Student Name:

GN #

ZIAUDDIN UNIVERSITY FACULTY OF NURSING AND MIDIWIFERY

FON SKILLS CHECK LIST

FOR

YEAR I BScN PROGRAMME

Revised and Updated by:

FON Team
Ms. Nadia Ali Muhammad
Ms. Fatima Jawad
Ms. Gulshan Imran

1
Introduction:

The booklet is prepared by the Ziauddin University Faculty of Nursing and Midwifery (ZUFONAM), Karachi,
Pakistan. It consists of skills’ performance rules in the form of checklists.
Training nurses to deliver competent and safe nursing care to patients, families, and their communities is one of
the primary goals of ZUFONAM undergraduate nursing programs. Psychomotor skill performance is one of the
most significant elements of nursing care.

In order to prepare nursing students to perform skills in both simulated and practical clinical settings, the
handbook and advice from nursing faculty members will serve as guidance.

The manual consists of skills’ performance checklists according to the nursing courses which are accessible
within each semester of each academic year. Each checklist consists of objectives and purposes of the skill
followed by list of equipment. Procedure in form of steps with supporting justification for each intervention
forms the key part of the checklist.

Acknowledgment
FON Team
Ziauddin University Faculty of Nursing and Midwifery
Karachi, Pakistan
AKUSON

2
Table of content

S.# Skills Page #

1. Interviewing skills 4-6
2. Patient health history form 7-9
3. Sitz bath 10-12
4. Indwelling Cather Care 13-16
5. Mouth Care of an Unconscious 17-19
6. Intake and Output 20-21
7. Specimen collection (voided, stool, sputum and vomitus) 22-27
8. Urine Testing (Multistix Test) 28
9. Turning and lifting 29-38
10. Comfort Devices 39-44

11. Assessing Height And Weight 45-48

12. Wet shaving 49-52
13. Tepid sponging 53-55
14. Deep breathing and coughing 56-58
15. Steam inhalation 59-60
16. Hot and cold fomentation 61-66
17. Glucose monitoring 67-68
18. Administrating Nebulizers 69-71

3
INTERVIEW AND HISTORY TAKING

PURPOSES:

 To establish a complete data base for problems identified.

 To utilize data for future interventions.
 To build rapport and trust with the patient.
 To provide health teaching.

EQUIPMENT:

 Paper / pen/ pencil / chair.

PROCEDURE:

S# STEPS RATIONALE S* U*
Identify the patient To give required care to the right patient
01.
Introduce self and explain the Helps to minimize anxiety and to gain
02. purpose of interview. cooperation.
03. Establish comfortable environment.  Facilitates more exchange of
 space information without fear and
 lighting anxiety.
 noise  Avoid interference with
 ventilation concentration
04. Maintain eye contact throughout Conveys your willingness to listen, and
Interview. helps to build trust.
Ask open ended questions and one Give the patient a broader aspect to give
05. question at a time. detailed explanation. Double
questioning limits the patient to one
choice and creates confusion.
06. Use appropriate communication It communicates respect, interest; it
skills promotes understanding and trust.
 Speaking softly
 Silence
 Listen carefully
 Simplicity, clarity.

4
Gives appropriate non-verbal Encourages patient to continue and lets
7. responses. the patient know that attention is being
 Nodding paid.
 Posture/Gait
 Hand movement/Gestures
 Silence
 Listening
8. Encourage patient to ask questions. Makes the patient feel involved in
his/her own care and ensures two way
Communications.
Respond to patient’s questions Imposing your own values on patient or
9. appropriately. giving false assurance can break trust
and rapport.
10. Use therapeutic touch, when  Giving gentle touch may help the
appropriate. patient talk about difficult or painful
experience.(May vary from culture
to culture)
 Expresses care and concern.
Do not interrupt unnecessarily. This can break trend of thoughts,
11. continuity of conversation and can
cause important information to be
missed
Terminate the interview by: To maintain the rapport and trust
12. Summarization (in patient’s own established during the interview and
words) facilitate future interactions.
Document date, time, and patient’s Provides information valuable for
13. responses in the assessment form and assessing patient’s needs and problem.
Nursing notes.

*S: satisfactory; U: unsatisfactory

Faculty comments: (performance in the skills lab and in an in-patient or community setting, please
include number of attempts that student carried out to achieve satisfactory status in the skill).

5
Faculty name and signature: Date:

6
PATIENT HEALTH HISTORY FORM*

PATIENT’S NAME: Pt.’s MR #: BED #:

SEX: DATE OF BIRTH: AGE:

MARITAL STATUS: RELIGION:

LANGUAGE: OCCUPATION:

EDUCATIONAL ACCOMPLISHMENTS:

DATE OF ADMISSION: MEDICAL DIAGNOSIS:

SURGERY:

DATE PATIENT WAS INTERVIEWED:

HEALTH PERCEPTION HEALTH MANAGEMENT PATTERN:

 How do you define your health?

 What are the things you do to keep yourself healthy?
 What is the reason for admission in the hospital?
 Have you ever been hospitalized before?
 If yes, what were the reasons?
 Tell me about your immunization status?
 Are you allergic to anything (Such as dust, pollen, drug or hay)?

ACTIVITY AND EXERCISE PATTERN:

 How do you spend your day at home?

 What is your occupation?
 Tell me about your responsibilities at job?
 Do you come across any difficulties while performing activities of daily living (ADLs)?
 Do you exercise? If yes, specify

NUTRITION/METABOLIC PATTERN:

 Describe your daily food and fluid intake?

 Do you take any supplements (Vitamins, iron, etc)?
 Tell me about your food likes and dislikes?
 Do you have any problems related to eating, digestion such as, loss of weight, vomiting,
loss of appetite, difficulty in swallowing?
 Do you have any skin problems, e.g. lesions, dryness, allergies?
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 Do you have any hair problem: dry hair, excessive hair fall etc.
COGNITIVE-PERECPTUAL PATTERN:

 What languages can you speak and write?

 Tell me about your vision/hearing?
 Do you wear glasses or lenses? Use any hearing aid?
 Have you noticed any changes in your memory concentration? Please specify
 Do you have any discomfort? Pain?
 If yes, describe your pain/discomfort (type, location, intensity, duration)?

ELIMINATION PATTERN:

 Describe your bowel elimination pattern (frequency, problems in control)?

 Describe your urinary elimination pattern (frequency, problems in control)?
 Do you use any substance, drugs or home remedies to pass stool?
 Do you have excess perspiration problems?

SLEEP-REST PATTERN:

 Tell me about your sleep pattern?

 Do you take naps at day time?
 Do you have any problems with sleep such as, early wakening, night mares, walking during
sleep
 Do you use sleeping aids (such as reading, special pillow) or perform any rituals? Please
specify
 Do you feel rested and ready for daily activities after sleep?

SELF PERCEPTION/SELF CONCEPT PATTERN:

 How do you describe yourself?

 What makes you feel good or bad about you?
 What are the things that frequently make you angry, annoyed, fearful, anxious, and
depressed? Not being to control things?
 What are your future plans?
 How does this illness affect your goals in life?

COPING STRESS TOLERANCE PATTERN:

 Have you come across any big changes/crisis in life in the last year or two?
 What is your support system?
 How do you cope with your problems?
 Do you use any medicines, drugs, alcohol to relax?

8
ROLE RELATIONSHIP PATTERN:

 Tell me about your family (family structure, members etc.)?

 Tell me about your role in the family?
 Do you have any family problems that are difficult to handle?
 Do you have any history of hereditary diseases in your family such as, heart disease, high
blood pressure, diabetes, etc.?
 How does your family feel about your illness/hospitalization?
 Who supports your family?
 Do you belong to any social group?

SEXUALITY-REPRODUCTIVE PATTERN:

 How is your relationship with your parent/spouse/children?

 How do you feel being a parent?
 How many children do you have?

VALUE BELIEF PATTERN:

 What religious practices are affected because of your hospitalization?

 Are there any cultural practices which affect your treatment in the hospital? If, yes, specify.

*Note: This is an example of assessment tool according to Gordon’s Functional Health

Pattern. You are advised to use assessment tools used by faculty according to policy

Reference:
Health History Interview and Physical Assessment. Lippincott Procedures. Retrieved from
[Link]

9
ASSISTING PATIENT FOR SITZ BATH

OBJECTIVE:

By the end of the skill students will be able to:

 Verbalize the purpose of sitz bath
 Demonstrate proper technique in assisting the patient for sitz bath.

PURPOSES:

 It helps relieve discomfort, especially after perineal or rectal surgery or childbirth

 Promoting circulation.
 Reducing edema and inflammation.
 Decreases pain by relaxing muscles.

EQUIPMENT:

1. Chair.
2. Clean basin/ tub
3. Prescribe solution/ tap water warmed to be at appropriate temperature.
4. Prescribe medication (if ordered)
5. Bath thermometer.
6. Gloves.
7. Blanket / Bed sheet.
8. Bath towel/ cloth.

PROCEDURE:

S# STEPS RATIONALE S* U*
1. Check doctors order or hospital policy for Ensures safe and correct application of
its use. moist heat
2. Identify the patient. Gives right treatment to right patient.
3.  Explain the procedure to the patient. Helps reduce client anxiety and promote
cooperation.
 Instruct the patient to void. Avoid interruption during procedure
4. Wash hands Reduces risk of cross infection.
5. Collect necessary equipment’s. Saves time and energy of nurse.
6. Close the door and window of room or Controls for drafts that can cause
bath room or draw curtains. cooling and provide privacy.
7. Assess condition of skin of the body part Provides base line to determine the
to be immersed. changes in skin during therapy.

10
8. Fill basin or tub with water approximately Correct temperature reduces risk of
37 – 41 C /99 - 105 F (Tap water is burns.
commonly used for sitz bath) or as
tolerable for patient.

S# STEPS RATIONALE S* U*
9.  Prevents risk of fall.
 Assist patient in comfortable position
 The wound area is tender. Assure
in tub or basin (water level till groin)
the patient that the warm water will
 Explain that the initial sensation may soon relieve this discomfort.
be unpleasant

10. Cover the patient with bath blanket or Prevent chilling and enhance patient’s
towel as desired. ability to relax.
11. Make sure that water temperature remain Ensure proper therapeutic effects.
constant and check for any skin changes
during the procedure.
12. After 15- 20 minutes remove patient from Enhances patients comfort.
the soak or bath and dry the body parts
thoroughly. (Wear Gloves if drainage is
present)
13. Replace all the equipment and soiled linen Reduces transmission of micro organism
and wash hands
14. Document the patient’s response in the Ensures continuation of care.
nurse’s notes. Communicates information for making
treatment decisions.

*S: satisfactory; U: unsatisfactory

Faculty comments: (performance in the skills lab and in an in-patient or community setting, please
include number of attempts that student carried out to achieve satisfactory status in the skill).

11
Faculty name and signature: Date:

Reference:
Sitz Bath. Lippincott Procedures. Retrieved from
[Link]

12
INDWELLING CATHETER CARE

OBJECTIVES:

By the end of the procedure the students will be able to:

 Verbalize the purpose of the care of indwelling catheter.
 Demonstrate the proper technique for the care of indwelling catheter.

PURPOSE:

 To minimize infection and discomfort.

 To promote self-esteem.

EQUIPMENTS:

 Disposable gloves (2 pairs).

 Clean wash cloth or towel.
 Warm water and soap.
 Water proof absorbent pad/ incopad.
 Cotton balls or large swabs
 Wash basin.
 A drape/ top sheet to cover the legs
 Adhesives tape
 Optional: light source, gown, mask
PROCEDURE:

S# STEPS RATIONALE S* U*
1. Identify the patient. Gives required care to the correct patient.

2. Assess for episode of bowel Accumulation of secretions or feces causes

incontinence or client’s report of irritation to perineal tissues and acts as site
discomfort at catheter insertion site. for bacterial growth.
3. Prepare necessary equipment. Ensures orderly procedure.
4. Explain procedure to the patient/family. Reduces anxiety and promotes
cooperation.
5. Draw curtains/ close the door. Maintains privacy.
6. Adjust the bed to working condition. Facilitates good body mechanics and
nurse’s safety.

13
7. Lower down the side rail at working site Ensures patient’s safety.
and ensure that the opposite side rails
are raised.
8. Wash hands. Reduces transmission of infection.
9. Loosen patient’s trouser and uncover Provides exposure to urethra and catheter
patient’s perineal area. insertion point. Reduces transmission of
infection.

10. Place water proof pad under patient’s Protects bed linen from soiling.
perineal area.
11. Position the patient and cover with the Reduce patient’s embarrassment and
sheet. Ensures easy access to perineal tissues.
Female: Dorsal recumbent
Male: Supine position
12. Drape the patient with top sheet, so that Prevents unnecessary exposure of body
only perineal area is exposed. parts.
13. Remove anchor tapes. It frees catheter tubing.
14. Don gloves. Reduce transmission of microorganism
15. Assess urethral meatus and surrounding Determines condition of perineum and
tissues for inflammation, swelling and presence of local infection and status of
discharge. (Note amount, color, odor hygiene.
and consistency of discharge. Ask
patient if burning or discomfort is felt).

16. Provide routine perineal care with soap Effective in reducing the bacterial growth
and water if needed. (Refer Complete and keep the area cleans.
perineal care checklist. In the video, for
students learning purpose, we are Provides full visualization of urethral
considering that routine perineal care is meatus. Full retraction prevents
already been given to the patient) contamination of meatus during cleansing.
Female:
a. Clean the labia majora and labia
minora
b. Gently retract Labia minora (to
expose Urethral meatus and
Catheter insertion site).
c. Clean Clitoris. Urinary meatus
and Vagina.

14
17. Male:
Retract foreskin (if patient is not Provides full visualization of urethral
circumcised) and hold penis at shaft meatus.
just below gland While spreading
urethral meatus, clean around catheter
and move down.

18. a. Stabilize the catheter with one hand Reduces presence of secretion present on
and clean the catheter from insertion outside the catheter.
site to the connection point using
soap. Move down in circular motion.
Avoid placing tension on the Tension can cause urethral trauma.
catheter.

b. Stabilize the catheter with one hand

and clean the catheter from insertion
site to the connection point using
water. Move down in circular
motion. Avoid placing tension on
the catheter.

c. Stabilize the catheter with one hand

and clean the catheter from insertion
site to the connection point using dry
cotton. Move down in circular
motion. Avoid placing tension on
the catheter.
19. Remove gloves Prevents spread of infection

20. Secure the catheter with adhesive tape at Keep the catheter secure.
thigh.
21. Don gloves again Provides privacy.
Lower down patient’s legs. Remove
incopad. Help patient to wear her
trouser and fasten the trouser. Cover the
patient appropriately.

22. Remove contaminated drape sheet. Prevents spread of infection

Cover the patient with clean top sheet.
23. Place patient in safe, comfortable Promotes comfort.
position.

15
24.  Discard used supplies in appropriate  Prevents spread of infection.
receptacles.  To prevent falls and maintain the
 Remove Gloves/ PPE if worn patient's safety
 Return the bed to the lowest
position

25. Wash hands Reduces transmission of microorganisms.

26. Documentation:
Communicates care given and patient’s
Document in patient care flow sheet, condition. Protects legally.
and nursing notes; date & time of
procedure performed, condition of
perineal tissue, catheter, patient’s
response and any pertinent observation.

*S: satisfactory; U: unsatisfactory

Faculty comments: (performance in the skills lab and in an in-patient or community setting, please
include number of attempts that student carried out to achieve satisfactory status in the skill).

Faculty name and signature: Date:

Reference:

Indwelling urinary catheter (foley) care and Management. Lippincott Procedures. Retrieved from
[Link]
heters&a=false&ad=false

16
MOUTH CARE OF AN UNCONSCIOUS

OBJECTIVES:

By the end of the procedure the students will be able to:

 Verbalize the purpose of mouth care of a unconscious patient
 Demonstrate the proper mouth care technique.

PURPOSES:

 To maintain intact and well-hydrated lips, tongue and mucus membranes of the mouth.
 To remove secretions from oral cavity.
 To prevent fowl breathing, dental carries and infection.
 To enhance the client’s feelings of well-being.

EQUIPMENT:

1. Kidney basin (Emesis basin)

2. Face towel.
3. Tissue roll.
4. Disposable/ latex gloves.
5. Tongue blade/Tongue depressor (Padded)
6. Mouth applicator/ Artery forceps.
7. Mouth gag (padded)
8. Gauze swabs (pack)
9. Gallipots.
10. Paper bag/ thrash bin.
11. Large tray.
12. Petroleum jelly.
13. Glass with water.
14. Pair of scissors.
15. Cotton balls.
16. Pyodine mouths wash.
17. Torch.
18. Suction tube and suction apparatus

PROCEDURE:

S# STEPS RATIONALE S* U*
1. Identify the patient. Give care to right patient.
2. Explain the procedure to patient and Reduces anxiety and to provide meaningful
family member (if present). stimulation to unconscious patient. Unconscious
patient may retain ability to hear. To gain
cooperation of family members.

17
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. Draw curtains or close the door. Maintains privacy.
7. Place patient in side lying position with Prevents aspiration of saliva.
head of the bed lowered.
8. Place towel under patient’s face and Receives secretions and to prevent soiling of bed
kidney dish under patient’s chin. linen.
9. Wear gloves. Minimizes cross infection.
10. Inform the patient and retract patient’s Avoids biting down by unconscious patient and to
upper and lower teeth with padded provide access to oral cavity.
tongue blade between back molars.
11. Assess the oral cavity for dry mucosa, Provides baseline data.
blisters, sores or inflammation,
12. Insert oral airway to open patients For having a clear vision
mouth (2nd Nurse holds it).
NOTE: (Never put your fingers in an
unconscious patient’s mouth).
13. Perform the following steps: Mechanical action removes food particles
 Dip the tongue blade (padded) or between the teeth and chewing surfaces.
mouth applicator in pyodine Swabbing helps to remove secretions and crust
solution, squeeze it and clean. from mucosa and moistens it.
 Chewing and inner surfaces first.
 Outer tooth surfaces.
 Swab roof of mouth and inside
cheeks.
 Gently swab the tongue.
14. Moisten the tongue blade/ applicator in Helps to remove pyodine that can be irritating to
clean water to rinse several times. mucosa.
15. Remove the open airway, gently Prevents injury to jaws and tongue bite.
supporting lower Jaw and informing
the
patient that procedure is finished.
16. Remove the towel and kidney dish. To make patient comfortable
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 To make patient comfortable
20. Raise the side rails Ensure patients safety.
21. Return equipment to designated placeKeep patients environment neat and reduces
transmission of infection.
22. Wash hands Prevents transmission of microorganism.
23. Document in nurses notes about oral Communicates care given and patient’s condition.
assessment and the care given. Protects legally.

18
*S: satisfactory; U: unsatisfactory
Faculty comments: (performance in the skills lab and in an in-patient or community setting, please

include number of attempts that student carried out to achieve satisfactory status in the skill).

Faculty name and signature: Date:

Reference:

Oral care of an intubated patient. Lippincott Procedures. Retrieved from

[Link]
d=false

19
INTAKE AND OUTPUT MONITORING

Purpose:
To assess and document a patient’s fluid balance by accurately measuring all fluid intake and
output over a specified time period.
Objectives:
By the end of the procedure, the student will be able to:
1. Identify the patient and explain the procedure.
2. Accurately measure and record all oral, intravenous, and other fluid intake.
3. Accurately measure and record all fluid output (urine, vomit, drains, etc.).
4. Maintain aseptic and safe handling during the procedure.
5. Document and report findings accurately.

Equipment:
1. Intake and output chart or flow sheet
2. Measuring container
3. Bedpan or urinal (if required)
4. Disposable gloves
5. Pen and watch
6. Emesis basin (for vomit, oral secretions)
7. Foley bag (if applicable)
8. Waste disposal bag

PROCEDURE:
Skills
S. No. General Steps Sign Off
S U
1 Identify the patient
2 Explain the purpose and process of I&O monitoring to patient
3 Wash hands and don gloves
4 Place measuring container near bedside or bathroom (as appropriate)
5 Record all oral intake (water, IV fluids, tube feeding, etc.) with exact
amounts in ml.
6 Measure and record urine output using urinal/bedpan/Foley bag
accurately
7 Measure and record other outputs (vomitus, diarrhea, suction, drain
output)
8 Use correct units (ml) and record time and type of fluid
9 Maintain aseptic technique while handling bodily fluids
10 Calculate total intake and total output every shift or as ordered
11 Identify signs of fluid imbalance (e.g., dehydration, fluid overload)
12 Report any abnormal findings to the In charge nurse/ doctor
13 Document intake and output accurately in the patient’s I&O chart
20
14 Assess and document COCA

AN EXAMPLE OF INTAKE AND OUTPUT RECORDING

A. Mrs. ABC is admitted to medical ward. She has been diagnosed to have congestive cardiac
failure. Her intake and output chart is to be maintained.

Timing Intake Output

0700 – 0830 hours A cup of milk Urine 250 cc/ml
1000 hours Frost 250 ml
1200 hours A glass of juice (bed side Vomited 150 cc/ml
glass)
1400 hours A glass of juice and a glass Urine 550 cc/ml
of water
1600 hours 20 cc/ml medication
1800 hours A dish of soup Suction 50 ml
2200 hours A glass of juice & frost (bed Urine 230 cc/ml
side glass)

1. Record the intake and output in l/O sheet or as per hospital or practice setting.
2. Indicate whether the patient is in positive or negative balance

B. Mrs. ABC is admitted to surgical ward. She has been diagnosed to have gastric ulcers.
Her intake and output chart is to be maintained.

Timing Intake Output

0800 – 0830 hours A cup of milk Vomited 50 cc/ml
1000 hours Vomited 150 cc/ml
1230 hours Medication 20
1345 hours A glass of juice (bedside Diarrhea 150 cc/ml
glass)
1500 hours A glass of ORS (bedside
glass)
1700 hours A Cup of tea Vomited 250 cc/ml
1800 hours A glass of juice & frost (bed
side glass)
2200 hours Juice and frost (bedside Diarrhea 230 cc/ml
glass)

1. Record the intake and output in I/O sheet or as per hospital or practice setting.
2. Indicate whether the patient is in positive or negative balance

21
SPECIMEN COLLECTION

OBJECTIVE:

By the end of the skill students will be able to:

 Verbalize the purpose of specimen collection
 Demonstrate proper technique of specimen collection.
GENERAL GUIDE LINE FOR SPECIMEN COLLECTION:

1. Verify Doctors order.

2. Identify the patients.
3. Explain the procedure to the patients and how to collect the specimen.
4. Label the specimen bottle and wear gloves.
5. Collect the specimen as pre procedure (Follow steps)
6. Send to the laboratory with the request slip as soon as possible.
7. Remove the gloves and wash hands
8. Document no need details in the nurse notes.

1. CLEAN SINGLE SPECIMEN/ URINE ANALYSIS/URINE DETAIL REPORT (D/R):

PURPOSES:

 To check the kidney function.

 To aid in diagnosis.
 To assess the effectiveness of therapy.
 To determine progress of patient.

EQUIPMENT:

1. Clean specimen container (urine D/R bottle).

2. Bed pan or urinal.
3. Measuring jug.
4. Toilet tissues.
5. Disposable gloves.

PROCEDURE:

1. Have patient void in a clean bedpan or urinal or if possible have patient void directly into the
specimen container.
2. Collect at least 50 ml of urine.
3. Place the lid tightly on the specimen container and wash urine that splashed outside the
container.
4. Label specimen bottle and send to the lab within 15 minutes with request slip.
5. Remove and discard your gloves.
6. Perform hand hygiene and instruct the patient to wash her hands.
22
7. Perform hand hygiene.
8. Document the procedure.

2. CLEAN VOIDED/MID STREAM/ STERILE VOIDED SPECIMEN:

PURPOSE:

 To check the bacteriological culture and sensitivity. (C/S)

EQUIPMENT:

1. Sterile specimen container (urine C/S bottle).

2. Disposable gloves.

PROCEDURE:

1. Instruct patient to drink plenty of fluid at least 30 minutes before collecting urine specimen.
2. Instruct patient not to void and notify nurse if desires to void.
3. Don gloves.
4. Assist patient to clean perineum, including urethral orifice and surrounding area.
5. Open specimen container to receive urine. Avoid contaminating the inside of the container by
exposing it to air or unnecessary touching.
6. Have patient void small amount of initial urine in the wash room/ bed pan.
7. Have patient void rest of the urine directly into the specimen container.
8. Remove specimen container before flow of urine stops. Place the lid tightly on the specimen
container and wash urine that splashed outside the container.
9. Label specimen bottle and send to the lab with request slip.
10. Remove and discard your gloves.
11. Perform hand hygiene and instruct the patient to wash her hands.
12. Document the procedure

3. TIMED URINE SPECIMEN (24 HOUR'S URINE COLLECTION):

PURPOSE:

 To determine the levels of creatinine dements e.g. hormones (adrenocortical steroid), Glucose
and Protein etc.

EQUIPMENT:

1. 24 hours urine collection bottle.

2. Disposable gloves.
23
PROCEDURE:

1. Label container (24 hours urine collection bottle) and place it in an appropriate location (near
patient's bed).
2. Place sign indicating 24-hrs urine collection on patient's bedside.
3. Instruct patient to save all urine during 24 hours period and note the time of first void.
4. Start collection of urine according to the 24 hours cycle at a time specified.
5. Discard first random urine specimen and note time for beginning of test and document in the
notes.
6. Collect all urine voided after that for next 24 hours period.
7. Have patient void to collect the last specimen as close as possible to the end of the time
period.
8. Record volume of urine voided if patient is on flow sheet II.
9. Send entire specimen to lab with request slip.
10. Remove sign and inform patient that specimen collection period is completed.

SPECIMEN FROM A CATHETER

PURPOSE:

 To collect specimen of urine i.e. Detail report (D/R) and Culture and sensitivity (C/S)
EQUIPMENT:

1. Disposable gloves
2. 3 cc/ 5 cc syringe
3. Spirit swab.
4. Specimen bottle.
5. Clamp.

PROCEDURE:

1. Clamp the catheter from the Foley’s site 30 - 45 minutes before collecting the specimen.
2. Wipe the area above clamp where the needle will be inserted with spirit swab.
3. Insert the needle to sampling port.
4. When urine starts to enter the tubing, aspirate the specimen into the syringe.
5. Withdraw 30 ml of urine.
6. Transfer the urine into sterile container for C/S or into non sterile container for routine analysis.
7. Make sure the needle should not touch the outside of container if C/S bottle is used.
8. Cap and label the container and send it to the lab with request slip.
24
9. Unclamp the catheter.
10. Remove and discard your gloves.
11. Perform hand hygiene.
12. Document the procedure.

STOOL SPECIMEN

PURPOSES:

 To aid in diagnosis such as, hemorrhage, infection, mal-absorption problem etc.

 To assess the effectiveness of therapy.
 To determine patient's progress.

Stool test includes:

 Stool D/R.
 Stool Culture.
 Microscopic test to check the presence of blood.

EQUIPMENT:

1. Specimen container.
2. Tongue blade/scoop.
3. Bed pan with plastic bag.
4. Toilet tissues.
5. Disposable gloves.

PROCEDURE:

1. Ask patient to void before defecation to keep specimen free from urine.
2. Don gloves
3. Provide bedpan to the patients to pass stool.
4. Inspect stool for any unusual appearance, (presence of fresh or old blood, pus or mucus). If
the patient passes blood, mucus, or pus with the stool, include it with the specimen. Notify
the practitioner of abnormal findings.
5. Take 2-3 scoops of stool into the specimen container with the help of a transfer device i.e.
tongue blade and cap the container.
6. Wrap the used tongue blades in a paper towel and discard.
7. Label specimen bottle and send to lab as soon as possible with request slip.
8. Provide the patient with the opportunity to thoroughly clean the perianal area and perform
hand hygiene. Assist the patient as needed.
9. Remove and discard your gloves and any other personal protective equipment worn.
25
10. Perform hand hygiene.
11. Document the procedure.

VARIATIONS FOR STOOL SPECIMEN:

Collection of stool specimen after an enema and liquid stool:

1. Let bed pan contents stand for 5-10 minutes.

2. Discard the top fluid and take 2-3 scoops of stool into the specimen container with the help of
tongue blade.
3. Follow all the above steps from stool specimen collection.

SPUTUM SPECIMEN

PURPOSES:

 Culture and sensitivity: to identify a specific microorganism and its drug sensitivities.
 Cytology: to identify the origin, structure, function and pathology of cells present.
 To identify presence of Acid Fast Bacillus (AFB).
 To assess the effectiveness of therapy.

EQUIPMENT:

1. Specimen container.
2. Tissue paper.
3. Disposable gloves.

PROCEDURE:

1. Collect specimen early in the morning or after respiratory therapy and postural drainage.
2. Don disposable gloves.
3. Ask patient to rinse mouth with water.
4. If the patient has a surgical incision or localized area of discomfort, instruct the patient to
place the hands or a pillow firmly over the affected area.
5. Instruct the patient to take three slow, deep breaths and then to cough deeply from a
maximal inspiration while covering the mouth with a tissue. Instruct the patient to repeat
the procedure, as necessary, until the patient has produced sputum. Allow rest periods
between each maneuver.
6. Have patient use tissue to cover mouth when coughing. Ask patient to hold container, and to
expectorate directly into specimen container.
7. When the patient has mobilized the sputum, instruct the patient to expectorate directly into
a sterile specimen container without touching the inside or rim of the container. Have the
patient continue until the amount totals at least 5 mL, if possible.
26
8. Assess the sputum specimen to ensure that it's sputum and not saliva. Assess the color, odor,
consistency and amount of the sputum.
9. Avoid contaminating the inside of the container by exposing it to air or unnecessary touching.
10. Label specimen container and send to the lab as soon as possible with request slip or
refrigerate if here is any delay in sending.
11. Offer mouthwash to patient.
12. Wash hands and document.

VOMITUS SPECIMEN

PURPOSES:

 To aid in diagnosis.
 To assess the effectiveness of therapy

EQUIPMENT:

1. Specimen container.
2. Emesis basin/ kidney tray.
3. Tissue paper.
4. Disposable gloves.

PROCEDURE:

1. Check doctors order.

2. Inform and explain to the patient about the vomitus specimen collection for test.
3. Provide a clean emesis basin to patient to collect vomitus and also provide tissue for mouth
cleaning.
4. Don disposable gloves.
5. Take 1 - 2 ounces of vomitus in specimen container, cap securely, and label.
6. Record volume of vomitus if patient is on intake and output monitoring.
7. Send specimen to lab as soon as possible with request slip or keep for observation by the
physician as ordered.
8. Wash hands and document in the intake output sheet / nurses notes.

27
URINE TESTING (MULTISTIX TEST)

PURPOSE:

Multistix are commonly used to check specific gravity, pH, and presence of Glucose,
Albumin, Ketone, Occult blood, Bilirubin, Protein, Urobilinogen, Nitrite, and Leukocytes in
urine.
 Easy to perform with no pain
EQUIPMENT:

1. Fresh urine specimen in clean container.

2. Multistix.
3. Multistix color chart.
4. Disposable gloves.
5. Tissue paper
6. Watch with seconds

PROCEDURE:

1. Wash hands.
2. Identify the patient and explain the procedure.
3. Use Multistix reagent strip and check for the expiry date.
4. Wear disposable gloves and ask/obtain a fresh urine specimen in a clean container.
5. Remove one strip from the bottle and close the bottle tightly.
6. Immerse designated tip into the urine and remove it immediately.
7. Tap the edge of the strip while holding it horizontally against the container.
8. Wait for few seconds (as specified on the bottle).
9. Compare test strip with color chart printed on the bottle in good light.
10. Discard reagent strip and gloves in trash.
11. Wash hands and document the findings immediately on appropriate flow sheet.

*S: satisfactory; U: unsatisfactory

Faculty comments: (performance in the skills lab and in an in-patient or community setting, please
include number of attempts that student carried out to achieve satisfactory status in the skill).

Faculty name and signature: Date:

28
TURNING AND LIFTING

OBJECTIVES:

By the end of the procedure students will be able to:

 Verbalize the purpose of turning and lifting.
 Demonstrate proper technique of turning and lifting.

PURPOSES:

 To help patient to regain independence.

 To maintain and improve joints’ movement and physical activity.

EQUIPMENT:

 Pillows
 Foot board
 Bed linen
TURNING AND LIFTING: ASSIST PATIENT IN SITTING POSITION (WITH LIMITED
MOBILITY AND STRENGTH).

PROCEDURE:

S# STEPS RATIONALE S* U*
01. Identify the patient. Gives care to the right patient.
02. Explain the procedure to the patient. Minimizes anxiety and gains
cooperation.
03. Collect equipment. Saves time and energy.
04. Wash hands. Reduces transfer of
microorganisms.
05. Draw curtains and close the door. Maintains privacy.

06. Raise the bed to working position and Avoids back strain and provides
lock the bed. safety.

07. Remove all pillows from the bed Decreases interference while
positioning.
08. Raise the side rails. Ensures safety.

S# STEPS RATIONALE S* U*

29
09. Move patient up on the bed (Obtain Helps in maintaining proper position
assistance)
I. With draw sheet
a. Stand on either side of the patient.
b. Loosen the draw sheet and hold it’s
corners firmly.
c. Pull patient up at the count of 3.
II. Without draw sheet
a. Stand on either side of the patient
with the feet apart.
b. First nurse places one hand under
patient’s back and the other hand
under the thighs. Second nurse places
one hand under the sacrum and the
other hand under the calves.
c. Move patient towards head of the bed
on the count of 3.
10. Raise the head end of the bed up to: Maintains required position.
Low fowler’s = 15 - 300
Semi fowler’s = 30 - 450
High fowler’s = 900
11. Place pillow under head & shoulders, Helps to maintain maximum
arms, legs, and the knees and/or as per comfort and retain patient in
patient’s comfort. Be sure the heels are proper position.
not resting on pillow.
12. Place small pillow / rolled towel at the Helps to maintain maximum comfort
lower back (If needed). and retain patient in proper
position.
13. Place a footboard to support the heels. Prevents foot drop.
(Canvas shoes may be put on if
available)
14. Cover the patient. Provides privacy.
15. Document position and patient’s Communicates care given and
response in nurse’s notes sheet. patient condition. Protects legally.
*S: satisfactory; U: unsatisfactory
Faculty comments: (performance in the skills lab and in an in-patient or community setting, please
include number of attempts that student carried out to achieve satisfactory status in the skill).

Faculty name and signature: Date:

30
TURNING AND LIFTING: ASSISTING PATIENT TO A SITTING POSITION AT THE
EDGE OF THE BED

PROCEDURE:

S# STEPS RATIONALE S* U*
1. Identify the patient. Gives care to the right patient.
2. Collect equipment. Saves time and energy.
3. Explain the procedure to the patient. Makes patient comfortable and
decreases anxiety.
4. Wash hands. Reduces transfer of microorganisms.
5. Raise the bed to working position and Avoids back strain and provides
lock the bed. safety.
6. Remove all pillows from the bed. Decreases interference while
positioning.

7. Draw curtains and close the door. Maintains privacy.

8. Raise head of the bed until patient Saves patient’s energy.
tolerates.
9. *Place feet apart with foot closer to Increases balance and allows nurse to
head of the bed in front of other foot. transfer weight.
10. *Place one hand under patient’s Maintains alignment of head and
shoulders supporting patient’s head and cervical vertebrae and prevents patient
cervical vertebra and the other arm on from falling.
patient’s thigh.
11. Assist patient to turn to the edge of the Helps maintain position.
bed
allowing him/her to swing the legs
down ward.
12. Support patients’ feet with foot stool (if Maintains proper body alignment.
required)
13. Document in nurses' notes: Date, time, Communicates care given and
procedure performed and Patient's patient’s condition. Protects legally.
response.

S: satisfactory; U: unsatisfactory

31
TURNING AND LIFTING: MOVING PATIENT FROM BED TO CHAIR / WHEEL
CHAIR
PROCEDURE:

S# STEPS RATIONALE S* U*
01. Identify the patient. Gives care to the right patient.
02. Collect equipment such as chair or Saves time and energy. Reduces
wheel chair interruption during procedure
03. Explain the procedure to the patient Minimizes anxiety and gains
cooperation
04. Wash hands & draw curtains and close. Reduces transfer of
microorganisms.& Maintains privacy.
05. Adjust bed to working position and Avoids back strain and provides
lock the bed. safety.
06. Position chair/ wheel chair parallel and Reduces risk of fall and helps in
closer to the bed at foot end transfer of patient.
07. Set brakes and raise foot pedals of wheel- Maintains patient's safety and
chair. reduces risk of fall.
08. Make patient sit on the edge of the bed. Facilitates in shifting.
09. Stand in front of patient with your arms Maintains balance while transferring.
around his/her waist and his/her arms on
your shoulders. Between the patient’s
feet, flex your knee. Place one foot
forward and one backward. Bring the
patient to a standing position while
straightening your hips and
knees.
10. Observe for any adverse response Prevents risk of falling. Helps in early
from patient (fainting, perspiration). detection of postural hypotension and
timely intervention.
11. Flex your hips and knees and Maintains balance while transferring.
pivot patient to the chair /wheel
chair at the
count of 3.
12. Instruct patient to grasp arms of chair Provides a broader base and greater
to move back in wheel chair. stability.
13. Cover patient with top sheet. Provides privacy.
14. Lower foot pedals and position feet Provides support.
on pedals.
15. Document in nurse’s notes. Communicates care given and
patient’s condition. Protects legally.
32
*S: satisfactory; U: unsatisfactory
Faculty comments: (performance in the skills lab and in an in-patient or community setting, please
include number of attempts that student carried out to achieve satisfactory status in the skill).

33
TURNING AND LIFTING: ASSISTING A PATIENT TO TRANSFER FROM BED TO
STRETCHER

PROCEDURE:

S# STEPS RATIONALE S* U*
1. Identify the patient. To give care to the right patient.
2. Collect equipment. Saves time and energy.
3. Explain procedure to the patient. Minimizes anxiety and gains
cooperation.
4. Wash hands. Reduces transfer of microorganisms.

5. Draw curtains and close the door. Maintains privacy

6. Lower the head of patient's bed (as Reduces resistance, avoids back strain
tolerated). Raise the bed higher than and provides safety.
the stretcher & lock it.
7. Place stretcher parallel to bed and Prevents fall and subsequent injury.
lock wheels. Fill the gaps between
stretcher and the bed with blanket or
sheet.
8. Fan fold top sheet at the foot end. Makes transfer easy.

9. Ask patient to move to the edge of Provides safety and maintains privacy.
the bed and then to slide on to the
stretcher. Keep patient well draped.
10. Make patient comfortable. Promotes comfort.
11. Raise side rails. Provides safety.
12. Document in nurse’s notes. Communicates care given and
patient’s condition. Protects legally.

* S: satisfactory; U: Unsatisfactory

Faculty comments: (performance in skills lab and in an in-patient or community setting. please include
number of attempts that student carried out to achieve satisfactory status in the skill)

36
Faculty name and signature: Date:

37
TURNING AND LIFTING: TRANSFER FROM BED TO STRETCHER
(3-MEN LIFT)
PROCEDURE:

S# STEPS RATIONALE S* U*
01. Identify the patient. Gives care to the right patient.
02. Collect equipment. Saves time and energy.
03. Wash hands. Reduces transfer of microorganisms.
04. Explain procedure to the patient. Minimizes anxiety and gains
cooperation.
05. Raise bed to working position and lock Avoids back strain and provides
it. safety.
06. Position stretcher at right angle to bed Saves nurses energy while
with head end of stretcher next to the transferring. Locking ensures safety.
foot end of bed and lock it.
07. Obtain assistance of 2 other nursing care Distributes patient’s body weight
personnel for lifting and guide them for equally.
the procedure.
08. Place arms under assigned areas: Distributes patient’s body weight
First Person - head and shoulders equally.
Middle Person – sacrum and upper thighs
Third Person - ankle and calves
09. a. Assume a wide base of support and Avoids back strain and provides
bent knees slightly. safety.
b. On the count of 3, pull the patient to
the edge of bed.
c. Then on second count of 3, lift patient
and roll him towards your body.
10. At the next count of 3, step back and Maintains nurses’ alignment during
pivot towards the stretcher. transfer.
11. Place the patient at the edge of the Enables lifters to work together and
stretcher on the count of 3 and then again ensures patients’ safety.
count 3 and move patient to the center.
12. Make patient comfortable.
13. Cover patient with sheet. Provides privacy.
14. Raise side rails. Maintains safety.
15. Document in nurse’s notes. Communicates care given and
patient’s condition. Protects legally.
*S: satisfactory; U: unsatisfactory
Faculty comments: (performance in the skills lab and in an in-patient or community setting, please include number of
attempts that student carried out to achieve satisfactory status in the skill).

Faculty name and signature: Date:

38
COMFORT DEVICES

GUIDELINES FOR ALL COMFORT DEVICES

1. Check the devices for safety and proper functioning.

2. Utilize the device best suited for the comfort of the patients.
3. Apply protective covering over device e.g. Air ring to prevent irritation to the skin.

DEFINITION

These devices are used for the safety and comfort of the patient confined to bed.

PURPOSE:

a. It maintains good body alignment.

b. Prevents discomfort or pressure on various parts of the body.

1. PILLOW

PURPOSE

a. To provide support.
b. To elevate a body part, relieve swelling and promote breathing.
c. To maintain good body alignment or help maintain a therapeutic position.
d. To splint incisional area.

2. CARDIAC TABLE (NA) (Bed top table

PURPOSES

a. To reduce dyspnea.
b. To serve meals for patient.
c. To be used for writing.

REQUISTIES

a. Over bed table.

b. Extra pillows.

PROCEDURE

When used for relieving dyspnea, arrange enough pillows on the over bed table so that the patient's
head and shoulders are supported on it. Arms are flexed over the pillows around the head and the face
is turned to one side. In cold weather, make sure that the back is well covered.

39
3. AIR CUSHION AND DOUGHNUTS (Air-ring, rubber ring)

PURPOSE:

To relieve pressure on bony prominence by lifting them from the mattress surface.

PROCEDURE:

a. Inflate air rings with the pump or by blowing air through, the valve which is covered with
gauze piece.
b. Inflate only to the extent required for providing relief of pressure without discomfort.
c. Close valve and check for leakage.
d. Protect with a cover.

4. BED RAILS/ SIDE RAILS

DEFINITION

These are metal rails, which are fixed on the side of the beds to prevent the patients from falling out of
bed.

PURPOSE

a. Side rails offer protection to the patient if he is weak, or is receiving certain drugs, is confused
and cannot prevent himself from falling.
b. For allowing the patient to roll himself from one side to the other or to sit up with assistance.

PRECAUTIONS

a. Always check that the side rails are well fixed and secure before leaving the patient.
b. Pad the sides with blankets or pillows if patient is mentally confused or has fits.

5. BED BOARDS

These are usually wooden boards, which are placed under the mattress to make
it firm and straight.

PURPOSE:

a. To provide a firm surface. e.g. for spinal injuries, fractures of pelvis.(The size of the board
is selected in accordance with to the area required to be firm).
b. To provide CPR.

6. BED REST/ BACK REST

113

41
DEFINITION:

It is attached to the bed or available separate and adjustable.

PURPOSE:

a. To keep patient in Fowler’s position, to relieve dyspnea or to help in sitting, or to have

meal etc.
b. To prevent exhaustion and fatigue in-patients who are weak and need to sit on bed for a
short time.

PROCEDURE:

The bed rest is arranged on the head end of the bed and pillows are placed on it, to comfort the
patient.

7. FOOT BOARD

DEFINITION:

They are made of wood and are used to support the feet in the normal anatomical position.

PURPOSE:

a. To keep the feet at right angles to the legs and the toes pointing straight up
b. To prevent foot drop.

8. TRAPEZE BAR/ MONKEY BAR

DEFINITION:

A trapeze bar is a handgrip (which is a triangular piece of metal) hung from a frame on the head of
the bed.

PURPOSE:

a. The patient can grasp the trapeze and move him/ herself to a sitting position in bed.
b. It makes turning easier for the patient.

9. BED CRADLE:

DEFINITION:
42
A bed cradle is a metal frame, which keeps the bed linen away from the patient’s body part.

PURPOSE:

a. It is used to relieve the weight of bedclothes on any part of the patient’s body which are
tender or painful e.g. joint pain, ulcers or wounds.
b. In case of burns, it provides warmth and protection, prevents from touching the affected
part with bedding.
c. To allow the air to reach the body for e.g.
i. To dry plaster cast.
ii. For open treatment of burns.
iii. To enhance healing after genital surgeries/ repair.

REQUISITES:

Bed cradle of desired size and shape.

PROCEDURE:

a. Place the cradle in position before spreading top sheet or blanket on the bed.
b. Arrange the upper bedding to protect the patient.
c. The cradle should be placed on an even surface and fixed well so that it does not slide or
fall on the patient.

10. SAND BAGS/ WATER BAGS

These are bags filled with sand and are of various sizes. Sandbags are placed alongside
the hip, knee or ankle. Later gloves filled with water are also used.

USES:

a. To raise shoulders during tracheotomy and tonsillectomy.

b. To prevent foot drop.
c. To give a firm support to an extremity.
d. To apply pressure to a body part.
e. To maintain good alignment of the feet that may turn outward from lying supine for a long
time.

PRECAUTIONS:

a. Always cover bag before placing near the patient.

b. They should not be placed in such a way that prominence as this may
hey create pressure lead to formation
on bony
of decubitus ulcer.
11. TROCHANTER ROLLS

PURPOSE:
43
These are used to prevent the legs from turning outward (external rotation) when sandbags are not
available.

REQUISITES:

Bed sheet, blanket or 2 bath towels

PROCEDURE:

Trochanter rolls are made in the following manner:-

a. Fold a sheet lengthwise in half or thirds and place it under the patient from the hip to the
knees.
b. Roll the sheet on either side closer to the patient’s body.
c. Fix the rolls closely and firmly against the hip and thighs on each side so that the legs
cannot turn outward.

12. HAND ROLLS:

DEFINITION

A hand roll is made of a rubber ball, sponge rubber, folded washcloth

PURPOSES:

a. When patients are paralyzed or unconscious, the thumb needs to be kept in the correct
position to prevent a contracture or deformity.
b. It is used to give protective support to the hand and to promote correct positioning of the
thumb. Patients should be encouraged to do finger exercises with special attention to
exercise the thumb to touch the tips of each finger.

13. SPLINTS:
DEFINITION:

They are made from cardboard, wood etc. They should be firm and well padded.

PURPOSE:

a. Splints are used for the purpose of immobilizing the joints above and below the fracture.
b. To support and to prevent movement e.g. when an I.V drip is in progress.

44
ASSESSING HEIGHT AND WEIGHT
OBJECTIVES:

By the end of the skill students will be able to:

 Verbalize the purpose of taking height and weight.
 Demonstrate the proper technique of taking height and weight.

PURPOSE:

 To provide a general measure of health.

 To provide a base line comparison in nutritional status.
 To provide a measurement of patient's fluid status.
 To calculate drug dose.
 To see effects of drug.

EQUIPMENT:

 Weighing scale
 Patient care documentation form.
 Black pen

TYPES OF SCALE:

There are various Scales available to weigh patients, including standing, chair and bed scales.

 Standing Scale: Used for ambulatory patients and can easily be found in all clinical areas
including clinics and wards set up.

 Wheel chair scale: Used for Acutely ill or debilitated patients. In our hospital setting, this
weighing scale is under use at dialysis department.

PROCEDURE:

S# STEPS RATIONALE S* U*
01. Identify the patient. To give care to the correct patient.
02. Explain procedure to the patient. Ensures accurate reading.
Ensure that patient has: Voided
Removed: shoes, heavy jewelry
and extra clothing.
03. Wash hands Reduces transmission of microorganism
04. Measure height: Height is measured by placing smooth,
Have patient remain standing on flat surface against crown or vertex of
scale platform, facing away from head. Patient position encourages
scale. Instruct patient to: keeping head erect. Erect posture
45
 Stand erect, with heels together. ensures accurate reading.
 Buttocks should touch to scale
stick.
 Look straight ahead.
 Raise metal L shaped rod on
weighing scale, until it rests on
top of the patient's head.
05. Note Height in centimeters. Ensures compliance with hospital
setting.

06. Ask the patient to step down from

the weighing scale.

07. Measure weight using a Standing Calibrated scale ensures accurate

Scale: measurements.
Set the scale at zero.
Have patient standing on scale
platform, facing towards scale.

08. Move the large weight calibrator, Ensures accurate measurements.

keeping the approximate weight of
the patient in mind.
Now move the small weight
calibrator, to measure the accurate
weight.

09. Note weight in kilograms Ensures Compliance with hospital

setting
Ask the patient to step down from
the weighing scale.
Promotes participation in care and
10. Ask the patient to rest in the
comfortable position. Understanding of health status.
Inform patient about their measured
height and weight.
To help prevent the wheelchair from
11 Measure weight using an rolling off the scale.
Electronic wheelchair scale:
Position the patient properly in the
wheelchair on the wheelchair scale.
Lock the wheelchair brakes.

46
Weigh the patient and the To ensure accurate reading.
12
wheelchair together while
monitoring the patient's safety.
Read the display and record the
combined weight measurement.
To prevent patient from Fall or any
13 Unlock the wheelchair brakes and
injury.
transport the patient in the
wheelchair off the scale.
Assist the patient with transfer to
another surface, if possible.

Position the empty wheelchair on To ensure accurate readings.

14
the scale and weigh it. Read the
display and record the weight of the
empty wheelchair.

Subtract the weight of the empty To determine the patient's weight

15
wheelchair from the combine
weight of the patient and the
wheelchair.

Assist the patient with transfer back To help prevent patient injury.
16
into the wheelchair. Ensure that the
wheelchair is positioned properly
and that the brakes are locked
before transfer.

17. Wash hands Reduces transmission of microorganism

18. Record Weight and height in Serves as a record and communicates
patient care documentation form. continuity of care

References:
Weight measurement. Lippincott Procedures. Retrieved from
[Link]

Weight measurement, ambulatory care. Lippincott Procedures. Retrieved from

[Link]

*S: satisfactory; U: unsatisfactory

47
Faculty comments: (performance in the skills lab and in an in-patient or community setting, please
include number of attempts that student carried out to achieve satisfactory status in the skill).

Faculty name and signature: Date:

48
WET SHAVING (SURGICAL SKIN PREPARATION)

OBJECTIVE:
By the end of the skill students will be able to:
 Verbalize the purpose of wet shaving.
 Demonstrate the safe technique while performing the wet shaving and maintain asepsis.

PURPOSES:

 To reduce the chances of post-operative wound infection.

 To prepare the skin for certain procedures e.g. insertion of I/V cannula and pre operatively.

GENERAL EQUIPMENT:
1. Tray
2. Shaving cream or soap in soap dish
3. Small bowl with water
4. Small towel and tissue paper
5. Cotton balls
6. Gloves (optional)
7. Antimicrobial agent (optional)
8. Light source
9. Optional: personal protective equipment (gown, mask and goggles or mask with face
shield)

For shaving with a disposable safety razor

 Soap or shaving cream

 Bath towel
 Washcloth
 Basin
 Facility-approved disinfectant
 Optional: aftershave lotion, bedside stand or over bed table

For shaving with an electric or a battery-operated razor

 Bath towel
 Disinfectant wipes

49
Preparation of Equipment

If you're using a safety razor, make sure that the If you're using an electric razor, check its cord
for fraying and other damage that could create
blade is sharp, clean, even, and rust-free. an electrical hazard.

Reuse of a razor is permissible but only on the If the razor isn't double-insulated or battery
same patient. operated, use a grounded three-pronged plug.

If the patient is bedridden, gather the equipment Examine the razor head for sharp edges and dirt.
on the bedside stand or over bed table;
If the patient is ambulatory, gather the Read the manufacturer's instructions, if
equipment at the sink. available.

PROCEDURE

S# STEPS RATIONALE S* U*
1. Check doctor’s order/ hospital policy Identifies the right patient and site.
2. Wash hands and dry them thoroughly To reduce the risk of contamination
and cross infection.
3. Collect equipment. Save time and energy
4. Identify the patient and explain Give care to the right patient and
procedure to the patient. relieves anxiety.
5. Draw curtains and expose only the area Maintains privacy.
to be shaved
6. Assess the condition of the skin to be Obtains base line data regarding
shaved. abnormal growth, rashes, pustules, or
bruises etc.
7. Lather the area by applying soap. (In the Makes the shaving smooth.
beginning and during the procedure as
required).
8. Hold razor in dominant hand at 45 degree Prevents injury, facilitates shaving
angle to patient’s skin, use non dominant with less discomfort.
hand to gently pull the skin and shave in
the direction of hair growth.

50
9. Dip razor in water as shaving cream or Keep cutting surface of the razor blade
soap accumulate on blades edge or as clean.
required.
10. Wash the shaved area with clean water Keep the area clean and dry.
after completion and pat dry.
11. Apply antimicrobial agent if prescribed. Reduces the resident microbial count
Or after shave lotion. to sub pathogenic amounts in short
period of time.
12. Replace all the equipment to proper Maintain cleanliness of patient
place. environment.
13. Wash hands. To reduce the risk of contamination
and cross infection.
14. Discard all disposable items and sharps
safely in sharp bin.
15. Document condition of skin and care Communicates care given. Protects
given. legally

Reference:
Shaving. Lippincott Procedure. Retrieved from
[Link]
e

*S: satisfactory; U: unsatisfactory

Faculty comments: (performance in the skills lab and in an in-patient or community setting, please
include number of attempts that student carried out to achieve satisfactory status in the skill).

Faculty name and signature: Date:

51
TEPID SPONGE BATH FOR REDUCING BODY TEMPERATURE

PURPOSES:
 To reduce fever by promoting heat loss through conduction and evaporation.

EQUIPMENT:

 Basin with tepid water (Temperature 370C / 98.60F)

 Towels (6 small) / wash cloth / mittens (6)
 Dry linen
 1pair of gloves (if patient is on body fluids precaution)
 1 Mackintosh - Long enough to cover the whole bed.
 Tray containing equipment for monitoring temperature, pulse and respiration & flow sheet
 1Bath thermometer (optional)

PROCEDURE:

S# STEPS RATIONALE S* U*
1. Identify the patient. To give care to the correct patient.
2. Wash hands. Helps to prevent cross contamination.
3. Explain procedure to patient and Ensures cooperation of patient and
family. family.
4. Adjust bed to working position. Ensures proper body mechanics and
prevent strain on nurse’s back.
5. Take patient’s temperature, pulse and Serves as a baseline for determining the
respiration prior to the procedure. effectiveness of treatment.
(Refer to T.P.R. Procedure).
Note: Tepid sponging should be done
if body temperature is above 390C
(102. 20 F)
6. Administer antipyretic medication as Sponging combined with administration
prescribed. of antipyretic medication minimizes the
affect.
7. Spread mackintosh under the bottom Prevents patients’ bed from spoiling or
sheets. getting wet.
8. Ensure that fans are switched off To avoid excessive shivering.

9. Fill basin with tepid water and check Tepid water prevents chilling.

52
temperature of water with your inner
aspect of wrist. (Temperature should
be around 37ºC)

10. Expose only the body parts that are to Helps prevent chills and shivering.
be sponged. Shivering increases the metabolic rate
and can cause hypothermia and shock.

11. Allow the family to participate in Family involvement in the procedure

procedure, gives psychological support. Provides
opportunity to nurses for family
teaching.
13. Place soaked wash cloth on each axilla, Most of the body temperature is lost
groin, head and neck area. Remove through the large superficial vessels.
wet wash cloth once it gets warm.
Repeat this step as required.

14 Bathe each extremity separately for 5

minutes. Then bathe the chest and
abdomen for 5 minutes. Turn the
patient and then bathe the back and
buttocks for 5 to 10 minutes. Keep the
patient covered, except for the body
part you're sponging.
15 Slowly stroke the body with the wet Gentle friction brings the blood vessels
cloth, using gentle friction. to the surface of the skin, thus
a. Stroke each arm from the neck increasing the heat loss and preventing
to the axilla and down to the chilling.
palm of the hand.
b. Stroke each leg from groin to
foot.
c. Bathe the back and buttocks.
Pat each area dry using a towel after
sponging. Avoid rubbing the patient's
skin with the towel.
16. Change the water after every 3 cycles. Tepid water temperature must be
maintained.

53
16. Continue this procedure for a period
not exceeding 15 minutes. Assess
patient’s temperature. Then proceed as
follows: a. Ongoing assessment provides data
a. If temperature > 380C repeat for nursing decision-making.
procedure for a further 15 minutes
and reassess temperature. If there is
no change inform the concerned
doctor.
b. If the temperature is 10C above
normal, stop the procedure.

17. Observe for shivering, cyanosis or These symptoms indicate a change in

mottling of the skin or if the pulse vasomotor tone, leading to hypothermia
become rapid or irregular. If these signs and shock.
occur then:
a. Stop the sponging, dry and
cover the patient.
b. Assess and record the
temperature.
c. Inform doctor
18. Remove wet linen. Pat the patient dry Helps prevent chilling and promotes
and place a dry gown on the patient. comfort.
Remake bed with clean dry linen.
(Refer the procedure of “Occupied Bed
Making”.
19. Wash hands. Prevents cross contamination.

20. Monitor vital signs of patient every 10 For continuity in care and to monitor
min for half an hour, then half hourly any alterations in vital signs
for 1 hour. Then switch to 2-4 hourly
vital signs monitoring and record as
indicated.
21. Record the following on nurses notes Communicates care given and patient
and graphic sheet according to hospital/ condition. Protects legally.
practice setting policy:
a. Base line, during procedure and
post sponge vital signs.
b. Any untoward reaction during
the sponge (e.g. cyanosis,
mottling or chilling, changes in
vital signs).

54
Reference:
Tepid Sponge Bath for Temperature Reduction. Lippincott Procedures. Retrieved from
[Link]
false

* S: satisfactory; U: Unsatisfactory

Faculty comments: (performance in skills lab and in an in-patient or community setting. please
include number of attempts that student carried out to achieve satisfactory status in the skill)

Faculty name and signature: Date:

55
DEEP BREATHING AND COUGHING EXERCISES

PURPOSES:

By the end of the skill students will be able to:

 To improve gas exchange.
 To enhance lung compliance/ expansion.
 To loosen secretions.
 To relieve shortness of breath.
 Deep breathing exercise can be used as diversional therapy.

PROCEDURE:

S# STEPS RATIONALE S* U*
01. Identify the patient. Gives required care to the correct
patient.
02. Wash hands. Reduces transmission of
microorganism.
03. Explain the procedure and purpose to Involves patient in his own care
patient. and patient is aware of what is
being done.
04. Draw curtain or close door. Maintains patients’ comfort
dignity and privacy.
05. Help the patient assume a semi Fowlers/ Allows easier lung expansion;
supine position. relaxes abdominal muscles.
06. Have the patient place one or both hands Feels the rise and fall of the chest.
on the abdomen just below the ribs.
07. PURSED LIP/ DIAPHRAGMATIC
BREATHING
Instruct the patient to: When the patient breathes in, the
Breathe in deeply with the mouth closed. Diaphragm contracts, the lungs
Not to bend/ arch the back and to stay fill with air and abdomen rises or
relaxed. Concentrate on feeling the protrudes.
abdominal rise as far as possible.
08. Instruct the patient to purse the Creates a resistance to air flowing
lips as if about to whistle to out of the lungs and minimizes
breathe out slowly and gently collapse.
Making a slow “whooshing “sound.

56
S# STEPS RATIONALE S* U*
09. COUGHING EXERCISE
Instruct the patient Helps in mobilizing secretion and
a. To breathe through the nose and expectoration.
inflate the lungs to fill little less than
full inspiration.
b. Simultaneously exhale and cough two
or more abrupt, sharp coughs in rapid
succession.
10. Instruct the patient to use these exercises Regular practice enables patient to
for 5 – 10 minutes four times a day. improve lung compliance.
11. DOCUMENTATION

Record in nursing notes the patient’s Communicates given care and

responses and the effectiveness of patient’s condition. Protects
exercise legally.

Reference:
Coughing and Diaphragmatic Breathing exercises. Lippincott Procedures. Retrieved from
[Link]
h&a=false&ad=false

*S: satisfactory; U: unsatisfactory

Faculty comments: (performance in the skills lab and in an in-patient or community setting, please
include number of attempts that student carried out to achieve satisfactory status in the skill).

Faculty name and signature: Date:

57
STEAM INHALATION

PURPOSES:

By the end of the skill students will be able to:

 To relieve the congestion of bronchioles
 To loosen secretions and enable the patient to expectorate.

EQUIPMENT TRAY:

 Steam inhaler
 Large bowl or a small basin.
 Bath towel.
 Medication if ordered.
 Menthol.
 Tincture benzoin (Fria’s balsam)
 Sputum Mug.
 Tissue.
 Clothes.

PROCEDURE:

S# STEPS RATIONALE S* U*
01. Check the doctor’s order. Makes sure that the correct type
of inhalation is given.
02. Identify the patient. Gives right care to the right
patient.
03. Assess the condition of the patient. Gathers baseline data.
04. Explain the procedure to the patient. Involves patient in his own care
and promote comfort and
cooperation.
05. Wash hands. Prevents transmission of
micro-organism
06. Collect equipment Saves time and energy.
07. Turn off fans and close windows. Prevents draughts
08. Rinse the steamer with hot water, and then Prevents fast cooling of water.
pour tap water.
10. Help the patient to assume sitting position Sitting position enhances lung
or lateral position (if contraindicated). Expansion.
11. Place the Steamer on the overhead table. For safety purposes.
12. Cover the patient with bath towel and For retaining the maximum
switch on the button. steam

58
13. Inhaling steam should be done through the For effectiveness of treatment.
nose and exhale through the mouth
S# STEPS RATIONALE S* U*
14. Request the patient to cough up and spit To clear the air way passage.
into the sputum mug and wipe lips as
necessary.
15. Give the inhalation for 15-20 minutes.

16. Wipe sweat at the end of the inhalation and Promotes comfort.
change clothes as necessary.
17. Instruct patient.
a. To remain in bed.
B Not to have cool drinks for 2 hrs.
18. Clean and put away all equipment. For next use.

19. Wash hands Prevents transmission of

microorganism.
20. DOCUMENTATION
Patient’s response to the inhalation e.g. Communicates given care and
patient expectorated (bought out) lot of patient’s condition. Protects
white frothy phlegm. legally.

*S: satisfactory; U: unsatisfactory

Faculty comments: (performance in the skills lab and in an in-patient or community setting, please
include number of attempts that student carried out to achieve satisfactory status in the skill).

Faculty name and signature: Date:

59
FOMENTATION APPLICATION OF HOT WATER BOTTLE

PURPOSE

By the end of the skill students will be able to:

 To promote blood flow to an injured part by vasodilatation.
 To promote muscle relaxation and reduce muscle spasm and pain.
 To decrease venous congestion in an injured part.
 To decrease muscle tension.

EQUIPMENT:

1. Rectangular tray.
2. Hot water bottle with lid.
3. Pillow cover / towel.
4. Pint measure.
5. Kettle with water.
6. Bath thermometer.
7. Duster.

Heat Application Methods:

1. Hot-water bottle: Fill the bottle with hot tap water to detect leaks and to warm the
bottle and then empty it. Run hot tap water into a pitcher and measure the water
temperature with the bath thermometer. Adjust the temperature, as ordered—usually to
between 115° F and 125° F (46.1° C and 51.7° C) for adults.
2. Electric heating pad: Check the cord for frayed or damaged insulation. Then plug in the
pad and adjust the control switch to the desired setting. Wrap the pad in a protective cloth
covering, and secure the cover with tape or roller gauze. If the pad comes with its own
cover, inspect the cover and fasteners to ensure that all are intact. Follow the
manufacturer's instructions for use for an electric heating pad that circulates water.
3. Chemical hot pack: Select a pack of the correct size. Then follow the manufacturer's
directions (strike, squeeze, or knead) to activate the heat-producing chemicals. Place the
pack in a protective cloth covering and secure the cover with tape or roller gauze.
4. Sterile warm compress or pack: Warm the container of sterile water or solution by
setting it in a sink or basin of hot water. Measure its temperature with a sterile bath
thermometer. If a sterile thermometer is unavailable, pour some heated sterile solution into
a clean container, check the temperature with a regular bath thermometer, and then discard
the tested solution. Adjust the temperature by adding hot or cold water to the sink or basin
until the solution reaches 120° F (48.9° C) for adults.
5. Non-sterile warm compress or pack: Fill a bowl or basin with hot tap water or other
solution and measure the temperature of the fluid with a bath thermometer. Adjust the
60
temperature, as ordered—usually to 120° F (48.9° C) for adults.

6. Hot-water bottle: Fill the bottle with hot tap water to detect leaks and to warm the
bottle and then empty it. Run hot tap water into a pitcher and measure the water
temperature with the bath thermometer. Adjust the temperature, as ordered—usually to
between 115° F and 125° F (46.1° C and 51.7° C) for adults.
7. Electric heating pad: Check the cord for frayed or damaged insulation. Then plug in the
pad and adjust the control switch to the desired setting. Wrap the pad in a protective cloth
covering, and secure the cover with tape or roller gauze. If the pad comes with its own
cover, inspect the cover and fasteners to ensure that all are intact. Follow the
manufacturer's instructions for use for an electric heating pad that circulates water.
8. Chemical hot pack: Select a pack of the correct size. Then follow the manufacturer's
directions (strike, squeeze, or knead) to activate the heat-producing chemicals. Place the
pack in a protective cloth covering and secure the cover with tape or roller gauze.
9. Sterile warm compress or pack: Warm the container of sterile water or solution by
setting it in a sink or basin of hot water. Measure its temperature with a sterile bath
thermometer. If a sterile thermometer is unavailable, pour some heated sterile solution into
a clean container, check the temperature with a regular bath thermometer, and then discard
the tested solution. Adjust the temperature by adding hot or cold water to the sink or basin
until the solution reaches 120° F (48.9° C) for adults.
10. Non-sterile warm compress or pack: Fill a bowl or basin with hot tap water or other
solution and measure the temperature of the fluid with a bath thermometer. Adjust the
temperature, as ordered—usually to 120° F (48.9° C) for adults.

PROCEDURE:

S# STEPS RATIONALE S* U*
1. Check doctor’s order or hospital Policy Ensures likelihood of safe application
for its use.
2. Identify the patient. To give treatment to right patient.
3. Explain procedure to the patient. Reduces anxiety and gains cooperation.
4. Assess the condition of the skin Provides baseline to determine changes in
Where it has to be applied. skin during heat therapy.
5. Collect equipment. Saves time and energy.
6. Wash hands Reduces spread of infection.
7. Rinse the hot water bottle with hot Prevents rapid cooling of water.
Water.

61
8. Pour the water into the pint measure and Correct temperature prevents accidental
check the temperature. burns.
Desired temperature:
a. Normal adults 52 C (125 F).
b. Unconscious or weak adults 40.5-
46 C(105- 115 F)
S# STEPS RATIONALE S* U*

9. Fill two thirds of the bottle with hot water. Over filling will prevent spilling

10. Expel the air by molding the bag to the Prevents rapid cooling from air currents.
body part

11 Apply the screw cap tight and invert the Ensures that there is no leakage of water.
bottle.

12 Wipe the outside of the bag and cover Moisture outside the bag will wet the
with towel or pillow case. cover and hasten cooling

13 Place the hot water bottle over patient’s Prevents skin burns
clothes.

14 Check the skin every 5 – 10 minutes Identifies untoward reaction

62
15 Remove after 30 – 45 minutes. Maximum effect occurs in 20 – 30
minutes. Continued exposure to moisture
will lacerate skin

16 Document condition of the skin and Communicates effectiveness of therapy

Patient’s response to the procedure.

Reference:
Heat Application. Lippincott Procedures. Retrieved from
[Link]
&a=false&ad=false

63
COLD COMPRESSION
APPLICATION OF ICE CAP

PURPOSE:
 To prevent blood flow to an injured part by vasoconstriction.
 To prevent edema.
 To decrease pain (local anesthetic effect)
 To decrease muscle tension.

EQUIPMENT:
1. A rectangular tray.
2. Ice cap with lid.
3. Pillow cover.
4. Bowl of ice cubes.
5. Ice pick (if large cubes to be broken).
6. Water proof material (mackintosh)
7. Patient’s towel.

PROCEDURE:

S# STEPS RATIONALE S* U*
1. Ensures likelihood of safe application
Check doctor’s order or hospital policy.
2. Identify the patient. To give treatment to right patient.
3. Explain the procedure to the patient. Reduces anxiety and gains cooperation.
4. Assess the condition of the skin where it Provides baseline data.
has to be applied.
5. Wash hands. Prevents spread of infection.
6. Collect equipment. Saves time and energy.
7. Allow sharp corners of the cubes to Reduces discomfort to the patient
Melt in the bowl. caused by pricking.
8. Fill the ice cap 2/3 with ice. OR Fill the Over filling prevent spilling
Zipper bag 1/2 with ice.
9. Expel the air and screw the lid tight. Prevents melting of ice rapidly.
10. Wipe the outside of the ice cap and cover Minimizes discomfort to the patient and
it. prevents skin laceration.
11. Spread the mackintosh and patients towel Prevents soiling of bed linen.
Under the area the ice cap has to be
applied.
12 Apply the ice cap To prevent blood flow to an injured part
by vasoconstriction
64
13. Lift and check the area every 5 – 10 Monitoring determines if there is
minutes. adverse response to cold.
Frequently inspect the treatment site for
signs of tissue intolerance. Be alert for
shivering and complaints of burning or
numbness. If these issues develop,
discontinue treatment and notify the
practitioner.
14. Remove after 30 – 45 minutes. Prolonged exposure to cold may cause
tissue injury.
15. Document care given, condition of skin Communicates effectiveness of therapy.
and patients response. Therapeutic effects include decreased
edema, less discomfort and area cool to
touch. Non- therapeutic effects include
redness, bluish appearance, burning and
numbness in the affected area.

Reference:
Cold Application. Lippincott Procedures. Retrieved from
[Link]
&a=false&ad=false

*S: satisfactory; U: unsatisfactory

Faculty comments: (performance in the skills lab and in an in-patient or community setting, please
include number of attempts that student carried out to achieve satisfactory status in the skill).

Faculty name and signature: Date:

65
CHECKING BLOOD GLUCOSE LEVEL VIA GLUCOMETER (REFLO CHECK)

OBJECTIVE:

By the end of the skill students will be able to:

 Verbalized the purpose of the Reflo checking.

 Demonstrate the proper and safe technique for monitoring the blood glucose level.
PURPOSE:

 To determine or monitor blood glucose in blood to have quick glucose results.

 To promote the blood glucose regulation by the client
 To evaluated the need and effectiveness of insulin.
Note: For a patient who's receiving nutrition, glucose monitoring should be performed
before meals. For a patient who isn't receiving nutrition, glucose monitoring should be
performed every 4 to 6 hours.

EQUIPMENT:

1. Glucometer
2. Lancets (Single-use)
3. Blood glucose strip compatible with the meter.
4. Antiseptic swap
5. Disposable gloves.
6. Tissue /cotton/ gauze
PROCEDURE:

S# STEPS RATIONALE S* U*
1. Check doctor’s order. Prevents error, and verifies doctor’s
orders.
2. Wash hands and dry them thoroughly To reduce the risk of contamination and
cross infection.
3. Assemble all the equipment at the bed side. Work efficiently, save time and energy.
Reduce the interruptions.
4. Identify the patients and introduce To perform the required procedure on
yourself. the right patient.
5. Explain procedure to the patient/family. To gain cooperation and reduce anxiety.

6. Ask patient to wash hands with soap and Reduces the number of microorganism
warm water and towel dry. on the skin; warmth dilates the
capillaries and increases the blood flow.

66
7. Provide for client privacy (if required) Promote client comfort.
8. Insert lancet in the lancing device and Loads and holds the lancet in place.
adjust the numbers.
S# STEPS RATIONALE S* U*
9. Turn on the machine; observe the last Prepares the machine for testing the
blood glucose reading, current test strip blood sample. The machine retains the
code, and the message “insert strip”. last glucose measurement in its memory.
Displayed on the glucometer screen.
10. Place the notched end of the test strip into. Locates the strip in position for the
Insert the blood glucose test strip into the application of blood.
glucometer holder with the test spot up, To ensure that the calibration code
wait for the calibration code to appear stored in the sensor matches with the
before ready is display on the gluco meter calibration code printed on the strip.
screen.
11. Wear clean gloves, before starting the Provides a barrier against contact with
procedure.(as per police and requirement) blood.
12. Select non-traumatized sides of a finger or Avoid puncturing an area where there
thumb, avoid the central pads. Always are sensitive nerve endings.
change the finger.
13. Clean the site with alcohol / spirit swab Reduces the number of microorganism
and allow it to dry completely. on the skin. Wet skin with alcohol may
( according to the hospital policy) alter the results if not totally evaporated.
14. Apply the cap covering the lancet firmly to This action thrusts the lancet into the
the side of the finger and press the release skin.
button. Inform patient about slight pain.
15. Release the lancet and holder. Opens a path for blood.

16. Gently squeeze the finger or thumb so that Uses gravity to aid in collecting blood.
a large hanging drop of blood forms.
17. Touch the hanging drop of blood to the test Saturates the test spot ensure accurate
spot on the strip, making sure that the spot test results.
is completely covered and stays wet during Smearing of blood may result in
the test. Do not smear the blood. inaccurate reading
18. Listen for the meter to beep, followed by Activates the timing mechanism.
series of beeps 45 seconds later.
19. Apply pressure on the fingertip with gauze Absorbs blood and controls bleeding.
or tissue paper.
20. Read the display result on the meter after Identifies the patient’s blood sugar level.
the series of beeps.
21. Inform the results of the test to the patient. To gain cooperation and reduce anxiety.
22. Discard the test strip in the dustbin and the Prevents injury and transmission of
lancet in the danger box. blood-borne infection.
67
23. Turn off the machine. Extends the life of the battery.
24. Clean the tip of the lancing device with To reduce the risk of transmission of
spirit/ alcohol swabs. infection from the lancing device.
25. Make patient comfortable. To reduce anxiety.
S# STEPS RATIONALE S* U*
26. Keep all equipment in the designated area. Facilitates the use of equipment that
may be needed for other patients.
27. Wash hands after the procedure. To reduce the risk of infection.
28. Documentation: Documents essential data.
 Documents the results in the flow sheet
II / Critical flow sheet.
 Inform the results to the team leader; Ensures continuation of care.
nurse in charge, and to the concern
doctor if necessary.
 Document abnormal findings and Communicates information for making
treatment in the nurse’s notes. treatment decisions.

Reference:
Blood Glucose Monitoring. Lippincott Procedures. Retrieved from
[Link]

*S: satisfactory; U: unsatisfactory

Faculty comments: (performance in the skills lab and in an in-patient or community setting, please
include number of attempts that student carried out to achieve satisfactory status in the skill).

Faculty name and signature: Date:

References:

 Erb, G., & Kozier, B. (2008). Fundamentals of Nursing: concepts, process and practice.
(8th Edition). Pearson Education.
 The Aga Khan University Hospital, Division of nursing services (2009). Clinical Protocol.
(Pro C C-040) Checking Blood Glucose Level via Glucometer. (Reflo Check).
 Perry, A. G., &Potter, P. A. (2009). Clinical nursing skills and techniques.(7th edition).
Mosby, Elsevier.

68
ADMINISTRATING NEBULIZERS

Objective:

By the end of the procedure students will be able to:

 verbalized the purposes of administrating nebulizers

 perform the skill properly in clinical setting

Scope:
This procedure applies to BScN students for the Utilization of nursing knowledge through the application of
critical thinking, judgment and skill. It is stranded in the principles of nursing education.

Purposes:
 Nebulizers are administered for:
 Airway hydration
 Aerosolized medication
 Adjunct therapy for mobilization of retained secretions

Important Requirements:
 Nebulizer set
 Oxygen with flow meter (cylinder or wall fixed)
 Normal saline
 3cc sterile syringes (2)
 Mar sheet and active profile
 Medication ?(any bronchodilator)
 Medication chart/tray/bin

Procedure:

[Link] Steps Rationales U US

1 Check physician’s order from Ensure that drug will be administered
active profile and compare with safely and accurately
MAR sheet
2 Wash hands Educe transfer of microorganism
from hands to medications
3 arrange medications chart, Organizing workplace saves times
medication tray and reduces error
4 Select proper medications from the Cross checking label against
bin read label (first time ) and transcribed order decreases error
compare with MAR sheet and
69
check for
 Patients name MR
 Bed number
 Drug dosage, frequency and
route
 Starting and finishing date and
time
5 Check for expiry date of the Maintains safety. deteriorated for
medication expired drug may be less effective
and cause harm to the patient
6 Calculate the dosage Ensures patents safety
7 Prepare medication and fill the Ensure correct medication and
required amount in sterile syringes accuracy of the medication
and pour medication in the
nebulizer.
Salbutamol/ventloin 5mg=1ml
(adult patient)+1.5ml of normal
saline=2.5ml of total solutions
8 Take the medications tray to the
assigned patient’s bedside
9  Identify the patient by To ensure right drug administration
 Checking ID band for name to right patient
and MR
 Ask patient to state his name
 Verity with relative/name plate
10 Explain and instruct the procedure To reduce the patient anxiety
to the patient
11 Wash hands To prevent cross contaminations
12 Place the patient high fowlers To facilitate maximum chest
position expansion
13 Pour the medication and carefully
tighten the nebulizer cup
14 Contact the oxygen tubing to the
flow meter and place the face
mask on the patient. ensure the cup
is maintained in upright position
15 Initiate the therapy and adjust the Flow of oxygen or air convents a
rate at 6-8l/min or above 8l/min as liquid into an aerosol mist. a
per doctor order humidifier acts as a barrier to the
Note: do not use with humidifier force of the flow of oxygen and does
not allow the nebulizer to work
70
effectively
16 Observe the fin spray from the It ensures that its working
nebulizer
17 Encourage patients to take deep It facilitate maximum chest
breathes expansion and get to minimum
benefit to treatment
18 When finish, switch off the
oxygen flow immediately and
remove the face mask from the
patient
19 Check the cup to ensure that Patient may find easier to expectorate
medication is finished the nebulizer
20 Encourage the patient to perform Patient may find easier to expectorate
deep breathing and coughing the nebulizer
exercise each time after nebulizer
21 Observe the amount and color of
sputum and record in the nurses
notes required
22 Leave the patient n comfortable Patient may wish to rest following the
position medication
23 Observe the breathing of patient Nebulizer may have improve his/her
periodically breathing by reducing the respiratory
rate and effort required to breath
24 Wipe the nebulizer and face mask To keep equipment in working order
with a moist tissue and then dry. and prevent infection
wrap in a polythene bag/glove for
the patient next treatment
25 Document in MAR sheet and To ensure continuity of care
nurses notes
Medication dosage, route and
duration therapy
Record respiratory rate, oxygen
saturation, breath sounds/HR and
patient response to the therapy

References:
 Audrey Berman, S. J. (2016). Kozier & Erbs Fundamental of Nursing tenth edition
 .Peterson, V. R. (2017). Fundamental of Nursing ninth edition
Remarks________________________________________________________

Faculty Signature___________________________________

71