Medical Surgical Nursing Department Clinical of Fundamentals of Nursing I

Accredited Faculty By The National Authority For Quality Assiut University

Assurance Of Education And Accreditation Medical-Surgical - Nursing Department

Clinical of Fundamentals of Nursing I

For
First Year Nursing Students
First Semester

By
Teaching Staff Members
of
Medical Surgical Nursing Department
Faculty of Nursing - Assiut University

2022 - 2023

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Medical Surgical Nursing Department Clinical of Fundamentals of Nursing I

Unit Content Page

I Body Mechanics 3
II Asepsis and infection control: 5
- Performing hand hygiene using soap and water . 6
- Performing hand hygiene using an alcohol-based 11
hand rub.
- Establishing and maintaining a sterile field. 13
- Donning and removing face mask 18
- Surgical hand washing (Scrubbing) 20
- Donning and removing a sterile gown 25
- Donning and Removing Sterile Gloves 27
III Vital signs: 31
- Measuring body temperature (oral, axillary & rectal). 32
- Heat and cold measures. 50
- Assessing the pulse. 57
- Assessing respiration. 64
- Assisting a patient with an incentive spirometer. 67
- Measuring blood pressure. 70
- Using a pulse oximetry. 80
- Assessing and recording pain. 83
IV Relaxation technique 86
V Hygienic care: 90
- Bed bath 91
- Oral care 100
- Denture care 104
- Mouth care for unconscious patients 107
- Shampooing a patient's hair in bed 111
- Hand and foot care 117
VI Bed making: 120
- Unoccupied bed making. 121
- Occupied bed making. 129
VII Range of motion exercises (ROM). 134
VIII Turning & Moving: 142
- Assisting a Patient with turning in bed. 142
- Moving a patient up in bed with the assistance. 146
IX Diagnostic test (monitoring blood glucose) 149
X Oxygen therapy 153
- Administering oxygen by nasal cannula. 153
- Administering oxygen by mask. 156

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Medical Surgical Nursing Department Clinical of Fundamentals of Nursing I

Body Mechanics
Performance objectives:
The students will be able to do the following:
1. Define body mechanics.
2. Mention the purposes of body mechanics.
3. Prepare the patient before procedure.
4. Demonstrate the techniques of body mechanics correctly
and accurately.
Definition:
Using alignment, posture, and balance in a coordinated effort
to perform activities such as lifting, bending and moving.
Purposes:
1. Prevent injury to the nurse's musculoskeletal system.
2. Prevent injury to the patient during transfer.
Preparation:
1. Evaluate weight of patient to be lifted.
2. Assess position and height of patient to be lifted.
3. Assess patient's balance and ability to bear weight.
4. Assess patient's knowledge about body alignment and
how to maintain it with position changes.

Steps of Procedure Notes

1. Always lock wheels on bed, stretcher, or wheelchair.
Rationale: Unexpected movements may move bed,
stretcher, or wheelchair and result in injury to yourself or
patient.
2. Allow patient to assist during move.
Rationale: Patient participation helps overcome forces
resisting the move, encourages patient's sense of
independence, and provides exercise for patient.
3. Use mechanical aids (e.g., lifters, slide boards, body
mobilizes) or additional personnel to move heavy
patients.
Rationale: Having assistance decreases stress of movement
for patient and nurse thus reducing risk of injury.
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Medical Surgical Nursing Department Clinical of Fundamentals of Nursing I

4. When possible, slide, push, or pull patient rather than

lifting and carrying.
Rationale: Rocking your own body weight can balance the
patient's weight when assisting to a standing position.
5. Tighten abdominal and gluteal muscles before lifting or
moving patient.
Rationale: Tightening supports the abdomen and stabilizes
the pelvis to provide a firm base of support.
6. Use smooth, rhythmic, coordinated motions.
Rationale: Smooth motions use less energy and lead to
less muscle strain than jerky motions.
7. If another person is assisting, plan your movement
before beginning.
Rationale: Planning prevents uncoordinated movements
that may result in muscle strain or injury.
8. Face patient to be moved, and plan to pivot your entire
body without twisting your back.
Rationale: To avoids back strain and injury.
9. Place both feet flat on floor; bend knees slightly with
one foot slightly in front of the other or one step apart.
Rationale: Balanced positioning increases base of support
and stability.
10.Bend knees to lower center of gravity toward patient.
Rationale: This maintains body balance, reduces risk of
falling and allows larger muscle groups to work together.
11.Elevate beds to waist level & lower side rails.
Rationale: Adjusting the bed and side rails prevents
stretching and muscle strain.
12.Carry objects close to body, and stand as close as
possible to work area.
Rationale: To maintain the workload near center of gravity
to prevent muscle strain and fatigue caused by
hyperextension.

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Medical Surgical Nursing Department Clinical of Fundamentals of Nursing I

Asepsis and infection control

Performance objectives:

At the end of this lecture the student will be able to do

the following:
1. Performing hand hygiene using soap and water.
2. Performing hand hygiene using an alcohol-based hand
rub
3. Establishing and maintaining a sterile field.
4. Donning and removing face mask.
5. Performing surgical hand washing (scrubbing).
6. Donning and removing a sterile gown.
7. Donning and removing sterile gloves.

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Medical Surgical Nursing Department Clinical of Fundamentals of Nursing I

Performing Hand Hygiene Using Soap and Water

(Hand washing)
Definition:
Hand washing is a vigorous rubbing together of all surfaces
of the hands using soap or other cleansing agent.
Purposes:
1. To clean hands.
2. To break the chain of infection from patient to patient,
patient to nurse, nurse to patient.
Time for hand washing:
1. Before:
- Invasive procedures.
- Caring for susceptible individuals such as newborns and
immune-compromised patients.
- Handling wounds.
- Serving or consuming food.
2. After:
- Handling wounds.
- Handling contaminated items such as bed pans or wet
linens.
- Using the bathroom.
Preparation:
1. Assess the environment to establish if facilities are
adequate for cleansing the hands. Is the water clean? Is
soap available? Is there a clean towel to dry hands?
2. Assess the hands to determine if they have open cuts,
hangnails, broken skin, or heavily soiled area.
3. Gather the necessary supplies.
Equipment and supplies:
1. Liquid antibacterial soap.
2. Nailbrush or orange stick.
3. Paper towels.
4. Warm running water.
5. Regular waste container.

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Medical Surgical Nursing Department Clinical of Fundamentals of Nursing I

Steps of Procedure Notes

1. Stand in front of the sink. Do not allow your clothing to
touch the sink during the washing procedure.
Rationale: The sink is considered contaminated. Clothing
may carry organisms from place to place.
2. Remove jewelry and secure in a safe place.
Rationale: Removal of jewelry facilitates proper cleansing.
Microorganisms may accumulate in settings of jewelry.
3. Turn on water and adjust force. Regulate the temperature
until the temperature is warm.
Rationale: Water splashed from the contaminated sink will
contaminate clothing. Warm water is more comfortable and
is less likely to open pores and remove oils from the skin.
4. Wet the hands and wrists
area. Keep hands lower than
the elbows to allow water to
flow toward fingertips Fig. (1).
Rationale: Water should flow
from the cleaner area to the
more contaminated area; hands Fig. (1): Wet the hands and
are more contaminated than wrists
forearms.
5. Use about 1 teaspoon of
liquid soap from dispenser or
rinse bar of soap and lather
thoroughly. Cover all areas of
hands with soap product.
Rinse soap bar again and
return to soap rack without
touching the rack Fig. (2). Fig. (2): Cover all areas of
Rationale: Rinsing the soap hands with soap product.
before and after use removes
the lather, which may contain
microorganisms.

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Medical Surgical Nursing Department Clinical of Fundamentals of Nursing I

6. With firm rubbing and

circular motions, wash the
palms and backs of the hands,
each finger, the areas between
the fingers, and the knuckles,
wrists and forearms. Rub as
the following manner:
a. Hands palm to palm. Fig. (3): Firm rubbing of
b. Palm to back with finger hands
interlaced and with palm of
other hand.
c. Palm to palm with finger
interlaced
d. Rub with back of fingers to
opposing palm then rub Fig. (4): Firm rubbing of
thumb. wrists
f. Tip of fingers in circular
motion
g. Each wrist with opposite
hand.
7. Wash at least 1 inch above
area of contamination. If hands
are not visibly soiled, wash to
1 inch above the wrists Fig. (3
& 4).
Rationale: Friction caused by
firm rubbing & circular motions
helps to loosen dirt &
organisms that can lodge
between the fingers. Cleaning
less contaminated areas after
hands prevents spreading
microorganism.

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Medical Surgical Nursing Department Clinical of Fundamentals of Nursing I

8. Continue this friction motion for at least 20 seconds.

Rationale: Length of hand washing is determined by
degree of contamination. Hands that are visibly soiled need
a longer scrub.
9. Use fingernails of the
opposite hand or Use the
orangewood stick to clean
under finger nails Fig. (5).
Rationale: Area under nails has
a high microorganism count,
and organisms may remain
under the nails, where they can
grow and spread to other Fig. (5): Clean under
persons. finger nails
10.Rinse thoroughly with water
flowing toward fingertips
Fig. (6)
Rationale: Running water
rinses microorganisms and dirt
into the sink. Fig. (6): Rinse the hand with
water
11.Pat hands dry with a paper
towel, beginning with the
fingers and moving upward
toward forearms, and discard
the paper towel Fig (7).
Rationale: Patting the skin dry
prevents chapping. Dry hands
first because they are
considered the cleanest and less Fig. (7): Pat hands dry with a
contaminated area. paper towel
Use another clean towel to turn
off the faucet. Discard the paper
towel immediately without

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Medical Surgical Nursing Department Clinical of Fundamentals of Nursing I

touching other clean hand. Fig.

(8).
Rationale :turning off the
faucet with a clean paper towel
protects the clean hands from
contact with a soiled surface.
Fig. (8): Turn off the faucet
by clean towel
12.Use oil-free lotion on hands if desired.
Rationale: Oil-free lotion helps to keep the skin soft and
prevents chapping.

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Medical Surgical Nursing Department Clinical of Fundamentals of Nursing I

Performing Hand Hygiene Using

An Alcohol-Based Hand Rub
Introduction:
The center for disease control and prevention (CDC)
recommends the use of alcohol-based hand rubs by all health
care providers during patient care. These rubs significantly
reduce the number of microorganisms on the skin, are fast
acting (e.g., 15 to 20 seconds), and cause less skin irritation
than regular hand washing techniques. When hands are not
visibly soiled, recommends the use of an alcohol-based hand
rub for hand asepsis. Acceptable hand rubs are preparations
containing 60% to 95% alcohol.
Purposes:
1. Before and after patient contact.
2. Before applying gloves and after removing gloves.
3. After removal of gloves when minimal contact with body
fluids or excretions, mucous membranes, wounds, and
dressings has occurred.
4. After contact with medical equipment used during patient
care.
Equipment and supplies:
Alcohol-based hand rub containing 60% to 95% ethanol or
isopropanol (gel, foam, or lotion) Fig. (9)

Fig. (9): Alcohol lotion

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Medical Surgical Nursing Department Clinical of Fundamentals of Nursing I

Steps of Procedure Notes

1. Visibly inspect hands for obvious contaminants or
debris.
Rationale: When hands are visibly dirty, contaminated
with protein aceous material, or visibly soiled with blood
or other body fluids, they must be washed with either a
non-antibacterial soap and water or an antibacterial soap
and water.
2. Remove rings and watch or push watch up on the
forearm so the wrist is clear of any jewelry.
Rationale: The wearing of jewelry increases the number of
microorganisms on the hands. Moving the watch up on the
forearm provides complete access to fingers, hands, and
wrists.
3. When decontaminating hands with an alcohol-based
hand rub, dispense an ample amount of the product into
the palm of one hand. Follow the manufacturer’s
recommendations regarding the amount of product to use.
4. Rub the hands together covering all surfaces of hands
and fingers, up to 1 2 inch above the wrist.
5. Rub hands together until hands are dry, approximately
15 to 30 seconds.
6. Use oil-free lotion on hands if desired.
Rationale: Oil-free lotion helps to keep the skin soft and
prevents chapping.

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Medical Surgical Nursing Department Clinical of Fundamentals of Nursing I

Establishing and maintaining a sterile field

Definition: Sterile field is a microorganism-free area.
Purposes:
1. To maintain the sterility of supplies and equipment.
2. To provide a work area for placement of sterile
supplies. to perform a sterile procedure.
Equipment:
1. Package containing a sterile drape.
2. Sterile equipment:
- Wrapped sterile gauze.
- Bowl.
- Antiseptic solution.
- Sterile forceps.
Preparations:
1. Ensure that the package is clean and dry (If moist it
considered contaminated and must be discarded).
2. Check the sterilization expiration dates on the
package, and look for any indication that it has been
previously opened.
3. Wash your hands.
Steps of Procedure
1. Introduce self, and explain to the patient what you
will do, why it is necessary and he or she can cooperate,
then provide patient's privacy.

2. Select a clean dry work surface that is at a

comfortable working height.
Rationale: A wet surface beneath a sterile field permits
transmission of microorganisms through the drape by
capillary action.
3. Place the package in the center of the work area so
that the top flaps of the wrapper open away from you.
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Medical Surgical Nursing Department Clinical of Fundamentals of Nursing I

Rationale: This position prevents the nurse from

subsequently reaching directly over the exposed sterile
contents which could contaminate them.
4. Reaching around the package (not over it), pinch the
first flap on the outside of the wrapper between the
thumb and index finger. Pull the flap open, laying in
flat on the far surface. Fig (10)
Rationale: Touching only the outside of the wrapper
maintains the sterility of the inside of the wrapper.

Fig. (10): pinch the first flap and laying on the far surface

5. Repeat for the side flaps, opening the top one first use
right hand for right flap, and left hand for the left flap
Fig (11).
Rationale: To avoid reaching over the sterile content.

Fig.(11): Open the right and left flap

6. Pull the fourth flap toward you by grasping the corner

that is turned down. Make sure that the flap does not

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Medical Surgical Nursing Department Clinical of Fundamentals of Nursing I

touch any un-sterile article. If inner surface touches

any un-sterile article, it is contaminated Fig (12).

Fig.(12): open the last flap toward you

7. If the nurse wanted to open a wrapped package while
holding it: she should hold it in one hand and use the
other hand to open as described in step 4,5,6.
Rationale: The hands are considered contaminated and at
no time should they touch the contents of the package.
8. Add necessary sterile supplies to a sterile field:
- Open each wrapped package in the same previous
steps.
- With the free hand, grasp the corner of the wrapper
and hold them against the wrist of the other hand.
Rationale: Un-sterile hand is now covered by the sterile
wrapper.
- Place the sterile bowl, drape, or other supply on sterile
field by approaching from an angle rather than
holding the arm over the field.
- Drop small lightweight gauze items near the center of
the field from a height of about 15-cm, keep in mind
that 2.5cm around the edge of the field is considered
contaminated.
Rationale: To prevent items from contacting the un-
sterile border of the field.

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Medical Surgical Nursing Department Clinical of Fundamentals of Nursing I

- Before pouring any liquid to a sterile bowl, read the

label three times to make sure you have the correct
solution and concentration.
- Remove the cap from bottle and invert the lid before
placing it on a surface that is not sterile.
Rationale: To maintain the sterility of the inside surface
by preventing touching un-sterile surface.
- Hold the bottle at a slight angle so that the label is
uppermost.
Rationale: So solution will not damage or obliterate the
label.
- Hold the bottle of fluid at a height of 10-15cm over the
bowl and to the side of the sterile field, so that as little
of the bottle as possible is over the field.
Rationale: so less likelihood of contaminating the sterile
field by touching the field or by reaching an arm over it.
- Pour the solution gently to avoid splashing the liquid
and obtain exact amount of fluid if possible.
Rationale: Any moisture will contaminate the field by
facilitating the movement of microorganisms through the
sterile drape.
- Tilt the nick of the bottle back to the vertical quickly
when done pouring so that none of the liquid flows
down the outside of the bottle, then replace the cap on
the bottle.
- If the bottle will be used again, replace the lid securely
write on the label the date and time of opening.
Rationale: Replacing the lid immediately maintains the
sterility of the inner aspect of the lid and the solution.
Depending on agency policy, a sterile container of solution
that is opened may be used only once and then discarded
or kept up to 24 hours.

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The following considerations should be followed to keep

the sterility of items:
- Keep the tip of wet forceps lower than the wrist at all
times unless you are wearing sterile gloves. (To prevent
liquid from flowing to the handles and later back to the
tip and make forceps un-sterile).
- Hold sterile forceps above waist level and within sight
(any forceps that go out of sight should be considered
un-sterile)
- Hold the sterile forceps within sight. While out of sight
forceps may unknown to the user, become un-sterile.
(Any forceps that go out of sight should be considered
un-sterile).
- When lifting sterile supplies out of prepared package, be
sure that the forceps don’t touch the edges or outside of
the wrapper. (The edge or outside the package are
exposed to the air and handled and are thus un-sterile).
- When placing forceps whose handles were in contact
with bare hand, position the handles outside the sterile
area (handles of these forceps harbor microorganisms
from the bare hand).
- Deposit a sterile item on a sterile field without
permitting moist forceps to touch the sterile field.
- Document that the sterile technique was used in the
performance of the procedure.

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Donning and removing face mask

Definition: Masks are worn when dealing closely with the
infected patients, by all persons entering an infected room.
Purposes:
1. To reduce the risk for transmission of organisms by the
droplet contact and airborne routs, and by splatters of
body substances.
Equipment:
- Disposable mask.
Steps of Procedure
1. Locate the top edge of the mask .The mask usually has
a narrow metal strip along the edge.
2. Hold the mask by the top strings or loops.
A-Donning:
3. 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. If glasses are worn, fit
the upper edge of the mask under the glasses Fig (13).
Rationale: with the edge of the mask under the glasses,
clouding of the glasses is less likely to occur.

Fig.(13): Put the mask

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4. Secure the lower edge of the mask under the chin, and
tie the lower tie at the nape of the neck.
Rationale: to be effective, a mask must cover both the
nose and the mouth , because air moves in and out of
both.
5. If the mask has a metal strip, adjust this firmly over
the bridge of the nose.
Rationale: a secure fit prevents both the escape and the
inhalation of microorganisms around the edges of the
mask and fogging of eyeglasses.
6. Wear the mask only once, and do not wear any mask
longer than the manufacturer recommends or once
become wet.
Rationale: Because it became ineffective when moist.
7. Don’t leave a used mask hanging around the neck.
Removing the mask:
8. Remove the mask at the doorway to the patient's
room.
9. If using a mask with strings, first untie the lower
strings of the mask.
Rationale: This prevents the top part of the mask from
falling onto the chest.
10.Untie the top strings and while holding the ties
securely, remove the mask from the face. If side loops are
present, lift the side loops up and away from the ears and
face. Don't touch the front of the mask.
Rationale: The front of the mask through which the
nurse has been breathing is contaminated.
11.Discard a disposable mask in the waste container.
12.Perform proper hand hygiene again.

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Surgical hand washing (Scrubbing)

Definition: The act of washing the finger nails, hands, and
forearms in a prescribed manner for a specific period, with a
bactericidal soap or solution before surgical procedure.
Purposes:
1. To remove debris from nails, hands, and forearms.
2. To reduce the numbers of transient and colonizing
microorganisms on the skin.
3. To inhibit rapid rebound growth of microorganisms.
4. To decrease the patient risk for infection. (In the operating
room).
Assessment:
1. Assess the scrub environment for equipments and
cleanliness.
2. Assess your preparation (overhead mask, over shoes,
sterile towels).
Equipment:
1. Surgical scrub items (anti-microbial soap, two brushes,
and nail file).
2. Surgical shoe covers (booties) and cap, facemask, sterile
gown, proper size gloves.
3. Sterile towel.
Steps of Procedure
1. Remove all jewelry, watches. Ensure that fingernails are
short and free of polish and that cuticles are in good
condition.
Rationale: Minimize number of resident and transient
microorganisms.
2. Use deep sink with foot pedals or knee controls for
dispensing soap and controlling water temperature and flow
Fig (14).
Rationale: To prevents hands from touching a solid surface.

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Fig. (14): Deep sink

3. Have two disposable hand brushes and disposable nail file
available.
Rationale: Enhance mechanical friction during scrub.
4. Apply cap covering hair completely contain pierced
earrings within cap.
Rationale: prevents introduction of contamination into
environment.
5. Apply facemask making certain to cover nose and mouth.
Rationale: provides respiratory barrier.
6. Before beginning the surgical scrub:
- Open the sterile package containing the gown: using
aseptic technique, make a sterile field with the inside of
the gowns wrapper.
- Open the sterile towel and drop it on to the center of
field.
- Open the outer wrapper from the sterile gloves and drops
the inner package of gloves onto the sterile field beside the
folded gown and towel.
Rationale: preparing the sterile items prior to the scrub
decreases the risk of contaminating scrubbed hands.
7. At deep sink with foot or knee controls. Turn on warm
water; under flowing water, wet hands, beginning at tips of
fingers, to forearms.

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Medical Surgical Nursing Department Clinical of Fundamentals of Nursing I

Keeping arms and hands above elbow level during entire

procedure. Pre wash hands and forearm to 2 inches above the
elbow.
Rationale: Hot water removes protective oils from skin and
increases sensitivity to soap. Also the water should flow from
the hands to the elbow to promote taking contaminations away
from the hands).
8. Apply a liberal amount of soap (2 to 5 ml) into hands and
lather hand arms to 5 cm (2 inches) above elbows.
Rationale: Reduces number of microorganisms.
9. Clean nails with file under running water, discard file.
Rationale: Removes dirt and organic material that harbor
large numbers of microorganisms.
10. Wet brush and apply anti-microbial soap. Scrub
fingernails hand, arm in following manner:
- Scrub nails of hand 10strokes.
- Using circular motion scrub palm of hand and anterior
surface of fingers 10 strokes.
- Scrub side of thumbs 10 strokes and posterior aspect of
thumb 10 strokes.
- Scrub sides and back of each finger 10 strokes each area.
- Scrub back of hand 10strokes.
Rationale: Remove resident bacteria that adhere to skin’s
surface.
11. Rinse brush thoroughly and reapply soap.
Rationale: Rinsing of brush removes microorganisms and
avoids contamination of arms.
12. Mentally divide arms into thirds. Scrub each surface of
lower forearm with circular motion for 10strokes, scrub
middle and upper forearm in same manner then discard
brush into the sink.
Rationale: decreases transfer of microorganisms over wide
area.

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13. Raise hand and arms above elbow level, place fingertips
under running water and rinse thoroughly from fingertips to
elbow in one motion allowing water to run off at elbow Fig
(15).
Rationale: Allows water to flow from least to most
contaminated area.

Fig.(15): Rinse from fingertips to elbow in one motion

14. Take the second scrub brush and repeat steps 10 through 13
for second arms.
15. Keeping arms flexed discard brush. Turn off water with
foot pedal proceed to operating room
Rationale: prevents water from flowing from least (elbows) to
the most (hands) clean area
16. Pick up sterile towel found on top of sterile gown pack. Be
sure it does not touch your uniform.
Rationale: Dry from cleanest to least clean area. Drying
prevents chapping facilitates of gloves and prevents
contamination of gown
17. Open towel full length. Holding one side away from scrub
attire.
Rationale: Avoid contact with microorganisms on scrub gown
18. Dry each hand separately. To dry one arm. Hold towel from
fingers up to elbow
Rationale: Drying hands first prevents contaminating hands

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from areas proximal to elbow

19. Carefully reverse towel and dry other hand and arm
Rationale: Prevent contamination of the gown
20. Discard towel, into a linen hamper
Rationale: Keep the environment clean

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Donning and removing a sterile gown

Definition: Gown is worn during procedures when the
nurse’s uniform is likely to become soiled, gowns can be
disposable, plastic, water resistance, or sterile.
Purposes:
1. To enable the nurse to work close to a sterile field and
handle sterile objects freely.
2. To protect patients from becoming contaminated with
microorganisms on the nurse's hands, arms, and clothing.
Equipment:
Sterile pack containing a sterile gown.
Steps of Procedure
1. Introduce self and explain to the patient what you are going
to do.
2. Provide privacy to the patient.
A-Donning:
3. Unwrap the sterile gown pack.
4. Hand washing.
5. Grasp the sterile gown at the crease near the neck hold it
away from you and permit it to unfold freely without
touching anything including the uniform.
Rationale: The gown will be un sterile if its outer surface
touches any un sterile objects
6. Put the hand inside the shoulders of the gown without
touching the outside of the gown Fig (16).

Fig.(16): Put on the gown

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Medical Surgical Nursing Department Clinical of Fundamentals of Nursing I

7. Have a coworker grasp the neck ties without touching the

outside of the gown and pull the gown upward to cover
the neckline of your uniform in front and back. Fig (17).

Fig.(17): Grasp the neck of the gown

8. Have a coworker hold the waist tie of your gown. Fig

(18).

Fig.(18): Tie the waist of gown

B-Removing: If soiled remove the gown by turning it inside

out.

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Medical Surgical Nursing Department Clinical of Fundamentals of Nursing I

Donning and Removing Sterile Gloves

Definition :Gloves are worn during many procedures to
maintain sterility of equipment and protect a patient’s
wound.
Purposes:
1. To enable the nurse to handle sterile objects freely.
2. To prevent patients at risk (those with open wounds)
from becoming infected by microorganisms on the nurse’s
hands.
Equipment:
Package of sterile gloves.
Steps of Procedure
1. Place the package of gloves on the center of the sterile
field Fig (19)
Rationale: Any moisture on the surface could
contaminate the gloves.

Fig.(19): Place the package of gloves

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2. Peeling the outer package without contaminating inner

package Fig (20).

Fig.(20): Peeling outer package

3. Open the inner package as in step 6-8 in the procedure
of sterile field, by pluck the flap so the fingers do not
touch the inner surfaces Fig (21).

Fig.(21): Open the inner package

4. Grasp the glove for the dominant hand by its cuff with
the thumb and first finger of the non-dominant hand.
Touch the inside of cuff only Fig (22).
Rationale: The hands are not sterile.

Fig.(22) Grasp the folded cuff for the dominant hand

5. Insert the dominant hand into the glove and pull the
glove on. keep the thumb of inserted hand against the
palm of the hand during insertion Fig (23)
Rationale: To reduce the contamination of the outside of
glove.

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Medical Surgical Nursing Department Clinical of Fundamentals of Nursing I

Fig.(23): Insert dominant hand palm up into glove

6. Leave the cuff in place once the un sterile hand releases
the glove
Rationale: Attempting to further unfold the cuff is likely
to contaminate the glove
7. 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 Fig (24).
Rationale: To prevent accidental contamination of the
glove by the bare hand

Fig.(24): Place the gloved hand under the cuff

8. Pull on the second glove, hold the thumb of gloved first
hand as far as possible from the palm Fig (25)
Rationale: In this position, the thumb is less likely to
touch the arm and become contaminated.

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Medical Surgical Nursing Department Clinical of Fundamentals of Nursing I

Fig. (25): Pull glove up to wrist

9. Adjust each glove so that it fits smoothly; pull the cuffs
up by sliding the fingers under the cuffs.
Removing the gloves:
10.To remove the gloves, turn them inside out, once
removed the glove may be held in the opposite hand,
then slip ungloved thumb or fingers inside remaining
glove and remove it by turning it inside out Fig (26)

Fig. (26): Grasp the opposite glove near cuff end on the outside
exposed area
11. Don’t touch outside of gloves, and discard them
according to agency policy. Fig (27)

Fig. (27): Slide fingers between the remaining glove and the wrist

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Medical Surgical Nursing Department Clinical of Fundamentals of Nursing I

Vital Signs
Measuring Body Temperature

Performance objectives:
The student will be able to do the following:
1. Define the body temperature.
2. List purposes of measuring body temperature.
3. Identify routes of measuring body temperature.
4. Prepare the patient before procedure.
5. Collect necessary equipment for measuring body
temperature.
6. Perform technique for measuring oral, axillary, and rectal
temperature.
7. Apply the post procedure.
8. Document the result.

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Medical Surgical Nursing Department Clinical of Fundamentals of Nursing I

A. Measuring Body temperature

Introduction:
The most common sites for measuring body temperature are
oral, rectal, axillary, and tympanic. Site most often used for
body temperature measurement is sublingual. Monitor
patients who are at risk for temperature alterations (those
exposed to extreme temperatures; patients at risk for or with
a diagnosis of infection; patients with a leukocyte count
below 5000 or above 12,000).
Purposes:
1. Determine if core temperature is within normal range.
2. To acquire a baseline measurement on admission.
3. To monitor abnormalities of body temperature.
4. Determine changes in core temperature in response to
specific therapies (e.g., antipyretic medication,
immunosuppressive therapy, or invasive procedures).
Preparation:
1. Assess patient to determine appropriate method to obtain
body temperature.
2. For an oral temperature, obtain reading 15 to 30 minutes
after ingestion of hot or cold food or fluids or smoking.
3. Oral route is contraindicated if patient is unable to hold
thermometer properly or if there is a risk that patient may
bite thermometer.
4. Rectal thermometer must be held securely in place and
never left unattended.
5. Assess signs and symptoms of temperature alteration and
factors that influence body temperature.
6. Assist patient in comfortable position.
Routes for measuring a patient's temperature:
1. Oral temperature (mercury thermometer).
2. Axillary temperature (mercury thermometer).
3. Rectal temperature (mercury thermometer).

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Medical Surgical Nursing Department Clinical of Fundamentals of Nursing I

1. Oral temperature (mercury thermometer):

Equipment:
1. An oral thermometer.
2. Soft gauze.
3. Vital sign flow-sheet and pen.

Steps of Procedure Notes

1. Check medical order or nursing care plan for frequency
of measurement and routes.
Rationale: frequent temperature measurement may be
appropriate based on medical &nursing assessment
2. Introduce self and verify patient’s identity.
Rationale: Attain patient's cooperation and prevent
mistakes.
3. Explain procedure to patient.
Rationale: to reduces anxiety. And assess the patient’s
ability to assist with the procedure.
4. Gather appropriate equipment.
Rationale: Ease performance of the procedure.
5. Perform hand hygiene and wear gloves
Rationale: Reduces transmission of microorganisms &
prevents spread of infection.
6. Maintain body mechanics.
Rationale: Prevent strain on nurse's back.
7. Close curtains around bed and close the door of the room.
Rationale: To maintain patient privacy.
8. Ask if patient has ingested hot/cold food or drink,
smoked, or chewed gum within last 20 minutes.
Rationale: Because hot/cold foods affect oral temperature.
9. Wipe the thermometer with clean, soft tissue gauze using
a firm twisting motion. Fig (28)

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Medical Surgical Nursing Department Clinical of Fundamentals of Nursing I

Fig. (28): Wipe the thermometer

Rationale: Chemical solution may irritate the mucous
membrane.
10. Wipe from the bulb toward the fingers with soft gauze.
Rationale: Wiping from an area where there are few or no
organism.
11. Hold color-coded end of glass thermometer tightly with
thumb and forefinger.
Rationale: Prevents contamination of bulb to be inserted
into patient’s mouth.
12. Slowly rotate thermometer at eye level to read mercury
level.
Rationale: Mercury is to be below 96 F (35.5 C).
Thermometer reading must be below patient’s actual
temperature before use.
13. If mercury is higher than desired level, using a sharp,
snapping motion of the wrist, shake down mercury below
35C.
Rationale: This moves the mercury back into bulb.
14. Ask patient to open mouth
and gently place thermometer at
base of tongue to the right or left
of the frenulum, in the posterior
sublingual pocket. Fig (29)
Rationale: Reflects the core
temperature of the blood in the
larger blood vessels. Fig. (29): Ask patient to
open mouth

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Medical Surgical Nursing Department Clinical of Fundamentals of Nursing I

15. Ask patient to close the lips, not the teeth, around the
thermometer. Fig (30)

Fig. (30): Ask patient to close the lips, around the thermometer

Rationale: Maintains the proper position of the

thermometer. Biting could cause the thermometer to break
and can injure the oral mucosa and cause mercury
poisoning.
16. Wait at least 3 minutes.
Rationale: Allowing sufficient time for the mercury to
expand ensures an accurate measurement.
17. Carefully remove thermometer from patient mouth.
Rationale: Gentle handling prevents discomfort to patient
and ensures an accurate reading.
18. Wipe off glass thermometer using gauze pad with one
downward motion toward bulb end.
Rationale: Wiping from an area where there are a few
organisms.
19. Read thermometer.
Rationale: To see & record the point at which the mercury
reach.
20. Dispose of gauze in a container.
21. Wash thermometer in cool soapy water. Dry and place
it in a container, shake down the thermometer and return it
to its container.
22. Hand washing.

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Medical Surgical Nursing Department Clinical of Fundamentals of Nursing I

23. Rearrange the equipment.

24. Place patient in comfortable position.
25. Documentation: time, site, and reading to supervisor
immediately.
Rationale: Patient data must be recorded properly to aid
the physician in the diagnosis and to provide future
reference.

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Medical Surgical Nursing Department Clinical of Fundamentals of Nursing I

B. Measuring Oral Body temperature by

Electronic Thermometer
Equipment:
1. Electronic thermometer. Fig (31)
2. Oral probe (blue collar).
3. Plastic probe cover.
4. Waste container.
5. Vital sign flow-sheet and pen.

Fig (31): Electronic thermometer

Steps of Procedure Notes
1. Introduce self and verify patient’s identity.
Rationale: Attain patient's cooperation and prevent
mistakes.
2. Explain procedure to patient.
Rationale: Attain patient's cooperation.
3. Gather appropriate equipment.
Rationale: Ease performance of the procedure.
4. Perform hand hygiene and observe other appropriate
infection control procedures.
Rationale: Prevents spread of infection.
5. Maintain body mechanics.
Rationale: Prevent strain on nurse's back.
6. Attach the oral probe (blue tip) to the electronic display
unit. Grasp the top of the stem, using caution not to apply
pressure to the eject button
Rationale: Ejection button releases the plastic cover from
the probe.
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Medical Surgical Nursing Department Clinical of Fundamentals of Nursing I

7. Slide a clean disposable plastic cover over the

temperature probe until it locks in place.
Rationale The soft plastic cover will not break in the
patient’s mouth and it prevents transmission of
microorganisms between patients.
8. Ask If the patient has recently ingested hot or cold food
or beverages or has been smoking, you must wait 15 to 30
minutes before taking the temperature.
Rationale: Ingestion of hot or cold food or beverages and
smoking changes the temperature of the mouth, which
could result in an inaccurate reading.
9. Grasp the probe by the
collar, and remove it from the
face of the thermometer. Slide
the probe into a disposable
plastic probe cover until it
locks into place. Fig (32).
Rationale: Removing the
probe from the thermometer Fig. (32): Grasp the probe of
automatically turns on the electronic thermometer
thermometer.
10.Ask the patient to open
mouth and gently place the
probe under the tongue, on
either side of the frenulum. Fig
(33).
11. Rationale: There is a good
blood supply in the tissue
under the tongue This ensures Fig. (33): Gently place the
accurate reading. probe under the tongue
12.Have patient keep the probe in place until the alarm on
the electronic thermometer sounds and the temperature
reading appears on the digital display.
Rationale: Electronic units register the body temperature
within seconds.
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Medical Surgical Nursing Department Clinical of Fundamentals of Nursing I

13.Remove the probe from the patient’s mouth. Discard the

probe cover by firmly pressing the ejection button while
holding the probe over a regular waste container. Do not
allow your fingers to come in contact with the probe cover.
Rationale: The probe cover should not be touched so as to
prevent the transfer of microorganisms from the patient to
the medical assistant. Saliva is not considered regulated
medical waste; the probe can be discarded in a regular
waste container.
14. Return the probe to its stored position in the
thermometer unit. Return the thermometer unit to its
storage base.
Rationale: Returning the probe to the unit automatically
turns off and resets the thermometer.
15.Hand washing.
16.Rearrange the equipment.
17.Place patient in comfortable position.
18. Documentation: Record and report readings to
supervisor immediately.
Rationale: Patient data must be recorded properly to aid
the physician in the diagnosis and to provide future
reference.

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Medical Surgical Nursing Department Clinical of Fundamentals of Nursing I

2. Axillary temperature
A. Measuring Axillary Body Temperature by mercury
thermometer
1. A thermometer (mercury).
2. Soft gauze.
3. Vital sign flow-sheet and pen.
4. Gauze pads to remove perspiration from axilla.
5. Vital sign flow-sheet and pen.
Preparation: As oral temperature.
Steps of Procedure Notes
1. Introduce self and verify patient’s identity.
Rationale: Attain patient's cooperation and prevent
mistakes.
2. Explain procedure to patient.
Rationale: Attain patient's cooperation.
3. Gather appropriate equipment.
Rationale: Ease performance of the procedure.
4. Perform hand hygiene and observe other appropriate
infection control procedures.
Rationale: Prevents spread of infection.
5. Provide for patient’s privacy.
Rationale: Avoid patient's embarrassment.
6. Maintain body mechanics.
Rationale: Prevent strain on nurse's back.
7. Position patient either sitting or lying position.
8. Expose axillary area.
9. Pat axilla dry with the gauze pads.
Rationale: Perspiration cools the skin which would cause
an inaccurate reading.
10. Shake down thermometer below 35C.

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Medical Surgical Nursing Department Clinical of Fundamentals of Nursing I

11. Place thermometer or

probe into axilla with bulb
in center of axilla. Fig (34).

Fig. (34): Place thermometer

into axilla
12. Lower the arm over the thermometer, and place the
patient’s forearm across the chest.
Rationale: To maintains the proper position of the
thermometer against the blood vessels in the axilla.
13. Wait 5 minutes, remain with the patient and hold the
thermometer in place if the patient is unable to do so.
Rationale: This time is required to obtain a valid reading
& Prevents injury to the patient.
14.Lift patient's arm at elbow and remove thermometer.
15.Wipe off thermometer using gauze pad with one
downward motion toward bulb end.
Rationale: Wiping from area where there are a few
organism.
16.Read thermometer.
Rationale: See and record the point at which the mercury
reaches.
17. Dispose of gauze in a container.
18.Wash thermometer in cool soapy water. Dry and place
it in a container, shake down the thermometer and return it
to its container.
19. Hand washing.
20. Rearrange the equipment.
21.Place patient in comfortable position.
22.Record and report readings to supervisor immediately.

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Medical Surgical Nursing Department Clinical of Fundamentals of Nursing I

B. Measuring Axillary Body Temperature by

Electronic Thermometer
Equipment:
1. Electronic thermometer.
2. Oral probe (blue collar).
3. Plastic probe cover.
4. Waste container.
5. Vital sign flow-sheet and pen.

Steps of Procedure Notes

1. Introduce self and verify patient’s identity.
Rationale: Attain patient's cooperation and prevent
mistakes.
2. Explain procedure to patient.
Rationale: Attain patient's cooperation.
3. Gather appropriate equipment.
Rationale: Ease performance of the procedure.
4. Perform hand hygiene and observe other appropriate
infection control procedures.
Rationale: Prevents spread of infection.
5. Provide for patient’s privacy.
Rationale: Avoid patient's embarrassment.
6. Maintain body mechanics.
Rationale: Prevent strain on nurse's back.
7. Remove the thermometer unit from its storage base, and
attach the oral (blue collar) probe to it. This is accomplished
by inserting the latching plug (on the end of the coiled cord
of the oral probe) to the plug receptacle on the thermometer
unit until it locks into place. Insert the probe into the face of
the thermometer.
8. Remove clothing from the patient’s shoulder and arm.
Ensure that the axilla is dry. If it is wet, pat it dry with a
paper towel or a gauze pad.
Rationale: Clothing removal provides optimal exposure of

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Medical Surgical Nursing Department Clinical of Fundamentals of Nursing I

the axilla for proper placement of the thermometer. Rubbing

the axilla causes an increase in the temperature in that area
owing to friction, resulting inaccurate temperature reading.
9. Grasp the probe by the collar, and remove it from the face
of the thermometer. Slide the probe into a disposable probe
cover until it locks into place.
10. Take the patient’s temperature by placing the probe in
the center of the patient’s axilla. Instruct the patient to hold
the arm close to the body.
Rationale: Interference from outside air currents is reduced
when the arm is held in the proper position.
11. Hold the probe in place until you hear the tone. At that
time, the patient’s temperature appears as a digital display on
the screen. Make a mental note of the temperature reading.
12. Remove the probe from the patient’s axilla. Discard the
probe cover by firmly pressing the ejection button while
holding the probe over a regular waste container.
13. Return the probe to its stored
position in the thermometer unit.
Return the thermometer unit to its
storage base. Fig (35).

Fig. (35): Return the probe

to its stored position
14.Hand washing.
15.Rearrange the equipment.
16.Place patient in comfortable position.
17.Record and report readings to supervisor immediately.
Rationale: Patient data must be recorded properly to aid the
physician in the diagnosis and to provide future reference.

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Medical Surgical Nursing Department Clinical of Fundamentals of Nursing I

3. Rectal temperature
A. Measuring Rectal Body Temperature by Mercury
Thermometer
Equipment:
1. Rectal thermometer (mercury).
2. Soft gauze.
3. Lubricant.
4. Vital sign flow-sheet and pen.
5. Clean gloves.
Preparation:
As oral temperature.

Steps of Procedure Notes

1. Introduce self and verify patient’s identity.
Rationale: Attain patient's cooperation and prevent
mistakes.
2. Explain procedure to patient.
Rationale: Attain patient's cooperation.
3. Gather appropriate equipment.
Rationale: Ease performance of the procedure.
4. Perform hand hygiene and observe other appropriate
infection control procedures.
Rationale: Prevents spread of infection.
5. Provide for patient’s privacy.
Rationale: Avoid patient's embarrassment.
6. Maintain body mechanics.
Rationale: Prevent strain on nurse's back.
7. Assist patient into sims position or side-lying position
(position patient lying on his side with top knee flexed).
Children may be placed in a prone position.

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Medical Surgical Nursing Department Clinical of Fundamentals of Nursing I

Fig. (36): Assist patient into sims position

Rationale: This provides for optimal exposure of the anal
area for correct placement of the thermometer & allow
visualization of the anus.
8. Shake down thermometer below 35C.
9. Squeeze a liberal amount of water-soluble lubricant onto
a tissue. Lubricate thermometer (2.5-4cm) for adult and (1-
1.5 cm) for infant.
Rationale: Insertion of the thermometer into the lubricant
container would contaminate contents of the container. Use
of lubrication minimizes trauma to the rectal mucosa during
insertion.
10. With the non-dominant hand, raise the patient’s upper
buttock to expose the anus.
Rationale: to full completely exposes anus of the patient .
11. Ask patient to take deep breath.
Rationale: This will relax rectal sphincter muscle.
12. Gently insert the thermometer
into the anus in the direction of the
umbilicus. Fig (37). Insert the
thermometer (1.5 inch) for adults.
Do not force the thermometer.
Insert the thermometer as the
patient takes in a breath. If
resistance is felt, immediately Fig (37):Gently insert the
remove the thermometer. thermometer into the anus

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Medical Surgical Nursing Department Clinical of Fundamentals of Nursing I

Rationale: To the mucosa or the

breakage of the thermometer.
13. Hold in place for 2 minutes.
14. Remove the thermometer from patient's rectum.
15. Wipe off thermometer using gauze pad with one
downward motion toward bulb end.
Rationale: Wiping from area where there are a few
organism.
16. Read thermometer.
Rationale: To see and record the point at which the
mercury reach.
17. Dispose of gauze in a container.
18. Wash thermometer in cool soapy water. Dry and place
it in a container, shake down the thermometer and return it
to its container.
19. Hand washing.
20. Rearrange the equipment.
21. Place patient in comfortable position.
22. Record and report readings to supervisor immediately.

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Medical Surgical Nursing Department Clinical of Fundamentals of Nursing I

B. Measuring Rectal Body Temperature by

Electronic thermometer
Equipment:
1. Electronic thermometer.
2. Rectal probe (red collar).
3. Plastic probe cover.
4. Lubricant.
5. Disposable gloves.
6. Tissues.
7. Waste container.

Steps of Procedure Notes

1. Introduce self and verify patient’s identity.
Rationale: Attain patient's cooperation and prevent
mistakes.
2. Explain procedure to patient.
Rationale: Attain patient's cooperation.
3. Gather appropriate equipment.
Rationale: Ease performance of the procedure.
4. Perform hand hygiene and observe other appropriate
infection control procedures.
Rationale: Prevents spread of infection.
5. Provide for patient’s privacy.
Rationale: Avoid patient's embarrassment.
6. Maintain body mechanics.
Rationale: Prevent strain on nurse's back.
7. Remove the thermometer unit from its storage base.
Attach the rectal (red collar) probe to it. This is
accomplished by inserting the latching plug (on the end of
the coiled cord of the rectal probe) to the plug receptacle
on the thermometer unit. Insert the probe into the face of
the thermometer.
Rationale: The rectal probe is color-coded with a red
collar for ease in identifying it.

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Medical Surgical Nursing Department Clinical of Fundamentals of Nursing I

8. Provide the patient with a gown. Instruct the patient to

remove enough clothing to provide access to the anal area
and to put on the gown with the opening in the back.
Rationale: It is important to explain what you will be
doing because body temperature may be higher in a
fearful or apprehensive patient. The patient gown provides
the patient with modesty and comfort.
9. Apply gloves. Position the patient in the Sim's position,
and drape the patient to expose only the anal area.
Rationale: Gloves protect the medical assistant from
microorganisms in the anal area and feces. Correct
positioning allows clear viewing of the anal opening and
provides for proper insertion of the thermometer. Draping
reduces patient embarrassment and provides warmth.
10. Grasp the probe by the collar,
and remove it from the face of the
thermometer. Slide the probe into a
disposable plastic probe cover until it
locks into place. Apply a lubricant to
the tip of the probe cover up to a level
of 1 inch. Fig (38).
Rationale: A lubricated thermometer
can be inserted more easily and does Fig. (38): Apply a
lubricant to the tip of
not irritate the delicate rectal mucosa. the probe
11. Instruct the patient to lie still. Separate the buttocks to
expose the anal opening, and gently insert the thermometer
probe approximately 1 inch into the rectum of an adult, 5
/8 inch in children, and ½ inch in infants. Do not force
insertion of the probe. Hold the probe in place until the
temperature registers
Rationale: The probe must be inserted correctly to
prevent injury to the tissue of the anal opening. The probe
should be held in place to prevent damage to the rectal
mucosa.

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Medical Surgical Nursing Department Clinical of Fundamentals of Nursing I

12. Hold the probe in place until you hear the tone. At that
time, the patient’s temperature appears as a digital display
on the screen. Make a mental note of the temperature
reading.
13. Gently remove the probe from the rectum in the same
direction as it was inserted. Avoid touching the probe
cover. Discard the probe cover by firmly pressing the
ejection button while holding the probe over a regular
waste container. Return the probe to its stored position in
the thermometer unit and return the thermometer unit to its
storage base.
Rationale: Fecal material is not considered regulated
medical waste; the probe can be discarded in a regular
waste container.
14. Wipe the patient’s anal area with tissues to remove
excess lubricant. Dispose of the tissues in a regular waste
container.
Rationale: Wiping the anal area makes the patient more
comfortable.
15. Hand washing.
16. Rearrange the equipment.
17. Place patient in comfortable position.
18. Record and report readings to supervisor immediately.
Rationale: Patient data must be recorded properly to aid
the physician in the diagnosis and to provide future
reference.

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Medical Surgical Nursing Department Clinical of Fundamentals of Nursing I

Heat and Cold measures

Performance objectives:
The student will be able to do the following:
1. Define the heat and cold measures.
2. Prepare the patient before procedure.
3. Collect necessary equipment for heat and cold measures.
4. Perform technique for measuring heat and cold measures
5. Apply the post procedures.
6. Document the result.
Definition:
Heat and cold application are therapeutic uses of heat and
cold to promote healing and patient comfort.
Preparation:
1. Test all equipment for proper functioning and integrity
(lack of leaks) before taking it to the patient.
2. Discuss how the results will be used in planning further
care or treatments.
3. Assist the patient to perform hygienic care to area that
receives heat or cold treatment.
4. Assess the area to receive heat or cold treatment.
5. Assess the patient physical condition for signs of
potential intolerance to heat and cold.
6. Assess the level of patient's consciousness influences the
ability to perceive heat, cold or pain.
7. Assess the skin sensation and integrity around the area to
be treated.
8. Identification of conditions that contraindicate for heat or
cold therapy.
9. Check the physician's order and the reason for warm or
cold compress.
Equipment:
1. Hot water and a thermometer.
2. Solution for heat treatment (sterile saline).
3. 4x4 gauze and waterproof pads.
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Medical Surgical Nursing Department Clinical of Fundamentals of Nursing I

4. Gloves.
5. Towel.
6. Bath basin
7. Sterile basin

Fig. (39): Sites of heat and cold applications

Steps of Procedure Notes

1. Introduce self and verify patient’s identity.
Rationale: Attain patient's cooperation and prevent
mistakes.
2. Explain procedure to patient.
Rationale: Attain patient's cooperation.
3. Gather appropriate equipment.
Rationale: Ease performance of the procedure.
4. Perform hand hygiene and observe other appropriate
infection control procedures.
Rationale: Prevents spread of infection.
5. Provide for patient privacy.
Rationale: Avoid patient's embarrassment.
6. Maintain body mechanics.
Rationale: Prevent strain on nurse's back.

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Medical Surgical Nursing Department Clinical of Fundamentals of Nursing I

7. Warm the container of sterile saline or tap water by

placing it in a bath basin filled with hot tap water. Sterile
saline should be warmed to 105˚ - 110˚ F.
Rationale: Sterile saline is used to prevent any
contamination of the wound. A temperature above 110ْ
F will cause further injury.
8. Place a waterproof pad under the body area that needs
the warm compress.
Rationale: To protect the patient’s bed.
9. A thin layer of petroleum jelly may be placed on the
patient's skin in the area to be treated.
Rationale: To protect the patients' skin.
10. Pour the sterile saline into the sterile basin, soaks an
appropriate size piece of gauze or a towel.
Rationale: A sterile basin is used to prevent further
contamination.
11. Place it on the affected area. Wear sterile gloves if
there is an open wound.
Rationale: To prevent any contamination of the wound.
12. Check the patient’s skin periodically for signs of heat
intolerance. Tell the patient to report any signs of
discomfort immediately.
Rationale: Signs of intolerance may include redness or
further swelling.
13. Leave the compress in place for approximately 30
minutes if it is tolerated, then remove it.
Rationale: Application of moist heat for a longer period of
time may damage the patient’s skin.
14. Dry the affected area.
Rationale: The patient may feel chilled when the warm
compress is removed. Dry the area completely to prevent
chilling.
15. Proper dispose of all single use equipment.
Rationale: To reduce the transmission of microorganisms.

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Medical Surgical Nursing Department Clinical of Fundamentals of Nursing I

16. Clean the bath basin and thermometer. Return the

sterile basin to the appropriate place for re-sterilization.
Rationale: To reduce the transmission of microorganisms
and gets the equipment ready for use again.
17. Remove gloves if they were worn and wash your
hands.
Rationale: To reduce the transmission of microorganisms.

18. Reassess the condition of the patient’s skin.

Rationale: The condition of the patient’s skin and any
signs of heat sensitivity should be assessed and
documented.
19. Clean and rearrange the equipments.
20. Hand washing.
21. Documentation:
- Document the application of the compress / pack and
the patient's response in the patient's record using
forms.
- Document the condition of the skin.
- Recode the result of the treatment and the patient
tolerance.

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Medical Surgical Nursing Department Clinical of Fundamentals of Nursing I

A. Cold Application
Preparation
1. Test all equipment for proper functioning and integrity
(lack of leaks) before taking it to the patient.
2. Discuss how the results will be used in planning further
care or treatments.
Equipment:
1. Pan for cold soak.
2. Ice or ice bag.
3. Gauze or towel.
4. Water bottles.
5. Compresses (if moist cold) consisting of gauze dressing,
iced or chilled solution, and a container of the
appropriate size for the body part.
6. Commercially prepared ice pack.
7. Disposable ice pack.

Steps of Procedure Notes

1.Introduce self and verify patient’s identity.
Rationale: Attain patient's cooperation and prevent
mistakes.
2. Explain procedure to patient.
Rationale: Attain patient's cooperation.
3. Gather appropriate equipment.
Rationale: Ease performance of the procedure.
4.Perform hand hygiene and observe other appropriate
infection control procedures.
Rationale: Prevents spread of infection.
5. Provide for patient’s privacy.
Rationale: Avoid patient's embarrassment.
6.Maintain body mechanics.
Rationale: Prevent strain on nurse's back.
7. Determine the diagnosis. Identify whether the patient
has a history of circulatory impairment or neuropathy.

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Medical Surgical Nursing Department Clinical of Fundamentals of Nursing I

Rationale: Cold causes vasoconstriction and can cause

tissue damage in people with impaired circulation and
sensation.
8. Fill the bag three-fourths full with ice and remove the
remaining air from the bag.
Rationale: If air is removed from the bag, the bag will be
easier to mold to the patient’s body.
9. Close the bag. Check for leaks. Wrap the bag in a towel
or protective cover and place it on the affected area.
Rationale: The bag is wrapped to prevent injury to the
patient’s skin or exposed tissue because direct cold can
cause damage.
10. Fill the collar three-fourths full with ice.
Rationale: Easier to mold to the patient's body.
11. Remove the remaining air from the collar before
closing in a protective cover and around the patient’s neck.
Rationale: The collar is wrapped to prevent injury of skin.
12. Activate the pack according to the manufacturers'
direction if a disposable cold pack is used.
Rationale: When the pack is squeezed or kneaded, an
alcohol-based solution is released, cannot be used again.
13. Assess the patient’s skin periodically for signs of cold
intolerance or tissue damage.
Rationale: Signs of intolerance to cold are pallor;
blanching, mottling, or numbness of the skin.
14. Leave the cold application in place for approximately
20-30 minutes at approximately 15 C (59 F) if the patient
can tolerate the cold.
Rationale: Longer application can cause tissue damage,
especially because the patient’s pain sensation is decreased.
15. Reassess the condition of the patient’s skin
Rationale: The patient’s skin should be assessed, and any
signs of cold changes & intolerance should be documented.
16. Clean and rearrange the equipments.

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Medical Surgical Nursing Department Clinical of Fundamentals of Nursing I

17. Hand washing.

18. Documentation:
- Document the application of the compression or pack
and the patient's response in the patient record using
forms.
- Document the condition of the skin.
- Recode the result of the treatment and the patient
tolerance

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Medical Surgical Nursing Department Clinical of Fundamentals of Nursing I

Assessing the Pulse

Performance objectives:
The student will be able to do the following:
1. Define the pulse.
2. List purposes of measuring pulse.
3. Identify indications of measuring pulse.
4. Prepare the patient before procedure.
5. Collect necessary equipment for measuring pulse.
6. Perform techniques for measuring radial, apical, and
radio-apical pulse.
7. Apply the post procedures.
8. Document the result.
Definition:
Pulse is a wave of blood created by contraction of the left
ventricle of the heart.
Purposes:
1. To obtain a baseline measurement of heart rate, rhythm
and volume.
2. To evaluate the heart's response to various therapies and
medications.
3. To assess local blood flow to an extremity.
Indications:
1. Before any invasive procedure.
2. Heart and respiratory disorders.
3. Pallor or cyanosed patient.
Preparation:
1. Review medical history to determine risk factors for
alterations in pulse rate (heart disease, fluid or electrolyte
imbalance, pain, and hemorrhage).
2. Assess for physical signs and symptoms of alteration in
cardiac or vascular status (dyspnea, chest pain, and
palpitations).
3. Identify factors that influence pulse (age, medications,
fever, and exercise).
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Medical Surgical Nursing Department Clinical of Fundamentals of Nursing I

4. Identify site most appropriate for pulse assessment.

5. Review previous and baseline pulse assessment.
Equipment:
1. Wristwatch with second hand.
2. Stethoscope.
3. Antiseptic wipes.
4. Gloves
5. Vital sign flow-sheet and pen.
A. Assessing radial (wrist) pulse:
Steps of Procedure Notes
1. Wash hands.
Rationale: Reduces transmission of microorganisms.
2. Inform patient of the site (s) where pulse will be
measured.
Rationale: Encourages participation and allays anxiety.
3. Flex patient's elbow and place lower part of arm across
chest.
Rationale: Maintains wrist in full extension and exposes
artery for palpation. Placing patient’s hand over chest will
facilitate later respiratory assessment without undue
attention to the nurse.
4. Support patient's wrist by grasping outer aspect with
thumb.
Rationale: Stabilizes wrist and allows for pressure to be
exerted.
5. Place index and middle
fingers on inner aspect of
patient’s wrist over the
radial artery, and apply
light but firm pressure until
pulse is palpated. Fig
(40&41).
Rationale: facilitating
palpation of pulsating Fig. (40)

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Medical Surgical Nursing Department Clinical of Fundamentals of Nursing I

pulse.

Fig. (41):
Place index and middle fingers
over radial artery.
6. Identify pulse rhythm.
Rationale: Palpate pulse until rhythm is determined.
Describe as regular or irregular.
7. Determine pulse volume.
Rationale: Quality of pulse strength is an indication of
stroke volume. Describe as normal, weak, strong, or
bounding.
8. Count pulse rate by using
second hand on watch. For a
regular rhythm, count number of
beats for 30 seconds and multiply
by 2. For an irregular rhythm,
count number of beats for a full
minute. Fig (42).
Rationale: An irregular rhythm Fig. (42): Count pulse
requires a full minute of rate for 60 seconds.
assessment to identify the number
of inefficient cardiac contraction
hat fail to transmit a pulsation.
9. Hand washing.
10. Rearrange the equipment.
11. Place patient in comfortable position.
12. Document the pulse rate, rhythm, and volume.

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Medical Surgical Nursing Department Clinical of Fundamentals of Nursing I

B. Assessing apical pulse:

Steps of Procedure Notes
1. Wash hands.
Rationale: Reduces transmission of microorganisms.
2. Raise patient's gown to expose sternum and left side of
chest.
Rationale: Allows access to patient's chest for proper
placement of stethoscope.
3. Cleanse earpiece and diaphragm of stethoscope with an
alcohol swab.
Rationale: Decreases transmission of microorganisms
from one prescribing practitioner to another (earpiece) and
from one patient to another (diaphragm).
4. Put stethoscope around neck.
Rationale: Ensures stethoscope is nearby for frequent use.
5. Locate apex of heart: Fig (43)
- With patient lying on left side,
locate suprasternal notch.
- Palpate second intercostal space
to left of sternum.
- Place index finger in intercostal
space, counting downward until
fifth intercostal space is located.
- Move index finger along fourth
intercostal space left of the
sternal border and to the fifth
intercostal space left of the
midclavicular line to palpate the
point of maximal impulse (PMI) Fig. (43): Palpating the
Rationale: Identification of apical pulse.
landmarks facilitates correct
placement of the stethoscope at
the fifth intercostal space in order
to hear PMI.

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Medical Surgical Nursing Department Clinical of Fundamentals of Nursing I

6. Inform patient that his or her heart will be listened to.

Instruct patient to remain silent.
Rationale: Elicits patient support. Stethoscope amplifies
noise.
7. With dominant hand, put earpiece of the stethoscope in
ears and grasp diaphragm of the stethoscope in the palm of
the hand for 5 to 10 seconds.
Rationale: Dominant hand facilitates for placement of
earpiece with one hand. Heat warms metal or plastic
diaphragm & prevents startling patient.
8. Place diaphragm of stethoscope
over the PMI and auscultate for
sounds S1 and S2 to hear lub-dub
sound. (Fig (44).
Rationale: Movement of blood
through the heart valves creates S1 Fig. (44): Place
and S2 sounds. diaphragm of stethoscope
over the PMI
9. Note regularity of rhythm.
Rationale: Listen for a regular rhythm before counting.
10.Start to count while looking at second hand of watch.
Count lub-dub sound as one beat: For a regular rhythm,
count rate for 30 seconds and multiply by 2. For an
irregular rhythm, count rate for a full minute, noting
number of irregular beats.
Rationale: Establishment of a rhythmic pattern
determines length of time to count the heartbeats to ensure
accurate measurement.
11.Share findings with patient.
Rationale: Promotes patient participation in care.
12.Record the rate, rhythm, and number of irregular beats.
Rationale: For accurate documentation.
13.Wash hands.
Rationale: Reduces transmission of microorganisms.

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C. Assessing apical-radial pulse:

Fig (45): Assessing apical-radial pulse

Definition:
Measuring both the apical and radial pulse simultaneously
Purpose:
To determine adequacy of peripheral circulation
Preparation:
If using the two-nurse technique ensures that the other nurse
is available at this time.
Steps of Procedure Notes
1. Introduce self and verify patient’s identity.
Rationale: Attain patient's cooperation and prevent
mistakes.
2. Explain procedure to patient.
Rationale: This decreases the patient’s anxiety.
3. Gather appropriate equipment.
Rationale: Ease performance of the procedure.
4. Perform hand hygiene and observe other appropriate
infection control procedures.
Rationale: Prevents spread of infection.
5. Provide for patient’s privacy.
Rationale: Avoid patient's embarrassment.
6. Maintain body mechanics.
Rationale: Prevent strain on nurse's back.
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Medical Surgical Nursing Department Clinical of Fundamentals of Nursing I

7. Position patient in supine or sitting position.

Rationale: This exposes the portion of the chest wall for
the site of the apical pulse.
8. Locate the apical and radial pulse sites.
Two-nurse technique:
9. Place the watch where both nurses can see it.
10. The nurse who is taking the radial pulse hold the watch.
Rationale: To facilitate accurate measure
11. Decide on a time to begin counting.
Rationale: This ensures that both counts are done
simultaneously.
12. The nurse taking the radial pulse says start at the same
time.
Rationale: This ensures that simultaneous counts are taken.
13. Each nurse counts the pulse rate for 60 seconds.
Rationale: A full 60 seconds count is necessary for
accurate assessment.
14. Both nurses end the count when the nurses taking the
radial pulse say stop.
15. Compare the rates obtained. If a difference is noted
between the rates, subtract the radial rate from the apical
rate.
Rationale: This determines if a pulse deficit exists. A pulse
deficit represents the number of ineffective or non-perfused
heartbeats.
One-nurse technique:
16. Assess the apical pulse for 60 seconds.
17. Assess the radial pulse for 60 seconds.
18. Hand washing.
19. Rearrange the equipment.
20. Replace the patient’s clothing, and Place patient in
comfortable position.
Rationale: This restores patient’s privacy.
21. Document the pulse rate, rhythm, and volume.

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Assessing Respiration
Performance objectives:
The student will be able to do the following:
1. Define respiration.
2. List purposes of assessing respiration.
3. Identify indications of assessing respiration.
4. Identify equipment used to assess respiration.
5. Perform techniques for assessing respiration, safely and
accurately.
6. Identify the preparation for measuring respiration.
7. Apply measures taken to maintain the patient's physical
comfort and safety during the techniques.
8. Apply the post procedures.
9. Document the result.
Definition:
Respiration includes the intake of oxygen (inhalation) and
the output (exhalation) of carbon dioxide.
Purposes:
1. To acquire a baseline measurement on the patient's
admission in which future measurements can be
compared.
2. To determine the rate, rhythm, depth, and character of
the patient's respiration.
3. To monitor abnormal respiration for patients, with chest
or heart disease.
4. To assess a patient's respiration prior to the
administration of general anesthetic or medication such
as morphine.
Indications:
1. Before any invasive procedure.
2. Heart and respiratory diseases.
3. Pallor or cyanosed patient.
Preparation:
1. Observe the color of the skin and mucous membranes of
patient, e.g., for cyanosis and/or pallor.
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Medical Surgical Nursing Department Clinical of Fundamentals of Nursing I

2. Patient who has been exercising will need to rest for a

few minutes before measuring respiration.
3. Avoid explain the procedure to the patient.
4. Assess rate when patient is at rest.
Equipment:
1. A watch with a second hand.
2. The vital signs book or worksheet and pen.

Steps of Procedure Notes

1. Introduce self and verify patient’s identity.
Rationale: Attain patient's cooperation and prevent
mistakes.
2. Gather appropriate equipment.
Rationale: Ease performance of the procedure.
3. Perform hand hygiene and observe other appropriate
infection control procedures.
Rationale: Prevents spread of infection.
4. Provide for patient’s privacy.
Rationale: Avoid patient's embarrassment.
5. Maintain body mechanics.
Rationale: Prevent strain on nurse's back.
6. Place the patient in a position of comfort, preferably
sitting. Place one hand on the patient's wrist as if taking the
radial pulse.
Rationale: To measure accurate respiration, discomfort
can cause the patient to breathe more rapidly
7. Place the patient's arm across his or her chest if the
respirations cannot be readily observed.
Rationale: The nurse's hand feels the patient's chest
movements. The complete inhalation and exhalation count
as one respiration (complete respiratory cycle).
8. Count the respiration for 30 second. Multiply this
number by 2 to calculate the respiratory rate per minute if
regular respiratory rate. If respirations are abnormal in any

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way, count the respiration for at least 1 full minute.

Rationale: To measure accurate respiration.
9. Observe the respirations for depth, rhythm, character,
and chest movement, if indicated.
Rationale: It will be indicated on the nursing care plan for
the patient with respiratory problems.
10. Assist the patient back into the comfortable position.
11. Rearrange equipment.
12. Hand washing.
13. Documentation:
- The rate, depth, rhythm, and character of the
breathing.
- The position that the patient assumed for breathing.
- Any change that might indicate cerebral anoxia, e.g.,
anxious behavior, irritability, restlessness, drowsiness,
or loss of consciousness.
- Report any abnormal characteristics such as dyspnea.

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Medical Surgical Nursing Department Clinical of Fundamentals of Nursing I

Assisting a Patient with an Incentive Spirometer

Performance objectives:
The student will be able to do the following:
1. Define the incentive spirometer.
2. Identify uses of incentive spirometer.
3. Identify how to assess patient before using incentive
spirometer.
4. Collect necessary equipment for apply incentive
spirometer.
5. Identify educational needs of patient who use incentive
spirometer.
6. Demonstrate steps of using incentive spirometer.
Definition:
Spirometer is an instrument for measuring the volume of
air entering and leaving the lungs.
Purposes:
1. Encourage patient to sustain deep voluntary breathing
and maximum inspiration to open airways.
2. Encourage coughing.
3. Prevent or reduce atelectasis.
Preparations:
1. Assess need for incentive spirometer.
2. Assess the patient's respiratory status by general
observation, auscultation of breath sounds, & percussion of
thorax to be able to compare.
3. Review medical record for recent arterial blood gases to
determine need for using incentive spirometer.
Equipment:
1. Stethoscope.
2. Incentive spirometer with appropriate mouthpiece.
a. Flow-oriented.
b.Volume-oriented.
3. T tube.

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Medical Surgical Nursing Department Clinical of Fundamentals of Nursing I

Fig. (154): Types of incentive spirometer

Steps of Procedure
1. Wash hands.
Rationale: Reduce the transmission of microorganism.
2. Check chart for previous respiratory assessment.
Rationale: Establish spirometer a baseline for comparison.
3. Gather equipment.
Rationale: Ensure preparation.
4. Explain procedure to the patient.
Rationale: Encourage patient's cooperation.
5. Demonstrate deep, sustained inspiration.
Rationale: Demonstration incentive spirometer a reliable
teaching technique.
6. Instruct patient to assume a semi-fowlers position.
Rationale: Promotes optimal lung expansion.
7. Set pointer on incentive spirometer at appropriate level or
point to level where dike or ball should reach.
Rationale: Encourage patient to reach appropriate goal.

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8. Use incentive spirometer,

have patient breath in and
exhale completely before using
incentive spirometer. Fig. (155).
Rationale: Promotes clearing
of secretions before using the
incentive spirometer.
Fig. (155): Use
incentive spirometer
9. Hold unit upright
Rationale: prevents ineffective use of the spirometer.
10. Have patient seal lips around mouthpiece and inhale
slowly and deeply until desired volume is attained.
Rationale: Prevents ineffective use of the spirometer.
11. Sustain inspiration for at least 3 seconds & exhale
slowly
12. Repeat 10 to 20 times every 1 to 2 hours while awake for
72 hours.
Rationale: Ensure airways remain open and prevents
atelectasis.
13. Teach patient to perform incentive spirometer every
hour and verify that patient incentive spirometer complaint.
Rationale: Encourage patients to take responsibility for
their health care.
14. Dispose soiled equipment or tissues and wash hands.
Rationale: Reduce the transmission of microorganism.
15. Documentation:
- Record lung volume
- Record respiratory assessment including breath sounds,
rate, and depth
- Note the type and amount of secretions expectorated .

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Medical Surgical Nursing Department Clinical of Fundamentals of Nursing I

Measuring blood pressure

Performance objectives:
The student will be able to do the following:
1. Define the blood pressure.
2. List purposes of measuring blood pressure.
3. Identify indications of measuring blood pressure.
4. Prepare the patient before procedure.
5. Collect necessary equipment for measuring blood
pressure.
6. Perform techniques for measuring blood pressure.
7. Apply the post procedures.
8. Document the result.
Definition:
Measuring of the pressure exerted by blood as it pulsates
through the arteries
Purposes:
1. To obtain a baseline reading upon admission to an
agency.
2. To monitor the status of cardiovascular system.
3. To determine the adequacy of blood supply to a body
part.
4. To provide early detection of problems such as
hemorrhage.
Indications:
1. Before any invasive procedure.
2. Heart and respiratory disease.
3. Pallor or cyanosed patient.
Preparation:
1. Ensure that the equipment is intact and functioning
properly.
2. Check for leaks in the tubing of sphygmomanometer.
3. Make sure that the patient has not smoked or ingested
caffeine because it causes a temporary increase in blood
pressure.
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Equipment:
1. Stethoscope.
2. Sphygmomanometer blood pressure cuff
- Blood pressure cuff consists of a rubber bag that can be
inflated with air called the bladder.
- It is covered with cloth and has two tubes attached to it.
- One tube connects to a rubber bulb that inflates the
bladder.
- A small valve on the side of this bulb traps and releases
the air in the bladder. The other tube is attached to a
Sphygmomanometer.

Fig (46): Accessories for mercury (47): Parts of

Sphygmomanometer Sphygmomanometer cuff

3. Gloves, if required
4. Antiseptic wipes.
5. Vital signs flow-sheet and pen.

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A. Auscultation method using brachial artery:

Steps of Procedure Notes
1. Wash hands.
Rationale: Reduces transmission of microorganisms.
2. Determine which extremity is most appropriate for
reading. Do not take a pressure reading on an injured or a
painful extremity or one in which an intravenous line is
running.
Rationale: Cuff inflation can temporarily interrupt blood
flow and compromise circulation in an extremity.
3. Select a cuff size appropriate
for the patient. Estimate by
measure with a tape the
circumference of the bare upper
arm at the midpoint between the
shoulder and the elbow Fig (48).
Rationale: The bladder inside the
cuff should encircle 80% of the
arm in adults and 100% of the arm
of children less than 13 years old. Fig(48): Select proper
cuff size
4. Have the patient’s bare arm resting on a support so the
midpoint of the upper arm is at the level of the heart.
Extend the elbow with palm turned upward.
Rationale: Blood pressure increases when the arm is
below the level of the heart and decreases when the arm is
above the level of the heart.
5. Make sure the bladder cuff is fully deflated and the
pump valve moves freely. Place the manometer so the
center of the mercury column or aneroid dial is at eye level
and easily visible to the observer.
Rationale: Equipment must be visible and must function
properly to obtain an accurate reading.

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6. Palpate the brachial artery, in

the antecubital space, and place
the cuff so that the midline of the
bladder is over the arterial
pulsation. Wrap and secure the
cuff around the patient’s bare Fig. (49): Palpate the
brachial artery.
upper arm. The lower edge of the
cuff should be 1 inch (2 cm)
above the antecubital fossa (bend
of the elbow (Fig 49).
Rationale: Rolling up the sleeve
may form a tourniquet around
the upper arm. Always use a bare
arm. Fig. (50): Center the blood
pressure cuff over the
brachial artery
7. Insert the earpieces of the stethoscope into the ear
canals with a forward tilt to fit snugly.
Rationale: The bell, the low-frequency position of the
stethoscope, enhances sound transmission from chest piece
to ears.
8. Place the bell of the
stethoscope over the brachial
artery pulsation. The bell should
be held firmly in place.
Rationale: Sound is heard well
directly over the artery.

Fig. (51): The stethoscope

chest piece should not
touch the blood pressure
cuff.

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Fig. (52): Place the bell of the

stethoscope over the brachial artery
pulsation
9. With dominant hand, turn the
valve clockwise to close.
Compress the pump to inflate the
cuff rapidly and steadily until the
manometer registers 20 to 30
mm Hg above the level
previously determined by the
palpation Fig. (53). Fig. (53): Compress the
Rationale: Prevents air leaks pump to inflate the blood
during inflation. Ensures the cuff pressure cuff.
is inflated to a pressure greater
than the patient’s systolic
pressure.
10. Partially open valve counter clock wise to deflate the
bladder at 2 mm/sec while listening for the pulse sounds.
Rationale: Maintains constant release of pressure to
ensure hearing first systolic sound.

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11. After the last sound is heard,

deflate the cuff slowly for at least
another 10 mm Hg to ensure that no
other sounds are audible; then, deflate
rapidly and completely Fig (54).
Rationale: Prevents arterial occlusion Fig. (54):Deflate
and patient discomfort from numbness the cuff completely
12. Allow patient to rest for at least 30 seconds and
remove cuff. Take 2 or more additional readings and
average them.
Rationale: Ensures accurate measurement.
13. Inform the patient of the reading.
Rationale: Promotes patient’s participation in health care.
14. The systolic and diastolic pressure should be
immediately recorded, rounded off (upward) to the nearest
2 mmHg.
Rationale: Ensures accuracy.
15. If appropriate, lower bed, raise side rails, and place
call light within easy reach.
Rationale: Promotes patient’s safety.
16. Put all equipment within proper place.
Rationale: Fosters maintenance of equipment.
17. Wash hands.
Rationale: Reduces transmission of microorganisms

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B. Measuring blood pressure from the thigh:

Steps of Procedure Notes
1. Introduce self and verify patient’s identity.
Rationale: Attain patient's cooperation and prevent
mistakes.
2. Explain procedure to patient.
Rationale: Attain patient's cooperation.
3. Gather appropriate equipment.
Rationale: Ease performance of the procedure.
4. Perform hand hygiene and observe other appropriate
infection control procedures.
Rationale: Prevents spread of infection.
5. Provide for patient’s privacy.
Rationale: Avoid patient's embarrassment.
6. Maintain body mechanics.
Rationale: Prevent strain on nurse's back.
7. Help the patient to assume prone position if the patient
cannot measure the blood pressure in a supine position with
the knee slightly flexed.
8. Expose the thigh.
9. Locate the popliteal artery.
10.Warp the cuff evenly around the mid-thigh.
11.Compress bladder over the
posterior aspect of the thigh
and the bottom edge above the
knee Fig (55).
Rationale: The bladder must
be over the posterior popliteal
artery to give accurate reading.

Fig. (55): put bladder over the

posterior aspect of the thigh
12. Carry out steps from 9 to 14.

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13. Hand washing.

14. Rearrange the equipment.
15. Place patient in comfortable position.
16. Document the result.

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C. Measuring blood pressure by the palpation method

(palpatory method):

Fig (56): Measuring blood pressure by the palpation method

Indications:
1. If is not possible to use stethoscope.
2. If the sounds cannot be heard.
Methods:
1. Palpate the radial or brachial pulse site as the cuff
pressure is released.
2. The manometer reading at the point where an estimate of
the systolic blood pressure is.

Steps of Procedure Notes

1. Explain the procedure to the patient
Rationale: This decreases anxiety and promotes patient
cooperation.
2. Wash hands.
Rationale: Prevents transmission of microorganisms.

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3. Locate the patient’s

brachial or radial pulse Fig
(57). Rationale: This
locates the pulse that offers
the best palpable volume for
the procedure.
Fig. (57): palpate radial pulse
4. Place the cuff on the patient’s arm.
Rationale: This position help in cuff for inflation.
5. Palpate again for the pulse. When the pulse is felt,
continue to palpate.
Rationale: This relocates the pulse for the procedure.
6. Inflate the cuff until unable to palpate the pulse.
Rationale: This occludes the arterial blood flow.
7. Inflate the cuff until the measurement gauge is 20 mm
Hg past the point at which the pulse was lost on palpation.
Rationale: This identifies the point of pulse return.
8. Slowly deflate the cuff at a rate of 2 to 3 mm Hg per
second.
Rationale: This prevents the nurse from missing the first
palpable beat.
9. Note the reading on the measurement gauge when the
pulse returns. Remove cuff from the patient’s arm.
Rationale: This identifies the systolic blood pressure
reading.
10. Documentations:
- Document blood pressure measurement on appropriate
form.
- Report significant change in the patient’s blood
pressure to physician.
- Method of blood pressure measurement.
- Patient’s condition.

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Using a Pulse Oximetry

Performance objectives:
The student will be able to do the following:
1. Define pulse oximetry.
2. Assess patient when using a pulse oximetry.
3. Collect necessary equipment needed for using a pulse
oximetry.
4. Perform of using a pulse oximetry.
Definition:
Pulse oximetry is a quick, easy, noninvasive method to
assess the arterial blood oxygen saturation of a patient by
using an external sensor.
Preparations:
1. Assess the patient’s hemoglobin level. Because pulse
oximetry measures the percent of SaO2.
2. Assess the patient’s color. If the patient has
vasoconstriction of the extremities, an inaccurate recording
may be obtained.
3. Assess the patient’s mental status because this will assist
in general evaluation of oxygen delivery to the brain.
4. Assess the patient’s pulse rate. Manually assessing pulse
can be used as a cross-reference to indicate functioning of
the oximeter.
5. Assess the area where the sensors will be placed to
determine whether it is an area with adequate circulation (no
scars, thickened nails, or fingernail polish).
Equipment:
1. Pulse oximeter.
2. Proper sensor.
3. Alcohol wipe or soap and water.
4. Nail polish removal if necessary.

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Fig. (152): Types of Pulse Oximeter

Steps of Procedure
1. Wash hands.
Rationale: Reduces the transmission of microorganisms.
2. Select an appropriate site for
the sensor. Fingers are most
commonly used; however, toes,
ear lobes, nose, forehead, hands,
and feet can be used Fig. (153).
Rationale: The sensor should be
selected based on the size of the
person and the site to be used. Fig. (153 ): ear sensor
3. Assess for capillary refill and proximal pulse. If the
patient has poor circulation, use an earlobe, forehead, or
nasal sensor instead.
Rationale: Decreased circulation alters the O2 saturation
measurement.
4. Clean the site with an alcohol wipe.
Rationale: Reduces the transmission of microorganisms.
5. Remove artificial nails or nail polish if present or select
another site. Clean any tape adhesive and use soap and water
if necessary to clean site.
Rationale: Polish and artificial fingernails alter the results.
6. Apply the sensor and make sure the photo detectors are
aligned on opposite sides of the selected site.
Rationale: Proper application is necessary for accurate
results.
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Medical Surgical Nursing Department Clinical of Fundamentals of Nursing I

7. Connect the sensor to the oximeter with a sensor cable.

Turn on the machine. Initially a tone can be heard, followed
by an arterial waveform fluctuation with each arterial pulse.
Rationale: The tone and wave-form fluctuation indicate
that the machine is detecting blood flow with each arterial
pulsation.
8. Adjust the alarm limits for high and low O2 saturation
levels according to the manufacturer’s directions. Pulse rate
limits most often can also be set. Adjust volume.
Rationale: The alarms indicate that the saturation levels or
pulse rates are out of the designated levels and alert the
nurse of abnormal O2 saturation levels and pulse rates.
9. If taking a single reading, move the site of spring.
Sensors every 2 hours.
Rationale: Prevents skin breakdown from pressure and
skin irritation from the adhesive.
10. Cover the sensor with a sheet or towel to protect it from
exposure to bright light.
Rationale: Ambient light sources such as sunlight or
warming lights may interfere with the sensor and alter the
SaO2 results.
11. Notify the physician or qualified practitioner of
abnormal results.
Rationale: Low SaO2 levels require medical attention
because permanent tissue damage may result from low
oxygen saturation.
12. Record the results of O2 saturation measurements and
- The type of sensor used.
- The site of application.
- The hemoglobin levels.
- Assessment of the patient’s skin at the sensor site.
Rationale: Communicates the findings to the other
members of the health care team and contributes to the legal
record.

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Assessing and recording pain

Performance objectives:
The student will be able to do the following:
1. List purposes of measuring pain.
2. Prepare the patient before procedure.
3. Perform techniques for measuring pain.
4. Apply the reassessment of pain.
5. Document the result.
Purposes:
1. To obtain a baseline measurement of pain.
2. To evaluate the patient response to various therapies and
medications of Relief pain or decrease in intensity of
pain.
Preparation:
1. Review medical history to determine risk factors for pain.
2. Assess for physical signs and symptoms of pain.
3. Identify factors that influence pain.
4. Review previous and baseline pain assessment.
Equipment:
1. pain scales
2. Vital sign flow-sheet and pen.
Assessing pain:
Steps of Procedure Notes
1. Wash hands.
Rationale: Reduces transmission of microorganisms.
2. Inform patient of the steps of pain measurement.
Rationale: Encourages participation and allays anxiety.
3. Reassure patient that you know pain is real and will
assist him or her in dealing with it.
Rationale: Fear that pain will not be accepted as real
increases tension and anxiety and decreases pain tolerance.
4. History assessment
5. Use pain assessment scale to identify intensity of pain.

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Rationale: Provides baseline for assessing changes in

painlevel and evaluating interventions.
6. COLDERR: ask the patient about:
- Characteristic: describe the sensation (sharp, aching,
burning).
- Onset: when it started.
- Location: where it hurts.
- Duration: constant, intermittent, how long.
- Exacerbation: factors that make it worse.
- Relief: factors that make it better.
- Radiation: pattern of shooting/spreading/location of
pain away from its origin.
7. PQRST: ask the patient about
P _ What precipitated (triggered, stimulated) the pain?
Has anything relieved the pain? What is the pattern of
the pain?
Q _ What are the quality and quantity of the pain?
Is the pain sharp, stabbing, aching, burning, stinging,
deep,
crushing, viselike, gnawing?
R _ What is the region (location) of the pain?
Does the pain radiate to other areas of the body?
S _ What is the severity of the pain?
T_ What is the timing of the pain?
When does it begin, how long does it last, and how is it
related to other events in the client’s life?
8. Administer balanced analgesics as prescribed to
promote optimal pain relief.
Rational: Analgesics are more effective if administered
early in pain cycle. Simultaneous use of analgesics that
work on different portions of the nociceptive system
will provide greater pain relief.
9. Re use the same pain assessment scale.
Rational: Permits assessment of effectiveness of analgesia

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and identifies need for further action if ineffective

10.Hand washing.
11.Place patient in comfortable position.
12.Document severity of patient’s pain on chart.
Rational: Assists in demonstrating need for additional
analgesic or alternative approach to pain management

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Relaxation techniques

Performance objectives:
The student will be able to do the following:
1. Define the relaxation techniques.
2. Identify benefits of relaxation techniques.
3. List types of relaxation techniques.
4. Demonstrate steps of whole body and deep breathing
relaxation techniques.
Definition: are therapeutic exercises designed to assist
individuals by decreasing tension and anxiety, physically and
psychologically.
Benefits:
Practicing relaxation techniques can have many benefits,
including:
1. Slowing heart rate.
2. Lowering blood pressure.
3. Slowing breathing rate.
4. Improving digestion.
5. Maintaining normal blood sugar levels.
6. Reducing activity of stress hormones.
7. Increasing blood flow to major muscles.
8. Reducing muscle tension and chronic pain.
9. Improving concentration and mood.
10. Improving sleep quality.
11. Lowering fatigue.
12. Reducing anger and frustration.
13. Boosting confidence to handle problems.
Types:
1. Guided Imagery: is a relaxation exercise intended to
assist patients with visualizing a calming environment.
Imagery employs all five senses to create a deeper sense
of relaxation. Guided imagery can be practiced
individually or with the support of a narrator.

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2. Visualization. In this relaxation technique, you may form

mental images to take a visual journey to a peaceful,
calming place or situation.
3. Biofeedback-Assisted Relaxation: is measure body
functions and give information about them so that the
person can learn to control them. It uses electronic
devices.

Fig (58): Biofeedback

4. Aromatherapy: is uses essential oils in a controlled way
to promote personal wellbeing. Essential oils are
concentrated, naturally occurring, chemicals extracted
from flowers, trees and other plants
5. Whole-body technique:
1. Feet
- Bring your attention to your feet.
- Point your feet downward, and curl your toes under.
- Tighten your toe muscles gently, but don’t strain.
- Notice the tension for a few moments, then release,
and notice the relaxation. Repeat.
- Become aware of the difference between the muscles
when they’re tensed and when they’re relaxed.
- Continue to tense and relax the leg muscles from the
foot to the abdominal area.
2. Abdomen
- Gently tighten the muscles of your abdomen, but don’t
strain.
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- Notice the tension for a few moments. Then release,

and notice the relaxation. Repeat.
- Become aware of the difference between the tensed
muscles and the relaxed muscles.
3. Shoulders and neck
- Very gently shrug your shoulders straight up towards
your ears. Don’t strain.
- Feel the tension for a few moments, release, and then
feel the relaxation. Repeat.
- Notice the difference between the tensed muscles and
the relaxed muscles.
- Focus on the neck muscles, first tensing and then
relaxing until you feel total relaxation in this area.
4. Localized technique
- Close your hands tightly to feel the tension. Hold for 5
seconds, and slowly allow the fingers to release one
by one until they’re completely relaxed.
- Press your lips tightly together and hold for 5 seconds,
feeling the tension. Slowly release. The lips should be
completely relaxed and barely touching after the
release.
- Finally, press your tongue against the roof of your
mouth for 5 seconds, and notice the tension. Slowly
relax the tongue until it’s sitting on the floor of the
mouth and your jaws are slightly unclenched.

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6. Deep breathing exercise:

1. Sit upright in a comfortable chair with your feet

placed side by side on the floor. Close your eyes.
2. Place one hand on your belly, with your pinky finger
just above your belly button.
3. Start to pay attention to the rise and fall of your belly.
What you are feeling is your diaphragm, working to
draw air in and out of your lungs.
4. Notice that as you breathe in, it feels like a balloon is
being filled with your hand. As you breathe out it
should feel like the balloon is deflating.
5. Place your other hand on your chest. You will want to
try to keep this hand as still as possible and to just let
the diaphragm do all of the work of breathing. While
you are at it, keep your shoulders relaxed — you don't
need your shoulders to breathe!
6. Inhale slowly to the count of three from your nose.
7. Then exhale slowly to the count of three from your
mouth through pursed lips, thinking the word "relax"
as you do so.
8. Stay focused on the action of your diaphragm. Your
bottom hand should move outward as you fill your
lungs with air and move inward as you exhale.

Fig (59 ): Diaphragmatic breathing

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Medical Surgical Nursing Department Clinical of Fundamentals of Nursing I

Hygienic Care

Performance objectives:
The student will be able to do the following:
1. Define the terms.
2. Identify the purposes for each hygienic care procedure.
3. Prepare the patient for each hygienic care procedure.
4. Collect and prepare the equipment for each hygienic care
procedure.
5. Demonstrate bed bath, oral care, hair care, foot and nail
care correctly and accurately.
Definition:
Cleaning and washing all parts of the body by warm water
and cleaning solution e.g. soap.
Purposes:
1. Clean the skin.
2. Promote self-esteem.
3. Stimulate circulation.
4. Assess of skin and physical mobility.
5. Provide range of motion exercises for joint.
6. Promote relaxation and comfort.
 Types of bed bath
» Complete bed bath: A complete bed bath is provided to
dependent patients confined to bed. The nurse washes the
patient’s entire body during a complete bed bath.
» Partial bed bath: Bed bath that consists of bathing only
body parts that would cause discomfort if left unbathed
such as the hands, face, axilla, and perineal area. Partial
bath also includes washing back and providing back rub.
Dependent patients in need of partial hygiene or
bedridden patients who are unable to reach all body parts
receive a partial bed bath.

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Preparation:
1. Assess self-care ability of the patient.
2. Prepare necessary bath equipment and linens.
3. Caution is needed when bathing patient who are
receiving intravenous (IV) therapy.
4. Prepare environment; close doors and windows to ensure
that the room is at a comfortable temperature.
5. Assist the patient with use of bedpan, or urinal, if needed.
 Complete bed bath:
Equipment:
1. Bath towels.
2. Wash cloths.
3. Bath blanket.
4. Wash basin with warm water.
5. Soap.
6. Soap dish.
7. Personal hygiene products (e.g. lotion, deodorant,
powder).
8. Clean gown.
9. Clean linen.
10. Disposable gloves.
Steps of procedure Notes
1. Introduce self and verify patient’s identity.
Rationale: Attain patient's cooperation and prevent
mistakes.
2. Explain procedure to patient.
Rationale: Attain patient's cooperation.
3. Gather appropriate equipment.
Rationale: Ease performance of the procedure.
4. Perform hand hygiene and wear gloves.
Rationale: Prevents spread of infection.
5. Provide for patient privacy.
Rationale: Avoid patient's embarrassment.
6. Maintain body mechanics.

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Rationale: Prevent strain on nurse's back.

7. Raise bed to comfortable working height. Lower side rail
closest to you and help patient assume comfortable supine
position, maintaining body alignment. Bring patient toward
side closest to you.
Rationale: Having the patient positioned near the nurse and
lowering the side rail prevent unnecessary stretching and
twisting of muscles on the part of the nurse.
8. Place bath blanket over top sheet. Remove top sheet from
under bath blanket. Place soiled linen in laundry bag.
Remove patient’s gown. Bath blanket should be folded to
expose only the area being cleaned at that time. (Top sheets
or towels may also be used for bath blankets).
Rationale: Promotes privacy and protects from chills.
9. Fill washbasin two-thirds full with warm water. have
patient place fingers in water to test temperature tolerance
Rationale: Warm water promotes comfort, relaxes muscles,
and prevents unnecessary chilling. Testing temperature
prevent accidental burns or chills.
10. Make a bath mitten with the washcloth Fig. (60).
Rationale: Prevents ends of washcloth from dragging across
skin and promotes friction during bath.

A B C

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A B C D
Fig. (60): Make a bath mitten with the washcloth
11. Wet the washcloth and
wring it out.
Rationale: Prevents
unnecessarily wetting of
patient.

Fig (61):Wet the washcloth and

wring it out.
12. Wash eyes use a
separate corner of the
washcloth for each eye,
wiping from inner to outer.
Soak any crusts on eyelid
for 2 to 3 minutes with a
warm, damp cloth before
attempting removal. Dry
around eyes gently and
thoroughly. Fig. (61).
Rationale: Use of separate
sections of mitt reduces Fig. (62): Wash eyes
infection transmission.
Bathing eye gently from
inner to outer canthus
prevents secretions from
entering nasolacrimal duct.
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Pressure causes internal

injury.
13. Wash, rinse, and dry forehead, cheeks, nose, neck, and
ears without using soap. Ask men if they want to be shaved
Rationale: Patting dry reduces skin irritation and drying.
14. Wash hand, forearm,
and arms. Remove bath
blanket from patient’s arm
that is closest to you. Place
bath towel lengthwise under
arm. Bathe with water and
minimal soap using long,
A
firm strokes from distal to
proximal (fingers to axilla).
Fig (63). Rinse, and dry
thoroughly Rationale: Long
strokes promote circulation.
Strokes directed distal to
proximal promote venous
return. B

C
Fig (63) A–C): Wash from distal
to proximal—from hands to
forearms to upper arms.

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15.Raise and support arm

above head (if possible)
to wash axilla, rinse, and
dry thoroughly Fig. (64).
Apply deodorant or
powder if desired.
Rationale: Provide
patient comfort. Fig (64): wash axilla

16. Immerse patient’s hand into basin of water. Allow hand

to soak about 3–5 minutes. Wash hands, interdigit area,
fingers, and fingernails. Rinse and pat dry.
Rationale: Soaking hands softens nails and loosens soil
from skin and nails.
17. Fold bath blanket down
to umbilicus. Wash chest
using long, firm strokes.
Wash skin fold under the
female breast. Rinse and pat
dry Fig. (65).
Rationale: For patient
comfort Fig. (65): Wash chest
18. Fold bath blanket down to suprapubic area. Use another
towel to cover chest area. Wash abdomen using long, firm
strokes. Rinse and pat dry. Replace bath blanket over chest
and abdomen.
Rationale: Cover chest or abdomen area in between
washing, rinsing, and drying to prevent chilling.

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19. Wash legs and

feet. Expose leg
farthest from you by
folding bath blanket to
midline. Fig (66) Bend
the leg at the knee.
Grasp the heel, elevate
the leg from the bed,
Fig. (66): Wash leg from ankle to the
and cover bed with knee to the thigh.
bath towel. Place
washbasin on towel.
Place patient’s foot
into washbasin. Fig
(67) Allow foot to soak
while washing the leg
with long, firm strokes
in the direction of
distal to proximal.
Rinse and pat dry.
Clean soles, interdigits,
and toes. Rinse and pat
dry. Perform same
Fig (67): Place patient’s foot into
procedure with the
washbasin
other leg and foot.
Rationale: to promote
circulation by
stimulating venous
blood flow.
20. Assist patient into
prone or side - lying
position. Wash back
and buttocks. Rinse,
pat dry &apply lotion
Fig. (68).
Rationale: Back rub
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promotes relaxation
and circulation. Lotion
Fig. (68): Wash back and buttocks
lubricates skin.
21. Assist patient to supine position. Perform perineal care
» Perineal care for a female. Fig (69)
a. Drape patient with bath blanket placed in shape of a
diamond. Lift lower edge of bath blanket to expose
perineum. Fold lower corner of bath blanket up between
patient’s legs onto abdomen and under hip

Fig. (69): Drape patient for perineal care.

Rationale: Removes genital secretions and soil.
b. Wash labia majora. Use non dominant hand to gently
retract labia from thigh. Use dominant hand to wash
carefully in skinfolds. Wipe in direction from perineum to
rectum (front to back). Repeat on opposite side using
separate section of washcloth. Rinse and dry area
thoroughly.

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Fig. (70): Clean from perineum to rectum (front to back)

Rationale: Maximizes cleaning; prevents spread of rectal
flora to vagina.
a. Gently separate labia with non-dominant hand to expose
urethral meatus and vaginal orifice. With dominant hand
wash downward from pubic area toward rectum in one
smooth stroke. Use separate section of cloth for each
stroke. Clean thoroughly over labia minora, clitoris, and
vaginal orifice. Avoid tension on indwelling catheter if
present and clean area around it thoroughly.
b. Rinse and dry area thoroughly, using front-to-back
method.
Rationale: Residual moisture provides an ideal
environment for the growth of microorganisms.
» Perineal care for a male
a. Wash tip of penis at urethral meatus first. Using circular
motion, clean from meatus outward. Discard washcloth
and repeat with clean cloth until penis is clean. Rinse and
dry gently and thoroughly.
b. Gently clean shaft of penis and scrotum by having
patient abduct legs. Pay special attention to underlying
surface of penis. Lift scrotum carefully and wash
underlying skinfolds. Rinse and dry thoroughly.
22. Apply lotion & powder as desired. Apply clean gown.
Rationale: Lotion lubricates skin.
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23. Change bed linens. Dispose of soiled linens according

to agency policy.
Rationale: reduces the risk for infection transmission and
contamination of other items.
24. Place patient in comfortable position & raise side rails.
Rationale: Proper positioning with raised side rails
provides for patient comfort and safety.
25. Wash hands.
Rationale: Reduces the transmission of microorganisms.
26. Documentation: Document procedure and assessment
findings; skin assessment, such as erythema, rashes
drainage, or skin breakdown.
Rationale: to ensure continuity of care.

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Oral Care

Definition:
Brushing, cleansing and moistening the teeth and oral
mucosa by rinsing with water.
Purposes:
1. Clean tooth surfaces to prevent odor and caries.
2. Maintain the integrity of the oral mucosa.
3. Promote self- esteem and comfort.
Preparation:
1. Inspect lips, gums, oral mucosa, and tongue for lesions
or inflammation.
2. Identify presence of oral problems such as tooth caries.
3. Determine patient's ability to assist with procedure.
4. Assess patient's risk for aspiration.
Equipment:
1. Tooth brush and tooth paste.
2. Towel.
3. Clean gloves.
4. Emesis basin.
5. Cup of water.
6. Mouthwash.
7. Dental floss, at least two pieces 20 cm in length.
8. Nonsterile gloves
9. Lip moisturizer

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A. Brushing and flossing teeth:

1. Brushing:

1. Introduce self and verify patient’s identity.

Rationale: Attain patient's cooperation and prevent
mistakes.
2. Explain procedure to patient.
Rationale: Attain patient's cooperation.
3. Gather appropriate equipment.
Rationale: Ease performance of the procedure.
4. Perform hand hygiene and apply gloves.
Rationale: Prevents spread of infection.
5. Provide for patient privacy.
Rationale: Avoid patient's embarrassment.
6. Maintain body mechanics.
Rationale: Prevent strain on nurse's back.
7. Place patient in a high fowler's position.
Rationale: Decreases risk of aspiration.
8. Place the towel under the patient's chin.
Rationale: Keep patient chin and neck dry.
9. Moisten toothbrush in cup of water and apply
toothpaste to bristles.
Rationale: Softens brush bristles. Toothpaste act as a
cleansing agent.
10. Place the emesis basin under patient's chin.
Rationale: Keep patient chin and neck dry.
11. Inspect the mouth, gums and teeth.
Rationale: To perform assessment.

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12. Brush the patient's teeth

holding the bristles at a 45-
degree angle. Brush from gum
line to the crown of the tooth
Fig. (71).
Rationale: Remove plaque
buildup and food particles. The
45-degree angle of brushing
permits cleansing of all surface Fig. (71): Brush the
areas of the tooth. patient's teeth
13. Move the bristles up and down gently. Repeat until all
outer and inner surfaces of the teeth are cleaned.
Rationale: Remove plaque buildup and food particles.
14. Brush the biting surfaces of
the teeth by moving the brush
back and forth on top of the
tooth's surface Fig. (72).
Rationale: Remove plaque
buildup and food particles
Fig. (72): Moving the
brush back & forth on top
of the tooth's surface
15. Brush tongue gently with
toothbrush Fig. (73).
Rationale: Removes coating on
the tongue. Gentle motion does
not stimulate gag reflex.

Fig. (73): Brush tongue

16. Assist patient in rinsing of mouth with cup of water.
Rationale: Remove waste contents from the oral cavity.

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2. Flossing:
Steps of procedure Notes
1. Wrap one end of the floss
around the third finger of each
hand Fig. (74).
Rationale: To prevent
slipping Fig. (74): Wrap one end of
the floss around the finger
2. Ask patient to open mouth and smile to reveal teeth.
Rationale: Easy access to areas between the teeth.
3. Gently insert floss between
teeth and move it back and
forth Fig. (75)
Rationale: Remove plaque
buildup and food particles.

Fig. (75): Gently insert floss

between teeth
4. Move the floss up and down between the teeth.
Rationale: Remove plaque buildup and food particles.
5. Assist patient to rinse mouth thoroughly with water and
spit into emesis basin. Help to wipe his or her mouth.
Rationale: Remove waste contents from the oral cavity.
6. Apply lubricant to patient lips as needed.
Rationale: Prevent cracking of lips.
7. Remove and dispose of equipment appropriately.
8. Remove and discard gloves and wash hands.
9. Place patient in comfortable position.
10. Document procedure and assessment findings of the
teeth, tongue, gum, and oral mucosa. Any problems as
sores or inflammation, bleeding, or swelling of the gum.
Rationale: Provides evidence of nursing care and ensures
continuity of care.

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B. Denture care:
Purpose:
To prevent irritation and infection of the gums.
Equipment:
1. Denture brush.
2. Denture cleaner.
3. Emesis basin.
4. Towel.
5. Cup of water.
6. Non sterile gloves.
7. Tissue.
8. Denture cup.
Preparation:
1. Assess the patient’s oral hygiene preferences: frequency,
time of day, and type of hygiene products.
2. Assess for any physical activity limitations.
3. Assess for difficulty chewing, pain, tenderness, and
discomfort.
4. Assess patient’s oral cavity: look for inflammation,
edema, lesions, bleeding, or yellow/white patches. The
patches may indicate a fungal infection called thrush.
5. Assess patient’s ability to perform own care.

Steps of procedure Notes

1. Verify patient’s identity and introduce self.
Rationale: Ensure the right patient receives the
intervention and helps relive anxiety.
2. Explain procedure to patient.
Rationale: Attain patient's cooperation and helps relive
anxiety.
3. Provide privacy.
Rationale: Relaxes the patient.
4. Assist patient to a High-Fowler’s position.
Rationale: Facilitates removal of dentures.

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5. Assemble articles for denture cleaning.

Rationale: Promotes efficiency.
6. Wash hands and apply gloves.
Rationale: Reduces microorganism transfer and exposure.
7. Maintain body mechanics.
Rationale: Prevent strain on nurse's back.
8. Assist patient with denture
removal (Top denture): With
tissue, grasp the denture with
thumb and forefinger and pull
downward. Place in denture cup
Fig. (76).
Rationale: Prevent breaking of
denture

Fig. (76): Denture

removal
9. Assist patient with denture removal (Bottom denture):
Place thumbs on the gums and release the denture. Grasp
denture with thumb and forefingers and pull upward.
Place in denture cup.
Rationale: Prevent breaking of denture.
10. Apply toothpaste to brush, and
brush dentures either with cool
water in the emesis basin or under
running water in the sink. Pad
sink with towel Fig. (77).
Rationale: Facilitates removal of
microorganisms. Pad sink with
Fig. (77): Apply
towel to protect dentures.
toothpaste to brush &
brush dentures

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11. Rinse denture thoroughly.

Rationale: Removes toothpaste.
12. Assist patient with rinsing mouth & replacing
dentures.
Rationale: Freshens mouth & facilitates intake food.
13. Reposition patient, with side rails up.
Rationale: Promotes comfort, safety.
14. Rinse, dry, and return articles to proper place.
Rationale: Maintains a clean environment.
15. Remove gloves and wash hands.
Rationale: Reduces the transmission of microorganisms
16. Documentation:
a. Oral assessment, significant observations and unusual
findings, such as bleeding or inflammation.
b. Any teaching done.
c. Procedure and patient response.
Rationale: Provides evidence of nursing care and ensures
continuity of care.

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C. Mouth care for unconscious patients:

Purposes:
1. To prevent dental caries.
2. To improve the patient’s self-image.
3. To promote oral hygiene.
Preparation:
4. Assess the patient’s gag reflex. Decreased or absent gag
reflex increases the risk for aspiration.
5. Assess patient’s oral cavity and teeth. Look for any
inflammation or bleeding of the gums. Look for ulcers,
lesions, and yellow or white patches.
Equipment:
1. Soft toothbrush or toothette.
2. Tongue blade
3. Bite-block.
4. Emesis basin.
5. Plastic Asepto syringe.
6. Prescribed solution
7. 3×3 gauze sponges
8. Towel.
9. Cup of water.
10. Clean gloves.
11. Lip lubricant.
12. Suction machine and catheter.

Fig (78): Equipments for Mouth care for unconscious patients

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Steps of procedure Notes

1. Introduce self and verify patient’s identity.
Rationale: Attain patient's cooperation and prevent mistakes.
2. Explain procedure to patient.
Rationale: Attain patient's cooperation.
3. Gather appropriate equipment.
Rationale: Ease performance of the procedure.
4. Perform hand hygiene and apply gloves.
Rationale: Prevents spread of infection.
5. Provide for patient privacy.
Rationale: Avoid patient's embarrassment.
6. Maintain body mechanics.
Rationale: Prevent strain on nurse's back.
7. Place the patient in a lateral position, with the head turned
toward the side.
Rationale: Prevents aspiration.
8. Place the towel under the patient's chin.
Rationale: Keep patient chin and neck dry.
9. Place the emesis basin against the patient's chin and lower
cheek.
Rationale: Receive the fluid from the mouth.
10. Gently open the patient’s mouth by applying pressure to
lower jaw at the front of the mouth.
Rationale: It facilitates access to the oral cavity without
harming or injuring the patient.
11. Place bite block in patient's mouth never fingers in an
unconscious patient's mouth.

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Fig (79): Place bite block in patient's mouth

Rationale: Keep patient's mouth open.
12. Moisten toothbrush or toothette,
and brush the teeth and gums using
friction in circular motion. Do not
use toothpaste Fig. (80).
Rationale: Permits cleaning of back
and sides of teeth and decreases
microorganism growth in mouth.
Fig. (80): brush teeth &
Toothpaste may foam and cause
gums
aspiration.
13. Rinse mouth with syringe (do
not force water into the mouth) Fig.
(81).
Rationale: Promotes cleansing and
removal of secretions and prevents
aspiration. Fig. (81): Rinse mouth with
syringe
14. Allow fluid to run out from
patient mouth into basin. If needed,
suction may be used to remove
excess fluid from the mouth Fig.
(82).
Rationale: Prevent aspiration. Fig. (82): Allow fluid to
run out of mouth into basin

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15. Swab roof of mouth and tongue with toothette as well.

Rationale: Clean areas and provides moisture.
16. Dry the patient's mouth.
Rationale: Prevent skin irritation.
17. Apply lip lubricant. Fig (83)

Fig (83): Apply lip lubricant

Rationale: Maintains skin integrity of lips.
18. Raise side rails and lower bed.
Rationale: Promotes patient comfort and safety.
19. Remove and dispose of equipment appropriately.
Rationale: Maintains a clean environment.
20. Remove and discard gloves and wash hands.
Rationale: prevents the spread of microorganisms.
21. Place patient in comfortable position.
Rationale: Promotes patient comfort and safety.
22. Documentation: Document the procedure and assessment
findings of the teeth, tongue, gums, and oral mucosa. Any
problems such as sores or inflammation, bleeding, and
swelling of the gum.
Rationale: Provides evidence of nursing care and ensures
continuity of care.

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Shampooing A Patient's Hair in Bed

Purposes:
1. To wash a patient’s hair if unable or not allowed to get
out of bed.
2. Clean hair and scalp.
3. Promote circulation to the scalp.
4. Provide relaxation.
5. Promote comfort and self-esteem.
Preparation:
1. Assess the condition of hair and scalp.
2. Assess patient for ability to tolerate procedure.
3. Provide safety measures for patient.
4. Raise bed to convenient height for procedure
Equipment:
1. Bedside/chair-side table.
2. Clean comb (with dull teeth) and hairbrush (soft but firm
bristles)
3. Washcloth.
4. 2 or 3 bath towels.
5. Shampoo tray.
6. Washbasin or pail.
7. Water pitchers/container: 1 large (1–2 gal.) and 1 small
(2–3 cup).
8. Linen saver or plastic bag.
9. Nonsterile gloves.
10. Liquid shampoo.
11. Bath thermometer.
12. Hair dryer (safety approved).

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Steps of procedure Notes

1. Identify the patient and introduce self.
Rationale: To identify correct patient for procedure and
helps relive anxiety.
2. Explain the procedure to the patient.
Rationale: To reduce the patient's anxiety.
3. Provide privacy.
Rationale: To decrease patient anxiety.
4. Gather appropriate equipment.
Rationale: Promotes efficiency.
5. Wash hands and apply disposable gloves.
Rationale: To avoid cross contamination.
6. Maintain body mechanics.
Rationale: Prevent strain on nurse's back.
7. Lower the head of the bed. Remove pillow and place
protective pad under patient’s head and shoulders.
Rationale: protective pad keeps the sheets from getting
wet.
8. Place linen saver (or plastic
bag) covered by a towel under
patient’s shoulders and head Fig.
(84).
Rationale: Catches loose hair and Fig. (84): Place plastic
dirt and prevents wetting of linens bag under patient’s
shoulders and head
9. Fill the large pitcher/s with
warm water (105°–110°F),
checking temperature with
thermometer or volar surface of
your arm. Place on bedside table
Fig. (85).
Rationale: Warm water promotes Fig. (85): Fill the large
scalp circulation and prevents pitcher with warm water
chilling and skin injury.
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10. Place the shampoo tray under

the patient’s neck and head with
neck in the U-shaped opening.
Adjust the fan-folded neck towel
to cushion the tray Fig. (86).
Rationale: Positions to facilitate
drainage of water, maintain Fig. (86): Place the
patient comfort, and avoid shampoo tray under the
patient’s neck & head
pressure to neck
11. Position pail/washbasin in
direct line with the spout of the
shampoo tray. Position as close to
the spout as possible. You may
need to set it on a chair, or a low
table Fig. (87).
Fig. (87): Position
Rationale: Minimizes splashing
pail/washbasin
as water runs into the pail
12. Offer washcloth for patient to hold over or above eyes
and cotton balls to place in ears during shampooing.
Rationale: Prevents shampoo or water from irritating
eyes\ ears and moisture from collecting in ear canals.
13. Fill small pitcher with water
by dipping it into the larger
pitcher. Double-check water
temperature. Carefully pour the
warm water over the hair,
moistening thoroughly. Take care
not to overfill the shampoo tray
Fig. (88).
Rationale: Smaller container is
easier to manipulate and prevents Fig. (88): pour the warm
splashing. Water temperature can water over the hair
change while sitting. Moistened
hair facilitate the cleansing step.

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14. Place a small amount of

shampoo into your palms and
massage it into the hair, working
the shampoo into a lather. Using
your fingertip, gently massage the
shampoo into the scalp Fig. (89).
Rationale: Shampoo lather
facilitates removal of dirt, debris, Fig. (89): Place a
and excess oils from scalp and shampoo into the
hair. Massage promotes lather, palms & massage it
stimulates scalp circulation and into the hair
relaxes patient.
15. Rinse the hair using the
pitcher to pour warm water over
the hair and scalp Fig. (90).
Rationale: Removes shampoo
and debris

Fig. (90): Rinse the hair

16. Repeat application of shampoo and massage scalp and
hair gently but vigorously for a longer period of time.
Observe hair and scalp for lesions, scaling, infection, and
so on.
Rationale: Promotes thorough cleansing of hair and scalp,
provides opportunity to observe hair and scalp
abnormalities as fingers move through hair and across
scalp.
17. Rinse again using several pitchers of water until hair
and scalp are free of shampoo.
Rationale: Removes remaining residue of shampoo.
18. Support patient's head while remove the shampoo
tray.
Rationale: Clears the area for completion of procedure.
Prevent injury

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19. Wrap patient's hair by gently

pulling fan- folded bath towel
from shoulders up and over scalp.
Gently and briskly massage the
scalp and hair with the towel.
Repeat with a dry towel as
needed. Leave hair covered with
the towel until ready to use the
dryer Fig. (91).
Rationale: Absorbs water from Fig. (91): Gently and
the hair and scalp while briskly massage the scalp
stimulating scalp circulation. and hair with the towel
Prevents chilling while waiting to
dry the hair.
20. Remove the linen saver and
towel from the bed by carefully
folding inward Fig. (92).
Rationale: Prevents debris from
falling onto the bed or floor.

Fig. (92): Remove the

linen saver and towel
21. Elevate the head of bed to desired angle within
prescribed and/or patient-tolerated limits.
Rationale: Promotes access to hair and patient comfort.
22. Thoroughly dry your hands and/or change gloves.
Rationale: Promotes safety.
23. Turn on hair dryer to warm setting and check the
temperature on your inner arm.
Rationale: Prevents injury from dryer heat.
24. Dry hair, concentrating on one section at a time,
moving your fingers, comb, or brush gently through the
hair while drying.
Rationale: Facilitates drying and removes tangles.

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25. Gently comb/brush the hair.

Rationale: Removes all tangles and stimulates the scalp.
26. Reposition the patient comfortably, adjust bed as
requested within medical orders, safety measures,
communication needs (call light).
Rationale: Maintains patient comfort, rest, and safety.
27. Empty the water. Remove, clean, and return
equipment.
Rationale: Provides clean environment.
28. Remove gloves and wash your hands.
Rationale: Reduces the transmission of microorganisms.
29. Document the following:
- Assessment, significant observations, and unusual
findings, such as bleeding or inflammation;
- Any teaching done.
- Procedure and patient response
Rationale: Provides evidence of nursing care and ensures
continuity of care.

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Hand and foot care

Purposes:
1. Maintain skin integrity.
2. Provide for patient's comfort and sense of well-being.
3. Prevent infection.
4. Controls odor.
5. Encourage self-care.
Preparation:
1. Assess color and temperature of toes, feet, and fingers.
2. Determine patient's ability to perform self-care.
3. Assess areas between toes for dryness and cracking.
4. Assist ambulatory patient to sit in bedside chair.
5. Place towel on linen.
Equipment:
1. Waterproof pad.
2. Wash cloth.
3. Towels.
4. Wash basin.
5. Warm water.
6. Soap.
7. Talc powder.
8. Gloves.
9. Nail clippers, file, and stick.
10.Nail Scissors.
11.Nail brush.
12.Bath thermometer.
13.Gauze pads.
14.Linen.

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Steps of procedure Notes

1. Identify the patient and introduce self.
Rationale: To Identify correct patient for procedure.
2. Explain the procedure to the patient.
Rationale: To reduce the patient's anxiety.
3. Provide privacy.
Rationale: To decrease patient anxiety.
4. Wash hands /apply gloves.
Rationale: Reduce the transmission of microorganisms.
5. Gather appropriate equipment.
Rationale: Ease performance of the procedure.
6. Maintain body mechanics.
Rationale: Prevent strain on nurse's back.
7. Fill washbasin halfway with warm water. Test water
temperature and place basin on the linen saver.
Rationale: Warm water stimulates circulation.
8. Soak hand/foot from 2 to 10 minutes, depending on
patient health and tolerance.
Rationale: Softens skin, nails, and debris, relaxes muscles
and promotes patient comfort.
9. Wash hand/foot with scant
amount of mild antibacterial
soap, cetaphil lotion may be used
in place of soap Fig. (93).
Rationale: Cetaphil is soapless,
Fig. (93): Wash foot with
mild antibacterial cleanser mild antibacterial soap
10. Rinse well to be sure all soap is removed.
Rationale: To remove all residual soap.
11. Remove hand/foot from basin & place onto clean
towel.
Rationale: To absorb moisture.
12. Pat and then gently rub dry, paying close attention to
between and under the fingers/toes.
Rationale: Dry without rubbing harsh to prevent skin

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damage.
13. Using the towel, or cuticle stick, gently push the
cuticle and subungual skin back
Rationale: Cuticle function to prevent infection and
hangnails.
14. Scrub callused areas of feet with washcloth.
Rationale: Friction removes dead skin layers.
15. Apply powder between and under fingers/toes.
Rationale: Maintains dryness between fingers and toes to
discourage infection and skin break down. Talc adsorbs
moisture.
16. Check pulses, turgor, and capillary refill.
Rationale: Assess circulation and hydration of extremity.
17. Empty basin & refill. Repeat procedure with other
hand /foot.
Rationale: Provide warm water for opposite extremity.
18. While other hand /foot soak, perform nail care on the
first hand /foot.
Rationale: Maximize use of time.
19. Cut toenails straight across.
Rationale: To prevent ingrown nails and injury skin
20. Lightly apply cream (not lotion), massaging into the
hand/foot. Pay special attention to dry areas. Avoid
between and under fingers/toes.
Rationale: Maintains hydration, rehydrates skin.
21. Remove, clean, and replace equipment/supplies.
Rationale: Avoids accidents and maintains cleanliness.
22. Dispose of gloves and wash hands.
Rationale: Reduces the transmission of microorganisms.
23. Documentation:
- Record the time and date care was performed.
- Note any unusual findings.
Rationale: Provides evidence of nursing care and ensures
continuity of care.

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Bed Making
(Changing bed linens)

Performance objectives:
The student will be able to do the following:
1. Describe bed that used for patient in the hospital.
2. Differentiate between different types of bed making.
3. Identify the purpose for types of bed making.
4. Identify the necessary equipment for bed making.
5. Perform patient preparation.
6. Demonstrate the procedure as a whole independently&
accurately.
Definition of bed:
Is a piece of equipment used most by a patient, it consists of
a firm mattress on a metal frame. That can be raised and
lowered horizontally.
Bed Making:
The technique of preparing different types of bed making
patients comfortable in his/ her suitable position for a
particular condition.
Types of beds:
1. Unoccupied Bed:
One not occupied by a patient. There are three types.
a. Closed bed: The top sheet, blanket, and bed spread are
drawn up to the top of the bed (covering the bed) and
under the pillows. The closed bed is often used in long –
term care setting.
b. Open bed: The top sheet, blanket, and bed spread are
folded down toward the bottom of the bed to make it
easier for patient to get in the bed.
c. Surgical bed: Is used for patient who is having surgery
and will return to the bed for the post-operative phase.
When making a surgical bed, the linens are horizontally
fan folded to facilitate transfer of the patient to the bed.

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2. Occupied bed:
The patient remains in the bed while the nurse changes
the bed linens and makes the bed.

1. Making an Unoccupied Bed:

Purposes:
1. To prepare the bed while there is no patient.
2. To decrease stress on the patient and the nurse when
changing linens.
3. Prepare a bed for a patient who is having surgery to
promote easy patient transfer.
Preparation:
2. If patient in bed, before performing the procedure,
introduce self and explain to the patient what you are
going to do, why it is necessary, and how he or she can
participate.
3. Assess the patient health status to determine that the
patient can safely get out of bed.
4. The patient's blood pressure, pulse, and respirations must
be measure if indicated; the patient may experience
postural hypotension when moved from lying to standing
to setting.
5. Assess the patient mobility status; this may influence the
need for additional assistance with transferring the patient
from the bed to a chair.
Equipment:
1. Bottom sheet.
2. Top sheet.
3. Draw sheet (optional).
4. Blanket.
5. Bedspread (change only if soiled).
6. Mattress pad (change only if soiled).
7. Pillowcases (for each pillow used by the patient).
8. Water proof pads (as needed).
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9. Linen bag or hamper.

a. Making a Closed Unoccupied Adult Bed:

Steps of procedure Notes

1. Hand washing.
Rationale: To prevent the spread of microorganisms.
2. Place hamper by patient’s door if linen bags are not
available.
Rationale: Provides for proper disposal of soiled linens.
3. Gather linens and gloves. Place linens on a clean, dry surface
in reverse order of usage at the patient’s bedside (pillowcases,
top sheet, draw sheet, bottom sheet).
Rationale: Provides easy access to items.
4. Position bed: flat, side rails down, adjust height to waist
level.
Rationale: To promotes good body mechanics and decreases
back strain..
5. Apply clean gloves.
Rationale: Reduces risk of infection from soiled, contaminated
linens.
6. Maintain body mechanics.
Rationale: Prevent strain on nurse's back.
7. Place pillows on bedside chair or table after removing soiled
pillow slips.
Rationale: To avoid contamination.
8. Fold reusable linens (bed spread,
blanket and top sheet on the bed) into
a fourth. First, fold the linen in half
by bringing the top edge with the
bottom edge, and then grasp it at the
center of the middle fold and bottom
edges Fig. (94).
Rationale: Folding linens saves time Fig. (94): Fold top
and energy. sheet on the bed

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9. Remove soiled pillowcases by grasping the closed end with

one hand and slipping the pillow out with the other. Place
the soiled cases on top of the soiled sheet, and place the
pillows on clean work area.
Rationale: Allows easy removal of the pillowcases without
contamination of uniform and keeps pillows clean.
10. Fold soiled linens: head of bed
to middle, foot of bed to middle.
Place in linen bag or hamper,
keeping soiled linens away from
uniform Fig. (95)
Rationale: To prevent the
transmission of microorganisms. Fig. (95): Fold soiled linens
11. Check mattress. If the mattress is soiled, clean it with an
antiseptic solution and dry it thoroughly.
Rationale: Reduces the transmission of microorganisms.
12. Remove and discard gloves. Perform hand washing.
Rationale: To prevent the infection.
13. Apply the bottom sheet and
draw sheet; Place the folded
bottom sheet with its center fold
on the center of the bed. Spread
the sheet on over the mattress, Fig. (101)
and allow a sufficient amount of
sheet at the top to tuck under the Fig. (96): Apply bottom sheet
mattress Fig. (96 & 97). Fig. (102)
Rationale: To remain top sheet
securely in place
Fig. (102)

Fig. (97): Apply draw sheet

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14. Miter 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 Fig. (98).
a. Tuck in the bedcover (sheet,
blanket, and /or spread) firmly
under the mattress at the bottom
or top of the bed Fig. (98): Tuck in the
bedcover
b. Lift the bedcover so that it
forms a triangle with side edge
of the bed and the edge of the
bedcover is parallel to the end
of the bed Fig. (99).
Fig. (99): forms a triangle
with side edge of the bed
c. Tuck the part of the cover that
hangs below the mattress under
the mattress while holding the
triangle up or against the bed
Fig. (100)
Fig. (100): Tuck the part of
the cover under the mattress
& holding the triangle up
d. Bring the tip of the triangle
down toward the floor while the
other hand holds the fold of the
cover against the side of the
mattress Fig. (101)
Fig. (101): Hold the fold of
the cover against the side of
the mattress

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e. Remove the hand and tuck the

remainder of the cover under
the mattress, if appropriate. The
sides of the top sheet, blanket,
and bedspread may be left
hanging freely rather than
tucked in, if desired Fig. (102)
Fig. (012): Tuck the
remainder of the cover under
the mattress
15. Move to the other side and secure the bottom linens. Tuck
in the bottom sheet under the head of the mattress; pull the
sheet firmly and with no wrinkles. And miter the corner of
the sheet.
Rationale: Wrinkles can cause discomfort for the patient and
breakdown of the skin.
16. Apply or complete the top sheet, blanket, and spread; Place
blanket over top sheet, smooth out. Place spread over
blanket, smooth out.
17. Allow for toe pleat:
a. Vertical toe pleat: Make a fold
in the sheet 5 to 10 cm
perpendicular to the foot of the
bed Fig. (103)

Fig. (103): Vertical toe pleat

b. Horizontal toe pleat: Make a
fold in the sheet 5 to 10 cm across
the bed near the foot Fig. (104)

Fig. (104): Horizontal toe pleat

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18. Fold the top edge of top sheet

down over the spread
providing a cuff Fig. (105)
Rationale: the cuff of sheet
makes it easier for the patient to
pull the covers up Fig. (105): Fold the top edge of
top sheet down over the spread
19. Apply clean pillowcase on
pillow as required.
a. Grasp the closed end of the
pillowcase at the center with
one hand Fig. (106)
Fig. (106): Put clean
pillowcase
b. Gathers up the sides of the pillowcase and place them over
the hand grasping the case.
c. With the free hand, pull the
pillowcase over the pillow
Fig. (107)

Fig. (107): pull the pillowcase

over the pillow
d. Adjust the pillowcase so that
the pillow fits into the corners
of the case and seems are
straight with the free hand,
pull the pillowcase over the
pillow, where smooth pillow F
case is more comfortable than
wrinkled one Fig. (108). Fig. (108): Adjust the
pillowcase

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b. Making open unoccupied adult bed:

Steps of procedure Notes
1. Carry out the steps from 1: 13.
2. Fan fold the top sheet
and bed spread down to
no more than half length
of the bed Fig. (109).
Rationale: Ensure easy
access to the bed
Fig. (109): Open unoccupied
adult bed
c. Making a surgical unoccupied adult bed:
Steps of procedure Notes
1. Carry out the steps from 1: 13.
14. Place and leave the pillow on the bedside chair.
Rationale: To facilitate transferring the patient into the bed.
15. On the side of the bed
where the patient
transferred, fold up the two
outer corners of the top
linens so they meet in the
middle of the bed forming a Fig. (110): fold up the two outer
triangle Fig. (110). corners of the top linens
16. Pick up the apex or
point of the triangle and
fanfold the top linens
lengthwise to the side of the
bed opposite from where
the patient will enter the
bed Fig. (111). Fig. (111): Fanfold the top
Rationale: This facilitates linens to the side
the patient's transfer into
the bed

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17. Leave the bed in high position with the side rails down.
Rationale: To facilitates the transfer of the patient.
18. Lock the wheels of the bed.
Rationale: To keep the bed from rolling when the patient is
transferred from the stretcher to the bed.
19. Return the bed to the lowest position and elevate the
head of the bed 30 to 45 degrees.
20.Assist patient back into the bed and pull the side rails.
21.Attach the call light so the patient can reach it.
22.Place the bed side cabinet and over bed table so that
they are available to the patient.
23.Hand washing.
Rationale: To prevent the infection.
24.Document the procedure.
Rationale: To ensures continuity of care.

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3. Making an Occupied Adult Bed:

Purposes:
1. Used when the patient may be too weak to get out of the
bed.
2. Immobilized patient may be restricted in the bed by the
presence of traction or others therapies.
Preparation:
1. Assess condition and need for footboard, bed cradle, or
heel protectors.
2. Assess the patient activity level.
3. Assess need for assistance with procedure.
4. Determine presence of incontinence or excessive
drainage from other sources indicating the need for
protective waterproof pads.
5. If bathing is to done, perform bathing procedure first.
6. Note specific orders or precautions for moving and
positioning the patient.
Equipment:
1. Bottom sheet.
2. Top sheet.
3. Draw sheet (optional).
4. Blanket.
5. Bedspread (change only if soiled).
6. Mattress pad (change only if soiled).
7. Pillow slips (for each pillow used by the patient).
8. Water proof pads (as needed).
9. Linen bag or hamper.

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1. Carry out the steps from 1: 6 (making an unoccupied

bed).
7. Maintain patient's privacy.
Rationale: Protect the patient's rights.
8. Explain procedure to patient.
Rationale: Promotes patient cooperation.
9. Remove any equipment attached to the bed linen, such as
signal light.
Rationale: To ensure patient safety and ease of activity.
10.Remove blanket and bedspread and loosen sheet.
Rationale: Do not need bulky linens when performing
bath.
11.Place bed in a flat a position as the patient can tolerate.
Rationale: bed making is easier with bed flat.
12.Leave the top sheet over the patient.
Rationale: To provide sufficient warmth.
13.Replace the top sheet with a
bath blanket as follows.
a. Spread the bath blanket over
the top sheet Fig. (112).
b. Ask the patient to hold the top
edge of the blanket. Fig. (112): Spread the bath
c. Reaching under the blanket, blanket over the top sheet
grasp the top edge of 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 Fig. (113). Fig. (113): Remove the
sheet & place it in linen
hamper
14.Change the bottom sheet and draw sheet:
a. Raise the side rail that the patient will turn toward.

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Rationale: To protect the patient from falling.

b. Assist the patient 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 Fig. (114).

Fig. (114): Loosen the

bottom linens
d. Fanfold the dirty linens (draw
sheet and bottom sheet) toward
the center of the bed as close to
and under the patient as possible
Fig. (115).
Rationale: This leaves the near
Fig. (115): Fanfold draw &
half of the bed free to be changed
bottom sheet
e. Place the new bottom sheet on
the bed, and vertically fanfold
the half to bed used on the far
side of the bed as close to the
patient as possible Fig. (116).

Fig. (116): Place the new

bottom sheet on the bed

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f. Place the clean draw sheet on

the bed with the center fold at the
center of the bed. Fanfold the
upper most half vertically at the
center of the bed and tuck the
near side edge under the side of
the mattress Fig. (117 & 118).

Fig. (117): Place the clean

draw sheet on the bed

Fig. (118): Tuck near side

edge under the mattress
15.Assist patient to roll slowly
toward nurse over folds of
linen and go to opposite side
of bed & lower side rails. Fig
(119). Rationale: Maintain
the patient's safety.
Fig (119): Assist patient
to roll slowly toward
nurse
16. Loosen and remove all
bottom linens. Discard soiled
linen in laundry bag or
hamper. Do not place on floor
or furniture. Do not hold
soiled linens against the
uniform Fig. (120).

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Rationale: To prevent the spread Fig. (120): Loosen &

of microorganisms. remove all bottom linens
17.Pull bottom sheet to proper
position and miter corners.
Stretch draw sheets into place
and tuck under mattress. Fig
(121).

Rationale: To secure in place.

Fig. (121): Pull bottom
sheet to proper position and
miter corners
18.Cover pillow with clean pillow case.
Rationale: Ensure a neat appearance.
19. Tuck in all linens at foot of bed, raise side rails & make
opposite side of bed.
Rationale: Secures top sheet and blanket in place.
20.Make toe pleat.
Rationale: To prevent pressure on feet.
21. Ensure continued safety of the patient:
a. Raise the side rail.
b. Place the bed to the lowest position and elevate the head
of the bed 30 to 45 degrees.
c. Attach the call light so, the patient can reach it.
d. Put items used by the patient within easy reach.
22.Hand washing.
Rationale: Reduces the transmission of microorganisms.
23.Documentation: Report and record the procedure,
patient's response during the procedure, & record any
nursing assessments.
Rationale: To ensure continuity of care.

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Range of Motion Exercises (ROM)

Performance objectives:
The student will be able to do the following:
1. Define range of motion exercises.
2. List types of range of motion exercises.
3. List purposes of range of motion exercises.
4. Collect necessary equipment for range of motion
exercises.
5. Identify preparations needs for performing range of
motion exercises.
6. Demonstrate of range of motion exercises.
Definition:
The range of motion (ROM) is the maximum movement that
is possible for the joint.
Types:
1. Active range of motion exercises.
2. Passive range of motion exercises.
3. Active–assistive range of motion exercises.
1. Active range of motion exercises:
Are isotonic exercises in which the patient independently
moves each joint in the body through its complete range of
movement, maximally stretching all muscle groups.
2. Passive range of motion exercises:
During passive range of motion exercises, another person
moves each of the patient's joints through their complete
range of movement and maximally stretches all muscle
groups.
3. Active–assistive ROM:
They are exercises carried out by the patient with assistance
of the nurse.
Purposes:
1. Maintain or increase muscle strength and endurance.
2. Help to maintain cardio respiratory function in an
immobilized patient.
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3. Prevent deterioration of joint capsules, and contractures.

4. Prevent atrophy of muscles.
5. Prevent change in the structure of joint.
6. Increase patient independence by maintaining joint
function.
Preparations:
1. Determine the patient's ability to perform active, passive,
or active–assistive ROM exercises.
2. Assess the presence of any joint contractures, swelling,
redness, or pain that may limit the patient's range of
motion.
3. Help the patient to assume a comfortable position.
4. Raise the bed to a comfortable position.

Equipment:
No special equipment is needed, except gloves when
contact with body fluids is possible.

Steps of Procedure Notes

1. Wash hands, wear gloves if contact with body fluids.
Rationale: To reduces the transmission of microorganism.
2. Explain procedure to patient.
Rationale: To decrease anxiety, encourages participation.
3. Provide for privacy, including exposing only the extremity
to be exercised.
Rationale: To decrease anxiety.
4. Adjust bed to comfortable height for performing ROM.
Rationale: To prevent muscle strain and discomfort for
nurse.
5. Lower bed rail only on the side to the nurse.
Rationale: To prevent patient falls.
6. Support the limb being ranged above and below the joint.
Rationale: To facilitate support and comfort.
7. Apply ROM slowly, gently, and smoothly.

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Rationale: To encourage relaxation and lengthening of

muscles.
8. Start at the patients head and perform exercises down each
side of the body.
Rationale: To provide a systematic method to ensure that
all body parts are exercised.
9. Repeat each ROM exercise as the patient tolerates, to a
maximum of 5 times.
Rationale: To provide exercise to the patient's tolerance or
to a level that will maintain the joint function.
10. Neck ROM:
- Flexion: bring chin to rest on
chest Fig. (122).
- Extension: return to erect
position Fig. (122).
- Hyperextension: bend back
as far as possible.
- Lateral flexion: tilt as far as Fig. (122): Flexion &
possible toward each shoulder Extension
Fig. (123).
- Rotation: the patient looks
straight and rotates in circle.
Rationale: To preserve muscle
tone and joint flexibility.
Fig. (123): Lateral flexion
11. Shoulder ROM:
- Flexion: raise arm from side
position forward to above Fig.
(124).
- Extension: return arm to
position at side of body Fig. Fig. (124): Flexion of
shoulder
(125).
- Hyperextension: move arm
behind body keeping elbow

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straight.
- Abduction: raise arm to side
to position above with palm
turned away.
- Adduction: lower arm
sideways and across body as Fig. (125): Extension of
far as possible. shoulder
- Internal rotation: move arm
to side at shoulder level with
elbow bent at 45 degrees Fig.
(126).
- External rotation: with
elbow flexed move arm until
thumb is upward and lateral Fig. (126): External/ internal
Fig. (126). rotation of shoulder
- Circumduction: move arm in
full circle Fig. (127).
Rationale: To preserve muscle
tone and joint flexibility.

Fig. (127):Circumduction of
shoulder
12. Elbow ROM:
- Flexion: extend the arm then
bend elbow so that lower arm
moves toward the shoulder
Fig. (128).
- Extension: straighten elbow
by lowering hand Fig. (128).
- Hyperextension: bend lower
arm back as far as possible.
Rationale: To preserve muscle
tone & joint flexibility.
Fig. (128): Flexion &
Extension of elbow

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13. Forearm ROM:

- Supination: turn lower arm
and hand so that palm is up
Fig. (129).
- Pronation: turn lower arm so
Fig. (129): Supinating the
that palm is down Fig. (130).
forearm
Rationale: To preserve muscle
tone and joint flexibility.

Fig. (130): Pronating the

forearm
14. Wrist ROM:
- Flexion: move palm toward
inner aspect of forearm Fig.
(131).
- Extension: move fingers so
fingers, hands, and forearm
are in straight line Fig. (131). Fig. (131): Flexion/ extension
- Hyperextension: bring dorsal
surface of hand back as far as
possible Fig. (132).
- Abduction: bend wrist
medially toward thumb.
- Adduction: bend wrist
Fig. (132): Hyperextension
laterally toward fifth finger.
Rationale: To preserve muscle
tone and joint flexibility.
15. Fingers ROM:
- Flexion: make fist Fig. (133).
- Extension: straighten fingers
Fig. (133).
- Hyperextension: bend
Fig. (133): Flexion /extension
fingers back.
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- Abduction: spread fingers a

part
Fig. (134).
- Adduction: bring fingers
together Fig. (134).
Rationale: To preserve
muscle tone and joint Fig. (134): Abduction /
flexibility. adduction
16. Thumb ROM:
- Flexion: move thumb
across palmer surface of the
hand Fig. (135).
- Extension: move thumb
straight away from hand Fig.
(135). Fig. (135): Flexion /extension
- Abduction: extend thumb
laterally.
- Adduction: move thumb
back toward hand Fig. (136).
- Opposition: touch thumb to
each finger of same hand Fig. Fig. (136): Abduction
(137). /adduction
Rationale: To preserve muscle
tone and joint flexibility.

Fig. (137): Opposition

17. Hip and leg ROM:
- Flexion: move leg
forward and up Fig. (138).
- Extension: move leg
back beside other leg.
- Hyperextension: move Fig. (138): Flexion the knee
leg back beyond normal
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extension.
- Abduction: move leg
laterally away from body Fig.
(139).
- Adduction: move leg back
toward medial position.
- Internal rotation: Turn foot
and leg in ward.
- External rotation: Turn foot
and leg out ward.
Fig. (139): Abducting the leg
- Circumduction: move leg in
circle.
Rationale: To preserve muscle
tone and joint flexibility.
18. Ankle ROM: Fig. (140).
- Dorsiflexion: move foot so
toes are pointed up ward.
- Planter flexion: move foot
so toes are pointed down
ward.
Rationale: To preserve muscle Fig. (140): Dorsiflexion
with tone and joint flexibility. /Planter flexion of ankle
19.Foot ROM:
- Inversion: turn the whole
foot inward Fig. (141).
- Eversion: turn the whole foot
outward Fig. (142).
- Flexion: bend toes downward Fig. (141): Inverting the foot
Fig. (143).
- Extension: bend toes upward
Fig. (144).
- Abduction: spread toes a
part.
- Adduction: bring toes Fig. (142): Everting the foot

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together.
Rationale: To preserve muscle
tone and joint flexibility.

Fig. (143): Flexing the toes

Fig. (144): Extending the toes

20.Documentation:
1. Document the performance of ROM exercises includes
the joints and extremities on which ROM was performed.
2. Report of the type and degree of limitation observed.
3. Report the extent of the patient's active involvement in
exercises, pain or discomfort.
4. Record any unusual finding.

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Assisting a Patient with Turning in Bed

Performance objectives:
The student will be able to do the following:
1. List purpose of turning patient in bed.
2. Collect necessary equipment for turning patient in bed.
3. Assess patient before turning in bed.
4. Demonstrate steps of turning patient in bed.
Purpose:
To prevent complications for a patient who is immobile.
Preparation:
1. Perform a pain assessment before the time for the
activity. If the patient reports pain, administer the
prescribed medication in sufficient time to allow for the
full effect of the analgesic.
2. Assess the patient’s ability to assist with moving, the
need for assistive devices, and the need for a second or
third individual to assist with the activity.
3. Assess the patient’s skin for signs of irritation, redness,
edema, or blanching.
Equipment:
1. Friction-reducing sheet or draw sheet.
2. Bed surface that inflates to aid in turning.
3. Pillows or other supports to help the patient maintain the
desired position after turning and to maintain correct
body alignment for the patient.
4. Additional caregivers to assist based on assessment.
5. Non sterile gloves, if indicated; other personal protective
equipment (PPE) as indicated.

Steps of procedure Notes

1. Follow standard protocol.
- Identify the patient.
- Introduce yourself and explain the procedure.
- Provide privacy.

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- Perform hand hygiene and put on PPE

Rationale:
To ensures the right patient receives the intervention and
helps relive anxiety, and prevent the microorganisms.
2. Prepare the bed.
- Position at least one nurse on either side of the bed.
- Place pillows, wedges, or any other support to be used for
positioning within easy reach.
- Place the bed at an appropriate and comfortable working
height, usually elbow height of the caregiver.
- Lower both side rails and locks the wheels on the bed.
Rationale: Proper positioning minimizes strain on the
nurses. Proper bed height helps reduce back strain while
performing the procedure. Lowering the side rails facilitates
moving the patient and locking the wheels to promote safety.
3. Position a friction-reducing sheet under the patient if not
already in place.
Rationale: Sheets aid in preventing shearing and in reducing
friction and the force required to move the patient.
4. Reposition the patient:
- Move the patient to the edge of the bed (opposite the side
to which the patient will be turned) using the friction sheet.
- Raise the side rails.
Rationale:
- The patient will be on the center of the bed after turning is
accomplished.
- Raising side rails ensures patient safety.
5. Prepare the patient for turning.
Able patient: Have the patient grasp
the side rail on the side of the bed
toward which he or she is turning
Fig. (145).
Rationale: This facilitates the turning
motion and protects the patient’s arms Fig. (145): turning
able patient
during the turn.
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6. Unresponsive patient: Fig. (146)

Place the patient’s arms across his or
her chest and cross the far leg over the
leg nearest to the nurse where to be
turned.
Rationale:
This facilitates the turning motion and Fig. (146): turning
protects the patient’s arms during the unresponsive patient
turn.
7. If available, activate the bed mechanism to inflate the side
of the bed behind the patient’s back if available.
Rationale: This helps avoid straining the nurse’s lower
back.
8. Use body mechanics during turning
Fig. (147).
- The nurse on the side of the bed
toward which the patient is turning
should stand opposite the patient’s
center with feet spread about
shoulder width and with one foot
ahead of the other. Fig. (147): Use body
- Tighten the gluteal and abdominal mechanics during
muscles and flex your knees. turning
- Use leg muscles to do the pulling.
Rationale: These maneuvers support
the patient’s body and makes use of the
nurse’s weight to assist with turning.
9. The other nurse should position hands on the patient’s
shoulder and hip, assisting to roll the patient to the side.
- Instruct the patient to pull on the bed rail at the same
time.
- Use the friction-Reducing sheet to gently pull the
patient over on his or her side.
10. Support the patient’s back.
- Use a pillow or other support behind the patient’s back.
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- Pull the shoulder blade forward and out from under.

Rationale:
- Pillow will provide support and help the patient maintain
the desired position.
- Positioning the shoulder blade removes pressure from the
bony prominence.
11. Ensure patient’s safety and comfort.
- Make the patient comfortable and position in proper
alignment, using pillows or other supports under the leg
and arm, as needed.
- Readjust the pillow under the patient’s head.
- Elevate the head of the bed as needed for comfort.
- Place the bed in the lowest position, with the side rails up.
- Make sure the call bell and other necessary items are
within easy reach.
Rationale:
- Positioning in proper alignment with supports ensures that
the patient will be able to maintain the desired position and
will be comfortable.
- Adjusting the bed height ensures patient safety.
12. Remove gloves and other PPE, if used. Perform hand
hygiene.
Rationale:
- Removing PPE properly reduces the risk for infection
transmission and
Contamination of other items.
- Hand hygiene prevents the spread of microorganisms.

13. Document the following:

- Time the patient’s position was changed.
- Use of supports.
- Any pertinent observations including skin assessment.
- Patient tolerance of the position change, and aids used to
facilitate movement.
Rationale: This ensures continuity of care.
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Moving a patient up in Bed with the Assistance of

Another Caregiver

Performance objectives:
The student will be able to do the following:
1. List purpose of moving patient in bed.
2. Prepare patient before moving in bed.
3. Collect necessary equipment for moving patient in bed.
4. Demonstrate steps of moving patient in bed with the
assistance of another caregiver.
Purpose:
1. To facilitate and maintain correct body alignment, reduce
discomfort.
2. Promote normal tissue integrity.
Preparation:
1. Check prescribed orders for specific restrictions.
2. Assess patient’s ability to assist with moving.
3. Determine patient’s and/or caregiver’s ability to
understand and follow instructions.
4. Assess patient’s activity tolerance.
5. Determine comfort level of patient.
Equipment:
1. Hospital bed with side rails
2. Pillows
3. Trapeze if indicated
4. Turn sheet or draw sheet
5. Clean gloves
6. Personal protective equipment (if indicated).

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Steps of procedure Notes

1. Follow Standard Protocol.
- Identify the patient.
- Introduce yourself and explain the procedure.
- Provide privacy.
- Perform hand hygiene and put on PPE
Rationale: To ensures the right patient receives the
intervention and helps relive anxiety, and prevent the
microorganisms.
2. With two nurses on opposite sides of bed, lower side rails
and locks the wheels on the bed.
Rationale: Promotes patient safety.
3. Remove pillow and place against headboard.
Rationale: Prevents striking patient’s head against top of
bed.
4. Place draw sheet on bed under patient’s midsection.
Rationale: Supports patient’s weight and reduces friction
during move.
5. Roll or bunch sheet so edges are close to patient’s body
and grasp firmly next to patient’s shoulders and hips.
Rationale: Provides support under heavy parts of the body
and places the nurse’s hands close to the weight to be
moved.
6. If able to assist, have patient flex knees and place feet flat
on bed.
Rationale: Allows patient to assist with move.
7. Facing head of bed, the nurses stand on either side of the
Patient’s center with knees flexed and feet apart in a broad
stance.
Rationale: Increases stability and provides balance.
Promotes good body mechanics.

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8. On signal, rock and shift

weight from back to front leg,
moving patient upward in bed in
one smooth motion. If possible,
patient can assist with this move
by pushing with his or her legs.
Repeat the move if necessary Fig.
(148).
Fig. (148): moving patient
Rationale: by two nurses
- Provides additional force of
body weight.
- Reduces force needed to move
load and decreases work of
muscles during movement.
9. After each positioning, realign patient, replace pillows
and other positioning aids. Replace bed to safe position.
Rationale: Promotes patient comfort. Maintains correct
body alignment.
10. Remove gloves and other PPE, if used. Perform hand
hygiene.
Rationale:
- Removing PPE properly reduces the risk for infection
transmission and contamination of other items.
- Hand hygiene prevents the spread of microorganisms.
11. Document the following:
- Time the patient’s position was changed.
- Use of supports.
- Any pertinent observations including skin assessment
- Patient’s tolerance of the position change; and aids used
to facilitate movement.
Rationale: This ensures continuity of care.

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Obtaining a Blood Glucose Level by Finger Stick

Performance objectives:
The student will be able to do the following:
1. Define the blood glucose test.
2. List purposes of measuring blood glucose level.
3. List patient assessment before procedure.
4. Enumerate equipment needed for procedure.
5. Prepare the patient before procedure.
6. Perform procedure accurately and correctly.
7. Document the result.

Definition: A drop of capillary blood is obtained by skin

puncture on the finger by a single lancet or a device that
holds a lancet and then is applied to testing strips that is
placed in a glucose monitor to be read.
Purposes:
1. To determine or monitor blood glucose levels of patients
at risk for hyperglycemia or hypoglycemia.
2. To promote blood glucose regulation by the patients.
3. To evaluate the effectiveness of insulin administration.
Patient assessment:
1. Make sure enough blood is obtained to ensure accurate
test results.
2. Before obtaining a capillary blood specimen:
- Determine the policies and procedures for the facility.
- The frequency and type of testing.
- The patient’s understanding of the procedure.
- The patient’s response to previous testing.
3. Assess the patient’s skin at the puncture site to determine
if it is intact and the circulation is not compromised. Check
color, warmth, and capillary refill.

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4. Review the patient’s record for medications that may

prolong bleeding such as anticoagulants, or medical
problems that may increase the bleeding response.
5. Assess the patient’s self-care abilities that may affect
accuracy of test results, such as visual impairment.
Equipment/Supplies:
1. Blood glucose meter.
2. Sterile single lancet or automatic lancet.
3. Testing strips for meter.
4. Cotton ball or gauze squares.
5. Skin cleanser soap and water or alcohol swab.
6. Clean gloves.
7. Biohazard bag & sharps container.

Fig. (149): Blood glucose meter, automatic lancet and testing strips for
meter

Preparation:
1. Review the type of meter and the rnanufacturer’s
instructions.
- Some meters turn on when a test strip is inserted into the
meter.
-Calibrate the meter and run a control sample and/or confirm
the code number.
2. Assemble the equipment at the bedside.
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Steps of Procedure
1. Check prescriber’s order for frequency of glucose status.
Identify patient and explain procedure; provide privacy.
Rationale: To confirm the scheduled times for checking
blood glucose.
2.Gather equipment, and wash hands.
Rationale: This provides organized approach to the task
and reduces transmission of microorganisms.
3. Don clean gloves.
Rationale: Provides protective barrier.
4. Choose and assess area for puncture site should be free
from lesions and edema.
Rationale: The most vascular areas with fewer nerve
endings are the outer aspect of heel and toes, sides of
fingers. Areas with lesion are not suitable for capillary
sampling.
5. Lowering the hand or massage toward puncture site.
Rationale: Increases blood flow to puncture site.
6. Cleanse with soap and water or alcohol swab; allow it to
dry completely.
Rationale: Warm water increases blood flow. Reduces
bacteria on skin surface from invading puncture site.
7. Uncover lancet or activate the automated lancet twisting.
Fig (150)
Rationale: Facilitates proper skin penetration.

Fig. (150): Uncover lancet

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8. Stroke from base of finger, toe, or heel to puncture site.

Do not squeeze puncture site.
Rationale: Stroking in a massaging motion will increase
blood flow; squeezing will increase serum and dilute
specimen.
9. Place automated lancet firmly against side of finger, and
gently press the activating button. Hold the single lancet
perpendicular to site Fig (151).
Rationale: Ensures correct position.

Fig. (151 ): Proper position of lancet

10. Wipe away the first drop of blood with gauze or cotton
ball.
Rationale: The first drop of blood contaminated by serum or
cleansing product ,producing an inaccurate reading.
11. Fill capillary tube with blood by placing tip of tube at
base of drop of blood, making sure that enough blood is
applied on the strip for accurate results.
Rationale: Ensures accuracy of testing.
12. Apply pressure to puncture site for 15 to 30 seconds with
gauze to stop bleeding.
Rationale: Direct pressure reduces bleeding.
13. Read the blood glucose results and turn off the meter.
14. Discard used equipment into biohazard bags or sharps
container, remove gloves and wash hands.
Rationale: Decreases spread of blood-borne pathogens.
15. Document time and site of stick, patient’s glucose level,
any teaching provided and report abnormal result to primary
health care provider.
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Oxygen therapy
Administering Oxygen by Nasal cannula

Performance objectives:
The student will be able to do the following:
1. Collect necessary equipment for apply nasal cannula.
2. Demonstrate of application of nasal cannula.
Equipment:
1. Stethoscope.
2. Oxygen source-portable or in-line.
3. Oxygen flow meter.
4. Oxygen delivery device: nasal cannula.
5. Oxygen tubing.
6. Humidifier and distilled or sterile water (not needed with
low flow rates per nasal cannula).
Steps of Procedure
1. Wash hands.
Rationale: Reduce the transmission of microorganism.
2. Verify the health care provider's order.
Rationale: Ensures correct dosage and route.
3. Explain procedure and hazards to the patient. Remind
patients who smoke of the reasons for not smoking while
oxygen is in use.
Rationale: Increase compliance with the procedures.
4. If using humidity, fill humidifier to fill line with distilled
water and close container.
Rationale: Prevents drying of patient's airway and thins
any secretions.
5. Attach humidifier to oxygen flow meter.
Rationale: Allows the oxygen to pass through the water
and become humidified.
6. Insert humidifier and flow meter into oxygen source in
wall or portable unit.

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Rationale: For access to oxygen. Many institutions also

have compressed air available from outlets very similar in
appearance to oxygen outlets.
7. (1 to 5 liters/min). Use extension tubing for Attach the
oxygen tubing and nasal cannula to the flow meter and turn
it on to the prescribed flow rate ambulatory patient so they
can get up to go to the bathroom
Rationale: Rates above 6 liters/min are not efficacious and
can dry the nasal mucosa.
8. Check for bubbling in the humidifier.
Rationale: Ensures proper functioning.
9. Place the nasal prongs in
the patient's nostrils. Secure
the cannula in place by
adjusting the tubing around the
patient's ear and using the slip
ring to stabilize it under the
patient's chin Fig. (156).
Rationale: Keeps delivery
system in place. Fig. (156): Nasal Cannula
10. Check for proper flow rate every 4 hours and when the
patient returns from procedures.
Rationale: Ensure that patient receives proper dose.
11. Assess patient nostrils every 8 hours. If the patient
complains of dryness, use sterile lubricant to keep mucous
membranes moist. Add humidifier if not already in place.
Rationale: Dry membranes are more prone to breakdown
by friction or pressure from nasal cannula.
12. Monitor vital signs, oxygen saturation, and patient
condition every 4 to 8 hours (or as indicated or ordered) for
signs and symptoms of hypoxia.
Rationale: Detects any untoward effects from therapy.
13. Wean patient from oxygen using standard protocols.
Rationale: Oxygen is not without side effects and should be

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used only as long as needed. Problems with reimbursement

may develop if criteria for therapy are not met.

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Administering Oxygen by Mask

Performance objectives:
The student will be able to do the following:
1. Assess patient with oxygen by mask.
2. Collect necessary equipment needed for using oxygen by
mask.
3. Perform of using oxygen by mask.

Preparations:
1. Assess patient’s oxygen saturation level before starting
oxygen therapy to provide a baseline for determining the
effectiveness of therapy.
2. Assess patient’s respiratory status, including respiratory
rate and depth and lung sounds.
3. Note any signs of respiratory distress, such as tachypnea,
nasal flaring, use of accessory muscles, or dyspnea.
Equipment:
1. Flow meter connected to oxygen supply
2. Humidifier with sterile distilled water, if necessary, for
the type of mask prescribed
3. Face mask, specified by physician
4. Gauze to pad elastic band (optional)
5. Protective personal equipment (PPE), as indicated.

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Steps of Procedure
1. Follow Standard Protocol.
- Verify or Check Doctor’s Order.
- Identify the patient.
- Introduce yourself and explain the procedure.
- Provide privacy and position comfortably.
- Perform hand hygiene and put on PPE.
Rationale: This ensures that the correct intervention is
performed on the correct patient.
2. Attach face mask to oxygen
source (with humidification, if
appropriate, for the specific
mask) Fig. (157).
Rationale: Oxygen forced
through a water reservoir is
humidified before it is
delivered to the patient, thus Fig. (157): Attach face mask
preventing dehydration of the with humidification
mucous membranes.
3. For a mask with a
reservoir, be sure to allow
oxygen to fill the bag before
proceeding to the next Fig.
(158).
Rationale: A reservoir bag
must be inflated with oxygen
because the bag is the oxygen
Fig. (158 ): Attach mask
supply source for the patient.
4. Position face mask over the patient’s nose and mouth.
Rationale: This ensures correct placement.

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5. Adjust elastic strap so that

mask fits snugly but comfortably
on the face Fig. (159).
Rational: A loose or poorly
fitting mask will result in
oxygen loss and decreased Fig. (159): Adjust the
therapeutic value. elastic strap
6. Adjust the flow rate to the
prescribed rate Fig. (160).
Rationale: This ensures correct
flow rate.
Fig. (160 ): Adjust flow rate
7. If the patient reports irritation or redness is noted, use gauze
pads under the elastic strap at pressure points to reduce
irritation to ears and scalp.
Rationale: Pads reduce irritation, pressure & protect skin.
8. Reassess patient’s respiratory status, including respiratory
rate, effort, and lung sounds.
Rationale: Helps assess effectiveness of oxygen therapy.
9. Remove PPE, if used. Perform hand hygiene.
Rational: to reduces the risk for infection transmission and
contamination of other items.
10. Remove mask and the skin every 2 to 3 hours if the oxygen
is running continuously. Do not use powder around the mask.
Rational: The tight fitting mask and moisture from
condensation can irritate the skin on the face. There is a danger
of inhaling powder if it is placed on the mask.
11. Document the following:
- Type of mask used.
- Amount of oxygen used.
- Oxygen saturation level.
Lung sounds and rate/pattern of respiration.

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