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BSN2
Leopold’s Maneuver
DEFINITION OF THE PROCEDURE: a systematic method of observation and palpation to determine the fetal
presentation and position and are done as part physical examination.
Tape measure
Stethoscope/doppler
Pinard fetoscope or sonic fetal heart sound device
Client record
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-Diaphragmatic breathing or deep breathing is breathing that is done by contracting the diaphragm, a muscle
located horizontally between the thoracic cavity and abdominal cavity. Air enters the lungs; the chest does not
rise and the belly expands during this type of breathing. Diaphragmatic breathing is also known as scientifically
as eupnea, which is a natural and relaxed form of breathing in all mammals.
-Coughing is a forceful release of air from the lungs that can be heard. Coughing protects the respiratory system
by clearing it of irritants and secretions.
-Splint is defined as a rigid or flexible device that maintains in position a displaced or movable part, also used to
protect an injured part, or as a rigid or flexible material used to mobilized, or restrict motion in a part.
Moving
- To maintain blood circulation
- To stimulate respiratory function
- To decrease stasis of gas in the intestine
- To facilitate early ambulation
Leg exercise
- To stimulate blood circulation, thereby preventing thrombophlebitis and thrombus formation.
Deep Breathing and coughing
- To facilitate lung aeration, thereby preventing atelectasis and pneumonia.
Splinting
- May reduce pain while coughing if the incision is near any of this muscles
- Pillow
- Teaching materials
1. Check the patient’s chart for the To be able to know and understand the previous
type of surgery and review the medical order before start the procedure
medical orders.
2. Gather the necessary supplies and To save time and effort
bring to the bedside stand or over bed
table.
7. Explain the rationale for performing To make sure that the patient will know and
deep breathing exercises, coughing understand the process of the procedure
and splinting of the incision.
e. Have the patient practice the Performing exercise every three times to promote
breathing exercise three times. airway clearance without overtiring the client
f. Instruct the patient that this Inform the client about the expected frequency of
exercise should be performed every 1 there exercise.
to 2 hours for the first 24 hours after
surgery.
9. Provide teaching regarding Several cough are more effective than one single
coughing and splinting (providing cough at moving mucus up and out of the
support to the incision). respiratory tract.
a. Ask the patient to sit up (semi- Coughing uses abdominal and respiratory muscles
Fowler’s position) and apply a folded which may have been cut during surgery.
bath blanket or pillow against the part
of the body where the incision will be
(e.g., abdomen or chest).
10. Validate patient’s understanding To ensure that the patient understand the
of information. Ask the patient to give procedure and to be able to perform the
a return demonstration. Ask the procedure.
patient if he or she has any questions.
Encourage the patient to practice the
activities and ask questions, if
necessary.
11. Remove PPE, if used. Perform To avoid spread of infection and to prevent cross
hand hygiene. contamination
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Collecting Specimens
PROCEDURE TO BE PERFORMED:
Collecting a urine specimen
Collecting stool specimen
Collecting of Sputum specimen
Urine specimen- is a procedure used to obtain a sample of urine from a patient. The sample is used for
diagnostic test.
Collecting Stool Specimen- is the process of obtaining a sample of a patient’s faces for diagnostic purposes.
Collecting of Sputum specimen- is a test to detect and identify bacteria or fungi that infect the lungs or
breathing passages. It is a thick fluid produced in the lungs and in the adjacent airways.
To determine the presence of microorganisms, the type of organism and the antibiotics to which the
organisms are sensitive
1. Check for a written doctor’s order To be aware and understand the importance of
for such examination. accurate record keeping
3. Perform hand hygiene and put on To avoid cross contamination and prevent spread
PPE, if indicated. of infection
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DEFINITION OF THE PROCEDURE: a device self-imposed or set to keep the body and mind trim.
Active ROM EXERCISE are isotonic (muscle tension is constant and the muscle shortens to produce muscle
contraction and active movement).
PASSIVE ROM EXERCISE- are those in which the nurse or therapist moves each of the client joints through its
complete range of motions.
ACTIVE- ASSISTIVE ROM EXERCISE- are those in which the client uses a stronger, opposite arm or leg to move
the joints of immobile limb.
IN-HEALTH
3. Identify the patient. Explain the A client at ease and relaxed about exercising can
procedure to the patient. more actively take part in it.
4. Close curtains around bed and Promote privacy and Decreases embarrassment
close the door to the room, if
Place the bed at an appropriate to prevent muscle
possible. Place the bed at an
strain and discomfort for nurse.
appropriate and comfortable
working height, usually elbow height
or the caregiver. Adjust the head of
the bed to a flat position or as low as
the patient can tolerate.
5. Stand on the side of the bed To promote comfortable and to prevent muscle
where the joints are to be exercised. strain
Lower side rail on that side, if in
Provide systematic method to ensure that all body
place. Uncover only the limb to be
parts are exercised
used during the exercise.
6. Perform the exercises slowly and Provide exercise to the clients tolerance
gently, providing support by holding
the areas proximal and distal to the
joint. Repeat each exercise two to
five times, moving each joint in a
smooth and rhythmic manner. Stop
movement if the patient complains
of pain or if you meet resistance.
9. Move the head from side to side, To optimize the performance of the movements
bringing the chin toward each
shoulder.
10. Start with the arm at the To prevent muscle tone and joints
patient’s side and lift the arm
forward to above the head. Return
the arm to the starting position at
the side of the body.
11. With the arm back at the Stretch muscles and keep the joint flexible
patient’s side, move the arm
laterally to an upright position above
the head, and then return it to the
original position. Move the arm
across the body as far as possible.
12. Raise the arm at the side until To stretch muscles and and keep joint flexible
the upper arm is in line with the
shoulder. Bend the elbow at a 90-
degree angle and move the forearm
upward and downward, then return
the arm to the side.
13. Bend the elbow and move the Done to the amount of reps recommended to check
lower arm and hand upward toward if the joint will react abnormally to the movement
the shoulder. Return the lower arm or it helps the joint
and hand to the original position
while straightening the elbow.
14. Rotate the lower arm and hand To check if gliding joint and muscles present are
so the palm is up. Rotate the lower clearly function, it helps maintaining the
arm and hand so the palm of the movements easily
hand is down.
15. Move the hand downward To ease the joint maintain the normal movements
toward the inner aspect of the with complication
forearm. Return the hand to a
It helps to detect any problems with the joints and
neutral position even with the
muscles.
forearm. Then move the dorsal
position of the hand backward as far
as possible.
16. Bend the fingers to make a fist, To maintain the joint and muscles normal
and then straighten them out. movements and to check any abnormalities
Spread the fingers apart and return
them back together. Touch the
thumb to each finger on the hand.
17. Extend the leg and lift it upward. To detect any abnormalities and problems in the
Return the leg to the original limb to improve the movements in the muscles and
position beside the other leg. joint
18. Lift the leg laterally away from Exercise the movements of the joints and muscles
the patient’s body. Return the leg to help maintain functioning well
back toward the other leg and try to
extend it beyond the midline.
19. Turn the foot and leg toward the to rotate the foot and leg it helps to relax and keep
other leg to rotate it internally. Turn the joint flexible
the foot and leg outward away from
the other leg to rotate it externally.
20. Bend the leg and bring the heel To detect any abnormalities and problems in the
toward the back of the leg. Return hinge joint in the knee to induce the exercise
the leg to a straight position. making the joint and muscles at an optimum state
21. At the ankle, move the foot up To check if the ankle joint are will functioning
and back until the toes are upright. without any soar or pain
Move the foot with the toes pointing
downward.
22. Turn the sole of the foot toward To check if the joint are functioning well in moving
the midline. Turn the sole of the foot toward the midline movement
outward.
23. Curl the toes downward, and To keep muscles and joint flexible
then straighten them out. Spread
the toes apart and bring them
together.
24. Repeat these exercises on the Passive exercises only help prevent contractures
other side of the body. Encourage and retard atrophy
the patient to do as many of these
exercises by him- or herself as
possible.
25. When finished, make sure the To promote client comfort and relax
patient is comfortable, with the side
rails up and the bed in the lowest
position.
26. Remove gloves and any other To prevent cross contamination
PPE, if used perform hand hygiene.
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3. Remove the cap with small finger and To maintain sterility of the solution and field
side of the palm. Hold the bottle with the
label upward.
4. Pour a small amount of solution away This ensure sterility of the solution
from the label into the sink or waste
container to cleanse tip of bottle.
5. Pour the needed amount of solution To avoid splash solution that might cause
into the provided container, catching the contamination.
last drop with the slightly twist.
Keep solution in the bottle sterile and avoid use
6. Recap the bottle.
of solution that passed expire
Total Score
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Signature of C.I.
Signature of Student