NUR 101 FUNDAMENTAL OF NURSING PROCEDURE MANUAL for PCL course

Table of Contents I. Basic Nursing Care/ Skill 1. Bed making a. Making an Un-occupied bed b. Changing an Occupied bed c. Making a Post-operative bed 2. Performing oral care a. Assisting the client with oral care b. Providing oral care for dependent client 3. Performing bed bath 4. Performing back care 5. Performing hair washing 6. Care for fingernails/ toenails 7. Performing perineal care 8. Taking vital signs a. Taking axillary temperature by glass thermometer b. Measuring radial pulse c. Counting respiration d. Measuring blood pressure 9. Performing physical examination 10. Care for Nasal-gastric Tube a. Inserting a Nasal-Gastric Tube b. Removal a Nasal-Gastric Tube 11. Administering Nasal-Gastric tube feeding 12. Cleaning a wound and Applying a sterile dressing 13. Supplying oxygen inhalation a. Nasal Cannula Method b. Mask Method: Simple face mask II. Administration of Medications 1. Administering oral medications 2. Administering oral medications through a Nasal-Gastric Tube 3. Removing medications from an ampoule 4. Removing medications from a vial 5. Prevention of the needle-stick injuries 6. Giving an Intra-muscular injection 7. Starting an Intra-venous infusion 8. Maintenance of I.V. system 9. Administering medications by Heparin Lock 10. Performing Nebulizer Therapy a. Inhaler b. Ultrasonic nebulizer 7 9 13 16 19 21 23 26 30 32 35 37 39 41 43 45 46 49 98 98 101 102 106 109 111 113 115 117 120 123 126 129 130 135 140 144 147 148 149 III. Specimen collection 1. Collecting blood specimen a. Performing venipuncture b. Assisting in obtaining blood for culture 2.Collecting urine specimen a. Collecting a single voided specimen b. Collecting a 24-hour urine specimen c. Collecting a urine specimen from a retention catheter d. Collecting a urine culture 3. Collecting a stool specimen 4. Collecting a sputum specimen a. Routine test b. Collecting a sputum culture Appendix References 151 153 153 157 159 160 161 163 164 166 168 168 169 171 181 I. Basic Nursing Care/ Skill Bed making a. Making an Un-occupied Bed Definition: Abed prepared to receive a new patient is an un-occupied bed. Fig.1. Un-occupied bed Purpose 1. To provide clean and comfortable bed for the patient 2. To reduce the risk of infection by maintaining a clean environment 3. To prevent bed sores by ensuring there are no wrinkles to cause pressure points Equipment required: 1. Mattress (1) 2. Bed sheets(2): Bottom sheet (1) Top sheet (1) 3. Pillow (1) 4. Pillow cover (1) 5. Mackintosh (1) 6. Draw sheet (1) 7. Blanket (1) 8. Savlon water or Dettol water in basin 9. Sponge cloth (4): to wipe with solution (1) to dry (1) When bed make is done by two nurses, sponge cloth is needed two each. 10. Kidney tray or paper bag (1) 11. Laundry bag or Bucket (1) 12. Trolley(1) Fig. 2. Equipment required on a trolley Procedure: by one nurse Care Action Rationale 1. Explain the purpose and procedure to the client. • Providing information fosters cooperation. 2. Perform hand hygiene. • To prevent the spread of infection. 3. Prepare all required equipments and bring the articles to the bedside. • Organization facilitates accurate skill performance 4. Move the chair and bed side locker • It makes space for bed making and helps effective action. 5. Clean Bed-side locker: Wipe with wet and dry. • To maintain the cleanliness 6. Clean the mattress: 1) Stand in right side. 2) Start wet wiping from top to center and from center to bottom in right side of mattress. 3) Gather the dust and debris to the bottom. 4) Collect them into kidney tray. 5) Give dry wiping as same as procedure 2). 6) Move to left side. 7) Wipe with wet and dry the left side. • To prevent the spread of infection 7. Move to right side. Bottom sheet: 1) Place and slide the bottom sheet upward over the top of the bed leaving the bottom edge of the sheet. 2) Open it lengthwise with the center fold along the bed center. 3) Fold back the upper layer of the sheet toward the opposite side of the bed. 4) Tuck the bottom sheet securely under the head of the mattress(approximately 20-30cm). (Fig.3) Make a mitered corner. Pick up the selvage edge with your hand nearest the hand of the bed. Lay a triangle over the side of the bed (Fig.4 ) Tuck the hanging part of the sheet under the mattress.( Fig. 5) Drop the triangle over the side of the bed. ( Fig. 6Ⓓ→ 6ⓑ) ⑤Tuck the sheet under the entire side of bed.(Fig. 7) 5) Repeat the same procedure at the end of the corner of the bed 6) Tuck the remainder in along the side • Unfolding the sheet in this manner allows you to make the bed on one side. • Amitered corner has a neat appearance and keeps the sheet securely under the mattress. • Tucking the bottom sheet will be done by turn, the corner of top firstly and the corner of the bottom later. • To secure the bottom sheet on one side of the bed. 8. Mackintosh and draw sheet: 1) Place a mackintosh at the middle of the bed ( if used), folded half, with the fold in the center of the bed. used), folded half, with the fold in the center of the bed. 2) Lift the right half and spread it forward the near Side. • Mackintosh and draw sheet are additional protection for the bed and serves as a lifting or turning sheet for an immobile client. Fig.3 Tuck the bottom sheet under the mattress Fig.6a Putting and holding the sheet bedside the mattress at the level of top Fig.4 Picking the selvage and laying a triangle on the bed Fig.5 Tucking the hanging part of the sheet under the mattress Fig.6b Dropping the triangle over the side of the bed Fig.7 Tucking the sheet under the entire side of the bed Care Action Rationale 3) Tuck the mackintosh under the mattress. 4) Place the draw sheet on the mackintosh. Spread and tuck as same as procedure 1)-3). 9.Move to the left side of the bed. Bottom sheet , mackintosh and draw sheet: 1) Fold and tuck the bottom sheet as in the above procedure 7. 2) Fold and tuck both the mackintosh and the draw sheet under the mattress as in the above procedure 8. • Secure the bottom sheet, mackintosh and draw sheet on one side of the bed 10. Return to the right side. Top sheet and blanket: 1) Place the top sheet evenly on the bed, centering it in the below 20-30cm from the top of the mattress. 2) Spread it downward. 3) Cover the top sheet with blanket in the below 1 feet from the top of the mattress and spread downward. 4) Fold the cuff (approximately 1 feet) in the neck part 5) Tuck all these together under the bottom of mattress. Miter the corner. 6) Tuck the remainder in along the side • Ablanket provides warmth. • Making the cuff at the neck part prevents irritation from blanket edge. • Tucking all these pieces together saves time and provides a neat appearance. 11. Repeat the same as in the above procedure 10 in left side. • To save time in this manner 12. Return to the right side. Pillow and pillow cover: 1) Put a clean pillow cover on the pillow. 2) Place a pillow at the top of the bed in the center with the open end away from the door. • Apillow is a comfortable measure. • Pillow cover keeps cleanliness of the pillow and neat. • The open end may collect dust or organisms. • The open end away from the door also makes neat. 13. Return the bed, the chair and bed-side table to their proper place. • Bedside necessities will be within easy reach for the client . 14. Replace all equipments in proper place. Discard lines appropriately. • It makes well-setting for the next. • Proper line disposal prevents the spread of infection. 15. Perform hand hygiene • To prevent the spread of infection. Nursing Alert • Do not let your uniform touch the bed and the floor not to contaminate yourself. • Never throw soiled lines on the floor not to contaminate the floor. • Staying one side of the bed until one step completely made saves steps and time to do effectively and save the time. Bed making b. Changing an Occupied Bed Definition The procedure that used lines are changed to a hospitalized patient is an occupied bed. Fig. 8 Occupied bed Purpose: 1. To provide clean and comfortable bed for the patient 2. T reduce the risk of infection by maintaining a clean environment 3. To prevent bed sores by ensuring there are no wrinkles to cause pressure points Equipment required: 1. Bed sheets(2) : Bottom sheet( or bed cover) (1) Top sheet (1) 2. Draw sheet (1) 3. Mackintosh (1) (if contaminated or needed to change) 4. Blanket (1) ( if contaminated or needed to change) 5. Pillow cover (1) 6. Savlon water or Dettol water in bucket 7. Sponge cloth (2): to wipe with solution (1) to dry (1) When the procedure is done by two nurses, sponge cloth is needed two each. 8. Kidney tray or paper bag (1) 9. Laundry bag or bucket (1) 10. Trolley (1) Procedure: by one nurse Care Action Rationale 1. Check the client’s identification and condition. • To assess necessity and sufficient condition 2. Explain the purpose and procedure to the client • Providing information fosters cooperation 3. Perform hand hygiene • To prevent the spread of infection. 4. Prepare all required equipments and bring the articles to the bedside. • Organization facilitates accurate skill performance 5. Close the curtain or door to the room. Put screen. • To maintain the client’s privacy. 6. Remove the client’s personal belongings from bed-side and put then into the bed-side locker or safe place. • To prevent personal belongings from damage and loss. 7. Lift the client’s head and move pillow from center to the left side. • The pillow is comfortable measure for the client. 8. Assist the client to turn toward left side of the bed. Adjust the pillow. Leaves top sheet in place. • Moving the client as close to the other side of the bed as possible gives you more room to make the bed. • Top sheet keeps the client warm and protect his or her privacy. 9.Stand in right side: Loose bottom bed linens. Fanfold (or roll) soiled linens from the side of the bed and wedge them close to the client. • Placing folded (or rolled) soiled linen close to the client allows more space to place the clean bottom sheets. 10. Wipe the surface of mattress by sponge cloth with wet and dry. • To prevent the spread of infection. 11. Bottom sheet, mackintosh and draw sheet: 1) Place the clean bottom sheet evenly on the bed folded lengthwise with the center fold as close to the client’s back as possible. 2) Adjust and tuck the sheet tightly under the head of the mattress, making mitered the upper corner. 3) Tighten the sheet under the end of the mattress and make mitered the lower corner. 4) Tuck in along side. 5) Place the mackintosh and the draw sheet on the bottom sheet and tuck in them together. • Soiled linens can easily be removed and clean linens are positioned to make the other side of the bed. 12. Assist the client to roll over the folded (rolled) linen to right side of the bed. Readjust the pillow and top sheet. • Moving the client to the bed’s other side allows you to make the bed on that side. 13. Move to left side: Discard the soiled linens appropriately. Hold them away from your uniform. Place them in the laundry bag (or bucket). • Soiled linens can contaminate your uniform, which may come into contact with other clients. 14. Wipe the surface of the mattress by sponge cloth with wet and dry. • To prevent the spread of infection. 15. Bottom sheet, mackintosh and draw sheet: 1) Grasp clean linens and gently pull them out from under the client. 2) Spread them over the bed’s unmade side. Pull the linens taut • Wrinkled linens can cause skin irritation. Care Action Rationale 3) Tuck the bottom sheet tightly under the head of the mattress and miter the corner. 4) Tighten the sheet under the end of the mattress and make mitered the lower corner. 5) Tuck in along side. 6) Tuck the mackintosh and the draw sheet under the mattress. 16. Assist the client back to the center of the bed. Adjust the pillow. • The pillow is comfort measure for the client. 17. Return to right side: Clean top sheet, blanket: 1) Place the clean top sheet at the top side of the soiled top sheet. 2) Ask the client to hold the upper edge of the clean top sheet. 3) Hold both the top of the soiled sheet and the end of the clean sheet with right hand and withdraw to downward. Remove the soiled top sheet and put it into a laundry bag (or a bucket). 4) Place the blanket over the top sheet. Fold top sheet back over the blanket over the client. 5) Tuck the lower ends securely under the mattress. Miter corners. 6) After finishing the right side, repeat the left side. • Tucking these pieces together saves time and provides neat, tight corners. 18. Remove the pillow and replace the pillow cover with clean one and reposition the pillow to the bed under the client’s head. • The pillow is a comfortable measures for a client 19. Replace personal belongings back. Return the bed-side locker and the bed as usual. • To prevent personal belongings from loss and provide safe surroundings 20. Return all equipments to proper place. • To prepare for the next procedure 21. Discard linens appropriately. Perform hand hygiene. • To prevent the spread of infection. Bed making c. Making a Post-operative Bed Definition: It is a special bed prepared to receive and take care of a patient returning from surgery. Fig.9 Post-operative bed Purpose: 1. To receive the post-operative client from surgery and transfer him/her from a stretcher to a bed 2. To arrange client’s convenience and safety Equipment required: 1. Bed sheets: Bottom sheet (1) Top sheet (1) 2. Draw sheet (1-2) 3. Mackintosh or rubber sheet (1-2) According to the type of operation, the number required of mackintosh and draw sheet is different. 4. Blanket (1) 5. Hot water bag with hot water (104- 140 ℉) if needed (1) 6. Tray1(1) 7. Thermometer, stethoscope, sphygmomanometer: 1 each 8. Spirit swab 9. Artery forceps (1) 10. Gauze pieces 11. Adhesive tape (1) 12. Kidney tray (1) 13. Trolley (1) 14. IV stand 15. Client’s chart 16. Client’s kardex 17. According to doctor’s orders: - Oxygen cylinder with flow meter - O2 cannula or simple mask - Suction machine with suction tube - Airway - Tongue depressor - SpO2 monitor - ECG - Infusion pump, syringe pump Procedure: by one nurse Care Action Rationale 1. Perform hand hygiene • To prevent the spread of infection 2.Assemble equipments and bring bed-side • Organization facilitates accurate skill performance 3. Strip bed. Make foundation bed as usual with a large mackintosh, and cotton draw sheet. • Mackintosh prevents bottom sheet from wetting or soiled by sweat, drain or excrement. • Place mackintosh according to operative technique. • Cotton draw sheet makes the client felt dry or comfortable without touching the mackintosh directly. 4. Place top bedding as for closed bed but do not tuck at foot • Tuck at foot may hamper the client to enter the bed from a stretcher 5. Fold back top bedding at the foot of bed. (Fig.10 ) • To make the client ‘s transfer smooth 6. Tuck the top bedding on one side only. (Fig. 11 ) • Tucking the top bedding on one side stops the bed linens from slipping out of place and 7. On the other side, do not tuck the top sheet. 1) Bring head and foot corners of it at the center of bed and form right angles. (Fig.12 ) 2) Fold back suspending portion in 1/3 (Fig. 13 )and repeat folding top bedding twice to opposite side of bed(Fig.14, 15) • The open side of bed is more convenient for receiving client than the other closed side. 8. Remove the pillow. • To maintain the airway 9 Place a kidney-tray on bed-side. • To receive secretion 10. Place IV stand near the bed. • To prepare it to hang I/V soon 11. Check locked wheel of the bed. • To prevent moving the bed accidentally when the client is shifted from a stretcher to the bed. 12.Place hot water bags(or hot bottles) in the middle of the bed and cover with fanfolded top if needed • Hot water bags (or hot bottles) prevent the client from taking hypothermia 13.When the patient comes, remove hot water bags if put before • To prepare enough space for receiving the client 14. Transfer the client: 1) Help lifting the client into the bed 2) Cover the client by the top sheet and blanket immediately 3) Tuck top bedding and miter a corner in the end of the bed. • To prevent the client from chilling and /or having hypothermia Fig. 10 Folding back top bedding at the foot Fig. 11 Tucking the top bedding on left side Fig. 12 Bringing both head and foot corners to the center and forming right angles Fig. 13 Folding 1/3 side of top bedding at right side Fig.14 Rolling top bedding again Fig. 15 Folding it again and complete top bedding Performing Oral Care Definition: Mouth care is defined as the scientific care of the teeth and mouth. Purpose: 1. To keep the mucosa clean, soft, moist and intact 2. To keep the lips clean, soft, moist and intact 3. To prevent oral infections 4. To remove food debris as well as dental plaque without damaging the gum 5. To alleviate pain, discomfort and enhance oral intake with appetite 6. To prevent halitosis or relieve it and freshen the mouth Equipment required: 1. Tray (1) 2. Gauze-padded tongue depressor (1): to suppress tongue 3. Torch(1) 4. Appropriate equipments for cleaning: - Tooth brush - Foam swabs - Gauze-padded tongue depressor - Cotton ball with artery forceps (1) and dissecting forceps (1) 5. Oral care agents: Tooth paste/ antiseptic solution NURSING ALERT You should consider nursing assessment, hospital policy and doctor’s prescription if there is, when you select oral care agent. Refer to Table 1. on the next page 6. If you need to prepare antiseptic solution as oral care agent: Gallipot (2): to make antiseptic solution(1) to set up cotton ball after squeezed (1) 7. Cotton ball 8. Kidney tray (1) 9. Mackintosh (1): small size 10. Middle towel (1) 11. Jug with tap water (1) 12. Paper bag(2): for cotton balls (1) for dirt(1) 13. Gauze pieces as required: to apply a lubricant 14. Lubricants: Vaseline/ Glycerin/ soft white paraffin gel/ lip cream (1) 15. Suction catheter with suction apparatus (1): if available 16. Disposable gloves( 1 pair): if available NOTE: Table 1. Various oral care agents for oral hygiene The choice of an oral care agent is dependent on the aim of care. The various agents are available and should be determined by the individual needs of the client. Agents Potential benefits Potential harms Tap water • To refresh • be available • Short lasting • not contain a bactericide Tooth paste • Not specified • To remove debris • To refresh • It can dry the oral cavity if not adequately rinsed *1 Nystatin • To treat fungal infections • Tastes unpleasant Chlorhexidine gluconate: a compound with broad-spectrum anti-microbial activity *2 • To suppress the growing of bacteria in doses of 0.01-0.2 % solution *2 • not be significant to prevent chemotherapy- induced mucositis *2 • Tastes unpleasant • be stainable teeth with prolonged use Sodium bicarbonate: • To dissolve viscous mucous*3 • Tastes unpleasant • may bring burn if not diluted adequately • can alter oral pH allowing bacteria to multiply *1 Fluconazole: an orally absorbed antifungal azole, soluble in water • for the treatment of candidosis of the oropharynx, oesophagus and variety of deep tissue sites *3 • not reported Sucralfate: a mouth-coating agent Initially for the clients under radiotherapy and chemotherapy • To reduce pain of mucositis • not reported Fluoride • To prevent and arrest tooth decay • especially radiation caries, demineralization and decalcification • To show toxicity in high density Glycerine an thymol • To refresh • Refreshing lasts only 20-30 seconds *1 • Can over-stimulate the salivary glands leading to reflex action and exhaustion *1 Another solutions for oral care such as Potasium permanganate(1:5000), Sodium chloride(I teaspoon to a pint of water), Potasium chroride( 4 to 6 %), Hydrogen perpxide(1: 8 solution) are used commonly*4. References: 1. Penelope Ann Hilton(2004) fundamental nursing skills , I.K. International Pvt. Ltd., p.63 2. 3. 4. I Clement(2007) Basic Concepts on Nursing Procedures, Jaypee, p. 68 Procedure: a. Assisting the client with Oral care Care Action Rationale 1.Explain the procedures • Providing information fosters cooperation, understanding and participation in care 2. Collect all instruments required • Organization facilitates accurate skill performance 3. Close door and /or put screen • To maintain privacy 4. Perform hand hygiene and wear disposable gloves if possible • To prevent the spread of infection 5. If you use solutions such as sodium bicarbonate, prepare solutions required. • Solutions must be prepared each time before use to maximize their efficacy 6. Assist the client a comfortable upright position or sitting position • To promote his/her comfort and safety and effectiveness of the care including oral inspection and assessment 7. Inspect oral cavity 1) Inspect whole the oral cavity ,such as teeth, gums, mucosa and tongue, with the aid of gauze-padded tongue depressor and torch 2) Take notes if you find any abnormalities, e.g., bleeding, swollen, ulcers, sores, etc. • Comprehensive assessment is essential to determine individual needs • Some clients with anemia, immunosuppression, diabetes, renal impairment epilepsy and taking steroids should be paid attention to oral condition. They may have complication in oral cavity. 8. Place face towel over the client chest or on the thigh with mackintosh (Fig. 16) • To prevent the clothing form wetting and not to give uncomfortable condition 9. Put kidney tray in hand or assist the client holding a kidney tray • To receive disposal surely Fig16 Setting the kidney tray up with face towel covered mackintosh Care Action Rationale 10. Instruct the client to brush teeth Points of instruction 1) Client places a soft toothbrush at a 45 °angle to the teeth. 2) Client brushes in direction of the tips of the bristles under the gum line with tooth paste. Rotate the bristles using vibrating or jiggling motion until all outer and inner surfaces of the teeth and gums are clean. 3) Client brushes biting surfaces of the teeth 4) Client clean tongue from inner to outer and avoid posterior direction. • Effective in dislodging debris and dental plaque from teeth and gingival margin • Cleansing posterior direction of the tongue may cause the gag reflex 11. If the client cannot tolerate toothbrush (or cannot be available toothbrush), form swabs or cotton balls can be used • When the client is prone to bleeding and/or pain, tooth brush is not advisable 12. Rinse oral cavity 1) Ask the client to rinse with fresh water and void contents into the kidney tray. 2) Advise him/her not to swallow water. If needed, suction equipment is used to remove any excess. • To make comfort and not to remain any fluid and debris • To reduce potential for infection and 13. Ask the client to wipe mouth and around it. • To make comfort and provide the well-appearance 14. Confirm the condition of client’s teeth, gums and tongue. Apply lubricant to lips. • To moisturize lips and reduce risk for cracking 15. Rinse and dry tooth brush thoroughly. Return the proper place for personal belongings after drying up. • To prevent the growth of microorganisms 16. Replace all instruments • To prepare equipments for the next procedure 17. Discard dirt properly and safety • To maintain standard precautions 18. Remove gloves and wash your hands • To prevent the spread of infection 19. Document the care and sign on the records. • Documentation provides ongoing data collection and coordination of care • Giving signature maintains professional accountability 20. Report any findings to senior staffs • To provide continuity of care b. Providing oral care for dependent client Fig. 17 Equipments required for oral care in depending client Procedure: The procedure with cotton balls soaked sodium bicarbonate is showed here. Care Action Rationale 1. Check client’s identification and condition • Providing nursing care for the correct client with appropriate way. 2. Explain the purpose and procedure to the client • Providing information fosters cooperation and understanding 3.Perform hand hygiene and wear disposable gloves • To prevent the spread of infection. 4. Prepare equipments: 1) Collect all required equipments and bring the articles to the bedside. 2) Prepare sodium bicarbonate solutions in gallipot. Nursing Alert If the client is unconscious, use plain tap water. 3) Soak the cotton ball in sodium bicarbonates solution(3 pinches / 2/3 water in gallipot) with artery forceps. 4) Squeeze all cotton balls excess solution by artery forceps and dissecting forceps and put into another gallipot • Organization facilitates accurate skill performance • Solutions must be prepared each time before use to maximize their efficacy • To reduce potential infection • Cleaning solutions aids in removing residue on the client’s teeth and softening encrusted areas. • To avoid inspiration of the solution 5. Close the curtain or door to the room. Put screen. • It maintains the client’s privacy 6. Keep the client in a side lying or in comfortable position. • Proper positioning prevents back strain • Tilting the head downward encourages fluid to drain out of the client’s mort and it prevents aspiration.