prevent spread of microorganisms.

To gain clients cooperation.
Microorganisms thrive in wet areas.

Ensures clients comfort.
Ensures accurate testing and

documentation.
82

Obtaining a midstream urine specimen:
A. Collection done by the patient:
1 Instruct the client on the purposes of
urine collection and to prepare the
needed supplies and equipment:
a. Sterile urine container properly labeled
with clients identification.
b. Soap and water
c. Disposable washcloth.
d. Antiseptic solution
e. Sterile cotton balls
f. Laboratory requisition form
2 Instruct the client of the procedure.
Cleansing the female urinary

meatus, spread the labia minora
with one hand and with the other
hand, cleanse the perineal area
from front to back.
Retract the foreskin if

needed. Using a towelette,
cleanse the urinary meatus
by moving in a circular
motion from the center of the
uretral openining around the
glans and down the distal
portion of the shaft of the
penis.
a. Wash hands
b. Clean the perineal area around the
urinary meatus using the disposable
washcloth.
c. Wash hands again.
d. Soak the cotton ball after one use.
e. Using a cotton ball, clean around
external meatus with a single stroke.
f. Discard cotton ball after on use.
g. Continue the cleansing action
discarding all used balls.
h. Void a small amount; hold the urinary
stream.
i. Void urine into the sterile specimen
container, holding the container only
on the outside.
j. Stop voiding when container is about three-
To prevent transfer of microorganisms.
k. Wash hands.
Final hand wash is to remove any contamination

of hands from possible contact with urine.
quarters full; void remaining urine in toilet,

bedpan, or urinal. Cover the container tightly
without touching the inside of the container.
B. Collection done by the Nurse:

1 Wash hands and put on clean gloves.
Removes most pathogenic organisms from the area

around urethra, thus decreasing potential contamination of
the urine specimen.

Removes microorganisms from peri-urethral
area.
Avoids contamination.
Removes microorganisms from the peri-urethral
area.
Flushes away microorganisms from urethra.
Collects specimen with minimal contamination.
Prevents overflow in specimen container.
83

2
a.
b.
c.
d.
e.
f.
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
Gather needed supplies and

equipment:
Sterile urine container.
Bedpan or urinal.
Sterile cotton balls.
Antiseptic soap.
Disposable washcloth.
Disposable gloves.
Explain purposes and procedure to the
client.
Pull on the curtain or close the door.
Put on disposable gloves.
Soak the cotton balls with antiseptic
soap and set them aside.
Place the female client on a bedpan.
Place urinal under the male clients
penis.
Clean the area around the urinary
meatus using disposable washcloth.
Discard gloves, wash hands, and put
on clean gloves.
Clean around the meatus (if client is
male); clean from pubis to rectum (if
client is female) with the cotton balls
using single strokes.
Discard balls after single use. Repeat
cleansing.
Instruct the client to void a small
amount of urine into the bedpan or
urinal, then to hold the urine stream.
Place a sterile specimen near urethra;
instruct the client to void again.
When container is nearly full, instruct
the client to hold the urine into the
bedpan or urinal.
Instruct the client to void the remainder
of the urine into the bedpan of urinal.
Lift the client from bedpan or remove
urinal. Leave the client comfortable.
Close specimen container with a sterile
top and without touching the inside of
the container.
Discard gloves and wash hands.
Send to laboratory immediately with
properly filled up laboratory requisition
form.

To provide privacy.
Prepares equipment; client will not have to wait
for this part of the procedure.
Removes microorganisms, a decreasing

possible contamination of specimen.
Removes microorganisms that may be present
after cleaning the perineal area.
Prevents fecal contamination of meatus.
Prevents recontamination with used cotton balls.

Washes away microorganisms in and around
meatus.
Collects the specimen with few if any
microorganisms.
Prevents overflow from specimen container.
Prevents further contamination by

microorganisms.
84

Collecting urine specimen from Indwelling Catheter:
1
Wash hands.
Prepare needed supplies and

equipment:
a. Sterile urine container properly
labeled with clients identification.
b. Disposable 10 ml syringe with
needle.
c. Antiseptic swab or alcohol swab.
d. Clamp.
e. Disposable clean gloves.
3 Explain the purposes and procedure to
the client.
4 Pull the curtain or close the door.
5 Put on disposable gloves.
6 Inspect the urinary drainage tubing for
amount of urine in the tubing.
7 Clamp the drainage tubing at least 3
in. below the sampling port (if it
contains little urine) by using a U
clamp or folding the tubing and
securing a band around the fold.
8 Leave the clamp in place for 30
minutes.
9 Locate the specimen port with an
antiseptic swab.
10 Clean the port with an antiseptic swab.
To prevent the spread of

microorganisms.

To provide privacy.
Determines if sufficient amount is
present to withdraw for specimen.
Blocks urine from draining into the
collecting bag; thus rubber
accumulates a sufficient amount
of specimen.
Allows enough time for urine to
drain.
Identifies the area designated for
withdrawing urine from a drainage
system.
Removes microorganisms from
the port.
11 Insert the needle of the 10 ml syringe

through the port.
Obtaining a urine specimen from a retention catheter:
A.
From a specific area near the end of the

catheter.
B.
From an access port in the tubing.
12 Unclamp the tubing and withdraw the

required amount of urine.
13 Transfer the urine to the specimen
container.
For example, 3 mL for a urine culture or

30 mL for a routine urinalysis.
(Depending on the system).
If a sterile culture tube is used, make
sure the needle or syringe does not touch
the outside of the container to prevent
recontamination.
14 Discard the syringe and needle in an

appropriate sharps container.
85

15 Cap the container.
16 Remove gloves and discard. Perform
hand hygiene.
17 Label the container, and send the
urine to the laboratory immediately for
analysis or refrigerator.
18 Record collection of the specimen and
any pertinent observations of the urine
on the appropriate records.
Collecting 24-hour urine specimen:

1
a.
b.
c.
d.
2
4
5
6
7
Collect the needed supplies and

equipment.
Large size urine collector properly
Bedpan or urinal
Bucket with container or
refrigerator.
Laboratory requisition form.
Explain the procedure to the client.
Place the container in a large

container filled with ice; place this on
the clients bathroom or nearby
storage area.
Instruct the client to void and discard
the specimen.
Record the time and date of
discarded specimen on the
collection container. This is the
starting time of the collection.
Place all voided urine in the
container during the next 24 hours.
Let client void (in toilet, bedpan, or
urinal). Collect urine or pour urine
from the bedpan or urinal into the
urine container.
Send to the laboratory immediately
requisition form.
Informs the client and gives

instructions on what he or she is to
do to help. Often the client is the key
person in the success of a 24-hour
collection because he or she
reminds all people to save the urine.
Prevents the urine from
deteriorating.
Ensures that all urine from this point

on is collected.
Ensures that urine is saved; this is

critical for the accuracy of the test.
86

Testing urine for contents (sugar and ketones):
A. Double-voided urine.
1 Prepare needed supplies and
equipment.
a. Urine container properly labeled
with clients identification.
b. Tissue
c. Urinal or bedpan.
d. Water to drink.
2 Explain purpose and procedure to
client.
3 Pull on the curtain or close the door. To provide privacy.
4 Ask client to void and discard urine.
5 Let client drink water, around 8 oz.
6 Wait for 30 45 minutes.
7 Let client to void (in toilet, bedpan, or urinal).
Collect urine or pour urine from the bedpan
or urinal.
Send to the laboratory immediately

requisition form.
To ensure accuracy.
Using reagent strip.
After dipping the reagent strip (dipstick)

into fresh urine, wait the stated time
period and compare the results to the
color chart.
1
2
3
4
5
6
7
8
Wash hands.
Prepare needed supplies and
equipment
a. Sterile urine container properly
b. Reagent strip.
c. Disposable gloves (optional)
Explain to the client what will be
done.
Read instructions on the testing kit to
determine how much urine is
needed.
Wash hands and put on gloves.
Collect the urine specimen.
Take the specimen to a work area.
Dip reagent strip in the urine
specimen and pull it out immediately.
To prevent the spread of

microorganisms.
Informs the client.

Instructs on how to use the test
materials. Techniques vary with
many different brands.
Strip contains chemicals that

change colors when exposed to
glucose and ketones.
87

9
10
11
12
13
14
Remove excess urine from the

reagent strip.
Wait for 15 to 30 seconds depending
on the manufacturers instructions.
Compare the strips color with that of
the chart on the bottle.
The color scale measures the

quality of glucose and ketones The
range of the color scales extends
from negative, trace, 1+, 2+, 3+.
Discard urine and reagent strip.

Remove gloves and wash hands.
Inform the client of the results and
record.
COLLECTION and TESTING of STOOL

I.
Introduction:
Stool specimen yields information related to functioning of the
gastrointestinal system and its accessory organs.
a. Test for ova and parasites (O & P) indicates the presence of
gastrointestinal parasites and / or their eggs ova.
b. Guaiac or Hemoccult or occult blood test used to test presence of
blood in stool.
Fecal Characteristics:
Character
Normal
Color
Infant: Yellow
Adult: Brown due to
metabolism of bile
pigments to
stercobilin.
Odor
Consistency
Pungent: affected by
food type results
from the presence of
indole and skatole,
end products of
protein catabolism by
bacterial action in the
large intestines.
Soft, formed
Abnormal
White or Clay
Cause
Absence of bile.
Black or tarry
Iron ingestion or
upper GI bleeding.
Red (melena)
Lower GI bleeding,
hemorrhoids.
Pale with fat

Noxious change.
Malabsorption of fat.
Blood in feces or
infection.
Liquid
Diarrhea, reduced
absorption.
Hard
Constipation.
88

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

week.
Amount
150 Gm/day
shape
resembles diameter
of rectum.
Constituents Undigested food,
dead bacteria, fat,
bile pigment, cells
lining intestinal
mucosa, water.
Infant: more than 6 x

/ day or less than
once every 1 2
days.
Adult: More than 3 x
a day or less than
once a week.
Narrow, pencil
shaped.
Blood, pus, foreign
bodies, mucus,
worms.
Hypomotility or
hypermotility.
Obstruction, rapid
peristalsis.
Internal bleeding,
infection, swallowed
objects, irritation,
inflammation.
II.
Objectives:
1. The client understands the purpose of the diagnostic test, as evidenced
by ability to explain it.
2. The client eliminates sufficient stool to provide a specimen for the
diagnostic test.
III.
Key Points:
1. Assess the clients understanding of the test and ability to collect the
specimen independently.
2. Determine the time of the clients last bowel movement.
3. Wearing disposable gloves use a tongue depressor to transfer stool
from bedpan to specimen container.
4. Label specimen correctly.
5. Test specimen by following instructions on test packet.
6. Record results of specimen test in the health record.
IV.

Action
1. Bedpan, commode, ordinary
collecting hat.
2. Toilet tissue.
3. Disposable gloves.
4. Tongue blades.
5. Specimen container.
V.
Rationale
Provides receptacle for stool
Cleans perineal area after defecation.
Protects the nurses hands.
Transfers stool from one container to
another.
Collects stool for testing.
Procedure:
Action
Collecting s Stool Specimen:

1 Explain the purpose of the test to
the client.
Rationale
Informs the client and encourages

participation.
89

2
3
Describe how the specimen is to be

collected.
Instruct the client to save his or her
stool in a bedpan and to discard
toilet paper elsewhere.
Instructs the client who is to collect

own stool.
Collects specimen that is free of
urine, water, and toilet paper.
If the client is unable to collect specimen:

1 Wash hands.
To prevent spread of
microorganisms.
2 Gather the needed equipment and
supplies; label the specimen
container with appropriate
identification and fill up the lab.
request form.
3
Explain the purposes(s) and
procedure of the test.
participation.
4 Pull on the curtain or close the door. To provide privacy.
5 Remove bedpan (or commode pan)
with stool after the client evacuates.
6 Cover the bedpan and take it to the
Removes stools from the clients
bathroom or dirty work area.
bed unit to minimize embarrassment
or discomfort.
7 Use tongue blades to transfer stool
from bedpan to a specimen
container. Transfer as much as is
required for the test. Place lid
securely on the container.
8 Discard tongue blades and excess
stool, wash bedpan.
9 Discard gloves and wash hands.
10 Send specimen to the laboratory
Ensures accurate testing.
immediately.
11 Record date and time of stool
collection and results.
OBTAINING A CAPILLARY BLOOD SPECIMEN TO MEASURE

BLOOD GLUCOSE
PURPOSES
1. To determine or monitor blood glucose levels of clients at risk for hyperglycemia or
hypoglycemia
2. To promote blood glucose regulation by the client
3. To evaluate the effectiveness of insulin administration
90

ASSESSMENT
Before obtaining a capillary blood specimen, determine:
1.
2.
3.
4.
5.
The policies and procedures for the facility

The frequency and type of testing
The clients understanding of the procedure
The clients response to previous testing
Assess the clients skin at the puncture site to determine if it is intact and the circulation
is not compromised. Color, warmth, and capillary refill.
6. Reviewed the clients record for medications that may prolong bleeding such as
anticoagulants, or medical problems that may increase the bleeding response.
7. Assess the clients self-care abilities that may affect accuracy of test results, such as
visual impairment and finger dexterity.
PLANNING
Delegation
Check the policy and procedure manual to determine who can perform this skill. It is
usually considered an invasive technique and one that requires problem solving and
application of knowledge. It is the responsibility of the nurse to know the results of the
test, and supervises unlicensed assistive personnel responsible for assisting the nurse.
EQUIPMENT
1. Blood glucose meter (glucometer)
2. Blood glucose reagent strip compatible with the
meter
3. 2 x 2 gauze
4. Antiseptic swab
5. Clean gloves
6. Sterile lancet ( a sharp device to puncture the skin)
7. Lancet injector (a string-loaded mechanism that
holds the lancet)
IMPLEMENTATION
Preparation
Review the type of meter and the manufacturers instructions.

Assemble the equipment at the bedside.
STEPS
1
Prior to performing the procedure, introduce self

and verify the clients identity using agency
protocol.
Explain to the client what you are going to do, why
it is necessary, and how he or she can participate.
Discuss how the results will be used in planning
further care or treatments.
Perform hand hygiene and observe other
appropriate infection control procedures (e. g.,
gloves).
Rationale
91

3
Provide privacy.
Prepare the equipment.

a
Some meter turn on when a test strip is

inserted into the meter ( 1 )
b Confirm the code number.
Select and prepare the vascular puncture site.
a Choose a vascular puncture site (e.g., the side
of an adults finger). Avoid sites beside bone.
Hold a finger in a dependent (below heart
level) position. If the earlobe is used, rub it
gently with a small piece of gauze.
b Clean the site with the antiseptic swab or soap
and water and allow it to dry completely.
(1) Insert the test strip into

the meter.
Obtain the blood specimen.

a Apply gloves.
b Place the injector, if used, against the site, and
release the needle, thus permitting it to pierce
the skin. Make sure the lancet is perpendicular
to the site.
c
d
These actions increase the

blood flow to the area, ensure
an adequate specimen, and
reduce the need for a repeat
puncture.
Alcohol can affect accuracy
and the site stings when
punctured when wet with
alcohol.
The lancet is designed to

pierce the skin at a specific
depth when it is a
perpendicular position relative
to the skin. (2).
Prick the site with a lancet or needle, using a

darting motion.
Gently squeeze (but do not touch) the
puncture site until a drop of blood forms. The
size of the drop of blood can vary depending
on the meter. Some meters require as little as
0.3 mL of blood to accurately test blood sugar.
(2) Place the injector against

the site.
Hold the reagent strip under the puncture site

until adequate blood covers the indicator
square. The pad will absorb the blood and a
chemical reaction will occur. Do not smear the
blood. This will cause an inaccurate reading.
-
Some meters wick the blood by just

touching the puncture site with the strip. (3)
Ask the client to apply pressure to the skin

puncture site with 2x2 gauze. Pressure will
assist hemostasis.
Expose the blood to the test strip for the period
and the manner specified by the manufacturer. As
soon as the blood is placed on the test strip:
(3) Apply the blood to the test
strip.
92

a
Follow the manufacturers recommendations

on the glucose meter and monitor for the
amount of time indicated by the manufacturer.
Some glucometers have the test strip placed

in the machine before the specimen is
obtained.
Measure the blood glucose.
a Place the strip into the meter according to the
manufacturers instructions.
Refer to the specific

manufacturers
recommendations for the
specific procedure.
1
0
After the designed time, most glucose meters

will display the glucose reading automatically.
Correct timing ensures accurate results. (4).
c Turn off the meter and discard the test strip
and 2x2 gauze in a biohazard container.
Discard the lancet into a sharps container.
d Remove and discard gloves. Perform hand
hygiene.
Document the method of testing and results on the
clients record. If appropriate, record the clients
understanding and ability to demonstrate the
technique.
The clients record may also include a flow sheet
on which capillary blood glucose results and the
amount, type, route, and time of insulin
administration are recorded. Always check if a
diabetic flow sheet is being used for the client.
Check for orders for sliding scale insulin based on
capillary blood glucose results. Administer insulin
as prescribed.
The blood must remain in

contact with the test strip for a
prescribe time to obtain
accurate results.
(4) Read the results
EVALUATION
1. Compare glucose meter reading normal blood glucose level, status of puncture site, and
motivation of the client to perform the test independently.
2. Relate blood glucose reading to previous reading and the clients current health status.
3. Report abnormal results to the primary care provider. Some agency may have a
standing policy to obtain a venipuncture blood glucose if the capillary blood glucose
exceeds a certain value.
4. Conduct appropriate follow-up such as asking the client to explain the meaning of the
results and/or demonstrating the procedure at the next scheduled test.
5. Prepare the client for home glucose monitoring and review frequency, record keeping,
and insulin administration if appropriate.
Collecting Samples from the Nose or Throat

I.
Introduction
The oronasopharyngeal cavity is lined with mucous membrane that secretes

mucus, moistening the membrane and the air that is inhaled. Lachrymal fluid and
saliva also drain into the cavity. Viral infections are common problems in the
upper airways, but bacterial infections occur as well. Because bacterial infections
can be treated pharmacologically, samples for cultures are taken of the upper
airway secretions to distinguish between viral and bacterial infections. When
bacteria are cultured, sensitivity tests determine the proper treatment.
II.
Purposes:
1. The client can accurately report the reason for the culture and explain when
and how its result will be learned.
2. The clients nose and throat are without discomfort or bleeding from taking the
culture as evidenced by his or her report and an inspection of the area.
III.
Key Points:
1. Assess the client for evidence of respiratory infection.

2. Observe the clients ability to cough deeply.
3. Place the client in high Fowlers position.
IV.
1. Sterile cotton-tipped or polyestertipped swab or applicator in a

culture tube.
2. Tongue depressor.
3. Penlight.
4. Facial tissues.
5. Identification labels.
Rationale
Removes exudate from pharyngeal
mucosa without contamination.
Depresses tongue for better visualization
of pharynx.
Illuminates area to be cultured.
Available for the client if there is
excessive tearing or coughing following
culture.
Prevents errors by correctly labeling the
culture tube.
93
94

6. Laboratory requisition form.
7. Emesis basin.
V.
Informs the laboratory of the clients

identification or other required
information.
Available in case the client gags and
vomits following the throat culture.
Procedure:
STEPS
Rationale
Collecting Culture Samples from the Pharynx

1
2
3
4
5
6
7
8
9
1
0
1
1
Wash hands.
Gather needed supplies and equipment.
Explain the exact procedure to the client.
Tell him or her that a ticking sensation in
the throat may be felt and that the client
may even gag as the throat is swabbed.
Pull on the curtain or close the door.
Instruct the client to sit upright or help
into that position.
Place tissues and emesis basin within
the clients reach.
Ready the swab by loosening it from the
culture tube; place it within reach.
Depress the tongue with the tongue
depressor while illuminating the pharynx
with the penlight.
Inspect the pharynx for reddened or
inflamed areas or patches of exudates.
Set the penlight aside and grasp the
swab.
Insert the swab through the mouth,
carefully avoiding the tongue, teeth, or
cheeks.

discussions of anxiety or discomfort.
Prepares for the discomfort of the
culture.
To provide privacy.
Allows easier view visualization of the
access to the pharynx.
Prepares the client if need arises.
Prepares the swab.
Permits visualization of the pharynx so
that it can be inspected.
Prevents contamination of the swab tip
95
1
2
Rub the swab quickly but firmly over the

area of inflammation or patchy exudate.
If no exudate is seen:
1 Rub the swab quickly but firmly over the
3 nasopharyngeal area behind the uvula.
1
4
1
5
1
6
Withdraw the swab quickly without

touching the oral tissues.
Replace the swab in the culture tube.
1
7
1
8
1
9
Secure the top of the culture tube.
2
0
2
1
2
2
Insert the swab tip into the medium.
Ensures collection of secretions from

suspicious areas.
Ensures collection of secretions in an

area representative of the entire
pharynx.
Prevents contamination of the swab.
Inserting the collected secretions directly

into the medium ensures that the
bacteria will survive until cultured by the
laboratory.
Prevents contamination.
Discard the tongue blade.

Provide comfort measures for the client
as necessary; facial tissues, a drink of
water.
Wash hands.
Secure labels to the culture tube.
Send the culture to the laboratory
according to agency guidelines.

Prevents identification errors by the
laboratory.
Ensures accurate results.
B. Collecting Culture Samples from the nasal Mucosa

96
1
2
3
Wash hands.
Gather needed supplies and equipment.
Explain the exact procedure to the client.
Tell him or her that she will feel itching
and discomfort or a desire to sneeze as
the swab passes through the nose.
Pull on the curtain or close door.
Instruct the client to sit upright or help
into that position.
Place tissues within the clients reach.
Ready the swab by loosening it from the
culture tube; place it within reach.
Instruct the client to blow his or her
nose.
Instruct the client to tilt head back.
Inspect the nostrils to determine
patency; using the penlight for
illumination.
Insert the wire swab gently through the
most patent nostril; avoid touching the
nasal tissue.

Informs the client of the procedure;
encourages participation; prepares for
the discomfort.
1
2
Force the swab through the resistance

met when it enters the turbinates.
1
3
1
4
1
5
Place the tip of the swab against the

turbinate tissue and rotate.
Withdraw the swab quickly without
touching the sides of the nares.
Replace the swab in the culture tube.
Ensures that the swab tip rests against

the tissues of the turbinates rather than
the anterior nares.
Collects the secretions.
4
5
6
7
8
9
1
0
1
1
To provide privacy.
Allows easier visualization of the access
to the nares.
Prepares the client if need arises.
Prepare the swab.
Prepare the swab.
Allows easier access to the turbinates.
Determines which nostril to use; select
the nostril without visible obstruction.
Prevents contamination of the swab tip.
A wire swab is preferable for this
procedure because it is less likely to
injure tissues. Bend the swab into a
curve that permits easier entry before
the package is opened.
Prevents contamination of the swab.
97

1
6
Insert the swab tip into the medium.
1
7
1
8
Secure the top of the culture tube.
Inserting the collected secretions directly

into the medium ensures that the
bacteria will survive until cultured by the
laboratory.
Prevents contamination.
Provide comfort measures for the client

as necessary; facial tissues, a drink of
water.
Wash hands.
1
9
2
0
2
1
Secure labels to the culture tube.

Send the culture to the laboratory
according to agency guidelines.
Prevents identification errors by the

laboratory.
Ensures accurate results.
Insert the wire swab gently through the most patent nostril; avoid touching the nasal tissue.
BANDAGES AND BINDERS

Introduction / Definition:
A simple gauze dressing is often not enough to immobilize or provide support to a wound.
Bandages and binders are devices that secure large dressings, wrap body parts, provide
support to body areas and facilitate immobilization of the limits.
Bandage is a strip or roll of material that is wrapped around a body part to support or
immobilize a body part, or to secure a dressing that cannot be taped to the skin.
Bandages are available in rolls of various widths and material including gauze, elasticized
knits, elastic webbing, flannel, and muslin.
Gauze is used for bandages because it is light and porous and conforms to body parts;
permit air circulation to underlying skin to prevent maceration, inexpensive, and can be
discarded after one use.
Elastic bandage adhere to the skin providing support and pressure and conform to body
parts.
A binder is a broad bandage made of a shape and size to fit and supports the underlying
muscles or incisions or dressings on a body part; is made of cotton or muslin fabric that may
or may not be elasticized. Some binders have metal or plastic ribbing (stays) to prevent

bending and add additional support. Other binders are made of netting that stretches to
accommodate shape as they encircle the entire body to secure dressings.
Bandages and binders applied over or around dressings can provide extra protection
and therapeutic benefits by:
1. Creating pressure over a body part.
2. Immobilizing a body part.
3. Supporting a wound.
4. Reducing or preventing edema.
5. Securing a splint, or
6. Securing dressings.
Principles for Applying Bandages and Binders:

Correctly applied bandages and binders do not cause injury to underlying or nearby
body parts or create discomfort for the client.
1.
2.
3.
4.
Inspect the skin for abrasions, edema, discoloration, or exposed wound edges.
Cover exposed wounds or open abrasions with sterile dressing.
Assess the condition of underlying dressings and change them if they are soiled.
Assess the skin of underlying body parts and parts that will be distal to the bandage
for signs of circulatory impairment; (coolness, pallor, or cyanosis, diminished or
absent pulses, swelling, numbness, and tingling) to provide a means for comparing
changes in circulation after bandage application.
BANDAGING
Techniques of Applying Bandages:
1. Circular turn is used to anchor the bandage at its beginning and end. It may also be
used to bandage small areas such as finger and wrist.
2. Spiral turn to cover part that is uniform in shape like upper arm or leg.
3. Spiral reverse to bandage areas of the body that are not uniform in shape such as
lower leg.
4. Recurrent turn used to cover distal ends such as the skull, distal end of the finger,
or the stump of an amputation.
5. Figure-of-eight turn is used to support joint areas such as knees and elbows while
slowing some movement of the body part covered.
6. Spica turn (modification of figure-of-eight turn) used to cover larger areas such
as upper thigh of lower hip area / upper arm with shoulder.

For Bandages:
98
99

1
Bandage of approximate materials, width,
Various conditions and purpose determine
and length.
the type of use of different bandage.
Dressing change supplies.
Available to change dressing if required.
Safety pins, clips, or tape.
Secure the bandage.
Key Points for Bandage Application:

1
Action
Position body parts to be bandaged in
comfortable position of normal
anatomical alignment.
Rationale
Bandages can cause restriction in
movement. Immobilization in normal
functioning position reduces risks of
deformity or injury.
Skin surfaces in contact with each other
(e.g., between toes or under breasts) can
rub against each other to cause abrasion or
chafting. Bandages over bony prominences
may rub against each other to cause
breakdown.
Prevent friction between and against

surfaces by applying gauze or cotton
padding.
Apply bandages securely to prevent

slipping during movement.
Friction between bandages and skin can

cause skin breakdown.
When bandaging extremities, apply

bandage first at distal end and progress
toward trunk.
Gradual application of pressure from distal

toward proximal portion of extremity
promotes venous return and minimizes risk
of edema or circulatory impairment.
Apply bandages firmly, with equal

tension exerted over each turn on layer.
Avoid excess overlapping of bandage
layers.
Position pins, knots, or ties away from
wound or sensitive skin areas.
Equal tension prevents unequal pressure

distribution over bandaged body part.
Localized pressure causes circulatory
impairment.
Pins and ties used to secure bandages and
binders can exert localized pressure and
irritation.
100
Procedure for BANDAGING:

1
2
3
4
5
Explain the procedure and its purposes to

the client.
Prepare all the materials needed.
Wash hands.
Close door or draw the curtains.
Inspect the skin for abrasions, edema,
discoloration, or exposed wound edges.
For the client to cooperate and participate.

Organizes the procedure saving time,
effort and energy.
Provide privacy.
Assess the condition of underlying

dressings and change them if they are
soiled.
Cover exposed wounds or open

abrasions with a sterile dressing.
Assess skin of underlying body parts that
will be distal to the bandage for signs of
circulatory impairment (coolness, pallor
or cyanosis, diminished or absent pulses,
swelling, numbness, and tingling.
Assist the client to assume a comfortable
position, maintaining a position of normal
function for the body.
Provide a means for comparing changes

in circulation after bandage application.
Prevents deformity and increase

circulation to the affected area.
Bandages on the lower extremities are

applied before the client sits or stands.
8
9
10
11
12
An extremity may be elevated for 15 to

30 minutes before wrapping.
Hold the bandage in the dominant hand
with the roll up.
Unroll 3 to 4 inches of the bandage.
Hold the end of the bandage in place on
top of the distal part using the fingers of
the non-dominant hand.
Leave a portion of the distal part exposed,
such as the toes or fingers.
Bring the bandage down and around the
body part unrolling and stretching slightly
if elastic.
To encourage adequate venous return.

Facilitates control when stretching and
unrolling the bandage.
Maintains uniform tension.
Allows later inspection and palpation of

distal parts for neuro-vascular assessment.
101

13
Wrap the bandage directly over the held

end and fasten it with safety pin, clip, or
tape.
Note:
Use circular turns to begin and end a
bandage. This is called anchoring.
Anchors the bandage at the end.
Provides security and support to the

bandage.
In bandaging the foot, start at the side of

the foot so that the end will not cause
pressure over the bony area on the upper
foot or create discomfort on the bottom of
the foot when the patient walks.
To wrap a Spica Bandage:

14
15
16
17
18
19
Anchor with two circular turns.

Bring the bandage up and around the body
part.
Wrap bandage down and around the other
body part forming a figure-8.
Continue in this pattern until the area is
covered. Leave tips of finger and toes
exposed.
End with two circular turns.
Fasten with tape, safety pins, or clips.
Varies the figure-8 turn used to cover

large areas.
Covers body areas such as thumb, groin,
breast, shoulder, and hip.
Provides a means of checking circulation
in the bandaged extremity.
Prevents unwrapping.
For all bandage types:

20
Inspect bandage at frequent intervals for

intactness and constant tension; assess the
neurovascular status of the extremity.
Ensures the bandage is in place and is of

benefit to the client.
102
Types of Bandage Turns

Type
Description
Cecil/Feb./08
Purpose or Use
Spiral Reverse
Figure of Eight
Spica
103
BINDERS
Types and Purposes of binders:
1. The abdominal binder (straight) is used to
provide support and protection to the
abdomen. It is made of a rectangular fabric
(a bath blanket or draw sheet) and long
enough to encircle the body and extend from
the lower ribs to the symphysis pubis.
Commercially made binders are rectangular
and made from heavy fabric or elastic
with a Velcro closure.
2. The scultetus or many-tailed binder is also to provide support to the abdomen or to
secure dressings. This binder is made of flannel and has three to six tails on either side
of solid back. The tails are secured starting above the groin and alternated across the
abdomen to an area just below the ribs.
3. The breast binder is a vest with adjustable

straps and a front closure of safety pins.
Adjustments are made to provide a smooth
fit that does not interfere with respiration.
This binder is used to provide support the
breasts and thorax.
4. The double T-binder (A) is of the same

design as the single T-binder with the
addition of a second trip to aid in securing
rectal and perineal dressings for men. The
straps attached to the waist on either sides of
the penis and scrotum.
5. The single T-binder (B) is made of muslin.
Two narrow strips are sewn together at right
angles, one strip encircles the waist and the
other secures rectal or perineal dressings.
These are most often used for women.
104
6. The sling or triangular binder is made

commercially of muslin. Its purpose is to
provide support to the arm, shoulder, or
hand. Additionally, it limits movement while
not impairing circulation, and reduces edema
to the lower arm and hand.
Objectives:
1. The clients abdominal or scultetus binder is properly applied as evidenced by the
ability to breathe normally; the presence of pulses distal to the binder, and intact skin
integrity.
2. The clients T-binder is properly applied as evidenced by secured perineal or rectal
dressings, adequate scrotal support, and the clients ability to remove and reapply the
binder when needed for elimination.
3. The clients triangular binder (sling) is applied as evidenced by immobilization of the
arm, shoulder, and elbow as therapeutically prescribed without compromised
circulation.
4. The clients binder provides adequate support to the body tissues without discomfort
to the client as evidenced by verbal and nonverbal responses.

For Binders:
Gloves, if wound drainage is present.

Abdominal binder:
o Correct size cloth/elastic
straight binder
o Safety Pins (unless Velcro
closure or metal fasteners are
attached)
T and double T Binders:

o Correct size
o Safety pins
Breast binder:
o Correct size
o Safety pins (unless Velcro closure
or metal fasteners are attached)
105
106
Preparing for the application of a binder

RATIONALE
STEPS
1. Wash hands.
2. Take supplies to the bedside.
3. Explain the procedure to the client.
4. Close door or draw bedside curtains.
Limits transfer of
microorganism.
Promotes client cooperation and
understanding and reduces
anxiety.
Provides privacy.
Procedure:
STEPS
Observe client with need for support of thorax
or abdomen. Observe ability to breath deeply
and cough effectively.
Review medical record if medical prescription

for particular binder is required and reasons
for application.
Inspect the skin for actual or potential

alterations in integrity. Observe for irritations,
abrasions, skin surfaces that rub against each
other, or allergic response to adhesive tape
used to secure dressing.
Inspect any surgical dressing.
RATIONALE
Baseline assessment determines
clients ability to breathe and
cough. Impaired ventilation of
lung can lead to alveolar
atelectasis and inadequate arterial
oxygenation.
Application of supportive binders
may be used on nursing judgment.
In some situations, physician
input is required.
Actual impairments in skin
integrity can be worsened with
application of binder. Binder can
cause pressure and excoriation.
Dressing replacement or
reinforcement precedes
application of any binder.
107

Critical decision point:
Dressing should be clean, dry, and incision/wound should be entirely covered
by dressing.
5
Assess clients comfort level, using analog

scale 0 to 10, and noting any objective signs
and symptoms.
Data will determine effectiveness

of binder placement.
Numerical
A
0
1
No pain
9
10
Severe
pain
Descriptive
B
No
pain
Mild
pain
Moderate
pain
Severe
pain
Unbearable
pain
Visual analog
C
No pain
Unbearable pain
Client designates a point on the scale corresponding to his perception of the

pains severity at the time of assessment.
6
7
Gather necessary data regarding size of client

and appropriate binder.
Explain procedure to patient.
Teach skill to client or significant other.
Wash hands and apply gloves. (if likely to

contact wound drainage).
Close curtains or room door.
10
11
12
13
14
15
16
Apply binder.
Remove gloves and wash hands.
Observe site for skin integrity. Circulation and
characteristics of wound. (Periodically remove
binder and surgical dressing to assess wound
characteristics).
Assess comfort level of client, using analog
scale of 0 to 10 and noting any objective signs
and symptoms.
Assess clients ability to ventilate properly,
including deep, breathing and coughing.
Identify clients need for assistance with
activities such as: hair combing, dressing, and
ambulating.
Ensures proper fit of binder.

Promote clients understanding
and cooperation.
Reduces anxiety and ensures
continuity of care after discharge.
microorganisms.
Maintains clients comfort and
dignity.
Prevents cross infection.
Determines that binder has not
resulted in complication to the
skin, wound or underlying organs.
Binders should not increase
discomfort.
Identifies any impaired ventilation
and potential pulmonary
complications.
Mobility of upper extremities may
be limited depending on severity
and location of incision.
108

Report any skin irritation to nurse at between shift reports.
Record application of binder, condition of skin, circulation, integrity of dressing,
and clients comfort level.
Report ineffective lung expansion to physician immediately.
Home care considerations:
Abdominal, T, and breast binders are washable and are placed over a line to dry.
Instruct care giver to avoid excessive pressure with binder application.
Cecil/Feb./08
Applying a Breast Binder

1
2
3
4
Assist client in placing arms through

binders armholes.
Assist client to supine position in bed.
Pad area under breasts if necessary.

Using Velcro closure tabs, or
horizontally placed safety pins, Secure
binder at nipple level first. Continue
closure process above and then below
nipple line until entire binder is closed.
Make appropriate adjustments,
including individualizing fit if shoulder
straps and pinning waistline darts to
reduce binder size.
Instruct and observe skill development
in self care related to reapplying breast
binder.
Eases binder placement process.

Supine position facilitates normal
anatomical position of breasts;
facilitates healing and comfort.
Prevents skin contact with undersurface.
Horizontal placements of pins may
reduce risk of uneven pressure or
localized irritation.
Maintains support to clients breasts.
Self care is integral aspect of discharge

planning. Skin integrity and comfort
level goals are insured.
Applying an Abdominal Binder

1
Position client in supine position with

head elevated and knees slightly
flexed.
Fanfold binder to its midline.
Instruct and assist client to roll away

from nurse toward raised side rail
while firmly supporting abdominal
incision and dressing with hands.
Minimizes muscular tension on

abdominal muscles.
Supports the muscles and viscera,
reduces tension on an incision, if
present.
Reduces time client remains
uncomfortable position.
Aids in placement of the binder.
Reduces pain and discomfort.
109

4
5
6
7
Place fanfold ends of binder under

client.
Permits placements and centering of

binder with minimal discomfort.
Place fanfold binder under the client,

with its upper border at the waist and
lower border at the gluteal folds.
Instruct client to roll over folded ends.
Unfold and stretch ends out smoothly
on far side of bed.
Reach over the client and straighten the
fanfolded binder until it is smooth and
wrinkle free. Adjust binder so that the
supine client is centered over binder
using symphysis pubis and costal
margins as lower and upper landmarks.
Ensures proper placement that does not

interfere with breathing, ambulation, or
defecation.
Instruct client to roll toward the nurse

back into supine position and over the
fanfold binder.
Maintains skin integrity and comfort.

Assures placement of binder and is
comfortable for the client. A smoothly
applied binder is less likely to impair
skin integrity. Centers support from
binder over abdominal structures, which
reduces incidence of decreased lung
expansion.
Facilitates chest expansion and adequate
wound support when the binder is
closed.
Critical decision point:

Cover any exposed areas of incision or wound with sterile dressing.
9
Pad the bony prominences.
10
15
Check the dressing, if present, to

ensure that it covers wound edges.
Reinforce dressing if needed.
Bring the farthest portion of the binder
firmly over abdomen.
Place the nearest binder end over the
center of the abdomen, while holding
tension on the other binder.
Close binder. Secure by placing safety
pins horizontally or secure the Velcro
closure from the distal to proximal
edges. Rub the Velcro surfaces firmly
together to ensure full contact.
Place darts or tucks as needed to
provide a snug fit. Allow room for
breathing.
Assess clients comfort level.
16
Adjust binder as necessary.
11
12
13
14
Prevents skin breakdown from

prolonged pressure.
Limits potential for infection.
Applies firm support against the

abdominal structures.
Provide continuous support and comfort.
Enhances venous blood flow.
Provides tailored fit that is comfortable

and provides uniform support.
Helps determine effectiveness of binder
application.
Promotes comfort and chest expansion.
110
Applying Scultetus Binder

1
2
5
6
Complete steps 1 through 10 as before.

Bring the distal tail on the side
opposite you across the clients
abdomen and hold it firmly against the
abdomen; if longer than the abdomen,
fold it back on itself.
Bring the opposite tail across the
abdomen while maintaining tension on
the first tail.
Fasten the tail with safety pin or Velcro
or Repeat steps 11 through 12,
smoothing Away wrinkles, until all
tails are in place.
Sculpture tail to accommodate body
shape.
Fasten visible tail ends with safety pins
or Velcro straps.
Provides maximum upward support.
Provides smooth, even surfaces of

tension against the abdomen.
Reduces pressure areas from wrinkles.
Provides adequate support while

maintaining comfort.
Secures binder in position with sufficient
pressure against the muscles to provide
support.
Applying a Single or Double T Binder

1
2
3
4
5
6
7
Prepare for the application.

Assist the client to a dorsal recumbent
position.
Have client raise hips.
Check or change the perineal rectal
dressing
Help the client to turn away from you.
Positions client for proper placement of

the binder.
Place the horizontal band (waistband)

around the waist above the iliac crest.
Bring the remaining strap (perineal
Secures dressing in place.
strap) down the mid-back and through
the perineal area to the lower abdomen.
Attach the perineal strap to the waist
Secures the strap in place.
band by overlapping them and securing
with a horizontal safety pin.
111
If a double T-binder
1
2
3
Apply in the same manner but place

the perineal straps on either side of the
genitalia.
Observe the client for comfort as he
lies, sits, or stands.
Adjust dressings and binder as needed
for comfort and to reduce pressure and
rubbing.
Instruct client to remove and reapply
binders as necessary.
Ensures adequate fit without discomfort

from rubbing or chafing of the binder.
Prevents skin breakdown by pressure
ischemia.
Encourages independence.
Applying Single T and Double T Binders

1
Assist client to dorsal recumbent position,

with lower extremities slightly flexed and
hips rotated slightly outward.
2
Have client raise hips and place horizontal
band around clients waist (or above iliac
crest) with vertical tails extending past
buttocks. Overlap waistband in front and
secure with safety pins.
3
Complete binder application:
a. Bring remaining vertical strip over
perineal dressing and continue up and
under center front of horizontal band.
Bring ends over waist band and secure all
thickness with safety pin.
4
Assess clients comfort level with client in
lying, sitting, and standing positions.
Readjust front pins and tails as necessary,
ensuring that tails are not too tight.
Increase padding if any area rubs against
surrounding tissues.
5
Instruct client regarding removal of binder
before defecating or urinating and need to
replace binder after performing these
bodily functions.
Minimizes tension on perineal

organs.
Permits placement of binder. Secures
binder around client.
T binders provide support to perineal

muscles and organs and help
maintain placement of perineal or
suprapubic dressing.
Determines efficacy of binder to
maintain dressings and support
perineal structures.
Cleanliness of binders reduces

infection risk.
112
Applying a Triangular Bandage (Sling)

1
2
3
4
5
7
8
9
Prepare for application.

Close the door or draw bedside curtains.
Place the client in a sitting position with
fingers higher than hand, hand higher
than the arm, and elbow flexed 90, in
correct alignment.
Place the open end of the bandage on the
uninjured shoulder.
Place the open bandage under the
affected arm with the longest edge of the
hand.
Bring bandages other point up over the
arm, across the affected shoulder, and
around the neck.
Adjust the arm for the correct angle

and alignment.
Tie a square knot with the points at the
shoulder level.
Support the wrist and hand of the
affected arm by manipulating the edge
of the bandage.
Provides privacy.
Allows easier application of the sling.
Elevation of the extremity increases
venous return.
Positions the bandage so that it can

be secured to immobilize the arm.
Assures adequate venous return and

reduces potential for edema.
Avoids exerting pressure on the neck by
the knot.
Lessens pressure of the bandage against
the hand and wrist, thus reducing the
potential for edema.
113

10
11
12
13
Fold the apex smoothly around the

elbow and fasten with a safety pin.
Apply padding to areas where the
bandage presses against the soft
tissues. (This may happen around the
neck, the axilla, and between the wrist
and a cast.
Inspect the bandage for proper support
of the arm, alignment of the arm, and
pressure of the knot against the
shoulders, assess the neurovascular
condition of the skin and arms.
Instruct the client or caregiver to apply
the sling using these same steps.
Provides adequate elbow support and

alignment.
Prevents development of pressure points
of sores.
Detects improper alignment,

compromised circulation, or nerve
compression.
Applying Collar and Cuff:

1
2
3
Secure the cuff to the client's wrist.

Place the collar around the client's neck
making sure it is secure but not restrictive.
Loop a strap through the cuff and collar to
suspend the wrist. The final position of the
elbow should be at slightly less than
degrees flexion.
Applying Commercial Sling:

1
2
Place the injured arm in the fabric holder with the elbow in the seamed corner.
Loop the attached strap across the chest toward the uninjured side, and loop it
behind the neck, and then down the chest to the D-rings at the wrist end of the
holder.
Pass the strap upward through the rings, and secure the Velcro edges together with
the elbow flexed as slightly less than 90 degrees.
Age-specific Considerations:
1. Slings are generally not suitable for children with fractures of the humerus or elbow.
The preferred treatment is a sling and swathe, plaster casting, or surgical
interventions. Subluxation of the radial heads
2. Additional padding behind the neck may be needed for an elderly patient to avoid
excessive pressure over the spine from the weight of the arm in the sling.
Complications of the Sling:

1. Compression of soft tissues in the back.
2. Increased edema of the distal limb as a result of greater than 90 degrees elbow flexion
in the sling.
Patient Education of the Sling:

1. Keep the knot positioned at the side of the neck and not directly over the spine to
avoid excessive pressure on blood vessels, nerves, and spinous processes.
114

2. Keep the hand above elbow level and open and close hand and wiggle fingers
frequently to prevent or decrease swelling.
SHOULDER IMMOBILIZATION
(also known as sling and swathe and Velpeau's bandage)
Indications:
1. To immobilize the clavicle, acromioclavicular joint, shoulder, or proximal humerus. A
sling and swathe is also useful for anterior dislocations of the shoulder.
2. To immobilize unstable fractures of the proximal humerus to prevent recurrent
dislocation as a result of contraction of the pectoralis major muscles (Velpau's
bandage.
3. Too provide greater immobilization than a sling alone because the chest wall acts as a
splint.
Equipment:
1. Commercial sling and swathe or
2. 2 to 3 triangular bandages to create a sling and swathe or
3. 3 to 4 of 6-inch wide elastic bandage or 3 to 4 M length of stockinette to create a
Velpau's bandage.
4. Safety pins.
5. Axillary padding (i.e., gauze dressing, bandage, cast padding).
Patient Preparation:
1. Pad the axilla on the affected side, across the chest where the arm will lie, and over
the opposite shoulder where the bandaging material will lie.
2. Flex the elbow on the injured side and place the forearm across the chest.
Procedure:
A. Shoulder Immobilizer.
Follow steps of "sling Application".
Apply the elastic band around the chest, and secure with the Velcro fastener.
Fasten the arm strap around the humerus, and then fasten the wrist strap around the
lower forearm.
B. Valpeau's Bandage.
1. Position the affected arm across the chest so that the hand rests on the opposite
shoulder.
2. Roll the bandage away from the injury beginning underneath the crossed arm in the
center of the chest, and pass the roll under the uninjured axilla.
3. Continue the roll diagonally behind the client's back and over the top of the affected
115

shoulder.
4. Roll downward diagonally over the folded arm and then loop the bandage behind the
elbow, across the middle of the humerus, and through the axilla.
5. Repeat the diagonal roll over the shoulder on the affected side, covering the upper
arm and supporting the elbow. Continue into the axilla.
6. Encircle the entire thorax and affected arm.
7. Continue the pattern of alternating the roll of the bandage over the shoulder and arm
with a pass around the torso.
Gilchrist Stockinette-Velpeau Sleeve:

1. Cut a piece of 4-inch wide stockinette into a 3 to 4 M (approximately 10 to 12 ft)
length. Make a horizontal alit halfway across the width of the stockinette
approximately on third from one end.
2. Insert the client's affected arm into longer end of stockinette until the axilla rests in
the slot.
3. Place the injured arm across the chest. Pass the long end of the stockinette around the
client's back, through the space between the injured arm and chest, and loosely drape
it over the client's forearm.
4.
Pass the shorter end of the stockinette around the client's neck, loop it around the
wrist, and secure with a safety pin.
5. Pull the loose end of the stockinette tightly, wrap it around the affected arm, and
secure
116
117
118
APPENDIX A
HANDWASHING
PERFORMANCE CHECK LIST
Name: _________________________________ ID # _______________Date: ________
Objectives/Purposes: Hand washing is performed to:

1. Remove the natural body oil and dirt from the skin.
2. Remove transient microbes, those normally picked up by the hands in the usual
activities of daily living.
3. Reduce the number of resident microbes, those normally found in the skin.
4. Prevent the transmission of microorganisms from client to client / from nurse to family /
from client to nurse.
5. Prevent the cross-contamination among clients.
Equipment and Supplies

o Source of running water
(warm if available)
o Soap
o Soap dish
o Orangewood stick
o Towel or tissue paper
o Lotion
Procedure:
STEPS
5 4
1
2
3
Scale
3 2
Stand in from of the sink. Do not allow

your uniform to touch the sink during
the washing procedure.
Remove jewelries.
Turn on water and adjust the force.
Regulate the temperature until the water
is warm.
Wet the hands and wrist area. Keep
hands lower than the elbows to allow
water to flow toward the fingertips.
Comments
1
119

5
Use about one teaspoon of liquid soap

from the dispenser or lather thoroughly
with bar soap. Rinse bar, and return it to
soap dish.
With firm rubbing and circular motions,
wash the palms and back of the hands,
each finger, areas between the fingers,
the knuckles, wrists, and forearms at
least as high as contamination is likely
to be present.
Continue this friction motion for 10 to

30 seconds.
8 Use fingernails of the other hand or use
orangewood stick to clean under
fingernails.
9 Rinse thoroughly.
10 Dry hands and wrists with paper towel.
Use paper towel to turn off the faucet.
11 Use lotion on hands if desired.
TOTAL
Legend:
%
Scale
Description
Verbal Description
93-100
86-92
5
4
Excellent
Very Satisfactory
80-85
Satisfactory
75-79
72-74
2
1
Fair
Poor
Demonstrated all the time or outstandingly

Demonstrated in the fullest sense,
completely or absolutely
Demonstrated at a given time or good
enough
Demonstrated rarely or in a fair manner
Not demonstrated at anytime
COMMENTS:
Evaluator Signature
Student Signature
120
DONING OF GLOVES
Performance Checklist
Name:
id#
Date:
Equipment:
Clean gloves
Trash receptacle
Procedure:
STEPS
SCALE
1
2
3
4
5
6
7
COMMENTS
5
Wash your hands.
Remove the gloves from the dispenser

Hold glove at wrist edge and slip fingers into
openings .Pull glove up to wrist
Place gloved hand under wrist of second
glove and slip fingers into opening
Remove glove by pulling off. touch only
outside of the glove at cuff,so that gole turns
inside out
Place rolled-up glove in palm of second hand
Remove second glove by slipping one
finger under glove edge and pulling down
and off so that glove turns inside out.
Dispose off gloves in proper container , not

at bedside.
TOTAL:
Legend:
%
Scale
Description
Verbal Description
93-100
86-92
5
4
Excellent
Very Satisfactory
80-85
Satisfactory

enough
121

75-79
72-74
2
1
Fair
Poor

COMMENTS:
Evaluator Signature
Student Signature
122
AXILLARY TEMPERATURE (ELECTRONIC )

Performance checklist
Name:
id#
Date:
Purpose:
To establish subsequent data for baseline evaluation.
To identify whether the core temperature is within normal range.
To determine changes in the core temperature in response to specific
therapies(medication, surgeries, etc.)
To monitor clients at risk of imbalanced body temperature.(eg. infection, extremes of
temperature exposure).
Assessment:
Clinical signs of fever/hyperpyrexia.
Clinical signs of hypothermia.
Equipment:
Electronic Thermometer.
Thermometer sheath or cover.
Towel if required.
Procedure:
STEPS
SCALE
0
1
2

Prior to performing the procedure introduce
self .Explain the procedure to the client, why
it is necessary, and how he or she can
participate.
3 Gather the equipment.
4
Perform hand wash.
5
6 Remove the clients arm and shoulder from
the sleeve of the gown to expose the axilla.
7 Make sure axillary skin is dry, If necessary
pat dry.
8 Place disposable protective sheath over
probe.
9 Place the probe in the centre of the axilla .
Fold the client's arm across chest. place until
audible signal of recording is heard.
10 Hold the probe in place until audible signal
of recording is heard.
11 Read the temperature reading dispose off the
probe cover by pressing the probe release
button.
12 Inform the client about the temperature
reading.
COMMENTS
2
123

13
14
15
Wash hands.
Record reading.
Replace the thermometer in its charger or
holder.
TOTAL:
Legend:
%
Scale
Description
Verbal Description
93-100
86-92
Excellent
Very Satisfactory
80-85
Satisfactory
75-79
72-74
Fair
Poor

enough
COMMENTS:
Evaluator Signature
Student Signature
124
RECTAL TEMPERATURE (ELECTRONIC )

Name:
id#
Date:
Purpose:
to identify whether the core temperature is within normal range.
Assessment:
Equipment:
Water soluble lubricant for rectal temperature.
Clean gloves for rectal temperature.
Procedure:
STEPS
SCALE
0
1
2
3
4
5
6
7
8

participate.
Perform hand wash .
Don gloves
Place client in semi- lateral position or Sims
position.
Place disposable protective sheath over probe
and lubricate it with a water soluble
lubricant.
With the dominant hand, grasp the
thermometer. With the other hand separate
the buttocks so that the anal sphincter is seen
clearly.
COMMENTS
2
125

10 Instruct the client to take a deep breath and
gently insert the thermometer into the anus.(
about 3.8 cm in adult,2.5cm in child and
1.25cm in infants.)
11 Holding the thermometer in place ,let the
buttocks fall into place, keep holding until
audible signal of recording is heard.
12 Read the temperature reading dispose off the
probe cover by pressing the probe release
button.
13 Inform the client about the temperature
reading.
14 Remove Gloves and wash hands.
15 Record reading.
16 Replace the thermometer in its charger or
holder.
TOTAL:
Legend:
%
Scale
Description
Verbal Description
93-100
86-92
Excellent
Very Satisfactory
80-85
Satisfactory
75-79
72-74
Fair
Poor

enough
COMMENTS:
Evaluator Signature
Student Signature
126
ORAL TEMPERATURE (ELECTRONIC )

Name:
id#
Date:
Purpose:
To identify whether the core temperature is within normal range.
Assessment:
Equipment:
Procedure:
STEPS
SCALE
0
1
2
3
4
5
6
7
8
9
10
11
12
13
Identify the patient.

participate.
Perform hand wash .
Place disposable protective sheath over
probe.
.Grasp top of the probe's stem and place the
tip of the thermometer under the clients
tongue and along the gum line.
Instruct the client to keep mouth closed
around the probe.
Hold the probe in place until audible signal
of recording is heard.
.Read the temperature reading dispose off
the probe cover by pressing the probe release
button.
. Inform the client about the temperature
reading.
Wash hands.
Record reading.
COMMENTS
2
127

14
Replace the thermometer in its charger or

holder.
TOTAL:
Legend:
%
Scale
Description
Verbal Description
93-100
86-92
Excellent
Very Satisfactory
80-85
Satisfactory
75-79
72-74
Fair
Poor

enough
COMMENTS:
Evaluator Signature
Student Signature
128
Heart Rate
Name:
id#
Date:
Equipment:
Watch with a second hand or indicator.
If using Doppler/ultrasound stethoscope:
Transducer in the probe
Stethoscope headset
Transmission gel
Procedure:
STEPS
0
1
Determine need to assess radial or apical

pulse:
c. Note risk factors for alterations in
apical pulse
Assess for signs and symptoms of altered
SV (stroke volume) and CO such as
dyspnea, fatigue, chest pains,
orthopnea, syncope, palpitations, jugular
venous distension, edema of dependent
body parts, cyanosis or pallor of skin.
Assess for factors that normally influence

apical pulse rate and rhythm:
a.
b.
c.
d.
e.
f.
3
4
5
6
Age
Exercise
Position changes
Medications
Temperature
Emotional Stress, anxiety, fear
Determines previous baseline balance apical

site.
Explain that PR or HR is to be assessed
Wash hands
If necessary, draw curtain around bed and/or
close door.
COMMENTS

7
Obtain pulse measurement.
A. Radial Pulse
1.Assist client to assume supine position
2. If supine, place clients forearm along
side or across lower chest or upper abdomen
with wrist extended straight. If sitting, bend
clients elbow 90 and support lower arm on
chair on nurses arm. Slightly extend wrist
with palms down.
3.Place tips of first two fingers of hand over
groove along radial or thumb side of clients
inner wrist.
4.Lightly compress against radius, obliterate
pulse initially, and then relax pressure so
pulse becomes easily palpable.
5.Determine strength of pulse. Note whether
thrust of vessel against fingertips is
bounding, strong, weak or thready.
6.After pulse can be felt regularly, look at
watchs second and begin to count rate; when
sweep hand hits number on dial, start
counting with zero, then one, two, and so on.
If pulse is regular, count rate for 30 seconds
and multiply by 2,
If pulse is regular, count rate for 60 seconds.
Assess frequency and pattern if irregularity.
B. Apical pulse
1
Assist client to supine or sitting position.

Move aside bed linen and gown to expose
sternum and left side of chest.
Locate anatomical landmarks to identify the

points of maximal impulse (PMI), also called
the apical impulse. Heart is located behind
and to left of sternum with base at top and
apex at bottom.
Find angle of Louis just below suprasternal
notch between sternal body and manubrium;
can be felt as a bony prominence. Slip fingers
down each side of angle to find second
intercostal space. (ICS).
Carefully move fingers down left side to the
left midclavicular line (MCL).
A light tap felt within an area 1 to 2 cm (
to 1 inch) of the PMI is reflected from the
apex of the heart
129
130

3
Place diaphragm of stethoscope in palm of

hand for 5 to 10 seconds.
Place diaphragm of stethoscope over PMI at

the fifth ICS, at left MCL, and auscultate for
normal S1 and S2 heart sounds (heard as lub
dub).
When S1 and S2 are heard with regularity, use
watchs second hand and begin to count rate;
when sweep hand hits number on dial, start
counting with zero, then one, two, and so on.
If apical rate is regular, count for 30 seconds

and multiply by 2.
If HR is irregular or client is receiving

cardiovascular medications, count for
1 minute (60 seconds).
Discuss findings with client as needed.
Clean earpieces and diaphragm of

stethoscope with alcohol swab as needed.
10 Wash hands.
11 Compare readings with previous baseline
and/or acceptable range of heart rate for
clients age.
12 Compare peripheral pulse rate with apical
pulse rate and note discrepancy.
13 Compare radial pulse equality and note
discrepancy.
14 Correlate PR with data obtained from BP and
related signs and symptoms (palpitations,
dizziness).
TOTAL:
Legend:
%
Scale
Description
Verbal Description
93-100
86-92
Excellent
Very Satisfactory
80-85
Satisfactory
75-79
72-74
Fair
Poor

enough
131
COMMENTS:
Evaluator Signature
Student Signature
132
Respiratory Rate
Name:
id#
Equipment:
Watch with second hand.
Date:
Paper, pencil
Vital signs record.
Procedure:
STEPS
0
1
Determine need to assess clients

respirations::
A .Note risk factors for respiratory
alterations.
b. Assess for signs and symptoms of
respiratory alterations such as bluish or
cyanotic appearance of nail beds, lips,
mucous membranes, and skin;
restlessness, irritability, confusion,
reduced level of consciousness; pain
during inspiration; labored or difficult
breathing; adventitious sounds, inability
to breathe spontaneously; thick, frothy,
blood-tinge, or copious sputum
produced on coughing.
2
3
4
5
6
7
Assess pertinent laboratory values:

ABGs, (SpO2, CBC,
Determine previous baseline respiratory rate
(if available) from clients record.
Be sure client is in comfortable position,
preferably sitting or lying with the head of
the bed elevated 45 to 60 degrees.
Wash hands
Draw curtain around bed and/or close door.
Wash hands.
Be sure clients chest is visible. If necessary,
move bed linen or gown.
COMMENTS
133

8
Place clients arm in relaxed position across

the abdomen or lower chest, or place nurses
hands directly over clients upper abdomen.
Observe complete respiratory cycle (one
inspiration and one expiration).
10 After cycle is observed, look at watch s

second hand and begin to count rate: when
sweep hand hits number on dial, begin time
frame, counting one with first full respiratory
cycle.
respirations in 30 seconds and multiply by 2.
If rhythm is irregular, less than 12, or greater
than 20, count for 1 full minute.
respirations in 30 seconds and multiply by 2.
If rhythm is irregular, less than 12, or greater
than 20, count for 1 full minute.
13 Note depth of respirations subjectively
assessed by observing degree of chest wall
movement while counting rate. Nurse can
also objectively assess depth by palpating
chest wall excursion after rate has been
counted. Depth is shallow, normal, or deep.
14 Note rhythm of ventilatory cycle. Normal
breathing is regular and uninterrupted.
Sighing should not be confused with
abnormal rhythm.
15 Replace bed linen and clients gown.
16 Wash hands.
17 Discuss findings with client as needed.
TOTAL:
Legend:
%
Scale
Description
Verbal Description
93-100
86-92
Excellent
Very Satisfactory
80-85
Satisfactory
75-79
72-74
Fair
Poor

enough
COMMENTS:
Evaluator Signature
Student Signature
134
Moving the Client up in the Bed

Turning sheet
This is a bath blanket or sheet folded in half or

quarters and positioned under the client and over the
bottom bed liners. It is used for moving the client.
Trapeze
Siderails
Provides the client with a means to move in bed.
Procedure:
1. Introduce yourself, verify the client identity, explain to the client what you are going
to do, why, how he-she can participate.
2. Perform hand hygiene.
3. Provide privacy
2.
3.
STEPS
Adjust the bed of the client:
a) Head of bed flat position or low as
the client can tolerate.
b) Raise the entire bed to the height
necessary to avoid bending down
when working with client.
c) Lock the wheels of the bed and raise
the rail on the side of the bed
opposite to you.
d) Remove the pillow from under the
clients head and place it upright
against the headboard
For the client who is able to reposition

without assistance:
a) Stand by and instruct him to move
his self. Assess if the client can move
without friction of the skin.
b) Ask if positioning device required
(pillow)
For the client who is partially able to assist:
a) For the client who weigh less than
90kg, use a friction reducing device
and two to three assistants.
b) For the client who weigh more than
90 kg use a friction reducing device
and three assistants.
Comments

c) Ask the client to flex the hips and
knees and position the feet so that
they can be used effectively for
pushing.
d) Position the clients arms on chest,
one arm folded on the other. Ask the
client to flex the neck during the
move and to keep the head off the
bed surface.
d. Use a friction reducing device and
assistants to move the client up in the
bed. Ask the client to push on the count
of three.
135
136

4
Position yourself appropriately:

a) Stand at an angle to the side of the
bed with your feet about 2 ft. apart,
one foot on front of the other. Flex
the hip knees and ankles.
b) Tighten your gluteal, abdominal, leg
and arm muscles and rock from the
back leg to the front leg and back
again. Then shift your weight on the
front leg as the client pushes with
heels so that the client moves toward
the head of the bed.
For the client who is unable to assist:

( using turn sheet)
a) Place a drawsheet or a full sheet
folded in half under the shoulders to
the thighs. Each person rolls up or
fanfolds the turn sheet close to the
client\s body on either side.
b) Both individuals grasp the sheet
close to the shoulders and buttocks
of the client.
c) Assist the client to flex the knees.
Place the arms across the chest.
d) Position yourself as described
previously.
Ensure client comfort

Elevate the head of the bed and
provide appropriate support devices
for the client\s new position.
Document all relevant information, record:
a) Time and change of position moved
from and position moved to.
b) Any signs of pressure ulcer.
c) Use of support device.
d) Ability of the client to assist in
moving and turning.
e) Response of the client to moving or
turning
(anxiety,
discomfort,
dizziness)
TOTAL
Legend:
%
Scale
Description
Verbal Description
93-100
86-92
Excellent
Very Satisfactory

137

80-85
Satisfactory
75-79
72-74
Fair
Poor

enough
COMMENTS:
Evaluator Signature
Student Signature
138
Moving the Client to Lateral or Prone Position

Procedure
1
STEPS
Position yourself and the client appropriately, other person
stand on the opposite side of the bed:
a) Adjust the bed of the client:
b) Head of bed flat position or low as the client can
tolerate.
c) Raise the entire bed to the height necessary to
avoid bending down when working with client.
d) Lock the wheels of the bed and raise the rail on the
side of the bed opposite to you.
e) Move the client closer to the side of the bed
opposite the side the client will face when turned.
Use a friction reducing device to pull the client to
the side of the bed.
f) While standing on the side of the bed nearest the
client; place the client near arm across the chest.
Abduct the clients far shoulder slightly from the
side of the body and externally rotate the shoulder.
g) Place the clients near ankle and foot across the far
ankle and foot.
h) The person on the side of the bed toward which the
client will positioned directly in the line with the
client\s waistline and as close to the bed as possible
Roll the client to the lateral position. The second person

standing on the opposite side of the bed helps roll the
clients from the other side:
a) Place one hand on the clients far shoulder and the
other hand on the clients far hip.
b) Position the client on his or her side with the arms
and leg positioned and supported properly.
Comments
139

3
To turn the client to the prone position follow the

preceding steps with two exception:
a) Instead of abducting the arm, keep the client's arm
alongside the body for the client to roll over
b) Roll the client completely onto the abdomen.
c) Never pull a client across the bed while the client is

in the prone position
4
Document all relevant information:

a) Time and change of position moved from and
position moved to.
b) Any signs of pressure ulcer.
c) Use of support device.
d) Ability of the client to assist in moving and turning.
e) Response of the client to moving or turning
(anxiety, discomfort, dizziness)
TOTAL
Legend:
%
Scale
Description
Verbal Description
93-100
86-92
Excellent
Very Satisfactory
80-85
Satisfactory
75-79
72-74
Fair
Poor

enough
COMMENTS:
Evaluator Signature
Student Signature
140
BODY MECHANICS
Steps of Procedure
1
2
3
4
5
6
7
8
10
11
12
13
14
15
Collect your equipment

Wash your hands
Provide privacy
Introduce yourself to patient
LIFTING
Stand near object of the load to be lifted.
Put on internal girdle.
Method 1
Bend toward object by flexing all the hips and
partially flexing at the knees.
Grasp object and bring it to thigh level by pulling
with arm and shoulder, muscles while thigh and
leg muscles provide an upward thrust.
Bring object to waist level by using the leg and
thigh muscles for greater thrust while beginning
to straighten the back.
Method 2
Position feet 18 inches apart with left foot
forward.
Tuck chin in and squat down with back straight.
Grasp object with both hands, tipping it if
necessary to attain balance.
Rest left elbow on left thigh, just above knee and
apply pressure as needed to stand up. Straighten
legs.
PUSHING
19
Stand close to the object.

Place feet in a walking position (one is in front of
the other)
With hands placed on the object, flex elbows and
lean into the object.
Place the weight from the flexor to the extensor
portions of the leg.
Apply pressure using leg muscles.
20
PULLING
16
17
18
21
22
23
24
Stand close to the object.

Place feet in a walking position (one is in front of
the other)
Hold object and flex elbows and lean away from
the object.
Shift weight from the extensor to the flexor
portions of the leg.
Avoid sudden, jerky movements.
Score
1
Comments
141
25
26
27
28
29
30
PIVOTING
Place one foot slightly ahead of the other.
Turn both feet at the same time, pivoting on the
heel of one foot and the toe of the other.
Maintain a good center of gravity while holding
or carrying the object.
Squat (bending at the hips and knees).
Avoid stooping (bending at the waist).
Use your leg muscles to return to an upright
position.
TOTAL
Legend:
%
Scale
Description
Verbal Description
93-100
86-92
Excellent
Very Satisfactory
80-85
Satisfactory
75-79
72-74
Fair
Poor

enough
COMMENTS:
Evaluator Signature
Student Signature
142
Logrolling a Client
Student Name:
University ID Number:
Procedure
Date:
STEPS
1. Prior to performing the procedure, introduce
self and verify the clients identity using agency

protocol. Explain to the client what you are
going to do, why it is necessary, and how he or
she can participate.
2. Perform hand hygiene and observe other
3. Provide for client privacy.
4. Position yourselves and the client

appropriately before the move.
1) Place the clients arms across the chest
5. Pull the client to the side of the bed.
1) Use a turn sheet or friction-reducing device to
facilitate logrolling. First, stand with another
nurse on the same side of the bed. Assume a
broad stance with one foot forward, and grasp
half of the fanfolded or rolled edge of the turn
sheet or friction-reducing device. On a signal,
pull the client toward both of you. (A)
2) One nurse counts: One, two, three, go. Then,
at the same time, all staff members pull the
client to the side of the bed by shifting their
weight to the back foot.
Feedback
143

6. Move to the other side of the bed, and place
supportive devices for the client when turned.
1) Place a pillow where it will
support the clients head after
the turn.
2) Place one or two pillows
between the clients legs to
support the upper leg when the
client is turned.
7. Roll and position the client in proper alignment.
1) Go to the other side of the bed (farthest from
the client), and assume a stable stance.
2) Reaching over the client, grasp the far edges
of the turn sheet or friction-reducing device,
and roll the client toward you. (B)
3) One nurse counts: One, two, three, go.
Then, at the same time, all nurses roll the
client to a lateral position.
4) The second nurse (behind the client) helps
turn the client and provides pillow supports to
ensure good alignment in the lateral position.
5) Support the clients head, back, and upper and
lower extremities with pillows.
6) Raise the side rails and place the call bell
within the clients reach.
7. Document all relevant information.
Record:
1) Time and change of position moved from
and position moved to
2) Any signs of pressure areas
3) Use of support devices
4) Ability of client to assist in moving and
turning
5) Response of client to moving and turning
(e.g., anxiety, discomfort, dizziness).
Legend:
%
Scale
Description
Verbal Description
93-100
86-92
Excellent
Very Satisfactory
80-85
Satisfactory
75-79
72-74
Fair
Poor

enough
COMMENTS:
Evaluator Signature
Student Signature
144
Dangling A Client
Student Name:
University ID Number:
Procedure
Date:
STEPS
1. Prior to performing the procedure, introduce
self and verify the clients identity using agency

protocol. Explain to the client what you are
going to do, why it is necessary, and how he or
she can participate.
2. Perform hand hygiene and observe other
3. Provide for client privacy.
4. Position yourself and the client appropriately

before performing the move.
1) Assist the client to a lateral
position facing you.
2) Raise the head of the bed
slowly to its highest position.
3) Position the clients feet and
lower legs at the edge of the
bed.
4) Stand beside the clients hips
and face the far corner of the
bottom of the bed (the angle in
which movement will occur).
Assume a broad stance,
placing the foot nearest the
client and head of the bed
forward. Lean your trunk
forward from the hips. Flex your
hips, knees, and ankles.
5. Move the client to a sitting position.
COMMENTS
145

1) Place the arm nearest to the
head of the bed under the
clients shoulders and the other
arm over both of the clients
thighs near knees.
2) Tighten your gluteal,
abdominal, leg, and arm
muscles.
3) Pivot on the balls of your feet in
the desired direction facing the
foot of the bed.
4) Keep supporting the client until
the client is well balanced and
comfortable.
5) Assess vital signs (e.g., pulse,
respirations, and blood
pressure) as indicated by the
clients health status.
6. Document all relevant information.
Record:
1) Ability of client to assist in
moving and turning
2) Response of client to moving
and turning (e.g., anxiety,
discomfort, dizziness).
Legend:
%
Scale
Description
Verbal Description
93-100
86-92
Excellent
Very Satisfactory
80-85
Satisfactory
75-79
72-74
Fair
Poor

enough
COMMENTS:
Evaluator Signature
Student Signature
146
Applying and Removing Personal Protective Equipment (gloves, gown, mask)

Name: ___________________________ ID# _________ Date: ___________
STEPS
Verify client identity and introduce yourself, explain for

the client what you are to do, why it is necessary, and
how he or she can participate.
Perform hand hygiene.
Apply a clean gown:

a. Pick up a clean gown, and allow it to unfold in
front of you without allowing it to touch any
area soiled with body substances.
b. Slide the arms and the hands through the sleeves.
c. Fasten the ties at the neck to keep the gown in
place.
d. Overlap the gown at the back as much as possible
and fasten the waist ties
Applying the face mask:

a. Locate the top edge of the mask; the mask usually
has a narrow metal strip along the edge.
b. Hold the mask by the top two strings.
c. Place the upper edge of the mask over the bridge of
the nose, and tie the upper ties at the back of the
head or secure the loops around the ears.
d. Secure the lower edge of the mask under the chin,
and tie the lower ties at the nape of the neck.
e. If the mask has a metal strip, adjust this firmly over
the bridge of the nose
f. Wear the mask only once
g. Do not let a used mask hanging around the neck.
Apply clean gloves.

If wearing gowns pull the gloves up to cover the cuffs
of the gown
Remove the gloves first since they are the most soiled.
If wearing gown that is tied in front undo ties before
removing the gloves.
Perform hand hygiene
COMMENTS
147

8
Remove the gown when preparing to leave the room

a. Avoid touching soiled parts on the outside of the
gown.
b. Grasp the gown along the inside of the neck and
pull down over the shoulders. Do not shake the
gown.
c. Roll up the gown with the soiled part inside, and
discard it in the appropriate container.
Remove the mask

a)
Remove the mask at the doorway to the clients
room. If using respirator mask, remove it after leaving
the room and closing the door.
a. If using mask with strings, first untie the lower
strings
b. Untie the top string and, while holding the ties
securely, remove the mask from the face. If side
loops are presents , lift the side loops up and away
from the ears and face. Do not touch the front of
the mask.
c. Discard a disposable mask in the waste container.
d. Perform proper hand hygiene again
Verbal description
Description
Able to perform
Able to perform with assistance or

incomplete
Cannot PERFORM at any time
Legend:
%
Scale
Description
Verbal Description
93-100
86-92
Excellent
Very Satisfactory
80-85
Satisfactory
75-79
72-74
Fair
Poor

enough
COMMENTS:
Evaluator Signature
Student Signature
ASSESSING BLOOD PRESSURE
Name: _________________________________________ ID# __________ Date: ______
PURPOSES:
1. To obtain a baseline measure of arterial blood pressure for subsequent evaluation
2. To determine the clients hemodynamic status (e.g., stroke volume of the heart and blood
vessel resistance)
3. To identify and monitor changes in blood pressure resulting from a disease process and
medical therapy (e.g., presence or history of cardiovascular disease, circulatory shock, or
acute pain; rapid infusion of fluids or blood products).
ASSESSMENT
1. Signs and symptoms of hypertension (headache, ringing in the ears, flushing of face,
nosebleeds, fatigue)
2. Signs and symptoms of hypotension
( e.g., tachycardia, dizziness, mental confusion,
restlessness, and clammy skin, pale or cyanotic skin)
3. Factors affecting blood pressure (e.g., activity, emotional stress, pain, and time the client last
smoked or ingested caffeine)
PLANNING
-
Blood pressure measurement may be delegated to UAP (Unlicensed assistive personnel).

The interpretation of abnormal blood pressure readings and determination of appropriate
responses are done by the nurse.
EQUIPMENT:
1.
2.
3.
Stethoscope
Blood pressure cuff of the appropriate size
Sphygmomanometer
IMPLEMENTATION
Preparation
1.
2.
Ensure that the equipment is intact and functioning properly. Check for leaks in the
rubber tubing of the sphygmomanometer.
Make sure that the client has not smoked or ingested caffeine within 30 minutes prior
to measurement.
148
149
STEPS
SCALE COMMENTS
Explain to the client what you are going to do?
e. Why it is necessary, and how he or she can
cooperate.
f. Discuss how the results will be used in planning
further care or treatments.
2
3
4
5
Observe appropriate infection control procedures.

Position the client appropriately.
Wrap the deflated cuff evenly around the upper arm..
a. Locate the brachial artery.
b. Apply the center of the bladder directly over the
artery.
If this is the clients initial examination, perform a

preliminary palpatory determination of systolic
pressure.
a. Palpate the brachial artery with the fingers.
b. Close the knob clockwise.
c. Pump up the cuff until you no longer feel the
brachial pulse.
d. Release the pressure completely in the cuff, and wait
1 to 2 minutes before making further measurements.
Position the stethoscope appropriately.

d. Cleanse the earpieces with alcohol or recommended
disinfectant.
e. Insert the ear attachments of the stethoscope in your
ears so that they tilt slightly forward.
f. Ensure that the stethoscope hangs freely from the
ears to the diaphragm.
g. Place the bell side of the amplifier of the
stethoscope over the brachial pulse.
h. Hold the diaphragm with the thumb and index
finger.
Auscultate the clients blood pressure.

e. Pump up the cuff until the sphygmomanometer
reads 30 mm Hg above the point where the brachial
pulse disappeared.
f. Release the valve on the cuff carefully so that the
pressure decreases at the rate of 2 to 3 mm Hg per
second.
g. As the pressure falls, identify the manometer
reading at each of the five phases.
h. Deflate the cuff rapidly and completely.
i. Wait 1 to 2 minutes before making further
determinations.
If this is the clients initial examination, repeat the

procedure on the clients other arm.
10 Remove the cuff.
11 Wipe the cuff with an approved disinfectant.
9
COMMENTS
150

12 Document and report pertinent assessment data
according to agency policy.
Verbal description
Description
2
1
Able to perform
Able to perform with assistance or
incomplete
Cannot PERFORM at any time
Legend:
%
Scale
Description
Verbal Description
93-100
86-92
Excellent
Very Satisfactory
80-85
Satisfactory
75-79
72-74
Fair
Poor

enough
COMMENTS:
Evaluator Signature
Student Signature
151
CHANGING AN UNOCCUPIED BED
Name:_________________________________________ID#____________Date:________
STEPS
0
1 If the client is in bed, prior to performing the procedure, introduce self and verify the clients
identity using agency protocol. Explain to the client what you are going to do, why it is
necessary, and how he or she can cooperate.
2 Perform hand hygiene and observe other appropriate infection control procedures.
3 Provide for client privacy.
4 Place the fresh linen on the clients chair or over bed table; do not use another clients bed.
5 Assess and assist the client out of bed.
a Make sure that this is an appropriate and convenient time for the client to be out of bed.
b Assist the client to a comfortable chair.
6 Raise the bed to a comfortable working height.
7 Apply clean gloves if linens and equipment have been soiled with secretions and/or
excretions.
8 Strip the bed.
a Check bed linens for any items belonging to the client, and detach the call bell or any
drainage tubes from the linen.
b Loosen all bedding systematically, starting at the head of the bed on the far side and
moving around the bed up to the head of the bed on the near side.
c Remove the pillowcases, if soiled, and place the pillows on the bed-side near the foot of
the bed.
d Fold reusable lines, such as the bedspread and top sheet on the bed, into fourths, First,
fold the linen in half by bringing the top edge even with the bottom edge, and then grasp
it at the center of the middle fold and bottom edges.
e Remove the waterproof pad and discard it if soiled.
f Roll all soiled linen inside the bottom sheet, hold it away from your uniform, and place it
directly in the linen hamper.
g Grasp the mattress securely. Using the lugs if present, and move the mattress up to the
head of the bed.
h Remove and discard gloves if used. Perform hand hygiene.
9 Apply the bottom sheet and draw sheet.
a Place the folded bottom sheet with its center fold on the center of the bed. Make sure the
sheet is hem side down for a smooth foundation. Spread the sheet out over the mattress,
and allow a sufficient amount of sheet at the top to tuck under the mattress. Place the
sheet along the edge of the mattress at the foot of the bed and do not tuck it in (unless it
is a contour or fitted sheet.
b Miler the sheet at the top corner on the near side and tuck the sheet under the mattress,
working from the head of the bed to the foot.
c If a waterproof drawsheet is used, place it over the bottom sheet so that the centerfold is
at the centerline of the bed and the top and bottom edges extend from the middle of the
clients back to the area of the midthigh or knee. Fanfold the uppermost half of the folded
draw sheet at the center or far edges of the bed and tuck in the edge.
d OPTIONAL: before moving to the other side of the bed, place the top linens on the
hemside up, unfold them, tuck them in, and miter the bottom corners.
10 Move to the other side and secure the bottom linens.
a Tuck in the bottom sheet under the head of the mattress, pull the sheet firmly, and miter
the corner of the sheet.
b Pull the remainder of the sheet firmly so that there are no wrinkles. Tuck the sheet in at
the side.
152
c Tuck in the drawsheets, if appropriate.

11 Apply or complete the top sheet, blanket, and spread.
a Place the top sheet, hem side up; on the bed so that its centerfold is at the center of the
bed and the top edge is even with the top edge of the mattress.
b Unfold the sheet over the bed.
c Follow the same procedure for the blanket and the spread, but place the top edges about
15 cm (6 in.) from the head of the bed to allow a cuff of sheet to be folded over them.
d Tuck in the sheet, blanket, and spread at the foot of the bed, and miter the corner, using
all three layers of linen. Leave the sides of the top sheet, blanket, and spread hanging
freely unless toe pleats were provided.
e Fold the top of the top sheet down over the spread, providing a cuff.
f Move to the other side of the bed and secure the bedding in the same manner.
12 Put clean pillowcases on the pillows as required.
a Grasp the closed end of the pillowcase at the center with one hand.
b Gather up the sides of the pillowcase and place them over the hand grasping the case.
Then grasp the center of one short side of the pillow through the pillowcase.
c With the free hand, pull the pillowcase over the pillow.
d Adjust the pillowcase so that the pillow fits into the corners of the case and the seams are
straight.
e Place the pillows appropriately at the head of the bed.
13 Provide for client comfort and safety.
a Attach the signal cord so that the client can conveniently reach it. Some cords have
clamps that attach to the sheet or pillowcase. Others are attached by safety pin. Most bed
now have call light bottom on the side rail.
b If the bed is currently being used by a client, either fold back the top covers at one side or
fanfold them down to the center of the bed.
c Place the bedside table and the overbed table so that they are available to the client.
d Leave the bed in the high position if the client is returning by stretcher, or place in the
low position if the client is returning to bed after being up.
14 Document and report pertinent data.
a Bed-making is not normally recorded.
b Recording any nursing assessments, such as the clients physical status and pulse and
respiratory rates before and after being out of bed, as indicated.
Legend:
%
Scale
Description
Verbal Description
93-100
86-92
Excellent
Very Satisfactory
80-85
Satisfactory
75-79
72-74
Fair
Poor

enough
COMMENTS:
Evaluator Signature
Student Signature
153
CHANGING AN OCCUPIED BED
Name:_______________________________________ID#_______________________Date:_______________
_
STEPS
1
Prior to performing the procedure, introduce self and verify the clients identity using agency protocol. Explain to the
client what you are going to do, why it is necessary, and how he or she can cooperate.
2
Perform hand hygiene and observe other appropriate infection control procedures. Apply clean gloves if linens are
soiled with body fluids.
3
4
Remove the top bedding.
a Remove any equipment attached to the linen, such as signal light.
b Loosen all top linen at the foot of the bed, and remove the spread and the blanket.
c
Leave the top sheet over the client (the top sheet can remain over the client if it is being changed and if it will
provide sufficient warmth), or replace it with a bath blanket as follows:
a Spread the bath blanket over the top sheet.
b Ask the client to hold the top edge of the blanket.
c
Reaching under the blanket from the side, grasp the top edge of the sheet and draw it down to the foot of
the bed. Leaving the blanket in place.
d Remove the sheet from the bed and place it in the soiled linen hamper.
5
Change the bottom sheet and draw sheet.
a
Raise the side rail that the client will turn toward. If there is no side rail, have another nurse support the client at
the edge of the bed.
b
Assist the client to turn on the side away from the nurse and toward the raised side rail.
c
Loosen the bottom linens on the side of the bed near the nurse.
d
Fanfold the dirty linen (e.g., draw sheet and the bottom sheet toward the center of the bed. As close to and
under the client as possible.
e
Place the new bottom sheet on the bed, and vertically fanfold the half to be used on the far side of the bed as
close to the client as possible. Tuck the sheet under the near half of the bed and miter the corner if a contour
sheet is not being used.
f
Place the clean drawsheet on the bed with the center fold at the center of the bed. Fanfold the uppermost half
vertically at the center of the bed and tuck the near side edge under the side of the mattress.
g
Assist the client to roll over toward you, over the fanfold bed linens at the center of the bed, onto the clean side
of the bed.
h
Move the pillows to the clean side for the clients use. Raise the side rail before leaving the side of the bed.
i
Move to the other side of the bed and lower the side rail.
j
Remove the used linen and place it in the portable hamper.
k
Unfold the fanfold bottom sheet from the center of the bed.
l
Facing the side of the bed, use both hands to pull the bottom sheet so that it is smooth and tuck the excess
under the side of the mattress.
m Unfold the drawsheet fanfold at the center of the bed and full it tightly with both hands. Pull the sheet in three
divisions: (a) face the side of the bed to pull the middle division, (b) face the far top corner to pull the bottom
division, and (c) face the far bottom corner to pull top division.
6
n
Tuck the excess drawsheet under the side of the mattress.
Reposition the client in the center of the bed.
a
Reposition the pillows at the center of the bed.
b
Assist the client to the center of the bed. Determine what position the client requires or prefers and assist the
client to that position.
Apply or complete the top bedding.
a
Spread the top sheet over the client and either ask the client to hold the top edge of the sheet or tuck it under
the shoulders. The sheet should remain over the client when the bath blanket or used sheet is removed.
b
Complete the top of the bed.
Ensure continued safety of the client.
a
Raise the side rails. Place the bed in the low position before leaving the bedside.
b
Attach the call light bed linen within the clients reach
c
Put items used by the client within easy reach.
EVALUATION
COMMENTS:
Evaluator Signature: ____________________
Students' signature: _________________________
0 1
REFERENCES:
1. Kozier & Erbs, (2011). Fundamentals of Nursing. 9th Edition.
2. Potter & Perry, (2009). Fundamentals of Nursing, 7th Edition, by
Elsevier Faculty Development and Training.
3. Delaune S.C., & Ladner P.K. (2002). Fundamentals of Nursing/
Standards & Practice. 2nd Edition. Published by Delmar & Thomson
Learning.
4. Gaylene Bouska Altman.(2005). Delmars Fundamental & Advanced
Nursing Skills. 2nd Ed. Thomson and Delmar Learning.
5. Carol R. Taylor, (2009). Fundamentals of Nursing: The Art and Science
of Nursing Care (Fundamentals of Nursing: The Art & Science of
Nursing Care)
6. Kozier & Erb's, (2011). Fundamentals of Nursing with My Nursing Lab
and Pearson e-Text (Access Card) (9th Edition)
7. Potter &Perry, (2009). Clinical Nursing Skills and Techniques, 7th
Edition
By Anne Griffin Perry, Patricia A. Potter.
8. Springhouse, (2006). Fundamentals of Nursing Made Incredibly Easy!
(Incredibly Easy! Series).
9. Burton & Ludwig, (2010). Fundamentals of Nursing Care: Concepts,
Connections & Skills.
10. Mosby's Medical Dictionary, 9th Edition., ISBN: 978-0-323-08541-0.
11. Lippincott & Williams, (2006). Lippincott Manual of Nursing Practice:
Handbook, 3rd edition.
12. Kaplan Nursing, (2002). Th Basics; Essential Conten for International
Nurses. 2nd Edition.
154

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NURS 241 Nursing Skills Procedure: Manual

NURS 241 Nursing Skills Procedure: Manual

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

NURS 241 Nursing Skills Procedure: Manual

The NURS 241 Nursing Skills Procedure Manual

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

NURS 241 Nursing Skills Procedure: Manual

NURS 241 TEAM

Dr. James M. Alo

Mr. Robin Easow

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

NURS 241 Nursing Skills Procedure: Manual

NURS 241 Nursing Skills Procedure: Manual

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

NURS 241 Nursing Skills Procedure: Manual

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

NURS 241 Nursing Skills Procedure: Manual

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

Before and after eating.

Before and after contact with any patient.

When handling patients food, blood, body fluids, secretions or excretions.

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

After urinary or bowel elimination.

Purposes: Handwashing is performed to:

Potential for infection.

Altered body temperature.

Impaired skin integrity.

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

NURS 241 Nursing Skills Procedure: Manual

Equipment and Supplies

Turn on water and adjust the force.

Wet the hands and wrist area. Keep

Use about one teaspoon of liquid

Rinsing the soap removes the

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

NURS 241 Nursing Skills Procedure: Manual

With firm rubbing and circular

Friction caused by firm rubbing and

Continue this friction motion for 10

Use fingernails of the other hand or

Length of hand washing is

Dry hands and wrists with paper

Use lotion on hands if desired.

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

NURS 241 Nursing Skills Procedure: Manual

MEASURING BODY TEMPERATURE or VITAL SIGNS

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

NURS 241 Nursing Skills Procedure: Manual

Temperature sensitive strips

(Liquid crystal thermometer)

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

Fahrenheit scale usually extended from 94 F to 108 F.

Factors affecting body temperature:

Age: children; old age.

Sex: males; c females and

Food intake; fasting

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

NURS 241 Nursing Skills Procedure: Manual

Ranges of normal temperature values and

Sites/Routes for temperature assessment:

36.4 C (97.6 F) 36 .7 C (98

Alterations in body temperature:

NURS 241 Nursing Skills Procedure: Manual

Soft tissue papers