INTERVIEWING SKILLS

PURPOSES:

1. To establish a complete database for problem identification.

2. To utilize data for future intervention.
3. To build rapport and trust with the patient.
4. To provide health teaching

EQUIPMENTS

 Paper, pen and chairs.

S.NO STEPS RATIONALE S U

1 Identify the patient. To give required care to right patient.
2 Introduce self and explain the Helps minimize anxiety and to gain co-
purpose of interviewing. operation.
3 Establish comfortable Facilitates more open exchange of
environment. information without fear and anxiety.
 Space, lighting, noise, and
ventilation.
4 Maintain eye contact throughout It ensures that the interviewer is giving
the interview maximum attention.
5 Ask open – ended questions and Give the patient a broader aspect to give
one question at a time. details explanation to one choice and creates
confusion.
6 Use appropriate communication It communicates interests, promotes
skills understanding and trust.
 Speaking softly, Silence and
Listen carefully.
7 Give appropriate non-verbal Encourages patient to continue and ensure
response that attention is being paid.
 Nodding, Posture / Gait, Hand
movements, Silence and
Listening
8 Encourage patient to ask Makes the patient feel involved in his own
questions. care and ensure two way communications.
9 Respond to patient to ask Imposing your own values on patient or
questions. giving false assurance can break trust and
rapport.
10 Use therapeutic touch, when a) Give gently touch may help the patient talk
appropriate about difficult or painful experience.
b) Express care and concern.
11 Do not interrupt unnecessarily. This can break continuity of conversation and
 can miss important information.
12 Terminates the interview by: To maintain the rapport and trust established
 Summarization. during the interview and facilitates future
interactions.
13 Documents date, time patient Provides information valuable for assessing
observation and patient responses patient’s needs and problem.
in the assessment form and nursing
notes.

MEDICAL HAND WASHING

PURPOSES:

1. To reduce the number of microorganisms on hands.

2. To reduce the risk of transmission of microorganisms to patient.
3. To reduce the risk of cross contamination among patient.
4. To reduce the risk of transmission of infectious organisms to oneself.
(Erb & Kozier: FON (2004) pp. 641-645)
EQUIPMENTS:

 Soap in soap dish.

 Hand towel.
 Tissue paper.
 Tray.

STEPS RATIONALE S U
1. Check hands for break in the skin. For your own protection.
2. File nails short. Short nails are less likely to harbor
microorganisms, scratch client, or puncture
gloves.
3. Remove all jewelry (ring, bangles, Microorganisms can lodge in jewelry and
wristwatch) removal facilitates proper cleaning.
4. Stand in front of the sink. Keeping hands and Inside the risk is contaminated. Reaching over
uniform away from the sink surface. the sink increases risk of touching
contaminated edge.
5. Turn on the water tap, using towel paper Water will not splash on uniform.
(Adjust the flow of water).
6. Wet hands, holding the hands lower than the Water should flow from the least contaminated
elbow. to the most contaminated area.
7. Apply soap to the hands (if a soap bar is used, Soap cleanses by emulsifying fat oil and
rinse it before returning to the dish) lowering surface tension.
8. Use friction – 1 min Friction and rubbing mechanically loosens and
 Palm to path removes dirt and transient bacteria.
 Rub right palm over left dorsum
  Inter lace fingers and clasp palm to palm
 Clasp back of fingers to opposing palm
 Rub right thumb in rotational fashion.
 Rub left thumb in rotational fashion.
 Use circular movement for wrist and
back of palm and rub them.
9. Thoroughly wash soap off and rinse hands use The circular actions help remove soap and
firm rubbing and circular movements. microorganisms mechanically.
10. Turn off tap using paper towel. Prevent recontamination of washed fingers.
11. Dry hands thoroughly, including b/w fingers. Moisture can easily damage and promotes
growth of microorganisms.

MAKING AN UN OCCUPIED BED

PURPOSES:

1. To promote patient’s comfort.

2. To provide a clean, neat environment for the patient.
3. To provide a smooth, wrinkle free bed foundation, thus minimizing sources of skin
irritation.

EQUIPMENTS:

 Two large sheets.

 Draw sheet.
 Blanket (optional)
 Mackintosh.
 Pillow Cases
 Hamper bag.
 Chair.

STEPS RATIONALE S U
1. Wash hands. Prevent transmission of microorganisms.
2. Check from RN / patient’s chart for orders or Ensure patient’s safety as well as use of proper
specific precautions for movement and body mechanics.
positioning.
3. Prepare needed equipment and supplies. It saves time and energy.
4. Place the fresh linen on the patient’s chair in Prevent delays.
order of use at the food end of the bed. Place
the hamper bad in a convenient position.
5. Explain and assist the patent out of bed. Promotes cooperation from patient.
6. Raise the height of the bed to a working Minimizes strain and bed.
position. Remove call bell.
7. Loosen all the linen, starting from the head Loosing linen makes easier to work.
end to the chair under the linen.
8. Remove the pillowcase and place the pillow Organization of linen prevents delays.
on the chair under the linen.
9. Roll all soiled linen inside the bottom sheet Prevents the transmission of microorganisms.
and place them directly in the hamper bad
(unless patient is on isolation).
10. Grasp the mattress, from the head end and Provides comfort to the patient. Prevent mattress
moves it up. Turn the mattress from bottom from becoming hollowed out in one place.
to top.
11. Place the folded bottom sheet with its center Ensure the adequate length to cover the mattress.
fold on the center of the bed and spread it out
over the mattress.
12. Tuck in 8-10” of sheet at the head end under The top of the sheet needs to be well tucked to
the mattress. Mattress the corner. remain securely in place.
13. Place the mackintosh 18” from the upper Prevents soakage.
margin of the mattress and tuck it in
(Complete the whole side).
14. Place the draw sheet 2” above the upper Prevent skin irritation.
border of the mackintosh and tuck it in.
15. Move to the other side of the bed and repeat Completing the entire side of the bed saves time
steps 11 – 14. and energy.
16. Place the top sheet on the bed, then side up,
and fold back 6” from above to make a
cuff. (Place blanket on the top sheet if
required).
17. Make a vertical toe pleat and tuck in the Provides additional room foe the patient’s feet.
bathroom end.
18. Miter the corners of the bottom sheet at the
foot end if long.
19. Apply clean pillowcase and position at the Maintains neat appearance.
center of head of the bed turning the
opening away from the main entrance.
20. For a closed bed, cover the pillow with the
top sheet. For and open bed, fan fold top
sheet to the bottom.
21. Place call bell within patient’s reached and Makes it easier and safe for the patient to get in
adjust bed to lowest position. and out of bed.
22. Place over bed table and chair in proper Neat environment promotes sense of wellbeing
place, arranging personal items within easy and minimizes exertion in the patient.
reach on beside dooly.
23. Return all equipment to its proper place. Ensure readiness for net use.
24. Wash hands. Prevents transmission of microorganism.
 MAKING AN OCCUPIED BED
PURPOSES:

1. To conserve patient’s energy and maintain current health status.

2. To provide comfort.
3. To provide a clean, neat environment.
4. To provide a smooth, wrinkle free bed foundation, thus minimizing sources of skin
irritation.

EQUIPMENTS:

 Two large sheets.

 Draw sheet.
 Blanket (optional).
 Mackintosh.
 Pillow cases.
 Hamper bag.
 Chair.

PROCEDURE RATIONALE S U
1. Identify the patient. To give care to the right patient.
2. Check from RN / patient’s chart for orders or Ensure patient’s safety as well as use of
specific precautions for movement and proper body mechanics for nurse and
positioning. patient.
3. Prepare needed equipment and supplies. Saves time and energy.
4. Place the fresh linen on the patient’s chair in Organizing linen in order of use saves
order of use, at the food end of bed. time and energy.
5. Place hamper bag in a convenient position. Facilitates disposal of soiled linen.
6. Explain procedure to the patient. Minimizes anxiety and promotes
cooperation.
7. Wash hands. Prevent transmission of microorganisms.
8. Draw room curtains around the bed or close the Maintain privacy thus promoting
door. emotional and physical comfort.
9. Remove call bell / light. Provides easy access to bed and linen.
10. Adjust bed in working position and lock the Minimizes strain on nurse back. Ensures
bed. safety.
11. Assist the patient to turn on far side of the Protects accidental fall.
bed. Raise the side rail of the side. Adjust the
pillow.
12. Loosen all linen starting from head end of the Makes work easy.
bed from the working side.
13. Fan folds soiled linen near the patient. Provides maximum space for clean linen.
14. Fan folds half of the clean bottom sheet
 vertically as close to the patient as possible.
Tuck and miter the corner at the head end and
tuck in the working side.
15. Place the mackintosh and the draw sheet Tuck sheet eliminates irritating wrinkles
vertically at the center of the bed and tuck and folds.
the firmly.
16. Assist the patient to roll over towards you, Prevents accidental fall.
adjust the pillow and raise the side rail.
17. Move on to the other side and lower the side Provides easy access.
rail.
18. Remove the used linen and place them in the Reduces transmission of microorganisms.
hamper bag.
19. Pull the bottom sheet, mackintosh and the Provides comfort.
draw sheet firmly.
20. Mitten the head end corner of the bottom
sheet and tuck it in.
21. Tuck mackintosh and draw sheet firmly.
22. Change the pillow cases(s) and repositions it
at the center of the bed, turning the opening Maintains patients comfort.
away from the door / main entrance.
23. Assist the patient to a comfortable position.
24. Spread the top sheet over the patient (You
may ask patient to hold it while removing the
used sheet). A blanket may be used if
required.
25. Ask the patient to slightly flex the knees. Helps in making the pleat easily.
26. Make a vertical toe pleat. Provides additional space for the patient’s
feet.
27. Tuck the foot ends of top sheet and mitten the
corners.
28. Fold 6” of the top sheet to make a cuff. Makes it easier for the patient to pull the
sheet up.
29. Adjust call bell and return bed to a Ensures patients safety and comfort.
comfortable position.
30. Place over bed table and chair in proper place,
arranging personal items within easy reach Promotes sense of wellbeing and
on bedside dooly. minimizes exertion on the patient.
31. Replace all equipment Promotes sense of wellbeing and
minimizes exertion on the patient.
32. Wash hands. Prevents transmission of microorganisms.

HEIGHT & WEIGHT

 PURPOSES:

1. To provide a general measure of health.

2. To provide as base line comparison in nutritional status.
3 To provide a measurement of patient`s fluid status.
4. To calculate drug dose.

EQUIPMENTS:

 Weight Scale / Measuring Tape.

 Flow Sheet.
 Initial Assessment form.

STEPS RATIONALE S U
1. Identify the patient. Give care to the correct patient.
2. Ensure that patient has: Have correct reading.
 Voided
 Removed
o Shoes
o Heavy jewelry
o Extra Clothing
3. Set the scale at Zero. Calibrated scale ensures accurate
measurement.
4. Weight: Patient`s movement causes balance beam to
A. Stand on the center of platform facing oscillate and may result in inaccurate
scale and to remain still. reading.
B. Slowly adjust scale weight until
balance beam registers in middle of
the mark until digital scale shows
display.

5. Measures height: Height is measured by placing smooth, flat

Have patient remain standing on scale surface against crown or vertex of head.
platform, facing away from scale, instruct Patient`s position encourage keeping head
patient to: erect. Erect posture ensures accurate
A. Stand erect, with heels together. reading.
B. Buttocks should touch to scale stick.
C. Look straight ahead.
D. Raise metal L shaped rod on
weighing scale, until it rests on top
of the patient`s head.

6. Read height inches / cm as recorded on

height scale.
7. DOCUMENTS: Serves as a record and communicates
Record Weight and Height in given sheet. continuity of care.
BACK CARE
PURPOSES:

1. To assess skin condition.

2. To promote relaxation and comfort.
3. To stimulate circulation.
4. To relieve muscle tension.
5. To decreases risk of skin breakdown.
 EQUIPMENTS:

 Lotion
 Bath towel
 Soap.
 Basin with warm water necessary.
 Mittens.

STEPS RATIONALE S U
1. Identify the patient. To give care to the correct patient.
2. Assess the need for back care. Determine patient’s potential for
benefit from a back rub, signs of
fatigue, movement reflecting muscle
stiffness.
3. Explain procedure and desired position to the Minimizes anxiety and gains
patient. cooperation.
4. Collect equipment and arrange it in Prevents waste of time and energy and
convenient place. interruption during procedure.
5. Draw curtain or close door and put off fans. Maintains privacy and decreases the
loss of body heat by convection and
avoids chilling.
6. Adjust bed to working position. Ensures proper body mechanics and
prevents strain on nurses back.
7. Wash hands. Prevents risk of cross infections.
8. Turn patient to a lateral or position with back Provides easy access and exposure.
facing towards nurse.
9. Expose patients back from shoulder to Prevents unnecessary exposure of body
buttocks. Cover remaining part of the body. parts. Privacy promotes relaxation.
10. Clean back if required (refer “bed bath”
procedure).
11. Observe for any discoloration and skin break Facilities early detection and timely
down paying special attention to the bony interventions.
prominence.
12. Pour small amount of lotion into hands and Prevents friction and promotes comfort.
rub hands together to warm the lotion.
13. Massage the sacral area in circular motion.
Move up along the spine; massage the
scapulae with circular firm strokes. Do not Gentle, firm strokes promote
allow hands to leave patients skin. Continue relaxation. Continuous contact with
massage moving down the sacral area and skin is soothing and stimulation
repeat for 3 minutes. Pay special attention to circulation to tissues.
bony prominence.
14. Need first up the vertebral column and then Increases circulation to muscles and
over the entire back. releases tension.
15. End massage with long stroking movements. Long stroking is most soothing of
 Lessen the pressure with each massage stoke massage movement.
and tell patient you are ending the massage.
16. If patient is lying on side, ask patient to turn
to opposite side, and massage the other side.
17. Wipe excess lotion with bath towel. Assist Excess lotion can be an irritant.
the patient to lay the gown or pajamas.
18. Make patient comfortable.
19. Clean and replace equipment. Ensures readiness for next use and
maintains medical asepsis.
20. Wash hands. Prevent the risk of cross infection.
21. Document in nurse’s notes: Date / time, Communicates care given and patient‘s
procedure performed any pertinent condition. Protects legally.
observation and patient response.

SHAMPOOING PATIENT

PURPOSES:
1. To clean the patient’s hair thoroughly
2. To stimulate the blood circulation to the scalp through massage
3. To increase the patients sense of well being
4. To prevent infestation lice

EQUIPMENTS:

 Bath towels
 Face towel or wash cloth
  Shampoo or soap
 Basin / bucket of water form return
 Basin and mug
 Plastic apron / plastic sheet (mackintosh)
 Cotton balls in a container
 Comb / brush
 Linen hamper
 Bed linen

STEPS RATIONALE S U
1. Identify the patient. Give care to the right patient.
2. Assess the need for shampooing Certain medical condition could place patient at
risk for injury during shampooing because of
positioning, exposure to moisture or manipulation
of head and neck.
3. Explain procedure to patient. Minimize anxiety and gain cooperation.
4. Wash hands. Prevents the risk of cross infection.
5. Collect equipment and arrange it in Save time and prevents interruption during
Convenient place. procedure.
6. Draw curtain and switch off fun. Air current increases the loss of body heat by
convection. Maintain privacy and avoids chilling.
7. Place one basin on over bed table and Prevents soiling of bed.
the other basin on chair.
8. Adjust bed to working position Ensure proper body mechanics and prevent strain
on nurse`s back.
9. Assist the patients head to the edge Able to work comfortable. Avoids back strain.
of bed from which you will work.
10. Spread the mackintosh lined with bath Prevents soiling of bed linen.
towel under patients head and shoulder
11. Place the through over the towel allowing Prevents wetting of bed and the floor.
one end fall into the bucket / basin
12. Remove pins and ribbons from the hair Result in more thorough cleansing.
and brush or comb it to remove any tangles.
13. Remove the pillow from the patients head Helps to drain off the water easily and keeps the
and place it under the mattress on the opposite shoulder dry.
head end.
14. Give a wash cloth to the patient hand to Washed cloth protects the eyes from soap and
wipe away water getting into the eyes. water getting into the patients eyes.
15. Plug the ears with cotton wool. Prevents water / shampoo entering into the ears.
16. Fill basin with warm water and check Promotes comfort, and prevents accidental
water temperature with your inner aspect of burning.
wrist (as tolerate) 1(400C to 430C or 1000F).
17. Wear apron to cover the uniform Prevents nurse`s uniform to get soiled.
18. Observe the scalp, nape and hair for nits, Determine need for further intervention.
lice dandruff, boils etc.
19. Wet the hair thoroughly with the water. Water aids distribution of shampoo over hair.
20. Pour shampoo into hand and apply to
patient’s hair and scalp.
21. Massage scalp well with the finger pads Stimulates the blood circulation. The pads of the
for 3-5 minutes. Start at hairline and work fingers are used so that finger nails will not
towards nape of neck. Lift head slightly with scratch the scalp.
one hand to wash back of the head. Then
shampoo the sides of the head.
22. Rinse hair well, especially behind the ears Shampoo deposits accumulation easily behind the
and scalp until they are clean. ears and base of scalp.
23. Repeat washing and rinsing hair and scalp Shampoo remaining in the hair when dry irritates
until they are clean. the hair and scalp.
24. Squeeze maximum water out of hair and
remove the trough.
25. Wrap patient’s hair in the towel. Dry Retained moisture may cause cooling and chills.
patients face with cloth to protect eyes. Dry
off any moisture along neck or shoulder.
26. Remove cotton plug from the ear.
27. Dry hair well. Retained moisture may cause cooling and chills.
28. Position patient comfortable / replace Makes patient comfortable.
pillow.
29. Place clean towel under head or over Prevents breaking and pulling of hair.
shoulder if sitting and start combing the hair.
Comb or brush by beginning at ends and up to
scalp.
30. Arrange the hair in a pleasant simple For attractive grooming and comfort during sleep.
style.
31. Remove towel.
32. Make the patient comfortable.
33. Adjust the bed according to patient’s Ensure safety of the patient.
comfort.
34. Clean and return all equipment in the Ensure readiness for next use and maintain
assigned. medical asepsis.
35. Keep patient’s area neat and tidy. Promotes environmental safety.
36. Wash hands. To prevent cross contamination.
37. DOCUMENTS:
Document in nurse’s notes.
- Date, time Communicates care given and patient condition.
- Type of hygiene care given Protects legally.
- Condition of hair and scalp
- Patient’s response.
HYGIENE CARE: COMPLETE OR PARTIAL BED BATH

1. PURPOSES

 To remove transient microorganism, body secretions and execration, and dead skin
cells.
 To stimulate peripheral circulation.
 To estimate patients self-esteem.
 To produce a sense of wellbeing.
 To promote relaxation and comfort.
 To prevent or eliminate unpleasant body odors.

2. EQUIPMENT
 Bath Basin (one)
 Bath towel (two)
 Soap with soap dish.
 Mittens / Wash cloth.
 Bed linen.
 Gown and pajama.
 Linen, hamper bag.
 Comb or brush.
 Lotion.
 Gloves (Disposable)
 Side rails
 Bath Thermometer ( optional)
 Side rails
 Bath Thermometer (optional)

S.# Procedures Rationales S U

1 Identify the patient To give care to the correct patient
2 Explain procedure to Promotes patients cooperation and
patient participation
3 Assess patient level of Participation if possible improve patients
independence and self esteem
involvement in
procedure
4 Arrange equipment in Easy access and order of equipment’s.
convenient place prevents waste of time and energy and
prevent interruption during procedure
5 Close the doors or draw Air current increases the loss of body heat
curtains and put off by conviction. Maintains privacy and
pains avoid chilling
6 Keep side rails up while Raising, side rails, maintains clients safety
away from the patient as nurse leaves besides
bedside
7 Adjust bed to working Ensure proper body mechanics and
position prevents strain on nurses back
8 Wash hands Prevents the rick of cross infection
9 Offer bed pan/urinal (if Prevents interruption and promote comport
required) (follow
respective checklist)
10 Assist with oral hygiene
as necessary (refer to
mouth care procedure)
11 Position patient Facilitates access and prevents strain on
comfortably. Move back muscles
patient towards the side
close to the nurse
12 Fill basin 2/3 with worm Prevents accidental burning of patient’s
water check water skin
temperature with your
inner aspect of wrist,
(41Co and 43Co or 105Fo
to 109Fo. Allow patient
to check water
temperature
13 Remove gown and Provides full exposure of body parts for
pajama (Remove bathing
clothing according to
patient convenience) If
the patient has an
intravenous line asks for
help.
14 Drape patient with sheet Maintain privacy
15 Spread towel patient’s Presents linen from getting soiled or wet
chest on top of sheet
16 Wash patient’s eyes with Prevents Transmitting of microorganisms
water only and dry them
well use of separate
comer for each eye.
17 Wipe the eyes from the Prevents secretions from entering the
inner to outer canthus nasolacrimal duets
18 Wash patent’s face, ears, Soap lower surface tension thus facilitates
and neck with soap removal of debris and bacteria
19 Rinse each part of the Removes soap microorganisms. Moisture
face, ears and neck with promotes bacterial growth
the other wash cloth,
Dry them well
20 Explore the far arm of Eliminates contamination of the area once
the patient. Please bath it is washed. Protects the bed linen from
towel length wise under becoming wet.
arm
21 Wash arm with soap and Soap lower surface tension thus facilitates
water using long, firm removal of debris and bacteria long,
strokes from distal to strokes from distal to proximal area
proximal areas (fingers increase venous return
to axilla)
22 Rinse and dry arm and Removes soap and microorganism drying
axilla thoroughly prevents bacterial growth.
23 Repeat steps 19 to 21 for
the other arm.
24 Place towel directly on Soaking softens cuticles of hand, loosens
bed and put the basin on debris beneath nails, and enhances feeling
it. Immerse patient’s of cleanliness.
hands in water. Allow
hands to soak for 3 to 5
minutes
25 Assist patient to wash Secretion and dust present between fingers
rinse. And dry the hands may damage the skin.
paying particular
attention to inter digital
spaces
26 Change the water and Maintains patients’ comfort and prevent
check temperature of accidental burning
water with the inner
aspect of wrist.
Note: change water more
frequently if it becomes
dirty or cool
27 Cover patient’s chest Prevent unnecessary exposure. Towel
with bath towel and fold maintains warmth and privacy.
top sheet down to Secretions and dirt collect easily in areas
umbilicus. With one of skin folds and may damage the skin.
hand. Lift edge of towel
away from chest. With
mitten hand, bath chest
using circular strokes.
Take special care to
wash skin folds under
female breasts. Keep
patients chest covered
between washing and
rinsing. Dry well.
28 Keep towel over chest. Prevalent chilling and unnecessary
 Fold top sheet down to exposure.
the public region.
29 Bath abdomen with Soap lower surface tension thus facilitates
mitten hand, giving removal of debris and bacteria.
special attention to
umbilicus and
abdominal folds. Use
abdominal folds. Use
circular strokes. Rinse
and dry well. Keep
abdomen covered
between washing and
rinsing
30 Pull top sheet back to Maintains privacy, comfort and warmth.
neck and remove the
bath towel.
31 Expose the far leg of Eliminates contamination of the area once
patient and place the it is clean.
bath towel length wise Protects the bed linen from becoming wet.
under the leg. Flex
patient leg slightly at
knee Joint.
32 Wash legs with soap and Soap lowers surface tension thus facilitates
water using long, firm removal of debris and bacteria. Long firm
strokes from ankle to strokes from distal to proximal area
thigh. Rinse and dry increases venous return.
well
33 Repeat step 30 to 31 for
the other leg.
34 Place the basin on the Soaking softens nails, loosen debris
bed and allow feet to beneath nails and enhances feeling of
soak for 3-5 minutes. cleanliness.
35 Wash Feet paying Secretions and dust present between toes
particular attention to may damage skin
inter digital spaces Rinse
and dry well
36 Change water and check Maintains patients comport and preventing
its temperature with the accidental burning.
inner aspect of wrist.
( 41o – 43o C or 105o –
109oF)
37 Assist patient to turn on Expose back and buttocks for bathing.
to the other side. Place
towel length wise along
with the patient back.
38 Wash back using Promote relaxation and prevent skin break
 circular strokes from down. ( prolong pressure on bony
shoulder to buttocks. prominence may impair circulation and
Rinse and dry lead to development of decubitus ulcer).
thoroughly. Pay special
attention to clean gluteal
folds. Observe for any
redness or skin break
down.
39 Provide back care .
( Refer back care
procedure)
40 Change water and check Maintains patients comport and prevent
water temperature with accidental burning.
the inner aspect of wrist.
(41o – 46o C or 105o-109o
P).
41 Assist patient to turn in Prevent unnecessary exposure. Patients
supine position. Cover may prefer to wash their own genitalia.
chest and upper
extremities with towel
and lower extremities
with top sheet. Expose
only genitalia. Wash
rinse and dry perineum.
If patient can wash,
assist the patient. Give
special attention to skin
folds. (Refer to perineal
care procedure).
42 Change bed linen,(refer Prevent infection and promotes comfort.
occupied bad making
procedure).
43 Assists patient to put on Maintains warmth, comfort and promotes
clean clothing. Comb/ self esteem
brush hair and make
him/ her comfortable
44 Perform hand and foot
care .( Refer hand and
put care procedure)
45 Adjust bed according to Ensure Safety
patient comfort and raise
the side rails.
46 Clean and replace Ensures Readiness for next use and
equipment. maintains medical asepsis
47 Keep patient area neat Promotes Environment safety
and tidy.
 48 Wash Hands Prevent the risk of cross infection
49 Document in nursing Communicate care given and patient’s
note Data / Time type of condition protects nurses legally.
hygiene care given any
pertinent observation
and patients response.
Signature

ASSISTING PATIENT IN SHOWER BATH

1. Purposes
 To remove transient microorganism body secretions and excretion, and dead skin
cells
 To stimulate peripheral circulation.
 To improve patient self-esteem.
 To produce a sense of wellbeing.
 To promote relaxation and comport.
 To prevent or eliminate unpleasant body odors.

2. Equipment:

 Bath towel
 Shampoo/soap
 Bed Linen
 Gown and pajama
 Lotion
 Bath slipper (patient own)
 Plastic apron (For nurses)
 Plastic chair
 Hamper bag

S. Steps Rationale S U
#
1 Identify the patient Gives care to correct patient
2 Asses patient level of Improve patient self esteem
independence involvement
3 Discuss time for bath with Gives patient feeling of autonomy
patient
4 Check shower for Saves time and prevents transmission of
cleanliness and proper microorganism and delays
functioning.
5 Collect equipment and Prevent possible falls when patient reaches for
 arrange it at convenient equipment.
place.
6 Assist patient to the Prevents accidental falls
bathroom use wheel chair if
necessary
7 Shower Bath Prevents accidents.

a. Without Assistance:
Demonstrate patient how to
use call bell for assistance. Protect from burn and cold.
 Instruct him/her to
call immediately if-
feeling faint or
weakness.
 Demonstrate patient Conserve energy and prevents accidents.
how to adjust the
knob of the shower
to regulate water Conserve energy and prevent accidents
temperature.
B. With Assist:
 Place a chair in the
shower room. Prevents the risk of cross infection ( ring
 Have patient wear wormer other fungal infection)
slippers.
 Put on plastic Protects clothes.
apron.
 Regulate water Prevents accidental bums and promotes patient
temperature comfort.
according to patient
tolerance
Prevents unnecessary exposure.
 Assist patient to
remove gown and
pajama. Place a
towel across the
patients laps when
removing the gown
 Assist patient in
shower.
8 Assist patient out of the Ensure safety.
shower and back to his /
her room. Provide
assistance if needed.
9 Provide back care (if Maintains integrity of skin.
required).
10 Clean and replace Ensures readiness for next use and maintains
equipment. medical asepsis.
 11 Dispose of soiled linen in Prevents transmission of microorganisms.
hamper bag and take
hamper bag to soiled utility
room.
12 Wash hands Prevent cross infection
13 Document in nurses notes: Communicate care given and patient’s
Date / time procedure condition protect legally
performed and patient
response
14 Signature.

MOUTH CARE OF A CONSCIOUS PATIENT

PURPOSES:

1. To maintain cleanliness of the tooth surface and tongue.

2. To prevent dental problems.
3. To maintain an intact and well-hydrated mucosa.
4. To maintain / promote appetite.
5. To promote self-esteem and comfort.

A: CONSCIOUS PATIENT: WITHOOUT ASSISTANCE

EQUIPMENTS:

 Tooth paste and tooth brush.

 Glass with water.
 Kidney dish.
 Towel.
 Container for dentures, if necessary.
 Vaseline / Petroleum jelly.

STEPS RATIONALE S U
1. Identify the patient. To give care to the correct patient.
2. Explain procedure to patient. Gains cooperation of the patient.
3. Place equipment to left side and place it Easy accessibility of supplies ensures smooth
on the over bed table within easy reach and safe procedure. Saves time and energy.
of patient.
4. Draw curtain or close room door Promotes privacy.
(optional).
5. Wash hands. Prevents the risk of cross infection.
6. a) Assist patient to the Positioning patient prevent nurse’s from
 bathroom/sink(use wheelchair if sustaining muscle strain. Semi fowler / sitting
required) OR position prevents patient from choking or
b) Assist patient in sitting position on a aspiration.
beside chair OR
c) Raise the head of the bed to the semi
fowler position.
7. Place towel across patient’s chest. Prevents soiling of gown and bed linen.
8. Provide patient tooth paste, tooth brush
kidney tray and a glass of water. Help
patient applying paste on brush if
required.
9. *Let patient brush teeth gently in Vibrating motion dislodges food particles
vibrating motion, instruct patient to caught between teeth and along chewing
brush gums gently. surface. Vigorous brushing may cause
bleeding.
10. Allow patient to rinse mouth Irrigation removes food particles.
thoroughly by talking several sips of
water, and spitting into kidney dish.
11. *Remove kidney dish, assist in wiping
patient’s mouth and remove chest
towel.
12. Assist patient to a comfortable Provides comfort and safety.
position.
13. Clean and replace equipment. Maintains medical asepsis and ensures
readiness for next use.
14. *Wash hands. Prevents cross infection.
15.Document in nursing notes Communicate care given and patient’s
Date/time, type of hygiene care given any condition protect legally
pertinent observation and patient’s
response.

MOUTH CARE OF AN UNCONSIOUS PATIENT:

PURPOSES:

1. To maintain an intact and well hydrated.

2. To remove secretions from oral cavity.
3. To prevent fowl breathing dental carries and infection.
4. To prevent injury from aspiration.
 EQUIPMENTS:

 Kidney basin (Emesis basin)

 Gallipots.
 Face towel.
 Tissue roll.
 Large tray.
 Disposable / latex gloves.
 Petroleum jelly./Paraffin
 Glass with water.
 Tongue depressor (Padded).
 Pair of scissors.
 Cotton balls.
 Mouths gag (Padded).
 Mouth wash.
 Gauze swabs (pack).
 Torch.
 Suction tube

PROCEDURE RATIONALE S U
1. Identify the patient. Give care to patient.
2. Explain the procedure to patient and Reduces anxiety and to provide meaning full
family member (if present). stimulation to unconscious patient.
Unconscious patient may relation ability to
hear. To gain cooperation of family members.
3. Collect equipment and check for Saves time and energy.
working condition.
4. Adjust the bed to working position; Avoids back strain.
lower the side rails of working side.
5. Wash hands. Minimizes cross infection.
6. Place patient in side lying position hand Prevents aspiration of saliva.
of the bed lowered.
7. Draw curtain or close the door. Maintains privacy.
8. Place towel under patient’s face and Receives secretion and to prevent soiling of
kidney dish under patient’s chin. bed linen.
9. Wear gloves. Minimizes cross infection.
11. Assess the oral cavity for dry mucosa, Provides baseline data.
blisters, sores or information.
12. Insert mouth gag to open patients
mouth (2nd Nurse holds it).

NOTE: (Never pour your fingers in an

unconscious patient’s mouth).
13. Perform the following steps: Mechanical action removes food particles
a. Dip the tongue blade (padded) or between the teeth and chewing surfaces.
 mouth application in solution,
squeezes it and clean.
- Chewing and inner surfaces first. Swabbing helps to remove secretions and crust
- Tooth surfaces. from mucosa.
- Swab roof of mouth and inside cheeks.
- Gently swabs the tongue.
14. Moisten the tongue blade/ application Proper cleaning. It helps to remove solution
in clean water to rise several times. that can be irritating to mucosa.
16. Remove the towel and kidney dish.
17. Apply thin layer of petroleum jelly to Avoids lip cracking.
lips.
18. Remove gloves and wash hands. Minimizes cross infection.
19. Adjust bed to original place and make
patient comfortable.
20. Raise the side rails. Ensure patient’s safety.
21. Return equipment to designated place. Keep patients environment neat and reduces
transmission of infection.
22. Document it nurses notes about oral Communicates care given and patient’s
assessment and the care given. condition. Protects legally.

TEMPERATURE
PURPOSE:

1. To obtain a baseline data for subsequent evaluation.

2. To determine changes in body temperature in response to specific treatment.
3. To monitor patient at risk for elevated temperature.

EQUIPMENTS:

Rectangular tray containing.

 (A).Thermometer (oral).
(B).Gallipots
(C). Tissue /cotton balls.
(D) Smallkidney tray.
(E).Jar of antiseptic solution. (Dettol 1%, Savlon 2%, or alcohol 70%) or jar of soapy solution.
(F).Jar of clean water.
 Black pen.
 Watch with second hand.
 Piece of paper / graphic sheet.

Additional equipment for Axillary temperature:

1. Towel / tissue for drying the axilla.
Additional equipment for rectal temperature:
1. Thermometer (rectal). 2. Lubricant. 3. Disposable gloves. 4. Tissue paper.

STEPS RATIONALE S U
1. Identify the patient. To give care to the patient.
2. Assess the site for temperature. Helps in identifying the most appropriate
site for reading temperature.
3Wash hands. And collect equipment. Reduces risk of cross infection.
4Check thermometer for damaged bulb. Mercury may leak through cracks and
broken glass and may cause injury.
5Explain the procedure to the patient. Relieves patient’s anxiety and facilities
cooperation.
6If thermometer is in the case. Clears the thermometer and decreases the
I. Take out thermometer from the case. chance of infection.
II. Wash the thermometer with soap and water from bulb
end finger end in firm twisting motion. Clears the thermometer from least
III. Rinse it with cold water. Dry with cotton swab. Tissue contaminated to most contaminated area.
from bulb end towards finger end using firm twisted
motion.
7If thermometer is in bottle. Clears the thermometer and decreases the
Take out the thermometer from antiseptic solution and put chance of infection.
in clear water.
8Wipe with dry cotton swab from bulb end to finger end Clears the thermometer from least
using firm twisted motion. contaminated to most contaminated area.
Mercury should be below 350 C.
9Lower the level of mercury below 350 C by gently Thermometer reading must be below client’s
shaking it with firm grip. actual temperature before use. Gently shake
lowers mercury level in glass tube.
10Oral Method
(a) Ensure patient has not taken hot/ cold fluids and not
smoked for at least 10-15 minutes Gives false reading.
(b) Place thermometer under the tongue at 45oC angle in a
position that allows the bulb to rest against the tongue The thermometer needs to reflect the core
tissue. temperature of the blood in larger blood
vessels of the posterior pocket.
(c) Instruct the patient to:
- Close his/her mouth To ensure accurate result and prevent
- Carefully with lips held firmly together. thermometer from falling out or breaking.
- Avoid biting down on the thermometer
- Refrain from speaking
(d) Leave the thermometer in place for 2-3 minutes
(e) Grasp the stem of the thermometer, ask the patient to To ensure correct reading.
open his/her mouth remove the thermometer.
(f) Wipe off any secretion from thermometer with cotton Less likely to chip on the patient teeth or
swab / tissue. break the thermometer.
Wipe in rotating fashion from finger to bulb end.
(g) Read the thermometer at eye level (by slowly rotating)
Wiping allows clear reading of thermometer,
wiping is done from area of great
contamination.
11Axillary Method Provides privacy and comfort.
(a) Put the curtains around patient’s bed or close door (as
required
(b) Ensure that axilla is dry
(c) Move clothing or gown away from patient’s shoulder
and arm. Provides optimal exposure of axilla
(d) Place the thermometer in center of axilla, lower the
patient’s arm over the thermometer, and place the
forearm across the chest.
(e) Gently hold the arm in place (if required).
(f) Leave the thermometer in place for a minimum of 3-5
minutes.
Remove the thermometer, raise it to eye level. And note
the reading.
12Wash thermometer with soap and warm water using
firm twisted motion.
13Rinse with cold water
14Dry it with cotton swab / tissue firm.
15Replace thermometer in the provided case / antiseptic
solution.
16Wash hands,
17Document accurately of flow sheet.
 ASSESSING PULSE

PURPOSES:

1. To establish baseline data for subsequent evaluation.

2. To identify whether pulse rate is within normal range.
3. To determine whether the pulse rhythm is regular and pulse volume is appropriate.
4. To monitor patient at risk for pulse alterations.

EQUIPMENT:

 Watch with second hand.

 Paper or flow sheet.
 Pen (red ink)

PROCEDURE RATIONALE S U
1. Identify the patient. And wash hands. To give care. Prevents infections.
2. Explain procedure to patient. Gains cooperation.
3. Place patient in a comfortable position. Relaxed position of lower arm and
extension of wrist permits full exposure of
 Rest patient’s arm alongside his body with artery for palpation.
the wrist extended and the palm of the hand
downward or inward.
 Patient can sit with his forearm at a 900
angle to the body resting on a support and
with wrist extended and the palm of the
hand downward.
4. Place tips of first two or middle three Fingers of Fingertips are most sensitive parts of hand
dominant hand over groove along radial or thumb to palpate arterial pulsation. Thumb has
side of patient’s inner wrist. pulsation that may interfere with accuracy.
5. Lightly compress against radius; press pulse Pulse is more accurately assessed with
initially, and then relax pressure so pulse moderate pressure. Too much pressure
becomes easily palpable. occludes pulse and impairs blood flow.
6. Using a watch with a second hand count the Sufficient time is necessary to access the
number of pulsation felt for 1 minute. rate, rhythm and amplitude of the pulse.
7. Assess the pulse, rhythm, aptitude and elasticity
of the vessel while counting rate.
8. Wash hands and Record pulse on sheet.
Assess the following peripheral pulses
1. Temporal
2. Carotid
3. Brachial
4. Radial
5. Femoral
6. Popliteal
7. Posterior tibial
8. Dorsalis pedis
 ASSESSING RESPIRATION
PURPOSES:

1. To acquire line date for subsequent evaluation.

2. To monitor abnormal respiration and identify changes.
3. To monitor patients at risk for respiratory alterations (fever, respiratory disease) etc.

EQUIPMENTS:

 Wash with second hand.

 Flow sheet.
 Pen (Black).

STEPS RATIONALE S U
1. Identify the patient. Give care to the right patient.

2. Wash hands. Prevents the risk of cross infection.

3. Collect equipment. Easy access to equipment prevents delay,

saves time and energy and prevents
interruption during procedure.
4. Assess patient activity prior to checking A patient who has been exercising will need
respiration. to rest for few minutes to permit the
accelerated respiratory rate return to normal.
5. Place patient in a comfortable position.

6. a. Place hand against patient’s chest to feel his

chest movement or Awareness of respiratory rate assessment
b. Place patient’s arm across the chest and would cause the patient voluntarily to alter the
observe the chest movement while supposedly respiratory pattern.
taking redial pulse
.
7. Check the respiratory rate, rhythm and depth for
1 minute.
8. Wash hands. Prevents the risk of across infection.
9. Documents in flow sheet and (if required) nurses Promotes continuity of care
notes

BLOOD PRESSURE
PURPOSES:

1. To main a base line measure of arterial pressure.

2. To assess the homodynamic (i.e. the study of movement of blood and the forces concerned) status of
a patient.
3. To monitor response of the circulatory system to various disease conditions and therapeutics.
EQUIPMENTS:

 Sphygmomanometer (B.P apparatus). The B.P cuff (Appropriate Size).

 Stethoscope
 Spirit Swab
 Flow Sheets
 Black Pen
 STEPS RATIONALE S U
1. Identify the patient. To give care to the right patient.
2. Explain procedure to patient. Reduce anxiety and encourages cooperation.
3. Collect equipment. Check them. Ensure proper functioning of apparatus.
4. Have patient in sitting or supine position. Promotes comfort and relaxes patient.
5. Wash hands. Prevents cross infections.
6. Clean the ear piece of stethoscope with the Prevents transmission of micro-organisms.
spirit swab.
7. Be sure that the manometer is positioned Ensure accurate reading of mercury level.
vertically at eye level.
8. Support patient’s for-arm at hear level with Blood pressure reading of mercury level.
palm turned up.
9. Expose patient’s left upper arm fully. Ensure proper cuff application. Tight sleeves interfere
with the ability to hear pulsation and may cause
inaccurate readings.
10. Wrap the deflated cuff evenly around the Even wrapping produces equal pressure too loose /
upper arm, by placing the lower edge of tight cuff give inaccurate reading. The bladder directly
the cuff 2.5 cm (1-2 inches) above the over the brachial artery gives accurate readings.
antecubital space. Ensure the center of the
bladder is applied directly over the medial
aspect of the upper arm.
11. Place the stethoscope in your ears and Tapping is done to check whether the sound is audible
check the diaphragm by tapping. (hear).
12. Make sure to unlock the mercury column
before inflating.
13. Palpate brachial or radial pulse with one Indicates approximately systolic pressure (Done if it is
hand. Close the valve of the bulb: inflate the initial examination performed on the patient).
the cuff noting the level of mercury where
pulse disappears.
14. Deflate cuff quickly and wait for 30 Prevent venous congestion and false high readings.
seconds tighten the valve.
15. Relocate brachial artery and place the Proper stethoscope placement ensures optimal sound
diaphragm of stethoscope over the reception. Improper position of diaphragm cause
brachial pulse and hold it in place. (Do not muffled sounds and often results in false low systolic
let the diaphragm touch the cuff or and false high diastolic readings.
patient’s clothing).
16. Inflate the cuff 30 mm Hg above where the Ensure accurate measurement of systole pressure.
pulse disappeared.
17. Slowly release the valve and allow mercury Too rapid or too slow a decline of mercury level can
to fall at the rate of 2-3 mm Hg per sec. cause inaccurate readings.
18. Note point on manometer when first clear First Korotkoff sound indicates the systolic pressure.
sound in heard.
19. Continue to deflate cuff gradually nothing This is noted as the diastolic pressure.
point at which sounds disappear.
20. Deflate cuff rapidly and completely. Prevent arterial occlusion resulting in numbness and
Remove cuff from patient’s arm. Lock tingling of patient’s arm.
mercury column unless measurement
must be repeated.
21. Assist patient to a comfort position. Cover To ensure patient’s comfort.
upper arm.
22. Wash hands Prevents transmission of micro-organisms.
23. Record accurately in the flow sheet Timely document ensures accurate therapeutic
according to hospital policy. intervention, if needed.
 TEPID SPONGE BATH
PURPOSES:

1. To reduce fever by promoting heat loss through conduction and evaporation.

EQUIPMENTS:

 Basin with tepid water (temperature 37 0C / 98 0F)

 Towels (6 small), wash cloth / mittens (6)
 Dry linen
 Gloves (if patient’s is on body fluids precaution)
 Mackintosh – Long enough to cover the whole bed.
 T.P.R Tray & flow sheet
 Bath thermometer (optional)

STEPS RATIONALE U S
1. Identify the patient. Give care to right the patient.
2. Wash hands Helps to prevent cross contamination
3. Explain procedure to patient and family Ensures cooperation of patient and family.
4. Adjust bed to working position Ensures proper body mechanics and prevent
strain on nurse back.
5. Take patients temperature, pulse and respiration
prior to the procedure (refer to T.P.R procedure)
Serves as a baseline for determining the
Note: tepid sponging should be done if body effectiveness of treatment
temperature is above 39 C

6. Administer antipyretic medication as prescribed Sponging combined with administration of

antipyretic medication minimize the effect.
7. Draw curtain around patient bed close room Air current increases the loss of body heat by
sponging fan on. convection. Maintains privacy and avoid chilling
and drafts.

8. Allow the family to participate in procedure, A. family involvement in the procedure gives
whenever possible. psychological support.

B. Provides opportunity to nurse for family

teaching

9. expose only the body part to be sponged keep the Helps prevent chills and shivering. Shivering
rest of the body covered increases the metabolic rate and can cause
hypothermia and shock.

10. Fill basin with tepid water and check Tepid water prevents chilling
temperature of water with your inner aspect of wrist.
11. Remove gown. Cover patient with the top sheet. Protects bed linen. Removing gown provides
Place a bath towel under part of body to be sponged. access to all skin surfaces.
12. Place wash cloth in each axilla, groin head and Most of the body temperature is lost through the
neck area. larger superficial vessels.
13. Slowly stroke the body with the wet cloth, using
gentle frication.
Gentle friction brings the blood vessels to the
A. Strokes each arm from the neck to the axilla and
surface of the skin, thus increasing the heat loss
down to the palm of the hand.
and preventing chilling.
B. Strokes each lag from groin to foot.
C. Bathe the back and buttocks.
Tepid water temperature must be maintained
A. Ongoing assessment provides data for
Nursing decision – making.
14. Change the water after every 3 cycle.
B. Combined effect of medication and s
Sponging should bring the temperature to
normal.
15. Continue this procedure for a period not
exceeding 15 minutes. Take the temperature. Then
proceed as fellows:-
A. if temperature > 38 0C repeat procedure for a
further 15 minutes and take the temperature. If there
is no change inform RMO.
B. If the temperature is 1 0C above normal stop
the procedure.
16. Observe for shivering, cyanosis or mottling of
the skin or If the pulse become rapid or irregular. These symptoms indicate a change in vasomotor
A. Stop the sponging, dry and cover the patient. tone, leading to hypothermia and shock.
B. Take and record the temperature in red ink.
17. Remove wet linen. Dry the patient and place a
dry gown on the patient. Remake bed with clean dry
linen ( Refer the procedure of occupied bed making) Helps prevents chilling and promotes comfort.

17. Wash hands Prevents cross contamination

18. Maintains 2 hourly or 4 hourly vital signs,
record as indicated.
19. DOCUMENTATION: Communicates care given and patient’s
condition. Protects legally
Record the following on nurses note and graphics
sheet:
A. Base line vital signs.
B. Post sponge vital signs
C. Vital signs during the sponge (e.g. cyanosis,
mottling or chilling).
Adult one Rescuer BLS
PERFORMANCE Guidelines:

S Procedure S U
#
1 Establish unresponsiveness by tapping and shouting.
2 Yells for help, activities the emergency response system, and send for AED.
3 Rule out injury. Checks breathing and carotid pulse. (Breathing and pulse check
can be performed simultaneously) for at least 5 seconds and no more than 10
seconds.
4 GIVES HIGH-QUALITY CPR
 Correct compression HAND PLACEMRNT on lower half of stream.
 ADEQUATE RATE: 100 to 120/min(i.e., delivers each set of 30 chest
compressions in no less than 15 seconds and no more than 18 second.
 ADEQUATE DEPTH: Delivers compressions at least 2 inches (5 cm)
in depth.
 ALLOWS COMPLETE CHEST RECOIL after compression.
 OPEN AIR WAY ADEQUATELY (head tilt- chin lift maneuver or jaw
thrust)
 MINIMIZES INTERRUPTIONS: Gives 2 breaths with pockets mask in
less than 10 second.
 Each breath gives over one second.]Visible chest rise over one second.
 Each breath gives over one second.
 Visible chest rise will each breathe.
 Resume compression less than 10 seconds.
5 If breathing present: place the victim in recovery position. If not then.
6 Then give two effective breaths watch, watch chest rise, allow for exhalation
between breaths.
7 Check for carotid pulse not more than 10 seconds.
8 If not pulse begin chest compression.
9 Give 30 chest compressions followed by 2 slow breaths
10 Reassess after 6-8 cycles of 30 : 2 (about 1 minute)
11 If pulse present continue rescue breathing that is 1 breath every 5 second.
Repeat step 7-10 until breathing and pulse resumes.
` Signature.

Adult Foreign-Body Airway obstruction (FBAO) Conscious Adult

Performance Guidelines:

S Procedure S U
#
1 Ask, “Are you choking?” Encourage coughing if the victim can cough
forcefully.
2 Give Heimlich maneuver / abdominal thrust if cough weakness ( chest
trust for pregnant or obese victim)
3 Repeat thrust until effective or victim becomes unconscious
Adult FBAO- Conscious to unconscious.
4 Activate the EMS System ( if possible)
5 Perform a tongue-jaw lift if you see an object, remove it
6 Open airway and try to ventilate, if still obstructed, reposition head and
try to ventilate again.
7 If breath does not go in begin abdominal thrust.
8 Repeat steps 5 to 7 until object removed.
Signature

Adult Foreign-body airway obstruction (FBAO) unconscious adult.

Performa Guidelines:

S Procedure S U
#
1 Established unresponsiveness. Call for help / EMS.
2 Open airway- (head tilt-chin lift or jaw thrust) and look, listen and feel
for breathing.
3 Give two breaths. If breath does not go in, reposition head and try to
ventilate again.
4 If breaths still does not go in.
5 Perform a tongue-jaw lift, if you see an object, remove it
6 Begin abdominal thrust, give 5 abdominal thrust.
7 Repeat step 5 to 6 until object removed.
Signature

Infant One Rescuer CPR Conscious:

Performance Guidelines:

S Procedure S U
#
1 Establish unresponsiveness by taping and shouting
2 Yells for help, activates the emergency response system and send for an
AED
3 Check for no breathing or no normal breathing (only gasping).
4 Scan from head to chest for a minimum of 5 seconds not more than 10
seconds
5 Check brachial pulse ( breathing and pulse check can be performed
simultaneously ) for at least 5 seconds and no more than 10 seconds
6 Perform high quality chest compression during 1-rescuer CPR (initiate
compressions within 10 seconds of identifying the cardiac arrest)
 Correct placement of hand / fingers on center of chest. I rescuer
two fingers just billow the nipples line.
 Compression rate: 100 to 120/ min (i-e., delivers each set of 30
chest compressions between 15 to 18 seconds.
 ADEQUATE DEPTH : Delivers compression at least one third
the depth of the chest (1.5 inches or 4 cm)
 Allows complete chest recoil after compression
 Appropriate ratio for age and rescuer.
  I rescuer 30 compression to 2 breaths
 Minimize interruption in compression
 OPEN AIRWAY ADEQUATELY (Head tilt-chin lift
maneuver or jaw thrust)
 Delivers 2 breaths with pocket mask so less than 10 seconds
elapses between last compressions of next cycle.
 Each breath gives over 1 second.
 Avoid excessive ventilation.
 Visible chest rise with each breath.
 Resume compression less than 10 second.
7 Perform high quality chest compression during 2-rescuers CPR.
 Correct placement of hand / fingers on center of chest.
 2 rescuer: 2 thumb encircling the hands just below the nipple
line
 Compression rate: 100 to 120 / min (i.e., delivers each set of 15
chest compression between 7-9 seconds.
 ADEQUATE DEPTH: delivers compression at least one third
the depth of the chest (1.5 inches or 4 cm).
 Allows complete chest RECOIL after compression.
 Appropriate ratio for age and rescuer.
 2 rescuer 13 compression to 2 breaths.
 Minimize interruption in compressions.
 OPEN AIRWAY ADEQUATELY (head tilt-chin lift maneuver
or jaw thrust)
 Delivers 2 breaths with pocket mask so less than 10 seconds
elapses between last compressions of next cycle.
 Each breath gives over one second.
 Avoid excessive ventilation.
 Visible chest rise with each breath.
 Resume compression less than 10 seconds.

8 Continue steps until breathing and pulse resume or EMS arrived.

Signature

Infant Foreign- body Airway obstruction (FBAO) conscious:

Performance Guidelines:

S# Procedure S U
1 Conform completely airway obstruction check for serious breathing
difficulty ineffective cough no or weak cough.
2 Give up to 5 back blows and 5 abdominal thrusts.
3 Repeat step 2 until effective or victim become unconscious
4 INFANT FOREIGN – BODY AIRWAY OBSTRUCTION (FBAO)
VICTIM BECOMES UNCONSCIOUS:

If second rescuer is available, have him/her activate the EMS system.

5 Perform a tongue- jaw lift if you see an object; perform a finger sweep
to remove it.
6 Open air way and try to ventilate if still obstructed reposition head and
try to ventilate again.
7 Give up to 5 back blows and 5 abdominal thrusts
8 Repeat step 5 through 7 until effective.
9 If airway obstruction is not relieved after about one minute, activate the
EMS system

Infant foreign-body airway obstruction (FBAO) Unconscious:

Performance Guidelines:

S Procedure S U
#
1 Establish Unresponsiveness. if seconds rescuer is availed, available,
have him/her activate EMS System
2 Open airway –( head tilt-chin lift or jaw thrust)
3 Check breathing (look, listen and feel)
4 Open airway and try to ventilate, if still obstructed. Reposition head and
try to ventilate again.
5 Give up to 5 back blows and 5 abdominal thrust
6 Perform a tongue-jaw lift if you see an object; perform a finger sweep
to remove it.
7 Repeat step 4 through 6 until effective
8 If airway obstruction is not relieved after about one minute, activate the
EMS system
SIGNATURE

Admission, Transfer and Discharge of a patient in Hospital

Objectives

Upon completion of this lesson, the student will be able to:

1. Recognize and demonstrate established procedures for admitting transferring and discharging a
patient at a healthcare facility.

2. Assess the importance of observing the patient's general physical condition, appearance, and
behavior.

3. Communicate what information must be documented concerning the admission, transfer, or

discharge of a patient.

. Equipment

Admission checklist

1. Pen or pencil
2. Gown or pajamas (if the patient is to be put to bed)
 3. Portable scale
4. Thermometer
5. Sphygmomanometer
6. Stethoscope
7. Envelope for the patient's valuables
1. Helping Patients Adjust to the Healthcare Facility.

 Every patient admitted to a healthcare facility is nervous, even if it is not a first admission. The
strange surroundings, the busy nursing staff, the sight of other patients may add to the patient's
feelings of helplessness.
 If this is a first admission, the patient will not know what to expect.
 Whether temporary or permanent, admission to a healthcare facility causes many changes in their
life style. Confusion and disorientation often occur when patient* are first admitted because they
have left friends, family, and everything familiar behind.

2. Preparing the Patient's Room

 Before a patient is admitted, make sure the room is ready for his/her arrival > Check
necessary equipment
 Make sure there is adequate light and proper ventilation
 Open the bed for patients by fan-folding the covers back, and attach the signal cord
within easy reach.
 Ensure patient supplies and equipment are present. (Washbasin, emesis basin, soap,
towels, lotion, bedpan, urinal for male patients).
3. Greeting the Patient
The patient's first impression of the facility will depend on how he/she is greeted.
 Greet each patient in a friendly, cheerful manner.
 Introduce yourself, and take the patient to their room.
 If the patient has a friend or relative with him/her, invite them to accompany you to
the room.
 A preliminary interview of the patient is done to obtain the necessary medical and
financial information.
 It is important for the family to remain with the patient for this interview.
 If an ID bracelet is used, it may be placed on the patient's wrist at this time.
4. The Admission Procedure

 Help the patient become familiar with the new surroundings.

 Explain the facility's policy on visitors, and the use of the television and telephone.
 Tell the patient when meals are served.
 Answer any questions he/she has about daily routine.
 In a healthcare facility, the patient's clothing and other belongings will be marked with
the patient's name and room number.
 Make a list of the clothing, have the patient or a member of the family sign the list, and
give it to the nursing supervisor to include in the patient's chart.
 If the patient has brought valuables, suggest that a relative take them home.
 Valuables should be placed in an envelope—properly labeled with the patient's name,
room, date, and a complete description of the articles included. The list of valuables
should also be given to the nursing supervisor to record in the patient's chart.
 The envelope will be kept in a safe until the patient is ready to go home.
 Ask the patient to put on a hospital gown, or a gown or pajamas brought from home.
  Assist the patient-as needed.
 If the patient wants a family member to be present, invite the person in.
 Assess the patient's general physical condition, appearance, and behavior as the
admission process is continued.
 Observe the patient for unusual conditions (cuts or bruises, loss of function, signs of
weakness, any prosthesis).
 Record vital signs
 Ask about previous hospitalizations, allergies, or diseases other than the one for which
the patient is being admitted.
 Record all information and Observations on the admissions checklist. Records taken
during admission should be thorough with as much pertinent information about the
patient as possible.
 Make the patient comfortable. If the patient is ambulatory, he/she may wish to sit up and
visit with family members.
 If the patient is unconscious or unable to answer the admission questions. Have a family
member help you with the information needed on the admission checklist. Get as much
information as you can about the patient.
 Allow the patient time to get acquainted with you and the healthcare setting
 Create an atmosphere of warmth and understanding for the patient and the patient's
family.
 Record the Admission Data. (Date and time of admission, method of admission -the
way the patient came into the room, observations or unusual conditions noted, chief
complaint of the patient).

Transferring the Patient

 A patient may be transferred from one room to another within the healthcare facility for several
reasons.
 Sometimes the transfer is made at the patient's request, medical staff may request it. The
physician may request the patient be transferred from one level of nursing care to another because
of a change in the patient's condition that might require more or less specialized care.
 The patient may be moved into intensive care when his/her condition becomes more
 Critical transferred onto a regular medical floor when his/her condition improves.
 Sometimes the nursing staff will transfer a patient closer to the nursing station where the patient's
condition can be supervised more closely.
 Make sure all. The patient's belongings are transferred with him/her. Collect the belongings and
any equipment that will be moved.
 Check with the head Nurse / nursing supervisor before moving any equipment to another floor.
 Check drawers, closets, tables, the bathroom, and the bed covers for articles that might be
forgotten.
 The nurse will collect the patient's chart and medicines.
 The ward receptionist will make the necessary changes in the patient's records, billing charges,
and other forms. (Time of transfer, reason for transfer, room numbers transferred from and to).
 Before moving, the patient, make sure the new room or floor is ready to receive the patient.
 If the patient is moved in the bed, personal belongings can be placed on the bed. > The patient
should be in a comfortable position with the side rails raised.
 If the patient is moved by stretcher or wheelchair, move the patient first. Then move the patient's
belongings on a cart.
 To -prevent falls, never leave the patient alone in the hallway when you are transferring
him/her to another floor.
  When the patient arrives at the new room, introduce the patient to the personnel who will be
caring for them.
 Orient the patient to the new room.
 Assist the patient into the bed or a comfortable chair, attach the signal cord within easy reach, and
make sure the patient is comfortable before leaving.
 After transferring the patient in the new unit, return any wheelchair or stretcher used to transport
the patient to the proper place.
 Clean the patient's room. Report to the nursing supervisor when the room is ready for another
patient.
Planning for the Patient Discharge

 There are many things to consider when planning for the patient's discharge.
 If the illness has not been long, complicated, or severe, no special preparation is made other than
general health instructions and information concerning the actual discharge (such as the time and
date the patient will be discharged).
 For other patients, the discharge process is more complicated.
 The patient's attitude towards discharge and continued progress toward recovery must be
considered.
 If being discharged to home, the patient may need reassurance that recovery will continue
at home.
 The patient may be concerned about being able to manage for himself/herself.
 These worries may keep the patient from looking forward to leaving the healthcare facility.
 The patient may wonder what kinds of treatment, if any, will be needed at home and how it will
be done.
 Provisions for special nursing care, such as provided by visiting nurses, may be needed for the
patient who is unable to manage his/her own hygiene and personal care.
 An important consideration may be whether help will be required for meals, grocery shopping,
etc., for a patient living alone and how long such help will be needed. Planning for the patient's
discharge involves the entire healthcare team.
 The patient, the family, the medical and nursing staff, and other personnel working in the facility
(such as the social worker and dietician) work together to coordinate the patient's discharge.
 The doctor plans the discharge with the patient and leaves a written order on the patient's chart.
 The nurse makes sure the discharge order has been written by the doctor.
 The nurse will then make the necessary arrangements with other departments to prepare for the
patient's discharge.
 The nurse will also make sure the patient has been given instructions by the doctor for home care
and understands the instructions.( taking medications, exercise programs, physical therapy,
changing dressings, giving injections, respiratory treatments that will be continued at home.)
 If possible, the nurse will give the patient a written copy of the instructions, such as a copy-of-the
diet or an appointment card for a return visit to the doctor.
 The family must be notified of the patient's discharge time so they can make arrangements for
transportation.
 Patient care does not end when the patient is discharged.
 The patient may receive visits from a home health agency to supervise the care and treatment.
 The patient's home care should make use of existing community resources so the patient and the
family will not have to undertake the financial and emotional burden of extensive home nursing
care alone.
 Always check with the nursing supervisor to be sure the patient has officially been discharged by
the doctor.
 Set up a schedule for the patient's care so that the patient does not become too tired.
 Make sure the patient is ready when the family members arrive.
 As you help the patient with his/her care make sure the instructions are understood about home
care and follow up visits.
 Help the patient into the wheelchair and the wheel his/her to the entrance of the healthcare facility
nearest to the car.
 To avoid injuries do not allow the patient unattended until the family members have arrived with
their car and help the patient into the car.
 Make sure allow the patients belonging are out into the car.
 Say goodbye and wish the patient well.
 Return the wheelchair to its proper place.
 Chart the patent discharged.(the date and time the patient was discharged, the way the patient left
the healthcare facility, any special instructions, diet, or medications the patients to continue after
discharge)