ADMITTING A PATIENT/CLIENT

Objective

• To welcome the patient/client and establish a positive relationship with the patient and
immediate relative(s).
• To offer immediate management and care in acute condition.
• To orient the patient/client to immediate environment and services available.
• To obtain baseline data of a patient/client through history-taking and physical examination.

Assessment

• Observe physical, emotional and mental status of the patient/client.

• Assess the patient/client's general appearance, noting signs and symptoms of physical
distress
• Assess the patient/client's level of comfort.
• Observe for disability, limitation and risk for fall.
• Determine patient/client's understanding of the reason for hospitalization.
• Identify the medication that patient/client is currently taking.
• Assess patient/client ability to adapt to the hospital environment.

Equipment

Trolley - top shelf Trolley - bottom shelf

• Admission kit (optional) • Weighing scale

• Hospital attire • Bedpan and urinal (optional)

• Thermometer • Kidney dish or emesis basin (optional)

• Blood pressure apparatus • General waste receiver

• Wristband •

• Instrument for physical assessment •

1
 • Admission form •

• Document (follow institutional policy) •

Preparation

• Prepare the bed-lower the bed and fold top sheet/blanket.

• Gather equipment and supplies.
• Arrange room furniture for easy access from bed.
• Assemble special equipment if needed and make sure it is functioning, such as:
o suction equipment
o oxygen supplies
o intravenous (IV) drip stand, etc.
• Prepare the patient/client's record with the necessary information like name, registration
number, unit and room or bed number in each record.
• Perform hand hygiene.

Implementation

No Interventions Rationale

1. Greet the patient and family member by name. To reduce anxiety about
admission.

2. Introduce self by name and job title. To establish rapport.

3. Accompany the patient and family member to the To reduce anxiety about
assigned room or bed. hospitalization.

4. Encourage the patient to send valuables home. If To be accountable for safe

patient prefers to keep them, list items on paper and placement of valuables
have patient or family member to sign it. and prevent loss.

5. Tell the patient to change into hospital attire. To provide privacy.

• Advice family or friend to leave the room unless

patient wishes them to assist in changing into
hospital attire. OR

• Assist patient to change to hospital attire.

2
6. Obtain health history and perform physical To provide baseline
assessment. assessment of condition.

7. Check the patient’s height, weight and vital signs. To provide baseline
assessment of condition.

8. Orient the patient to the physical set up of the ward To reduce stress of finding
such as the nurse’s station, treatment room, toilet and the details on their own.
bathroom facilities, drinking water supplies, patient’s
cupboard and call bell.

9. Explain the hospital policies regarding visiting hours, To reduce stress of finding
gate pass, family member staying with patient and the details.
restriction in the ward.

10. Explain the hospital policies regarding visiting hours, To gain cooperation.
gate pass, family member staying with patient and
restriction in the ward.

11. Obtain specimens such as urine, blood or any other For basic screening.
specimen as ordered.

12. Inform the patient about procedures or treatment To keep patient informed.
scheduled for the next shift or next day and clarify
any related matters.

13. Initiate care which do not require doctor’s order if For comfort.
needed.

14. Be sure call bell is within reach, bed is in lowered For safety.
position and side rails are raised

15. Perform hand hygiene. To reduce transmission of

microorganisms.

16. Notify doctor of patient’s arrival and report any For immediate attention.
abnormal findings.

17. Inform dietary department regarding patient’s To ensure appropriate diet

admission and type of diet ordered. is served.

18. Record health history and assessment findings in For documentation and
appropriate forms. further evaluation.

• Write the admission notes including the following

details.
o Date

3
 o Time of admissio
o Age
o Mode of arrival
o Patient’s chief complain
o Variations on vital signs and other
abnormalities such as pressure sores, rashes,
etc.
o Orientation given
o Full signature of the nurse and patient

Evaluation

• Patient/client adapts to hospital environment.

• Patient/client participates in the individual plan of care.
• Patient/client understands the rules and regulation of the policy.
• Significant changes are reported to the staff in-charge and/or doctor

4
 TRANSFERRING A PATIENT/CLIENT
Objectives

• To facilitate transfer within or to another unit.

• To facilitate safe and individualized continuity of care.

Assessment

• Check doctor's order for transferring of patient/client.

• Verify reason for patient/client’s transfer.
• Observe and record the patient/client’s physical, emotional and mental status prior to
transfer.
• Assess the patient/client’s knowledge and understanding of reason for the transfer.

Equipment

• Patient’s record • Required medical equipment

• Transfer forms • Wheelchair/stretcher

Preparation

• Identify the patient/client for transfer.

• Perform hand hygiene.
• Prepare the medical equipment as needed.
• Determine the mode of transportation.
• Gather patient/client’s belonging.

Implementation

No Interventions Rationale

1. Greet and explain the purpose of transfer to To obtain patient’s cooperation.

the patient.

2. Check doctor’s order for transferring of To ensure correct procedure.

patient.

5
 3. Inform the nurse in charge of the receiving Prior information will help the staff
unit/ward regarding the transfer of patient . in the new unit/ward to receive the
patient with adequate preparation.

4. Contact to inform admitting office and To keep them informed.

family member about the transfer.

5. Inform the patient of impending transfer. To facilitate the adjustment to the

new unit.

6. Obtain necessary staff assistance. For smooth transferring of patient. .

7. Perform final assessment of patient such as To minimize risk of patient

vital signs, etc. developing complications during
transfer.

8. Accompany the patient to the receiving To ensure smooth and safe transfer
unit/ward/hospital. of patient.

9. Hand over all documents and belongings of To ensure completion of transfer

patient to the receiving nurse and ensure procedure.
that the items given are documented.

10. Complete the needed documentation after For record and documentation.
transfer according to institutional policies.
Evaluation

• Patient/client understands and accepts the transfer to a new care unit/ward/hospital.

• Patient/client is transferred to new unit/ward/hospital without complication.
• All documentation and patient/client’s belonging are handed over accordingly.

6
 DISCHARGING A PATIENT/CLIENT
Objectives

• To provide instruction on the discharge to patient/client and family member.

• To allow the patient/client to verbalize feeling about discharge.
• To identify the patient/client’s strengths and needs.

Assessment

• Check the discharge order.

• Perform final assessment such as physical, emotional, social status, etc.
• Review care plan during hospitalization to determine if the goals are achieved.
• Assess the patient/client’s ability to continue self-care and possible need for continued
health supervision.

Equipment

• Patient's diagnostic reports • Doctor's prescription slip

• Appointment card (TCA) • Documentation form (follow institutional policy)

Preparation

• Identify the patient/client for discharge.

• Prepare the documentation as needed.
• Identify specific problems and health education as needed for the patient/client.
• Perform hand hygiene.
• Gather patient/client’s belonging.

Implementation

No Interventions Rationale

1. Greet and inform about the discharge to To alert patient of impending

the patient. discharge.

2. Notify family member or caregiver about To keep them informed.

the discharge of the patient.

7
 3. Review written homecare instructions with To ensure that the patient or caregiver
the patient or the person who will be has the information needed for
providing or assisting with care at home. effective care after discharge.

4. Check all the closet and drawers and To prevent loss of items and
return belongings to the patient or family institutional liability.
member.

5. Provide the patient with the medication To ensure patient obtains the
prescription and information for follow up medication and attends regular follow
care. up.

6. Allow the patient and family member to To relieve anxiety and ensure safe
ask questions. care is provided. .

7. Advice the patient or family member to To facilitate discharge.

settle payment.

8. Remove the wristband and any medical To facilitate discharge.

devices such as cannula.

9. Complete discharge checklist and obtain For documentation.

full signature of the nurse and patient.

Evaluation

• Patient/client’s condition is stable at the time of discharge.

• Patient/client and caregiver understands the diagnosis, anticipated level of functioning,
discharge medication and anticipated follow up.
• All documents and patient/client’s belongings are handed over accordingly.

8
 MEDICAL ASEPSIS HANDWASHING
Objectives

• To reduce the number of microorganisms on the hands and inhibit their growth.
• To disrupt transmission of microorganisms from healthcare personnel to patients/clients
and vice versa.
• To prevent cross infection among patient/client.

Assessment

• Assess hands for cuts, abrasions or traumatized skin that can harbour microorganisms.
• Assess length and condition of nails and cuticles. Long nails, artificial nails and nail polish
should be removed.
• Assess the environment to ensure ample space for working.

Equipment

• Sink with running water • General waste receiver

• Facility approved liquid soap/bar soap with dish •

• Paper towels •

Preparation

• Gather equipment and supplies.

• Remove jewellery and watch from hands and arms.
• Roll the sleeves up to mid-forearm level.

Implementation

No Interventions Rationale

1. Turn on the faucet and adjust the force of To avoid splashing and spread of
water. Keep body away from sink. microorganisms to other areas.

2. Wet hands and wrists area, pointing fingers Movement of water and dirt will
towards the bottom of the sink. flow from hands to finger tips.

9
3. Apply small amount of liquid soap (about 1
teaspoon).

4. Wash hands. •

• Use 10 strokes for each step (7 steps of

hand hygiene).

• Rub hands, palm to palm. •

• Rub right palm over left dorsum with •

interlaced fingers and vice versa.

• Rub palm to palm with fingers interlaced. •

• Rub back of fingers to opposing arm with •

fingers interlocked.

• Rotational rubbing of left thumb clasped in •

right palm and vice versa

• Rotational rubbing, backwards and forwards •

with clasp fingers of right hand in left palm
and vice versa.

• Rotational rubbing of right wrist in left palm •

and vice versa.

5. Rinse the wrist, hands and finger tips pointing To rinse off the dirt and
downward. Avoid touching any part of the microorganisms away.
sink or faucet.

10
 6. Turn off the faucet using elbow.

7. Pat dry hand with clean paper towel, beginning To prevent growth of
at the fingertips towards the wrist. microorganisms.

Evaluation

• Hands and nails are clean following the 7-steps of handwashing.

11
 SURGICAL ASEPSIS HANDWASHING
Objectives

• To remove debris and transient microorganisms from the nails, hands and forearms.
• To reduce the resident microbial count to a minimum.
• To inhibit rapid rebound growth of microorganisms.
• To prevent transfer of microorganisms from healthcare personnel to patient/client and vice
versa.

Assessment

• Assess the situation for the necessity of surgical hand wash.

• Assess hands for cuts, abrasions or traumatized skin that can harbour microorganisms.
• Assess length and condition of nails and cuticles. Long nails, artificial nails and nail polish
should be removed.
• Assess the environment to ensure ample space for working.

Equipment

• Sink with running water • General waste

receiver

• Antimicrobial foam in dispenser e.g. 2%-4% chlorhexidine, •

povidone-iodine or triclosan

• Sterile hand towel •

• Surgical face mask •

Preparation

• Gather equipment.
• Remove jewellery and watch from hands and arms.
• Roll up long sleeve 10 cm above elbow.
• Apply surgical face mask.

12
Implementation

No Interventions Rationale

1. Turn on the faucet and adjust the force of water. To avoid splashing and spread
Keep body away from sink. of microorganisms to other
areas.

2. Wet hands and arms from the tip of fingers to 10 To allow movement of water
cm above the elbows (keep elbows bent). and dirt flowing from fingers
to less clean areas.

3. Apply adequate amount of antimicrobial foam. To reduce number of transient

and resident microorganisms.

4. Wash hands. Rubbing and friction will help

to remove resident and
transient microorganisms.
• Use 10 strokes for each step (7 steps of hand
hygiene)

• Rub hands, palm to palm. •

• Rub right palm over left dorsum with interlaced •

fingers and vice versa.

• Rub palm to palm with fingers interlaced. •

• Rub back of fingers to opposing palms with •

fingers interlocked.

• Rotational rubbing of left thumb clasped in right •

palm and vice versa.

• Rotational rubbing, backwards and forwards with •

clasp fingers of right hand in left palm and vice
versa.

• Rub one hand starting from the wrist in a rotating •

manner till elbow and vice versa.

13
 • Rinse fingers, hands and arm thoroughly starting To prevent contamination of
from finger tips under running water, keeping hands from dirtier areas.
hands and arms elevated to allow water to drip
from the elbow. Keep hands away from body. To prevent accidental
contamination.

5. Turn off the faucet using elbow. To prevent hand

contamination.

6. Dry hands with sterile hand towel. To prevent growth of

microorganisms.

• Using sterile towel, dry one hand thoroughly •

moving from fingers to elbow. Dry in a rotating
motion.

• Repeat drying method with the other hand by To prevent accidental

carefully reversing the towel or using a new sterile contamination.
towel.

7 Discard hand towel into general waste receiver.

Keep the hands and arms above waist level and To prevent contamination.
8 away from the body with hands and fingers
pointing up when moving.

Evaluation

• Correct method of surgical hand wash is carried out following the 7-steps of
handwashing.
• Transient and resident microorganisms are removed.

14
 ALCOHOL-BASED HANDS RUB
Objectives

• To reduce the number of microorganisms on the hands and inhibit their growth.
• To disrupt transmission of microorganisms from healthcare personnel to patient/client and
vice versa.
• To prevent cross infection among patients/clients.

Assessment

• Inspect hands and observe for visible soiling. If hands are visibly soiled (blood and body
secretions), perform hand wash instead of alcohol hand rub.
• Assess hands for cuts, abrasions or traumatized skin that can harbour microorganisms.
• Assess length and condition of nails and cuticles. Long nails, artificial nails and nail polish
should be removed.

Equipment

• Alcohol-based hand sanitizer

Preparation

• Gather equipment and supplies.

• Remove jewellery and watch from hands and arms.
• Roll the sleeves up to mid-forearm level.

Implementation

No Interventions Rationale

1. Turn on the faucet and adjust the force of water. To avoid splashing and
Keep body away from sink. spread of microorganisms to
other areas.

2. Apply the correct amount of product to left palm. Adequate amount is required
to cover all hand surfaces.

15
 • Dip all fingers of right hand into left palm, then •
pour hand rub solution over to right palm and dip
all fingers of left hand into the hand rub solution.

• Rub hands, palm to palm. •

• Rub right palm over left dorsum with interlaced •

fingers and vice versa.

• Rub palm to palm with fingers interlaced. •

• Rub back of fingers to opposing with fingers •

interlocked.

• Rotational rubbing of left thumb clasped in right •

palm and vice versa.

• Rotational rubbing of right wrist in left palm and •

vice versa until dry.

Evaluation

• Hands and nails are clean following the 7-steps of hands rub.

16
 USING PERSONAL PROTECTIVE EQUIPMENT
(PPE): GOWN, MASK, GLOVES
Objectives

• To reduce or minimize transmission of infectious disease microorganisms from one

patient/client to another.
• To prevent transfer of microorganisms via contact, droplets and airborne mode of
transmission from one patient/client to another.
• To prevent transmission of microorganisms to self or clothing during patient/client's care.

Assessment

• Check doctor's order to determine the types of precaution.

• Determine the types of equipment necessary based on the infection control practices for
the suspected or diagnosed organism, infection or communicable disease.
• Determine the potential for exposure to blood and body fluid.
• Assess the situation for the necessity of PPE.

Equipment

• Disposable gown • General waste receiver

• Mask (surgical or particulate respirator) • Clinical waste receiver

• Goggles or face shield (if splash is expected) •

• Disposable gloves •

• Alcohol-based hand sanitizer and paper towels •

Preparation

• Identify the patient/client.

• Gather equipment and supplies.
• Prepare environment.

17
 • Place signage at the entrance to the room notifying all staff of the necessary precautions.
• Perform hand hygiene.

Implementation

No Interventions Rationale

1. Don a gown. Don gown first, then apply mask and

gloves.

• Hold the gown by its neck area and allow it To facilitate donning of gown.
to unfold with the back opening towards
you.

• Slip arms into the sleeves. To provide protective covering of the

arm.

• Tie the strap behind the neck with ribbon To facilitate the opening of the gown
knot tying. ties/strap.

• Tie the strap at the waist with ribbon knot To cover the nurse’s clothing, front,
tying. back and both sides.

2. Don the face mask.

• Locate the top edge of the mask. •

• Hold the mask by the top two strings To avoid hand contact with mask.

• If respirator (N95) is used, perform a

fit check.
o Inhale: the respirator should
collapse
o Exhale: air should not leak out

• Place the upper edge of the mask over the •

bridge of the nose and tie the upper ties at

18
 top back of the head.

• Secure the lower edge of the mask under To cover both nose and mouth.
the chin and tie the lower ties at the nape of
the neck.

• Adjust metal strip firmly over the bridge of To prevent both the escape and
the nose. inhalation of microorganisms around
the edges of the mask and fogging of
the eye shield.

3. Don disposable gloves.

• Take out the gloves from the box. •

• Hold glove at wrist edge and slipped To avoid touching the skin of the
fingers into openings. Pulled glove up to forearm with gloved hands.
wrist and vice versa.

4. Provide nursing care.

5. Remove PPE To minimize contamination

• Removes gloves first then gown and

mask last.
o If the string of the gown is tied at
the waist in front, untie the waist
strings of the gown before
removing gloves.

6. Remove the gloves.

• Grasp the outer surface of one glove with To prevent contamination of the
the other gloved hand "rubber to rubber" skin.
and pull off the glove turning it inside out

19
 towards the fingertips.

• Hold it in the palm of the gloved hand. To avoid hand contact with mask.

• While still holding on to the first glove in To prevent contamination of hands.

the remaining gloved hand, slide the
fingers inside the cuff of the glove "skin to
skin".

• Pull it off, making sure it comes off inside To prevent contamination of hands.
out until it slips off your hand

• Discard contaminated gloves into the To prevent transmission of

clinical waste/biohazard bag. microorganisms.

7. To remove glove powders and any

Perform medical asepsis handwashing.
organism.

8. Remove the gown.

• Unfasten gown tie on the waist and then To prevent contamination. The front
the neck tie. Taking care that the sleeve and sleeve of the gown are
does not contact your body when reaching contaminated.
out for ties.

• Slide hand under inside back edges at the To avoid touching the skin of the
neck. forearm with gloved hands.

20
 • Pull the gown off turning inside out and To prevent contamination.
rolling down as it is removed.

• Fold or roll into a bundle and discard in the•

clinical waste bin.

9. Remove the mask.

• Pull the bottom of one side of the string To discard the mask.
follow by the upper string.

• Remove the mask from the face by holding To reduce transmission of

the string and discard into clinical microorganisms.
waste/biohazard bag.

10. Perform medical asepsis handwashing. To remove microorganisms.

Evaluation

• Transmission of microorganisms is prevented.

• Patient/client and staff remain free of exposure to potentially infectious microorganisms.

21
 DONNING AND REMOVING STERILE GLOVES
(OPEN METHOD)
Objective

• To perform sterile procedures and to handle sterile equipment and supplies.

• To prevent risk for infection to patient/client.
• To prevent spread of microorganisms from patient/client to healthcare provider.

Assessment

• Check doctor's order and determine the necessity for sterile gloves.
• Check patient/client's chart for information about a possible latex allergy.
• Assess hands for cuts, abrasions or traumatized skin that can harbour microorganisms.
• Assess length and condition of nails and cuticles. Long nails, artificial nails and nail polish
should be removed.

Equipment

Trolley - top shelf

• Sterile gloves (appropriate size) • Clinical waste receiver

• Sterile hand towel • General waste receiver

Preparation

• Identify the patient/client.

• Gather equipment.
• Determine appropriate gloves size.
• Check the integrity of the pack and expiry date.
• Prepare the environment
o Move any unnecessary equipment out of the immediate vicinity.
o Turn off the fan.
• Perform hand hygiene.
• Don a mask.

22
Implementation

No Interventions Rationale

1. Place sterile gloves package on clean, dry Moisture could contaminate the
surface above waist level. gloves. Any sterile items, below
waist are considered as
contaminated.

2. Open the outside wrapper by carefully peeling To maintain sterility of gloves in

the top layer without touching the inside the inner package.
package

3. Place the sterile package onto a sterile surface To maintain sterility of gloves in
the inner package.

4. Perform surgical handwashing and dry with To reduce transmission of

sterile towel. microorganisms.

5. Donning gloves. To maintain sterility of gloves.

The inner surface is considered as
• Carefully open the inner package without sterile. The outer 1” of the border
touching the inner surface of the package is considered as contaminated.
or the gloves.

• Unfold the top flap then bottom flap of the To keep the package open and
wrapper and both sides to expose the gloves. prevent folding back of the
wrapper that would contaminate
the gloves.

6. With the thumb and index finger of the non- To prevent contamination outside
dominant hand, grasp the folded cuff of the of the gloves.
glove for the dominant hand, lifting it up from
the inner package.

7. Fold the thumb of the dominant hand towards For easier insertion of the glove
the palm and carefully insert the fingers into and to prevent contaminating the
glove and pull glove on. Leave the cuff folded outside of the glove by the thumb.
until the opposite hand is gloved.

23
8. With the thumb of the gloved hand stretching To prevent contamination of the
outward, slide the fingers of the gloved hand gloves.
inside the cuff of the remaining glove. Lift it
up from the wrapper, taking care not to touch
anything with gloved hands.

9. Carefully insert non-dominant hand into the To prevent contamination.

glove. Pull the glove on, ensure skin does not
touch any of the outer surfaces of the glove.
Once the hand is settled in the glove, slide the
cuff up carefully over the wrist.

10. Slide the fingers of the gloved hand under the To prevent contamination.
cuff of the other glove and fully extend the
cuff up carefully over the wrist.

11. Adjust the fingers in the gloves by Fingers must be positioned

interlocking them to allow fingers to enter the properly to allow smooth
space in the gloves properly. movement during the procedure.

12. Removing gloves.

• Grasp the outer surface of one glove with the To prevent contamination of the
other gloved hand "rubber to rubber" and pull skin.
off the glove turning it inside out towards the
fingertips.

• Hold it in the palm of the gloved hand. •

• While still holding on to the first glove in the To prevent contamination of

remaining gloved hand, slide the fingers hands.
inside the cuff of the glove "skin to skin".

24
 • Pull it off, making sure it comes off inside out To prevent contamination of
until it slips off your hand. hands.

13. Discard contaminated gloves into the clinical To prevent transmission of

waste/biohazard bag. microorganisms.

14. Perform medical asepsis handwashing. To remove microorganisms.

Evaluation

• Appropriate size gloves are worn.

• Gloves are applied and removed without contamination.
• Patient/client remains free of exposure to infectious organisms.
• Patient/client does not exhibit signs and symptoms of latex allergy response.

25
 DONNING AND REMOVING SURGICAL GOWN
(WITH CLOSED METHOD GLOVING)
Objectives

• To don attire for carrying out sterile procedure safely.

• To prevent transmission of potentially infective organisms from hands to patient/client
during invasive procedure.

Assessment

• Assess the patient/client’s record and orders to determine requirement of donning sterile
gown and gloves.
• Check patient/client’s record and ask about latex allergy.
• Assess availability of sterile supplies.
• Assess the availability of personnel (e.g. circulating nurse) if help is required.
• Assess location of all sterile fields to avoid contamination.

Equipment

Trolley - top shelf

• Package of sterile gown with sterile hand towel • Clinical waste receiver

• Package of sterile gloves • General waste receiver

Preparation

• Identify the patient/client.

• Gather equipment, appropriate size of sterile gown and gloves.
• Ensure the integrity of the sterile gown pack and sterile gloves pack.
• Prepare environment.
• Perform hand hygiene.
• Don cap, mask, protective eye wear and shoe covers.

Implementation

No Interventions Rationale

1. Perform surgical hand scrub and dry To reduce the number of

with sterile hand towel. microorganisms.

26
2. Don a sterile gown.

• Grasp folded sterile gown at the neck To protect sterility of the gown.
line and step back.

• Allow gown to gently unfold, but not To protect sterility of the gown.
allowing it to touch the floor. (The
inside gown is toward you.)

• With hands at shoulder level, slide arms To protect the sterility of the gown and
in the sleeves until the fingers reaching prepare for closed gloving.
the cuff. But not through the cuff.

• The circulating nurse will step behind To maintain sterility of the gown.
and grasp the inside of the gown,
bringing it over the shoulders and secure
the ties at the neck and waist.

3. Closed gloving.

• Open the inner package containing the To maintain sterility of the gloves.
gloves and pick up one glove by the
folded cuff edge with the sleeve-covered
non-dominant hand.

• With your gown covering your fingers, For easier manipulation and insertion of
use non-dominant hand to remove the glove.
glove. Hold your dominant hand palm
up with fingers straight. Lay the glove
on your dominant wrist and grip the cuff

27
 with your thumb.

• Place your non-dominant thumb inside •

the top cuff edge. Make a fist with your
hand and stretch the glove over your
fingertips.

• Keeping your fingers straight, pull down•

the glove.

• Repeat the above procedure to don the •

other glove: use your gloved hand to lay
the glove on your wrist. Slide your
thumb inside the top of the cuff, make a
fist and stretch the cuff over your
fingertips. Pull down the sleeve and
glove together.

• Adjust glove for comfort and interlock To promote dexterity of gloved hands.
fingers if necessary to fit in snuggly.

• Keep gloved hands above waist level at To maintain sterility.

all times.

4. Removing gown.

• Untie surgical gown. Grasp the gown at•

the shoulders and pull it down over the
arms and off the gloved hands turning
the gown inside out.

• Repeat procedure for the opposite arm. •

28
 • Keep gown and arms away from body. To prevent transmission of
Pull the gown off, turning it inside out. microorganisms.
Fold or roll into a bundle and placed it
into the appropriate laundry bag.

5. Removing gloves.

• Grasp the outer surface of one glove To prevent contamination of the skin.
with the other gloved hand "rubber to
rubber" and pull off the glove turning it
inside out towards the fingertips.

• Hold it in the palm of the gloved hand. •

• While still holding on to the first glove To prevent contamination of hands.

in the remaining gloved hand, slide the
fingers inside the cuff of the glove "skin
to skin".

• Pull it off, making sure it comes off To prevent contamination of hands.

inside out until it slips off your hand.

6. Discard contaminated gloves into the To prevent transmission of

clinical waste/biohazard bag. microorganisms.

7. Perform medical asepsis handwashing. To remove microorganisms.

Evaluation

• Gown and gloves are donned by maintaining sterile technique.

• Gown and gloves are removed without contamination.

29
 OPENING A STERILE PACK AND PREPARING
STERILE FIELD
Objectives

• To create a sterile field to provide a surgically aseptic workspace.

Assessment

• Assess the situation to determine the necessity for creating a sterile field.
• Assess the area in which sterile field is to be prepared.

Equipment

Trolley - top shelf Trolley - bottom shelf

• Sterile package • Mask

• • Sterile gloves

• • Solution

• • Extra surgical supplies

Preparation

• Select a dry tabletop or trolley that is above waist level.

• Perform hand hygiene.
• Disinfect the trolley with 70% alcohol or trolley wipes.
• Gather required equipment.
• Check the integrity of the pack, sterilization indicator and expiry date.
• Prepare the environment
o Move any unnecessary equipment out of the immediate vicinity
o Turn off the fan.
• Perform hand rub.

30
Implementation

No Interventions Rationale

1. Place the sterile set on the trolley.

2. Don a mask. To reduce transmission of

microorganisms.

3. Position the package so that the top flap To prevent subsequently reaching
of the wrapper opens away from you. directly over the exposed sterile field
which can cause contamination.

4. Remove the tape indicator on the

package.

5. Opening the sterile package.

• Stand away from the package (15-30 To prevent contaminating the package.
cm).

• Reaching around the package (not To maintain the sterility of the inside
crossing over it), pinch the first flap on wrapper.
the outside of the wrapper between the
thumb and index finger. Pull the flap
open.

• Open the right side flap with the right •

hand.

• Open the left side flap with the left •

hand.

• Stand away from the package, pinch the•

last flap and pull the flap back towards

31
 the body, allowing it to fall flat.

6. Adding supplies or equipment to the

sterile field.

• Inspect the package to identify edge for •

opening.

• Bring both hands together and grasp the To establish the grip to open the
edge to be opened. package.

• Peel the two parts of the package apart To open the package, exposing the
by turning the hands outward to separate content of the package and allow gentle
the sealed edge. toss of content into the sterile field.

7. To pour sterile solution.

• Obtain appropriate solution and check To ensure appropriate solution and

expiry date. prevent contamination.

• Uncap the solution bottle and place the To prevent contamination of the inside
inverted lid on the table. of the lid.

• Hold bottle outside the edge of the Label remain dry and solution poured
sterile field with the label facing the without reaching across the sterile field.
palm of the hand and prepare to pour
from a height of 4 to 6 inches

• Pour the required amount of solution in To prevent splashing.

a steady stream.

• Touch only the outside of the lid when To prevent contamination and make
recapping. Label solution with date and available for future use.
time of opening.

32
 8. Continue with the procedure as
indicated.

9. Remove mask when procedure is

completed.

10. Perform medical asepsis handwashing. To remove microorganisms.

Evaluation

• Aseptic technique is adhered strictly.

• Sterile field is created without contamination.
• The content of the package remains sterile.
• Patient/client is free from exposure to microorganisms.

33
 USE OF CHEATLE FORCEPS
Objectives

• To move sterile instrument within the sterile field.

• To transfer sterile item from one sterile field to another.

Assessment

• Assess the situation to determine the necessity for creating a sterile field.
• Assess the area in which sterile field is to be prepared.

Equipment

Trolley - top shelf

• Sterile cheatle forceps and jar

• Mask

Preparation

• Gather equipment.
• Check the integrity of the pack and expiry date.
• Prepare the environment
o Move away any unnecessary equipment out of the immediate vicinity.
o Turn off the fan.
• Perform hand hygiene
• Don a mask.

No Interventions Rationale

1 Open the sterile package.

2 Hold the forceps by the handle.

3 Ensure that the tip of the forceps is closed.

4 Remove cheatle forceps without touching the sides of the jar. To maintain
asepsis.

5 Keep the tips of the forceps pointing down, above waist level and To maintain
within sight at all times. asepsis.

6 Move the sterile items with the forceps.

34
 7 Place the cheatle forceps into the jar without touching the sides of To maintain
the jar. asepsis.

Evaluation

• Sterile field is created without contamination.

• The content of the package remains sterile.
• Patient/client is free from exposure to microorganisms.

35
 TRANSFERRING A PATIENT/CLIENT FROM BED
TO CHAIR/WHEELCHAIR
Objectives

• To prepare patient/client for eating, to go to toilet or to another department.

• To provide comfort.
• To provide optimal lung excursion and ventilation.
• To promote optimal joint movement and prevent contractures.
• To help maintain skin integrity.

Assessment

• Identify the reason for moving the patient/client from bed to chair/wheelchair.
• Determine patient/client's physical ability to assist and understand instructions.
• Assess appropriate assistive device for moving the patient/client.
• Determine the assistance required for moving the patient/client.

Equipment

• Assistive device: overhead trapeze

• Chair/commode/wheelchair

Preparation

• Identify the patient/client who need to be moved from bed to chair/wheelchair.

• Determine the patient/client's overall condition.
• Note the presence of tubes and incisions.
• Prepare the environment-move the furniture, overhead table, locker, etc.
• Prepare chair/commode/wheelchair as appropriate to patient/client's need.
• Perform hand hygiene.

No Interventions Rationale

1 Greet and explain the procedure to the patient. To establish rapport, gain
cooperation and minimize
anxiety.

2 Provide privacy. To maintain patient's dignity.

3 Place chair at head of the bed. If using For patient's safety.

wheelchair, place parallel to the bed and lock the
wheel of the wheelchair.

36
4 Adjust the bed and the patient's position.

• Lock the wheels of the bed. For patient's safety.

• Lower the bed to its lowest position. To reduce risk of injury.

• Tell the patient to flex the knees with the feet flat •
on the bed.

• Position the patient's legs at the edge of the bed. •

5 Move the patient to a sitting position. To maintain asepsis.

• Stand beside the patient's hip with your head •

facing the bottom of the bed.

• Spread out your feet and place the foot nearest •

the patient slightly forward. Flex your knees

• Place one arm around the patient's shoulder and To support patient and prevent
fall.
other arm beneath both of the patient's thighs
near the knees and move the patient nearer to
you.

• Contract your gluteal, abdominal, leg and arm To maintain body mechanics.
muscles.

• Lift the patient's thighs slightly. To reduce the friction of the

patient's thighs and nurse's arm
against the bed surface.

• Pivot your feet in the desired direction facing the To prevent twisting of the nurse's
spine.
foot of the bed while pulling the patient's feet and
legs off the bed.

6 Steady the patient in that position before next

step.

7 Assist the patient in putting on a non-skid slippers To prevent injury.

or shoes.

37
8 Tell the patient to:

• Move forward and sit on the edge of the bed. To bring patient's centre of gravity
close to the nurse.

• Lean forward slightly from the hips. To bring patient's centre of gravity
more directly over the base of
support.

• Place the foot of the stronger leg beneath the To promote stability.
edge of the bed and put the other foot forward.

• Place hands on bed surface OR on your •

shoulders so that the patient can push while
standing

9 Position yourself correctly.

• Stand directly in front of the patient and lean your•

trunk forward from the hips.

• Spread out your feet and place near to the patient To prevent loss of balance during
the transfer.
slightly forward. Flex your knees.

• Encircle patient's waist with your arms and your •

hands together.

10 Assist patient to stand and move together toward

the chair/wheelchair.

• Lift patient up on a count of three, assist patient •to

standing position.

• •
Support patient in standing position until patient's
stabilized.

• Together, pivot until the patient's back is toward •

the chair/wheelchair.

11 Assist the patient to sit.

• Tell the patient to place both hands on your To increase stability.

shoulders OR on the wheelchair arms.

38
 • Flex your knees as patient lower into the chair. •

• Tell the patient to push back into the •

chair/wheelchair seat.

12 Make the patient comfortable.

13 Tidy up the unit.

14 Perform hand hygiene. To reduce transmission of

microorganisms.

15 Document all relevant information such as: For documentation and further
management.
• Time and change of position moved from and
position moved to.

• Any sign of pressure ulcers.

• Use of support devices and/or the ability to assist

in moving and turning.

Evaluation

• Patient/client's comfort is increased and condition is stable.

• Skin remains intact.
• Patient/client's body alignment is maintained.
• Patient/client is moved safely.
• Body mechanics are maintained.
• Significant changes are reported to the staff in-charge and/or doctor.

39
 ASSISTING A PATIENT TO SIT ON THE SIDE OF
BED (DANGLING)
Objectives

• To prepare the patient/client to walk, move to a chair or wheelchair and eating.

• To perform passive legs exercises, deep breathing and coughing exercises.
• To provide comfort.
• To help maintain skin integrity.

Assessment

• Identify the reason for moving the patient/client to sit on the side of the bed..
• Determine patient/client's physical ability to assist and understand instructions.
• Assess appropriate assistive device for moving the patient/client.
• Determine the assistance required for moving the patient/client.

Equipment

• Assistive device: overhead trapeze

Preparation

• Identify the patient/client to be put into sitting position on the side of the bed.
• Note the presence of tubes and incisions.
• Prepare the environment-move the furniture, overhead table, locker, etc.
• Perform hand hygiene.

No Interventions Rationale

1 Greet and explain the procedure to the patient. To establish rapport, gain
cooperation and minimize anxiety.

2 Provide privacy. To maintain patient's dignity.

3 Adjust the bed and the patient's position.

• Lock the wheels of the bed. For patient's safety.

• Raise the head of the bed to highest position as To reduce risk of injury.
tolerated by the patient.

40
 • Lower the side rail of the bed. •

• Tell patient to flex the knees with the feet flat on •

the bed.

• Position the patient's legs at the edge of the bed.•

4 Move the patient to a sitting position.

• Stand beside the patient's hip with your head •

facing the bottom of the bed.

• Spread out your feet and place your body near to•
the patient slightly forward. Flex your knees.

• Place one arm around the patient’s shoulder and To support patient and prevent
fall.
the other arm beneath both of the patient’s thighs
near the knees and move the patient nearer to
you.

• Contract your gluteal, abdominal, leg and arm To maintain body mechanics.
muscles.

• Lift the patient's thighs slightly. To reduce the friction of the

patient's thighs and nurse's arm
against the bed surface.

• Pivot your feet in the desired direction facing the To prevent twisting of the nurse’s
spine.
foot of the bed while pulling the patient's feet and
legs off the bed.

5 Support the patient until he/she is well balanced

and comfortable.

6 Make the patient comfortable.

7 Tidy up the unit.

8 Perform hand hygiene. To reduce transmission of

microorganisms.

9 Document all relevant information such as:

41
 • Time and change of position moved from and
position moved to.

• Any sign of pressure ulcers.

• Use of support devices and/or the ability to assist

in moving and turning.

Evaluation

• Patient/client's comfort is increased and condition is stable.

• Skin remains intact.
• Patient/client's body alignment is maintained.
• Patient/client is moved safely.
• Body mechanics are maintained.
• Significant changes are reported to the staff in-charge and/or doctor.

42
 MOVING A PATIENT/CLIENT UP IN BED
Objectives

• To provide comfort.
• To provide optimal lung excursion and ventilation.
• To promote optimal joint movement and prevent contractures.
• To facilitate patient/client's in deep breathing, coughing exercise and pressure leg exercise.
• To help maintain skin integrity.

Assessment

• Identify the reason for moving the patient/client up in bed.

• Determine patient/client's physical ability to assist and understand instructions.
• Assess appropriate assistive device for moving the patient/client.
• Determine the assistance required for moving the patient/client.

Equipment

• Assistive device: overhead trapeze

• Pull and/or turn sheet (drawsheet)

Preparation

• Identify the patient/client to be moved up in bed.

• Note the presence of tubes and incisions.
• Prepare the environment-move the furniture, overhead table, locker, etc.
• Perform hand hygiene.

No Interventions Rationale

1 Greet and explain the procedure to the patient. To establish rapport, gain
cooperation and minimize
anxiety.

2 Provide privacy. To maintain patient's

dignity.

3 Adjust the bed and the patient's position. For patient's safety.

• Lock the wheels of the bed.

43
 • Adjust the head of bed to a flat position or as low as the
patient can tolerate.

• Raise the bed to a comfortable working height.

• Lower the side rail of the bed.

• Remove all pillows and place one against the

headboard.

4 For patient who can assist: Obtain the patient's help,

position yourself correctly and move the patient.

• Tell the patient to hold on to the overhead trapeze if •

available.

• Tell the patient to bend knees and place the feet flat on To allow patient to assist in
the move.
the bed if able and/or no contraindication

• Face the direction of the movement, stand at a corner of To maintain body

mechanics.
the head of the bed, feet apart, knees bend, feet toward
the head of the bed.

• Slide one hand and arm under the patient’s shoulder, To promote good lifting
technique.
the other under the patient's thighs.

• Contract your gluteal, abdominal, leg and arm muscles To allow a smooth motion
to lift the patient.
and rock from right to left if in patient's right side (or vice
versa) and pulls with the arm as patient pushes with the
heels so that the patient moves toward the head of the
bed.

• Repeat these steps until the patient is moved up high •

enough in bed.

5 For patient who need assistance: Position patient and

yourself correctly and move the patient.

44
 • Lower side rails of the bed. •

• Fold the patient's arms across the chest. To prevent the patient's
arms trapped or injured
during the move.

• With two nurses, place turn sheet under patient's back To reduce shearing force.
and head.

• Roll the drawsheet on each side until it is next to patient. To provide support under
the heavy parts of the
body.

• Bend the patient’s knees and place the feet flat on the •
bed if able and/or no contraindication.

• The nurses stand on either side of the bed, at a corner To maintain body
mechanics.
of the head of the bed with knees flexed and feet wide
apart

• The nurses place their elbows as closely as possible to To assist the arm muscles
in bearing and moving the
their bodies.
weight of the patient.

• On the count of three by the head nurse, the nurses To allow smooth motion in
lifting the patient.
contract their gluteal, abdominal, leg and arm muscles
and lift up the turn sheet toward the head of the bed in
one smooth motion.

• Repeat these steps until the patient is moved up high •

enough in bed.

6 Make the patient comfortable. To promote comfort and

safety.
• Place the patient's pillow under the head

• Elevate the head of bed, if tolerated by patient.

45
 • Ensure the patient is in a correct alignment and raise the
side rails.

7 Tidy up the unit.

8 Perform hand hygiene. To reduce transmission of

microorganisms.

9 Document all relevant information such as: For documentation and

further management.
• Time and change of position moved from and position
moved to.

• Any sign of pressure ulcers.

• Use of support devices and/or the ability to assist in

moving and turning.

Evaluation

• Patient/client's comfort is increased and condition is stable.

• Skin remains intact.
• Patient/client's body alignment is maintained.
• Patient/client is moved safely.
• Body mechanics are maintained.
• Significant changes are reported to the staff in-charge and/or doctor.

46
 POSITIONING PATIENT/CLIENT TO
SUPINE/RECUMBENT
Objectives

• To provide comfort, rest and sleep.

• To help maintain skin integrity.
• For physical examination.

Assessment

• Identify the reason for positioning patient/client to supine/recumbent.

• Determine patient/client's physical ability to assist and understand instructions.
• Assess appropriate assistive device for moving the patient/client.
• Determine the assistance required for moving the patient/client.

Equipment

• Assistive device: overhead trapeze • pillows

• Pull and/or turn sheet (drawsheet) • Chair to place excess pillows

Preparation

• Identify the patient/client for positioning.

• Note the presence of tubes and incisions.
• Gather positioning supplies.
• Prepare the environment-move the furniture, overhead table, locker, etc.
• Obtain adequate assistance.
• Perform hand hygiene.

Implementation

No Interventions Rationale

1. Greet and explain the procedure to the To establish rapport, gain

patient. cooperation and minimize anxiety.

47
2. Provide privacy. To maintain patient's dignity.

3. Lock the wheels of the bed and raise level of To promote safety and reduce back
the bed to a comfortable working height. strain.

4. Adjust the head of bed to a flat position or as

low as the patient can tolerate.

5. Lower the side rail of the bed.

6. Remove pillows.

7. Move the patient to head of the bed.

8. For recumbent, place one pillow under the

patient's head and shoulders.

9. Make the patient comfortable. To promote comfort and safety.

• Straighten the patient’s hands and legs.

• Cover the patient with blanket (as needed).

• Ensure the patient is in correct alignment and

raise the side rail.

10. Tidy up the unit.

11. Perform hand hygiene. To reduce transmission of

microorganisms.

12. Document all relevant information such as: For documentation and further
management.
• Time and change of position moved from and
position moved to.

• Any sign of pressure ulcers.

• Use of support devices and/or the ability to

assist in moving and turning.

48
Evaluation

• Patient/client’s comfort is increased and condition is stable.

• Skin remains intact.
• Patient/client’s body alignment is maintained.
• Patient/client is moved safely.
• Body mechanics are maintained.
• Appropriate follow-up is conducted and signs of pressure ulcers for Fowler’s position are
checked: scapula, sacrum, elbows and heels.

49
 LOGROLLING A PATIENT/CLIENT
Objectives

• To avoid back injury when positioning a spinal injured patient/client.

Assessment

• Identify the reason for logrolling the patient/client.

• Determine the number of assistants required according to the patient/client's size. Usually 3
people are needed. For patient/client with cervical injury, an extra assistance is needed and
ensure patient/client's is fitted with cervical collar to maintain the head alignment.

Equipment

• Pull and/or turn sheet (drawsheet)

• Pillows/towels/blankets

Preparation

• Identify the patient/client to be logrolled.

• Note the presence of tubes and incisions.
• Prepare the environment-move the furniture, overhead table, locker, etc.
• Obtain sufficient assistance to complete the procedure with ease.
• Perform hand hygiene.

No Interventions Rationale

1 Greet and explain the procedure to the patient. To establish rapport, gain
cooperation and minimize anxiety.

2 Provide privacy. To maintain patient's dignity.

3 Lock the wheels of the bed and raise the side For patient's safety.
rail on the side where no nurses are standing.

4 Three nurses stand side by side facing the For better coordination.
patient. Designate person at head of the bed to
be in charge of coordinating the movement.

5 Prepare the patient's position to be moved.

• Fold the patient's arms across the chest. To prevent the patient's arms
trapped or injured during the move.

50
 • Nurse at head: place the hands and arms under•
patient's head and shoulders.

• Second nurse: place the hands and arms under•

patient's waist and hips.

• Third nurse: place the hands and arms under •

patient’s knees and ankles.

• Each nurse assumes wide base of support with To maintain body mechanics.
foot closer to bed in front and knees slightly
flexed.

6 On the count of three by the head nurse, roll the To maintain proper alignment, all of
patient towards the nurses by rocking backward the body parts must be moved at
on your heels. the same time.

7 One nurse moves to the other side of the bed

and lower the side rail.

8 Place a pillow between the patient's knees To prevent adduction of hip, thus
before turning the patient. prevent spinal twisting.

9 Turn the patient.

• Nurse at head: place hands on patient's •

shoulder and waist near the opposite nurse.

• Second nurse: place hands on patient's hip and•

knees near the opposite nurse.

• Third nurse: on the opposite side of the bed, •

place hands evenly distributed from the
shoulder to the patient's thigh.

• Each nurse assumes wide base of support. To maintain body mechanics.

• On the count of three by head nurse, turn the To maintain proper alignment.
patient to a lateral position facing the two
nurses.

10 Tidy up the unit.

11 Perform hand hygiene.

51
 12 Perform hand hygiene. To reduce transmission of
microorganisms.

13 Document all relevant information such as: For documentation and further
management.
• Time and change of position moved from and
position moved to.

• Any sign of pressure ulcers.

• Use of support devices and/or the ability to

assist in moving and turning.

Evaluation

• Patient/client's body alignment is maintained.

• Patient/client is moved safely.
• Patient/client's comfort is increased and condition is stable.
• Skin remains intact.
• Body mechanics are maintained.
• Significant changes are reported to the staff in-charge and/or doctor.

52
 POSITIONING PATIENT/CLIENT TO SEMI
PRONE/SIMS’ POSITION
Objectives

• To provide comfort.
• To help maintain skin integrity.
• To perform the following procedure.
o Administration of enema.
o Insertion of rectal suppository.
o Examination of anal/rectal area.
• To encourage drainage of oral secretion.
• To promote healing of wound at the back.

Assessment

• Identify the reason for positioning patient/client to semi prone position.

• Determine patient/client’s physical ability to assist and understand instructions.
• Assess appropriate assistive device for moving the patient/client.
• Determine the assistance required for moving the patient/client.

Equipment

• Assistive device: overhead trapeze • 3 pillows

• Pull and/or turn sheet (drawsheet) • Chair to place excess pillows

Preparation

• Identify the patient/client for positioning.

• Note the presence of tubes and incisions.
• Gather positioning supplies.
• Prepare the environment-move the furniture, overhead table, locker, etc.
• Obtain adequate assistance.
• Perform hand hygiene.

53
Implementation

No Interventions Rationale

1. Greet and explain the procedure to the patient. To establish rapport, gain
cooperation and minimize
anxiety.

2. Provide privacy. To maintain patient's dignity.

3. Lock the wheels of the bed and raise level of the To promote safety and reduce
bed to a comfortable working height. back strain.

4. Lower the side rail of the bed.

5. Remove pillows.

6. Place patient in supine position.

7. Cross the patient's arms over the chest. To prevent the patient's arms
trapped or injured during the
move.

8. Bring the patient to the side of the bed To prevent skin shearing.
accordingly:

• Slide your hands and arms under the patient's

head and shoulder and pull the body towards
you.

• Move your hands and arms down the patient's

waist and hip and pull the body towards you.

• Move your hands and arms down the patient's

legs and pull the body towards you.

9. Cross the nearer leg over the other leg.

10. Place both arms to the side. To maintain alignment for

turning.

11. Slip the far arm under the body.

12. Turn the patient onto his/her chest facing away

from you by placing your hands on the patients
shoulder and hip.

54
13. Support the head with a pillow (for conscious To decrease flexion of neck.
patient only).

14. Straighten the lower arm and place it at the side

of the body.

15. Straighten the lower leg.

16. Flex the upper arm upward toward the head of To decrease risk of joint
the bed and support with a pillow. dislocation.

17. Flex the patient's upper leg and place a pillow To promote dorsiflexion of knee
below the knee. flexion.

18. Make the patient comfortable. To promote comfort and safety.

• Cover the patient with blanket (as needed).

• Ensure the patient is in correct alignment and

raise the side rail.

19. Tidy up the unit.

20 Perform hand hygiene. To reduce transmission of

microorganisms.

21. Document all relevant information such as: For documentation and further
management.
• Time and change of position moved from and
position moved to.

• Any sign of pressure ulcers.

• Use of support devices and/or the ability to assist

in moving and turning.

55
Evaluation

• Patient/client’s comfort is increased and condition is stable.

• Skin remains intact.
• Patient/client’s body alignment is maintained.
• Patient/client is moved safely.
• Body mechanics are maintained.
• Appropriate follow-up is conducted and signs of pressure ulcers for semi prone position are
checked: clavicle, humerus, iliac crest, knees and ankles.

56
 POSITIONING PATIENT/CLIENT TO FOWLER'S
POSITION
Objectives

• To provide comfort.
• To prepare patient/client for eating.
• To promote lung expansion and reduce respiratory discomfort.
• To decrease potential for increased intracranial pressure for patient/client with neurological
problems.
• To encourage drainage of secretion from chest wound.
• To reduce venous return to the heart, e.g. patient/client with congestive cardiac failure.

Assessment

• Identify the reason for positioning patient/client to Fowler’s position.

• Determine patient/client’s physical ability to assist and understand instructions.
• Assess appropriate assistive device for moving the patient/client.
• Determine the assistance required for moving the patient/client.

Equipment

• Assistive device: overhead trapeze • 4 pillows

• Pull and/or turn sheet (drawsheet) • Chair to place excess pillows

Preparation

• Identify the patient/client for positioning.

• Note the presence of tubes and incisions.
• Gather positioning supplies.
• Prepare the environment-move the furniture, overhead table, locker, etc.
• Obtain adequate assistance.
• Perform hand hygiene.

57
Implementation

No Interventions Rationale

1. Greet and explain the procedure to the To establish rapport, gain

patient. cooperation and minimize anxiety.

2. Provide privacy. To maintain patient's dignity.

3. Lock the wheels of the bed and raise level of To promote safety and reduce back
the bed to a comfortable working height. strain.

4. Lower the side rail of the bed.

5. Remove pillows.

6. Move the patient to head of the bed.

7. Elevate head of the bed to meet the patient's •

needs.

• Low Fowler’s: 15-30°

• Fowler’s: 45°
• High Fowler’s: 60-90°

8. Make the patient comfortable. To promote comfort and safety.

• Rest head against mattress or on pillow.

• Support arms and hands with pillows.

• Place small pillow or roll under the legs (if

necessary).

• Cover the patient with blanket (as needed).

• Ensure the patient is in correct alignment and

raise the side rail.

9. Tidy up the unit.

58
 10. Perform hand hygiene. To reduce transmission of
microorganisms.

11. Document all relevant information such as: For documentation and further
management.
• Time and change of position moved from and
position moved to.

• Any sign of pressure ulcers.

• Use of support devices and/or the ability to

assist in moving and turning.

Evaluation

• Patient/client’s comfort is increased and condition is stable.

• Skin remains intact.
• Patient/client’s body alignment is maintained.
• Patient/client is moved safely.
• Body mechanics are maintained.
• Appropriate follow-up is conducted and signs of pressure ulcers for Fowler’s position are
checked: scapula, sacrum, elbows and heels.

59
 POSITIONING PATIENT/CLIENT TO LEFT OR
RIGHT LATERAL
Objectives

• To provide comfort.
• To help maintain skin integrity.
• To encourage drainage of secretion.
• To perform the following procedure (Left lateral).
o Administration of enema.
o Insertion of rectal suppository.
o Examination of anal/rectal area.

Assessment

• Identify the reason for positioning patient/client to lateral position.

• Determine patient/client’s physical ability to assist and understand instructions.
• Assess appropriate assistive device for moving the patient/client.
• Determine the assistance required for moving the patient/client.

Equipment

• Assistive device: overhead trapeze • 4 pillows

• Pull and/or turn sheet (drawsheet) • Chair to place excess pillows

Preparation

• Identify the patient/client for positioning.

• Note the presence of tubes and incisions.
• Gather positioning supplies.
• Prepare the environment-move the furniture, overhead table, locker, etc.
• Obtain adequate assistance.
• Perform hand hygiene.

60
Implementation

No Interventions Rationale

1. Greet and explain the procedure to the patient. To establish rapport, gain
cooperation and minimize anxiety.

2. Provide privacy. To maintain patient's dignity.

3. Lock the wheels of the bed and raise level of To promote safety and reduce back
the bed to a comfortable working height. strain.

4. Adjust the head of bed to a flat position or as

low as the patient can tolerate.

5. Lower the side rail of the bed.

6. Lie patient on one pillow.

7. Cross the patient’s arms over the chest. To prevent the patient's arms
trapped or injured during the move.

8. Bring the patient to the side of the bed To prevent skin shearing.
accordingly:

• Slide your hands and arms under the patient's

head and shoulder and pull the body towards
you.

• Move your hands and arms down the patient's

waist and hip and pull the body towards you.

• Move your hands and arms down the patient's

legs and pull the body towards you.

9. Place the patient’s arm close to the body •

• left arm for left lateral

• right arm for right lateral

10. Cross the patient’s legs •

• left lateral: right leg on top of left leg

• right lateral: left leg on top of right leg

61
11. Hold the patient by the shoulder and the hip •
and turn the patient 90° to the

• left for left lateral

• right for right lateral

12. Make the patient comfortable. To promote comfort and safety.

• Left lateral: bend the right leg more than the left
leg.

• Right lateral: bend the left leg more than the

right leg.

• Place the pillows:

• under patient’s head and neck

• between both hand with arms in slightly
flexed position
• between both semi flexed legs
• behind patient’s back

• Cover the patient with blanket (as needed).

• Ensure the patient is in correct alignment and

raise the side rail.

13. Tidy up the unit.

14. Perform hand hygiene. To reduce transmission of

microorganisms.

15. Document all relevant information such as: For documentation and further
management.
• Time and change of position moved from and
position moved to.

• Any sign of pressure ulcers

62
 • Use of support devices and/or the ability to
assist in moving and turning.

Evaluation

• Patient/client’s comfort is increased and condition is stable.

• Skin remains intact.
• Patient/client’s body alignment is maintained.
• Patient/client is moved safely.
• Body mechanics are maintained.
• Appropriate follow-up is conducted and signs of pressure ulcers for lateral position are
checked: ankles, knees, iliac crest and ear.

63
 POSITIONING PATIENT/CLIENT TO SEMI
PRONE/SIMS’ POSITION
Objectives

• To provide comfort.
• To help maintain skin integrity.
• To perform the following procedure.
o Administration of enema.
o Insertion of rectal suppository.
o Examination of anal/rectal area.
• To encourage drainage of oral secretion.
• To promote healing of wound at the back.

Assessment

• Identify the reason for positioning patient/client to semi prone position.

• Determine patient/client’s physical ability to assist and understand instructions.
• Assess appropriate assistive device for moving the patient/client.
• Determine the assistance required for moving the patient/client.

Equipment

• Assistive device: overhead trapeze • 3 pillows

• Pull and/or turn sheet (drawsheet) • Chair to place excess pillows

Preparation

• Identify the patient/client for positioning.

• Note the presence of tubes and incisions.
• Gather positioning supplies.
• Prepare the environment-move the furniture, overhead table, locker, etc.
• Obtain adequate assistance.
• Perform hand hygiene.

64
Implementation

No Interventions Rationale

1. Greet and explain the procedure to the patient. To establish rapport, gain
cooperation and minimize
anxiety.

2. Provide privacy. To maintain patient's dignity.

3. Lock the wheels of the bed and raise level of the To promote safety and reduce
bed to a comfortable working height. back strain.

4. Lower the side rail of the bed.

5. Remove pillows.

6. Place patient in supine position.

7. Cross the patient's arms over the chest. To prevent the patient's arms
trapped or injured during the
move.

8. Bring the patient to the side of the bed To prevent skin shearing.
accordingly:

• Slide your hands and arms under the patient's

head and shoulder and pull the body towards
you.

• Move your hands and arms down the patient's

waist and hip and pull the body towards you.

• Move your hands and arms down the patient's

legs and pull the body towards you.

9. Cross the nearer leg over the other leg.

10. Place both arms to the side. To maintain alignment for

turning.

11. Slip the far arm under the body.

12. Turn the patient onto his/her chest facing away

from you by placing your hands on the patients
shoulder and hip.

65
13. Support the head with a pillow (for conscious To decrease flexion of neck.
patient only).

14. Straighten the lower arm and place it at the side

of the body.

15. Straighten the lower leg.

16. Flex the upper arm upward toward the head of To decrease risk of joint
the bed and support with a pillow. dislocation.

17. Flex the patient's upper leg and place a pillow To promote dorsiflexion of knee
below the knee. flexion.

18. Make the patient comfortable. To promote comfort and safety.

• Cover the patient with blanket (as needed).

• Ensure the patient is in correct alignment and

raise the side rail.

19. Tidy up the unit.

20 Perform hand hygiene. To reduce transmission of

microorganisms.

21. Document all relevant information such as: For documentation and further
management.
• Time and change of position moved from and
position moved to.

• Any sign of pressure ulcers.

• Use of support devices and/or the ability to assist

in moving and turning.

66
Evaluation

• Patient/client’s comfort is increased and condition is stable.

• Skin remains intact.
• Patient/client’s body alignment is maintained.
• Patient/client is moved safely.
• Body mechanics are maintained.
• Appropriate follow-up is conducted and signs of pressure ulcers for semi prone position are
checked: clavicle, humerus, iliac crest, knees and ankles.

67
 POSITIONING PATIENT/CLIENT TO PRONE
Objectives

• To provide comfort.
• To help maintain skin integrity.
• To encourage drainage of oral secretion.
• To promote healing of wound at the back.
• To expose back area for treatment.

Assessment

• Identify the reason for positioning patient/client to prone position.

• Determine patient/client’s physical ability to assist and understand instructions.
• Assess appropriate assistive device for moving the patient/client.
• Determine the assistance required for moving the patient/client.

Equipment

• Assistive device: overhead trapeze • 1 big pillow and 2 small pillows

• Pull and/or turn sheet (drawsheet) • Chair to place excess pillows

Preparation

• Identify the patient/client for positioning.

• Note the presence of tubes and incisions.
• Gather positioning supplies.
• Prepare the environment-move the furniture, overhead table, locker, etc.
• Obtain adequate assistance.
• Perform hand hygiene.

68
Implementation

No Interventions Rationale

1. Greet and explain the procedure to the To establish rapport, gain cooperation
patient. and minimize anxiety.

2. Provide privacy. To maintain patient's dignity.

3. Lock the wheels of the bed and raise level To promote safety and reduce back
of the bed to a comfortable working strain.
height.

4. Lower the side rail of the bed.

5. Remove pillows.

6. Place patient in supine position.

7. Cross the patient's arms over the chest. To prevent the patient's arms trapped or
injured during the move.

8. Bring the patient to the side of the bed To prevent skin shearing.
accordingly:

• Slide your hands and arms under the

patient's head and shoulder and pull the
body towards you.

• Move your hands and arms down the

patient's waist and hip and pull the body
towards you.

• Move your hands and arms down the

patient's legs and pull the body towards
you.

9. Cross the nearer leg over the other leg.

10. Place both arms to the side. To maintain alignment for turning.

11. Slip the far arm under the body.

12. Turn patient's head to the side.

69
13. Place a small pillow below patient's To position pillow after turn. Aids
abdomen. respirations by decreasing pressure on
the diaphragm.

14. Turn the patient by placing your hands on

the patient’s shoulder and hip.

15. Turn patient's head to the side and support To decrease flexion of neck.
with a small pillow.

16. Support arms in flexed position level at To decrease risk of joint dislocation.
shoulders.

17. Support the lower leg with a pillow to To promote dorsiflexion of ankle and
elevate the toes. knee flexion.

18. Make the patient comfortable. To promote comfort and safety.

• Cover the patient with blanket (as

needed).

• Ensure the patient is in correct alignment

and raise the side rail.

19. Tidy up the unit.

20 Perform hand hygiene. To reduce transmission of

microorganisms.

21. Document all relevant information such For documentation and further
as: management.

• Time and change of position moved from

and position moved to.

• Any sign of pressure ulcers.

• Use of support devices and/or the ability to

assist in moving and turning.

70
Evaluation

• Patient/client’s comfort is increased and condition is stable.

• Skin remains intact.
• Patient/client’s body alignment is maintained.
• Patient/client is moved safely.
• Body mechanics are maintained.
• Appropriate follow-up is conducted and signs of pressure ulcers for prone position are
checked: ear, chin, hips and knees.

71
 POSITIONING PATIENT/CLIENT TO DORSAL
RECUMBENT
Objectives

• To prepare patient/client for procedure

o Examination of perineum
o Vulva swabbing
o Giving bedpan
o Catheterization
o Insertion of vaginal pessaries
o Vaginal packing

Assessment

• Identify the reason for positioning patient/client to dorsal recumbent.

• Determine patient/client’s physical ability to assist and understand instructions.
• Assess appropriate assistive device for moving the patient/client.
• Determine the assistance required for moving the patient/client.

Equipment

• Assistive device: overhead trapeze • Pillow

• Pull and/or turn sheet (drawsheet) • Chair to place excess pillows

• Drawsheet to drape the patient •

Preparation

• Identify the patient/client for positioning.

• Note the presence of tubes and incisions.
• Gather positioning supplies.
• Prepare the environment-move the furniture, overhead table, locker, etc.
• Obtain adequate assistance.
• Perform hand hygiene.

72
Implementation

No Interventions Rationale

1. Greet and explain the procedure to the To establish rapport, gain

patient. cooperation and minimize anxiety.

2. Provide privacy. To maintain patient's dignity.

3. Lock the wheels of the bed and raise level of To promote safety and reduce back
the bed to a comfortable working height. strain.

4. Lower the side rail of the bed.

5. Remove pillows.

6. Place patient in supine position.

7. Assist patient to bend her knees.

8. Assist patient to bend her knees. Place

patient’s feet about 2 feet apart.

9. Drape the patient.

10. Perform or assist with the procedure.

11. Make the patient comfortable after the

procedure.

12. Tidy up the unit.

13. Perform hand hygiene. To reduce transmission of

microorganisms.

14. Document all relevant information. For documentation and further

management.

Evaluation

• Procedure is performed appropriately.

• Skin remains intact.
• Patient/client’s body alignment is maintained.
• Patient/client is moved safely.
• Body mechanics is maintained.

73
POSITIONING PATIENT/CLIENT TO ORTHOPNOEIC
POSITION
Objectives

• To provide comfort.
• To facilitate respiration by allowing maximum chest expansion.
• To position for thoracentesis and patient/client with chest drainage tube.

Assessment

• Determine patient/client's physical ability to assist and understand instructions.

• Assess appropriate assistive device for moving patient/client.
• Determine the assistance required for moving the patient/client.

Equipment

• Cardiac table / overhead table • 2 pillows

• Pull and/or turn sheet (drawsheet) • Chair to place excess pillows

Preparation

• Identify the patient/client for orthopnoeic position.

• Determine the patient/client's overall condition.
• Note the presence of tubes and incisions.
• Gather positioning supplies.
• Prepare the environment-move the furniture, overhead table, locker, etc.
• Obtain adequate assistance.
• Perform hand hygiene.

Implementation

No Interventions Rationale

1. Greet and explain the procedure to the To establish rapport, gain

patient. cooperation and minimize anxiety.

74
2. Provide privacy. To maintain patient's dignity.

3. Lock the wheels of the bed and raise level of To promote safety and reduce back
the bed to a comfortable working height. strain.

4. Adjust the head of the bed to a flat position or

as low as the patient can tolerate.

5. Lower the side rail of the bed.

6. Remove pillows (as tolerated).

7. Move the patient to the head of the bed.

8. Elevate the head of the bed to 90.

9. Place the overhead table in front of the

patient.

10. Arrange two pillows on top of the overhead

table.

11. Assist patient to rest the lower part of the chest To promote maximum chest
against the edge of the overhead table. expansion.

12. Make the patient comfortable. To promote comfort and safety.

• Cover the patient with blanket (as needed).

• Ensure the patient is in correct alignment and

raise the side rail.

13. Tidy up the unit.

14. Perform hand hygiene. To reduce transmission of

microorganisms.

15. Document all relevant information such as: For documentation and further
management.
• Time and change of position moved from and
position moved to.

• Any sign of pressure ulcers.

75
 • Use of support devices and/or the ability to
assist in moving and turning.

Evaluation

• Patient/client's comfort is increased and condition is stable.

• Skin remains intact.
• Patient/client's body alignment is maintained.
• Patient/client is moved safely.
• Body mechanics are maintained.
• Significant changes are reported to the staff in-charge and/or doctor.

76
 PERFORMING PASSIVE RANGE OF MOTION
(ROM) EXERCISE
Objectives

• To improve or maintain joint function, muscle tone and strength.

• To counteract effects of prolonged bedrest or immobilization.
• To prevent contractures.
• To increase patient/client comfort.
• To prepare the patient/client for ambulation.

Assessment

• Check for any contraindication to perform ROM exercise.

• Assess the patient/client for areas of weakness or paralysis.
• Determine the frequency of ROM exercise to be performed.
• Determine patient/client's physical ability to perform ROM exercise.
• Determine patient/client's ability to understand instructions.
• Assess the patient/client's understanding of ROM exercise.
• Ascertain patient/client’s baseline level of joint movement and muscle strength.

Equipment

Blanket / drawsheet

Preparation

• Identify the patient/client who needs ROM exercise.

• Determine patient/client's overall condition and assess for areas of weakness or paralysis.
• Note the presence of tubes and incisions.
• Perform hand hygiene.

Implementation

No Interventions Rationale

1 Greet and explain the procedure to the patient. To establish rapport, gain
cooperation and minimize
anxiety.

77
2 Provide privacy. To maintain patient's dignity.

3 Lock the wheels and adjust the bed to a For safety measures. To prevent
comfortable height for performing ROM. muscle strain and discomfort for
the nurse.

4 Lower the side rail only on the side where you are To prevent fall.
working.

5 Describe the passive ROM exercise you are For better understanding and to
performing and encourage patient to perform encourage patient's participation
ROM exercise with your assistance as tolerated and cooperation.
by patient. Demonstrate movement if necessary.

6 Assist patient into a supine position and cover To ensure comfort and maintain
with blanket/sheet. Expose the part that requires dignity.
exercise.

7 Start providing passive ROM exercise from head To provide a systematic method
downwards. Begin exercise on patient's stronger to ensure that all body parts are
(or unaffected) side. exercised.
Working on patient's unaffected
side first promotes comfort and
allow nurses to assess limitations
or restrictions.

• Head and neck To exercise the neck and

trapezius muscles.
To promote cervical spine
• Support the head with both hands; flex the mobility.
head until chin touches the chest.
• Extend neck by elevating the chin and return
head to neutral position.
• Move head through flexion, extension, lateral
flexion, rotation and hyperextension of neck.
• Support head with both hands, turn to the
right and then left.
• Bend head laterally to the right and then left.

Movement of head is contraindicated in spinal

surgery, spinal trauma and other central nervous
trauma and for patient having central venous line.

• Shoulder To promote joint movement and

exercise the shoulder muscles.
To loosen the shoulder joints and
• Support the shoulder proximally and distally. promote relaxation.
• Move shoulder through flexion, extension,
hyperextension, abduction and circumduction,
external and internal rotation.

78
 • Tell patient to elevate shoulder as if shrugging
and lower the shoulders as far as possible
and return to normal plane.

• Elbow To promote joint movement.

• Support elbow joint proximally and distally.

• Move elbow through flexion, extension,
pronation and supination

• Forearm To promote joint movement.

• Move patient's arm in pronation and

supination.

• Wrist

• Move wrist through flexion, extension,

hyperextension and lateral flexion.

• Hand

• Move hand through flexion, extension,

hyperextension, abduction and adduction.

• Thumb and fingers

• Flex the thumb and then the fingers by

bending them onto the palm.
• Adduct and abduct the fingers.
• Circumduct the fingers and thumb by moving
them in circular motion.

• Hip

• Support the joints above and below.

• Move hip through flexion, extension,
abduction, adduction, internal rotation and
circumduction.

79
 • Knee

• Move knee through flexion and extension.

• Ankle and foot

• Move them through extension, plantar flexion,

dorsi flexion, eversion and inversion of foot.

• Toes

• Move through flexion, extension, abduction

and adduction.

8 Observe the patient for signs of exertion, pain or To alert the nurse to discontinue
fatigue during movement. exercise.

9 Make the patient comfortable.

10 Raise the side rail and adjust the bed to the To prevent fall and promote
patient’s comfort. comfort.

11 Tidy up the unit.

12 Perform hand hygiene. To reduce transmission of

microorganisms.

13 Document the time and performance of ROM and For documentation and further
any problems encountered. management.

Evaluation

• Patient/client's comfort is increased and condition is stable.

• Patient/client's range of motion and muscle tone are improved.
• Significant changes are reported to the staff in-charge and/or doctor.
• Subsequent ROM exercise: patient/client able to progress through range-of-motion with
minimal to no pain.
• For the purpose of preparing patient/client for ambulation: patient/client able to ambulate
without difficulty following a period of bedrest.

80
 BASIC HEAD-TO-TOE PHYSICAL EXAMINATION
Objectives

• To provide baseline data for further evaluation.

• To supplement, confirm or refute data from the history.
• To establish nursing diagnoses and plans of care.
• To identify the need for additional testing or examination.
• To evaluate the response of treatment and therapy.
• To identify areas for health promotion and disease prevention.

Assessment

• Identify the reason for performing physical examination.

• Identify special consideration according to age group and cultural beliefs.
• Determine patient/client's ability to obey command.

Equipment

Trolley - Top shelf Trolley - Bottom shelf

• Equipment for checking vital signs • Disposable gloves

• Penlight • Antiseptic hand rub

• Comb • General waste receiver

• Tuning fork • Clinical waste receiver

• Patella hammer •

• Cotton bud •

• Spatula •

81
 • Drawsheet •

• Pain score scale •

• Notepad •

Preparation

• Check to ensure all equipment are functioning properly.

• Identify the patient/client for physical examination.
• Prepare the environment-spacious, well lighted, room should be warm, no visitors, minimum
noise.
• Perform hand hygiene.

Implementation

No Interventions Rationale

1 Greet and explain the procedure to the patient. To establish rapport and gain
cooperation and minimize
anxiety.

2 Assist the patient to empty bladder (if necessary). To help patient to feel more
relaxed and facilitate
palpation of the abdomen and
pubic area.

3 Assist the patient for measuring height and weight.

4 Provide privacy. To maintain patient's dignity.

5 Place the patient in a comfortable position for head-to- For examination.

toe examination. Change patient's position as needed.

6 Perform the assessment using the techniques of

inspection, palpation, percussion and auscultation.
Expose and drape the patient when necessary.
Document the findings periodically in the notepad.

• Integument •

82
• Inspect and palpate skin for temperature, texture,
tender areas

• Inspect and palpate skin for temperature, texture,

tender areas

• Inspect and palpate scalp

• Inspect nails and cuticles

• Head and Neck •

• Inspect facial symmetry/expression, involuntary

movements, head position

• Inspect neck for symmetry, masses, scars

• Inspect and palpate thyroid for enlargement

• Palpate neck for lymph nodes

• Palpate neck for carotid pulse

• Ears •

• Inspect and palpate auricle

• Test gross acuity by whisper test

• Eyes •

• Inspect for alignment, symmetry, position

• Inspect lids, lashes, conjunctiva, lens, sclera, cornea

for any abnormalities

• Test for pupillary response and accommodation

• Nose •

• Inspect for symmetry, deformities, inflammation,

flaring

• Inspect mucosa, septum for any abnormalities

• Test patency

83
 • Mouth •

• Inspect for any abnormalities in the lips, gingiva, oral

mucosa and teeth

• Inspect for any abnormalities in the lips, gingiva, oral

mucosa and teeth

• Inspect tonsils, tongue for enlargement and

abnormalities

• Test gag reflex

• Chest/thorax

•
• Inspect thorax, respiratory rhythm/rate/quality

• Palpate supra and sub-clavicular lymph nodes

• Breast

• Inspect for size, symmetry, nodule

•
• Palpate for lump

• Female: inspect the areola, nipple pigmentation,

inversion and discharge

• Abdomen

• Inspect for pulsations, scars, contour

•
• Auscultate for bowel sound

• Light palpation for tenderness, masses, guarding,

organomegaly

• Upper and Lower extremities (hands & legs)

• Inspect skin and nails

•

• Inspect the length

• Observe gait & balance (bilateral)

84
 • Back

• Inspect spine for contracture

•

• Inspect for presence of scar

• Inspect the contour

• Genitalia
•

• Ask the patient-any discharge?

7 Assist the patient to dress up.

8 Perform vital signs assessment.

9 End the session by asking the patient if there are any To show courtesy and caring.
questions.

10 Make the patient comfortable.

11 Tidy up patient's unit and equipment.

12 Perform hand hygiene. To reduce transmission of

microorganisms.

13 Document assessment findings in patient file and/or For documentation and

according to the hospital practice and report any further management.
abnormalities.

Evaluation

• Accurate data have been obtained by performing a systematic assessment.

• Patient/client is comfortable and condition is stable.
• Significant changes are reported to the staff in-charge and/or doctor.
• Appropriate follow-up is conducted and compared to prior assessment data.
• Formulated nursing diagnoses and plans of care according to the assessment data.

85
 MEASURING HEIGHT AND WEIGHT
Objectives

• To provide baseline data for further evaluation.

• To obtain current weight.
• To determine nutritional status in relation to body requirement.
• To identify excess or deficit of fluid balance.

Assessment

• Identify the reason of measuring the patient/client’s height and/or weight.

• Check the need for daily or weekly body weight measurements.
• Determine appropriate method for obtaining patient/client’s weight.
• Determine patient/client's ability to stand for height measurement.

Equipment

• Weighing scale

• L-shaped sliding height bar

Preparation

• Check all equipment are functioning properly and calibrate the scale to "0".
• Identify the patient/client for measuring height and/or weight.
• Ensure the same scale is used each time weighing the patient/client (for subsequent
assessment).
• Make sure the patient/client wears the same type of clothing for each weighing (for subsequent
assessment).
• Check the patient/client's previous height and/or weight measurements (if applicable).
• Perform hand hygiene.

86
Implementation

No Interventions Rationale

1 Greet and explain the procedure to the patient. To establish rapport, gain
cooperation and minimize
anxiety.

2 Tell the patient to: For accurate reading.

• remove any belongings;

• remove the shoes.

3 Assist the patient to stand on the weighing scale. For accurate reading of weight.

4 Tell the patient facing straight and remain still. For accurate reading of weight.

5 Read patient's weight once the pointer stop moving For accurate reading of weight.
and inform finding to the patient.

6 Tell patient to face the front so back is toward the For accurate reading of height.
scale.

7 Instruct the patient to stand erect with heels For accurate reading of height.
together.

8 Place the L-shaped sliding height bar on top of the For accurate reading of height.
patient's head.

9 Read the patient’s height as measured and inform For accurate reading of height.
finding to the patient.

10 Assist the patient off the scale and make the patient
comfortable.

11 Document weight and height in the patient's file For documentation and further
and/or according to the hospital practice and report management.
any abnormalities.

12 Perform hand hygiene. To reduce transmission of

microorganisms.

Evaluation

• The patient/client's weight and height are measured accurately.

• Significant changes are reported to the staff in-charge and/or doctor.
• Appropriate follow-up is conducted and compared to prior assessment data.

87
 TAKING ORAL TEMPERATURE USING DIGITAL
THERMOMETER
Objectives

• To determine current body temperature.

• To provide baseline data for further evaluation.
• To monitor the patient/client at risk of abnormal body temperature.
• To identify changes in body temperature in response to specific therapies.

Assessment

• Identify the reason of taking oral temperature for the patient/client.

• Determine the frequency of temperature to be taken daily.
• Assess factors that may alter the patient/client's body temperature.

Equipment

Trolley - top shelf: Trolley - bottom shelf:

• Tray consist of: • General waste receiver

• Digital thermometer • Clinical waste receiver

• Thermometer sheath/cover
• 2 gallipot (S) for dry and spirit cotton balls/alcohol swab • Vital signs chart

• Antiseptic hand rub

Preparation

• Ensure equipment is functioning properly.

• Identify the patient/client's for taking body temperature.
• Ensure the same scale is used each time weighing the patient/client (for subsequent
assessment).
• Check the patient/client's previous temperature reading on vital signs chart (if applicable).
• Perform hand hygiene.

88
Implementation

No Interventions Rationale

1 Greet and explain the procedure to the patient. To establish rapport, gain
cooperation and minimize
anxiety.

2 Provide privacy. To maintain patient's dignity.

3 Enquire whether the patient had For accurate reading.

Temperature increases with
• rest/activity activity and ingestion of hot drink.
• taken hot or cold drink 15 minutes before
taking temperature

4 Swab the thermometer using To minimize microorganisms and

to maintain cleanliness.
• alcohol swab from bulb to stem
• dry cotton from bulb to stem

5 Cover the digital thermometer using the To ensure cleanliness.

sheath/cover.

6 Turn on the digital thermometer and wait for the For accurate reading.
buzzer to signal.

7 Instruct the patient to open the mouth and hold up To place thermometer under the
tongue. tongue.

8 Place the thermometer at the right or left frenulum To obtain an accurate reading.
of the tongue.

9 Hold the thermometer in position and ask the

patient to close his/her mouth and not to bite the
thermometer.

10 When the beep sound is heard, remove the

thermometer from the patient’s mouth.

11 Remove and throw the thermometer sheath in the To minimize transmission of

clinical waste. microorganisms.

12 Read the patient's temperature and turn off the

digital thermometer.

13 Swab the thermometer using To minimize microorganisms and

to maintain cleanliness.

89
 • alcohol swab from stem to bulb
• dry cotton from stem to bulb

14 Place the digital thermometer into the casing. To protect thermometer.

15 Inform temperature reading to the patient. To acknowledge his/her

temperature reading.

16 Make the patient comfortable.

17 Document in temperature chart. For documentation and further

management.

Evaluation

• The finding has been obtained accurately.

• Significant changes are reported to the staff in-charge and/or doctor.
• Appropriate follow-up is conducted and compared to prior assessment data.

90
 ASSESSING RADIAL PULSE
Objectives

• To determine current characteristics of the pulse.

• To provide baseline data for further evaluation.
• To monitor and assess changes in the patient/client's health status as ordered by the doctor or
before administering certain medications.

Assessment

• Identify the reason of assessing the patient/client's pulse.

• Determine the frequency of temperature to be taken daily.
• Assess for factors that may alter the patient/client’s pulse.

Equipment

• Vital signs chart

Preparation

• Identify the patient/client for assessing pulse.

• Check the patient/client’s previous pulse rate on vital signs chart (if applicable).
• Perform hand hygiene.

Implementation

No Interventions Rationale

1 Greet and explain the procedure to the patient. To establish rapport, gain
cooperation and minimize
anxiety.

2 Ask the patient about any activity within the last 15 For accurate reading. Pulse
minutes. rate increases with activity.

3 Provide privacy. To maintain patient's dignity.

4 Assist the patient to a comfortable resting position.

91
 5 Rest the patient's arm alongside the body with the
palm of hand facing downward or inward.

6 Palpate the pulse by placing the first, second and For accuracy
third fingers and press gently along the patient's
radial artery until the beat is felt.

7 Assess the pulse characteristics-rate, rhythm and

volume.

8 Count pulse for 1 minute. For accurate reading.

9 Inform findings to the patient.

10 Make the patient comfortable.

11 Document the pulse rate, rhythm and volume in the For documentation and further
vital signs chart correctly and report any management.
abnormalities.

12 Perform hand hygiene. To reduce transmission of

microorganisms.

Evaluation

• The finding has been obtained accurately.

• Significant changes are reported to the staff in-charge and/or doctor.
• Appropriate follow-up is conducted and compared to prior assessment data.

92
 ASSESSING RESPIRATIONS
Objectives

• To determine current characteristics of the pulse.

• To provide baseline data for further evaluation.
• To identify abnormal respirations and respiratory patterns.
• To assess respirations before the administration of a medication such as morphine.

Assessment

• Identify the reason of assessing the patient/client's respirations.

• Determine the frequency of respirations to be taken daily.
• Assess factors that may alter the patient/client's respirations.

Equipment

• Vital signs chart

Preparation

• Identify the patient/client for assessing respirations.

• Check the patient/client's previous pulse rate on vital signs chart (if applicable).
• Perform hand hygiene.

Implementation

No Interventions Rationale

1 Greet and explain the procedure to the patient. To establish rapport, gain
cooperation and minimize
anxiety.

2 Ask the patient about any activity within the last 15 For accurate reading.
minutes.

3 Provide privacy. To maintain patient's dignity.

4 Observe the respirations by watching the chest, To ensure the patient is

keeping your fingers in place after counting the comfortable.
pulse rate.

93
 5 Observe the depth, rhythm and quality of Abnormal characteristics
respirations. reveals specific disease
condition.

6 Count the respirations for 1 minute. For accurate reading.

7 Inform findings to the patient.

8 Make the patient comfortable.

9 Document the respiratory rate, depth, rhythm and For documentation and further
quality in the vital signs chart correctly and report management.
any abnormalities.

10 Perform hand hygiene. To reduce transmission of

microorganisms.

Evaluation

• The finding has been obtained accurately.

• Significant changes are reported to the staff in-charge and/or doctor.
• Appropriate follow-up is conducted and compared to prior assessment data.

94
 CHECKING BLOOD PRESSURE
Objectives

• To determine current blood pressure.

• To provide baseline data for further evaluation
• To identify and monitor changes in blood pressure.

Assessment

• Identify the reason of assessing the patient/client's blood pressure.

• Determine the frequency of blood pressure to be taken daily.
• Assess for factors that may alter the patient/client's blood pressure.

Equipment

Tray with • General waste receiver

• Kidney dish (M) • Clinical waste receiver

• Gallipot (S) for spirit cotton balls / alcohol swab • Vital signs chart

• Stethoscope •

• Sphygmomanometer •

Preparation

• Check to ensure all equipment are functioning properly.

• Identify the patient/client for assessing blood pressure.
• Check the patient/client's previous blood pressure reading on vital signs chart (if applicable).
• Perform hand hygiene
• Determine appropriate size cuff for the patient/client.

No Interventions Rationale

1 Greet and explain the procedure to the patient. To establish rapport, gain
cooperation and minimize
anxiety

2 Ask the patient about any activity within the last 15 For accurate reading.
minutes.

95
3 Provide privacy. To maintain patient's
dignity.

4 Place the patient in a relaxed reclining or sitting position.

5 Expose the patient's upper arm.

6 Place the sphygmomanometer at the heart level on a flat For accurate reading.
surface alongside of the arm and ensure the mecury level
is at "0".

7 Apply the deflated cuff smoothly to the patient's arm by:

• positioning the centre of the bladder over the brachial •

artery

• placing the cuff 1" to 2" (2.5 cm) above the antecubital For accurate
measurement.
space.

8 Perform a preliminary palpatory determination of systolic

pressure:

• palpate the radial artery with fingers tips; •

• close the valve on the bulb; •

• pump up the cuff until the radial pulse is no longer felt; •

• release the pressure completely in the cuff; •

• wait for 30 seconds •

9 Position the stethoscope correctly:

• clean the earpieces and the diaphragm with alcohol swab To decontaminate and
prevent transmission of
microorganisms.

• place the earpieces in the ears •

96
 • ensure the stethoscope hangs freely from the ears to the •
diaphragm

• locate the brachial artery and place the diaphragm of the •

stethoscope over it

• hold the diaphragm with the thumb and index finger •

10 Auscultate the patient's blood pressure:

• close the valve on the bulb; •

• pump up the cuff until the sphygmomanometer reads 20•

mm Hg above the point where the preliminary radial pulse
disappeared;

• release the valve of the cuff slowly and read pressure at•
eye level;

• note point on manometer when the first clear sound (first•

Korotkoff's sound: systolic pressure) is heard;

• continue to deflate cuff gradually, noting point at which •

muffling sound (fourth Korotkoff's sound: diastolic
pressure) is heard;

• listen for 20 to 30 mm Hg after the last sound (fifth •

Korotkoff's sound) is heard;

• deflate the cuff completely; *wait at least 1-2 minutes •

before rechecking the blood pressure (if needed);

• remove cuff from the patient's arm. •

11 Inform findings to the patient.

12 Make the patient comfortable.

13 Document the blood pressure readings (two pressures in For documentation and
the form of "120/80 mm Hg" - where "120" is the systolic further management
and "80" is the diastolic pressure) in the vital signs chart
correctly and report any abnormalities.

97
 14 Clean the earpieces and diaphragm of the stethoscope To decontaminate and
using alcohol swab. prevent transmission of
microorganisms

15 Perform hand hygiene. To reduce transmission of

microorganisms.

Evaluation

• The finding has been obtained accurately.

• Beginning and fourth Korotkoff sounds during blood pressure readings are evaluated and
documented.
• Significant changes are reported to the staff in-charge and/or doctor.
• Appropriate follow-up is conducted and compared to prior assessment data.

98
 PAIN ASSESSMENT
Objectives

• To assess pain using a developmentally and cognitively appropriate tool.

• To determine patient/client's pain experience in terms of quality, duration, intensity, location,
precipitating factors, effects of pain and alleviating factors.
• To provide baseline data for further evaluation
• To identify changes in pain level in response to specific therapies.

Assessment

• Identify the reason of performing pain assessment for the patient/client.

• Determine the frequency of pain assessment to be taken daily.
• Assess for factors that affecting patient/client’s pain experience.

Equipment

• Pain score scale

• Pain score scale

Preparation

• Identify the patient/client for pain assessment.

• Check the patient/client's previous pain score on vital signs chart (if applicable).
• Assess the patient/client's general condition and emotional status.
• Perform hand hygiene.

Implementation

No Interventions Rationale

1 Greet and explain the procedure to the patient. To establish rapport,

gain cooperation and
minimize anxiety.

2 Provide privacy. To maintain patient's

dignity.

3 Ask the patient the following information about the pain:

99
 For accurate and
• maintain eye contact during session and allow patient complete assessment.
to reply freely.

• quality - “How do you feel?”: throbbing, cramping, burning,

etc.

• duration - “Is the pain constant?”; "Does the pain come and
go": time of the painful episodes.

• intensity/severity - "Using this pain scale, what number best

describes you pain?" / "which picture best describe your
pain?": Rate on scale (0=no pain, 10=most pain).

• location/region - "Where does it hurt?"; "Which part of your

body is painful?": patient point to the affected area. 'Does
the pain radiate?" "Does it feel like radiating/moving
around?" "Did it start elsewhere and is now localize in one
spot?"

• triggers/provocations - "What makes the pain worse?";

"What lessens the pain?": certain positions, activities or
situation.

• effects - "How has the pain affected your life?"; "Do you
have any symptoms in addition to pain?": effects on work,
sleep, relationship, etc.

• alleviating factors - "What measures or methods have you

found helpful in lessening or relieving the pain?"; "What
pain medications do you use?"

4 End the session by asking patient for any other information To show courtesy and
to share in regards to pain experience. caring.

5 Make the patient comfortable.

100
 6 Perform hand hygiene. To reduce transmission
of microorganisms.

7 Document the patient's response in the vital signs chart For documentation and
and/or file (follow institutional practice) and report any further management.
abnormalities.

Evaluation

• Patient/client's shared a complete pain experience in terms of quality, duration, intensity,

location, precipitating factors, effects of pain and alleviating factors.
• Significant changes are reported to the staff in-charge and/or doctor.
• Appropriate follow-up is conducted and compared to prior assessment data.

101
 ASSESSING APEX BEAT/APICAL PULSE
Objective

• To obtain patient/client's heart rate.

• To provide baseline data for further evaluation.
• To determine characteristics of apical pulse.
• To determine apical pulse rate before medications are administered.

Assessment

• Identify the reason of assessing the patient/client's apical pulse.

• Assess for factors that may alter the patient/client's pulse.

Equipment

Tray with: • Draw sheet

• Kidney dish (M) • Vital signs chart

• Gallipot (S) for spirit cotton balls / alcohol swab • General waste receiver

• Stethoscope • Clinical waste receiver

Preparation

• Check to ensure all equipment are functioning properly.

• Identify the patient/client for assessing apical pulse.
• Check the patient/client's previous pulse rate on vital signs chart (if applicable).
• Perform hand hygiene.

Implementaion

No Interventions Rationale

1 Greet and explain the procedure to the patient. To establish rapport, gain
cooperation and minimize
anxiety.

2 Ask the patient about any activity within the last 15 For accurate reading.
minutes. For children, ask the mother about the child’s
activity.

3 Position the patient appropriately in a comfortable

supine position unless contraindicated.

102
4 Provide privacy by covering the chest area with To maintain patient's
drawsheet. dignity.

5 Expose left side of the chest over the apex of the heart.

6 Clean the earpieces and diaphragm of the stethoscope To reduce transmission of

using alcohol swabs. microorganisms.

7 Tap lightly on the diaphragm to be sure it is the active

side.

8 Locate the apex of the heart with non-dominant hand. To ensure correct
placement of stethoscope.
• Palpate the second intercostal space to the left of the
patient's sternum.

• Place index finger in the intercostal space and continue

palpating downward until the fifth intercostal space.

• Move the index finger laterally along the fifth intercostal

space to the midclavicular line.

9 Auscultate and count the heartbeat.

• Instruct the patient to remain silent. •

• With dominant hand, insert the earpieces of the To prevent startling the
patient.
stethoscope into your ears and warm diaphragm of the
stethoscope by holding it in the palm of the hand for a
moment (5-10 second).

• Place diaphragm of the stethoscope over the apex of the•

heart.

• Listen for the normal S1 and S2 heart sounds, which are To listen for regular rhythm
before counting.
heard as "lub-dub".

• Count the rate for 1 minute. Count "lub-dub" sound as For accurate reading.
one beat.

103
 • Assess the rate, rhythm and any abnormal heart sound. To detect abnormality.

10 Inform findings to the patient.

11 Make the patient comfortable.

12 Document heart rate and rhythm in the vital signs chart For documentation and
correctly and report any abnormalities. further management.

13 Perform hand hygiene. To reduce transmission of

microorganisms.

Evaluation

• The finding has been obtained accurately.

• Significant changes are reported to the staff in-charge and/or doctor.
• Appropriate follow-up is conducted and compared to prior assessment data.

104
 MAKING AN UNOCCUPIED BED
Objective

• To prepare to receive patient/client.

• To provide neat and clean environment.
• To provide smooth, wrinkle free bed foundation.

Assessment

• General condition and functional abilities of the patient/client.

Equipment

Trolley-top shelf • Laundry bag

• Bed sheet • General waste receiver

• Pillowcase • Clinical waste receiver

• Blanket •

• Linen protector •

Preparation

• Perform hand hygiene.

• Prepare the equipment.
• Prepare environment-move the furniture, overhead table, call bell, switch off fan, etc.
• Ensure mattress is clean and ready to be used.

Implementaion

No Interventions Rationale

1 Adjust the bed to appropriate working height and lock the To maintain body
wheels. mechanics and
safety.

2 Place the pillow on the bed side chair.

3 Apply the bed sheets:

105
 • Place the folded sheet on the bed. •

• Unfold and spread the bed sheet over the mattress, with its •
centre fold on the centre of the bed. Allow sufficient amount of
sheet at the top and bottom to tuck under the mattress.

• Make sure the sheet's hem side down.. •

• Tuck in the bed sheet under the mattress starting from the head•
of the bed.

4 Miter corner of the bed:

• Grasp up the side edge of the sheet so that it form a triangle. •

• Place the triangle (folded corner) on top of the mattress. •

• Tuck in the hanging portion of the bed sheet under the mattress•

• Bring the triangle down over the side of the mattress and tuck
into form an envelope corner. •

5 Make the bed at the foot of the bed:

• Pull the sheet firmly and tuck in the bed sheet under the •
mattress.

• Perform mitering following steps no.4 •

6 Pull the side of sheet firmly and tuck under the mattress.

7 Make the bed on the other side:

• Move to opposite side of the bed. •

106
 • Start from the top, pull the sheet firmly and tuck under the To remove wrinkle.
mattress.

• Perform mitering following steps no. 4 •

8 Place the linen protector on the centre of the bed.

9 Apply clean pillow case:

• Grasp the close end of the pillow case and the other hand
•
gather one side of open pillow up over the hand one side of the
close end.

• Grasp the pillow at the centre of one end through the pillow •
case.

• Pull the open edge of the pillow case down over pillow until •
completely covered.

10 Place the pillow at the head of the bed with the open end away
from the door.

11 Apply the blanket:

• Place the folded blanket lengthwise on the bed. •

• Unfold and spread the blanket over the mattress. •

• Tuck in the blanket at the foot of the bed. •

• Perform mitering follow step no. 4 •

12 Adjust bed to normal height. To maintain body

mechanics and
safety.

13 Tidy up the unit.

Evaluation

• An unoccupied bed and unit has been prepared appropriately and free from wrinkle and
ready to be occupied.

107
 MAKING AN OCCUPIED BED (SIDE TO SIDE)
Objectives

• To promote patient/client's comfort.

• To provide neat and clean bed.
• To provide smooth and wrinkle free bed.

Assessment

• General health and functional abilities of the patient/client.

Equipment

Trolley - top shelf • Laundry bag

• Bed sheet • General waste receiver

• Pillowcase • Clinical waste receiver

• Blanket • Disposable gloves (optional)

• Linen protector •

Preparation

• Perform hand hygiene.

• Prepare the equipment.
• Prepare environment-move the furniture, overhead table, call bell, switch off fan, etc
• Ensure mattress is clean and ready to be used
• Prepare linens:
o Roll half of the clean bed sheet lengthwise - place it on the linen trolley.
o Roll half of the linen protector lengthwise - place it on the linen trolley.

No Interventions Rationale

1 Greet and explain the procedure to the patient. To establish rapport, gain
cooperation and minimize
anxiety

2 Provide privacy. To maintain patient's dignity.

108
3 Adjust the bed to appropriate height and lock the To maintain body mechanics
wheels. and safety.

4 Level the head of the bed and lower the side rail. To facilitate the working
process

5 Remove extra pillow.

6 Check bed linen for patient's personal items, release

any equipment attached to the bed e.g. call bell,
intravenous tube, continuous bladder drainage bag
and drainage tube.

7 Loosen the bed linen. To facilitate easy removal of

linen.

8 Raise the bedside rail on the opposite side. For patient's safety.

9 Assist the patient to turn on his/her side towards the To provide space to place
side rail. Place bed sheet lengthwise on the clean linen.
mattress.

10 Fanfold the linen protector and the bottom sheet as To promote comfort when
close to the patient's back. patient later rolls to the other
side.

11 Remove debris from the bed.

12 Place the clean folded bed sheet, lengthwise To provide for maximum fit of
keeping the centre fold on the centre of the bed, bed sheet and decrease
followed by the clean linen protector. chance of wrinkles.

13 Tuck in the bed sheet under the mattress starting To decrease the risk of skin
from the head of the bed and miter the corner. irritation.
Perform likewise at the foot of the bed

14 Pull the side of the bed sheet firmly and tuck in under
the mattress.

15 Raise the side rail. For patient's safety.

16 Move to the other side of the bed. To complete the procedure.

17 Lower the side rail.

18 Assist the patient to turn over and ask to hold on to

the opposite side rail.

19 Remove the dirty linen and linen protector and place To prevent cross
them in the laundry bag without contact with the contamination.
uniform.

109
 20 Pull the clean bed sheet and linen protector towards
the edge of the bed. Miter the corner of the bed.

21 Repeat step 13 & 14.

22 Assist the patient to lie on his/her back (supine).

23 Change the pillow case.

24 Place the pillow on patient's head with open end

away from the door.

25 Place the patient in comfortable position and cover For comfort and to keep
with blanket if necessary. warm.

26 Raise the side rail. For patient’s safety.

27 Place back the call bell and other items.

28 Tidy up the unit.

29 Perform hand hygiene. To reduce transmission of

microorganisms.

30 Record observation. For documentation and further

management.
Evaluation

• Patient/client's comfort and safety are maintained throughout the procedure.

• Body mechanics is maintained.
• Patient/client expresses comfort.

110
 MAKING AN OCCUPIED BED (TOP TO BOTTOM)
Objectives

• To promote patient/client's comfort.

• To provide a smooth and wrinkle free bed.
• To conserve patient/client's energy.

Assessment

• Assess for general health and functional abilities of the patient/client.

• Determine the presence of incontinence or excessive drainage.
• Assess for contraindication concerning movement and positioning.
• Identify need for assistance.

Equipment

Trolley-top shelf • Laundry bag

• Bed sheet • General waste receiver

• Pillowcase • Clinical waste receiver

• Blanket • Disposable gloves (optional)

• Linen protector •

Preparation

• Identify need for assistance.

• Note the presence of drainage tubes or infusion.
• Prepare environment-move the furniture, overhead table, call bell, switch off fan, etc.
• Prepare linen trolley.
• Perform hand hygiene.

111
Implementation

No Interventions Rationale

1 Greet and explain the procedure to the patient. To establish rapport, gain
cooperation and minimize
anxiety.

2 Provide privacy. To maintain patient's

dignity.

3 Adjust the bed to appropriate height and lock the To maintain body
wheels. mechanics and safety.

4 Level the head of the bed and lower the side rail. To facilitate the working
process.

5 Remove extra pillow.

6 Check the bed linen for patient's personal items,

release any equipment attached to the bed e.g. call bell,
intravenous tube, continuous bladder drainage bag and
drainage tube.

7 Loosen the bed linen. To facilitate easy removal of

linen.

8 Prepare the linen:

• Arrange the linen in the order of use •

• Roll half of the clean bed sheet from the top •

• Fold and place it on the linen trolley •

• Roll half of the linen protector from the top •

• Fold and place it on the linen trolley •

9 Assist the patient to sitting position and instruct

assistant to hold the patient.

10 Tuck in the dirty linen under patient's body and push To provide space to place
against the patient's back. clean linen.

112
 11 Roll half of the clean bed sheet and linen protector on To promote comfort when
the bed. patient later rolls to the
other side.

12 Unfold and spread the clean linen and linen protector at

the patient's back.

13 Assist the patient to lift up buttocks unto clean linen.

14 Remove the dirty linens and place them in the laundry To prevent transmission of
bag. microorganisms.

15 Unfold the clean linen from the top and spread towards
the head of the bed.

16 Lie the patient in supine position and place pillow

underneath the head.

17 Tuck in the bed sheet under the mattress to form

mitered corner.

18 Pull the bottom sheet firmly and miter the corner of the To decrease the risk of skin
bed sheet. irritation.

19 Pull the sides of the bed sheet firmly under the

mattress.

20 Pull the linen protector firmly. To maintain patient's skin

integrity.

21 Place the patient in a comfortable position and cover For comfort and to keep
with blanket if required. warm.

22 Raise the side rail. For patient's safety.

23 Place back the call bell and other items.

24 Tidy the unit.

25 Perform hand hygiene. To reduce transmission of

microorganisms.

26 Record observation. For documentation and

further management.

Evaluation

• Patient/client's comfort and safety are maintained throughout the procedure.

• Body mechanics are maintained.
• Patient/client expresses comfort.

113
 SPONGING/BED BATH
Objectives

• To cleanse the patient/client.

• To stimulate blood circulation.
• To improve comfort and relaxation.
• To facilitate head-to-toe assessment.

Assessment

• Assess general health and functional abilities of the patient/client.

• Assess the need of bowel or urinary elimination
• Note the presence of drainage tubes or infusion.
• Identify need for assistance.

Equipment

Trolley-top shelf Trolley-bottom shelf

• 2 basins of warm water • 2 small towels / flannels

• Tray: • 2 bath blankets

• Soap/liquid Soap • 1 bath towel

• Lotion • 1 bed sheet

• Comb • Pillow case

• Nail clipper (optional) • Clean clothing

• Toilet roll • Linen protector

• Kidney dish: • Disposables gloves (optional)

• Tooth brush and tooh paste • Vomit bowl/receiver

114
 • Cip of water for gargle • General waste receiver

• Clinical waste receiver

• Laundry bag

Preparation

• Identify the patient/client for sponging

• Perform hand hygiene
• Prepare the equipment.
• Prepare environment-move the furniture, overhead table, call bell, switch off fan, etc.
• Prepare bed linen.

Implementation

No Interventions Rationale

1 Greet and explain the procedure to the patient. To establish rapport, gain
cooperation and minimize
anxiety.

2 Provide privacy. To maintain patient's dignity.

3 Adjust bed to appropriate height and lock the To maintain body mechanics
wheels. and safety.

4 Level the head of the bed and lower the side rail. To facilitate the working
process.

5 Remove extra pillow.

6 Offer bedpan or urinal to patient if required.

7 Perform hand hygiene. To reduce transmission of

microorganisms.

8 Loosen bed linen and place linen protector on the

bed.

9 Place bath towel underneath the patient. To prevent soiling of linen.

10 Position patient in semi Fowler/Fowler.

11 Provide mouth care.

115
12 Cover the patient with a bath blanket.

13 Remove the clothing.

14 Wash face:

• Place one bath towel on patient's chest. •

• Clean the patient's eyes with separate corner of To prevent discharge from
entering lacrimal duct.
small towel/flannel for each eye and wipe from inner
canthus to outer canthus.

• Wash, rinse and dry the patient's face, neck and •

ears.

• Ask the patient if he/she prefers using soap for the•

face.

15 Wash arms and hands:

• Place bath towel lengthwise under the farther arm.•

• Clean, rinse and dry the arms using long strokes •

from distal to proximal area.

• Clean axilla. •

• •
Immerse hand in basin and assist patient in washing
hand.

• Repeat entire procedure step no.15 for the other •

arm.

16 Clean chest and abdomen:

• Fold bath blanket down to patient's pubic area. •

• Place bath towel over chest and abdomen, giving •

attention to skin folds under breast.

116
• Keep chest and abdomen covered at all time and •
use circular motion to clean each separate area.

17 Wash legs and feet:

• Place bath towel lengthwise under farther leg. •

• Use long, smooth, firm stroke to clean from distal to To promote circulation.
proximal from ankle to knee and proceed to the
thigh.

• Bend leg at knee and ask assistant to maintain the•

position.

• Place the foot in the basin with the ankle and heel •
supported by your hand and the leg by your arm.

• Wash, rinse and dry the foot. •

• Repeat the entire procedure for the other leg. •

• Change water. •

18 Wash the patient's back:

• Assist the patient to lateral position. •

• Place bath towel lengthwise along the back of the •

patient.

• Wash, rinse and dry using long, firm stroke from •

back to buttocks, paying particular attention to the
gluteal folds.

19 Assist the patient back to supine position.

20 Don disposable gloves. Clean, rinse and dry

perineum if patient cannot wash himself/herself.

117
 21 Help the patient to put on clean clothing and assist in
grooming.

22 Perform bed making.

23 Make the patient comfortable.

24 Tidy up the unit.

25 Perform hand hygiene. To reduce transmission of

microorganisms.

26 Record observation. For documentation and further

management.

Evaluation

• Patient/client tolerated the procedure.

• Patient/client comfort and safety are maintained throughout the procedure.
• Body mechanics are maintained.
• Significant changes are reported to staff in-charge and/or doctor.

118
 MOUTH CARE FOR UNCONSCIOUS
PATIENT/CLIENT
Objectives

• To clean and moisten the membranes of the mouth and lips.

• To maintain integrity of the lips and oral cavity.
• To prevent oral infections.
• To prevent halitosis.

Assessment

• Assess for general health and functional abilities of the patient/client.

Equipment
Trolley - top shelf Trolley - bottom shelf

• Incopad • Solution:

• Normal Salinel
• Face towel

• Thymol gargle
• Kidney dish

• Sodium Bicarbonate
• Toothbrush/toothettes/orange stick/cotton buds

• Water for dilution • Disposable gloves

• Gauze • Receiver

• Wooden spatula • General waste receiver

• Lip moisturizer / Vaseline • Clinical waste receiver

• Mouth gag (optional)

Preparation

• Identify the patient/client for mouthcare.

• Perform hand hygiene.
• Prepare the equipment.

119
Implementation

No Interventions Rationale

1 Greet and explain the procedure to the patient. To establish rapport, gain
cooperation and minimize
anxiety.

2 Provide privacy. To maintain patient's dignity.

3 Position the unconscious patient in lateral position. To allow draining of cleansing

solution to prevent aspiration.

4 Don disposable gloves. To prevent cross

contamination.

5 Place incopad underneath the patient's chin. To protect patient's clothing.

6 Place the kidney dish under the cheek. To receive the fluid from the
mouth.

7 Apply mouth gag if necessary. For easier access to oral

cavity.

8 Clean the patient's teeth carefully with To avoid injuring the gums.
toothbrush/toothettes/orange sticks/cotton buds.

9 Clean the oral cavity.

• Wrap a piece of gauze on spatula, dip into solution •

and squeeze it dry.

• Clean all mouth tissues in orderly progression-the To ensure all areas are clean.
cheeks, roof of the mouth, base of the mouth and
tongue.

• Use a fresh one to clean each area. To prevent contamination.

10 Remove the kidney dish.

11 Remove and discard the gloves.

12 Dry around the patient's mouth with the face towel.

13 Lubricate the patient's lips with moisturizer. To prevent crack lips.

14 Make the patient comfortable.

120
 15 Tidy up the unit.

16 Perform hand hygiene. To reduce transmission of

microorganisms.

17 Record observation. For documentation and further

management.

Evaluation

• Patient/client tolerated the procedure.

• Patient/client comfort and safety are maintained throughout the procedure.
• Significant changes are reported to the staff in-charge and/or doctor.

121
 HAIR SHAMPOO
Objectives

• To cleanse the patient/client's hair and scalp.

• To treat conditions of the scalp with topical medications.
• To remove substances such as blood, body secretions or electrode jelly (used when an
electro encephalogram or other study is done).
• To stimulate blood circulation to the scalp through massage.
• To increase patient/client's sense of wellbeing.

Assessment

• General health and functional abilities of the patient/client.

• Assess any risks of contact with body fluid or minor cut.

Equipment

Trolley - top shelf Trolley - bottom shelf

• Basin with warm water • Long mackintosh

• 1-pint jug • Short mackintosh / linen protector

• Shampoo • Incopad

• Cotton in gallipot • Bath towel

• Comb • Disposable apron

• Small towel • Clean clothing

• Hair dryer (optional) • 1 set bed linen

• • Receiver

122
 • • General waste receiver

• • Clinical waste receiver

• • 1 pail / basin

• • Disposable gloves (optional)

• Laundry bag

Preparation

• Identify the patient/client for hair shampoo.

• Perform hand hygiene.
• Prepare the equipment.
• Prepare environment-move the furniture, overhead table, call bell, switch off fan, etc.

Implementation

No Interventions Rationale

1 Greet and explain the procedure to the patient. To establish rapport, gain
cooperation and minimize anxiety.

2 Provide privacy. To maintain patient's dignity.

3 Adjust the bed to appropriate height and lock the To maintain body mechanics and
bed. safety.

4 Don disposable gloves (if indicated). To comply with standard

precaution.

5 Position the patient.

• Remove the head board and the bar. •

• Remove the pillow. •

123
 • Fold the head end of the mattress. •

• Tuck the short mackintosh, towel and incopad •

under the shoulders.

• Roll the long mackintosh accordingly, to drain the •

water.

• Tuck the folded end of the long mackintosh under

•
the patient's neck and place the other end in the
pail.

6 Place the pail on the floor to collect draining

water.

7 Place a cotton ball into each of the patient's ear. To protect the ears.

8 Comb the patient's hair.

9 Place a small towel on the forehead. To protect patient's face.

10 Wet the hair thoroughly, apply shampoo to the

scalp and massage all parts of the head.

11 Rinse hair thoroughly by draining water slowly

from the jug.

12 Wrap the patient's hair with bath towel.

13 Remove incopad and long mackintosh.

14 Unfold the mattress.

15 Ensure the patient is comfortable.

16 Dry patient's hair, ears, face and neck.

17 Comb patient's hair.

18 Tidy up the unit and clear the equipment.

19 Perform hand hygiene. To reduce transmission of

microorganisms.

124
Evaluation

• Patient/client tolerated the procedure.

• Patient/client comfort and safety are maintained throughout the procedure.
• Significant changes are reported to the staff in-charge and/or doctor.

125
 GIVING AND REMOVING BEDPAN
Objectives

• To assist patient/client with elimination.

• To obtain an accurate measurement or assessment of the patient/client's output.

Assessment

• General health and functional abilities of the patient/client.

Equipment

Trolley - top shelf Trolley - bottom shelf

• Basin of water • Bedpan with cover

• Soap • Disposable gloves

• Linen protector • Receiver

• wsheet • General waste receiver

• Toilet tissue • Clinical waste receiver

Preparation

• Identify the patient/client for giving bedpan

• Prepare the equipment.
• Prepare environment.
• Perform hand hygiene.

Implementation

126
No Interventions Rationale

1 Greet and explain the procedure to the To establish rapport, gain cooperation
patient. and minimize anxiety.

2 Provide privacy. To maintain patient's dignity.

3 Don gloves. To prevent cross contamination.

4 Cover the lower part of the patient's body with To maintain patient's dignity.
drawsheet.

5 Assist the patient to remove trousers or pull

up the patient's sarong to waist level.

6 Offering bedpan.

• For patient who is able to assist the •

procedure:

• •
Tell the patient to bend his/her knees and lift
up the buttock.

• •
Help the patient by slipping your hand under
the sacrum to assist in lifting.

• Slip the bedpan gently until the patient's

buttock rests on the smooth, rounded rim of To ensure comfort of patient.
the bedpan.

• Elevate the head of the bed to a semi-

To promote elimination process and to
Fowler's position if not contraindicated. prevent back strain.

• Put the toilet tissue and call bell within reach To promote safety by preventing
patient from reaching over the bed for
of the patient.
objects out of reach.

• Leave the patient (with your judgment) and•

raise the side rail.

• For helpless patient: •

• Assist the patient to lateral position away •

from you.

127
• Tell the patient to grasp the side rail of the •
bed.

• •
Place the bedpan firmly against the buttocks.

• Hold the bedpan in place as you turn the •

patient's back to recumbent position.

7 Removing bedpan.

• For patient who is able to assist in the •

procedure:

• Hold the bedpan steady. •

• Place the other hand under patient's buttocks

•
to assist in lifting and simultaneously tell
patient to raise the buttocks.

• Assist the patient to clean the perineal area•

and perform hand hygiene.

• For helpless patient: •

• Gently turn patient to lateral position away To prevent spilling of contents. For
easy removal of bedpan, to prevent
from you while holding the bedpan firmly with
injury.
one hand.

• Wipe patient's perineal area using toilet •

tissue/perineum wipes.

8 Remove bedpan gently and cover it. Place

the bedpan on the foot of the bed.

9 Place the patient to a comfortable position.

10 Dispose the content and clean the bedpan

appropriately.

11 Remove gloves and perform hand hygiene. To reduce transmission of

microorganisms.

128
 12 Record observation (colour, odour, amount, For documentation and further
consistency and any abnormalities). management.

Evaluation

• Patient/client's comfort and safety are maintained throughout the procedure.

• Significant changes are reported to the staff in-charge and/or doctor.

129
 GIVING AND REMOVING URINAL
Objectives

• To assist patient/client with elimination.

• To promote comfort and hygiene.
• To obtain an accurate measurement of the patient/client's urine output.

Assessment

• General health and functional abilities of the patient/client.

Equipment

Trolley - top shelf Trolley - bottom shelf

• Basin of water • Urinal with cover

• Soap • Disposable gloves

• Linen protector • Receiver

• Drawsheet • General waste receiver

• Toilet tissue • Clinical waste receiver

Preparation

• Identify the patient/client for giving urinal.

• Perform hand hygiene.
• Prepare environment.

130
Implementation

No Interventions Rationale

1 Greet and explain the procedure to the To establish rapport, gain cooperation
patient. and minimize anxiety.

2 Provide privacy. To maintain patient's dignity.

3 Give the urinal to patient.

4 Put the toilet tissue and call bell within To promote safety by preventing from
reach of the patient. reaching over bed for object out of
reach.

5 Leave the patient (with your judgment). To respect privacy during elimination.

6 Removal urinal.

• Don gloves. •

• Remove the urinal. •

• Wipe the area around the urethral orifice •

with a tissue (if the patient needs help).

• Assist the patient to wash and dry the •

hands.

7 Dispose the urine and clean the urinal

appropriately.

8 Remove gloves and perform hand To reduce transmission of

hygiene. microorganisms.

9 Record observation (amount, colour, For documentation and further

clarity, odour and presence of abnormal management.
constituents).

Evaluation

• Patient/client's comfort and safety are maintained throughout the procedure.

• Significant changes are reported to the staff in-charge and/or doctor.

131
 APPLICATION OF HOT WATER BAG
Objectives

• To provide warmth and comfort.

• To relieve or reduce pain.
• To reduce muscle spasms.
• To reduce swelling.
• To relieve urinary retention.

Assessment

• Determine the indication of application of hot water bag.

• Identify and determine patient/client's general condition, sensation and skin condition.
• Determine the areas where the hot water bag is to be applied.

Equipment

Tray consists of:

• 1 Jug of hot water (5 min off boil) • Small towel for drying

• Hot water bag and cover • Drawsheet/towel

Preparation

• Identify the patient/client for heat therapy.

• Gather equipment.
• Perform hand hygiene.

No Interventions Rationale

1 Test the hot water bag for leaks. To prevent thermal injury.

• Fill the hot water bag with tap water.

• Close the knob of the hot water bag securely.

132
 • Invert the hot water bag.

• Check for leakage.

• Empty the hot water bag.

2 Fill the water bag with hot water. To facilitate procedure.

• Place the hot water bag on a flat surface with the

neck of the bag facing upward.

• Fill hot water till 2/3 full.

• Remove air from the bag by lowering the neck of

bag until water appears on the neck of bag.

• Close the knob of the hot water bag securely.

• Invert the hot water bag and check for leakage.

• Dry the outer part of the hot water bag.

• Put on the hot water bag cover and wrap the bag
with drawsheet/towel.

• Bring the hot water bag to the patient's bed.

3 Greet and explain the procedure to the patient. To establish rapport, gain
cooperation and minimize anxiety.

4 Provide privacy. To maintain patient's dignity.

5 Place the hot water bag over area to be treated To avoid scalding.
with the knob away from the patient's body.

133
 6 Change the position of the hot water bag as To prevent burn injury and
needed. complication of heat therapy.

7 Assess/observe the patient continuously during To detect any complications.

the procedure.

• patient's condition
• skin's condition
• leakage

8 Remove the hot water bag after 20-30 minutes or

the water is cold.

9 Make the patient comfortable.

10 Tidy up the unit.

11 Perform hand hygiene. To reduce transmission of

microorganisms.

12 Document the procedure in the nursing note. For documentation and further
management.

Evaluation

• Procedure is performed accordingly.

• Monitor patient/client's response to the therapy.
• Appropriate follow-up is conducted if the findings are abnormal. Compared findings to
previous assessment data if available.
• Significant changes are reported to the staff in-charge and/or doctor.

134
 APPLICATION OF ICE BAG
Objectives

• To reduce bruises.
• To prevent and reduce swelling.
• To relieve or reduce discomfort and pain.
• To control bleeding.
• To relieve urinary retention.

Assessment

• Determine the indication for application of ice bag.

• Identify and determine patient/client's general condition, sensation and skin condition.
• Determine the areas where the ice bag is to be applied.

Equipment

Tray consists of:

• Ice bag and cover • Ice breaker

• 1 bowl of ice cube • Wrapper

• Salt • Scissors

• 1 Jug of hot water (optional) • Spoon (optional)

Preparation

• Identify the patient/client for application of ice bag.

• Gather equipment.
• Perform hand hygiene.

135
Implementation

No Interventions Rationale

1 Prepare the ice bag. To facilitate procedure.

• Break the ice into smaller cubes if •

necessary.

• Smoothen the edge of the ice cubes using •

hot spoon if necessary.

• Fill the ice bag with ice cubes till ½ to 2/3 •

full.

• Sprinkle some salt on the ice. To slow the melting process.

• Remove air from the ice bag. •

• Dry the outer part of the ice bag. •

• Put on the ice bag cover and wrap the bag •

with drawsheet/towel.

• Bring the ice bag to the patient's bed. •

2 Greet and explain the procedure to the To establish rapport, gain cooperation
patient. and minimize anxiety.

3 Provide privacy. To maintain patient's dignity.

4 Place the ice bag over the area to be

treated.

5 Assess/observe the patient's skin every 5- To detect any complications.

10 minutes.

6 Remove the ice bag after 30 minutes.

7 Make the patient comfortable.

8 Tidy up the unit.

136
 9 Perform hand hygiene. To reduce transmission of
microorganisms.

10 Document the procedure in the nursing For documentation and further

note. management.

Evaluation

• Procedure is performed accordingly.

• Monitor patient/client's response to the therapy.
• Appropriate follow-up is conducted if the findings are abnormal. Compared findings to
previous assessment data if available.
• Significant changes are reported to the staff in-charge and/or doctor.

137
 TEPID SPONGING
Objectives

• To lower the body temperature when above 38.5°C.

Assessment

• Determine the patient/client's body temperature.

• Identify and determine patient/client's general condition.

Equipment

Trolley - top shelf Trolley - bottom shelf

• 1 basin of tepid water • 2 bath towels

• Tray with 6 flannels • 1 long mackintosh/linen protector

• 1 bath towel • Clothing and bed linens (as

required)

• Paper towel/tissue and a bowl of water (as • Disposable gloves

required)

• • General waste receiver

• Laundry bag

Preparation

• Identify the patient/client for tepid sponging.

• Gather equipment.
• Prepare the environment-space, switch off fan/air conditioner, etc.
• Perform hand hygiene.

138
Implementation
No Interventions Rationale

1 Greet and explain the procedure to the To establish rapport, gain

patient. cooperation and minimize anxiety.

2 Provide privacy. To maintain patient's dignity.

3 Position the patient in a comfortable position To facilitate procedure and provide

e.g., recumbent/semi Fowler. comfort.

4 Place the mackintosh/linen protector and bath To prevent soiling.

towel on the patient's bed.

5 Remove the patient's clothing gently and cover To maintain patient's dignity.
with bath towel.

6 Immerse or dip all flannels in the tepid water To avoid dripping.

and squeeze it.

7 Wipe the patient's face gently. To promote comfort.

8 Apply flannel on the To lower the temperature through

conduction.
• forehead-1 flannel
• axilla or armpits-2 flannels
• groins-2 flannels

9 Change the flannels on the forehead, axilla

and groin when they become warmer.

10 Wipe the patient using dabbing technique from To avoid skin friction and promote
distal to proximal: loss of body heat.

• hands
• neck
• chest and abdomen
• legs
• back

11 Allow the water droplets to remain on the skin. To promote heat loss through
evaporation.

12 Repeat steps 8-11 for about 15 to 20 minutes.

13 Assess/observe the patient continuously To detect any complications such as

during the procedure. rigor or shock.

139
 14 Change the patient's clothing and linen if To promote comfort.
necessary.

15 Make the patient comfortable.

16 Tidy up the unit.

17 Perform hand hygiene. To reduce transmission of

microorganisms.

18 Document the procedure in the nursing note. For documentation and further
management.

Evaluation

• Procedure is performed accordingly.

• Monitor the patient/client's response to the treatment by checking the body temperature 15
minutes post-procedure.
• Appropriate follow-up is conducted if the findings are abnormal. Compared findings to
previous assessment data if available.
• Significant changes are reported to the staff in-charge and/or doctor.

140
 ADMINISTERING OXYGEN THERAPY VIA NASAL
PRONG/FACE MASK
Objectives

• To reduce and relieve hypoxia and hypoxaemia.

• To return to normal breathing rate and pattern.
• To increase patient/client's comfort, breathing efficiency and activity tolerance.

Assessment

• Check the doctor's order and determine the indication for oxygen therapy and any specific
orders.
• Determine patient/client's general health condition and ability to follow instructions.
• Assess the patient/client breathing rate and pattern.
• Identify safety precautions required for oxygen therapy.

Equipment

Trolley - top shelf Trolley - bottom shelf

Tray consist of: • "No Smoking" signage

• Equipment to clean the nostril (for nasal

prong) • Distilled water
o 1 kidney dish (M)
o 2 gallipot (S)
o Cotton buds • Normal saline
o Non-tooth dissecting forceps
• Nasal prong or face mask
• Face towel • General waste receiver

• Flow meter • Clinical waste receiver

• Oxygen humidifier Oxygen cylinder with regulator (as

needed)

141
Preparation

• Identify the patient/client for oxygen therapy.

• Prepare the equipment and ensure it is functioning well.
• Check the size of face mask to ensure proper fitting.
• Prepare the environment.
• Perform hand hygiene

Implementation

No Interventions Rationale

1 Greet and explain the procedure to the patient. To establish rapport, gain
cooperation and minimize
anxiety.

2 Provide privacy. To maintain patient's dignity.

3 Set up the O2 equipment and the humidifier. To prepare the oxygen to be

administered.

• Fill up the humidifier and attach the humidifier bottle to To prevent dryness of the
nasal mucosa.
the base of the flowmeter.

• Attach flowmeter with the humidifier to the wall outlet •

or cylinder. The flowmeter should be in the off
position.

• Attach the prescribed O2 tubing and delivery device to•

the connector.

4 Test the oxygen flow. To ensure O2 supply and no

leakage from the tubing.
• Press the end of tubing between two fingers about 4
inches from the humidifier.

• Listen to the sound of bubble jet.

142
 • Feel the O2 flow at the back of the hands and patient's
cheeks.

5 Apply the O2 delivery device as ordered. To administer O2.

• Nasal prong

• Place the patient in Fowler's position.

• Clean the patient's nostrils.

• Regulate flow rate as prescribed and check the O2

flow.

• Place the nasal prong at the patient's nostrils correctly,

adjust O2tubing around the ears and tighten the tubing
at the patient’s chin.

• Face mask

• Place the patient in Fowler's position.

• Wipe the patient's face with a towel.

• Regulate flow rate as prescribed and check the

O2 flow.

• Fit mask to the patient's face from nose downward,

adjust the metal piece of the mask and place elastic
band around patient's head and adjust the band.

143
 6 Observe the patient's condition.

• Check for comfort level..

• Response to treatment.

7 Put the "No Smoking" signage and give instruction to To prevent fire and injury.
the patient and visitors on safety measures during O2
use.

8 Make the patient comfortable.

9 Tidy up the unit.

10 Perform hand hygiene. To reduce transmission of

microorganisms.

11 Document the following. For documentation and

further management.
• Record the procedure performed in the nursing
progress note.

• Patient's assessment and response.

Evaluation

• The oxygen therapy is administered accordingly.

• Patient/client tolerated the oxygen therapy.
• The "No Smoking" signage is displayed and patient/client and visitors understand the
instruction on safety measures.
• Appropriate follow-up is conducted and compared to prior assessment data.
• Significant changes are reported to the staff in-charge and/or doctor.

144
 NELSON/STEAM INHALATION
Objectives

• To relieve inflammation and congestion of mucous membranes of the respiratory tract.

• To loosen secretion and relieve irritation of mucous membranes of the respiratory tract.
• To maintain moisture of the mucous membranes.

Assessment

• Check the doctor's order and determine the indication for Nelson/steam inhalation and any
specific orders.
• Determine patient/client's general health condition and ability to follow instructions.
• Assess the patient/client breathing pattern.

Equipment

Trolley - top shelf Trolley - bottom shelf

• Nelson’s inhaler with glass mouthpiece in a bowl/basin • 2 pints jug

• Tray consist of: • Sputum mug

• Tincture benzoin/menthol crystal/Eucalyptus oil • Kettle

• 1 tea spoon • Tissue paper (if required)

• Gauze (to wrap the mouthpiece) • Receiver

• Towel • General waste receiver

• Nelson's inhaler case • Clinical waste receiver

• Plaster and scissors •

145
Preparation

• Identify the patient/client for Nelson/steam inhalation.

• Prepare the equipment and ensure it is functioning well.
• Perform hand hygiene.

No Interventions Rationale

1 Greet the patient. To establish rapport.

2 Explain the procedure to the patient. To gain cooperation and

minimize anxiety.

• Technique of placing the lips on the mouthpiece. •

• Technique of inhalation. •

3 Provide privacy. To maintain patient's

dignity.

4 Prepare Nelson's inhaler:

• Fill in hot water up to a level below the nozzle, which is To avoid hot water
spillage through the
2/3 full in the Nelson's inhaler.
nozzle.

• Add medication into the inhaler as ordered, for example, 1•

teaspoon Tincture benzoin or 2-3 pieces of menthol
crystals.

• Close the inhaler properly and make sure the mouthpiece To avoid water spillage
from the nozzle.
is facing opposite the nozzle.

• Wrap the glass mouthpiece with gauze and secure it with To avoid scalding.
plaster at the bottom.

• Dry the outer part of the inhaler. •

• Put the Nelson's inhaler case on. •

146
 • Wrap the Nelson's inhaler with towel. To maintain the water
temperature.

5 As for basin:

• Fill in hot water till 2/3 full in the basin. •

• Add medication into the basin as ordered, for example, 1 •

teaspoon Tincture benzoin or 2-3 pieces of menthol
crystals.

6 Bring the inhaler in a bowl close to the patient and put on For patient safety and to
an overhead table with the nozzle facing the opposite of avoid scalding.
patient. OR Bring the basin close to the patient

7 Place the patient in a suitable and comfortable position. *If

basin is used, tell the patient to cover the head and basin
with a towel.

8 Tell the patient to inhale slowly for 15-20 minutes as

follow.

• Inhale through the mouth. •

• Exhale through the nose. •

9 Encourage the patient to cough out the phlegm, if any.

10 Observe the patient throughout the procedure. To detect any

complication.

11 Make the patient comfortable.

12 Tidy up the unit.

13 Perform hand hygiene. To reduce transmission of

microorganisms.

14 Document the following. For documentation and

further management.
• Record procedure performed in the nursing progress
note.

147
 • Patient's assessment and response.

Evaluation

• Nelson/steam inhalation is performed accordingly.

• Patient/client tolerated the procedure.
• Appropriate follow-up is conducted and compared to prior assessment data.
• Significant changes are reported to the staff in-charge and/or doctor.

148
HEALTH EDUCATION ON DEEP BREATHING AND
COUGHING EXERCISE
Objectives

• To increase pulmonary ventilation and lung expansion.

• To promote oxygenation of body cells.
• To loosen respiratory secretions and promote breathing.
• To prevent hypoventilation that may result from post operative anaesthetic effects.

Assessment

• Check the doctor's order.

• Determine patient/client's general health condition and ability to follow instructions.
• Assess the patient/client breathing pattern.
• Identify contraindications for the procedure.
• Determine any special consideration.

Equipment

• Chair

• Pillow

Preparation

• Identify the patient/client for giving health education on deep breathing and coughing
exercises.
• Prepare the environment.
• Perform hand hygiene.

Implementation

No Interventions Rationale

1 Greet and explain the procedure to the patient. To establish rapport, gain
cooperation and minimize
anxiety.

2 Provide privacy. To maintain patient's dignity.

149
3 Help the patient to sit straight up in bed or on a chair. To promote maximum lung
expansion.

4 Demonstrate the deep breathing steps.

• Place your hand or ask the patient to place hands with To support deep breathing
and evaluate depth of
palm down around the sides of patient's lower ribs.
inspiration.

• Instruct the patient to breath slowly through the nose •

until the chest expands and the abdomen rises visibly.

• Tell the patient to hold inspiration for 3-5 seconds and•

exhale slowly through pursed lips.

5 Demonstrate the coughing exercise steps.

• Instruct the patient to take two or three deep breaths. •

• Then instruct the patient to inhale deeply, hold breath •

for 3-5 seconds, lean forward and cough.

6 Encourage the patient to repeat 2 to 3 times steps 4 to

5 as needed.

7 For the post operative patient, demonstrates

placement of hands on either side of the incision for
support. Place a pillow on the incision site for support.

8 Observe the patient for dizziness, shortness of breath To detect intolerance.

and pain.

9 Verify the patient's understanding. To ensure effectiveness of

teaching.

10 Make the patient comfortable.

11 Perform hand hygiene. To reduce transmission of

microorganisms.

12 Document the health education performed and For documentation and

patient's response. further management.

150
Evaluation

• The health education is delivered according to plan.

• Patient/client tolerated the procedure.
• Patient/client is able to provide feedback of the health education.
• Significant changes are reported to the staff in-charge and/or doctor.

151
 LAST OFFICE
Objectives

• To cleanse and dress the deceased before sending to mortuary.

• To make the deceased look as natural as possible.
• To maintain the body alignment before rigor mortis sets in.
• To protect the other patients from unpleasant sights of the deceased.

Assessment

• Check the doctor's certification of death

o Date and time
o Cause of death
• Identify types of death to perform last office according to the institutional policy
o Medico-legal case
o Infectious case e.g. HIV
• Assess the deceased condition
o What is required to be removed
o Body size

Equipment

Trolley - top shelf Trolley - bottom shelf

• Basin with warm water • 2 bath towels

• 2 flannels • Long mackintosh/long linen protector

• Tray containing: • Deceased clothing

• Soap • Mortuary sheet

• Gallipot with dry cotton balls
• Gallipot with wet cotton balls • Green corner for Muslims
• Kidney dish (M) containing: • Brown corner for non-Muslims
o Scissors
o Dressing forceps
o Sinus forceps • Tray containing:
o Comb
o Cotton bandage • Disposable gloves
• Extra swabs and bandages

152
 • General waste receiver

• Clinical waste receiver

• Identification Tag (documentation completed)

Laundry Bag

Preparation

• Identify the deceased for last office.

• Perform hand hygiene.
• Prepare the equipment.
• Prepare the environment.

Implementation

No Interventions Rationale

1 Inform procedure to the family members. To alleviate anxiety and gain

cooperation.

2 Screen the bed. To ensure privacy and reduce

unpleasant feeling of other patients in
the ward.

3 Position the deceased in supine position Rigor mortis sets in within 2 hours.
with limbs straightened.

4 Remove all tubing from the deceased.

5 Perform oral suction (if any secretion in the

mouth).

6 Clean and cover open wound with clean

gauze (if any).

7 Perform sponging/bed bath procedure. To clean the body.

8 Place the wet cotton ball on eyelids. To ensure the eyes are closed.

9 Pack all open orifices with dry cotton. To prevent drainage of secretion.

10 Apply cotton bandage to chin and tie at the To lift up the chin and avoid the
head. deceased’s mouth to stay open when
rigor mortis sets in.

153
 11 Place the deceased’s both hands on the To pay respect to the deceased's
lower chest with the right hand over the left religion.
hand especially for Muslims. To prevent hand from slipping to the
• Tie both hands at the wrists with cotton side during transportation.
bandage.

12 Place both legs together. To aid in transportation of body.

• Tie the big toes of both feet together.
• Tie both feet together at the ankles.

13 Tie identification tag on the hand. To identify the deceased.

14 Place mortuary sheet underneath the body

(side by side method).

15 Allow the family members to view the To respect wishes of the family
deceased's face before covering up the members.
body.

16 Cover the body neatly and tie with cotton To ensure body is covered completely
bandage at: and aid in transportation of body to
• both ends of the body mortuary.
• chest level
• knee level
• ankle level

17 Tie the identification tag at chest level on To identify body without opening the
mortuary sheet. mortuary sheet.

18 Assist the family members to clear up

deceased's belonging.

19 Check the death certificate and burial permit Burial permit is required for the funeral.
are completed and signed by the doctor.

20 Make arrangement to send body to Body must be sent to mortuary 1 hour

mortuary. after doctor certified death (follow
institutional policy).

21 Complete documentation in the deceased's For documentation.

report, admission book and the 24 hours
censes.

22 Tidy up the unit and perform terminal To prevent transmission of

disinfection. microorganisms.

Evaluation

• Body sent to mortuary on time.

• Documentation is completed and death registration is done.

154
 COLLECTION OF URINE FOR FULL
EXAMINATION, MICROSCOPIC EXAMINATION
(FEME)
Objectives

• To observe the characteristics of specimen.

• To determine the presence of microorganisms.
• To help doctor to determine the diagnosis and decide treatment.
• To be done as a routine investigation.

Assessment

• Check the doctor’s order to confirm type of specimen to be collected and type of investigation
to be done.
• Assess the patient/client's general condition:
o Ability to follow instruction
o Ability to help himself/herself

Equipment

Trolley - top shelf Trolley - bottom shelf

• Tray consist of: • Disposable gloves

• Kidney dish
• Bedpan with cover

• Specimen container for urine

• Draw sheet

• Specimen label
• Linen protector/small mackintosh

• Laboratory form
• Towel

• Specimen recording book • General waste receiver

• Hand sanitizer • Clinical waste receiver

155
 • Jug of water to clean perineum

Preparation

• Identify the patient/client for specimen collection.

• Complete label and stick onto the specimen container.
• Perform hand hygiene.
• Prepare the equipment.
• Prepare the environment.

Implementation

No Interventions Rationale

1 Greet and explain the procedure to the To establish rapport, gain cooperation
patient. and minimize anxiety.

2 Verify patient’s identity. To ensure accurate identification of

specimen to prevent errors in diagnosis
and treatment.

3 Provide privacy. To maintain patient's dignity.

4 Prepare the patient. To collect specimen.

• For ambulatory patient: •

• Give the kidney dish and specimen container

to the patient.

• Tell the patient to go to toilet, wash perineum

with soap and water.

• Tell the patient to pass urine into the kidney

dish.

• Tell the patient to open cap of specimen

container and pour till 2/3 full of urine into
the specimen container.

• Tell the patient to close the container tightly

and pass the urine specimen and kidney
dish to the nurse.

156
 • For non-ambulatory patient

• Place mackintosh under the patient's

buttocks.

• Cover the patient with drawsheet.

• Help the patient to remove trousers/sarong.

• Don disposable gloves.

• Place the bedpan under the patient's

buttocks.

• Clean the patient’s perineum with soap and

water.

• Tell the patient to pass urine into bedpan.

• Catch the urine with kidney dish and keep

aside.

• Tell the patient to finish urinating and clean

the perineum with water and dry it.

• Remove the bedpan and mackintosh.

• Open cap of specimen container and pour till

2/3 full of urine into the specimen container.

• Close the container tightly and place in the

tray.

• Remove gloves and perform hand hygiene.

• Assist the patient to put on the

trousers/sarong.

• Make the patient comfortable and tidy up the

unit.

5 Place the specimen into biohazard

bag/specimen carrier bag.

6 Record in specimen dispatch book. For documentation.

157
 7 Make arrangement to send the specimen to To maximize accuracy of testing.
laboratory as soon as possible.

8 Clean and keep instrument. To prevent transmission of

microorganism.

Evaluation

• Specimen is collected correctly.

• Specimen is sent in a timely manner.
• Trace and report the results to the staff in-charge and/or doctor.

158
 COLLECTION OF URINE FOR CULTURE &
SENSITIVITY (C&S)/ MIDSTREAM URINE
Objectives

• To diagnose urinary tract infection (UTI).

• To identify the bacteria causing the infection.
• To determine the type of antibiotics that are sensitive to the microbes causing the infection.
• To help doctor to determine the diagnosis and treatment.

Assessment

• Check the doctor's order to confirm type of specimen to be collected and type of investigation
to be done.
• Assess the patient/client's general condition:
o Ability to follow instruction
o Ability to help himself/herself

Equipment

Trolley - top shelf Trolley - bottom shelf

• Tray consist of: • Disposable gloves

• Sterile kidney dish • Bedpan with cover

• Specimen container for urine C&S • Draw sheet

• Specimen label • Linen protector/small mackintosh

• Laboratory form • Towel

• Specimen recording book • General waste receiver

• Hand sanitizer • Clinical waste receiver

159
 • Jug of water to clean perineum •

• Vulva swabbing set •

Preparation

• Identify the patient/client for specimen collection.

• Complete label and stick onto the specimen container.
• Perform hand hygiene.
• Prepare the equipment.
• Prepare the environment.

Imlementation

No Interventions Rationale

1 Greet and explain the procedure to the patient. To establish rapport, gain
cooperation and minimize
anxiety.

2 Verify patient's identity. To ensure accurate identification

of specimen to prevent errors in
diagnosis and treatment.

3 Provide privacy. To maintain patient's dignity.

4 Prepare the patient. To collect specimen.

• For ambulatory patient:

• Give the sterile kidney dish and specimen container

to the patient.

• Tell the patient not to touch the inner area of the

•
kidney dish.

• Tell the patient to go to the toilet and clean the

perineum with soap and water.

• Tell the patient to pass urine in the toilet bowl and

catch the middle part of the stream of urine with

160
 kidney dish, ensure do not let the urine come in
contact with the outer skin.

• Tell the patient to open cap of specimen container

with inner surface facing upward and do not touch
inner area of container.

• Tell the patient to pour till 2/3 full of urine into the
specimen container and cover the container tightly.

• Tell the patient to pass the urine specimen and

kidney dish to the nurse.

• For non-ambulatory patient:

• Place mackintosh under the patient's buttocks.

• Cover the patient with drawsheet.

• Help the patient to remove trousers/sarong.

• Don disposable gloves.

• Place the bedpan under the patient's buttock.

• Clean the patient's perineum with soap and water.

• Perform vulva swabbing for the patient (for female)

/ penile care (for male).

• Tell the patient to pass urine into bedpan.

• Catch the middle part of the stream of urine with

kidney dish and keep aside.

• Ask the patient to finish urinating and clean the

patient's perineum with water and dry it.

• Remove bedpan and mackintosh.

• Open cap of specimen container with inner surface

facing upward without touching the inner area of
container.

161
• Pour till 2/3 full of urine into the specimen container
and cover the container tightly.

• Remove gloves and perform hand hygiene.

• Assist the patient to put on the trousers/sarong.

• Make the patient comfortable and tidy up the unit.

5 Place the specimen into biohazard bag/specimen

carrier bag.

6 Record in specimen dispatch book. For documentation.

7 Make arrangement to send specimen to the To maximize accuracy of testing.

laboratory as soon as possible.

8 Clean and keep instrument. To prevent transmission of

microorganisms.

Evaluation

• Specimen is collected correctly.

• Specimen is sent in a timely manner.
• Trace and report the results to the staff in-charge and/or doctor.

162
 24-HOUR URINE COLLECTION
Objectives

• To observe the characteristics of urine.

• To detect nephrotic syndrome (glomerular disease) or any kidney disease.
• To detect nephrotic syndrome (glomerular disease) or any kidney disease.
• To help doctor to determine the diagnosis and treatment.

Assessment

• Check the doctor's order to confirm type of specimen to be collected and type of investigation
to be done.
• Assess the patient/client's general condition:
o Ability to follow instruction
o Ability to help himself/herself

Equipment

Trolley - top shelf Trolley - bottom shelf

• Urine specimen container for 24 hours collection • Urine measuring jug

• Specimen label •

• Laboratory form •

• Specimen recording book •

• Signage to indicate 24-hour urine specimen is being collected •

• Plain paper and pencil for patient to record urine output •

163
Preparation

• Identify the patient/client for specimen collection.

• Obtain a specimen bottle from the laboratory.
• Complete label and stick onto specimen container.
• Perform hand hygiene.
• Prepare the equipment.
• Prepare the environment.

Implementation

No Interventions Rationale

1 Greet and explain the procedure to the To establish rapport, gain cooperation and
patient. minimize anxiety.

2 Verify the patient's identity. To ensure accurate identification of

specimen to prevent errors in diagnosis and
treatment.

3 Place signage to indicate urine To promote accuracy.

specimen collection is in progress.

4 Explain to the patient on how to collect To maximize accuracy of testing.

the specimen:

• Urine will be collected over 24 hours

(e.g. 7am-7am).

• First urine specimen need to be

discarded (old urine).

• Place all urine into the specimen

container.

• Urinate into the measuring jug and

then pour inside the specimen
container.

• Record urine output and time in a

paper for 24 hours.

• Do not contaminate the urine and close

the cap of the container tightly.

164
 • Avoid caffeine-containing drinks during
the collection of urine

5 Ensure the specimen bottle cap is To prevent spillage.

closed tightly.

6 Remove signage and inform the patient

that specimen collection is completed.

7 Place the specimen into biohazard

bag/specimen carrier bag.

8 Record in specimen dispatch book. For documentation.

9 Make arrangement to send specimen To maximize accuracy of testing.

to the laboratory as soon as possible.

10 Clean and keep instrument. To prevent transmission of microorganism.

Evaluation

• Specimen is collected correctly.

• Specimen is sent in a timely manner.
• Trace and report the results to the staff in-charge and/or doctor.

165
 COLLECTION OF STOOL FOR FULL
EXAMINATION, MICROSCOPIC EXAMINATION
(FEME)/OVA & CYSTS/OCCULT BLOOD
Objectives

• To observe the characteristics of stool specimen.

• To determine the presence of microorganism and occult blood.
• To help the doctor to determine the diagnosis and treatment.

• Check the doctor's order to confirm type of specimen to be collected and type of investigation
to be done.
• Assess the patient/client's general condition:
o Ability to follow instruction
o Ability to help himself/herself

Equipment

Trolley - top shelf Trolley - bottom shelf

• Tray consist of: • Disposable gloves

• Specimen container for stool • Bedpan with cover

• Wooden spatula • Draw sheet

• Specimen label • Linen protector/small mackintosh

• Laboratory form • Towel

• Specimen recording book • General waste receiver

• Hand sanitizer • Clinical waste receiver

166
 • Jug of water to clean perineum •

Preparation

• Identify the patient/client for specimen collection.

• Complete label and stick onto the specimen container.
• Perform hand hygiene.
• Prepare the equipment.
• Prepare the environment.

Implementation

No Interventions Rationale

1 Greet and explain the procedure to the patient. To establish rapport, gain
cooperation and minimize anxiety.

2 Verify the patient's identity. To ensure accurate identification of

specimen to prevent errors in
diagnosis and treatment.

3 Provide privacy. To maintain patient's dignity.

4 Prepare the patient. To collect specimen.

• For ambulatory patient:

• Give the specimen container and wooden

spatula to the patient.

• Tell the patient to go to toilet and pass motion

in the clean bedpan.

• Instruct the patient not to urinate into the •

bedpan.

• Tell the patient to take a small amount of stool

from bedpan using spatula or spoon as
provided.

• Tell the patient to place stool into the

specimen container.

167
 • Tell the patient to discard spatula into clinical
waste bin.

• Tell the patient to cover the cap of the

specimen container tightly.

• Tell the patient to pass the specimen container

to the nurse.

• For non-ambulatory patient:

• Place mackintosh under the patient's buttocks.

• Cover the patient with drawsheet.

• Help the patient to remove trousers/sarong.

• Don disposable gloves.

• Place the bedpan under patient's buttocks.

• Tell the patient to pass motion into bedpan

and do not urinate in the bedpan.

• Open cap of specimen container and scoop a

small amount of stool from bedpan using
spatula or spoon as provided.

• Discard spatula into clinical waste and cover

the container tightly.

• Clean the patient's perineum with water and

dry it.

• Remove the bedpan and mackintosh.

• Remove gloves and perform hand hygiene.

• Assist the patient to put on the

trousers/sarong.

• Make the patient comfortable and tidy up the

unit.

5 Place the specimen into biohazard

bag/specimen carrier bag.

168
 6 Record in specimen dispatch book. For documentation.

7 Make arrangement to send specimen to the To maximize accuracy of testing.

laboratory as soon as possible.

8 Clean and keep instrument. To prevent transmission of

microorganism.

Evaluation

• Specimen is collected correctly.

• Specimen is sent in a timely manner.
• Trace and report the results to the staff in-charge and/or doctor.

169
 COLLECTION OF STOOL FOR CULTURE AND
SENSITIVITY (C&S)
Objectives

• To determine the type of microorganism present.

• To determine the type of antibiotics that are sensitive to the microbes causing the infection.
• To help doctor to determine the diagnosis and treatment.

Assessment

• Check the doctor's order to confirm type of specimen to be collected and type of investigation
to be done.
• Assess the patient/client's general condition:
o Ability to follow instruction
o Ability to help himself/herself

Equipment

Trolley - top shelf Trolley - bottom shelf

• Tray consist of: • Disposable gloves

• Sterile kidney dish • Bedpan with cover

• Specimen container for stool C&S • Draw sheet

• Sterile spatula • Linen protector/small mackintosh

• Specimen label • Towel

• Laboratory form • General waste receiver

• Specimen recording book • Clinical waste receiver

170
 • Hand sanitizer •

• Jug of water to clean perineum •

Preparation

• Identify the patient/client for specimen collection.

• Complete label and stick onto the specimen container.
• Perform hand hygiene.
• Prepare the equipment.
• Prepare the environment.

Implementation

No Interventions Rationale

1 Greet and explain the procedure to the patient. To establish rapport, gain
cooperation and minimize anxiety.

2 Verify the patient's identity. To ensure accurate identification of

specimen to prevent errors in
diagnosis and treatment.

3 Provide privacy. To maintain patient's dignity.

4 Prepare the patient. To collect specimen.

• For ambulatory patient:

• Give the sterile kidney dish and specimen

container to the patient.

• Tell the patient not to touch the inner area of the

kidney dish. •

• Tell the patient to go to the toilet and clean the

perineum with soap and water.

• Tell the patient to pass motion in the kidney

dish.

171
 • Instruct the patient not to urinate in the kidney
dish.

• Tell the patient to open cap of the specimen

container with inner surface facing upward and
not to touch inner area of container.

• Tell the patient to take a small amount of stool

from the kidney dish using sterile spatula and
place stool into the specimen container.

• Tell the patient to discard the spatula into the

clinical waste bin.

• Tell the patient cover the container tightly.

• Tell the patient to pass the stool specimen and

kidney dish to the nurse.

• For non-ambulatory patient:

• Place mackintosh under the patient's buttocks.

• Cover the patient with drawsheet.

• Help the patient to remove trousers/sarong.

• Don disposable gloves.

• Place the bedpan under the patient's buttocks.

• Place the sterile kidney into bedpan without

touching the inner area of sterile kidney dish.

• Tell the patient to pass motion and not to urinate

in sterile kidney dish.

• Open cap of specimen container with inner

surface facing upward and do not touch inner
area of container.

• Take a small amount of stool from kidney dish

using sterile spatula and place stool into the
specimen container.

172
• Cover the container tightly.

• Clean the patient's perineum with water and dry

it.

• Remove the bedpan and mackintosh.

• Remove gloves and perform hand hygiene.

• Assist the patient to put on the trousers/sarong.

• Make the patient comfortable and tidy up the

unit.

5 Place the specimen into biohazard

bag/specimen carrier bag.

6 Record in specimen dispatch book. For documentation.

7 Make arrangement to send specimen to the To maximize accuracy of testing.

laboratory as soon as possible.

8 Clean and keep instrument. To prevent transmission of

microorganism.

Evaluation

• Specimen is collected correctly.

• Specimen is sent in a timely manner.
• Trace and report the results to the staff in-charge and/or doctor.

173
 COLLECTION OF SPUTUM FOR CULTURE AND
SENSITIVITY (C&S)
Objectives

• To determine the type of microorganism present.

• To determine the type of antibiotics that are sensitive to the microbes causing the infection.
• To help doctor to determine the diagnosis and treatment.

Assessment

• Check the doctor's order to confirm type of specimen to be collected and type of investigation
to be done.
• Assess the patient/client's general condition:
o Ability to follow instruction
o Ability to help himself/herself

Equipment

Trolley - top shelf Trolley - bottom shelf

• Tray consist of: • Receiver to collect mouth rinse

• Specimen container for sputum C&S • General waste receiver

• Tissue paper • Clinical waste receiver

• Specimen label •

• Laboratory form •

• Specimen recording book •

• Water for mouth rinse •

174
Preparation

• Identify the patient/client for specimen collection.

• Complete label and stick onto the specimen container.
• Perform hand hygiene.
• Prepare the equipment.
• Prepare the environment.

Implementation

No Interventions Rationale

1 Greet and explain the procedure to the patient. To establish rapport, gain
cooperation and minimize anxiety.

2 Verify the patient's identity. To ensure accurate identification of

specimen to prevent errors in
diagnosis and treatment.

3 Provide privacy. To maintain patient's dignity.

4 Prepare the patient. To collect specimen.

• Tell the patient to rinse mouth with water. Do

not use mouthwash.

• Tell the patient to open cap of specimen

container with inner surface facing upward and
not to touch the inner area of the container.

• Tell the patient to take a deep breath and hold

for 5 seconds.

• Tell the patient to slowly breathe out.

•

• Tell the patient to take another deep breath

and cough forcefully.

• Tell the patient to spit the sputum into the

specimen container.

• Tell the patient to close the container tightly

and pass the container to the nurse.

• Make the patient comfortable and tidy up the

unit.

175
 5 Place the specimen into biohazard
bag/specimen carrier bag.

6 Record in specimen dispatch book. For documentation.

7 Make arrangement to send specimen to the To maximize accuracy of testing.

laboratory as soon as possible.

8 Clean and keep instrument. To prevent transmission of

microorganisms.

Evaluation

• Specimen is collected correctly.

• Specimen is sent in a timely manner.
• Trace and report the results to the staff in-charge and/or doctor.

176
 COLLECTION OF SPUTUM FOR ACID-FAST
BACILLI (AFB)
Objectives

• To observe the characteristics of specimen.

• To determine the presence of mycobacterium.
• To help doctor to determine the diagnosis and treatment.
• To assess the effectiveness of treatment.

Assessment

• Check the doctor's order to confirm type of specimen to be collected and type of investigation
to be done.
• Assess the patient/client's general condition:
o Ability to follow instruction
o Ability to help himself/herself

Equipment

Trolley - top shelf Trolley - bottom shelf

• Tray consist of: • Receiver to collect mouth rinse

• Specimen container for sputum AFB • Receiver to collect mouth rinse

• Tissue paper •

• Specimen label •

• Laboratory form •

• Specimen recording book •

• Water for mouth rinse •

177
Preparation

• Identify the patient/client for specimen collection.

• Complete label and stick onto the specimen container.
• Perform hand hygiene.
• Prepare the equipment.
• Prepare the environment.

No Interventions Rationale

1 Greet and explain the procedure to the patient. To establish rapport, gain
cooperation and minimize anxiety.

2 Verify the patient's identity. To ensure accurate identification of

specimen to prevent errors in
diagnosis and treatment.

3 Provide privacy. To maintain patient's dignity.

4 Prepare the patient. To collect specimen.

• Tell the patient to rinse mouth with water. Do

not use mouthwash.

• Tell the patient to open cap of the specimen

container with inner surface facing upward and
not to touch the inner area of the container.

• Tell the patient to take a deep breath and hold

for 5 seconds.

• Tell the patient to slowly breathe out.

•

• Tell the patient to take another deep breath and

cough forcefully.

• Tell the patient to spit the sputum into the

specimen container.

• Tell the patient to close the container tightly

and pass the container to the nurse.

• Make the patient comfortable and tidy up the

unit.

5 Place the specimen into biohazard

bag/specimen carrier bag.

178
 6 Record in specimen dispatch book. For documentation.

7 Make arrangement to send specimen to the To maximize accuracy of testing.

laboratory as soon as possible.

8 Clean and keep instrument. To prevent transmission of

microorganisms.

Evaluation

• Specimen is collected correctly.

• Specimen is sent in a timely manner.
• Trace and report the results to the staff in-charge and/or doctor.

179
 COLLECTION OF THROAT SWAB FOR CULTURE
AND SENSITIVITY (C&S)
Objectives

• To determine the type of microorganism present.

• To determine the type of antibiotics that are sensitive to the microbes causing the infection.
• To help doctor to determine the diagnosis and treatment.

Assessment

• Check the doctor's order to confirm type of specimen to be collected and type of investigation
to be done.
• Assess the patient/client's general condition:
o Ability to follow instruction
o Ability to help himself/herself

Equipment

Trolley - top shelf Trolley - bottom shelf

• Tray consist of: • Torchlight

• Kidney dish with wooden spatula • General waste receiver

• Sterile swab with culture tube • Clinical waste receiver

• Specimen label •

• Laboratory form •

• Specimen recording book •

180
Preparation

• Identify the patient/client for specimen collection.

• Complete label and stick onto the specimen container.
• Perform hand hygiene.
• Prepare the equipment.
• Prepare the environment.

Implementation

No Interventions Rationale

1 Greet and explain the procedure to the patient. To establish rapport, gain
cooperation and minimize anxiety.

2 Verify the patient's identity. To ensure accurate identification

of specimen to prevent errors in
diagnosis and treatment.

3 Provide privacy. To maintain patient's dignity.

4 Place the patient in semi Fowler's position.

5 Tell the patient to open mouth and stick the

tongue out.

6 Press down the tongue with wooden spatula to

visualize the throat using the torchlight.

7 Use sterile cotton swab from the specimen To maximize accuracy of testing.
container to swab both the tonsillar arches and
the posterior nasopharynx without touching the
sides of the mouth.

8 Insert the swab into the specimen container with To maximize accuracy of testing.
the culture medium without touching the sides of
tube.

9 Perform hand hygiene. To reduce transmission of

microorganisms.

10 Make the patient comfortable and tidy up the unit.

11 Place the specimen into biohazard bag/specimen

carrier bag.

12 Record in specimen dispatch book. For documentation.

181
 13 Make arrangement to send specimen to the To maximize accuracy of testing.
laboratory as soon as possible.

14 Clean and keep instrument. To prevent transmission of

microorganism.

Evaluation

• Specimen is collected correctly.

• Specimen is sent in a timely manner.
• Trace and report the results to the staff in-charge and/or doctor.

182
 COLLECTION OF VOMITUS
Objectives

• To observe the characteristics of specimen.

• To determine the type of antibiotics that are sensitive to the microbes causing the infection.
• To help doctor to determine the diagnosis (suicidal cases, food poisoning, etc.) and
treatment.

Assessment

• Check the doctor's order to confirm type of specimen to be collected and type of investigation
to be done.
• Assess the patient/client's general condition:
o Ability to follow instruction
o Ability to help himself/herself

Equipment

Trolley - top shelf Trolley - bottom shelf

• Tray consist of: • Torchlight

• Kidney dish with wooden spatula • General waste receiver

• Sterile swab with culture tube • Clinical waste receiver

• Specimen label •

•
• Laboratory form

• Specimen recording book •

• Cup of water for gargling •

183
 • Hand sanitizer •

Preparation

• Identify the patient/client for specimen collection.

• Complete label and stick onto the specimen container.
• Perform hand hygiene.
• Prepare the equipment.
• Prepare the environment.

Implementation

No Interventions Rationale

1 Greet and explain the procedure to the To establish rapport, gain cooperation and
patient. minimize anxiety.

2 Verify the patient's identity. To ensure accurate identification of specimen

to prevent errors in diagnosis and treatment.

3 Provide privacy. To maintain patient's dignity.

4 Tell the patient to vomit into a vomit

bowl when vomiting.

5 Tell the patient to seek assistance

when necessary (press call bell).

6 Assist the patient to gargle after

vomiting.

7 Make the patient comfortable and tidy

up the unit.

8 Don disposable gloves. To prevent contamination.

9 Scoop the vomitus into the specimen

container.

10 Observe and note the characteristics

of the vomitus.

11 Place the specimen into biohazard

bag/specimen carrier bag.

184
 12 Record in specimen dispatch book. For documentation.

13 Make arrangement to send specimen To maximize accuracy of testing.

to the laboratory as soon as possible.

14 Clean and keep instrument. To prevent transmission of microorganism.

Evaluation

• Specimen is collected correctly.

• Specimen is sent in a timely manner.
• Trace and report the results to the staff in-charge and/or doctor.

185
 TAKING BLOOD FILM FOR MALARIA PARASITE
(BFMP)
Objectives

• To confirm diagnosis of malaria.

• To assess the effects of anti-malarial drugs.

Assessment

• Determine patient/client's general condition and tolerance for the procedure.

• Determine patient/client's ability to understand instruction.
• Identify the reason for specimen taking.
• Assess general health and functional abilities of the patient/client.

Equipment

Trolley - top shelf Trolley - bottom shelf

• Tray consist of: • Disposable gloves

• Alcohol swab • General waste receiver

• Dry swab/cotton in gallipot • Clinical waste receiver

• Lancet • Sharp container

• 2 glass slides with container •

• Specimen label •

• Laboratory form •

• Specimen recording book •

186
 • Hand sanitizer •

Preparation

• Identify the patient/client for specimen collection.

• Complete label and stick onto the specimen container.
• Perform hand hygiene.
• Prepare the equipment.
• Prepare the environment.

Implementation

No Interventions Rationale

1 Greet and explain the procedure to the patient. To establish rapport, gain
cooperation and minimize
anxiety.

2 Verify the patient's identity. To ensure accurate

identification of specimen to
prevent errors in diagnosis
and treatment.

3 Provide privacy. To maintain patient's dignity.

4 Don disposable gloves. To prevent contamination.

5 Blood taking: To collect specimen.

• •
Choose appropriate finger (usually middle finger of the
left hand).

• Hold the finger and clean the fingertip with alcohol

swab, allow it to dry.

• Prick the finger with disposable needle/lancet.

• Discard the lancet into the sharp container.

• Wipe away the first drop of blood with dry swab.

• Take a clean glass slide.

187
 • Gently squeeze the finger to release a drop of blood on
1 cm from the edge of the slide and 3 drops of blood 1
cm from the first drop of blood.

• Take another clean slide with smooth edges and use it

as a spreader and make thick and thin smears.

• Thick smear: encircle the bigger drop with the corner of

the glass slide to form a bigger circle equivalent to the
size of a 10 cents coin.

• Thin film: hold the glass slide at a 45° angle toward the
drops of blood on the specimen slide. Wait until the
blood spreads along the entire width of the spreader
slide. While holding the spreader slide at the same
angle, push it forward rapidly and smoothly.

• Allow it to dry.

• Place in the glass slide container.

6 Discard disposable gloves and perform hand hygiene. To prevent contamination.

7 Make the patient comfortable and tidy up the unit.

8 Place the specimen into biohazard bag/specimen

carrier bag.

9 Record in specimen dispatch book. For documentation.

10 Make arrangement to send specimen to the laboratory To maximize accuracy of

as soon as possible. testing.

11 Clean and keep instrument. To prevent transmission of

microorganisms.

Evaluation

• Specimen is collected correctly.

• Specimen is sent in a timely manner.
• Trace and report the results to the staff in-charge and/or doctor.

188
 BANDAGING: CIRCULAR TURNS, SPIRAL TURNS,
REVERSE SPIRAL TURNS, FIGURE OF EIGHT
Objectives

• To immobilize an injured body part.

• To apply pressure to stop or reduce bleeding.
• To apply compression or support.
• To protect a wound and hold dressing in place.
• To retain warmth on a rheumatoid joint.
• To promote venous return.

Assessment

• Check the doctor's order to confirm the body part to be bandaged.

• Assess the patient/client's general condition:
o Comfortable or in pain
o Ability to help himself/herself
• Assess the part to be bandaged to determine the size and technique of bandaging.
• Assess the condition of the wound/injury:
o Clean/bleeding
o Any sign of infection

Equipment

Tray consist of:

• Bandages of appropriate type/size

• Adhesive tape/plaster

Preparation

• Identify the patient/client for bandaging.

• Ensure wound dressing is intact.
• Prepare the equipment.
• Prepare the environment.
• Perform hand hygiene.

189
Implementation

No Interventions Rationale

1 Greet and explain the procedure to the patient. To establish rapport, gain
cooperation and minimize
anxiety.

2 Provide privacy. To maintain patient's dignity.

3 Sit or lie the patient down supporting the affected To provide comfort and
body part. maintain body alignment.

4 Hold rolled bandage facing upwards. To comply with principles of

bandaging, from inner to outer
aspect.

5 Apply bandage at the distal end. To comply with principles of

bandaging from distal to
proximal.

6 Start bandaging with two circular turns. To anchor bandage.

7 Circular Turns: continue bandage with circular turns.

8 Spiral Turns: continue spiral turns at an angle of 30°

towards the proximal part of the affected part.

9 Spiral Reverse Turn: •

• Continue spiral turns at an angle of 30° towards the

proximal part of the affected limb.

• Place the thumb of the free hand on the upper edge

of the bandage.

• Fold bandage downwards on top of the thumb.

10 Figure of Eight: continue subsequent turns above the

joint, around it and then below it, making a figure of
eight above and below the joint.

11 Ensure each turn covers 2/3 the surface of the To comply with principles of
previous turn. bandaging.

190
 12 End the bandaging with two circular turns. To comply with principles of
bandaging.

13 Tidy and secure the bandage with adhesive To secure the bandage.
tape/plaster at the side or front of limb.

14 Make the patient comfortable and tidy up the unit.

15 Document the procedure and any finding. For documentation and further
evaluation.

Evaluation

• Bandage is tidy and secured.

• A baseline neurovascular assessment of both limbs (affected and nonaffected) are performed
and documented.
• Significant changes are reported to the staff in-charge and/or doctor.

191
 STUMP BANDAGING
Objectives

• To control swelling.
• To reshape contour of a body part for prosthesis such as below/above knee amputation.
• To protect a wound and hold dressing in place.

Assessment

• Check the doctor's order to confirm the body part to be bandaged.

• Assess the patient/client's general condition:
o Comfortable or in pain
o Ability to help himself/herself
• Assess the part to be bandaged to determine the size and technique of bandaging.
• Assess the condition of the wound/injury:
o Clean/bleeding
o Any sign of infection

Equipment

Tray consist of:

• Bandages of appropriate type/size:

• Above-Knee Amputation: 2-3 lengths of 4-6̎ elastic bandage

• Below-Knee Amputation: 2-3 lengths of 3-4̎ elastic bandage

• Adhesive tape/plaster

Preparation

• Identify the patient/client for bandaging.

• Ensure the dressing is intact.
• Prepare the equipment.
• Prepare the environment.
• Perform hand hygiene.

192
Implementation

No Interventions Rationale

1 Greet and explain the procedure to the patient. To establish rapport, gain
cooperation and minimize anxiety.

2 Provide privacy. To maintain patient's dignity.

3 Stand/sit in front of the patient. To comply with principles of

bandaging.

4 Start bandaging at the distal end of the stump to To comply with stump bandaging
reach the popliteal space. requirement.

5 Fold the bandage and bring bandage back to

the distal end of the stump.

6 Ensure each turn covers 2/3 the surface of To comply with principles of
previous turn. bandaging.

7 Make recurrent turns alternating with left and To comply with recurrent bandaging
right side of the stump. requirement.

8 End the bandaging with two circular turns at the To secure end of bandage.
anterior side of the stump.

9 Tidy and secure the bandage with adhesive To secure the bandage.
tape/plaster at the side or front of the limb.

10 Make the patient comfortable and tidy up the

unit.

11 Document the procedure and any finding. For documentation and further
evaluation.

Evaluation

• Bandage is tidy and secured.

193
• A baseline neurovascular assessment of both limbs (affected and nonaffected) are performed
and documented.
• Significant changes are reported to the staff in-charge and/or doctor.

TRIANGULAR BANDAGING
Objectives

• To support a fractured clavicle or dislocated shoulder.

• To support and immobilize the forearm.
• To immobilize the elbow and upper arm.

Assessment

• Check the doctor's order to confirm the body part to be bandaged.

• Assess the patient/client's general condition:
o Comfortable or in pain
o Ability to help himself/herself
• Assess the part to be bandaged to determine the size and technique of bandaging.
• Assess the condition of the wound/injury:
o Clean/bleeding
o Any sign of infection

Equipment

Tray consist of:

• Triangular bandage/arm sling

• Adhesive tape/plaster/safety pin

Preparation

• Identify the patient/client for bandaging.

• Ensure the dressing is intact.

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• Prepare the equipment.
• Prepare the environment.
• Perform hand hygiene.

Implementation

No Interventions Rationale

1 Greet and explain the procedure to the patient. To establish rapport, gain
cooperation and minimize
anxiety.

2 Provide privacy. To maintain patient's

dignity.

3 Stand in front of the patient. To provide comfort and

maintain body alignment.

4 Tell the patient to support the injured arm across in

front of the chest.

5 Place the triangular bandage under the injured arm. To comply with the
Ensure that: principles of bandaging.

• The arm is in the centre.

• The apex of the sling is below the elbow.
• The top corner is over the shoulder of the injured
side

6 Bring the lower portion of the triangular bandage over

the injured arm so that the bottom corner goes over the
shoulder of the uninjured side.

7 Bring the top corner behind the patient's back.

8 Tie the two corners together (reef knot/square knot) at To comply with principles of
the side of the neck on the uninjured side. bandaging.

• Place one end of the triangular bandage over the other.

• Bring the end of the right side over the left end.

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 • Then bring the left end over the right end.

• Pull on both ends firmly to secure the knot

9 Tidy and secure the bandage with adhesive To secure the bandage.
tape/plaster/safety pin.

10 Make the patient comfortable and tidy up the unit.

11 Document the procedure and any finding. For documentation and

further evaluation.

Evaluation

• Triangular bandage is tidy and secured.

• Significant changes are reported to the staff in-charge and/or doctor.

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