POWER COLLEGE

FOCUSED TASKES OR PROCEDURES MANUAL

OF COC EXAM SKILL GAP TRAINING FOR
LEVEL III NURSING STUDENTS.

ORGANIZED BY:

NURSING staff

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 Power college

2017 E C
CHAPTER ONE
DOCUMENTATION (RECORDING AND REPORTING)
1.1. Documentation and charting
1.1.1. Documentation
Definition: Documentation is defined as written evidence of interactions
between and among health professionals, clients, their families, and health
care organizations
Purpose
Through documentation someone ensures:
 Accurate data needed to plan the client’s care in order to ensure the
continuity of care
 A method of communication among the health care team members
responsible for the client’s care
 Written evidence of what was done for the client, the client’s response,
and any revisions made in the plan of care
 Compliance with professional practice standards (e.g., American
Nurses Association)
 Compliance with accreditation criteria (e.g., the Joint Commission on
Accreditation of Healthcare Organization [JCAHO])
 A resource for review, audit, reimbursement, education, and research
 A written legal record to protect the client, institution, and practitioner
1.1.2. Charting
Definition: Charting is written record of history, examinations tests,
diagnosis, prognosis, therapy and response to therapy.
Purpose
 For diagnosis or treatment of a patient while in the hospital
 After discharge if patient returns for treatment at a future time.
 For maintaining accurate data on matters demand by courts.
 For providing material for research.
 For serving as an information in the education of health personnel,
(Medical students, interns, nurses, dietitians. Etc.]
 For securing needed vital statistics
 For promoting public health
General rules for charting

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A. Spelling: Make certain you spell correctly (including medicine labels).
B. Accuracy: Records must be correct in every way. The nurse must be
absolutely honest in his or her charting. Mid- statements or changing
records may involve the nurse in criminal act.
C. Completeness: There must be no omission of important information
however; unnecessary words and statement should be avoided.
D. Exactness: Use the exact word that describes the conditions. Do not
use a word you are not sure of.
E. Objective information: The nurse records what he/she “sees” avoid
saying “condition better,” or “pulse improved”. Record the actual
condition. Also expressions do not show much thought on the part of
the nurse.
F. Legibility: Print as plainly and distinctly as possible. Do not use any
fancy words. There should be no question to the words and figures
used. This is especially true when recording temperature, pulse,
respiration and dosage of medicine.
G. Neatness: No blotches on chart sheets. No wrinkling of sheets. Proper
spacing of items and words. Begin each statement with a capital letter.
Place a period after all abbreviations and at the end of each statement.
H. Errors: If an error is made, use a ruler and draw one line through it,
print nearly above “Error” and sign your name. No erasing and using
correction fluid is permitted on the chart.
I. Each nurse should do her/his own charting, that is, she/he should name
and the father’s initial.
J. Composition: Chart carefully, composition and spelling must be
correct. Consult a dictionary when in doubt. Only approved
abbreviations can be used on nursing record. If in doubt consult the
supervisor. Do not use chemical formulas for drug as KMNO4 instead of
potassium permanganate.
K. Sentences: and not be complete but, they must be clear, avoid as
needless repetition of word “Pt.” Remarks should reflect as nearly as
possible the patient’s condition. (Watch your grammar).
L. Temperatures should be recorded on the graphic sheet.
M. All orders should be written and signed. Verbal or telephone should be
written in the order sheet and signed by the doctor on the next visit.
N. Time of charting: Charting must be done immediately after procedure
or observation. This is an absolute must. Chart the hour, as possible
state order must be recorded with the exact hour the treatment or
medication given. The exact time of sleeping pills and narcotics must
also be given. Do not record events taking place at different hours on

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 the same line. Be sure to write A.M or P.M. when charting the hour.
Twelve noon is written 12 M.D and twelve midnight is written 12 M.N Be
careful not to confuse Ethiopian and European time.
O. Space: Do not crowd notations nor skip lines unnecessarily.
P. Color of ink: All charting must be done in black or blue – black
important events are charted in red on the graphic sheet. E.g.
Transfusion, vaccination, day of surgery.
Q. Chart headings: All headings are to be filled in when the patient is
admitted, thereafter, each sheet, which is added, must be properly
filled out. No nurse shall every chart on a sheet that is not properly
filled out even though someone else may have done so. Even though
some one else has failed to do his duty, it will not excuse another for
making same mistake. Always give the complete name, the name of
the doctor, the room number and also the hospital chart number if
there is one.
Orders of assembling patients chart
A. Order sheet
B. Doctor’s progress notes
C. Nursing notes
D. Temperature graph
E. Laboratory reports
F. Input and output note

Patients or relatives and friends of patients are not allowed to read the chart.
Sign each entry with your full legal name and with your professional
credentials, or per your institutional policy.Never change another person’s
entry, even if it is incorrect.
Use quotation marks to indicate direct client responses (e.g., “I feel
lousy”).Document in chronological order (if chronological order is not used
state why).
N.B: The order of assembling chart may differ from hospital to hospital.
Equipment for charting and writing notes
 Report format
 Patient chart
 Pen
Procedure
The format of the chart varies from hospital to hospital. Most important is the
content of the notes.
1. First, your notes should describe the assessment that you completed at
the beginning of your shift.

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 2. Some hospitals require that all parts of the assessment to be
documented; others require that only abnormalities be documented.
3. As your shift progresses, you should always include certain items in your
notes, including changes in the patient’s medical, mental, or emotional
condition.
4. You should also chart if no change occurred in the patient’s condition so
that treatments can be modified as necessary. Normal aspects of the
patient’s condition should be noted also.
5. Reactions to any unscheduled or p.r.n. medications must be recorded.
To complete this of the entry, note the time the medication was given
the problem for which the medications were given the expected
solution.
6. Finally it is important to record the patient's response to teaching. These
notes may describe return demonstrations, verbalization of learning, or
resistance to instruction.
7. Frequently, respective aspects of Nursing can, such as vital signs, and
intake and output, and recorded on flow sheets.

CHAPTER TWO
INFECTION PREVENTION
Definition- Largely depends on placing barriers between a susceptible host
(person lacking effective natural or acquired protection) and the
microorganism
2.1. Hand Hygiene
Definition:Hand hygiene is a general term referring to any action of hand
cleansing. It includes care of hands, nails and skin.

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Hand hygiene can be accomplished by:
 Hand washing
 Hand antisepsis
 Antiseptic hand rub
 Surgical scrub plain
2.1.1. Hand washing
Definition: Hand washing is process of mechanically removing soil and
debris from the skin of hands using plain soap and water.
Purpose:
 Reduce number of resident and transient microorganisms on the hands
 Prevent transfer of microorganisms from health care personnel to the
client
Indication:
 Immediately after arriving and leaving work (the health facility)
 Before and after examining (coming in direct contact with) a
client/patient
 After touching contaminated instruments or items
 After exposure to mucous membranes, blood, body fluids,
secretions or excretions
 Before putting on gloves and after removing them
 Whenever our hands become visibly soiled
 After blowing nose or covering a sneeze
 Before eating or serving food
 After visiting the toilet
Equipment
1. Tap water or water in a jug and a basin
2. Soap and soap rack with drains
3. Clean towel (personal or disposable)
Procedure
1. Prepare necessary equipment
2. Remove all jewelry or false finger nails. Remove your watch or wear it well above the wrist.
3. Thoroughly wet hands.
4. Apply plain soap (antiseptic agent is not necessary).
5. Vigorously rub all areas of hands and fingers for 10–15 seconds, paying close attention to
fingernails (if necessary use orange sticks) and between fingers.
6. Rinse hands thoroughly with clean water.
7. Dry hands with a paper towel or a clean, dry personal towel.
8. Use a paper towel when turning off water if there is no foot control or automatic shut-off.

2.1.2. Hand antisepsis

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Definition: Washing hands with use of soap containing anti-microbial agent
Purpose
 To remove soil and debris
 Reduce both transient and resident flora on the hands.
Indication
 Before Examining or caring for highly susceptible patients (e.g.,
premature infants, elderly patients, or those with advanced AIDS)
 Before Performing an invasive procedure (e.g., intravascular device)
 Before Leaving the room of patients on Contact Precautions
Precaution:
 Hand washing with medicated soaps or detergents repeatedly is irritant
to the skin
Equipment
1. Tap water or water in a jug and a basin
2. Soap which contains anti-microbial agent (chlorohexidine, iodophors
or triclosan) e.g. Medeicum, Life boy, Dettol and soap rack with drains
3. Clean towel (personal or disposable)
4. Orange stick
5. Wall clock

Procedure:
1. Prepare necessary equipment
2. Remove all jewelry or false finger nails and your watch or wear it well
above the wrist.
3. Thoroughly wet hands.
4. Apply soap containing antimicrobial agent
5. Vigorously rub all areas of hands and fingers for 10–15 seconds, paying
close attention to fingernails (if necessary use orange stick) and
between fingers.
6. Rinse hands thoroughly with clean water.
7. Dry hands with a paper towel or a clean, dry personal towel.
8. Use a paper towel when turning off water if there is no foot control or
automatic shut-off.

2.1.3. Antiseptic hand rub

Definition- Use of a waterless, alcohol-based hand rub product to inhibit or
kill transient and resident flora.
Purpose:
 To inhibit or kill transient and resident flora.

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Equipment
o Alcohol (60-90%)
o glycerin
o measuring glass
o bottle

Preparation of hand rubs solution

 A nonirritating, antiseptic handrub can be made by adding glycerinea,
proplyene glycol or sorbitol to alcohol (2 mL in 100 mL of 60–90% ethyl
or isopropyl alcohol solution. .
Steps:
 Apply enough alcohol-based hand rub to cover the entire surface of
hands and fingers (about a teaspoonful -5ml)
 Continue rubbing the solution over hands until they are dry (15-30
seconds). ).
 Rub the solution vigorously into hands, especially between fingers and
under the nails, until dry.
2.2. Donning and removing Personal protective equipment
Definition: PPE is an equipment that is fluid-resistant (e.g., plastic or
rubber aprons) can protect health care workers from exposure to potentially
contaminated blood or other body fluids and clients from microorganisms
present on medical staff and others working in the healthcare setting.
2.2.1. Donning and removing gloves
Purpose
 To reduce the risk of staff acquiring infections from patients
 To prevent staff from transmitting their skin flora to patients
 To reduce contamination of the hands of staff by microorganisms that
can be transmitted from one patient to another (cross-contamination)
Indication
 There is a reasonable chance of hand contact with blood or other body
fluids, mucous membranes, or non-intact skin,
 Performing an invasive medical procedures,
 Before handling soiled instruments, contaminated waste items or touch
contaminated surfaces.
 When disposing contaminated waste items
 Handling chemicals or disinfectants
Types of glove

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 A. Surgical glove
B. Clean glove
C. Elbow length glove
D. Heavy duty gloves
A. Surgical glove used when performing invasive medical or surgical
procedures.
Purpose
 To ensure maximum asepsis to the patient and to protect the health
care workers from the patient's body fluid
Equipment
1. Table of soap or antiseptic 3. Sterile towels
2. Elbow controlled tap of 4. Sterile gloves
water
Procedure
1. Wash hands and dry them
2. Prepare necessary equipment
3. Scrub for at least 2 minutes
4. Keep hands up and away from the body, do not touch any surface or
article. and dry hands with a clean, dry towel
5. Check the package for integrity. Open the first non-sterile packaging by
peeling it completely off the heat seal (cover) to expose the second
sterile wrapper, but without touching it
6. Place the second sterile package on a clean, dry surface without
touching the surface. Open the package and fold it towards the bottom
so as to unfold the paper and keep it open.
7. Using the thumb and index finger of one hand, carefully grasp the folded
cuff edge of the glove
8. Slip the other hand into the glove in a single movement, keeping the
folded cuff at the wrist level
9. Pick up the second glove by sliding the fingers of the gloved hand
underneath the cuff of the glove
10. In a single movement, slip the second glove on to the ungloved hand
while avoiding any contact/ resting of the gloved hand on surface other
than the glove to be donned (contact/ resting constitutes a lack of
asepsis and requires a change of glove)
11. If necessary, after donning both gloves, adjust the fingers and inter-
digital spaces until the gloves fit comfortably.
12. Unfold the cuff of the first gloved hand by gently slipping the fingers of
the other hand inside the fold, making sure to avoid any contact with a

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 surface other hand the outer surface of the glove (lack of asepsis
requiring a change of gloves)
13. The hands are gloved and must touch exclusively sterile devices or the
previously –disinfected patient’s body area.
Removing gloves
14. Before removing the glove briefly immerse them in 0.5% chlorine
solution,
15. Remove the first glove by peeling it back with the fingers of the
opposite hand. Remove the glove by rolling it inside out to the second
finger joint
16. Remove the other glove by turning its outer edge on the fingers of the
partially ungloved hand
17. Remove the glove by turning it inside out entirely (ball forming) to
ensure that the skin of the health-care worker is always and exclusively
in contact with the inner surface of the glove.
18. Perform hand hygiene after glove removal according to the
recommended indication.
B. Examination glove
Purpose:
1. To reduce the risk of staff acquiring bacterial infections from
patients.
2. To prevent staff from transmitting their skin flora to patients.
3. To reduce contamination of the hands of staff by microorganisms
that can be transmitted from one patient to another (cross-
contamination).

Indication of donning Examination glove

1. When there is reasonable chance of hands coming in contact with
blood or other body fluids, mucous membranes or one intact skin
2. They perform invasive medical procedures (e.g., inserting vascular
devices such as peripheral venous lines)
3. When they handle contaminated waste items or touch contaminated
surfaces.
Equipment
1. Table of soap or antiseptic
2. Tap of water
3. Towels
4. Clean examination gloves
Procedure
a. Prepare necessary equipment

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 b. Wash hands and dry them
c. Take out glove from box
d. Touch only restricted surface of gloves (at the top age of the cuff)
e. Done the first glove
f. Done the second glove and touch only restricted surface of the glove
corresponding to the wrist
g. To avoid touching the skin of the forearm with the gloved hand, turn
the external surface of the glove to be donned on the folded fingers of
the gloved hand, thus permitting to glove the second hand
h. Once gloved, hands should not touch anything else that defined by
indications and conditions for glove use
Remove glove
i. Pinch one glove at the wrist level remove it, without touching skin of
forearm, and pill away from the hand, thus allowing the glove to turn
inside out
j. Hold the removed glove in the gloved hand and slide the fingers of the
ungloved hand inside between the glove and wrist. remove the
second glove by rolling it down the hand and fold in to the first glove
k. Discard the removed glove
C. Elbow length glove
Purpose:
 Used during manual removal of placenta and any other procedure
where there is a contact with a large volume of blood or body fluids.
D.Utility or heavy-duty gloves

Purpose
 used for processing instruments, equipment and other items,
 used for handling and disposing of contaminated waste, and when
cleaning contaminated surfaces

2.2.2. Donning and removing surgical Gowns

Purpose:-
 To protect patients from microorganisms present on the abdomen and
arms of the healthcare staff during surgery.
 To protect the healthcare workers’ clothing.
Equipment
 Sterile gown
Procedure
1. The sterile gown is folded inside out.

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 2. Grasp the gown inside the neckline, step back, and allow the gown to
open in front of you; keep the inside of the gown towardyou; do not
allow it to touch anything
3. Holding the neck band with both hand and gently shakes the folds from
the gown
4. With hands at shoulder level, slip both arms into the gown; keep your
hands inside thesleeves of the gown
5. The circulating nurse will step up behind you and grasp the inside of
the gown, bring it over your shoulders, and secure the ties at the
neckand waist.
6. Unfasten neck and then ties
7. Remove gown using a peeling motion; pull gown from each shoulder
towards the same hands.
8. Gown will turn inside out
9. Hold removed gown away from body, roll into a bundle and discard into
waste or linen receptacle.
3.2.3. Donning a Cap, Mask and goggle
Purpose
A. Masks:
 are worn in an attempt to contain moisture droplets expelled as the
health care workers speak, cough or sneeze
 protect the wearer from inhaling both large and small particle
droplets
B. Goggle/face shield:
 Prevent accidental splashing of the mouth and face during certain
procedures.
C. Cap:
 used to keep the hair and scalp covered so that flakes of skin and hair
are not shed into the wound during surgery
Equipment
1. Cap
2. Mask
3. Goggles/ Face Shield
Procedure
1. Wash hands.
2. Apply cap to head, being sure to tuck hair under cap. Males with facial
hair should use a hood to cover all hair on head and face
3. Secure mask around mouth and nose. For masks with strings:
a. Hold mask by top and pinch metal strip over bridge of nose.
b. Pull two top strings over ears and tie at upper back of head.

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 c. Tie two lower ties around back of neck so that bottom of mask fits
snugly under chin
4. For goggle Place over face and eyes and adjust to fit
5. After performing necessary tasks, remove cap and mask before leaving
room.
a. Untie bottom strings of mask first, then top strings, and lift off of
face. Hold mask by strings and discard.
b. Grasp top surface of cap and lift from head.
6. To remove goggle/ face shield handle by head band or ear pieces
7. After removing wash hands
8. Document the type of protective barriers used and client
understanding of the procedures
2.4. Instrument processing
Definition: Instrument processing is a process of making instruments safer
for handling and making free from microorganisms.
2.4.1. Decontamination, cleaning, drying and packing:
Definition
 Decontamination: is a Process that makes inanimate objects safer to
be handled by staff before cleaning.
 Cleaning: is a Process that physically removes all visible dust, soil,
blood or other body fluids from inanimate objects as well as removing
sufficient numbers of microorganisms.
Purpose:
 To reduce the number of microorganisms
 To removes all visible dust, soil, blood or other body fluids from
inanimate objects
 To eliminate microorganisms from inanimate objects

Equipment:
1. PPE (heavy duty glove/surgical glove, plastic apron, gown, goggle,
mask)
2. Plastic bucket (3)
3. Water
4. Chlorine solution (0.5%)
5. Measuring Jug
6. Timer (watch)
7. Brush
8. Drying cloth
9. Drape
10. Drum

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

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 Equipment:
1. Auto clave
2. Stove
3. Timer
4. Water
5. Time steam sterilizer indicator
2.4.2.1. Steam sterilization
Procedure
1. Wash hands and dry them
2. Prepare necessary equipment
3. Place Time steam sterilizer indicator / an indicator tape on the
container on packed items
4. Place instruments: gloves into steam pan
5. Stuck steam pans (maximum of 3 pans) on top of pan containing water
for boiling.
6. Cover top of steamer pan with lid
7. Bring water to a rolling boil; wait for steam to escape from between the
top pan and lid
8. Start timing and steam for 20 minutes
9. Remove steamer pans from heat; gently shake excess water from
items and place on an extra empty bottom pan
10. Allow to air dry and cool
11. Store in covered steamer pans
12. To Use immediately – remove items with high level disinfected
forceps.
2.4.2.2. Dry heat sterilization
Procedure
1. Wash hands and dry them
2. Prepare necessary equipment
3. Place metal instruments or glass syringes in a metal container with a
lid.
4. Put an indicator tape on the container.
5. place covered containers in oven and heat until 160ºc is reached and
heat for two hours
6. Begin timing when 160ºc is reached and heat for two hours.
7. After instruments are cool; remove and store in sterile containers.
8. Wash hands and dry them.
2.4.3. High level disinfection
Definition: is a Process that eliminates all microorganisms except some
bacterial endospores from inanimate objects.

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2.4.3.1. Chemical disinfection
Definition: This is the process of disinfecting used equipmentby using
chlorine/Glutaraldehyde/ formaldehyde or peroxide.
Purpose: To eliminate microorganisms from inanimate objects.
Equipment
1. Chlorine, Glutaraldehyde, Formaldehyde And Peroxide.
2. Container For Disinfection
3. Heavy Duty Gloves
4. Sterile Containers
5. Pick Up forceps
Procedure:
1. Wash hands and dry them
2. Prepare necessary equipment
3. Prepare fresh sterilant as per manufactures instructions
4. Submerge cleaned and dried items in: 2% Glutaraldehyde (cidex) for 8
– 10 hours 80% formaldehyde solution – 24 hours
5. Ensure items are completely immersed
6. Remove items from chemical solution using sterile gloves,
Forceps/pickups.
7. Rinse thoroughly with sterile water to remove all traces of chemical
sterile
8. Use item immediately or store in sterile containers?
9. Wash hands and dry them.

2.4.3.2. Boiling
Definition: Boiling in water is an effective practical way to high level
disinfectant instrument and other items
Purpose:
 To kill all vegetative forms of bacteria, viruses (including HBV, HCV
and HIV)
Equipment
1. Water
2. Boiler
3. Stove
4. Sterile forceps
5. Sterile container ( high level disinfected container)
Procedure

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 1. Wash hands and dry them
2. Decontaminate and clean all instruments and other items to be high
level disinfected
3. Prepare necessary equipment
4. Completely immense cleaned instruments and other items in water
5. Cover boiler with lid and bring water to a gently rolling boil
6. Start timing when rolling boil beings
7. Continue rolling boiling for 20 minutes
8. Remove items with high-level disinfected forceps
9. Place instruments in covered high level disinfected container
10. Wash hands and dry them.
Principles of Storing
 Store appropriately to protect them from dust, dirt, moisture, animals
and insects.
 The storage area should be located next to or connected to where
sterilization occurs, in a separate enclosed area
 In smaller clinics, this area may be just a room close to the Central
Supplies Department or in the Operatingm Roo
3.5. Healthcare waste management
Definition: refers to all activities, involved in the collection, handling,
treatment, conditioning, transport, storage and disposal of waste produced
at healthcare facilities
High Risk Wastes
 Infectious waste
 Anatomical waste
 Sharps wastes (used or unused)
 Chemical waste
 Pharmaceutical waste
 Radioactive wastes
 Pressurized containers

Low Risk Wastes

 Noninfectious waste/Communal wastes

2.5.1. Waste Segregation

Definition: Waste segregation is separating waste by type at the place
where it is generated

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Purpose:
 Protect people, who handle waste items from injuries,
 Prevent the spread of infections to HCWs who handle waste,
 Prevent the spread of infection to the community,
 Protect the environment
Equipment
1. Three different colored bags (Red, Yellow and Black)
2. Heavy duty glove
3. mask
4. gown
5. apron
6. boots
Procedure
1. Wash hands
2. Wear necessary personal protective equipment
3. Separate wastes based on their level of infection
4. Noninfectious (Black color code): Presents no risk. Examples: paper,
packaging materials, office supplies, drink containers, hand towels,
boxes, glass, plastic bottles, and food.
5. Infectious (Yellow color code): Contaminated with human blood and
has the ability to spread disease. Examples: gauze, cotton, dressings,
laboratory cultures, IV fluid lines, blood bags, gloves, anatomical
waste, and pharmaceutical waste.
6. Highly infectious (Red color code):Highly infectious Anatomical waste,
pathological waste
7. Sharps waste (Safety box, needle remover, or other puncture-resistant
and leak-resistant sharps containers): Syringes and needles should be
discarded without recapping.
8. Collect waste bags from the service point
9. Remove PPE
10. Wash hands
11. Documenting
3.6. House keeping
2.6.1. Patient unit care
Definition
 Patient's unit is a small separate room in which the patient rest
during his/her hospital stay. Patient's unit usually consists of basic
furniture and standard equipment

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  Cleaning of patient's unitis keeping of the patients room neat &
orderly. There are two types of cleaning that are concurrent and
terminal cleaning
 Concurrent Cleaning is a daily cleaning of the patients room. It
consists cleaning the room by damp mopping the floor and dusting
with damp cloth.

Purpose
 To keep the room clean & tidy
 To minimize cross infection
 To create comfortable environment for the patient
 To make the room ready for a new patient
Equipment
1. Wheeled utility cart
2. Wheeled laundry hampers
3. Cleaning cloths
4. Waste basket with paper bag / plastic liner
5. Basin of prescribed detergent, germicide solution
6. Utility glove
7. Mop
8. Chair
9. Clean water with bucket
Procedure:
1. Hand washing
2. Assemble the equipment in the utility room & take it to the patient
unit
3. Wear heavy duty/ utility glove
4. Clear the bed side cabinet and over bed table if used and discard
any waste in the waste basket
5. Strip the bed, remove pillow, and place the pillow on the chair &
pillow case in the hamper. Place all the line in the hamper and place
blanket on the cart for special laundry
6. Clean the bed, wash the top of mattress cover
7. Turn the other side & clean the spring
8. Wash the cabinet, inside & out
9. Complete the unit cleaning by washing the chair, bed lamp ( cord
unplugged) , singe cord & over bed table
10. discard the waste if cleaning cloth are to be reused place them in
the laundry hamper

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 11. Wash the collected utensils and place them in the utensils boiler
(sanitizer) for a 30 minute
12. Remove the clean utensils from the utensil boiler ,dry and return
them to the storage shelf
13. Wash hand
14. Record the procedure
2.6.2. Terminal cleansing of the patient care unit
Definition: The sanitation of the bed, bedside cabinet, and general area of
the patient care unit with a detergent/germicidal agent after the patient is
discharged or transferred from the Nursing care unit.Performed at every
patient care unit before the area is prepared for the next patient.

Purpose
 Prevention of the spread of microorganisms.
 Removal of encrusted secretions from framework or bedside rails.
 Removal of residue of body wastes from the mattress.
 Deodorizing of the bed frame, mattress, and pillow.
Guidelines for Terminal Cleaning.
 Reviews ward SOP for specific procedures.
 Use only authorized disinfectant/detergent or germicidal solution for
cleaning.
 Check to ensure the bedside cabinet is cleared of any valuables
belonging to the patient.
 Check bed linens for personal items (dentures, contact lenses,
money, jewelry, etc.) belonging to the patient.
 Prevent spread of microorganisms by carefully removing linen from
the bed.
 Use caution when cleaning the under frame and bedsprings.
 Replace any torn mattress or pillow covers.
 Allow the mattress and pillow to air-dry thoroughly before remaking
the bed.
2.7. Linen processing
Definitions: Processing linen-: consists of all the steps required to collect,
transport and sort soiled linen as well as to launder (wash, dry and fold or
pack), store and distribute it.
Equipment needed:
1. Heavy duty gloves
2. Mask
3. Protective eyewear

20
 4. Plastic or rubber aprons
5. Closed shoes
6. Plastic bag (hamper)
Procedure
A. Collecting soiled linen
1. Wear gloves and other PPE as appropriate
2. Roll heavily contaminated linen into the center
3. Collect used linen in cloth or plastic bags or containers with lids.
4. If carts or containers are available for soiled and clean linen should
be labeled accordingly.
5. Count and record the linen before transporting to the laundry.
B. Transporting soiled linen to Laundry
6. Transport clean and soiled linen separately.
7. Use different carts or containers to transport clean and soiled linen,
or wash and label before transporting clean linen.
8. Cover linen during transport.
9. Thoroughly clean container (plastic bag) that used to transport soiled
linen.

C. Sorting Soiled Linen

10. Keep clean linen in clean, closed storage areas.
11. Separate folding and storage room from soiled areas.
12. Keep shelves clean.
13. Handle stored linen as little as possible.
14. Ensure adequate ventilation and physical barriers between the
clean and soiled linen areas.
15. Wash hands after removing the gloves.
D. Distributing
16. Protect clean linen until it is distributed.
17. Do not leave extra linen in patient rooms.
18. Handle clean linen as little as possible.
19. Avoid shaking.
 Clean soiled mattresses before putting on clean
CHAPTER THREE
BODY MECHANICS AND MOVING
3.1. Maintaining body alignment
Definition:-Body alignment (posture) refers to the relative position of body parts in relation to each
other when lying down, standing, sitting, or any other activity results in balance, which is an individual’s
ability to maintain equilibrium

21
Purpose
 To promote client comfort
 To prevent contractures
 To promote circulation
 To lessen stress on muscle, tendons, nerves, and joints
 To Prevent foot drop (plantar flexion)
 Gives an appearance of confidence and health
3.2. Application of principles Body mechanics
Definition: -Body mechanics is the coordinated use of the body parts to produce motion and to
maintain balance
Propose
 Promotes the efficient use of muscles and conserves energy
Principles/steps in moving or lifting objects
1. Face the direction of movement
2. Use large muscle groups of the legs, arms, and shoulders to lessen the strain on the back and
abdominal muscles.
3. Bring the object to be lifted or carried as close to the body as possible before lifting. (This
keeps both centers of gravity close together.)
4. Bend the knees and keep the back straight when leaning over at work level.
5. Kneel on one knee, or squat, and keep the back straight when working at the floor level.
6. Push, pull, slide, or roll a heavy object on a surface to avoid unnecessary lifting.
7. Obtain help before attempting to move an obviously unmanageable weight.
8. Use of supportive devices (wheel chair )
9. Work in unison with an assistant. Give instructions and agree on the signal to start the
activity
3.3. Patient transfers
3.3.1. Transferring a Client from Bed to Chair
Definition: This is a procedure done to help clients in transferring from bed
to chair
Purpose:
 Helps client stands safety and gives time to assess status
 Moves client in to proper position to be seated
 Reduces risk of falling by maintaining clients stability during transfer
 Maintains clients stability and reduces pressure on axillae and strain on
back
Indication:
Clients unable to help themselves in transferring from bed to chair
Contraindication
 Unconscious patients
Equipment

22
 1. Bed pan (if necessary)
2. Chair /wheel chair
3. Slipper
Procedures
1. Greet the patient and explain the procedure.
2. Offer bed ban (Empty bladder will increase patient comfort)
3. Assess client’s ability to assist with the transfer and for presence of
cognitive or sensory deficits.
4. Take pulse and respiration
5. Lower the bed comfortable position.
6. Bring wheelchair close to the side of the bed, toward the foot of the
bed.
7. .Lock wheelchairs brakes and elevate the foot pedals.
8. Give the client slipper.
9. Assist client to side of bed until feet touch the floor.
10. Assess client for dizziness. Remain in front of client until
dizziness has subsided.
11. Assist the client to a standing position and provide support.
12. Stand facing the patient; place your hands under patient’s axilla.
(Have clients reach arm across shoulder) of the wheelchair.
13. Raise the patient, bend at the knees, and gently put in sitting
position.
14. Assist client to maintain proper posture.
15. Take pulse and respiration.
16. Watch for signs of tiredness
17. Record the procedure.

3.3.2. Transferring a Client from Bed to Stretcher

3.3.2.1. Three carrier lift
Definition: A three carrier lift is alternative method of transferring helpless
patients from bed to stretcher with three nurses or a nurse and two informed
assistants.
Purposes
 To reduces client’s anxiety and increases cooperation
 Decrease risk of client’s falling
Indication

23
  For patients unable to move from bed to areas where procedures
performed
Equipment
1. Stretcher
2. Pillow
3. Clean glove
Procedure
1. Greet the patent and explain the procedure to the patient
2. Wash your hand.
3. Make sure that assistants are available
4. Adjust the head of bed to the flat position.
5. Put stretcher parallel to patients head.
6. Each person must support one section of the patients’ body-head,
shoulders, and chest, hips and thighs and legs.
7. Slide your arms under the patient as far as possible and on signal,
simultaneously roll the patient towards your chest.
8. Walking together, move patient from bed to stretcher
9. Observe the patient condition
10. Document the procedure.
3.3.2.2. Draw sheet method of transferring patient from bed to
stretcher
Definition: This is method of transferring patient from bed to stretcher using
the sheet already under the patient as draw sheet.
Purpose, indication and contraindications
 similar with three carrier lift method
Equipment
1. Stretcher
2. Pillow
3. Lift sheet
4. Glove
5. Documentation format
Procedure
1. Greet the patient and explain the procedure
2. Wash your hand and dry it
3. Done glove if necessary
4. Loosen bottom sheet beneath patient
5. Position stretcher next to and parallel to bed
6. Prepare stretcher and adjust to bed height
7. Adjust the draw sheet

24
 8. Across stretcher and grasp sheet firmly at the patient’s head, chest,
hips and knees
9. Give direction
10. Slide the patient gently on to stretcher
11. 11. Comfort the patient
12. Observe the patient condition
13. Document the procedure.
3.4. Range of motion exercise/ROM
Definition:-Range of motion exercise refers to activities aimed at improving
movement of specific or group of joints
Purpose
 To maintain the current joint function
 To restore joint function that has been lost through disease or injury, or
lack of use
 To maintain muscle tone and strength
 To prevent contractures
 To improve circulation
Types
1. Active- movements of the joints independently by the client/patient on
a nonfunctioning joints.
2. Active-passive:-movement of nonfunctioning joint from partial
assistant from others carried
3. Passive:-movement applied by a nurse or other person or passive
motion machine on a pt’s immobilized joint.
Indication
 Unable to move joints
 Part of daily living activities
Contraindication
 Dislocation in specific joints
 Heart & respiratory disease and Swollen or inflamed joints or
musculoskeletal injury
Procedure passive range of motion exercise (PROM)
1. Wash hands
2. Explain the procedure to the client
3. Adjust the bed to a comfortable height.
4. Select one side of the bed to begin PROM exercises.
5. Uncover only the limb to be exercised.
6. Support all joints during exercise activity.
7. Use slow, gentle movements when performing exercises.
8. Repeat each exercise three times.

25
9. Stop if the client complains of pain or discomfort.
10. Begin exercise with the client’s neck and work down ward.
11. Exercise the neck
a. Flex, extend and rotate the client’s neck.
b. Support his or her head with your hands.
12. Exercise the client’s shoulder and elbow.
a. Support the client’s elbow with one hand and grasp the client’s
wrist with your other hand.
b. Raise the client’s arm from the side to above the head.
c. Perform internal rotation by moving the client’s arm across his or
her chest.
d. Externally rotate the client’s shoulder by moving the arm away
from the client.
e. Flex and extend the client’s elbow.
13. Perform all exercises on the client’s wrist and fingers
a. Flex and extend the wrist.
b. Abduct and adduct the wrist.
c. Rotate and pronate the wrist.
d. Flex and extend the client’s fingers.
e. Abduct and adduct the fingers.
f. Rotate the thumb.
14. Exercise the client’s hip and leg.
a. Flex and extend the hip and knee while supporting the leg.
b. Abduct and adduct the hip by moving the client’s straightened leg
toward you and then back to median position.
c. Perform internal and external rotation of the hip joint by turning the
leg inward and then outward.
15. Perform exercises on ankle and foot
a. Dorsiflexion and plantar flex the foot
b. Abduct and adduct the toes
c. Evert and invert the foot
16. Move to the other side of the bed and repeat exercise.
17. Position and cover the client. Return the bed to low position.
18. Wash your hands.
19. Document completion of PROM exercise

26
 CHAPTER FOUR
ESSENTIAL ASSESSMENT COMPONENTS
4.1. Measuring patient vital sign:
Physical assessment, an essential Nursing function, is performed on every
client. The measurement of vital signs and the execution of the physical
examination as part of the assessment process are done to gather
information regarding the physiological functioning of the body. The “taking
of vital signs” refers to measurement of the client’s:-
 Body temperature (T),
 Pulse (P)
 Respiratory (R) rates, and
 Blood pressure (BP).
These measurements can indicate if the circulatory, pulmonary, neurological
and endocrine body systems are functioning normally. Because of their
importance as indicators of the body’s physiological status and response to
physical, environmental and psychological stressors, they are referred to as
vital signs
4.1.1. Taking patient body temperature
Definition: The body temperature is the difference between the amount of
heat produced by body process and the amount of heat lost to the external
environment.
Purpose:
 To determine body temperature
 To assist in diagnosis
 To evaluate patient’s recovery from illness
 To determine if immediate measures should be implemented to reduce
dangerously elevated body temperature or converse body heat when
body temperature is dangerous low
 To evaluate patient’s response once heat conserving or heal reducing
measures have been implemented

27
4.1.1.1. Measuring oral temperature
Definition: it is technique of measuring body temperature through oral
route.
Contraindication
 Child below 7 yrs.
 If the patient is delirious, mentally ill
 Unconscious
 Uncooperative or in severe pain
 Surgery of the mouth
 Nasal obstruction
 If patient has nasal or gastric tubs in place

Precaution:
 Never use oral thermometer for rectal and vise verse

Equipment
1. Thermometer: glass or electronic
2. Two pairs of non-sterile gloves
3. Watch
4. Dry Cotton
5. Receiver/receptacle
6. Soapy water
7. tray
8. Pen or pencil
9. Vital following sheet or record form
Procedure
1. Explain the procedure
2. Wash hands
3. Assemble the necessary equipment
4. Remove thermometer from storage container and cleanse under cool
water.
5. Wipe thermometer dry with a tissue from bulb’s end toward fingertips.
6. Read thermometer by locating mercury level. It should read 35.5°C
(96°F).
7. If thermometer is not below a normal body temperature reading, grasp
thermometer with thumb and forefinger and shake vigorously by
snapping the wrist in a downward motion to move mercury to a level
below normal.

28
 8. Assist the client to assume semi fowlers position
9. Place thermometer in mouth under the tongue and along the gum line
to the posterior sublingual pocket. Instruct client to hold lips closed.
10. Leave in place as specified by agency policy, usually 3–5
minutes.
11. Remove thermometer and wipe with a tissue away from fingers
toward the bulb’s end.
12. Read at eye level and rotate slowly until mercury level is
visualized.
13. Shake thermometer down, and cleanse glass thermometer with
soapy water, rinse under cold water, and return to storage container.
14. Remove and dispose of gloves in receptacle.
15. Comfort the patient
16. Return used equipment and wash your hand
17. Record reading and indicate site as “OT.”(oral temperature)
4.1.1.2. Taking patient body temperature (axillary)
Definition; it is technique of measuring body temperature on arm pit.
Contraindication:
Equipment
1. Thermometer: glass or 6. Receiver/receptacle
electronic 7. Soapy water
2. Two pairs of non-sterile 8. Watch with secondhand
gloves 9. Pen or pencil
3. Dry Cotton 10. Vitalfollowingsheet or
4. Tray record form
5. Face towel

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

29
 9. Place thermometer or probe into center of axilla.
10. Fold client’s upper arm straight down and place arm across client’s
chest.
11. Leave glass thermometer in place as specified by agency policy
(usually 6–8 minutes). Leave an electronic thermometer in place until
signal is heard.
12. Remove and read thermometer.
13. Inform client of temperature reading.
14. Cleanse glass thermometer (Remove thermometer and wipe with a
tissue away from fingers toward the bulb’s end) and return to storage
container.
15. Assist client with replacing gown.
16. Comfort the patient
17. Return used equipment and wash your hand
18. Record reading and indicate site as “AT.”(Axillary temperature)
4.1.1.4 Measuring rectal temperature
Definition: Rectal temperature measurement: is method of measuring body
temperature by inserting thermometer through the anus into the rectum
Contraindication
 Patient with diarrhea
 Rectal surgery
 Disease of the rectum (anal fissure, hemorrhoid etc.)
Precaution:
 Never use oral thermometer for rectal and vise verse
 Never use rectal temperature if the immunosuppressant, hematologic
disorder, rectal surgery and diarrhea
Equipment
1. Thermometer: glass (client’s bedside); electronic
2. Lubricant (rectal, glass thermometer) and disposable protective sheath
3. tray
4. Two pairs of disposable gloves
5. Pen or pencil
6. Receiver /receptacle
7. Vital following sheet or record form
8. Tissue paper
9. Screen
Procedure
1. Explain the procedure
2. Wash hands
3. Assemble the necessary equipment

30
 4. Keep privacy
5. Place client in the Sims’ position with upper knee flexed. Adjust sheet to
expose only anal area.
6. Instruct client to take a deep breath.
7. Clean the anal area as necessary
8. Lubricate the tip of rectal thermometer or probe
9. Insert thermometer or probe gently into anus: infant, 1.2 cm (0.5 in.);
adult, 3.5 cm (1.5 in.)
10. If resistance is felt, do not force insertion.
11. Length of time (as specified by agency policy, usually 3–5 minutes).
12. Wipe secretions off glass thermometer with a tissue for reading
without touching the bulb. Dispose of tissue in a receptacle.
13. Read measurement and inform client of temperature reading.
14. While holding glass thermometer in one hand, wipe anal area with
tissue to remove lubricant or feces with other hand and dispose of
soiled tissue.
15. Comfort of the patient
16. Cleanse thermometer (Remove thermometer and wipe with a tissue
away from fingers toward the bulb’s end)
17. Hand washing and return in the place
18. Record reading and indicate site as “RT.”(Rectal temperature)
4.1.1.5. Measuring tympanic temperature
Definition: Tympanic temperature measurement: method of assessing body
temperature by inserting thermometer through ear
Contraindication
 Perforated ear drum
 Ear infection(Otitis media)

Precaution:
 Take tympanic and oral temperature for children above 6 year
 Never use tympanic temperature is any ear surgery

Equipment
1. Thermometer: glass (client’s 6. Receiver /receptacle
bedside); electronic 7. Vital following sheet or record
2. Two pairs of disposable gloves form
3. Probe cover 8. Dry cotton
4. tray 9. Cotton tipped applicator
5. Pen or pencil

31
Procedure
1. Explain the procedure
2. Wash hands
3. Assemble the necessary equipment
4. Assist clients for assuming comfortable position with hand toward one
side away from nurse for Right handed nurse take from right ear and
for Left handed nurse take from left ear
5. Note if any excess ear wax
6. Position client in Sims’ position
7. Remove probe from container and attach probe cover to tympanic
thermometer unit.
8. Turn client’s head to one side. For an adult, pull pinna upward and
back; for a child, pull down and back.
9. Gently insert probe with firm pressure into ear canal.
10. Remove probe after the reading is displayed on digital unit (usually 2
seconds).
11. Remove probe cover and replace in storage container.
12. comfort the client
13. Return tympanic thermometer to storage unit and wash hand
14. Record reading and indicate site as “ET.”(Ear temperature)
4.1.2. Assessing patient pulse
Definition:
1. Pulse assessment is the measurement of a pressure pulsation created
when the heart contracts and ejects blood into the aorta. Assessment of
pulse characteristics provides clinical data regarding the heart’s pumping
action and the adequacy of peripheral artery blood flow.
2. It is method of assessing patient pulse for depth, rate and rhythm
Purpose:
 To determine number of heart beats occurring per minute (rate)
 To gather information about heart rhythm and pattern of beats
 To evaluate strength of pulse
 To assess heart's ability to deliver blood to distant areas of the blood
viz. fingers and lower extremities
 To assess response of heart to cardiac medications, activity, blood
volume and gas exchange
 To assess vascular status of limbs
Equipment

32
 1. Watch with a second hand
2. Stethoscope
3. Swab
4. Tray
5. Waste Receiver
6. Vital Sign Flow Sheet
7. Pencil and pen

Procedure
1. Explain the procedure
2. Wash hands
3. Assemble the necessary equipment
4. Inform client of the site(s) at which you will measure pulse.
5. If supine, place client’s forearm straight alongside body or Flex client’s
elbow and place lower part of arm across chest.
6. Support client’s wrist by grasping outer aspect with thumb.
7. Place your index and middle finger on inner aspect of client’s wrist over
the radial artery or thumb side and apply light but firm pressure until
pulse is palpated
8. Identify pulse rhythm and then Determine pulse volume.
9. Count pulse rate by using second hand on a watch:
 For a regular rhythm, count number of beats for 30 seconds and
multiply by 2.
 For an irregular rhythm, count number of beats for a full minute,
noting number of irregular beats.
10. Comfort the client
11. Return equipment and wash hand
12. Record reading and indicate site as “PR.”(Pulse rate)
Apical pulse
1. Explain the procedure
2. Wash hands
3. Assemble the necessary equipment
4. Raise client’s gown to expose sternum and left side of chest.
5. Cleanse earpiece and diaphragm of stethoscope with an alcohol swab.
6. Put stethoscope around your neck.
7. Apex of heart:
 With client lying on left side, locate suprasternal notch.
 Palpate second intercostal space to left of sternum.

33
  Place index finger in intercostal space, counting downward until
fifth intercostal space is located.
 Move index finger along fourth intercostal space left of the sternal
border and to the fifth intercostal space, left of the midclavicular
line to palpate the point of maximal impulse (PMI) .
 Keep index figure of non-dominant hand on PMI
1. Inform client that you are going to listen to his/her heart.
2. Instruct client to remain silent
3. With dominant hand put ear piece of the stethoscope in your ear and
grasp diaphragm of the stethoscope in palm of your hand for 5 to 10
second
4. Comfort the client
5. Return equipment and wash hand
6. Record reading and indicate site as “PR.”(pulse rate)

4.1.3. Assessing patient respiration

Definition; is method of assessing patient breathing for depth, rate and
rhythm.
Purpose
 For diagnostic purpose
 To evaluate the progress of patient condition
 To evaluate the effect of administered drugs
 To evaluate breathing for rate, depth and rhythm
Equipment:-
1. Watch with a second hand
2. Pen
3. Pencil
4. Vital sign flow sheet or record form
Procedures
1. Explain the procedure
2. Wash hands
3. Assemble the necessary equipment
4. Be sure the patient is comfortable position; preferably, he sitting or
lying with head of bed elevated 45 to 60 degrees.
5. Before replacing client’s gown from auscultating heart sounds, assess
respirations.
6. Place your hand over client’s wrist and observe one complete
respiratory cycle.

34
 7. Start to count with first inspiration while looking at second hand sweep
of watch.
 Infants and children: count a full minute.
 Adults: count for 30 seconds and multiply by 2.
 If an irregular rate or rhythm is present, count for a full minute.
8. Observe depth of respirations by degree of chest wall movement and
rhythm of cycle (regular or interrupted).
9. Comfort the client
10. Return equipment and wash hand
11. Record reading
4.1.4. Assessing patient blood pressure
Definition: is the method of recording force exerted on arterial wall by
pulsing blood under pressure from the heart.
Purpose:
 To evaluate effect of some drugs affecting cardiovascular system
 To have baseline vital sign of patient on admission
 To diagnose hypertension and hypotension disorders of blood
Contraindications for brachial artery blood pressure measurement
When the client has any of the following, do not measure blood pressure on
the involved side
 Venous access devices, such as an intravenous infusion or
arteriovenous fistula for renal dialysis
 Surgery involving the breast, axilla, shoulder, arm, or hand
 Injury or disease to the shoulder, arm, or hand, such as trauma,
burns, or application of a cast or bandage.
Equipment:
1. Alcohol swabs
2. Sphygmomanometer with proper size cuff
3. Stethoscope
4. Tray
5. Vital sign sheet
6. Pen and pencil
Procedure
1. Explain the procedure
2. Wash hands
3. Assemble the necessary equipment
4. Determine which extremity is most appropriate for reading.
5. Have the client rest at least 5 minute before measurement.
6. Use appropriate size cuff
7. Move clothing away from upper aspect of arm.

35
 8. Position arm at heart level, extend elbow with palm turned upward
and for thigh, position with knee slightly flexed.
9. Make sure bladder cuff is fully deflated and pump valve moves
freely.
10. Locate brachial artery in the antecubital space.
11. Apply cuff comfortably and smoothly over upper arm, 2.5 cm (1
in.) above antecubital space with center of cuff over brachial artery.
12. Connect bladder tubing to manometer tubing. If using a portable
mercury-filled manometer, position vertically at eye level.
13. Palpate brachial artery ,turn valve clockwise to close and
compress bulb to inflate cuff to 30 mm Hg above point where
palpated pulse disappears, then slowly release valve (deflating
cuff), noting reading when pulse is felt again .
14. Insert earpiece of stethoscope in ears with a forward tilt,
ensuring diaphragm hangs freely
15. Relocate brachial pulse with your non dominant hand and place
bell or diaphragm chest piece directly over pulse. Chest piece
should be in direct contact with skin and not touchcuff
16. With dominant hand, turn valve clockwise to close. Compress
pump to inflate cuff until manometer registers 30 mm Hg above
diminished pulse point identified in step 13.
17. Slowly turn valve counterclockwise so that mercury falls at a rate
of 2–3 mm Hg per second. Listen for five phases of Korotkoff’s
sounds while noting manometer reading:
18. Deflate cuff rapidly and completely.
19. Remove cuff or wait 2 minutes before taking a second reading.
20. Inform client of reading
21. Lower bed, raise side rails, place call light in easy reach.
22. Put all equipment in proper place.
23. Comfort the client
24. Return equipment and wash hand
25. Record reading and interpret

CHAPTER FIVE
MAKING AND MAINTAINING BED
Bed making - is a technique, which provides enough area to the patient on
which s/he can be comfortable.
General instruction
1. Put bed coverings in order of use
Order of Beddings

36
 1. Mattress cover
2. Bottom sheet
3. Rubber sheet
4. Cotton (cloth) draw sheet
5. Top sheet
6. Blanket
7. Pillow case
8. Bed spread
2. Wash hands thoroughly after handling a patient's bed linen
3. Linens and equipment soiled with secretions and excretions harbor
micro-organisms that can be transmitted directly or by hand’s uniforms
4. Hold soiled linen away from uniform
5. Linen for one client is never (even momentarily) placed on another
client’s bed.
6. Soiled linen is placed directly in a portable linen hamper or a pillow
case before it is gathered for disposal.
7. Soiled linen is never shaken in the air because shaking can
disseminate secretions and excretions and the microorganisms they
contain.
8. When stripping and making a bed, conserve time and energy by
stripping and making up one side as completely as possible before
working on the other side.
9. To avoid unnecessary trips to the linen supply area, gather all needed
linen before starting to strip bed.
10. Make a vertical or horizontal toe pleat in the sheet to provide
additional room for the client’s feet.
11. While tucking bedding under the mattress the palm of the hand
should face down to protect your nails.

Note
 Pillow should not be used for babies
 The mattress should be turned as often as necessary to prevent
sagging, which will cause discomfort to the patient.

5.1. Stripping of a Bed

37
Definition: Stripping of a bed is removing the bed linen from a bed which
had been previously made-up.
Purpose:
 To prevent cross contamination
 Ventilate the bed and bedding, and
 Prepare the bed for remaking
 To prevent damage of bedding
Precautions
1. No bedding, either clean or soiled, should ever be put on the floor. It
should be discarded in hamper.
2. Do not let your uniform touch the bedding. Woollen blankets are
never discarded in soiled clothes hamper. If soiled, they should be
dry-cleaned or washed carefully or treated with direct sunlight.
3. Use glove it the bed soiled or used by patient
Equipment
 Bedside chair
 Hamper
 Glove as necessary
Procedure
1. wash hand
2. Place chair conveniently at the foot of the bed
3. place pillow on seat of chair
4. Loosen the bedding all around, starting from the right
5. Fold bedspread twice, bring top hem (edge) to bottom hem, pick up
from the center.
6. Fold the blanket and the top sheet in similar manner
7. Place soiled linen in the hamper
8. Place other soiled bedding on chair, and place that which is to be
used again, over back of chair
9. Fold the draw sheet in two and place it over the chair if clean or on
the- chair if soiled.
10. Do likewise with mackintosh.
11. Remove and fold the bottom sheet in the same manner as the
bedding
12. Turn mattress from top to bottom or from side to side.
13. Wash hands
14. Recording and documenting
15. Making Unoccupied Bed
5.1 Closed bed

38
Definition: Closed bed is a smooth, comfortable and clean bed, which is
prepared for a newly admitted patient.In closed bed: the top sheet, blanket
and bed spread are drawn up to the top of the bed and under the pillows.

Purpose:
 To receive new patient
 To keep the bed neat and clean until a new patient is admitted
Equipment
1. Mattress (1)
2. Bed sheets(2): Bottom sheet (1), Top sheet (1)
3. Pillow (1)
4. Pillow cover (1)
5. Mackintosh/ Rubber sheet (1)
6. Draw sheet (1)
7. Blanket (1)
8. Savlon water or Dettol water in basin.
9. Sponge cloth (4): to wipe with solution (1) to dry (1)
10. When bed make is done by two nurses, sponge cloth is needed two
each.
11. Laundry bag or hamper (1)
12. Trolley(1)
13. Clean glove
Procedure
1. Wash hands and collect necessary materials
2. Place the materials to be used on the chair. Turn mattress and clean
the mattress.
3. Move the chair and bed side locker.
4. Clean Bed-side locker, chair: Wipe with wet and dry.
5. Clean the mattress:
 Stand in right side.
A. Start wet wiping from top to center and from center to bottom
in right side of mattress.
B. Gather the dust and debris to the bottom.
C. Give wiping as same as procedure 2
 Move to left side.
A. Wipe with wet and dry the left side.
6. .Move to right side. Start making the bed, Place bottom sheet with
correct side up, center of sheet on center of bed and then at the head
of the bed.

39
 7. Tuck sheet under mattress at the head of bed and miter the corner.
8. Mitering steps:
 Face the side of bed and lift and lay the top edge of the sheet onto
the bed to form a triangular fold.
 With your palms down, tuck lower edge of sheet (hanging free at
side of mattress) under mattress.
 Grasp the triangular fold, bring it down over the side of the mattress
and tuck the sheet smoothly under the mattress Straighten the free
hanging sheet on mattress side
9. Remain on one side of bed until you have completed making the bed
on that side.
10. Tuck sheet on the sides and foot of bed, mitering the corners.
11. Tuck sheets smoothly under the mattress, there should be no
wrinkles.
12. Place rubber and draw sheet at the center of the bed and tuck
smoothly and tightly.
13. Place cotton draw sheet on top of rubber draw sheet and tuck.
The rubber draw sheet should be covered completely.
14. Place top sheet with wrong side up, center fold of sheet on center
of bed and wide it at head of bed.
15. Tuck sheet of foot of bed, mitering the corner.
16. Place blankets with center of blanket on center of bed, tuck at the
foot of beds and miter the corner.
17. Fold top sheet over blanket
18. Place bed spread with right side up and tuck it.
19. Miter the corners at the foot of the bed.
20. Go to other side of bed and tuck in bottom sheet, draw sheet,
mitering corners and smoothening out all wrinkles, put pillow case on
pillow and place on bed.
21. See that bed is neat and smooth
22. Leave bed in place and furniture in order
23. Wash hands
24. Recording and documenting.
5.2. Open bed
Definition: Open bed is one which is made for an ambulatory patient are
made in the same way but the top covers of an open bed are folded back to
make it easier of a client to get in.
Purposes of making open bed
 To provide clean and comfortable bed for the patient
 To reduce the risk of infection by maintaining a clean environment

40
  To prevent bed sores by ensuring there are no wrinkles to cause
pressure points
Equipment
1. Two large sheets
2. Rubber draw sheet
3. Draw sheet
4. Rubber sheet (Mackintosh )
5. Blankets
6. Pillow cases
7. Bed spread
8. Clean glove
9. Chart
Procedure
1. Wash hands and collect necessary materials.
2. Place the materials to be used on the chair. Turn mattress and arrange
evenly on the bed.
3. Place bottom sheet with correct side up, center of sheet on center of
bed and then at the head of the bed.
4. Tuck sheet under mattress at the head of bed and miter the corner.
5. Remain on one side of bed until you have completed making the bed
on that side.
6. Tuck sheet on the sides and foot of bed, mitering the corners.
7. Tuck sheets smoothly under the mattress, there should be no wrinkles.
8. Place rubber and draw sheet at the center of the bed and tuck
smoothly and tightly.
9. Place cotton draw sheet on top of rubber draw sheet and tuck. The
rubber draw sheet should be covered completely.
10. Place top sheet with wrong side up, center fold of sheet on center
of bed and wide it at head of bed.
11. Tuck sheet of foot of bed, mitering the corner.
12. Place blankets with center of blanket on center of bed, tuck at the
foot of beds and miter the corner.
13. Fold top sheet over blanket
14. Place bed spread with right side up and tuck it.
15. Miter the corners at the foot of the bed.
16. Go to other side of bed and tuck in bottom sheet, draw sheet,
mitering corners and smoothening out all wrinkles, put pillow case on
pillow and place on bed.
17. See that bed is neat and smooth
18. Leave bed in place and furniture in order

41
 19. Wash hands
20. Recording and documenting
5.3. Making an unoccupied Bed
Definition: An occupied bed is a bed prepared for a weak patient (bed
ridden) who is unable to get out of bed.
Purposes
 To provide comfort and to facilitate circulation of the patient
 To provide cleanliness and facilitate position of the patients bed
 To conserve patient’s energy and maintain current health status
 To comfort the patient
Equipment
1. Two large sheets
2. Draw sheet
3. Rubber sheet (mackintosh).
4. Pillow case
5. Pajamas or gown, if necessary
6. Spread sheet
7. Chart
8. Clean glove
Procedure
1. Wash hands and collect equipment
2. Explain procedure to the patient
3. Carry all equipment to the bed and arrange in the order it is to be
used.
4. Make sure the windows and doors are closed.
5. Make the bed flat, if possible
6. Loosen all bedding from the mattress, beginning at head of the bed,
and place dirty pillow cases on the chair for receiving dirty linen.
7. Have patient flex knees, or help patient do so. With one hand over the
patient’s shoulder and the other hand over the patient’s knees, turn
the patient towards you. Never turn a helpless patient away from you,
as this may cause him/her to fall out of bed.
8. When you have made the patient comfortable and secure as near to
the edge of the bed as possible, go to the other side carrying your
equipment with you.
9. Loosen the bedding on that side.
10. Fold, the bed spread half way down from the head. Fold the
bedding neatly up over patient.
11. Roll dirty bottom sheet close to patient

42
 12. Put on clean bottom sheet on used top sheet center, fold at
center of bed, rolling the top half close to the patient, tucking top and
bottom ends tightly and mitering the corner
13. Put on rubber sheet and draw sheet if needed.
14. Turn patient towards you on to the clean sheets and make
comfortable on the edge of bed.
15. Go to the opposite side of bed. Taking basin and wash cloths with
you, give patient back care.
16. Remove dirty sheet gently and place in dirty pillow case, but not
on the floor.
17. Remove dirty bottom sheet and unroll clean linen.
18. Tuck in tightly at ends and miter corners.
19. Turn patient and make position comfortable.
20. Back rub should be given before the patient is turned on his /her
back
21. Place clean sheet over top sheet and ask the patient to hold it if
she/he is conscious. Go to foot of bed and pull the dirty top sheet out
22. Replace the blanket and bed spread
23. Miter the corners
24. Tuck in along sides for low beds
25. Leave sides hanging on high beds
26. Turn the top of the bed spread under the blanket
27. Turn top sheet back over the blanket and bed spread
28. Change pillowcase, lift patient’s head to replace pillow. Loosen
top bedding over patient’s toes and chest.
29. Be sure the patient is comfortable
30. Clean bedside table
31. Remove dirty linen, leaving room in order
32. Wash hands.
33. Recording and documentation
NB: If a full bath is not given at this time, the patient’s back should be
washed and cared for
5.4. Making cardiac bed
Definition: Cardiac bed is a bed prepared for a patient with heart disease or
dyspnea and to provide easy breathing for patient with minimum strain.

Purpose
 In order to ease difficulty in breathing

43
  To Provide comfort and safety
 To relieve dyspnea
 To prevent complication
Equipment
1. Linens
2. Bed spread
3. Blanket
4. Extra pillows (4 – 6 Pillows)
5. Pillowcase
6. Cylinder with oxygen
7. Draw Sheet
8. Footrest& back rest
9. Rubber sheet
10. Over bed table
Procedure
1. Wash your hands
2. Assemble the necessary equipment and carry to bed side
3. Place chair at the foot of the bed
4. Arrange the linen on chair in the order that it will be used
5. Turn mattress and arrange on the bed.
6. Put on mattress cover if available
7. Place bottom sheet with right side up, center of sheet on center of bed
and wide hem at the head of the bed.
8. Tuck sheet under mattress at head of bed and miter the corner.
9. Remain on one side of bed until you have completed making the bed
on that side.
10. Tuck sheet on the sides and foot of bed mitering the corners.
11. Tuck sheets smoothly under the mattress. There should be no
wrinkles.
12. Place rubber draw sheet in the center of the bed and tuck tightly.
13. Place cotton draw sheet on top of rubber draw sheet and tuck.
Rubber draw sheet should be covered completely.
14. Place top sheet with wrong side up, center fold sheet at center of
bed and wide hem at foot of bed.
15. Tuck sheet at foot of bed mitering the corner.
16. Place blankets with center of blanket on center of bed and tuck at
the foot of bed and miter corner. Fold top sheet over blanket.
17. Place bed spread with right side up. Tuck at the foot of bed miter
corners and cover top bedding.

44
 18. Go to other side of bed fanfold the top covers at the center of bed
and tuck in bottom sheet and draw sheet mitering corners, smoothing
out all wrinkles, continue with blanket and spread the same with the
opposite side.
19. See that bed is neat and smooth
20. Put bed in semi fowler’s position by raising the head of bed; if
bed is gatched raise at the head of bed if bed is normal bed put extra
pillows.
21. Put footrest to prevent the patient from sliding down.
22. Place over bed table over the bed and a pillow over it to allow the
patient’s hands to rest on it.
23. Wash the hand thoroughly
24. Record in the nurse’s order of any observation made on the
patient
5.5. Post-operative/anesthetic bed making
Definition:Anesthetic bed is a bed especially prepared to receive a patient
after surgery and major recovery from general anesthesia.
Purposes
 To facilitate easy transfer of the patient from stretcher to bed.
 To facilitate removal of secretion
 To protect the mattress and bedding from bleeding, vomiting,
drainage or discharges.
 To protect the patient from becoming chilled or give warmth.
Equipment
A. For bed making
1. Two large sheets.
2. Draw sheet(two)
3. Bath blanket
4. Woolen blanket
5. Rubber sheet (Mackintosh)
6. Two tongue blades or a mouth gag.
7. Small towel.
8. Pillow case
9. Spread sheet
10. Additional Sheets and blanket
11. bed blocks as needed
12. An extra rubber sheet & draw sheet for operated areas
B. For first aid activity
1. Emergency drug 3. Vital sign equipment
2. Minor set 4. Suction machine

45
 5. Oxygen cylinder 12. Emesis basin and paper
6. Sterile Suction catheter bag.
7. Sterile glove 13. Iv fluid
8. Examination lamp (at hand if 14. Hot water bag
needed). 15. Safety pin
9. Airway tube 16. Bed cradle
10. Sterile drainage bottle 17. Tissue paper
with tubing, 18. An emesis basin
11. IV Stand. 19. Chart

20. Paper and pen for recording vital signs and charting

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

46
 13. Arrange emergency equipment{ B/P apparatus ,suction machine,
Drug}
14. Close the windows. Leave the room clean and in order
15. Receiving the patient from operation room
A. Remove folded to cover of the bed
B. Place the patient on bed and cover quickly
C. See that patient is properly placed in bed with head to the left side
and comfortable
D. Check patient s condition operated area, urine, vital sign, colour of
patient etc.
E. Do after care and Comfort the patient after procedure
16. Return used equipment to utility room and wash your hand
17. Proper documentation
5.6. Making an amputation bed:
Definition
A. Amputation: - is the surgical removal of a part of the body or a limb,
performed to treat recurrent infections or gangrene in peripheral vascular
disease, to remove malignant tumors, & in severe trauma.
B. Amputation bed/ stump bed is a regular bed with cradle, which is
prepared for amputated patient.

Purpose
 To give extra warmth
 To leave the part open for observation.
 To ensure more safety and comfort by preventing soiling and
staining.
 To keep the stump in a good position
 To prevent jerky movements for the amputated leg
 To prepare for emergency, to have easy access and economy of
time and energy
Equipment

1. Linens (3) 9. Draw sheet

2. Pillow 10. face &bath towel
3. Blanket(2) 11. Tourniquet
4. Pillow case 12. Rubber sheet
5. Bed cradle 13. Mackintosh
6. Trolley 14. Small rubber sheet with
7. sponge cover
8. safety pin 15. Dressing set

47
 16. Sand bags with cover

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

5.7. Fracture bed making

Definition: Fracture bed is a hard firm bed designed for a patient with
fracture.
Purpose
 To give firm, even support to the broken limbs and back.
 To maintain position.
 To make the patient comfortable.
 To provide a flat, unyielding surface to support the fractured limb.
Equipment

1. Articled as for a closed bed

48
 2. Small blanket or draw sheet
3. Fracture board
4. Bed cradle
5. Small rubber sheet
6. Draw sheet
7. Sand bags
8. Pillow if required
Procedure:
1. Place the fracture board directly over the bed springs and the mattress
on it. If the mattress is thin, an extra mattress must be added to
prevent pressure sore due to pressures on the head surface.
2. Make the bottom bed as usual, and then place the small rubber sheet
covered with draw sheet at the place where the injured part will be
resting. The small rubber and draw sheet are easier to change then the
whole bed. This applies specially to an arm or a leg, which is bleeding
or has discharge.
3. Fold back the bed cloths at foot of the bed for leg fracture. Cover the
uninjured limb with a small blanket. On draw sheet placed the cradle
over the linen to adjust the cover over it. Extra blanket and spreads
may be necessary. Be sure that the covers come high enough on the
shoulder
4. Do after care and Comfort the patient after procedure
5. Return used equipment to utility room and wash your hand
6. proper documentation
N.B:
 Never cover a plaster cast until it is thoroughly dry.
 The fracture board keeps the bed with no danger of sagging. It is also
used for fracture of the spine. A bed cradles are a frame made of wire
wood or iron .it is used to keep the top cover from touching the injured
part.
5.8. Baby crib
Definition: A the bed that prepare for pediatric case with bed side safety
Purpose
 To make comfort for baby with safety

Equipment
 The same with closed bed
Procedure
1. Place baby at the foot of bed

49
2. Loosen bottom sheet at head
3. Place clean bottom sheet and tuck in
4. Place small rubber sheet or water proof pad on top
5. Place baby at the head of bed
6. Remove soiled linen and tuck clean bottom sheet mitring corners
7. Place clean top sheet and tuck at the bottom
8. Place blanket and tuck, and place baby bed spread
9. Complete making bed on both sides
10. Raise side rails of bed and leave baby comfortable in bed.

CHAPTER SIX

50
 HYGIENE CARE AND GROOMING
6.1. Bed bath
Definition: Is a bath given to a patient who is unable to give care for
him/herself.
Purposes
F To promote comfort relaxation and cleanliness
F To stimulate circulation
F To prevent bad body odors
F To prevent pressure sores
F To relax and refresh the patient
F Maintain muscle tone & joint mobility
F To improve self-image
F To give an opportunity for the nurse to assess patients
F To prevent multiplication of pathogenic microorganisms on the
skin surface.
Indication:
1. Patients who are weak
2. seriously ill and for pt. that has certain heart conditions
3. unconscious, paralyzed or confused patient
Precautions
1. Avoid scratching the skin with jeweler or long sharp fingernails.
2. Avoid harsh scrubbing, use of rough towel or wash clothes.
3. Assess the status & level of mobility.
4. Maintain adequate privacy and warmth throughout the procedure and
drape appropriately.
5. Identify if there are limitation of movements or position for pt.
6. Bath water must be warm enough and change throughout the
procedure when it becomes cool, too soapy, dirty or after washing the
genital area
7. Always wash from clean to dirty.
8. Determine allergies to soap and other cream lotion.
9. Clean the eyes with water from the inner to the outer cantus.
Equipment
1. Washcloth (2) 5. Pajama
6. Oil, cream, lotion/powder
2. Washbasin (2) 7. Soap with soap dish

3. Bath towels (2) 8. Nail cutter

4. Basin and jug with warm 9. Bath blanket
water

51
 10. Trays for nail care or 16. Comp and brush
mouth care if necessary 17. Gloves disposable
11. Bed making materials 18. Screen
12. air freshener 19. Deodorant
13. Face towel 20. Humber for soiled
14. Lotion thermometer cloths
15. Bed pan or urinal 21. Trolley

Procedure
1. Assess the patient condition and Explain procedure to pt.
2. Wash your hands
3. Assemble the necessary equipment for bed bath.
4. Before starting bath, offer bedpan or urinal, remove bedpan or urinal;
find out what linen is needed.
5. If the patient is in the ward, screen patient and remove unnecessary
articles from bed side table, place linen on chair in order of use and
bring bath basin with hot water. and adjust the bed at the level of you
to prevent back strain
6. Remove top bedding, fold and place over back of chair. If there is no
chair, it should be placed on foot of bed. Cover the patient with bath
blanket. Have patient move to near side of bed and remove gown.
Remove pillow unless this is uncomfortable for patient.
7. Use pillow for turning patient if necessary; otherwise, remove soiled
pillowcase; place ` `soiled
gown in it and place it on chair or foot of bed between matters and foot
of bed.
8. Wash eyes with clean water only and face of patient before the other
parts of the body.
9. Do not expose patient unnecessary.
10. Work quickly and smoothly. Watch for signs of fatigue during
bath; report and chart any reddened spots, rash, sores or swelling.
Change water as often as necessary. Never use dirty or soapy water.
11. Remember to protect the bed from dampness by placing bath
towel under each part of body during bath.
12. Place one hand under each part to support it while washing and
drying the extremities.
13. Using long, firm, even strokes, wash from wrist to shoulder. Place
basin on towel on side of bed and allow patient to put hands in water.
Wash, take basin away, dry thoroughly.
14. Bath chest, dry and cover with towel, then bath abdomen.

52
 15. Flex knee on far side, uncover leg and thigh and drape to protect
bed. Wash and dry leg. Do the same for the other leg.
16. Get clean, warm water and turn patient on side. Spread towel
close to body, wash back and hips well. Rinse and dry carefully.
17. Rub back with alcohol and talcum powder or soapy water using
whole flat of hand and long smooth strokes. Use a circular movement
around the reddened areas or over boney prominences. If soap is used,
clean it off after the rub.
18. Place towel under hips. Put basin and soap within easy reach of
the patient. Give him the washcloth if he is able to wash the genitalarea
sothat he may finish hisbath. If the patient is unable to do so, the nurse
should finish the bath by cleaning the genital area of the patient by
wearing the glove.
19. Put on clean gown protect the pillow or bed with face towel and
comb patient’s hair. Cut and clean finger nails and toe nails.
20. Make the bed and leave patient comfortable.
21. Wash bedside table and take dirty linen, bath basins, soap and
alcohol to utility room. Wash basin well, dry and return to cupboard.
Return other equipment to proper place.
22. Before you leave patient, ask patient if there is anything else you
may do for him within reach and chart procedure, time and observation.

6.2. Giving tub bath

Definition: Type of bath that allow direct washing and rinsing by using
shower
Shower: - The pt. is assisted to the bathroom, sits or stands and spray of
water is usually directed on to the body.
Purpose
F To promote comfort relaxation and cleanliness
F To stimulate circulation
F To prevent bad body odors
F To relax and refresh the patient
F Maintain muscle tone & joint mobility
F To prevent multiplication of pathogenic microorganisms on the
skin surface.
Precautions
 Adjust temperature and flow of the water
 Avoid chilling
 Always keep bath room un locked
 Check pt. frequently for sign of exhaustion.

53
  Make sure that the tub shower clean and functioning
 Place disposable rubber or plastic materials on the floor of the shower
 Instruct patient not to use oil during bath
 If sensation is normal, ask client to test water, and adjust temperature
if water is too warm
Equipment
1. Soap and soap dish 6. Chair
7. Comb & Brush
2. Washcloth 8. Wheel chair (optional)

3. Bath towel 9. Bed pan/Urinal

10. Nail cutter
4. Gown 11. Oil/cream/lotion
5. Sleeper 12. Pajama

Procedure
1. Check the bath room temperature, which should be warmer than the
normal room temperature
2. Make sure the tub is clean. Scour it carefully with disinfectant. Unless
using a long-handled swab, wear glove when cleaning the tub.
3. Rinse the tab well
4. Place a chair near the tub, with a bath blanket opened over it
5. Place towels, washcloth and soap where the client can reach them
easily
6. Fill the tub about halfway(less for a child)
7. Test the water with a bath thermometer. Water temperature should be
warm to very warm, but never over 40.60c (1050F).
8. Bringing the client to the bathroom and assist patient to undress
9. Assist patient into the tub and avoid falling.
10. Allow patient to bath himself or assist as necessary.
11. Assist patient out of tub and dry his body and put on gown.
12. Return patient to room and put to bed.
13. Clean bathtub and leave room in order.
14. Discard soiled linen.

CHAPTER SEVEN
CARDIOPULMONARY RESUSCITATION (CPR)
Definition
Cardio-Pulmonary Resuscitation is an emergency procedure
consisting of external cardiac massage and artificial respiration

54
 Purpose
 To squeeze blood manually out of the heart for victim’s with
cardiac arrest
 To provide oxygenated blood to the brain and heart
 To restore blood circulation
Indications
 Respiratory Arrest: - Respiratory arrest refers to the absence of
breathing.
 Cardiac Arrest: When the heart stops, there is no pulse.
Precaution
1. The CPR Must begin within 4-6 minutes of collapse if not; the
brain is sensitive to hypoxia and will sustain irreversible damage
after 4-6 minutes of no oxygen.
2. The cause of cardiac arrest is important BUT do not delay CPR to
obtain history
3. Relative Contraindications
4. Ribs fractured
5. Burn of sternum( full thickness )
Equipment
 No special equipment are needed at emergency situation- just
hands and mouth & step by step procedure.
 At hospital level ( Ambu bag , firm board, stethoscope , spatula ,
air way )
Procedure
7.1. Adult CPR procedure
1. Check the Scene or Assessment of the Situation (Always Present if it is
out of Health Centers)
 Make sure it is safe for you to help.
 Don't become another victim and assess the environment to
know the cause of the problem
2. Check the Victim or Assessment of unresponsiveness
 Tap or gently shake the victim and shout “Are you ok”.
 To elicit a response a painful stimulus can be applied such as:
 Pinching the earlobe,
 Pressing over the eyelid and observing for grimacing.
 Other associations recommend rubbing on the sternum using the
knuckles of the fingers.
3. Call for Help or Activate EMS
 Rescuer who is alone should alter sequence of rescue based on
most likely cause.

55
  Sudden witnessed collapse (likely VF) arrest activates EMS
(Emergency medical service), do CPR.
 Hypoxic arrest (i.e., suffocation give 5 cycles of CPR (about 2
minutes) before alerting EMS. If there is no response, Call *****
and return to the victim. In most locations the emergency
dispatcher can assist you with CPR instructions

4. Positioning the victim

Place the victim first on His/ Her back on hard surface. If the
victim is lying face down, turn or roll the victim as unit,
supporting the head and neck
5. Airway
 Open the airway by the head tilt / chin lift maneuver for all
victims and Remove foreign body. We might also assess the
breathing status of the victim
 Health care personnel use:
o Head tilt- chin lift
o Jaw thrust in trauma patient

6. Breathing
Assessment of breathlessness and carotid pulse (5-10 seconds)
Place your ear just one inch above the mouth and the nose of the
victim and perform the following simultaneously: Use LLF
methods
o LOOK: for the chest to rise and fall
o LISTEN: for air escaping during exhalation, and
o FEEL: for the flow of air on your cheek
NB: Count the number
1001,1002,1003,1004,1005,1006,1007,1008,1009,1010 to be sure you
are checking for 10 seconds because 1001 represents 1 second, and
1002 represents 2, and continue others like this.
 Simultaneously assess the presence of pulses
o Assessment of pulselessness (5-10 sec.): check pulse at
carotid artery which is the most common and most
reliable.
o While maintaining the head tilt with one hand, locate the
victim’s Adams apple (thyroid cartilage) with two or three
fingers of the other hand. Slide your fingers into the
groove between the Adam’s apple and the muscle on the
side nearest you where the carotid pulse can be felt.

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  If breathing is not present, begin rescue breathing by giving two
slow breaths: pinch nose and cover the mouth with yours and
blow until you see the chest rise. Give 2 breaths.
 Time:
o Each breath should take 1.5 sec to 2 sec and watch for chest
rise and allow time for exhalation (3-3.5 sec).
 Volume:
o Sufficient volume
o No large volume or forceful breathing.
7. Circulation
 If pulse is not definitely felt within 10 seconds, proceed with chest
compression
 Provides 30% (or less) of normal circulation
 To locate the landmark for external chest compression
 The technique of costal margin that is as follows:
A. Run your index and middle fingers up the lower margin of
the rib cage and locate the sternal notch with your middle
finger. The index finger is place next to the middle finger on
the lower and of the sternum.

B. The heel of the other hand (the one nearest the victim’s
head) is placed on the lower half of the sternum, and the
other hand is placed on the top of the hand on the sternum
so that the hands are parallel.
C. Your fingers may be either extended or interlaced but must
be kept off the chest.
D. Lock your elbows into position, the arms are straightened
and shoulders directly over the victim’s sternum. Keep the
heel of your hand lightly in contact with the chest during
the relaxation phase of chest compression to maintain
correct hand position.
 Push hard- push fast: equal compression and relaxation allowing recoil
of chest wall.
 Chest compression – ventilation 30: 2, for 5 cycles (2 minutes rate of
100 per minute.
 Depth of 1.5 to 2 inches for adults
 Count compression in English in the sequence of:
o 1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20, and
1,2,3,4,5,6,7,8,9,1= for 1st cycle

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 o 1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20, and
1,2,3,4,5,6,7,8,9,2= for 2nd cycle
o 1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20, and
1,2,3,4,5,6,7,8,9,3= for 3rd cycle
o 1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20, and
1,2,3,4,5,6,7,8,9,4= for 4th cycle
o 1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20, and
1,2,3,4,5,6,7,8,9,5= for 5th cycle
8. Reassessment
 After 5 cycles of compressions and 6 cycle of ventilations (30:2),
check for return of carotid pulse/ and spontaneous breathing
 According to the findings (after 2 minutes):
o There is pulse – place in the recovery position, monitor vital signs
until EMS arrives.
o There is pulse but no breathing: continue rescue breathing every
5- 6 seconds (10-12 breaths). Recheck pulse every 2 minutes.
o No pulse or breathing continues CPR 30:2. Until provider arrives
Repeat A – B- C to 5 cycle of compression and 6 cycles of breathing.
(150:12)

When to Stop CPR

1. If another trained person takes over CPR for you
2. If more advanced medical personnel take over
3. If you are exhausted and unable to continue
4. If the scene becomes unsafe
5. If the victim's heart starts beating

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