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1. Fundamental of nursing skill lab manual
December 1, 2022

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Table of contents
Table of contents ........................................................................................................................................................... 1
List of acrnomies and abbreviations ............................................................................ Error! Bookmark not defined.
CHAPTER ONE:INTRODUCTION TO NURSING PROFESSION ........................................................................... 6
1.1. History of nursing ................................................................................... Error! Bookmark not defined.
1.2. Nursing Processes..................................................................................................................................... 6

CHAPTER THREE:INFECTION PREVENTION ..................................................................................................... 10
3.1. Hand Hygiene ......................................................................................................................................... 10
3.1.1. Hand washing ........................................................................................................................ 10
3.1.2. Hand antisepsis ..................................................................................................................... 11
3.1.3. Antiseptic hand rub ............................................................................................................... 12
3.1.4.Surgical hand scrub…………………………………………………………………………………………… ………….29
3.2. Donning and removing Personal protective equipment .......................................................................... 14
3.2.1. Donning and removing gloves .............................................................................................. 14
3.2.2. Donning and removing surgical Gowns ................................................................................ 18
3.2.3. Donning a Cap, Mask and goggle ......................................................................................... 19
3.3. Preparing and Maintaining a Sterile Field .............................................................................................. 20
3.4. Instrument processing ............................................................................................................................. 22
3.4.1. Decontamination, cleaning, drying and packing .................................................................. 22
3.4.2. Sterilization ........................................................................................................................... 24
3.4.3. High level disinfection .......................................................................................................... 25
3.5. Healthcare waste management ............................................................................................................... 27
Waste Segregation........................................................................................................................... 27
3.6. House keeping ........................................................................................................................................ 28
3.6.1. Patient unit care ..................................................................................................................... 28
3.6.2. Terminal cleansing of the patient care unit ........................................................................... 30
3.7. Linen processing .................................................................................................................................... 31
CHAPTER FOUR:MANAGING PATIENT SAFETY AND COMFORT ........................................................... 33
4.1. Applying cotton rings ............................................................................................................................. 34
4.2. Applying foot – board ............................................................................................................................ 35
4.3. Applying pillows .................................................................................................................................... 36
4.4. Applying air rings ................................................................................................................................... 37
4.5. Applying bed cradle ............................................................................................................................... 38
4.6. Adjusting side rails of the bed ................................................................................................................ 39
4.7. Applying sand bag .................................................................................................................................. 40
4.8. Applying splint ....................................................................................................................................... 41
4.9. Appling fracture board ........................................................................................................................... 43
4.10. Applying back rest................................................................................................................................ 43
CHAPTER FIVE:BODY MECHANICS AND MOVING ..................................................................................... 45
5.1. Maintaining body alignment................................................................................................................... 45
5.1.1. Checking proper/normal alignment of spine ......................................................................... 45
5.1.2. Checking proper standing body alignment ............................................................................ 46
5.1.3. Checking proper sitting posture ............................................................................................ 47
5.1.4. Checking proper alignment of client in lying posture ........................................................... 48
5.2. Lifting the patient ................................................................................................................................... 50
5.2.1 Dangling ................................................................................................................................. 50
5.2.2. Log rolling ............................................................................................................................ 51
5.2.3. Moving patient up in bed with two nurses using draw sheet ................................................. 54
5.3. Positioning the patient ............................................................................................................................ 55

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5.3.1. Front lying (prone) ................................................................................................................ 56
5.3.2. Semi-prone position(or Sims’ position) ................................................................................ 57
5.3.3. Supine (back lying) ............................................................................................................... 59
5.3.4. Dorsal recumbent position .................................................................................................... 60
5.3.5. Lateral recumbent (on either side) ........................................................................................ 62
5.3.6. Knee chest ............................................................................................................................. 64
5.3.7. Fowler's position (semi-upright with back and knee rests elevated) ..................................... 66
5.3.8. Trendelenburg position ......................................................................................................... 67
5.3.9. Lithotomy position ................................................................................................................ 69
5.4. Patient ambulation .................................................................................................................................. 70
5.4.1. Preparing the Client to Walk/ambulate ................................................................................. 71
5.4.2. Assisting patient with assistive devices................................................................................. 72
5.4.2.1. Gait belt ............................................................................................................... 72
5.4.2.2. Cane ..................................................................................................................... 73
5.4.2.3.Walker................................................................................................................... 75
5.4.2.4. Crutch .................................................................................................................. 77
5.4.2.1. Two-point gait ....................................................................................... 79
5.4.2.2. Three point gait ...................................................................................... 80
5.4.2.3. Four point gait ....................................................................................... 81
5.4.2.4. Swing to gait .......................................................................................... 83
5.4.2.5. Swing through gait ................................................................................ 84
5.4.2.6. Up and down stair gait ........................................................................... 85
5.5. Patient transfers ...................................................................................................................................... 87
5.5.1. Transferring a Client from Bed to Chair………………………………………………..115
5.5.2. Transferring a Client from Bed to Stretcher ..................................................................... 886
5.6. Range of motion exercise/ROM ............................................................................................................. 90
CHAPTER SIX:ESSENTIAL ASSESSMENT COMPONENTS .......................................................................... 93
6.1. Measuring patient vital sign ................................................................................................................... 93
6.1.1. Taking patient body temperature........................................................................................... 93
6.1.1.1. Taking patient body temperature Oral……………………………………….122
6.1.1.2.Taking patient body temperature (axilary) ............................................................ 95
6.1.1.3. Measuring rectal temperature .............................................................................. 96
6.1.1.4. Measuring tympanic temperature......................................................................... 97
6.1.2. Assessing patient pulse ......................................................................................................... 99
6.1.3. Assessing patient respiration ............................................................................................... 101
6.1.4. Assessing patient blood pressure......................................................................................... 102
6.1.5. Measuring height and weight .............................................................................................. 104
6.2. Collecting Specimen…………………… ….……………… ...……………...……………………………………146
6.2.1.Taking urine specimen ......................................................................................................... 105
6.2.1.1. Random collection ............................................................................................. 106
6.2.1.2.Timed urine specimen collection ........................................................................ 107
6.2.1.3.Mid stream (clean-voided) urine specimen ......................................................... 108
6.2.1.4.Catheterized urine specimen for female client .................................................... 110
6.2.1.5.Catheterized urine specimen for male client ....................................................... 111
6.2.2.Collecting stool specimen .................................................................................................... 113
6.2.3.Taking blood specimen ........................................................................................................ 114
6.2.3.1.Vein puncture ...................................................................................................... 114
6.2.3.1.Capillary or peripheral blood specimen .............................................................. 116
6.2.3.1.Arterial specimen by puncture ............................................................................ 117
6.2.4.Taking sputum specimen...................................................................................................... 119
6.2.5.Obtaining wound drainage specimen for culture.................................................................. 120
6.2.6.Collecting Nose, Throat, and Sputum Specimens ................................................................ 122

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CHAPTER SEVEN:MAKING AND MAINTAINING BED ............................................................................... 124
7.1. Stripping of a bed ................................................................................................................................. 125
7.2. Making unoccupied bed ....................................................................................................................... 126
7.2.1. Closed bed ........................................................................................................................... 126
7.2.2. Open bed ............................................................................................................................. 128
7.3. Making an occupied bed ....................................................................................................................... 130
7.4. Making cardiac bed .............................................................................................................................. 132
7.5. Post operative/anesthetic bed making................................................................................................... 134
7.6. Marking an amputation bed .................................................................................................................. 136
7.7. Fracture bed making ............................................................................................................................. 138
7.8. Baby crib .............................................................................................................................................. 139
CHAPTER EIGHT:HYGIENE CARE AND GROOMING ............................................................................... 141
8.1. Bed bath................................................................................................................................................ 141
8.2.Giving tub bath ...................................................................................................................................... 143
8.3.Giving back care .................................................................................................................................... 145
8.4.Mouth care............................................................................................................................................. 148
8.5.Care of dentures .................................................................................................................................... 150
8.6.Giving bedpan and urinals ..................................................................................................................... 151
8.7.Perineal care .......................................................................................................................................... 154
8.8.Sitz bath ................................................................................................................................................. 156
8.9.Hand and foot care ................................................................................................................................ 157
8.10.Facial hair shaving............................................................................................................................... 160
8.11.Assisting individuals to dress .............................................................................................................. 161
8.12.Giving hair Care .................................................................................................................................. 162
8.13.Hair shampoo ...................................................................................................................................... 163
8.14.Giving pediculosis treatment ............................................................................................................... 165
8.15.Care of eye …………………………………………………………………………………………..192
8.16.Ear care/irrigation ................................................................................................................................ 168
CHAPTER NINE:MEDICATION AND FLUID THERAPY ............................................................................. 170
9.1. Medication preparation ......................................................................................................................... 170
9.1.1. Withdrawing Medication from a Vial ................................................................................. 170
9.1.2. Withdrawing Medication from an Ampoule ....................................................................... 171
9.1.3. Mixing medications from two vials into one syringe .......................................................... 172
9.1.4. Preparing an Intravenous Solution ...................................................................................... 174
9.1.4.1.Plastic Bag .......................................................................................................... 175
9.1.4.2.Glass Bottle ......................................................................................................... 176
9.2. Medication administration .................................................................................................................... 176
9.2.1. Administering oral medication (Per Os) (Po) ...................................................................... 176
9.2.2. Administering sublingual medication ................................................................................. 178
9.2.3. Administration of eye drops and ointment .......................................................................... 180
9.2.4. Administration of ear drops ................................................................................................ 182
9.2.5.Topical Administration of medication……………………………………………………211
9.2.6. Instillation of nasal drops .................................................................................................... 186
9.2.7. Administering rectal medications ........................................................................................ 187
9.2.8. Administering Vaginal Medications ................................................................................... 189
9.2.9. Administering nebulizer Medications ................................................................................. 191
9.2.10. Parentral medication administration .................................................................................. 193
9.2.10.1.Administering an Intradermal Injection ............................................................ 194
9.2.10.2.Subcutaneous Injection ..................................................................................... 196
9.2.10.3.Intramuscular Injection ..................................................................................... 198
9.2.10.4.Intravenous Injections ....................................................................................... 201
9.2.10.5.Intravenous infusion ......................................................................................... 203

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9.2.10.6.Intravenous Therapy ........................................... Error! Bookmark not defined.
9.2.10.7.Administering an IV Solution ........................................................................... 205
9.2.10.8. Adding Solution to a Continuous Infusion Line .............................................. 207
9.2.10.8.1..Infusion Controller or Pump Regulation ........................................ 208
9.2.10.8.2.Volume Control Chamber (Buretrol) Regulation ............................ 209
9.2.10.8. 3.Adding a Solution to an Existing Heparin or PI Lock .................... 210
9.3. Blood transfusions ................................................................................................................................ 210
CHAPTER TEN:SKIN INTEGRITY AND WOUND CARE ............................................................................. 215
10.1. Wound dressing .................................................................................................................................. 215
10.1.1. Dressing clean wound ....................................................................................................... 217
10.1.2. Dressing septic wound ...................................................................................................... 219
10.1.3. Dressing with Drainage Tube ............................................................................................ 222
10.2. Wound Irrigation ................................................................................................................................ 224
10.3. Suturing .............................................................................................................................................. 226
10.4. Stitch removal .................................................................................................................................... 228
10.5. Clips Application ................................................................................................................................ 230
10.6. Removal of clips ................................................................................................................................. 232
CHAPTER ELEVEN :COLD AND HEAT APPLICATION ............................................................................... 234
11.1. Application of cold ........................................................................................................................................... 234
11.1.1. Tipped Sponge Bath ........................................................................................................................ 234
11.1.2.Cold compress .................................................................................................................................. 235
11.1.3.Application of ice pack ..................................................................................................................... 237
11.1.4. Application of ice collar .................................................................................................................. 238
11.2. Application of heat ........................................................................................................................................... 239
11.2.1.Application of warm soak ...................................................................................................................... 239
11.2.2. Applying Hot Compress........................................................................................................................ 242
11.2.3.Application of hot compress .................................................................................................................. 242
11.2.4.Application of hot water bag .................................................................................................................. 243
CHAPTER TEWELVE :NUTRITON AND METABOLISM ............................................................................. 246
12.1. Feeding a helpletient .......................................................................................................................... 246
12.2.Feeding the Helpless Patient General Instruction ................................................................................ 246
12.3.Gastrostomy feeding ............................................................................................................................ 266
12.4.Parentral Feeding ................................................................................................................................. 267
12.5.Nasogastric tube insertion ................................................................................................................... 269
12.6.Nasogastric tube medication administration ........................................................................................ 272
12.7.Gastric aspiration ................................................................................................................................. 273
12.8.Gastric lavage ...................................................................................................................................... 276
12.9.Gastric Gavage .................................................................................................................................... 279
12.10.Removal of a Nasogastric Tube......................................................................................................... 282
12.11.Measuring Intake and Output ............................................................................................................ 283
CHAPTER THIRTEEN :ELIMINATION ............................................................................................................ 293
13.1. Urinary elimination .............................................................................................................. 293
13.1.1.Urinary catheterization......................................................................................... 293
13.1.1.1..Catheterization using a straight or plain catheter ................................ 293
13.1.1.1.1. Female urinary catheterizationwith plain or straight catheter
13.1.1.1.2.Male catheterization with plain or straight catheter295
13.1.1.2.Catheterization using indwelling catheter ............................................ 293
13.1.1.2.Insertions of indwelling catheter for male patient ..... 297
13.1.1.2.Insertions of indwelling catheter for Female patient . 299
13.1.2..Applying a Condom Catheter ............................................................................. 301

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13.1.3.Bladder Irrigation (open and closed method) ...................................................... 302
13.1.4.Suprapubic catheter care ...................................................................................... 304
13.2. Bowel elimination ............................................................................................................... 304
13.2.1.Enema .................................................................................................................. 304
13.2.1.1.Cleansing enema/evacuating enema/ ................................................... 305
13.2.1.2.Retention enema .................................................................................. 307
13.2.1.3.Rectal wash out .................................................................................... 308
13.2.2.Inserting a rectal tube ........................................................................................... 310
13.2.3.Colostomy care and irrigation .............................................................................. 311
13.2.4.Digital removal of fecal impaction ...................................................................... 314
CHAPTER FOURTEEN :PERI-OPERATIVE CARE ......................................................................................... 317
14.1. Preoperative care……………………… …………… .………… .……..…………………………….307
14.2. Intraoperative care ……………………… ...…….……………………………… .………………….307
14.3. Post operative care ……………………………………… …………………………..……………………………… .………………….307
CHAPTER FITEEN:OXYGENATION ................................................................................................................ 324
15.1.Monitoring with pulse oximetery ........................................................................................................ 324
15.2.Oxygen Administration ....................................................................................................................... 325
15.2.1..Oxygen administration via face mask ............................................................................... 326
15.2.2. Oxygen by Nasal cannula (nasal prongs)……………………………………… ………………….……..……….319
15.2.3. Giving oxygen by tent/blood……………………………………. …………… ………………..322
15.3. Airway suctioning ………………………………………………… …………… …...………………324
15.3.1.Performing Nasopharyngeal and Oropharyngeal Suctioning Error! Bookmark not defined.
15.3.2. Performing endotracheal/tracheostomy Suctioning…………………………………. ….328
15.4. Tracheostomy care ............................................................................................................................. 338
15.5. Postural drainage…………………………………………..…………… …………………. ………..332
15.6. Cardiopulmonary resuscitation (CPR)…………………………… ………………… ………………343
15.6.1. Adult CPR………………………………………………… ……………….. ……………344
15.6.2.CPR for child below 8 years old ........................................................................................ 351
15.6.3.One rescuer CPR procedure for infant (to approximate 1 year) ......................................... 353
CHAPTER SIXTEEN :THERAPEUTIC AND DIAGNOSTIC PROCEDURE ................................................ 356
16.1. Assisting with thoracentesis ............................................................................................................... 356
16.2. Assisting with Water-seal chest drainage system ............................................................................... 359
16.3. Assisting with Bronchoscopy ............................................................................................................. 361
16.4. Assisting with an abdominal paracentesis .......................................................................................... 365
16.5. Assisting with liver biopsy ................................................................................................................. 366
16.6. Assisting with Bone marrow puncture/biopsy .................................................................................... 369
16.7. Assisting with Cast application and removal...................................................................................... 371
16.7.1.Cast application .................................................................................................................. 371
16.7.2.Care of patient with cast ..................................................................................................... 372
16.7.3.Cast Removal ..................................................................................................................... 373
16.9. Assisting with Traction Application .................................................................................................. 374
16.9.1. Skin Traction ..................................................................................................................... 374
16.9.2. Skeletal traction ................................................................................................................. 376
16.10. Assisting with lumbar puncture ........................................................................................................ 378
CHAPTER SEVENTEEN :CARE OF THE TERMINALLY ILL AND POST MORTEM CARE ................. 380
17.1. Care of terminally ill patient………………………………………...……… …………………. ……378
17.2. Post mortum care ……………….………………………………………… …………………. ……..380
References ................................................................................................................................................................. 386

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CHAPTER ONE
INTRODUCTION TO NURSING PROFESSION
Definition of nursing by American Nursing Associations (ANA)
Nursing is the protection, promotion and optimization of health and abilities, prevention of
illness and injury, alleviations of suffering through the diagnosis and treatment of human
response, and advocacy in the care of individuals, families, communities, and
populations(ANA,2003).
 Nursing is an art and science. This means that a professional nurse learns to deliver care
artfully with compassion, caring and a respected for each client dignity and personhood. As
a science, nursing is based upon a body of knowledge that is always changing with new
discoveries and innovations. When nurse integrate the science with art of nursing into their
practice, the quality of care provided to clients is at level of excellence that benefits a clients
in innumerable ways
1.1. Nursing Processes
Nursing Process is a method of organizing through process for clinical decision making and
problem solving. Using nursing process, the nurse can focus on the unique responses of patient
to actual or positional health problems.
Characteristics of nursing process
1.
2. Based on scientific problem solving
3. Systematic
4. Client centered
5. Continuous
6. Dynamic
There are five steps, or phases, in the nursing process: assessment, diagnosis, planning,
implementation, and evaluation. These steps are not distinct; rather, they overlap and build on
each other. To carry out the entire nursing process, you must be sure to complete each step
accurately and then build upon the information in that step to complete the next one.
A. Nursing Assessment

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The first step, or phase, of the nursing process is assessment. During this phase, you are
collecting data (factual information) from several sources. The collection and organization of
these data allow you to:
1. Determine the patient’s current health status.
2. Determine the patient’s strengths and problem areas (both actual and potential).
3. Prepare for the second step of the process—diagnosis.
Subjective Data
 What the patient tells you
 The history, from chief complaint through Review of Systems
 Example: Mrs. G is a 54-year-old hairdresser who reports pressure over her left chest “like an
elephant sitting there,” which goes into her left neck and arm.
Objective Data
 What you detect on the examination
 All physical examination findings
 Example: Mrs. G is an older white female, deconditioned, pleasant, and cooperative.
 BP 160/80, HR 96 and regular, respiratory rate 24, afebrile.
Methods of assessment are:-
1. Nursing health history
2. Physical assessment
3. Diagnostic evaluation
B. Nursing Diagnosis
Diagnosis means reaching a definite conclusion regarding the patient’s strengths and human
responses. This diagnostic process is complex and utilizes aspects of intelligence, thinking, and
critical thinking.
Nursing diagnosis is a clinical judgment about individual, family, or community responses to
actual or potential health problems/life processes. Nursing diagnoses provide the basis for
selection of nursing interventions to achieve outcomes for which the nurse is accountable.
C. Nursing planning

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Planning involves a series of steps in which the nurse and the client priorities problems and sated
goals or expected out comes to resolve or minimize the identified problems of the client
D. Nursing implementation
Implementation refers to the action phase of the nursing process in which nursing care plan is put
into action.
It is focused on resolving the patient’s nursing diagnoses and collaborative problems and
achieving expected outcomes, thus meeting the patient’s health needs.
E. Evaluation
Evaluation simply means assessing what progress has been made toward meeting the expected
outcomes; it is the most ignored phase of the nursing process.















Summary of nursing process steps
Assessment
1. Conduct the health history.
2. Perform the physical assessment.
3. Interview the patient’s family or significant others.
4. Study the health record.
5. Organize, analyze, synthesize, and summarize the collected data
Diagnosis
1. Nursing Diagnosis
a. Identify the patient’s nursing problems.
b. Identify the defining characteristics of the nursing problems.
c. Identify the etiology of the nursing problems.
d. State nursing diagnoses concisely and precisely.
2. Collaborative Problems
a. Identify potential problems or complications that require collaborative interventions.
a. Identify health team members with whom collaboration is essential
Planning
1. Assign priority to the nursing diagnoses.
2. Specify the goals.
o Develop immediate, intermediate, and long-term goals.
o State the goals in realistic and measurable terms.
3. Identify nursing interventions appropriate for goal attainment.
4. Establish expected outcomes.
o Make sure that the outcomes are realistic and measurable.
o Identify critical times for the attainment of outcomes.
5. Develop the written plan of nursing care.
o Include nursing diagnoses, goals, nursing interventions, expected outcomes, and critical times.
o Write all entries precisely, concisely, and systematically.
o Keep the plan current and flexible to meet the patient’s changing problems and needs.
6. Involve the patient, family or significant others, nursing team members, and other health team members in all
aspects of planning
Implementation
1. Put the plan of nursing care into action.
2. Coordinate the activities of the patient, family or significant others, nursing team members, and other health
team members.
3. Record the patient’s responses to the nursing actions.
Evaluation
1. Collect data.
2. Compare the patient’s actual outcomes with the expected outcomes.
3. Determine the extent to which the expected outcomes were achieved.
4. Include the patient, family or significant others, nursing team members, and other health care team members in

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CHAPTER THREE
INFECTION PREVENTION
Definition- Largely depends on placing barriers between a susceptible host (person lacking
effective natural or acquired protection) and the microorganism
3.1. Hand Hygiene
Definition: Hand hygiene is a general term referring to any action of hand cleansing. It includes
care of hands, nails and skin.
Hand hygiene can be accomplished by:
 Hand washing
 Hand antisepsis
 Antiseptic hand rub
 Surgical scrub plain
3.1.1. Hand washing
Definition: Hand washing is process of mechanically removing soil and debris from the skin of
hands using plain soap and water.
Purpose
 Reduce number of resident and transient microorganisms on the hands
 Prevent transfer of microorganisms from health care personnel to the client
Indication
 Immediately after arriving and leaving work (the health facility)
 Before and after examining a client/patient
 After touching contaminated instruments or items
 After exposure to mucous membranes, blood, body fluids, secretions or excretions
 Before putting on gloves and after removing them
 Whenever our hands become visibly soiled
 After blowing nose or covering a sneeze
 Before eating or serving food
 After visiting the toilet

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Equipment
1. Tap water or water in a jug and a basin
2. Soap with soap dish
3. Clean towel (personal or disposable)
4. nail cuter
5. orange stick
6. wall clock
Procedure
1. Prepare necessary equipment
2. Remove all jewelry or false finger nails. Remove your watch or wear it well above the
wrist & examine hands well
3. Thoroughly wet hands.
4. Apply plain soap (antiseptic agent is not necessary).
5. Vigorously rub all areas of hands and fingers for 10–15 seconds with appropriate steps,
paying close attention to fingernails (if necessary, use orange stick) and between fingers.
6. Rinse hands thoroughly with clean water.
7. Dry hands with a paper towel or a clean, dry personal towel.
8. Use a paper towel when turning off water if there is no foot control or automatic shut-off.



1.1.2. Hand antisepsis
Definition: Washing hands with use of soap containing anti-microbial agent
Purpose
 To remove soil and debris

 Reduce both transient and resident flora on the hands.
Indication

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• Before Examining or caring for highly susceptible patients (e.g., premature infants,
elderly patients, or those with advanced AIDS)
• Before Performing an invasive procedure (e.g., intravascular device)
• Before Leaving the room of patients on Contact Precautions
Precaution
 Hand washing with medicated soaps or detergents repeatedly is irritant to the skin
Equipment
1. Tap water or water in a jug and a basin
2. Soap which contains anti-microbial agent (chlorohexidine, iodophors or triclosan) e.g.
Medicum, Life boy, Dettol and soap rack with drains
3. Clean towel (personal or disposable)
4. Orange stick
5. Wall clock
7. Nail cuter
Procedure
1. Prepare necessary equipment
2. Remove all jewelry or false finger nails and your watch or wear it well above the wrist
assess hands well
3. Thoroughly wet hands.
4. Apply soap containing antimicrobial agent
5. Vigorously rub all areas of hands and fingers for 10–15 seconds following appropriate
step, paying close attention to fingernails (if necessary, use orange stick) and between
fingers.
6. Rinse hands thoroughly with clean water.
7. Dry hands with a paper towel or a clean, dry personal towel.
8. 0Use a paper towel when turning off water if there is no foot control or automatic shut-
off.
1.1.3. Antiseptic hand rub

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Definition- Use of a waterless, alcohol-based hand rub product to inhibit or kill transient and
resident flora
Purpose:
 Is to inhibit or kill transient and resident flora.
Equipment
1. Alcohol (60-90%)
2. glycerin
3. measuring glass
4. bottle
Preparation of hand rubs solution
 A nonirritating, antiseptic hand rub can be made by adding either glycerin, propylene
glycol or sorbitol to alcohol (2 mL in 100 mL of 60–90% ethyl or isopropyl alcohol
solution.
Steps:
 Apply enough alcohol-based hand rub to cover the entire surface of hands and fingers
(about a teaspoonful -5ml)
 Continue rubbing the solution over hands until they are dry (15-30 seconds)).
 Rub the solution vigorously into hands, especially between fingers and under the nails,
until dry.
1.1.4. Surgical Hand scrub

Definition: surgical hand scrub is mechanically removed of soil, debris, transient organisms
from the hands and forearm of sterile team member.
Purpose
 Remove as many microorganisms from the hands as possible before sterile procedure
 Decrease the risk of infection for high-risk groups (newborn, transplant recipients)
Equipment
1. Tap water or water in a jug and basin.
2. Soap/detergent on soap rack with drains
3. Sterile paper towel
4. Plastic nail stick
5. nail cleaner
Procedure

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1. prepare necessary equipment
2. Remove rings, watches, and bracelets & assess hands
3. open the tap and wet hands
4. Thoroughly wash hands and forearms to the elbow with soap and water
5. Clean nails with a nail cleaner & shortened the nail.
6. Rinse hands and forearms with water.
7. Apply an antiseptic agent (soap)
8. Vigorously wash all surfaces of hands, fingers, and forearms for at least 3-5 minutes.
9. Rinse hands and arms thoroughly with clean water, holding hands higher than elbows.
10. Keep hands up and away from the body, do not touch any surface or article. And dry
hands with a clean, dry towel.
11. Put on sterile or HLD gloves.
1.2. Donning and removing Personal protective equipment
Definition: PPE is an equipment that is fluid-resistant or water proof (e.g., plastic or rubber
aprons) can protect health care workers from exposure to potentially contaminated blood or other
body fluids and clients from microorganisms present on medical staff and others working in the
healthcare setting.

3.2.1. Donning and removing gloves
Purpose
 To reduce the risk of staff acquiring infections from patients
 To prevent transmitting of their skin flora to patients
 To reduce cross-contamination of microorganisms that can be transmitted from one
patient to another.
Indication
 Before contacting of blood or other body fluids, mucous membranes, or non-intact skin,
 Before performing an invasive medical procedure,

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 Before handling soiled instruments, contaminated waste items or touch contaminated
surfaces.
 When disposing contaminated waste items
 Handling chemicals or disinfectants
Types of gloves
A. Surgical glove
B. Clean glove
C. Elbow length glove
D. Heavy duty gloves
A. Surgical glove used when performing invasive medical or surgical procedures.
Purpose
 to ensure maximum asepsis to the patient and to protect the health care workers from
the patient's body fluid
Equipment
1. Table of soap or antiseptic
2. Elbow controlled tap of water
3. personal towels
4. Sterile gloves
5. Nail cuter
6. Orange stick
Procedure
1. Wash hands and dry them
2. Prepare necessary equipment
3. Scrub for at least 2 minutes
4. Keep hands up and away from the body, do not touch any surface or article. and dry hands
with a clean, dry towel
5. Check the package for integrity. Open the first non-sterile packaging by peeling it
completely off the heat seal (cover) to expose the second sterile wrapper, but without
touching it
6. Place the second sterile package on a clean, dry surface without touching the surface. Open
the package and fold it towards the bottom so as to unfold the paper and keep it open.

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7. Using the thumb and index finger of one hand, carefully grasp the folded cuff edge of the
glove
8. Slip the other hand into the glove in a single movement, keeping the folded cuff at the wrist
level
9. Pick up the second glove by sliding the fingers of the gloved hand underneath the cuff of the
glove
10. In a single movement, slip the second glove on to the ungloved hand while avoiding any
contact/ resting of the gloved hand on surface other than the glove to be donned (contact/
resting constitutes a lack of asepsis and requires a change of glove)
11. If necessary, after donning both gloves, adjust the fingers and inter-digital spaces until
the gloves fit comfortably.
12. Unfold the cuff of the first gloved hand by gently slipping the fingers of the other hand
inside the fold, making sure to avoid any contact with a surface other hand the outer surface
of the glove (lack of asepsis requiring a change of gloves)
13. The hands are gloved and must touch exclusively sterile devices or the previously –
disinfected patient’s body area.


Removing gloves
14. Before removing the glove briefly immerse them in 0.5% chlorine solution,
15. Remove the first glove by peeling it back with the fingers of the opposite hand. Remove
the glove by rolling it inside out to the second finger joint
16. Remove the other glove by turning its outer edge on the fingers of the partially ungloved
hand
17. Remove the glove by turning it inside out entirely (ball forming) to ensure that the skin of
the health-care worker is always and exclusively in contact with the inner surface of the
glove.
18. Perform hand hygiene after glove removal according to the recommended indication.

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B. Examination glove
Purpose:
1. To reduce the risk of staff acquiring bacterial infections from patients.
2. To prevent staff from transmitting their skin flora to patients.
3. To reduce contamination of the hands of staff by microorganisms that can be transmitted
from one patient to another (cross-contamination).
Indication of donning Examination glove
1. When there is reasonable chance of hands coming in contact with blood or other body
fluids, mucous membranes or one intact skin
2. They perform invasive medical procedures (e.g., inserting vascular devices such as
peripheral venous lines)
3. When they handle contaminated waste items or touch contaminated surfaces.
Equipment
1. Table of soap or antiseptic
2. tap of water
3. towels
4. clean examination gloves
Procedure
1. Prepare necessary equipment
2. Remove any jewelers below the wrist & examine your hands
3. Wash hands and dry them
4. Take out glove from box
5. Touch only restricted surface of gloves (at the top age of the cuff)
6. Done the first glove
7. Done the second glove and touch only restricted surface of the glove corresponding to the
wrist

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8. To avoid touching the skin of the forearm with the gloved hand, turn the external surface
of the glove to be donned on the folded fingers of the gloved hand, thus permitting to
glove the second hand
9. Once gloved, hands should not touch anything else that defined by indications and
conditions for glove use
Remove glove
10. Pinch one glove at the wrist level remove it, without touching skin of forearm, and pill
away from the hand, thus allowing the glove to turn inside out
11. Hold the removed glove in the gloved hand and slide the fingers of the ungloved hand
inside between the glove and wrist. remove the second glove by rolling it down the hand
and fold in to the first glove
12. Discard the removed glove
C. Elbow length glove
Purpose
 Used during manual removal of placenta and any other procedure where there is a contact
with a large volume of blood or body fluids.
D. Utility or heavy-duty gloves
Purpose
 used for processing instruments, equipment and other items,
 used for handling and disposing of contaminated waste, and when cleaning contaminated
surfaces

3.2.2. Donning and removing surgical Gowns
Purpose: -
 To protect patients from microorganisms, present on the abdomen and arms of the
healthcare staff during surgery.
 To protect the healthcare workers’ clothing.
Equipment
 Sterile gown
Procedure

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1. The sterile gown is folded inside out.
2. Grasp the gown inside the neckline, step back, and allow the gown to open in front
of you; keep the inside of the gown toward you; do not allow it to touch anything
3. Holding the neck band with both hand and gently shakes the folds from the gown
4. With hands at shoulder level, slip both arms into the gown; keep your hands inside
the sleeves of the gown
5. The circulating nurse will step up behind you and grasp the inside of the gown, bring
it over your shoulders, and secure the ties at the neck and waist.
6. Unfasten neck and then ties
7. Remove gown using a peeling motion; pull gown from each shoulder towards the
same hands.
8. Gown will turn inside out
9. Hold removed gown away from body, roll into a bundle and discard into waste or
linen receptacle.
3.2.3. Donning a Cap, Mask and goggle
Purpose
A. Masks
 are worn in an attempt to contain moisture droplets expelled as the health care
workers speak, cough or sneeze
 protect the wearer from inhaling both large and small particle droplets
B. Goggle/face shield
 prevent accidental splashing of the mouth and face during certain procedures.
C. Cap
 used to keep the hair and scalp covered so that flakes of skin and hair are not shed
into the wound during surgery
Equipment
1. Cap
2. Mask
3. Goggles/ Face Shield

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Procedure
1. Wash hands.
2. Apply cap to head, being sure to tuck hair under cap. Males with facial hair should use a
hood to cover all hair on head and face
3. Secure mask around mouth and nose. For masks with strings:
a. Hold mask by top and pinch metal strip over bridge of nose.
b. Pull two top strings over ears and tie at upper back of head.
c. Tie two lower ties around back of neck so that bottom of mask fits snugly under
chin
4. For goggle Place over face and eyes and adjust to fit
5. After performing necessary tasks, remove cap and mask before leaving room.
A. Untie bottom strings of mask first, then top strings, and lift off of face. Hold mask
by strings and discard.
B. Grasp top surface of cap and lift from head.
6. To remove goggle/ face shield handle by head band or ear pieces
7. After removing wash hands
8. Document the type of protective barriers used and client understanding of the procedures
3.3. Preparing and maintaining a Sterile Field
Definition-is the area of the operating room that immediately surrounds and is especially
prepared for the patient
Purpose
 To create an environment to prevent the transfer of microorganisms during sterile
procedure
 To create an environment that helps ensure the sterility of supplies and equipment during
a sterile procedure
Equipment
1. Antimicrobial soap for hand washing
2. Sterile drape
3. Sterile materials (antiseptic solution, bowl, Sterile solution dressing, instruments)

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4. Package of proper-sized sterile gloves
5. Additional sterile supplies (culture swab, gauze)
6. Container for disposal of waste materials
Procedure
1. Wash your hand
2. Inspect all sterile packages for package integrity, contamination or moisture
3. During the entire procedure, never turn your back on the sterile field or lower your hands
below the level of the field
Opening a sterile drape
4. Remove the sterile drape from the outer wrapper and place the inner drape in the center of
the work surface, at or above waist level, with the outer flap facing away from you
5. Touching the outside of the flap only, reach around (rather than over) the sterile field to
open the flap away from you
6. Open the side flaps in the same manner, using the right hand for the right flap and the left
hand for the left flap
7. Lastly, open the inner most flap that faces you, being careful that it does not touch your
clothing or any object
Adding sterile supplies to the field
8. prepackaged sterile supplies are opened by pealing back the partially sealed edge with both
hands or lifting up the unsealed edge, taking care not to touch the supplies with your hands
9. Hold supplies 10 to 12 inches above the field and allow them to fall to the middle of the
sterile field
10. Wrapped sterile supplies are added by grasping by the sterile object with one hand and un
wrapping the flaps with the other hand
11. Grasp the corners of the wrapper with the free hand and hold them against the wrist of the
other hand while you carefully drop the object on to the sterile field
Adding solutions to a sterile field
12. Read the solution label and expiration date. Note any signs of contamination

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13. Remove cap and place it with the inside facing up on a flat surface. Don't touch inside of
cap/rim of bottle
14. Hold bottle 6 inches above container on the sterile field and pour slowly to avoid spills
15. Recap the solution bottle and label it with date and time of opening if the solution is to be
reused
16. Add any additional supplies and don sterile glove before starting the procedure

3.4. Instrument processing
Definition: Instrument processing is a process of making instruments safer for handling and
making free from microorganisms.
3.4.1. Decontamination, cleaning, drying and packing
Definition
o Decontamination is a Process that makes inanimate objects safer to be handled by staff
before cleaning.
o Cleaning is a Process that physically removes all visible dust, soil, blood or other body
fluids from inanimate objects as well as removing sufficient numbers of microorganisms.
Purpose
 to reduce the number of microorganisms
 to removes all visible dust, soil, blood or other body fluids from inanimate objects
 to eliminate microorganisms from inanimate objects
Equipment
1. PPE (heavy duty glove/surgical
glove, plastic apron, gown, goggle,
mask)
2. Plastic bucket (3)
3. Water
4. Chlorine solution (0.5%)
5. Measuring Jug
6. Timer (watch)
7. Brush
8. Drying cloth
9. Drape
10. Drum

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Procedure
1. Wash hands and dry them
2. Prepare necessary equipment including 0.5% chlorine solution.
3. Don utility gloves or leave on surgical gloves after a procedure.
4. Place all instruments in 0.5% chlorine solution for10 minutes to decontaminate
immediately after completing the procedure and ensure instruments are fully immersed in
the solution.
5. Dispose off waste materials in leak proof container or plastic bag.
6. After 10 minutes remove instruments from chlorine solution and fully immerse in soap
water
7. Clean instruments immediately or leave in water until cleaning can be done.
8. If wearing surgical or examination gloves: immerse both gloved hands in 0.5% chlorine
solution.
9.
10. Remove gloves by turning them inside out.
11. Dispose in leak proof container or plastic bag if gloves are not to be reused
12. Leave utility gloves on until cleaning is completed.
13. Place instrument in container with clean water and mild non-abrasive detergent.
14. Under soapy water completely disassemble instruments and open jaws of jointed items.
15. Wash all instruments surfaces with a brush or cloth until visibly clean and Hold
instruments under water while cleaning. Pay special attention to serrated edges.
16. Wash surgical gloves inside out in soapy water.
17. Rinse all equipment/gloves until no soap or detergent remains
18. Dry instruments using clean dry towel or air dry.
19. Remove utility gloves and air dry
20. Pack the instrument with drape or drum

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3.4.2. Sterilization
Definition: - is the destruction of all microorganisms including bacterial endospores.
Purpose: to ensure instruments free from all microorganisms.
Equipments
1. Auto clave
2. Stove
3. Timer
4. Water
5. Time steam sterilizer indicator
3.4.2.1. Steam sterilization
Procedure
1. Wash hands and dry them
2. Prepare necessary equipment
3. Place Time steam sterilizer indicator / an indicator tape on the container on packed items
4. Place instruments: gloves into steam pan
5. Stuck steam pans (maximum of 3 pans) on top of pan containing water for boiling.
6. Cover top of steamer pan with lid
7. Bring water to a rolling boil; wait for steam to escape from between the top pan and lid
8. Start timing and steam for 20 minutes with 121 degree centigrade, if the equipment is
uncovered
9. Remove steamer pans from heat; gently shake excess water from items and place on an extra
empty bottom pan
10. Allow to air dry and cool
11. Store in covered steamer pans
12. To Use immediately – remove items with high level disinfected forceps.
3.4.2.2. Dry heat sterilization
Procedure
1. Wash hands and dry them

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2. Prepare necessary equipment
3. Place metal instruments or glass syringes in a metal container with a lid.
4. Put an indicator tape on the container.
5. place covered containers in oven and heat until 160ºc is reached and heat for two hours
6. Begin timing when 160ºc is reached and heat for two hours.
7. After instruments are cool; remove and store in sterile containers.
8. Wash hands and dry them.
3.4.3. High level disinfection
Definition: is a Process that eliminates all microorganisms except some bacterial endospores
from inanimate objects.
3.4.3.1. Chemical disinfection
Definition: This is the process of disinfecting used equipments by using
chlorine/Glutaraldehyde/ formaldehyde or peroxide.
Purpose: to eliminate microorganisms from inanimate objects.
Equipments
1. Chlorine, Glutaraldehyde, formaldehyde and peroxide.
2. Container for disinfection
3. Heavy duty gloves
4. Sterile containers
5. pick up forceps
Procedure:
1. Wash hands and dry them
2. Prepare necessary equipment
3. Prepare fresh sterilant as per manufactures instructions
4. Submerge cleaned and dried items in: 2% Glutaraldehyde (cidex) for 8 – 10 hours 8%
formaldehyde solution – 24 hours
5. Ensure items are completely immersed
6. Remove items from chemical solution using sterile gloves, Forceps/pickups.
7. Rinse thoroughly with sterile water to remove all traces of chemical sterile
8. Use item immediately or store in sterile containers?

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9. Wash hands and dry them.
3.4.3.2. Boiling
Definition: Boiling in water is an effective practical way to high level disinfectant instrument
and other items
Purpose:
 To kill all vegetative forms of bacteria, viruses (including HBV, HCV and HIV)
Equipment Water
1. Boiler
2. Stove
3. Sterile forceps
4. Sterile container (high level disinfected container)
Procedure
1. Wash hands and dry them
2. Decontaminate and clean all instruments and other items to be high level disinfected
3. Prepare necessary equipment
4. Completely immerse cleaned instruments and other items in water
5. Cover boiler with lid and bring water to a gently rolling boil
6. Start timing when rolling boil beings
7. Continue rolling boiling for 20 minutes
8. Remove items with high-level disinfected forceps
9. Place instruments in covered high level disinfected container
10. Wash hands and dry them.
Principles of Storing
 Store appropriately to protect them from dust, dirty, moisture, animals and insects.
 The storage area should be located next to or connected to where sterilization occurs, in a
separate enclosed area
 In smaller clinics, this area may be just a room close to the Central Supplies Department
or in the Operating Room

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3.5. Healthcare waste management
Definition: refers to all activities, involved in the collection, handling, treatment, conditioning,
transport, storage and disposal of waste produced at healthcare facilities
High Risk Wastes
 Infectious waste
 Anatomical waste
 Sharps wastes (used or unused)
 Chemical waste
 Pharmaceutical waste
 Radioactive wastes
 Pressurized containers
Low Risk Wastes
 Noninfectious waste/Communal
wastes
3.5.1. Waste Segregation
Definition: Waste segregation is separating waste by type at the place where it is generated
Purpose
 Protect people who handle waste items from injuries,
 Prevent the spread of infections to HCWs who handle waste,
 Prevent the spread of infection to the community,
 Protect the environment
Equipment
1. Three different colored bags (Red,
Yellow and Black)
2. Heavy duty glove
3. mask
4. gown
5. apron
6. boots

Procedure
1. Wash hands
2. Wear necessary personal protective equipment
3. Separate wastes based on their level of infection

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 Noninfectious (Black color code): Presents no risk. Examples: paper, packaging
materials, office supplies, drink containers, hand towels, boxes, glass, plastic bottles, and
food.
 Infectious (Yellow color code): Contaminated with human blood and has the ability to
spread disease. Examples: gauze, cotton, dressings, laboratory cultures, IV fluid lines,
blood bags, gloves, and pharmaceutical waste.
 Highly infectious (Red color code) : HHiigghhllyy iinnffeeccttiioouuss AAnnaattoommiiccaall wwaassttee,, ppaatthhoollooggiiccaall
wwaassttee
 Sharp’s waste (Safety box, needle remover, or other puncture-resistant and leak-
resistant sharps containers): Syringes and needles should be discarded without
recapping.
4. Collect waste bags from the service point
5. Remove PPE
6. Wash hands
7. Documenting
1.6. House keeping
1.6.1. Patient unit care
Definition
 Patient's unit is a small separate room in which the patient rest during his/her hospital
stay. Patient's unit usually consists of basic furniture and standard equipment
 Cleaning of patient's unit is keeping of the patient’s room neat & orderly. There are two
types of cleaning that are concurrent and terminal cleaning
 Concurrent Cleaning is a daily cleaning of the patient’s room. It consists cleaning the
room by damp mopping the floor and dusting with damp cloth.
Purpose:
 To prevent accumulation of dirty
 To promote the pt's health and comfort physically & mentally
 To remove germs & dust particles

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 To prevent spread of micro organisms
 To have neat appearance of the unit.
Equipment
1. Basin of water
2. powder soap
3. Brush
4. 2 cleaning clothes
5. Scouring powder /vim/
6. stretcher
7. Dust bin
8. Mop
9. Glove
10. Broom
Purpose
To keep the room clean & tidy
 To minimize cross infection
 To create comfortable environment for the patient
 To make the room ready for a new patient
Equipment
1. Wheeled utility cart
2. Wheeled laundry hampers
3. Cleaning cloths
4. Waste basket with paper bag / plastic
liner
5. Basin of prescribed detergent, germicide
solution
6. Utility glove
7. Mop
8. Chair
9. Clean water with bucket

Procedure
1. Hand washing
2. Assemble the equipment in the utility room & take it to the patient unit
3. Wear heavy duty/ utility glove
4. Clear the bed side cabinet and over bed table if used and discard any waste in the waste
basket
5. Strip the bed, remove pillow, and place the pillow on the chair & pillow case in the
hamper. Place all the line in the hamper and place blanket on the cart for special laundry

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6. Clean the bed, wash the top of mattress cover
7. Turn the other side & clean the spring
8. Wash the cabinet, inside & out
9. Complete the unit cleaning by washing the chair, bed lamp ( cord unplugged) , singe cord
& over bed table
10. discard the waste if cleaning cloth are to be reused place them in the laundry hamper
11. Wash the collected utensils and place them in the utensils boiler (sanitizer) for a 30
minute
12. Remove the clean utensils from the utensil boiler ,dry and return them to the storage shelf
13. Wash hand
14. Record the procedure
1.6.2. Terminal cleansing of the patient care unit
Definition: The sanitation of the bed, bedside cabinet, and general area of the patient care unit
with a detergent/germicidal agent after the patient is discharged or transferred from the nursing
care unit.
 Performed at every patient care unit before the area is prepared for the next patient.
Purpose
 Prevention of the spread of microorganisms.
 Removal of encrusted secretions from framework or bedside rails.
 Removal of residue of body wastes from the mattress.
 Deodorizing of the bed frame, mattress, and pillow.
Guidelines for Terminal Cleaning.
 Reviews ward SOP for specific procedures.
 Use only authorized disinfectant/detergent or germicidal solution for cleaning.
 Check to ensure the bedside cabinet is cleared of any valuables belonging to the patient.

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 Check bed linens for personal items (dentures, contact lenses, money, jewelry, etc.)
belonging to the patient.
 Prevent spread of microorganisms by carefully removing linen from the bed.
 Use caution when cleaning the under frame and bedsprings.
 Replace any torn mattress or pillow covers.
 Allow the mattress and pillow to air-dry thoroughly before remaking the bed.
1.7. Linen processing
Definitions: Processing linen-: consists of all the steps required to collect, transport and sort
soiled linen as well as to launder (wash, dry and fold or pack), store and distribute it.
Equipment needed
1. Heavy duty gloves
2. Mask
3. Protective eyewear
4. Plastic or rubber aprons
5. Closed shoes
6. Plastic bag (hamper)
Procedure
A. Collecting soiled linen
1. Wear gloves and other PPE as appropriate
2. Roll heavily contaminated linen into the center
3. Collect used linen in cloth or plastic bags or containers with lids.
4. If carts or containers are available for soiled and clean linen should be labeled
accordingly.
5. Count and record the linen before transporting to the laundry.

B. Transporting soiled linen to Laundry
6. Transport clean and soiled linen separately.
7. Use different carts or containers to transport clean and soiled linen, or wash and label
before transporting clean linen.

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8. Cover linen during transport.
9. Thoroughly clean container (plastic bag) that used to transport soiled linen.
C. Sorting Soiled Linen
10. Keep clean linen in clean, closed storage areas.
11. Separate folding and storage room from soiled areas.
12. Keep shelves clean.
13. Handle stored linen as little as possible.
14. Ensure adequate ventilation and physical barriers between the clean and soiled linen
areas.
15. Wash hands after removing the gloves.
D. Distributing
16. Protect clean linen until it is distributed.
17. Do not leave extra linen in patient rooms.
18. Handle clean linen as little as possible.
19. Avoid shaking.
 Clean soiled mattresses before putting on clean linen

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CHAPTER FOUR
MANAGING PATIENT SAFETY AND COMFORT
Safety and Comfort devices
o Safety: - It is to protect oneself from harm, e.g. mechanical injury.
 Safety is typically responsibility shared by everyone present in an environment, but this may not
be applicable in the health care environment because of different reasons such as
 Altered level of consciousness
 Loss of ability to move
 Loss of ability to think clearly
o Comfort:-Comfort is a feeling of physical and mental wellbeing freedom from worry, fears
or pain. In general comfort measures are aimed at reliving debilitating symptoms to conserve
energy for healing & fighting infection.
o Are the mechanical devices to promote comfort to the patient
o Are invented articles which would add to the comfort of the patient when used in the
appropriate manner, by reliving the discomfort and helping to maintain correct posture.
Causes of discomfort:-
1. Pain
2. Restriction of movements due to weakness
3. Wrinkled, soiled and wet sheet
4. Delayed or inadequate attention to meet the personal needs.
5. Lack of exercise
6. Temperature extremes
7. Too bright lights and glares
8. Fear and anxiety due to illness
9. Insecurity feeling
10. Lack of sleep
11. uncomfortable position
12. indigestion and irregular bowl movements

Purpose of patient safety and comfort:-

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 To relieve pain and worry
 To provide position of comfort and ease
 To place patient in comfortable bed.
 To provide proper atmosphere to increase the moral of patient during illness.
 To adjust bed and other apparatus in the proper manner
 To give maximum rest and sleep during illness
1.1. Applying cotton rings
Objectives: - At the end of this lesson, learner will be able to:-
 Define cotton rings
 List the Purpose of cotton rings application
 Describe the indications of cotton rings application
 Demonstrate application of cotton rings
Definition: - Cotton rings are small circle of cotton rolled with bandage or gauze with a
hole in the middle.
Purpose
 Used to lift the hip from bed to prevent bed sores or pressure sore or decubitus ulcer.
 To relieve pressure from small bony prominent areas such as sacral, heel, Elbow,
occipital.
 Improves the circulation.
Indication
 Bed ridden patients
 Unconscious patients.
Size: - Based on the body areas we are going to apply. The size differs from small to medium
size of bony prominent areas.
Equipments
1. Cotton

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2. Bandage
3. Chart showing human body prominent areas
Procedure
1. Explain the procedure to the patient
2. Wash hands
3. Assemble the necessary equipment
4. Prepare cotton ring based on the size of body to be applied.
5. Place cotton ring under the bony prominence such as elbow and heel
6. Wash hands
7. Document procedure
1.2. Applying foot – board
Definition: - A footboard is a flat plane often made of wood or plastic placed at the foot of
the bed.
Purpose
 To provide support for the client’s feet and maintain a natural foot position.
 To keep the top bed covers off the client’s felt relieving pressure.
 To make the foot comfortable/prevent foot drop.
 To prevent sagging of patient in to bed.
Indication
 Unconscious patients
 Patient with fracture
 Bedridden patients
Types of foot board:

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 Foot boards are often made in an L shaped – so that the base of L fits under foot of the
mattress.
 Some foot boards can moved along the mattress to adjust to the clients foot drop from
their normal right angle to the legs and assume plantar flections position.
Foot drop:-is a condition of plantar flexions or a muscular which occurs from poor foot or leg
alignment.
Cause –when patient in bed for long time when the top sheet and blanket are tightly tucked.
Equipments
1. A firm pillow
2. Box of board
3. Cotton/sheet of cotton
4. Bandage
Procedure
1. Explain the procedure to the patient
2. Wash hands
3. Prepare the equipment
4. Move the patient up in the bed to allow room for the footboard.
5. Loosen the top linens at the foot of the bed, and then fold them back over the patient to expose his
feet.
6. Lift the mattress at the foot of the bed, and place the lip of the footboard between the mattress and
the bedsprings. Alternatively, secure the footboard under both sides of the mattress.
7. Adjust the footboard so that the patient's feet rest comfortably against it. If the footboard isn't
adjustable, tuck a folded bath blanket between the board and the patient's feet.
8. Unless the footboard has side supports, place a sandbag, a folded bath blanket, or a pillow alongside
each foot to maintain 90-degree foot alignment.
9. Fold the top linens over the footboard, tuck them under the mattress, and miter the corners.
1. Wash hands
2. Document
1.3. Applying pillows

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Definition:-Pillows are used to give comfort, support and to position patient properly.
Pillows are placed:
 Under the head
 Under the back
 Between the knees
 At the foot of the bed
 Under the arm
Purpose:
 To elevate body part
 To support patient on side
 To prevent pressure on the skin
 To increase comfort
Necessary equipments
 Pillows
 Pillows case

1.4. Applying air rings
Definition: Air rings are used to relieve pressure from the buttock and other bony prominent
areas. For application they should be filled with air and covered with
pillow case
Purpose
 Used to lift the hip from bed to prevent bed sores or pressure sore or decubitus ulcer.
 To relieve pressure from small bony prominent areas such as heel, Elbow, occipital.
 Improves the circulation.
Indication
 Bed ridden patients
 Unconscious patients
Equipments:
1. Plastic air rings
2. Covering towel or pillow case
3. Chart showing body’s prominent areas
Procedure
1. Explain the procedure to the patient
2. Wash hands
3. Assemble the necessary equipment.

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4. Support the appropriate site
5. Applying air ring to body prominent area.
6. Observe patient comfort status
7. Wash hands.
8. Document
1.5. Applying bed cradle
Definition: Bed cradle is sometimes called an Anderson frame. It is a device designed to keep
the top bed clothes off the feet, leg, abdomen and chest of a client
Types: there are several types of bed cradles; the most commonly used is curved metal rod.
Purpose
 To keep bed top linen off the injured part of the body.
 To prevent the weight of the bedding from resting on some part of the body.
 To apply heat in case of drying plaster casts.
 In case of electronic bed cradles are used to supply the desired warm in the case of
shock.
Indication
 Client with fracture or soft tissue
injury.
 Client with burn.
 Client with some skin lesions.
Equipments:
1. Bed cradle
2. Roll gauze/bandage
3. Small size blanket
Procedure:
1. Explain the procedure to the patient
2. Wash hands
3. Assemble the necessary equipment.
4. Loosen and remove top linen.
5. However the cradle on to patients bed.

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6. Secure it in place.
7. Wrap gauze roll around both sides of the cradle.
8. Cover the cradle with top linen.
9. Wash hands.
10. Document
1.6. Adjusting side rails of the bed
Definition: Adjustable full or half said rails are used on hospital beds and stretchers to prevent
accidents
Types: they can be of various shapes and sizes usually made of metal
Position: side rails have two or three positions.
 These are high, intermediate and low.
 The down or low positions are employed when a side rail is not needed.
 The up or high side rail position is used when a client is in bed and requires protection.
Purpose
 Help weak patient turn independently
 Protects patient from falling out of bed
Indication:
 For unconscious patient.
 For weak and unable to control his/her body movement.
 For small children.
 For elderly patients
 Patient with seizure disorder
 Post operatively until the patient awake from anesthesia.
 When changing position.
 When making certain procedure.

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Equipment: bed with side rails
Procedure
1. Explain the procedure to the patient
2. Wash hands
3. Assemble the necessary equipment.
4. Position the side rail to the needed height
5. Secure lock and it should be far from reaching by the patient
6. Wash hands.
7. Document
1.7. Applying sand bag
Definition: Sand bags are canvas, rubber or plastic bags filled with sand and sewed.
Purpose
 To relive discomfort
 Sand bags are used for supporting or immobilizing limbs
 Used to support as in fractures bone
 They should be covered with towel and placed on either side of the limb
 To prevent foot drop or wrist drop
 To prevent contracture

Indication
 Fractured limb
 Amputated limb.
Equipments:
1. Bag
2. Rope
 Sand
 Covering towel

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 Weight scale
 Adhesive plaster for labeling
Procedure
1.Explain the procedure to the patient
2.Wash hands
. 3. Assemble the necessary equipment.
4. Positioning the patient
5. Apply the sand bags on the side of the area to be supported.
9. Wash hands.
10. Document and report
1.8. Applying splint
Definition: splints are devices applied to the arms, legs, or trunk to immobilize the injured part
of the body when it is needed.
Purpose
 To prevent movement of injured part of the body.
 To prevent further damage when transporting injured patient.
 To provide complete rest for injured part.
 To relieve pain and discomfort and encourage healing.
Types:-There are many varieties of splints available and they can also be made locally from
different material.
1. Wooden: straight pieces of woods of varying length and width.
2. Metal: Splints made of a tin end of aluminum which are molded to fit with natural
curvature of the body part.
3. Wire: It can be quickly cut to required length and easily bent to support a limb in
desired position.

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4. Plaster (P.O.P):-Often used by surgeon.
Nursing consideration
There are a number of important points to remember.
1. Choice:-The splint chosen should be sufficiently strong and of suitable length and width.
2. Padding:-The splint should be covered with cotton wool to prevent discomfort or damage.
3. Molding:-Choose one which is most suitable mold to fit the natural curvature of the limb.
4. Fixation:-Splints must be fixed to the insured fracture limbs by bandage placed above and
below the injured part. Do not apply bandage directly on the injured part.
Equipment
 Splints (wooden, metallic)
 Dressing material (if there is open wound)
 Glove
 Padding for splint (rolled bandage to cover the splint)
 Elastic bandage or roll bandage (to hold the splint in place)
Procedure
1.Explain the procedure to the patient
2.Wash hands
. 3. Assemble the necessary equipment.
4. Positioning the patient
5. First tie the bandage above the injured part
6. Joints must be immobilized above and below the location of injury.
7. Wash hands.
8. Document and report

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Follow up phase: - [ check compartment syndrome ]
Observation:-Look for the following condition.
 Presence of adequate circulation.
 Presence of adequate pulsation.
 Presence of any color change.
 Presence of numbness and tingling.
N.B:- Rings, bracelets and watch should be removed.
1.9. Appling fracture board
Purpose
 To maintain good body alignment.
 To prevent bed from sagging.
 To support the injured part when the patient has fractured spine, hips, lower limps.
Equipment
1. Fracture board
2. Thin foam mattress
Procedure
1. Explain the procedure to the patient
2. Wash hands
3. Assemble the necessary equipment.
4. Positioning the patient
5. First tie the bandage above the injured part
6. Joints must be immobilized above and below the location of injury.
7. Wash hands.
8. Document and report
1.10. Applying back rest
Back rest is used for elevating and supporting the head and back of the patient

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When back rest is used for the patient is liable to slip down to the foot of the bed,
therefore a foot board might be used.

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CHAPTER FIVE
BODY MECHANICS AND MOVING
4.1. Maintaining body alignment
Definition
 Body alignment (posture) refers to the relative position of body parts in relation to each other when
lying down, standing, sitting, or any other activity results in balance, which is an individual’s ability
to maintain equilibrium
Purpose
 To promote client comfort
 To prevent contractures
 To promote circulation
 To lessen stress on muscle, tendons, nerves, and joints
 To Prevent foot drop (plantar flexion)
 Gives an appearance of confidence and health
4.1.1. Checking proper/normal alignment of spine
Definition
1. Proper/normal alignment of the spine refers to cervical concavity, a thoracic convexity, and a
lumbar concavity in standing patients ( Figure.-----)
Purpose
2. To check the normal posture of spine

Equipment
1. Pen
2. Documentation/charting format
Procedure
1. Greet the patient and explain the purpose

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2. Instruct the patient to get stand
3. Observe the lateral view for cervical concavity, thoracic convexity and lumber concavity
4. Observe the posterior view (scapula, iliac crest and gluteal fold)
5. Document the findings

Figure. ----- Proper Spinal posture
4.1.2. Checking proper standing body alignment

Definition: Proper standing alignment cauterized by head upright, face forward, shoulders square, back
straight, abdominal muscles tucked in, arms straight at side, hands palm forward, legs straight and feet
forward with the center of gravity in the middle of the pelvis( about halfway between the umbilicus and
the symphysis pubis) (figure.-----)
Purpose
3. To check the normal posture in standing posture
Equipment
 Pen
 Documentation/charting format
Procedure

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1. Greet the patient and explain the purpose
2. Instruct the patient to get stand and face you
3. Let the patent put arms at the side and palm foreword
4. Feet flat on the ground and straight forward
5. Observe the patients shoulder, back, abdominal muscles, and arm. hands palm, legs and feet
6. Document the findings

Figure.----- Proper Alignment and Posture: Standing Male andFemale

4.1.3. Checking proper sitting posture

Definition
 Proper/normal alignment on sitting posture has similar characteristics with standing posture
except the hips and knees are flexed ( Figure.-----)
Purpose
 To check the normal posture on sitting posture

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Equipment
1. Pen
2. Documentation/charting format
3. Chair
Procedure
1. Greet the patient and explain the purpose
2. Instruct the patient to sit on chair facing you
3. Let the patent put arms on the respective thighs with palms facing downward
4. Feet flat on the ground , straight forward and thigh together
5. Observe the patients shoulder, back, abdominal muscles, and arm. hands palm, legs and feet
6. Document the findings

Figure.------- Proper sitting posture and center of gravity
4.1.4. Checking proper alignment of client in lying posture
Definition
Proper/normal alignment on sitting posture has similar characteristics with standing posture except
that the patient is in supine position ( Figure.-----)
Purpose
To check the normal posture on lying posture n

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Equipment
1. Pen
2. Documentation/charting format
3. Bed or examination couch
Procedure
1. Greet the patient and explain the purpose
2. Instruct the patient to lie flat on bed or examination couch
3. Let the patent put arms at the side with palms facing downward, neck straight, leg extended and
toes facing upward on the respective thighs
4. Observe the patients shoulder, back, abdominal muscles, and arm. hands palm, legs and feet
5. Document the findings


Figure. -----. Proper lying posture with center of gravity
4.1.5. Application of principles Body mechanics
Definition
 Body mechanics is the coordinated use of the body parts to produce motion and to maintain balance
Propose
 Promotes the efficient use of muscles and conserves energy
Principles/steps in moving or lifting objects
1. Face the direction of movement

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2. Use large muscle groups of the legs, arms, and shoulders to lessen the strain on the back and
abdominal muscles.
3. Bring the object to be lifted or carried as close to the body as possible before lifting. (This keeps both
centers of gravity close together.)
4. Bend the knees and keep the back straight when leaning over at work level.
5. Kneel on one knee, or squat, and keep the back straight when working at the floor level.
6. Push, pull, slide, or roll a heavy object on a surface to avoid unnecessary lifting.
7. Obtain help before attempting to move an obviously unmanageable weight.
8. Use of supportive devices (wheel chair )
9. Work in unison with an assistant. Give instructions and agree on the signal to start the activity
4.2. Lifting the patient
4.2.1. Dangling
Definition: Dangling is sitting on the side of the bed with the feet hanging down
Purpose
 To prepare patient before walking ,moving to chair or wheelchair or performing others
 To relive pressure in case of pulmonary edema
Indication
 Moving patient out of bed
Contraindication
 Uncurious patient
 Spinal injury
Precaution
 Do not leave the patient alone when dangling.
 If the patient becomes dizzy lie him down.
 Have the patient cough, deep breathe, and exercise their leg muscles when dangling
 Check the person’s pulse and respirations
Equipment

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 Turn sheet or draw sheet
 Screen
Procedure
1. Greet the patient and explain the procedure
2. Perform hand hygiene
3. Collect the necessary material
4. Provide privacy
5. Assess the patient condition
6. Position yourself and client appropriately before performing the move
a. Assist the client to a lateral position facing you
b. Raise the head of the bed slowly to its highest position
c. Position the clients feet and lower legs at the edge of the bed
d. Stand beside the client’s hips and face the far corner of the bottom of the bed
7. Move client to sitting position
a. Place one arm around the client shoulder and the other arm beneath both of the client
thighs near the knee
b. Tighten your gluteal , abdominal, leg and arm muscle
c. Lift the client thighs slowly
d. Private on your feet in the desired direction facing the foot of the bed while pulling the
client feet and legs off the bed
e. Keep supporting the client until client is well balanced and comforted
f. Assess vital signs as indicated
8. Document all relevant information
4.2.2. Log rolling

Definition: Logrolling is a technique used to turn a patient whose body must at all times be kept in a
straight alignment.

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Purpose
 To turn a patient to the side of bed
Indication
 Spinal injury
Note: logrolling is accomplished by two or three nurses working in a coordinated fashion( Figure …)

Figure … Log rolling

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Equipment
1. Hospital bed with side rails
2. Turn sheet or draw sheet
3. Pillows
Procedure
1. Wash your hands
2. Greet and explain the procedure
3. Provide privacy
4. Position the bed in the flat position at a comfortable working height
5. Lower the side rail on the side of the body at which you are working
6. Position yourself with your feet apart and your knees flexed close to the side of the bed
7. Fold the patient's arms across his chest
8. Place your arms or turn sheet under the patient so that a major portion of the patient's weight
is centered between your arms.
9. The arm of the other nurse should support the patient's head and neck.
10. On the count of three, move the patient to the side of the bed, rocking backward on your
heels and keeping the patient's body in correct alignment.
11. Move to the other side of the bed.
12. Place a pillow under the patient's head and another between his legs.
13. Position the patient's near arm toward you.
14. Grasp the far side of the patient's body with your hands evenly distributed from the shoulder
to the thigh.
15. On the count of three, roll the patient to a lateral position, rocking backward onto your heels.
16. Place pillows in front of and behind the patient's trunk to support his alignment in the lateral
position. Provide for the patient's comfort and safety.
17. Report and record as appropriate

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5.2.3. Moving patient up in bed with two nurses using draw sheet
Definition
 Moving patients up in bed refers to returning the patient to previous correct position in
bed if he/she slides to the foot side of the bed.
Purpose
 To make patients in comfortable position in bed
 To maintain good body alignment
Indication
 Patient slides to the foot of the bed
Equipment
 Documentation format
 Draw sheet
 Pillow
Procedure Steps
1. Explain the procedure
2. Perform hand washing
3. Collect necessary equipment
4. Lower head of the bed to flat position and raise level of bed to comfortable height
5. Remove all pillows from under the client. Leave one at head of bed
6. One nurse stands on each side of the bed with leg positioned for wide base of support and
one foot slightly in front of bed frame
7. Each nurse rolls up and grasps edges of turn sheet close to client’s shoulder buttocks
8. Flex knees and hips tighten abdominal and gluteal muscle.
9. Raise the patient up in bed
10. Observe the condition of the patient
11. Record the procedure

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5.3. Positioning the patient
Definition
 Positioning is turning or putting the patients in a proper body alignment for the purpose of preventive,
promotive ,curative and rehabilitative aspects of health
Purpose of positioning
 To relief pressure on various parts or lessen possible stress on pressure points
 To prevent formation of deformity
 To Improve circulation
 Preserve muscle function as different muscle group’s contract and relax.
 To provide comfort, support, and good body alignment
 To make the patient ready for different procedures
Type of positioning
Common positioning methods of patient in a bed include but not limited to
1. Front lying (prone):
2. semi-prone position(or Sims’ position)
3. Dorsal Supine (back lying):
4. Dorsal recumbent position
5. Lateral recumbent (on either side)
6. Fowler’s position position
7. Fowler's position (semi-upright with back and knee rests elevated)
8. Trendelenburg position
9. Lithotomy position

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5.3.1. Front lying (prone)
Definition
 Prone position is putting the patient in a flat on the abdomen, legs extended, feet over the edge of
the mattress, and toes pointing to the floor(figure.---).
Purpose
 To Promotes drainage from mouth
 To prevent contractures of hips and knee
 To examine the spine and the back
Indication
 Patient with excessive secretion from mouth
 Patient with potential risk of knee and hip contracture
Contraindication
 Cervical –spine fracture
 Respiratory impairment/breathing difficulties
 Foot drop
 Pregnant women
 Clients with abdominal incisions
Equipment
1. Small pillow (3)
2. Bed with side rails
3. Draw sheet or turn sheet
4. Documentation format
5. Receiver for drainage( if any)
Procedure
1. Great the patient ( if conscious ) and explain the procedure
2. Perform hand washing
3. Collect all necessary equipments
4. Provide privacy
5. Elevate bed to highest position.

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6. Place turn or draw sheet under client’s back and head
7. Assist the client to lie on abdomen.
8. Place a small pillow under client’s head; turn head to side.
9. Extend the client’s arms near side or flexed toward head.
10. Place a small pillow under chest for female clients and for clients with barrel chest.
11. Place a small pillow under ankles or allow toes to rest in space between foot of bed and the
mattress.
12. Assess client for comfort.
13. Lower the bed and elevate the side rails
14. Wash your hand
15. Note the patient reaction
16. Document the procedure


Figure. ----- Proper prone position
5.3.2. Semi-prone position (or Sims’ position)
Definition
 Semi-prone position putting or assisting patients with upper arm flexed at shoulder and
elbow; lower arm positioned behind client and both legs flexed in front of client with more
flexion in upper leg either of body side (Figure.--) .
Purpose
 To promotes drainage from mouth
 To prevents aspiration

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 Comfortable for sleeping.
 sacrum and greater trochanter of hip
 Promotes comfort especially in pregnant clients
Indication
 For rectal examination
 Pressure sore on the buttocks/sacrum and hips
Contraindication
o lumbar lordosis
o Foot drop
o client with leg injuries or arthritis

Equipment
1. Small pillow (3)
2. Bed with side rails
3. Draw sheet or turn sheet
4. Sand bag
5. Documentation format
6. Receiver for drainage( if any)
Procedure
1. Great the patient ( if conscious ) and explain the procedure
2. Perform hand washing
3. Collect all necessary equipments
4. Provide privacy
5. Elevate bed to highest position.
6. Place turn or draw sheet under client’s back and head
7. Flexed at shoulder and elbow
8. Position lower arm behind and away from the back
9. Put pillow between chest and upper arm;
10. Flex both legs in front with more flexion in upper leg.
11. Put pillow between legs

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12. Support ankle with sand bag (if necessary )
13. Lower the bed and elevate the side rails
14. Wash your hand
15. Note the patient reaction
16. Document the procedure

Figure.--- Proper Semi prone position
1.3.3. Supine (back lying)
Definition: Supine position is putting patient in back lying often with a small pillow to support the head
and shoulder (Figure---).
Purpose
 Promote comfort
 To help healing after certain abdominal operations
Indication
 After abdominal, chest and neck surgery
 For physical examination of anterior part of the body
 Usual position for the patient
Contraindication
 Spinal injury
 Cardiac patient (CHF)
 Breathing impairments
 Pressure sore (buttock, scrum, heal and shoulder )

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Equipments
1. Pillow of different size (3)
2. Bed with side rails
3. Draw sheet or turn sheet
4. Wrist splint
5. Air rings
6. Cotton rings
7. Footboard or high-top tennis shoes
8. Documentation format
Procedure
1. Great the patient (if conscious) and explain the procedure
2. Perform hand washing
3. Collect all necessary equipments
4. Provide privacy
5. Elevate bed to highest position.
6. Place turn or draw sheet under client’s back and head
7. Place bed in a flat position.
8. Place the patient’s head in a straight line with his or her back, shoulders, hips and knees
9. Place small pillows under head, back and ankles.
10. Place air ring under the hips/buttock
11. Flex the arm and rest on the stomach or straighten and support with wrist splint
12. Support the feet with padded footboard or high-top tennis shoes
13. Place the cotton ring under the heal
14. Lower the bed and elevate the side rails
15. Wash your hand
16. Note the patient reaction
17. Document the procedure

1.3.4. Dorsal recumbent position
Definition: Dorsal recumbent position is putting patient in back lying position with knees are flexed and
the soles of the feet flat on the bed (figure….).

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Purpose
 Promote comfort
 For visualize the perineum
 To insert urinary catheter
 To relief pressure from ileum, knee and ankle
Indication
 Rectal, vulval and vaginal examination
 Pelvic surgical procedures
 Vaginal douche
 Perineal care
 Catheterization
 Supra-pubic puncture
Contraindication
 Spinal injury
 Cardiac patient (CHF)
 Breathing impairments
 Pressure sore (buttock, scrum, heal and shoulder)
Equipments
1. Pillow of different size (3)
2. Bed with side rails
3. Draw sheet or turn sheet
4. Bath Blanket or sheet
5. Air rings
6. Cotton ring
7. Bed block (if necessary)
8. Documentation format
Procedure
1. Great the patient (if conscious) and explain the procedure
2. Perform hand washing
3. Collect all necessary equipments
4. Provide privacy

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5. Elevate bed to highest position.
6. Place turn or draw sheet under client’s back and head
7. Place bed in a flat position.
8. Cover the client with a sheet or a bath blanket folded once across the chest.
9. Place the patient’s head in a straight line with his or her back, shoulders, hips and knees
10. Place small pillows under head and shoulder or elevate the top of the bed with block.
11. Place air ring under the hips/buttock
12. Flex the leg and wide apart
13. Place cotton ring under the heels
14. Lower the bed and elevate the side rails
15. Wash your hand
16. Note the patient reaction
17. Document the procedure

1.3.5. Lateral recumbent (on either side)
Definition: Lateral recumbent position is putting patient on either of the side with the legs flexed
at knee (The upper leg is more flexed than the lower leg) (Figure….).
Purpose
 To perform back care
 To relieves pressure on sacrum and heels
 To perform enema
 To take rectal body temperature
 To insert suppositories
Indication
 Enema and colonic irrigation
 Pressure sore on heel and sacrum
 Rectal examination

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 To measure rectal temperature
Contraindication
 Arm and rib fracture
 Spinal injury
 Flank injury
Equipments
1. Pillow of different size (4)
2. Bed with side rails
3. Draw sheet or turn sheet
4. Documentation format
Procedure
1. Great the patient (if conscious) and explain the procedure
2. Perform hand washing
3. Collect all necessary equipments
4. Provide privacy
5. Place turn or draw sheet under client’s back and head
6. Elevate bed to highest position
7. Logroll client to side
a. For left lateral position, place the patient on left side with buttocks to the edge of the
bed both thighs flexed and left arm underneath
b. For right lateral position, Place the patient on right side with buttocks to the edge of
the bed both thighs flexed and right arm underneath
8. Place a small pillow under client’s head.
9. Place pillow or foam wedges behind client’s back.
10. Put a pillow tucked by the client’s abdomen.
11. Place a pillow between client’s legs.
12. Run your hand under the client’s dependent shoulder and move the shoulder slightly forward
13. Lower the bed and elevate the side rails
14. Wash your hand
15. Note the patient reaction

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16. Document the procedure

Figure….. Proper Lateral Recumbent position
1.3.6. Knee chest
Definition: Knee chest position is putting a patient on the Knee and the chest with the head turned one
side, arms above the head and one cheek on a pillow(Figure…)
Purpose
1. Used for vaginal and rectal examination
2. Used in first aid treatment in cord Prolapse or retroverted uterus
3. Assumed for postpartum and gynecologic exercises
Indication
1. Sigmoidoscopic examination
2. Vaginal and rectal examination
3. Cord Prolapse
4. Retroverted uterus
Contraindication
 Cardio-pulmonary problem
 Upper arm, spine and ribs fracture
 Increased intra-cranial pressure (IICP)
Equipments

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1. Pillow (1)
2. Drape/ Bath Blanket or sheet
3. Screen
4. Documentation format

Procedure
1. Great the patient ( if conscious ) and explain the procedure
2. Perform hand washing
3. Collect all necessary equipments
4. Provide privacy
5. Elevate bed to highest position.
6. Make the patient on the knees and chest
7. Turn the head to one side with the cheek on pillow
8. Extend the arms on the beds and flex it at the elbows to support the patient partially
9. The weight should rest on the chest and knees which are flexed so that the thighs are at right
angles to the legs
10. Cover the client with a sheet or a bath blanket.
11. Lower the bed and elevate the side rails
12. Wash your hand
13. Note the patient reaction


Figure …..Proper knee chest position

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1.3.7. Fowler's position (semi-upright with back and knee rests elevated)
Definition: Fowler's position is sitting position in which the head is elevated at different angle
(15-90)
o
angle and may have knees either bent or straight ( Figure….).
 Type
1. High Fowler's position is when the patient's head is raised 80-90 degrees,
2. Semi-Fowler's position is when the patient's head is elevated 30-45 degrees.
3. Low Fowler's position is when the head of bed is elevated 15-30 degrees
4. Fowler's which is 45-60 degrees
Purpose
1. To relive dyspnea
2. To improve circulation
3. To prevent thrombosis
4. 00To prevent aspiration during the introduction of feeding tubes
5. To facilitate drainage from abdomen and pelvic cavity post operatively
6. To relax the muscle of the abdomen, back and thighs
7. To relive tension on abdominal suture
8. To promote comfort
9. Increase comfort during eating
10. To relieve edema of the chest and abdomen
Indication
 Cardio-pulmonary problem (Respiratory distress, CHF, pulmonary edema..)
 Increased intra-abdominal pressure
 Thrombosis
 Abdominal, back and thigh muscle strain
 Nasal or oral passageway procedures (e.g. NGT…)

Contraindication

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1. Comatose/unconscious patients
2. Spinal injury
3. Foot drop
4. Head injury
5. Shoulder dislocation
Equipment
1. Small pillow (3)
2. Foot rest/foot board
3. Back support
4. Hand wrist support
5. Screen if necessary
Procedure
1. Great the patient ( if conscious ) and explain the procedure
2. Perform hand washing
3. Collect all necessary equipments
4. Provide privacy
5. Place the patient in sitting position with arms at sides knees raised with pillow
6. Place bed in a 15° to 30° angle for low-Fowler’s position, 45° to 60° angle for Fowler’s
position, or 70° to 90° angle for high-Fowler’s position.
7. Turn patients head to one side and align the patient in good position
8. Place a small pillow under client’s head.
9. Support the backs and arms with pillows.
10. Place a pillow between client’s legs.
11. Lower the bed and elevate the side rails
12. Wash your hand
13. Note the patient reaction
14. Document the procedure

1.3.8. Trendelenburg position

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Definition: Trendelenburg is putting the patient in a flat on the back with the feet higher than the head
by 15-30 degree (Figure….) .
Purpose
 To increase cerebral perfusion pressure
 To allow better access to pelvic organ during pelvic surgery
 To help in surgical reduction of hernia
 To enhance access to central venous line
Indication
 Hypotension/shock
 Abdominal and gynecologic surgery
 Placing central venous line
 Surgical reduction of hernia
Contraindication
 Cervical –spine fracture
 Respiratory impairment/breathing difficulties
 Brain injury with increased intracranial pressure
Contraindication
 Spinal injury
 Cardiac patient (CHF)
 Breathing impairments
 Pressure sore (buttock, scrum, heal and shoulder)
Equipments
1. Bed block (if necessary
2. Drape
3. Screen
4. Documentation format
Procedure

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1. Great the patient (if conscious) and explain the procedure
2. Perform hand washing
3. Collect all necessary equipments
4. Provide privacy
5. Place the patient’s head lower than the feet with arms at the side
6. Place bed blocks at the foot end of the bed.
7. Lower the bed and elevate the side rails
8. Wash your hand
9. Note the patient reaction
10. Document the procedure


1.3.9. Lithotomy position
Definition: Lithotomy position is positioning the client feet above or the same level as hips with
perineum positioned at the edge of examination table (Figure….).
Purpose
 To provide good visual and physical access to perineum
 To perform simple pelvic procedures to major surgeries
 To conduct delivery
Indication
 Pelvic medical examination and surgeries
 Delivery
Contraindication
 Spinal injury
 Breathing impairments
Equipments

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1. Pillow (1)
2. Bed with side rails/examination
table/delivery couch
3. Draw sheet /drape
4. Screen
5. Documentation format
Procedure
1. Great the patient and explain the procedure
2. Perform hand washing
3. Collect all necessary equipments
4. Provide privacy
5. Elevate bed to highest position.
6. Place bed in a flat position.
7. Cover the client with a sheet or a bath blanket
8. Lie the patient flat with pillow under the head
9. Flex the feet above or the same level as hips and support with knee rest over a couch ( if
available)
10. Wash your hand
11. Note the patient reaction
12. Document the procedure

1.4.Patient ambulation
Definition: Client ambulation is assisted or unassisted walking which encouraged soon after the onset of
illness or surgery to prevent the complications of immobility
Purpose
 To Keeps client more active
 To prevent the complications of immobility
 To improves muscle tone and strength in his legs
 To slow down loss of bone mass and density related to osteoporosis

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 To improves appetite, peristalsis and circulation
 To give a sense of accomplishment and maintains greater independence for clients(
psychological wellbeing)
Indication
 Immobile patients unless contraindicated
 Postoperative patient
Contraindication
 Unstable vital sign
 Spinal fracture
 Patient with traction
Equipment
 Assistive devices (Gait belt, Cane, Walker and Crutch

1.4.1. Preparing the Client to Walk/ambulate
Precaution for ambulation
 Determine the client’s activity level and tolerance for physical exertion (strength, endurance,
general status and mobility status)
 Assess for factors that may negatively affect ambulation (e.g., mental status, fatigue, pain,
medications).
 Evaluate the environment for safety (e.g., presence of obstacles in walkway, adequate lighting,
nonslip floor, handrails).
 Check assistive devices for safety hazards
 Check client’s clothing (e.g., nonslip shoes, adequate covering for privacy and warmth).
Procedure
1. Inform client about the purposes and distance of the walking exercise
2. Elevate the head of the bed and wait several minutes to prevents orthostatic hypotension

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3. Lower the bed height
4. With one arm under the client’s back and one arm under the client’s upper legs, move the client
into the dangling position
5. Encourage client to dangle at side of bed for several minutes
6. Stand in front of client with your knees touching client’s knees
7. Place arms under client’s axilla
8. Assist client to a standing position, allowing client time to balance
9. Help client ambulate desired distance or distance of tolerance by placing your hand under the
client’s forearm and ambulating close to the client
1.4.2. Assisting patient with assistive devices
Definition: Assistive device is a material used to support client/patient who unable to walk
independently
Common types
1. Gait belt
2. Cane
3. Walker
4. Crutch
1.4.2.1.Gait belt
Definition: Gate belt is an assistive used during simple assisted ambulation (Figure…..)

Purpose
 To aid patient/client in ambulation
Indication
 One body part weakness
Equipment
 Gait belt
Procedure

1. Explain what you are going to do.
2. Wash your hands

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3. Assist the client to sit on the edge of the bed.
4. Pause and allow the client to sit on the edge of the bed for a few moments to regain balance.
5. Assist the client in putting on socks and nonskid shoes.
6. Put a gait belt around the client's waist.
7. Stand in position of good body mechanics.
8. Assist the client to a standing position by straightening your legs as you lift with the gait belt and the
client pushes down with his hands on the mattress.
9. Pause to allow the client to regain balance.
10. Walk with the client by placing one hand on the gait belt in front of his waist and your other hand in
back under the gait belt.
11. Walk in the same pattern as the client (both step with left foot at the same time).
12. Assist the client to step forward with strong foot first.
13. Walk the client the distance instructed by supervisor or as indicated by the service plan
14. Return the client to the bed/chair.
15. Make sure the client is comfortable.
16. Remove the gait belt.
17. Wash your hands.
18. Record observations.

Figure …..Gait belt
1.4.2.2.Cane
Definition: A cane is assistive devices that can be used by clients who can bear weight on both legs but
have some weakness in one leg or hip
Type

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1. Standard Cane
2. T-handle Cane
3. Tripod Cane
4. Quad (Quadruped) Cane
Indication
 Some weakness in one leg or hip
Purpose
 To support the patient during walking
Equipment
 Appropriate type of cane
 Gait belt
 Documentation format
Procedure
1. Explain what you are going to do.
2. Wash your hands
3. Lower the bed to lowest level; assist client to sit on edge of bed.
4. Pause and allow the client to sit on the edge of the bed a few moments to regain his balance.
5. Assist the client in putting on socks and nonskid shoes.
6. Apply a gait belt.
7. Stand in a position of good body mechanics.
8. Assist the client to a standing position by straightening your legs as you lift with the gait belt and the
client pushes down with his hands on the mattress.
9. Instruct the client to move the cane forward and a little to the outside of his strong leg (Client should use
the cane on his stronger side).
10. Instruct the client to take short steps and keep his head up and eyes looking forward.
11. Instruct the client to move his weak foot forward to line up evenly with the tip of the cane.
12. Instruct the client to put weight on the cane and weak foot while swinging his strong foot forward.

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13. Walk in the same pattern as the client (both step with left foot at the same time).
14. Walk the client the distance instructed by supervisor/nurse as indicated in the service plan.
15. Return the client to bed/chair.
16. Make sure the client is comfortable.
17. Wash your hands.
18. Record observations.


Figure ….. Canes
1.4.2.3.Walker
Definition: A walker is a waist-high metal tubular device with a handgrip and four legs characterized by
the presence of rubber tips on all four legs or have wheels on the two front legs
Purpose
 To provide extra support, sense of security, and independence
Indication

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 Weakness in lower Limbs
 Disability
 Postoperative (as needed)
Equipment
1. Walker
2. Gait belt
3. Documentation format
Procedures
1. Wash your hands.
2. Explain what you are going to do.
3. If using a hospital bed, lower the bed to lowest level.
4. Assist the client to sit on the edge of the bed.
5. Pause and allow the client to sit on the edge of the bed a few moments to regain balance.
6. Assist the client in putting on socks and nonskid shoes.
7. Apply a gait belt.
8. Stand in a position of good body mechanics.
9. Assist the client to a standing position by straightening your legs as you lift with the gait belt and
the client pushes down with his hands on the mattress.
10. Instruct the client to position his body within the frame of the walker.
11. Instruct the client to move the walker forward by lifting it up, moving it forward, and setting it
down.
12. Instruct the client to take a step forward with the weak leg.
13. Instruct the client to move strong leg forward.
14. Instruct the client to take short steps and keep his head up and eyes looking forward.
15. Walk the client the distance instructed by supervisor/nurse as indicated in the service plan.
16. Return the client to bed or a chair. To ambulate backward, the client steps back with his strong foot,
takes a step back with his weak foot, then walker is moved back. Have the client feel for the arm of
chair or top of mattress with his hand.

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17. Assist the client into the chair or bed; make sure the client is comfortable.
18. Wash your hands
19. Record observations.



Figure …..walker
1.4.2.4.Crutch
Definitions
 Crutch is walking aids made of wood or metal in the form of a shaft which reaches from the ground
to the client’s axilla.
 Crutch walking; is one of the patient ambulation techniques which helps the client to stand and
walk with the help of Crutch
Purpose
 Reduces anxiety and promotes client’s autonomy
 To improve muscle strength
Types of Crutch
Axillary:
 Fits under the axilla with the weight being placed on the handgrips

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Figure …. Axillary crutch
Forearm:
 It has a handgrip and a metal cuff that fits around the arm
 More convenient but provides less stability than the axillary crutch

Figure ….Forearm crutch
Types of Crutch walking gaits
1. Two-point gait
2. Three-point gait

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3. Four-point gait
4. Swing to gait
5. Swing through gait
6. Up and down stair gait
5.4.2.1. Two-point gait
Definition: Two-point gait is an assisted gait used for partial weight bearing on each leg which
provides a strong base of support
Purpose
 To reduces anxiety and promotes client’s autonomy
 To improve muscle strength
 To Helps clients able to cope with disabilities
 To Support patient during walking
Indication
 Weakness of both leg with partial ability to bear weight
Contraindication
 Patients unable to bear weight fully on each leg

Equipment
 Properly fitted crutches
 Regular, hard soled street shoes
 Gait /Safety belt, if needed
Procedure
1. Great and explain the procedure.
2. Assess client for strength, mobility, range of motion, visual acuity, perceptual difficulties, and
balance

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3. Adjust crutches to fit the client.
4. Lower the height of the bed.
5. Dangle the client at the side of bed for several minutes.
6. Apply the gait belt around the client’s waist if balance and stability are impaired.
7. Assist the client to a standing position with crutches. Support as needed.
8. Instruct client on method to hold and walk with the crutches
o Move the left crutch and right leg forward 4 to 6 in then Move the right crutch and left
leg forward 4 to 6 in.
9. Help the client practice the gait by repeating step 8 until the client independently practice it
10. Assess the client’s progress, and correct any mistakes as they occur.
11. Observe the patient condition
12. Record the procedure
5.4.2.2.Three-point gait
Definition: Assisted gait with weak/non weight bearing one leg supported with two Crutches
Purpose
 Reduces anxiety and promotes client’s autonomy
 To assist weak or non-weight bearing one leg
 Helps clients able to cope with disabilities
Indication
 Those patients having weakness in one leg or amputated one leg
Contraindication
 Patients having weakness in both legs
Equipment
1. Properly fitted crutches
2. Regular, hard soled street shoes
3. Safety belt, if needed
4. Documentation chart/format

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Procedure
1. Great and explain the procedure.
2. Assess client for strength, mobility, range of motion, visual acuity, perceptual difficulties, and
balance
3. Adjust crutches to fit the client.
4. Lower the height of the bed.
5. Dangle the client at the side of bed for several minutes.
6. Apply the gait belt around the client’s waist if balance and stability are impaired.
7. Assist the client to a standing position with crutches. Support as needed.
8. Instruct client on method to hold the crutches to hold and walk with the crutches
o Advance both crutches and the weaker leg forward together 4 to 6 in then move the
stronger leg forward, even with the crutches.
9. Help the client practice the gait by repeating step 8 until the client independently practice it
10. Assess the client’s progress, and correct any mistakes as they occur.
11. Observe the patient condition
12. Record the procedure
5.4.2.3. Four-point gait
Definition: Very stable but slow gait for weight bearing with both legs follows the pattern of
right crutch forward, left foot forward, left crutch forward, then right foot forward
Purpose
 Reduces anxiety and promotes client’s autonomy
 To improve muscle strength
 Helps clients able to cope with disabilities
Indication
 Weight bearing difficulties on both legs

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Contraindication
 Patients unable to bear weight on both leg
 Bearing weight on axilla
Equipment needed
1. Properly fitted crutches
2. Regular, hard soled street shoes
3. Safety belt, if needed
Procedure
1. Great and explain the procedure.
2. Assess client for strength, mobility, range of motion, visual acuity, perceptual difficulties, and
balance
3. Adjust crutches to fit the client.
4. Lower the height of the bed.
5. Dangle the client at the side of bed for several minutes.
6. Apply the gait belt around the client’s waist if balance and stability are impaired.
7. Assist the client to a standing position with crutches. Support as needed.
8. Instruct client on method to hold the crutches to hold and walk with the crutches
 Position the crutches 4.5 to 6 in. to the side and in front of each foot then move the right crutch
forward 4 to 6 in. and move the left foot forward, even with the left crutch.
 Move the left crutch forward 4 to 6 in. and move the right foot forward, even with the right
crutch.
9. Help the client practice the gait by repeating step 8 until the client independently practice it
10. Assess the client’s progress, and correct any mistakes as they occur.
11. Observe the patient condition
12. Record the procedure

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5.4.2.4. Swing to gait
Definition: Crutch walking gait in which both crutches move together then Lift body weight
by the arms and swing to the crutches (at the level)
Purpose
 To relax and strengthen muscle
 To promote the client/autonomy
 To support the disability
Indication
 Weakness of both legs
Contraindication
 Improper body balance
Equipment
1. Properly fitted crutch
2. Regular, hard soled street shoes
3. Safety belt, if needed
Procedure
1. Great and explain the procedure.
2. Assess client for strength, mobility, range of motion, visual acuity, perceptual difficulties, and
balance
3. Adjust crutches to fit the client.
4. Lower the height of the bed.
5. Dangle the client at the side of bed for several minutes.
6. Apply the gait belt around the client’s waist if balance and stability are impaired.
7. Assist the client to a standing position with crutches. Support as needed.
8. Instruct client on method to hold the crutches to hold and walk with the crutches

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 Move BOTH crutches together then Lift body weight by the arms and swing to the
crutches (at the level)
9. Help the client practice the gait by repeating step 8 until the client independently practice it
10. Assess the client’s progress, and correct any mistakes as they occur.
11. Observe the patient condition
12. Record the procedure
5.4.2.5.Swing through gait
Definition: Crutch walking gait in which the pattern of crutches forward, then legs swing
forward together through the crutch
Purpose
 To relax and strengthen muscle
 To promote the client/autonomy
 To support the disability
 To Speed up the walking
Indication
 Weakness of both legs
Contraindication
 Improper body balance
Equipment
1. Properly fitted crutch
2. Regular, hard soled street shoes
3. Safety belt, if needed
Procedure
1. Great and explain the procedure.
2. Assess client for strength, mobility, range of motion, visual acuity, perceptual difficulties, and
balance
3. Adjust crutches to fit the client.

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4. Lower the height of the bed.
5. Dangle the client at the side of bed for several minutes.
6. Apply the gait belt around the client’s waist if balance and stability are impaired.
7. Assist the client to a standing position with crutches. Support as needed.
8. Instruct client on method to hold the crutches to hold and walk with the crutches
o Move BOTH crutches together then Lift body weight by the arms and swing to the
crutches (beyond the level)
9. Help the client practice the gait by repeating step 8 until the client independently practice it
10. Assess the client’s progress, and correct any mistakes as they occur.
11. Observe the patient condition
12. Record the procedure
5.4.2.6.Up and down stair gait
Definition: Crutch walking gait helps to climb up and move down stair.
Purpose
 To promote clients level of activity in moving up and down stair
 Relax and strengthen muscle
 To promote the client/autonomy
 To support the disability
Indication
 Musculo-skeletal injury
Contraindication
 Improper body balance
Equipment
1. Properly fitted crutch
2. Regular, hard soled street shoes
3. Safety belt, if needed

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Procedure
1. Great and explain the procedure.
2. Assess client for strength, mobility, range of motion, visual acuity, perceptual difficulties, and
balance
3. Adjust crutches to fit the client.
4. Lower the height of the bed.
5. Dangle the client at the side of bed for several minutes.
6. Apply the gait belt around the client’s waist if balance and stability are impaired.
7. Assist the client to a standing position with crutches. Support as needed.
8. Instruct client on method to hold the crutches to hold and walk with the crutches
Up stair
a) Place unaffected leg on the stair
b) Client transfer body weight to unaffected leg
c) Client moves crutches and affected leg to stair
Down stair
a) Start with weight on uninjured leg and crutches on the same level.
b) Put crutches on the first step
c) Put weight on the crutch handles and transfers unaffected extremity to the step where
crutches are placed
9. Help the client practice the gait by repeating step 8 until the client independently practice it
10. Assess the client’s progress, and correct any mistakes as they occur.
11. Observe the patient condition
12. Record the procedure

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5.5. Patient transfers
1.5.1. Transferring a Client from Bed to Chair
Definition: This is a procedure done to help clients in transferring from bed to chair
Purpose
 Helps client stands safety and gives time to assess status
 Moves client in to proper position to be seated
 Reduces risk of falling by maintaining clients stability during transfer
 Maintains clients stability and reduces pressure on axillae and strain on back
Indication
Clients unable to help themselves in transferring from bed to chair
Contraindication
 Unconscious patients
Equipment
1. Bed pan (if necessary)
2. Chair /wheel chair
3. Slipper
Procedures
1. Greet the patient and explain the procedure.
2. Offer bed ban (Empty bladder will increase patient comfort)
3. Assess client’s ability to assist with the transfer and for presence of cognitive or sensory
deficits.
4. Take pulse and respiration
5. Lower the bed comfortable position.
6. Bring wheelchair close to the side of the bed, toward the foot of the bed.
7. .Lock wheelchairs brakes and elevate the foot pedals.
8. Give the client slipper.

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9. Assist client to side of bed until feet touch the floor.
10. Assess client for dizziness. Remain in front of client until dizziness has subsided.
11. Assist the client to a standing position and provide support.
12. Stand facing the patient; place your hands under patient’s axilla. (Have clients reach arm
across shoulder) of the wheelchair.
13. Raise the patient, bend at the knees, and gently put in sitting position.
14. Assist client to maintain proper posture.
15. Take pulse and respiration.
16. Watch for signs of tiredness
17. Record the procedure.
1.5.2. Transferring a Client from Bed to Stretcher
1.5.2.1. Three carrier lift
Definition: A three carrier lift is alternative method of transferring helpless patients from bed to
stretcher with three nurses or a nurse and two informed assistants.
Purposes
 To reduces client’s anxiety and increases cooperation
 Decrease risk of client’s falling
Indication
 For patients unable to move from bed to areas where procedures performed
Equipment
 Stretcher
 Pillow
 Clean glove
Procedure
1. Greet the patent and explain the procedure to the patient
2. Wash your hand.

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3. Make sure that assistants are available
4. Adjust the head of bed to the flat position.
5. Put stretcher parallel to patients head.
6. Each person must support one section of the patients’ body-head, shoulders, and chest,
hips and thighs and legs.
7. Slide your arms under the patient as far as possible and on signal, simultaneously roll the
patient towards your chest.
8. Walking together, move patient from bed to stretcher
9. Observe the patient condition
10. Document the procedure.
1.5.2.2. Draw sheet method of transferring patient from bed to stretcher
Definition: This is method of transferring patient from bed to stretcher using the sheet already
under the patient as draw sheet.
Purpose, indication and contraindications
 similar with three carrier lift method
Equipment
1. Stretcher
2. Pillow
3. Lift sheet
4. Glove
5. Documentation format
Procedure
1. Greet the patient and explain the procedure
2. Wash your hand and dry it
3. Done glove if necessary
4. Loosen bottom sheet beneath patient
5. Position stretcher next to and parallel to bed
6. Prepare stretcher and adjust to bed height
7. Adjust the draw sheet

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8. Across stretcher and grasp sheet firmly at the patient’s head, chest, hips and knees
9. Give direction
10. Slide the patient gently on to stretcher
11. Comfort the patient
12. Observe the patient condition
13. Document the procedure.
1.6. Range of motion exercise/ROM
Definition
 Range of motion exercise refers to activities aimed at improving movement of specific or group
of joints
Purpose
 To maintain the current joint function
 To restore joint function that has been lost through disease or injury, or lack of use
 To maintain muscle tone and strength
 To prevent contractures
 To improve circulation
Types
1. Active- movements of the joints independently by the client/patient on a nonfunctioning joints.
2. Active-passive:-movement of nonfunctioning joint from partial assistant from others carried
3. Passive:-movement applied by a nurse or other person or passive motion machine on a pt.’s
immobilized joint.
Indication
 Unable to move joints
 Part of daily living activities
Contraindication
 Dislocation in specific joints

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 heart & respiratory disease and Swollen or inflamed joints or musculoskeletal injury
Procedure passive range of motion exercise (PROM)
1. Wash hands
2. Explain the procedure to the client
3. Adjust the bed to a comfortable height.
4. Select one side of the bed to begin PROM exercises.
5. Uncover only the limb to be exercised.
6. Support all joints during exercise activity.
7. Use slow, gentle movements when performing exercises.
8. Repeat each exercise three times.
9. Stop if the client complains of pain or discomfort.
10. Begin exercise with the client’s neck and work down ward.
11. Exercise the neck
a. Flex, extend and rotate the client’s neck.
b. Support his or her head with your hands.
12. Exercise the client’s shoulder and elbow.
a. Support the client’s elbow with one hand and grasp the client’s wrist with your other
hand.
b. Raise the client’s arm from the side to above the head.
c. Perform internal rotation by moving the client’s arm across his or her chest.
d. Externally rotate the client’s shoulder by moving the arm away from the client.
e. Flex and extend the client’s elbow.
13. Perform all exercises on the client’s wrist and fingers
a. Flex and extend the wrist.
b. Abduct and adduct the wrist.
c. Rotate and pronate the wrist.
d. Flex and extend the client’s fingers.
e. Abduct and adduct the fingers.
f. Rotate the thumb.

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14. Exercise the client’s hip and leg.
a. Flex and extend the hip and knee while supporting the leg.
b. Abduct and adduct the hip by moving the client’s straightened leg toward you and
then back to median position.
c. Perform internal and external rotation of the hip joint by turning the leg inward
and then outward.
15. Perform exercises on ankle and foot
a. Dorsiflex and plantar flex the foot
b. Abduct and adduct the toes
c. Evert and invert the foot
16. Move to the other side of the bed and repeat exercise.
17. Position and cover the client. Return the bed to low position.
18. Wash your hands.
19. Document completion of PROM exercise

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CHAPTER SIX
ESSENTIAL ASSESSMENT COMPONENTS

6.1. Measuring patient vital sign
Physical assessment, an essential nursing function, is performed on every client. The
measurement of vital signs and the execution of the physical examination as part of the
assessment process are done to gather information regarding the physiological functioning of the
body. “taking of vital signs” refers to measurement of the client’s:-
 Body temperature (T),
 Pulse (P)
 Respiratory (R) rates, and
 Blood pressure (BP).
These measurements can indicate if the circulatory, pulmonary, neurological and endocrine body
systems are functioning normally. Because of their importance as indicators of the body’s
physiological status and response to physical, environmental and psychological stressors, they
are referred to as vital signs
6.1.1. Taking patient body temperature
Definition: The body temperature is the difference between the amount of heat produced by
body process and the amount of heat lost to the external environment.
Purpose
1. To determine body temperature
2. To assist in diagnosis
3. To evaluate patient’s recovery from illness
4. To determine if immediate measures should be implemented to reduce dangerously
elevated body temperature or converse body heat when body temperature is dangerous
low
5. To evaluate patient’s response once heat conserving or heal reducing measures have been
implemented

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6.1.1.1.Measuring oral temperature
Definition: it is technique of measuring body temperature through oral route.
Contraindication
 Child below 7 yrs.
 If the patient is delirious, mentally ill
 Unconscious
 Uncooperative or in severe pain
 Surgery of the mouth
 Nasal obstruction
 If patient has nasal or gastric tubs in place
Precaution:
 Never use oral thermometer for rectal and vise verse
Equipment
1. Thermometer: glass or electronic
2. Two pairs of non-sterile gloves
3. Watch
4. Dry Cotton
5. Receiver/receptacle
6. Soapy water [alcohol]
7. tray
8. Pen or pencil
9. Vital following sheet or record form

Procedure
1. Explain the procedure
2. Wash hands
3. Assemble the necessary equipment
4. Remove thermometer from storage container and cleanse under cool water.
5. Wipe thermometer dry with a tissue from bulb’s end toward fingertips.
6. Read thermometer by locating mercury level. It should read 35.5°C (96°F).
7. If thermometer is not below a normal body temperature reading, grasp thermometer
with thumb and forefinger and shake vigorously by snapping the wrist in a downward
motion to move mercury to a level below normal.
8. Assist the client to assume semi fowlers position
9. Place thermometer in mouth under the tongue and along the gum line to the posterior

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sublingual pocket. Instruct client to hold lips closed.
10. Leave in place as specified by agency policy, usually 3–5 minutes.
11. Remove thermometer and wipe with a tissue away from fingers toward the bulb’s
end.
12. Read at eye level and rotate slowly until mercury level is visualized.
13. Shake thermometer down, and cleanse glass thermometer with soapy water, rinse
under cold water, and return to storage container.
14. Remove and dispose of gloves in receptacle.
15. Comfort the patient
16. Return used equipment and wash your hand
17. Record reading and indicate site as “OT.”(oral temperature)
6.1.1.2.Taking patient body temperature (axillary)
Definition; it is technique of measuring body temperature on arm pit.
Contraindication:
Equipment
 Thermometer: glass or electronic
 Two pairs of non-sterile gloves
 Dry Cotton
 tray
 Face towel
 Receiver/receptacle
 Soapy water
 Watch with secondhand
 Pen or pencil
 Vital following sheet or record form

Procedure
1) Explain the procedure
2) Wash hands
3) Assemble the necessary equipment
4) Maintain privacy if necessary
5) Remove client’s arm and shoulder from one sleeve of gown. Avoid exposing
chest.
6) assist the client assume supine or semi sitting position
7) Make sure axillary skin is dry; if necessary, pat dry
8) Prepare thermometer (If thermometer is not below a normal body
temperature reading, grasp thermometer with thumb and forefinger and shake

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vigorously by snapping the wrist in a downward motion to move mercury to
a level below normal).
9) Place thermometer or probe into center of axilla .
10) Fold client’s upper arm straight down and place arm across client’s chest.
11) Leave glass thermometer in place as specified by agency policy (usually 6–8
minutes). Leave an electronic thermometer in place until signal is heard.
12) Remove and read thermometer.
13) Inform client of temperature reading.
14) Cleanse glass thermometer (Remove thermometer and wipe with a tissue
away from fingers toward the bulb’s end) and return to storage container.
15) Assist client with replacing gown.
16) Comfort the patient
17) Return used equipment and wash your hand
18) Record reading and indicate site as “AT.”(Axillary temperature)
6.1.1.3.Measuring rectal temperature
Definition: Rectal temperature measurement: is method of measuring body temperature by
inserting thermometer through the anus into the rectum
Contraindication
 Patient with diarrhea
 Rectal surgery
 Disease of the rectum(anal fissure, hemorrhoid etc)
Precaution:
 Never use oral thermometer for rectal and vise verse
 Never use rectal temperature if the immunosuppressant, hematologic disorder, rectal
surgery and diarrhea
Equipment
1. Thermometer: glass (client’s
bedside); electronic
2. Lubricant (rectal, glass thermometer)
and disposable protective sheath
3. tray
4. Two pairs of disposable gloves
5. Pen or pencil
6. Receiver /receptacle
7. Vital following sheet or record form
8. Tissue paper
9. Screen

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Procedure
1. Explain the procedure
2. Wash hands
3. Assemble the necessary equipment
4. Keep privacy
5. Place client in the Sims’ position with upper knee flexed. Adjust sheet to
expose only anal area.
6. Instruct client to take a deep breath.
7. Clean the anal area as necessary
8. Lubricate the tip of rectal thermometer or probe
9. Insert thermometer or probe gently into anus: infant, 1.2 cm (0.5 in.);
adult, 3.5 cm (1.5 in.)
10. If resistance is felt, do not force insertion.
11. Length of time (as specified by agency policy, usually 3–5 minutes).
12. Wipe secretions off glass thermometer with a tissue for reading without
touching the bulb. Dispose of tissue in a receptacle.
13. Read measurement and inform client of temperature reading.
14. While holding glass thermometer in one hand, wipe anal area with tissue
to remove lubricant or feces with other hand and dispose of soiled tissue.
15. Comfort of the patient
16. Cleanse thermometer (Remove thermometer and wipe with a tissue away
from fingers toward the bulb’s end)
17. Hand washing and return in the place
18. Record reading and indicate site as “RT.”(Rectal temperature)

6.1.1.4.Measuring tympanic temperature
Definition: Tympanic temperature measurement: method of assessing body temperature by
inserting thermometer through ear
Contraindication
 Perforated ear drum
 Ear infection(Otitis media)
Precaution:

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 Take tympanic and oral temperature for children above 6 year
 Never use tympanic temperature is any ear surgery
Equipment
1. Thermometer: glass (client’s bedside); electronic
2. Two pairs of disposable gloves
3. Probe cover
4. tray
5. Pen or pencil
6. Receiver /receptacle
7. Vital following sheet or record form
8. Dry cotton
9. Cotton tipped applicator
Procedure
1. Explain the procedure
2. Wash hands
3. Assemble the necessary equipment
4. Assist clients for assuming comfortable position with hand toward one side away from nurse for
Right handed nurse take from right ear and for Left handed nurse take from left ear
5. Note if any excess ear wax
6. Position client in Sims’ position
7. Remove probe from container and attach probe cover to tympanic thermometer unit.
8. Turn client’s head to one side. For an adult, pull pinna upward and back; for a child, pull down and
back.
9. Gently insert probe with firm pressure into ear canal.
10. Remove probe after the reading is displayed on digital unit (usually 2 seconds).
11. Remove probe cover and replace in storage container.
12. comfort the client
13. Return tympanic thermometer to storage unit and wash hand
14. Record reading and indicate site as “ET.”(Ear temperature)

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6.1.2. Assessing patient pulse
Definition:
1. Pulse assessment is the measurement of a pressure pulsation created when the heart
contracts and ejects blood into the aorta. Assessment of pulse characteristics provides
clinical data regarding the heart’s pumping action and the adequacy of peripheral artery
blood flow.
2. Is method of assessing patient pulse for depth, rate and rhythm.

Purpose
 To determine number of heart beats
occurring per minute( rate)
 To gather information about heart
rhythm and pattern of beats
 To evaluate strength of pulse
 To assess heart's ability to deliver
blood to distant areas of the blood
viz. fingers and lower extremities
 To assess response of heart to
cardiac medications, activity, blood
volume and gas exchange
 To assess vascular status of limbs
Equipment
 Watch with a second hand
 Stethoscope
 Swab
 tray
 west receiver
 Vital sign flow sheet
 pencil and pen


Procedure
1. Explain the procedure
2. Wash hands
3. Assemble the necessary equipment
4. Inform client of the site(s) at which you will measure pulse.
5. If supine, place client’s forearm straight alongside body or Flex client’s elbow and
place lower part of arm across chest.
6. Support client’s wrist by grasping outer aspect with thumb.
7. Place your index and middle finger on inner aspect of client’s wrist over the radial
artery or thumb side and apply light but firm pressure until pulse is palpated
8. Identify pulse rhythm and then Determine pulse volume.
9. Count pulse rate by using second hand on a watch:

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 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, noting number
of irregular beats.
10. Comfort the client
11. Return equipment and wash hand
12. Record reading and indicate site as “PR.”(pulse rate)
Apical pulse
1. Explain the procedure
2. Wash hands
3. Assemble the necessary equipment
4. Raise client’s gown to expose sternum and left side of chest.
5. Cleanse earpiece and diaphragm of stethoscope with an alcohol swab.
6. Put stethoscope around your neck.
7. Apex of heart:
 With client 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) .
 Keep index figure of no dominant hand on PMI
8. Inform client that you are going to listen to his/her heart.
9. Instruct client to remain silent
10. With dominant hand put ear piece of the stethoscope in your ear and grasp diaphragm
of the stethoscope in palm of your hand for 5 to 10 second
11. Comfort the client
13. Return equipment and wash hand
14. Record reading and indicate site as “PR.”(pulse rate)

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6.1.3. Assessing patient respiration
Definition; is method of assessing patient breathing for depth, rate and rhythm.
Purpose
 For diagnostic purpose
 To evaluate the progress of patient condition
 To evaluate the effect of administered drugs
 To evaluate breathing for rate, depth and rhythm
Equipment:-
 Watch with a second hand
 Pen
 Pencil
 Vital sign flow sheet or record form
Procedures
1. Explain the procedure
2. Wash hands
3. Assemble the necessary equipment
4. Be sure the patient is comfortable position; preferably, he sitting or lying with
head of bed elevated 45 to 60 degrees.
5. Before replacing client’s gown from auscultating heart sounds, assess
respirations.
6. Place your hand over client’s wrist and observe one complete respiratory cycle.
7. Start to count with first inspiration while looking at second hand sweep of
watch.
 Infants and children: count a full minute.
 Adults: count for 30 seconds and multiply by 2.
 If an irregular rate or rhythm is present, count for a full minute.
8. Observe depth of respirations by degree of chest wall movement and rhythm of
cycle (regular or interrupted).
12. Comfort the client
15. Return equipment and wash hand
13. Record reading and

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6.1.4. Assessing patient blood pressure
Definition: is the method of recording force exerted on arterial wall by pulsing blood under
pressure from the heart.
Purpose:
 To evaluate effect of some drugs affecting cardiovascular system
 To have baseline vital sign of patient on admission
 To diagnose hypertension and hypotension disorders of blood
Contraindications for brachial artery blood pressure measurement
When the client has any of the following, do not measure blood pressure on the involved side
 Venous access devices, such as an intravenous infusion or arteriovenous fistula for renal
dialysis
 Surgery involving the breast, axilla, shoulder, arm, or hand
 Injury or disease to the shoulder, arm, or hand, such as trauma, burns, or application of a
cast or bandage
Equipment:
 Alcohol swabs
 Sphygmomanometer with proper
size cuff
 Stethoscope
 Tray
 Vital sign sheet
 Pen and pencil

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Procedure
1. Explain the procedure
2. Wash hands
3. Assemble the necessary equipment
4. Determine which extremity is most appropriate for reading.
5. Have the client rest at least 5 minute before measurement.
6. Use appropriate size cuff
7. Move clothing away from upper aspect of arm.
8. Position arm at heart level, extend elbow with palm turned upward and for thigh, position
with knee slightly flexed.
9. Make sure bladder cuff is fully deflated and pump valve moves freely.
10. Locate brachial artery in the antecubital space.
11. Apply cuff comfortably and smoothly over upper arm, 2.5 cm (1 in.) above antecubital
space with center of cuff over brachial artery.
12. Connect bladder tubing to manometer tubing. If using a portable mercury-filled manometer,
position vertically at eye level.
13. Palpate brachial artery ,turn valve clockwise to close and compress bulb to inflate cuff to 30
mm Hg above point where palpated pulse disappears, then slowly release valve (deflating
cuff), noting reading when pulse is felt again .
14. Insert earpiece of stethoscope in ears with a forward tilt, ensuring diaphragm hangs freely
15. Relocate brachial pulse with your non dominant hand and place bell or diaphragm chest
piece directly over pulse. Chest piece should be in direct contact with skin and not touch
cuff
16. With dominant hand, turn valve clockwise to close. Compress pump to inflate cuff until
manometer registers 30 mm Hg above diminished pulse point identified in step 13.
17. Slowly turn valve counterclockwise so that mercury falls at a rate of 2–3 mm Hg per
second. Listen for five phases of Korotkoff’s sounds while noting manometer reading:
18. Deflate cuff rapidly and completely.
19. Remove cuff or wait 2 minutes before taking a second reading.
20. Inform client of reading
21. Lower bed, raise side rails, place call light in easy reach.
22. Put all equipment in proper place.
23. Comfort the client

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24. Return equipment and wash hand
25. Record reading and interpret
6.1.5. Measuring height and weight
Objective: At the end of this lesson learner, will able to:
 Accurately measure patient weight and height
 Calculate bmi and interpret the measurement
Purpose
 to have base line information of client
 to assess the nutritional level of the client
 to assess the developmental stage of the
 as requirement for drug dose calculation
Equipment
 Weight scale
 Height scale
 Pen and pencil
 Recording chart
Procedure
1. Calibrate the standing scale by setting both weight indicators to zero. The balance beam
will be at the top. When calibrated the balance beam will be at the midway point.
2. Digital display scales should read zero. If they do not, follow the manufacturer’s
instructions to recalibrate the scale.
3. Assist the client to a standing position. Have the client empty his or her bladder before
the weight measurement.
4. Make sure the scale is sitting evenly on the floor and assist the client onto the scale.
5. Instruct the client to remain still. Avoid touching the client.
6. Slowly move the standing scale’s weight indicators on the balance beam until the tip of
the beam registers in the middle of the mark. Digital scales will automatically display the
weight.
7. Read and record the weight.
8. Assist the client back to the former position.

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6.2. Specimen Collecting
Introduction
Definition: it is collection of samples for laboratory examination of urine, stool, sputum,
blood and wound drainage specimens provides important information about body functioning
and contributes to the assessment of the client’s health status.
Instructions and precautions
1. See that the specimen bottles/containers are clean.
2. Every specimen must have a label with the patient's full name, room no., ward no., and
hospital no. and nurse's signature, with date and time.
3. Specimens must be placed at the specified place on the laboratory specimen shelf.
6.2.1. Taking urine specimen
Objective: At the end of this lesson, the learner will able to:
1. Assemble necessary equipment
2. Demonstrate proper technique of taking urine specimen collection
3. Interpret the result after taking the urine
4. specimen
5. Demonstrate proper handling of urine sample
Definition: is method of taking small portion of urine from client, which can represent the
client’s quality of whole urine.
Purposes
 diagnostic purposes
 Routine laboratory analysis and culture and sensitivity tests
Indication
 End stage renal failure(acute)
 Drug toxicity
 Acute hemolytic problems
 Post-operative evaluation
 etc.
Precaution
 Never contaminate with fecal matter
 Send immediately to lab dept.
 Follow instruction for type of urine specimen
 Specimen should be free of toilet tissue

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6.2.1.1.Random collection (routine Urinalysis)/ a single voided specimen
Definition: Routine Urinalysis/screening in which the components of urine are identified and can be
collected at any time of the day
Purpose
 To diagnose illness
 To monitor the disease process
 To evaluate the efficacy of treatment
Precaution
 Label specimen containers or bottles before the client voids
 Note on the specimen label if the female client is menstruating at that time
Equipment
 Laboratory request form
 Clean container with lid or cover (1): wide-mouthed container is recommended
 Bedpan or urinal (1): as required
 Disposable gloves (1): if available
 Toilet paper as required
Procedure
1. Explain the procedure
2. Assemble equipment and check the specimen form with client’s name, date and content of
urinalysis
3. Label the bottle or container with the date, client’s name, department identification, and Dr’s
name
4. Perform hand hygiene and put on gloves
5. Keep privacy (if necessary)
6. Instruct the client to void in a clean receptacle.
7. Remove the specimen immediately after the client has voided
8. Pour about 10-20 mL of urine into the labeled specimen bottle or container and cover the bottle
or container
9. Comfort patient
10. Dispose of used equipment or clean them. Remove gloves and perform hand hygiene.
11. Send the specimen bottle or container to the laboratory immediately with the specimen form.
Document the procedure in the designated place and mark it off on the kardex

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6.2.1.2.Timed urine specimen collection
Definition: is method of collecting urine specimen for specified period. Some tests of renal
function and urine composition require urine to be collected over 2 to 72 hr. The 24 hour timed
collection is most common.
Purpose:
 The test allow for the measurement of elements such as amino acids, creatinine,
hormones, glucose and adrenocorticosteroids, whose levels change over time.
 A timed urine collection can also provide a means to measure the concentration or
dilution of urine.
 Used to monitor input and output
Equipment
 Large bottle or container
 Funnel if available and necessary
 format for recording
 Label for bottle
 Glove
Procedures
1. Explain the procedure
2. Wash hands
3. Assemble the necessary equipment
4. Label container with correct information
5. Take a clean chamber with a cover or a large bottle.
6. Attach the label with patient's name and keep it in a safe place, marked-"24 hours specimen."
Or prescribed duration .
7. Instruct the sweeper and patient's relative not to empty it.
8. Tell the patient that all urine for the full 24 hours/prescribed duration must be saved, after
passing it separate from stool.
9. If at any time the urine is not saved the procedure must be started all over again.
10. Preferably Start at 6 a.m. by having the patient void and throw the first specimen away,
because it was secreted during the night.
11. After that each time the patient voids, pour the urine into the same container and keep it
covered.
12. After 6 a.m. the next morning’s has the patient again void and add this as the last specimen

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to the previous amount.
13. Measure the total amount and then take to laboratory, properly labeled.
26. Comfort the client
14. Return used equipment and wash hand.
15. Document
6.2.1.3.Mid-stream (clean-voided) urine specimen
Definition: Mead stream urine specimen is method of collecting part of urine stream by avoiding
first and last part of urine in receptor.
Purpose
 To take the specimen for culture and sensitivity
 To identify possible microorganism in the urine
 To detect and measure the presence of abnormalities in the urine like RBC, WBC, PH
and albumin
Equipment
A. Commercial kit for clean –voided
urine containing:
 Sterile cotton balls and/or 2X2
inch gauze pads.
 Antiseptic solution
 Sterile water or saline
 Sterile specimen collection
container and sterile glove
B. Soap, water, washcloth and towel
Bedpan(for non-ambulatory
client),specimen hat(if all urine
needs to be measured),potty-chair
(for young child )
C. Completed specimen identification
label
D. Completed laboratory requisition
form
Procedures
1) Explain the procedure
2) Wash hands
3) Assemble the necessary equipment
4) Provide privacy for client around the bed or closing room door. Allow mobile client to
collect specimen in bathroom or toilet
5) Give client cleansing towel, washcloth, and soap to cleanse perineum, or assist client with
cleansing perineum (if able)
6) Assist bedridden client onto bedpan
7) Using surgical asepsis, open sterile kit or prepare sterile tray.

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8) Wear sterile gloves
9) Pour antiseptic solution over cotton balls (unless kit contains prepared gauze pads in
antiseptic solution)
10) Open specimen container, and place cap with sterile inside surface up, and do not touch
inside of container.
11) Perform urine collection by assisting or allowing client to independently cleanses perineum
and collect specimen. The amount of assistance needed varies with each client. The nurse
will assess client’s ability to perform procedure and assist as needed.
Male client
12) Either nurse or client will hold client’s penis with one hand. using circular motion and
antiseptic swab, cleanse meatus ,moving from center to outsides
13) If agency procedure indicates, rinse area with sterile water and dry with cotton balls or
gauze pad.
14) After client has initiated urine stream into toilet or bed pan, pass urine specimen container
into stream and collect 30-60ml of urine
Female client
15) Either nurse or client will spread client’s labia minora with thumb and forefinger of non-
dominant hand.
16) Use dominant hand to cleanse urethral area with swab(cotton ball or gauze),moving from
front(above urethral orifice) to back(toward anus).using a fresh swab each time, repeat
front to back motion three times (begin with center, then do left side, then do right side
17) While continuing to hold labia apart, client should initiate urine stream into toilet or
bedpan; after stream is achieved, pass specimen container into stream and collect 30 to 60
ml of urine.
For both
18) Remove specimen container before flow of urine stops and before releasing labia or penis.
Client finishes voiding into bedpan or toilet
19) Replace cap securely on specimen container (touch only outside)
20) Cleanse urine from external surface of container
21) Comfort patient
22) Empty bedpan (if applicable), remove and discard gloves, and perform hand hygiene
23) Label specimen and attach laboratory requisition
24) Take specimen to laboratory within 15 to 20 minutes.
25) Return equipment and wash hand

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26) Proper documentation
6.2.1.4.Catheterized urine specimen for female client
Definition: it is a collection of urine specimen by introducing catheter in the urethral of the
patient
Purpose
 To collect sterile urine specimen
 To have a sample for a patient who has difficulty of passing urine
Equipment
Sterile
 Kidney dish
 Galipot(2)
 Gauze
 Forceps four
 Four Towel
 Lubricant
 Two Catheter
 Syringe
 Distill Water
 Specimen bottle
 Two Gloves
Clean
 Waste receiver
 Rubber sheet
 Flash light
 Measuring jug
 Screen
 Disposable glove
 Antiseptic Solution
 Two small basin
 Soap
 Wash cloth(2)
Procedures
1. Explain the procedure
2. Wash hands
3. Assemble the necessary equipment
4. Keep patient privacy
5. Turn top bed linen upwards from the bottom to the patient’s chest to protect her from
complete exposure.
6. Place patient in dorsal position with knees flexed and thighs apart, then put mackintosh
under her buttocks.
7. Apply disposable glove
8. Clean starting from mid-thigh with clean warm water and soap and dry the area
9. Remove used clean glove and wash hand
10. Open sterile filed

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11. Done sterile gloving
12. Create a sterile field and Drape the client with a sterile drape
13. Prepare the equipment and Put receiver for urine near the vulva.
14. Wash the outer skin folds then inner labia and urethral meatus with antiseptic solution from
front to back. (Starting from outer proceeding to inside)
15. Put forceps in the receiver kidney dish
16. Wash and Rinse the area well from outer skin folds then inner labia and urethral meatus
finally with distil water from front to back.
17. Put forceps in the receiver kidney dish
18. Dry with dry gauze the outer skin folds then inner labia and urethral meatus from front to
back
19. Put forceps in the receiver kidney dish
20. Lubricate the insertion tip of the catheter (5-7 cm in)
21. Expose the urinary meatus adequately by retracting the tissue or the labia minora in an
upward direction
22. Gently insert the catheter into meatus until urine is noted. Continue inserting for 2.5 to 5cm
additional.
23. Instruct the client to immediately report pain, discomfort or pressure if so discontinue the
procedure and investigate the cause
24. Take sterile specimen and cover it
25. Remove the catheter and discard it
26. Make patient comfortable by covering her up properly.
27. Label and send to laboratory room immediately
28. Return used equipment and wash hand
29. Proper documentation
6.2.1.5.Catheterized urine specimen for male client
Definition: it is a collection of urine specimen by introducing catheter in the urethral of the
patient
Purpose
 To collect sterile urine specimen
 To help a patient who has difficulty of passing urine

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Equipment
Sterile
1. Kidney dish
2. Galipot(2)
3. Gauze
4. Forceps four
5. Four Towel
6. Lubricant
7. Two Catheter
8. Syringe
9. Distill Water
10. Specimen bottle
11. Two Gloves
Clean
1. Waste receiver
2. Rubber sheet
3. Flash light
4. Measuring jug
5. Screen
6. Disposable glove
7. Antiseptic Solution
8. Two small basin
9. Soap
10. Request chart
11. Wash cloth(2)
Procedures
1. Explain the procedure
2. Wash hands
3. Assemble the necessary equipment
4. Keep patient privacy
5. Turn top bed linen upwards from the bottom to the patient’s chest to protect her from
complete exposure.
6. Place patient in supine position, then put mackintosh under his buttocks.
7. Apply disposable glove
8. Clean starting from mid-thigh with clean warm water and soap and dry the area
9. Open sterile filed
10. Done sterile gloving
11. Create a sterile field and Drape the client with a sterile drape
12. Prepare the equipment and Put receiver for urine near the genital area
13. Gently raise penis. If the client develops an erection, delay perineal care. Gently grasp
the shaft of the penis. If the client is uncircumcised, retract the foreskin
14. Take first forceps and wash with antiseptic solution starting from glans of penis to
down with circular manner.
15. Put forceps in the receiver kidney dish

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16. Take second forceps and wash with distil water starting from glans of penis to down
with circular manner.
17. Put forceps in the receiver kidney dish
18. Dry with dry gauze from up to down with circular manner
19. Put forceps in the receiver kidney dish
20. Lubricate the insertion tip of the catheter (5-7 cm in)
21. Hold the shaft of penis in 90 degree
22. Gently insert the catheter into meatus until urine is noted or 20 cm
23. Instruct the client to immediately report pain, discomfort or pressure if so discontinue
the procedure and investigate the cause
24. Take sterile specimen and cover it
25. Remove the catheter and discard it
26. Make patient comfortable by covering her up properly.
27. Label and send to laboratory room immediately
30. Return used equipment and wash hand
31. Proper documentation
6.2.2. Collecting stool specimen
Objective: At the end of this lesson, the learner will able to:
 Assemble necessary equipment
 Demonstrate proper technique of taking stool specimen
 Interpret the result after taking the stool specimen
 Demonstrate proper handling of stool sample
Definition: Taking small pieces of stool from patientfor chemical, bacteriological or
parasitological analysis
Purpose:
 To identify specific pathogens
 To determine presence of ova and parasites
 To determine presence of blood and fat
 To examine for stool characteristics such as color, consistency and odor
Equipment
1. Clean disposable glove
2. Tongue depressor
3. Bed pan
4. Screen
5. Air fresher as needed
6. Tissue paper

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7. Specimen bottle
8. Labeling tape
9. Lab request
10. Glove
11. Request chart
Procedures
1. Explain the procedure
2. Wash hands
3. Assemble the necessary equipment
4. Keep patient privacy
5. Offer clean bed pan to the patient
6. Take bed pan to the utility room
7. Take a portion of faces from different area of stool specimen
8. Throw tongue depressor into the waste can
9. Spray air fresher as necessary
10. Label bottle properly
11. Send to the laboratory
12. Return used equipment and wash hand
13. Proper documentation
NB:
 Stool from a Client with Hepatitis:- When collecting a stool specimen from a client
with hepatitis, write on the lab requisition form that the client has hepatitis. This increases
the laboratory personnel’s awareness to be extra careful when handling the specimen..
 Send fresh stool immediately to the lab
6.2.3. Taking blood specimen
Objective: At the end of this lesson, the learner will able to:
 Assemble necessary equipment
 Demonstrate proper technique of taking blood specimen
 Interpret the result after taking the blood specimen
 Demonstrate proper handling of blood sample
6.2.3.1.Vein puncture
Definition: it is the procedure of using a needle to withdraw blood from a vein
Purpose: for diagnosis and for determining variation in blood composition if any
Site of taking venous blood

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 Ante cubital vein
 Ulnar vein
Equipment
1. Test tube
2. Sterile syringe with needle
3. Tourniquet
4. Alcohol swab
5. Tray
6. Glove
7. Bed protector
8. Safety box
9. West receiver
10. adhesive plaster for labeling
11. Dry gauze
12. Pen and pencil
13. Lab request form


Procedures
1. Explain the procedure
2. Wash hands
3. Assemble the necessary equipment
4. Label the test tube with patient name ,bed number, ward, date and time
5. Put on glove
6. Position the patient
7. Apply bed protection
8. Apply tourniquet above the injection site
9. Ask the patient to open and close his fist
10. Clean the site with antiseptic swab
11. Select possible vein
12. Insert the needle at 15 to 45 degree
13. Draw slowly back on the plunger of the syringe after you become sure that you are in
the vein
14. Obtain the amount of blood required for the test
15. Release tourniquet
16. With draw the needle and apply pressure with dray cotton
17. Withdraw the needle from the syringe and bend the test tube then transfer the blood
to the test tube slowly.
18. Send to the laboratory room

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19. Return used equipment and wash hand
20. Proper documentation
21. Return used equipment and wash hand

6.2.3.2.Capillary or peripheral blood specimen
Definition: it is method of taking small drop of blood from capillary by pricking the skin.
Site for pricking
 Tip of the finger (ring finger of the left hand)
 Lobe of the ear
 Infants plantar surface of the heal and the plantar surface of the big toe
Purpose
 To detect hemo-parasite
 To detect blood cell abnormalities
Equipment
1. Antiseptic swab
2. Glove
3. Tray
4. Safety box
5. West receiver
6. Lancet
7. pen and pencil
8. capillary tube
9. record chart
10. Glass of slide
 dry cotton
Procedures
1. Explain the procedure
2. Wash hands
3. Assemble the necessary equipment
4. Put on glove
5. Clean the site with antiseptic swab
6. Prick the site with lancet
7. Collect a drop of blood on the glass slide
8. Spread the drop of blood along slide(smearing)
9. Try to work quickly so not to allow clothing on the slide
10. Give alcohol for client to apply pressure to the site

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22. Return used equipment and wash hand
23. Proper documentation
NB: While smearing doesn’t use sharp edge to avoid scratching of slide
Precaution
 Use safety box
 Blood should never be taken from IV line or above an existing line
 Use personal protective equipment
6.2.3.3.Arterial specimen by puncture
Definition
 Arterial Puncture is an invasive procedure using a needle to withdraw blood from a peripheral
artery (e.g., radial or femoral) or from an arterial line in a 5-ml heparinized syringe
Purpose
 Done for blood gas analysis to determine Oxygenation, Ventilation and the effectiveness of
respiratory therapy and Acid-base level of the blood
Contraindication
 Anticoagulant therapy
 Clotting disorders
 Symptomatic peripheral vascular disease
 Negative Allen test
 If the client is hyperthermic
 Immediately after breathing and suctioning treatments
If there have been changes on ventilator settings
Complication

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o Hematoma
o Arteriospasm
o Air or clotted-blood emboli
o Anaphylaxis from local
anesthetic
o Infection
o Hemorrhage
o Trauma to the vessel
o Arterial occlusion
o Vasovagal response
o Pain
Equipment
1. 5cc syringe with needle(2)
2. Specimen/test tube
3. Fenestrated sterile towel
4. Antiseptic solution
5. Towel
6. Cotton ball or sterile gauze
7. Adhesive tape
8. Glove
9. Local aesthesia
10. Heparin
Procedure
1. Explain the procedure
2. Collect necessary equipment
3. Make sure the patient is seated comfortably.
4. Assess the patency of ulnar artery and adequacy of distal arteries to wrist by Allen test. Rest patients
hand in his/her lap palms up. Clenching of fist blanches skin of the palms. Now compress Radial artery
and have patient relax hands in partly flexed position. Normally the skin should turn pink indicating
normal ulnar artery and collateral flow. If there is a problem select a different artery for arterial puncture.
5. Next, the area over the radial artery should be cleaned with alcohol wipes. Wear gloves.
6. Draw 2% xylocaine into a syringe and infiltrate the skin and the area around the radial artery
draw heparin into a glass syringe and with it and then empty the syringe. Kits nowadayshave pre-
heparinised syringes, in which case skip this step.
7. The small amount of heparin left in the needle and syringe is sufficient.
8. Hyper extend the patient's hand to stretch the radial artery. Line up the artery with two fingers with
the beveled edge facing upper portion of the vessel. Enter the artery and attempt to go through
and through the vessel.
9. Slowly withdraw the syringe, stopping as soon as it begins to fill spontaneously.
10. Withdraw the needle while applying pressure to the vessel with gauze.
11. Expel any air from the syringe and then cap the needle. Caution. Leave the cap on table and thread the
needle into it to avoid accidental needle puncture
12. Gently roll the syringe between the palms of your hands to mix the heparin with the blood.
13. Place the syringe in ice and send the specimen immediately to the lab for analysis.
14. Either you or the patient should keep applying pressure to the vessel for a few minutes. Then apply a
band-aid and the procedure is complete

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6.2.4. Taking sputum specimen
Objective: At the end of this lesson, the learner will able to:
 Assemble necessary equipment
 Demonstrate proper technique of taking sputum specimen
 Interpret the result after taking the sputum specimen
 Demonstrate proper handling of sputum sample
Definition: is method of collection of coughed sputum from diagnostic purpose( to rule out
respiratory pathology).
Purpose: Examination of sputum may aid in the diagnosis and treatment of several conditions
ranging from simple bronchitis to lung cancer.
Three major types of sputum specimen’s are-
A. Cytology- cytology or cellular examination of sputum may identify aberrant cells or
cancer.
B. Culture and sensitivity – used to identify specific microorganism and to determine
antibiotics to which they are most sensitive.
C. Acid-fast bacilli (AFB)-used to support the diagnosis of tuberculosis (TB)
 Suctioning may be indicated to collect sputum from the client who is unable to
spontaneously produce a sample for laboratory analysis.
 Suctioning may provoke violent coughing, which can induce constriction of
pharyngeal, laryngeal and bronchial muscles.
Equipment
1. Sterile specimen container with
cover
2. Clean disposable gloves
3. Facial tissue
4. Emesis basin (optional)
5. Toothbrush (optional)
6. Completed identification label
7. Completed laboratory request
Procedure
1. Explain the procedure
2. Wash hands
3. Assemble the necessary equipment
4. Keep patient privacy
5. Position client: semi-Fowler’s position, setting on side of bed or chair, standing
for coughing and expectorating specimen
6. Apply clean disposable gloves
7. Provide client with specimen container, and instruct client not to touch inside.

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8. Instruct client to take three to four slow deep breaths
9. Instruct client to emphasize slow, full exhalation
10. After series of deep breaths, ask client to cough after full inhalation
11. Instruct client to expectorate sputum directly into specimen container
12. Have client repeat coughing until an adequate amount of sputum has been
collected
13. Comfort patient
14. Send specimen to lab department with its request
15. Return used equipment and wash hand
16. Proper documentation
6.2.5. Obtaining wound drainage specimen for culture
Objectives: At the end of this lesson, the learner will be able to:
 Define what obtaining wound specimen mean
 Assemble the necessary equipments for the procedure
 Demonstrate how to perform wound specimen collection
 Demonstrate proper handling and labeling of wound specimen
Definition: isthe technique of taking a sample from wound for laboratory analysis and culture to
identify the specific microorganisms on the wound.
Purpose:
 To identify the microorganisms potentially causing an infection and the antibiotics to
which they are sensitive
 To evaluate the effectiveness of antibiotic therapy
Equipments
1. Personal protective equipments (PPE), goggles, and gown
2. Tray
3. Clean gloves
4. Sterile gloves
5. Moisture proof bag
6. sterile dressing set
7. normal saline and irrigation
8. culture tube with swab and culture medium (aerobic and anaerobic tubes are available)
and /or sterile syringe with needle for anaerobic culture
9. completed label for each container
10. completed requisition to accompany the specimens to the laboratory
Procedure
1. Explain the procedure
2. Hand hygiene and observe appropriate infection control procedures (e.g. gloves)

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3. Maintain privacy
4. Assemble the necessary equipments
5. Remove any moist outer dressing that cover the wound
A. Put on clean gloves
B. Remove the outer dressing and observe any drainage on the dressing. Hold the
dressing so that the client does not see the drainage
C. Determine the amount of drainage, for example ‘one 2x2 gauze saturated with pale
yellow drainage
D. Discard the dressing in the moisture proof bag. Handle it carefully so that the
dressing does not touch the outside of the bag.
E. Remove gloves and dispose of the properly
6. Open the sterile dressing set using sterile technique
7. Assess the wound
A. Put on sterile gloves
B. Assess the appearance of the tissues in and around the wound and the drainage.
Infection can cause reddened tissues with a thick discharge, which may be foul
smelling, whitish, or colored.
8. Cleanse the wound
A. Using gauze swabs or irrigation: cleanse the cleanse the wound with normal saline
until all exudates has been removed
B. After cleansing apply sterile gauze pad to the wound
C. If a topical antimicrobial ointment or cream is being used to treat the wound use a
swab to remove it.
D. Remove and discard sterile gloves
9. Obtain the aerobic culture
A. Open a specimen tube and place the cup upside down on a firm, dry surface so that
the inside will not become contaminated, or if the swab is attached to the lid, twist
the cap to loosen the swab. Hold the tube in one hand and take out the swab in the
other.
B. Rotate the swab back and forth over clean areas of granulation tissue from the sides
or base of the wound.
C. Do not use pus or pooled exudates to culture
D. Avoid touching the swab to intact skin at the wound edges.
E. Return the swab to the culture tube, taking care not to touch the top or outside of the
tube.
F. Crush the inner ampule containing the medium for organism growth at the bottom of
the tube.
G. Twist the cap to secure.

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H. If specimen is required from other site, repeat the steps. Specify the exact site(e.g.
inferior drain site or lower aspect of incision) on the label of each container. Be sure
to put swab in the appropriately labeled tube.
10. Dress the wound
A. Apply any ordered medication to the wound
B. Cover the wound with sterile wound dressing
11. Arrange for the specimen to be transported to the laboratory immediately. Be sure to
include the completed requisition.
12. Document all relevant information.
A. Record on the client’s chart the taking of the specimen and source.
B. Include the date and time, the appearance of the wound; the color, consistency,
amount, and odor of any drainage; the type of culture collected; and any discomfort
experienced by the client.
6.2.6. Collecting Nose, Throat, and Sputum Specimens
Objective: at the end of this lesson learner will able to:-
1. Assessable necessary equipment
2. take specimen with minimal discomfort and damage
Definition: it is sample taken from nose and throat for diagnosis of respiratory tract or sinus
infections.
Purpose: Examination of sputum may aid in the diagnosis and treatment of several conditions
ranging from simple Upper respiratory tract infections.
Equipment
1. Two sterile swabs in sterile culture
tubes or a flexible wire sterile swab
with cotton tip for nose or throat
cultures
2. Tongue blades
3. Penlight
4. Facial tissues
5. Clean, disposable gloves
6. Nasal speculum (optional)
7. Emesis basin or clean container
8. Sterile specimen cup, or sputum
specimen collector
Procedures
1. Explain the procedure
2. Wash hands
3. Collect the necessary equipment
4. Put on clean gloves.
5. Ask client to sit erect in bed or on chair facing nurse.
6. Prepare sterile swab for use by loosening top from container

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Collecting Throat Culture
7. Ask client to tilt head backward, open mouth, and say “ah.”
8. Depress anterior one third of tongue with tongue blade for better visualization.
9. Insert swab without touching cheek, lips, teeth, or tongue.
10. Swab tonsillar area from side to side in a quick, gentle motion
11. Withdraw swab without touching adjacent structures and place swab in culture tube.
Crush ampule at bottom of tube and push swab into liquid medium.
12. Secure top to culture tube and label with client’s name.
13. Discard tongue depressor, and remove gloves and discard. Wash hands.
14. Document the procedure
6.2.7. Collecting Nose Culture
15. Instruct client to blow nose and check nostrils for patency with penlight.
16. Ask client to occlude one nostril, then the other, and exhale.
17. Ask client to tilt head back.
18. Insert swab into nostril until it reaches the inflamed mucosa and rotate the swab.
19. Withdraw the swab without touching adjacent structures and place swab in culture tube.
Crush ampule at bottom of tube and push swab into liquid medium.
20. Secure top to culture tube and label with client’s name.
21. Comfort patient
22. Remove gloves and Wash hands.
23. Document the procedure
6.2.8. Collecting of Nasopharyngeal Culture
24. Follow Actions 15–23 except use a swab on a flexible wire that can reach the
nasopharynx via the nose.
Important points
1. Standard precautions are used when collecting specimen involving any body fluids
2. Routine specimen collection is usually scheduled for early in the morning
3. Take sputum before brushing or rinsing the mouth and close the container without
touching inside of lid
4. Any specimen collected should be transported to the laboratory immediately to ensure
the most accurate results
5. Sputum specimen collection requires the client to expectorate or cough up secretions
from lower in the respiratory tract. The early morning the most accurate

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CHAPTER SEVEN
MAKING AND MAINTAINING BED
Bed making - is a technique, which provides enough area to the patient on which s/he can be
comfortable.
General instruction
1. Put bed coverings in order of use
Order of Beddings
1. Mattress cover
2. Bottom sheet
3. Rubber sheet
4. Cotton (cloth) draw sheet
5. Top sheet
6. Blanket
7. Pillow case
8. Bed spread
2. Wash hands thoroughly after handling a patient's bed linen
3. Linens and equipment soiled with secretions and excretions harbor micro-organisms that can
be transmitted directly or by hand’s uniforms
4. Hold soiled linen away from uniform
5. Linen for one client is never (even momentarily) placed on another client’s bed.
6. Soiled linen is placed directly in a portable linen hamper or a pillow case before it is gathered
for disposal.
7. Soiled linen is never shaken in the air because shaking can disseminate secretions and
excretions and the microorganisms they contain.
8. When stripping and making a bed, conserve time and energy by stripping and making up one
side as completely as possible before working on the other side.
9. To avoid unnecessary trips to the linen supply area, gather all needed linen before starting to
strip bed.
10. Make a vertical or horizontal toe pleat in the sheet to provide additional room for the client’s
feet.
11. While tucking bedding under the mattress the palm of the hand should face down to protect
your nails.
Note

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 Pillow should not be used for babies
 The mattress should be turned as often as necessary to prevent sagging, which will cause
discomfort to the patient.
7.1. Stripping of a Bed
Definition: Stripping of a bed is removing the bed linen from a bed which had been
previously made-up.
Purpose:
 To prevent cross contamination
 Ventilate the bed and bedding, and
 Prepare the bed for remaking
 To prevent damage of bedding
Precautions
1. No bedding, either clean or soiled, should ever be put on the floor. It should be discarded
in hamper.
2. Do not let your uniform touch the bedding. Woolen blankets are never discarded in soiled
clothes hamper. If soiled, they should be dry-cleaned or washed carefully or treated with
direct sunlight.
3. Use glove it the bed soiled or used by patient
Equipment
 Bedside chair
 Hamper
 Glove as necessary
Procedure
1. wash hand
2. Place chair conveniently at the foot of the bed
3. place pillow on seat of chair
4. Loosen the bedding all around, starting from the right
5. Fold bedspread twice, bring top hem (edge) to bottom hem, pick up from the center.

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6. Fold the blanket and the top sheet in similar manner
7. Place soiled linen in the hamper
8. Place other soiled bedding on chair, and place that which is to be used again, over back of
chair
9. Fold the draw sheet in two and place it over the chair if clean or on the- hamper if soiled.
10. Do likewise with mackintosh.
11. Remove and fold the bottom sheet in the same manner as the bedding
12. Turn mattress from top to bottom or from side to side.
13. Wash hands
14. Recording and documenting
7.2. Making Unoccupied Bed
7.2.1. Closed bed
Definition: Closed bed is a smooth, comfortable and clean bed, which is prepared for a newly
admitted patient.
In closed bed: the top sheet, blanket and bed spread are drawn up to the top of the bed and
under the pillows.
Purpose:
 To receive new patient
 To keep the bed neat and clean until a new patient is admitted
Equipment
 Mattress (1)
 Bed sheets (2): Bottom sheet (1), Top
sheet (1)
 Pillow (1)
 Pillow cover (1)
 Mackintosh/ Rubber sheet (1)
 Draw sheet (1)
 Blanket (1)
 Savlon water or Dettol water in basin.
 Sponge cloth (4): to wipe with solution
(1) to dry (1)
 When bed make is done by two nurses,
sponge cloth is needed two each.
 Laundry bag or hamper (1)
 Trolley (1)
 Clean glove

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Procedure
1. Wash hands and collect necessary materials
2. Place the materials to be used on the chair. Turn mattress and clean the mattress.
3. Move the chair and bed side locker.
4. Clean Bed-side locker, chair: Wipe with wet and dry.
5. Clean the mattress:
 Stand in right side.
A. Start wet wiping from top to center and from center to bottom in right side of mattress.
B. Gather the dust and debris to the bottom.
C. Give wiping as same as procedure 2
 Move to left side.
 Wipe with wet and dry the left side.
6. Move to right side. Start making the bed, Place bot
7. tom sheet with correct side up, center of sheet on center of bed and then at the head of the
bed.
8. Tuck sheet under mattress at the head of bed and miter the corner.
Mitering steps:
A. Face the side of bed and lift and lay the top edge of the sheet onto the bed to form a
triangular fold.
B. With your palms down, tuck lower edge of sheet (hanging free at side of mattress) under
mattress.
C. Grasp the triangular fold, bring it down over the side of the mattress and tuck the sheet
smoothly under the mattress Straighten the free hanging sheet on mattress side.

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9. Remain on one side of bed until you have completed making the bed on that side.
10. Tuck sheet on the sides and foot of bed, mitering the corners.
11. Tuck sheets smoothly under the mattress, there should be no wrinkles.
12. Place rubber and draw sheet at the center of the bed and tuck smoothly and tightly.
13. Place cotton draw sheet on top of rubber draw sheet and tuck. The rubber draw sheet should
be covered completely.
14. Place top sheet with wrong side up, center fold of sheet on center of bed and wide it at head
of bed.
15. Tuck sheet of foot of bed, mitering the corner.
16. Place blankets with center of blanket on center of bed, tuck at the foot of beds and miter the
corner.
17. Fold top sheet over blanket
18. Place bed spread with right side up and tuck it.
19. Miter the corners at the foot of the bed.
20. Go to other side of bed and tuck in bottom sheet, draw sheet, mitering corners and
smoothening out all wrinkles, put pillow case on pillow and place on bed.
21. See that bed is neat and smooth
22. Leave bed in place and furniture in order
23. Wash hands
24. Recording and documenting.
7.2.2. Open bed
Definition: Open bed is one which is made for an ambulatory patient are made in the same way
but the top covers of an open bed are folded back to make it easier of a client to get in.

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Purposes of making open bed
 To provide clean and comfortable bed for the patient
 To reduce the risk of infection by maintaining a clean environment
 To prevent bed sores by ensuring there are no wrinkles to cause pressure points
Equipment
 Two large sheets
 Rubber draw sheet
 Draw sheet
 Rubber sheet (Mackintosh)
 Blankets
 Pillow cases
 Bed spread
 Clean glove
 Chart
Procedure
1. . Wash hands and collect necessary materials.
2. . Place the materials to be used on the chair. Turn mattress and arrange evenly on the bed.
3. . Place bottom sheet with correct side up, center of sheet on center of bed and then at the head
of the bed.
4. . Tuck sheet under mattress at the head of bed and miter the corner.
5. . Remain on one side of bed until you have completed making the bed on that side.
6. . Tuck sheet on the sides and foot of bed, mitering the corners.
7. . Tuck sheets smoothly under the mattress, there should be no wrinkles.
8. . Place rubber and draw sheet at the center of the bed and tuck smoothly and tightly.
9. . Place cotton draw sheet on top of rubber draw sheet and tuck. The rubber draw sheet should
be covered completely.
10. Place top sheet with wrong side up, center fold of sheet on center of bed and wide it at head
of bed.
11. Tuck sheet of foot of bed, mitering the corner.
12. Place blankets with center of blanket on center of bed, tuck at the foot of beds and miter the
corner.
13. Fold top sheet over blanket

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14. Place bed spread with right side up and tuck it.
15. Miter the corners at the foot of the bed.
16. Go to other side of bed and tuck in bottom sheet, draw sheet, mitering corners and
smoothening out all wrinkles, put pillow case on pillow and place on bed.
17. See that bed is neat and smooth
18. Leave bed in place and furniture in order
19. Wash hands
20. Recording and documenting
7.3. Making an unoccupied Bed
Definition: An occupied bed is a bed prepared for a weak patient (bed ridden) who is unable to
get out of bed.
Purposes
 To provide comfort and to facilitate circulation of the patient
 To provide cleanliness and facilitate position of the patient’s bed
 To conserve patient’s energy and maintain current health status
 To comfort the patient
Equipment
 Two large sheets
 Draw sheet
 Rubber sheet (mackintosh).
 Pillow case
 Pajamas or gown, if necessary
 Spread sheet
 Chart
 Clean glove
Procedure
1. Wash hands and collect equipment
2. Explain procedure to the patient
3. Carry all equipment to the bed and arrange in the order it is to be used.
4. Make sure the windows and doors are closed.
5. Make the bed flat, if possible

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6. Loosen all bedding from the mattress, beginning at head of the bed, and place dirty pillow
cases on the chair for receiving dirty linen.
7. Have patient flex knees, or help patient do so. With one hand over the patient’s shoulder and
the other hand over the patient’s knees, turn the patient towards you. Never turn a helpless
patient away from you, as this may cause him/her to fall out of bed.
8. When you have made the patient comfortable and secure as near to the edge of the bed as
possible, go to the other side carrying your equipment with you.
9. Loosen the bedding on that side.
10. Fold, the bed spread half way down from the head. Fold the bedding neatly up over patient.
11. Roll dirty bottom sheet close to patient
12. Put on clean bottom sheet on used top sheet center, fold at center of bed, rolling the top half
close to the patient, tucking top and bottom ends tightly and mitering the corner
13. Put on rubber sheet and draw sheet if needed.
14. Turn patient towards you on to the clean sheets and make comfortable on the edge of bed.
15. Go to the opposite side of bed. Taking basin and wash cloths with you, give patient back
care.
16. Remove dirty sheet gently and place in dirty pillow case, but not on the floor.
17. Remove dirty bottom sheet and unroll clean linen.
18. Tuck in tightly at ends and miter corners.
19. Turn patient and make position comfortable.
20. Back rub should be given before the patient is turned on his /her back
21. Place clean sheet over top sheet and ask the patient to hold it if she/he is conscious. Go to
foot of bed and pull the dirty top sheet out
22. Replace the blanket and bed spread
23. Miter the corners
24. Tuck in along sides for low beds
25. Leave sides hanging on high beds
26. Turn the top of the bed spread under the blanket
27. Turn top sheet back over the blanket and bed spread

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28. Change pillowcase, lift patient’s head to replace pillow. Loosen top bedding over patient’s
toes and chest.
29. Be sure the patient is comfortable
30. Clean bedside table
31. Remove dirty linen, leaving room in order
32. Wash hands.
33. Recording and documentation
NB: If a full bath is not given at this time, the patient’s back should be washed and cared for
7.4. Making cardiac bed
Definition: Cardiac bed is a bed prepared for a patient with heart disease or dyspnea and to
provide easy breathing for patient with minimum strain.
Purpose
 In order to ease difficulty in breathing
 To Provide comfort and safety
 To relieve dyspnea
 To prevent complication
EQUIPMENT
 Linens
 Bed spread
 Blanket
 Extra pillows (4 – 6 Pillows)
 Pillowcase
 Cylinder with oxygen
 Draw Sheet
 Footrest& back rest
 Rubber sheet
 Over bed table
Procedure
1. Wash your hands
2. Assemble the necessary equipment and carry to bed side
3. Place chair at the foot of the bed

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4. Arrange the linen on chair in the order that it will be used
5. Turn mattress and arrange on the bed.
6. Put on mattress cover if available
7. Place bottom sheet with right side up, center of sheet on center of bed and wide hem at the
head of the bed.
8. Tuck sheet under mattress at head of bed and miter the corner.
9. Remain on one side of bed until you have completed making the bed on that side.
10. Tuck sheet on the sides and foot of bed mitering the corners.
11. Tuck sheets smoothly under the mattress. There should be no wrinkles.
12. Place rubber draw sheet in the center of the bed and tuck tightly.
13. Place cotton draw sheet on top of rubber draw sheet and tuck. Rubber draw sheet should be
covered completely.
14. Place top sheet with wrong side up, center fold sheet at center of bed and wide hem at foot of
bed.
15. Tuck sheet at foot of bed mitering the corner.
16. Place blankets with center of blanket on center of bed and tuck at the foot of bed and miter
corner. Fold top sheet over blanket.
17. Place bed spread with right side up. Tuck at the foot of bed miter corners and cover top
bedding.
18. Go to other side of bed fanfold the top covers at the center of bed and tuck in bottom sheet
and draw sheet mitering corners, smoothing out all wrinkles, continue with blanket and
spread the same with the opposite side.
19. See that bed is neat and smooth
20. Put bed in semi fowler’s position by raising the head of bed; if bed is gatched raise at the
head of bed if bed is normal bed put extra pillows.
21. Put footrest to prevent the patient from sliding down.
22. Place over bed table over the bed and a pillow over it to allow the patient’s hands to rest on
it.
23. Wash the hand thoroughly

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24. Record in the nurse’s order of any observation made on the patient
7.5. Post-operative/anesthetic bed making
Definition: - Anesthetic bed is a bed especially prepared to receive a patient after surgery and
major recovery from general anesthesia.
Purposes
 To facilitate easy transfer of the patient from stretcher to bed.
 To facilitate removal of secretion
 To protect the mattress and bedding from bleeding, vomiting, drainage or discharges.
 To protect the patient from becoming chilled or give warmth.
Equipment
A. For bed making
1. Two large sheets.
2. Draw sheet(two)
3. Bath blanket
4. Woolen blanket
5. Rubber sheet (Mackintosh)
6. Two tongue blades or a mouth gag.
7. Small towel.
8. Pillow case
9. Spread sheet
10. Additional Sheets and blanket
11. bed blocks as needed
12. An extra rubber sheet & draw sheet for operated areas
B. For first aid activity
1. Emergency drug
2. Minor set
3. Vital sign equipment
4. Suction machine
5. Oxygen cylinder
6. Sterile Suction catheter
7. Sterile glove
8. Examination lamp (at hand if
needed).
9. Airway tube
10. Sterile drainage bottle with tubing,
11. IV Stand.
12. Emesis basin and paper bag.
13. Iv fluid
14. Hot water bag
15. Safety pin
16. Bed cradle
17. Tissue paper

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18. An emesis basin 19. Chart
20. Paper and pen for recording vital signs and charting
Procedure
1. Wash your hand & prepared equipment
2. Strip the bed
3. Make the foundation of the bed as usual with large sheet, rubber draw sheet, bath blanket,
draw sheet, etc.
4. Place one rubber sheet where the site of operation will rest
5. Place other rubber sheet across head of the bed where head will lie to protect bed from
vomitus}
6. Cover each rubber sheet with draw sheet tucking it firmly under matters
7. Place top bedding as before but do not tuck in the bottom. Fold down the top as you would
do in an occupied bed.
8. Then fold the bottom of the linens up so that the fold is even with the bottom of the
mattress. Do not tuck the linen in. Unfold the top linens to the side so that they lay opposite
from where you will place the client’s stretcher. Alternatively, you may fanfold the linens
to the foot of the bed. Leave a tab on top for easy grasping.
9. In cold season, place hot water bottles in middle of the bed, and cover with fanfold top
bedding temperature of hot water is never to exceed 50°C (122°F).
10. Have two or more pillows available, but do not put them on the bed. Rationale: A pillow
may be contraindicated for a client; usually the physician or charge nurse will determine
when it is safe for the client to have one.
11. Place pillow at the head of the bed between bed & mattress and tie it back with a piece of
bandage to protect had of patient.
12. Place all necessary materials at the side of the bed opposite to the stretcher on which the
patient will come
13. Arrange emergency equipment {B/P apparatus ,suction machine, Drug}
14. Close the windows. Leave the room clean and in order
15. Receiving the patient from operation room

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A. Remove folded to cover of the bed
B. Place the patient on bed and cover quickly
C. See that patient is properly placed in bed with head to the left side and comfortable
D. Check patient s condition operated area, urine, vital sign, color of patient etc.
E. Do after care and comfort the patient after procedure
16. Return used equipment to utility room and wash your hand
17. Proper documentation
7.6. Marking an amputation bed
Definition
A. Amputation: - is the surgical removal of a part of the body or a limb, performed to treat
recurrent infections or gangrene in peripheral vascular disease, to remove malignant tumors,
& in severe trauma.
B. Amputation bed/ stump bed is a regular bed with cradle, which is prepared for amputated
patient.
Purpose
 To give extra warmth
 To leave the part open for observation.
 To ensure more safety and comfort by preventing soiling and staining.
 To keep the stump in a good position
 To prevent jerky movements for the amputated leg
 To prepare for emergency, to have easy access and economy of time and energy
Equipment
1. Linens (3)
2. Pillow
3. Blanket (2)
4. Pillow case
5. Bed cradle
6. Trolly

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7. sponge
8. safety pin
9. Draw sheet
10. face &bath towel
11. Tourniquet
12. Rubber sheet
13. Mackintosh
14. Small rubber sheet with cover
15. Dressing set
16. Sand bags with cover

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Procedure
1. Wash hands thoroughly
2. Collect equipments arrange fresh folded linens in following order on trolly. (blanket, towel, sponge, face
and bath towel, draw sheet , mackintosh , bottom sheet, mattress cover)
3. Clean mattress, similar with open bed
4. Cover mattress with fresh cover and tuck firmly
5. Spread long mackintosh length and top to bottom covering mattress
6. Spread bottom sheet and tuck neatly
7. 7. Top sheet, draw mackintosh and draw sheet will be received along the patient which should be
firmly tucked
8. To make the lower half, use one sheet and blanket, for upper also, one top sheet and blanket
9. Keep the lower half of the bed overlapped with the upper half as, in this way, we can easily separate the
two halves and observe the stump
10. Elevate the stump over the soft pillow covered with mackintosh
11. Place the sand bags on either side of the stumps to prevent it from jerking, sand bags help prevent
bleeding from jerking
12. Bed cradles are used to take up the weight of the bed linen
13. Cover the patient and make the unit tidy.
14. Wash the hand thoroughly
15. Document in the nurse’s order of any observation made on the patient
7.7. Fracture bed making
Definition: Fracture bed is a hard firm bed designed for a patient with fracture.

Purpose
 To give firm, even support to the broken limbs and back.
 To maintain position.
 To make the patient comfortable.
 To provide a flat, unyielding surface to support the fractured limb.

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Equipment
 Articled as for a closed bed
 Small blanket or draw sheet
 fracture board
 Bed cradle
 Small rubber sheet
 Draw sheet
 Sand bags
 Pillow if required
Procedure:
1. Place the fracture board directly over the bed springs and the mattress on it. If the mattress is
thin, an extra mattress must be added to prevent pressure sore due to pressures on the head
surface.
2. Make the bottom bed as usual, and then place the small rubber sheet covered with draw sheet
at the place where the injured part will be resting. The small rubber and draw sheet are easier
to change then the whole bed. This applies specially to an arm or a leg, which is bleeding or
has discharge.
3. Fold back the bed cloths at foot of the bed for leg fracture. Cover the uninjured limb with a
small blanket. On draw sheet placed the cradle over the linen to adjust the cover over it.
Extra blanket and spreads may be necessary. Be sure that the covers come high enough on
the shoulder
4. Do after care and comfort the patient after procedure
5. Return used equipment to utility room and wash your hand
6. proper documentation
N.B:
 Never cover a plaster cast until it is thoroughly dry.
 The fracture board keeps the bed with no danger of sagging. It is also used for
fracture of the spine. A bed cradles are a frame made of wire wood or iron .it is used
to keep the top cover from touching the injured part.
7.8. Baby crib
Objective: At the end of this lesson learner will be able to:
1. Define a baby crib
2. List the purpose of baby crib

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3. Prepare equipment for baby crib
4. Apply the correct steps in Preparing baby crib
Definition: A the bed that prepare for pediatrics case with bed side safety
Purpose
 To make comfort for baby with safety
Equipment
 The same with closed bed
Procedure
1. Place baby at the foot of bed
2. Loosen bottom sheet at head
3. Place clean bottom sheet and tuck in
4. Place small rubber sheet or water proof pad on top
5. Place baby at the head of bed
6. Remove soiled linen and tuck clean bottom sheet mitering corners
7. Place clean top sheet and tuck at the bottom
8. Place blanket and tuck, and place baby bed spread
9. Complete making bed on both sides
10. Raise side rails of bed and leave baby comfortable in bed.

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CHAPTER EIGHT
HYGIENE CARE AND GROOMING
Objective: At the end of the Lesson, the learner will be able to demonstrate basic hygienic skills such as
bathing, shampooing hair, perineal care, foot care, back massage, toileting and bed making.
8.1. Bed bath
Definition: - Is a bath given to a patient who is unable to give care for him/her self.
Purposes
 To promote comfort relaxation and
cleanliness
 To stimulate circulation
 To prevent bad body odors
 To prevent pressure sores
 To relax and refresh the patient
 Maintain muscle tone & joint
mobility
 To improve self-image
 To give an opportunity for the nurse
to assess patients
 To prevent multiplication of
pathogenic microorganisms on the
skin surface.
Indication:
 Patients who are weak
 seriously ill and for pt that has certain heart conditions
 unconscious, paralyzed or confused patient
Precautions
 Avoid scratching the skin with jeweler or long sharp fingernails.
 Avoid harsh scrubbing, use of rough towel or wash clothes.
 Assess the status & level of mobility.
 Maintain adequate privacy and warmth throughout the procedure and drape
appropriately.
 Identify if there are limitation of movements or position for pt.
 Bath water must be warm enough and change throughout the procedure when it
becomes cool, too soapy, dirty or after washing the genital area
 Always wash from clean to dirty.
 Determine allergies to soap and other cream lotion.

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 Clean the eyes with water from the inner to the outer cantus.
Equipment
 Washcloth (2)
 Washbasin (2)
 Bath towels (2)
 Basin and jug with warm water
 Pajama
 Oil, cream, lotion/powder
 Soap with soap dish
 Nail cutter
 Bath blanket
 Trays for nail care or mouth
care if necessary
 Bed making materials
 air freshener
 Face towel
 Lotion thermometer
 Bed pan or urinal
 Comp and brush
 Glove’s disposable
 Screen
 Deodorant
 Humber for soiled cloths
 Trolley
Procedure
1. Assess the patient condition and Explain procedure to pt.
2. Wash your hands
3. Assemble the necessary equipment for bed bath.
4. Before starting bath, offer bedpan or urinal, remove bedpan or urinal; find out what linen
is needed.
5. If the patient is in the ward, screen patient and remove unnecessary articles from bed side
table, place linen on chair in order of use and bring bath basin with hot water. and adjust
the bed at the level of you to prevent back strain
6. Remove top bedding, fold and place over back of chair. If there is no chair, it should be
placed on foot of bed. Cover the patient with bath blanket. Have patient move to near side
of bed and remove gown. Remove pillow unless this is uncomfortable for patient.
7. Use pillow for turning patient if necessary; otherwise, remove soiled pillowcase; place
soiled gown in it and place it on chair or foot of bed between matters and foot of bed.
8. Wash eyes with clean water only and face of patient before the other parts of the body.
9. Do not expose patient unnecessary.

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10. Work quickly and smoothly. Watch for signs of fatigue during bath; report and chart any
reddened spots, rash, sores or swelling. Change water as often as necessary. Never use
dirty or soapy water.
11. Remember to protect the bed from dampness by placing bath towel
each part of body during bath.
12. Place one hand under each part to support it while washing and
drying the extremities.
13. Using long, firm, even strokes, wash from wrist to shoulder. Place basin on towel on side
of bed and allow patient to put hands in water. Wash, take basin away, dry thoroughly.
14. Bath chest, dry and cover with towel, then bath abdomen.
15. Flex knee on far side, uncover leg and thigh and drape to protect bed. Wash and dry leg.
Do the same for the other leg.
16. Get clean, warm water and turn patient on side. Spread towel close to body, wash back
and hips well. Rinse and dry carefully.
17. Rub back with alcohol and talcum powder or soapy water using whole flat of hand and
long smooth strokes. Use a circular movement around the reddened areas or over boney
prominences. If soap is used, clean it off after the rub.
18. Place towel under hips. Put basin and soap within easy reach of the patient.Give him
thewashcloth if he is able to wash the genitalarea sothat he may finish hisbath. If the
patient is unable to do so, the nurse should finish the bath by cleaning the genital area of
the patient by wearing the glove.
19. Put on clean gown protect the pillow or bed with face towel and comb patient’s hair. Cut
and clean finger nails and toe nails.
20. Make the bed and leave patient comfortable.
21. Wash bedside table and take dirty linen, bath basins, soap and alcohol to utility room.
Wash basin well, dry and return to cupboard. Return other equipment to proper place.
22. Before you leave patient, ask patient if there is anything else you may do for him within
reach and chart procedure, time and observation.
8.2. Giving tub bath
Objective: At the end of the lesson, the leaner will be able to

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1. Define tub bath
2. Identify necessary equipment
3. Demonstrate the procedure of tub bath
Definition: Type of bath that allow direct washing and rinsing by using shower
Shower: - The pt is assisted to the bathroom, sits or stands and spray of water is usually directed
on to the body.
Purpose
 To promote comfort relaxation and cleanliness
 To stimulate circulation
 To prevent bad body odors
 To relax and refresh the patient
 Maintain muscle tone & joint mobility
 To prevent multiplication of pathogenic micro organisms on the skin surface.
Precautions
o Adjust temperature and flow of the water
o Avoid chilling
o Always keep bath room un locked
o Check pt frequently for sign of exhaustion.
o Make sure that the tub shower clean and functioning
o Place disposable rubber or plastic materials on the floor of the shower
o Instruct patient not to use oil during bath
o If sensation is normal, ask client to test water, and adjust temperature if water is
too warm
o
Equipment
a. Soap and soap dish

b. Washcloth

c. Bath towel

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d. Gown
e. Sleeper
f. Chair
2. Comb & Brush
3. Wheel chair ( optional)
4. Bed pan/Urinal
5. Nail cutter
6. Oil/cream/lotion
7. Pajama
Procedure
1. Check the bath room temperature, which should be warmer than the normal room
temperature
2. Make sure the tub is clean. Scour it carefully with disinfectant. Unless using a long-handled
swab, wear glove when cleaning the tub.
3. Rinse the tab well
4. Place a chair near the tub, with a bath blanket opened over it
5. Place towels, washcloth and soap where the client can reach them easily
6. Fill the tub about halfway(less for a child)
7. Test the water with a bath thermometer. Water temperature should be warm to very warm,
but never over 40.6
0
c (105
0
F).
8. Bringing the client to the bathroom and assist patient to undress
9. Assist patient into the tub and avoid falling.
10.Allow patient to bath himself or assist as necessary.
11.Assist patient out of tub and dry his body and put on gown.
12.Return patient to room and put to bed.
13.Clean bathtub and leave room in order.
14.Discard soiled linen.



8.3. Giving back care
Objective: At the end of the lesson, the leaner will be able to
 Define back care

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 Identify the necessary materials for back care
 Perform the procedure of back care
Definition: Is purpose full manipulation (massage) of the muscle and tissues. It is also known as
back message, back rub.
Purpose
 Provide psychological & physical comfort (reduce tension, anxiety stress,
stimulate and relax muscles)
 Increase general and local circulation
 Improves muscle and skin functioning
 Prevent bedsore.
 To relieve insomnia(inability to sleep)
 It provides opportunity for the nurse to assess the patient condition.
Precautions
1 Massage pressure areas gently massage the back by using appropriate technique.-
duration of massage should not exceed 20 minutes
2 Apply the all four patterns of stroke at least three times
 Pertissage (kneading): press on muscle groups or single muscle, picking them up
and squeezing them gently. Use the palms of the hand for the large muscle; use
finger and thumbs for single muscle. Use this for outer aspect of back.
 Effeurage (stroking): massaging upward and down ward from vertebral column,
and back again in the direction of heart.
 Friction: rub around the bony prominence of the clients bony, such as at the end of
the spine and along each shoulder blade.
 Tapping (tapotement): use light tapping with the edge of the hands (the edge
farthest from the thumb) at times to stimulate circulation.
3 Repeated back massage may possibly cause subcutaneous tissue degeneration.
4 Frequent positioning is preferable to back massage
5 Inspect skin areas of pressure points for whitened or reddened areas that do not disappear
after rubbing.
6 Covering areas not being massaged & prevent unnecessary exposure
7 Lubricating palms to decreases friction on skin during massage.
8 Identify location of bony prominences to avoid direct pressure

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Equipment
1. Soap and soap dish
2. Draw sheet
3. Wash cloth
4. Lotion
5. Bath towel
6. Powder
7. Alcohol
8. Screen
9. Basin with water
10. Rubber sheet with its cover
11. Other medication as ordered
12. Air ring, cotton ring as
necessary
13. Pillow
Procedure
1. Assess and explain procedure to patient
2. Wash your hands
3. Assemble the equipment
4. Assist the client to assume either a prone, Sim’s, supine, or sitting position,
depending on client’s condition
5. Place towel under patient’s side
6. Wash with soap and water
7. Apply powder or lotion and rub back. pay special attention to bony Prominences
8. Choose stroke technique based on desired effects

9. Circular movement should be used on bony prominences.
10. Begin with light to medium effleurage at lower back and continue upward
following muscle groups, being careful to avoid the spine and spinal processes.
11. Move hands up toward the base of the neck and continue outward over the trapezius
muscles with circular motions, over and around shoulders and upper arms, and return
with lighter downward strokes laterally over the latissimus dorsi to the upper gluteals

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12. Use lotion to avoid friction and to give lubrication & prevent from dry.
13. Dry back and apply powder.
14. Turn patient on back and put pillow as necessary.
15. Report reddened area on the back.
16. If there is pressure sore (breakage of the skin) sterile dressing should be applied
using whatever solution or ointment is ordered.
17. Clean and return the used equipments in to their proper place.
18. Wash your hands and charting.
8.4. Mouth care
Objectives: - At the end of the lesson, the leaner will be able
1. Define mouth care
2. Identify necessary equipments
3. Perform mouth care
Definition
 Mouth care: -Care of the mouth which includes brushing the teeth, mouth and tongue with
mouth wash solution and rinse it with water
 Routine mouth care:- is providing oral care at least three times a day for hygienic purpose.
 Special mouth care: - Is a care given to entire mouth, teeth, tongue and gum in an increased
frequency using mouthwash solution for helpless patient.
Purpose
 Keep the mouth clean and fresh, which provide the pt sense of well being.
 Stimulate appetite
 Prevent dental decays & halitosis (bad breath)
 Remove food particles, dead epithelial cells, microorganisms from around and b/n the
teeth tongue & lips.
 Prevent inflammation of tongue gums & oral mucous.
 Prevent spread of infection to other parts of the body
Indications for special mouth care

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 Is un conscious
 Is not taking oral food or fluid
 Has mouth infection or inflammation e.t.c.
Equipment
 Solutions
 Sodium bicarbonate solution ½ Tsp in 250 ml, of water
 Hydrogen per oxide solution
 Glass of Clean water
 Normal saline solution
 Lemon juice
 Other mouth wash solution if a specially ordered.
 Mouth gag
 Emesis basin
 Glycerin/petrolatum
 Cotton tipped application
 Receiver
 Towel
 Tissue paper or piece of gauze

 Denture care cup

 Toothbrush and paste

 Forceps

 Sputum mug
 Tongue depressor wrapped with
gauze bandage
 Lubricate (liquid paraffin or mineral
oil, cold cream, glycerin , Vaseline)
 Drinking tube (straw)
Procedure
1. Explain procedure to the patient and wash your hands
2. Have all equipment read on the bed side table
3. Set on the semi sitting position and up the head of the bed
4. Place towel under patient’s chin across his/her chest
5. Turn patient’s head to the side and arrange basin at corner of the mouth.
6. Dip applicator in mouth washes solution and cleans the inside of the mouth, the tongue, and
the teeth gently and carefully.
7. Discard the swab.
8. If the teeth are difficult to clean, a larger swab can be used. This is done by Wrapping several
turns of cotton around a tongue depressor.

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9. If the tongue or lips are dry and cracked, moisten an applicator with lubricant and gently
wipe them with mineral oil, liquid paraffin, Vaseline or any suitable cream. A mixture of
lemon and glycerin is also good.
10. If he/she is unconscious, hold the mouth open with a tongue depressor padded with gauze.
11. This care should be done in the morning, at night and after each meal if possible.
12. Wait at least ten minutes after patient has eaten to prevent nausea. Do not go far back on the
patient’s tongue as it may gag him.
13. Chart – procedure, time and observation.
8.5. Care of dentures
Objectives: - At the end of the lesson, the learner will be able
1. Identify necessary equipments
2. Perform care of denture
Definition:-it is a care for artificial teeth.
Purpose
 To Freshens mouth and facilitates intake of solid food.
 To remove microorganisms
Equipment:
 Denture brush
 Denture cleaner
 Emesis basin
 Towel
 Cup of water
 Non sterile gloves
 Denture cup
 Tissue paper

Procedures
1. Assemble articles for denture cleaning.
2. Provide privacy.
3. Assist client to a high-Fowler’s position.
4. Wash hands and don gloves.

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5. Assist client with denture removal:
Top denture:
• With tissue, grasp the denture with thumb and forefinger and pull downward.
• Place in denture cup.
Bottom denture:
• Place thumbs on the gums and release the denture. Grasp denture with thumb and
forefingers and pull upward.
• Place in denture cup
6. Apply toothpaste to brush and brush dentures either with cool water in the emesis basin or
under running water in the sink.
7. Rinse thoroughly.
8. Assist client with rinsing mouth and replacing dentures.
9. Reposition client, with side rails up and call button within reach
10. Rinse, dry, and return articles to proper place
8.6.Giving bedpan and urinals
Objectives: - At the end of the session the student will be able to:-
 Identify necessary equipments for offering bedpan and urinals
 Offer and receive bed pan and urinals
Definition: -Giving bedpan and urinals is the process of giving bedpan or urinal for pts in bed.
Purpose
 To provide receptacle for elimination of waste material for clients confined to bed.
 To obtain specimen of urine or stool for laboratory examination.
 To obtain an accurate measurement or assessment of the client’s urine or stool.
Indication
 Bed ridden patients
 Patient with problem of the spine
 Patient with cast or fracture
 For critically ill patients

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 Post operative patients
Type of bed pans
 Regular bed pans-made of metal or hard plastic ,has a curved smooth upper end and
tapered lower end
 A fractured pan- designed for clients with body or legs casts or clients restricted from
raising their hips

Type of urinals: Males, Females
Time
 Early morning, after each meal and at
bed time-PRN (when required).
 For maternity patients four hourly during
the day.
 For patients with diarrhea or dysentery-
PRN (when ever necessary).
 In case of frequency of urine-PRN.

Equipment
1. Bedpan or urinal and cover
2. Toilet paper(toilet tissue)
3. Disposable gloves
4. Specimen container as necessary
5. Basin in which soap and water,
may or may not be necessary
6. Air fresher (optional)

Procedure
1. explain the procedure
2. wash hand
3. assemble equipment
4. keep privacy
Fracture bedpans
Regular bedpans

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5. Obtain a bedpan, if one is not available in the bed side cabinet
6. Put on glove
7. Raise the bed to a comfortable height. Lower the near side rail
8. Fold the bed linen away from the client, exposing as little of his or her body as possible.
9. Place an incontinence pad on the bed if the client is confused or if using a fracture pan
10. Warm and dry the outer of the bedpan and carry to bed side and place in on a chair
11. Assist the client on to pan. If the client is able to help, encourage him/her to flex the knee
and lift the hips:
 Place the bedpan under the buttocks, with the round curved end toward the clients
back and the narrower opened end toward the feet.
 Turn back covers at the side. Place free hand under patient’s buttocks and have
him flex knees and help in lifting his body. With the other hand adjust bedpan
under him.
 If the patient unable to use regular bed pan use a fracture bedpan. Place it under
the buttocks with the flat end toward the client’s back.
12. If the client is immobile, roll the client onto his or her side away from you. Position the
bedpan against the client’s buttocks, hold it firmly in place and turn the client onto his or
her back. Check the pans location
13. Replace the bed linen over the client
14. Elevate the head of the bed to semi-fowler’s position if the client can tolerate it. Raise the
side rail again.
15. Place the call light and toilet tissue within the client’s reach and leave him or her alone if
possible. Tell the client to call if he or she needs help and also when finished. If leaving
the bedside, remove gloves and wash hands.
16. To remove the bedpan:
A. Wash hands and put on gloves
B. Lower the side rail and the head of the bed
C. Uncover the client
D. Fold the toilet tissue and wipe from the front(pubic area) to the back (anus) if the
clients is unable to do so independently

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E. Steady the bedpan as the client either lift the hips or is assisted to turn away from
you.
F. Place the bed pan on the chair cover it.
G. Cleanse the area with soap and water if necessary. Shaving-cream lather works
well and is soothing. Dry carefully.
17. Offer hand washing supplies to the client
18. Return the client to a comfortable position. Lower the bed and raise the side rail. Use air
freshener if necessary.
19. Empty the pan into the toilet and rise. Measure output or obtain stool sample if ordered
.remove gloves and wash hands.
20. Document results according to agency policy on flow sheet, intake and output summary
or chart.
Perineal care
Objective: - at the end of the lesson, the learner will be able to:-
1. Define Perineal care
2. Identify necessary equipments
3. Perform Perineal care
Definition
 Perineal care:- is a cleaning procedure prescribed for cleansing the perineum and
genitalia of male or female patient. It can be clean or sterile procedure.
 Routine Perineal care: - Is done for hygienic purposes routinely twice a day and more
frequently during menstruation and excess vaginal discharge.
 Special Perineal care: - Is a care given after various procedures for therapeutic and
preventive purpose using strict aseptic technique.

Purpose
 To remove normal perinea
secretions and odors
 To prevent infection
 To promote client comfort
 To facilitate healing
 To prevent irritation and
ulceration of the genitalia.

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Indication
 Infection on the genital and
perineum
 Surgery of the genitalia and
perineum
 Post delivery
 Incontinent patients
 pts with indwelling catheter
 Abnormal or un pleasant
discharge from the genitalia.
Equipment
1. Pitcher or container with warm water
2. Prescribed solution
3. Sterile forceps or glove
4. Protecting materials ,draw sheet
5. Gauze swabs
6. Sterile Perineal pad
7. Bowl or kidney basin
8. Bed pan/urinals
9. Screen
Procedure
1.Prepare tray or trolley with the above equipment, cover & take to patient’s room.
2. Explain procedure to patient.
3. Assist patient to use bedpan.
4. Remove soiled pad and place in bowel or kidney basin.
5. Move tray or trolley near bed.
6. Fold the blanket to foot of the bed
7. Flex patient’s knees and cover with top sheet.
8. Take the sterile cotton swabs with forceps, pour solution on the cotton and clean
perineum using downward strokes. Use only one cotton swab for each strokes.
9. Repeat cleansing the perineum pouring the solution over the genitalia.
10. Avoid hurting the perineum with the forceps. Be careful with episiotomies stitches
11. Dry perineum and genitalia thoroughly using cotton swabs. If patient has episiotomy
observed for any signs of infection – swelling, discharge etc. medicated powder or
solution may be applied according to the orders.
12. Remove bedpan
13. Turn patient on one side and dry anal area.
14. Place perineal pad across perineum.

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15. Avoid contaminating the inner side of pad
16. Apply T – Binder ( as needed)
17. Straighten bed and leave patient comfortable
18. Remove soiled article, clean and return to their proper places. Perinea swabbing should
be done at least three times daily and each time following bowl movement.
8.7. Sitz bath
Objectives: - At the end of the lesson, the learner will be able
1. Define sitz bath
2. Identify necessary equipments
3. Demonstrate how to perform sitz bath
Definition: A sitz bath can refer to a bath where the pelvic region is immersed in warm water, or
to a type of tub, which makes taking the sitz bath easier.
Purpose
 To cleanse perineal area
 To soothe perineal are
 To reduce sign of inflammation of perineal ,vaginal area after child birth
 Cleanse and soothe and reduce inflammation after vaginal or rectal surgery
 Hemorrhoids or fissures
Indication
 Following surgery in anorectal region
 Following incision in the perineal(episiotomy)
 Swollen painfull hematoma

Contraindication
 DM and Peripheral vascular function
 Impaired peripheral sensory function
 Immediate post hemorroidioctomy
Equipment
1. Large Basin 2. Fenestrated chair (sitz bath chair)

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3. Glove
4. Bath thermometer
5. Tissue paper or towel
6. Common Medication (Common salt
,KMnO4, Betadine solution)
Procedure
1. Check for specific order
2. Assemble equipment and take to the bath room ( may be given in the room in mobile
sitz bath chair if available)
3. Clean tub and fill half – full.
4. Check temperature of water (must be as patient can bear).
5. Close windows and explain procedure to patient
6. Take patient to the bathroom and assist to undress as necessary.
7. Assist patient to sit in a big bowl of warm water or in a tub.
8. Observe patient’s condition and check pulse. Discontinue treatment if patient feels
dizzy.
9. Avoid chilling, drape shoulders with bath towel.
10. Allow pt to stay in the water for about 20 – 30 minutes, check patient frequently.
11. Assist patient to dry, dress and return to room.
12. Clean bowl or tub and discard used linen.
13. Apply dressing if needed.





8.8. Hand and foot care
Objective : at the end of this lesson, the learnerwill able to
1. Define hand and foot care
2. Perform hand and foot care
Definition: Feet and nail often need special attention. Assess the appearance of feet & nail

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to identify existing problems or clients at risk of developing foot or nail problems.
Purpose:
 To prevent the client’s hands and feet odour
 To soft, hydrated skin.
 To maximized functional ability of hands and feet.
 To make client comfort and relax.
Indication:
 Paralyzed client and geriatric .
 People with diabetic mellitus and clients with poor circulation are at high risk for
foot difficulties/ problems.
Equipment
1. Gloves
2. Bath/washbasin (plastic dishpan, bucket, or wastebasket will work as well)
3. Warm water
4. Towels (1–2)
5. Washcloth (soft but textured)
6. Soap (liquid preferable) or Cetaphil
7. Nail brush (soft)
8. Cotton-tip applicators
9. Nail clippers: one for fingernails, plier-type for toenails
10. Nail scissors (for cutting hangnails)
11. Talcum powder (water absorbent without cornstarch)
12. Body cream, petrolatum, or oil
13. cotton or lamb’s wool pieces
14. bath thermometer
procedure
1. Explain to client planned procedure and
2. Assemble equipment.

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3. Seat client in stable, comfortable chair.
For feet:
 Remind patient not to sit on side of bathtub.
 If bedridden, pull bedding out at the foot of the bed and fold upward to expose
feet/lower legs.
 If bedridden and bathing concurrently, cover client with bath blanket.
4. Place linen saver (or towel) under client’s hands/feet.
5. Wash your hands; apply gloves.
6. Fill basin halfway with warm water. Test temperature and place basin on the linen
saver .
7. Assist (place) client’s hand/foot Immerse into the basin.
 If bedridden, have client bend knees to immerse foot in the water, place a pillow
under the knees , cushion the basin rim with the edge of the towel.
8. Soak hand/foot 2–10 minutes, depending on client’s health and tolerance.
9. Wash hand/foot with soap.
10. Rinse well to be sure all soap is removed.
11. Remove hand/foot from the basin and place directly onto clean towel and dry.
12. 12. Use a towel on any thickened, dry skin areas (usually heels and medial side )
13. Lightly powder between and under fingers/ toes. (Don’t shake directly onto client.)
14. Concurrently assess skin and function. Observe color, shape, texture. Note dryness,
redness, cracks, blisters, discoloration, trauma, pain, numbness, tingling, swelling,
muscle wasting, decreased sensation, hair growth, or pulses, turgor, and capillary
refill.
15. Empty basin and refill. Repeat procedure with other hand/foot.
16. While other hand/foot soaks, perform nail care on the first hand/foot.
 Ask client’s permission prior to cutting nails, especially fingernails.
 Note any areas where toenails may be injuring adjacent toes. Trim to prevent
further damage.
 Cut toenails straight across.

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 Trim fingernails according to client taste. If the client is confused or comatose,
trim to prevent the client from injuring self or others.
17. Lightly apply cream (not lotion), massaging into the hand/foot. Pay special attention
to dry areas. Avoid between and under fingers/toes.
18. “Towel” off any excess cream.
19. Perform range of motion (ROM) exercises (repeat each movement 3–10 times): flex,
extend, rotate clockwise. Place lamb’s wool or cotton to protect areas that are
rubbing or irritated. Put on clean, dry, absorbent (cotton) socks after foot care.
20. Run your hand around the interior of shoes and slippers to be sure there are no
foreign objects or scratchy edges prior to putting them on.
21. Remove, clean, and/or replace equipment/ supplies.
22. Dispose of gloves and wash hands.
8.9. Facial hair shaving
Objective : At the end of the lesson, the learner will able to
1. Demonstrate Facial hair shaving.
Definition:facial hair removal of male clientthat un able to complete self-care.
Purpose :
 to well groomed the client.
 To keep skin integrity.
Equipment
1. Electric razor or disposable razor
2. Shaving cream or soap
3. Warm water
4. Washcloth and bath towel
5. Washbasin
6. After-shave lotion (if the client has no skin irritation and if the client prefers lotion)
7. Mirror

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8. Sharp scissors and comb
9. Gloves
procedure
1. Wash hands and apply gloves
2. Assist the client to a comfortable position. If the client can shave himself, set up the
equipment and supplies, including warm water, and watch the client for safety.
Adjust lighting as needed.
3. Place a towel over the client’s chest and shoulder
4. Position the client. Raise the bed to a comfortable height, move the client to the sink,
or have the client sit in a comfortable position. Fill a washbasin with water at
approximately 44°C (110°F). Check temperature for comfort.
5. Place the washcloth in the basin and wring out thoroughly . Apply the cloth over the
client’s entire face.
6. Apply shaving cream.
7. Take the razor in the dominant hand and hold it at a 45° angle to the client’s skin.
Start shaving across one side of the client’s face. Use the non dominant hand to
gently pull the skin taut while shaving. Use short, firm strokes in the direction hair
grows. Use short, downward strokes over the upper lip area .
8. Dip the razor in water as cream accumulates.
9. Check the face to see if all the facial hair is removed.
10. After all the facial hair is removed, rinse the face thoroughly with a moistened
washcloth
11. Dry the face thoroughly and apply after-shave lotion if desired.
12. Assist the client to a comfortable position and allow him to inspect the results of
your shave.
13. Dispose of equipment in proper receptacle.
14. Wash hands.
8.10. Assisting individuals to dress
Objective: at the end of this session the learner will able to :

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1. Assisting individual to dress
Purpose:
2. To maintain client self esteem
3. To providing protection
4. To promote the client’s dignity
Equipment
1. Suitable clothes
2. Mirror
3. Screen
Procedure
1. Assist the client to select suitable clothes. This may be their own personal clothing or
clothing from the clinical area’s supplies.
2. Ensure privacy
3. Assist client to remove soiled clothing, outer garments first. If necessary assist in
cleansing prior to redressing.
4. Have clothing available and ready to use. If client has limited mobility or limb
injuries as identified during their mobility assessment remove clothing from
unaffected side first.
5. Be aware of wounds, drains and indwelling catheters when removing clothing and
re-dressing client.
6. Give the client time, and encourage them to
7. perform as much of the activity as possible. Remove clothing in a systematic way,
e.g. top to bottom, replacing with clean clothing as each item is removed.
8. Choose clothing with easy fitting fastenings.
9. Give client access to mirror to check overall appearance
10. Ensure client is left comfortable. Record any changed care needs in nursing record.
Giving hair Care

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Objectives: - At the end of the lesson, the learnerwill be able
1. Identify necessary equipments
2. Perform hair care
Equipment
 Brush and comb
 Towel & oil or Vaseline
Procedure
1. Place patient in comfortable position
2. Place towel on top of pillow under patient’s head and shoulder.
3. If hair is badly tangled, comb small part at a time. Oil or Vaseline may be
applied to untangle the hair.
4. If the hair is long, it should be braided and fastened with rubber band.
5. Observe carefully for pedicli or nits
6. Remove towel and leave patient comfortable.
7. Remove hair from comb & brush, wash and dry.
Hair shampoo
Objectives: - At the end of the lesson, the learner will be able
1. Identify necessary equipments
2. Perform hair shampooing
Equipment
1. Bowel with Vaseline
2. Cotton
3. Mackintosh
4. Dustbin
5. Shampoo
6. Kidney tray
7. Comb or fine-toothed comb.
8. Shampoo or soap solution

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9. Hair oil
10. Apron
11. Lukewarm water
12. Towel
13. Protection materials (rubber sheet)
14. Large pitcher of warm water
15. Small pitcher for pouring water
16. Large basin or pail
Procedure
1. Carry equipment to the bedside arrange it.
2. Remove all but one pillow and place on foot of bed.
3. Loosen gown, and cover patient’s shoulder with a towel.
4. Move patient to the edge of bed. Place him on the side with his back towards you.
5. Roll the two sides of the large rubber sheet towards each other. Slip one end of
rubber sheet under patient’s head and the lower end in the basin or pail.
6. Give patient the washcloth to protect his eyes. Cotton may be used in the ears if
desired.
7. Moisten hair, pour on shampoo or soap solution and rub into scalp; wash head
thoroughly, rinse well, and repeat procedure if necessary. Hold pitcher so it will not
be suspended over patient’s face while pouring. Avoid pouring water over fore head.
Dry hair as much as possible after rinsing thoroughly.
8. Draw rubber sheet out from under patient’s head and drop it in basin. Straighten
pillow under head and dry with towel, rubbing briskly. Avoid tangling hair more
than necessary. Dry thoroughly and avoid chilling. Arrange hair according to
patient’s desire.
9. Comb hair using clean comb and brush. Use oil or hair cream as desired by the
patient.

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8.12. Giving pediculosis treatment
Objectives: - At the end of the lesson, the learner will be able
1. Define pediculosis
2. Identify necessary equipments
3. Perform pediculosis treatment
Definition: -Pediculosisis a condition in which the hair is infested with lice or pedicles.
pediculosis treatment: - is an application of pesticides such as gamma benzene
hexachord (BHC)
Purpose
 To kill and remove pedicles and nits from head and hair
 To prevent transmission of pedicles.
 To make patient comfortable
Precaution
 Avoid treatment from interring the eyes, nose and throat
 Apply Vaseline on the fore head to prevent irritation
 Instruct the pt not to wash before 12 – 24 hrs
 Contact family member of the pt and treat then as well.
 Teach the pt and pts relative the importance of keeping the hair and the body
clean.
 Hands must be washed after scratching the hair.
Equipment
1. Gown and cap (for the nurse)
2. Rubber sheet and cover
3. Bowel with swabs -
4. Gauze or cotton
5. Bowel with Vaseline
6. Bowel with medicine to be applied

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7. Kidney tray
8. Comb or fine-toothed comb
9. Dustbin
10. Cape to cover patient after treatment
Procedure
1. Position patient conveniently
2. Wear gown and cap to protect yourself.
3. Place towel and rubber sheet over pillow.
4. Apply Vaseline to forehead and around the edges of hair to prevent skin
reaction.
5. Apply medication on entire head
6. Wrap head with head cover or clean scarf and leave for several hours (12-
24hrs) wash hair.
7. Comb hair with fine tooth comb to remove dead lice.
8. Chart – treatment, time and observation
9. Repeat treatment as needed.
10. Collect used rubber and cover, Send to the laundry separately.

Ca 8.15. Care of eyes
Objectives: - At the end of the lesson, the learner will be able
1. Define eye care
2. Identify necessary equipments
3. Perform care of eyes
Definition:- a care given for eyes with aseptic technique
Purpose
 To prevent infection
 To remove foreign bodies

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Indication
 client’s with artificial eye
 Comatose patients
Equipment
1. Sterile eye-dressing packs
2. Sterile 0.9 per cent sodium chloride
3. Tray for equipment
4. Clinical waste bag
5. Gloves (if risk of contact with blood or body fluids).
6. Apron
Procedure
1. Explain procedure to client
2. Apply apron and wash hands
3. Gather all equipment
4. Ensure privacy for the client
5. Ensure good light source
6. Assist the client into a comfortable position
7. Prepare equipment, wash hands
8. Cover the client’s chest using the towel from dressing pack
9. Instruct client to close their eyes
10. Moisten swab in the solution and gently swab from the inner canthus outwards, using one
wipe. Repeat in the same direction until the eye is free from crusts/discharge. Repeat on the
other eye, all the time observing the general condition of the eyes
11. If the client has an infection, wash hands before moving from one eye to the other and
always swab the non-infected eye first
12. If the eye is to be touched to remove a foreign body, a cotton bud should be used
13. Gently dry the client’s eyelids
14. Remove and dispose of equipment safely
15. Leave the client comfortable. Remove apron and wash hands

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16. Evaluate care delivery, document and report any change in client’s condition
17. Update care plan as necessary
8.16. Ear care/irrigatio
Objective: - At the end of the lesson, the learner will be able
1. Define ear irrigation
2. Identify necessary equipments
3. Perform ear irrigation
Definition: - Ear irrigation is the process of flushing the external ear canal with sterile water
or sterile saline.
Purpose
 To remove ear wax or foreign object lodged in the ear canal. Less invasive than
using an instrument
Precautions
 The ear canal should be examined with an otoscope prior to ear irrigation
 Ear irrigation is contraindicated if the eardrum is ruptured, because the procedure
may force bacteria through the perforation into the inner ear
 Ear irrigation is also contraindicated in patients with fever and ear pain, as these
symptoms may indicate an inner ear infection.
 If a foreign object is made of vegetable matter (e.g., a bean or pea), irrigation is
contraindicated because the water will cause the object to swell and complicate
extraction of the object.
Equipments
 Irrigating solution at room temperature: Example Luke water
 A container for the solution.
 A syringe or bulb suction(50–60-cc syringe (20–30-cc syringe for children) or ear irrigation
set)
 A small basin/kidney dish as receiver

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 A towel
 cotton ball
 Hydrogen per oxide solution
Procedure
1. Wash your hands
2. Wipe out the ears with a clean wash cloth and remove the excess wax. Usually you can
loosen the wax by pulling the ear lobe downward.
3. If the wax can still not be dislodged, you may need to irrigate the ear canal.
4. To irrigate ear
a) Fill the syringe or bulb suction with the irrigating solution
b) Gently pull the ear lobe up and back to straighten out the ear canal, so that the
solution can flow through the whole canal.
c) Put towel on shoulder at the side of ear of ear to be clean
d) Insert the tip of the syringe or bulb suction into the ear and very gently direct the
solution into the canal.
e) Let the solution drip out with the kidney dish at the ear side and be sure the syringe
does not block it
5. When you have finished, wipe the outside of the ear and ask the patient to turn onto one side
with the ear down.
6. Put a towel under the ear to keep the bed dry.

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CHAPTER NINE
MEDICATION AND FLUID THERAPY
General objective: - At the end of the chapter learner will be able to:-
1. Perform medication withdrawing from a vial and ampoule
2. apply rights of medication administration
3. Identify necessary equipment for administering medication via SC, ID, IM and IV.
4. administer medication and fluid with acceptable technique
5. re-demonstrate how to administer drug via different routes
6. Apply the necessary steps to carry out the proper mixing of drugs
9.1. Medication preparation
9.1.1. Withdrawing Medication from a Vial
Objectives: At the end of this lesson, the learner will be able to:-
1. List the equipments needed to withdraw medication from a vial
2. Perform medication withdrawing from a vial
Definition:Vials are often used to package multi-dose or single-dose parenteral medication. A
vial is a small glass bottle with a rubber seal at the top. Glass vials come with a protective plastic
or metal cap that prevents the rubber from being punctured prior to use.
Purpose
- To prepare needed amount of medication
EquipmentNeeded:
1. Medication vial
2. Syringe with needle
3. Alcohol sponge pad
4. Gloves (optional)
5. Clean work space
6. Medication administration record (MAR)
Procedure
1. Wash hands. Apply gloves (optional).
2. Select the appropriate vial.
3. Verify physicians or qualified practitioner’s orders.
4. Check expiration date.

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5. Determine the route of medication delivery and select the appropriate size syringe and
needle.
6. While holding the syringe at eye level, with-draw the plunger to the desired volume of
medication.
7. Clean the rubber top of the vial with a 70% alcohol pad. Use a circular motion starting at
the center and working out.
8. Using sterile technique, uncap the needle.
9. Lay the needle cap on a clean surface.
10. Placing the needle in the center of the vial, inject the air slowly. Do not cause turbulence.
11. Invert the vial and slowly; using gentle negative pressure, withdraw the medication. Keep
the needle tip in the liquid.
12. With the syringe at eye level determine that the appropriate dose has been reached by
volume
13. Slowly withdraw the needle from the vial. Follow the institution’s policy regarding
recapping needles.
14. Using ink, mark the current date and time and initials on the vial.
15. Label the syringe with drug, dose, date, and time.
16. Wash hands.
9.1.2. Withdrawing Medication from an Ampoule
Objectives: At the end of this lesson, the learner will be able to
1. Mention necessary equipments for withdrawing drugs from an ampoule
2. Practice the procedure according to the steps
Definition:Ampoule is made of clear glass with a constricted neck that must be snapped off to
allow access to the medication. It contain volumes from 1ml to 10 ml or more
Purpose:
- To make drugs available for injection
- To avoid medication errors
Equipment Needed:

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1. Medication ampoule
2. Sterile gauze pad or alcohol pad
3. Syringe with filter needle
4. Replacement needle
5. Clean work space
6. Medication administration record (MAR)
Procedures
1. Wash hands.
2. Select appropriate ampoule
3. Select syringe with filter needle.
4. Obtain a sterile gauze pad.
5. Select and set aside the appropriate length of needle for planned injection.
6. Clear a work space.
7. Observe ampoule for location of the medication.
8. If the medication is trapped in the top, flick the neck of the ampoule repeatedly with your
fingernail while holding the ampoule upright
9. Wrap the sterile gauze pad around the neck and snap off the top in an outward motion.
10. Invert ampoule and place the needle into the liquid. Gently withdraw medication into the
syringe
11. Alternately, place the ampoule on the counter, hold and tilt slightly with the nondominant
hand. Insert the needle below the level of liquid and gently draw liquid into the syringe,
tilting the ampoule as needed to access all the liquid.
12. Remove the filter needle and replace with the injection needle.
13. Dispose of filter needle and glass ampoule (including lid) in appropriate container
14. Label the syringe with drug, dose, date, and time.
15. Wash hands.
9.1.3. Mixing medications from two vials into one syringe
Objectives: At the end of this session, students will be able to
1. Mention the purpose of mixing medications in to one syringe

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2. State contraindication of mixing medications
3. List the needed equipments
4. Apply the necessary steps to carry out the proper mixing of drugs
Definition: When giving ordered subcutaneous or intramuscular medication to a client, it
sometimes becomes necessary to mix medications in one syringe from two separate vials.
Purpose
 Avoids the discomfort of two injections
Contraindicated
 When the drugs aren't compatible
 When the combined doses exceed the amount of solution that can be absorbed from a
single injection site
Equipment Needed:
1. Medication administration record (MAR)
2. Medication vials
3. Syringe
4. Alcohol wipes
Procedures
1. Check MAR against the physician’s or qualified practitioner’s written orders.
2. Check for drug allergies.
3. Wash your hands.
4. Gather the equipment needed. Prepare the medication for one client at a time.
5. Check need for one medication to be drawn up before the other.
6. Determine the total medication volume (in milliliters) you will have in the syringe when
you have finished drawing both medications into the syringe.
7. Swab the top of each vial with alcohol
8. Draw air into the syringe equal to the amount of medication to be draw up from the
second vial. Inject air into the second vial and remove the syringe and needle from the
vial

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9. Draw air into the syringe equal to the amount of medication to be drawn up from the first
vial. Inject air into the first vial. Keep the needle and syringe in the vial
10. Pulling back on the plunger, withdraw the correct amount (in milliliters) of medication
from the first vial.
11. Remove the syringe from the first vial and insert it into the second vial. Withdraw
medication from the second vial to the volume (in milliliters) total of both medications
summed together
12. Either leave the needle in the second vial until just prior to injecting the medication or
follow the institution’s policy regarding recapping needles.
13. Wash hands.
9.1.4. Preparing an Intravenous Solution
Objectives: At the end of this lesson, the learner will be able to
1. Identify the indications for iv solution
2. List equipments to prepare an iv solutions
Definition: An IV solution preparation is a method of correcting or preventing a fluid and
electrolyte disturbance.
Indications
 Clients who are acutely ill
 Clients who are NPO after surgery, or
 Have severe burns
Equipment
1. IV solution (bag or bottle)
2. Administration set (vented or nonvented)
3. Extension set IV pole
4. IV line filter
Procedures
1. Wash hands before preparing IV equipment.
2. Check the health care practitioner’s order for the type and amount of solution.
3. Check integrity of the IV solution and equipment.
4. Select IV tubing in accord with agency policy.
5. Prepare IV solution label with client’s name, date, time, additives, and your initials.

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9.1.4.1. Plastic Bag
6. Prepare the IV solution bag for administration
 Remove outer wrapper around IV bag of solution.
 Inspect bag for tears or leaks by noting any moisture on the protective covering.
 Apply gentle pressure and observe for leakage.
 Examine solution for discoloration, cloudiness, or particulate matter by holding the
bag against a dark and light background; if there is any evi-dence of contamination,
do not use and return bag to agency’s dispensing department.
7. Hang IV bag on the IV pole.
8. Remove administration set from the package and close the roller clamp on the IV tubing.
9. Remove the protective cap from the non vented IV tubing spike and maintain the sterility
of the spike.
10. Grasp the port of the IV bag with your non dominant hand. With your dominant hand,
remove the plastic tab covering the port and insert the full length of the spike into the
bag’s port.
11. Squeeze and quickly release pressure on the drip chamber of the IV tubing until the
chamber is one-third to one-half full.
12. Connect IV filter to tubing.
 Remove cap from filter.
 Fit tubing’s male adapter into filter’s female connector, and twist to ensure tight
connection.
 Hold filter so connector joint is pointed down.
 Hold tubing’s end tip higher than the tubing’s dependent loop to displace the air.
 Open roller clamp on IV tubing to prime the tubing and filter (Figure 37-18).
 Tap the filter as the IV solution runs through.
 Close the roller clamp on the IV tubing.
13. Replace the cap on the IV tubing’s free end.
14. Attach a Dial-a-Flo fluid regulator at the end of the IV tubing if fluids are to be
administered with this device. With the cap off the end of the tubing, turn the Dial-a-Flo

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to the open position, open all the tubing regulator clamps, and clear the tubing of air;
close the regulator clamp and replace the cap on the end of the tubing.
15. Tag tubing with date and time and your own initials.
16. Explain to the client what you are doing before taking the IV equipment into the client’s
room.
9.1.4.2. Glass Bottle
17. Repeat steps 1–5.
- Vented tubing is used for glass bottles that are not vented.
18. Prepare the IV solution for administration.
- Check bottle for cracks or leaks.
- Remove metal cap, metal disk, and rubber diaphragm from top of glass bottle, or
remove protective additive cap if pharmacy has added medications to the IV bottle.
- Listen for the escape of air when the rubber diaphragm is removed.
19. Close the roller clamp on the IV tubing.
20. Remove the protective cap from the IV tubing spike and maintain the sterility of the
spike.
21. Place the glass bottle on a firm surface, and, using firm downward pressure, insert the
spike through designated port on the bottle cap.
22. Invert IV bottle (if the bottle is vented, the fluid inside the vent tube will escape), and
hang the bottle on an IV pole.
23. Continue steps 11–16.
9.2. Medication administration
Medication: - is any substance which may be administered in a variety of forms and by different
routes for the purpose of preventing, diagnosing or treating a disease or condition.
9.2.1. Administering oral medication (Per Os) (Po)
Objective: - Atthe end of this lesson, the learner will be able to
1. Identify drugs given by mouth
2. Identify the 8 rights of medication administration
3. List indications and contraindications of oral rout administration
4. Collect necessary equipment’s needed for oral administration

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5. Provide oral drug to the patient
Definition is an administration of medication through the mouth and ensuring that patient
swallows the medicine.
Purpose
 To provide local effects
 To prolong systemic action
 To prevent the disease
 To give palliative treatment
 To give symptomatic treatment
Contraindication
 Vomiting.
 Patient with gastric or intestinal
suction.
 Patient who are unable to swallow.
 Patient on NPO.
 Unconscious patient.
Equipment
A trolley containing
1. A bowl of water for used medication
cup.
2. Towel
3. Measuring spoon.
4. A jag of water (bed side water).
5. Mortar and pestle to crush and
powder the tablet if necessary
6. Kidney dish and paper bag to discard
the waste
7. Chart and medication card.
8. Ordered medication.
9. Straw if necessary.
10. Glass
Producer
1. Explain the procedure to the patient
2. Wash hands
3. Prepare your tray and take it to the patients room
4. Begin by checking the order.(Read the label 3 times)
5. If the patient is allowed to sit assist him to sit
6. Place solution and tablets in a separate container
7. If suspension, shake the bottle well before pouring.
8. Take it to the patient’s bed side.
9. Keep the medication insight at all times.
10. Identify the patient carefully using all precautions (patient’s

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name, bed number…).
11. First give little water to moisten the mouth and then give the
medicine one at a time.
12. Remain with the patient until each medicine is swallowed.
13. Offer additional fluid as necessary unless contra-indicated.
14. Remove the towel and wipe the face with it
15. Position the patient for good body alignment
16. Take all articles to the utility room. /wash dry all articles and put
them in their proper place.
17. Wash hands
18. Recode the medication given, reaction observed, refused or
omitted immediately





9.2.2. Administering sublingual medication
Objective: - Atthe end of this practical lesson, learner will be able to
1. Identify drugs given by sublingual rout
2. List indications and contraindications of sublingual rout administration
3. Collect necessary equipment’s needed for sublingual l administration
4. Demonstrate sublingual drug administration to the patient
Definition: - Is a medication that is placed under the tongue and allowed to dissolve completely
Purpose
 To provide local effects
 To prolong systemic action
 To prevent the disease
 To give palliative treatment
 To give symptomatic
treatment
Indication
 Patient with gastric and intestinal problems
 Patients with gastric and intestinal surgery
Contraindication
 Patients with nausea and
vomiting
 Oral surgery
 Patients with
 Unconscious patient.
 Patients with gastric and
intestinal suctioning

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Precaution
 Tell the patient not to drink liquid and smoke for an hour because some tablets take up to an
hour to dissolve.
 Tell the patient to keep the medication in place until it dissolves completely to insure
absorption
 Tell the patient to avoid chewing the tablet or touching the tablet with the tongue to prevent
accidental swallowing.
 When the client is receiving repeated doses of a buccal medication, the nurse should indicate
the site, such as right buccal cavity, to prevent irritation of the same site.
Equipments
A trolley containing
1. A bowl of water for used medication cup.
2. Towel
3. Kidney dish and paper bag to discard the waste
4. Chart and medication card.
5. Ordered medication.
Procedure
1. Explain the procedure to the patient and assess the client’s
knowledge of the drug and its action
2. Wash hands
3. Prepare your tray and take it to the patients room
4. Begin by checking the order.(Read the label 3 times)
5. If the patient is allowed to sit assist him to sit
6. Take it to the patient’s bed side.
7. Keep the medication insight at all times.
8. Identify the patient carefully using all precautions (patient’s
name, bed number…).
9. Don non-sterile gloves.
10. To give a drug sublingually, ask the client to open the mouth and
lift the tongue; place the drug under the client’s tongue.
11. To give a drug buccally, instruct the client to open the mouth
wide, and place the tablet between the client’s cheek and teeth.

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12. Remove the towel and wipe the face with it if necessary
13. Position the patient for good body alignment
14. Take all articles to the utility room. /wash dry all articles and put
them in their proper place.
15. Wash hands
16. Recode the medication given, reaction observed, refused or
omitted immediately



Fig. Sublingual and buccal areas for medication administration.
9.2.3. Administration of eye drops and ointment
Objective:Atthe end of this lesson, the learner will be able to
1. Describe the purposes of administering eye drops and ointment
2. List equipments needed for application of eye drops and ointment
3. Perform the installation of eye drops and ointment
Definition:Instillation of topical medication in to the eye for local effect
Purpose
 To apply medication to the eye for local effects
 To dilate or contract the pupil
 To treat inflammation and infection

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 To apply local anesthesia prior to operation
 To relieve pain and itching
Precautions
 Never point tip of dropper towards eye always hold dropper parallel to the eye
 Never exert pressure on post- operative cases
 Never use a broken dropper
 The patient should be instructed not to touch the eye
 Never apply expired medication maintain strict aseptic technique and use separate supply
for each eye
 Always see the eyes are absolutely clean before application of medication.
Equipment
1. Eye drop with dropper
2. Eye ointment
3. Cotton balls/eye swabs
4. Receiver
5. Medication administration record
Procedure
1. Explain the procedure to the patient and assess the client’s knowledge of the drug and
its action
2. Wash hands
3. Prepare the equipments
4. Begin by checking the order.(Read the label 3 times)
5. The patient is placed supine or sitting position with head tilted back
6. Hold the lower eyelids open with thumb and index finger, pressing against bones of
socket. Tell pt to look up
(In case of eye ointment open eyelids and gently apply ointment from inner to outer
cantus of the lower lid of both eyes )
7. Apply prescribed amount of medication in to the conjunctiva sac or lower central eyelid
8. Instruct the patient close the eye and roll the eyeball w/c helps to spread the medication
over the entire conjunctiva

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9. Use cotton balls to wipe excess medication with from inner cantus to outer cantus
10. Clean and return used equipments to its proper place
11. Make the patient to the comfortable position
12. Wash your hands very carefully and chart procedure and observations.
9.2.4. Administration of ear drops
Objective:Atthe end of this lesson, the learner will be able to
1. Describe the purposes of administering ear drops
2. List equipments needed for application of ear drops
3. Demonstrate the installation of ear drops
Definition: - installation of ear drop in to the auditory canal
Purpose
 To treat inflammation and infection
of the ear
 To soften ear wax
 To clean the ear canal
 To reduce infection and relieve pain
 To anesthesis
 To kill an insect lodged in the ear
Equipment
Small tray containing
 Medicine with dropper
 Cotton tip applicator
 Normal saline
 Cotton balls
 Receiver
Procedure
1. Explain the procedure to the patient and assess the client’s knowledge of the drug and
its action
2. Wash hands
3. Prepare the equipments
4. Begin by checking the order.(Read the label 3 times)
5. The patient is placed supine or sitting position with head to side and the affected ear up
6. Pull the pinna up and back in case of adult and down and back in case children.

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7. Apply prescribed amount of medication directly in to the ear canal.
8. Place a loose cotton in the outer ear to absorb any excess medicine
9. Keep the patient head turned to the un affected side 10-15 minutes
10. Clean and return used equipments to its proper place
11. Make the patient to the comfortable position
12. Wash your hands very carefully and chart procedure and observations.
9.2.5. Topical Administration
Objectives:-At the end of this lesson, the learners are expected to:
1. List purpose of topical administration
2. Identify patients needed to use topical administration
3. Apply topical medications
Definition: - is application of a drug directly to the body sites (skin or mucus membrane), it is
called topical application.
Purpose:
 to have direct (local) action on a particular site
 To produce systemic effect if
Indications
 Skin infection/ dermatitis
 Burn
 Allergic reaction on the skin
 Extensive wound
Contraindication
- Those who are exposed to sun light
Precaution
- Do not rub the area where medication is applied vigorously as absorption can
be altered.
Equipment
1. Patient's medication record and chart
2. Prescribed medication
3. Gloves
4. Sterile tongue blades
5. Sterile gauze pads

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6. Transparent semipermeable dressing
7. Adhesive tape
8. Solvent (such as cottonseed oil).
Procedures
1. Wash hands.
2. Obtain order for medication with physician or qualified practitioner.
3. Ascertain client’s allergic status.
4. If unfamiliar with medication, read label and read insert or seek appropriate information.
5. Select medication and verify medication with orders (first medication verification).
6. Check expiration date.
7. Read medication label again before leaving medication room or cart as available in
facilities (second medication verification).
8. Take medication to client’s room and introduce self. In some facilities topical
medication used for skin irritations are kept in the client’s room and therefore
verification may be done at the bedside.
9. Ask the client if he or she has had the medication before and its effect and ascertain if
the client has any drug allergies or untoward reactions.
10. Explain the purpose of the medication.
11. Read the label for the third time (third medication verification) and check the client’s
identification band.
12. Position the client appropriately for administration of medication. Keep client draped for
privacy.
13. Put on gloves. If dressing is over area to be treated, remove, discard, and change gloves.
14.If an open wound, clean area to be treated with mild soap (if no allergies or reactions to
soap) and water. If skin is irritated, use only warm water. If administering a systemically
absorbed topical medication, clean the skin surface thoroughly and pat skin dry, leaving no
residues of soap.
14. Assess the client’s skin condition, making notation of circulation, drainage color,
temperature, or any altered skin integrity.
15. Change gloves.

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16. Apply medication according to label. If lotion or ointment, apply a thin layer and smooth
into skin as indicated.
17. If an aerosol spray is used, shake the container and administer according to direction.
Spray evenly over affected area and avoid spraying close to client’s or caregiver’s face.
18. If gels or pastes are used, applicators may be needed. Apply evenly. If applying over an
area with hair growth, follow direction of hair.
19. If powders are used, dust lightly and avoid inhalation by client and caregiver.
20. If nitroglycerin ointment or pastes are used, follow instructions and orders carefully to
administer correct dosage.
- Remove the old ointment strip and clean the old site thoroughly. New ointment
will be applied in different area.
- Cleanse the new site with the appropriate cleaner.
- Squeeze the dose out onto the enclosed. Medication measuring strip Nitroglycerin
paste dosages are measured in inches and applied to the paper measuring strip
before being applied to the client.
Fig squeeze the correct dose out onto the enclosed medication measuring strip
- Flatten the roll of nitroglycerin so the ointment will be spread over a wider area
when applied to the client.
- Apply the measuring paper, ointment side down, to no hair portion of the client’s
body.
- Tape the paper in place.
21. If a transdermal patch is used, follow the manufacturer’s directions and apply the patch
to a smooth, cleaned skin surface.
- Remove the old patch and wash the site of the old patch.
- Wash and prepare the skin at a new site.
- Remove the protective covering over the
- Transdermal portion of the patch and apply the new patch
22. Remove gloves; wash hands.
23. Document the medication given, the site it was applied to, and the client’s response to
the medication.

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9.2.6. Instillation of nasal drops
Objective: Atthe end of this lesson, the learner will be able to
1. Describe the purposes of administering nasal drops
2. Assemble equipments needed for application of nasal drops
3. Demonstrate the installation of nasal drops
Definition: installation of medication in to the nose in the form of nasal drop
Purpose
 To relive nasal congestion
 To treat pain and inflammation of the nasal cavity
 To prevent and control bleeding
Precaution
 Avoid touching the tip of the nose with dropper since it may contaminate
 Avoid touching the inner surface of the nose with dropper since it cause the patient to
sneeze
 Do not use oily solutions as nasal drops since it interferes with the normal cilary’s action
 Do not use decongestants excessively or frequently as they became ineffective and may
actually worsen the patients nasal congestion
Equipment
Small tray containing
 Medication with rubber tipped dropper
 Cotton balls / handkerchief
 Receiver
 Cotton tipped applicator
Procedure
1. Explain the procedure to the patient and assess the client’s knowledge of the drug and its
action
2. Wash hands
3. Prepare the equipments
4. Begin by checking the order.(Read the label 3 times)

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5. Position the pt with the head tilted back ward
6. Clean the nostrils with cotton applicator
7. Apply prescribed amount of medication directly in to the nostrils.
8. Keep patient’s head tilted back for a few minutes/five minutes to ensure that the drops
run in to the back of the nose and to allow the medicine to act on mucus membrane and
avoid blowing the nose.
9. Clean and return used equipments to its proper place
10. Make the patient to the comfortable position
11. Wash your hands very carefully and chart procedure and observations
9.2.7. Administering rectal medications
Objective: Atthe end of this lesson, the learner will be able to
1. Describe the purposes of administering rectal suppository
2. Assemble equipments needed for application rectal suppository
3. Demonstrate the installation of rectal suppository
Rectal suppository – a conical mass to be introduced in to the rectum usually containing
medication (easily melted at body temperature).
Purpose:
 To produce laxative effect (bowel movement).
 To produce local sedative in the treatment of hemorrhoids or rectal abscess.
 To produce general sedative effects when medications cannot be taken by mouth.
 To stop rectal bleeding and to relieve pain and soothe tissue irritated by diarrhea.
Equipment –
1. Suppository (as ordered)
2. Water soluble lubricant/k-y jelly
3. Gauze square
4. Glove or finger cot
5. Toilet paper
6. Receiver for soiled swabs

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7. Bed pan, if the Rx is in order to produce defection
8. Screen
9. Mackintosh and towel
Procedure
1. Explain the procedure to the patient and assess the client’s knowledge of the drug and its
action
2. Wash hands
3. Prepare the equipments
4. Begin by checking the order.(Read the label 3 times)
5. Screen the patient and put on gloves
6. Assist the client to the sim’s position or the left lateral position with the upper leg flexed
7. Fold back the bed linen to expose the rectum
8. Apply small amount of lubricant to the smooth rounded end of the suppository to reduce
mucosal irritation. Lubricate the gloved index finger
9. Instruct the client to breathe through the mouth.
10. Insert the suppository in to the client’s anal canal at least 4 inches (10 cm) for an adult and
5cm (2 inches)for a child. This position ensures placement of the suppository above the
client’s internal sphincter and maximizes medication absorption (lubrication makes the
insertion easier)
11. Ask the client to maintain the position for 15-20 minutes to resist urge to defecate and
maintaining the position allows time for the medication to melt.
12. Press the folded tissue against anus for a few minutes until the pt’s urge to expel the
suppository has passed.
13. Clean the anus with a toilet paper
14. Dispose of gloves and wash hands
15. Document the time, type, or given medication. Indicate the strength or dosage of the drug
Follow up phase
Check on the client 20-30 minutes and document client’s response or result of the Rx and
the reaction of the pt to the Rx.

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Figure Administering a Rectal Suppository
9.2.8. Administering Vaginal Medications
Objective: Atthe end of this lesson, the learner will be able to
1. Define administration of vaginal suppositories
2. Identify the purposes of vaginal medication administration
3. List all the necessary equipments for the procedure
4. Practice all the steps to administer vaginal medication
Definition: is an insertion of suppositories into the vagina canal
Purpose
 To treat or prevent infection
 To remove an offensive or irritating discharge
 To reduce inflammation
 To relieve vaginal discomfort
Equipment
1. Medication administration record (MAR)
2. Non-sterile gloves
3. Prescribed vaginal suppository
4. Water-soluble lubricant/k-y jelly
5. Disposable applicator
6. Tissue

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Procedures
1. Check with the client and the chart for known allergies or medical conditions that would
contraindicate the use of the drug.
2. Gather necessary equipment.
3. Check the MAR against written health care practitioner orders.
4. Wash your hands.
5. Follow the five rights of medication administration. Check the client’s identification
band.
6. Ask the client to void.
7. Position the client in a dorsal recumbent position with knees flexed and hips rotated
laterally or in a Sims’ position if the client cannot maintain the dorsal recumbent position.
8. Don non-sterile gloves.
9. Explain procedure to patient. If client plans to self-administer, be very specific with
instructions. Provide for privacy.
10. Assess perineal area, inspect vaginal orifice, note any odor or discharge from the vagina,
and inquire about any problems such as itching or discomfort.
11. If secretion or discharge is present, cleanse the perineal area with soap and water.
12. Remove suppository from the foil wrapper and, if applicable, insert into applicator tip.
Apply a small amount of lubricant to rounded tip of suppository. If not using an
applicator, apply a small amount of lubricant to gloved index finger.
13. With non-dominant hand, spread labial folds. Insert the suppository into the vaginal canal
at least 2 inches (5 cm) along the posterior wall of the vagina or as far as it will go. If
using an applicator, insert as described above and depress plunger to release suppository.

Figure----. Administering a vaginal suppository along the posterior wall of the vagina.

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14. Wipe the perineum with clean, dry tissue
15. Instruct the client to remain in bed for 15 minutes.
16. Wash applicator under cool running water to clean (warm water promotes coagulation of
protein secretions) and return to appropriate storage in the client’s room.
17. Remove gloves, turning them inside out; dispose of gloves in the proper receptacle. Wash
hands.
18. Record on the MAR the drug’s name dosage, route, and date and time of administration;
document any evidence of discharge or odor from the vagina.
19. Check with the client in 15 minutes to ensure that the suppository did not slip out and to
allow the client to verbalize any problems or concerns.
20. Observe for effectiveness of the medication; inspect the condition of the vaginal canal
and external genitalia between applications.
9.2.9. Administering nebulizer Medications
9.2.9.1.Teaching Self-administration with a Metered-dose Inhaler(Nebulizer)
Definition: - Is administration of medication by the form of spray by inhalation.
Purpose
 improve airway patency
 facilitate mucous drainage; mucolytic, which attain a high local concentration to
liquefy tenacious bronchial secretions;
 to decrease inflammation.
Contraindications
 In patients who can't form an airtight seal around the device
 In patients who lack the coordination or clear vision necessary to assemble a turbo-
inhaler.
 Inhalant drugs may also be contraindicated. For example, bronchodilators are
contraindicated if the patient has tachycardia or a history of cardiac arrhythmias
associated with tachycardia.
Equipment
1. Medication administration record (MAR)
2. Wash basin or sink to rinse mouth
3. Inhaler Tissue (optional)
4. Non-sterile gloves

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Procedure
1. Check with the client and the chart for known allergies or medical conditions that would
contraindicate the use of the drug.
2. Gather necessary equipment.
3. Check the MAR against written health care practitioner orders.
4. Wash your hands.
5. Follow the five rights of medication administration. Check the client’s identification band.
6. Review with the client the purpose of each prescribed medication.
7. Allow the client to hold and manipulate the canister. Explain how the canister fits into the
inhaler. Have the client demonstrate insertion of the canister.
8. Explain metered-dose concept to client, and discuss frequency of prescribed medications.
9. Explain that the inhaler must be shaken before each use.
10. Remove the mouthpiece and cap from the bottle and insert the stem into the small hole on the
flattened portion of the mouthpiece.
- Client should grasp the inhaler with thumb and first two fingers.
Figure -----Self-administration with a Metered-dose Inhaler.
11. Instruct the client to exhale, place the mouth piece into the mouth, and ensure that the lips
form a tight seal around the mouthpiece.
9.2.9.2.Insert mouthpiece into mouth, forming a tight seal with the lips.
12. Instruct the client to firmly push the cylinder down against the mouthpiece only once
while slowly inhaling until the lungs feel full.
13. Ask the client to remove the mouthpiece while holding breath for about 10 seconds and then
to exhale slowly through pursed lips.
- If the client had difficulty coordinating the inhalation and medication
dispensing,aerochanber may be added

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14. Repeat doses as ordered, waiting 1 minute between puffs.
15. Inform client that a mouthwash can be used to remove the taste of the medication.
16. Show client how to wash the mouthpiece under tepid running water to remove secretions.
17. If two or more metered-dose medications are ordered, wait 5–10 minutes between inhalations
or as specifically ordered by the health care practitioner.
18. Record on the MAR the drug’s name, dose, date, and time of medication.
19. Observe for effectiveness of the medication and relief of client symptoms.
9.2.10. Parentral medication administration
Definition: - Giving therapeutic agents including foodby routes other than the alimentary
canal/tract
Types
 Intradermal (ID)
 Subcutaneous (SC)
 Intramuscular (IM)
 Intravenous (IV)

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Fig. Angles of insertion for parental injections
9.2.10.1. Administering an Intra dermal Injection
Objective :At the end of this lesson, the learner will be able to
1. Define intera dermal route of medication administration
2. Identify the proper sites for intra dermal injection
3. Assemble the necessary equipments
4. Demonstrate intra dermal injection
Definition: - The introduction of medication, using hypodermic needle in the dermis. (corneum)
Purpose
 To obtain a local effect at the site of injection of local anesthesia
 Diagnostic purpose as in tuberculin skin test
 To test for allergic reactions to a drug eg. Penicillin serum
Site of injection: - The inner part of the forearm (midway between the wrist and elbow) and the
middle of the back.These sites are used due to the lack of hair found in these areas and the
thinness of the skin. Because of the location of the injection, aspiration and massaging are not
necessary when performing intradermal injections. Maximum 0.1ml of medication with 1ml
syringe can be given by this route.

Figure. Intra dermal injection sites: A. inner aspect of the fore arm, B. Upper chest. C. Upper
back.

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Equipments
A tray containing
1. Medication administration record
(MAR)
2. Syringe & needle(sterile) (25-
27gauge)
3. Receiver
4. Alcohol
5. Cotton balls
6. Disposable glove
7. Safety box
8. Marking pen
9. Medication
Procedures
1. Check with the client and the chart for any known allergies
2. Explain procedure to patient
3. Follow the five rights
4. Prepare the medication from an ampoule or vial
5. Explain the procedure to the client
6. Place the client in a comfortable position; provide privacy
7. Wash hands and don sterile gloves
8. Select and clean the site
 Assess the client’s skin for bruises, redness, or broken tissue
 Select an appropriate site using appropriate anatomic landmarks
 Cleanse the site with an alcohol wipe using a firm circular motion; cleanse from
inside to outside; allow alcohol to dry
9. Prepare the syringe for injection
 Remove the needle guard
 Express any air bubbles from the syringe
 Check the amount of solution in the syringe
10. Inject the medication.
 Hold the syringe in dominant hand
 With nondominant hand, grasp the client’s dorsal forearm and gently pull the
skin taut on ventral forearm(Figure 29-20)
 Place the needle close to the skin, bevel side up.

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 Insert the needle at a 10° to 15° angle until resistance is felt, and
advance the needle approximately 3 mm below the skin surface;
the needle’s tip should be visible under the skin.
 Administer the medication slowly; observe the development of a bleb (large
flaccid vesicle that resembles a mosquito bite). If none appears, withdraw the
needle slightly.
 Withdraw the needle.
 Pat area gently with a dry 2 ×2 sterile gauze pad.
 Do not massage the area after removing the needle.
11. Discard the needle and syringe in a sharps container
12. Remove gloves, dispose of in appropriate recep-tacle, and wash hands.
13. Observe for signs of an allergic reaction.
14. Draw a circle around the perimeter of the bleb with a ball point pen.
15. Document medication and site of injection on the MAR.

figure Administering intradermal injection
9.2.10.2. Subcutaneous Injection
Objectives:-At the end of the lesson, the learner will be able to:
1. Define subcutaneous route of administration
2. Describe the purposes subcutaneous route of administration
3. Assemble the necessary equipments
4. Perform subcutaneous route of administration
Definition: - Injection of drug under the skin in the sub-cutaneous tissue.
Purpose:

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- To obtain quick absorption than oral administration.
- When it is impossible to give medicines in other routes
Site:Fatty outer portion of the upper arms, the lower abdomen, the middle and lower back, and
the thigh region. The majority of drugs given through this route should be aspirated, but
aspiration is contraindicated in a select few drugs. Maximum of 1ml can be given by 1-3ml
syringe through this route.
-

Figure. Subcutaneous injection sites: A. Abdomen; B. Lateral and anterior aspect of upper arm
and thigh; C. Scapular area on back; D. Upper ventrodorsal gluteal area
Equipment
1. Tray
2. Sterile syringe & needle
3. Sterile forceps in a container
4. Alcohol swabs
5. Medication
6. File
7. Safety box
8. Medication chart
9. Disposable gloves
Procedure
1. Check with client and the chart for any known allergies.
2. Wash your hands
3. Follow the five rights
4. Prepare the medication from an ampule or vial; refer to Procedure 29-2 or 29-3 as
appropriate.
5. Take medication to the client’s room and place on a clean surface

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6. Check the client’s identification armband
7. Explain the procedure to the client
8. Place the client in a comfortable position; pro-vide for privacy
9. Don nonsterile gloves
10. Select and clean the site.
A. Assess the client’s skin for bruises, redness, hard tissue, or broken skin.
B. Cleanse the site with an alcohol swab; cleanse from inside outward.
11. Prepare for the injection.
A. Remove the needle guard and express any air bubbles from the syringe; check the
dosage in the syringe.
B. With dominant hand, hold the syringe like a dart between your thumb and
forefingers.
C. Pinch the subcutaneous tissue between the thumb and forefinger with the non
dominant hand.
D. If the client has substantial sub-cutaneous tissue, spread the tissue taut.
E. Administer the injection.
F. Insert the needle quickly at a 45° or 90° angle.
G. Release the subcutaneous tissue and grasp the barrel of the syringe with
nondominant hand.
H. With dominant hand, aspirate by pulling back on the plunger gently, except when
administering an anticoagulant injection.
I. If blood appears, remove needle and discard in a sharps container.
J. Inject medication slowly if there is no blood present.
K. Remove the needle quickly and lightly mas-sage area with alcohol swab; do not
massage the injection site after the administration of an anticoagulant.
L. Do not recap the needle; discard the needle in a sharps container.
12. Position client for comfort.
13. Remove gloves and wash hands.
14. Record on the MAR the route, site, and time of injection.
15. Observe the client for any side or adverse
16. Effects and assess the effectiveness of the medication at the appropriate time
9.2.10.3. Intramuscular Injection
Objectives:-At the end of the lesson, the learner will be able to:
1. Define interamuscular route of administration
2. Describe the purposes of interamuscular route of administration
3. Assemble the necessary equipments
4. Perform subcutaneous route of administration

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Definition: - It is an introduction of a drug into a body's system via the muscles.
Purpose
1. To obtain quick action next to the intra- venous route
2. To avoid an irritation from the drug if given through other rout
Common intramuscular injection sites and muscles
Site Muscle
- Dorsogluteal - Gluteus maximus
- Ventrogluteal - Gluteus medius
- Anterolateral aspect of thigh - Vastus lateralis
- Upper arm - Deltoid

Figure____ Sites for administering an intramuscular injection

Equipments
1. Medication administration
report (MAR)
2. Sterile 2 ×2 gauze pad
3. Tray
4. Ordered drug ( ampule, Vial)
5. sterile syringe and needle in a
container
6. Alcohol swab
7. Receiver
8. A bowl of water for used
syringe and needle
9. File
10. Sterile jar with sterile forceps.
11. Chart.
12. safety box

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13. Disposable glove
Procedures
1. Check with client and the chart for any known allergies
2. Wash hands
3. Follow the five rights
4. Prepare the medication from an ampule or vial
- Add 0.1 to 0.2 ml of air to the syringe.
- Take medication to the client’s room and place on a clean surface.
5. Check the client’s identification armband
6. Explain the procedure to the client; provide for privacy
7. Place the client in an appropriate position to expose the site
- Deltoid: sitting position
- Ventrogluteal:-Side-lying: flex the knee, pivot the leg forward from the hip
about 20° so it can rest on the bed
- Supine: flex the knee on the injection side.
- Prone: point toes inward toward each other to internally rotate the femur
8. Don non sterile gloves
9. Select and clean the site
- Assess the client’s skin for redness, scarring, breaks in the skin, and palpate for
lumps or nodules.
- Select site using the anatomic landmarks.
- Cleanse the area with an alcohol swab, cleanse from inside outward using friction;
wait 30 seconds to allow drying.
10. Prepare for the injection.
- Remove the needle cap by pulling it straight off, and expel any air bubbles from
the syringe.
- Pull the skin down or to one side (Z-track technique) with nondominant hand.
11. Administer the injection.
 Deltoid: quickly insert the needle with a dart-like motion at a 90° angle
 Ventrogluteal: quickly insert the needle using a dartlike motion and steady
pressure at a 90° angle to the iliac crest in the middle of the V
 Aspirate by pulling back on the plunger, and observe for blood
 If blood appears, remove the needle and discard

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Fig. Administering intramuscular injection in to the ventrogluteal site

 If blood does not appear, inject the medication slowly, about 10 sec/ml.
 Wait 10 seconds after the medication has been injected, then smoothly withdraw
the needle at the same angle of insertion.
 Apply gentle pressure at the site with a dry, sterile 2 ×2 gauze; do not massage
the injec-tion site. Swab using gentle pressure.
 Discard the needle and syringe in a sharps container; do not recap the needle
12. Position client for comfort; encourage client receiving ventrogluteal injections to perform
leg exercises (flexion and extension)
13. Remove gloves, wash hands
14. Record on the MAR the dosage, route, site, and time
15. Inspect the injection site within 2 to 4 hours and evaluate the client’s response to the
medication
9.2.10.4.Intravenous Injections
Objectives:-At the end of the lesson, the learner will be able to:
1. define intravenous injection
2. describe the purposes of intravenous infusion
3. assemble the necessary equipments
4. demonstrate intravenous injections
Definition: - Introduction of drugs or fluid in to the circulation through vein or taking
blood from vein often the amount is not more than 10ml at a time.
Purpose:-
 When the given drug is irritating to the body tissue if given through other routes.
 When quick action is desired.
 When blood drawing is needed.
Site of IV injection

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ChildrenAdult
- Jugular Vein - Basalic vein
- Temporal vein - Cephalic vein
- Femoral vein - Radial vein
- Basalic vein - Great sophanous vein
- Cephalic vein
Equipment
Tray containing
1. Sterile syringe and needle (16-
18gauge )
2. Medication
3. Alcohol swab
4. File
5. Tourniquet
6. Patient chart
7. Towel and rubber sheet
8. Receiver
Procedures
1. Gather prepared equipment (medication labeled with the client’s name, and time tape for
fluids to infuse per hour)
2. Wash hands
3. Check the client’s armband
4. Explain the procedure to the client
5. Assess the puncture site
A. Observe for redness and puffiness.
B. Palpate for tenderness
6. Check patency of infusion site.
A. Observe fluid infusing.
B. Remove IV container from the pole and lower the container below the level of
infusion site
C. Observe for backflow of blood into the hub of the venous access device.
D. Replace container on IV pole
7. Secure medication bag prepared and labeled by pharmacy and check health care
practitioner’s prescription and the MAR.
8. Check the client’s chart for allergies, and check the drug compatibility chart.
9. Hang the secondary bag on IV pole.
10. Add the administration set to the secondary bag and prime the tubing.
11. Affix a needle-less locking cannula to the end of tubing
.

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12. Cleanse needle-less Y–site injection port of pri-mary IV tubing closest to infusion site with
an alcohol swab; allow to dry.
13. Insert needle-less locking cannula of secondary bag set into Y–site injection port of primary
set and secure in place with tape
14. Affix the extension hook to the primary bag on the IV pole so that the primary bag hangs
below the level of the secondary bag.
15. Open clamp of secondary tubing and adjust drip rate to desired infusion rate
 Slowly close the regular clamp while observ-ing the drip chamber until the
fluid is drip-ping at a slow, steady pace
 Count the drops for a 15-second interval and multiply by 4
 Recount the drop rate in 5 minutes.


Figure. Connect locking cannula to a Y-site injection port of primary infusion set.
16. Observe client for any signs of adverse reactions to the medication.
17. When secondary bag and drip chamber are empty, close the clamp on secondary system,
readjust drip rate of primary solution as indicated, and remove the secondary system.
18. Record medication infusion on the MAR and note any client responses in the nurses’
notes
9.2.10.5.Intravenous infusion
Objectives:-At the end of the lesson, the learner will be able to:
1. define intravenous infusion
2. state the purposes of intravenous infusion
3. assemble the necessary equipments
4. demonstrate intravenous infusion
Definition:-
1. IV infusion is the administration of a large amount of fluid (50-500 even more) into the
system through a vein.

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Purpose
 When the giving drug is irritating to the body tissue if given through other routes.
 When quick action is desired.
 When it is particularly desirable to eliminate the variability of absorption.
 When blood drawing is needed ( exsanguinations)
2. An I.V. injection is the introduction of a drug in solution from into a vein. Often the
amount is not more than 50 ml. at a time.
Purpose:
 To maintain fluid & electrolyte balance.
 To introduce medication particularly antibiotics.
Administration Sets
1. Piercing pin: A hollow spike that is inserted into the administration port of the IV bag. It
is important this remains sterile when inserted.
2. Drip chamber : This is where the solution flows prior to its entry into the tubing; it acts
as a pressurizing chamber for non-vented bags.
3. Roller clamp: This is used to regulate the flow of fluids through the IV tubing.
4. IV cannula or catheter : A flexible tube that is used to insert medication within body
cavity or blood vessel. It has a trocar (a sharp-pointed needle) attached to it that punctures
the skin to get the catheter within the vein.
5. Slide clamp: This is used to restrict fluid flow and act as a quick on/off control of the IV
tubing. The tubing ends in a sterile-capped adapter, which is attached to the cannula.

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Equipment
1. IV fluid as ordered
2. Sterile syringe & needle.
3. Rubber & towel
4. Receiver
5. Examination glove
6. safety box
7. Alcohol swabs
8. Arm board
9. Bandage & scissors.
10. Tourniquet
11. I.V. Pole
12. Adhessive tape
13. Medication chart
14. Preparation of the patient
9.2.10.6..Administering an IV Solution
Objectives: At the end of this lesson, the learner will be able to
1. Define an IV therapy
2. Assemble the necessary equipments
3. Mention the purposes of intravenous therapy
4. Practice the recommended intravenous therapy procedures
Definition: It is administration of a large amount of fluid into the system through a vein.
Medications are administered IV by the following:-
 Intra venous push (IVP or bolus)
 Intra venous infusion
Purpose
 To supply fluids and electrolytes
 To restore fluid volume due to
dehydration, hemorrhage, vomiting,
diarrhea etc.
 To meet patients basic requirements
 To treat emergency condition some
medications are given intravenously
 To prevent and treat shock and
collapse


Indication
 To save the patients in life treating
condition
 To introduce drug in to circulation
for diagnostic and treatment purpose
 Malnutrition
 Septicemia / sepsis

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Equipment
Adding Solution to a Continuous Infusion Line
1. Sterile IV solution
2. Sterile IV infusion
3. Sterile IV needle or cannula
4. Syringe
5. Forceps
6. Prepared IV solution and
medication
7. Adding a Secondary Line,
Additive Bag (IV Piggyback)
8. Prepared and labeled medication
solution bag from pharmacy
9. Alcohol swab
10. Tourniquet
11. Adhesive tap
12. Bed protective
materials/mackintosh and towel
13. IV stand/pole
14. Secondary administration set
15. Splint
16. Needleless locking cannula
Adding a Solution to an Existing Heparin or PI Lock
1. Prepared IV solution system with needleless locking cannula
2. Needleless injection cap (if one is not in place)

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3. 2 prefilled syringes of 2 ml each of normal saline
4. Alcohol or iodophor swab
5. Nonsterile gloves
Procedure
1. Explain the procedure to the client.
2. Wash hands
3. Gather prepared equipment (solution labeled with the client’s name, and time-taped for fluids
to infuse per hour). Check the prescriber’s order for the type and amount of solution Wash
hands, and don gloves if you have to perform a venipuncture or connect the tubing to an
existing PI. Gloves are not necessary if you are adding fluids to an existing infusion line.
4. Check the client’s armband.
5. Assess the puncture site.
 Observe for redness and puffiness.
 Palpate for tenderness.
6. Check patency of infusion site.
 Verify that fluid is infusing.
 Remove IV container from the pole and lower the container below the level of
infusion site.
 Observe for backflow of blood into the hub of the venous access device.
 Replace container on IV pole.
9.2.10.6.1. Adding Solution to a Continuous Infusion Line
7. Check the date on the tubing tag.
8. Hang the new bag of fluids on the IV pole and remove the cover from the port.
9. Remove the current infusion bag of fluids from the IV pole.
10. While maintaining aseptic technique, remove the tubing spike from the port of the infusing
bag of fluids and reinsert the tubing spike into the port on the new bag of fluids; push the full
length of the spike into the port.
11. Set the infusion rate.

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Manual Rate Regulation
A. Open regulator clamp; close slowly while observing the drip chamber until the fluid
is dripping at a slow, steady pace.
B. Count the number of drops for a 15-second interval and multiply by 4; for example,
if the drop factor of tubing is 10 drops/ml then the drop rate should be 21
drops/minute to infuse 1000 ml/8 hours.
C. Open the regulator clamp slowly to increase the drip flow rate; close the regulator
clamp to decrease the drip rate to achieve 21 drops/minute.
D. Recount the drop rate after 5 and 15 minutes.
E. Proceed to steps 12–19.
Dial-a-Flo Regulation
1. Turn Dial-a-Flo regulator until arrow is aligned with desired volume of fluid to infuse
over 1 hour.
2. Check drip rate over 15 seconds, and multiply by 4.
3. Adjust height of IV pole if necessary.
4. Recount drip rate after 5 minutes and again after 15 minutes.
5. Proceed to steps 12–19.
9.2.10.6.2. Infusion Controller or Pump Regulation
1. Insert tubing into infusion controller or pump in accord with manufacturer’s instruction
2. Close door to controller or pump and open all tubing clamps and regulators.
3. Set volume dials to regulate the volume to infuse per hour or drops per minute in accord
with the type of machine.
4. If the controller or pump has an electronic eye, clamp it over the upper portion of the drip
chamber that does not contain fluid.
5. Push the start or on bottom.
6. If desired, set the volume infusion alarm.
7. Proceed to steps 12–19.

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9.2.10.6.3. Volume Control Chamber (Buretrol) Regulation
A. Close regulators both above and below the chamber.
B. If adding a new Buretrol, open regulator above the chamber and fill the chamber
with 10 ml of fluid, close the top regulator, and slowly open the regulator below
the chamber to remove air from the tubing. Close the bot-tom regulator
C. Open the top regulator and fill the chamber with the volume of fluid to infuse in 1
hour or 2 hours if the volume is small.
D. Close top regulator and ensure that air vent is open.
E. Open bottom regulator and regulate drops to calculated drip rate in accord with
the drop factor.
F. Count drip rate over 15 seconds and multiply by 4.
G. Time-tape the chamber if a controller or pump is not used.
H. Check chamber every 1 to 2 hours depending on the volume placed in the
chamber.
I. Proceed with steps 12–19.
12. On the time tape, write the time the fluids were initiated and your initials.
13. Monitor the volume delivered every 1 to 2 hours and compare with the time tape.
14. If fluids are not infusing at the prescribed rate as indicated by time tape:
A. Check setting on controller or pump or Dial-a-Flo and adjust as indicated.
B. Increase height of IV pole.
C. Assess puncture site, reposition the venous access device, lower the IV fluid
container below the puncture site and observe for a backflow of blood.
D. Replace container on pole.
15. Instruct client to limit movement of puncture site and to notify a nurse of any problems or
discomfort.
16. Apply an armboard, if indicated
17. Position the client for comfort and place the call light in easy reach.
18. Wash hands and disposes of used supplies.
19. Document on the client’s medical record:
- Time of initiation of fluid infusion

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- Type and volume of fluid infusing
- Infusion device used, if applicable
- Status of the venous access insertion site
- Problems encountered: for example, if venous access device is repositioned
- Client’s tolerance to the fluid infusion
- Client teaching and learning
9.2.10.6.4. Adding a Solution to an Existing Heparin or PI Lock
20. Repeat steps 1–5.
21. Hang IV solution on IV pole.
22. Don non-sterile gloves and cleanse needleless injection port with alcohol or iodophor swab.
Allow to dry.
23. Insert saline syringe into port, slowly aspirate, and observe for blood; flush system and
observe for swelling at puncture site.
24. Connect needleless locking cannula into injection port, open tubing clamp, and adjust rate as
indicated in step 11.
25. Dispose of equipment and gloves in proper receptacle and wash hands.
26. When secondary bag and drip chamber are empty, don gloves, close the clamp, and
disconnect the needleless locking cannula from the port’s lock.
27. Flush port with second saline syringe and place sterile needleless injection cap on the port.
28. Dispose of equipment and gloves in proper receptacle and wash hands.
29. Record fluid administration on MAR and client response in nurses’ notes
9.3. Blood transfusions
Objectives: At the end of this lesson, the learner will be able to
1. Define blood transfusion
2. Identify the purpose of blood transfusion
3. Assemble the essential equipments needed for blood transfusion
4. Perform the blood transfusion procedures
Definition: A blood transfusion the infusion of whole blood or its components such as blood
cells and plasma from one person (donor) to another person (recipient).

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Purpose:
 To increase the 02 carrying capacity in anemia in suitable cases
 During major surgery where much blood loss may be possible
 To maintain blood pressure and blood volume during hemorrhage
 To replace blood platelets and clotting factors in hemophilia
 To provide antibodies and leucocytes
Indications:
 Patient with Severe anemia
 Patient with excessive blood loss
 In severely ill patients , Burns, Accidents
Precaution:
 Always remember to have anti-histamine injection available in case a pt has allergic
 Be familiar with the most common symptoms of blood reaction
 If there is any reaction. Immediately clamp and stop the flow of drop and report
 Blood should be fresh
 Blood must be stored at a temperature 1-6
0
c
 The blood should be given at a slower rate
 Whole blood and packed cells are administered cold.Avoid shaking the container
Equipment
1. Y-administration set tubing with in-line filter Regular administration set
2. 2 bags of 250 to 500 ml of normal saline Blood unit as prescribed by health care
practitioner
3. 18 or 19-gauge needle or 18- or 19-gauge catheter; if blood is to be administered rapidly,
14-gauge needle
4. Regular administration set
5. Blood unit as prescribed by health care practitioner
6. Venipuncture supplies, if client does not have an IV in place
7. Alcohol swabs and tape
8. Non-sterile gloves
9. Needleless injection cap

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Procedure
1. Check prescriber’s orders for number of units and client’s signed consent form.
2. Check with the blood laboratory or blood bank that type and cross match have been
completed and that blood is ready.
3. Gather equipment and check integrity of the equipment.
4. Check client’s arm for an identification band (special band that contains essential data,
blood group and type).
5. Explain procedure to client and his relatives, and answer questions to get co-operation.
6. Assess IV site for patency, gauge size of needle or catheter and verify that IV is in place.
7. Check vital signs.
8. Obtain whole blood unit or packed cells from the blood laboratory or blood bank.
 Check requisition form with laboratory personnel.
 Check blood label against blood unit for client’s name and identaband number,
blood group (ABO) and type (Rh), blood unit num-ber, and expiration date of
blood unit.
9. Check requisition form and blood label with another RN and sign form with another RN
in accord with agency protocol
10. Check blood unit for bubbles, cloudiness, dark color, or sediment; if any of these signs is
present, return blood unit to laboratory and process a written report of actions in accord
with agency protocol.
11. Check label on blood unit against client’s identaband: name, identification number, blood
group, blood type, and blood unit number.
12. Hang one bag of normal saline on IV pole, pull back tab, and spike with regular
administration set; prime tubing, replace protective cap on distal end of tubing.
13. Prepare Y-set tubing with in-line filter:
 Hang second bag of normal saline and blood bag on pole.
 Remove Y-tubing from package and close roller clamp. Note red and white caps
of tubing spikes.
 Remove tab from normal saline port.

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 Remove white cap from Y-tubing spike, insert into port of normal saline bag,
and hang on IV pole.
14. Prime Y-set with normal saline.
- Open clamp to saline bag.
- Squeeze sides of drip chamber until filter is half covered and drip chamber is full
- Open main clamp, remove protective cap from distal end of tubing, and prime
tubing.
- Close main clamp when tubing is primed, and replace protective cap.
15. Don nonsterile gloves.
16. Gently rotate blood bag.
17. Continue preparing Y-set.
- Remove tab from blood bag to expose port.
- Remove red cap from tubing spike; insert spike into port of blood bag.
18. Cleanse injection port with alcohol swab.
19. Affix large-gauge needle to end of Y-tubing and prime needle.
20. Insert needle into injection port, and tape.
21. Open roller clamp to saline bag, and open main clamp on Y-set; infuse slowly to clear the
lock.
22. Clamp off saline bag, and open clamp to blood bag; if administering packed RBCs, allow
saline to infuse simultaneously with RBCs.
23. Squeeze sides of Y-set drip chamber to allow blood to cover entire filter.
24. Regulate drip rate with main clamp to deliver gtts per minute for the first 15 minutes.

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25. Take vital signs, and observe closely for reactions: chilling, skin rash, backache,
headache, nausea or vomiting, tachycardia, tachypnea, fever, or hypotension; if reaction
occurs, stop transfusion.
26. Adjust flow rate as prescribed. If no adverse reac-tions, complete blood transfusion in
less than 4 hours.
27. Instruct client to call a nurse if there are any unusual symptoms; test call light, and place
within easy reach.
28. Monitor client throughout transfusion in accord with protocol; observe IV site for
formation of a hematoma. If this occurs, stop transfusion and discontinue IV site.
29. Initiate transfusion record.
30. Discontinue Y-set when transfusion is complete.
 Close blood roller clamp.
 Open saline roller clamp, and allow all blood in tubing to infuse.
 Don nonsterile gloves.
 Close main clamp.
 Disconnect tubing from injection port. If other fluids are to follow, connect or
reestablish the lock.
31. Discard Y-set tubing and blood bag in a biohazard bag and follow protocol regarding
disposition.
32. Remove gloves, wash hands.
33. Obtain post infusion vital signs.
34. Document to transfusion record:
 Date and time of starting and completing the transfusion
 Type of blood transfused
 Vital signs
 Absence or presence of any reaction or complications
 Status of the IV site
 Disposition of the blood bag and tubing

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CHAPTER TEN
SKIN INTEGRITY AND WOUND CARE
Objective: At the end of the chapter, the learner will be able to
1. Define wound
2. Explain the purpose of wound care.
3. Identify important equipment needed to provide wound care.
4. Perform dressing of clean and septic wounds.
5. Provide care for the patient with draining wound.
6. Demonstrate skill of wound suturing and irrigation.
7. Apply clip and remove it when indicated.
Definitions: Wound is a disruption in the integrity of body tissue which may be intentional or
unintentional
10.1. Wound dressing
Objectives: At the end of the lesson, the learner will be able to
1. Define wound dressing
2. List the types of wound dressings
3. Collect necessary material
4. Demonstrate the different types of wound dressing techniques
Definitions: Dressing: Any of various materials used for covering and protecting a wound
Wound dressing is process of covering wound or applying sterile protective covering using
aseptic technique
Types of wound dressing
1. Clean wound dressing
2. Septic wound dressing
3. Wound dressing with drainage tube
Purpose of wound dressing
 To Keep the wound moist and
therefore enhance epithelialization
 To Keep the wound clean
 To keep locally applied drugs in
position
 To keep edges of the wound together
by immobilization

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 To relief pain and comfort the patient
 Provide physical, psychological, and
aesthetic comfort
 Remove necrotic tissue
 Prevent, eliminate, or control
infection
 Maintain a moist wound environment
 Protect wound from further injury
 Protect skin surrounding wound
 To protect the wound from
mechanical injury.
 To protect the wound from microbial
contamination.
 To absorb drainage
 To prevent hemorrhage.
 To splint or immobilize the wound
site and there by facilitate healing and
prevent injury
General Precautions in wound dressing
1. Wash hands thoroughly before, after and between several dressings.
2. Dressing should be done after the wards have been cleaned
3. Clean wounds should be dressed before wounds with drainage.
4. Never do a dressing when the air is dusty from sweeping, bed making or in dust.
5. Wear gloves when touching blood, body fluids, mucous membrane and handling soiled
items with blood or body fluids.
6. Do talk , cough and sneeze over wound
7. Wear mask and protective eye wear as necessary
8. Practice strict aseptic techniques to reduce transmission of micro organism
9. Soaked wound with frequent drainage should be changed frequently.
10. Clean wound from the cleanest area to the less clean area
11. Separate instruments should be used for each dressing.
12. Keep forceps lower than the handles at all times
13. Saline should be used to remove adherent dressings.
14. Medicines are given and applied if necessary.
15. Be economical on using gauze , sponges’ applicators, adhesive or medication.
16. Adhesive marks on skin can be removed with solvent such as ether alcohol or benzene.

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10.1.1. Dressing clean wound
Objective: At the end of the lesson, the learner will be able to
1. Define dressing clean wound
2. Collect the necessary equipments for clean wound dressing
3. Identify the purpose of clean wound dressing
4. Demonstrate clean wound dressing procedures
Definition:
 Clean wound dressing is aseptic technique of covering clean wound after cleaning
Purpose
 To keep wound clean
 To prevent the wound from injury &
contamination
 To keep in position drugs applied
locally
 To keep edges of the wound together
by immobilization
 To enhance wound healing
 To relief pain and comfort the patient
 To apply pressure
Equipment:-
Sterile dressing set
1. One kidney dish
2. Sterile gloves
3. Cotton balls in a galipot
4. Sterile gauze (4×4 inch) or squares
5. Sterile Dressing forceps (3)
6. Sterile Scissor
7. Sterile galipot
8. Sterile fenestrated towel (drape)
9. Spatula if ointment
Clean try
1. Clean glove
2. Cleaning solution (Normal
Saline,Sterile 0.9% sodium chloride),
chlorhexidine, povidone-iodine, and
hydrogen peroxide
3. Adhesive tape (Plaster)
4. Bath Blanket: (if needed)
5. Rubber and draw sheet
6. Bandage scissors or surgical blade
7. Anti microbial Ointment: if
prescribed
8. Bath Blanket: (if needed)
9. Screen
10. Adhesive remover
11. Protective apron: as the condition of
the wound

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12. Waste Receiver( disposable plastic
container)
13. Chart
Procedure
1. Check order for dressing change
2. Explain the procedure to the patient
3. Hand washing
4. Assemble the supplies at a convenient work area
5. Apply screen, close door and curtain.
6. Assist the patient to a comfortable position to expose the wound.
7. Place a rubber sheet under the patient to prevent soiling the linen.
8. Place opened, cuffed plastic bag near working area.
9. Loosen tape on dressing. Use adhesive remover if necessarily. If tape is soiled don gloves
10. Wear a protective apron when caring for a patient with a draining wound. Don non sterile gloves.
11. Gently remove and discard the old tape and soiled dressing in a plastic trash bag.
 Roll or lift an edge of the dressing, then gently remove it while supporting the surrounding
skin. When possible, remove the dressing in the direction of hair growth.
 If the dressing sticks to the wound, moisten with sterile normal saline and then remove.
 Sterile saline provides for easier removal of dressing. Assess amount, type and odor of
draining if present
12. Remove and discard non sterile gloves.
13. Using aseptic technique open the packed sterile instruments, sterile dressings, the irrigation and
cleaning solution, and the instrument set to provide a sterile field,
14. Pour cleaning solution to galipot, gauze and cotton from a drum.
15. Don sterile gloves
16. Gently remove and discard the old tape and soiled dressing in a plastic trash bag. Roll or lift an edge
of the dressing, then gently remove it while supporting the surrounding skin. When possible, remove
the dressing in the direction of hair growth. If the dressing sticks to the wound, moisten with sterile
normal saline and then remove. Sterile saline provides for easier removal of dressing. Assess
amount, type and odor of draining if present
17. Remove and discard the soiled gloves.

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18. Using aseptic technique open the packed sterile instruments, sterile dressings, the irrigation and
cleaning solution, and the instrument set to provide a sterile field, Pour cleaning solution to galipot,
gauze and cotton from a drum.
19. Don sterile gloves.
20. Apply fenestrated towel to the wound to increase the sterile field
21. If sample is needed, take the sample first then clean.
22. Take the second sterile forceps, and clean wound with cotton balls soaked in antiseptic solution
starting from inside to the outside.
23. Use one gauze square for each wipe, discard each square by dropping in to plastic bag, do not touch
bag with forceps.
24. Again use the second forceps to dry wound using gauze sponge and same motion by another new
forceps then discard.
25. Apply medication if any and dress the wound with sterile gauze with sterile another dressing forceps
o Ointment and paste must be smeared with spatula on gauze and then applied on the wound.
o Solutions or powder can be applied direct on the wound.
26. Make sure that the wound is properly covered
27. Fix dressing in place using adhesive tape or bandage.
28. Remove fenestrated towel, rubber and draw sheet.
29. Remove gloves from inside out, and discard them in plastic waste bag.
30. Provide patient comfort measures.
31. Clean and return equipment to proper place.
32. Wash your hands
33. Document the procedure
10.1.2. Dressing septic wound
Objective: At the end of this lesson, the learner should able to
1. Define septic wound dressing
2. Identify the purpose of septic wound dressings
3. Collect the necessary equipments for septic wound dressing
4. Demonstrate clean wound dressing procedures

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Definition: Dressing septic wound is method of covering infected wound that generally contain purulent
material (pus) draining from the wound site .
Purposes:-
 Absorb materials being discharged from the wound.
 Apply pressure to the area.
 Apply local medication.
 Prevent pain, swelling & injury.
Percussions
 If sterile forceps are not available use sterile gloves.
 Immerse used forceps, scissors and other instrument in strong antiseptic solution before
cleansing and discard soiled dressing properly.
 In a big ward it is best to give priorities to clean wounds and then to septic wounds when
changing dressings as this might lessen the risk of cross infection.
 Wounds should not be too tightly packed in effort to absorb discharge as this may delay
healing.
Equipment
Sterile Dressing set
1. Sterile galipot
2. Sterile kidney dish
3. Sterile gauze
4. terile forceps (3)Sterile test tube or
slide if necessary
5. Sterile cotton tipped application
6. Sterile pair of gloves if needed in
case of gas gangrene rabies etc
Clean try
1. Clean glove
2. Surgical glove
3. Cleaning solution (normal saline,
H2O2)
4. Ordered medication
5. Plaster
6. Bandage scissors or surgical blade
7. Bucket to put in soiled
dressing/water proof disposable bag
8. Rubber and cotton draw sheet
/Mackintosh with its cover
9. Spatula if ointment
10. Receiver with strong disinfectant to
immerse used instrument

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11. Probe and director if required
12. Benzene or ether
13. Bandage or adhesive tape and
Bucket to put in soiled dressing
Procedure
1. Check order for changing dressings/dressing
2. Great the patient and explain procedure to the patient.
3. Wash your hands
4. Clean trolley or tray, assemble sterile equipment on one side & clean items on the other
side and make sure that the sterile equipments are properly covered.
5. Put on single use examination glove
6. Apply screen (close door and curtain), drape, & put patient in comfortable position
7. Place rubber sheet and its cover under the patient to prevent soiling the linen.
8. Place a clean towel or draw sheet underneath the working area to minimize
contamination.
9. First remove the outer layer of the dressing.
10. Remove the outer layer of dressing and dispose with glove
11. Wear sterile gloves
12. Use forceps to remove the inner layer of the dressing smoothly & discard forceps
13. Observe wound and check if there is drainage rubber or tube.
14. Take specimen for culture or slide if ordered (do not cleanse wound with antiseptic
before you obtain the specimen).
15. Take the sterile cleaning forceps
16. Start cleaning wound from the cleanest part of the wound to the most contaminated part
using antiseptic solution (Hydrogen per oxide 3% is commonly used for septic wound).
17. Deberide dead tissue as needed
18. Discard cotton ball used for cleaning after each stroke over the wound.
19. Cleanse the skin around the wound to remove the plaster gum with benzene
20. Use gauze for drying the skin around properly.
21. Use third forceps for dressing the wound
22. Dress the wound and make sure that the wound is covered completely.
23. Make sure that the wound is properly covered

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24. Fix dressing in place with adhesive tape or bandages.
25. Remove gloves from inside out, and discard them in plastic waste bag.
26. Leave patient comfortable and tidy.
27. Clean and return equipment to proper place.
28. Wash your hands
29. Document the procedure
30. Send the specimen to laboratory
10.1.3. Dressing with Drainage Tube
Objective At the end of this procedure session the students should able to
 Define dressing with drainage tube
 Describe the purpose of dressing with drainage tube
 Assemble the necessary equipments for dressing with drainage tube
 Demonstrate dressing with drainage tube
Definition
 Dressing with drainage tube is the method of flushing wound with plenty of sterile fluid
Purpose
 Aids to prevent hematoma or collection of fluid in the affected area.
Precautions
 Safe method should be used for disposing old dressing.
 Gauze and cotton used for cleaning wound.
 Take preventive measure to avoid skin irritation and excoriation.
 If drainage tube is attached to the bottle precaution must be taken to secure the tube in
place and avoid the risk of cross infection.
Equipment
Sterile Field Set
1. Sterile kidney dish
2. Sterile galipot
3. Sterile scissors
4. Sterile forceps(3)
5. Sterile cotton balls
6. Sterile gauze
7. Sterile safety pins if needed
Clean tray

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1. Antiseptic solution as ordered
2. Cotton wool or absorbent
3. Receiver
4. Rubber sheet and its cover
5. Adhesive tape or bandage
6. Dressing scissors
7. Ointment paste or paraffin gauze
8. Spatula if needed
9. One pair sterile gloves if
available
Procedure
1. Check order for dressing / changing dressing
2. Great the patient
3. Check the order and the site of dressing drainage tube
4. Explain procedure to the patient.
5. Perform hand hygiene
6. Clean trolley or tray, assemble sterile equipment on one side & clean items on the other
side and make sure that the sterile equipments are properly covered.
7. Put on single use examination glove
8. Apply screen or close door and curtain
9. Drape and position the patient according to the need and put rubber sheet and its cover
under the part to be dressed.
10. Remove the outer layer of the dressing.
11. Use sterile forceps and remove the inner layer of the dressing (pay attention so that the
drainage tube is not pulled out with the old dressing).
12. Observe the wound for the type and amount of discharge.
13. Clean the wound with cotton balls soaked in antiseptic solution.
14. Grasp the top of drainage tube with sterile forceps. Pull it up a short distance while using
gentle rotation and cut off the tip of the drain with sterile scissors (the length to be cut
depends on the instruction or order).
15. Place sterile safety pin through the drainage tube close to the wound using sterile gloves
or sterile gauze, if it is in the abdomen to stop the drainage tube slipping down out of
sight.
16. Make sure the wound and the skin around are properly cleaned.

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17. Apply ointment or paste to the skin with spatula directly around to prevent irritation and
excoriation (if the excoriation exist use paraffin gauze to prevent further complications).
18. Cut the gauze towards its center to fit around rubber drainage tube so that it fits properly
around the tube thus preventing discomfort.
19. Use adhesive tape or bandage to secure the dressing in place.
20. Record state of wound and the drainage.
10.2. Wound Irrigation
Objective: At the end of this lesson, the learner should able to
1. Define wound irrigation
2. Describe the purpose and precaution consideration of wound irrigation
3. Assemble the necessary equipments for wound irrigation
4. Practice wound irrigation
Definition: Wound irrigation is the process of washing debris, drainage, or exudates out of the
wound to promote healing.
Purpose
1. To clean the area from pathogens and debris
2. To apply local heat
3. To irrigate with antiseptic solutions
4. To promote wound healing from the deepest area of a wound to the skin surface.
5. To remove and monitor drainage from wounds.
6. To manage wounds while preventing infection
Precaution
 Keep patient in convenient position.
 According to the need the solution will flow from wound down to the receiver.
 Use sterile technique and warn solution for irrigating the wound.
. Equipment
Sterile Field Set
1. Sterile gauze
2. Sterile gloves
3. Sterile forceps (3)
4. Sterile test tube or slide
5. Sterile cotton tipped application
6. Sterile galipot or kidney dish

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7. Sterile catheter
8. Sterile syringe 20 cc
9. Gown
10. Goggles
11. Mask
Clean tray
1. Clean glove
2. Bandage scissors or surgical blade
3. Bandage or adhesive tape and
Bucket to put in soiled dressing
4. Receiver (2)
5. Rubber sheet and its cover
6. Solution (hydrogen per oxide or
normal saline commonly used)
7. Adhesive tape or bandage
8. Bandage scissors
9. Receiver for soiled dressing
Procedure
1. Check order for irrigation
2. Great the patient
3. Check the order for irrigation and dressing
4. Explain procedure to the patient.
5. Wash your hands
6. Clean trolley or tray, assemble sterile equipment on one side & clean items on the other
side and make sure that the sterile equipments are properly covered.
7. Put on single use examination glove
8. Apply screen (close door and curtain) and drape
9. Position patient comfortably to permit gravitational flow of irrigation solution wound and
into collection receptacle
10. .Put rubber sheet and its cover under the part to be irrigated.
11. Check temperature of solution
12. Apply gown and goggle if needed
13. Remove the outer layer of the dressing by disposable glove and dispose the glove
14. Open sterile field
15. Put on sterile glove
16. Remove the inner layer of the dressing using the first sterile forceps.
17. Put the sterile receiver under patient to receive the out flow( may be sterile basin)

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18. Use syringe with desired amount of solution fitted with the catheter.
19. Use forceps to direct the catheter into the wound.
20. First inject the solution such as hydrogen per oxide at body temperature gently and wait
for the flow. This must be followed by normal saline for rinsing.
21. Make sure the wound is cleaned and dried properly with gauze.
22. Dress the wound and check if it is covered completely.
23. Secure dressing in place with adhesive tape or bandage.
24. Leave patient comfortable and tidy.
25. Clean and return equipment to proper place.
26. Wash your hands
27. Record the state of the wound.
10.3. Suturing
Objective: At the end of this lesson, the learner will be able to
1. Define suturing and suture
2. Describe the purpose of the different types of sutures
3. Re-demonstrate suturing
Definitions
 Suturing is the technique of uniting parts of the body by stitching them together.
 Sutures are threads used to sew body tissue together which can be absorbable
(Chromic Cat gut) and non absorbable (silk, cotton, linen, clips and wire nylon).
Purpose
 To approximate wound edges until healing occurs.
 To speed up healing of wound.
 To minimize the chance of infection
 For aesthetic purpose
Indication
 Open intentional and unintentional wound
Contraindication
1. Edema of the wound margins

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2. Infection
3. Puncture wounds
4. Animal bites
5. Tendon, nerve, or vessel involvement
6. Wound more than 12 hours old (body) and 24 hrs (face)
Precautions
1. Check that the patient gets TAT before he leaves the hospital.
2. Do not suture puncture (deep) wound.
3. Before you suture any wounds make sure it is free of any foreign body.
4. The completed knot must be tight, firm, and tied
5. To avoid wicking of bacteria, knot should not be placed in incision lines
6. Knots should be small and the ends cut short (2-3mm)
7. Avoid excessive tension to finer gauge materials as breakage may occur
8. Avoid using a jerking motion, which may break the suture
9. Do not tie suture too tightly as tissue ischemia may occur.
Equipments
Sterile field set
1. Tray or trolley covered with a sterile
towel
2. Sterile needle holder
3. Sterile suture scissors
4. Sterile round needle (2)
5. Sterile cutting needle (2)
6. Sterile hole towel (fenestrated towel)
7. Sterile kidney dish(2)
8. Sterile needle and syringe
9. Sterile gloves
10. Sterile tissue forceps(2)
11. Sterile cotton swabs in gallipots
12. Sterile gauze
13. Sterile artery forceps(3)
14. Sterile needle holder (2)
Clean tray
1. Silk and catgut
2. Antiseptic solution with its container
3. Adhesive plaster
4. Local anesthesia
5. Light bulb
Procedure

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1. Check the order for suturing
2. Great the patient, introduce yourself and explain the purpose of the procedure to the
patient.
3. Wash your hands
4. Clean trolley or tray, assemble sterile equipment on one side & clean items on the other
side and make sure that the sterile equipments are properly covered.
5. Adjust light
6. Put on sterile gloves.
7. Clean the wound thoroughly.
8. Drape the wound with the hold sheet
9. Infiltrate the edge of the wound to be sutured with local anesthesia.
10. Approximate the edge of fascia with the help of the tissue forceps and using the round
needle and catgut.
11. Suture the facial layer first followed by muscles. Suture the facial layer and muscle with
chromic catgut and.
12. Using cutting needle and silk suture the outer layer of skin approximating the edges with
the help of the tissue forceps
13. Clean wound area with iodine
14. Dress the wound with sterile gauze.
15. Remove the whole sheet.
16. Make the patient comfortable.
17. Remove all equipment wash and return to its proper place or send for sterilization.
18. Wash your hands
19. Record the state of the wound.
10.4. Stitch removal
Objective: At the end of this lesson, the learner will be able to
1. Define stitchremoval
2. Describe the purpose of stitchremoval
3. Assemble the necessary equipments for stitchremoval
4. Re-demonstrate stitchremoval

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Definition
 Stitch removal is the process of removing suture threads

Purpose
 To prevent further contamination
 To comfort the patient
 To relieve tension from wound site.
Precaution
 Keep wound clean and dry for the first 24 hours.
 Bathing is allowed after 48 hours.
 Stick to the day stitches should be removed.
 Keep wound clean and make dry dressing if no discharge.
 Change bandages often.
Equipment
Sterile field set
1. Sterile gauze
2. Sterile cotton balls
3. Sterile kidney dish
4. Sterile forceps (2)
5. Toothed tissue /pick up/pin forceps
(1)
6. Sterile stitch scissors/surgical blade
Clean tray
1. Rubber sheet and its cover
2. Antiseptic solution
3. Receiver/ waste container
4. Adhesive tape/ bandage
5. Plaster scissor
Procedure
1. Check the order for stitch removal
2. Greet the patient and Explain the purpose oe procedure.
3. Wash your hands

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4. Clean trolley or tray, assemble sterile equipment on one side & clean items on the other
side and make sure that the sterile equipments are properly covered.
5. Adjust light
6. Position the patient and protect bedding with rubber sheet and its cover.
7. Wear sterile glove
8. Remove the old dressing and discard it in the receiver.
9. Cleanse the wound using the 1
st
forceps with antiseptic solution starting from the
cleanest part of wound to the most contaminated part.
10. Place sterile gauze to receiver pieces of sutures.
11. Take a scissor in the right hand/ surgical blade.
12. Take pick up/pin set/ toothed tissue forceps in the left hand.
13. Pull up gently the knot resting against the skin with the forceps pass the point of the
scissors under the knot then cut the stitch on one side and remove.
14. Receiver pieces of stitches on sterile gauze and count number of stitches removed.
15. Inspect the wound for healing and apply iodine on suture site.
16. Apply dressing accordingly.
17. Keep patient comfortable and tidy.
18. Perform hand hygiene
19. Clean and return equipment to their proper place
20. Record the state of the wound.
10.5. Clips Application
Objective: At the end of this lesson, the learner will be able to
1. Define clips
2. Describe the purpose and indication of clips
3. Assemble the necessary equipments of clips
4. Practice application of clips following the steps
Definition
 Clips are metal sutures used to stitch the skin
 Clip application is the process of applying clips .
Purpose

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 To approximate wound edges until healing occurs
 To promote wound healing
 To minimize the chance of infection
 For aesthetic (cosmetics) purpose


Equipment
1. Tray or trolley covered with a
sterile towel
2. Sterile hole towel (fenestrated
towel)
3. Sterile kidney dish
4. Sterile needle and syringe
5. Sterile gloves
6. Mitchell’s clip applier
7. Tissue forceps (Tooth dissecting
forceps)
8. Sets of clip
9. Sterile cotton swabs in gallipots
10. Sterile Gauze
Clean tray
1. Antiseptic solution with its
container
2. Transferring with its container
3. Adhesive plaster
4. Local anesthesia (Lidocaine)
Procedure
1. Check the order for clips application
2. Great the patient and explain the purpose of clips application to the patient.
3. Wash your hands
4. Wear clean glove
5. Clean trolley or tray, assemble sterile equipment on one side & clean items on the
other side and make sure that the sterile equipments are properly covered.
6. Adjust light
7. Wash your hand again
8. Wear sterile glove
9. Clean the wound thoroughly.
10. Drape the wound with the hold sheet

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11. Infiltrate the edge of the wound to be sutured with local anesthesia.
12. Approximate the edge of skin with the help of the tissue forceps and apply clip to the
wound edge using the Mitchell’s clip applier.
13. Clean the wound and cover it with sterile gauze.
14. Remove the fenestrated/window towel .
15. Make the patient comfortable.
16. Remove all equipment wash and return to its proper place or send for sterilization.
17. Wash your hands
18. Record the state of the wound.
10.6. Removal of clips
Objective: At the end of this lesson, the learner should able to
1. Define removal of clips
2. Assemble the necessary equipments for clip removal
3. Demonstrate clipsremoval
Definition:-
Removal of clips is removal of clips from sutured area.
Purpose
 To prevent further contamination.
Precaution
 Stick to the day clips should be removed.
 Use aseptic technique
 Keep wound clean and make dry dressing if no discharge.
 Change bandages often.
Equipment
Sterile field set
1. Sterile gauze
2. Sterile cotton balls
3. Sterile kidney dish
4. Sterile forceps (3)
5. Sterile clip removal forceps
Clean tray
1. Rubber sheet and its cover 2. Receiver/ waste container

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3. Adhesive tape/ bandage
4. Plaster scissor
5. Antiseptic solution (Savalon 1%
and iodine)
6. Benzene or ether
Procedure
1. Check the order for clips application
2. Great the patient and explain the procedure.
3. Wash your hands
4. Wear clean glove
5. Clean trolley or tray, assemble sterile equipment on one side & clean items on the other
side and make sure that the sterile equipments are properly covered.
6. Adjust light
7. Wash your hand again
8. Position and drape the patient.
9. Protect the bedding with rubber sheet and its cover.
10. Wear sterile glove
11. Remove old dressing and discard.
12. Cleanse wound with antiseptic solution starting from cleanest part of the wound to the
most contaminated part and discard the cotton ball.
13. Place sterile gauze to receive removed clips.
14. Take clip remove with the right hand and dissecting forceps with the left hand.
15. Insert the lower blade of the clip remove below the middle of clip using the dissecting
forceps as a support of old the clips in place, and close the blade firmly as this will cause
disagreement of the clips from the skin.
16. Receive clips on sterile gauze and count the number of clips.
17. Apply iodine on the skin puncture in place with adhesive tape.
18. Leave patient comfortable and tidy.
19. Record the state of scar.
20. Clean and return used equipment to its proper place

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CHAPTER ELEVEN
COLD AND HEAT APPLICATION
Objective: At the end of this chapter, the learner will be able to :
1. List purpose of applying cold and heat
2. Identify and assemble necessary equipment to apply cold and heat
3. Demonstrate how to apply cold and heat with acceptable technique
11.1. Application of cold
11.1.1. Tipped Sponge Bath
Objective: at the end of this practical session the learner will be able to
 Define tipped sponge bath
 List purposes of tipped sponging
 Assemble necessary equipments required for the procedure
 Demonstrate the procedure
 Document the procedure
Definition:sponging of the skin with alcohol or cool water for reducing body temperature
(fever).
Purpose
 To relieve pain
 To reduce swelling and inflammation
 Reduce raised body temperature
 To relieve headache


Equipments
1. Basin
2. Towel
3. Syringe
4. Water at recommended temperature
5. Lotion thermometer
6. Body thermometer
7. Glove
8. Recording format
9. Bed pan
10. Screen
11. West receiver
12. Roll bandage
13. Alcohol
14. Grycline

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Procedure:
1.Explain the procedure
2.Wash hands properly
3.Assemble the necessary equipments
4.Give opportunity to use bed pans or urinals before tipped sponging
5.Take temperature and record
6.Note whether patient has antipyretic to reduce fever
7.Add tepid water to the bath basin (21.1
o
C to 29.4
o
C) use lotion thermometer to measure
Mix 3 parts water+ 1 part alcohol with 1% grycline.
8.Place moist, cool cloths wrung out just enough to prevent dripping in the client axillae and the groin
9. Perform the procedure for at least 25-30minute and Monitor the client’s body temperature throughout
the procedure to determine the treatment effects.
10. Sponge each limb for at least 5 minute and the back and buttocks for at least 10-15minute.
11. Stop the procedure if the client become very chilled or begins to shiver.
12. Stop sponging as soon as the client’s temperature approaches the normal range (38.7
o
C).give the
patient bath blanket.
13.Comfort the patient
14.Return equipments
13. Washhand.
14.document the procedure with patient reaction pre and post temperature
15. Take the temperature 30minute after you complete the bath.
11.1.2. Cold compress
Objective: at the end of this practical session the learner will be ableto:-
 Define cold compress
 List purposes of cold compress
 Assemble necessary equipments required for the procedure
 Apply cold compress
 Document the procedure
Definition: Cold compress is application of face towel or gauze wet in cold water to be applied
on specific body part.

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Purpose
 To relieve pain
 To reduce swelling and inflammation
 Reduce raised body temperature
 To relieve headache


Equipments
1. Basin
2. Towel
3. Ice pack
4. Water at recommended temperature
5. Lotion thermometer
6. Body thermometer
7. Glove
8. Recording format
9. Bed pan
10. Screen
11. West receiver
12. Roll bandage

Procedure:
1.Explain the procedure
2.Wash hands properly
3.Assemble the necessary equipments
4.Give opportunity to use bed pans or urinals before tipped sponging
5.measure client’s body temperature
5.Wear gloves if patient has open wound or has had surgery
6. Put the compresses in a basin containing pieces of ice and small amount of water.
7.Wring the compresses thoroughly and apply
8.Change the compresses frequently
9.Wrap the area with roll bandage if continuous compress needed
10. Continue the treatment as ordered, usually for 15-20 minutes. Repeat the treatment 2-4 hours as
ordered
13.Comfort the patient
14.Return equipments
13. Wash hand.
14.Document the procedure with patient reaction and pre and post temperature
15. Take the temperature 30minute after you complete the compress.
11.1.3. Dry cold application

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Objective: at the end of this practical session the learner will be ableto
 Define application of ice pack
 explain purposes of ice pack
 Describe contraindication for the
procedure
 Assemble necessary equipments
required for the procedure
 Demonstrate application of ice pack
 Document the procedure
Definition: application of dry cold by using ice in rubber bag /padded bowel/bag or container
Purpose
 To relieve pain of muscle strain
 To relieve congestion
 To check suppuration
 To decrease hemorrhage
 To reduce swelling or congestion
 To prevent cerebral congestion
 To relieve urinary retention
 To reduce temperature(fever)
Contraindication
 Muscle spasm
 Hypothermia
 Peripheral neuropathy
Equipment
1. Ice pack with cover
2. Ice in bowel
3. Water in bowel
4. Salt
5. Tablespoon
6. Duster to wipe ice cap after filling
7. Towel and mackintosh
8. Kidney dish
9. Steel tray
Procedure:
1.Explain the procedure
2.Wash hands properly
3.Assemble the necessary equipments
4.Give opportunity to use bed pans or urinals before tipped sponging
5.measure client’s body temperature
5.Wear gloves if patient has open wound or has had surgery
6.Add salt to ice chips to prevent fast melting of ice

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7.Cover the ice pack with towel
8.Apply ice pack to area as ordered(10-15minute)
9.Comfort the patient
10.Return equipments
11. Wash hand.
12.Document the procedure with patient reaction and pre and post temperature
13. Take the temperature 30minute after you complete the compress.
11.1.4. Application of Ice collar
Objective: at the end of this practical session the learner will be able to
1. Define application of ice collar
2. List purposes of ice collar
3. Describe contraindication for the procedure
4. Assemble necessary equipments required for the procedure
5. Demonstrate application of ice collar
6. Document the procedure
Definition: application of dry cold by using ice in rubber bag /padded bowel/bag or container.
Purpose
 To relieve pain of muscle strain
 To relieve congestion
 To check suppuration
 To decrease hemorrhage

 To reduce swelling or congestion
 To prevent cerebral congestion

Contraindication
 Muscle spasm
 Hypothermia
 Peripheral neuropathy
Equipment
 Ice collar
 Ice in bowel
 Water in bowel
 Salt

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 Tablespoon

 Towel and mackintosh
 Kidney dish
 Steel tray

Procedure
1.Explain the procedure
2.Wash hands properly
3.Assemble the necessary equipments
4.Give opportunity to use bed pans or urinals before tipped sponging
5.Measure client’s body temperature
5.Wear gloves if patient has open wound or has had surgery
6.Add salt to ice chips to prevent fast melting of ice
7. Fill the collar threefourthsfull with ice and remove the remainingair from the collar before
closing the collar.
8. Check for leaks. Place the collar in a protectivecover and place it around the client’s neck.
9. Apply ice collar to area as ordered.
9.Comfort the patient
10.Return equipments
11. Wash hand.
12.Document the procedure with patient reaction and pre and post temperature
13. Take the temperature 30minute after you complete the compress.
11.2. Application of heat
11.2.1. Applying warm soak
Objective: at the end of this practical session the learner will be able to
 Define application of warm soak
 List purposes of warm soak
 Describe indication/contraindication for warm soak application
 Assemble necessary equipments required for the procedure
 Demonstrate application of warm soak
 Document the procedure

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Definition: is method of immersing body part in a solution or plenty of warm water.
Purpose

 To relieve stasis of blood
 To relieve musclestiffness and
muscle pain
 To cleanse wound
 To relieve pain and swelling

 To increase blood circulation
 To apply heat to hasten suppuration
 To relieve distention and congestion
 To apply medication
 To provide warmth to the body
Indication
 Muscle spasm
 Prolonged Edema or hematoma
 Patient comfort
Contraindication

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 Acute appendicitis
 Acute inflammation
 Patient with sensory or neural deficit
 Open wound
 Malignancy
 Blisters or burn
 Unconscious patient
Equipment:
 Lotion thermometer
 Soak basin
 Measuring jug
 Large plastic sheet
 Bath towel
 Bath blanket
Procedure:
1. Explain the procedure
2. Wash hands properly
3. Assemble the necessary equipments
4. Position the patient for comfort on the far side of the bed (opposite the part to be soaked).
5. Secure Side rail
6. Cover the bed with a plastic sheet and towel.
7. Fill the soak basin half full with water at the prescribed temperature (usually 105°F). Check the
temperature with a lotion thermometer.
8. Take the soak basin from the over bed table and position it on the bed protector.
9. Assist the patient to gradually place the limb in the basin. Cover the basin with a towel to help to
maintain temperature.
10. Check the temperature every 5 minutes. Use a pitcher to get additional water and add to the soak
basin to maintain temperature. Remember to remove the patient’s limb before adding water to the
container.
11. Discontinue the procedure at the end of the prescribed time.
12. Lift the patient’s limb out of the basin.
13. Slip the basin forward and allow the limb to rest on the bath towel.
14. Place the basin on the over bed table. Gently pat the limb dry with a towel.
15. Remove the plastic sheet and towel.
16. Adjust bedding and remove the bath blanket. If the treatment is to be repeated, fold the bath
blanket and place it in the bedside stand. Leave the unit tidy and the call bell within reach.

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17. Lower the head of the bed and make the patient comfortable.
18. Return equipment to the utility room.
19. Wash hand.
20. Document the procedure with patient reaction
11.2.2. Applying Hot Compress
Objective: at the end of this practical session the learner will be able to:-
 Define application of hot compress
 List purposes of hot compress
 Assemble necessary equipments required for the procedure
 Demonstrate application of hot compress
 Document the procedure
Definition: Hot compress is application of face towel or gauze wet in warm water to be applied
on specific body part.
Purpose
 To relieve stasis of blood
 To relax muscle
 To relieve pain
 To increase blood circulation
 To promote suppuration
 To relieve distention and congestion
 To provide warmth to the body
 To promote healing
 To soften the exudate
 To decrease joint stiffness
Equipment:
 Disposable gloves
 Syringe
 Bed protector
 Compresses
 Lotion thermometer
 Binder or towel
 K pad as necessary
Pins or bandageProcedure
1. Explain the procedure
2. Wash hands properly
3. Assemble the necessary equipments
4. Protect the bed and the patient’s clothing with a bed protector.

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5. Check the temperature of the solution. Moisten the compresses; remove excess liquid.
6. Done clean glove
7. Expose only the area to be hot compressed.
8. Apply the hot compress to the specific body part.
9. Secure the compresses with a bandage or binder if long term compress needed
10. The compress must be in contact with the patient’s skin.
11. Help the patient to maintain a comfortable position throughout the procedure.
12. Un screen the unit. Leave the unit neat and tidy, with the signal cord within easy reach.
13. Maintain proper temperature and moisture.
14. If the compresses are to be kept warm, a K-Pad may be applied.
15. A syringe may be used to apply more solution to keep the compresses wet.
16. Remove the compresses when ordered. Change as ordered or once in 24 hours. Check skin
several times each day.
17. Discard the compresses.
18. Remove gloves
19. Comfort the patient.
20. Return equipment t.
21. Wash hands
22. Document the procedure with patient reaction
11.2.3. Hot Water Bag Application
Objective: at the end of this practical session the learner will be ableto
 Define application of hot water bag
 List purposes of hot water bag
 Assemble necessary equipments required for the procedure
 Apply hot water bag
 Document the procedure
Definition: - Hot water bag application is a process of applying dry heat by means of a rubber
bag on specific body part.

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Purpose
 To provide comfort and warmth
 To stimulate circulation
 To relive pain
 To relax muscles
 To promote healing
 To relieve congestion and
inflammation
 To relive bladder distension
Contraindications
 Open wounds
 Hypertension
 Metabolic disorders
 Impaired kidney, heart and lung
functions
 Acute inflammations
Equipment
 Hot water bag with cover
 Measuring Jugs-2
 Duster/towel -1
 Towel-1
 Vaseline or oil
 Lotion thermometer
Procedure:
1.Explain the procedure
2.Wash hands properly
3.Assemble the necessary equipments
4.Place in comfortable position
5.Arrange the equipments at the bed side
7.Check hot water bag for any leakage
8.Check the temperature of water with lotion thermometer
9.The temperature should be 105 to 115
o
F for children and 115 to 125
o
F for adults
10.Keep the bag in flat surface

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11.Pour hot water bag until 2/3
rd
is full
12.Expel excess air by permitting water to come to mouth of bag and then close
13.Hold bag upside down to check for leakage
14.Wipe outside with duster cover with towel and apply to body part
15. Expose only the part that needs treatment and apply on it.
16.Provide warmth by covering all non-treatment area with bath blanket or bed covers
17. Comfortthe patient.
18. Return equipment.
19. Wash hands
20.Document the procedure with patient reaction

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CHAPTER TEWELVE
NUTRITON AND METABOLISM
Objectives: At the end of this chapter the learner will be able to:-
1. Demonstrate how to feed a helpless patient
2. Demonstrate proper practice of Gastrostomy feeding
3. properly administer parental feeding
4. properly check placement of NG tube
5. accurately washout gastric mucosa
6. monitor input and output of patient
12.1. Feeding a helpless patient
Objectives: At the end of this lesson, the learner will be able to:
1. Define feeding a helpless patient
2. List the indication of feeding a helpless patient
3. Describe the purpose of feeding a helpless patient
4. Assemble the necessary equipments for feeding a helpless patient
5. Demonstrate how to feed a helpless patient
Definition: Feeding a helpless patient is providing nutritional intake for a pt that is unable
to feed him/her self.

Purpose
 To assist the patient to eat meal
 To meet the nutritional need
 To promote healthy
 To prevent dehydration
 To improve appetite
Indication
 General weakness or critically ill patient
 Paralysis or limitation of movement E.g. Presence of arm splints casts and traction.
 Small children.
12.2. Feeding the Helpless Patient General Instruction
 Check the diet ordered
 Make surrounding neat and clean.
 Prepare pt and over – bed table
 Hot food should be served hot and cold food cold.

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 The tray should be complete, clean and neat. The food, no matter how simple, should
be attractive and appetizing.
Precaution
 Control odors noise and unpleasant sights at meal equipment.
 Remove solid equipments & linens
Patient - Provide oral hygiene
 Hand washing
 Position comfortable preferable sitting up position
Meal tray: - Ensure correct tray for correct pt
 Arrange tray on table to be accessible to pt
 Adjust the bed table at appropriate height
 Assist in removing cover, cutting and preparing food.
 Present the food in attractive manner
 The meal should be placed near the pt where it can be seen & smelt to help in stimulating
appetite.
Equipment
1. Extra – pillow, if not a patch bedNap kin
2. Food on a clean tray
3. Towel
4. Glass of water
5. Meal tray
6. Drinking tube or feeding cup
7. Over bed table
8. Oral hygiene equipment
9. Feeding spoon

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Procedure
1. Make patient comfortable. Elevate head and shoulder if permissible.
2. Protect patient’s gown and bed with a towel.
3. Arrange tray conventionally. Place tray where it can be reached easily.
4. Feed patient as indicated.
12.3. Gastrostomy feeding
Objectives: At the end of this lesson, the learner will be able to:
1. Define Gastrostomy feeding
2. Describe the purpose of Gastrostomy feeding
3. Assemble the necessary equipments for Gastrostomy feeding
4. Demonstrate proper practice of Gastrostomy feeding
Definition: Gastrostomy is an operation performed to create an opening in to the stomach the
purpose of administering food and medications. For insertion of the gastrostomy tube requires
either upper abdominal midline incision or a left upper quadrant transverse incision.
Purpose
 For long term use and total feeding supplementation.
 For patients who cannot tolerate nasogastric or nasoentric tube.
Equipments
 Gastrostomy tube
 50 ml syringe
 Funnel
 Clamper
 Measuring jag
 Sterile gauze
 Adhesive tape
 Chart
Procedure
1. Explain the procedure to the patient
2. Wash hand
3. Assemble the necessary equipment
4. Position the patient in his/ her comfortable position (mostly sitting position).

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5. Pour the fluid (food) into the measuring jag as prescribed.
6. Connect the syringe with the tube.
7. Hold syringe at angle so that air doesn’t enter stomach and continue pouring the fluid
into the syringe or funnel.
8. Hold syringe perpendicular so feeding can enter by gravity.
9. After feeding rinse with water and remove the syringe.
10. Cover the tip of the tube with sterile gauze using a plastic band and attach to the
dressing.
11. Apply light dressing over the stoma and tube.
12. Comfort patient; keep the head of the bed elevated for at least 30minutes after procedure
to aid digestion.
13. Clean return used equipments
14. Wash hands and document procedure in the client’s medical record
12.4. Parentral Feeding
Objectives: At the end of this lesson, the learner will be able to:
1. Define parentral feeding
2. Describe the purpose of parentral feeding
3. List the indication of parentral feeding
4. Assemble the necessary equipments for parentral feeding
5. practice proper care for patients with parentral feeding
Definition: Parenteral fedding or nutrition (PN) is a method of providing nutrients to the
body by an IV route. It is a very complex admixture of individual chemicals combined in a
single container.
Purpose:
1. Provide parentral nutritional support to malnourished clients
2. Provide parentral nutritional support to clients who are NPO for extended periods of
time
3. Provide parentral nutritional support to clients requiring bypass of the GI tract for
prolonged period

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4. Provide parentral nutritional support to clients who have excess metabolic needs due to
trauma , cancer, or hyper metabolic state
Indication
Short-Term (up to 2 weeks)
1. Preoperative for severely depleted clients
2. Postoperative for abdominal surgery clients who have been NPO for several days
because of an ileus
3. Inflamed or ulcerated bowel needing 1 or more weeks of rest: acute exacerbations of
Crohn’s disease and colitis, radiation enteritis, acute or necrotizing pancreatitis, or an
enterocutaneous or high-output fistula
4. Congenital anomalies before surgical repair: intestinal obstruction, tracheo-esophageal
fistula, mid gut mal rotation, volvulus, and omphacele
5. Short-bowel syndrome: small-bowel resection of 75% or more to control diarrhea and
prevent dehydration and malnutrition
6. Cancer clients receiving chemotherapy or radiation therapy
Long-Term (greater than 2 weeks)
1. Hyperemesis gravidarum
2. Low-birth weight neonates
3. Failure to thrive
4. Intractable diarrhea
5. Severely burned clients
Precaution
1. Verify placement of feeding line prior to administration of liquids.
2. Administer nutrients in accordance with the prescribed time interval.
3. Keep PN refrigerated; remove from refrigerator 30 minutes prior to administration.
4. Change PN tubing every 24 hours.
Equipment
o TPN solution
o IV controllers or pumps

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o Appropriate IV tubing with filter
o IV pole
o TPN dressing kit
o Sterile Gloves and mask
o Blood glucose monitoring equipment
Procedure
1. Schedule and assist client with chest x-ray after central catheter insertion
2. Confirm correct solution is running at order rate.
3. Check solutions expiration date .
4. Use infusion controller to monitor and regulate flow rate
5. Inspect tubing and catheter connection for leaks or kinks. Tape all connections. Change
tubing every 24 hours accordingly to agency policy
6. Inspect insertion site for infiltration thrombophelibits or drainage. If present, notify
physician. Note the physician may order removal of the catheter and culture of the catheter
tip
7. Monitor vital signs , including temperature every 4 hours
8. Assess for symptoms of air embolism (i.e., decrease level of consciousness, tachycardia,
dyspnoea, anxiety, ”feeling of impending doom”, chest pain, cyanosis, hypotension) Note :
if suspected ,lay clients on left side with head in trendelenburg position.
9. Use the TPN line only for administration of TPN and lipids. Don’t use the line for any other
reason
10. Perform test for g glucose every 6 hours. Notify the physician if abnormal
11. Monitor laboratory test of electrolyte, BUN, glucose as order and report abnormal finding
12. Maintain accurate record of intake and output to monitor fluid balance
13. Weigh client daily and record
14. Inspect dressing once shift for drainage and intactness. Change whenever loose or moist and
at least every 48 hours.
15. Wash hands and document procedure in the client’s medical record
12.5. Nasogastric tube insertion

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Objectives: On the completion of the lesson learners will be :
 Define Nasogastric tube.
 List the purpose of nasogastric tube.
 Collect the necessary equipment for nasogastric tube insertion .
 Perform the procedure according to the steps.
 Apply proper checking of NG tube placement.
Definition: Passing a tube through a nasal cavity down the nasopharynx and oesophagus in to
the stomach
Purpose
 To administer tube feeding and medication to clients unable to eat by mouth or swallow
a sufficient diet without aspirating food or fluids in to the lungs.
 To establish a means for suctioning stomach contents to prevent gastric distension,
before and after surgery ,nausea and vomiting
 To remove stomach contents for laboratory analysis
 To decompress abdominal distension.
 To lavage (wash) the stomach in case of poisoning or overdose of medications
Indication
 Surgery
 Abdominal distension
 Poison
 Unconscious
 Severe dehydration
 Diagnostic analysis
Equipment
 NGT, (Ryle’s tube) plaster,
 Gauze
 Water soluble lubricant
 Disposable glove
 Glass of water
 20 to 50 ml syringe
 Stethoscope
 Blue litmus paper
 Ink
 Spigot to close the tube
 Cotton applicator to clean nostril
 Waster receiver
 Rubber sheet and draw sheet
 Mouth wash tray

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 Tongue depressor
 Flash light
 Basin with warm water or ice
 Denature cup
 Safety pin and rubber band
 Bath towel
 Normal saline
 Emesis basin( bowel)
 Clamper or artery forceps to clamp the tube to avoid air entry
Procedure
1. Explain the procedure to the patient
2. Wash hands and prepare equipments
3. Position:
 For conscious patient sitting or a semi-upright position and support the head on a
pillow It is often easier to swallow in this position and gravity helps the passage of
the tube
 For uncoinscious patient lying in the left lateral position with the head slightly lower
than the body.
 For infants and young children, do not hyper extend or hyper flex the neck may
occlude air way but in young person ask to hyper extend the neck
4. Done examination glove
5. Drape plastic sheet and lower around patient’s neck.
6. Assess client’s necks
7. After hyperextend the head of the client observe the patent of the tissues of the nostrils,
including any irritations or abrasions by using a flash light and examine the nares for
any obstructions or deformities by asking the client to breathe through one nostril while
occluding the other
a. Check that the nostrils are patent by asking the patient to sniff with one nostril
closed
b. Repeat with the other nostril. If necessary cleanse the nostrils with water using
cotton wool on applicator.
8. Prepare the tube for insertion. If a rubber tube is being used, place it on ice this stiffens
the tub, facilitating insertion. If a plastic tube is being used, place it in warm water. This
makes the tube more flexible, facilitating insertion

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9. Use the tube to mark off the distance from the tip of the client’s nose to the tip of the ear
lobe and then from the tip of the earlobe to the tip of the sternum. This distance varies
among individuals. For infant and young children, measure then to the point midway
between the umbilicus and the xiphoid process. Mark this length with adhesive tape /ink
if the tube does not have markings.
10. Lubricate about 15-20 cm of the tube with a water soluble lubricant using a swab
11. Insert the rounded end of the tube in hyper extend the neck in to the cleanest nostril and
slide it backwards and in wards along the floor of the nose to the nasopharynx.
a. If any obstruction is felt, withdraw the tube and try again in a slightly different
direction or use the other nostril.
12. As the tube passes down in the nasopharynx, ask the patient to start swallowing and
sipping water this will close the glottis, enabling the tube to pass in to the oesophagus.
a. Slight pressure is sometimes necessary to pass tube but never forced against
resistance, because of the danger of injury
13. Advance the tube through the pharynx, as the patient swallow’s until the predetermined
mark has been reached.
 While inserting the tube observe for patient condition for Coils in the mouth by
opening the mouth by tongue depressor
 If Client gag, stop passing the tube momentarily with each wall insert 5 to 10 cm
with each swallow.
 If client continues to gag and the tube does not advance with each swallow,
withdraw it slightly.
 If the patient shows signs of distress like gasping or cyanosis, remove the tube
immediately and try again the procedures.
14. Continue in advancing the tube until the mark on and the tube reach his/her nostril.
15. Taping a tube to the bridge of the nose
16. Check the position of the tube to confirm that it is in the stomach by:-
A. Introducing 10-20ml of air in to the stomach via the tube and check for a whooshing
sound using a stethoscope placed over the epigastrium.

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B. Aspirating the contents of the stomach with a syringe. The aspirate turns blue litmus
paper to red, due to HCI.
C. Insert/immerse the tip of tube in the glass of water and if you see bubble that show
you are in the lung.
17. Clamp the end of the tube with clamper or forceps or spigot
18. Secure the tube to the nostril and attach to forehead with adhesive tape. Ensure patient
is comfortable.
19. Attach the tube to a suction source or feeding apparatus as ordered
20. Assist the patient into position and comfort
21. Remove and clean the used equipment return it in to proper place
22. Wash hands and dry
23. Document relevant information
12.6. Nasogastric tube medication administration
The nurse checks the patency and placement of a nasogastric tube before adding any water
or medications by performing the following actions:
 Wash hands and done non sterile gloves.
 Unclamp the tube.
 Check the placement of the tube in the stomach
If the nurse fails to hear the swish sound and aspirates gastric contents, the tube may have
risen into the client’s esophagus. Do not administer the medication until placement in the
stomach is verified.
 When different types of medications are administered, each type is given separately,
using a cccccbolus method that is compatible with the medication’s preparation.
 The tube is flushed with 20 to 30 mL of water after each dose.
 If a liquid form of a medication is not available and the medication can be crushed, it
must first be reduced to a fine powder or the tube will become clogged
For clients who have an NG tube for decompression (removal) of gastric contents, turn off
the suction for 20 to 30 minutes after the instillation of the medication to allow time for the
gastric contents to be emptied into the intestines, where most drugs are absorbed

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12.7. Gastric aspiration
Objectiveat the end of this lesson, the learner will able to:-
1. Define gastric aspiration
2. List the purpose of gastric aspiration
3. Collect the necessary equipment for gastric aspiration
4. Perform the gastric aspiration according to the steps
Definition: Aspiration is the withdrawal of fluid or gas from gastric cavity by sectioning.
Gastric content analysis is examination of the contents of the stomach, primarily to determine
the quantity of acid present and incidentally to ascertain the presence of blood, bile, bacteria,
and abnormal cells.
Purpose
1. To relieve stomach or intestinal distension following abdominal surgery.
2. In case of gastrointestinal obstruction to remove the stomach content,
3. To keep the stomach empty before an emergency abdominal operation is done.
4. To aspirate the stomach contents for diagnostic purpose ,like detect acid-fast bacillus
in a client with undiagnosed tuberculosis, total absence of hydrochloric acid is
diagnostic of pernicious anaemia.
Equipments
1. Nasogastric tube (NGT)
2. Syringe with needle((2)
3. 50ml syringe
4. Towel
5. Water with kidney dish
6. Specimen container
7. Sphygmomanometer
8. Litmus paper
9. Adhesive tape
10. Chart
11. Tray
12. Gauze
13. Draw sheet rubber sheet
14. Spigot
15. Stethoscope
16. Water base lubricant
17. Scissor

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18. Ink
19. Histamine
20. Cotton applicator
21. Spatula

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Procedure
1. Explain the procedure to the patient
2. Wash hand
3. Assemble the necessary equipments
4. Put on gloves and use the cotton and rubber sheet to cover the bed.
5. Put up the client to high- fowler's (semi sitting) position by raising the bed or with the help or
back rest pillow.
6. Place towel on the patient’s chest.
7. Examine the patency of nostrils by hyper extending the head. Ask the client to breathe
through each nostril while compressing the other nostril to select the more patient one. Select
the nostril through which air passes more easily.
8. Select the appropriate distances mark on the tube by measuring the distance on the tube from
the client’s bridge of the nose to ear lobe plus the distance form ear lobe the to the bottom of
the xiphistemu (xyphoid process).
9. Clean the nostril and lubricate 20-30 meter of the tip of the tube with water soluble lubricant
to reduce friction
10. Gently insert the tube, with its natural curve toward the client, into the selected nostril.
Have the client hyper extend the neck, and gently advance the tube toward the nasopharynx.
And direct the tube along the floor of the nostril in dawn ward and back ward way. If the tube
meets resistance withdraw it, lubricate it, and insert in the other nostril. Swallowing or
sipping water through a straw may be helpful.
11. Once the tube reaches the throat / oropharynx/, have the client tilt the head forward and tell
him to swallow.
12. Instruct the client to open his/her mouth to make sure that the tube is not coiled in the mouth
and it is in the stomach.
13. Insert the tube until it reaches about 50 centimetres or until it reaches the measured point.
14. Determine that the tube is in client’s stomach.
 Place the tip of the tube in the water in kidney dish; if bubbling happens it indicates that
the tube is in respiratory system, immediately remove the tube.

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 Or aspirate 20-30ml of the content of the stomach with syringe then test the content by
using Litmus paper. Gastric content is yellow to green in colour and usually presents in
amounts greater than 10 ml.
 Take 20 cc syringe aspirate air and administer the air through NG tube, place
stethoscope on epigastric area then listen to a gurgling sound. If you hear the sound it
means that the tube is wit in the stomach.
 Chest x- ray
15. After being sure that the tube is in the right position secure the tube by taping to bridge of the
client's nose
16. Aspirate gastric fluid using 20-50 ml syringe and collect specimen if needed, or aspirate with
suction machine or attach with bag or clamp end of tubing as ordered.
17. Histamine will be given subcutaneously to stimulate gastric secretions.
18. Continuously monitor the blood pressure to detect hypotension.
19. Collect gastric specimen every 15 minutes for 1 hour.
20. Label the specimen to indicate specimen before and after histamine injection
21. Comfort the patient
22. Clean or discard used equipments.
23. Record
12.8. Gastric lavage
Objective:On the completion of the lesson learners will be:
1. Define gastric lavage.
2. List the purpose of gastric lavage.
3. Collect the necessary equipment for gastric lavage.
4. Perform the gastric lavage according to the steps.
Definition: Gastric lavage is the introduction of solution into the stomach and removing gastric
contents through nasogastric tube for washing out the stomach.
Purpose
 To remove inserted poison, other than corrosive substances like ammonia and mineral
substances.
 To introduce ice water or normal saline solution in tackling bleeding.

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 To cleanse the stomach before operation.
 For diagnostic purposes.
 To relief congestion, nausea and vomiting .
Indication
 Pyloric stenosis
 Poisoning
 Preoperative care
Equipments
1. Equipments for NG tube insertion
2. Measuring jug
3. 2-3 litters prescribed solution.
4. IV stand
5. Tap water or ice if ordered
6. 50ml syringe
7. Funnel
8. Gloves
9. Rubber and cotton sheet
10. Towel
11. Litmus paper
12. Suction machine (optional)
13. Labelled specimen container
14. Laboratory request form
15. Charcoal tablets ( universal antidote)
16. Emesis basin
17. Tissue paper
18. Drainage container
19. Vital sign instruments
20. Chart
Procedure
1. Explain the procedure to the patient
2. Wash your hand
3. Assemble the necessary equipments.
4. Keep patient privacy and position the patient
 Position in left lateral position for conscious patient but if unconscious, place in prone
position with head over the edge of the bed or head lower than the body (semi prone
position)
5. Protect client and bed linen with towel and rubber sheet
6. Done single use examination glove

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7. Select the appropriate distances mark on the tube by measuring the distance on the tube from
the client’s bridge of the nose to ear lobe plus the distance form ear lobe the to the bottom of
the xiphistemu(xyphoid process).
8. Lubricate the tube.
9. Gently insert and pass the tube, the tongue, the mouth forward the posterior pharynx (If the
client is unconscious, mouth gag may be used)
 If air bubbles, cough and cyanosis are noticed withdraw the tube and recommence the
procedure.
10. Advance the tube slowly to prevent injury until the pre measured mark,
11. Assess the correct placement by aspirating stomach contents, or by listening gosh of air while
the client exhales.
12. After the NG tube is in place, allow the stomach contents to empty in to the drainage
container before instilling any irrigating solutions. This confirms proper placement of the
tube and decreases the risk of over filling of the stomach and inducing of vomiting.
13. Once you confirm proper placement of the tube, begin gastric lavage by instilling about
250ml of irrigating solution to assess the patient’s tolerance and prevent vomiting.
 If you are using simple rubber tube for the lavage
a. Fill the small jug with water/ solution, measure and pour gently until the funnel is
empty, then invent over the pail (the funnel is connected with the funnel end of
the oesophageal tube)
b. Take specimen, if required, and continue the process until the returned fluid
becomes clear and the prescribed solution had been used.
 If you are using a tube with a bulb
a) Clamp the tube below the bulb,
b) With right hand, squeeze the bulb thus forcing the air out through the funnel.
c) With left hand, pinch tubing above the bulb/proximal to you/ and at the same time
with right hand, release the clamp. This creates a suction which will draw the
stomach contents into the bulb.
d) Lower funnel and allow excess gastric contents to drain into the pail.

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e) Pour 200-300 cc of solution/water into funnel. Before funnel is empty allow
solution to drain.
f) Before a solution stops running. Turn up funnel and add another quantity of
solution
g) Repeat this procedure until returns are clean.
14. Instruct the client to take deep breath and hold it to close epiglottis
15. Monitor patient’s vital signs, urine output, and level of consciousness every 15 minutes and
notify the physician for any changes.
16. Give mouth wash
17. If ordered, gently remove the tube, feel the client’s tube, and watch the respiration
18. Remove glove, hand wash, Clean or discard used equipments.
19. Comfort the patient
20. Record the procedure, including the time, date, type of irrigating solution and the amount of
gastric contents drained.
12.9. Gastric Gavage
Objective: at the end of thislesson, the learner will be able to:-
1. Define gastric gavage.
2. List the purpose of gastric gavage.
3. Collect the necessary equipment for gastric gavage.
4. Perform the gastric gavage according to the steps.
Definition: Gastric gavage is providing nutritional supplement when the patient is unable or not
willing to take food per mouth with normal GI tract functioning.
Purpose
1. To provide total supplemental nutrition
2. Restore fluid, electrolyte and acid base balance.
3. Reduce or eliminate catabolism and negative nitrogen balance.
Precaution
 Severe pancreatitis
 Enterocutaneous fistulae
 GI ischemia

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Contra indication
 Diffused peritonitis
 Intestinal obstruction that prohibits normal bowel functioning
 Intractable vomiting; paralytic ileus
 Severe diarrhea
Patient assessment
1. Assess the client for signs of gastric distress, such as nausea, vomiting, and cramping, to
determine the client’s tolerance for the tube feeding.
2. Assess the feeding tube placement every 4 hours to confirm tube placement in the GI tract.
3. Assess the client’s respiratory status to evaluate for pulmonary aspiration of gastric contents.
4. Assess the client’s ongoing nutritional status to evaluate the effectiveness of the tube feeding.
5. Assess the client’s intake and output to evaluate feeding impossible.
Equipment
1. NG tube
2. Tap water
3. Formula /Liquid food ( at room
temperature)
4. IV stand
5. Tray
6. Clean Glove
7. 50ml syringe
8. Funnel
9. Disposable gavage bag and tubing
10. Towel
11. Tissue paper
12. Dirty receiver
13. Chart
Procedure
1. Explain the procedure to the patient, provide privacy
2. Wash hands and assemble the necessary equipments.
3. Assist the client to a fowler's position in bed or a sitting position in a chair, the normal
position for eating
 If this position is contraindicated, a slightly elevated right side lying position is acceptable.
These position help/ enhance the gravitational flow of the solution & prevent aspiration.

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4. Assess the client for feelings of abdominal distension, blenching, loose stools, flatus or plain;
bowel sounds and allergies to foods.
5. If NG tube is not in place follow the NG tube insertion procedure and insert the tube and
secure it.
6. Confirm correct placement of the tube
7. Cover the patient’s chest with the towel to protect him/her from spills of food.
8. Aspirate stomach contents to determine amount of residual and measure it.
 If the residual is over 50-100 ml in adults and 10 ml or more infants, hold the
feeding until residual diminishes or subtract the withdrawn amount from the total
feeding and administer the rest. All these are based on the policy agency.
9. Reinstall the gastric contents to the stomach to prevent electrolyte imbalance.
10. Before the feeding solution has drained from the neck of the bottle, instil 50-60 ml of water
through the tube, to prevent tube feeding syndrome and further blockage.
11. Remove air from the feeding tubes and attach it to the nasogastric tubes and to prevent air
from entering to the stomach, never allow the syringe or the gavage bag to empty completely.
12. Hang bottle on IV stand beside patient and run the food through the giving set or if a syringe
is to be used remove plunger from barrel of syringe and attack barrel to nasogastric tube.
 Deliver feeding over the desired length of time (as ordered). Usually 200-350 ml
over 10-15 minutes is given.
 Replace any formula administered by an open system every 4 hours with fresh
formula. Formula should be at room temperature or cool (not cold).

13. After the administration of the appropriate amount of food, flush the tube by adding about
60ml of water to the syringe. This maintains the patency of the tube by removing excess food
particles which could block the tube.
14. If you are administering a continuous feeding, flush the tube every 4hours to help prevent
tube occlusion.
15. To discontinue the NG tube feeding disconnect the syringe from the feeding tube.
16. Close the tip of the NG tube with its plug cap before all of the rinse solution has run through
to prevent leakage and contamination.

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17. Leave the patient in semi sitting position of slightly elevated right lateral position for at least
30minutes.
18. Communicate with your patient.
19. Clean and return used equipments.
20. Wash your hand
21. Record the amount given and the patient’s general condition.
Complications
 Diarrhoea – due to hyper osmolar feeding, rapid infusion, bacteria contaminated feedings,
lactase deficiency and food allergies etc.
 Nausea/ vomiting- due to Change in rate of feeding, offensive smell, in adequate gastric
emptying.
 Cramping/ gas- due to air in tube.
 Constipation- high milk content, low fiber intake, inadequate fluid intake.
 Aspiration pneumonia- due to improper tube placement, flat in bed, too large tube etc.
 Tube displacement- due to excessive coughing/ vomiting, tracheal suctioning etc.
 Tube obstruction- due to inadequate flushing/ formula rate.
 Nasopharengeal irritation- due to tube position and large tubes.
 Hyperglycaemia- glucose intolerance and high carbohydrate feeding content.
12.10. Removal of a Nasogastric Tube
Objective:at the end of this lesson, the learner will be able to:-
1. Define Nasogastric Tube removal.
2. Collect the necessary equipment for Nasogastric Tube removal.
3. Perform the Nasogastric Tube removal according to the steps.
Definition: Nasogastric Tube removal is the process of withdrawing the nasogastric tube which
was placed in client’s stomach for different purpose.
When the physician determines that the client’s nutritional status no longer warrants EN therapy
or the need to provide decompression of the gastric contents, the nasogastric tube is removed. If
the client is connected to suction for decompression, the physician may prescribe clamping the
tubing for several hours prior to removal, to ensure a functioning GI tract.

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Equipment:
1. Tube plug or clamp,
2. Towel, washcloth,
3. Paper towel,
4. Receptacle for contaminated items,
5. Don sterile gloves.
Procedure
1. Hand wash
2. Verify the physician’s prescription.
3. Check the client’s armband and explain the procedure.
4. Provide for privacy.
5. Wash hands and don gloves.
6. Place the client in a high Fowler’s position and adjust the height of the bed to a
comfortable working position.
7. Place the towel across the client’s chest.
8. Clamp or plug the tube and unpin the tube from client’s gown.
9. Remove the tape securing the tube from the client’s nose.
10. Hold the paper towel open in your non dominant hand under the client’s chin; with your
dominant hand, grasp and pinch the tube near the nostril, and remove the tube with a
steady, continuous pull, allowing the tube to fall into the paper towel.
11. Dispose of the tube and paper towel in the receptacle.
12. Clean the client’s nares and provide oral hygiene.
13. Position the client comfortably, place call light in easy reach, and return bed to a low
position.
14. Remove gloves, place in receptacle, and dispose of receptacle in accord with agency
policy.
15. Wash hands and document procedure in the client’s medical record
12.11. Measuring Intake and Output
Objectives: At the end of this lesson, the learner will be able to:
1. Define intake and output measurement

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2. Describe the purpose of intake and output measurement
3. Assemble the necessary equipments for intake and output measurement
4. Practice how to measureintake and output
Definition: The measurement and recording of all fluid intake and output during 24 hours
period which provides important data about the clients fluids and electrolyte balance .
Purpose
 Initiated to monitor the client’s fluid status over a 24-hour period
Precaution
 Elicit client and family member input when selecting household items to be used for
intake measurement.
 Provide containers for measuring output; adapt the urinary container to home facilities,
and include teaching relative to proper washing and storage.
 Teach hand washing technique.
 Provide written instructions on what is to be measured.
 Provide sufficient I&O forms to last between the nurse’s visits.
 Identify the parameters for evaluating a discrepancy between the intake and output and
for notifying the nurse or health care practitioner.
Equipment
 I&O form at bedside
 I&O graphic record in chart
 Glass or cup
 Bedpan, urinal, or bedside commode
 Graduated container for output
 Non sterile gloves
Procedures
1. Wash hands.
2. Explain purpose of keeping I&O record to client. Explain that:
3. All fluids taken orally must be recorded.
4. Form for recording must be used.
5. Client must void into bedpan or urinal, not into toilet.
6. Toilet tissue should be disposed of in plastic lined container, not in bedpan.
Oral Intake
7. Measure all oral fluids in accord with agency policy (e.g., cup = 150 ml, glass = 240 ml).

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8. Record time and amount of all fluid intake in the designated space on bedside form (oral,
tube feedings, IV fluids).
9. Transfer 8-hour total fluid intake from bedside I&O record to graphic sheet or 24-hour
I&O record on client’s chart.
10. Record all forms of intake, except blood and blood products, in the appropriate column of
the 24-hour record.
11. Complete 24-hour intake record by adding all 8-hour totals.
Output
12. Don non sterile gloves.
13. Empty urinal, bedpan, or indwelling catheter drainage bag into graduated container or
commode “hat.”
14. Remove gloves, and wash hands.
15. Record time and amount of output (urine, drainage from nasogastric tube, drainage tube)
on bedside I&O record.
16. Transfer 8-hour output totals to graphic sheet or 24-hour I&O record on the client’s chart.
17. Complete 24-hour output record by totalling all 8-hour totals.
Intake and output documentation form
Intake out put
Night Time PO/NG amount Time urine stool Emesis/gastri
c
other


Night total
day

day total


evening

evening total

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CHAPTER THIRTEEN
3.2 ELIMINATION
Definition- act of voiding or expelling waste material from the bowels
13.1. Urinary elimination
Categories of urethral catheters
1. Straight or Robinson catheter a single lumen tube
2. Retention or Foley catheter contains second lumen (two- and three-way catheter)
3. Coode (elbowed): - used for elderly men who have BPH- which is curved tip
Types of Catheterization (routes)
 Urinary catheterization
 Suprapubic catheterization
13.1.1. Urinary catheterization

Unit One
Catheterization
Definition Is the Introduction of a tube (catheter) through the urethra in to the urinary bladder.
- Is performed only when absolutely necessary
Note Strictly a sterile procedure i.e., aseptic technique should always follow
- Catheter is a tube with a hole at the tip
Types of Catheters
 Straight (Plain) Catheter
 Foley (Indwelling, retention) Catheter

1.1 Plain Catheterization
Definition The Insertion of a tube through the urethra in to the urinary bladder for shorter periods
(5-10 minutes)
Purpose
 To relieve discomfort due to bladder distention
 To assess residual urine
 To obtain a urine specimen

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 To Empty the bladder prior to surgery
1.2 Folly Catheterization
Definition: The insertion of a tube through the urethra in to the urinary bladder
for a continuous drainage.
Purpose
- To empty the bladder in case of retention of urine, occurring as a post-operative
complication
- In case of retention due to injury or tumor of the spinal cord
- In case of obstruction due to the blockage of the urethra causing stricture
- To obtain sterile specimen of urine
- To ensure that the bladder is empty before an abdominal or pelvic operation or
Paracentesis
- To keep incontinent patient dry
- To avoid contamination after operation of vagina or perineum
- To empty bladder irrigation or instillation of the bladder
- To determine if residual urine is present in the bladder
- For an accurate measurement of urinary out put
- To facilitate healing of urethra
-
Male catheterization
- Catheterizing a male client either by indwelling or straight catheter
- The position of client during male catheterization is on the back with the thighs slightly
a part. (Supine position)
- The size of tube for male adult, 18 and 20 French catheters commonly are used
- 8 and 10 French catheters commonly are used for children

Equipment
 Sterile
- Sterile gloves
- Sterile drapes & fenestrated towel
- Antiseptic solution
- Lubricant
- Cotton balls or gauze Squares

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- Forceps for male 3,
- Straight or Indwelling Catheter
- Syringe
- Kidney dish 2
- Specimen container if needed
- Galipot for cleansing solution
- appropriate size catheter
- Urine collection bag
Clean
- Flashlight of lamp if needed
- Rubber Sheet & draw sheet
- Screen
- Soap with soap dish
- Wash cloth 3
- Basin 2
- Warm water
- Lotion thermometer
- Clean glove
- Ky-jelly
Procedure for male catheterization
1. explain the procedure and Its purpose to the client
2. wash your hands
3. Assemble the necessary equipment
4. Provide for good light
5. Provide for privacy by closing the door or by using screen
6. Position the client on his back with thighs slightly apart.
7. Done clean glove & appley rubber & cotton draw sheet
8. Check water temperature & clean the genital & perineal area with warm soapy water – Rinse &
dry
9. Open sterile filed then wear sterile glove
10. Appley fenestrated towel so that only the area around the penis is exposed
11. Prepare urine drainage set up if indwelling catheter is to be inserted
12. Place the catheter set on the sterile drape between client’s legs.

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13. Check the catheter balloon if the catheter is to be indwelling
14. Lubricate the catheter for about 15 to 18 cm (6-7 inches)
15. the penis with your non dominant hand, which is then considered contaminated – Retract the
fore - skin in the uncircumcised male client. Clean the area at the meatus with cotton ball held
with a forceps. Use circular motion, moving from the meatus toward the base of the penis for
two cleansings then dray.
16. Hold the penis with slight upward tension and perpendicular to the client’s body 90 degree.
17. Insert the tip into the meatus Advance the catheter 15 – 20 cm (6 to 8 inches) or until urine
flows. Do not use force to introduce the catheter. If the catheter resists Entry, ask the client to
breathe deeply rotate the catheter slightly lower the penis to 60 degree. For Indwelling catheter,
once urine drains, advance the catheter another 1.3 to 2.5 cm (1/2–1 inch). Then lower the penis
18. Hold the catheter securely with the non- dominant hand while the bladder empties – collect a
specimen if required.
19. Remove the catheter smoothly & slowly if a straight catheterization was ordered.
20. If the catheter is to be indwelling

a/ Inflate the ballon
b/ pull gently the catheter after the balloon is inflated to feel resistance then advance 1 cm again.
c/ attach the catheter to the drainage system if necessary
d/ Secure to the upper thigh tape.
e/ Check that the drainage tubing is not kinked
21. Return the equipment and make the client comfortable in bed
22. Wash your hands
23. Record the time of the catheterization the amount or urine removed, description of the urine, The
client’s reactions to the procedure, your name & signature.





Female Catheterization
-Insertion of a catheter tube through female urethra in to urinary bladder

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- The position of client during female catheterization is dorsal recumbent position with
the knees flexed, if preferable, the client can be placed in the side – lying position


Equipment
Sterile
- Sterile gloves
- Sterile drapes & fenestrated towel
- Antiseptic solution
- Lubricant
- Cotton balls or gauze Squares
- Forceps 11
- Straight or Indwelling Catheter
- Syringe
- Kidney dish 2
- Specimen container if needed
- Galipot for cleansing solution
- appropriate size catheter
- Urine collection bag
Clean
- Flashlight of lamp if needed
- Rubber & draw sheet
- Screen
- Soap with soap dish
- Wash cloth 3
- Basin 2
- Warm water
- Lotion thermometer
- Ky-jelly
Procedure for female catheterization
1. Assess general condition of the patient, explain the procedure and its purpose to the client
2. Wash your hand.
3. Provide for good light

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4. Assemble equipment
5. Provide privacy
6. Assist the client to the dorsal recumbent position with the knees flexed & separated
7. Wear clean glove, appley rubber & draw sheet under the buttock area.
8. Check water temperature with lotion thermometer or dorsal part of the palm.
9. Clean the genital & perineal area with warm soapy water & dry, wash your hand again if
necessary
10. Open sterile filed & Put-on sterile gloves
11. If the catheter is to be indwelling, test the catheter balloon & lubricate 1 to 2 inches of the
catheter tip
12. Clean labia majora & dray both said
13. grasp the upper corners or the drape and unfold the drape without touching unsterile areas. Fold
back a cuff over gloved hands.
14. Ask the client to lift her buttocks & slide the sterile drape under her with gloves protected by cuff
15. Appley fenestrated sterile drape placed over the perineal area exposing the labia
16. Place the sterile tray {equipment} on the drape between the client’s thighs
17. With the thumb and one finger of your non-dominant hand, spread the labia & identify the
meatus.
18. Using gauze held with forceps, clean both labial folds and then directly over the meatus. Move
gauze above the meatus down toward the rectum. Discard each gauze after one down ward stroke.
19. With the uncontaminated gloved hand, place the drainage end of the catheter in the receptacle.
For insertion of an indwelling catheter that is reattached to sterile tubing and drainage container
(closed drainage system)
20. Insert the catheter tip in to the meatus 5 to 7 cm (2 – 3 inches) or until urine flows
21. For an indwelling catheter, once urine drains, advance the catheter another 1.3 to 2.5 cm (½ to 1
inch)
22. During insertion instruct the pt to take deep breath exercise
23. Hold the catheter securely non dominant hand while the bladder empties. Collect the specimen if
required.
24. Remove the catheter smoothly & slowly if a straight catheterization was ordered.
25. If the catheter is Indwelling
- Inflate the balloon
- Pull gently the catheter after the balloon is inflated to feel resistance.

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- Attach the catheter to the drainage system if necessary.
- Secure to the upper thigh with a tape
- Check that the drainage tubing is not kinked
26. Remove the equipment and make the client comfortable in bed
27. Wash your hands.
28. Record the time of catheterization, the amount of urine removed, a description of the urine, the
client’s reaction to the procedure and your name
Removal
- With draw the solution from the balloon using a syringe
- And remove gently

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CHAPTER THIRTEEN
ELIMINATION
Definition- act of voiding or expelling waste material from the bowels
13.2. Urinary elimination
Categories of urethral catheters
4. Straight or Robinson catheter a single lumen tube
5. Retention or Foley catheter contains second lumen (two- and three-way catheter)
6. Coode (elbowed): - used for elderly men who have BPH- which is curved tip
Types of Catheterization (routes)
 Urinary catheterization
 Suprapubic catheterization
13.2.1. Urinary catheterization
Learning objective: At the end of the lesson, the learner will be able to
1. Define urinary catheterization
2. List the purpose of urinary catheterization
3. Identify the necessary equipment for catheterization
4. Perform procedure of urinary catheterization
Definition: Urinary Catheterization- involves inserting a small tube/ catheter through the
urethra in to the bladder to allow urine to drain
 Catheters: are tubes commonly made of rubber or plastics, although certain types are
made of woven silk or metal.
Purpose
13.2.1.1. Straight or plain catheterization
13.2.1.1.1. Catheterization using a straight or plain catheter for female

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Definition: introducing plain or straight catheter through the female urethra to the urinary
bladder
Purpose
 To relieve discomfort due to bladder distention
 To obtain a sterile urine specimen
 To empty the bladder prior to surgery
Equipment
Sterile
1. 2 Sterile plain catheter rubber or plastic
2. A bowl for antiseptic
3. Gauze
4. Sterile towel(3#)
5. forceps 3#
6. Sterile receiver
7. Kidney dish
8. Sterile urine specimen container if needed
Clean
1. Rubber and draw sheet
2. Antiseptic solution
3. Receiver
4. Measuring jug
5. Flash light
6. Screen
7. Specimen form
Procedure
1. Explain procedure to the patient
2. Screen the bed
3. Wash hands
4. Turn blanket and bedspread down to foot of bed
5. Turn top linen up wards to the patient’s chest to protect form complete exposure.
6. Place patient in dorsal recumbent position with the knees flexed and thigh apart then
7. Put rubber and draw sheet under buttocks, cover patient with the linen(if patient soaked use
examination glove)
8. Apply disposable glove

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9. Clean starting from mid thigh with clean warm water and soap and dry the area
10. Open sterile filed
11. Done sterile gloving
12. Create a sterile field and Drape the client with a sterile drape (bottom far side nearside
pubic area)
13. Prepare the equipment and Put receiver for urine near the genital area
14. Place sterile equipment on drape between patient tight
15. Prepare the equipment and Put receiver for urine near the vulva.
16. Use nondominant hand to separate labia until the catheter is inserted
17. Wash the outer skin folds then inner labia and urethral meatus with antiseptic solution from
front to back. (Starting from outer proceeding to inside)
18. Put forceps in the receiver kidney dish
19. Wash and Rinse the area well from outer skin folds then inner labia and urethral meatus
finally with distil water from front to back.
20. Put forceps in the receiver kidney dish
21. Dry the dry gauze the outer skin folds then inner labia and urethral meatus from front to back
22. Put forceps in the receiver kidney dish
23. Lubricate the insertion tip of the catheter (5-7 cm in)
24. Expose the urinary meatus adequately by retracting the tissue or the labia minora in an
upward direction
25. Gently insert the catheter into meatus until urine is noted. Continue inserting for 2.5 to 5cm
additional.
26. Remove catheter after desired duration or all expected urine expelled
27. Measure urine, dry area with dry gauze, remove bed protection
28. Position patient comfortable and cover
29. Remove and clean equipment
30. Send specimen to the laboratory
13.2.1.1.2. Male plain or straight urinary catheterization
Definition: Introducing plain or straight catheter through the male urethra to the urinary bladder
Equipment

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Sterile
1. 2 Sterile plain catheter rubber or plastic
2. A bowl for antiseptic
3. Cotton swab
4. Gauze
5. Large sterile fenestrated towel
6. Sterile towel
7. forceps ( 3 )
8. Sterile receiver
9. Kidney dish
10. Lubricant
11. Sterile urine specimen container if needed
Clean
1. Rubber and draw sheet
2. Antiseptic solution
3. Receiver
4. Measuring jug
5. Flash light
6. Screen
7. Specimen forms
Procedure
1. Explain procedure to the patient
2. Screen the bed
3. Wash hands
4. Turn top linen up wards to the patient’s Umbilicus and blanket and bed spread up to
mid-thigh.
5. Place patient in dorsal recumbent position with the knees flexed and thigh apart then put
rubber and draw sheet under buttocks, cover patient with the linen
6. Wash the perennial area with warm water and soap
7. Wash hands
8. Open sterile field
9. Put on sterile gloves
10. Place sterile towel under the patient and fenestrated towel over the patient thigh
11. Prepare antiseptic swabs and Pick up penis with non-dominate hand protract foreskin if
not circumcised, grasp directly behind glans and spread meatus between forefingers and
thumbs.

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12. Cleanse penis using circular motion, starting over meatus and working down wards
glans, repeat procedure twice using new swabs always by the help of forceps.
13. Pick up catheter, lubricated at least 7.5cm from distal end. Draw penis upwards and
forwards at 90
0
angle to the leg insert the catheter, lower penis when feeling resistance at
an angle of 60 degree
14. Insert catheter about 18-20cm till urine flow
15. Remove catheter, replace foreskin to avoid complication
16. Remove catheter measure urine, dry area with dry cotton swab, remove bed protection
position patient comfortable and cover
17. Remove and clean equipment
18. Send specimen to the laboratory
13.2.1.2. Insertions of indwelling Urinary catheter
13.2.1.2.1. Insertions of indwelling catheter for male patient
Learning Objective: At the end of the lesson, the learner will be able to
1. Define insertions of indwelling catheter
2. Identify the nocessary equipment for insertions of indwelling catheter
3. Demonstrating the procedure of indwelling catheter
Definition: introductions of indwelling catheter through the male urethra in to the bladder
Purpose
 To prevent retention by use of an indwelling catheter
 To prevent frequent catheterization in case where pt is unable to pass urine
 To prevent bed sore in case of urine incontinence
 To prevent infection in cases of perineal operation
Equipment
1. Indwelling catheter rubber or plastic
2. A bowl for antiseptic
3. Cotton swab
4. Gauze
5. Large sterile fenestrated
towel
6. Sterile towel
7. Forceps ( 3 )

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8. Sterile receiver
9. Kidney dish
10. Syringe
11. Sterile water
12. Lubricant
13. Sterile urine specimen container if needed
Clean
1. Rubber and draw sheet
2. Antiseptic solution
3. Receiver
4. Urinary drainage bag
5. Screen
6. Adhesive plaster
Procedure
1. Explain procedure to the patient
2. Screen the bed
3. Wash hands
4. Turn top linen up wards to the patient’s chest to protect from complete exposure.
5. Place patient in dorsal recumbent position with the knees flexed and thigh apart then put
rubber and draw sheet under buttocks, cover patient with the linen
6. Wash the perennial area with warm water and soap
7. Wash hands
8. Prepare sterile trolley
9. Uncover patient,
10. Put on sterile gloves, place sterile towel under the patient and fenestrated towel over
the patient thigh
11. Test balloon before insertion on sterile filed with recommended amount of sterile water
12. Prepare antiseptic swabs and Pick up penis with non-dominate hand retract foreskin if
not circumcised, grasp directly behind glans and spread meatus between forefingers and
thumbs.
13. Cleanse penis using circular motion, starting over meatus and working down wards
glans, repeat procedure twice using new swabs always by the help of forceps.
14. Pick up catheter, lubricated at least 7.5cm from distal end. Draw penis upwards and
forwards at 90
0
angle to the leg insert the catheter, lower penis when feeling resistance at
an angle of 60 degree

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15. When catheter is inserted, inflate the balloon with 5-15ml as indicated on catheter
16. Pull gently on the end of the catheter to be sure it will not leave the bladder then push
back 2cm to relieve pressure from sphincter
17. Attach drainage tube to catheter and drainage bag
18. Tie tube and drainage bag to the bed ,put the bottle below the patient level
19. Cover and comfort the patient
20. Return the equipment
21. Wash hands and document the procedure
13.2.1.2.2. Insertions of indwelling catheter for Female patient
Leaning objective: At the end of the lesson, the learner will be able to
1. Define indwelling catheter for female pt
2. Identify equipments for insertions of indwelling catheter
3. Demonstrate insertions of indwelling catheter
Definition: Introduction of the indwelling catheter through the female urethra in the bladder
Purpose
 To prevent retention by use of an indwelling catheter
 To prevent frequent catheterization in case where pt is unable to pass urine
 To prevent bed sore in case of urine incontinence
 To prevent infection in cases of perineal operation
Equipment
Sterile
1. Indwelling catheter rubber or plastic
2. A bowl for antiseptic
3. Cotton swab
4. Gauze
5. Large sterile fenestrated
towel
6. Sterile towel
7. Forceps ( 3)
8. Sterile receiver
9. Kidney dish
10. Syringe
11. Sterile water
12. Lubricant
Clean
1. Rubber and draw sheet 2. Antiseptic solution

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3. Receiver
4. Urinary drainage bag
5. Screen
6. Adhesive plaster
Procedure
1. Explain procedure to client and Provide for privacy
2. Set the bed to a comfortable height to work, and raise the side rail on the side opposite
you.
3. Assist the client to a supine position with legs spread and feet together or to a side-lying
position with upper leg flexed.
4. Drape client’s abdomen and thighs.
5. Ensure adequate lighting of the perineum.
6. Wash hands, don disposable gloves, and wash perineal area from the mid thigh.
7. Remove gloves and wash hands.
8. bring urine collection bag ready for attaching near to side of bed
9. Done sterile gloving
10. Create a sterile field and Drape the client with a sterile drape (bottom far side
nearside pubic area)
11. Prepare the equipment and Put receiver for urine near the genital area
12. Place sterile equipment on drape between patient tight
13. Prepare the equipment and Put receiver for urine near the vulva.
14. Use nondominant hand to separate labia until the catheter is inserted
15. Wash the outer skin folds then inner labia and urethral meatus with antiseptic solution
from front to back. (Starting from outer proceeding to inside)
16. Put forceps in the receiver kidney dish
17. Wash and Rinse the area well from outer skin folds then inner labia and urethral meatus
finally with distil water from front to back.
18. Put forceps in the receiver kidney dish
19. Dry the dry gauze the outer skin folds then inner labia and urethral meatus from front to
back
20. Put forceps in the receiver kidney dish
21. Lubricate the insertion tip of the catheter (5-7 cm in)

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22. Expose the urinary meatus adequately by retracting the tissue or the labia minora in an
upward direction
23. Gently insert the catheter into meatus until urine is noted. Continue inserting for 2.5 to
5cm additional.
24. After catheter insertion, the balloon is inflated to hold the catheter in place within the
bladder.
25. Instruct the client to immediately report discomfort or pressure during balloon inflation;
if pain occurs, discontinue the procedure, deflate the balloon, and insert the catheter
further into the bladder.
26. Gently pull the catheter until the retention balloon is snuggled against the bladder neck
(resistance will be met) re-push back 2cm after the test
27. If laboratory test is prescribed, collect some amount of urine in the sterile specimen
bottle straight from the catheter
28. Secure the catheter to the abdomen or thigh and connect to drainage tube
29. Place the drainage bag below the level of the bladder.
30. Remove gloves, dispose of equipment, and wash hands.
31. Help client adjust position.
32. Assess and document
13.2.1.3. Applying a Condom Catheter
Definition- The condom catheter is an external drainage system to collect urine from male
clients who have incontinence
Purpose
 Provide a means of collecting urine and controlling incontinence without the risk of
infection that an indwelling urinary catheter imposes
Equipment
 Condom catheter kit with adhesive strip
• Urinary drainage bag/bed pan
• Clean gloves
• Basin with warm water and soap

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 Towel and washcloth
Procedure
1. Wash hands and apply gloves.
2. Select an appropriate condom catheter.
3. Cleanse the penile shaft.
4. Inspect the penile shaft for excessive hair.
5. Inspect the penis for altered skin integrity.
6. Stretch the shaft of the penis and unroll the condom to the base of the penis.
7. Follow product directions for the application of the sealant
8. Attach the condom to the drainage apparatus,
9. either a leg bag or bedside drainage bag.
10. Remove gloves and wash hands.
11. Remove and reapply the condom catheter every 24 to 48 hours, or when leakage occurs.
13.2.2. Bladder Irrigation (open and closed method)
Definition: it is the washing out of the bladder to clear the catheter and/or the bladder.
Purpose
 To clean the bladder before operation depending on the surgeon’s order
 To arrest bleeding from the bladder
 To clean the catheter from mucous or blood clots
 To clean bladder from pus
Precaution
 Care should be taken not air into the balder as it may cause spasm
 Not more than 100-300ml must be instilled at a time after bladder operation capacity may
be limited.
 If the catheter is blocked by blood clots, a suction of the catheter must be proceeding the
irrigation

Equipment
 a complete set to catheterization  A sterile bladder syringe for open
method

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 Irrigation solution e.g. normal saline or
cold solution to stop bleeding
 Irrigation solution in a bag, infusion set,
Y-piece, urine drainage tube and bag
clamp for closed method
 Receiver with plaster to put the catheter
end (open method)
 Rubber and draw sheet
 clamp
 pail
 glove
Procedure for open method
1. Insert catheter as in catheterization
2. If catheter is already in the bladder
3. Put bed protection
4. Draw solution in the syringe
5. Clamp catheter, attach syringe in the catheter, place drainage tube on a swab
6. Decamp instill the solution gently into the bladder
7. With draw syringe, put end of catheter on the receiver which is placed on the bed
protection
8. Repeat this procedure 2-3 times or more until the return solution is clear
9. Clean catheter and drainage tubing with a swab and connect it again
Closed method
1. Prepare solution bag with IV set
2. Connect Y-place to the catheter and IV set to one end of the “Y” and drainage tube to
the other end
3. Intermittent irrigation clamps the drainage tube and let irrigation solution run in the
bladder (100-200ml) then close the set and open the drainage tube empty the bladder.
4. Repeat this procedure as soften as necessary
5. Empty the collection bag frequently

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6. Subtract the irrigation solution form the total urinary output if balance
13.2.3. Suprapubic catheter care
Definition: A Suprapubic catheter is inserted through the abdominal wall above the symphysis
pubis into the urinary bladder.
Purpose
o to prevent bladder infection
o To keep skin integrity
Care of clients with Suprapubic catheter include
 Regular assessment of the client’s urine, fluid drainage system.
 Skin care around the insertion site involves sterile technique.
 Periodic clamping of the catheter preparatory to removing it and measurement of
residual urine.
 Leaving the catheter open to drainage for 48to 72 hours then clamping the catheter for
3-to-4-hour periods during the day the client can void satisfactory amounts.
 Dressing should be changed whenever they are soiled.
 A small amount of iodine is used.
13.3. Bowel elimination

13.3.1. Enema
Definition:
 Is an injection of a liquid in to the rectum, to be returned or retained.
 The term enema is used to refer to the process of instilling fluid through the anal
sphincter into the rectum and lower intestine for a therapeutic purpose.
Purpose:
 To cleanse the lower bowel,
 To assist in the evacuation of stool or flatus
 To instill medication

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13.3.1.1. Cleansing enema/evacuating enema/
Definition: - an enema is the cleansing of a portion of the bowel by insertion of fluid rectally
Purpose
 To relieve gas, constipation or fecal impaction
 To cleanse the bowel prior to surgery, childbirth, or diagnostic examination.
 To evacuate the bowel in patients with neurologic dysfunction.
 Evacuates feces in clients with hemiplegia, quadriplegia or paraplegia
 Delivers medication
Types of liquid used for cleansing enema
1. Tape water = 5000 to 1000 cc
2. Soap solution= 5000 to 1000 cc
3. Normal saline - made by mixing one teaspoon of salt in a liter of water usually contains
1000cc of normal saline.
4. Epsom salt 15 gm - 120 gm in 1000 cc of water
Precautions
 No need to use too much soap - this may produce sever irritation of the membrane of the
colon.
 Tap water must be administered consciously for infants or adults who have altered kidney
or cardiac reserve this is to avoid water intoxication.
Contraindications
 Rectal surgery
 Rectal /anal/ cancer
 Rectal infection
 for a patient with appendicitis
 Rectal /Ana/ fissure
Equipment
 Container for solution
 Ordered Solution at temperature for
adult 40-43
0
c
 Bath thermometer for infant (37.7
0
c)
 Water proof material /mackintosh/
 Screen, bath blanket, towel
 Enema can with tube
 Gauze

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 West receiver
 Bed pan covered by towel and toilet
tissue paper
 PPE
 IV pole/stand
 Gloves
 Receiver /kidney dish/
 Lubricant
 Rectal tube /catheter /
 Clamper, connector
Procedure
1. Check physician's order assess patient condition & explain the procedure to patient
2. Wash your hands & assemble necessary equipment
3. Prepare ordered solution & mix ingredients thoroughly for cleansing enema & adjust
water temperature with lotion thermometer or dorsal part of the palm {elbow}.
4. Provide privacy
5. Raise the enema can to a maximum height of 45cm from bed
6. Connect enema tube to enema can nozzle, then connect rectal tube with enema tube by
connecter
7. Fill water container with 500to 1000 cc of warm solution
8. Allow solution to run through the tubing so that air is removed from tube to prevent
abnormal distention
9. Adjust bed at comfortable position and lower side rails
10. Place patient on left side /left lateral / in a sim’s position with the Rt. Leg flexed, for
adequate exposure of anus
11. Place rubber & cotton sheet under patient
12. Lubricate the tip of the tubing with water soluble lubricant about 5 cm
13. Retract the buttock with non-dominant hand with tissue paper,
14. Gently insert tubing with rotation movement 7-10 cm in an adult, 5-7.5cm in children,
2.5-3.75 cm in an infant to patient’s rectum,
15. During insertion, instruct the patient to take deep breath to pass the external and internal
sphincters anus to prevent irritation
16. Remove clumper & allow solutions to flow slowly

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17. If patient complains of abdominal fullness, cramp & pain During administration of fluid
in to the rectum, stop the flow for 30 seconds and restart at slower rate. Hold the tubing in
place in the patient's rectum at all times.
18. After you have instilled the solution or when the patient has strong desire to defecate,
gently remove the tubing instruct patient to hold solution for 10 to 15 minutes.
19. Elevate the head of the bed so that the patient can assume as squatting or sitting position
on the bedpan or assist to bathroom.
20. Provide privacy until the patient has expelled the total volume of the instilled solution
21. Removal and cover bed pan
22. Assist patient with perineal care and help patient to assume a comfortable position
23. If the patient is on strict input and out measure returns to make sure total volume of the
solution is expelled.
24. Clean all equipment and replace in bath room or appropriate vocation
25. Wash your hands and document

13.3.1.2. Retention enema
Definition: - it is the injection of a liquid in to the rectum, to be retained in the rectum for some
period of time
Purpose:
 To supply the body with fluid
 To give medication
 To soften impacted fecal matter
Equipment
 Enema can
 clean glove
 Lubricant
 Gauze/tissue paper
 Clamper
 Connecter
 Screen, kidney dish

 Clean bedpan
 rectal tube

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 Towel
 enema tube
 Rubber &cotton draw
sheet sheet
 Possible solution
(normal saline, tab
water etc.)
 Ordered medication
Procedure
1. Check the order & assess the patient condition
2. Explain the purpose of the procedure to the patient
3. Wash hand and assemble necessary equipment
4. Prepare the solution ordered by physician & arrange temperature
5. Fill the ordered solution to the enema can
6. Run the fluid through a tube to expel air & clamp it
7. Lubricate rectal tube
8. Screen and position the patient on left lateral with buttocks on the edge of bed
9. Expose anal opening and separate buttocks with left hand & instruct the patient to
take deep breath during insertion, insert rectal tube tip of container 3-4 inches
10. Open the clamper and allow to run
11. Squeeze contents slowly and empty entire amount in to rectum
12. Remove rectal tube gently
13. Explain to patient that the solution should be retained for one to three hours
before it is expelled
14. A cleaning enema may need to be given to remove the solution (oil) and stimulate
defecation
15. Clean all equipment and wash your hand
16. documentation



13.2.1.3 Rectal wash out
Definition: - is the injection of a liquid in to the rectum to be wash out the rectum and colon

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Purpose
 To prepare the patient for x-ray examination and sigmoidoscopy
 To prepare the patient for rectum and colon operation
Precaution
 The rectal wash out should not exceed for more than 2 hours
 The rectal wash out should be finished one hour be for examination (e.g. x-ray,
sigmoidoscopy) this is to give time for the large intestine to absorb the rest of the fluid
 Give cleansing enema half hour be for the rectal wash out.
Equipment
 Pitcher
 Newspaper
 small jug
 Large mug for fluid {basin}
 Bucket
 Funnel
 Bedpan
 Lotion thermometer
 Screen
 Measuring jak
 Clean glove
 Tissue paper /gauze
 Tubing and glass connecting
 Rectal tube or catheter and clamp
 lotion thermometer
 Mackintosh and towel
 swab and Vaseline
 Solution of (40 c
o
)
 glove
Procedure
1. Check the order, assess general condition & explain the purposes of the procedure to
patient
2. Wash hand, assemble necessary equipment and bring to bedside
3. Prepare the solution ordered by the physician
4. Check the temperature of the fluid and fill the small jug
5. Run the fluid through to expel air and clamp it.
6. Lubricate the catheter

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7. Screen the bed and place the patient in the left lateral position with the buttocks on
the edge of the bed
8. Place the mackintosh and towel underneath the buttocks
9. Expose the anal region separate the buttocks, with one hand and insert the rectal tube
in to the rectum 8-10 cm
10. Open the clamp and allow to run about 100 cc of fluid in the bowl, then siphon back in to
the bucket.
11. Carry on the procedure until the fluid returned is clear
12. Remove the catheter and leave the patient comfortable
13. The amount returned should be measured to ensure that none has been retained
14. Record or chart the time, result and effect on the patient
13.3.2. Inserting a flatus tube
Definition: - The insertion of a rectal tube is done to manage flatulence (gas) following abdominal
surgery and/or reduce abdominal distention due to flatulence.
Purpose
 It can be used to alleviate abdominal distention.
 It is used to control diarrhea that cannot be controlled with medical management and/or
the use of rectal pouches, pads, or diapers due to extensive skin breakdown
Equipment
 Rectal tube or catheter, 22 to 30 French
 Water-soluble lubricant
 Bedside drainage bag (optional, if rectal tube used to manage diarrhea)
 Ostomy odor eliminator or similar product (optional)
 Clean gloves
 Disposable pads or towels
 Bucket with water
Procedure
1. Check the order, assess general condition & Explain rationale regarding need of tube and its
short duration of use for the patient.

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2. Wash hands.
3. Assemble the necessary equipment.
4. Wear gloves
5. Position client in left lateral position with upper leg bent over lower leg
6. Place disposable pads (if not available, use towels).
7. Use odor eliminator per manufacturer (optional).
8. Apply lubricant to a gloved finger.
9. Insert lubricated finger into rectum to check for possible obstructions prior to insertion of
rectal tube.
10. Change gloves if soiled from rectal exam.
11. Lubricate end of catheter.
12. Gently insert catheter into anal canal approximately 10–15 cm (4–6 inches)
13. Attach plastic bag or drainage bag to end of catheter if needed to control odor or stool
14. Inflate balloon of catheter or tape tube to the lower buttock if rectal tube is not to be removed
within 30 minutes
15. Dispose of pad. Remove soiled gloves and place in appropriate receptacle.
16. Wash hands
13.3.3. Colostomy care
Definition: Colostomy: is an opening created as a permanent or temporary diversion of the
bowel at the level of the colon
Purpose: - to empty the large colon of stool

Equipment
 Appropriate pouch
 Skin barrier/colostomy belt/
 Pouch clip or rubber band
 Skin past
 Soap with soap dish
 Warm water
 Wash cloth
 West receiver
 Screen
 Blade /razor/

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
 Tape, if gauze is used
 Clean gloves
 Ostomy odor eliminator
 Bedpan with cover, toilet, or
basin
Procedure
1. Check the order and assess general condition of the patient
2. Explain the procedure
3. Wash hands and assemble necessary equipment
4. Screen the patient
5. Apply clean gloves.
6. Position, assist the patient to a standing {preferable}, sitting or left lateral
7. Remove the solid pouch by gently pressing on the skin while pulling the pouch
8. Dispose of the pouch in plastic bag after removing the clip used.
9. Remove the skin barrier & clean the barrier with soap solution
10. Cleanse the skin and stoma with clean warm water
11. Observe the peristomal skin for redness, altered skin integrity, or rashes
12. Remove excessive hair with a safety razor blade or electric razor
13. Inspect the pouch opening and ensure that it fits the stoma
14. Apply skin past around stoma skin barrier and knot the belt
15. Gently apply pouch and press in to place, file inferior opening with the clip or a rubber
band
16. Comfort the patient, return used equipment, remove glove, wash hand and document



13.2.4 Colostomy irrigation
Definition: -
Purpose: -

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Necessary equipment
 Clean gloves
 IV stand
 Oder eliminator
 bowel for cleansing solution
 Bed pan, toilet, basin
 Lubricant
 Warm water
 irrigation sleaves
 Cane with tube
 Wash towel
 PPE, rubber and cotton draw sheet

Steps of procedure
1. Check the order, assess the patient condition and appearance of stoma explain the
procedure to the patient
2. Wash hand and assemble necessary equipment
3. Hung cane or irrigation bag at height of patient shoulder or 18 inches above the stoma, if
client is supine stand and fill the cane /bag/ with 1000cc warm water
4. Open clamp and run water from the irrigation bag to fill the tubing & remove air
5. Wear clean glove
6. Provide privacy
7. Expose the ostomy sit and apply clean towel across patient’s abdomen under the existing
pouch
8. Detach pouch from skin barrier and allow feces to drain into bed pan or toilet
9. Inspect stoma & peristomal skin
10. Lubricate gloved finger, Check direction of intestine by inserting a gloved finger into
orifice of stoma.

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11. Place irrigation sleeve over stoma and hold in place with belt /attach to skin barrier/
12. Spray inside of irrigation sleeve and bathroom with odor eliminator (usual dose is two
sprays).
13. Lubricate the cone end of the irrigation tubing and insert into orifice of stoma through the
top opening of irrigation sleeve
14. Close top of irrigation sleeve over the tubing
15. Slowly run water through tubing into colon for 5-10 mint
16. Remove cone after all water has emptied out of irrigation bag.
17. Close end of irrigation sleeve by attaching it to the top of the sleeve.
18. Encourage client to ambulate to facilitate emptying of remaining stool from colon.
19. Place cuff end of irrigation sleeve into toilet bowl (if client is in bathroom) or bedpan (if
client is in bed or chair).
20. Remove irrigation sleeve after 20–30 minutes or when stool is no longer emptying from
colon.
21. Cleanse stoma and skin with warm tap water. Pat to dry.
22. Place gauze pad over stoma to absorb mucus from stoma.
23. Secure gauze with hypoallergenic tape.
24. Remove gloves and wash hands.
25. Document the procedure


13.3.4. Digital removal of fecal impaction
Objective- at the end of this lesson, the learner will be able to
1. define manual fecal impaction
2. list the necessary equipment for manual removal of fecal impaction
3. demonstrate digital removal of fecal impaction
Definition
Removal of hard and large fecal mass that cannot pass through the anus without tissue damage
by inserting one or two gloved fingers into the rectum.
Purpose
 to make client’s rectum free of feces

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Limitation
 This procedure can be uncomfortable and embarrassing for the client.
 Manipulating the rectal mucosa can cause local trauma and possibly bleeding.
 The vagus nerve is easily stimulated rectally and may cause the client’s heart rate to slow
dangerously.
Precaution
This procedure should be performed with caution in clients with a history of cardiac disease,
dysrhythmias, or recent rectal or pelvic surgery.
Equipment
1. Disposable absorbent pads
2. Bed pan
3. Clean gloves
4. Water-soluble lubricant
5. Washcloth, towel
6. Basin of water or perianal cleanser
Procedure
1. Explain the procedure to the client
2. Wash hands.
3. Assemble equipment.
4. Explain procedure to client.
5. Position client in the left lateral position (Sims’) with upper leg bent over lower leg
6. Place disposable pads (if not available, use towels) underneath client. Position a bedpan near the
client.
7. Use odor eliminator per manufacturer (optional).
8. Apply gloves
9. Apply lubricant to a gloved finger.
10. Insert lubricated finger into rectum to check for fecal impaction.
11. Gently probe for stool by moving finger upward toward the umbilicus, moving finger back and
forth to dislodge stool
12. Once anus relaxes and opens, several fingers can be inserted into rectal canal to assist in removal
of stool. Be sure to lubricate additional fingers.

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13. Manipulate the stool mass with the fingers, breaking it up into small pieces.
14. Move the stool pieces toward the anus and remove them. Place removed stool into appropriate
receptacle (i.e., bedpan or disposable bed pad).
15. Monitor the client for complications such as rectal bleeding or slowed heart rate.
16. With clean gloves, provide pericare
17. Dispose of stool in appropriate receptacle.
18. Assist client to use the bedpan or commode if he needs to defecate.
19. Remove gloves and wash hands

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CHAPTER FOURTEEN
PERI-OPERATIVE CARE
Definition: Perioperative care is a period of time that constitutes the surgical experience including
preoperative, intra-operative and post-operative phases.
.1. Pre-operative care
Definition: - preoperative care is a care given for a patient from the time the decision is made for
surgical intervention to the transfer of the patient to the operating room.
Purpose
 To prepare the patient emotionally, mentally for surgery
 To prevent complication before surgery unless it is an emergency operation
 To promote patient and family involvement in care
Equipment:
1. Blood pressure apparatus
2. Stethoscope
3. Enema equipment and solution as needed
4. Catheterization equipment
a. Flashlight
b. Preoperative checklist
c. Container for dentures, glasses
d. Appropriate storage for valuables
and clothes
e. Information packets regarding
surgery
f. Informed consent forms
g. Intravenous fluids, IV set, syringe
and needles, and equipment as
needed
h. Preoperative medication
i. Transfer cart
Procedures
1. Explain the procedure
2. Check whether the client has any questions regarding the surgery and understands the
procedure.
3. Wash hands
4. Verify admission orders regarding type of surgery, any risks (including recent changes in vital
signs), and client preparation

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5. Verify the client by checking name tag and asking name
6. Make the patient NPO for six to eight hours
7. Complete the preoperative checklist, including history, physical assessment, and check of
valuables.
8. Perform neurological assessment, including checks for orientation, eye coordination, hand-
grips, knee bends, and plantar and dorsi-flexion of the feet
9. Perform vascular assessment including checks of pulse, blood pressure, and apical pulse
rhythm, peripheral pulses, and temperature. Compare with previous information. Clients over
50 years may require baseline electrocardiogram
10. Auscultate the lungs bilaterally front and back. If any wheezes, rhonchi, coughs, upper
respiratory infections, or increased temperature, notify physician or qualified practitioner
11. Assess the gastrointestinal system (time of last meal, food allergies, bowel sounds, last bowel
movement, time of last fluids).
12. Assess the genital/urinary system (last menstrual period, last void, state of pregnancy, estrogen
replacement therapy).
13. Assess skin and muscle tone for any skin breakdown, redness, bruises, decreased skin integrity
14. Ascertain any allergies or adverse reactions during previous surgeries or use of anesthesia.
15. Obtain medication history, including the time and date of the last dose of medication
16. Ascertain any history of drugs/alcohol use and when they were last used.
17. Check weight.
18. Check if family is available and who is present
19. Ascertain if client has signed the surgical consent. Determine if the client has a living will or
has designated resuscitation status.
20. Remove all valuables with the exception of wedding rings if requested. Tape rings in place.
Check and document whether valuables are placed in a locked area, safe storage area, or given
to family.
21. Check if eyeglasses and dentures are removed; place in a labeled container
22. Maintain elimination as needed (catheterization, enema)
23. Administer intravenous fluids according to orders
24. Administer medications according to orders.
25. Ascertain that preoperative checklist is complete.
26. Transport the client to appropriate area.

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27. Inform family members where surgical waiting area is and establish a way to contact them
when surgery is completed
.2. Intra-operative care
Definition: intra-operative care is a care given for a patient from when the patient is transferred to
operation room table to when the patient is admitted to the recovery room or post anesthesia care
unit.
Purpose
• To prevent risk of infection
• To reduce risk of injury related to positioning
• To reduce risk of injury related to chemical hazards
• To reduce risk of injury related to foreign objects left in the body

Equipment
1. Gloves (clean for shaving; sterile for
cleaning surgical site)
2. Razor and sharp blades
3. Sterile gauze (to clean the razor)
4. Warm water
5. Antibacterial cleansing agent
6. Sterile cotton swabs
7. Sterile cotton sponges
8. Transfer forceps in antiseptic solution
9. Solution for surgical site cleaning, such
as 70% alcohol
10. Solution basins
Procedures
1. Review chart for surgery to be performed and determine the exact area to be prepped.
2. Wash hands.
3. Assess client’s level of consciousness and mobility
4. Explain the procedure to client.
5. Be sure that hairpins, jewelry, nail polish, con-tact lenses, prostheses, and dentures were re-moved
during the preoperative preparation.
6. Assist client with transfer from wheelchair or bed to the surgical table.
7. Position the client for optimal access to the surgical site according to institutional protocol

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8. Cover with blanket
9. Cover hair if required
10. Assemble equipment needed
11. \Remove ring(s) and watch. Wash hands and apply clean gloves.
12. The surgical prep sites follow, depending on the type of surgery to be performed.
 Head and neck: The site extend from above the eyebrows, over the top of the head, and
includes the ears and both anterior and posterior areas of the neck. The face and eyebrows
are not shaved.
 Lateral neck: Clean the external auditory canal with a cotton swab. Anteriorly, prepare the
side of the face, from above the ear to the upper thorax to just below the clavicle.
Posteriorly, prepare from the neck to the spine including the area above the scapula.
 Chest surgery: The site extends from the neck to the bottom of the rib cage and to the
lateral midline. The shoulder and arm of the operative side should be included.
 Abdominal surgery: The preparation site ex-tends from the axilla to the pubis extending
bilaterally to the lateral midline. All visible pubic hair should be shaved.
 Perineal surgery: Shave all pubic hair and the inner thighs to the midthigh. The area starts
above the pubic bone anteriorly and extends beyond the anus posteriorly.
 Cervical spine surgery: Posteriorly from the top of the ears to the waist. The area extends
on each side to the midaxillary line.
 Lumbar spine surgery: Posteriorly from the axilla down to the midluteal level of the but-
tocks. The area extends on each side to the midaxillary line
 Rectal surgery: Shave the buttocks from the iliac crest down to the upper third of the
thighs, including the anal region. The area ex-tends to the midline on each side.
 Flank surgery: Extends anteriorly from the axilla, down to the upper thigh, including the
external genital area. Posteriorly the area ex-tends from the midscapular to the midgluteal
regions
 Hand and forearm surgery: The area includes the full circumference of the affected arm,
from the axilla to the fingertips.
 Lower extremity surgery: The area includes the entire leg, toes, and foot of the affected
leg from the umbilicus anteriorly and the top of the buttocks posteriorly.
 Lower leg surgery: The area to be prepared includes the circumference of the entire region
from midthigh to the distal toes of the affected leg.

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13. Arrange for adequate light on the area to be prepared.
14. Using warm water, hold the skin taut and hold the razor at a 45° angle. Shave the area care-fully by
stroking in the direction of hair growth. Rinse the razor carefully to remove ac cumulated hair from
the blade.
15. Dry the client’s skin with a sterile towel.
16. Clear the shaving supplies from the preparation area.
17. Apply sterile gloves and gown.
18. Scrub the surgical site with an antibacterial cleaner. Using a rotary movement to clean the skin,
begin in the center and gradually enlarge the area with each rotation.
19. Continue this process for three to ten minutes as prescribed by institutional policy.
20. Clean any hidden areas in the surgical site (the ear canals, under the fingernails, the umbilicus)
using cotton swabs.
21. Rinse the area with sterile water. Wait for the site to dry or pat dry with a sterile towel.
22. Cover the area with sterile drapes leaving the surgical site exposed

13.3. Postoperative Care
Definition: postoperative care is a care given for a patient which begins with the admission of the
patient to the post anesthesia care unit and ends after follow up evaluation in the clinical setting.
Purpose
 To prevent any complication from anesthesia
 To detect sign of post-operative complications
 To rehabilitate the patient
 To re-establish physiological equilibrium
 To alleviate pain
Equipment
1. Vital sign equipment
 Stethoscope
 Sphygmomanometer
 Thermometer
2. Watch
3. Oximeter
4. Blankets
5. Cardiac monitoring equipment

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6. Sterile dressings as needed
7. Client’s chart with postoperative
orders
8. Incentive spirometer (may be optional)
9. Supplemental oxygen, if needed
10. Sequential stockings and/or anti
embolic stockings (as ordered)
11. Gloves
Procedures
1. Wash hands and apply gloves.
2. Check the client’s temperature, pulse, respiratory rate, and blood pressure upon the client’s arrival
in the unit.
3. Identify client via armband and verify the client’s identity with the chart.
4. Inform the client that she/he is out of the operating room and in the recovery room.
5. If bedside electrocardiogram monitoring is available, attach the leads to the client and run a
baseline electrocardiogram strip.
6. Attach the oximeter to the client and monitor the client’s oxygen saturation
7. Check intravenous (IV) site using gloves. Check IV solution(s), flow rate, and that the IV line is
taped as necessary
8. Check surgical dressing and site, if visible. Assess dressings for amount and type of drainage.
Reinforce the dressings as needed.
9. Complete a total head to toe assessment
10. Encourage the client to deep breathe, cough, and use the incentive spirometer
11. Check and implement postoperative orders.
12. Inform the client’s family or significant other that the client is in the recovery room.
13. Turn the client every hour, maintaining proper alignment.
14. Upon discharge by the postanesthesia care-giver, a full report of the postanesthesia phase and
intraoperative course of events should be given to the nurse assuming care of the client.
15. Remove gloves and wash hands.

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Perioperative Nursing Care
When caring for post-surgical patient,
think of the “4 W’s”
Wind: prevent respiratory
complications
Wound: prevent infection
Water: monitor I & O
Walk: prevent thrombophlebitis
By Agezegn A Hawassa University

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CHAPTER FITEEN
OXYGENATION
15.1.Monitoring with pulse oximetry
Definition
 Monitoring with pulse oximetry refers to the process of determining effectiveness of
pulmonary gas exchange and arterial gas saturation.
Purpose
 To monitor arterial oxygen saturation non-invasively.
 To detect clinical hypoxemia promptly.
 To assess client tolerance to tapering of oxygen therapy or activity.
Indications
 COPD
 Sleep apnea
 monitor oxygenation during sleep apnea, acute illness perioperatively, pulmonary exercise,
stress testing and while the patient is on mechanical ventilation
Equipment
1. Pulse oximetry apparatus
2. Documentation chart
Procedures
1. Select appropriate type of sensor
2. Explain purpose of procedure to client and family
3. Perform hand washing
4. Instruct client to breathe normally.
5. Select appropriate site to place sensor.
6. Avoid using lower extremities that may have compromised circulation, or extremities receiving
infusions or other invasive monitoring
7. If clients have poor tissue perfusion due to peripheral vascular disease or is receiving
vasoconstrictor medications nasal sensor or forehead sensor may be considered.
8. Remove nail polish from digit to be used.
9. Attach sensor probe and connect it to the pulse oximetry. Make sure the photo sensors are
accurately aligned.

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10. Watch for pulse sensing bar on face of oximetry to fluctuate with each pulsation and reflect
pulse strength.
11. Double check machine pulsations with client’s radial or apical pulse.
12. If continues pulse oximetry is desired, set the alarm limits on the monitor to reflect the high
and low oxygen saturation and pulse rate.
13. Inspect the sensor site every four hours for tissue irritation or pressure from the sensor.
14. Read saturation on monitor and document as appropriate with all relevant information on
client’s chart.
15. Wash your hands
16. Return used equipment
17. Document and report abnormal results to the responsible clinician
15.2.Oxygen Administration
Definition
 Oxygen administration is provision of oxygen for a patient with a serious respiratory problem by
using oxygen administration methods
Purpose
 Used primarily to reverse hypoxemia
 To provide and maintain a normal supply of oxygen for blood, and tissues.
 To provide adequate transport of oxygen in the blood while decreasing the work of breathing
and reducing stress on the myocardium.
 Decrease work of the heart in clients with cardiac disease
 To relieve dyspnea
Indication
 Respiratory failure:
• Type 1 (hypoxemic): Saturation <
90%. PaO2 <60 mm Hg
• Type 2 (hypercapnic): PCO2>50
mmHg, pH<7.35
 Lung diseases and injury
• COPD
• Pneumonia
• Bronchial asthma
• Cystic fibrosis
• Chest injury
 Blood disorders such as anemia
 Cardiac insufficiency
 High metabolic demands
 Hypoxia
 Hypoxemia
 Asphyxia
 Gas poisoning

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Precautions
 A “no smoking” sign must be posted in the client’s room to prevent the risk of fire 3 meters
 The catheter tip and the cylinder itself must not be lubricated with Vaseline, oil.
 Never use alcohol on the patient’s skin while the oxygen is run.
 Never use an electrical facial shaver (razor) while the oxygen is in use.
 The cylinder must be handling carefully as the oxygen is under pressure
 The fine adjustment must always be closed when the main tap is turned on.
 Check that if there is obstacle in the patient airway before giving oxygen in order to prevent
patient from suffocation.
 The rate of flow will be ordered by the doctor.
 Protect patient from asphyxiation by inspecting regularly the pressure gauge and flow
 Monitor the vital signs, and mental status.
 Transport oxygen cylinder always by the transport cart.
 Never deliver more than 2-3 liters of oxygen to patients with chronic lung disease, e.g. COPD
Methods of oxygen administration
1. Face mask
2. Nasal cannula
3. Nasal catheter
4. Oxygen tent/hood
15.2.1. Oxygen administration via face mask
Definition
 Oxygen administrations via face mask administering oxygen to the patient by means of face
mask according to requirement of patient ( Figur..).
Purpose
 Used to administer higher concentration of oxygen.
Equipment
1. A cylinder of oxygen.
2. Face Mask of appropriate size
3. Regulator
• Gauge
• Flow meter
4. Oxygen tube
5. Humidifier with distil water
6. Gauzes
7. No smoking signs
8. Equipment for V/S

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9. Receiver 10. Chart
Procedure
1. Check order for rate, device to be used and concentration.
2. Greet the patient and explain the procedure (if conscious) to the relatives (if unconscious).
3. Determine need for oxygen therapy
4. Wash hands.
5. Assemble equipment to the bedside
6. Perform an assessment of vital signs, level of consciousness, lab. Values etc. and record.
7. Assess risk factors for oxygen administration in patient and environment like – hypoxia drive
in patient and faulty electrical connection.
8. Post “No smoking” signs on patient’s door “oxygen in use” sign on the bed
9. Place the patient on fowlers position unless contraindicated
10. Check for patency of air ways
11. Set up oxygen equipment and humidifier:
a. Attach regulator to source. Set flow meter in “Off” position.
b. Open main tap while flow meter is closed then turn on fine adjustment to release small
amount of oxygen, to clean the inside of regulators
c. Read the gauges (or check the color in gauges) of the cylinder to determine the amount
of oxygen.
d. Fill humidifier with sterile water between the maximum and minimum mark on it.
e. Attach humidifier bottle to base of the flow meter.
f. Check the presence of bubbling in humidifier to confirm the flow of oxygen through.
g. Attach tubing and face mask to humidifier.
h. Adjust flow meter to prescribed level
12. Check the flow of oxygen through the tube and mask before applying to the patient (feel the
incoming air with your cheek).
13. Clean the mouth if there is visible soiled
14. Apply mask to patient face from nose to down ward
15. Secure elastic band around patient head.
16. Apply gauze behind ears as well as scalp where elastic band passes.
17. Ensure that safety precautions are followed.

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18. Inspect patient and equipment frequently for flow rate, clinical condition, level of water in
humidifier etc.
19. Wash hands
20. Remove the mask and dry the skin every 2-3 hours if oxygen is administered continuously
21. Document relevant data in patient record

Simple mask Partial rebreather mask

Nonrebreather mask
Figure …. Oxygen administration via face mask
15.2.2. Nasal Cannula (Nasal Prongs) or nasal catheter
Definition
 A method by which oxygen is administered in low concentration through a cannula which is a
disposable plastic device with two protruding prongs for insertion in to the nostrils (Figure.)
Purposes

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 To administer low concentration of oxygen to patients
 To allow uninterrupted supply of oxygen during activities like eating, talking
 Light weight, comfortable, continuous use with meals and activity
Equipment
1. A cylinder of oxygen.
2. Nasal cannula
3. Regulator
 Gauge
 Flow meter
4. Oxygen tube
5. Humidifier with distil water
6. Gauzes
7. No smoking signs
8. Equipment for V/S
9. Receiver
10. Chart
Procedure
1. Determine need for oxygen therapy
2. Check order for rate, device to be used and concentration.
3. Greet the patient and explain the procedure (if conscious) to the relatives (if unconscious).
4. Wash hands.
5. Assemble equipment to the bedside
6. Perform an assessment of vital signs, level of consciousness, lab. Values etc and record.
7. Assess risk factors for oxygen administration in patient and environment like – hypoxia drive
in patient and faulty electrical connection.
8. Post “No smoking” signs on patient’s door “oxygen in use” sign on the bed
9. Place the patient on fowlers position unless contraindicated
10. Check for patency of air ways
11. Set up oxygen equipment and humidifier:
i. Attach regulator to source. Set flow meter in “Off” position.
j. Open main tap while flow meter is closed then turn on fine adjustment to release small
amount of oxygen, to clean the inside of regulators
k. Read the gauges (or check the color in gauges) of the cylinder to determine the amount
of oxygen.
l. Fill humidifier with sterile water between the maximum and minimum mark on it.
m. Attach humidifier bottle to base of the flow meter.
n. Check the presence of bubbling in humidifier to confirm the flow of oxygen.
o. Attach tubing to humidifier and then to the nasal cannula

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p. Adjust flow meter to prescribed level
12. Check the flow of oxygen through the tube before applying to the patient (feel the incoming
air).
13. Place tips of cannula to patient’s nares and adjust straps around ear for snug. The elastic band
may be fixed behind head or under chin. If nasal catheter it should be lubricated preferably
with water and passed backward into pharynx till the tip of the catheter is opposite the uvula.
14. Pad tubing with gauze pads over ear and inspect skin behind ear periodically for
irritation/break down.
15. Ensure that safety precautions are followed.
16. Inspect patient and equipment frequently for flow rate, clinical condition, level of water in
humidifier etc.
17. Wash hands
18. Remove the mask and dry the skin every 8 hours if oxygen is administered continuously
19. Document relevant data in patient record
Figure…. Oxygen administration via nasal cannula

NB: A patient receiving oxygen by catheter requires special mouth and nose care since the catheter
tends to irritate the mucous membrane.

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15.2.3. Giving oxygen by tent/hood
Definition
 Methods of administering oxygen via tent /hood
Purposes
 To administer high concentration of oxygen to patients
 To administer oxygen for infants
Equipments
1. A cylinder of oxygen.
2. Oxygen tent/hood
3. Regulator
a. Gauge
b. Flow meter
4. Oxygen tube
5. Humidifier with distil water
6. Gauzes
7. No smoking sign
8. Equipments for V/S
9. Receiver
10. Chart
Procedure
1. Determine need for oxygen therapy, check physicians order for rate, device to be used and
concentration.
2. Identify the patient
3. Explain the procedure to the relatives of the infant.
4. Wash hands.
5. Assemble equipment to the bedside
6. Perform an assessment of vital signs, level of consciousness, lab. Values etc and record.
7. Assess risk factors for oxygen administration in patient and environment like – hypoxia drive
in patient and faulty electrical connection.
8. Post “No smoking” signals on patient’s door in view of patient and visitors and explain to
them the danger of smoking when oxygen is on flow.
9. Place the patient on fowlers position unless contraindicated
10. Instruct him/her to clean his nostril to avoid obstruction (if well enough)
11. Set up oxygen equipment and humidifier:
q. Attach regulator to source. Set flow meter in “Off” position.
r. Open main tap while flow meter is closed then turn on fine adjustment to release small
amount of oxygen, to clean the inside of regulators

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s. Read the gauges (or check the color in gauges) of the cylinder to determine the amount
of oxygen.
t. Fill humidifier with sterile water between the maximum and minimum mark on it.
u. Attach humidifier bottle to base of the flow meter.
v. Check the presence of bubbling in humidifier to confirm the flow of oxygen.
w. Attach tubing to humidifier and then to the oxygen tent
x. Adjust flow meter to prescribed level
12. Check the flow of oxygen through the tube before applying to the patient (feel the incoming
air).
13. Prepare tent and position over bed attach to oxygen source
14. Place client in tent observe all safety precautions
15. secure tent by folded towels
16. Change cloth and linens as necessary
17. Ensure that safety precautions are followed.
18. Inspect patient and equipment frequently for flow rate, clinical condition, level of water in
humidifier etc.
19. Wash hands
20. Oxygen catheter are removed every 8 hrs and a clean catheter is inserted into the other nostril.
21. Document relevant data in patient record

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15.3.Air way suctioning
15.3.1. Performing Nasopharyngeal and Oro pharyngeal Suctioning
Definition
 The removal of secretion from the nasopharynx and oropharynx by using suction catheter and
suction machine
Purposes
 To clear secretions the client cannot remove by coughing.
 To relief dyspnea caused by secretion accumulation
 To maintain patent air way
 To collect sputum or secretions for diagnostic testing
 To prevent aspiration
Indications
 For nasopharyngeal suctioning
o Post operative patient
o Conscious patients who cannot maintain airway
o Can be used with intact gag reflex
 For oropharyngeal
o Unconscious patients
o Secretion in oral cavity
Precaution
 Limit suctioning to 3 times per day for adult but if needed consult your physician
 Never insert the catheter in to nares or mouth while the suction is on and the port is closed
 Never suction more than 15 seconds for adult and 10 seconds for infant at a time to avoid
hypoxia.
Contraindication
 For oropharyngeal suctioning
o Mouth/buccal burn
o Conscious patient
 For nasopharyngeal suctioning
o Head injuries
o Nosebleeds

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Equipments
1. Suction machine: Wall suction/portable
suction with extension tubing connected
to suction device
2. Sterile glove
3. Sterile suction catheter
o French of suction catheter
 For infant from 5-8 fr
 For child from 8-10 fr
 For Adult from 12-16 fr
4. Sterile solution container (or sterile
kidney dish)
5. Normal saline
6. Sputum cup (if conscious)
7. Stethoscope
8. Pen light (if nasopharyngeal)
9. Gauze/soft tissue
10. Waste receiver
11. Ambo bag
12. Gown and mask and goggles or face
shield if indicated
13. Sterile towel/water proof/
14. Mouth care set
Procedures
1. Determine the need for suctioning, check physicians order.
2. Identify the patient
3. Explain the procedure to the patient if conscious otherwise for his/her relatives. Advice that
suctioning may cause coughing or gagging but emphasize the importance of clearing the airway.
4. Wash hands.
5. Assemble equipment to the bedside
6. Assess the client’s need for suctioning: inability to effectively clear the airway by coughing and
expectoration; coarse bubbling or gurgling noises with respiration.
7. Choose the most appropriate route (nasopharyngeal or oropharyngeal) for your client. If
nasopharyngeal approach is considered, inspect the nares with a penlight to determine patency.
Alternatively, you may assess patency by occluding each nare in turn with finger pressure while
asking the client to breathe through the remaining nare if conscious.
8. Position the client in a high Fowler’s or semi- Fowler’s position
9. If the client is unconscious or otherwise unable to protect his or her airway, place in a side-lying
position.
10. Connect extension tubing to suction device if not already in place, and adjust suction control to: If
portable suction unit If wall unit suction machine
 For infant from 2-5 mmHg -For infant from 50-95 mmHg
 For child from 5-10 mmHg -For child from 95-110 mmHg

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 For Adult from 10-15 mmHg -For Adult from 100-120 mmHg
11. Open packed sterile instrument and prepare on a sterile field.
12. Pour about 100 ml of solution into the sterile container, unpack sterile suction catheter.
13. Oxygenate the patient with ambo bag 3-5 ventilation
14. Put on gown and mask and goggles or face shield if indicated.
15. Put on the gloves using sterile gloving technique and apply sterile water proof towel over the chest
of the patient.
16. Using your sterile hand (Dominant hand), pick up the suction catheter. Grasp the plastic
connector end between your thumb and forefinger and coil the tip around your remaining fingers.
17. Pick up the extension tubing with your clean hand (non-dominant). Connect the suction catheter
to the extension tubing, taking care not to contaminate the catheter.
18. Position your clean hand on the extension tube.
19. Dip the catheter tip into the sterile solution, and activate the suction with your non-dominant hand.
Observe as the solution is drawn into the catheter. It will also lubricate the catheter
20. For oropharyngeal suctioning, ask the client to open his or her mouth. Without activating the
suction, gently insert the catheter and advance it until you reach the pool of secretions or until the
client coughs or insert 4 inches (12 cm).
21. For nasopharyngeal suctioning, estimate the distance from the tip of the client’s nose to the
earlobe and grasp the catheter between your thumb and forefinger at a point equal to this distance
from the catheter’s tip.
22. Insert the catheter tip into the nare with the suction control port uncovered. Advance the catheter
gently with a slight downward slant. Slight rotation of the catheter may be used to ease insertion.
Advance the catheter to the point marked by your thumb and forefinger
23. If resistance is met, do not force the catheter. Withdraw it and attempt insertion via the opposite
nare.
24. Apply suction intermittently by occluding then suction control port with your thumb; at the same
time, slowly rotate the catheter by rolling it between your thumb and fingers while slowly
withdrawing it. Apply suction for no longer than 15 seconds at a time.
25. Repeat step 2-3 until all secretions has been cleared, allowing 20-30 seconds brief rest periods
between suctioning episodes.
26. Give ambo bag between each single suctioning

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27. Instruct the patient to have deep breathing and coughing exercise if conscious. Give sputum cup if
he/she needs to spit secretion then clean with soft tissue/gauze.
28. Withdraw the catheter by looping it around your fingers as you pull it out.
29. Dip the catheter tip into the sterile solution and apply suction after a brief rest.
30. Disconnect the catheter from the extension tubing, holding the coiled catheter in your gloved
hand.
31. Provide the client with oral hygiene if indicated or desired.
32. Return used supplies in the appropriate container.
33. Remove the glove by pulling it over the catheter; discard catheter and gloves in an appropriate
container.
34. Check the effectiveness of the procedure with Stethoscope
35. Wash your hands.
36. Document the procedure, noting the amount, color, and odor of secretions and the client’s
response to the procedure.
15.3.2. Endotracheal tube/tracheal suctioning
Definition: Endotracheal tube/tracheal suctioning is the process of applying a negative pressure to the
distal trachea by introducing a catheter to clear excess, or abnormal, secretions.
Purpose: The nurse performs Endotracheal and tracheostomy suctioning to:
1. Maintain a patent airway.
2. To improve oxygenation and reduce the work of breathing.
3. To remove accumulated trachea-bronchial secretions using sterile technique.
4. Stimulate the cough reflex.
5. Prevent pulmonary aspiration of blood and gastric fluids.
6. Prevent infection and atelectasis.
Equipment:
1. Sterile normal saline
2. Suction machine: Wall suction/portable
suction with extension tubing connected to
suction device
3. Ambubag connected to 100% O2
4. Clear protective goggles/mask or face
shield
5. Sterile gloves for open suction
6. Clean gloves for (in-line) closed suction
7. Sterile catheter with intermittent suction
o French/size/ of suction catheter
 For infant from 5-8 fr
 For child from 8-10 fr
 For Adult from 12-16 fr

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8. Control port or In-line suction catheter
9. Sterile solution container (or sterile kidney
dish)
10. Stethoscope
11. Gauze/soft tissue
12. Waste receiver
13. Sterile or clean towel/water proof/
14. Normal saline
Procedures
1. Explain the procedure to the patient before beginning and offer reassurance during suctioning; the
patient may be apprehensive about choking and about an inability to communicate
2. Determine the need for suctioning, check physicians order.
3. Begin by carrying out hand hygiene.
4. Assess the client’s need for suctioning: inability to effectively clear the airway by coughing and
expectoration; coarse bubbling or gurgling noises with respiration.
5. Assemble equipment to the bedside
6. Position the client in a high Fowler’s or semi- Fowler’s position and apply clean water proof towel
over the chest of the patient.
7. If the client is unconscious or otherwise unable to protect his or her airway, place in a side-lying
position.
8. Connect extension tubing to suction device if not already in place, and adjust suction control to:
If portable suction unit If wall unit suction machine
 For infant from 2-5 mmHg -For infant from 50-95 mmHg
 For child from 5-10 mmHg -For child from 95-110 mmHg
 For Adult from 10-15 mmHg -For Adult from 100-120 mmHg
9. Open packed sterile instrument and prepare on a sterile field.
10. Fill basin with sterile normal saline solution.
11. Ventilate the patient with manual resuscitation bag and high flow oxygen.
12. Put on sterile glove.
13. Pick up sterile suction catheter with gloved hand (Dominant hand) and connect to suction.
14. Hyper oxygenate the patient’s lungs for several deep breaths.
15. Insert suction catheter at least as far as the end of the tube without applying suction, just far
enough to stimulate the cough reflex
16. Apply suction while withdrawing and gently rotating the catheter 360° (no longer than 10 to 15
seconds, because hypoxia and dysrhythmias may develop, leading to cardiac arrest).
17. Re oxygenates and inflates the patient’s lungs for several breaths.

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18. Repeat previous three steps until the airway is clear.
19. Rinse catheter in basin with sterile normal saline solution between suction attempts if necessary.
20. Suction oropharyngeal cavity after completing tracheal suctioning.
21. Rinse suction tubing.
22. Discard catheter, gloves, and basin appropriately.
23. Discard catheter, gloves, and basin appropriately.
15.4.Tracheostomy care
Definition:
Tracheostomy care is a care given to patient with tracheostomy.
Purpose
 To prevent infection
 To promote respiratory function.
 To bypasses the upper airways
 To maintain a patent airway
 Prevent pulmonary aspiration of blood and gastric fluids
 To prevent pneumonia that may result from accumulated secretions
 To allow removal of trachea-bronchial secretions
Indication
 When adventitious breath sounds are detected
 Whenever secretions are obviously present.
Equipment
1. Sterile Tracheal dilator
2. Sterile cotton-tip applicators
3. Sterile Hydrogen peroxide solution
4. Sterile Normal saline (0.9% sodium
chloride solution)
5. Sterile 0.9% sodium chloride solution
containers (2)
a. 1 for suctioning
b. 1 for rinsing the inner cannula
6. Sterile nylon brush
7. Sterile precut 4 × 4 dressing gauze
8. Sterile gauze for drying
9. Sterile drapes/water proof pad
10. Sterile glove
11. Clean glove
12. Suction kit and suction equipment
13. Tracheostomy ties
14. Ambo bag with 100% oxygen source
15. Mouth care set

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16. Personal protective devices: gown,
mask
17. Waste receiver/Plastic bag/
18. Chart
Procedure
1. Determine the need for suctioning, check physicians order.
2. Identify the patient
3. Explain the procedure to the patient if conscious otherwise for his/her relatives.
4. Wash hands.
5. Assemble equipment to the bedside
6. Put on goggles and mask or face shield and gown and don clean gloves
7. Position the client in a high Fowler’s or semi- Fowler’s position and apply clean water proof towel
over the chest of the patient; If the client is unconscious or otherwise unable to protect his or her
airway, place in a side-lying position.
8. Place plastic bag or disposal container within easy reach. Position in an area that does not require
crossing over the sterile field or stoma to discard soiled items.
9. Prepare sterile equipments. Loosen the caps on the bottles of sterile saline and hydrogen peroxide
then pour in to each galipot (containers) to 0.5 inch
NB: pour hydrogen peroxide in to one galipot/container and normal saline in to the rest two
containers
10. Don clean glove then remove the soiled tracheostomy dressing. Note the amount, color, and odor
of any drainage around the stoma.
11. Gently loosen the inner cannula of the tracheostomy tube by twisting the outer ring
counterclockwise; then withdraw the inner cannula in a smooth motion. Place the inner cannula
into the basin of peroxide.
12. Remove the gloves by pulling them over the discarded dressing, and discard the gloves and
dressing.
13. Put on the gloves using sterile gloving technique
14. Place the sterile drape on the patient’s chest, with its upper edge as near to the tracheostomy tube
as possible.
15. Using your sterile hand, pick up the cannula and pick up the nylon brush then scrub to remove
any visible crusts or secretions from inside and outside the cannula
16. Place the cannula into the container of sterile saline. Agitate so that all surfaces are bathed in
saline.

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17. Inspect the inner cannula again to be sure it is clean; then remove excess saline from the lumen by
tapping the cannula against a sterile surface then place at dry sterile gauze.
18. Perform suctioning.
NB:
 The pressure of tracheostomy suctioning is similar with nasopharyngeal suctioning
 Give 1 full minute rest between each single suctioning
 Oxygenation with ambo bag must be given 3-5 times between each single suctioning
19. Using your sterile hand, pick up a sterile cotton swab and saturate the tip with hydrogen peroxide.
Swab the peristomal skin, including the area under the tracheostomy tube’s faceplate. If you must
touch the tracheostomy tube or the client, do so with your clean hand

20. Gently replace the inner cannula, following the curve of the tube. When fully inserted, lock the
inner cannula in place by rotating the external ring clockwise until it clicks into place.
21. Place a new precut sterile gauze dressing around the stoma, between the faceplate and the skin.
22. Inspect the ties or strap securing the faceplate. If damp or soiled, carefully cut the ties (or loosen
the Velcro to remove a strap). Remove the ties or strap and inspect the underlying skin for redness
or breakdown. (Now no longer sterile procedure is needed)
23. To replace ties, cut a length of twill tape about as long as the circumference of the client’s neck.
Fold over one end to 1 inch and cut a small (1/2 inch) slit into the folded end.
 Thread the slit end of the tape through the eye of one side of the tracheostomy
faceplate from the underside of the faceplate. Thread the end of the tie through the cut
slit and secure it with a knot.
 Slip the tape under the client’s neck, keeping it smooth and flat against the skin.
 Bring the loose end of the tape around to the other side of the faceplate. Ask the client
to flex his or her neck and slip one of your fingers under the tape as you measure the
desired tightness of the tie.

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 Fold the end of the tape and cut a slit as in step then tie the end. Trim off excess tape
from the end and knot the cut ends of the tape.


24. To replace a Velcro™ strap:
 Place new strap behind client’s neck and thread ends through faceplate eyelets. Adjust
tightness as above and secure Velcro™.
25. Reconnect the patient to oxygen and reposition for comfort.
26. Discard soiled items in the appropriate container.
27. Remove and discard soiled gloves.
28. Wash hands.
29. Document the procedure, noting the appearance of the stomal site and any exudate.
15.5.Postural drainage
Definition: Postural drainage is positioning that allow the force of gravity to assist in the removal of
bronchial secretions.

Purpose
 To remove bronchial secretions
Indications
 Evidence of difficulty with secretion clearance
 Presence of atelectasis caused by mucus plugging diagnosis of diseases such as cystic fibrosis,
bronchiectasis, pneumonia, or cavitating lung disease
 Presence of foreign body in airway
Contraindication
All positions are contraindicated for:

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 Intracranial pressure (ICP) > 20 mm Hg
 Head and neck injury until stabilized
 Active hemorrhage with hemodynamic
instability
 Recent spinal surgery
 Acute spinal injury
 Active hemoptysis
 Empyema
 Bronchopleural fistula
 Pulmonary edema associated with
congestive heart failure
 Large pleural effusions
 Pulmonary embolism
 Aged, confused, or anxious patients
who do not tolerate position changes
 Rib fracture, with or without flail chest
 Surgical wound or healing tissue
 Cyanosis, shortness of breath, difficulty
breathing, weakness, or very ill feeling
experienced.
 Unstable vital signs.
Trendelenburg position is contraindicated for:
 Intracranial pressure (ICP) > 20 mm Hg
 Uncontrolled hypertension
 Distended abdomen
 Esophageal surgery
 Recent gross hemoptysis related to recent lung carcinoma
 Uncontrolled airway at risk for aspiration (tube feeding or recent meal)
Reverse Trendelenburg is contraindicated in the presence of hypotension or vasoactive medication
Precaution
 If sputum is foul-smelling, it is important to perform postural drainage in a room away from
other patients and/or family members.
 Aware on the patient’s diagnosis as well as the lung lobes or segments involved, cardiac status,
and any structural deformities of the chest wall and spine.
 Auscultating the chest before and after the procedure helps to identify the areas needing
drainage and to assess the effectiveness of treatment.
Equipment
1. Pillow
2. Sputum mug
3. Tissue paper
4. Bed block
5. Bronchodilator medications
6. Stethoscope
7. Specimen bottle and requisition
if required

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8. Mouth care set to clean and
freshen the mouth following the
treatment.
9. Hospital bed that can be
trenbelenburgs position
10.
Procedure
1. Great the patient and introduce your self
2. Explain the purpose of the procedure and the disease process to the patient.
3. Schedule the postural drainage treatments in to two or three times daily depending on the degree
of lung congestion especially best time before breakfast, before lunch, and late afternoon and
before bedtime.
4. Wash your hands
5. Clean trolley or tray and assemble the necessary equipments
6. Prepare nebulizer medication if necessary
7. Instruct the patient to inhale bronchodilators and mucolytic agents to improve bronchial tree
drainage
8. Assess the patients’ tolerance for postural drainage by assessing vital sign, respiratory status and
fatigue.
9. Instructs the patient to remain in each position for 10 to 15 minutes and to breathe in slowly
through the nose and then breathe out slowly through pursed lips to help keep the airways open
so that secretions can drain while in each position.
Positions
A. Upper lobes
Apical segment
 Client lies back at 30
0
angles.
 Percussion/vibration area- b/n the clavicle and above the scapulae.
Posterior segment
 Client sits upright in a chair or in bed with head bent slightly forward.
 Percussion/vibration area – between the clavicle and the scapula.
Inferior segment
 Position-Client lies on a flat bed with pillow under the knees to flex them.

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 Percussion vibration area –upper chest below the clavicle down to the nipple line
except for women
B. Right middle lobe.
Right lateral and medial segments.
 Client lies on left side and leans back slightly against pillows, extending at the back
from the should to the hip.
 Elevate foot of bed about 15
0
or 40
0
.
Percussion /vibration area
 For male client: over the right side of the chest at the level of the nipple beween the
fourth and sixth ribs.
 For female client beneath the breast, with the heel of the nurse’s hand positioned
toward her axila, cupped fingers extending for ward beneath breast.
Lower division of left upper lobe ( lingual)
 Position as above for right meddle lobe, but on the right side
 Percussion/vibration area –as above right meddle lobe, but on the left side.
C. Lower lobes
Superior lung segment
 Position lies on the abdomen on a flat bed, and place two pillows under the hips.
 Percussion /vibration area -the middle area of the back (below the scapula) on both
sides of the spine.
Anterior basal segments
 Lies on unaffected side with upper arm over the head and pillow between knees.
Elevated the foot of the bed about 3o
0
or 45
0
or to height tolerate by the client.
 Percussion /vibration area – over the lower ribs inferior to the axila on the affected side
of the chest.
Lateral basal lung segment
 Lies partly on unaffected side and partly on the abdomen. Elevate the foot of bed
about 30
0
or 45 cm or height tolerated, or elevated client’s hip with pillows.
 Percussion /vibration area – the upper most side of the lower ribs.
Posterior basal lungs segment
 Lies in prone position

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 Elevated foot of bed about 45 cm
 Elevated client’s hip on two or three pillows.
 Percussion /vibration area –over the lower ribs both sides closed to the spine.
20. The nurse should explain how to cough and remove secretions in each position. If the patient
cannot cough, the nurse may need to suction the secretions mechanically.
21. The nurse notes the amount, color, viscosity, and character of the expelled sputum.
22. Assess the patient’s skin color and pulse in the first few times the procedure is performed.
23. Perform mouth care
24. Remove gloves from inside out, and discard them in plastic waste bag.
25. Provide patient comfort measures.
26. Clean and return equipment to proper place.
27. Wash your hands
28. Document the patient status and procedure
15.6.Deep breathing and coughing exercise
Definition: deep breathing exercise is a type of voluntary breathing used to maximize inspiration, to
open air ways, to encourage coughing and to promote removal of respiratory secretions.
Purpose
 Management of excessive respiratory secretions
 All clients undergoing surgery
 Reopens small airways
 To prevent atelectasis and pneumonia
Equipment
1. Tissues
2. Water pitcher and glass
3. Emesis basin
4. Stethoscope
5. Pillows for splinting the client’s chest
and abdomen
Procedure
1. Assess the client’s pain status.
2. Explain the purpose and importance of the procedure.
3. Wash hands & assemble necessary equipment
4. Help client to sit in a high-Fowler’s position if able.
5. Auscultate lungs before procedure

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6. Place the palms of your hands on the client’s rib cage.
7. Place one hand on abdomen (umbilical area) during inhalation.
8. Expand the abdomen and rib cage on inspiration.
9. Inhale slowly and evenly through your nose until you achieve maximum chest expansion hold
breath for 2–3 seconds.
10. Use pillow or folded towels to splint the abdomen or chest if client has had surgery
11. Practice deep breathing with client:
 Instruct the client to cover the mouth with tissue (use mask, gloves, and gown for staff
as needed).
 Take a deep breath in and exhale slowly and repeat 2–3 times.
 Repeat 10 times every 1–2 hours as needed
12. Reassess lung fields after procedure.
13. Assist the client to cough as follows:
 Follow the procedure for deep breathing and have the client hold breath for 1–2seconds.
 Contract abdominal muscles, cough forcefully and expectorate secretions into tissue or
basin as nurse splints incision areas as appropriate
 Splint the client’s abdomen and chest as he coughs by pressing on lower chest wall and
abdomen with your hands.
14. Repeat as necessary to clear lung fields; however, be aware that excessive coughing can irritate
the trachea and bronchial tree
15. Observe for dizziness, shortness of breath, or other respiratory problems
16. Comfort patient
17. Dispose of all tissues and wash hands.
18. Record the procedure


15.7.Cardiopulmonary resuscitation (CPR)

Definition
Cardio-Pulmonary Resuscitation is an emergency procedure consisting of external cardiac massage
and artificial respiration
Purpose

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 To squeeze blood manually out of the heart for victims with cardiac arrest
 To provide oxygenated blood to the brain and heart
 To restore blood circulation
Indications
 Respiratory Arrest: - Respiratory arrest refers to the absence of breathing.
 Cardiac Arrest: When the heart stops, there is no pulse.
Precaution
 The CPR Must begin within 4-6 minutes of collapse if not; the brain is sensitive to hypoxia and
will sustain irreversible damage after 4-6 minutes of no oxygen.
 The cause of cardiac arrest is important BUT do not delay CPR to obtain history
Relative Contraindications
 Ribs fractured
 Burn of sternum (full thickness)
Equipments
 No special equipments are needed at emergency situation- just hands and mouth & step by step
procedure.
 At hospital level (Ambo bag, firm board, stethoscope, spatula, air way )
Procedure
15.6.1. Adult CPR procedure
1. Check the Scene or Assessment of the Situation (Always Present if it is out of Health Centers)
 Make sure it is safe for you to help.
 Don't become another victim and assess the environment to know the cause of the problem
2. Check the Victim or Assessment of unresponsiveness
 Tap or gently shake the victim and shout “Are you ok”.
 To elicit a response a painful stimulus can be applied such as:
 Pinching the earlobe,
 Pressing over the eyelid and observing for grimacing.
 Other associations recommend rubbing on the sternum using the knuckles of the
fingers.
3. Call for Help or Activate EMS

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 Rescuer who is alone should alter sequence of rescue based on most likely cause.
 Sudden witnessed collapse (likely VF) arrest activates EMS (Emergency medical service), do
CPR.
 Hypoxic arrest (i.e., suffocation give 5 cycles of CPR (about 2 minutes) before alerting EMS.
If there is no response, Call ***** and return to the victim. In most locations the emergency
dispatcher can assist you with CPR instructions
4. Positioning the victim
 Place the victim first on His/ Her back on hard surface. If the victim is lying face down, turn or
roll the victim as unit, supporting the head and neck
5. Airway
 Open the airway by the head tilt / chin lift maneuver for all victims and remove foreign body.
We might also assess the breathing status of the victim
 Health care personnel use:
o Head tilt- chin lift
o Jaw thrust in trauma patient

6. Breathing
 Assessment of breathlessness and carotid pulse (5-10 seconds)
 Place your ear just one inch above the mouth and the nose of the victim and perform the
following simultaneously: Use LLF methods
o LOOK: for the chest to rise and fall
o LISTEN: for air escaping during exhalation, and
o FEEL: for the flow of air on your cheek

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NB: Count the number 1001,1002,1003,1004,1005,1006,1007,1008,1009,1010 to be sure you are
checking for 10 seconds because 1001 represents 1 second, and 1002 represents 2, and
continue others like this.
 Simultaneously assess the presence of pulses
o Assessment of pulselessness (5-10 secs.): check pulse at carotid artery which is the most
common and most reliable.
o While maintaining the head tilt with one hand, locate the victim’s Adams apple (thyroid
cartilage) with two or three fingers of the other hand. Slide your fingers into the groove
between the Adam’s apple and the muscle on the side nearest you where the carotid pulse
can be felt.
 If breathing is not present, begin rescue breathing by giving two slow breaths: pinch nose and
cover the mouth with yours and blow until you see the chest rise. Give 2 breaths.
 Time:
 Each breath should take 1.5 sec to 2 sec and watch for chest rise and allow time for exhalation
(3-3.5 sec).
 Volume:
o Sufficient volume
o No large volume or forceful breathing.
7. Circulation
 If pulse is not definitely felt within 10 seconds, proceed with chest compression
 Provides 30% (or less) of normal circulation
To locate the landmark for external chest compression
 The technique of costal margin that is as follows:
A. Run your index and middle fingers up the lower margin of the rib cage and locate the sternal
notch with your middle finger. The index finger is place next to the middle finger on the lower
and of the sternum.

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B. The heel of the other hand (the one nearest the victim’s head) is placed on the lower half of the
sternum, and the other hand is placed on the top of the hand on the sternum so that the hands
are parallel.
C. Your fingers may be either extended or interlaced but must be kept off the chest.

D. Lock your elbows into position, the arms are straightened and shoulders directly over the victim’s
sternum. Keep the heel of your hand lightly in contact with the chest during the relaxation
phase of chest compression to maintain correct hand position.

 Push hard- push fast: equal compression and relaxation allowing recoil of chest wall.
 Chest compression – ventilation 30: 2, for 5 cycles (2 minutes rate of 100 per minute.
 Depth of 1.5 to 2 inches for adults
 Count compression in English in the sequence of:
o 1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20, and 1,2,3,4,5,6,7,8,9,1= for 1
st
cycle
o 1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20, and 1,2,3,4,5,6,7,8,9,2= for 2
nd
cycle
o 1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20, and 1,2,3,4,5,6,7,8,9,3= for 3
rd
cycle

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o 1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20, and 1,2,3,4,5,6,7,8,9,4= for 4
th
cycle
o 1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20, and 1,2,3,4,5,6,7,8,9,5= for 5
th
cycle
8. Reassessment
 After 5 cycles of compressions and 6 cycle of ventilations (30:2), check for return of carotid
pulse/ and spontaneous breathing
 According to the findings (after 2 minutes):
o There is pulse – place in the recovery position, monitor vital signs until EMS arrives.
o There is pulse but no breathing: continue rescue breathing every 5- 6 seconds (10-12
breaths). Recheck pulse every 2 minutes.
o No pulse or breathing continues CPR 30:2. Until provider arrives
Repeat A – B- C to 5 cycle of compression and 6 cycles of breathing. (150:12)
When to Stop CPR
1. if another trained person takes over CPR for you
2. if more advanced medical personnel take over
3. if you are exhausted and unable to continue
4. if the scene becomes unsafe
5. if the victim's heart starts beating
15.6.2. CPR for child below 8 years old
1. Check the Scene or Assessment of the Situation (Always Present if it is out of Health Centers)
 Make sure it is safe for you to help.
 Don't become another victim and assess the environment to know the cause of the problem
2. Check the Victim or Assessment of unresponsiveness
 Tap or gently shake the victim and shout “Are you ok”.
 To elicit a response a painful stimulus can be applied such as:
 Pinching the earlobe,
 Pressing over the eyelid and observing for grimacing.
 Other associations recommend rubbing on the sternum using the knuckles of the
fingers.
3. Call for Help or Activate EMS
 Rescuer who is alone should alter sequence of rescue based on most likely cause.

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 Sudden witnessed collapse (likely VF) arrest activates EMS (Emergency medical service), do
CPR.
 Hypoxic arrest (i.e., suffocation give 5 cycles of CPR (about 2 minutes) before alerting EMS.
If there is no response, Call ***** and return to the victim. In most locations the emergency
dispatcher can assist you with CPR instructions
4. Positioning the victim
 Place the victim first on His/ Her back on hard surface. If the victim is lying face down, turn or
roll the victim as unit, supporting the head and neck
5. Airway
 Open the airway: perform head-tilt, chin lift maneuver. If liquids turn the victim’s head to side
and let it drain
6. Breathing
1. Assessment of breathlessness and pulse (carotid) together– (5-10 seconds)
2. Place your ear just one inch above the mouth and the nose of the victim and perform the following
simultaneously.
 Look for the chest to rise and fall
 Listen for air escaping during exhalation, and
 Feel for the flow of air on your cheek
3. Assessment of pulselessness (5-10 seconds) check carotid
 If breathing is not present, begin rescue breathing by giving two slow breaths: pinch nose and
cover the mouth with yours and blow until you see the chest rise. Give 2 breaths.
4. Time: each breath should take 1.5 sec and watch for chest rise and allow time for exhalation.
5. Volume – sufficient volume. No large volume or forceful breathing.
7. Circulation
 If the pulse is absent begin external chest compressions
 Land mark for compression is not to be used; that is as follows:
o Run your index and middle fingers along the lower rib cage until the middle finger
reaches the notch (xyphoid process). The index finger is placed next to the middle
finger.
o The heel of the same hand is placed next hand is placed next to the point where the
index finger was located. (One hand can be used.)

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 Lock your elbows into position, the arms are straightened and shoulders directly over the
victim’s sternum. Keep the heel of your hand lightly in contact with the chest during the
relaxation phase chest compression to maintain correct hand position.

 Push hard- push fast without any interruption
 Rate of compression: 100 per minute
 Depth of compression: 1/2 -1 inch the depth of the chest
 Compression /ventilation ration: 30:2
 Compression / relaxation cycle should be equal
8. Reassessment: -
 After 5 cycles of compressions and 6 cycles of ventilations (30:2), check for return of carotid
pulse and spontaneous breathing
 According to the findings (after 2 minutes):
o There is pulse – place in the recovery position carefully; monitor vital signs until EMS
arrives.
o There is pulse but no breathing: continue rescue breathing every 3-5 seconds (12-20
breaths per minute). Recheck pulse every 2 minutes.
o No pulse or breathing continues CPR 30:2. , until provider arrives
15.6.3. One rescuer CPR procedure for infant (to approximate 1 year)
1. Check the Scene or Assessment of the Situation (Always Present if it is out of Health Centers)
 Make sure it is safe for you to help.
 Don't become another victim and assess the environment to know the cause of the problem
2. Check the Victim or Assessment of unresponsiveness
 Tap the infant and shake to elicit a response, or palpate the sole of the feet
 To elicit a response a painful stimulus can be applied such as:
o Pinching the earlobe,
o Pressing over the eyelid and observing for grimacing.
 If unresponsive start CPR immediately. If second rescuer or someone is available, have him or
her activate the EMS system.
3. Call for Help or Activate EMS (if second rescuer is available otherwise call after 2 min.)

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 Sudden witnessed collapse (likely VF) arrest activates EMS (Emergency medical service), do
CPR.
 Hypoxic arrest (i.e., suffocation give 5 cycles of CPR (about 2 minutes) before alerting EMS.
If there is no response, Call ***** and return to the victim. In most locations the emergency
dispatcher can assist you with CPR instructions
4. Position the victim in supine, firm and flat surface
5. Airway
 Open the airway:
o Apply head tilt- chin lift to ‘sniffing’ or neutral position.
o Jaw thrust maneuver in trauma patient
6. Breathing
 Assessment of breathlessness and brachial pulse (5-10 seconds)
o Place your ear just one inch above the mouth and the nose of the infant and perform
the following.
 Look for the chest to rise and fall
 Listen for air escaping during exhalation
 Feel for the flow of air on your check
 Assessment of pulselessness: brachial pulse (5-10 seconds)
o Feel for the brachial pulse while maintaining head tilt with the other hand, never use
carotid pulse for infants because you may interrupt circulation to brain if present.
o The brachial pulse is located on the inside of the upper arm, between elbow and
shoulder.

 If the breathing is not present, make a tight seal over the mouth and the nose of the infant
and begin rescue breathing by giving two slow breaths.
 Time: 1 second per breath and watch chest rises and allows time for exhalation.
 Volume; enough to see the chest of the infant rise during ventilation (cheek)
7. Circulation
 If pulse is absent give 5 cycles of external 30 chest compressions followed by 2 slow
breaths.
Land mark for external chest compressions

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 Nipple line technique
o The area of compression is just below the imaginary line, using the middle and ring
fingers. draw a line between your baby's nipples, and go 1 finger length lower than the
nipple line. hold your index finger up, and use your other 2 fingers to do chest
compressions.
 Rate of compression: 100 per minute
 Depth of compression: 1/3-1/2 the depth for the chest
 Compression / ventilation ratio: 30:2
 Compression / relaxation cycle should be equal
8. Reassessment
 Reassess the infant after every 5 cycles of 30 compressions and 6 cycles of 2 ventilations (2
minutes).
 According to the findings:
o There is pulse and breathing, place the infant in the recovery position, monitors
vital signs until EMS arrives
o There is pulse but no breathing continues rescue breathing one breath every 3-5
seconds (12-20 per minute) and reassess.
o No pulse or breathing continues CPR 30:2. Ratio, assess for pulse and breathing
after 5 cycles (2minutes)

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CHAPTER SIXTEEN
THERAPEUTIC AND DIAGNOSTIC PROCEDURE
Assisting with thoracentesis
Definition: thoracentesis is the procedure in which a puncture is made into the chest wall to withdraw
fluid or air from the pleural cavity for diagnostic or therapeutic purposes.


Indication
A. When unexplained fluid or air accumulates in the
chest cavity outside lung.
B. Pleural effusions
C. Compromised cardiovascular status due to air
fluid or blood outside the lung,
D. Pleural fluid analysis
E. Instillation of medication into the pleural space

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Purpose
 Removal of fluid and air from the pleural cavity
 Aspiration of pleural fluid for analysis
 Pleural biopsy
 Instillation of medication into the pleural space
Contraindication
1. Absolute contraindications.
 Uncooperative patient
 Coagulation disorders that cannot be corrected
2. Relative contraindications
 the site of insertion has known bullous disease (e.g. emphysema)
 use of positive end-expiratory pressure (PEEP, see mechanical ventilation)
 Only one functioning lung (due to diminished reserve).
Precaution: The aspiration should not exceed 1L as there is a risk of development of
pulmonary edema.
Equipment
Sterile:
1. 2 Gallipots
2. 1 pair of dissecting forceps
3. 1 pair of artery forceps
4. Swabs and gauze in a receiver
5. towel with a hole (fenestrated towel)
6. hand towel
7. Gloves
8. Syringe and needle for local anaesthesia
9. Rubber tube which fit the opening of the
two-way tap
10. 10 or 20 cc aspiration syringe and needle
11. two - way tap
12. 2 glass tube for specimen
13. Receiver to collect fluid specimen
Clean
1. Rubber sheet and towel
2. Receiver for used instrument
3. Measuring jug
4. Trolley
5. Local anaesthesia
6. Cleaning lotion such as ether, tincture of
iodine
7. Plaster with scissor
8. Sputum mug
9. Lab request-form
Procedure:
1. Check clinical record for order and possible allergy
2. Alert physician if any abnormal lab result
3. Explain the procedure to the patient and inform them to try not to cough, not to breathe
deeply, and not to move suddenly during the procedure to avoid puncture of the visceral
pleura or lung
4. Verify informed written consent
5. Wash hands
6. Collect necessary equipment and bring to patient bedside
7. Take baseline vital sign including pulse oximetry
8. Screen the patient.

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9. Remove clothes to expose chest.
10. Position the patient as directed by the physician. The position may be either one of the
following or a similar position, as directed by the physician.
(a) Position the patient to sit on the side of the bed, facing away from the physician, with
feet supported on a chair and the head and arms resting on an over bed table padded
with pillows. The arms are elevated slightly to widen the intercostals spaces.
(b) If the patient is unable to sit, turn him on the unaffected side with the arm of the
affected side raised above his head. Elevate the head of the bed 30
0
to 45
0
.
11. Place the thoracentesis tray on instrument table. Open sterile wrapper cover to provide a
sterile field.
12. Place other supplies on adjacent bedside stand or over bed table. Open glove wrapper.
13. Assist with handling of local anesthetic vial. Hold vial with label uppermost so that the
physician can personally check the label before withdrawing any of the solution. Cleanse
stopper with alcohol swab. Invert vial and hold firmly while the doctor, with gloved
hands, withdraws the required solution.
14. Support and help patient to avoid moving and coughing while the thoracentesis needle is
introduced.
15. Assist as directed with collection of specimens as the physician manipulates the syringe,
the stopcock, and drainage tubing. Use care not to contaminate the end of the tubing, the
cap, or the open end of the specimen tubes. Cap the tubes and place them upright in a
clean glass provided for this purpose. Label each tube as directed by the physician.
16. If drainage of a large amount of accumulated fluid is necessary, assist the doctor by
placing the free end of the tubing in the drainage bottle.
17. Watch the patient's color; check pulse and respiration. Immediately report any sudden
change, as this may indicate damage to the visceral pleura from a nick or puncture by the
needle.
18. After the needle is withdrawn, apply a sterile occlusive dressing over the puncture site.
19. Position patient comfortably (usually Fowler's position).
20. Complete entries on appropriate laboratory request forms as directed.
21. Send properly labeled specimens with completed request forms to laboratory immediately
if required
22. Measure and record amount of fluid withdrawn and discard this fluid unless directed
otherwise.
23. Return used equipment and wash hand
24. Proper documentation
Complications
 Pneumothorax
 Hemorrhage into the pleural space or chest wall,
 Vasovagal syncope (fainting)
 Air emboli
 Infection
 puncture of the spleen or liver,

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16.1. re-expansion pulmonary edema due to rapid removal of more than one liter of fluid
16.2. Assisting with Water-seal chest drainage system
1.
Water-seal chest drainage
Definition: Underwater-seal chest drainage is a closed (airtight) system for drainage of air and
fluid from the chest cavity.
Indication
Pneumothorax
 Hemothorax
 Empyema
 Chest trauma
 Flail chest
Purpose
 To re-establish expansion of the pleural space
 To remove the air or bloody fluid from pleural space and allow for expansion of the lung (or
to evacuate fluid & blood).
 To re-establish negative intra pulmonary and intrathoracic pressure or restoration of the
normal negative pressure in the pleural space.
Contraindications for chest tubes:
 Infection over insertion site
 Uncontrolled bleeding
Patient Positioning and Insertion Sites for Chest tubes
Pneumothorax: (AIR)
 The best position is supine or with head elevated anywhere from low to high fowler’s.
 The chest tube will be inserted into the 2
nd
or 3
rd
intercostal space anterior chest at the
mid-clavicular line
Effusions: (FLUID)
 If patient able, the best position is sitting on the side of the bed leaning over a pillow
placed on a bedside table.
 The chest tube is inserted between the 7
th
to 8
th
intercostal space in the mid-axillary line
Precaution
 To protect occlusion of tube use rolled towels.
 The patient should be encourage to cough and deep breath once hourly to prevent atelectasis
and assist in removing air and fluid.
 Use aseptic technique when preparing equipment and changing the bottle.

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 Make sure that the system is air tight at any time
 Keep a clamp with the pt for emergency.
Equipment
1. Sterile gloves
2. suture set (or sterile scissors and
sterile forceps)
3. Sterile Vaseline gauze
4. Sterile glass tube
5. Sterile water/saline
6. Suction machine with tube
7. Dressing material
8. Wide tape
9. Local anaesthesia
10. Drainage bottle and tube
11. Vital sign equipment
Procedures
1. Check consent form is signed
2. Identify the patient and explain the procedure
3. Check vital sign
4. Collect equipment after washing your hands
5. Assist patient to the upright position, have the patient sit upright in bed and lean forward resting
on the over bed table.
6. Open the chest tube tray and assist the physician as indicated.
o Pour antiseptic over the cotton ball
o Hold the vial of local anaesthesia
o Apply an occlusive dressing to the tube-inserting site.
o Make sure a chest firm in order to check proper placement.
7. Reassure and observe the patient throughout the procedure.
8. If a specimen needed take specimen, label it and send to the laboratory immediately.
9. Return the patient to comfortable position
10. Check vital signs

Nursing intervention
1. If using a chest drainage system with a water seal, fill the water seal chamber with sterile
water to the level specified by the manufacturer.
2. When using suction in chest drainage systems with a water seal, fill the suction control
chamber with sterile water to the 20-cm level or as prescribed.
 In systems without a water seal, set the regulator dial at the appropriate suction level.
3. Attach the drainage catheter exiting the thoracic cavity to the tubing coming from the
collection chamber. Tape securely with adhesive tape.
4. If suction is used, connect the suction control chamber tubing to the suction unit. If using a
wet suction system, turn on the suction unit and increase pressure until slow but steady
bubbling appears in the suction control chamber.
 If using a chest drainage system with a dry suction control chamber, turn the regulator
dial to 20 cm H2O.
5. Mark the drainage from the collection chamber with tape on the outside of the drainage unit.
Mark hourly/daily increments (date and time) at the drainage level.

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6. Ensure that the drainage tubing does not kink, loop, or interfere with the patient’s
movements.
7. Encourage the patient to assume a comfortable position with good body alignment. With
the lateral position, make sure that the patient’s body does not compress the tubing. The
patient should be turned and repositioned every 1.5 to 2 hours. Provide adequate analgesia.
8. Assist the patient with range-of-motion exercises for the affected arm and shoulder several
times daily. Provide adequate analgesia.
9. Gently “milk” the tubing in the direction of the drainage chamber as needed.
10. Make sure there is fluctuation (“tidaling”) of the fluid level in the water seal chamber (in
wet systems), or check the air leak indicator for leaks (in dry systems with a one-way valve).
 Fluid fluctuations in the water seal chamber or air leak indicator area will stop when:
a. The lung has re-expanded
b. The tubing is obstructed by blood clots, fibrin, or kinks
c. A loop of tubing hangs below the rest of the tubing
d. Suction motor or wall suction is not working properly
11. Observe for air leaks in the drainage system; they are indicated by constant bubbling in the
water seal chamber, or by the air leak indicator in dry systems with a one-way valve. Also,
assess the chest tube system for correctable external leaks. Notify the physician immediately
of excessive bubbling in the water seal chamber not due to external leaks.
12. When turning down the dry suction, depress the manual high negativity vent, and assess for
a rise in the water level of the water seal chamber.
13. Observe and immediately report rapid and shallow breathing, cyanosis, pressure in the
chest, subcutaneous emphysema, symptoms of hemorrhage, or significant changes in vital
signs.
14. Encourage the patient to breathe deeply and cough at frequent intervals. Provide adequate
analgesia. If needed, request an order for patient-controlled analgesia. Also teach the patient
how to perform incentive spirometry.
15. If the patient is lying on a stretcher and must be transported to another area, place the
drainage system below the chest level. If the tubing disconnects, cut off the contaminated
tips of the chest tube and tubing, insert a sterile connector in the cut ends, and reattach to the
drainage system. Do not clamp the chest tube during transport.
16. When assisting in the chest tube’s removal, instruct the patient to perform a gentle Valsalva
maneuver or to breathe quietly.
 The chest tube is then clamped and quickly removed.
 Simultaneously, a small bandage is applied and made airtight with petrolatum gauze
covered by a 4 × 4-inch gauze pad and thoroughly covered and sealed with nonporous
tape.
16.3. Assisting with Bronchoscopy
Definition: Bronchoscopy is the direct inspection and examination of the larynx, trachea, and
bronchi through either a flexible fiberoptic bronchoscope or a rigid bronchoscope.
Purposes

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A. Diagnostic:
 To examine tissues or collect secretions
 To determine the location and extent of the pathologic process and to obtain a tissue
sample for diagnosis (by biting or cutting forceps, curettage, or brush biopsy)
 To determine if a tumor can be resected surgically, and
 To diagnose bleeding sites (source of hemoptysis).
B. Therapeutic:
 Remove foreign bodies from the tracheobronchial tree
 Remove secretions obstructing the tracheobronchial tree when the patient cannot clear
them
 Treat postoperative atelectasis, and
 Destroy and excise lesions.
Indications
 Abnormal chest x-ray: presence of a lesion, persistent atelectasis, infiltrates in the
lung fields.
 Hemoptysis
 Unexplained cough, localized wheeze, or stridor
 Need to obtain lower respiratory tract secretions or tissue for diagnostic purposes
 To assess and/or evaluate airways
 To perform difficult intubations
 To remove a foreign body
Contraindications
 Inability to adequately oxygenate the client during the bronchoscopy
 Clients with severe obstructive lung disease
 Unstable hemodynamic status
 Lack of client consent
 Recent myocardial infarction
 Unstable angina
 Hypoxemia or hypercarbia
 Low platelet count
Precautions
1. Determine whether the client has been NPO for 4 to 8 hours.
2. Determine the presence of a current chest x-ray and blood work (especially bleeding
times).
3. Assess where the procedure is to be performed (in a hospital room, or in the
bronchoscopy suite)
4. Identify the drugs ordered: action, purpose, normal dosage, common side affects, time of
onset and peak action, duration of action and implications.
5. Assess the client’s vital signs, including lung sounds and blood oxygen levels,
6. Assess the client’s chart for a signed consent form

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7. Assess the client’s level of understanding regarding the procedure as well as the client’s
level of anxiety
Equipments
1. Bronchoscope (The scope size will be determined by the physician or qualified
practitioner based on the client and the procedures to be performed.)
2. Light source for the bronchoscope and any related video or photographic equipment
3. Brushes (cytology, protected for microbiology tissue samples)
4. Specimen traps
5. Syringes of various sizes for bronchoalveolar lavage, drug delivery, and needle aspiration
6. Bite block (to protect the scope)
7. Intubation tray
8. Intravenous supplies
9. Resuscitation bag
10. Monitoring devices: pulse oximeter, ECG monitor, sphygmomanometer
11. Oxygen delivery equipment: cannula, masks
12. Suction supplies for scope and/or mouth
13. Fluoroscopy equipment, including personal protection and radiation badge
14. Adequate ventilation, to prevent the spread of infection
15. Ultraviolet light, to prevent transmission of tuberculosis
16. Cleaning, disinfection, and sterilizing equipment
Procedure
1. Explain the procedure
2. Wash hands.
3. Set up for the bronchoscopy. Plug the appropriate bronchoscope in a light source and
connect the suction tubing. Set up an emergency oral suction.
4. Draw up medication per physician’s or qualified practitioner’s orders and label each
syringe with drug and dosage per milliliter.
5. Ready syringes of saline for the broncho-alveolar lavage and saline washes.
6. Lay out traps, biopsy forceps, cytology brushes, and protected brushes as needed. Have
everything ready for an IV placement (if an outpatient; an inpatient should already have an
IV).
7. Make sure all the required paperwork is filled out and ready for the client and the
physician or qualified practitioner.
8. Check that emergency medications and supplies are available.
9. Verify client’s identity.
10. Have client put on a gown if she is an outpatient
11. Place monitoring devices for vital signs. Record baseline vital signs and continue to
monitor every 5–15 minutes depending on institution policies.
12. For outpatients, confirm the presence of a family member or caregiver to provide
transportation after the procedure.
13. Obtain informed consent from the client prior to the bronchoscopy procedure.

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14. Start supplemental oxygen.
15. Have client remove false teeth (if appropriate).
16. Give the anticholinergic agent if the doctors have ordered it. Watch the heart rate closely.
17. The physician or qualified practitioner may also want a nebulizer given with a
bronchodilator diluted with lidocaine.
18. Anesthetize the nares and the throat with topical lidocaine and cocaine.
19. Give first dose of IV sedation; may be required to give PRN prior to and during procedure
depending on client’s tolerance to the drugs and comfort level.
20. Lubricate the distal end of the scope using a water-soluble lubricant.
21. If you are introducing the scope orally, place a mouth guard or airway in client’s mouth.
Secure if possible.
22. As the physician or qualified practitioner passes the scope into the airways the assistant
will inject lidocaine into the scope, numbing the airways as they go. This is usually 2 cc of
2% lidocaine (no preservatives) with 3 cc of air as a push in the syringe.
23. Instruct the client not to talk. If she needs something have her use the prearranged hand
signals.
24. Assist the physician or qualified practitioner in obtaining the type of samples needed:
25. While obtaining the samples, make sure to label all of them immediately with clients
name, ID number, date, time, and location in lung.
26. After the bronchoscopy, rinse the scope by suctioning approximately 240 ml of soapy
water through the working channel of the scope
27. During the recovery period (at least 30 minutes), wean the client off the oxygen (if none
was required prior to the procedure).
28. Remember to keep a close watch on the oxygen saturation and the vital signs.
29. When client is awake and vital signs have returned to baseline, take out the IV, and
instruct the client or the caregiver to withhold food and liquids for at least 2 hours after the
procedure.
30. Instruct the client and/or caregiver about common side effects to expect following the
bronchoscopy.
a. Outpatients should not drive for at least 6 hours after the bronchoscopy.
b. For inpatients, call a report to the floor if the physician or qualified practitioner has not
already done so.
31. Deliver samples to the various laboratories if you have not already done so.
32. Check the scope for any leaks or damage sustained during the procedure.
33. If there are no leaks or damage, clean the scope inside and out with soft brushes. Rinse
well and sterilize.
34. Periodic post procedure follow-up monitoring of client condition is advisable for 24–48
hours for inpatients. Outpatients should be instructed to contact the physician or qualified
practitioner regarding fever, chest pain or discomfort, dyspnea, wheezing, hemoptysis, or
any new findings presenting after the procedure has been completed.
35. Comfort the patient after the procedure
36. Return equipment and Wash hands.

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37. Proper documentation

Complications
 Hypoxemia
 Hypercarbia
 Hypotension
 Laryngospasm
 Bradycardia
 Pneumothorax
 Hemoptysis
 Adverse effect of medication used
before and during the bronchoscopy

16.4. Assisting with an abdominal paracentesis
Objective: at the end of this lesson learner will be able to:-
 Prepare equipment for abdominal paracentesis
 Prepare the patient for abdominal paracentesis
 Monitor the patient during and after the abdominal paracentesis
Definition: -Paracentesis is the removal of fluid (ascites) from the peritoneal cavity through a
small surgical incision or puncture made through the abdominal wall under sterile conditions.
Purpose:
1. For diagnostic purpose:- to obtain a specimen of fluid
2. For therapeutic purpose: - to relieve pressure on the organs of the abdomen and chest.
Precaution
 During and after the procedure watch patient carefully for signs of shock
 If the puncture is done on the site, lay the patient on the unaffected site at the end of the
procedure
 Make sure the abdomen binder is under the patient before the procedure
Equipment
Sterile set
1. Sterile trochar and cannula—small
pieces of tubing attached to the
cannula with clamp.
2. Towel with hole/ fenestrated towel
3. Hand towel
4. Gloves, swabs & gauze in a bowel
5. 2 gallipots
6. Syringe and needle for local
anaesthesia
7. Dissecting forceps & artery forceps
8. Small scalpel if needed
9. 2 Test tubes
10. Cotton balls
11. Knife and small scalpel
Clean
1. Rubber sheet with cover
2. Abdominal binder with safety pin
3. Cleansing lotion and local anesthesia
4. Pail or other receiver to collect fluid
5. adhesive tape
6. Screen
Procedure
1. Explain the procedure to the patient

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2. Wash hands
3. Assemble equipments
4. Keep patient privacy
5. Empty the bladder immediately before tapping
6. Position the patient (sitting up position) depending on the degree of the ascites.
 The usual site for the paracentesis is half way between the umbilicus and the symphysis
pubis on mid line of the abdomen.
7. Place the abdomen binder in position so that it can be used during or after the procedure.
8. The nurse opens the set, pours of cleaning lotion in bowel (galipot). The Doctor then will
scrub his hands, put gloves & clean the area. He inserts the torcher and cannula; the nurse
should hold the anesthetic bottle for the doctor.
9. At the end of the procedure, dray the punctured area; adjust the binder & secure it in place
with safety pin; leave the patient in the comfortable position
10. Check for leakage and report.
11. Measure the liquid with drawn & record the time of the procedure the colure, amount
&condition of the patient.
12. Comfort patient
13. Return used equipment to its place and wash hand
14. Proper documentation
16.5. Assisting with liver biopsy
Definition: It is sterile procedure performed to aspirate a sample of liver tissue for laboratory diagnosis
Purpose
 To evaluate diffuse disorders of the parenchyma
 To diagnose space-occupying lesions.
 Useful when clinical findings and laboratory tests are not diagnostic.
Site: between 6
th
and 7
th
ribs on right lower chest wall patient lay in supine position with right hand over
the head.
Equipment
Sterile
1. Gallipot
2. Fenestrated towel
3. Swabs and gauze in a receiver
4. Hand towel
5. Gloves
6. Syringes for needle for local anaesthesia
7. Dressing forceps, scissors and scalpel if
needed
8. Liver biopsy needle
9. Test tubes
Clean
 Rubber sheet and towel
 A small bottle containing formalin
for the specimen
 Local anesthesia
 Cleaning solution
 Plaster and scissors

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 A laboratory required paper

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Procedure
1. Explain the procedure to the patient
2. Wash hands
3. Assemble equipments
4. Keep patient privacy
5. Do general assessment
6. Assess the client general appearance and health status.
7. Determine drug allergies (local anesthesia, and antiseptics)
8. Determine the clients understanding of the procedure
9. Give procedural medication as ordered E.g Vit.k before hand
10. Ensure the patient fasting for at list 2 hours before the procedure
11. Administer appropriate sedative about 30 minutes before hand or at the specified time.
12. Help the client assume a supine position, with the upper right quadrant of the abdomen exposed.
Cover the client with the bed cloths so that only the abdominal areas exposed.
13. Open the sterile set and the sterile gloves for the physician pour antiseptic solution over the
sterile sponges or gauze or in to a container as needed done disposable gloves
14. Support the client in a supine position.
15. Instruct the client to take a few deep inhalation and exhalation and hold the breath after the final
exhalation for up to 10 seconds as the needle is inserted, the biopsy, obtained and the needle
withdrawn.
16. Instruct the patient to resume breathing when the needle is withdrawn
17. Apply pressure to the site of the puncture
18. Apply a small dressing to the site of the puncture.
19. Assist the patient/ client to a right side –lying position with a small pillow or folded towel under
the biopsy site. And instruct the client to remain in this position for several hours
20. Assess the client vital sign every 15 minutes for the first hours following the test or until the
sign are stable.
21. Determine whether the patient experiencing pain, severe abdominal pain indicate bile peritonitis
22. Check the biopsy site for any leaking if occurs pressure dressing may be needed if bleeding
occurs.
23. Send the labeled specimen immediately to the laboratory along with the completed requisition
24. Comfort patient
25. Return used equipment to its place and wash hand
26. Document the procedure

Complication:
 Bleeding
 Bile peritonitis

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16.6. Assisting with Bone marrow puncture/biopsy
Definitions:
1. Bone marrow aspiration is the removal of a small amount of organic material
from the medulla of certain bones by a large-bore needle.
2. A bone marrow biopsy is the removal of a core of bone marrow cells by a biopsy
needle.
Purpose: The biopsy or aspiration is used to diagnose
 Leukemia
 Anemia
 Thrombocytopenia
 Other malignancies such as non–Hodgkin’s lymphoma or multiple myeloma.
Precaution:
 The client may be at increased risk for bleeding, infection, or other problems
Equipments:
Sterile set
1. Tray
2. Fenestrated towel
3. Hand towel
4. Gloves
5. Swabs and gauze (4x4) in a receiver
6. Dressing forceps
7. Syringe and needle (two 3-ml with
23- to 25-gauge) for local anaesthesia
8. Two 10-ml syringes for marrow
aspiration
9. Two bone marrow needles with inner
stylus
10. One biopsy needle
11. Two 10 ml syringe and adaptor if
needed
12. Sterile test tube, water, glass slide
13. Sterile gauze and tape or Band-Aid

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Clean
1. Sodium oxalate solution for preservation
2. Rubber sheet and towel for bed protection
3. Antiseptic solution as tincture of iodine, ether or alcohol
4. Local anaesthetic
5. Receiver for used instruments
6. Masks and goggles
7. Pain medication or sedative as ordered
8. Plaster and scissors.
Procedure:
1. Do general assessment
2. Explain the procedure.
3. Have the client void.
4. Administer medication for sedation or pain
5. Wash hands and assemble the necessary equipments
6. Help the client assume a supine position (with one pillow if desired) for biopsy of the
sternum (sternal puncture) or prone position for a biopsy of either iliac crest; fold the
bed clothes back to expose the area.
7. Open the bone marrow set and pass sterile gloves to the physician, pour the antiseptic
solution into a container in the set or over sterile gauze squares.
8. Open and hold the ampoule or vial of local anaesthetic if it is not in the set.
9. Wear disposable gloves.
10. Describe the steps of the procedure and provide verbal support, observe the client for
pallor, diaphoresis, and faintness.
11. Nurse may assist with applying pressure to the site and applying the ointment and
dressing to the site of the puncture after the needle is withdrawn.
12. Assess for discomfort and bleeding from the site.
13. Provide analgesia as needed and ordered.
14. Arrange for the specimen with the completed request and label to be transported to the
laboratory.
15. Assist client into a comfortable position.
16. Put on gloves and discard supplies appropriately.
17. Wash hands
18. Document the procedure.
19. Regularly assess for discomfort and bleeding for several days.

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16.7. Assisting with Cast application and removal
Objectives: at the end of this lesson, the learner will be able to:
1. Define cast
2. Assemble equipments for application and removal of cast
3. Identify the preventive and health teaching needs of the patient with a cast
4. Demonstrate the nursing care for a patient with cast.
16.7.1. Cast application
Definition:- A cast is a rigid external immobilizing device that is molded to the contours
of the body.
Purpose:
 To immobilize a body part in a
specific position
 To apply uniform pressure on
encased soft tissue
 To immobilize a reduced fracture
 To correct a deformity
 To support and stabilize
weakened joints
Contraindications (relative)
 Skin diseases
 Peripheral vascular disease
 Diabetes mellitus
 Open or draining wounds
 Susceptibility to skin irritations
Equipment
1. Drape for patient
2. Knitted material (eg, stockinette)
3. Nonwoven roll padding
4. Casting material (POP)
5. Water and basin
6. Cast knife or cutter
7. Trolly
Procedure
1. Perform neurovascular assessment
2. Explain the procedure
3. Wash hands
4. Assemble necessary equipments
5. Support extremity or body part to be casted.
6. Position and maintain part to be casted in position indicated by physician during
casting procedure.
7. Drape patient.
8. Wash and dry part to be casted.
9. Place at least three layers of knitted material (eg, stockinette) over part to be
casted.
 Apply in smooth and non constrictive manner.
 Allow additional material.
10. Wrap soft, nonwoven roll padding smoothly and evenly around part.

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 Use additional padding around bony prominences to protect superficial nerves
(eg, head of fibula, olecranon process).
11. Apply plaster or fiberglass casting material evenly on body part.
 Choose appropriate-width bandage.
 Overlap preceding turn by half the width of the bandage.
 Use continuous motion, maintaining constant contact with body part.
 Use additional casting material (splints) at joints and at points of anticipated
cast stress.
12. “Finish” cast.
 Smooth edges.
 Trim and reshape with cast knife or cutter.
13. Remove particles of casting materials from skin.
14. Support cast during hardening.
 Handle hardening casts with palms of hands.
 Support cast on firm, smooth surface.
 Do not rest cast on hard surfaces or on sharp edges.
 Avoid pressure on cast.
15. Promote drying of cast.
 Leave cast uncovered and exposed to air.
 Turn patient every 2 hours, supporting major joints.
 Fans may be used to increase air flow and speed drying.

16.7.2. Care of patient with cast
Nursing intervention:
1. Wash hands.
2. Check circulation, movement, and sensation
 Note color and temperature of skin.
 Pinch finger or toe and watch for capillary refill within 2 to 4 seconds.
 Ask client to twist fingers or toes.
 Ask client to tell you if s/he feels you touching the extremity
3. Assess skin.
 Tell client not to put objects under the cast.
 Use powders or creams only outside the cast.
4. Assess pain or soreness.
 Reposition the extremity q2h.
 Elevate the extremity and apply ice.
5. Assess cast for intact cotton padding. Pad or add additional padding to areas of
redness or irritation
6. Assess cast for intact edges.

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 If edges are crumbling or peeling, or if the cast has been bivalved or windowed,
use tape to petal the edges
 Do not allow the cast to get wet. Teach the client how to cover the cast when
bathing or showering.
7. Assess safety. If client is to ambulate provide cast boot for traction
8. Instruct client and caregiver about symptoms to report to the physician or qualified
practitioner:
 An increase in swelling.
 A tingling or burning sensation.
 An inability to move muscles around the cast.
 A foul odor around the edges of the cast.
 Any drainage, which may show through the cast.
 Any cracks or breaks in the cast.
9. Support the cast.
 Use pillows for arms and legs.
 Use a bed board under the mattress for a spica cast.
10. Assess for infection.
 Check for foul odor under cast.
 Check for drainage on cast.
 Mark drainage and date on cast.
11. Synthetic casts should be kept dry. If the physician or qualified practitioner does
permit bathing or swimming, the wet cast should be dried quickly and thoroughly.
Dry the cast with a towel and then a hair dryer set on low. Dry until the padding
underneath does not feel cold or damp to the skin.
12. Wash hands.

16.7.3. Cast Removal
Indication

 When a fracture heals
 If it requires further manipulation.
Less common indications include:
 Cast damage
 Pressure ulcer under the cast
 Excessive drainage or bleeding
 Constrictive cast
Equipment
 Cast cutter
 cast splitter

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 Bandage scissors
 Surgical or plaster knife

Procedure
1.Introduce yourself to client and explain the planned procedure.
2.Wash hands.
3.Assess vascular status.
4.Prepare equipment and have it at bedside.
5.Assess client’s ability to communicate during cast removal.
6.Prepare environment and client.
7.Wear protective clothing as needed.
8.Prepare client for how extremity will look after reduction.
 Extremity will look thinner than non-fractured site.
 Mobility will be less than non-fractured site.
9.Client may need to continue to use crutches or immobilizer until full mobility of
extremity is regained
10. The cast removal technician will cut the cast with the saw. Support the limb in the
proper position as requested.
11. The cast technician will split the cast with a cast splitter, and cut the padding
underneath
12. The cast technician will then pull the cast apart and remove it. Support the limb,
and reassure the client, as this step can be anxiety producing and sometimes
uncomfortable
13. Assess the skin underneath the cast. Gently clean the skin with warm water. Do
not rub or use friction on the skin.
14. May need to apply Ace wrap after cast removal.
15. Document the extremity where the cast was removed and how the extremity looks
16. Wash hands.



16.8. Assisting with Traction Application
16.8.1. Skin Traction
Definition: Skin traction is immobilizing body part intermittently over an extended time
through direct application of a pulling force on the skin.
Purpose
 To control muscle spasms

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 To immobilize an area before surgery.
 To reduce fracture
 To treat dislocation
 To correct/prevent deformity
 To improve or correct contractures
Equipment
 Pain medication, if necessary
 Overhead traction bars if needed
 Weights in various pounds
 Traction line and pulleys
 Skin traction device as ordered by the physician or qualified practitioner
 Adhesive traction tape and elastic bandage if appropriate
 Razor, if needed
 Benzoin solution, if needed


Procedure:
1. Explain the procedure to client
2. wash hands
3. Assemble equipments
4. Assessing the site of traction application.
5. Clean the skin area to which the traction will be applied
For adhesive Traction
6. Shave the area if there is a large amount of hair.
7. Apply tincture of benzoin to the area to be taped.
8. Place the adhesive traction tape on the body part to provide the appropriate direction of pull.
9. Add spreader bars or hooks needed to attach the tape to the traction rope and weights.
10. Wrap the body part and adhesive tape with the elastic bandage.
For Non-adhesive Traction
11. Apply the traction appliance to the appropriate body part
12. Secure it with the fasteners provided (Velcro, straps and buckles, ties) If no fastener is provided,
an elastic bandage may be wrapped around the appliance or adhesive tape
13. Asses for pain, shifting, or slipping of the traction.
14. Comfort the patient
15. Return equipments
16. Wash hand
17. Document the procedure with patient reaction

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16.8.2. Skeletal traction
Definition: Skeletal traction is procedure of immobilizing body part intermittently over
an extended time through direct application of a pulling force on the bone.
Purpose
 To control muscle spasms
 To immobilize an area before surgery.
 To reduce fracture
 To treat dislocation
 To correct/prevent deformity
 To improve or correct contractures
Equipment
1. Pain medication
2. Sterile pins
3. Sterile pin insertion kit
4. Local anesthetic
5. A topical cleanser such as povidone-iodine for cleaning the insertion site
Procedure:
1. Explain procedure to patient
2. Wash hands
3. Assemble all the needed equipment at the bedside.
4. Assess the client’s skin and circulation, sensation, and movement (CSM) of
extremity
5. Check orders for pain medications and local anesthetics needed for the procedure.
6. Check for drug allergies.
7. Administer systemic pain medications.
8. Wash hands. If there is risk for contact with body fluids, gloves should be worn.
9. Adjust the bed to a comfortable working height. If applicable, support extremity
on pillows.
10. Physician or qualified practitioner will open pin insertion kit, administer local
analgesic
11. Assist during the pin insertion procedure.
12. Reassure the client.

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13. The physician or qualified practitioner will attach the pins to traction, if
appropriate. Provide help in connecting the traction line through the pulley and
secure appropriate weights
14. Place the patient on a comfortable position
15. Assess the patient as necessary
16. Return equipments and wash hand
17. Properly document the procedure

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16.9. Assisting with lumbar puncture
Definition: - Lumbar puncture is the introduction of a needle into the subarachnoid space
of the spinal column.
Purpose:
 To collect specimen of cerebrospinal fluid for diagnostic purpose
 To measure and reduce CSF pressure
 To determine the presence or absence of blood in CSF
 To detect the spinal subarachnoid block
 To administer antibiotics intrathecal in certain cases of infection.
Indications
 Infection of CNS such as suspected meningitis, encephalitis
 Brain or spinal cord tumors
 subarachnoid hemorrhage, hydrocephalus, benign intracranial hypertension
 to inject medications into the cerebrospinal fluid ("intrathecally"),
Contraindications
 Present or suspected epidural infection,
 Topical infections or dermatological conditions at the puncture site
 Patients with severe psychosis or neurosis with back pain
Precaution
 Patient anxiety during the procedure can lead to increased CSF pressure.
Equipment:
Sterile:
1. Gallipots
2. Sterile towel with hole
3. Hand towel
4. Sterile gloves
5. Dissecting forceps and artery forceps
6. Two lumbar puncture needle with different size (Barker's needle) (5 to 12.5 cm long)
7. A measure for fluid to be collected
8. A short length of rubber tubing to be attached to the needle.
9. Needle (5⁄8 to 11⁄2 inches, 21 to 25 gauge) and syringe for local anaesthesia (3 to 5
ml).
10. Four test tubes for specimen.
11. Ten gauze sponges (4 x 4) (dressing and tape)
Clean
1. Tray

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2. Monometer with three-way stopcock
3. local anesthetic (lidocaine)
4. Skin cleansing lotion (ether, povidone-iodine, saline, etc.)
5. Rubber sheet and towel.
6. Plaster and scissors,
7. Receiver for used instruments
8. Alcohol swabs
9. Straight chair
10. Pillow for placing between client’s knees
11. Masks and goggles (optional)
Procedure:-
1. Explain the procedure to the patient
2. Have the client void before the procedure.
3. Wash hands
4. Assemble the necessary equipment
5. Maintain privacy of the client
6. Position the patient: lying on the side with the knee flexed and the head bent forward
with the chin touching the chest or sitting up with knees and spine flexed.
7. Have client grasp knees with hands if it helps maintain the position.
 Place pillow between knees.
 Expose the spine.
8. Put the rubber sheet and towel under the patient.
9. Open the sterile set and pour antiseptic solution into the gallipots.
10. Wear glove.
11. Hold anaesthetic bottle for the doctor.
12. During the procedure, the nurse/assistant might be asked to press the internal jugular
veins in order to see the pressure of the fluid.
13. Observe the patient for signs of shock, nausea and vomiting.
14. The procedure is ended by withdrawing the needle while placing pressure on the
puncture site & applying sterile dressing.
15. After the procedure place the patient comfortably flat (can be raised if needed) and
watched for headache.
16. Label the specimen and send to the laboratory.
17. Return equipments to proper place.
18. Record time of procedure, amount, colour and consistency of the fluid withdrawn
19. Observe client after the procedure for neurologic changes:
 Change in level of consciousness, pupil size, or reaction.
 Vital signs, respiratory status.
 Numbness, tingling, or pain in legs.

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CHAPTER SEVENTEEN
CARE OF THE TERMINALLY ILL AND POST MORTEM CARE

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17.1. Care of the terminally ill patient
.
Purpose
 To provide personal hygiene
 To provide spiritual support
 To support the family
Equipment
1. Clean bed linens, clean gowns, gloves
2. Water-filled basin
3. Soap and washcloth
4. Towels, lotion, linen-saver pads
5. Lemon-glycerin swabs
6. Petroleum jelly
7. Suction and resuscitation equipment, as
necessary
8. Optional: indwelling urinary catheter.
Procedures
1. Introduce self and verify client’s identity.
2. Explain the procedure to the client
3. Gather appropriate equipment.
Meeting physical needs
4. Take vital signs often, and observe for pallor, diaphoresis, and decreased LOC
5. Reposition the patient in bed at least every 2 hours because sensation, reflexes, and mobility diminish
first in the legs and gradually in the arms. Make sure the bed sheets cover him loosely to reduce
discomfort caused by pressure on arms and legs.
6. When the patient's vision and hearing start to fail, turn his head toward the light and speak to him from
near the head of the bed. Because hearing may be acute despite loss of consciousness, avoid whispering
or speaking inappropriately about the patient in his presence.
7. Change the bed linens and the patient's gown as needed. Provide skin care during gown changes, and
adjust the room temperature for patient comfort if necessary.
8. Observe for incontinence or anuria, the result of diminished neuromuscular control or decreased renal
function. If necessary, obtain an order to catheterize the patient, or place linen saver pads beneath the

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patient's buttocks. Put on gloves and provide perineal care with soap, a washcloth, and towels to prevent
irritation.
9. With suction equipment, suction the patient's mouth and upper airway to remove secretions. Elevate the
head of the bed to decrease respiratory resistance. As the patient's condition deteriorates, he may breathe
mostly through his mouth.
10. Offer fluids frequently, and lubricate the patient's lips and mouth with petroleum jelly or lemon-glycerin
swabs to counteract dryness.
11. If the comatose patient's eyes are open, provide eye care to prevent corneal ulceration. Such ulceration
can cause blindness and prevent the use of these tissues for transplantation should the patient die.
12. Provide ordered pain medication as needed. Keep in mind that, as circulation diminishes, medications
given I.M. will be poorly absorbed. Medications should be given I.V., if possible, for optimum results.
Some medications can be given sublingually or rectally if the patient can't swallow or has no I.V. access.
Meeting emotional needs
13. Fully explain all care and treatments to the patient even if he's unconscious because he may still be able
to hear. Answer any questions as candidly as possible without sounding callous.
14. Allow the patient to express his feelings, which may range from anger to loneliness. Take time to talk
with the patient. Sit near the head of the bed, and avoid looking rushed or unconcerned.
15. Notify family members, if they're absent, when the patient wishes to see them. Let the patient and his
families discuss death at their own pace.
16. Offer to contact a member of the clergy or social services department, if appropriate.
17. Record changes in the patient's vital signs, intake and output, and LOC. Note the times of cardiac arrest
and the end of respiration, and notify the physician when these occur.
Special considerations
 If the patient has signed a living will, the physician will write a Do-not-resuscitate (DNR) order on his
progress notes and order sheets. Know your state's policy regarding the living will. If it's legal, transfer
the DNR order to the patient's chart or Kardex and, at the end of your shift, inform the incoming staff of
this order.
 If family members remain with the patient, show them the location of bathrooms, lounges, and
cafeterias. Explain the patient's needs, treatments, and care plan to them. If appropriate, offer to teach

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them specific skills so they can take part in nursing care. Emphasize that their efforts are important and
effective. As the patient's death approaches, give them emotional support.
 At an appropriate time, ask the family whether they have considered organ and tissue donation. Check
the patient's records to determine whether he completed an organ donor card.
17.2.Postmortem care/Care after Death
Definition: Postmortem care involves the physical caring for the body after death, respecting as much as
possible the wishes of the deceased and family.
Purpose
 To show respect for the dead
 To prepare the body for morgue
 To prevent spread of infection
 To show kindness to the family
 To preserve the natural appearance of the body for the family and relatives
Equipment
1. Gauze or soft string ties, gloves, plaster
2. Chin straps, ABD pads, cotton balls, plastic
shroud or body wrap
3. Three identification tags
4. Adhesive bandages to cover wounds or
punctures
5. Plastic bag for patient's belongings
6. Water-filled basin, soap, towels, washcloths,
stretcher
Procedure
1. Note the exact time of death and chart it
2. If the doctor is present call him to pronounce death
3. Document any auxiliary equipment, such as a mechanical ventilator, still present. Put on gloves.
4. Place the body in the supine position, arms at sides and head on a pillow. Then elevate the head of the
bed 30 degrees to prevent discoloration from blood settling in the face.
5. If the patient wore dentures and your facility's policy permits, gently insert them; then close the mouth.
Close the eyes by gently pressing on the lids with your fingertips. If they don't stay closed, place moist

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cotton balls on the eyelids for a few minutes, and then try again to close them. Place a folded towel under
the chin to keep the jaw closed.
6. Remove all indwelling urinary catheters, tubes, and tape, and apply adhesive bandages to puncture sites.
Replace soiled dressings.
7. Collect all the patient's valuables to prevent loss. If you're unable to remove a ring, cover it with gauze,
tape it in place, and tie the gauze to the wrist to prevent slippage and subsequent loss.
8. Clean the body thoroughly, using soap, a basin, and washcloths. Place one or more ABD pads between
the buttocks to absorb rectal discharge or drainage.
9. Cover the body up to the chin with a clean sheet.
10. Offer comfort and emotional support to the family and intimate friends. Ask if they wish to see the
patient. If they do, allow them to do so in privacy. Ask if they would prefer to leave the patient's jewelry
on the body.
11. After the family leaves, remove the towel from under the chin of the deceased patient. Pad the chin, and
wrap chin straps under the chin and tie them loosely on top of the head. Then pad the wrists and ankles to
prevent bruises, and tie them together with gauze or soft string ties.
12. Fill out the three identification tags. Each tag should include the deceased patient's name, room and bed
numbers, date and time of death, and physician's name. Tie one tag to the deceased patient's hand or foot,
but don't remove his identification bracelet to ensure correct identification.
13. Place the shroud or body wrap on the morgue stretcher and, after obtaining assistance, transfer the body
to the stretcher. Wrap the body, and tie the shroud or wrap with the string provided. Then attach another
identification tag to the front of the shroud or wrap, and cover the shroud or wrap with a clean sheet. If a
shroud or wrap isn't available, dress the deceased patient in a clean gown and cover the body with a sheet.
14. Place the deceased patient's personal belongings, including valuables, in a bag and attach the third
identification tag to it.
15. If the patient died of an infectious disease, label the body according to your facility's policy.
16. Close the doors of adjoining rooms if possible. Then take the body to the morgue. Use corridors that
aren't crowded and, if possible, use a service elevator.
17. Although the extent of documentation varies among facilities, always record the disposition of the
patient's possessions, especially jewelry and money. Also note the date and time the patient was
transported to the morgue.

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