College of applied medical science -Nursing department

Checklist book for nursing

care of adult II
Level 5 – 2020-2021

College of applied medical science

HAFR AL BATIN UNIVERSITY
 Table of content
No Topic Name Page No Dr-
signature
1 Pre-operative care 1-4
2 Leg exercise 5-6
3 breathing exercise 7-9
4 Intra operative care, preparing a sterile Field 10-12
& Adding sterile items.
5 Providing Postoperative Care 13-17
6 Surgical drain care 18
7 Colostomy care 19-20
8 Nasogastric tube insertion 21-22
9 Administering nasogastric tube feeding 23-24
10 Removal of nasogastric tube 25
11 Hemodialysis 26.27.28
13 Sutures and staples removal 29-30-31
14 Blood transfusion 32-33
15 Glasgow coma score 34-35

1
 Providing Preoperative Patient Care: (Day of Surgery)
Steps of the procedure Not
Done
done
1. Check the patient’s chart for the type of surgery and review the medical
orders.

2-Review the nursing database, history, and physical examination. Check

that the baseline data are recorded; report those that are abnormal.

3. Gather the necessary supplies and bring to the bedside stand or over bed
table.
4. Perform hand hygiene and put on PPE, if indicated.

5. Identify the patient

6. Close curtains around bed and close the door to the room, if possible.

7-Explain what you are going to do and why you are going to do it to the
patient.
8. Check vital signs. Notify primary care provider and surgeon of any
pertinent changes (e.g., rise or drop in blood pressure, elevated temperature,
cough, symptoms of infection).
9. Provide hygiene and oral care. Assess for loose teeth and caps. Remind
patient of food and fluid restrictions before surgery
10. Instruct the patient to remove all personal clothing, including underwear,

2
and put on a hospital gown.
11. Ask patient to remove cosmetics, jewelry including body piercing, nail
polish, and prostheses (e.g., contact lenses, false eyelashes, dentures, and so
forth).
12-Some facilities allow wedding band to be left in place depending on the
type of surgery, provided it is secured to the finger with tape

13. If possible, give valuables to family member or place valuables in

appropriate area, such as the hospital safe.
14. Have patient empty bladder and bowel before surgery
15. Attend to any special preoperative orders, such as starting an IV line.
16. Complete preoperative checklist and record of patient’s preoperative
preparation
17. Question patient regarding the location of the operative site.
18-Document the location in the medical record according to facility policy.

19. Administer preoperative medication as prescribed by

physician/anesthesia provider
20. Raise side rails of bed; place bed in lowest position. Instruct patient to
remain in bed or on stretcher. If necessary, use a safety belt.
21. Help move the patient from the bed to the transport stretcher, if
necessary.

3
22-Reconfirm patient identification and ensure that all preoperative events
and measures are documented
23. Tell the patient’s family where the patient will be taken after surgery
and the location of the waiting area where the surgeon will come to explain
the outcome of the surgery.
24- After the patient leaves for the operating room, prepare the room and
make a postoperative bed for the patient.
25-Anticipate any necessary equipment based on the type of surgery and
the patient’s history.
26- Remove PPE, if used. Perform hand hygiene
Total / 26

4
 Leg exercise
Steps of procedure
Done Not done

1. Check the patient’s chart for the type of surgery and review the
medical orders.
2. Gather the necessary supplies and bring to the bedside stand or
over bed table.
3. Perform hand hygiene and put on PPE, if indicated.

4. Identify the patient.

5. Close curtains around bed and close the door to the room,
if possible.
6. Explain what you are going to do and why you are going to do
it to the patient.

7. Identify the patient’s level of knowledge regarding

leg exercises.
10. Explain the rationale for performing leg exercises.
11. Assist or ask the patient to sit up (semi-Fowler’s position) and
explain to the patient that you will first demonstrate, exercise one
leg at a time.
12. Straighten the patient’s knee, raise the foot, extend the lower
leg, and hold this position for a few seconds.
13. Lower the entire leg. Practice this exercise with the other leg.

5
14. Assist or ask the patient to point the toes of both legs toward
the foot of the bed, and then relax them. Next, flex or pull the toes
toward the chin.
15. Validate the patient’s understanding of information.
16. Ask the patient to give a return demonstration.
17. Ask the patient if he or she has any questions.
19. Remove PPE, if used. Perform hand hygiene
20. Record.
Total /20

6
 Breathing and coughing exercise
Steps of the Procedure Done Not
done
1. Check the patient’s chart for the type of surgery and
review the medical orders.
2. Gather the necessary supplies and bring to the bedside
stand or over bed table.
3. Perform hand hygiene and put on PPE, if indicated.

4. Identify the patient

5. Close curtains around bed and close the door to the
room, if possible.
6. Explain what you are going to do and why you are
going to do it to the patient.
7. Identify the patient's level of knowledge regarding
deep breathing exercises, coughing, and splinting of the
incision.
8. Explain the rationale for performing deep breathing
exercises, coughing, and splinting of the incision.
9. Assist or ask the patient to sit up (semi- or high-
Fowler's position) and instruct the patient to place the
palms of both hands along the lower ante.
10. Instruct the patient to exhale gently and completely.

7
 11. Instruct the patient to breathe in through the nose as
deeply as possible and hold breath for 3 seconds.
12. Instruct the patient to exhale through the mouth,
pursing the lips like when whistling.
13. Have the patient practice the breathing exercise three
times.
14. Instruct the patient that this exercise should be
performed every 1 to 2 hours for the first 24 hours after
surgery

15. Provide teaching regarding coughing and splinting

(providing support to the incision).
16. Ask the patient to sit up (semi-Fowler’s position) and
apply a folded bath blanket or pillow against the part of
the body where the incision will be (e.g., abdomen or
chest)
17. Instruct the patient to inhale and exhale through the
nose three times.
18. Ask the patient to take a deep breath and hold it for 3
seconds and then cough out three short breaths.
19. Ask the patient to take a breath through the mouth
and strongly cough again two times.
20. Instruct the patient that he or she should perform
these actions every 2 hours when awake after surgery

8
 21. Validate patient’s understanding of information.

22-Ask the patient to give a return demonstration.

23. Remove PPE, if used. Perform hand hygiene

24. Record.
Total / 24

9
 Intraoperative Care
Preparing a Sterile Field Using a Packaged Sterile Drape and Sterile Kit

Done Not done

1. Perform hand hygiene and put on PPE, if indicated.

2. Identify the patient. Explain the procedure to the patient.
3. Check that packaged sterile drape is dry and UN opened. Also, note
Expire date, making sure that the date is still valid
4. Select a work area that is waist level or higher.

5. Open the outer covering of the drape. Remove sterile drape, lifting it
carefully bits corners.
6-Hold away from body and above the waist and work surface.

7- Continue to hold only by the corners. Allow the drape to unfold, away
from your body and any other surface.
8- Position the drape on the work surface with the moisture proof side
down. This would be the shiny or blue side.
9-Avoid touching any other surface or object with the drape.

10-If any portion of the drape hangs off the work surface, that part of the
drape is considered contaminated
11- Place additional sterile items on field as needed.
12-Continue with the procedure as indicated.

13-When procedure is completed, remove PPE, if used. Perform hand

hygiene

10
 Adding sterile items to a sterile field
Steps the procedure Done Not done

1. Perform hand hygiene and put on PPE, if indicated.

2. Identify the patient. Explain the procedure to the patient.
3. Check that the sterile, packaged drape and supplies are dry and
unopened.
4-Also note expiration date, making sure that the date is still valid.
5. Select a work area that is waist level or higher.
6. Prepare sterile field
7. Add sterile item
A-To Add an Agency-Wrapped and Sterilized Item
8-Hold agency-wrapped item in the dominant hand, with top flap
opening away from the body.

9-With other hand, reach around the package and unfold top flap and
both sides.

10--Keep a secure hold on the item through the wrapper with

the dominant hand. Grasp the remaining flap of the wrapper closest to
the body, taking care not to touch the inner surface of the wrapper or
the item.
11-Hold the item 6 inches above the surface of the sterile field and
drop onto the field. Be careful to avoid touching the surface or other
items or dropping onto the 1-inch border.
B-To Add a Commercially Wrapped and Sterilized Item
12. Hold package in one hand. Pull back top cover with other hand.
Alternately, carefully peel the edges apart using both hands.
13-After top cover or edges are partially separated, hold the item 6
inches above the surface of the sterile field.

11
14-Continue opening the package and drop the item onto the field.

15-Be careful to avoid touching the surface or other items or dropping

onto the 1-inch border

16-Discard wrapper

C-To Add a Sterile Solution

17. Obtain appropriate solution and check expiration date.
18- Open solution container per directions and place cap on table
away from the field with edges up
19-. Hold bottle outside the edge of the sterile field with
the label side facing the palm of your hand and prepare to
pour from a height of 4 to 6 inches (10 to 15 cm).
20-The tip of the bottle should never touch a sterile container or field
21-Pour required amount of solution steadily into
sterile container previously added to the sterile field and positioned
at side of sterile field or onto dressings.
22-Avoid splashing any liquid.
23- Continue with procedure as indicated.
24- When procedure is completed, remove PPE, if used. Perform
hand hygiene
Total / 24

12
 Providing Postoperative Care
Steps of the procedure Done Not done
A-Immediate Care
1-When patient returns from the post-anesthesia care unit obtain

a report from the PACU nurse

2. Perform hand hygiene and put on PPE (protective
personal equipment), if indicated.
3. Identify the patient.
4. Close curtains around bed and close the door to the room, if possible.
5-Explain what you are going to do and why you are going to do it to
the patient.
6- Place patient in safe position (semi- or high Fowler’s or side-lying).
Note level of consciousness.
7. Obtain vital signs. Monitor and record vital signs frequently. includes
taking vital signs every 15 minutes the first hour, every 30 minutes
the next 2 hours, every hour for 4 hours, and finally every 4 hours.
8. Assess the patient’s respiratory status. Measure the patient's
oxygen saturation level.
9. Assess the patient’s cardiovascular status.
10. Assess the patient’s neurovascular status, based on the
type of surgery performed.
11. Provide for warmth, using heated or extra blankets, as necessary.
12- Assess skin color and condition.

13
13- Check dressings for color, odor, presence of drains, and amount
of drainage.
14-Mark the drainage on the dressing by circling the amount,
and include the time.
15- Verify that all tubes and drains are patent and
equipment is operative; note amount of drainage in collection device.
16- If an indwelling urinary (Foley) catheter is in place, note
urinary output

17- Verify and maintain IV infusion at correct rate

18- Assess for pain and relieve it by administering medications
ordered by the physician.
19-If the patient has been instructed in use of PCA for pain
management, review its use.
20. Provide for a safe environment.
21-Keep bed in low position with side rails up, based on facility policy.
Have call bell within patient’s reach.
22- Remove PPE, if used. Perform hand hygiene.

b-Ongoing Care
1. Promote optimal respiratory function.
2. Assess respiratory rate, depth, quality, color, and capillary refill.

3. Ask if the patient is experiencing any difficulty breathing.

14
4. Assist with coughing and deep breathing exercises
5. Assist with incentive spirometry
6. Assist with early ambulation.
7. Provide frequent position change.
8. Administer oxygen as ordered.
9. Monitor pulse oximetry
10.Promote optimal cardiovascular function:
11.Assess apical rate, rhythm, and quality and compare with
peripheral pulses, color, and blood pressure.

12.Ask if the patient has any chest pains or shortness of breath

13.Provide frequent position changes.

14.Assist with early ambulation.
15.Apply anti embolism stockings or pneumatic compression devices,
if ordered and not in place. If in place, assess for integrity.
16.Provide leg and range-of-motion exercises if not contra indicated.
17.Promote optimal neurologic function
18.Assess level of consciousness, motor, and sensation.
19.Determine the level of orientation to person, place, and time.
20.Test motor ability by asking the patient to move each extremity
21.Evaluate sensation by asking the patient if he or she can feel your
touch on an extremity.
22.Promote optimal renal and urinary function and fluid
and electrolyte status.

15
23.Assess intake and output, evaluate for urinary retention
and monitor serum electrolyte levels.
24.Promote voiding by offering bedpan at regular intervals
25.noting the frequency, amount, and if any burning or urgency
symptoms.
26.Monitor urinary catheter drainage if present.
27.Measure intake and output.
28.Promote optimal gastrointestinal function and meet
nutritional needs:
29.Promote voiding by offering bedpan at regular intervals, noting
the frequency, amount, and if any burning or urgency symptoms.
30.Assess abdomen for distention and firmness. Ask if patient
feels nauseated, any vomiting, and if passing flatus.
31.Auscultate for bowel sounds.
32.Assist with diet progression; encourage fluid intake;
monitor intake.
33.Medicate for nausea and vomiting, as ordered by physician.
34.Promote optimal wound healing.
35.Assess condition of wound for presence of drains and any drainage.
36.Use surgical asepsis for dressing changes.
37.Inspect all skin surfaces for beginning signs of pressure ulcer
development and use pressure-relieving supports to minimize
potential skin breakdown.

16
38.Promote optimal comfort and relief from pain.
39.Assess for pain (location and intensity).
40.Provide for rest and comfort; provide extra blankets, as needed,
for warmth.
41.Administer pain medications, as needed, or other non-
pharmacologic methods.
42.Promote optimal meeting of psychosocial needs:
43.Provide emotional support to patient and family, as needed.
44.Explain procedures and offer explanations regarding
postoperative recovery, as needed, to both patient and
family members
Total / 44

17
 Surgical drain care
Steps of the procedure Done Not done
1-Assess client’s level of comfort and/or pain Prior to beginning
procedure.
2. Medicate client for pain, if needed
3-wash hand
-4-Assemble equipment
5.Open sterile packages of gauze, suction
catheter, and transparent film or Sterile-drape.
6. Apply clean gloves and remove old dressing, placing it in an
appropriate receptacle
7. Change to a new pair of clean or sterile gloves
8-The choice of gloves is determined by institutional policy
9. Moisten several packages of gauze with normal saline
10. Cleanse wound bed with moistened (NS) gauze pads
11. Lay drain/catheter over the fistula site in wound bed.
12. Open moistened gauze pads and lay them in the wound bed
over the drain
13. Cover the entire wound with the transparent film, Sterile-
drape, or other occlusive dressing

. 14.Attach drain/catheter to intermittent low wall suction.

15. Empty and record drainage from suction apparatus at least
every 8 hours
16. Change dressing system as needed depending on intactness
of seal
Total / 16

18
 Colostomy care
Steps of the procedure Done Not done
1. 1-Explain the procedure to the patient (to alleviate
anxiety).
2. 2-Screen the patient (to provide for privacy).
3. Prepare all materials needed (to conserve time and
energy).
4. Wash your hands thoroughly (to prevent spread of
infection).
5. Wear gloves
6. Remove contents of the pouch; Turn the bottom of the
pouch upward, and then take off the clamp. Let
contents drain into the bedpan. Wipe the end of the
pouch with tissue paper, and then return the clamp.
7. Remove the pouch by taking off the tape, while
pressing underneath the skin.
8. Wipe the stoma with a wet wash cloth, then flushes it
with a doctor prescribed cleansing solution. Rinse
thoroughly
9. Start dries the skin around the stoma (the pouch will
adhere effectively to a dry surface).
10.If needed, shave surrounding hair (to provide a better
adhesion, and prevent irritation from hair pulling
against the adhesive).

19
 11.Measure stoma with guide provided. Select a flange
size at least 1/2 cm. larger than the stoma
12.Trace stoma size on to the white backing paper,
centering around the starter hole.
13. Cut along tracing using curved scissors. Remove
white backing paper. Center enlarged hole over stoma,
then press firmly the sticky side to the skin
14.(to ensure adhesion).
15.Carefully pull on the pouch (to check if the pouch is
fixed firmly over the stoma).
16.Allow a bit of air in the pouch (so drainage will fall to
the bottom). Put on closure clamp (to prevent
leakage).
17. Discard old appliance and used gloves properly.
18.Document.
Total / 18

20
 Nasogastric tube insertion:
steps Done Not done

1. Check physician’s order for insertion of nasogastric tube

2. Identify patient
3. Explain procedures
4. Collect equipment
5. Wash hands
6. Provide privacy
7. Stand at right side
8. Elevate level of bed
9. Put side rail down at working area
10.Prepare equipment at bed side
11.Put patient in high fowler position
12.Place towel over chest
13.Instruct patient to relax and breathe normally while occluding
one narks then repeat for other naris. Select nostril with greater
air flow
14.Put on sterile gloves
15.Roll tube from distill end around non –dominant hand
16.Measure distance for NGT placement
17.Mark with marker this length
18.Curve 10 to 15 cm of tube tightly around index finger then
release for easy insertion
19.Lubricate about 7.5 cm with water soluble gel

21
 20.Insert tube while asking patient to keep head extended,
continue to insert tube
21.If you meet resistance, try to rotate tube and advance
downward
22.If it still resists, with draw tube and try in other naris

23.If tube passed nasopharyngeal ask patient to swallow and flex

neck while you continue advance tube to marked point
24. If patient begin to cough, gag reflex stop advance tube
25. Allow take sips of water
26.Take breath. If she still coughing remove tube
27.Verify tube placement
28.Ask patient to speak
29.Inspect posterior pharynx for presence of tube coiled
30.Push 30 cc air and auscultate over stomach
31.Aspirate stomach content
32.Measure PH of aspirate with color –code PH indictors
33.Anchor tube
34.Clamp distal end of tube
35.Tape to nose correctly by wrapping two split ends of tape
around tube
36. Once tube is confirmed, place mark on tube indicate where
tube exit the nares
37. Cover patient

38.Put side rail up

39.Put bed level down
40.Wash hands
41.Record
Total / 41

22
 Administering nasogastric tube feeding
Steps Done Not
done
1. Identify patient
2. Explain procedures
3. Collect equipment
4. Wash hands
5. Provide privacy
6. Stand at right side
7. Elevate level of bed
8. Put side rail down at working area
9. Be sure the formula is at room temperature
10. Arrange equipment beside bed
11. Move patient up in bed. Put patient in high fowler position

12. Check the placement of tube. Aspirate gastric content by

50 ml syringe if no fluid come push 30 ml air and try again

13.Use PH indicator to confirm it is gastric fluid (PH of gastric

content between 1 to 4)

14. Check gastric residual by aspirating content measure

residual

15. If more than 100 ml return to stomach and hold feeding

Recheck after 1 hour

23
 16. Flush tube before feeding with 30 ml water
17. Administer feeding

18.Remove plunger from syringe

19. Pinch open end of tube to remove clamp without allow

for air flow

20. Attach barrel of syringe to open end while maintain

pinching end
21. Fill syringe with formula

22. Release pinching to allow formula flow

23. Hold syringe 45 cm above stomach to allow gravity draw

formula

24. Continue refill syringe before, it become empty-or

using infusion pump and adjust flow rate-or feeding bag

25. Flush tube by 30 to 50 ml water

26. Keep patient in fowler position for 30 min
27. Follow care
28. Cover patient
29. Put side rail up
30. Put bed level down
31. Wash equipment
32. Wash hand
33. Record time, amount, type and pt. response
Total / 33

24
 Removal of nasogastric tube
Steps of the procedure Done Not done

1. Check the physician order

2. Explain procedure the patient
3. Wash hands
4. Collect the equipment's -gloves -paper tissues
5. Wash clothes to clean naris -bag to dispose used supple
6. Provide privacy
7. Elevate bed level and put down side rail

8. Put patient in high fowler position

9. Clamp tube

10. Loosen tape securing tube

11. Pinch tube near nostril and remove with continuous pull
12. As tube being removed, hold in paper towel
13. Provide oral, nasal care
14. Dispose equipment and wash hand
15. Record

Total /15

25
 Hemodialysis
Procedure steps Done Not
done
Make sure the machine is ready
1. Apply standard protocol
2. Weigh the patient.
3. Record his baseline vital signs.
4. Check his mental status
5. Condition and patency of the access site.
6. Also check for problems occurring since the last dialysis,
7. Evaluate previous laboratory data.
8. Help the patient into a comfortable position (supine or sitting
in recliner chair with feet elevated).
9. If the patient is undergoing Hemodialysis for the first time,
explain the procedure in detail.
10.Wash your hands and put on glove
11.Flush the fistula needles, using attached syringes containing
heparin flush solution, and set them aside.
12. Place a linen-saver pad under the patient’s arm.
13.Using sterile technique, clean area of skin over the fistula with
povidone-iodine pads. 14. Discard each pad after one wipe.

26
 (If the patient is sensitive to iodine, use chlorhexidine
gluconate or alcohol instead.)
14.Apply a tourniquet above the fistula.
15.Put on clean gloves. Perform the venipuncture with a fistula
needle. Insert the arterial needle at least (2.5 cm) above the
anastomosis, being careful not to puncture the fistula.
16.Release the tourniquet and flush the needle with heparin flush
solution.
17.Clamp the arterial needle tubing with a hemostat, and secure
the wing tips of the needle to the skin with adhesive tape.
18.Perform another venipuncture with the venous needle a few
inches above the arterial needle. Flush the needle with heparin
flush solution. Clamp the venous needle tubing, and secure.
19.Remove the syringe from the end of the arterial tubing, and
connect the two lines securely. Repeat these two steps for the
venous line.
20. Release the hemostats and begin Hemodialysis
according to your unit's policy
21.Apply standard protocol during intervention
Implementation of the Procedure
1. Wash your hands.
1. Unclamp the saline solution to allow a small amount to flow
through the line. Unclamp the hemostat on the machine line.

27
 2. Rinse and disinfect Hemodialysis machine according to the
manufacturer's instructions
3. Turn the blood pump on the Hemodialysis machine 50 - 100
ml/minute.
4. Blood is returned from the dialyzer to the reticent through the
second needle or blue catheter lumen.
5. Adjust ultrafiltration by creatinine positive pressure on the
blood side or negative pressure on the dialysate side or by a
correct nation controllers that equalize negative and positive
pressures.
6. The dialysis system has alarm systems to warn of blood
leaking into the dialysate or leaking into the blood alterations
in dialysate temperature, concentration, or pressure, and
extremes in BP readings.
7. Documentation
8. Record the time treatment began and finishes problems with it.
9. Patient's vital signs
10.Weight before and after treatment.
11.Blood samples were taken for testing, the test results, -
treatment for complications.
12.Record the time the treatment was completed and the patient's
response to it.

28
 Sutures and staples removal
No steps Done Not done
1 Assessment
 Review physician's order and ensure that
day seven or more is reached.
 Review the pt file or chart for.
 Diagnoses.
 Medical history.
 History of allergens.
 Identification.
 Explanation of the procedure.
 Environmental assessment.
 General and specific pt. assessment.
2 Planning:
 Develop goals based on nursing diagnoses to
avoid injuring the surrounding tissues and
minimizing discomfort.
 Prepare dressing equipment +staples extractor
3 Implementation:
 Take supplies to bed side and rein form
the pt.
 Prepare the environment.

29
  Pt. position.
 Apply dry dressing steps.
Remove staples:
 Are removed by extractors.
 Place the lower tip under the first staple
while opening it.
 When it is secured in place carefully close
it.
 Discard the staple in the pre prepared bag
or even piece of gauze. Continuous sutures
Removing intermittent sutures:
 Hold scissor in the dominant hand and the
forceps in the none dominant one.
 With sterile gauze compress few inches
from the sutures line to release them.
 Grasp the knot with tissue forceps, and by
the scissor or blade tip cut from close to
skin and pull to removed.
 Observe healing after each suture removal
as removal of all suture or intermittent
removal is a Nursing judgment.
• Removing continuous sutures:
 Hold your scissor and forceps.

30
  Compress with sterile gauze few inches
from suture to release them. Snip the first
suture close to skin distal to knot.
 Snip the second suture in the same side
continue till the whole line removed.
 For all apply gentle pressure to wound
site, proper wiping, drying and dressing
with light cover.
4 Evaluation:
 Assess site where suture are removed through
good inspection of soft tissues and skin.
 Determine whether the client has pain along
the incision
5 • Recording and reporting:
 Record number of sutures removed.
 Date and time of removing.
 Immediate notification of the physician of
any of the following:
 Dehiscence: Burst outer layer.
 Evisceration: Burst inner layer.
 Bleeding or purulent discharge

31
 BLOOD TRANSFUSION

N o Steps Done Not

done
1 Assessment:
1.Assess clinical signs of reactions

2
Planning:
2.Verify physician order for transfusion.
3.Verify client consent and obtain baseline.
4.Determine any known allergies
3 Implementation:
5.Explain the procedure to the patient to reduce his
anxiety from transfusion.
6.Insert cannula and start infusion of normal saline.

4 Performance:
1- Obtain the correct blood component for the
patient.
7.Check the physician order with the request.
8.Check the requisition form and the blood bag label
with a laboratory technician, check client name,
identification number, blood type (A, B, AB, O) and
rhesus group, the blood donor number, and the
expiration date of the blood.
9.Observe the blood for abnormal color, RBCs
clumping or gas bubbles.

32
 2-Verify the client identify ask about full name and
check the client arm band for name if available.
3. Stablish the blood transfusion:
10.Observe the client closely for the first 5 – 10
minute.
4. Document relevant data:
11.Record starting the blood include vital signs, type
of blood, blood unit number, sequence number, site of
Venipuncture and the needle & drip rate.
12. Monitor the client:
5. Terminate the transfusion:
13.Put on clean gloves.
14.Clamp the blood tubing. & remove the needle, if
another infusion is to be follow clamp the blood &
open the saline infusion arm.
15.Discard the administration set according to the
agency policy
16.Put needle in a labeled puncture resistant
container.
17.Bagged & label the administration set & blood bag
before being sent to decontamination according to the
hospital policy.
18.Remove the gloves.
19.Monitor patient vital signs.
•
5 Evaluation:
Changes in vital signs or health status and the presence
of chills , nausea , vomiting or skin rash

33
 Glasgow coma score
Steps of the procedure Done Not done

1. Use universal precautions. Wear facemask, gown, gloves and

goggles when attending to a patient.
I. Assess eyes

2. Observe the patient’s eyes. A patient that has eyes that are
opening spontaneously receives a 4.
3. Supply vocal stimulus by asking the patient loudly and clearly
to open their eyes. If the patient responds by opening their
eyes they receive a 3.
4. Elicit a pain response by pushing down behind the ear
anterior to the mastoid process. You can also push down on
the patient’s finger nail bed. If the patient then opens their
eyes they receive a score of 2.
5. If there is not any response to pain the patient receives a score
of 1.

II. Assess verbal response

6. Ascertain whether the patient is orientated to time and place.
Patients’ that respond appropriately receive a 5.

7. If the patient appears slightly confused and/or disorientated

during conversation they receive a 4.
8. Inappropriate speech. If the patient has random or muddled
speech without exchange of information during
conversation they receive a 3.

9. Incomprehensible: If the patient is making sounds but is

unable to formulate words they receive a 2.

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 10. A patient that is unable to produce sounds receives a None
1. This does not refer to aphasia due to any cause, such as airway
obstruction or laryngeal injury.

III. Assess motor response

11. Obeys Commands (6): A patient who responds to you and

does what you ask receives a 6.
12. Elicit a pain response through the techniques previously
mentioned. If the patient purposefully attempts to remove the
stimulus they receive a 5 Localizing to pain.
13. Elicit a pain response through techniques previously
mentioned. If the patient pulls away from the stimulus they
receive 4 a Withdraws to pain.

14. Elicit a pain response. If the patient’s arms move toward

their chest, their fingers and wrists flex on their chest and they
point their toes, then they are said to have decorticate posturing
and receive a 3 Abnormal Flexion (Decorticate).
15. Elicit a pain response. If the patient’s arms and legs extend,
their wrists rotate away from their body and they point their toes,
then they are said to have decerebrate posturing Abnormal
Extension and receive a 2.
16. A patient that does not have a motor response receives a
1. No Response.

17. Record

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