FUNDAMENTAL OF NURSING

PROCEDURE MANUAL

for PCL course

Nursing Department,

KhwopaPoly-Technic Institute ＆

JapanInternationalCooperation Agency(JICA)

Fundamental of Nursing Procedure Manual

Publishedby:

JapanInternationalCooperationAgency(JICA)NepalOffice

BlockB,Karmachari SanshayaKoshBuilding

Hariharbhavan,Lalitpur,NEPAL

(P.O.Box 450,Kathmandu,NEPAL)

Tel:(977-1)5010310

Fax:(977-1)5010284

Allcopyright reservedby JICA

FirstEdition: March,2008

Re- print: November,2008

Fundamental of Nursing Procedure Manual

✽✽✽✽✽✽✽✽✽✽✽✽✽✽✽✽✽✽✽✽✽✽✽✽✽✽✽✽✽✽

Contributor: SanjitaKhadka

DurgeshoriKisi

PadmaRaya

SaphaltaShrestha

Edited byKei Miyamoto(NursingEducation,Senior Volunteer,JICA)

✽✽✽✽✽✽✽✽✽✽✽✽✽✽✽✽✽✽✽✽✽✽✽✽✽✽✽✽✽✽

Khwopa polytechnic institute, Nursingdepartment

Principle: Dr.RajanSuwal

Faculty membersof NursingDepartment

Headof Department:SharmilaShrestha

Lecturer: SanjitaKhadka(1

yearcoordinator)

Chitra KalaSharma(2

yearcoordinator)

Merina Giri(3

yearcoordinator)

Bishnu Uprety

Assistantlecturer: DurgeshoriKisi

PadmaRaya

SushilaChaudhari

Sunita Batas

Instructor: Saphalta Shrestha

Sumitra Budhathoki

SabitraKhadka

Thankforcontributingyour professionalknowledge andexperience.Wewould liketoappreciate

to allour teachersand the former teachers,Ms. Junely Koju,Ms.Uttam Tara, andMs. Rashmi

Joshi.

Fundamental of Nursing Procedure Manual

Table ofContents

I. BasicNursing Care/ Skill

1. Bedmaking

a.MakinganUn-

occupiedbed

b.ChanginganOccupiedbed

c.Makinga Post-operativebed

2. Performingoralcare

a.Assistingtheclientwithoralcare

b.Providingoralcare fordependentclient

3. Performingbedbath

4. Performingbackcare

5. Performinghairwashing

6. Careforfingernails/toenails

7. Performingperinealcare

8. Takingvitalsigns

a.Takingaxillarytemperaturebyglassthermometer

b.Measuringradialpulse

c.Countingrespiration

d.Measuringbloodpressure

9. Performingphysicalexamination

10. Carefor Nasal-gastricTube

a.Insertinga Nasal-GastricTube

b.RemovalaNasal-GastricTube

11.AdministeringNasal-Gastrictubefeeding

12. Cleaninga woundandApplyinga steriledressing

13. Supplyingoxygeninhalation

a.NasalCannulaMethod

b.MaskMethod:Simplefacemask

II. Administrationof Medications

1. Administeringoral medications

2. Administeringoral medicationsthrougha Nasal-GastricTube

3. Removingmedicationsfroman ampoule

4. Removingmedicationsfroma vial

5. Preventionofthe needle-stickinjuries

6. GivinganIntra-muscularinjection

7. Startingan Intra-venousinfusion

8. MaintenanceofI.V.system

9. Administeringmedicationsby HeparinLock

10. PerformingNebulizerTherapy

a.Inhaler

b.Ultrasonicnebulizer

101

102

106

109

111

113

115

117

120

123

126

129

130

135

140

144

147

148

149

Fundamental of Nursing Procedure Manual

III. Specimencollection

1.Collectingbloodspecimen

a. Performingvenipuncture

b. Assistinginobtainingbloodfor culture

2.Collectingurinespecimen

a. Collectingasinglevoidedspecimen

b. Collectinga24-hoururinespecimen

c. Collectingaurinespecimenfromaretentioncatheter

d. Collectingaurineculture

3.Collectinga stoolspecimen

4.Collectinga sputumspecimen

a. Routinetest

b. Collectinga sputumculture

Appendix

References

151

153

157

159

160

161

163

164

166

168

169

171

181

Fundamental of Nursing Procedure Manual

I. Basic Nursing Care/ Skill

Fundamental of Nursing Procedure Manual

Bed making

a. Making anUn-occupied Bed

Definition:

Abedpreparedtoreceivea newpatientis anun-occupiedbed.

Fig.1.Un-occupiedbed

Purpose

1. To providecleanandcomfortablebed forthepatient

2. To reducethe riskofinfectionby maintainingacleanenvironment

3. To preventbedsoresby ensuringthereareno wrinklesto causepressurepoints

Equipmentrequired:

1. Mattress(1)

2. Bed sheets(2): Bottomsheet(1)

Topsheet (1)

3. Pillow (1)

4. Pillowcover (1)

5. Mackintosh (1)

6. Draw sheet (1)

7. Blanket (1)

8. Savlonwateror Dettolwaterin basin

9. Spongecloth(4):to wipewithsolution(1)

todry (1)

✽ Whenbed makeisdoneby twonurses,

spongeclothis neededtwoeach.

10. Kidneytrayor paperbag(1)

11. Laundrybagor Bucket (1)

12. Trolley(1)

Fig.2.Equipmentrequiredona trolley

Fundamental of Nursing Procedure Manual

Procedure:

byone nurse

CareAction Rationale

1.Explainthepurposeandprocedureto theclient.

 Providinginformationfosterscooperation.

2.Performhandhygiene.

 Topreventthe spreadof infection.

3. Prepare all required equipments andbring the

articlesto thebedside.

 Organization facilitates accurate skill

performance

4. Move thechairandbedside locker

 Itmakesspacefor bedmakingandhelpseffective

action.

5.CleanBed-sidelocker:

Wipewithwetanddry.

 Tomaintainthe cleanliness

6.Cleanthemattress:

1)Standin rightside.

2) Start wet wiping from top to center and from

centerto bottominrightsideof mattress.

3)Gatherthedustand debristo thebottom.

4)Collectthemintokidneytray.

5)Givedry wipingas sameasprocedure2).

6)Moveto leftside.

7)Wipewithwet anddrytheleft side.

 Topreventthe spreadof infection

7.Moveto rightside.

Bottomsheet:

1)Place and slidethebottomsheetupwardover

thetopof thebedleavingthebottomedgeof the

sheet.

2)Open itlengthwisewith thecenterfoldalongthe

bedcenter.

3)Foldback theupperlayerofthe sheettoward the

oppositesideof thebed.

4)Tuckthebottomsheetsecurelyunderthe headof

themattress(approximately20-30cm).(Fig.3)

Makeamiteredcorner.

➀Pick up the selvage edge with your hand

nearestthe handofthebed.

➁Layatriangleoverthesideof thebed(Fig.4)

➂Tuck the hanging partof the sheet underthe

mattress.(Fig.5)

➃Dropthetriangleoverthesideof thebed.

(Fig.6ⓐ→ 6ⓑ)

⑤Tuckthe sheetunderthe entire sideofbed.(Fig.

5) Repeat the same procedure at the end of the

cornerof thebed

6)Tucktheremainderinalongtheside



Unfoldingthe sheetin this manner allows you to

makethebedon oneside.

Amiteredcornerhasa neatappearanceandkeeps

thesheetsecurelyunderthe mattress.

 Tucking the bottom sheet will be done by turn,

the corner of top firstly and the corner of the

bottomlater.

 To securethe bottomsheeton onesideof thebed.

8.Mackintoshand drawsheet:

1)Placea mackintoshatthe middleof thebed( if

used),foldedhalf,withthe foldinthecenterof

thebed.used),foldedhalf,withthefoldin the

centerof thebed.

2)Liftthe righthalfandspreaditforwardthenear

Side.



Mackintosh and draw sheet are additional

protectionforthebed andservesasa liftingor

turningsheetfor animmobileclient.

Fundamental of Nursing Procedure Manual

Fig.3Tuckthe bottomsheetunderthemattress

Fig.4Pickingthe selvageand layinga triangleon

thebed

Fig.5Tucking the hanging partof the sheetunder

themattress

Fig.6aPuttingandholdingthesheetbedsidethe

mattressatthe leveloftop

Fig.6bDroppingthetriangleoverthe sideofthebed

Fig.7Tuckingthe sheetunderthe entire sideof the

bed

Fundamental of Nursing Procedure Manual

CareAction Rationale

3)Tuckthemackintoshunderthe mattress.

4)Place thedrawsheet onthe mackintosh.Spread

andtuckas sameasprocedure1)-3).

9.Moveto theleftsideof thebed.

Bottomsheet, mackintoshanddraw sheet:

1) Foldand tuckthe bottomsheet as inthe above

procedure7.

2)Foldand tuckboththemackintoshandthe draw

sheetunderthemattressas intheabove

procedure8.

 Secure the bottom sheet, mackintosh and draw

sheetononeside ofthebed

10.Returntothe rightside.

Topsheetandblanket:

1)Placethetop sheetevenlyon thebed,centering

itin thebelow20-30cmfrom thetopof the

mattress.

2)Spreaditdownward.

3) Cover thetop sheetwith blanket in thebelow 1

feet from the top of the mattress and spread

downward.

4) Foldthe cuff (approximately1 feet) in the neck

part

5) Tuck all these together under the bottom of

mattress.Miterthecorner.

6)Tucktheremainderinalongtheside

 Ablanketprovideswarmth.

 Making the cuff at the neck part prevents

irritationfromblanketedge.

 Tuckingall these pieces together saves timeand

providesa neatappearance.

11.Repeatthesameas intheaboveprocedure10in

leftside.

 Tosavetimein thismanner

12.Returntothe rightside.

Pillowand pillowcover:

1)Puta cleanpillowcoveronthe pillow.

2)Place a pillow atthe top ofthe bedin the center

withtheopenend awayfromthedoor.

 Apillowisa comfortablemeasure.

 Pillow cover keepscleanliness of the pillowand

neat.

 Theopenendmay collectdustor organisms.

 The open end away from the door also makes

neat.

13.Returnthebed,thechairand bed-sidetableto

theirproperplace.

Bedside necessities willbe within easy reach for

theclient.

14. Replace all equipments in proper place.

Discardlinesappropriately.

Itmakeswell-settingforthe next.

Proper line disposal prevents the spread of

infection.

15.Performhandhygiene

Topreventthespreadofinfection.

NursingAlert

 Donotlet youruniformtouchthe bedandthe floornot tocontaminateyourself.

 Neverthrowsoiledlineson thefloornotto contaminatethefloor.

 Staying oneside of thebed untilone step completelymade saves stepsand timeto do effectivelyand

savethetime.

Fundamental of Nursing Procedure Manual

Bed making

b. Changingan Occupied Bed

Definition

Theprocedurethatusedlinesare changedto ahospitalizedpatientisan occupiedbed.

Fig.8Occupiedbed

Purpose:

1. To providecleanandcomfortablebed forthepatient

2. T reducetheriskof infectionbymaintaininga cleanenvironment

3. To preventbedsoresby ensuringthereareno wrinklesto causepressurepoints

Equipmentrequired:

1. Bed sheets(2): Bottomsheet(or bedcover)(1)

Topsheet (1)

2. Draw sheet (1)

3. Mackintosh (1)(ifcontaminatedor neededto change)

4. Blanket (1)( if contaminatedor neededto change)

5. Pillowcover (1)

6. Savlonwateror Dettolwaterin bucket

7. Spongecloth(2):to wipewithsolution(1)

todry (1)

✽Whenthe procedureisdone bytwonurses,spongeclothisneededtwoeach.

8. Kidneytrayor paperbag(1)

9. Laundrybagor bucket(1)

10. Trolley (1)

Fundamental of Nursing Procedure Manual

Procedure:

byone nurse

CareAction Rationale

1.Checktheclient’sidentificationandcondition.

 Toassessnecessityandsufficientcondition

2.Explainthepurposeandprocedureto theclient

Providinginformationfosterscooperation

3.Performhandhygiene

Topreventthespreadofinfection.

4. Prepare all required equipments andbring the

articlesto thebedside.

Organizationfacilitatesaccurateskillperformance

5.Closethecurtainordoor totheroom.Put screen.

Tomaintainthe client’sprivacy.

6. Remove the client’s personal belongings from

bed-sideand puttheninto thebed-side lockeror

safeplace.

Topreventpersonalbelongingsfrom damageand

loss.

7.Liftthe client’sheadandmovepillowfromcenter

totheleft side.

Thepillowiscomfortablemeasurefortheclient.

8. Assistthe clientto turn towardleft side of the

bed.Adjustthepillow.Leavestopsheetin place.

Movingthe client as closeto theother sideof the

bedas possiblegivesyou moreroom to makethe

bed.

Topsheetkeepstheclientwarmand protecthis or

herprivacy.

9.Standin rightside:

Loosebottom bedlinens. Fanfold (or roll)soiled

linens fromthe side of thebed and wedgethem

closetotheclient.

Placing folded(or rolled)soiled linenclose to the

client allows morespaceto placetheclean bottom

sheets.

10. Wipethe surface of mattress by sponge cloth

withwetanddry.

Topreventthespreadofinfection.

11.Bottomsheet,mackintoshand drawsheet:

1) Placethe cleanbottomsheet evenly on the bed

folded lengthwisewiththe centerfoldas closeto

theclient’sbackas possible.

2)Adjustandtuck thesheettightlyunder thehead

of the mattress, making mitered the upper

corner.

3)Tightenthe sheetundertheend of themattress

andmakemiteredthelowercorner.

4)Tuckin alongside.

5)Placethe mackintoshand thedrawsheeton the

bottomsheetand tuckinthemtogether.

Soiled linens can easily be removed and clean

linens arepositionedto makethe othersideof the

bed.

12. Assist the client to roll overthe folded(rolled)

linento rightsideof thebed. Readjustthe pillow

andtopsheet.

Movingtheclienttothe bed’sothersideallowsyou

tomakethe bedonthatside.

13.Moveto leftside:

Discard the soiled linens appropriately. Hold

themawayfrom youruniform.Placethem inthe

laundrybag (orbucket).

Soiled linens can contaminate your uniform,

whichmaycomeintocontactwithotherclients.

14.Wipethesurfaceofthe mattressby spongecloth

withwetanddry.

Topreventthespreadofinfection.

15.Bottomsheet,mackintoshanddrawsheet:

1)Graspcleanlinensandgentlypullthemoutfrom

undertheclient.

2)Spreadthemoverthebed’sunmadeside.Pullthe

linenstaut

Wrinkledlinenscancauseskinirritation.

Fundamental of Nursing Procedure Manual

CareAction Rationale

3) Tuck thebottomsheet tightlyunder thehead of

themattressand miterthecorner.

4)Tightenthe sheetunderthe endof the mattress

andmakemiteredthelowercorner.

5)Tuckin alongside.

6) Tuck themackintosh and thedraw sheetunder

themattress.

16.Assist the client backto the centerof the bed.

Adjustthe pillow.

Thepillowiscomfortmeasurefortheclient.

17.Returntorightside:

Cleantopsheet,blanket:

1)Placethecleantop sheetatthetop sideofthe

soiledtop sheet.

2)Askthe clientto holdtheupperedgeof theclean

topsheet.

3)Hold boththetop of thesoiledsheetandthe end

ofthe cleansheetwith righthandand withdraw

to downward. Removethe soiled top sheet and

putitinto alaundrybag(ora bucket).

4) Place the blanket over the top sheet.Fold top

sheetbackovertheblanketovertheclient.

5)Tuckthelowerends securelyunderthemattress.

Mitercorners.

6)Afterfinishingtherightside,repeattheleftside.

 Tucking these pieces together saves time and

providesneat,tightcorners.

18.Removethepillowandreplacethepillowcover

withclean one and reposition the pillowto the

bedundertheclient’s head.

 Thepillowisa comfortablemeasuresfora client

19. Replace personal belongings back.Return the

bed-sidelockerandthebed asusual.

 To prevent personal belongings from loss and

providesafesurroundings

20.Returnallequipmentsto properplace.

 Topreparefor thenextprocedure

21. Discard linens appropriately. Perform hand

hygiene.

Topreventthespreadofinfection.

Fundamental of Nursing Procedure Manual

Bed making

c. Making aPost-operativeBed

Definition:

Itis aspecialbedpreparedtoreceiveandtakecareof apatientreturningfromsurgery.

Fig.9Post-operativebed

Purpose:

1.Toreceivethepost-operativeclientfromsurgeryandtransferhim/herfroma stretcherto abed

2.Toarrangeclient’sconvenienceandsafety

Equipmentrequired:

1. Bed sheets:Bottomsheet(1)

Topsheet(1)

2. Draw sheet (1-2)

3. Mackintoshorrubbersheet(1-2)

✽According to the type of operation, the

number required of mackintoshand draw

sheetisdifferent.

4. Blanket(1)

5. Hot waterbagwithhotwater(104-140 ℉)

ifneeded(1)

6. Tray1(1)

7. Thermometer, stethoscope,

sphygmomanometer:1 each

8. Spiritswab

9. Arteryforceps(1)

10.Gauzepieces

11. Adhesive tape(1)

12. Kidneytray(1)

13. Trolley(1)

14. IV stand

15. Client’schart

16. Client’skardex

17. Accordingtodoctor’sorders:

-Oxygencylinderwith flowmeter

-O

cannulaor simplemask

-Suctionmachinewith suctiontube

-Airway

-Tonguedepressor

-SpO

monitor

-ECG

-Infusionpump,syringepump

Fundamental of Nursing Procedure Manual

Procedure:

byonenurse

CareAction Rationale

1.Performhandhygiene

 Topreventthe spreadof infection

2.Assembleequipmentsandbringbed-side

 Organization facilitates accurate skill

performance

3.Stripbed.

Makefoundationbedas usualwithalarge

mackintosh,andcottondrawsheet.

 Mackintoshpreventsbottom sheetfrom wetting

orsoiledbysweat,drainor excrement.

 Place mackintosh according to operative

technique.

 Cotton draw sheet makes the client felt dry or

comfortable without touching the mackintosh

directly.

4. Placetop bedding as for closedbed but do not

tuckatfoot

 Tuckat foot mayhamper theclient to enterthe

bedfroma stretcher

5.Foldbacktop beddingat thefootof bed.(Fig.10)

 Tomaketheclient‘stransfersmooth

6.Tuckthetop beddingon onesideonly.(Fig.11)

 Tuckingthe topbeddingonone sidestopsthebed

linensfrom slippingoutof placeand

7. On theotherside,do nottuckthetop sheet.

1)Bring headand footcorners ofit at thecenterof

bedandformrightangles.(Fig.12)

2)Fold backsuspendingportion in1/3 (Fig.13)and

repeat folding top bedding twiceto opposite side

ofbed(Fig.14,15)

 The open side of bed is more convenient for

receivingclientthantheotherclosedside.

8.Removethepillow.

 Tomaintainthe airway

9Placea kidney-trayonbed-side.

 Toreceivesecretion

10.PlaceIVstandnearthe bed.

 Toprepareit tohang I/Vsoon

11.Checklockedwheelof thebed.

 Topreventmovingthebed accidentallywhenthe

clientis shiftedfrom astretcherto thebed.

12.Place hot water bags(or hot bottles) in the

middle of thebed andcover withfanfolded topif

needed

 Hotwater bags(or hotbottles)prevent theclient

fromtakinghypothermia

13.Whenthe patient comes, removehot waterbags

ifputbefore

 Toprepareenoughspaceforreceivingtheclient

14.Transfertheclient:

1)Helpliftingtheclientintothebed

2) Cover the client by the top sheet and blanket

immediately

3)Tucktopbeddingandmitera cornerinthe endof

thebed.

 Topreventtheclientfrom chilling and/or having

hypothermia

Fundamental of Nursing Procedure Manual

Fig.10Foldingbacktopbeddingatthefoot

Fig.11Tuckingthe topbeddingonleftside

Fig.12Bringingbothheadandfootcornerstothe

centerandformingrightangles

Fig.13Folding1/3sideof topbeddingat rightside

Fig.14Rollingtopbeddingagain

Fig.15Foldingitagainandcompletetopbedding

Fundamental of Nursing Procedure Manual

PerformingOral Care

Definition:

Mouthcareisdefinedasthe scientificcareofthe teethand mouth.

Purpose:

1. Tokeepthe mucosaclean,soft,moistandintact

2. Tokeepthe lipsclean,soft,moistandintact

3. Topreventoralinfections

4. Toremovefooddebrisaswell asdentalplaquewithoutdamagingthe gum

5. Toalleviatepain,discomfortandenhanceoral intakewithappetite

6. Topreventhalitosisor relieveit andfreshenthemouth

Equipmentrequired:

1. Tray(1)

2. Gauze-paddedtonguedepressor(1):to suppresstongue

3. Torch(1)

4. Appropriateequipmentsfor cleaning:

-Toothbrush

-Foamswabs

-Gauze-paddedtonguedepressor

-Cottonballwitharteryforceps(1)anddissectingforceps(1)

5. Oral careagents:

Toothpaste/antisepticsolution

❖NURSINGALERT❖

Youshouldconsidernursingassessment,hospitalpolicyand doctor’sprescriptionifthereis,

whenyouselectoralcareagent.RefertoTable1.on thenextpage

6. Ifyouneedto prepareantisepticsolutionasoralcareagent:

Gallipot(2):to makeantisepticsolution(1)

tosetup cottonballaftersqueezed(1)

7. Cottonball

8. Kidneytray(1)

9. Mackintosh(1):smallsize

10.Middletowel(1)

11.Jugwithtapwater(1)

12.Paperbag(2):for cottonballs(1)

fordirt(1)

13.Gauzepiecesasrequired:to applyalubricant

14.Lubricants:Vaseline/Glycerin/softwhiteparaffingel/ lipcream (1)

15.Suctioncatheterwithsuctionapparatus(1):ifavailable

16.Disposablegloves(1pair):if available

Fundamental of Nursing Procedure Manual

NOTE:

Table1. Variousoralcareagentsfororalhygiene

Thechoiceof anoral careagentisdependentonthe aimof care.Thevariousagentsareavailableandshould

bedeterminedby theindividualneedsoftheclient.

Agents Potentialbenefits Potentialharms

Tapwater

 Torefresh

 beavailable

 Shortlasting

 notcontainabactericide

Toothpaste

 Notspecified

 Toremovedebris

 Torefresh

 It can dry the oral cavity if not

adequatelyrinsed*1

Nystatin

 Totreatfungalinfections  Tastesunpleasant

Chlorhexidinegluconate:

a compound with

broad-spectrum

anti-microbialactivity*2

 To suppress the growing of bacteria in

dosesof0.01-0.2% solution*2

 not be significant

to prevent

chemotherapy-inducedmucositis*2

 Tastesunpleasant

 bestainableteethwithprolongeduse

Sodiumbicarbonate:

 Todissolveviscousmucous*3  Tastesunpleasant

 may bring burn if not diluted

adequately

 canalteroralpH allowingbacteriato

multiply*1

Fluconazole:

an orally absorbed

antifungalazole,solublein

water

 for the treatment of candidosis of the

oropharynx, oesophagus and variety of

deeptissuesites*3

 notreported

Sucralfate:

amouth-coatingagent

Initially for the clients under radiotherapy

andchemotherapy

 Toreducepainofmucositis

 notreported

Fluoride

 Topreventandarresttoothdecay

 especially radiation caries,

demineralizationanddecalcification

 Toshowtoxicityinhighdensity

Glycerineanthymol

 Torefresh  Refreshing lastsonly 20-30 seconds

 Can over-stimulate the salivary

glandsleading to reflex action and

exhaustion*1

Another solutions fororal care suchas Potasiumpermanganate(1:5000),Sodiumchloride(Iteaspoonto a pint of

water),Potasiumchroride(4to 6 %),Hydrogenperpxide(1:8 solution)are used commonly*4.

References:

1. PenelopeAnnHilton(2004)fundamentalnursingskills, I.K.InternationalPvt.Ltd.,p.63

2. http://www.herhis.nhs.uk/RMCNP/content/mars32.htm TheRoyalMarsdenHospitalManualof

ClinicalNursingprocedure,6

edition,Personalhygiene:mouthcare

3. http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=7153&nbr=4285

Nursingmanagementof oralhygiene,NationalGuidelineClearinghouse

4.I Clement(2007)BasicConceptsonNursingProcedures,Jaypee,p. 68

Fundamental of Nursing Procedure Manual

a.Assistingthe client withOral care

Procedure:

CareAction Rationale

1.Explaintheprocedures

 Providing information fosters cooperation,

understandingandparticipationincare

2.Collectallinstrumentsrequired

 Organization facilitates accurate skill

performance

3.Closedoorand/or putscreen

 Tomaintainprivacy

4. Perform hand hygiene and wear disposable

glovesif possible

 Topreventthe spreadof infection

5.If youusesolutionssuch assodiumbicarbonate,

preparesolutionsrequired.

 Solutionsmustbe preparedeachtimebeforeuse

tomaximizetheir efficacy

6.Assisttheclientacomfortableuprightpositionor

sittingposition

 To promote his/her comfort and safety and

effectiveness ofthe care includingoral inspection

andassessment

7.Inspectoralcavity

1) Inspect whole the oral cavity ,such as teeth,

gums, mucosa and ton gue, wi th the aid of

gauze-pad ded tongue depre ssor and torch

2) Take notesif you find any abnormalities, e.g.,

bleeding,swollen,ulcers,sores,etc.

 Comprehensive assessment is essential to

determineindividualneeds

 Some clients with anemia, immunosuppression,

diabetes, renalimpairment epilepsyand taking

steroidsshouldbepaidattentiontooralcondition.

Theymayhavecomplicationinoral cavity.

8. Placeface towel overthe clientchest or on the

thighwithmackintosh(Fig.16)

 Topreventthe clothingform wettingand not to

giveuncomfortablecondition

9. Put kidney tray in hand or assist the client

holdinga kidneytray

 Toreceivedisposalsurely

Fig16 Settingthe kidneytrayup withfacetowelcoveredmackintosh

Fundamental of Nursing Procedure Manual

CareAction Rationale

10.Instructthe clientto brushteeth

Pointsof instruction

1)Clientplacesa softtoothbrushata 45 °angleto

theteeth.

2) Client brushes in direction of the tips of the

bristles under the gum line with tooth paste.

Rotate the bristles using vibrating or jiggling

motion until all outer and innersurfacesof the

teethandgumsareclean.

3)Clientbrushes bitingsurfacesoftheteeth

4)Clientcleantonguefrominnertoouterand avoid

posteriordirection.

 Effective in dislodgingdebris and dentalplaque

fromteethandgingivalmargin

 Cleansing posterior directionof the tongue may

causethegagreflex

11. If the client cannot tolerate toothbrush (or

cannot be availabletoothbrush), form swabsor

cottonballscan beused

 Whenthe clientis proneto bleedingand/orpain,

toothbrushisnotadvisable

12.Rinseoralcavity

1)Ask theclientto rinsewithfresh waterandvoid

contentsintothekidneytray.

2) Advise him/her notto swallowwater.If needed,

suctionequipment isusedto removeany excess.

 Tomakecomfortand notto remain anyfluidand

debris

 Toreducepotentialforinfectionand

13. Asktheclienttowipemouthand aroundit.

 Tomakecomfortandprovidethe well-appearance

14.Confirmtheconditionof client’steeth,gumsand

tongue.Applylubricantto lips.

 Tomoisturizelipsandreduceriskforcracking

15. Rinse and dry toothbrush thoroughly. Return

the proper place for personal belongings after

dryingup.

 Topreventthe growthof microorganisms

16.Replaceallinstruments

 Toprepareequipmentsfor thenextprocedure

17. Discarddirtproperlyandsafety

 Tomaintainstandardprecautions

18.Removegloves andwashyourhands

 Topreventthe spreadof infection

19.Documentthe careandsignon therecords.

 Documentationprovides ongoingdata collection

andcoordinationofcare

 Giving signature maintains professional

accountability

20.Reportanyfindingsto seniorstaffs

 Toprovidecontinuityof care

Fundamental of Nursing Procedure Manual

b. Providingoral care fordependentclient

Fig.17 Equipmentsrequiredfororalcarein dependingclient

Procedure:

Theprocedurewithcottonballssoakedsodiumbicarbonateis showedhere.

CareAction Rationale

1.Checkclient’sidentificationandcondition

 Providingnursingcare forthe correct clientwith

appropriateway.

2.Explainthepurposeandprocedureto theclient

 Providing information fosters cooperation and

understanding

3.Performhandhygieneandweardisposablegloves

 Topreventthe spreadof infection.

4.Prepareequipments:

1) Collectall required equipments and bring the

articlesto thebedside.

2)Preparesodium bicarbonatesolutionsingallipot.

❖NursingAlert❖

Iftheclientis unconscious,use plaintapwater.

3) Soak the cotton ball in sodium bicarbonates

solution(3pinches / 2/3water in gallipot) with

arteryforceps.

4)Squeezeall cotton ballsexcesssolutionby artery

forceps and dissecting forceps and put into

anothergallipot

 Organization facilitates accurate skill

performance

 Solutionsmust be preparedeach timebeforeuse

tomaximizetheir efficacy

 Toreducepotentialinfection

 Cleaning solutions aids in removingresidue on

theclient’steethandsofteningencrustedareas.

 Toavoidinspirationofthesolution

5.Closethecurtainordoor totheroom.Put screen.

 Itmaintainsthe client’sprivacy

6. Keepthe clientin a sidelying or in comfortable

position.

 Properpositioningpreventsbackstrain

 Tilting the head downwardencouragesfluid to

drain out of the client’s mort and it prevents

aspiration.

Fundamental of Nursing Procedure Manual

CareAction Rationale

7. Placethe mackintosh andtowel on the neckto

chest.

 Thetowel andmackintosh protect theclient and

bedfromsoakage.

8. Put the kidney tray over the towel and

mackintoshunderthechin.(Fig.18)

 Itfacilitatesdrainagefrom theclient’smouth.

9.Inspectoralcavity:

1) Inspect whole the oral cavity, such as teeth,

gums, mucosa and tongue, with the aid of

gauze-paddedtonguedepressorand torch.

2) Take notesif you find any abnormalities, e.g.,

bleeding,swollen,ulcers,etc.

 Comprehensive assessment is essential to

determineindividualneeds.

 Some clients with anemia, immunosuppression,

diabetes, renal impairment, epilepsy and taking

steroidsshouldbepaid attentiontooral condition.

Theymayhavecomplicationinoral cavity.

10.Cleanoralsurfaces:(Fig.19)

1) Askthe clientto openthe mouthand insert the

padded tong depressor gently from the angleof

mouthtowardthe backmolararea.Youneveruse

yourfingersto opentheclient’smouth.

 Thetong depressorassistsin keepingthe client’s

mouthopen. As a reflexmechanism, the client

maybiteyourfingers.

2) Cleanthe client’s teeth fromincisorsto molars

using up and down movements from gums to

crown.

 Frictioncleansestheteeth.

3)Cleanoralcavityfromproximal todistal,outer

toinnerparts,usingcottonballforeachstroke.

 Frictioncleansestheteeth.

11.Discardusedcottonballintosmallkidneytray.

 Topreventthe spreadof infection.

12.Cleantonguefrominnertoouteraspect.

 Microorganisms collect and grow on tongue

surfaceand contributetobadbreath.

Fig.18Placinga kidneytrayonthemackintosh

covereda facetowel

Fig.19Cleansingteethwithsupportingpadded

tonguedepressor

Fundamental of Nursing Procedure Manual

CareAction Rationale

13.Rinseoralcavity:

1) Provide tapwater to gargle mouthand position

kidneytray.

2)If theclientcannotgargleby him/herself,

a) r

inse the areas using moistened cottonballs

b) insertof rubber tip of irrigating syringe into

theclient’smouthand rinse gentlywitha small

amountof water.

3)Assistto voidthecontentsintokidneytray. Ifthe

client cannot spit up, especially i

n the case of

unconsciousclient,suctionanysolution.

 Toremovedebrisand makerefresh

 Rinsing or suctioning removes cleaningsolution

anddebris.

 Solution that is forcefully irrigated may cause

aspiration

 Toavoidaspirationofthe solution

14. Confirm the conditionof client’s teeth, gums,

mucosaand tongue.

 Toassess theefficacyof oral careand determine

anyabnormalities

15.Wipe mouthand aroundit. Apply lubricantto

lips by using foam swab or gauze piece with

arteryforceps

 Lubricantpreventslipsfrom dryingand cracking.

16.Repositiontheclientin comfortableposition.

 Toprovidesfor theclient’scomfortandsafety.

17.Replaceallequipmentsinproperplace.

 Toprepareequipmentsfor thenextcare

18.Discarddirtproperlyandsafety

 Tomaintainstandard precautions

19.Removegloves andperformhandhygiene

 Topreventthe spreadof infection

20.Documentthe careandsignon therecords.

 Documentation provides ongoing data collection

andcoordinationofcare.

 Giving signature maintains professional

accountability

21.Reportanyfindingsto theseniorstaff.

 Toprovidecontinuityof care

❖NursingAlert❖

Oralcareforthe unconsciousclients

1. Specialprecautionswhiletheprocedure

 Theclientshouldbe positionedinthe lateralpositionwiththeheadturnedtowardtheside.

(Rationale:It cannotonly providefordrainagebutalsopreventaccidentalaspiration.)

 Suctionapparatusis required.( Rationale:Itprevents aspiration.)

 To use plain water for cleaning of oral cavity of unconscious clients may be

advisable.(Rationale: Potentialinfectionmay be reduced by usingplain water when

thesolutionflowsintothe respiratorytractbyaccident.)

2. Frequencyofcare

Oralcareshouldbe performedat leasteveryfour hours.( Rationale:Four hourlycarewillreducethe

potential for infection from microorganisms. by

http://www.heris.nhs.uk/RMCNP/contant/mars32.htm The Royal Marsden Hospital Manual of

ClinicalNursingProcedures6

edition.)

Fundamental of Nursing Procedure Manual

PerformingBed Bath

Definition:

Abathgivento clientwho isin thebed(unabletobathitself)

Purpose:

1. To preventbacteriaspreadingonskin

2. To cleantheclient’sbody

3. To stimulatethecirculation

4. To improvegeneralmusculartoneand joint

5. To makeclientcomfortandhelpto inducesleep

6. To observeskincondition andobjectivesymptoms

Equipmentsrequired:

1. Basin(2): forwithoutsoap(1)

forwithsoap(1)

2. Bucket(2):for cleanhotwater(1)

forwaste(1)

3. Jug (1)

4. Soap withsoapdish(1)

5. Spongecloth(2):for washwithsoap(1)

forrinse(1)

6. Face towel(1)

7. Bath towel(2): Ⓐ forcoveringover mackintosh(1)

Ⓑ forcoveringoverclient’sbody(1)

8. Gauzepiece(2-3)

9. Mackintosh(1)

10. Trolley(1)

11.Thermometer(1)

12.Oldnewspaper

13.Paperbag(2):for cleangauze(1)

forwaste(1)

Fundamental of Nursing Procedure Manual

Procedure:

completebed bath

CareAction Rationale

1.ConfirmDr.’sorder.

Checkclientidentificationandcondition.

Thebathordermay havechanged.

Insomeinstancesabed bathmaybeharmfulfora

client,who isinpain,hemorrhaging,orweak.Ns

needtodeferthe bath.

2.Explainthepurposeandprocedureto theclient.

Ifhe orshe isalertor oriented,questionthe client

aboutpersonalhygienepreferencesand abilityto

assistwith thebath.

Providinginformationfosterscooperation.

 Encourage the client to assist with care and to

promoteindependence.

3.Gatherallrequiredequipments. Organizationfacilitatesaccurateskillperformance

4.Washyourhandsandput ongloves. Topreventthespreadoforganisms.Glovesare

optionalbut youmustwear themif youaregiving

perinealandanalcare.

5.Bringall equipmentstobed-side.  Organization facilitates accurate skill

performance

6.Closethecurtainorthe door. Toensurethattheroomis warm.

Tomaintainthe client’sprivacy.

7.Putthescreenorcurtain. Toprotecttheclient’sprivacy.

8.Preparehotwater(60℃).

Waterwillcoolduringtheprocedure.

9.Removethe client’scloth.Covertheclient’s body

withatop sheetorblanket.

If an IV is present on the client’s upper

extremity,threadthe IVtubingandbag through

the sleeve of the soiled cloth. Rehang the IV

solution.ChecktheIV flowrate.

Removingthe clothpermitseasieraccesswhen

washingthe client’supperbody.

Besurethat IVdeliveryisuninterruptedand

thatyoumaintainthesterilityof thesetup.

10.Filltwo basinsabouttwo-thirdsfullwith warm

water(43-46℃or 110-115F).

Wateratpropertemperaturerelaxeshim/herand

provideswarmth.Waterwillcool duringthe

procedure.

11.Assistthe client tomove toward theside ofthe

bedwhereyou willbe working.Usuallyyou will

domostworkwith yourdominanthand.

Keeptheclientnearyouto limitreachingacross

thebed.

12.Face,neck,ears:

1) Put mackintosh and big towel Ⓐunder the

client’s bodyfrom the head to shoulders. Place

facetowel underthe chinwhich isalso covered

thetopsheet.

2)Make amitt withthespongetoweland moisten

withplainwater.

3) Wash the client’s eyes. Cleanse frominner to

outercorner.Usea differentsectionofthemittto

washeacheye.

4)Washtheclient’sface,neck,and ears.

Usesoapon theseareasonlyifthe clientprefers.

Rinseanddrycarefully.

Topreventthebottomsheetfrommakingwet.

Soapirritatesthe eyes.

Washingfrominnerto outercornerprevents

sweepingdebrisintotheclient’seyes.Usinga

separateportionofthemitt foreacheyeprevents

thespreadofinfection.

Soapisparticularlydryingtothe face.

Fundamental of Nursing Procedure Manual

CareAction Rationale

13.Upperextremities:

1)Move themackintosh andbig towel○

tounder

theclient’sfar arm.

2)Uncoverthefararm.

3)Foldthe spongeclothand moisten.

4)Wash thefar armwith soapand rinse. Uselong

strokes: wrist to elbow→ elbow to shoulder→

axilla→ hand

5)Dryby facetowel

6)Move themackintosh andbig towel○

tounder

theneararmand uncoverit

7) Wash,rise, and dry the near arm as same as

procedure4).

 Topreventsheetfrommakingwet

 Washingthe farside firstprevents drippingbath

waterontoacleanarea.

 Longstrokesimprove circulation be facilitating

venousreturn

14.Chestandabdomen:

1) Move the mackintosh and bath towel ○

undertheuppertrunk

2)Putanotherbathtowel ○

tooverthe chest

3)Foldthe spongetoweland moisten

4)Washbreastswithsoapandrinse.Dry bythe big

towelcovering.

5) Move the bath towel ○

covering the chest to

abdomen.

6)Foldthe spongeclothand moisten.

7)Washabdomenwithsoap,rinseanddry

8) Cover the trunkwithtop sheet andremovethe

bathtowel ○

fromtheabdomen.

 Mackintosh and bath towel ○

prevent sheet

fromwetting

 Bathtowel ○

provideswarmthandprivacy

15.Exchangethe warmwater.  Cool bathwater is uncomfortable. The water is

probablyunclean.Youmay changewaterearlierif

necessarytomaintainthepropertemperature.

16.Lowerextremities:

1) Move the mackintosh and bath towel ○

underthefarleg. Putpilloworcushionunderthe

bending knee. Cover the near legg with bath

towel○

2)Foldthe spongeclothand moisten.

3)Washwithsoap,rinseanddry.

Directionto wash:fromfoot jointto knee→from

kneetohip joint

4)Repeatthesameprocedureas16.1)-3)on the

nearside.

5)Coverthelowerextremitieswithtop sheet

Removethe cushion,mackintoshandbig towel

○

 Pillow or cushioncan supportthe lowerleg and

makestheclientcomfort.

17.Turnthe clienton leftlateralposition withback

towardsyou.

 Toprovide clear visualizationand easiercontact

tobackand buttockscare

Fundamental of Nursing Procedure Manual

CareAction Action

18.Backand buttocks:

1) Move the mackintosh and big towel ○

under

thetrunk.

2)Covertheback withbigtowel ○

3)Foldthe towelandmoisten.Uncovertheback.

4)Washwithsoapand rinse.Dry withbigtowel ○

5)Backrub ifneeded

✽ Seeour nursingmanual“BackCare”

6)Removethemackintoshand bigtowel ○

 Skin breakdown usually occurs over bony

prominences. Carefully observe the sacral area

andbackforany indications.

19.Returntheclienttothe supineposition.  Tomakesustainablepositionfor perinealcare

20.Perinealcare:

✽Seeournursingmanual“Perinealcare”

 Cleantheperinealareato preventskin irritation

and breakdown and to decrease the potential

odor.

21.Assisttheclienttowearcleancloth.  To provideforwarmthandcomfort

22.Afterbedbath:

1) Make the bed tidy and keep the client in

comfortableposition.

2)ChecktheIV flowandmaintainitwiththe speed

prescribediftheclientis givenIV.

 Thesemeasuresprovideforcomfortandsafety

 ToconfirmIV systemisgoingproperlyand safely

23.Document onthe chart withyoursignatureand

reportany findingsto seniorstaff.

 Documentationprovidescoordinationof care

 Giving signature maintains professional

accountability

Fundamental of Nursing Procedure Manual

PerformingBack Care

Definition:

Backcare meanscleaningand massaging back,paying special attention to pressurepoints. Especially

backmassage providescomfortandrelaxestheclient,therebyitfacilitatesthe physicalstimulationto the

skinandtheemotionalrelaxation.

Purpose:

1.Toimprovecirculationtothe back

2.Torefreshthemodeand feeling

3.Torelievefromfatigue,pain andstress

4.Toinducesleep

Equipmentsrequired:

1. Basinwith warmwater(2)

2. Bucketfor wastewater(1)

3. Gauzepieces(2)

4. Soap withsoapdish(1)

5. Face towel(1)

6. Spongecloth(2):1 forwithsoap

1for rinse

7. Big Towel(2):1 forcoveringamackintosh

1for coveringthebody

8. Mackintosh(1)

9. Oil/ Lotion/Powder(1):accordingto skinconditionandfavor

10.Tray(1)

11.Trolley(1)

12.Screen(1)

Fundamental of Nursing Procedure Manual

Procedure:

CareAction Rationale

1.Performhandhygiene  Topreventspreadof infection

2.Assembleall equipmentsrequired.  Organization facilitates accurate skill

performance

3.Checktheclient'sidentificationandcondition.  Toassesssufficientconditiononthe client

4.Explaintothe clientaboutthe purposeand the

procedure.

 Providinginformationfosterscooperation

5.Putallrequiredequipmentsto thebed-sideand

setup.

 Appropriate setting can make the time of the

procedureminimumand effective.

6.Closeall windowsanddoors,andput thescreen

or/ andutilizethecurtainifthereis.

 To ensurethatthe roomiswarm.

 To maintaintheprivacy.

7.Placingtheappropriateposition:

1)Movethe clientneartowardsyou.

2)Turntheclientto her/hissideandput the

mackintosh covered by big towel under the

client'sbody.

 To makehim/her morecomfortable and provide

thecareeasily.

 Mackintoshcanavoidthesheetfromwetting.

8.Exposetheclient'sbackfullyandobserveit

whetherif thereareany abnormalities.

 To find any abnormalities soon is important to

that you prevent more complication and/ or

provide proper medication and/or as soon as

possible.

 If you find out someredness,heat or sores,you

cannotgive anymassageto thatplace.

 If the clienthas already someredsore orbroken-

downarea,you need toreportto the seniorstaff

and/ordoctor.

9.Lathersoapby spongetowel.Wipewith soapand

rinsewithplainwarmwater.

 To make cleanthe backbeforewe give massage

withoil/lotion/powder.

10.Put somelotionor oilintoyour palm.Applythe

oil or the lotion and massage at least 3-5

minutesby placingthe palms:

1)fromsacralregiontoneck

2)from upper shoulder to the lowest parts of

buttocks

 Don’t applyoilor lotiondirectlytothe backskin.

Too much apply may bring irritation and

discomfort

11.Helpfortheclientto putonthe clothesand

returnthe clientto comfortableposition.

 To provideforwarmthand comfort

12.Replaceallequipmentsinproperplace.  Toprepareforthe nextprocedure

13.Performhandhygiene.  Topreventthe spreadof infection

14. Document on the chart with your signature,

including date, time and the skin condition.

Reportany findingsto seniorstaff.

 Documentationprovidescoordinationof care

 Giving signature maintains professional

accountability

Fundamental of Nursing Procedure Manual

Performing HairWashing

Definition:

Hairwashing definesthat isoneof generalcareprovided toa clientwhocannotcleanthehair byhimself/

herself.

Purpose:

1. To maintainpersonalhygieneofthe client

2. To increasecirculationtothe scalpandhairandpromotegrowingof hair

3. To makehim/herfeelrefreshed

Equipmentsrequired:

1. Mackintosh(2):topreventwet(1)

tomakeKellypad(1)

2. Big towel(2):to covermackintosh(1)

toroundtheneck(1)

3. Middletowel(1)

4. Shampooor soap(1)

5. Hair oil(1):if necessary

6. Brush,comb: (1)

7. Paperbag (2):forclean(1)

fordirty(1)

8. Cottonbollwithoil ornon-refinedcotton

9. Bucket(2):for hotwater (1)

forwastedwater(1)

10. Plasticjug(1)

11. Clothpinorclips(2)

12. Steel Tray(1)

13. Kidneytray(1)

14. Cushionor pillow(1)

15. Cleanclothif necessary

16. Oldnewspaper

17. Trolley(1)

Fundamental of Nursing Procedure Manual

Procedure:

CareAction Rationale

1.Performhandhygiene  Topreventsthe spreadof infection

2.Gatherallequipments  Organizationfacilitatesaccurateskillperformance

3.Check the condition of client. Explain the

purposeand theprocedureto theclient.

 Proper explanationmay allayhis/heranxietyand

fostercooperation

4.Bringandset upallequipmentsto thebed-side  Tosave thetimeandpromoteeffectivecare

5.Help theclientmove his/herhead towardsedge

ofthebed andremovethepillowfromthehead.

 To arrange appropriatepositionwith considering

yourbodymechanics

6.Putanotherpillowora cushionunderthe

bending knee. Make him/her comfortable

position.

 Putting a pillow or a cushion couldprevents from

havingsome painwhilethehairwashingprocess

7.Settingmackintoshandtoweltothe client:

1)Placea mackintoshcovereda bigtowelunder

theupwards fromtheclientheadto the

shouldersofclient

2)Havea bigtowelaroundhis/her neck

3)Rollanothermackintoshtomakethe shapeofa

funnel,by usingthewayto holdfrombothsides

ina slantingway.Thenarrowendshouldbe

foldedand putundertheclient’sneck andthefree

endshouldbeputinto thebuckettodrainfor

thewastewater.

4)Putthe foldingmackintoshunderthe client’s

neck.

 Topreventthe sheetfromsoiling

 Topreventthe clothandthebodyfromsoling

 Toinducewaterdrainage

8.Washing:

1)Brushthehair.

2)Insertthecottonballsintotheears

3) Wet the hair by warm water and wash it

roughly

4) Applysoapor shampooand massagethe scalp

wellwhilewashingthe hairusingfingernails

5) Rinse the hair and reapply shampoo for a

secondwashing,ifindicated

6)Rinsethehair thoroughly

7) Apply conditioner if requested or if the scalp

appearsdry

 Toremovedandruffandfallenhairs,andmake the

haireasierwashing

 Topreventwaterfrom enteringintotheears

9.Wrappingthe hair:

1)Removethecottonballsfromtheears intothe

paperbagandmackintoshwiththe towelfrom

theclient'sneck.

2)Wrapthehairsin thebigtowelwhichare used

tocovertheclient'sneckpart.

Fundamental of Nursing Procedure Manual

CareAction Rationale

10.Dryingthehair:

1)Wipetheface andneckifneeded

2)Drythe hairasquickas possible

3)Massagethescalpwithoilas required

4)Comb thehairand arrangethe hairaccording to

theclient’spreference

5) Make the client tidy and provide comfortable

position

 Topreventhim/herfrombecomingchilled

 Toincreasecirculation of the scalpand promote

senseofwell-being

 Toraiseself-esteem

10. Clean the equipments and replace them to

properplace.Discarddirty.

 Topreparefor thenextprocedure

11.Performhandhygiene Topreventthespreadof infection

12. Documentthe conditionof the scalp,hair and

any abnormalities on the chart with your

signature. Report any abnormalities to senior

staff.

 Documentationprovidescoordinationof care

 Giving signature maintains professional

accountability

Fundamental of Nursing Procedure Manual

Caringfor fingernails andtoenails

Definition:

Nailcuttingthatone of nursingcareand general carefor personal hygiene isto cut nailson handsand

foots.

Purpose:

1.Tokeepnailsclean

2.Tomakeneatness

3.Topreventtheclient’sskin fromscratching

4.Toavoidinfectioncausedby dirtynail

Equipmentsrequired:

1.NailCutter(1)

2.Gallipotwithwater(1):forcotton

3.Kidneytray(1)

4.Spongecloth(1)

5.Middletowel(1)

6.Mackintosh(1)

7.Plasticbowlinsmallsize(1)

8.Soapwithsoap dish(1)

Fig.20Equipmentsrequiredfornailcutting

Fundamental of Nursing Procedure Manual

Procedure:

Caringfor Fingernails

CareAction Rationale

1.Performhandhygiene  Topreventthe spreadof infection

2.Gatherallthe requiredequipments.  Organization facilitates accurate skill

performance

3.Checktheclient’sidentification.  Toassessneeds

4. Explain tothe clientabout thepurposeand the

procedure.

 Providingexplanationfosterscooperation

5. Putall the required equipmentsto the bed-side

andsetup it.

 Tosavethetimean promoteeffectivecare

6.Assisttheclienttoa comfortableuprightposition.  To providefor comfort

7.Insittingposition:

1)Soaking

①Puta mackintoshwith covering towel on the

bed.

②Put the basin with warm water over the

mackintosh.

③Soakthe client’s fingers in a basin of warm

waterandmildsoap.

④Scruband washthemup.

⑤Drythe client’shandsthoroughly by using the

middletowelcoveringthemackintosh.

 Mackintoshcanpreventthesheetfromwetting

 To make nails soft, thereby you can cut nails

easilyand safety

2)Cutting

①Trimthe client’snailswithnailclippers.

②Wipe allfingernailsfromthumbto 5

nailside

by sideby wet cottonball. One cotton ball is

usedforonenail finger.

③Shapethe fingernailswith afile,roundingthe

cornersand wipebothhandsbya spongetowel.

Specialordersare requiredbeforecuttingthe nails

or cuticles of a client with diabetes to avoid

accidentalinjuryto softtissues.

8.Replaceequipmentsanddiscarddirty.  Toprepareequipmentsfor thenextprocedure

9.Performhandhygiene.  Topreventthespreadofinfection

Procedure:

Caringfor Toenails

Followthe sameprocedureas forthefingernailswithsomeexceptions:

CareAction Rationale

2)Cutting

①Cuttoenailsstraight acrossand do not round

offthecorners

②Donotshapecorners

 Cutting into the corners may cause ingrown

nails. If the nails tend to grow inward at the

corners,place a wispof cottonunderthe nailto

preventtoe pressure.

 Anotchcut in thecenter willpull inedges and

corners. Sometimes, very thick, hard toenails

requiresurgicalremoval.

NURSINGALERT

Nevercutthetoenailsofthe clients withdiabetesor hemophilia.Theseclientsare particularlysusceptible

toinjury.

Fundamental of Nursing Procedure Manual

PerformingPerinealCare

Definition:

Perinealcare is bathingthe genitalia andsurroundingarea.Proper assessmentandcare of theperineal

areawillneedprofessionalclinicaljudgment.

Purpose:

1.Tokeepcleanlinessand preventfrominfectionin perinealarea

2.Tomakehim/hercomfortable

Equipmentsrequired:

1.Gloves(non-sterile)(1 pair)

2.Spongecloth(1)

3.Basinwithwarmwater(1)

4.Waterproofpador gauze

5.Towels(1)

6.Mackintosh(1)

7.Soapwithsoap dish(1)

8.Toiletpaper

9.Bedpan (1):asrequired

Procedure:

Forgeneralcase (withouturinarycatheter)

CareAction Rationale

1.Gatherallrequiredequipments.  Organization facilitates accurate skill

performance

2.Explaintheprocedureto theclient.  Providinginformationfosterscooperation.

3. Perform hand hygiene and wear on gloves if

available.

 Topreventthe spreadof infection

4.Closethedoor totheroomand placethescreen.  Toprotecttheclient'sprivacy.

5.Raisethe bedtoa comfortableheightifpossible.  Properpositioningpreventsbackstrain.

6.Preparationtheposition:

1)Uncovertheclient'sperinealarea.

2)Placea mackintoshandtowel( orwaterproof

pad)undertheclient'ships.

 A towel or padprotectsthe bed.You canuse the

toweltodrythe client'sperinealand rectalarea.

7.Cleansethethighsandgroin:

1)Makea mittwiththespongecloth.

2)Cleansetheclient'supperthighsandgroinarea

withsoapandwater.

3)Rinseanddry.

4)Washthegenitalareanext.

Fundamental of Nursing Procedure Manual

CareAction Rationale

Femaleclient:(Fig.21)

①Useaseparateportionof thespongetowelfor

eachstroke

②Changespongetowelasnecessary.

③Separatethelabiaandcleansedownwardfrom

thepubictoanalarea.

④Washbetweenthelabiaincludingtheurethral

meatusand vaginalarea.

⑤Rinsewelland patdry.

 Cleanse fromthe pubistowardthe anusto wash

from a clean to a dirty area. Prevent

contaminating the vaginal area and urinary

meatuswith organismsfromtheanus.

MaleClient:(Fig.22)

①Gentlygrasptheclient’spenis.

②Cleansein acircularmotionmovingfromthe

tipofthe penisbackwardstowardthepubicarea

③Inanuncircumcisedmale,carefullyretractthe

foreskinpriortowashingthepenis.

④Returntheforeskintoits formerposition.

⑤Wash,rinse,anddrythe scrotumcarefully.

 Cleanse from the tip of the client's penis

backwardto prevent transferringorganismsfrom

theanusto theurethra.

 Secretions that collect under the foreskin can

causeirritation and odor. Returnthe foreskin to

itsnormalpositionto preventinjurytothe tissue.

8.Assisttheclienttoturnon theside.Separatethe

client'sbuttocksand usetoiletpaper,if necessary,

toremovefecalmaterials.

 Removing fecal material provides for easier

cleaning.

9.Cleansetheanalarea,rinsethoroughly,anddry

withatowel.Changespongetowelasnecessary.

 Keepthe analarea cleanto minimize the riskof

skinirritationandbreakdown.

10.Applyskincareproductstothearea according

toneedor doctor'sorder.

 Lotionsmay beprescribedto treatskinirritation.

11.Returntheclienttoa comfortableposition.  Toprovidefor comfortand safety.

12.Removegloves andperformhandhygiene.  Topreventthe spreadof infection

13.Documentthe procedure,describingtheclient's

skincondition.Signthechart.

 Toprovidecontinuityof care

 Giving signature maintains professional

accountability

(fromCarolineBunkerRosdabl:Textbookof BasicNursing,1999,p.591)

Fig.21Femaleclient Fig.22Maleclient

Fundamental of Nursing Procedure Manual

Taking VitalSigns：

Temperature, Pulse,Respiration, Blood pressure

Definition:

Taking vital signsare defined as the procedure that takesthe sign of basic physiology that includes

temperature, pulse, respirationand blood pressure.If any abnormality occurs in the body, vital signs

changeimmediately.

Purpose:

1. To assessthe client’scondition

2. To determinethebaselinevaluesfor futurecomparisons

3. To detectchangesandabnormalitiesintheconditionoftheclient

Equipmentsrequired:

1. Oral/axilla/ rectalthermometer(1)

2. Stethoscope(1)

3. Sphygmomanometerwith appropriatecuff size(1)

4. Watchwitha secondhand(1)

5. Spiritswabor cotton(1)

6. Spongetowel(1)

7. Paperbag (2):forclean(1)

fordiscard(1)

8. Recordform

9. Ball-pointpen:blue (1)

black(1)

red (1)

10. Steeltray (1):toset allmaterials

Fig.23 Equipmentsrequiredoftakinga vitalsigns

Fundamental of Nursing Procedure Manual

Fig.24 Stethoscope

Astethoscopeconsistsof :ear pieces,tubing,twoheadssuchas thebelland thediaphragm.

Fig.25 Thebellofheadof stethoscope

Thebellhascup-shapedand isusedto correct

low-frequencysounds,suchasabnormal

heartsounds.

Fig.26Thediaphragmofheadof stethoscope

Thediaphragmis flatside of the headand is usedto

testhigh-frequencysounds:breath,normalbreath,and

bowelsounds.

Fig.27Aneroidmanometer

Aneroidmanometerisa kindofsphygmomanometer.Sphygmomanometerconsistsof:

aninflatablebladder,attachedtoa bulbanda diameter,enclosedin acuff,witha

deflatingmechanism

Fundamental of Nursing Procedure Manual

a. Taking axillarytemperature byglass thermometer

Definition:

Measuring/monitoringpatient’sbodytemperatureusingclinicalthermometer

Purpose:

1. To determinebodytemperature

2. To assistin diagnosis

3. To evaluatepatient’srecoveryfromillness

4. To determine if immediate measures shouldbe implemented to reducedangerously elevated body

temperatureorconversebody heatwhenbodytemperatureisdangerouslow

5. To evaluate patient’s response once heat conserving or heal reducing measures have been

implemented

Procedure:

CareAction Rationale

1.Washyourhands.  Handwashingpreventsthespreadof infection

2.Prepareallrequiredequipments  Organization facilitates accurate skill

performance.

3.Checktheclient’sidentification.  Toconfirmthe necessity

4. Explainthe purpose and the procedure to the

client.

 Providing information fasters cooperation and

understanding

5.Closedoorsand/orusea screen.  Maintains client’s privacy and minimize

embarrassment.

6. Takethe thermometer and wipe it withcotton

swabfrombulbtowardsthetube.

 Wipe from the area where few organisms are

present to the area where more organisms are

presentto limitspreadof infection

7.Shake the thermometer with strong wrist

movementsuntilthemercurylinefallsto at least

95 ℉ (35 ℃).

 Lower the mercury level within the stem so

that it is less than the client’s potential body

temperature

8.Assisttheclienttoa supineorsittingposition.  Toprovideeasyaccesstoaxilla.

9.Moveclothingawayfromshoulderand arm  To expose axilla for correct thermometer bulb

placement

10.Besure theclient’saxillaisdry. Ifitis moist,pat

itdrygentlybeforeinsertingthethermometer.

 Moisture will alter the reading. Under the

condition moistening, temperature is generally

measuredlowerthanthereal.

11.Placethebulbof thermometerinhollowofaxilla

atanteriorinferiorwith45 degreeor horizontally.

(Fig.28)

 Tomaintainproperpositionof bulb againstblood

vesselsin axilla.

12. Keepthe arm flexedacross the chest, closeto

thesideof thebody( Fig.29)

 Closecontact ofthe bulbofthe thermometerwith

thesuperficial blood vessels in theaxillaensures

amoreaccuratetemperatureregistration.

13.Hold the glass thermometer in place for 3

minutes.

 Toensureanaccuratereading

Fundamental of Nursing Procedure Manual

CareAction Rationale

14.Remove and read the level of mercury of

thermometerateyelevel.

 Toensureanaccuratereading

15. Shake mercury down carefully and wipe the

thermometerfrom the stem to bulb with spirit

swab.

 Topreventthe spreadof infection

16.Explaintheresultandinstructhim/herifhe/she

hasfeverorhypothermia.

 To share his/her data and provide care needed

immediately

17. Dispose of theequipmentproperly. Wash your

hands.

 Topreventthe spreadof infection

18.Replaceallequipmentsinproperplace.  To prepareforthe nextprocedure

19. Record in the client’schart and givesignature

onthechart.

 Axillary temperaturereadings usually

arelower

thanoralreadings.

 Giving signature maintains professional

accountability

20.Reportanabnormalreadingto theseniorstaff.  Documentationprovidesongoingdatacollection

Fig.28 Placingtheglassthermometerintothe axilla Fig.29 Keepingtheforearmacrossthechest

Fundamental of Nursing Procedure Manual

b. Measuring aRadial Pulse

Definition:

Checkingpresence,rate,rhythmandvolumeofthrobbingofartery.

Purpose:

1. To determinenumberofheartbeatsoccurringperminute(rate)

2. To gatherinformationaboutheartrhythmandpatternofbeats

3. To evaluatestrengthof pulse

4. To assessheart'sabilitytodeliverbloodtodistantareasofthebloodviz.fingersandlowerextremities

5. To assessresponseofheartto cardiacmedications,activity,bloodvolumeand gasexchange

6. To assessvascularstatus oflimbs

Procedure:

CareAction Rationale

1.Washhands.  Handwashingpreventsthespreadof infection

2.Prepareallequipmentsrequiredon tray.  Organizationfacilitatesaccurateskillproblems

3.Checktheclient’sidentification  Toconfirmthe necessity

4.Explaintheprocedureand purposeto theclient.  Providing information fosters cooperation and

understanding

5. Assist theclientin assuminga supineor sitting

position.

1)If supine,placeclient’sforearmstraightalongside

bodywith extended straight (Fig.30ⓐ) or upper

abdomenwithextendedstraight(Fig.30ⓑ)

2) If sitting, bend client’s elbow 90 degrees and

support lower arm on chair (Fig.31ⓐ) or on

nurse’sarmslightlyflexthewrist(Fig. 31ⓑ)

 Toprovideeasy accessto pulsesites

 Relaxed position of forearm and slightflexionof

wrist promotes exposure of artery to palpation

withoutrestriction.

6.Countandexaminethepulse

1)Placethe tipsofyourfirst,index,andthirdfinger

overthe client'sradialarteryon the inside ofthe

wristonthethumbside.

 Thefingertipsare sensitiveand betterable tofeel

thepulse.Donot useyourthumbbecauseithas a

strongpulseof itsown.

2)Applyonlyenoughpressureto radialpulse  Moderate pressure facilitates palpation of the

pulsations. Too much pressure obliterates the

pulse, whereasthe pulseisimperceptiblewithtoo

littlepressure

3) Using watch, count the pulse beatsfor a full

minute.

 Counting a fullminute permits a moreaccurate

readingand allowsassessmentof pulsestrength

 andrhythm.

4) Examine the rhythm and the strength of the

pulse.

 Strength reflectsvolume of bloodejectedagainst

arterialwallwitheachheartcontraction.

7.Recordtherateon theclient’schart.

Signonthe chart.

 Documentationprovidesongoingdatacollection

 Tomaintainprofessionalaccountability

8.Washyourhands.  Handwashingpreventsthespreadof infection

9. Report to the senior staff if you find any

abnormalities.

 Toprovidenursingcare andmedication properly

andcontinuously

Fundamental of Nursing Procedure Manual

Fig.30 ⓐ CareAction5. 1) → 6.

Placingthe client'sforearmstraightalongsidebodyand

puttingthe fingertipsovertheradialpulse

Fig.30 ⓑ 5.1)→6.

Placing the client’sforearm straightof across upper

abdomen and putting the fingertips over the radial

pulse

Fig.31 ⓐ CareAction5.2) → 6.

Placingthe client’sforearmonthe armrestof chairand

puttingyourthe fingertipsovertheradialpulse

Fig.31 ⓑ 5.2) →6.

Supportingtheclient’sforearmbynurse’spalm

with extended straight and your putting three

fingertips

Fundamental of Nursing Procedure Manual

c. CountingRespiration

Definition:

Monitoringtheinvoluntaryprocessof inspirationandexpirationin apatient

Purposes:

1. To determinenumberofrespirationoccurringperminute

2. To gatherinformationaboutrhythmanddepth

3. To assessresponseofpatienttoany relatedtherapy/medication

Procedure:

CareAction Rationale

1.Closethedoor and/oruse screen.  Tomaintainprivacy

2.Makethe client'spositioncomfortable,preferably

sittingor lyingwiththeheadof theelevated45to

60degrees.

 Toensureclearview ofchestwall andabdominal

movements.Ifnecessary,movethebed linen.

3. Prepare count respirations by keeping your

fingertipsonthe client’spulse.

 Aclientwhoknowsare countingrespirationsmay

notbreathenaturally.

4.Countingrespiration:

1) Observe the rise and fall of the client’s (one

inspirationandoneexpiration).

2)Countrespirationsforonefullminute.

3) Examinethe depth, rhythm,facial expression,

cyanosis,coughandmovementaccessory.

 One full cycle consistsof an inspiration and an

expiration.

 Allow sufficient time to assess respirations,

especiallywhentherateis withanirregular

 Children normallyhave an irregular, morerapid

rate.Adultswith an irregular raterequiremore

careful assessment includingdepth and rhythm

ofrespirations.

5. Replace bedlinens if necessary. Record the rate

ontheclient’schart.Sign thechart

 Documentationprovidesongoingdatacollection.

 Giving signature maintains professional

accountability

6.Performhandhygiene  Topreventthe spreadof infection

7.Reportanyirregularfindingstothe seniorstaff.  To providecontinuityof care

Fundamental of Nursing Procedure Manual

d. MeasuringBlood Pressure

Definition:

Monitoringbloodpressureusingpalpationand/orsphygmomanometer

Purpose:

1. To obtainbaselinedatafordiagnosisand treatment

2. To comparewithsubsequentchangesthatmayoccurduringcareof patient

3. To assistin evaluatingstatusofpatient’sbloodvolume,cardiacoutputandvascularsystem

4. To evaluatepatient’sresponseto changesin physicalconditionasa resultof treatment withfluidsor

medications

Procedure

:by palpationandaneroidmanometer

CareAction Rationale

1.Washyourhands.  Handwashingpreventsthespreadof infection

2.Gatherallequipments.Cleansethestethoscope's

ear pieces and diaphragm with a spirit swab

wipe.

 Organizationfacilitatesperformanceof theskill.

 Cleansing the stethoscope prevents spread of

infection.

3. Check the client’s identification. Explain the

purposeand proceduretothe client.

 Providing information fosters the client’s

cooperationandunderstanding.

4. Have the client restat least5 minutes before

measurement.

 Allowtheclientto relaxandhelpsto avoidfalsely

elevatereadings.

5.Determinethepreviousbaselineblood pressure,

ifavailable,fromthe client’srecord.

 Toavoidmisreading ofthe client’s bloodpressure

andfind anychangeshis/her blood pressurefrom

theusual

6.Identifyfactors likely tointerfere whichaccuracy

of bloodpressuremeasurement: exercise,coffee

andsmoking

 Exercise andsmokingcan cause falseelevations

inbloodpressure.

7.Settingtheposition:

1)Assisttheclienttoa comfortableposition.Besure

roomiswarm,quietandrelaxing.

2) Support the selected arm. Turn the palm

upward.(Fig.32 )

3)Removeanyconstrictiveclothing.

 The client's perceptions that the physical or

interpersonal environmentis stressfulaffect the

bloodpressuremeasurement.

 Ideally, the arm is at heart level for accurate

measurement. Rotate the arm so the brachial

pulseiseasilyaccessible.

 Not constrictedby clothing is allowedto access

thebrachialpulseeasilyandmeasureaccurately.

Do not use an arm where circulation is

compromisedinanyway.

Fig.32 CareAction7. 2)

Placingthe selected armon thebedand turnthe palm

upward

Fundamental of Nursing Procedure Manual

CareAction Rationale

8.Checkingbrachialarteryandwrappingthe cuff:

1) Palpatebrachialartery.

2)Centerthecuff’sbladderapproximately2.5 cm

(1 inch)above thesite where youpalpatedthe

brachialpulse

3)Wrapthe cuffsnuglyaround theclient’sarm and

securethe endapproximately(Fig.33)

4) Check the manometerwhether if it is at level

withtheclient’sheart(Fig.34 ).

 Center the bladderto ensure evencuff inflation

overthebrachialartery

 Loose-fitting cuff causes false high readings.

Appropriatewayto wrapis thatyoucan putonly

2fingersbetweenthearmandcuff.(Fig.33)

 Improperheightcanalterperceptionof reading.

Fig.33CareAction8.3)

Wrappingthecuffwithappropriateway

Fig.34CareAction8.4)

Placingmanometeratthelevelof heart

CareAction Rationale

9.Meausrebloodpressureby twostepmethod:

(A)Palpatorymethod

1) Palpate brachial pulse distal to the cuff with

fingertipsofnondominanthand.

2)Closethescrewclampon thebulb.

3)Inflatethecuffwhilestillcheckingthepulsewith

otherhand.(Fig. 35)

4) Observe the point where pulse is not longer

palpable.

5)Inflatecuffto pressure20-30mmHgabovepoint

atwhichpulsedisappears.

6)Open the screw clamp, deflate thecuff fullyand

wait30seconds.

 Palpation identifies the approximate systolic

reading. Estimatingprevents falselow readings,

whichmayresultinthe presenceof anauscultory

gap.

 Maximal inflationpoint foraccuratereadingcan

bedeterminedby palpation.

 Shortintervaleases any venous congestion that

mayhaveoccurred.

(B)Auscultation

1) Position the stethoscope’s earpiecescomfortably

in yourears(turn tipsslightlyforward). Besure

soundsare clear,not muffled.

2) Place the diaphragm over the client’s brachial

artery. Do not allow chestpieceto touch cuff or

clothing.(Fig.36)

 Eachearpieceshouldfollowangleof ear canalto

facilitatehearing.

 Proper stethoscope placement ensures optimal

soundreception.

 Stethoscope improperly positioned sounds that

oftenresultinfalselow systolicand highdiastolic

readings.

Fundamental of Nursing Procedure Manual

CareAction Rationale

9.(B)

3)Closethe screw clampon thebulb andinflatethe

cuff to a pressure30 mmHg above the point

wherethepulsehaddisappeared

4)Open theclampandallowthe aneroid dialtofall

atrateof 2to 3 mmHgpersecond.

5)Note thepointon thedial whenfirstclearsound

is heard. The sound will slowly increase in

intensity.

6) Continue deflating the cuff and note the point

wherethe sounddisappears. Listen for 10to 20

mmHgafterthelastsound.

7)Releaseanyremainingair quicklyin thecuffand

removeit.

8) Ifyou must recheck thereadingfor any reason,

allow a 1 minute interval before taking blood

pressureagain.

 Ensure that the systolic reading is not

underestimated.

 If deflation occurs too rapidly, reading may be

inaccurate.

 This first sound heard represents the systolic

pressure or the point wherethe heart is ableto

forcebloodintothebrachialartery.

 Thisis the adultdiastolic pressure.It represents

the pressure that the arterywalls exert on the

bloodatrest.

 Continuous cuff inflation causes arterial

occlusion,resultingin numbnessand tingling of

client’sarm.

 The interval eases any venous congestion and

providesfor anaccuratereadingwhen yourepeat

themeasurement.

10. Assist the client to a comfortable position.

Advisethe client ofthereading.

 Indicate your interest in the client's well-being

andallowhim/herto participateincare.

11.Washyourhands.  Handwashingpreventsthespreadof infection.

12.Recordbloodpressure onthe client’schart.Sign

onthechart.Reportanyfindingstoseniorstaffs.

 Documentationprovidesongoingdatacollection.

 Giving signature maintains professional

acountability

13. Replace the instrumentsto proper place and

discard.

 Topreparefor thenextprocedure.

Fig.35CareAction9.(A)3) : Palpatorymethod

Inflatingthecuffwhilecheckingbrachialartery

Fig.36CareAction9.(B)2) :Auscultation

Placingthediaphragmwithouttouchingthecuff

Fundamental of Nursing Procedure Manual

PerformingPhysicalExamination

Definition：

Physicalexaminationis animportanttoolin assessingtheclient’shealth status.Approximate15 % ofthe

informationused in the assessment comesfrom the physical examination. It is performed to collect

objectivedataandto correlateitwith subjectivedata.

Purpose:

1.Tocollectobjectivedatafromthe client

2.Todetecttheabnormalitieswithsystematictechniqueearly

3.Todiagnosediseases

4. Todeterminethe statusof presenthealth in healthcheck-up and referthe clientfor consultation if

needed

PrinciplesofPhysicalExamination:

A systematic approach should be used while doing physical examination. This helps avoiding any

duplicationoromission.Generallyacephalocaudalapproach(headto toe)isused,but inthecase ofinfant,

examinationofheartandlungfunctionshouldbe donebeforetheexaminationofotherbodyparts,because

whentheinfantstartscrying, his/herbreathand heartratemaychange.

Methodsof PhysicalExamination:



Inspection



Palpation



Percussion



Auscultation

1.Inspection

Inspectionmeans looking at the clientcarefullyto discoverany signs of illness. Inspectiongives more

informationthanothermethodand isthereforethe mostuseful methodof physicalexamination.

2.Palpation

Palpationmeansusinghandsto touchand feel.Differentpartsof handsare usedfordifferentsensations

suchas temperature,textureof skin,vibration,tenderness,andetc.For examples,fingertipsare usedfor

finetactilesurfaces, the backof fingersfor feeling temperatureand theflat of the palmand fingers for

feelingvibrations.

3.Percussion

Percussiondeterminesthe densityof various partsof thebody fromthe soundproducedby them,when

theyaretappedwithfingers. Percussionhelpstofindout abnormalsolidmasses,fluidandgasin thebody

andtomap outthesizeand bordersof thecertainorganliketheheart.Methodsof percussionare:

① Putthe middlefingersof his/herhandof thelefthandagainstthebodypartto bepercussed

② Tapthe endjointofthisfingerwiththemiddlefingerofthe righthand

③ Givetwo orthreetapsat eachareatobe percussed

④ Comparethesoundproducedat differentareas

Fundamental of Nursing Procedure Manual

4.Auscultation

Auscultationmeanslisteningthesoundstransmittedbya stethoscopewhichisusedto listentotheheart,

lungsandbowelsounds.

Equipmentsrequired:

1.Tray(1)

2.Watchwitha secondshand(1)

3.Heightscale(1)

4.Weightscale(1)

5.Thermometer(1)

6..Stethoscope(1)

7.Sphygmomanometer(1)

8.Measuringtape(1)

9.Scale(1)

10.Tourchlightorpenlight(1)

11.Spatula(1)

12Reflexhammer(1)

13.Otoscopeif available(1 set)

14.Disposablegloves(1pair)

15.Cottonswabsandcottongauzepad

16.Examinationtable

17.Recordform

18.Ballpointpen,pencils

Procedure

Action(✽Rationale)

Normalfindings Abnormalfindings/

Changesfromnormal

1.Explainthepurposeandprocedure

( ✽ Providing information fosters

his/her cooperation and allays

anxiety)

2. Closedoors and put screen.(✽ To

provideprivacy)

3. Encourage the client to empty

bladder(✽ A full bladder makes

him/heruncomfortable)

４．Performphysicalexamination

A.General examination

Assess overall bodyappearance and

mentalstatus

Inspection

Observethe client’sabilityto respond

to verbal commands.( ✽Responses

indicate the client’s speech and

cognitivefunction.)

 The client responds

appropriatelyto commands

 The client confused,

disoriented, or inappropriate

responses

Fundamental of Nursing Procedure Manual

Action(✽Rationale)

Normalfindings Abnormalfindings/

Changesfromnormal

Observe the client’s level of

consciousness( ; LOC) and

orientation. Ask the client to state

his/her own name, current location,

and approximate day, month, or

year.(✽Responsesindicatetheclient’s

brainfunction. LOC is the degree of

awareness of environmental stimuli.

It varies from full wakefulness and

alertness to coma. Orientation is a

measure of cognitive function or the

abilityto thinkandreason.)

 The client is fullyawake and

alert: eyesareopenand follow

people orobjects.The clientis

attentive to questions and

responds promptly and

accuratelytocommands.

 If he/she is sleeping, he/she

responds readily to verbal or

physical stimuli and

demonstrates wakefulness

andalertness.

 The client is aware of who

he/she is( orientation to

person), where he/she is

( orientation to place), and

when it is( orientation to

time).

 Client hasloweredLOC and

shows irritability, short

attention span, or dulled

perceptions.

 He/she is uncooperative or

unable to follow simple

commandsor answersimple

questions.

 At a lowered LOC, he/she

may respond to physical

stimuli only. The lowest

extreme is coma, when the

eyesareclosedand theclient

failsto respond to verbalor

physical stimuli, when no

voluntarymovement.

 If LOC is between full

awareness and coma,

objectively note the client’s

eye movement: voluntary,

withdrawal to stimuli or

withdrawal to noxious

stimuli(pain)only.

Observe the client’s abilityto think,

remember, process information, and

communicate.( ✽ These processes

indicatecognitivefunctioning.)

Inspect articulation on speech, style

andcontentsof speacking

 The client is able to follow

commands and repeat and

rememberinformation.

 smooth/ appropriate native

language

 Dysphasia

 Dysarthria

 Memoryloss

 Disorientation

 Hallucinations

 not clear/ not smooth/

inappropriatecontents

Observe the client’s ability to see,

hear, smell and distinguish tactile

sensations.

 The client can hear even

though the speaker turns

away.

 He/she can identify objects or

readsa clockin the roomand

distinguish between sharp

andsoftobjects.

 The client cannnot hear low

tonesand mustlook directly

atthespeaker.

 He/she cannotreada clockor

distinguishsharpfrom soft.

Observesigns ofdistress(✽ Alertthe

examiner to immediate concerns. If

you note distress, the client may

require healthcare interventions

beforeyou continuetheexam.)

The client shows labored

breathing,wheezing,coughing,

wincing,sweating,guarding of

body part (suggests pain),

anxious facial expression, of

fidgetymovements.

Fundamental of Nursing Procedure Manual

Action(✽Rationale)

Normalfindings Abnormalfindings/

Changesfromnormal

Observefacialexpressionandmood

( ✽ These could be effected by

diseaseor illcondition)

 Eyesare alert and in contact

withyou.

 Theclientis relaxed,smilesor

frowns appropriately and has

acalmdemeanor.

 Eyesareclosedoraverted.

 The client is frowning or

grimacing.

 He/she is unable to answer

questions

Observegeneralappearance:posture,

gait, and movement(✽ To identify

obviouschanges)

 Postureis upright

 Gait is smooth and equal for

the client’s age and

development. Limb

movementsarebilateral.

 Postureis stoppedor twisted.

 Limbs movements are

unevenor unilateral.

Observe grooming,personalhygiene,

and dress(✽ Personal appearance

can indicate self-comfort. Grooming

suggests his/her ability to perform

self-care.)

 Clothing reflects gender, age,

climate.

 Hair, skin , and clothing are

clean, well-groomed, and

appropriatefortheoccasion.

 He/she wears unusual

clothing for gender, age, or

climate.

 Hairis poorgroomed, lackof

cleanliness

 Excessiveoilis ontheskin.

 Bodyodorispresent.

Measurement

 Height

1)Ask theclientto removeshoesand

standwith his/herback and heels

touchingthewall.

2) Placea pencilflat on his/her head

so that it makes a mark on the

wall.

3) This shows his/her height

measured with cm tape from the

floorto the mark on the wall(or if

available,measurethe height with

measuring scale)

>140(or145)cminfemale <140(or145)cm infemale

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 Weight

Weighhim/herwithoutshoesand much

clothing.

BodyMassindex(;BMI)is usedtoassessthe statusof nutrition

usingweightand heightin theworld.

Formulafor BMI=weight(kg)/height(m)

Table2 BMI

InAdults Women Men

anorexia

< 17.5

underweight

innormalrange

marginallyoverweight

overweight

obese

< 19.1

19.1-25.8

25.8-27.3

27.3-32.3

> 32.3

< 20.7

20.7-26.4

26.4-27.8

27.8-31.1

> 31.1

severelyobese 35-40

morbidityobese 40-50

superobese 50-60

Takevital signs(✽ Vital signs provide

baselinedata)

 Temperature

36-37℃ hypothermia <35 ℃

pyrexia 38-40 ℃

hyperpyrexia > 40.1 ℃

 Pulse(rate/minute)

Talethepulserateandcheckthebeats  rate/minutein adult

60-80/min.

 regularand steady

 rate/minutein adult

bradycardia

tachycardia

 pulsedeficit,arrhythmia

 Respiration

Countthebreathswithoutgivingnotice  Breaths/minute 16-20/min.

 clearsoundofbreaths

 regularand steady

 Breaths/minute

bradypnea <10/min.

tachypnea >20/min.

Biot’s

Cheyne-Stokes

Kussmaul’s (Fig.37-41)

 wheeze,stridor

Fig.37 Bradypnea Fig.38Tachypnea Fig.39 Biot’s

Fig.40Cheyne-Stokes Fig.41Kussmaul’s

(fromCarolineBunkerRosdabl,p.509)

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 Bloodpressure

Take blood pressure under quiet and

warmroom.

 Hypotension:In normaladults < 95/60

 Hypertension

Table3 WHO/ISHclassificationofHypertension(1999)

Classification SBP(mmHg) DBP(mmHg)

Normal

Pre-hypertension

Grade1

Grade2

Grade3

<120

120-139

140-159

160-179

>/=180

<80

80-89

90-99

100-109

>/=110

SBP:SystolicBloodPressure,DBP:DiastolicBloodpressure

B.SkinAssessment

Assess integumentary structures(skin,

hair,nails)andfunction

Skin

Inspectionandpalpation

1) Inspect the back and palms of the

client’s hands for skin color. Compare

therightand leftsides. Makea similar

inspection of the feet and toes,

comparing theright and left sides. (✽

Extremities indicate peripheral

cardiovascularfunction)

 The color varying from

black brown or fair

depending upon the

geneticfactors

 Color variations on dark

pigmented skin may be

best seen in the mucous

membranes, nail beds,

sclera,or lips.

 erythema

 lossofpigmentation

 cyanosis

 pallor

 jaundice

1) Palpate the skin on the back and

palms of the client’s hands for

moisture,texture.

a.moisture

b.texture

 slight moist,no excessive

moistureor dryness

 firm,smooth, soft, elastic

skin

 Excessive dryness indicates

hypothyreidision

 Oilinessin acne.

 Roughness in

hypothyroidism

 Velvety texture in

hyperthyroidism

 flaking

 perspiration(diaphoresis)

3)Palpate the skin’s temperature

withthebackof yourhand.

 warmth  Generalized warmth infever

localwarmth

 Coolnessin hypothyroidism

4)Pinch andreleasetheskin on theback

of the client’shand. (✽ This palpation

indicatesthe skin’sdegreeof hydration

andturgor.)

Pinched skinthatpromptly

or gently returns to its

previous stste when

released signifies normal

turgor.

Pinched skin is very slow to

returnto normalposition.

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Depressionrecoversquickly Depression recovers slowly or

remains. Edema indicates

fluid retention, a sign of

circulatorydisorders.

5) Press suspected edematous areas

withthe edgeof yourfingers for10

seconds, and observe for the

depression

Fig.42 Pittingedema(fromCarolynJarvis,p.547)

6) Inspect the skin for lesions. Note

the appearance, size, location,

presence and appearance of

drainage.(✽Locate abnormal cell,

growths, or trauma that suggest

abnormalphysiologicprocesses.)

Skinis intact,withoutreddened

areas but with variations in

pigmentation and texture,

dependingon thearea’slocation

and exposure to light and

pressure.Freckles,moles,warts

arenormal.

 Erythema

 Eccymosis

 Lesions includes rashes,

macules, papules, vesicles,

wheals, nodules, pustules,

tumors,or ulcers.

 Wounds include incisions,

abrasions, lacerations,

pressureulcers.

Nail

1)Inspectand palpatethe fingernails

andtoenails.Notecolor,shapeand

anylesions.

2) Check capillary refillby pressing

the nail edge to blanch and then

releasepressurequickly,notingthe

returnof color.

 Pinkcolor

 Logitadionalbandsof pigment

may be seen in the nails of

normalpeople.

 Normally color return is

instant(<3seconds)

 Nails should have no

discoloration, ridges, pitting,

thickening,orseparationfrom

theedge.

 Cyanosisandmarkedpallor

 Clubbeingnails

 Koilonychia(spoon nail)

 Onycholysis( fungal

infection)

 Cyanosis nail beds or

sluggish color return

consider cardiovascular or

respiratorydysfunction.

Hairandscalp

1) Inspect the hairfor color,texture,

growth,distribution

 Color may vary from pale

blondeto totalblack.

 Texture varies fine to coarse

andlooksstraightto curly.

 Hairisexcessivelydryor oily

 Excessivehair loss(alopecia)

or coarse hair in

hypothyroidism

 fine silky hair in

hyperthyroidism

 pediculosis

 dandruff

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2) Inspectthe scaly, lumps, nevi, or

otherlesions.

 All area should be clean and

free of any lesions, scaly,

lumps,and nevi.

 redness and scaling in

seborrheicdermatitis

 psoriasis

C.Headand NeckAssessment

Assesscentralneurologicfunction,

vision,hearing,andmouth

structures.

Skull

1) Observe for thesize, shape, and

symmetry.

2) Palpate and noteany deformities,

depressions,lumps,or tenderness.

 Head is symmetrical, round,

anderectinthe midline.

 Enlarged skull in

hydrocephalus, Paget’s

diseasesof bone.

 Rednessaftertrauma

Face

Inspect the client’s facialexpression,

asymmetry, involuntary movements,

edema,and masses

 relaxedfacialexpression

 He/she doesn’t have

involuntarymovement

 Moonfacewithred cheeks in

Cushing’ssyndrome

 Edematous face aroundthe

eyes (in the morning ) and

paleinnephriticsyndrome

 Decreased facial mobility

and blunt expression in

Parkinson’sdisease

Eyes

1)Positionandalimentation:

Stand in front of the client and

inspect the both eyes for position

a n d a l i g n m e n t .

2)Eyebrows:

Inspectthe eyebrows, notingtheir

quantityanddistributionandany

scaliness

3)Eyelids:

Inspect the position, presence of

edema, lesions , c ondition and

direction of the eyelashes, and

adequ acy wi th eyel ids doz e.

 No deviation and abnormal

profusion

 Inward and outward

deviation

 Abnormalprofusionin

diseaseor ocular tumors

 Scaliness in seborrheic

dermatitis

 Lateral sparseness in

hypothyroidism

 Ptosis

 Entropian

 Ectropion

 Lidriraction

 Chalazion

 Sty

 Dacryocystitis

 Redinflamedlid margin

 Inwardsdirection

 Failureof the eyelidsto close

exposes the corneas to

seriousdamage

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4)Lacrimalapparatus

Inspect the region of the lacrimal

glandandlacrimalsac forswelling.

Look for excessive tearing or

drynessof theeye

5)Conjunctivaandsclera

① Expose the sclera and

conjunctiva

② Inspect the color of palpebral

conjunction, vascular pattern

against the white scleral

background and any nodules or

swelling.

Fig.43 Inspection conjunctiva and

sclera(fromCarolynJarvis,p.311)

6)CorneaandLens

Withobliquelighting,inspectthe

corneaof eacheyefor opacitiesand

noteanyopacitiesin thelens.

7)Pupils

( ✽ Pupillary size, shape, and

accomonation indicatethe status

odintracranialpressure)

Inspectthe size,shapesand

comparesymmetry.If thepupils

arelarger(>5mm),small(<3mm)or

unequal,measurethem.

 No lumps and swelling

aroundthe eyes

 Transparent white color of

sclera

 Darkpinkcolorofconjunctiva

 Nopaleness

 No nodules or swelling and

redness

 Transparent, no abrasions

andwhitespots

 Pupils are equal, round, and

symmetry.

 Lumpsandswelling

 Excessive tearing may be

due to increased production,

drainage of tear and

infection ( such as

conjunctiva inflammation

andcornealirritation)

 A yellow sclera indicates

jaundice

 Paleness in palpebral

conjunctiva indicates the

anaemia.

 Local redness due to

infection

Fig.44Conjunctiviis

(fromCarolynJarvis,p.335)

 Opacities in the lens due to

cataract

 A superficial grayish veiled

opacity in the corneadue to

oldinjuryorto inflammation

 Pupilsare unequal.

 Miosis refers to constriction

ofthepupils

 Mydriasistodilation

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 As the torch approaches the

eye,the pupil constricts.And

as the torch removed, the

pupildilates.

 Both eyes move together

while following the objects:

coordination

 Unresponsiveto light

 Pupil remains dilated even

after torch removed due to

oculomotiornerveparalysis.

 Small irregular pupils seen

as central nervous system

syphilis.

 Eyes do not move together

when the object moves in

paralysis of the cranial

nerve.

 Strabismus(cross-eyed or

wall-eyed)

 Client reports

diplopia(double-vision)

8)Pupillaryresponsetolight

①Ask the client to look into the

distance and light a torch from

thesideof theeye

②Remove it on the other side to

andobservehowpupilreacts

③Repeat other side with same

procedure

Fig.45 Papillaryresponse

(fromCarolyneJarvis,p.703)

9)Coordinationof eyemovements

(✽Coordination of eye movements

indicates brain function and

muscularattachmentstoeyes.)

①Hold asobjectat a distance from

theclient

②Askhim/herto keephis/herhead

stillandfollowtheobjectwiththe

eyesonly

③Move the object towards his/her

rightand left eye ,then towards

theceilingandfloor.

④Repeatit ontheothersideto

10)Convergencetest

①Ask the client to follow your

finger or a pencilas you moveit

intowardthebridgeofthe nose.

② The converging eyes normally

follows theobject towithin 5 cm

to8 cmof theeyes

11)Snelleneye charttest

(✽ Tocheckvisualacuity)

①UsetheSnelleneyechart,

whichincludesobjects,letters,or

numbersof differentsizesin

rows,underwell-light

② Position the client 20 feet

fromthe chart andask theclient

toidentifytheitems.

③ Comparesvisualacuityof the

clientwith normalvision

 Goodconvergence

 20/20visionas normal

 Poor convergence in

hypothyroism

 Myopia(near-sightedness)

 Hyperopia(far-sightedness)

is impaired in middle and

elderpeople.

 Legalblindness

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Ears

Inspectand palpatetheexternalears.

1)Inspectlocationof ears

2)Inspecttheshapeandmeasurethe

size.

 Thetop of thepinnaemeet or

crosses the eye-occiput line

(imaginary line drawn from

theoutercanthusofthe earto

theoccipitalprotuberance)

 Equalsizebilaterally

 Noswellingorthickening

 Unusual size and shape may

be familial trail without

clinicalsignificance

Fig.46Auricle(fromCarolyneJarvis,p.342)

3)Tenderness

①Movethe pinnaandpushon the

tragus

② Palpatethemastoidprocess

4)Externalauditorymeatus

Inspect the external auditory canal

(by touch or otoscope) (✽ To inspect

swelling, redness, discharge, foreign

bodyorcerumen.)

 Nopainwhilemovingthe

pinna,pushingthetragus,

andpalpatingmastoidprocess

 The top of the pinnae don’t

meet or cross the eye –

occiputline.

 Microtia(:earssmallerthan4

cmvertically)

 Macrotia(: ears larger than

10cm vertically)

 Edema

 Asymmetry shape due to

trauma

 Pain withmovement occurs

withotitisexternaand

 Pain at the mastoid process

may indicate mastoiditis or

lymphadenitis of the

posteriorauricularnode.

 Atresia(:absenceorclosureof

theearcanal)

 Clear blood of the brain

haemorrhage

 A sticky yellow discharge

accompaniesotitisexternaor

otitismedia.

 Impacted cerumen is a

common causeof conductive

hearingloss

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5)Voicetest

(✽ Whispered is a high frequency

sound and is used to detect high

toneloss)

①Testoneear ata time.

②Stay30-60cm fromclient’sear.

③Exhale and whisper slowly some

two syllable words (such as

Tuesday,Baseballandfourteen.)

 Normally the client repeats

eachword correctly after you

saidit.

 Theclientisunabletohear

 Hightoneloss

Nose

1)Inspecttheanteriorand inferior

surfaceof thenose.

① Give gentlepressurein the tip

of the nose with your thumb to

widenthenostrils

②with the aidof penlight, youcan

get a partial view of each nasal

vestibule.

③ Observe symmetry, deformity,

size,andflaring.

④ If indicated by pressing on

eachala nasi in turn and ask the

clientto breathin.

(✽Totestfor nasalobstruction)

2)Inspecttheinsideofthe nose

Inspectthe insidewithotoscopeor

penlightcafefully.

(✽ To detect any deformities or

abnormalities in nasal mucosa,

nasalseptum.)

 Nopain

 Symmetryin size

 Nostriluniforminsize

 Noflare

 no obstruction in both

vestibule

 Asymmetry of two sides'

shapeisnormal.

 Nodeviation

 Nopolyp

 Nasalmucosa redderthan the

oralmucosa

 No bleeding, swelling or

exudatesin nasalmucosa

 no bleeding, perforation or

deviationofthe septum

 No polyps, ulcers or foreign

bodies

 Tendernessof nasaltipor ala

suggestslocalinfection

 Asymmetryinsize

 Asymmetricalin size

 Flaringnostrils

 Obstruction in right

vestibulebypolyp.

 Deviation of the lower

septum is commonand may

be easily visible above

deviation, seldom obstructs

airflow.

 In viralrhinitis, the mucosa

isreddenedandswollen

 Inallergicrhinitis, itmay be

palebluishorred.

 Freshblood orcrustingmay

be seen causes of septal

perforationincludes trauma,

surgery, and the intranasal

useofcocaine.

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3)Palpateforsinustenderness

① Press up on thefrontalsinuses

from under the bony brows,

avoidingpressureon theeyes.

② Press upon the maxillary

sinuses

Fig.47Pressingoverthefrontalsinuses→

Fig.48 Pressing over the maxillary

sinuses(fromCarolyneJarvis,p.382)

→

 Polyps are pale translucent

masses that usually come

fromthemiddlemeatus

 Ulcers mayresultfromnasal

useofcocaine

 Local tenderness, together

withsymptomssuch aspain,

fever and nasal discharge,

suggest acute sinusitis

involving the frontal or

maxillarysinuses.

Mouth

If the client wears dentures, offer a

piece of paper towel and ask to

remove it so that you can see the

mucosaunderneath.

1)Lips

① Observethecolor,moisture

② Note any lumps, ulcers,

crackingor scaliness.

2)Oralmucosa/gums/teeth

① Inspect the color, presence of

ulcers, swelling,white patchesand

nodulesin mucosaand gums

 Pink,moistandintactskin

 No bluish, discoloration,

cracksand ulcers.

 Pinkcolorinboth oralmucosa

andgums

 Patches brownness may be

present, especially in black

people.

 Lips bluish(: cyanosis) and

pallor

 Cracks,ulcer

 Aphthousulcer

 Yelloishspots

 Koplik’sspots

 Smallredspots(:petechiae)

 Thickened white patch( :

Leuloplakia)

 Rednessof gingivitis

 Blacklineofleadpoisoning

 Swollen interdental papillae

ingingivitis

 Ulcerativegingivitis

 Gumsenlargements

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② Inspect the teeth for missing,

discolored, misshapen or

abnormally positioned. Palpate

them for check looseness with

glovedthumband indexfinger.

③ Inspect the color of roof of the

mouth and architecture of the

harelip.

3)Tongueandfloorofthe mouth

Inspectthe tongueforcolor,texture

ofdorsum,papillaesymmetry

4)Inspectthe sides andundersurface

of the tongueand the floor of the

mouth.

 No lesions, white plaque and

extrabonygrowth

 Pink,moistandpapillae

 Midline fissure presents and

besymmetrical.

 Nowhitor reddenedareas

Nonodulesorulcerations

 Missingor loosenessofteeth

 Dentalcaries

 Attritionofteeth

 Erosionof teeth

 Abrasion of teeth with

notching

 Thrush on the palpate(:

thick,whiteplaques)

 Kaposi’s sarcoma(: deep

purple color of lesions) in

AIDs

 Torus palatinus (: midline

bony growth in the hard

palate)

 Hairytongue

 Fissuredtongue

 Smoothtongue

 Whiteningcoatingtongue



Red or pale, dry papillae

fissureabsent

 Asymmetric protrusion

suggests a lesion of cranial

nerveXII

 Any persistent nodule or

ulcer

 Red or white area must be

suspectedthecancer

Pharynx

1)Askthe client to open the mouth

and say “ah”.This actionshelp to

see the pharynx well. If not press

the tongue, press spatula firmly

down upon the midpoint of the

archedtongue.

2) Inspect soft palate anterior and

posteriorpillars,uvula, tonsils,and

pharynx( ✽ To detect color,

symmetry, presence of exudates,

swelling, ulceration or tonsillar

enlargement,and tenderness.)

 Pinkthroat

 Pinkandsmalltonsils

 No swelling, exudates, and

ulceration

 Nodifficultyin swallowing

 Exudative tonsillitis(: red

andenlargedtonsils)

 Throatwith white exudates

 Redness and varcularity of

the pillars and uvula in

pharyngitis

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 Throat is dull red and gray

exudatesis presentin uvula,

pharynx and tongue, which

causeairwayobstruction

 Difficultyinswallowing

 In CN X paralysis, the soft

palate fails to rise and the

uvula deviates to the

oppositesite.

Neck

1)Inspecttheneck

(✽To detect its symmetryand any

masses or scars, enlargmentof the

parotid or submandibular glands,

andconditionof any visible lymph

nodes)

2)Rangeof Motion(;ROM)

①Asktheclienttotouchthe chinto

thechestturnthe headto theright

andleft

②Try to touch each ear to the

shoulder without elevating

shoulders

③ Extendtheheadbackward

 (Headlift occurswith muscle

spasm.) Head positions

centered in the midline and

theheadshouldbehelderect

 Lymph nodes are neither

visibleor redness

 Rigidhead and neck occurs

witharthritis

 Scaratthyroidsite

 Enlargementoflymphnodes

 Rednessof lymphnodes

 Pain at any particular

movement, limited

movement due to cervical

arthritisor inflammation on

oftheneck muscles

 Rigidneckwitharthritis

② Posteriorauricular

③ Occipital

⑥ Jugulodigstric

⑦ Superficialcervical

⑨ Posteriorcervical

⑩ Supraclavicular

Fig.49Lymphnodes(fromCarolyneJarvis,p.281)

① Preauricular

⑤ Submandibular

④ Submental

⑧ Deepcervicalchain

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Lymphnodes

1)Palpate thelymph nodes by using

thepads of your index and middle

fingers

2)Movethe underlyingtissuesin each

area

3)Examinebothsidesatonce

4)Feel in sequence for the following

nodes:(Fig.49)

① preauicular

② posturiaduricular

③ occipital

④ tonsillar

⑤ submandibular

⑥ submental

⑦ superficialcervical

⑧ posteriorcervical

⑨ deepcervicalchain

⑩ supracravicular

(✽To detect anypalpablenodes with

location, size, shape, delimitation,

mobility, consistency, and

tenderness.)

 Cervical nodes often are

palpate in healthy person,

although this palpability

decreasewithage

 Normal nodes feel movable,

discrete,soft,non-tender

 Parotid is swollen with

mumps

 Tender nodes suggest

inflammation

 Hardor fixed nodessuggest

malignancy

 Lymphadenopathy is

enlargement of the lymph

nodes( > 1 cm) due to

infection, allergy or

neoplasm

 Enlargement of a

supraclavicular node,

especially on the left,

suggests possible metastasis

from a thorax or an

abdominalmalignancy

 Diffuse lymphadenopathy

raises the suspicious of

HIV/AIDs

Trachea

1) Inspect the trachea (✽To detect

any deviation from its usual

midlineposition)

2)Palpateforany tracheashift.Place

yourindexfingeron the trachea in

the sternal notchand slip it off to

each side( ✽ To detect any

abnormalities)

 Normally trachea is in

midline.

 The space should be

symmetry on bothsides

 Nodeviationfrom themidline

 Masses in the neck may

pushthetracheatooneside.

 Tracheal deviationmay also

signify important problems

in thorax, such as a

mediastinalmass,atelectasis

orlargepneumothorax

Thyroidgland

1)Inspectthyroidgland:

① Askthe clienttosip somewater,

toextendtheneck,andswallow.

② Observefor upward movement

of the thyroid gland, noting its

contourand symmetry.

③You must confirm that thyroid

gland rise with swallowing and

thenfalltotheirrestingposition.

 Normally trachea is in

midline

 The space should be

symmetryin bothsides

 Nodeviationfrom themidline

 Goiter as a general tern for

anenlargedthyroidgland

Fundamental of Nursing Procedure Manual

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2)Palpatethethyroidgland:

① movebehindtheclient

② Ask the client to flex the neck

slightly forward to relax the

sternomastoidmuscles.

③ Place thefingers of bothhands

on the client's neck so that your

index fingers are just below the

cranialcartilage.

④ Ask theclient tosip as swallow

waterasbefore.Feelforthe thyroid

isthmus rising up tender your

fingerspads.

⑤ Displacethetracheatothe right

with the fingersof the left hand,

withtherighthandfingers,palpate

laterally for the right lobe of the

thyroid in the space between the

displaced trachea and the relaxed

sternomastoid. Find the lateral

margin. Examine the left lobe in

sameway.

 Normally you cannotpalpate

thethyroidgland

 No enlargement, presence of

nodules,andtenderness

 Diffuse enlargement in

endemicgoiter

 SoftinGravesdisease

 Firminmalignancy

 Tendernessin thyroiditis

 Multinodular goiter is

additional risk factors for

malignancy

Fig.50 PosteriorapproachtoThyroidgland Fig.51 Anteriorapproachtothyroidgland

(fromCarolyneJarvis,p.284) (fromCarolyneJarvis,p.284)

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D.Chestand Lungs

Initial surveyof respiration and the

thorax

1)Remove or open the client’s

clothing.

2)Have the client sit on the side of

examining table or bed. When

examine in supine position, the

client should lie comfortably with

armssomewhatabducted. A client

who is having difficultybreathing

should be examined is the sitting

position or with head of the bed

elevatedto acomfortlevel.

Examinationoftheposteriorchest

Inspection:

Observethe shapeand movementof

theposteriorchest.Compareoneside

withother.(✽Toidentify

asymmetricalshapeor movement;

assessrespiratorymovement.)Note:

① deformitiesorasymmetry

② abnormalretractionofthe lower

interspaces

③ impairment in respiratory

movement

Palpation

Palpatethe posteriorwallover

areas.(✽ Todistinguishbetween

normaland abnormalstructures:

tender,masses,swellingorpainful

area)

Inspection

Standbehindthe clientand observe

theposteriorchestforshapeand

movement. (✽To identify shape or

movement; assess respiratory

movement)

 Shoulders are level; breast,

lower rib margin are

symmetrical.

 Chest wall rises and falls

slightly with inspiration and

expiration.

 equalrespiratorymovement

 noretractionorbulgingof the

interspaces should occur on

inspiration

 Thorax in normal adult is

wider that it is deep, its

lateraldiameterislargerthan

inanterioposterior(;AP)

 AP diameter may increase

withage.

 No tenderness, superficial

lumpsor masses,normalskin

mobilityandturgor

 Shoulders are even;scapulae

areat the samelevel;spineis

midlineand straight.

 Posterior chest slightly rises

andfallsonrespiration.

 Movement of the chest wall

is asymmetrical on

respiration; shoulders are

uneven; rib cage, or breasts

areasymmetrical:

funnel chest(:depression in

the lower portioning

sternum)

barrel chest(: increased AP

diameter)

 Client has supraclavicular

retractionsor contractions of

accessory muscles during

inspiration:

 APdiametermayincreasein

chronic obstructive

pulmonarydisease

 Tender pectoral muscles or

costalcartilage

 Pain

 Masses

 Structural deformities or

asymmetryarepresent:

Scoliosis(:lateralcurvature)

Lordosis(: pronounced

lumbarcurvature)

Kyphosis(: abnormal spinal

curvature and vertebral

rotationdeformthechest)

Fundamental of Nursing Procedure Manual

Normaladultthorax Barrelthorax

Funnelbreast Pigeonbreast

Scoliosis Kyphosis

Fig. 52 Abnoramalthorax

(fromCarolyneJarvis,p.470-471)

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Inspectionandpalpation:

1) Assess chest expansion on the

posterior chest: Symmetric

expansion(Fig.53)

① Place your hands in the

posterolateral chest wall with

thumbsat thelevelof T9or T10

② Slide your hands medially to

pinch up a small fold of skin

betweenyourthumbs

③Ask the client to take a deep

breath.

④Watch your thumbs’move apart

symmetrically and not smooth

chestexpansionwithyourfinger

2)Assesstactile(vocal)fremitus ( Fig.

54)

①Beginpalpatingbyusingthe ball

or ulnar surface of yourhandfrom

thelungapices

② Touch the client’s chest while

he/sherepeats the words

“ninety-nine”or “bluemoon”

③ Compare vibration from one

sidetothe other

 Chestexpansionissymmetric.

 Vibrations should feel the

same in the corresponding

areaoneachside

 An abnormally wide costal

angle with little inspiratory

variation occurs with

emphysema.

 A lag in expansion occurs

with atelectasis and

pneumonia

 Pain accompanied deep

breathing whenthe pleurae

areinflamed

 A palpablegratingsensation

with breathing indicates

pleuralfrictionfremitus

 Decreased fremitus occurs

when anything obstructs

transmission of vibration,

e.g., obstructed bronchus,

pleural effusion,

pneumothorax, or

emphysema.

 Increased fremitus occurs

with compression or

consolidation of lung tissue,

e.g.,lobarpneumonia.

 Rhonchal fremitus is

palpablewiththickbronchial

secretions

 Pleural friction fremitus is

palpable with inflammation

ofthepleura.

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Fig.53 Palpationsymmetricexpansion Fig.54 Palpationtactilefremitus

intheposteriorchest intheposteriorchest

(fromCarolyneJarvis,p.450) (fromCarolyneJarvis,p.450

Percussion

LungFields

Percuss the posterior chest

comparing both sides.( ✽ To

identify and locate any area

with an abnormal

percussion).( ✽ To enhance

percussion)(Fig.55 )

1) Percuss the posterior chest

from the apices and then to

interspaces with a -5 cm

intervals.

2)Noteany abnormalfindings

 Resonance is normal lung

sound: except heart area

because heart normally

produces dullness bound, liver

produces dullness stomach

producestympany,musclesand

boneproducesflat

 Dullness replaces resonance

when fluid or solid tissue

replaces air containinglung or

accupies thepleuralspace, i.g.,

pneumonia, pleural effusion,

atelectasis,or tumor.

 Hyperresonance is found in

COPDandasthma

 Hyperresonantor tympaniticin

pneumothorax

Diaphragmexcursion

(✽To map out the lower lung

border, both in expiration and

inspiration)(Fig.56)

1) Ask the client to exhale and

holditbrieflywhileyoupercuss

downthescapular line

 The diaphragm excursion

should be equalbilaterallyand

measure about 3 to 5 cm in

adults

 An abnormal high level of

dullnessor absenceof excursion

occurs with pleural effusionor

atelectasisofthelowerlobes

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2) Continue percussionuntil the

sounds changesfrom resonant

todullon eachside

3)Markthe spot

Fig.55 Sequenceforpercussion(fromCarolyneJarvis,p.452)

Fig.56A.Determinediaphragmexcursion B.Measuringthe differences(fromCarolyneJarvis,p. 452-453)

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Auscultation

1)Listen to the breath

posteriorilly with mouth open

and more deeply than the

normal (✽ To note intensity,

identify any variation and any

adventitioussounds)

2) Repeat auscultation in the

posteriorchest.

 Breath sounds are usually

louder in upper anterior lung

fields

 Bronchial, bronchovesicular,

vesicular sounds are normal

breathsounds

 Noneadventitioussounds

Fig.57Auscultationtheposteriorchestusingthesequence

(fromCarolyneJarvis,p.455)

 Decreased or abscent breath

sounds occur i.g., atelectasis,

pleural effusion,

pneumothorax, chironic

obstructd pulmonary disease(;

COPD)

 Increased breath soundsoccur

when consolidation or

compression yields a dense

lung area, i.g., pneumonia,

fluidintheintrapleuralspace

Examinationoftheanterior

chest

Palpatethe anteriorchest

1)Assesssymmetricexpansion

① Place your hands on the

anterolateral wall with your

thumbs along the costal

margins and pointing toward

thexiphoidprocess

② Ask theclientto takea deep

breath

③ Watchyourhandmoveapart

Symmetrically

 Symmetricalexpansion

 Smoothchestexpansion

 Anabnormalwidecostalangle

withlittleinspiratoryvariation

occurswith emphysema

 A lag expansion occurs with

atelectasisorpneumonia

 A palpable grating sensation

with breathing indicates

pleuralfremitus

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2)Assesstactilefremitus

① Begin palpating over the

lung apices in the

supraclavicularareas

② Comparevibrationsfromone

side to other side while

repeating“ninety-nine”

③Avoid palpating over female

breast tissue because breast

tissue normally clamps the

sound.

3)Palpatetheanteriorchestwall

(✽To note any tenderness,and

detect anysuperficial lumpsor

masses)

Note skin mobility,

turgor, skin temperature and

moisture

Percussthe anteriorchest

1) Begin percussingthe apices in

thesupraclavicularareas

2) Percuss the interspaces and

compareone sidetotheother

3)Movedownthe anteriorchest

Auscultation

1)Auscultatethelungsfieldsover

the anterior chest from the

apices in the supraclavicular

areasdowntothe 6

rib

2) Progressfrom sideto side and

listen to one fullrespiration in

eachlocation

3) Evaluate normal breath

sounds and note abnormal

breathsounds

(Referto theposteriorchest) (Referto theposteriorchest)

 Lungs with chronic

emphysema result in

hyperresonnance

Fundamental of Nursing Procedure Manual

Fig.58Palpateanteriorexpansion Fig.59Assesstactilefremitus Fig.60Sequenceofpercussionand

auscultation

(fromCarolyneJarvis,p.40-461)

Table4 Abnormal/adventitiouslungsounds

(fromCarolyneJarvis,p.474)

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E.Heart/Precordium

For most of the cardiac

examination, theclientshouldbe

supine with the head elevated

30°.Two otherposition arealso

needed,a. turningtothe leftside,

b. leaning forward.the examin

should stand at the client’s

right.

Inspection

Inspect the anterior chest for

pulsation, you may or may not

seetheapicalimpulse.

PalpatetheApicalimpulse

(✽ To detect some abnormal

conditions)

1) Localizethe apicalimpulseby

usingonefingerpad

2) Asking the client to “exhale

and then hold it “aids the

examiner in locating the

pulsation.

3)Ask theclienttorollmidwayto

theleftto find

4) Notelocation, size,amplitude,

andduration

 It is easier to see in children

andinthosewith thinnerchest

 The apical impulseis palpable

inabouthalfof adult

 Not palpable in obese clients

withthickchestwalls

 Location: the apical impulse

should occupy only one

interspace, the fourthor fifth,

and be at or medial to the

midclavicularline

 Size:Normally1cm×2cm

 Amplitude: normally a short,

gentletap

 Duration: Short, normally

occupiesonlyfirsthalfof systole

 A heave or lift is a sustained

forceful thrusting of the

ventricle during systole. it

occurs with ventricular

hypertrophy; A right

ventricularheaveis seenat the

sternalborder.Aleftventricular

heaveisseenat theapex

Cardiacenlargement:

 Left ventricular dilatation

displacesimpulse downand to

left , and increases size more

thanonespace

 Increased fore and duration

occurs with left ventricular

hypertrophy

 Not palpable with pulmonary

emphysema due to overriding

lungs

→

Fig.61Localizingtheapicalimpulse Displacingthe apicalimpulse(fromCarolyneJarvis,p.504)

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Palpateacrosstheprecordium

1)Using the palmer aspects of

yourfourfingers,gentlypalpate

theapex, theleftsternalborder,

andthebase

2)Searching for any other

pulsations

3)If anypresent,notethe timing

Percussion

(✽To outlinethe heart’sborders

anddetectheartenlargement)

1) Place yourstationary finger in

the client’s fifth intercostals

spaceoveron theleft sideof the

chestnear the anterior axillary

line

2) Slide your stationary finger

toward yourself, percussing as

yougo

3)Note thechangeof soundfrom

resonance over the lung to

dull(overtheheart)

 Noneoccur

 The left border of cardiac

dullnessis at the midclavicular

linein the fifthinterspace,and

by the second interspace the

border ofdullness concideswith

theleftsternalborder.

 The right border of dullness

matchesthe sternalborder

 Percussion sounds doesn’t

enlarge

 A thrill is a palpable vibration.

The thrill signifies turbulent

blood flow and accompanies

loudmurmurs

 Cardiac enlargement is due to

increasedventrivular volumeor

wall thickness: it occurs with

hypertension, heart failure and

cardiomyopathy

Auscultation

Identify the auscultatory areas

where you listen. These include

the four traditional valveareas.

Theyare:

 Second rightinterspace– aortic

valvearea

 Second left interspace-

pulmonicvalvearea

 Leftlower sternal border-

tricuspidvalvearea

 Fifthinterspace at around left

midclavicular line- mitralvalve

area

Fig.62 Auscultatoryareas (fromCarolyneJarvis,p.506)

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(continuedfromtheformer)

1)Placethestethoscope

2)Try closing eyesbrieflyto tune

out any distractions.

Concentrate, and listen

selectively to one sound at a

time

3)Notethe rateandrhythm:

① When you notice any

irregularity, check for a pulse

deficit by auscultating the

apical beat while

simultaneously palpating the

radialpulse

② Count a serial

measurement(one after the

other) of apical beatand radial

pulse

4)IdentifyS

andS

①First heart sound is S

(lub)

caused by closure of the AV

valves.S

signalsthe beginning

ofsystole

② Second heart sound is

(dup) is associated with

closure of the aortic and

pulmonicvalves.

5)ListenS

andS

① Focus on systole, then

diastole

②Listen for any extra heart

sounds to note its timing and

characteristics

6)Listenformurmurs

Ifyou heara murmur,describe

it by indicating these

characteristics: timing,

loudness(Grade i- vi), pitch,

pattern, quality, location.

radiation,andposture

 Rate ranges normally from 60

-100beats/minute

 The rhythm shouldbe regular,

although sinus arrhythmia

occurs normally is youngadult

andchildren

 S

isloudestatthe apex

 S

isloudestatthe base

 Lub-dup is the normal heart

sound

 S

occurs immediately afterS

andS

occursjust beforeS

 Some clients may have

innocentmurmurs

 Premature beat; an isolated

beatisearly

 Irregularly irregular; no

patternto thesounds

 Pulse deficit signals a wear

contractionofthe ventricules; it

occurs with atrial fibrillation

andheartfailure

Both heart sounds are

diminished in emphysema,

obesityand pericardialfluid.

 A pathologic S

(ventricular

gallop)occursuntilheartfailure

 A pathologic S

(atrial gallop)

occurswith CAD

 A systolic murmur may occur

with a normal heart or with

heartdisease

 A diastolic murmur always

indicatesheartdiseases

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F.Breasts andAxillae

Generalappearance

Notesymmetryof sizeandshape

Skin

Inspect color, textile, bulging,

dimpling, any skin lesions or

edema.

Lymphaticdrainageareas

Observe the axillary and

supraclavcularregions.Note any

bulging,discoloration,or edema

Nipple

Inspectsymmetry,shape,anydry

scaling,any fissureor ulceration,

andbleedingor otherdischarge.

 Symmetry or a slight

asymmetryinsize

 Oftenthe left breast is slightly

largerthan theright

 The skin normally is smooth

andofeven color

 A finebluevascularnetworkis

visible normally during

pregnancy

 Pale linear striae, or stretch

marks,oftenfollowpregnancy

 Noedema

 The nipples should be

symmetrically placed on the

sameplaneonthe twobreasts

 Nipplesusuallyprotrude

 Anormalvariationin about1%

o men and women is a

supernumerarynipple

 Asuddenincreasein thesizeof

one breast signifies

inflammationor newgrowth

 Hyperpigmentation

 Redness and heat with

inflammation

 Unilateral dilated superficial

veinsina nonpregnantwoman

 Edema

 Deviationinpointing

 Recent nipple retraction

signifiesacquireddisease

 Explore any discharge,

especiallyin the presence of a

breastsmass

 Rarely, glandular tissue, a

supermumerary breast, or

polymastiaispresent

Fig.63 Paget’sdisease Fig.64 Mastitis Fig.65 Breastabscess

(fromCarolyneJarvis,p.433)

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Maneuverstoscreen

(✽Toinspectskinretractionsigns

due to fibrosis in the breasts

tissue)

1) Direct the woman to change

position while you check the

breastsfor skinretractionsings

2) Firstask her to lift the arms

slowlyover thehead

3) Next ask her to push her

hands onto her hips and to

pushhertwopalmstogether

4) Ask the woman with large

pendulous breasts to lean

forward whileyou supporther

forearms

Inspectand palpatetheaxillae

1)Ask thewomanto havesitting

position

2) Inspect the skin, noting any

rashorinfection

3) Lift the woman’s arm and

supportit yourself

① use your right hand to

palpatethe leftaxilla

② Reachyourfingershighinto

axilla

③ Move them firmlydown in

fourdirections: downthe chest

wallina linefromthemiddleof

the axxila, along the anterior

border of the axilla, along te

posteriorborder,and alongthe

inneraspectof theupperarm

④ Move the woman’s arm

through ROM to increase the

surfaceareayou canreach

Palpatethe breasts

1)Helpher toa supineposition

2) Tuck a small pad or towel

underthe side to be palpated

and raise her arm over her

head

 Both breasts should move up

symmetrically

 A slight lifting of both breast

willoccur

 Both breast show the

symmetric free-forward

movement

 Usuallynodesare notpalpable

 Anyenlargedand tenderlymph

nodes

 A lag in movement of one

breast

 A dimplingor a pucker(,which

indicatesskinretraction)

 Fixation to chest wall or skin

retraction

 Nodes enlarge with any local

infectionof the breast, arm,or

hand, and with breast cancer

metastases

 Anysignificantlumps

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3) Use the pads of your three

fingers and make a gentle

rotarymotionon thebreast

① Start at the nipple and

palpate outto the peripheryas

if “Spokes-on- a- wheelpattern

ofpalpation”,or

② Start at the nipple and

palpate in “Concentric-circles

pattern of palpation”,

increasingoutto theperiphery

③ M

ove in a clockwise

direction, taking care to

examine every square inch of

thebreast

④ Ifyou feel a lumpor mass,

notethesecharacteristics:

Location, shape, consistency,

movable, distinctness, nipple(;

is it displaced or retracted?),

skinoverthe lump, tenderness,

lymphadenopahy

4) Palpatethe nipple,notingany

indurationorsubareolarmass

① Use your thumbs and

forefinger to apply gentle

pressure or stripping action to

thenipple

② Start at the outside of the

areola, “milk” your fingers

toward the nipple, repeat from

afew differentdirections

③ if any discharge appears,

noteitscolorandconsistency

Themalebreast

1) Inspect the chestwall, noting

theskinsurfaceandany lumps

orswelling

2)Palpatethenippleareafor any

lumportissueenlargement

 In nulliparous women, normal

breast tissuefeels firm, smooth,

andelastic

 Afterpregnancy,the tissue feels

softerand looser

 Premenstrual enlargement is

normal

 Inflammary ridge(; a firm

transverseridge of compresses

tissuein thelowerquadrants)

 The normal male breast has

flatdisk of undevelopedbreast

tissue

 Gynecomastia; an enlargement

ofbreasttissueoccursnormally

during pubertyon onlyoneside

andistemporary

 Heat,redness,and swellingin

nonlactating and

nonpostpartumbreastsindicate

inflammation

 Except in pregnancy and

lactation,dischargeisabnormal

 Gynecomastia also occurs with

use of anabolic steroids, some

medications, and some disease

states.

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Fig.66 Gynemastia

(fromCarolyneJarvis,p.434)

G.Abdomen

Preparation

 Expose the abdomen to be visible

fully

 The client should be emptied the

bladder(✽ Topreventdiscomfort)

 Keep the room warm. The

stethoscope endpiece , yourhands

mustbe warm(✽ To avoid chilling

andtensingofmuscles)

 Position theclientsupine,with the

headon a pillow, thekneesbent or

onpillow,andarmsat thesidesor

across the chest( ✽ To enhance

abdominalwallrelaxation)

 Inquire about any painful areas

andexaminesuchan arealast(✽To

avoidanymuscleguarding)

Inspectthe abdomen

Contour

1)Standon the client’srightsideand

lookdownonthe abdomen

2) Stoop or sit to gaze across the

abdomen. Your head should be

slightlyhigherthantheabdomen

3) Determinethe profile fromthe rib

marginto thepubicbone

Symmetry

1) Shinea light acrossthe abdomen

toward you or shine it lengthwise

acrossthe client

 Normally ranges from flat

torounded

 The abdomen should be

symmentricbilaterally

 Scaphoidabdomen

 Protuberantabdomen

 Abdominaldistension

 Bulges,masses

 Hernia; protrusion of

abdominal viscera through

abnormal opening in muscle

wall

Fundamental of Nursing Procedure Manual

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Normalfindings Abnormalfindings/

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2) Note any localized bulging,

visible mass, or asymmetric

shapewhile the clienttakes a

deepbreath

Skin

1)Inspecttheskin(✽Todetect

abnormalities, i.g.,

pigmentation)

2)Note striae, scars, lesions,

rashes, dilated veins, and

turgor

Umbilicus

Observeits contour,location,

inflammationor bulges

Pulsationormovement

1)Observe the pulsations from

the aorta beneath the skin in

theepigastricarea

2)Observeforperistlsiswaves

 Theabdomenshouldbe smooth

andsymmetric

 Thesurfaceissmoothandeven,

withhomogenouscolor

 Old silver striae or stretch

marks is normal after

pregnancy or gained excessive

weight

 Recentstriaearepink orblue

 Goodturgor

 Normally it is midline and

inverted, with no sign of

discoloration, inflammation, or

hernia

 It becomes evertedand pushed

upwardwith pregnancy

 Normally, aortic pulsations is

visiblein epigastrium

 Waves of peristalsissometimes

arevisibleinverythinpersons

 Localized bulges in the

abdominalwalldueto hernia

 Bulging flanks of ascites,

suprapubicbulgeof adistended

bladderor pregnantuterus

 Lower abdominal mass of an

ovariumor uterinetumor

 Asymmetry from an enlarged

organormass

 Redness with localized

inflammation

 Jaundice

 Skinglistening,taut,andstriae

inascites

 Pink-purple striae with

Cushing’ssyndrome

 Prominent, dilated veins of

hepatic cirrhosis or of inferior

venacavalobstruction

 Lesions,rashes

 Poor turgor occurs with

dehydration

 Everted with ascites, or

underlyingmass

 Enlarged and everted with

umbilicalhernia

 Bluish periumbilical color

occurs with intraabdominal

bleeind

 Marked pulsation of the aorta

occurs with widened pulse

pressure; i.g., hypertension,

aortic insufficiency,

thyrotoxicosis

 Increased peristalsis waves

with a distended abdomen

indicatesintestinalobstruction

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Action(✽Rationale)

Normalfindings Abnormalfindings/

Changesfromnormal

Auscultate Bowel sounds and

Vascularsounds

Bowelsounds

1) Listento the abdomen before

performing percussion or

palpation(✽Not to alter the

frequencyofthe bowelsounds)

2) Place the diaphragm of your

stethoscope gently in the

abdomen

3) Listen for the sounds, and

noting the character and

frequencyofbowelsounds

4) If suspected the absence of

bowelsounds, youmust listen

for 5 minutes by your watch

before deciding bowel sounds

arecompletelyabsent

Vascularsounds

1)Listento theabdomen, noting

the presence of any vascular

soundsor bruits

2) Using firmer pressure, check

over the aorta, renal arteries,

iliac, and femoral arteries,

especially in person with

hypertension

3) Note location, pitch, and

timingof a vascularsound

4)Listenoverthe liverandspleen

forfrictionrubs

 Normal soundsconsist of clicks

and gurgles, occurring at

estimated frequencyof 5 to 30

(-34)timesper minute

 Usually no such sounds is

present

Fig.67 Vascularsounds （fromCarolyneJarvis,p.574）

Twodistinctpatternsofabnormal

bowelsoundsoccur:

 Hyperactive sounds: loud,

highpitched, rushing, tinkling

sounds that signal increased

motility

 Hypoactive or absent sounds:

abdominal surgery or with

inflammation of the

peritoneum,paralyticileus

 A systolic bruit(; a pulsatile

blowing sound) occurs with

stenosis or occlusion of an

artery

 Friction rubsin liver tumor or

abscess, gonococcal infection

aroundliver, splenicinfection

Fundamental of Nursing Procedure Manual

Action(✽Rationale)

Normalfindings Abnormalfindings/

Changesfromnormal

Percussion general tympany, liver

span,andsplenicdullness

(✽Toassesstheamountand

distributiongas intheabdomen

andtoidentifypossiblemasses

thataresolidor liquidfilled,

alsotoestimatethesizeof the

liverandspleen)

1) Percuss the abdomenlightly in

all four quadrants(✽ To assess

the distribution of tympanyand

dullness)

2) Note any large dull areasthat

might indicate an underlying

massorenlargedorgan

3)On each ofside of a protuberant

abdomen, notwhere abdominal

tympany changes to the

dullness of solid posterior

structure

 Tympany should

predominatebecauseof gasin

gastrointestinaltract

 Scattered area of dullness

fromfluidandfeces

 Normal dullnessin the liver

andspleen

 A protuberant abdomen thatis

tympaniticthroughoutsuggests

intestinalobstruction

 Large dullness in pregnant

uterus, ovarian tumor,

distended

 Bladder,largeliverorspleen

 Dullness in both flanks

indicates further assessment

forascites

 Absenceof tympany

Fig.68 Percussingfor generaltympany

Fig.69Shiftingdullness A: insupineposition B:in rightlateralposition

(fromCarolyneJarvis,p.574andp.578)

Fundamental of Nursing Procedure Manual

Action(✽Rationale)

Normalfindings Abnormalfindings/

Changesfromnormal

Palpatesurfaceanddeepareas

Perform palpation( ✽

To judge

thesize,location, andconsistency

of certainorgans,mobilityof any

palpableorgansand to screen for

any abnormal enlargement,

massesor tenderness)

Lightpalpation

(✽To froman overallimpression

ofthe skinsurfaceand superficial

musculature)

1) Place the client is the supine

position, keeping your hand

and forearm on a horizontal

planewiththefirst fourfingers

closetogether and flat on the

abdominalsurface

2)Ask him/her to relax his/her

abdomen

3)Depresstheabdominalsurface

about1cm

2)Make a light andgentlerotary

motion, sliding the fingers and

skintogether

3) Lift the fingers and move

clockwise to the next location

aroundthe abdomen

4)Palpateinall quadrants

Deeppalpation

Performdeeppalpation

(Fig.70A.–B.)

 Noabdominalmass

 Notenderness

 Muscleguarding

 Mass

 Tenderness

 Involuntaryrigidityindicates

acuteperitonealinflammation

Fig.70Deeppalpation ( fromCarolyneJarvis,p.578)

A.withSinglehand B.Bimanualtechnique

Fundamental of Nursing Procedure Manual

Action(✽Rationale)

Normalfindings Abnormalfindings/

Changesfromnormal

1) Perform deep palpation using

the same technique described

earlier, but push down 5 to 8

cm(2 to3 inches)

2) Movingclockwise, explore the

entireabdomen

3) Toover comethe resistanceof

a verylargeor obeseabdomen,

usea bimanualtechnique

① The top hand does the

pushing

② The bottomhandis relaxed

and can concentrate on the

senseofpalpation

Liver

1)Standon theclient’srightside

2)Place yourlefthand underthe

client’s back parallel to

the

and12

ribs

3) Lift up to support the

abdominalcontents

4) Place yourright hand on the

RUQ, with fingers parallel to

themidline(Fig.71)

5) Push deeply down and under

therightcostalmargin

6) Ask the client to take a deep

breath

7) Feel for liversliding overthe

fingersas theclientinspires

8) Note any enlargement or

tenderness.

 Normally palpable structure:

xiphoid process, normal liver

edge, right kidney, pulsatile

aorta, rectus muscles, sacral

promontory, cecum ascending

colon,sigmoidcolon,uterus,full

bladder

 Mild tenderness is normally

present when palpating the

sigmoidcolon

 Liverisnotusuallypalpable

 People may be palpable the

edge of the liver bump

immediately below the costal

margin as the diaphragm

pushes it down during

inhalation:a smooth structure

with a regular contour, firm

andsharpedge

 Tenderness occurs with local

inflammation, with

inflammation of the

peritoneum or underlying

organ, and with an enlarged

organ whose capsule is

stretched

 Liverpalpableas soft hedge or

irregularcontour

 Except with a depressed

diaphragm, a liver palpated

morethan 1 to 2 cm below the

rightcostalmarginis enlarged

 If enlarged, estimate the

amount of enlargement beyond

the right costal margin.

Express it in centimeters with

itsconsistencyandtenderness

Fig.71Palpationthe liverintheRUQ

(fromCarolyneJarvis,p.582)

Fundamental of Nursing Procedure Manual

Action(✽Rationale)

Normalfindings Abnormalfindings/

Changesfromnormal

Spleen

Insupineposition:

1) Reachyour lefthand overthe

abdomen and behind the left

sideatthe 11

and12

ribs(Fig.

72A.)

2)Liftup forsupport

3)Placeyourrighthandobliquely

on the LUQ with the fingers

pointing towardthe left axilla

and just inferior to the rib

margin

4) Push yourhand deeply down

and under the left costal

margin

5) Ask the client to take a deep

breath

Inrightlateralposition:

1) Roll the client onto his/her

rightsideto displacethespleen

more forward and

downward(Fig.72 B.)

2)Palpateasdescribedearlier

 Normallyspleenisnot palpable

 No enlargement and

tenderness

 The spleen must be enlarged

threetimesitsnormalsizetobe

felt

 Theenlargedspleenispalpable

about2 cmbelowthe leftcostal

marginon deepinspiration

Fig.72 A. Palpationthespleeninsupineposition B.Palpationthespleeninrightlateralposition

(fromCarolyneJarvis,p.583)

Fundamental of Nursing Procedure Manual

Action(✽Rationale)

Normalfindings Abnormalfindings/

Changesfromnormal

Kidneys

Palpationinthe rightkidney:

1) Placethe client in the supine

position

2) Place your left hand on the

client between lowest rib and

thepelvicbone

3) Place yourright hand on the

client’s side below the lowest

ribor in the RUQ.Yourhands

are placed together in a

“duck-bill” position at the

client’srightflank(Fig.73 A.)

4) Ask the client to take a deep

breath.

5) At the peak of inspiration,

press your right hand and

deeply into the RUQ, just

belowthecoastal margin

6) Try to capture the kidney

betweentwo hands

7) Note the enlargement or

tenderness.

Palpationinthe leftkidney:

1) Search for the left kidney by

reaching yourleft hand across

the abdomen and behind the

leftflankforsupport(Fig.73B.)

2)pushyour righthanddeepinto

theabdomen

3) Ask the client to take a deep

breath

4)Feelthe changewhileinspiring

 Both kidneys are not usually

palpable

 A normalright kidney may be

palpablein well-relaxedwomen

 No change while breathing

deeplyon bothsides

 Normallyno change

 Enlargedkidney

 Tenderness

 Kidneymass

 Causes of kidney enlargement

include hydronephrosis,cyst or

tumors

 Bilateralenlargement suggests

polycystickidney disease

Fig.73Palpationthe kidney A.Rightkidney B.Leftkidney

(fromCarolyneJarvis,p.584)

Fundamental of Nursing Procedure Manual

Action(✽Rationale)

Normalfindings Abnormalfindings/

Changesfromnormal

Percussioninthekidney:

(✽Toassessthetendernessin the

kidney)

1) Placethe ball of one hand in

thecostovertebralangle

2)Strikeit withtheulnarsurface

of yourfist,using enough force

tocausea perceptible

Rebound tenderness

(Bulumberg’ssign)

(✽ To test rebound tenderness

when the client feels abdominal

pain or when you elicit

tendernessduringpalpation)

1) Choose a site away from the

painfularea

2)Hold yourhand 90 degrees,or

perpendicular,tothe abdomen

3) Pushdown slowlyand deeply

andthenliftup suddenly

(Fig.74A.,B.)

 Painlessjarin fistpercussion

 As a normal or negative, no

painonreleaseofpressure

 Pain with fist percussion

suggests pyelonephritis, but

may also have a

musculoskeletalcause

 Pain in release of pressure

confirms rebound tenderness,

which is a reliable sign of

peritoneal inflammation.

Peritoneal inflammation

accompaniesappendicitis

Fig.74Reboundtendernessn(fromCarolyneJarvis,p.585)

A.Pushingdowntheabdomenslowly B.Liftyourhandup quickly

Action(✽Rationale)

Normalfindings Abnormalfindings/

Changesfromnormal

Inguinalarea

1) Lift the drape or cloth to

expose the inguinal area and

legs

2)Inspectand palpateeach groin

for the femoralpulse and the

inguinalnodes

Normallyno palpablenodules  Palpablenodes

 Swollen,tenderness

Fundamental of Nursing Procedure Manual

Action(✽Rationale)

Normalfindings Abnormalfindings/

Changesfromnormal

Bladder

1) The bladder normally cannot

be examined unless it is

distendedabovethe symphysis

pubisonpalpation.

2)Checkfortenderness

3) Use percussion to check for

dullnessand to determinehow

high the bladder rises above

thesymphysispubis

 Normally not palpable and

tenderness

 Thedome of distendedbladder

feelssmoothand round

 Bladder distension from outlet

obstruction

 Suprapubic tenderness in

bladderinfection

NOTE:

Table5 Commonsitesofreferredabdominalpain

(fromCarolyneJarvis,p.593)

Fundamental of Nursing Procedure Manual

Action(✽Rationale)

Normalfindings Abnormalfindings/

Changesfromnormal

H.Musculoskeletalsystem

Inspectionthemuscleandjoints

1)Askthe clientto stand

2)Inspecthis/herneck, shoulder,

arms,hands,hips, knees,legs,

ankleandfeet.

3) Compare one side with other

side

4) Note the size and contour of

thejoint, skinand tissues over

the joints for color, swelling,

andanymassesordeformities

Rangeofmotion(;ROM)

(✽Toinspectthe client’sabilityto

movemusculoskeletalsystem)

1) Askthe clientto move his/her

neck,shoulders,elbows,wrists,

fingers, hip,knees, ankles and

toesone by one in all possible

directions

2) Notethe range of motion and

watchforthesignsof pain

Supine

1)Asktheclienttostand

2)Placeyourselffar enoughback

3) Inspect and notethe line and

the equal horizontal positions

for the shoulders, scapulae,

iliac crests, gluteal folds, and

equalspacesbetweenarm and

lateralthoraxon thetwosides.

4)Fromthe side,notethe normal

convex thorax curve and

concavelumbarcurve.

 Noboneor jointdeformities

 Norednessorswellingofjoints

 Nomusclewasting

 Abletomovejoinsfreely

 No sign of pain while moving

joints

 The kneel and feet should be

aligned with the trunk and

shouldbe pointingforward

 An enhanced thorax curve, or

kyplosis , is common in aging

people

 A pronouncedlumbarcurve,or

lordosis, is common in obese

people

 Presenceof bone deformitiesor

jointdeformities

 Redness or swelling is

significant and signals joint

irritation

 Musclewasting

 Swelling may be dueto excess

joint fluid, thickening of the

synoviallining,inflammationof

surroundingsofttissueor bony

enlargement

 Deformitiesincludedislocation,

subluxation, contracture, or

ankylosis

 Limitedmovementofthejoints

 Signof pain when movingthe

joints

 A difference of shoulder

elevation and in level of

scapulae and iliac crest occur

withscoliosis

 Lateral tilting and forward

bending occur witha herniated

nucleuspulposus

Fundamental of Nursing Procedure Manual

Action(✽Rationale)

Normalfindings Abnormalfindings/

Changesfromnormal

Palpation

1) Palpate each joint, including

its skin for tenderness, its

muscles, bony articulations,

andareaof jointcapsule

2) Note any heat, tenderness,

swellingor masses.

3) If anytenderness occur, tryto

localize it to specific anatomic

structure(skin, muscle,

ligaments,tendons, fatpads or

jointcapsule)

4) Holding the eachjoint one by

one, ask the client to move

theseareas. note the rangeof

motion and for any rough

sensationatthe joint

 No swelling, tenderness or

rednessin joint

 Normaltemperature

 The synovial membrane

normallyis notpalpable

 A small amount of fluids is

presentin the normal joint, but

notpalpable

 Fullrangeofjointmovement

 Smoothjointmovement

 Redness,swellingortenderness

Limitedjointmovement

 Hard muscle with muscle

spasm

 Inoreased, temperature over

thejoint

 Palpablefluid

 Limitedjointmovement

 Roughsensation(crepitation)in

movinga joint

Peripheralvascularexamination

Inspectionandpalpation

1)Inspectthe armsforcolor,size,

anylesionandskinchanges

2) Palpate pulses: radial and

brachialpulse

3) Inspect legsfor color, size, any

lesions,trophicskinchangesor

swelling

4) Palpate temperature of feet

andlegs

5)Palpateinguinalnodes

6) Palpate pulses: femoral,

popliteal, posterior tibial,

dorsalispedis

 Symmetricalinsizeandshape

 Noedema

 Nolesion

 Nochangesinskincolors

 Normalpulserate

 Symmetricalinsizeandshape

 Noedema

 Nolesion

 Nochangesinskincolors

 Warmandequalbilaterally

 Not palpable nodes and non

tenderness

 Normalpulse

 Edemaofupperextremitis

 Increasedordecreasedpulse

 Pallor with vasoconstriction

Cyanosis

 Varicosevein

 A unilateral cool foot or leg

occurs

 Witharterialdeficit

 Enlargednodes,tenderorfixed

 A bruit occurs with turbulent

blood flow indicating partial

occlusion

Fundamental of Nursing Procedure Manual

Action(✽Rationale)

Normalfindings Abnormalfindings/

Changesfromnormal

Palpation

1) Press the skin gently and

firmly at thearms, handsover

theskinof thetibia,anklesand

feet for 5 seconds, and then

release.

2)Note whetherthe fingerleaves

an impression on the skin

indicationedema

3) Askthe client to standso that

youassessthevenoussystem

4) Note any visible dilated and

tortuousveins

Musclesstrengthen

1) Push against the client’s

hands,and thenfeet

2)Askhim/hertoresistthepush

 No impressionleft on the skin

whenpressed

 Pit edema commonly is seen if

the person has been standing

alldayor duringpregnancy

 Equalstrengthenis bothhands

andfeet

 Nomuscularweakness

 Bilateral pitting edema occurs

with heart failure, diabetic

neuropathy,or hepaticcirrhosis

 Unilateral edema occurs with

occlusionofa deepvein

 Uni- or bilateral edemaoccurs

withlymphaticobstruction

 Varicosities occur in the

saphenousveins

 Muscular weakness on one or

bothhandsandfeet

I.Nervoussystem

Forsensation

1)Askthe clientto closetheeyes

2) Select areas on face , arms,

hands,legs andfeet

3) Give a superficial pain, light

touchandvibrationto eachsite

byturn

4) Note the client’s ability of

sensationoneachsite

Testfor Cranialnerves

CranialnerveI: Olfactorynerve

(✽Totestthe senseofsmell)

1)Askthe client to close his/her

eyes

2)Askhim/herthesourceof smell

using familiar, conveniently

obtainable, and non-noxious

smell such as coffee or tooth

paste

 Feels pain, light touch and

vibration

 Equally in both side of his/her

body

 Decreased pain sensation or

touchsensation

 Unableto feelvibration

 One can not test smell when

upper respiratory infection or

withsinusitisdecreases or loss

of smell with tobacco smoking

orcocaineuse

Fundamental of Nursing Procedure Manual

Action(✽Rationale)

Normalfindings Abnormalfindings/

Changesfromnormal

Teststereognosis

1) Ask the client to close his/ her

eyes

2) Place a familiar object(i.g., clip,

keyorcoin)in theclient’shand

3)Askthe clientto identifyit

Test for the cerebellar function of

theupperextremities

Use finger-to- nose test or

rapid-altering–movementtest

Test for the cerebellar function of

thelowerextremities

1)Ask theclienttoreachheeldown

theoppositeshin or

2)Ask theclientto standand walk

across the room in his/her

regular walk back ward, and

thenturntowardyou

Deeptendonreflex

(✽Toelicitthe intactnessof thearc

atspecificspinallevel)

Bicepsreflex(C5toC6)

1) Support the client’s forearm on

yours

2) Placeyour thumbon the biceps

tendon andstrikea blowon your

thumb

3)Observetheresponse

Tricepsreflex(C7to C8)

1)Tellthe clientto letthe arm“just

go dead” as you suspend it by

holdingthe upperarm

2)Strikethe tricepstendondirectly

justabovetheelbow

3)Observetheresponse

Brachioradialisreflex(C5to C6)

1) Hold the client’s thumb to

suspend the forearms in

relaxation

 Normal client canidentifythe

familiarobject

 Coordinated, smooth

movement

 Straightandbalancedwalk

 Normal response is

contraction of the biceps

muscle and flexion of the

forearm

 Normal response is extension

oftheforearm

 Normal response is flexion

andsupinationofthe forearm

 Inability to identify object

correctly, especially in brain

stroke

 Uncoordinatedmovement

 Limping, unbalanced walk,

uncoordinatedor unsteadygait

 Hyperreflexia

 Hyporeflexia

Fundamental of Nursing Procedure Manual

Action(✽Rationale)

Normalfindings Abnormalfindings/

Changesfromnormal

2) Strike the forearm directly,

about 2 to 3 cm above the

radialstyloidprocess

3)Observetheresponse

Quadriceps reflex(“Knee jerk”)

(L2toL4)

1)Let thelowerlegsdanglefreely

to flex the knee stretch the

tendons

2) Strike the tendon directly just

belowthepatella

3) Observe the response and

palpate contraction of the

quadriceps

Achilles reflex(“Ankle jerk”) (L5

toS2)

1) Position the client with the

kneeflexed andhip externally

rotated

2)Holdthe footindorsiflexion

3) Strike the Achilles tendon

directly

4)Feelthe response

Superficialreflex

Planterreflex(L4to S2)

1) Position the thigh in slight

externalrotation

2) With the reflex hammer

draw a light stroke up the

lateral side of the sole of the

footand inward acrosstheball

ofthefoot

3)Observetheresponse

 Normal responseis extensionof

thelowerleg

 Normal response is the foot

planter flexes against your

hand

 Normal response is planter

flexion of all the toes and

inversion and flexion of the

forefoot

 Babinski sign:this occurs with

uppermotorneurondisease

Fundamental of Nursing Procedure Manual

Fig.75 Bicepsreflex Fig.76 Tricepsreflex

Fig.77Brachioradilisreflex Fig.78 Quadricepsreflex

Fig.79Achillesreflex (fromCarolyneJarvis,p.687,688,689)

Fundamental of Nursing Procedure Manual

Action(✽Rationale)

Normalfindings Abnormalfindings/

Changesfromnormal

J.Anus

Inspect theperinealarea forany

irritation, cracks, fissure or

enlargedvessels

 Noirritation,fissure,cracks

 No enlarged blood vessels in

anus

 Presenceof analirritation,anal

fissure, enlarged and blood

vessels

K.Male Genitalia

Inspectand palpatethepenis

1) Inspect the skin, glans, and

urethralmeatus

2) Ifyou noteurethraldischarge,

collect a smear formicroscopic

examinationandaculture

3) Palpate the shaft of penis

between your thumband first

twofingers

Inspectand palpatethescrotum

1)Inspectthescrotum

2)Palpategentlyeachscrotalhalf

between your thumband first

twofingers

 The skin normally looks

wrinkled,hairless, andwithout

lesions.The dorsalveinmay be

apparent

 Theglanslookssmoothwithout

lesions

 Foreskineasilyretractable

 The urethral meatus is

positionedjustaboutcentrally

 Normally the penis feels

smooth, semifirm, and

non-tender

 Asymmetryis normal, withthe

left scrotal half usually lower

thantheright

 Noscrotallesions

 Theskin ofscrotumis thinand

loose

 Nolump,no tenderness

 Testesareequalin size

 Inflammation

 Lesions

 Presenceof soreorlump

 Phimosis:unable toretractthe

foreskin

 Edges that are red, everted,

edematous,alongwithpurulent

discharge,suggestedurethritis

 Nodule or induration,

tendernessonthe penis

 Scrotal swelling occurs with

heart failure, renal failure, or

localinflammation

 Lesions

 Thickorswollenscrotalskin

 Abnormalities in the scrotum:

hernia, tumor, orchitis,

epididymitis, hydrocele,

spermatocele,varicocele

L.Femalegenitals

For inspection of female

genitals placethe clientin the

supine positionwith the knee

flexed and feet resting on the

examinationtable.

Externalgenitalia

Inspection

1)Note skin color, hair

distribution, labiamajora, any

lesions, clitoris, labia minora,

urethral opening, vaginal

opening,perineum,and anus.

 Labiaareof thesame colorand

size

 norednessorswellinginlabia

 Urethral opening appears

stellateandin midline

 Excoriation, nodules, rash, or

lesions

 Inflammation

 Polypinurethralopening

 Foul-smelling, white, yellow,

greendischargefromvagina

Fundamental of Nursing Procedure Manual

Action(✽Rationale)

Normalfindings Abnormalfindings/

Changesfromnormal

2) Look for any discharge or

bleeding, prolapse, from the

vagina

 Vaginalopeningmayappearas

averticalslit

 Perineumis smooth

 Anushas coarse skinincreased

pigmentation

 No usual discharge from the

vagina

 Noprolapse

 No bleeding from the vagina

exceptduringmensturation

 Bleeding

Fundamental of Nursing Procedure Manual

Carefor Nasal-Gastric Tube

a. Insertinga Nassal-Gastric Tube

Definition:

Methodof introducingatube throughnoseintostomach

Purpose:

1. Tofeed clientwithfluidswhenoralintakeis notpossible

2. Todiluteand removeconsumedpoison

3. Toinstillicecoldsolutiontocontrolgastricbleeding

4. Topreventstressonoperatedsitebydecompressingstomachof secretionsandgas

5. Torelievevomitingand distention

Equipmentsrequired:

1. Nasogastrictubein appropriatesize(1)

2. Syringe10ml (1)

3. Lubricant

4. Cottonballs

5. Kidneytray(1)

6. Adhesivetape

7. Stethoscope(1)

8. Clamp(1)

9. Markerpen(1)

10.SteelTray(1)

11.Disposableglovesif available(1pair)

Fundamental of Nursing Procedure Manual

Procedure:

CareAction Rationale

1.ChecktheDoctor’sorderforinsertionof

Nasal-gastrictube.

 This clarifies procedure and type of equipment

required.

2.Explaintheprocedureto theclient. Explanationfacilitatesclientcooperation.

3.Gathertheequipments.  Organizationprovidesaccurateskillperformance.

4.Assessclient’sabdomen  Assessmentdeterminespresence ofbowelsounds

andamountofabdominaldistention.

5.Performhandhygiene.Weardisposableglovesif

available.

 Hand hygiene deters the spread of

microorganisms. But sterile technique is not

neededbecausethedigestivetractis notsterile.

 Gloves protect from exposure to blood or body

fluids.

6.Assistthe clientto high Fowler’s position,or 45

degrees,if unableto maintainuprightposition.

 Upright position is more natural for swallowing

and protects against aspiration, if the client

shouldvomit.

7.Checkingthenostril:

1)Checkthe naresforpatencybyaskingtheclient

to occlude one nostril and breathe normally

throughthe other.

2)Cleanthenaresby usingcottonballs

3)Selectthenostrilthroughwhichairpassesmore

easily.

 Tubepassesmoreeasilythroughthe nostril with

thelargestopening.

8. Measure the distance to insert the tube by

placing:

1)Place thetipof tubeat client’s nostrilextending

totipof earlobe

2)Extenditto thetipof xiphoidprocess

3)Marktubewith amarkerpenor apieceof tape

 Measurementensuresthat thetube willbe long

enoughto entertheclient’sstomach.

9.Lubricantthe tipofthe tube(at least1-2inches)

withawatersolublelubricant

 Lubricantreducesfrictionandfacilitates passage

ofthetube intothestomach.

 Xylocaine jelly may not be recommendedto use

asa lubricantdueto theriskof xylocaineshock.

 Water–soluble lubricant will not cause

pneumoniaiftube accidentallyentersthelungs.

10.Insertingthe tube:

1) Insert the tubeinto the nostril whiledirecting

thetubedownward andbackward.

2) Theclientmay gag whenthe tube reaches the

pharynx.

3)Instructtheclienttotouchhischinto hischest.

4) Encouragehim/herto swallow evenif no fluids

arepermitted.

 Following the normal contour of the nasal

passage while inserting the tube reduces

irritationandthelikelihoodof mucosalinjury

 Thegagreflexstimulatedby thetube

 Swallowing helpsadvance the tube, causes the

epiglottisto covertheopeningof thetrachea,and

helpstoeliminategaggingandcoughing

Fundamental of Nursing Procedure Manual

100

CareAction Rationale

5)Advancethetube ina downward andbackward

directionwhentheclientswallow.

6)Stopwhenthe clientbreathes

7) If gagging and coughing persist, check

placementof tube witha tongue depressorand

flashlightifnecessary.

8) Keepadvancing the tubeuntil themarking or

thetapemarkingisreached.

❖NursingAlert❖

 Donot useforce.Rotatethetubeif it meets

resistance.

 Discontinue theprocedureand remove the

tubeifthe tubearesignsofdistress,suchas

gasping, coughing, cyanosis, and the

inabilitytospeakor hum.

 Excessivecoughingand gaggingmay occurif the

tubehascurledinthe backofthroat.

 Forcingthe tubemayinjuremucousmembranes.

 The tube is not in the esophagus if the client

showssignsof distress andis unableto speakor

hum.

11.Whilekeepingonehandon thetube, verifythe

tube’splacementinthestomach.

a. Aspiration of a small amount of stomach

contents:

Attach thesyringeto the endof the tubeand

aspirate small amount of stomach contents.

Visualizeaspiratedcontents,checkingforcolor

andconsistency.

b.Auscultation:

Inject a smallamountof air( 10- 15 ml)into

the nasogastrictube while you listen with a

stethoscopeapproximately3 inches ( about8

cm)belowthesternum.

c. Obtain radiographof placement of tube( as

orderedby doctor.)

 Thetube is in thestomachif its contents can be

aspirated.

 If thetube is in thestomach,you will beable to

heartheair enter(awhooshingsound)If thetube

is in the esophagus, injecting the air will be

difficultor impossible.In addition,injection ofair

oftencauses theclienttobelchimmediately.Ifthe

tubeis inthe larynx,the clientusuallyis unable

tospeak.

12.Securethetubewithtapeto theclient’snose.

❖NursingAlert❖

Be careful not to pull the tube too tightly

againstthe nose.

 Constant pressure of the tube against the skin

andmucousmembranescausestissueinjury.

13.Clamp theend ofnasal-

gastric tubewhileyou

bendthetubeby fingersnot toopen

 Bendingtubepreventstheinducingof secretion

14.Putt off anddisposethe gloves, Perform hand

hygiene

 Topreventthe spreadof infection

16.Replaceandproperlydisposeofequipment.  Toprepareforthenextprocedure

17. Record the date and time, the size of the

nasal-gastric tube, the amount and color of

drainageaspirated andrelevantclientreactions.

Signthechart.

 Documentationprovidescoordinationof care

18.Reporttothe seniorstaff.  Toprovidecontinuityof care

Fundamental of Nursing Procedure Manual

101

b. Removal a Nasal-GastricTube

Procedure:

Careaction Rationale

1.Assemblethe appropriateequipment,suchas

kidney tray, tissues or gauze and disposable

gloves,at the client’sbedside.

 Organization facilitates accurate skill

performance

2.Explaintheclientwhatyouraregoingto do.  Providingexplanationfosterscooperation

3.Puton thegloves  Topreventspreadof infection

4.Removethetube

1)Takeoutthe adhesivetapewhichholdingthe

nasal-gastrictubeto theclient’snose

2)Removethetubeby deflatinganyballoons

3) Simplypulling it out, slowly at first and then

rapidlywhenthe clientbeginsto cough.

4)Concealthetube.

5) Be sure to remove any tapes from the client’s

face.Acetonemaybe necessary.

 Do not remove the tube if you encounter any

resistancenotto harmanymembranes ororgans.

Doanotherattemptsin anhour.

 Continuousslow pullingit out canlead coughing

ordiscomfort

 Acetone helpsany adhesive substancesfrom the

face. You should also wipe acetone out after

removed tapesbecauseacetoneremainedon the

skinmayirritate.

6.Providemouthcareifneeded. Toprovidecomfort

7.Putoff glovesandperformhandhygiene.  Topreventthe spreadof infection

8.Recordthedate,timeand theclient’sconditionon

thechart.Andbe alertforcomplainsof discomfort,

distension, or nausea after removal. Sign the

signature.

 Documentationprovidescoordinationof care

 Giving signature maintains professional

accountability

9.Disposetheequipmentsandreplacethem.  To prepareforthe nextprocedure

10.Reporttothe seniorstaff.  Toprovidecontinuityof care

Fundamental of Nursing Procedure Manual

102

Administering a Nasal-gastric TubeFeeding

Definition:

Anasal-gastrictubefeedingisa meansof providingliquidnourishmentthrougha tubeintotheintestinal

tract,when clientis unabletotakefoodor anynutrientsorally

Purpose:

1.Toprovideadequatenutrition

2.Togivelargeamountsoffluidsfortherapeuticpurpose

3. To provide alternativemanner to some specific clients who has potential or acquired swallowing

difficulties

Equipmentsrequired:

1. Disposable gloves(1)

2. Feedingsolutionas prescribed

3. Feedingbagwithtubing(1)

4. Waterin jug

5. Largecathetertipsyringe(30mLor largerthanit) (1)

6. Measuringcup(1)

7. Clampif available(1)

8. Papertowelas required

9. Dr.’sprescription

10. Stethoscope(1)

Fundamental of Nursing Procedure Manual

103

Procedure:

CareAction Rationale

1. Assemble all equipments and supplies after

checkingtheDr.’sprescriptionfortubefeeding

 Organization facilitates accurate skill

performance

 Checking the prescription confirms the type of

feeding solution, route, and prescribed delivery

time.

2.Prepareformula:

a.in thetypeofcan:

Shake the can thoroughly. Check expiration

date

b.in thetypeofpowder:

Mix according to the instructions on the

package,prepareenoughfor24 hoursonlyand

refrigerateunused formula.Labeland datethe

container. Allow formula to reach room

temperaturebeforeusing.

c.in the typeof liquidwhichprepareby hospital

orfamilyata time:

Makeformulaat a time and allowformulato

reachroomtemperaturebeforeusing.

 Feeding solution maysettleand requiresmixing

beforeadministration.

 Outdated formula maybe contaminatedor have

lessenednutritionalvalue.

 Formula loses its nutritional value and can

harbormicroorganismsifkeptover24 hours.

 Cold formula cause abdominal discomfort or

sometimesdiarrhea.

3.Explaintheprocedureto theclient  Providingexplanation fosters client’scooperation

andunderstanding

4. Perform hand hygiene and put on disposable

glovesif available

 Topreventthe spreadof infection

5. Position the client with the head of the bed

elevated at least 30 degree angle to 45 degree

angle

 Thispositionhelpsavoidingaspirationof feeding

solutionintolungs

6.Determineplacementoffeedingtubeby:

a.Aspirationof stomachsecretions

① Attachthesyringetothe endoffeedingtube

② Gentlypullbackon plunger

③ Measureamountof residualfluid

④ Return residual fluid to stomachvia tube

andproceedtofeeding.

❖NursingAlert❖

If amountof the residualexceed hospital

protocolor Dr.’sorder,refer totheseorder.

 Aspirationof gastricfluidindicates thatthe tube

iscorrectlyplaced in thestomach

 Theamount ofresidualreflectsgastricemptying

time and indicates whether the feeding should

continue.

 Residual contents are returned to the stomach

because they contain valuable electrolytes and

digestiveenzymes.

 In the case of non present

of residual, you

shouldcheckplacementcarefully.

 Residual over120 mL maybe causedby feeding

too fast or taking time more to digest. Hold

feedingfor 2hours,andrecheckresidual.

b.Injecting10- 20mL ofairintotube:

① Attachsyringe filledwithair totube

② Inject air while listening with stethoscope

overleftupperquadrant

 Inject3-5 mLof airforchildren

 A whooshingor gurgling soundusuallyindicates

thatthetubeis inthestomach

Fundamental of Nursing Procedure Manual

104

CareAction Rationale

c.Takinganx-rayor ultrasound  It may be needed to determine the tube’

placement

Fig.79

a.Aspirationofstomachsecretion b.Injecting10-20mLair intoTube

(fromCaroline: TextbookofBasicNursing,1999,p.355)

CareAction Rationale

Intermittentor Bolusfeeding

Usingafeedingbag:

7.Feedingthefollowing

1) Hang the feeding bag set-up 12 to 18 inches

abovethestomach.Clampthe tubing.

2)Fill thebagwith prescribedformula andprepare

the tubing by opening the clamp. Allow the

feedingto flowthroughthetubing. Reclampthe

tube.

3) Attach theend of the set-up to thegastrictube.

Opentheclampand adjust flowaccordingto the

Dr.’sorder.

4) Add 30-60 mL of water to the feeding bag as

feedingis completed.Allowtheflowintobasin.

5) Clamp the tube and disconnect the feeding

set-up.

 Rapidfeedingmay causenauseaand abdominal

cramping.

 Waterclearsthetube,keepingitpatent.

 Clampingwhen feedingis completedpreventsair

fromenteringthestomach

Usingthesyringe:

7.Feedingthefollowing

1)Clampthetube.Insertthetip ofthelargesyringe

with plunger, or bulb removedinto the gastric

tube.

2)Pourfeedingintothesyringe

Fundamental of Nursing Procedure Manual

105

CareAction Rationale

3) Raise the syringe 12 to 18 inches above the

stomach.Opentheclamp.

4) Allow feeding to flow slowly intothe stomach.

Raiseandlower thesyringeto controlthe rateof

flow.

5)Add additional formula to the syringe as it

emptiesuntilfeedingiscomplete

 Gravity promotes movement of feeding into the

stomach

 Controlling administration and flow rate of

feeding prevents air from entering the stomach

and nausea and abdominal cramping from

developing

8.Terminationfeeding:

1)Terminatefeedingwhencompleted.

2)Instillprescribedamountofwater

3)Keepthe client’sheadelevatedfor 20-30minutes.

 Tomaintainpatencyofthe tube

 Elevated position discourages aspiration of

feedingsolutionintothelung

9.Mouthcare:

1)Providemouthcarebybrushingteeth

2)Offermouthwash

3)Keepthe lipsmoist

 Mouthcare promotes oral hygiene and provide

comfort

10.Cleanandreplaceequipmentstoproperplace  To prevent contamination of equipment and

preparefor thenextprocedure

11. Removeglovesandperformhandhygiene  To preventthespreadof infection

12. Document date, time, amount of residual,

amount of feeding, and client’s reaction to

feeding.Signthe chart

 Documentationprovidescontinuityofcare

 Giving signature maintains professional

accountability

Fundamental of Nursing Procedure Manual

106

PerformingSurgicalDressing:

Cleaning aWound and Applyinga Sterile Dressing

Definition:

Sterileprotectivecoveringappliedto awound/incision,usingaseptictechniquewithor withoutmedication

Purpose:

1.Topromotewoundgranulationandhealing

2.Topreventmicro-organismsfromenteringwound

3.Todecreasepurulentwounddrainage

4.Toabsorbfluidandprovidedryenvironment

5.Toimmobilizeand supportwound

6.Toassistin removalof necrotictissue

7.Toapplymedicationto wound

8.Toprovidecomfort

Equipmentsrequired:

1.Sterilegloves(1)

2.Gauzedressingset containingscissorsandforceps(1)

3.Cleaningdisposableglovesif available(1)

4Cleaningbasin(optional)(1)as required

5.Plasticbagforsoileddressingsor bucket(1)

6.Waterproofpador mackintosh(1)

7.Tape(1)

8.Surgicalpadsasrequired

9.Additionaldressingsuppliesasordered,e.g.antisepticointments,extradressings

10.Acetoneor adhesiveremover(optional)

11.Sterilenormalsaline(Optional)

Fundamental of Nursing Procedure Manual

107

Procedure:

CareAction Rationale

1.Explaintheprocedureto theclient  Providinginformationfosters his/hercooperation

andallaysanxiety.

2.Assembleequipments  Organization facilitates accurate skill

performance

3.Performhandhygiene  Topreventthe spreadof infection

4.Check Dr’s order for dressing change. Note

whetherdrainis present.

 Theorderclarifiestypeof dressing

5.Closedoorand putscreenorpullcurtains.  Toprovideprivacy

6.Positionwaterproofpador mackintoshunderthe

clientif desired

 To prevent bed sheets from wetting body

substancesanddisinfectant

7.Assistclientto comfortablepositionthatprovides

easyaccesstowoundarea.

 Properpositioningprovidesforcomfort.

8.Place opened, cuffed plastic bag near working

area.

 Soiled dressings may be placed in disposal bag

withoutcontaminationoutsidesurfacesofbag.

9. Loosen tapeon dressing. Use adhesive remover

ifnecessary.Iftapeis soiled,put ongloves.

Itis easierto loosentapebeforeputtingin gloves.

10.

1)Puton disposablegloves

2) Removedsoiled dressingscarefully in a cleanto

lesscleandirection.

3)Do notreachoverwound.

4)If dressingisadheringto skinsurface,it maybe

moistened by pouring a smallamount of sterile

salineor NSonto it.

5) Keep soiled side of dressing away from client’s

view.

 Using clean gloves protect the nurse when

handlingcontaminateddressings.

 Cautious removal of dressing(s) is more

comfortablefor client and ensures that drainis

notremovedifit ispresent.

 Sterile saline provides for easier removal of

dressing.

11.Assessamount,type,andodorof drainage.  Wound healing process or presence of infection

shouldbe documented.

12.

1)Discarddressingsinplasticdisposablebag.

2) Pulloff glovesinsideout and dropit in the bag

whenyour gloveswere contaminatedextremely

bydrainage.

 Proper disposaldressingsprevent the spread of

microorganismsbycontaminateddressings.

13.Cleaningwound:

a.Whenyou cleanwearingsterilegloves:

1)Opensteriledressingsand supplieson workarea

usingaseptictechnique.

2)Opensterilecleaningsolution

3) Pour over gauzesponges in placecontaineror

overspongesplacedin sterilebasin.

4)Puton gloves.

5)Cleanwoundor surgicalincision

①Clean from top to bottom or from center

outward

 Supplies are within easy reach, and sterilityis

maintained.

 Sterilityofdressingsandsolutionis maintained.

 Cleaningis donefromleastto mostcontaminated

area.

Fundamental of Nursing Procedure Manual

108

CareAction Rationale

5) ② Use one gauze square for each wipe,

discardingeachsquareby droppingintoplastic

bag.Donot touchbagwithgloves.

③Clean around drainif present,movingfrom

centeroutwardin acircularmotion.

④Use one gauze square for each circular

motion.

 Previouslycleanedareais re-contaminated.

b.Whenyou cleanusingsterileforceps:

1)Opensteriledressingsand supplieson workarea

usingaseptictechnique.

2)Opensterilecleaningsolution

3) Pour over gauze sponges or cottons in place

container or over sponges or cottons placed in

sterilebasin.

4)Cleanwoundor surgicalincision:

Followthe formerprocedureusingsterilegloves.

 Do not touch bag with sterile forceps to prevent

contamination

14. Dry wound or surgical incision using gauze

spongeand samemotion.

 Moisture provides medium for growth of

microorganisms.

15.Applyantisepticointmentby forcepsif ordered.  Growth of microorganisms maybe retardedand

healingprocessimproved.

16.Applya layerofdry,steriledressingover wound

usingsterileforceps.

 Primarydressingservesas a wickfordrainage.

17.Ifdrainageispresent:

Use sterile scissors to cut sterile 4 X 4 gauze

squareto placeunderandarounddrain.

 Drainageis absorbed, andsurroundingskin area

isprotected.

18.Applysecondgauzelayerto woundsite.  Additionallayersprovidefor increasedabsorption

ofdrainage.

19. Placesurgical pad overwound as outer most

layerifavailable.

 Wound is protected from microorganisms in

environment.

20. Remove gloves from inside out and discard

theminplasticbagif youworn.

 Topreventcross-infection

21.Applytapeorexistingtapetosecuredressings  Tape is easier to apply after gloves have been

removed.

22.

1)Performhandhygiene.

2) Remove all equipments and disinfect them as

needed.Makehim./hercomfortable.

 Topreventthe spreadof infection

23.Documentthe following:

1)Recordthedressingchange

2) Note appearance of woundor surgical incision

includingdrainage,odor,redness,and presenceof

pusandany complication.

3)Signthe chart

 Documentationprovidescoordinationof care.

 Giving signature maintains professional

accountability

24.Checkdressingand woundsiteeveryshift.  Close observation can find any complication as

soonaspossible.

Fundamental of Nursing Procedure Manual

109

Supplying OxygenInhalation

Definition:

Methodby whichoxygenissupplementedathigherpercentagesthanwhatis availableinatmosphericair.

Purpose:

1.Torelievedyspnoea

2.Toreduceor preventhypoxemiaand hypoxia

3.Toalleviateassociatedwithstruggleto breathe

Sourcesof Oxygen:

Therapeuticoxygenis availablefromtwosources

1. WallOutlets(;Centralsupply)

2. Oxygencylinders

❖NursingAlert❖

 Explainto theclientthe dangersof lighting matchesor smokingcigarettes,cigars,pipes.Be sure

theclienthasno matches,cigarettes,orsmokingmaterialsinthe bedsidetable.

 Make surethat warningsigns (OXYGEN- NO SMOKING) areposted on the client’sdoor and

abovetheclient’sbed.

 Donotuseoilon oxygenequipment.(Rationale:Oilcanigniteifexposedtooxygen.)

 Withalloxygendeliverysystems,theoxygenisturnedon beforethe maskisappliedtothe client.

 Makesurethe tubingis patentatalltimesand thattheequipmentis workingproperly.

 Maintain aconstantoxygenconcentrationforthe client tobreathe;monitorequipmentat regular

intervals.

 Givepainmedicationsas needed,preventchillingand trytoensurethatthe clientgetsneededrest.

Be alert to cues about hunger and elimination.( Rationale: The client’s physical comfort is

important.)

 Watchforrespiratorydepressionordistress.

 Encourageor assisttheclientto moveaboutin bed.( Rationale:Topreventhypostaticpneumonia

orcirculatorydifficulties.)Many clientsare reluctanttomovebecausetheyareafraidof theoxygen

apparatus.

 Providefrequent mouthcare. Makesure the oxygen contains proper humidification.(Rationale:

Oxygencan bedryingtomucousmembrane.)

 Discontinue oxygen only after a physician has evaluated the client. Generally,you should not

abruptly discontinue oxygen given in medium-to-high concentrations( above 30%). Gradually

decrease it in stages, and monitor the client’s arterialblood gases or oxygensaturationlevel.

(Rationale:Thesestepsdeterminewhethertheclientneedscontinuedsupport.)

 Alwaysbecarefulwhenyougivehighlevelsof oxygento a clientwithCOPD.The elevatedlevelsof

oxygenin thepatient’sbodycan depresstheirstimulustobreathe.

 Neveruseoxygeninthe hyperventilationpatient.

 Wear gloves any time you might come into contact with the client’s respiratory

secretions.(Rationale:To preventthespreadof infection).

Fundamental of Nursing Procedure Manual

110

Equipmentsrequired:

1. Client’schartandKardex

2. Oxygenconnectingtube(1)

3. Flowmeter(1)

4. Humidifierfilledwithsterilewater(1)

5. Oxygensource:WallOutletsorOxygencylinder

6. Traywithnasalcannulaof appropriatesizeoroxygenmask(1)

7. Kidneytray(1)

8. Adhassivetape

9. Scissors(1)

10. Oxygenstand(1)

11. Gauzepieces,Cottonswabsifneeded

12. “No smoking”signboard

13. Globesif available(1)

NOTE:

Table6 Characteristicsof lowflowsystemofoxygenadministration

Method Flow

rate

(L/

min.)

Oxygen

concentration

delivered

Advantages Disadvantages

1 22-24%

2 26-28%

3 28-30%

4 32-36%

5 36-40%

Nasalcannula

6 40-44%

 Convenient

 Comfortablemore thanface

mask

 bringlessanxiety

 Allowsclientto talkandeat

 Mouth breathing does not

affect the concentration of

deliveredoxygen

 Assumes an adequate

breathingpattern

 Unable to deliver

concentrations above

44%

5-6 40 %

6-7 50 %

Simplefacemask

7-8(-10) 60 %

 Can deliver high

concentration of oxygen

morethannasalcannula

 Maycauseanxiety

 able to lead hotness and

claustrophobic

 maycausedirty easier,so

cleansing is needed

frequently

 shouldbe removed while

eatingand talking

 Tightsealorlong wearing

can cause skin irritation

onface

Thereare anotherhigh flowdevicessuch as venturemask, oxygen hood andtracheostomy mask.You

should choose appropriate method of oxygen administration with Dr’s prescription and nursing

assessment.

Fundamental of Nursing Procedure Manual

111

Procedure:

a.NasalCannulaMethod

CareAction Rationale

1. Check doctor’s prescription includingdate, time,

flowliter/minute andmethods

 Toavoidmedicalerror

2. Perform hand hygiene and wear gloves if

available

 Topreventthe spreadof infection

3.Explain the purpose and procedures to the

patient

 Providing information fosters the client’s

cooperationandallayshis/heranxiety

4.Assembleequipments  Organization facilitates accurate skill

performance

5.Preparetheoxygenequipment:

1)Attach the flow meter into the wall outlet or

oxygencylinder

2)Fill humidifier about 1/3 with sterile water or

boiledwater

3)Blowout dustsfromtheoxygencylinder

4)Attachthe cannula withtheconnecting tubing to

theadapteronthehumidifier

 Humidification prevents drying of the nasal

mucosa

 Toprevententering dustfromexist ofcylinderto

thenostril

6. Test flow bysetting flowmeter at 2-3L/minute

andchecktheflowon thehand.

 Testing flow before use is needed to provide

prescribedoxygentotheclient

7.Adjusttheflowmeter’ssettingto theorderedflow

rate.

 Theflow rate viathe cannulashouldnot exceed

6L/m.Higher rates may causeexcess dryingof

nasalmucosa.

8. Insert the nasal cannula into client’s nostrils,

adjust the tubing behinds the client’s earsand

slidethe plastic adapter under the client’schin

untilheor sheiscomfortable.

 Proper position allowsunobstructedoxygen flow

andeasestheclient’srespirations

9.Maintainsufficientslackinoxygentubing To preventthe tubingfrom getting outof place

accidentally

10.Encouragethe clientto breathethroughthenose

rather than the mouth and expire from the

mouth

 Breathingthroughthe noseinhalesmoreoxygen

intothetrachea,whichis lesslikelytobe exhaled

throughthe mouth

11.Initiateoxygenflow To maintain doctor’s prescription and avoid

oxygentoxicity

1 12. Assess the patient

’s response to oxygen and

comfortlevel.

 Anxietyincreasesthe demandforoxygen

13.Disposeof gloves ifyou woreand perform hand

hygiene

 Topreventthe spreadof infection

14.Place“No Smoking” signboardat entry intothe

room

 The sign warns the client and visitors that

smoking is prohibited because oxygen is

combustible

15.Documentthefollowing:

Date, time, method, flow rate, respiratory

conditionandresponsetooxygen

 Documentationprovidescoordinationof care

 Sometimes oxygeninhalation can bring oxygen

intoxication.

16.Signthechart  Tomaintainprofessionalaccountability

Fundamental of Nursing Procedure Manual

112

CareAction Rationale

17. Reportto theseniorstaff To provide continuity of care and confirm the

client’scondition

18. Check the oxygen setup including the water

levelin the humidifier. Cleanthe cannulaand

assessthe client’snaresatleastevery8 hours.

 Sterile water needsto be added when the level

falls below the line on the humidification

container.

 Naresmaybecomedryand irritatedandrequired

theuseof awater-solublelubricant.

 Inlong usecases,evaluatefor pressuresoresover

ears,cheeksand nares.

❖NursingAlert❖

Afterusedthenasalcannula,you shouldcleanseitas follows:

1. Soak thecannulain salvonwaterforanhour

2. Dry itproperly

3. Cleansethetip ofcannulabyspiritswabbeforeapplyingto client

Fundamental of Nursing Procedure Manual

113

Procedure:

b.OxygenMaskMethod;Simplefacemask

Careaction Rationale

1.Perform hands hygiene and put on gloves if

available

 Topreventthe spreadof infection

2.Explainthe procedureandthe needfor oxygen to

theclient.

 Theclienthas aright toknow whatishappening

andwhy.

 Providingexplanationsalleyhis/heranxiety

3.Preparetheoxygenequipment:

1)Attach the humidifier to the threadedoutlet of

theflowmeteror regulator.

2)Connectthe tubingfrom thesimple maskto the

nippleoutleton thehumidifier

3)Settheoxygenattheprescribedflowrate.

 Tomaintainthe propersetting

 Theoxygenmust beflowingbeforeyou applythe

masktothe client

4.Toapplythe mask,guidetheelasticstrapoverthe

topof the client's head.Bring thestrap downto

justbelowtheclient’sears.

 Thispositionwillholdthe maskmostfirmly

5.Gently, but firmly, pull the strap extensions to

center the maskon the client’s facewith a tight

seal.

 Thesealpreventsleaksas mushas possible

6.Makesure thattheclientiscomfortable.  Comfort helpsrelieve apprehension, and lowers

oxygenneed

7.Removeandproperlydisposeof gloves.Washyour

hands

 Respiratory secretions are considered

contaminated

8.Documentthe procedureand record the client’s

reactions.

 Documentationprovidesforcoordinationofcare

9.Signthe chartandreporttheseniorstaffs Tomaintainprofessionalaccountability

10.Check periodically for depressesrespirations or

increasedpulse.

 To assess the respiratorycondition and find out

anyabnormalities assoonas possible

11.Check for reddened pressure areas under the

straps

 The straps, when snug, place pressure on the

underlyingskinareas

❖NursingAlert❖

TheSimplemaskis a low-flowdevicethatproviders anoxygenconcentrationinthe 40-60%range,with a

literflow6to 10L/m. BUT! The simplemask requiresa minimumoxygenflowrateof 6 L/mtoprevent

carbondioxidebuildup

Fundamental of Nursing Procedure Manual

114

Fundamental of Nursing Procedure Manual

115

II. Administration of Medications

Fundamental of Nursing Procedure Manual

116

Ourresponsibilitiesfor administrationof medication

Stepthe principleprocedure forsafetyand thebest-efficacybasedon 5 Rights: Rightdrug,Rightdose,

Rightroute,Righttime,Rightclient(,Rightform)

 Performhandhygiene.(Rationale:to preventthe spreadof infection)

 Collect prescription and ensure that the client is available and understandable to take the

medication.(Rationale:tosecureinformed-consent)

 Check themedicineas thepoints:name,components, dose,expirydate(Rationale:to providesafe

andefficientmedication)

 Prior to administrationensureyou areknowledgeableabout thedrug(s)to be administered. This

should include: therapeutic use, normal dosage, routes/forms, potential side effects,

contra-indications.(Rationale: toensure safety and well-beingof clientand enableyou to identify

anyerrorsinprescribing)

 Confirm identityof client verbally andwith chart,prescription,checkingfull name,age, dateof

birth: Rightclient.(Rationale:to ensurethatthe correctdrug isbeing administered to thecorrect

client)

 Ensurethatthe medicationhasnotbeengiventillthat time(Rationale:toensurerightdose)

Fundamental of Nursing Procedure Manual

117

Administering OralMedications

Definition:

Oralmedicationisdefinedasthe administrationofmedicationbymouth.

Purposes:

1.Topreventthediseaseandtakesupplementin ordertomaintainhealth

2.Tocurethe disease

3.Topromotethehealth

4.Togivepalliativetreatment

5.Togiveas a symptomatictreatment

Equipmentsrequired:

1.Steeltray(1)

2.Drinkingwaterin jug(1)

3.Dr’sprescription

4.Medicineprescribed

5.Medicinecup(1)

6.Pillcrusher/tabletcutterif needed

7.Kidneytray/paperbag(todiscardthewaste)(1)

Fundamental of Nursing Procedure Manual

118

Procedure:

CareAction Rationale

1.Performhandhygiene  Topreventthe spreadof infection

2.Assembleall equipments Organization facilitates accurate skill

performances

3. Verify the medication order using the client’s

kardex.Checkany inconsistencieswithDr.before

administration

 Toreducethechanceofmedicationerrors

4.Prepareoneclient’smedicationat atime  Lessenthechancesfor medicationerrors

5. Proceed fromtop to bottomof the kardexwhen

preparingmedications

 Thisensures thatyoudo notmissany medication

orders

6. Select the correct medication fromthe shelf or

drawer andcomparethelabel tothe medication

orderonthekardex

a.Fromthe multidosebottle:

Poura pillfrom the multidose bottle into the

containerlidand transferthecorrectamountto

amedicinecup.

b.In thecaseof unitpacking:

Leaveunit dose medicationin wrappersand

placethemina medicationcup

c.Liquidmedications:

Measure liquid medications by holding the

medicinecup at eyeleveland reading thelevel

at the bottom of the meniscus. Pourfrom the

bottle with the labeluppermost and wipe the

neckifnecessary

 Comparing medicationto the written order is a

checkthathelpstopreventerrors

 Pouring medication into the lid eliminates

handlingit.

 Unitdose wrappers keep medicationsclean and

safe.

 Holding a cup at eyelevel to poura liquid gives

themostaccuratemeasurement.

 Pouring away fromthe label andwiping the lip

helpskeepthelabelreadable

7.RecheckeachmedicationwiththeKardex  Toensurepreparationofthecorrectdose

8. When you have prepared all medicationson a

tray, compare each one againto the medication

order.

 To check all medications threetimes to prevent

errors

9. Crush pills if the client is unable to swallow

them:

1)Place thepill in apill crusher andcrush thepill

untilitis inpowderform

❖NursingAlert❖

Do not crush time-release capsules or

enteric-coatedtablets

2)Dissolvesubstancein wateror juice,ormix with

applesaucetomaskthe taste

3)If noneedto crush,cut tabletsat scoremarkonly

 Crushedmedicationsareofteneasierto swallow

 Enteric-coated tablets that are crushed may

irritate the stomach’s mucosal lining. Opening

and crushing the contents of a time-release

capsulemay interferewithitsabsorption

10.Bring medication to the client you have

prepared.

 Hospital/ Agency policy considers 30 minutes

before or afterthe ordered timeas an acceptable

variation

Fundamental of Nursing Procedure Manual

119

CareAction Rationale

11.Identifytheclientbeforegivingthemedication:

a.Askthe clienthis/hername

b.Aska staffmembertoidentifythe client

c.Checkthenameon theidentificationbracelet

ifavailable

 To abide by Five rights to prevent medication

errors

 Checking the identification bracelet is the most

reliable

12. Complete necessaryassessments before giving

medications

 Additional checking includes taking vital signs

and allergies to medications, depending on the

medication’saction

13.Assisttheclienttoa comfortablepositionto take

medications

 Sitting as upright as possible makesswallowing

medication easier and less likely to cause

aspiration

14.Administerthemedication:

1)Offerwateror fluidswiththe medication

2) Open unit dose medication package and give

themedicationto themedicinecup

3) Reviewthe medication’snameandpurpose

4) Discardanymedicationthatfallson thefloor

5) Mix powder medications with fluids at the

bedsideif needed

6) Recordfluidintakeonthe balancesheet

 Youshouldbeaware ofany fluidrestrictionsthat

exist

 Powdered forms of drugs may thicken when

mixed with fluid. You should give them

immediately

 Recording fluid taken with medications

maintainsaccuratedocumentation

15. Remain withthe clientuntil he/shehas taken

all medication. Confirm the client’s mouth if

needed.

 Be sure that the client takes the medication.

Leavingmedicationat thebedsideisunsafe.

16.Performhandhygiene  Topreventthespreadofinfection

17. Record medication administration on the

appropriateform:

1)Signafteryou havegiventhemedication  Documentation providescoordinationof careand

giving signature maintains professional

accountability

2) If a client refused the medication, record

according to yourhospital/agency policyon the

record.

 To verifies thereason medicationswere omitted

as well as the specific nursing assessments

neededto safelyadministermedication

3) Documentvital sign’s or particularassessments

accordingtoyourhospital’sform

 Toconfirmmedication’saction

4) Sign in the narcotic record for controlled

substances when you remove them from the

lockedarea(e.g,draweror shelf).

 Federal law regulates special documentation for

controllednarcoticsubstances

18.Checkthe clientwithin30 minutesafter giving

medication.

 Toverifytheclient’sresponsetothemedication

 Particularly,you shouldcheckthe response after

administered pain killer whether if the

medicationrelievespainor not.

Fundamental of Nursing Procedure Manual

120

Administering oralmedications througha Nasal-Gastrictube

Definition:

Administering through a nasal-gastric tube is a process that administer oral medication through a

nasal-gastrictubeinsteadofmouth.

Purpose:

as “Administeringoralmedication”

Equipmentsrequired:

1.Client’skardexandchart

2.Medicationprescribed

3.Medicinecup(1)

4.Wateroranotherfluidsasneeded

5.Mortarandpestleorpill crusherif anordertocrushmedicationshas beenobtained()

6.Disposablegloves(1):if available

7.Largesyringe(20-30mL) (1)

8.Smallsyringe(3-5mL) (1)

9.Stethoscope(1)

Fundamental of Nursing Procedure Manual

121

Procedure:

CareAction Rationale

1.Confirmationthemedication:

1)Checkthename,dosage,type,timeof medication

withtheclient’skardex.

2) If you are going to give more than one

medication,makesuretheyarecompatible

 Besure to administerthecorrectmedication and

dosageto thecorrectclient

2. Check the kardex and the client’s record for

allergiestomedications

 Youcannotadministera medicationto whichthe

client previously experienced an allergic

reaction

3.Performhandhygiene  Topreventthe spreadof infection

4.Assembleall equipments Organizationhelps to eliminatethe possibilityof

medicationerrors

5. Set up medication following the Five right of

administration

 Strictly adhere to safetyprecautions to decrease

thepossibilityoferrors

6.Explaintheprocedure  Toallayhis/heranxiety

7. Put onglovesifavailable  To maintainstandardprecautionswhichindicate

to avoid possibility to be infected by any body

fluidsor secretions

8. Checkthe placementofthe nasal-gastrictube

1)Connectasmallsyringetothe endoftube

2)Gentlyaspiratethe gastricjuiceor endogastric

substancesbya syringe

❖NursingAlert❖

Donotaspirateifthe clienthas abutton–type

gastric-tube

 Ensure thatmedicationwill bedeliveredintothe

stomach

 If you cannot confirm the tubing’s placement,

consult senior staffs and be sure the correct

placement.

 Aspirationcandamagetheantirefluxvalve

9. Afterchecking forthe gastric-tube’splacement,

pinchorclampthetubingandremovethesyringe

 Pinchor clamp the tubing prevents endogastric

substancesformescapingthroughthetubing

 Ensure that no air entersthe stomach, causing

discomfortfortheclient

10.Administeringmedications:

1) Remove theplungerfrom the largesyringeand

reconnectthesyringetothe tube

2) Releasethe clampand pourthe medicationinto

thesyringe

3) If themedication does notflow freelydown the

tube,inserttheplungerandgentlyapplya slight

pressureto startthe flow.

4)If medicationflowdoesnot start,determineifthe

gastric-tubeof plugged.

5) After you have administered the medication,

flushthetubewith15 to30 mlof water.

6)Clampthetubingandremovethesyringe

7) Replacethe tubingplug. Iffeedingis continued,

reconnectthetubingtothe feedingtubing

 Toclear thetube and decreasethe chanceof the

tubingbecomingclogged

 To prevent the medication and water from

escaping