NURSING PROCEDURES

Índice
1) VITAL SIGNS
Temperature
Pulse
Blood Pressure
Respirations

2) INJECTIONS
Preparatory stage
Intramuscular injection
Subcutaneous injection
Intravenous injection

3) NASOGASTRIC PROCEDURES
Nasogastric lavage
Tube feeding

4) WOUNDS
Cure of an aseptic wound
Cure of a septic wound
How to take stitches
How to take stitches out
Colostomy care

5) PHYSICAL EXAMINATION
Breast examination
Gynecological exam (Preparatory stage)
Gynecological exam
Cytological exam
Rectal examination
Chest auscultation

6) MISCELANEOUS
Warning when taking BP
Blood infusion (Transfusions)
Caution with Blakemore-sengstaken tube
Measures to avoid cross infections
Cautions in pelvic or rectal exam
I. VITAL SIGNS

1. TEMPERATURE

Equipment: Tray with: Thermometer, kidney dish, gauze/ cotton swabs, pen.
Procedure:
 Read the indications on the patient’s chart.
 Identify the patient and prepare him/her psychologically.
 Wash your hands.
 Prepare the equipment.
 Put the patient in the correct position.
 Check the thermometer´s temperature before placing it in the patient´s armpit.
 Place the thermometer and wait for 3 to 5 minutes.
 Take out the thermometer, clean it with a gauze swab, read it and write your observations
on the patient´s chart.
 Collect the equipment and put it on the tray.
 Wash your hands again.

2. PULSE
Equipment : Watch, pen
Procedure :
 Read the indications on the patient’s chart.
 Identify the patient and prepare him /her psychologically.
 Wash your hands and prepare the equipment.
 Put the fingers of one hand on the inside of the patient´s wrist. Just below the base of the
thumb
 Feel the beats and count them for a minute.
 Repeat the procedure once more to be sure of the exact number of beatings.
 Write your observations on the patient´s chart.
 Wash your hands again.

3. BLOOD PRESSURE
Equipment: Sphygmomanometer, stethoscope, pen.
Procedure:
 Read the indications on the patient’s chart.
 Identify the patient and prepare him / her psychologically.

 Wash your hands and prepare the equipment.

 Put the patient in the correct position (sitting, lying on bed etc)
 Put the inflatable bag round the patient´s inside arm, five finfers above the elbow and secure
the cuff tightly.
 Put the stethoscope´s diaphragm over the brachial artery.
 Place the stethoscope in your inner ears.
 Close the valve and inflate the cuff (reaching for the highest levels)
 Open the valve slowly and observe the manometer.
 Take the systolic and diastolic pressures.
 Repeat the procedure to be sure of the exact pressure.
 Deflate the cuff completely and remove it.
  Write your observations on the patient´s chart.
 Collect the equipment and put it on the tray.
 Wash your hands again.

4. RESPIRATIONS
Equipment: Watch, pen
Procedure:
Count the patient´s respirations along with the radial pulse. Leave your hand on the patient´s wrist
as if taking the pulse, but watch the chest or the abdomen rise and fall. Count respirations for a
minute. Normal adult respirations are from 14 to 20 breaths per minute.

II. INJECTIONS

1. PREPARATORY STAGE
Equipments: Tray with: Sterile pack containing: needles, syringe, kidney dish / receiver, rubber
band, buhl saw, medicine (vial, ampule, etc) cotton sponge.
Procedure:

 Read the indications on the patient’s chart.

 Identify the patient and prepare him / her psychologically.
 Wash your hands and prepare the equipment.
 Take a syringe and needle of the approppriate size and caliber from the sterile pack.
 Prepare the syringe, putting the needle with a forcep or a swab in a barrel.
 Clean the vial or ampule with soap, water and an alcohol sponge.
 Insert the needle into the vial and the water for injection equal to the dose into the syringe.
 Push down the plunger and invert it into the medicine vial.
 Insert the needle into the medicine vial to withdraw the dose.
 Draw air equal to the prescribed dose in the syringe and expel the air. Change the needle by
another new one.
 In case of an ampule, cut the ampule with the buhl saw and withdraw the dose prescribed.
 Withdraw the prescribed dose and expel the air.
 Put everything into the container.
 Moisten the cotton swab / sponge with alcohol.
 Wash your hands and go to the patient´s unit.
 Go to the patient’s unit.

3. INTRAMUSCULAR INJECTION
Equipment: Syringe, needle, kidney dish, alcohol sponge.
Procedure :
 Read the indications on the patient’s chart.
 Identify the patient and prepare him / her psychologically.
 Wash your hands and prepare the equipment.
 Select the site and palpate it.
 Clean the skin with an alcohol sponge.
 Stretch the skin.
 Insert the needle at an angle of 90 degrees and introduce the indicated dose.
 Test that the needle is not in a blood vessel.
  Inject the drug by pressing the plunger slowly.
 Withdraw the needle and make slight digital pressure.
 Observe the patient´s reaction.
 Collect the equipment and put it on the tray.
 Wash your hands.
 Write your observations on the patient´s chart.

4. SUBCUTANEOUS INJECTION
Procedure:
 Read the indications on the patient’s chart.
 Identify the patient and prepare him / her psychologically
 Wash your hands and prepare the equipment.
 Select the site and palpate it.
 Clean the skin with an alcohol sponge.
 Take the skin between the thumb and index.
 Insert the needle at an angle of 45 degrees.
 Inject the drug by pressing the plunger slowly.
 Withdraw the needle and make slight digital pressure.
 Observe the patient´s reaction.
 Collect the equipment and put it on the tray.
 Wash your hands.
 Write your observations on the patient´s chart.

5. INTRAVENOUS INJECTION
Equipments: Syringe, needle, kidney dish, alcohol sponge, rubber band.
Procedure:
 Read the indications on the patient’s chart.
 Identify the patient and prepare him / her psychologically.
 Wash your hands and prepare the equipment.
 Select the site and put the rubber band above it
 Clean the skin with an alcohol sponge.
 Insert the needle at an angle of 30 degrees.
 Test that the needle is in the blood vessel.
 Take off the rubber band.
 Introduce the medicine slowly.
 Withdraw the needle.
 Put a swab on the punctured site
 Observe the patient´s reaction.
 Collect the equipment and put it on the tray.
 Wash your hands.
 Write your observations on the patient´s chart.

III. NASOGASTRIC PROCEDURES

1. NASOGASTRIC LAVAGE
Equipments : Tray with: NG tube, syringe,container or jar, hand towel, kidney dish, icy water.
Procedure :
 Identify the patient and prepare him / her psychologically.
 Wash your hands and prepare the equipment.
 Measure dimension from nose to stomach.
 Put the towel on the patient´s chest.
 Lubricate the NG tube and introduce it slowly through the nose ( If the patient is conscious,
tell him/her to take a deep breath and swallow it)
 Test that the tube is in the stomach.
 Draw any digestive juice first.
 With the syringe introduce water slowly to avoid damaging the vessels.
 Withdraw the same amount of water introduced.
 Continue the procedure until the liquid comes out transparent.
 Observe the patient´s reaction .
 Pick up the equipments and wash your hands.
 Write your observations on the patient´s chart.

2. TUBE FEEDING
Equipments: Tray with: NG tube, kidney dish, syringe, towel or washcloths, glass of water,
blenderized food, adgesive tape.
Procedure :
 Identify the patient and prepare him / her psychologically.
 Wash your hands and prepare the equipment.
 Go to the patient´s unit.
 Put the towel on the patient´s chest.
 With the syringe, draw or aspirate any gastric content emptying it in the kidney dish. ( If the
patient has more than 100ml of gastric content he/ she must not be fed).
 Introduce the blenderized food slowly. (No more than 300 ml each time or according to the
doctor´s prescription)
 Pour water into the tube to clean it.
 If the tube is permanent, fix it with adhesive tape and close it.
 If not withdraw it slowly.
 Take off the towel and observe the patient´s reaction
 Pick up the equipments and wash your hands.
 Write your observations on the patient´s chart.

IV WOUNDS

1. CURE OF AN ASEPTIC WOUND

Equipment : Tray with sterile pack containing alcohol, forceps,sterile dressing, kidney dish,
scissors, instrument – handling forceps, bucket for used materials.
Procedure:
 Identify the patient and prepare him / her psychologically.
 Wash your hands and prepare the equipment.
 Go to the patient´s unit.
  Remove the dressing if there is any with forceps.
 Wash your hands again.
 Cure the wound with alcohol.
 Pick up the equipments and wash your hands.
 Write your observations on the patient´s chart.

2. CURE OF A SEPTIC WOUND

Equipment: Tray with: sterile pack containing gloves, syringe, gauze swab, scissors, saline
solution, jar with soapy water, adhesive tape, kidney dish, antibiotic in cream. Also carry a folding
screen to the patient´s unit.
Procedure:
 Identify the patient and prepare him / her psychologically.
 Wash your hands and prepare the equipment.
 Go to the patient´s unit and place the folding screen.
 Remove the dressing if there is any with forceps.
 Wash your hands again and put on gloves
 Clean the wound with soap and water.
 Irrigate it with antiseptic solution using a syringe.
 Dry the wound with a gauze swab.
 Apply the antibiotic prescribed by the doctor.
 Cover the wound with sterile dressing and fix it with adhesive tape.
 Take off gloves.
 Observe the patient´s reactions.
 Pick up the equipments and wash your hands.
 Write your observations on the patient´s chart.

3. HOW TO TAKE STITCHES

Equipment: Suture set containing: sponges, gloves, gauze bandage, needle, surgical thread,
forceps, antiseptic solution (Hydrogen peroxide, tincture of iodine etc.), adhesive tape, suture
scissors, container of kidney dish, cotton.
Procedure:
 Identify the patient and prepare him / her psychologically.
 Wash your hands and prepare the equipment.
 Clean the wound with soap and water and antiseptic solution.
 Put on gloves.
 Administer anesthesia.
 Put the wound edges together to suture it.
 Put antiseptic and antibiotic if necessary.
 Cover the wound with sterile dressing.
 Take off the gloves.
 Observe the patient´s reactions.
 Pick up the equipments and wash your hands.
  Write your observations on the patient´s chart.

4. HOW TO TAKE STICHES OUT

Equipment: Dissecting forceps, suture scissors, cotton swabs.
Procedure:
 Identify the patient and prepare him / her psychologically.
 Wash your hands and prepare the equipment.
 Take the dissecting forceps in one hand and withdraw the stitches.
 Clean the site with alcohol.
 Wash your hands again.
 Observe the patient´s reactions.
 Pick up the equipments and wash your hands.
 Write your observations on the patient´s chart.

5. COLOSTOMY CARE
Equipment : Kocher´s forceps , cotton swabs, folded gauze, depressor and applicator sticks,
scissors, plastic bag, bucket, solutions (soapy water, saline etc.) toilet paper.
Procedure:
 Identify the patient and prepare him / her psychologically.
 Wash your hands and prepare the equipment.
 Go to the patient´s unit and place the folding screen.
 Uncover the colostomy, remove the plastic bag and the dirty gauze with forceps.
 Clean the area with toilet paper or gauze if necessary using soapy water.
 Wash your hands.
 Clean the site with saline solution.
 Put lubricant ariund the stomach.
 Place the sterile bag.
 Observe the patient´s reactions.
 Pick up the equipments and wash your hands.
 Write your observations on the patient´s chart.

V. PHYSICAL EXAMINATION

1. BREAST EXAMINATION
Equipment : Examining table, chair , pillow.
Procedure:
 Identify the patient and prepare him / her psychologically
 Wash your hands.
 Tell the patient to slower her slip to the waist.
 Put the patient sitting straight with her hands on the hips.
 Inspect and palpate each breast looking for: symetry,size, color, nipple retraction,
discharge, masses, ulcerations etc..
 With the patient lying down with a pillow under her shoulders and arms over her head,
continue the examination with the pads of your fingers..
 Compress the breast tissue gently, examining it entirely ( periphery and aureola)
 Observe the patient´s reactions.
  Pick up the equipments and wash your hands.
 Write your observations on the patient´s chart.

2. GYNECOLOGICAL EXAM (PREPARATORY STAGE)

Equipment: Folding screen, examining table, sheet, pillow.
Procedure:
 Identify the patient and prepare him / her psychologically
 Tell the patient to empty her bladder.
 Place a folding screen in front of the examing table.
 Put the patient in the lithotomy position, her feet resting on stirrups and the buttocks on the
edge of the table.
 Cover her with a sheet up to her tigh or knees.
 Put a pillow under the patient´s head to support it.
 Tell her to put her arms at her sides or folded accross the chest.

3. GYNECOLOGICAL EXAM
Equipment: Vaginal speculum, good light, gloves, lubricant ( if cytological or other exams are
not planned)
Procedure:
 Identify the patient and prepare him / her psychologically.
 Wash your hands and prepare the equipment.
 Go to the patient´s unit and place the folding screen.
 Turn on the lamp and sit yourself comfortably.
 Put on gloves and select the speculum of approppriate size
 Lubricate the speculum.
 Place two fingers at the introitus and press down.
 With the other hand introduce the closed speculum.
 After the speculum is in the vagina, remove your fingers.
 Put the blades of the speculum into a horizontal position.
 Open the blades and secure them with the thumb screw.
 Inspect the cervix and its color, any mass, bleeding, discharge, ulcerations etc.
 After the inspection withdraw the speculum slowly, release the screw and close the blades.
 Take off gloves.
 Observe the patient´s reactions.
 Pick up the equipments and wash your hands.
 Write your observations on the patient´s chart.

4. CYTOLOGICAL EXAM
Equipment: Speculum, gloves, good light, ether, alcohol, fixative material or bacteriologic
cultures, cotton applicator stick, swab, glass slide.
Procedure:
 Follow the same procedure of the previous technique.
 Before withdrawing the speculum take the sample (smear the glass slide with it gently).
 Remove the speculum gently.
 Put the slide into the fixative at once.
 Take off gloves.
  Observe the patient´s reactions.
 Pick up the equipments and wash your hands.
 Write your observations on the patient´s chart.

5. RECTAL EXAMINATION
Equipment: Good light, folding screen, gloves, lubricant.
Procedure:
 Identify the patient and prepare him / her psychologically.
 Wash your hands and prepare the equipment.
 Go to the patient´s unit and place the folding screen.
 Put the patient lying down in lateral position, legs somewhat flexed, buttocks close to the
edge of the examinig table.
 Put on gloves and lubricate index finger.
 With your left hand spread buttocks appart.
 Ask the patient to strain down.
 Insert your finger into the anal canal, trying to reach the rectum.
 Ask the patient to relax.
 Examine the rectal wall carefully.
 Identify size, shape,irregularities, any nodularity, tenderness, consistensy of the prostate
( in men).
 After the exam withdraw your fingers gentlyº
 Take off the gloves and wash your hands.
 Observe the patient´s reactions.
 Write your observations on the patient´s chart.

6. CHEST AUSCULTATION
Equipment : Stethoscope, folding screen.
Procedure:
 Identify the patient and prepare him / her psychologically.
 Wash your hands and prepare the equipment.
 Go to the patient´s unit and place the folding screen.
 Put the patient in the sitting position, undressed to the waist.
 Put on the stethoscope.
 Tell the patient to take a deep breathand to continue breathing through the mouth.
 Listen for clarity, intensity of the sounds as well as abnormal sounds.
 Ask the patient to say : “ninety nine” and compare symetrical sites of the chest and lungs,
from above – down.
 Write your observations on the patient´s chart

VI MISCELANEOUS

1. WARNING WHEN TAKING BP.

 If the patient is anxious, make repeated measurements of the BP before giving a final
conclusion. Anxiety is a frequent cause of HBP.
 If BP is inaudible
1. Check for erroneous placements of the stethoscope.
 2. There may be blood clotting in the arm for repeated inflation of the cuff. So
remove the cuff, elevate the patient´s arm for two minutes and try again.

 If the right arm has any difficulty or incapacity, then check the BP on the left arm and add 10
mmHg to the meassure.

2. BLOOD INFUSION (Transfusion)

 First check the patient´s blood, group and factor.
 Chek the blood to be used has the adequate temperature.
 Avoid shaking the blood containent.
 Test that the needle is deep in the selected vein.
 Observe the patient´s reaction carefully.

3. CAUTIONS WITH THE BLAKEMORE-SENGSTAKEN TUBE

 The tube should not be left down in the patient´s stomach for more than 58 hours. He / she
may get pressure necrosis.
 If the patient gets regurgitation of saliva, it may lead to aspiration pneumonia.

4. MEASSURES TO AVOID CROSS INFECTIONS.

 Wash your hands.
 Wear gloves when necessary.
 Use forceps.
 Use sterile material
 Cover aseptic wound like bedsores and others.

5. CAUTIONS IN PELVIC OR RECTAL EXAM.

 After touching the patient, never touch the tube of lubricant with your gloved hands.
 If you should perform a vaginal exam after a rectal one on the same patient, change gloves
to avoid spreading infections.