Nursing skills procedure manual.drjma

NURS 241 Nursing Skills Procedure: Manual 1

NURS 241 Nursing Skills Procedure: Manual
(cover page)

1st released in November 6, 2012@ UoD College of Nursing (Male)


The NURS 241 Nursing Skills Procedure Manual
Is a compilation of

The University of Dammam, College of Nursing(Male) faculty.

1st edition 2012-2013

The author and contributor have prepared this work for the
student nurses. Furthermore, no warranty, express or implied and
disclaim any obligation, loss as a consequence of the use and
application of any contents of this activity.

THE AUTHORS,

Nursing Course Coordinator:
Dr. James M. Alo, RN, MAN, MAPsycho., PhD.

Clinical Staff:
Mr. Robin Easow, RN, MAN
Mr. Abdullah Ghanem, RN, MAN
Mr. Fhaied Mobarak, RN, MAPPC
Mr. Shadi Alshadafan, RN, MAN
Mr. Darwin Agman, RN
Mr. Fathi Alhurani, RN



Preface
This manual will help the student learn knowledge and

demonstrate nursing skills related to the fundamental management

of patient care especially to patient with medical and surgical

impediments.

Special attention of the student to this manual will aid them in

developing, enhancing their learned skills from their dedicated

clinical staff.

The authors and contributors recognize the student as an

active participant who assumes a collaborative role in the learning

process. Content is presented to challenge the student to develop

clinical nursing skills.

NURS 241 TEAM

Course Coordinator:
Dr. James M. Alo
Clinical Staff:
Mr. Robin Easow
Mr. Abdullah Ghanem
Mr. Fhaied Mobarak
Mr. Shadi Alshadafan
Mr. Darwin Agman
Mr. Fathi Alhurani



NURS 241 Nursing Skills Procedure: Manual

TABLE OF CONTENTS

Sec. CONTENTS Page #
Cover Page
Acknowledgment
Preface
Handwashing 6
Measuring Body Temperature/ Vital Signs 9
-Oral Temperature Measurement 13
-Oral Temperature Measurement w/ E-Thermomemter 15
-Rectal Temperature Measurement w/ glass 15
thermometer
-Rectal Temperature Measurement w/ e-thermometer 17
-Axillary Temperature Measurement w/ glass 18
thermometer
-Axillary Temperature Measurement w/ e- 19
thermometer
-Tympanic Membrane Measurement w/ e- 20
thermometer
Advantages & Disadvantages of Selecting Temperature 21
Measurement
Assessing Radial and apical Pulse 22
-Radial Pulse 25
-Apical Pulse 26
-Apical-Radial Pulse 28
Assessing Respiration 32
-Abnormal breathing patterns 34
Assessing BP 37
Applying and Removing sterile gloves 44
Changing an occupied bed 47
Changing an unoccupied bed 50
Body mechanics 55
Lifting an object from the floor 58
Positioning clients 59
Transferring patient from bed to chair 66
Bathing adult client 69
Collecting sputum specimen 76
Collecting and testing of urine 78
Collecting a specimen from indwelling catheter 84
Collecting and testing of stool 87
Obtaining a capillary blood specimen 89
Collecting samples from nose and throat 93
Collecting samples from nasal mucosa 96
Bandage and binders 97
Bandaging 99
-Types of bandage turns 102
-Types and purpose of binders 104


Shoulder immobilization 115
APPENDIX A /Performance Checklist 118
Handwashing 118
Applying and removing of gloves 120
Axillary temperature (electronic) 122
Rectal temperature (electronic) 124
Oral temperature (electronic) 126
Heart rate 128
Respiratory rate 132
Moving the client up in bed 134
Moving the client to lateral position 138
Body mechanics 140
Logrolling a client 143
Dangling a client 145
Applying and removing gloves, gowns and mask 147
Assessing Blood Pressure 148
Changing an Unoccupied Bed 151
Changing an occupied Bed 152

REFERENCES 154


HANDWASHING

Introduction:

Hand washing is important in every setting, including hospitals. It is
considered one of the most effective infection control measures. There are two types
of microorganisms (bacteria) present on the hands: Resident bacteria, which cannot
be removed by hand washing. The second type is transient bacteria, which is easily
removed by hand washing.

It is important that hands be washed at the following time:
 Before and after eating.
 Before and after contact with any patient.
 When handling patient’s food, blood, body fluids, secretions or excretions.
 When there is contact with any object that is likely to be a reservoir of
organisms such as soiled dressings or bedpan.
 After urinary or bowel elimination.

Purposes: Handwashing is performed to:

1. Remove the natural body oil and dirt from the skin.
2. Remove transient microbes, those normally picked up by the hands in the
usual activities of daily living.
3. Reduce the number of resident microbes, those normally found in creases of
the skin.
4. Prevent the transmission of microorganisms from client to client / from nurse
to family / from client to nurse.
5. Prevent the cross-contamination among clients.

Key Points:
Handwashing is a basic aseptic practice involved in all aspects of providing care to
persons who are sick or well. It becomes especially important when the client have
nursing diagnoses such as:
 Potential for infection.
 Altered body temperature.
 Impaired skin integrity.


Equipment and Supplies
o Source of running water o Orangewood stick
(warm if available) o Towel or tissue paper
o Soap o Lotion
o Soap dish

Procedure:
STEPS RATIONALE
1 Stand in from of the sink. Do not The sink is considered
allow your uniform to touch the sink contaminated. Uniforms may carry
during the washing procedure. organisms from place to place.
2 Remove jewelries. Remove watch 3- Removal of jewelries facilitates
5 inch above wrist proper cleansing. Microorganisms
may accumulate in settings of
jewelries.
3 Turn on water and adjust the force. Water splashed from the
Regulate the temperature until the contaminated sink will contaminate
water is warm. Do not allow water to your uniform. Warm water is more
splash. comfortable and has fewer
tendencies to open pores and
remove oils from the skin.
Organisms can lodge in roughened
and broken areas of chapped skin.
4 Wet the hands and wrist area. Keep Water should flow from the cleaner
hands lower than the elbows to area toward the more
allow water to flow toward the contaminated area. Hands are
fingertips. more contaminated than the
forearm.

5 Use about one teaspoon of liquid Rinsing the soap removes the
soap from the dispenser or lather lather, which may contain
thoroughly with bar soap. Rinse bar, microorganisms.
and return it to soap dish.


6 With firm rubbing and circular Friction caused by firm rubbing and
motions, wash the palms and back circular motions helps to loosen the
of the hands, each finger, areas dirt and organisms which can lodge
between the fingers, the knuckles, between the fingers, in skin crevices
wrists, and forearms at least as high of knuckles, on palms and backs of
as contamination is likely to be the hands, as well as the wrist and
present. forearms. Cleaning least
contaminated areas (forearms and
wrists) prevents spreading
organisms from the hands to the
forearms and wrists.

7 Continue this friction motion for 10 Length of hand washing is
to 30 seconds. determined by the degree of
contamination.
8 Use fingernails of the other hand or Organisms can lodge and remain
use orangewood stick to clean under the nails where they can grow
under fingernails. and be spread to others.
9 Rinse thoroughly. Running water rinses organisms and
dirt into sink.
10 Dry hands and wrists with paper Drying the skin well prevents
towel. Use paper towel to turn off chapping. Dry hands first because
the faucet. they are the cleanest and least
contaminated area after hand
washing. Turning the faucet off with
a paper towel protects the clean
hands from contact with a soiled
surface.
11 Use lotion on hands if desired. Lotion helps to keep the skin soft
and prevents chapping.


MEASURING BODY TEMPERATURE or VITAL SIGNS

Objectives:
1. To measure the body temperature accurately and safely.
2. Recognize deviations from the normal.

Purposes:
1. To establish baseline data.
2. To identify if the body temperature is within normal range.
3. To determine changes in the body temperature in response to specific
therapies.
4. To monitor client’s at risk for alterations in temperature.

Types of Thermometers:

Clinical glass mercury
thermometers:
• Oral (long tip)
• Stubby
• Rectal

Electronic thermometer

Infra-red thermometer
(Tympanic thermometer)



Temperature sensitive strips
(Disposable thermometer strips)

(Liquid crystal thermometer)

Temperature Scales:
 Celsius (centigrade) scale – normally extends from 34.0 to 42.0 C.
 Fahrenheit scale – usually extended from 94 F to 108 F.

Factors affecting body temperature:
 Age:  children;  old age.  Stress
 Sex:  males;  c females and  Environment
during menstruation.   Obesity
 Diurnal variations.   Food intake;  fasting
 Exercise  Drugs  or 
 Hormones  Disturbance in hypothalamus



Ranges of normal temperature values and
physiological consequences of abnormal body temperature.

Sites/Routes for temperature assessment:
1. Core temperature – is the temperature of the deep tissues of the body, such
as the cranium, thorax, abdominal and pelvic cavity.
2. Surface temperature – is the temperature of the skin, the subcutaneous tissue
and fat. It rises and falls in response to the environment; varies from 20 to
40 C.

Route Normal Reading Timing
Oral 37 C (98.6 F) 3 minutes
Axillary 37.5 C (99.6 F) 5 minutes
Rectal 36.4 C (97.6 F) – 36 .7 C (98 1 minute
F)
Tympanic - 1 – 2 sec.

Alterations in body temperature:
1. Pyrexia / hyperthermia / fever (above usual range).
2. Hyperpyrexia – very high fever.
3. Afebrile – no fever.



CONTRAINDICATIONS / CAUTIONS:

A. Oral:
1. Children younger than 4 to 5 years.
2. Confused, combative or comatose individuals.
3. Irritable clients or with mental diseases.
4. With history of convulsive disorders.
5. Mouth breathers.
6. With oral infections or with injuries or conditions that prevent them from
closing their mouths fully.
7. Immediate post-op under anesthesia.
8. Surgery for nose and mouth.
9. Patient receiving oxygen therapy.
10. Wait at least 15 to 30 minutes after person smokes / drinks / eats.

B. Rectal:
1. With rectal or perineal injuries or surgeries.
2. With diarrhea, diseases of the rectum.
3. Patient with heart disease.
4. Lubricate the thermometer well and insert gently to avoid damage to the
mucosa or perforation of the rectum.
C. Axillary : NONE.
D. Tympanic: NONE.

Equipment:
 Appropriate thermometer
 Soft tissue papers
 Lubricant (for rectal measurement only)
 Pen, pencil, vital signs flow sheet or record form.
 Disposable gloves, plastic thermometer sleeves or disposable probe covers.


Procedure:
STEPS RATIONALE
1 Assess for signs and symptoms of Physical signs and symptoms may
temperature alterations and for indicate abnormal temperature.
factors that influence body Nurse can accurately assess nature
temperature. of variations.
2 Determine any previous activity that Smoking and hot or cold substances
would interfere with accuracy of can cause false temperature
temperature measurement. When readings in oral cavity.
taking temperature, wait 20 to 30
minutes before measuring
temperature if client has smoked or
ingested hot or cold liquids or foods.
3 Determine appropriate site and Chosen on basis of preferred site for
measurement device to be used. temperature measurement.
4 Explain why temperature will be Clients are often curious about such
taken and maintaining the proper measurements and should be
position until reading is complete. cautioned against prematurely
removing thermometer to read
results.
5 Wash hands. Reduces transmission of
microorganisms.
6 Assist client in assuming Ensures comfort and accuracy of
comfortable position that provides temperature reading.
easy access to mouth.
7 Obtain temperature reading.

A. Oral temperature measurement with glass thermometer:

1 Apply disposable gloves. Maintains standard precautions
when exposed to items soiled with
body fluids. (e.g., saliva)
2 Hold end of glass thermometer with Reduces contamination of
fingertips. thermometer bulb.
3 Read mercury level while gently Mercury should be below 35 C.
rotating thermometer at eye level, Thermometer reading must be
grasp tip of thermometer securely, below client’s actual temperature
stand away from solid objects, and before use. Brisk shaking lowers
sharply flick wrist downward. mercury level of glass tube.
Continue shaking until reading is
below 35 C (96 F).
4 Insert thermometer into plastic Protects from contact with saliva.
sleeve or cover.


5 Ask client to open mouth and gently Heat from superficial blood vessels
place thermometer under tongue in in sublingual pockets produces
posterior sublingual pocket lateral to temperature reading.
the center of lower jaw.

6 Ask client to hold thermometer with Maintains proper position of
lips closed. Caution against biting thermometer during recording.
down the thermometer Breakage of thermometer may
injure mucosa and cause mercury
poisoning.
7 Leave thermometer in place for 3 Studies vary as to proper length of
minutes or according to agency time for recording. Holtzclaw (1992)
policy. recommends 3 minutes.
8 Carefully remove thermometer, Prevents cross contamination.
remove and discard plastic sleeve Ensures accurate reading.
cover in appropriate receptacle, and
read at eye level. Gently rotate until
scale appears.
9 Cleanse any additional secretions Avoids contact of microorganisms
on thermometer, by wiping with with nurse’s hands. Wipe from area
clean, soft tissue. Wipe in rotating of least contamination to area of
fashion from fingers toward bulb. most contamination. Glass
Dispose of tissue in appropriate thermometers should not be shared
receptacle. Store thermometer in between clients unless terminal
appropriate storage container. disinfection is performed between
each measurement. Protective
storage container prevents
breakage and reduces risks of
mercury spills.
10 Remove and dispose of gloves in Reduces transmission of
appropriate receptacle. Wash microorganisms.
hands.



B. Oral temperature measurement with electronic thermometer.

1 Apply disposable gloves. (Optional) Use of probe covers, which can be
removed without physical contact,
minimizes needs to wear.
2 Remove the thermometer pack from Charging provides battery power.
charging unit. Attach oral probe to Ejection button releases plastic
thermometer unit. Grasp top of cover from probe.
stem, being careful not to apply
pressure to ejection button.
3 Slide disposable plastic cover over Soft plastic cover will not break in
thermometer probe until it locks in client’s mouth and prevents
place. transmission of microorganisms
between clients.
4 Ask client to open mouth, then place Heat from superficial blood vessels
thermometer probe under the in sublingual pocket produces
tongue in posterior sublingual temperature reading. With electronic
pocket lateral to center of lower jaw. thermometer temperatures, in right
and left posterior sublingual pocket
are significantly higher than in area
under front of tongue.
5 Ask client to hold thermometer Maintains proper position of
probe with lips closed. thermometer during recording.
6 Leave thermometer probe in place Probe must stay in place until signal
until audible signal occurs and occurs to ensure accurate
client’s temperature appears on recording.
digital display; remove thermometer
probe under client’s tongue.
7 Push ejection button on Reduces transmission of
thermometer stem to discard plastic microorganisms.
cover into appropriate receptacle.
8 Return thermometer stem to storage Protects probe from damage.
well of recording unit. Automatically causes digital reading
to disappear.
9 If gloves are worn, remove and Reduces transmission of
dispose in appropriate receptacle. microorganisms.
Wash hands.
10 Return thermometer to charger. Maintains battery charge.

C. Rectal temperature measurement with glass thermometer.

1 Draw curtain around bed and / or Maintain client’s privacy, minimizes
close room door. Assist client to embarrassment, and promotes
Sim’s position with upper leg flexed comfort. Exposes anal area for
Move aside bed linen to expose only correct thermometer placement.
anal area. Keep covered with sheet
or blanket.


2 Apply disposable gloves. Maintains standard precautions
when exposed to items soiled with
body fluids (e.g., feces).

3 Hold end of glass thermometer with Reduced contamination of
fingertips. thermometer bulb.
4 Read mercury level while gently Mercury should be below 35 C.
rotating thermometer at eye level. If Thermometer reading must be
mercury is above desired level, below client’s actual temperature
grasp tip of thermometer securely, before client’s actual temperature
and stand away from solid objects, before use. Brisk shaking lowers
and sharply flick wrist downward. mercury level in glass tube.
Continue shaking until reading is
below 35 C.
5 Insert thermometer into plastic Protects from contact with feces.
sleeve cover.
6 Squeeze liberal portion of lubricant Lubrication minimizes trauma to
on tissue. Dip thermometer’s blunt rectal mucosa during insertion.
end into lubricant, covering 2.5 cm Tissue avoids contamination of
(1 to 1 ½ inch) for adult. remaining of remaining lubricant in
container.
7 With non-dominant hand, separate Fully exposes anus for thermometer
client’s buttocks to expose anus. insertion. Relaxes anal sphincter for
Ask client to breathe slowly and easier thermometer insertion.
relax.

8 Gently insert thermometer into anus
3.5 cm (1 ½ inches) for adult. Do not
force themselves.
9 If resistance is felt during insertion, Prevents trauma to mucosa. Glass
withdraw thermometer immediately. thermometers can break.
Never force thermometer.

If thermometer cannot be adequately inserted into the rectum, remove the
thermometer and consider alternative method for obtaining temperature.

10 Hold thermometer in place for 2 Prevents injury to client. Studies
minutes or according to agency vary as to proper length of time for
policy. recording. Holtzclaw (1992)
recommends 2 minutes.


11 Carefully remove thermometer, Prevents cross contamination. Wipe
remove and discard plastic cover in from area of least contamination to
appropriate receptacle and wipe off area of most contamination.
remaining secretions with clean
tissue. Wipe in rotating fashion from
fingers toward the bulb. Dispose of
tissue in appropriate receptacle.
12 Read thermometer at eye level. Ensures accurate reading.
Gently rotate until scale appears.

13 Wipe client’s anal area with soft Provides for comfort and hygiene.
tissue to remove lubricant or feces
and discard tissue. Assist client in
assuming a comfortable position.
14 Store thermometer in appropriate Glass thermometers should not be
storage container. shared between clients unless
terminal disinfection is performed
between each measurement.
Protective storage container
prevents breakage and reduces risk
of mercury spill.
appropriate receptacle. Wash microorganisms.
hands.

D. Rectal temperature measurement with electronic thermometer.

1 Follow steps C-1 and C-2.
2 Follow steps C-5, 6, 7, 8, 9
3 Leave thermometer in place until Probe must stay in place until signal
audible signal occurs and client’s occurs to ensure accurate reading.
temperature appears on digital
display; remove thermometer probe
from anus.
probe cover into appropriate
receptacle.
5 Return thermometer stem to storage Protects probe from damage.
well of recording unit. Automatically causes digital reading
to disappear.
6 Wipe client’s anal area with soft Provides comfort and hygiene.
tissue to remove lubricant or feces
and discard tissue. Assist client in
assuming a comfortable position.
appropriate receptacle. microorganisms.
8 Return thermometer to charger. Maintains battery charge.



E. Axillary temperature measurement with glass thermometer.

microorganisms.
2 Draw curtain around bed and/or Provides privacy and minimizes
close door. embarrassment.
3 Assist client to supine or sitting Provides easy access to axilla.
position.
4 Move clothing or gown away from Exposes axilla.
shoulder and arm.
5 Prepares glass thermometer Mercury must be below client’s
following steps A –2, 3. temperature level before insertion.
6 Insert thermometer into the center of Maintains proper position of
axilla, lower arm over thermometer, thermometer against blood vessels
and place arm across chest. in axilla.

7 Hold thermometer in place for 3 Studies as to proper length of time
minutes or according to agency for recording vary. They concluded
policy. that changes after 3 minutes had
little or no significance.
8 Remove thermometer, remove Avoids nurse’s contact with
plastic sleeve, and wipe off microorganisms. Wipe from are of
remaining secretions with tissue. least contamination to area of most
Wipe in rotating fashion from fingers contamination.
toward bulb. Dispose of sleeve and
tissue in appropriate receptacle.
9 Read thermometer at eye level. Ensures accurate reading.
10 Inform client of reading. Promotes participation in care and
understanding of health status.
11 Store thermometer at bedside in Glass thermometers should not be
protective covering container. shared between clients unless
terminal disinfection is performed
between each measurement.
Storage container prevents
breakage and reduces risk of
mercury spill.


12 Assist client in replacing clothing pr Restore sense of well-being.
gown.
microorganisms.

F. Axillary temperature measurement with electronic thermometer.

1 Position client lying supine or sitting. Provides easy access to axilla.
2 Move clothing or gown away from Provides optimal access to axilla.
shoulder and arm.
3 Remove the thermometer pack from Ejection button releases plastic
charging unit. Be sure oral probe cover from probe.
(blue tip) is attached to thermometer
unit. Attach oral probe to
thermometer unit. Grasp top of
stem, being careful not to apply
pressure to ejection button.
4 Slide disposable plastic cover over Soft plastic cover will not break in
thermometer probe until it locks in client’s mouth and prevents
place. transmission of microorganisms
between clients.
5 Raise client’s arm away from torso, Maintains proper position of probe
inspect for skin lesion and excessive against blood vessels in axilla.
perspiration. Insert probe into the
center of axilla, lower arm over
thermometer, and place arm across
chest.
6 Leave probe in place until audible Probe must stay in place until signal
signal occurs and client’s occurs to ensure accurate reading.
temperature appears on digital
display.
7 Remove probe from axilla.
probe cover into appropriate
receptacle.
9 Return probe to storage well of Protects probe from damage.
recording unit. Automatically causes digital reading
to disappear.
10 Assist client in assuming a Restores comfort and promotes
comfortable position. privacy.
microorganisms.



G. Tympanic membrane temperature measurement with
electronic thermometer.
1 Assist client in assuming Ensures comfort and exposes
comfortable position with head auditory canal for accurate
turned toward side, away from the temperature measurement.
nurse.
2 Remove thermometer handheld unit Base provides battery power.
from charging base, being careful Removal of handheld unit from base
not to apply pressure to ejection prepares it to measure temperature.
button.
3 Slide disposable speculum cover Soft plastic probe cover prevents
over otoscope like tip until it locks transmission of microorganisms
into place. between clients.
4 Insert speculum into ear canal Correct positioning of the probe with
following manufacturer’s instructions respect to ear canal ensures
for tympanic probe positioning. accurate readings. The ear tug
straightens the external auditory
canal, allowing maximum exposure
of the tympanic membrane.
a. Pull ear pinna upward and back
for Some manufacturers recommend
adult. movement of the speculum tip in a
b. Move thermometer in a figure– figure – 8 pattern that allows the
eight pattern. sensor to detect maximum tympanic
c. Fit probe snug into canal and membrane heat radiation. Gentle
do not move. pressure seals ear canal from
d. Point toward nose. ambient air temperature.

5 Depress scan button on handheld Depression of scan button causes
unit. Leave thermometer probe in infrared energy to be detected.
place until audible signal occurs and Probe must stay in place until signal
client’s temperature appear on occurs to ensure accurate reading.
digital display.

6 Carefully remove speculum from
auditory meatus.


7 Push ejection button on handheld Reduces transmission of
unit to discard plastic probe cover microorganisms. Automatically
into appropriate receptacle. causes digital readings to
disappear.
8 Return handheld unit into charging Protects probe from damage.
base.
9 Assist client in assuming a Restores comfort and sense of well
comfortable position. being.
microorganisms.

Recording and reporting:
 Record temperature in vital signs flow sheet or record form.
 Report abnormal findings to nurse in charge or physician.

ADVANTAGES AND DISADVANTAGES OF SELECTED
TEMPERATURE MEASUREMENT, SITES, AND METHODS.

Advantages Disadvantages

Electronic Thermometer:
1 Plastic sheath unbreakable; ideal May be less accurate by axillary route.
for children.
2 Quick readings.

Tympanic Membrane Sensor:
1 Easily accessible site Hearing aids must be removed before
measurements.
2 Minimal client repositioning Should not be used for clients who have
required. had surgery of the ear or tympanic
membrane.
3 Provides accurate care reading. Requires disposable probe cover.
4 Very rapid measurements (2 to 5 Expensive.
sec.).
5 Can be obtained without disturbing
or waking client.
6 Ear drum close to hypothalamus,
sensitive to core temperature
changes.

Oral:
1 Accessible; requires no position Affected by ingestion of fluids or foods,
changes. smoke, and oxygen delivery (Neff and
others, 1992).


2 Comfortable for client. Should not be used with clients who
have had oral surgery, trauma, history of
epilepsy, or shaking chills.
3 Provides accurate surface Should not be used with infants, small
temperature reading. children, or confused, unconscious, or
uncooperative client.
4 Indicates rapid change in core Risk of body fluid exposure.
temperature.

Axilla:
1 Safe and non-invasive. Long measurement time.
2 Can be used with newborns and Requires continuous positioning by
uncooperative clients. nurse.
Measurement lags behind core
temperature during rapid temperature
changes. Requires exposure of thorax.

Skin:
1 Inexpensive Lags behind other sites during
temperature changes, especially during
hyperthermia.
2 Provides continuous reading Diaphoresis or sweat can impair
adhesion.
3 Safe and non-invasive.

ASSESSING RADIAL AND APICAL PULSES

Definition: The pulse is a wave of blood created by contraction of the left ventricle
of the heart.

Objectives:
 To establish baseline data for subsequent evaluation.
 To identify whether the pulse is within normal range.
 To determine whether the pulse rhythm is regular and pulse volume is
appropriate.
 To compare the equality of corresponding peripheral pulses on each side of
the body.
 To monitor and assess changes in the client’s health status.
 To monitor clients at risk for pulse alterations. (e.g., clients with a history of
heart disease or having cardiac arrhythmias, hemorrhage, acute pain, infusion


of large volumes of fluids, fever).

Key Points:
 Locate the pulse point properly.
 Always count pulse for one full minute if dysrhythmias or other abnormality is
present.
 Have another nurse locate and count the radial pulse while you auscultate the
apical pulse. Determine an apical-radial pulse rate by counting simultaneously
for one full minute.

Equipment:
 Watch with a second hand or indicator.
 If using Doppler/ultrasound stethoscope:
 Transducer in the probe
 Stethoscope headset
 Transmission gel

Procedure:
STEPS RATIONALE
1 Determine need to assess radial or Certain conditions place clients at
apical pulse: risk for pulse alterations. Heart
a. Note risk factors for rhythm can be affected by heart
alterations in apical pulse disease, cardiac dysrhythmias,
b. Assess for signs and onset of sudden chest pain or acute
symptoms of altered SV pain from any site, invasive
(stroke volume) and CO such cardiovascular diagnostic tests,
as dyspnea, fatigue, chest surgery, sudden infusion of large
pains, orthopnea, syncope, volume of IV fluids, internal or
palpitations, jugular venous external hemorrhage, and
distension, edema of administration of medications that
dependent body parts, alter heart function.
cyanosis or pallor of skin. Physical signs and symptoms may
indicate alterations in cardiac
functions.


2 Assess for factors that normally Allows nurse to accurately assess
influence apical pulse rate and presence and significance of pulse
rhythm: alterations.
a. Age Normal PR change with age.

b. Exercise Physical activity requires an
c. Position changes increase in CO that is met by an
increase HR and SV. HR increases
temporarily when changing from
lying to sitting or standing position
d. Medications
Anti-dysrhythmics,
sympathomimetics, and cardiotonics
affect rate and rhythms of pulse.
Large doses of narcotic analgesics
can slow HR; general anesthetics
slow HR; CNS stimulants such as
e. Temperature caffeine can increase the HR.

Fever or exposure to warm
environments increases HR; HR
f. Emotional Stress, anxiety, declines with hypothermia.
fear
Results in stimulation of the
sympathetic nervous system, which
increases the HR.
3 Determines previous baseline Allows nurse to assess change in
balance apical site. condition. Provides comparison with
future apical pulse measurements.
4 Explain that PR or HR is to be Activity and anxiety can elevate HR.
assessed. Client’s voice interferes with nurse’s
ability to hear sound when apical
pulse is measured.
microorganisms.
6 If necessary, draw curtain around Maintains privacy.
bed and/or close door.
7 Obtain pulse measurement.


A. Radial Pulse
STEPS RATIONALE
1 Assist client to assume supine Provides easy access to pulse sites.
position.
2 If supine, place client’s forearm Relaxed position of lower arm and
along side or across lower chest or extension of wrists permits full
upper abdomen with wrist extended exposure of artery to palpation.
straight. If sitting, bend client’s
elbow 90 and support lower arm on
chair on nurses’ arm. Slightly extend
wrist with palms down.

3 Place tips of first two fingers of hand Fingertips are most sensitive parts
over groove along radial or thumb of hand to palpate arterial
side of client’s inner wrist. pulsations. Nurse’s thumb has
pulsation that may interfere with
accuracy.
4 Lightly compress against radius, Pulse is more accurately assessed
obliterate pulse initially, and then with moderate pressure. Too much
relax pressure so pulse becomes pressure occludes pulse and
easily palpable. impairs blood flow.
5 Determine strength of pulse. Note Strength reflects volume of blood
whether thrust of vessel against ejected against arterial wall with
fingertips is bounding, strong, weak each heart contraction.
or thready.
6 After pulse can be felt regularly, look Rate is determined accurately only
at watch’s second and begin to after nurse is assured pulse can be
count rate; when sweep hand hits palpated. Timing begins with zero.
number on dial, start counting with Count of one is first beat palpated
zero, then one, two, and so on. after timing begins.
7 If pulse is regular, count rate for 30 A 30 second count is accurate for
seconds and multiply by 2, rapid, slow, or regular pulse rates.
8 If pulse is regular, count rate for 60 Inefficient contraction of heart fails
seconds. Assess frequency and to transmit pulse wave, interfering
pattern if irregularity. with CO2, resulting in irregular
pulse. Longer time ensures accurate
count.



B. Apical pulse
1 Assist client to supine or sitting Expose portion of chest wall for
position. Move aside bed linen and selection of auscultation.
gown to expose sternum and left
side of chest.
2 Locate anatomical landmarks to Use of anatomical landmarks allows
identify the points of maximal correct placement of stethoscope
impulse (PMI), also called the apical over apex of heart, enhancing ability
impulse. Heart is located behind and to hear heart sounds clearly. If
to left of sternum with base at top unable to palpate the PMI,
and apex at bottom. reposition client on left side. In the
Find angle of Louis just below presence of serious heart disease,
suprasternal notch between sternal the PMI may be located to the left of
body and manubrium; can be felt as the MCL, or at the sixth ICS.
a bony prominence. Slip fingers
down each side of angle to find
second intercostal space. (ICS).

Carefully move fingers down left
side to the left midclavicular line
(MCL).
A light tap felt within an area 1 to 2
cm ( ½ to 1 inch) of the PMI is
reflected from the apex of the heart
3 Place diaphragm of stethoscope in Warming of metal or plastic
palm of hand for 5 to 10 seconds. diaphragm prevents client from
being startled and promotes
comfort.


4 Place diaphragm of stethoscope Allow stethoscope tubing to extend
over PMI at the fifth ICS, at left straight without kinks that would
MCL, and auscultate for normal S1 distort sound transmission. Normal
and S2 heart sounds (heard as “lub S1 and S2 are high pitched and best
dub”). heard with the diaphragm.

5 When S1 and S2 are heard with Apical rate is determined accurately
regularity, use watch’s second hand only after nurse is able to auscultate
and begin to count rate; when sounds clearly. Timing begins with
sweep hand hits number on dial, zero. Count of one is first sound
start counting with zero, then one, auscultated after timing begins.
two, and so on.
6 If apical rate is regular, count for 30 Regular apical rate can be assessed
seconds and multiply by 2. within 30 seconds.
7 If HR is irregular or client is Irregular is more accurately
receiving cardiovascular assessed when measured over long
medications, count for intervals.
1 minute (60 seconds). Regular occurrence of dysrhythmias
within 1 minute may indicate
inefficient contraction of heart and
alteration on cardiac output.
8 Discuss findings with client as Promotes participation in care and
needed. understanding of health status.
9 Clean earpieces and diaphragm of Control transmission of
stethoscope with alcohol swab as microorganisms when nurses share
needed. stethoscope.

microorganisms.
11 Compare readings with previous Evaluates for change in condition
baseline and/or acceptable range of and alterations.
heart rate for client’s age.
12 Compare peripheral pulse rate with Differences between measurements
apical pulse rate and note indicate pulse deficit and may warn
discrepancy. of cardiovascular compromise.
Abnormalities may require therapy.
13 Compare radial pulse equality and Differences between radial arteries
note discrepancy. indicate compromised peripheral
vascular system.


14 Correlate PR with data obtained PR and BP are interrelated.
from BP and related signs and
symptoms (palpitations, dizziness).

 Record PR with assessment site in nurses’ notes or vital signs flow sheet.
Measurement of PR after administration of specific therapies should be
documented in narrative form in nurses’ notes.
 Report abnormal finding to nurse in charge or physician.

C. Assessing the Apical-Radial Pulse
Normally, the apical and radial pulses are identical. Any discrepancy between two
pulse rates needs to be reported promptly. An apical-radial pulse can be taken by
two nurses to be more accurate at the same time with a signal of start and stop.

A peripheral pulse (usually, the radial pulse) is assessed by palpation in all
individuals except: Newborns and children up to 2 or 3 years (apical pulse is
assessed).
Very obese or elderly clients apical pulse is assessed.
Individuals with a heart disease (apical pulse is assessed).

Procedure:
STEPS Rationale
1 Palpate the radial pulse while Identifies differences between
listening for apical pulse. Using both pulsations and heart sounds.
senses, determine if the apical and
radial pulses are synchronous. If the
apical and radial pulses are not
synchronous, get a second nurse
and
2 Explain to the client that one nurse Informs the client’s answers his or
is counting his or her heart beats her questions because the unusual
while the second counts his or her procedure may arouse his or her
radial pulse. anxiety; simple straight forward
explanations usually are helpful.
Listen to the client’s fears or anxiety
with empathy.
3 Prepare to monitor the apical pulse.
4 Direct the second nurse to locate
and count the radial pulse.
5 Look at the watch dial. Note the Synchronizes the count, essential to
location of the second hand and determine if deficit is present.
signal the second nurse to begin
counting at “one, two …”
6 Count the remaining 60 seconds Ensures accuracy.
silently as the second nurse counts
the radial pulse silently.


7 Say “Stop” when exactly 60 seconds Ensures accuracy.
have passed.
8 Reposition the client comfortable.
9 Record the apical and radial rates Ensures prompt and accurate
immediately. Note any deficits. documentation.

Applying moderate pressure Assessing the radial pulse
to accurately assess the pulse

Mapping the apical pulse Assessing apical pulse



Comparing radial pulse equality and Assessing pedal pulse
discrepancy.


ASSESSING RESPIRATION

Respiration is a complex vital function with two complementary processes, the
internal and external respirations. Respiration is the act of breathing. One act of
respiration consists of one inhalation and on exhalation. Inhalation or inspiration is
the act of breathing in, and exhalation, or expiration, is the act of breathing out.

External respiration is a combination of movements delivering air to the body’s
circulatory system.
1. Ventilation 3. Diffusion and
2. Conduction of air 4. Perfusion.

Objectives/Purposes:
The respiratory rate is assessed to:
 Determine the per minute rate on admission as a base for comparing future
measurements.
 Monitor the effect of injury, disease or stress on the client’s respiratory
system.
 Evaluate the client’s response to medications or treatments that affect the
respiratory system.

Key Points:
 Assess the client for factors that could indicate respiratory variations.
 Without telling the client what you are doing, watch the chest movements in
and out.
 Count in each ventilatory movement as one respiration.
 Count for 30 seconds or one full minute.


Equipment:
 Watch with second  Paper, pencil  Vital signs record.
hand.

Observe the rate, rhythm, and depth of respiration.
Normal respiration is regular in depth and rhythm.

Place hands on chest when respirations are difficult to count.


Abnormal Breathing Patterns

Procedure:

STEPS RATIONALE
1 Determine need to assess client’s
respirations:
a Note risk factors for respiratory Certain conditions place client at
alterations. risk for alterations in ventilation
detected by changes in respiratory
rate, depth, and rhythm. Fever,
pain, anxiety, diseases of chest wall
or muscles, constrictive chest or
abdominal dressings, gastric
distention, chronic pulmonary
disease (emphysema, bronchitis,
asthma), traumatic injury to chest
wall with or without collapse of
underlying lung tissue, presence of
a chest tube, respiratory infection
(pneumonia, acute bronchitis),
pulmonary edema, and emboli,
head injury with damage to brain
stem, and anemia can result in
respiratory alteration.
b Assess for signs and symptoms of Physical signs and symptoms may
respiratory alterations such as bluish or indicate alterations in respiratory
cyanotic appearance of nail beds, lips, status related to ventilation.
mucous membranes, and skin;
restlessness, irritability, confusion,
reduced level of consciousness; pain
during inspiration; labored or difficult
breathing; adventitious sounds, inability
to breathe spontaneously; thick, frothy,
blood-tinge, or copious sputum
produced on coughing.

2 Assess pertinent laboratory values:
a. Arterial blood gases (ABGs): normal Arterial blood gases measure
ABGs (values may vary slightly within arterial blood pH, partial pressure of
institutions. O2, and CO2, and arterial O2
saturation, which reflects client’s
oxygenation.
b. Pulse oxymetry (SpO2): normal SpO2 = SpO2 less than 85% is often
90% - 100%; 85% – 89% may be accompanied by changes in
acceptable for certain chronic disease respiratory rate, depth, and rhythm.
conditions less than 85% is abnormal.


c. Complete blood count (CBC): normal Complete blood count measures red
CBC for adults (values may vary within blood cell count, volume of red
institutions) blood cells, and concentration of
hemoglobin, which reflects client’s
capacity to carry O2.
1) Hemoglobin: 14 to 18 g/100 ml, males;
12 to 16 g/100 ml, females.
2) Hematocrit: 40% to 54%, males; 38% to
47%, females.
3) Red blood cell count: 4.6 to 6.2 million/μl,
males; 4.2 to 5.4 million/μl, females.

3 Determine previous baseline respiratory Allows nurse to assess for
rate (if available) from client’s record. change in condition. Provides
comparison with future
respiratory measurements.
4 Be sure client is in comfortable position, Sitting erect promotes full
preferably sitting or lying with the head of ventilatory movement.
the bed elevated 45 to 60 degrees.

Critical Decision Point:
Clients with difficulty of breathing (dyspnea) such as those with congestive heart
failure or abdominal ascites or in late stages of pregnancy should be assessed in
positions of greatest comfort. Repositioning may increase the work of breathing,
which will increase respiratory rate.

5 Draw curtain around bed and/or close Maintains privacy. Prevents
door. Wash hands. transmission of microorganisms.
6 Be sure client’s chest is visible. If Ensures clear view of chest wall and
necessary, move bed linen or gown. abdominal movements.
7 Place client’s arm in relaxed position A similar position used during pulse
across the abdomen or lower chest, or assessment allows respiratory rate
place nurse’s hands directly over client’s assessment to be inconspicuous.
upper abdomen. Client’s or nurse’s hand rises and
falls during respiratory cycle.
8 Observe complete respiratory cycle (one Rate is accurately determined only
inspiration and one expiration). after nurse has viewed respiratory
cycle.
9 After cycle is observed, look at watch’ s Timing begins with count of one.
second hand and begin to count rate: Respirations occur more slowly than
when sweep hand hits number on dial, pulse; thus timing does not begin
begin time frame, counting one with first with zero.
full respiratory cycle.
10 If rhythm is regular, count number of Respiratory rate is equivalent to
respirations in 30 seconds and multiply number of respirations per minute.
by 2. If rhythm is irregular, less than 12, Suspected irregularities require
or greater than 20, count for 1 full assessment for at least 1 minute.
minute.


11 Note depth of respirations subjectively Character of ventilatory movement
assessed by observing degree of chest may reveal specific disease state
wall movement while counting rate. restricting volume of air from moving
Nurse can also objectively assess depth into and out of the lungs.
by palpating chest wall excursion after
rate has been counted. Depth is shallow,
normal, or deep.
12 Note rhythm of ventilatory cycle. Normal Character of ventilations can reveal
breathing is regular and uninterrupted. specific types of alterations.
Sighing should not be confused with
abnormal rhythm.
13 Replace bed linen and client’s gown. Restores comfort and promotes
sense of well-being.
microorganisms.
15 Discuss findings with client as needed. Promotes participation in care and
understanding of health status.
16 If respirations are assessed for the first Used to compare future respiratory
time, establish rate, rhythm, and depth assessment.
as baseline if within normal range.
17 Compare respirations with client’s Allows nurse to assess for changes
previous baseline and normal rate, in client’s condition and for
rhythm, and depth. presence of respiratory alterations.

Recording and Reporting:
 Record respiratory rate and character in nurses’ notes or vital sign flow sheet.
Indicate type and amount of oxygen therapy if used by client during
assessment. Measurement of respiratory rate after administration of specific
therapies should be documented in narrative form in nurses’ notes.

Home care Considerations:
Assess for environmental factors in the home that may influence client’s respiratory
rate such as second-hand smoke, poor ventilation, or gas fumes.


ASSESSING BLOOD PRESSURE

Definition:

Blood pressure is the force exerted produced by the volume of blood pressing on
the resisting walls of the arteries Blood pressure is commonly abbreviated BP. Its
measurement is expressed as a fraction.

The numerator or the upper figure is the systolic pressure/ systole (the phase
during which the heart works or contracts) and the denominator or the lower figure is
the diastolic pressure/ diastole (the heart’s resting phase).

The pressure is expressed in millimeters of mercury, abbreviated mmHg. Thus a
recording of
120/80 means systolic blood pressure was measured at 120 mmHg and the diastolic
blood pressure was measured at 80 mmHg. The difference between two readings is
called pulse pressure.

Blood is circulated through a loop involving the heart and blood vessels.

Purposes: The blood pressure is assessed by:

1. Determine the systolic and diastolic pressure of the client during
admission in order to compare his current status with normal changes.
2. Acquire data that may be compared with subsequent changes that
may occur during the care of the client.
3. Assist in evaluating the status of the client’s blood volume, cardiac


output and vascular system.
4. Evaluate the client’s response to changes in his medical condition as a
result of treatment with fluids or medications.

Key Points:
1. Blood pressure is the measurements of the pressure exerted by the
blood on the walls of the arteries. The rate and force of the heartbeat
determines the reading as the ventricles contract and rest.
2. Do no take BP reading on person’s arm if:
 is injured/diseased.
 Is on the same side of body where a female has had a radical
mastectomy.
 has a shunt or fistula for renal dialysis, or is site for an
intravenous infusion.

Equipment and Supplies:

o Stethoscope o Blood pressure cuff of appropriate size
o Sphygmomanometer – an aneroid or a mercury manometer may be
available. The gauge should be inspected to validate that the needle
or mercury is within the zero mark.
o Alcohol swab o Paper, pencil, pen, V/S flow sheet or
record form

Procedure: AUSCULTATION METHOD


STEPS RATIONALE
microorganisms.
2 With client sitting or lying, position If arm is unsupported, client may
client’s forearm, supported if needed, perform isometric exercise that can
with palms turned up. increase diastolic pressure 10%.
Placement of arm above the level of
the heart causes false low reading.
3 Expose upper arm fully by removing Ensures proper cuff application.
constricting clothing.
4 Palpate brachial artery. Position cuff Inflating bladder directly over brachial
2.5 cm (1inch) above site of brachial artery ensures proper pressure is
pulsation (antecubital space). Center applied during inflation. Loose-fitting
bladder of cuff above artery. With cuff causes false high readings.
cuff fully deflated, wrap evenly and
snugly around upper arm.
5 Position manometer vertically at eye Accurate readings are obtained by
level. Observer should be no farther looking at the meniscus of the mercury
than 1 meter (approximately 1 yard) at eye level. The meniscus is the point
away. where the crescent-shaped top of the
mercury column aligns with the
manometer scale. Looking up or down
at the mercury results in distorted
readings.
6 Palpate brachial or radial artery with Identifies approximate systolic
fingertips of one hand while inflating pressure and determines maximal
cuff rapidly to pressure 30 mmHg inflation point for accurate reading.
above point at which pulse Prevents auscultatory gap. If unable to
disappears. palpate artery because of weakened
pulse, an ultrasonic stethoscope can
be used.
7 Deflate cuff fully and wait 30 Prevents venous congestion and false
seconds. high readings.
8 Place stethoscope earpieces in ears Each earpiece should follow angle of
and be sure sounds are clear, not ear canal to facilitate hearing.
muffled,
9 Relocate brachial artery and place Proper stethoscope placement
bell or diaphragm (chest piece) of the ensures optimal sound reception.
stethoscope over it. Do not allow Stethoscope improperly positioned
chest piece to touch cuff or clothing. causes muffled sounds that often
result in false low systolic and false
high readings.
10 Close valve of pressure bulb Tightening of valve prevents air leak
clockwise until tight. during inflation.
11 Inflate cuff to 30 mmHg above Ensures accurate measurement of
palpated systolic pressure. systolic pressure.
12 Slowly release valve and allow Too rapid or slow a decline in mercury
mercury to fall at rate of 2 to 3 level can cause inaccurate readings.
mmHg/sec.
13 Note point on manometer when first First Korotkoff sound indicates systolic
clear sound is heard. pressure.


14 Continue to deflate cuff, noting point Fourth Korotkoff sound involves
at which muffled or dampened sound distinct muffling of sounds and is
appears. recommended as indication of
diastolic pressure in children. (Perloff
and others, 1993).

15 Continue to deflate cuff gradually, Beginning of fifth Korotkoff sounds is
noting point at which sound recommended by American Heart
disappears in adults. Note pressure Association as indication of diastolic
to nearest 2 mmHg. pressure in adults. (Perloff and others,
1993).
16 Deflate cuff rapidly and completely. Continuous cuff inflation causes
Remove cuff from client’s arm unless arterial occlusion, resulting in
measurement must be repeated. numbness and tingling of client’s arm.
17 If this is the first assessment of Comparison of BP in both arms
client, repeat procedure on other detects circulatory problems (Normal
arm. difference of 5 to 10 mmHg exists
between arms).
18 Assist client in returning to Restores comfort and promotes sense
comfortable position and cover arm if of well-being.
previously clothed.
19 Discuss findings with client as Promotes participation in care and
needed. understanding of health status.
20 Wash hands Reduces transmission of
microorganisms.
21 Compare readings with previous Evaluates for changes in condition and
baseline and/or acceptable value of alterations.
BP for client’s age.
22 Compare BP readings in both arms. Arm with higher pressure should be
used for subsequent assessment
unless contraindicated.
23 Correlate BP with data obtained from Blood pressure and heart rate are
pulse assessment and related interrelated.
cardiovascular signs and symptoms.

 Inform client of value and need for periodic re-assessment.
 Record BP. Measurement of BP after admission of specific therapies
should be documented.


Applying and Removing Personal Protective Equipment (gloves, gown, mask)

Purpose:
 To protect health care workers and clients from transmission of potentially
infective materials.

Assessment:
 Consider which activities will be required while the nurse is in the clients room
at this time.

Equipment:
 Gown
 Mask
 Clean gloves

Procedure:

STEPS Rationale
1. Verify client identity and
introduce yourself, explain for
the client what you are to do,
why it is necessary, and how
he or she can participate.

2. Perform hand hygiene.

3. Apply a clean gown:  Overlapping securely covers the
a) Pick up a clean gown, uniform at the back, waist ties keep
and allow it to unfold in the gown from falling away from the
front of you without body, which can cause inadvertent
allowing it to touch any soiling of the uniform.
area soiled with body
substances.
b) Slide the arms and the
hands through the
sleeves.
c) Fasten the ties at the
neck to keep the gown
in place.
d) Overlap the gown at the
back as much as
possible and fasten the
waist ties


4. Applying the face mask:  To be effective the mask must cover
a) Locate the top edge of both the nose and the mouth,
the mask; the mask because the air moves in and out of
usually has a narrow both.
metal strip along the
edge.
b) Hold the mask by the
top two strings.
c) Place the upper edge of
the mask over the
bridge of the nose, and
tie the upper ties at the
back of the head or
secure the loops
around the ears.
d) Secure the lower edge
of the mask under the
chin, and tie the lower
ties at the nape of the
neck.
e) If the mask has a metal  A sure fit prevents both the escape
strip, adjust this firmly and the inhalation of microorganisms
over the bridge of the around the edges of the mask.
nose  Mask should used only once because
f) Wear the mask only it becomes ineffective when wet.
once
g) Do not let a used mask
hanging around the
neck.

5. Apply clean gloves.
If wearing gowns pull the
gloves up to cover the cuffs of
the gown.

To remove soiled PPE:


6. Remove the gloves first since
they are the most soiled. If
wearing gown that is tied in
front undo ties before
removing the gloves.

7. Perform hand hygiene  Contact with microorganisms may
occur
8. Remove the gown when
preparing to leave the room
a) Avoid touching soiled
parts on the outside of
the gown.
b) Grasp the gown along
the inside of the neck
and pull down over the
shoulders. Do not
shake the gown.
c) Roll up the gown with
the soiled part inside,
and discard it in the
appropriate container .


9. Remove the mask  This prevents the top part of the
a) Remove the mask at mask from falling onto the chest.
the doorway to the
clients room. If using
respirator mask,
remove it after leaving
the room and closing
the door.
b) If using mask with
strings, first untie the
lower strings  The front of the mask through which
c) Untie the top string and, the nurse has been breathing is
while holding the ties contaminated.
securely, remove the
mask from the face. If
side loops are presents
, lift the side loops up
and away from the ears
and face. Do not touch
the front of the mask.
d) Discard a disposable
mask in the waste
container
e) Perform proper hand
hygiene again.

Applying and Removing Sterile Gloves

Purpose
 To enable the nurse to handle or touch sterile objects freely without
contaminating them.
 To prevent transmission of potentially infective organisms from the nurse's
hands to clients at high risk for infection.

Assessment
 Review the client's record and orders to determine exactly what procedure will
be performed that require sterile gloves. Check the client record and ask
about latex allergies. Use nonlatex gloves whenever possible.

Equipment
 Package of sterile gloves.

Procedure:


Step Rationale
1. Perform hand hygiene

2. Open the package of sterile gloves
a. Place the package on a clean, dry  Any moist on the surface could
surface.
b. Remove the inner package from contaminate the gloves.
the outer package.  To keep the inner surface sterile
c. Open the inner package as
instructed, if no tabs are provided,
pluck the flap so that the fingers
 Put the first glove on the dominant hand
do not touch the inner surface.
d. Grasp the glove for the dominant  The hands are not sterile. By touching
hand by its folded cuff edge on
only the inside of the gloves, the nurse
the palmer side with the thumb
and first finger of the avoids contaminating the outside.
nondominant hand. Touch only
the inside of the cuff.  If the thumb is kept against the palm, it is
e. Insert the dominant hand into the less likely to contaminate the outside of
glove and pull the glove on. Keep
the thumb of the inserted hand the glove.
against the palm of the hand
during the insertion.
f. Leave the cuff in place once the
unsterile hand releases the glove.

 Attempting to further unfold the cuff is
likely to contaminate the glove.


3. Put the second glove on the
nondominante hand
a. Pick up the other glove with the  This helps prevent accidental
sterile gloved hand. Inserting the
gloved fingers under the cuff and contamination by the bare hand.
holding the gloved thumb close to
the gloved palm
b. Pull on the second glove
carefully. Hold the thumb of the
gloved first hand as far as
possible from the palm.  In this position, the thumb is less likely to
c. Adjust each glove so that it is fits
smoothly, and carefully pull the touch the arm and become
cuffs up by sliding the fingers contaminated.
under the cuffs.

4. Remove and dispose the gloves.
 Same technique as removing
non-sterile gloves.
 Document that sterile technique
was used in the procedure.



CHANGING AN OCCUPIED BED
PURPOSES

1. To conserve the client’s energy
2. To promote client comfort.
3. To provide a clean, neat environment for the client
4. To provide a smooth, wrinkle-free bed foundation, thus minimizing sources of
skin irritation
ASSESSMENT Rationale
Assess
1 Skin condition and need for a special mattress
(e.g., an egg-crate mattress), footboard, bed
cradle, or heel protectors)
2 Client’s ability to reposition self. This will determine if additional
assistance is needed.
3 Determine presence of incontinence or excessive
drainage from other sources indicating the need
for protective waterproof pads.
4 Note specific orders or precautions for moving and
positioning the client.
PLANNING
Delegation
Bed-making is usually delegated to UAP (Unlicensed Assistive Personnel). Inform. Inform the UAP to
what extent the client can assist or if another person will be needed to assist the UAP.
Instruct the UAP about the handling of any dressing and/or tubes of the client and also the
need for special equipment (e.g., footboard, heel protectors), if appropriate.
EQUIPMENT
1. Two flat or one fitted and one flat sheet
2. Cloth draw sheet (optional)
3. One blanket
4. One bedspread
5. Pillowcase(s) for the head pillow(s)
6. Waterproof drawsheet or waterproof pads (optional)
7. Plastic laundry bag or portable lines hamper, if available

IMPLEMENTATION
Preparation

Determine what lines the client may already have This avoids stockpiling of
in the room to avoid stockpiling of the unnecessary extra linens.
unnecessary extra linens
Performance Rationale
1 Prior to performing the procedure, introduce self
and verify the client’s identity using agency
protocol. Explain to the client what you are going
to do, why it is necessary, and how he or she can
cooperate.
2 Perform hand hygiene and observe other
appropriate infection control procedures. Apply
clean gloves if linens is soiled with body fluids.

3 Provide for client privacy.
4 Remove the top bedding.
a Remove any equipment attached to the linen,
such as signal light.
b Loosen all top linen at the foot of the bed, and
remove the spread and the blanket.
c Leave the top sheet over the client (the top
sheet can remain over the client if it is being
changed and if it will provide sufficient
warmth), or replace it with a bath blanket as
follows:
a Spread the bath blanket over the top sheet.
b Ask the client to hold the top edge of the
blanket.
c Reaching under the blanket from the side, (1) Removing top linens under a bath
blanket.
grasp the top edge of the sheet and draw it
down to the foot of the bed. Leaving the
blanket in place. ( 1 )
d Remove the sheet from the bed and place
it in the soiled linen hamper.
5 Change the bottom sheet and draw sheet.
a Raise the side rail that the client will turn This protects clients from falling
toward. If there is no side rail, have another and allows them to support
nurse support the client at the edge of the bed. themselves in the side-lying
position.
b Assist the client to turn on the side away from
the nurse and toward the raised side rail.
c Loosen the bottom linens on the side of the
bed near the nurse.
d Fanfold the dirty linen (e.g., draw sheet and
the bottom sheet toward the center of the bed.
(2) As close to and under the client as
possible.

(2) Moving soiled linen as close to the
client as possible.
Doing this leaves the near half of
the bed free to be changed.
e Place the new bottom sheet on the bed, and
vertically fanfold the half to be used on the far
side of the bed as close to the client as
possible. (3) Tuck the sheet under the near
half of the bed and miter the corner if a contour
sheet is not being used.

(3) Placing new bottom sheet on half of the
bed.


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